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Template Allergy Or Intolerance Entry 2016‑11‑12

Id2.16.756.5.30.1.1.10.4.98
ref
ch-pcc-
Effective Date2016‑11‑12
Statusactive ActiveVersion Label2016
Namechpcc_entry_AllergyOrIntoleranceDisplay NameAllergy Or Intolerance Entry
Description

Allergies or intolerances are a special form of a 'Problem Entry'.

In relation with immunizations, substances in vaccines SHALL be recorded here, using the WHO ATC Code along with a possible additional egg-protein allergy or a severe eczema.

ContextParent nodes of template element with id 2.16.756.5.30.1.1.10.4.98
LabelIHE PCC TF2 Rev.11, 6.3.4.15
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 2 templates, Uses 7 templates
Used by as NameVersion
2.16.756.5.30.1.1.10.3.51linkactive Allergies and other Adverse Reactions Section - coded (2016)2016‑11‑12
2.16.756.5.30.1.1.10.4.91Containmentactive Allergies and Intolerances Concern Entry (2016)2016‑11‑12
Uses as NameVersion
2.16.756.5.30.1.1.10.4.2Containmentactive Annotation Comments (2016)DYNAMIC
2.16.756.5.30.1.1.10.4.99Containmentactive Severity Entry (2016)DYNAMIC
2.16.756.5.30.1.1.10.4.100Containmentactive Problem Status Observation (2016)DYNAMIC
2.16.756.5.30.1.1.10.4.120Containmentactive Reaction Observation (2016)DYNAMIC
2.16.756.5.30.1.1.10.9.14Includedraft Narrative Text Reference (2021)DYNAMIC
2.16.756.5.30.1.1.10.9.49Includedraft Original Text Reference (2021)DYNAMIC
2.16.756.5.30.1.1.10.9.54Containmentactive Author Compilation with id, name, addr and telecom (2020)DYNAMIC
RelationshipSpecialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.6 IHE Allergies And Intolerances Entry (DYNAMIC)
ref
ch-pcc-

Specialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.756.5.30.1.1.10.4.98"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.6"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>  <templateId root="2.16.840.1.113883.10.20.1.28"/>  <templateId root="2.16.840.1.113883.10.20.1.18"/>  <id root="2.999" extension="your id"/>  <code code="DINT" codeSystem="2.16.840.1.113883.5.4" displayName="Drug Intolerance"/>  <text>
    <reference value="#ar1"/>  </text>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20121213"/>  </effectiveTime>  <value type="CD" code="303300008" codeSystem="2.16.840.1.113883.6.96" displayName="Egg protein (substance)"/>  <author>
    <!-- template 2.16.756.5.30.1.1.10.9.54 'Author Compilation with id, name, addr and telecom' -->
  </author>  <participant typeCode="CSM">
    <participantRole classCode="MANU">
      <playingEntity classCode="MMAT">
        <code nullFlavor="NAV" codeSystem="2.16.840.1.113883.6.73" codeSystemName="WHO ATC" displayName="displayName">
          <!-- template 2.16.756.5.30.1.1.10.9.49 'Original Text Reference' -->
        </code>        <name>name</name>      </playingEntity>    </participantRole>  </participant>  <entryRelationship typeCode="MFST">
    <!-- template 2.16.756.5.30.1.1.10.4.120 'Reaction Observation' -->
  </entryRelationship>  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <!-- template 2.16.756.5.30.1.1.10.4.99 'Severity Entry' -->
  </entryRelationship>  <entryRelationship typeCode="REFR" inversionInd="false">
    <!-- template 2.16.756.5.30.1.1.10.4.100 'Problem Status Observation' -->
  </entryRelationship>  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <!-- template 2.16.756.5.30.1.1.10.4.2 'Annotation Comments' -->
  </entryRelationship></observation>
ItemDTCardConfDescriptionLabel
hl7:observation

Allergies or intolerances are a special form of a 'Problem Entry'.

