Draft| Description |
This template reflects a discrete observation about a patient's problem. 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 heart attack that occurred five years ago, the effectiveTime is five years ago. The effectiveTime of the Problem Observation is the definitive indication of whether or not the underlying condition is resolved. If the problem is 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". |
| Used by 0 transactions and 0 templates, Uses 5 templates | ||||||||||||||||||||||||
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ccda-
Specialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
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ad1bbr-
Version: template 2.16.840.1.113883.10.20.22.4.4 Problem Observation (2013‑01‑31)
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ccda-
| Item | DT | Card | Conf | Description | Label | |
|---|---|---|---|---|---|---|
| cda:observation | Prob onV3 | |||||
| @classCode | cs | 1 … 1 | F | OBS | CONF9041 | |
| SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-9041). | ||||||
| @moodCode | cs | 1 … 1 | F | EVN | CONF9042 | |
| SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1198-9042). | ||||||
| @negationInd | bl | 0 … 1 | MAY contain zero or one [0..1] @negationInd (CONF:1198-10139). | CONF0139 | ||
| hl7:templateId | II | 1 … 1 | M | ProbonV3 | ||
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.3.1937.99.61.26.10.59 | ||
| cda:templateId | II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-14926) such that it | CONF4926 | |
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.4.4 | CONF4927 | |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.4" (CONF:1198-14927). | ||||||
| @extension | st | 1 … 1 | F | 2015-08-01 | CONF2508 | |
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32508). | ||||||
| cda:id | II | 1 … * | SHALL contain at least one [1..*] id (CONF:1198-9043). | CONF9043 | ||
| cda:code | CD | 1 … 1 | SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Problem Type urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2012-06-01 (CONF:1198-9045). | CONF9045 | ||
| CONF |
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| cda:translation | 1 … * | M | This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 2014-09-02 (CONF:1198-32848). | CONF2848 | ||
| CONF |
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| cda:statusCode | CS | 1 … 1 | M | SHALL contain exactly one [1..1] statusCode (CONF:1198-9049). | CONF9049 | |
| @code | CONF | 1 … 1 | F | completed | ||
| cda:effectiveTime | IVL_TS | 1 … 1 | M | SHALL contain exactly one [1..1] effectiveTime (CONF:1198-9050). If the problem is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. Therefore, the existence of an high element within a problem does indicate that the problem has been resolved. | CONF9050 | |
| cda:low | 1 … 1 | R | This effectiveTime SHALL contain exactly one [1..1] low (CONF:1198-15603). The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | CONF5603 | ||
| cda:high | 0 … 1 | R | This effectiveTime MAY contain zero or one [0..1] high (CONF:1198-15604). The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved. | CONF5604 | ||
| cda:value | CD | 1 … 1 | M | CONF9058 | ||
| @code | 0 … 1 | This value MAY contain zero or one [0..1] @code (CONF:1198-31871). | CONF1871 | |||
| CONF |
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| cda:qualifier | 0 … * | This value MAY contain zero or more [0..*] qualifier (CONF:1198-31870). The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML. | CONF1870 | |||
| cda:translation | 0 … * | This value MAY contain zero or more [0..*] translation (CONF:1198-16749) such that it | CONF6749 | |||
| @code | 0 … 1 | MAY contain zero or one [0..1] @code (CodeSystem: ICD10CM urn:oid:2.16.840.1.113883.6.90 STATIC) (CONF:1198-16750). | CONF6750 | |||
| cda:author | 0 … * | R | SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1198-31147). Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13) | CONF1147 | ||
| cda:entryRelationship | 0 … 1 | Contains 2.16.840.1.113883.10.20.22.4.31 Age Observation (2015‑08‑13) | CONF9059 | |||
| @typeCode | cs | 1 … 1 | F | SUBJ | CONF9060 | |
| SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1198-9060). | ||||||
| @inversionInd | bl | 1 … 1 | F | true | CONF9069 | |
| SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1198-9069). | ||||||
| cda:entryRelationship | 0 … 1 | Contains 2.16.840.1.113883.10.20.22.4.113 Prognosis Observation (2015‑08‑13) | CONF9951 | |||
| @typeCode | cs | 1 … 1 | F | REFR | CONF1531 | |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31531). | ||||||
| cda:entryRelationship | 0 … * | Contains 2.16.840.1.113883.10.20.22.4.143 Priority Preference (2015‑08‑13) | CONF1063 | |||
| @typeCode | cs | 1 … 1 | F | REFR | CONF1532 | |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31532). | ||||||
| cda:entryRelationship | 0 … 1 | Contains 2.16.840.1.113883.10.20.22.4.6 Problem Status (2014‑06‑09) | CONF9063 | |||
| @typeCode | cs | 1 … 1 | F | REFR | CONF9068 | |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-9068). | ||||||