Template

Show index

Template IPS Allergy or Intolerance 2016‑11‑10

Id2.16.840.1.113883.10.22.4.1Effective Date2016‑11‑10
Statuspending Under pre-publication reviewVersion LabelSTU1
NameIPSEntryAllergyOrIntoleranceDisplay NameIPS Allergy or Intolerance
Description
This template reflects a discrete observation about a patient's allergy or intolerance.
Because it is a discrete observation, it will have a statusCode of "completed".
The effectiveTime, also referred to as the "biologically relevant time" is the time at which the observation holds for the patient.
For a provider seeing a patient in the clinic today, observing a history of penicillin allergy that developed five years ago, the effectiveTime is five years ago.
The effectiveTime of the Allergy - Intolerance Observation gives an indication of whether or not the underlying allergy/intolerance is resolved. If known to be resolved, then an effectiveTime/high would be present. 
If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK". 
It is recommended that the agent responsible for an allergy or adverse reaction would be used for describing the allergy, however the possibility that pre-coordinate codes (e.g. "allergy to nuts") will be used has been here also considered.
The agent responsible for  an allergy or adverse reaction it is not always a manufactured material (for example, food allergies), nor is it necessarily consumed; however  the playingEntity classCode = "MMAT" for all agents, manufactured or not is expected to be used. This choice depends on thecharacteristics of the base CDA R2 specification.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.1
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 12 concepts
IdNameData Set
hl7ips-dataelement-188draft End Date draft CEN/TC 251 prEN 17269
hl7ips-dataelement-173draft Agent draft CEN/TC 251 prEN 17269
hl7ips-dataelement-191draft Type of propensity draft CEN/TC 251 prEN 17269
hl7ips-dataelement-196draft Agent code draft CEN/TC 251 prEN 17269
hl7ips-dataelement-189draft Criticality draft CEN/TC 251 prEN 17269
hl7ips-dataelement-182draft Allergies/Intolerances Content Status draft CEN/TC 251 prEN 17269
hl7ips-dataelement-187draft Onset date draft CEN/TC 251 prEN 17269
hl7ips-dataelement-190draft Certainty draft CEN/TC 251 prEN 17269
hl7ips-dataelement-184draft Allergy/Intolerance draft CEN/TC 251 prEN 17269
hl7ips-dataelement-185draft Diagnosis draft CEN/TC 251 prEN 17269
hl7ips-dataelement-186draft Clinical Status draft CEN/TC 251 prEN 17269
hl7ips-dataelement-192draft Reaction draft CEN/TC 251 prEN 17269
Used by / Uses
Used by 0 transactions and 1 template, Uses 4 templates
Used by as NameVersion
2.16.840.1.113883.10.22.4.5Containmentpending IPS Allergy and Intolerance Concern (STU1)2016‑11‑11
Uses as NameVersion
2.16.840.1.113883.10.22.4.6Containmentpending IPS Reaction Manifestation (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.18Containmentpending IPS Criticality Observation (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.21Containmentpending IPS Allergy Status Observation (STU1)DYNAMIC
2.16.840.1.113883.10.22.10Containmentpending IPS Allergy Certainty Observation (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.20.1.18 Alert observation (DYNAMIC)
ref
ccd1-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (DYNAMIC)
ref
IHE-PCC-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.6 IHE Allergies And Intolerances Entry (DYNAMIC)
ref
IHE-PCC-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.1"/>  <id root=" " extension=" "/>  <!-- This is the code that shows what kind of allergy or intolerance -->
  <code code="OINT" displayName="Allergy or Intolerance" codeSystem="2.16.840.1.113883.5.4"/>  <text>
    <reference value="#ref1"/>  </text>
  <statusCode code="completed"/>  <effectiveTime>
    <low value="20170701"/>  </effectiveTime>
  <!-- This is the allergen - the substance that caused the allergy -->
  <participant typeCode="CSM">
    <participantRole classCode="MANU">
      <playingEntity classCode="MMAT">
        <code code=" " codeSystem=" ">
          <originalText>
            <reference value="#substance"/>          </originalText>
        </code>
        <name>...</name>      </playingEntity>
    </participantRole>
  </participant>
  <!-- This is how the allergy manifests itself -->
  <entryRelationship typeCode="MFST" inversionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.6 'IPS Reaction Manifestation' (dynamic) -->
  </entryRelationship>
  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.18 'IPS Criticality Observation' (dynamic) -->
  </entryRelationship>
  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.19 'IPS Certainty Observation' (dynamic) -->
  </entryRelationship>
  <entryRelationship typeCode="REFR" inversionInd="false">
    <!-- template 2.16.840.1.113883.10.22.4.21 'IPS Allergy Status Observation' (dynamic) -->
  </entryRelationship>
</observation>
Example
No Known Allergies
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.1"/>  <code code="allergy" displayName="Allergy" codeSystem="2.16.840.1.113883.4.642.1.122"/>  <statusCode code="completed"/>  <effectiveTime>
    <low nullFlavor="UNK"/>  </effectiveTime>
  <value code="X-NoKnownAllergy" displayName="No known allergy" codeSystem="2.16.840.1.113883.5.1150.2"/></observation>
Example
No Information available about allergies or intolerances
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.1"/>  <code code="OINT" displayName="Allergy or Intolerance" codeSystem="2.16.840.1.113883.5.4"/>  <statusCode code="completed"/>  <effectiveTime>
    <low nullFlavor="NA"/>  </effectiveTime>
  <value code="no-allergy-info" displayName="No information about allergies" codeSystem="2.16.840.1.113883.5.1150.1"/></observation>
Example
Minimum Set (active propensity; agent known)
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.1"/>  <code code="OINT" displayName="Allergy or Intolerance" codeSystem="2.16.840.1.113883.5.4"/>  <statusCode code="completed"/>  <effectiveTime>
    <low nullFlavor="UNK"/>  </effectiveTime>
  <participant typeCode="CSM">
    <participantRole classCode="MANU">
      <playingEntity classCode="MMAT">
        <code code="13577000" codeSystem="2.16.840.1.113883.6.96" displayName="Nut"/>      </playingEntity>
    </participantRole>
  </participant>
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
RIPSEdotsance
 
