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Template Allergy - Intolerance Observation (V2) 2014‑06‑09

Id2.16.840.1.113883.10.20.22.4.7
ref
ccda-
Effective Date2014‑06‑09
Statusdraft DraftVersion Label2.1
NameAllergy-IntoleranceObservationV2Display NameAllergy - Intolerance Observation (V2)
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 is the definitive 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". 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.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.7
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 9 transactions and 22 templates, Uses 4 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.31Transactionfinal Transfer Summary (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.25Transactionfinal Discharge Summary (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.29Transactionfinal Progress Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.26Transactionfinal History and Physical (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.22Transactionfinal Consultation Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.28Transactionfinal Procedure Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.23Transactionfinal Continuity of Care Document (CCD) (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.30Transactionfinal Referral Note (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.21Transactionfinal Care Plan (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.61.26.10.61Containmentdraft Allergy Concern Act (V3) (2.1)2019‑03‑09 13:34:13
2.16.840.1.113883.3.1937.99.61.26.10.62linkrejected Allergies and Intolerances Section (entries optional) (V3) (2.1)2019‑03‑09 13:37:11
2.16.840.1.113883.3.1937.99.61.26.10.112linkrejected Adverse Events Section (entries optional) (V3) (2.1)2019‑03‑25 06:01:02
2.16.840.1.113883.3.1937.99.61.28.10.3linkdraft CDA de Consulta (1)2017‑04‑22 23:20:01
2.16.840.1.113883.3.1937.99.61.30.10.54Containmentcancelled Health Concern Act (harmonized) (0.1)2020‑10‑08 10:55:41
2.16.840.1.113883.3.1937.99.61.67.10.24Containmentcancelled XeH Alert Act2021‑04‑20 10:00:04
2.16.840.1.113883.3.1937.99.61.67.10.25Containmentcancelled XeH Risk Concern Act2021‑04‑20 10:06:56
2.16.840.1.113883.10.20.22.1.2linkdraft Continuity of Care Document (CCD) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.3linkdraft History and Physical (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.4linkdraft Consultation Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.6linkdraft Procedure Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.8linkdraft Discharge Summary (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.9linkdraft Progress Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.13linkdraft Transfer Summary (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.14linkdraft Referral Note (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.15linkdraft Care Plan (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.6linkdraft Allergies and Intolerances Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.6.1linkdraft Allergies and Intolerances Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.58linkdraft Health Concerns Section (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.30Containmentdraft Allergy Concern Act (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.132Containmentdraft Health Concern Act (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.136Containmentdraft Risk Concern Act (V2) (2.1)2015‑08‑01
Uses as NameVersion
2.16.840.1.113883.10.20.22.4.8Containmentdraft Severity Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.9Containmentdraft Reaction Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.119Containmentdraft Author Participation (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.145Containmentdraft Criticality Observation (2.1)2015‑08‑13
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.4.7 Allergy - Intolerance Observation (2013‑01‑31)
ref
ccda-
ItemDTCardConfDescriptionLabel
cda:observation
AlledotsonV2
@classCode
cs1 … 1FOBSCONFdots7379
 SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7379).
@moodCode
cs1 … 1FEVNCONFdots7380
 SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7380).
@negationInd
bl0 … 1 MAY contain zero or one [0..1] @negationInd (CONF:1098-31526).CONFdots1526
cda:templateId
II1 … 1MC-CDA R1.1 templateId root without an extensionCONFdots2936
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.7
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1098-7381) such that itCONFdots7381
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.7CONFdots0488
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.7" (CONF:1098-10488).
@extension
st1 … 1F2014-06-09CONFdots2526
 SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32526).
cda:id
II1 … *SHALL contain at least one [1..*] id (CONF:1098-7382).CONFdots7382
cda:code
CD1 … 1MSHALL contain exactly one [1..1] code (CONF:1098-15947).CONFdots5947
@code
CONF1 … 1FASSERTION
@codeSystem
1 … 1F2.16.840.1.113883.5.4
cda:statusCode
CS1 … 1MSHALL contain exactly one [1..1] statusCode (CONF:1098-19084).CONFdots9084
@code
CONF1 … 1Fcompleted
cda:effectiveTime
IVL_TS1 … 1MSHALL contain exactly one [1..1] effectiveTime (CONF:1098-7387).CONFdots7387
cda:low
1 … 1This effectiveTime SHALL contain exactly one [1..1] low (CONF:1098-31538).CONFdots1538
cda:high
0 … 1This effectiveTime MAY contain zero or one [0..1] high (CONF:1098-31539).CONFdots1539
cda:value
CD1 … 1MSHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Allergy and Intolerance Type urn:oid:2.16.840.1.113883.3.88.12.3221.6.2 DYNAMIC (CONF:1098-7390).CONFdots7390
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.6.2 Allergy/Adverse Event Type (DYNAMIC)
cda:author
0 … *RSHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31143).
Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13)
CONFdots1143
cda:participant
1 … 1MSHALL contain exactly one [1..1] participant (CONF:1098-7402) such that itCONFdots7402
@typeCode
cs1 … 1FCSMCONFdots7403
 SHALL contain exactly one [1..1] @typeCode="CSM" Consumable (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1098-7403).
cda:participantRole
1 … 1MSHALL contain exactly one [1..1] participantRole (CONF:1098-7404).CONFdots7404
@classCode
cs1 … 1FMANUCONFdots7405
 This participantRole SHALL contain exactly one [1..1] @classCode="MANU" Manufactured Product (CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110 STATIC) (CONF:1098-7405).
cda:playingEntity
1 … 1MThis participantRole SHALL contain exactly one [1..1] playingEntity (CONF:1098-7406).CONFdots7406
@classCode
cs1 … 1FMMATCONFdots7407
 This playingEntity SHALL contain exactly one [1..1] @classCode="MMAT" Manufactured Material (CodeSystem: EntityClass urn:oid:2.16.840.1.113883.5.41 STATIC) (CONF:1098-7407).
cda:code
CD1 … 1This playingEntity SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet Substance-Reactant for Intolerance urn:oid:2.16.840.1.113762.1.4.1010.1 DYNAMIC (CONF:1098-7419).CONFdots7419
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113762.1.4.1010.1 Substance-Reactant for Intolerance (DYNAMIC)
cda:entryRelationship
0 … *RContains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (V2) (2014‑06‑09)CONFdots7447
@typeCode
cs1 … 1FMFSTCONFdots7907
 SHALL contain exactly one [1..1] @typeCode="MFST" Is Manifestation of (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7907).
@inversionInd
bl1 … 1FtrueCONFdots7449
 SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-7449).
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.8 Severity Observation (V2) (2014‑06‑09)CONFdots9961
@typeCode
cs1 … 1FSUBJCONFdots9962
 SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-9962).
@inversionInd
bl1 … 1FtrueCONFdots9964
 SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-9964).
 ConstraintUse of the Severity Observation at this level of the Allergy-intolerance template is deprecated. It SHOULD NOT be used here.
cda:entryRelationship
0 … 1RContains 2.16.840.1.113883.10.20.22.4.145 Criticality Observation (2015‑08‑13)CONFdots2910
@typeCode
cs1 … 1FSUBJCONFdots2911
 SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32911).
@inversionInd
bl1 … 1FtrueCONFdots2912
 SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-32912).
 Schematron assertrolered error 
 testnot(hl7:entryRelationship/hl7:observation/hl7:code[@code='SEV']) 
 MessageUse of the Severity Observation at this level of the Allergy-intolerance template is deprecated. It SHOULD NOT be used here. 

