This section documents the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy.
At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.
If no information about allergies is available, or if no allergies are known this should be clearly documented in the section.
The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
Context
Parent nodes of template element with id 2.16.840.1.113883.10.22.3.2
Classification
CDA Section Level Template
Open/Closed
Open (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 7 templates, Uses 4 templates
<sectionclassCode="DOCSECT"> <templateIdroot="2.16.840.1.113883.10.22.3.2"/><idroot="1.2.3.999"extension="__example only__"/><codecode="48765-2"codeSystem="2.16.840.1.113883.6.1"displayName="Allergies and adverse reactions"/><title>Allergies and Intolerances</title><text> <!-- Textual description of the Allergies and Intolerances --> </text><author> <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) --> </author><informant> <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (dynamic) --> </informant><entrytypeCode="COMP"contextConductionInd="true"> <!-- template 2.16.840.1.113883.10.22.4.5 'IPS Allergy and Intolerance Concern' (dynamic) --> </entry><component> <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (dynamic) --> </component></section>
Example
No information available
<hl7:section> <cda:templateIdroot="2.16.840.1.113883.10.22.3.2"/><cda:idroot="1.2.3.999"extension="--example only--"/><cda:codecode="48765-2"codeSystem="2.16.840.1.113883.6.1"displayName="Allergies and adverse reactions"/><cda:title>Allergies and Intolerances</cda:title><cda:text> <!-- Textual description of the Allergies and Intolerances --> </cda:text><cda:entry> <cda:actclassCode="ACT"moodCode="EVN"> <cda:templateIdroot="2.16.840.1.113883.10.22.4.5"/><cda:idroot="1.2.3.999"extension="__example only__"/><cda:codecode="CONC"codeSystem="2.16.840.1.113883.5.6"/><cda:statusCodecode="active"/><cda:effectiveTime> <cda:lownullFlavor="NA"/></cda:effectiveTime><cda:entryRelationshiptypeCode="SUBJ"inversionInd="false"> <cda:observationclassCode="OBS"moodCode="EVN"> <cda:templateIdroot="2.16.840.1.113883.10.22.4.1"/><cda:codecode="OINT"displayName="Allergy or Intolerance"codeSystem="2.16.840.1.113883.5.4"/><cda:statusCodecode="completed"/><cda:effectiveTime> <cda:lownullFlavor="NA"/></cda:effectiveTime><cda:valuecode="no-allergy-info"displayName="No information about allergies"codeSystem="2.16.840.1.113883.5.1150.1"/></cda:observation></cda:entryRelationship></cda:act></cda:entry></hl7:section>