target
hl7ips-dataelement-184draft Allergy/Intolerance draft CEN/TC 251 prEN 17269
@classCode
cs1 … 1FOBS
@moodCode
cs1 … 1FEVN
hl7:templateId
II1 … 1MIPSEdotsance
@root
uid1 … 1F2.16.840.1.113883.10.22.4.1
hl7:id
II0 … *RIPSEdotsance
hl7:code
CD.IPS1 … 1MThis element describes whether this condition refers to an allergy, non-allergy intolerance, or unknown class of intolerance (not known to be allergy or intolerance).IPSEdotsance
 
target
hl7ips-dataelement-191draft Type of propensity draft CEN/TC 251 prEN 17269
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.2 Allergy or Intolerance Type (DYNAMIC)
hl7:text
ED0 … 1RThe text element if present points to the text describing the problem being recorded; including any dates, comments, et cetera. The contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.IPSEdotsance
hl7:reference
TEL1 … 1MIPSEdotsance
@value
1 … 1RWhen used it shall refer to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
CS1 … 1MA clinical document normally records only those condition observation events that have been completed, not observations that are in any other state. Therefore, the shall always have code='completed'.IPSEdotsance
@code
cs1 … 1Fcompleted
hl7:effectiveTime
IVL_TS1 … 1M The effectiveTime, also referred to as the "biologically relevant time" is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of penicillin allergy that developed five years ago, the effectiveTime is five years ago. The effectiveTime of the Allergy - Intolerance  Observation may give an indication of whether or not the underlying allergy/intolerance is resolved. 
The <low> and <high> values should be no more precise than known, but as precise as possible.
IPSEdotsance
hl7:low
IVXB_TS1 … 1RThe effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became biologically active.IPSEdotsance
 
target
hl7ips-dataelement-187draft Onset date draft CEN/TC 251 prEN 17269
hl7:high
IVXB_TS0 … 1CThe effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance became biologically resolved.
If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".
IPSEdotsance
 
target
hl7ips-dataelement-188draft End Date draft CEN/TC 251 prEN 17269
 ConstraintIf this condition is known to be resolved, then the effectiveTime/high would be present.
Choice0 … 1
The coded form of the observation value can be used :
  • either to indicate known absent conditions (e.g. NKA) or the nonavailability of information; 
  • or to provide pre-coordinated codes describing the propensity to specific substances (e.g. allergy to nuts). 
The choice reflects these options.
Elements to choose from:
  • hl7:value[1]
  • hl7:value[2]
hl7:value
CD.IPS (preferred)0 … 1IPSEdotsance
where [1]
 