Template Allergy - Intolerance Observation 2013‑01‑31

Id2.16.840.1.113883.10.20.22.4.7
ref
ccda-
Effective Date2013‑01‑31
Statusdraft DraftVersion Label1.1
NameAllergy-IntoleranceObservationDisplay NameAllergy - Intolerance Observation
Description
This clinical statement represents that an allergy or adverse reaction exists or does not exist. The agent that is the cause of the allergy or adverse reaction is represented as a manufactured material participant playing entity in the allergy observation. While the agent is often implicit in the alert observation (e.g. ""allergy to penicillin""), it should also be asserted explicitly as an entity. The manufactured material participant is used to represent natural and non-natural occurring substances. NOTE: 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.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.7
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 6 transactions and 10 templates, Uses 4 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.4Transactionfinal Progress Note (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.3Transactionfinal Discharge Summary (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.5Transactionfinal Procedure Note (US Realm – Release 1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.2Transactionfinal Consultation Notes (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.7Transactionfinal History and Physical (H and P) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.1Transactionfinal Continuity of Care Document (CCD) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.61.41.10.4linkdraft Discharge Summary (1.1)2018‑02‑19 15:30:38
2.16.840.1.113883.10.20.22.1.2linkdraft Continuity of Care Document (CCD) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.3linkdraft History and Physical (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.4linkdraft Consultation Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.6linkdraft Procedure Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.8linkdraft Discharge Summary (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.9linkdraft Progress Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6linkdraft Allergies Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6.1linkdraft Allergies Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.30Containmentdraft Allergy Problem Act (1.1)2013‑01‑31
Uses as NameVersion
2.16.840.1.113883.10.20.22.4.8Containmentdraft Severity Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.9Containmentdraft Reaction Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.28Containmentdraft Allergy Status Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.145Containmentdraft Criticality Observation (2.1)2015‑08‑13
ItemDTCardConfDescriptionLabel
cda:observation
Alledotstion
@classCode
cs1 … 1FOBSconf‑7379
@moodCode
cs1 … 1FEVNconf‑7380
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:7381) such that itconf‑7381
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.7confdots0488
cda:id
II1 … *RSHALL contain at least one [1..*] id (CONF:7382).conf‑7382
cda:code
CD1 … 1MSHALL contain exactly one [1..1] code (CONF:15947).confdots5947
@code
CONF1 … 1FASSERTION
@codeSystem
1 … 1F2.16.840.1.113883.5.4
cda:statusCode
CS1 … 1MSHALL contain exactly one [1..1] statusCode (CONF:19084).confdots9084
@code
CONF1 … 1Fcompleted
cda:effectiveTime
IVL_TS1 … 1RSHALL contain exactly one [1..1] effectiveTime (CONF:7387).