In relation with immunizations, substances in vaccines SHALL be recorded here, using the WHO ATC Code along with a possible additional egg-protein allergy or a severe eczema.

IHE PCC TF2 Rev.11, 6.3.4.15
@classCode
cs1 … 1FOBS
@moodCode
cs1 … 1FEVN
hl7:templateId
II1 … 1IHE PCC TF2 Rev.11, 6.3.4.15
@root
uid1 … 1F2.16.756.5.30.1.1.10.4.98
hl7:templateId
II1 … 1IHE PCC TF2 Rev.11, 6.3.4.15
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.6
hl7:templateId
II1 … 1IHE PCC TF2 Rev.11, 6.3.4.15
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.5
hl7:templateId
II1 … 1IHE PCC TF2 Rev.11, 6.3.4.15
@root
uid1 … 1F2.16.840.1.113883.10.20.1.28
hl7:templateId
II1 … 1IHE PCC TF2 Rev.11, 6.3.4.15
@root
uid1 … 1F2.16.840.1.113883.10.20.1.18
hl7:id
II0 … 1RAn ID for this item MAY be filled for traceability.IHE PCC TF2 Rev.11, 6.3.4.15
@root
uid1 … 1RMUST contain the OID of the system that issued the ID. OIDs of code systems, which are published in the public OID registry for the Swiss health care system (oid.refdata.ch) are REQUIRED. Others are NOT ALLOWED.
@extension
st0 … 1 Contains the ID itself. The ID MUST be unique within the system that issued the ID.
hl7:code
CD1 … 1MThe allergy or intolerance type code.IHE PCC TF2 Rev.11, 6.3.4.15
@code
cs1 … 1R
@codeSystem
oid1 … 1F2.16.840.1.113883.5.4
@codeSystemName
st1 … 1FObservationIntoleranceType
@displayName
st1 … 1R
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19700 ObservationIntoleranceType (DYNAMIC)
or
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19701 ObservationAllergyType (DYNAMIC)
or
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19702 ObservationNonAllergyIntoleranceType (DYNAMIC)
Included1 … 1 from 2.16.756.5.30.1.1.10.9.14 Narrative Text Reference (DYNAMIC)
The human-readable text MUST be generated automatically from the structured information of this element. The text element MUST contain the reference to the corresponding text in the human readable part, ONLY.
hl7:text
ED1 … 1MCDA‑CH V2
hl7:reference
TEL1 … 1MThe reference to the corresponding text in the human readable part must be specified by reference to content[@ID]: reference[@value='#xxx']CDA‑CH V2
@value
1 … 1RReference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding element.
 Schematron assertrolered error 
 teststarts-with(@value,'#') 
 MessageThe @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content' element. 
 Variable letNameidvalue 
 Valuesubstring-after(@value,'#') 
 Schematron assertrolered error 
 testancestor::hl7:structuredBody//*[@ID=$idvalue] 
 MessageNo narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>'). 
hl7:statusCode
CS1 … 1M

The statusCode shall be set to 'completed' for all allergies and intolerances.

IHE PCC TF2 Rev.11, 6.3.4.15
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20025 ActStatusCompleted (DYNAMIC)
hl7:effectiveTime
IVL_TS.CH.TZ1 … 1RIndicates the time interval over which the allergy or intolerance is known to be true.IHE PCC TF2 Rev.11, 6.3.4.15
hl7:low
TS.CH.TZ1 … 1MPoint of time of the first occurance of the allergy or intolerance.IHE PCC TF2 Rev.11, 6.3.4.15
hl7:high
TS.CH.TZ0 … 1CPoint of time when the allergy or intolerance was no longer valid. For all other cases this value remains empty.IHE PCC TF2 Rev.11, 6.3.4.15
hl7:value
CD0 … *

This value can be either a coded value or uncoded text. The type is always xsi:type='CD'. For coded values the attributes code, codeSystem, codeSystemName and displayName MUST be present. For uncoded values, the nullFlavor='NAV' attribute and the originalText element MUST be present.

