3.5 Problems

The template identifier for the problem section is 2.16.840.1.113883.10.20.1.11.

This section lists and describes all relevant clinical problems at the time the summary is generated. At a minimum, all pertinent current and historical problems should be listed. CDA R2 represents problems as Observations.

CONF-140: CCDSHOULD contain exactly one and SHALL NOT contain more than one Problem section (templateId 2.16.840.1.113883.10.20.1.11). The Problem section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more problem acts (templateId 2.16.840.1.113883.10.20.1.27). A problem act SHOULD include one or more problem observations (templateId 2.16.840.1.113883.10.20.1.28).

3.5.1 Section conformance

CONF-141: The problem section SHALL contain Section / code.
CONF-142: The value for “Section / code” SHALL be “11450-4” “Problem list” 2.16.840.1.113883.6.1 LOINC STATIC.
CONF-143: The problem section SHALL contain Section / title.
CONF-144: Section / titleSHOULD be valued with a case-insensitive language-insensitive text string containing “problems”.

3.5.2 Clinical statement conformance

The following figure shows a subset of the CDA Clinical Statement model containing those classes being constrained or referred to in the conformance statements that follow.

Figure 7. CDA R2 clinical statement model for problems

3.5.2.1 Representation of problems

The template identifier for a problem act is 2.16.840.1.113883.10.20.1.27.
The template identifier for a problem observation is 2.16.840.1.113883.10.20.1.28.

A problem is a clinical statement that a clinician is particularly concerned about and wants to track. It has important patient management use cases (e.g. health records often present the problem list as a way of summarizing a patient's medical history).

NOTE: The HL7 Patient Care Technical Committee is developing a formal model for condition tracking. In that model, observations of problems or other clinical statements captured at a point in time are wrapped in a "Concern" act which represents the ongoing process tracked over time. This allows for binding related observations of problems. For example, the observation of "Acute MI" in 2004, can be related to the observation of "History of MI" in 2006 because they are the same concern. The conformance statements in this section are compatable with the evolving Patient Care model and define an outer "problem act" (representing the “Concern”) which can contain a nested "problem observation" or other nested clinical statements.

3.5.2.2 Representation of “status” values

The template identifier for a problem status observation is 2.16.840.1.113883.10.20.1.50.
The template identifier for a problem healthstatus observation is 2.16.840.1.113883.10.20.1.51.

ASTM CCR, in addition to the Status observations defined in many sections, defines a restricted set of optional HealthStatus values (“Alive And Well”, “In Remission”, “Symptom Free”, “Chronically Ill”, “Severely Ill”, “Disabled”, “Severely Disabled”, “Deceased”) that describe the status of the patient overall as a result of a particular problem, represented in CCD as an associated problem healthstatus observation.

CONF-162: A problem observation MAY contain exactly one problem status observation.
CONF-163: A problem status observation (templateId 2.16.840.1.113883.10.20.1.50) SHALL be a conformant status observation (templateId 2.16.840.1.113883.10.20.1.57) (as defined in section 5.1 “Type” and “Status” values).
CONF-164: The value for “Observation / value” in a problem status observation SHALL be selected from ValueSet 2.16.840.1.113883.1.11.20.13 ProblemStatusCode STATIC 20061017.
CONF-165: A problem observation MAY contain exactly one problem healthstatus observation.
CONF-166: A problem healthstatus observation (templateId 2.16.840.1.113883.10.20.1.51) SHALL be a conformant status observation (templateId 2.16.840.1.113883.10.20.1.57) (as defined in section 5.1 “Type” and “Status” values), except that the value for “Observation / code” in a problem healthstatus observation SHALL be “11323-3” “Health status” 2.16.840.1.113883.6.1 LOINC STATIC.
CONF-167: The value for “Observation / value” in a problem healthstatus observation SHALL be selected from ValueSet 2.16.840.1.113883.1.11.20.12 ProblemHealthStatusCode STATIC 20061017.

3.5.2.3 Episode observations

The template identifier for an episode observation is 2.16.840.1.113883.10.20.1.41.

Episode observations are used to distinguish among multiple occurrences of a problem or social history item. An episode observation is used to indicate that a problem act represents a new episode, distinct from other episodes of a similar concern.

NOTE: The HL7 actRelationshipType “ELNK” (episodeLink) is used to indicate that linked observations are part of the SAME episode, whereas the ASTM CCR <Episodes> element is used to differentiate DIFFERENT episodes of the same condition.

CONF-168: A problem act MAY contain exactly one episode observation.
CONF-169: An episode observation (templateId 2.16.840.1.113883.10.20.1.41) SHALL be represented with Observation.
CONF-170: The value for “Observation / @classCode” in an episode observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC.
CONF-171: The value for “Observation / @moodCode” in an episode observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC.
CONF-172: An episode observation SHALL include exactly one Observation / statusCode.
CONF-173: The value for “Observation / statusCode” in an episode observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC.
CONF-174: The value for “Observation / Code” in an episode observation SHOULD be “ASSERTION” 2.16.840.1.113883.5.4 ActCode STATIC.
CONF-175: “Observation / value” in an episode observation SHOULD be the following SNOMED CT expression:

 <value xsi:type="CD" code="404684003" codeSystem="2.16.840.1.113883.6.96" displayName="Clinical finding"> <qualifier> <name code="246456000" displayName="Episodicity"/> <value code="288527008" displayName="New episode"/> </qualifier> </value>

CONF-176: An episode observation SHALL be the source of exactly one entryRelationship whose value for “entryRelationship / @typeCode” is “SUBJ” “Has subject” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC . This is used to link the episode observation to the target problem act or social history observation.
CONF-177: An episode observation MAY be the source of one or more entryRelationship whose value for “entryRelationship / @typeCode” is “SAS” “Starts after start” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC. The target of the entryRelationship SHALL be a problem act or social history observation. This is used to represent the temporal sequence of episodes.

3.5.2.4 Patient awareness of a problem

The template identifier for patient awareness is templateId 2.16.840.1.113883.10.20.1.48.