If it is unknown when the allergy began, this effectiveTime SHALL contain low/@nullFLavor="UNK"

If the allergy is no longer a concern, this effectiveTime MAY contain zero or one [0..1] high
conf‑7387
cda:value
CD1 … 1MSHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:7390).conf‑7390
@code
1 … 1Rconf‑9139
cda:originalText
0 … 1RThis value SHOULD contain zero or one [0..1] originalText (CONF:7422).conf‑7422
cda:reference
0 … 1The originalText, if present, MAY contain zero or one [0..1] reference (CONF:15949).

This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)
confdots5949
@value
0 … 1 confdots5950
 Schematron assertrolered error 
 testnot(@value) or starts-with(@value, '#') 
 MessageThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) 
cda:participant
0 … 1RSHOULD contain zero or one [0..1] participant (CONF:7402) such that itconf‑7402
@typeCode
cs1 … 1FCSMconf‑7403
cda:participantRole
1 … 1MSHALL contain exactly one [1..1] participantRole (CONF:7404).conf‑7404
@classCode
cs1 … 1FMANUconf‑7405
cda:playingEntity
1 … 1MThis participantRole SHALL contain exactly one [1..1] playingEntity (CONF:7406).conf‑7406
@classCode
cs1 … 1FMMATconf‑7407
cda:code
CD1 … 1RThis playingEntity SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet Substance-Reactant for Intolerance urn:oid:2.16.840.1.113762.1.4.1010.1 DYNAMIC (CONF:7419).
conf‑7419
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113762.1.4.1010.1 Substance-Reactant for Intolerance (DYNAMIC)
cda:originalText
0 … 1RThis code SHOULD contain zero or one [0..1] originalText (CONF:7424).conf‑7424
cda:reference
0 … 1RThe originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:7425).

This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)
conf‑7425
@value
0 … 1 confdots5952
 Schematron assertrolered error 
 testnot(@value) or starts-with(@value, '#') 
 MessageThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) 
cda:translation
CD0 … *This code MAY contain zero or more [0..*] translation (CONF:7431).conf‑7431
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.28 Allergy Status Observation (2013‑01‑31)conf‑7440
@typeCode
cs1 … 1FSUBJconf‑7906
@inversionInd
bl1 … 1Ftrueconf‑7446
cda:entryRelationship
0 … *RContains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (2013‑01‑31)conf‑7447
@typeCode
cs1 … 1FMFSTconf‑7907
@inversionInd
bl1 … 1Ftrueconf‑7449
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.8 Severity Observation (2013‑01‑31)conf‑9961
@typeCode
cs1 … 1FSUBJconf‑9962
@inversionInd
bl1 … 1Ftrueconf‑9964
 ConstraintUse of the Severity Observation at this level of the Allergy-intolerance template is deprecated. It SHOULD NOT be used here.
 Schematron assertroleorange warning 
 testfalse() 
 MessageUse of the Severity Observation at this level of the Allergy-intolerance template is deprecated. It SHOULD NOT be used here. 
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.145 Criticality Observation (2015‑08‑13)confdots2910
@typeCode
cs1 … 1FSUBJconfdots2911
@inversionInd
bl1 … 1Ftrueconfdots2912