Id2.16.840.1.113883.10.20.22.4.4Effective Date2015‑08‑01
Statusdraft DraftVersion Label2.1
NameProblemObservationV3Display NameProblem Observation (V3)
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".
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.4
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 10 transactions and 43 templates, Uses 5 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.27Transactionfinal Operative Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.31Transactionfinal Transfer Summary (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.29Transactionfinal Progress Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.26Transactionfinal History and Physical (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.21Transactionfinal Care Plan (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.25Transactionfinal Discharge Summary (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.22Transactionfinal 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
2.16.840.1.113883.3.1937.99.61.18.10.12Containmentdraft Encounter Diagnosis (V3) (2.1)2021‑02‑26 17:06:47
2.16.840.1.113883.3.1937.99.61.21.10.64Containmentdraft Complications (V3) (2.1)2020‑07‑08 21:07:44
2.16.840.1.113883.3.1937.99.61.21.10.74Containmentdraft BC Impressions (2.1)2020‑08‑07 23:26:00
2.16.840.1.113883.3.1937.99.61.26.10.60Containmentdraft Problem Concern Act (V3) (2.1)2019‑03‑09 13:32:50
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
2.16.840.1.113883.10.20.21.2.3linkdraft Interventions Section (V3) (2.1)2015‑08‑01
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
2.16.840.1.113883.10.20.22.1.7linkdraft Operative 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
2.16.840.1.113883.10.20.22.2.5linkdraft Problem Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.5.1linkdraft Problem Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.20Containmentdraft Past Medical History (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.22linkdraft Encounters Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.22.1linkdraft Encounters Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.24linkdraft Discharge Diagnosis Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.28Containmentdraft Procedure Findings Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.34linkdraft Preoperative Diagnosis Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.36linkdraft Postprocedure Diagnosis Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.37Containmentdraft Complications Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.37.2Containmentdraft BC CDA Complications Section (V3) (2.1)2017‑03‑29 12:32:13
2.16.840.1.113883.10.20.22.2.43linkdraft Admission Diagnosis Section (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
2.16.840.1.113883.10.20.22.4.3Containmentdraft Problem Concern Act (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.33Containmentdraft Hospital Discharge Diagnosis (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.34Containmentdraft Hospital Admission Diagnosis (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.49linkdraft Encounter Activity (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.51Containmentdraft Postprocedure Diagnosis (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.65Containmentdraft Preoperative Diagnosis (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.79Containmentdraft Deceased Observation (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.80Containmentdraft Encounter Diagnosis (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.131linkdraft Intervention Act (V2) (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
2.16.840.1.113883.10.20.22.4.146linkdraft Planned Intervention Act (V2) (2.1)2015‑08‑01
Uses as NameVersion
2.16.840.1.113883.10.20.22.4.6Containmentdraft Problem Status (2.1-OLD)2014‑06‑09
2.16.840.1.113883.10.20.22.4.31Containmentdraft Age Observation (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.113Containmentdraft Prognosis Observation (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.119Containmentdraft Author Participation (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.143Containmentdraft Priority Preference (2.1)2015‑08‑13
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.4.4 Problem Observation (2013‑01‑31)
ItemDTCardConfDescriptionLabel
cda:observation
ProbdotsonV3
@classCode
cs1 … 1FOBSCONFdots9041
 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
cs1 … 1FEVNCONFdots9042
 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
bl0 … 1 MAY contain zero or one [0..1] @negationInd (CONF:1198-10139).CONFdots0139
cda:templateId
II1 … 1MC-CDA R1.1 templateId root without an extensionCONFdots2936
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.4
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1198-14926) such that itCONFdots4926
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.4CONFdots4927
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.4" (CONF:1198-14927).
@extension
st1 … 1F2015-08-01CONFdots2508
 SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32508).
cda:id
II1 … *SHALL contain at least one [1..*] id (CONF:1198-9043).CONFdots9043
cda:code
CD (extensible)1 … 1SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Problem Type (SNOMEDCT) 2.16.840.1.113883.3.88.12.3221.7.2 DYNAMIC (CONF:1198-9045).

a. If code is selected from ValueSet Problem Type (SNOMEDCT) 2.16.840.1.113883.3.88.12.3221.7.2 DYNAMIC, then it SHALL have at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) 2.16.840.1.113762.1.4.1099.28 DYNAMIC (CONF:1198-32950).		CONFdots9045
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.3.88.12.3221.7.2 Problem Type (DYNAMIC)
hl7:translation
CD (extensible)0 … *CIf code is selected from ValueSet Problem Type (SNOMEDCT) 2.16.840.1.113883.3.88.12.3221.7.2 DYNAMIC, then it SHALL have at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) 2.16.840.1.113762.1.4.1099.28 DYNAMIC (CONF:1198-32950). (CONF:1198-32950)
CONFdots9045
 CONF
The value of @code should be drawn from value set 2.16.840.1.113762.1.4.1099.28 Problem Type LOINC (DYNAMIC)
 Schematron assertroleorange warning 
 testnot(../cda:code/@codeSystem='2.16.840.1.113883.6.96') or cda:translation 
 MessageIf code is selected from ValueSet Problem Type (SNOMEDCT) 2.16.840.1.113883.3.88.12.3221.7.2 DYNAMIC, then it SHALL have at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) 2.16.840.1.113762.1.4.1099.28 DYNAMIC (CONF:1198-32950).  
cda:statusCode
CS1 … 1MSHALL contain exactly one [1..1] statusCode (CONF:1198-9049).CONFdots9049
@code
CONF1 … 1Fcompleted
cda:effectiveTime
IVL_TS1 … 1MSHALL 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.		CONFdots9050
cda:low
1 … 1This 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.		CONFdots5603
cda:high
0 … 1This 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.		CONFdots5604
cda:value
CD (extensible)1 … 1CONFdots9058
@code
0 … 1 This value MAY contain zero or one [0..1] @code (CONF:1198-31871).CONFdots1871
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.3.88.12.3221.7.4 Problem (DYNAMIC)
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.		CONFdots1870
cda:translation
0 … *This value MAY contain zero or more [0..*] translation (CONF:1198-16749) such that itCONFdots6749
@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).CONFdots6750
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:1198-31147).
Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13)		CONFdots1147
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.31 Age Observation (2015‑08‑13)CONFdots9059
@typeCode
cs1 … 1FSUBJCONFdots9060
 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
bl1 … 1FtrueCONFdots9069
 SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1198-9069).
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.113 Prognosis Observation (2015‑08‑13)CONFdots9951
@typeCode
cs1 … 1FREFRCONFdots1531
 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)CONFdots1063
@typeCode
cs1 … 1FREFRCONFdots1532
 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 … 1MAY contain zero or one [0..1] entryRelationship (CONF:1198-9063) such that it

SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-9068).

SHALL contain exactly one [1..1] Problem Status (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.6) (CONF:1198-15591).
Contains 2.16.840.1.113883.10.20.22.4.6 Problem Status (2014‑06‑09)		CONFdots9063
@typeCode
cs1 … 1FREFRCONFdots9068
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-9068).