target
hl7ips-dataelement-185draft Diagnosis draft CEN/TC 251 prEN 17269
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.10 IPS Allergy or Intolerance Conditions (DYNAMIC)
hl7:value
CD.IPS (required)0 … 1CWhen the value is used to describe the absence of information the participant used for indicating the allergy agent shall be omitted.
IPSEdotsance
where [2]
 
target
hl7ips-dataelement-182draft Allergies/Intolerances Content Status draft CEN/TC 251 prEN 17269
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.9 Absent or Unknown Allergies (DYNAMIC)
hl7:participant
0 … 1CThe substance that causes the allergy or intolerance should be specified in the <participant> structure. 
This is the preferred way an allergy is supposed to be expressed.
However it is recognized that in some contexts a controlled vocabulary is used for describing the allergy to a substance; or for asserting known absence or unavailability of information. 
In this case the <participant> structure shall be omitted.
The agent responsible for an allergy or adverse reaction is not always a manufactured material (for example, food allergies), nor is it necessarily consumed. The following constraints reflect limitations in the base CDA R2 specification, and should be used to represent any type of responsible agent, i.e., use playingEntity classCode = "MMAT" for all agents, manufactured or not.
IPSEdotsance
 
target
hl7ips-dataelement-173draft Agent draft CEN/TC 251 prEN 17269
@typeCode
cs1 … 1FCSM
 ConstraintIF the observation/value element is present and valued with a code derived form the  2.16.840.1.113883.11.22.9 Absent or Unknown Allergies value set THEN the  observation/participant element used to describe the agent SHALL be omitted.
hl7:participantRole
1 … 1RIPSEdotsance
@classCode
cs1 … 1FMANU
hl7:playingEntity
1 … 1RIPSEdotsance
@classCode
cs1 … 1FMMAT
hl7:code
CD.IPS (preferred)1 … 1RCode for the substance causing the allergy or intolerance.IPSEdotsance
 
target
hl7ips-dataelement-196draft Agent code draft CEN/TC 251 prEN 17269
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.11 Adverse Reaction Agents (DYNAMIC)
hl7:entryRelationship
0 … *RThe contained entry describes the reactions that are manifestations (typeCode='MFST') of the reported allergy or intolerance.
Contains 2.16.840.1.113883.10.22.4.6 IPS Reaction Manifestation (DYNAMIC)
IPSEdotsance
 
target
hl7ips-dataelement-192draft Reaction draft CEN/TC 251 prEN 17269
@typeCode
cs1 … 1FMFST
@inversionInd
cs1 … 1Ftrue
hl7:entryRelationship
0 … 1RCriticality
The contained entry describes the gravity of the potential risk for future life-threatening adverse reactions when exposed to a substance known to cause an adverse reaction in that individual.
Contains 2.16.840.1.113883.10.22.4.18 IPS Criticality Observation (DYNAMIC)
IPSEdotsance
 
target
hl7ips-dataelement-189draft Criticality draft CEN/TC 251 prEN 17269
@typeCode
cs1 … 1FSUBJ
@inversionInd
cs1 … 1Ftrue
hl7:entryRelationship
0 … 1RCertainty or Verification Status
The contained entry describes the certainty associated with a propensity, or potential risk, of a reaction to the identified substance.
Contains 2.16.840.1.113883.10.22.10 IPS Allergy Certainty Observation (DYNAMIC)
IPSEdotsance
 
target
hl7ips-dataelement-190draft Certainty draft CEN/TC 251 prEN 17269
@typeCode
cs1 … 1FSUBJ
@inversionInd
cs1 … 1Ftrue
hl7:entryRelationship
0 … 1RStatus of the Allergy or Intolerance 
The contained entry describes the current status of the allergy or intolerance, for example, whether it is active, in remission, resolved, and so on ...
Contains 2.16.840.1.113883.10.22.4.21 IPS Allergy Status Observation (DYNAMIC)
IPSEdotsance
 
target
hl7ips-dataelement-186draft Clinical Status draft CEN/TC 251 prEN 17269
@typeCode
cs1 … 1FREFR
@inversionInd
cs1 … 1Ffalse