Draft| Description |
This template represents a patient's occupations, lifestyle, and environmental health risk factors. Demographic data (e.g., marital status, race, ethnicity, religious affiliation) are captured in the header. Though tobacco use and exposure may be represented with a Social History Observation, it is recommended to use the Current Smoking Status template or the Tobacco Use template instead, to represent smoking or tobacco habits. |
| Used by 8 transactions and 18 templates, Uses 1 template | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Transfer Summary (V2)
BC CDA ClinicalDocumentDischargeSummary (V3) (2.1)
Health Concern Act (harmonized) (0.1)ref
ad1bbr-
Version: template 2.16.840.1.113883.10.20.22.4.38 Social History Observation (2013‑01‑31)
| Item | DT | Card | Conf | Description | Label | |
|---|---|---|---|---|---|---|
| cda:observation | Soci onV3 | |||||
| @classCode | cs | 1 … 1 | F | OBS | CONF8548 | |
| SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-8548). | ||||||
| @moodCode | cs | 1 … 1 | F | EVN | CONF8549 | |
| SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1198-8549). | ||||||
| cda:templateId | II | 1 … 1 | M | C-CDA R1.1 templateId root without an extension | CONF2936 | |
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.4.38 | ||
| cda:templateId | II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-8550) such that it | CONF8550 | |
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.4.38 | CONF0526 | |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.38" (CONF:1198-10526). | ||||||
| @extension | st | 1 … 1 | F | 2015-08-01 | CONF2495 | |
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32495). | ||||||
| cda:id | II | 1 … * | SHALL contain at least one [1..*] id (CONF:1198-8551). | CONF8551 | ||
| cda:code | CD (extensible) | 1 … 1 | SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Social History Type urn:oid:2.16.840.1.113883.3.88.12.80.60 STATIC 2008-12-18 (CONF:1198-8558). Value Set: Social History Type urn:oid:2.16.840.1.113883.3.88.12.80.60 (Clinical Focus: Classification of questions bearing on a patient's behavior, achievement, and exogenous health factors),(Data Element Scope: ),(Inclusion Criteria: ),(Exclusion Criteria: ) This value set was imported on 11/5/2018 with a version of 20180917.Value Set Source: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.88.12.80.60/expansion | CONF8558 | ||
| CONF |
| |||||
| cda:translation | 0 … * | C | If code/@codeSystem is not LOINC, then this code SHALL contain at least one [1..*] translation, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1198-32951). | CONF2853 | ||
| @codeSystem | CONF | 0 … 1 | F | 2.16.840.1.113883.6.1 | ||
| Schematron assert | role |  error | ||||
| test | ../cda:code/@codeSystem = '2.16.840.1.113883.6.1' or cda:translation | |||||
| Message | If code/@codeSystem is not LOINC, then this code SHALL contain at least one [1..*] translation, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1 | |||||
| Schematron assert | role |  warning | ||||
| test | @codeSystem='2.16.840.1.113883.6.1' | |||||
| Message | The translation code SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1). | |||||
| cda:statusCode | CS | 1 … 1 | M | SHALL contain exactly one [1..1] statusCode (CONF:1198-8553). | CONF8553 | |
| @code | CONF | 1 … 1 | F | completed | ||
| cda:effectiveTime | IVL_TS | 1 … 1 | SHALL contain exactly one [1..1] effectiveTime (CONF:1198-31868). | CONF1868 | ||
| cda:value | 0 … 1 | R | SHOULD contain zero or one [0..1] value (CONF:1198-8559). | CONF8559 | ||
| Constraint | If Observation/value is a physical quantity (xsi:type="PQ"), the unit of measure *SHALL* be selected from ValueSet UnitsOfMeasureCaseSensitive (2.16.840.1.113883.1.11.12839) *DYNAMIC* | |||||
| 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:1198-31869). Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13) | CONF1869 | ||