Id2.16.840.1.113883.2.51.10.27Effective Date2021‑10‑01 08:20:28
Statusactive ActiveVersion Label1.0
NameXeHAdmissionDischargeDiagnosisDisplay NameXeH Admission / Discharge Diagnosis
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 2.16.840.1.113883.2.51.10.27
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 2 templates, Uses 3 templates
Used by as NameVersion
2.16.840.1.113883.2.51.10.28Containmentactive XeH Discharge Diagnosis Section (1.0)2021‑10‑01 08:29:04
2.16.840.1.113883.2.51.10.29Containmentactive XeH Admission Diagnosis Section (1.0)2021‑10‑01 08:54:36
Uses as NameVersion
2.16.840.1.113883.2.51.10.51Containmentactive XeH Prognosis Observation (1.0)DYNAMIC
2.16.840.1.113883.10.22.4.19Containmentpending IPS Certainty Observation (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.25Containmentpending IPS Severity Observation (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.22.4.8 IPS Problem Entry (2017‑02‑15)
ref
hl7ips-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (DYNAMIC)
ref
IHE-PCC-
Example
Active Problem
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.8"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>  <text>
    <reference value="#problem-1"/>  </text>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20100507"/>  </effectiveTime>  <value code="38341003" displayName="Hypertensive disorder, systemic arterial (disorder)" codeSystem="2.16.840.1.113883.6.96"/>  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.25 'IPS Severity Observation' (dynamic) -->
  </entryRelationship>  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.19 'IPS Certainty Observation' (dynamic) -->
  </entryRelationship>  <entryRelationship typeCode="REFR" inversionInd="false">
    <!-- template 2.16.840.1.113883.10.22.4.20 'IPS Problem Status Observation' (2017-03-29T00:00:00) -->
    <!-- this referred observation should report that the condition is still active -->
  </entryRelationship></observation>
Example
Closed Problem (resolution date known)
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.8"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="2010"/>    <high value="2015"/>  </effectiveTime>  <value code="38341003" displayName="Hypertensive disorder, systemic arterial (disorder)" codeSystem="2.16.840.1.113883.6.96"/>  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.25 'IPS Severity Observation' (dynamic) -->
  </entryRelationship>  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.19 'IPS Certainty Observation' (dynamic) -->
  </entryRelationship>  <entryRelationship typeCode="REFR" inversionInd="false">
    <!-- template 2.16.840.1.113883.10.22.4.20 'IPS Problem Status Observation' (2017-03-29T00:00:00) -->
    <!-- this referred observation should report that the condition is resolved -->
  </entryRelationship></observation>
Example
Known absent problems
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.8"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>  <statusCode code="completed"/>  <effectiveTime>
    <low nullFlavor="NI"/>  </effectiveTime>  <value code="no-known-problems" displayName="No known problems" codeSystem="2.16.840.1.113883.5.1150.1"/></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
RXeHAdotsosis
@classCode
cs0 … 1FOBS
@moodCode
cs1 … 1FEVN
hl7:templateId
II1 … 1MXeHAdotsosis
@root
uid1 … 1F2.16.840.1.113883.2.51.10.27
hl7:templateId
II1 … 1MXeHAdotsosis
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.67.10.21
hl7:id
II0 … *RXeHAdotsosis
hl7:code
CD.IPS1 … 1RThis element describes the type of condition this observation is referring to.XeHAdotsosis
 CONF
@code shall be "8646-2"
@codeSystem shall be "2.16.840.1.113883.6.1"
or
@code shall be "8651-2"
@codeSystem shall be "2.16.840.1.113883.6.1"
 Example<hl7:code code="8646-2" codeSystem="2.16.840.1.113883.6.1" displayName=""/>
hl7:text
ED0 … 1RThe element if present points to the text describing the problem being recorded; including any dates, comments, et cetera. The contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.XeHAdotsosis
 Example<text>
  <reference value="#problem-1"/></text>
hl7:reference
TEL1 … 1MXeHAdotsosis
@value
1 … 1RWhen used it shall refer to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
CS1 … 1MA clinical document normally records only those condition observation events that have been completed, not observations that are in any other state. Therefore, the shall always have code='completed'.XeHAdotsosis
@code
CONF1 … 1Fcompleted
hl7:effectiveTime
IVL_TS1 … 1M
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 <low> and <high> values should be no more precise than known, but as precise as possible.