The following value sets are allowed:

  • CHOP: 2.16.756.5.30.1.126.3.1
  • ICD-10: 2.16.756.5.30.1.126.3.2
  • ICPC-2: 2.16.840.1.113883.6.139
  • SNOMED CT: 2.16.840.1.113883.6.96

The SNOMED CT code '160245001', No current problems or disability (situation) MAY be used to indicate that the patient doesn't currently suffer on any problem.

For special cases a code from the value set "Special Case Allergies/Intolerances" SHALL be used.

In relation to eVACDOC, the value set 'Allergies for eVACDOC' contains the recommended values.

IHE PCC TF2 Rev.11, 6.3.4.15
@nullFlavor
st0 … 1FNAV
@code
cs0 … 1 
@codeSystem
oid0 … 1 
@codeSystemName
st0 … 1 
@displayName
st0 … 1 
 CONF
@codeSystem shall be "2.16.756.5.30.1.126.3.1"
or
@codeSystem shall be "2.16.756.5.30.1.126.3.2"
or
@codeSystem shall be "2.16.840.1.113883.6.139"
or
@codeSystem shall be "2.16.840.1.113883.6.96"
or
The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.68 Special Case Allergies/Intolerances (DYNAMIC)
or
The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.76 Allergies for eVACDOC (DYNAMIC)
 Schematron assertrolered error 
 test(@code and @codeSystem) or (@nullFlavor='NAV') 
 MessageEither a code with its code system or nullFlavor='NAV' is required. 
 Schematron assertrolered error 
 testnot(@nullFlavor) or (hl7:originalText) 
 MessageOther problems description MUST be declared in the originalText element in case of nullFlavor. 
Included0 … 1C from 2.16.756.5.30.1.1.10.9.49 Original Text Reference (DYNAMIC)
The human-readable text MUST be generated automatically from the structured information of this element. The text element MUST contain the reference to the corresponding text in the human readable part, ONLY.
hl7:originalText
ED0 … 1CCDA‑CH V2
hl7:reference
TEL1 … 1MThe reference to the corresponding text in the human readable part must be specified by reference to content[@ID]: reference[@value='#xxx']CDA‑CH V2
@value
1 … 1RReference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding element.
 Schematron assertrolered error 
 teststarts-with(@value,'#') 
 MessageThe @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content' element. 
 Variable letNameidvalue 
 Valuesubstring-after(@value,'#') 
 Schematron assertrolered error 
 testancestor::hl7:structuredBody//*[@ID=$idvalue] 
 MessageNo narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>'). 
 Schematron assertrolered error 
 testparent::*/text()=ancestor::hl7:structuredBody//*[@ID=$idvalue]/text() 
 MessageThe originalText content MUST be identical to the narrative text for this reference. 
hl7:author
0 … *CThe author of the statement SHALL be specified either here or in one of the ancestors.
Contains 2.16.756.5.30.1.1.10.9.54 Author Compilation with id, name, addr and telecom (DYNAMIC)		IHE PCC TF2 Rev.11, 6.3.4.15
 Schematron assertrolered error 
 test(hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]] or ancestor::*/hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]]) 
 MessageThe author of the statement SHALL be specified either here or in one of the ancestors. It shall contain the time, id, name, addr and telecom elements as specified in IHE PCC TF Vol. 2, section 6.3.4.1 Authors and Informants. 
 Schematron assertroleyellow info 
 test(not(hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]]) and ancestor::hl7:section/hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]]) 
 MessageThe author of the statement is specified by the ancestor section. 
