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International Patient Summary (IPS) - Templates

 
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IPS Social History Section
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History (7)
Date Author Status Type
2020-05-10 18:52:19 Giorgio Cangioli Under pre-publication review version
2017-12-15 22:54:18 Dr. Kai Heitmann Draft version
2017-12-12 18:54:55 Giorgio Cangioli Draft version
2017-10-30 19:35:37 Giorgio Cangioli Draft version
2017-10-30 17:15:27 Giorgio Cangioli Draft version
2017-10-27 18:40:40 Giorgio Cangioli Draft version
2017-07-20 18:07:37 Giorgio Cangioli Draft version
false
Issues (1)
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Request for Information/Education Status = Closed ( hl7ips-issue-36 ): Social History
Type Request for Information/Education Status Request for Information/Education Status = Closed Priority Normal
Current Labels
 
 (CDA) CDA Implementation 
 
 (TBD) To be discussed 
Events
Tracking / Status = Closed 2017-07-12 17:03:32 : Tracking by Giorgio Cangioli
 
 CDA 
 
 TBD 
Description
Alcohol consumption and tobacco use tenplates have been added
Tracking / Status = In Progress 2017-06-21 14:52:45 : Tracking by Giorgio Cangioli
 
 CDA 
 
 TBD 
Tracking / Status = Open 2017-06-08 09:36:54 : Tracking by Dr. Kai Heitmann
 
 CDA 
Description
For alcohol we might consider what is considered elsewhere:
observation with code
  • 228309001 Pattern of drinking through day (observable entity)
  • 228308009 Pattern of drinking (observable entity)
and as the value the number of alcohol units, where
  • for 228309001 the units are simply expressed as a PQ or coded
  • for 228308009 the units are expressed as a ratio alcohol units / per time period


Tracking / Status = Open 2017-06-07 17:56:50 : Tracking by Giorgio Cangioli
 
 CDA 
Description
Call June 7th, 2017: 
- consider tobacco templates for observation form C-CDA [recommended]  (defined constrained vocabulary for this)
- alcohol usage ?

From Didi Davis:
  https://www.healthit.gov/sites/default/files/2015Ed_CCG_CCDS.pdf - in this file section 7 gives constraints made by US for Common Clinical Data Set (CCDS).  See below:

(7) Smoking status
Clarifications:
• We provide the following OID to assist developers in the proper identification and exchange of health information coded to certain vocabulary standards.
 SNOMED CT® OID: 2.16.840.1.113883.6.96 [see also 80 FR 62612]
• Health IT Modules can present for certification to a more recent version of SNOMED
CT®, U.S. Edition than the September 2015 Release per ONC’s policy that permits certification to a more recent version of certain vocabulary standards. [see also 80 FR 62612]
• “Light smoker” means fewer than 10 cigarettes per day, or an equivalent (but less concretely) defined quantity of cigar or pipe smoke. [see also 77 FR 54205]
• “Heavy smoker” is interpreted to mean greater or equal to 10 cigarettes per day or an equivalent (but less concretely defined) quantity of cigar or pipe smoke. [see also 77 FR 54205 and FAQ #37]
• Smoking status is limited to any form of tobacco that is smoked. That would not prohibit a health IT system from capturing other forms of tobacco use that is not smoked (e.g., chewing tobacco), but it is not required to meet the 2015 Edition CCDS definition. [see also 77 FR 54205]
• Health IT developers are free to include clinically relevant information, such as lifetime pack year exposure in their interface and system. However, the specific SNOMED CT® codes listed are to be used to reflect the patient’s smoking status when such data is required to be included as part of the CCDS.
       
§ 170.207(h) – Smoking status must be coded in one of the following SNOMED CT® codes:
(1) Current every day smoker. 449868002
(2) Current some day smoker. 428041000124106
(3) Former smoker. 8517006
(4) Never smoker. 266919005
(5) Smoker, current status unknown. 77176002
(6) Unknown if ever smoked. 266927001
(7) Heavy tobacco smoker. 428071000124103
(8) Light tobacco smoker. 428061000124105

Tracking / Status = Open 2017-05-24 16:18:58 : Tracking by Giorgio Cangioli
 
 CDA 
Assignment 2017-04-26 16:18:17 : Assigned To Dr. Kai Heitmann by Giorgio Cangioli
 
 CDA 
Tracking / Status = Open 2017-04-26 16:18:16 : Tracking by Giorgio Cangioli
 
 CDA 
Description
Finding:

Consider the inclusion - at least as optional - of the the Social History observation 

Suggestion:

-

Further explanation:

-

 
 
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