Retired| Description |
(CCD) Any problem or allergy observation may reference a problem status observation. This structure is included in the target observation using the <entryRelationship> element defined in the CDA Schema. The clinical status observation records information about the current status of the problem or allergy, for example, whether it is active, in remission, resolved, et cetera. The example below shows the recording of clinical status of a condition or allergy, and is used as the context for the following sections. This CCD models a problem status observation as a separate observation from the problem, allergy or medication observation. While this model is different from work presently underway by various organizations (i.e., SNOMED, HL7, TermInfo), it is not wholly incompatible with that work. In that work, qualifiers may be used to identify problem status in the coded condition observation, and a separate clinical status observation is no longer necessary. The use of qualifiers in the problem observation is not precluded by this specification or by CCD. However, to support semantic interoperability between EMR systems using different vocabularies, this specification does require that problem status information also be provided in a separate observation. This ensures that all EMR systems have equal access to the information, regardless of the vocabularies they support. |
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Problem
IHE Problem Entry (2014)
IHE Problem Entry (2016)| Example |
| <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.1.57"/> <templateId root="2.16.840.1.113883.10.20.1.50"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1.1"/> <code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <text> <reference value="#cstatus-2"/> </text> <statusCode code="completed"/> <value type="CE" code=" " codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/></observation> |
| Item | DT | Card | Conf | Description | Label | |
|---|---|---|---|---|---|---|
| hl7:observation | eHDS tion | |||||
| @classCode | cs | 0 … 1 | F | OBS | ||
| @moodCode | cs | 0 … 1 | F | EVN | ||
| hl7:templateId | II | 1 … 1 | R | eHDStion | ||
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.1.57 | ||
| hl7:templateId | II | 1 … 1 | R | eHDStion | ||
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.1.50 | ||
| hl7:templateId | II | 1 … 1 | R | eHDStion | ||
| @root | uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 | ||
| hl7:code | CD | 1 … 1 | R | This observation is of clinical status, as indicated by the <code> element. This element must be present. | eHDStion | |
| @code | CONF | 0 … 1 | F | 33999-4 | ||
| @codeSystem | 0 … 1 | F | 2.16.840.1.113883.6.1 | |||
| @displayName | 0 … 1 | F | Status | |||
| @codeSystemName | 0 … 1 | F | LOINC | |||
| hl7:text | ED | 1 … 1 | M | The <text> element is required and points to the text describing the problem being recorded; including 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. | eHDStion | |
| hl7:reference | TEL | 1 … 1 | M | eHDStion | ||
| @value | 1 … 1 | R | Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1 | |||
| hl7:statusCode | CS | 1 … 1 | M | The code attribute of <statusCode> for all clinical status observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed. | eHDStion | |
| @code | CONF | 1 … 1 | F | completed | ||
| hl7:value | CE.EPSOS | 1 … 1 | R | The <value> element contains the clinical status. It is always represented using the CE datatype (xsi:type='CE'). It shall contain a code from the following set of values from SNOMED CT. | eHDStion | |
| CONF |
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