 Schematron assertroleyellow info 
 test(not(hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]] or ancestor::hl7:section/hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]]) and ancestor::hl7:ClinicalDocument/hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]]) 
 MessageThe author of the statement is specified by the author in the document header. 
hl7:participant
1 … *RThis element SHALL indicate the substance which causes the allergy or intolerance.IHE PCC TF2 Rev.11, 6.3.4.15
@typeCode
cs1 … 1FCSM
hl7:participantRole
IHE PCC TF2 Rev.11, 6.3.4.15
@classCode
cs1 … 1FMANU
hl7:playingEntity
1 … 1MIHE PCC TF2 Rev.11, 6.3.4.15
@classCode
cs1 … 1FMMAT
hl7:code
CD1 … 1RIHE PCC TF2 Rev.11, 6.3.4.15
@nullFlavor
st0 … 1FNAV
@code
cs0 … 1 
@codeSystem
oid0 … 1F2.16.840.1.113883.6.73
@codeSystemName
st0 … 1FWHO ATC
@displayName
st0 … 1 
 Schematron assertrolered error 
 test(@code and @codeSystem) or (@nullFlavor='NAV') 
 MessageEither a code with its code system or nullFlavor='NAV' is required. 
 Schematron assertrolered error 
 testnot(@nullFlavor) or (hl7:originalText) 
 MessageOther allergies or intolerances description MUST be declared in the originalText element in case of nullFlavor. 
Included0 … 1C from 2.16.756.5.30.1.1.10.9.49 Original Text Reference (DYNAMIC)
The human-readable text MUST be generated automatically from the structured information of this element. The text element MUST contain the reference to the corresponding text in the human readable part, ONLY.
hl7:originalText
ED0 … 1CCDA‑CH V2
hl7:reference
TEL1 … 1MThe reference to the corresponding text in the human readable part must be specified by reference to content[@ID]: reference[@value='#xxx']CDA‑CH V2
@value
1 … 1RReference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding element.
 Schematron assertrolered error 
 teststarts-with(@value,'#') 
 MessageThe @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content' element. 
 Variable letNameidvalue 
 Valuesubstring-after(@value,'#') 
 Schematron assertrolered error 
 testancestor::hl7:structuredBody//*[@ID=$idvalue] 
 MessageNo narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>'). 
 Schematron assertrolered error 
 testparent::*/text()=ancestor::hl7:structuredBody//*[@ID=$idvalue]/text() 
 MessageThe originalText content MUST be identical to the narrative text for this reference. 
hl7:name
ST0 … 1IHE PCC TF2 Rev.11, 6.3.4.15
hl7:entryRelationship
0 … *Reactions that are manifestations of the allergy or intolerance.
Contains 2.16.756.5.30.1.1.10.4.120 Reaction Observation (DYNAMIC)		IHE PCC TF2 Rev.11, 6.3.4.15
where [@typeCode='MFST']
@typeCode
cs1 … 1FMFST
hl7:entryRelationship
0 … 1Indicates the severity of the allergy or intolerance.
Contains 2.16.756.5.30.1.1.10.4.99 Severity Entry (DYNAMIC)		IHE PCC TF2 Rev.11, 6.3.4.15
where [@typeCode='SUBJ']
@typeCode
cs1 … 1FSUBJ
@inversionInd
bl1 … 1Ftrue
hl7:entryRelationship
0 … 1Indicates the clinical status of the allergy or intolerance.
Contains 2.16.756.5.30.1.1.10.4.100 Problem Status Observation (DYNAMIC)		IHE PCC TF2 Rev.11, 6.3.4.15
where [@typeCode='REFR']
@typeCode
cs1 … 1FREFR
@inversionInd
bl1 … 1Ffalse
hl7:entryRelationship
0 … *Additional comments (annotations) for the allergy or intolerance.
Contains 2.16.756.5.30.1.1.10.4.2 Annotation Comments (DYNAMIC)		IHE PCC TF2 Rev.11, 6.3.4.15
where [@typeCode='SUBJ']
@typeCode
cs1 … 1FSUBJ
@inversionInd
bl1 … 1Ftrue