XeHAdotsosis
 Example
Known onset date (active condition)
<effectiveTime>
  <low value="20100507"/></effectiveTime>
 Example
Unknown onset date (active condition)
<effectiveTime>
  <low nullFlavor="UNK"/></effectiveTime>
 Example
Unknown resolution date
<effectiveTime>
  <low value="2010"/>  <high nullFlavor="UNK"/></effectiveTime>
 Example
Known resolution date
<effectiveTime>
  <low value="201007"/>  <high value="201703"/></effectiveTime>
hl7:low
IVXB_TS1 … 1RThe effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.XeHAdotsosis
hl7:high
IVXB_TS0 … 1CThe effectiveTime/high (a.k.a. "resolution date") asserts when the condition e became biologically resolved.
If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".		XeHAdotsosis
 Constraint If this condition is known to be resolved, then the effectiveTime/high would be present.
hl7:value
CD.IPS (preferred)1 … 1MThe <value> is the condition that was found.
It may a coded or an un-coded string, but its type is always coded.
The coded form shall be used also to indicate known absent conditions or the nonavailability of information about them. 		XeHAdotsosis
@xsi:type
0 … 1FCD
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.5 CORE Problem List Disorders (DYNAMIC)
or
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.17 Absent or Unknown Problems (DYNAMIC)
or
The value of @code comes preferably from value set 2.16.840.1.113883.3.1937.99.61.67.11.2 International Classification of Diseases for Oncology (DYNAMIC)
 Example
Multiple Coding
<value code="302231008" displayName="Salmonella infection" codeSystem="2.16.840.1.113883.6.96">
  <translate code="A02.9" displayName="Infezioni da Salmonella non specificate" codeSystem="2.16.840.1.113883.6.3"/></value>
 Example
Local code not mappable in the reference terminology
<value nullFlavor="OTH">
  <translate code="12345" displayName="Not in the reference value set" codeSystem="1.2.3.999" codeSystemName="--example only--"/></value>
 Example
Textual Information
<value nullFlavor="NI">
  <originalText>
    <reference value="#value_as_text"/>  </originalText></value>
 Example
Known absent problems
<value code="160245001" displayName="No current problems or disability" codeSystem="2.16.840.1.113883.6.96"/>
hl7:originalText
R

The <originalText> element within the <code> element described above is used as follows: the <value> contains a <reference> to the <originalText> in order to link the coded value to the problem narrative text (minus any dates, comments, et cetera). The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.

XeHAdotsosis
hl7:reference
0 … 1R The URI given in the value attribute of the element points to an element in the narrative content that contains the complete text describing the medication. In a CDA document, the URI given in the value attribute of the element points to an element in the narrative content that contains the complete text describing the medication. XeHAdotsosis
 Example<reference value="#value_as_text"/>
hl7:translation
CD.IPS0 … *The translation element may be used to transmit a set of other concept descriptors, using for example ICD-10 or other international or jurisdictional code systems.XeHAdotsosis
hl7:qualifier
CR0 … *XeHAdotsosis
hl7:entryRelationship
0 … 1Severity
The contained entry describes a subjective assessment of the severity of the condition as evaluated by the clinician.
Contains 2.16.840.1.113883.10.22.4.25 IPS Severity Observation (DYNAMIC)		XeHAdotsosis
@typeCode
cs1 … 1FSUBJ
@inversionInd
bl1 … 1Ftrue
hl7:entryRelationship
0 … 1 Certainty or Verification Status 
The contained entry describes the certainty associated with a condition.
Contains 2.16.840.1.113883.10.22.4.19 IPS Certainty Observation (DYNAMIC)		XeHAdotsosis
@typeCode
cs1 … 1FSUBJ
@inversionInd
bl1 … 1Ftrue
hl7:entryRelationship
0 … 1 Prognosis 
The contained entry describes the prognosis associated with this diagnosis.
Contains 2.16.840.1.113883.2.51.10.51 XeH Prognosis Observation (DYNAMIC)		XeHAdotsosis
@typeCode
cs1 … 1FREFR