Id1.3.6.1.4.1.19376.1.5.3.1.4.13.4
ref
epsos-
Effective Date2013‑12‑20
Statusretired RetiredVersion Label
NameEntrySocialHistoryObservationDisplay NameSocial History Observation
Description

A social history observation is a simple observation that uses a specific vocabulary, and inherits constraints from CCD.

epSOS functional experts limited the social observations to smoke, alcohol and diet related observations.

The parent of this template is Simple Observation. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.33

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.13.4
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 9 concepts
IdNameData Set
ehr4cr2ehsdi-dataelement-237draft Smoking History draft Test
ehr4cr2ehsdi-dataelement-238draft Last Smoked draft Test
ehr4cr2ehsdi-dataelement-241draft Pack years draft Test
ehr4cr2ehsdi-dataelement-239draft Cigarettes Smoked Per Day draft Test
ehr4cr2ehsdi-dataelement-243draft Substance Use Start Date Time draft Test
ehr4cr2ehsdi-dataelement-244draft Substance Use End Date Time draft Test
ehr4cr2ehsdi-dataelement-240draft Years Smoked draft Test
ehr4cr2ehsdi-dataelement-242draft Alcohol Consumption draft Test
ehr4cr2ehsdi-dataelement-694draft Substance Abuse draft Test
RelationshipSpecialization: template 2.16.840.1.113883.10.20.1.33 (DYNAMIC)
ref
epsos-
ItemDTCardConfDescriptionLabel
hl7:observation
REntrdotstion
 Example<observation typeCode="OBS" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>  <templateId root="2.16.840.1.113883.10.20.1.33"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.4"/>  <id root=" " extension=" "/>  <code code=" " displayName=" " codeSystem=" " codeSystemName=" "/>  <text>
    <reference value="#xxx"/>  </text>  <statusCode code="completed"/>  <effectiveTime>
    <low value=" "/>    <high value=" "/>  </effectiveTime>  <value xsi:type=" "/></observation>
hl7:templateId
II.EPSOS1 … 1REntrdotstion
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.13
hl7:templateId
II.EPSOS1 … 1REntrdotstion
@root
uid1 … 1F2.16.840.1.113883.10.20.1.33
hl7:templateId
II.EPSOS1 … 1REntrdotstion
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.13.4
hl7:id
II.EPSOS1 … 1M

Since a Social History Observation is fulfilling the rules of a Simple Observation pattern, each Social History Observation shall have an identifier.

Entrdotstion
hl7:code
CD1 … 1M

The <code> element identifies the type social history observation.

The first two columns of following table describe the value set to be used for this attribute, derived from the code systeme SNOMED CT (2.16.840.1.113883.6.96). For each used concept the data type of the “value” attribute, and the related unit, is reported.

CODE

VALUE

Code

displayName

xsi:type

unit

229819007

Smoking

PQ

{pack}/d or {pack}/wk or {pack}/a

256235009

Exercise

{times}/wk

160573003

ETOH (Alcohol) Use

{drink}/d or {drink}/wk

364393001

Nutritional observable

CD

N/A

364703007

Employment detail

425400000

Toxic exposure status

363908000

Details of drug misuse behavior

228272008

Health-related behavior

ANY

Entrdotstion
 
target
ehr4cr2ehsdi-dataelement-237draft Smoking History draft Test
ehr4cr2ehsdi-dataelement-242draft Alcohol Consumption draft Test
ehr4cr2ehsdi-dataelement-238draft Last Smoked draft Test
ehr4cr2ehsdi-dataelement-239draft Cigarettes Smoked Per Day draft Test
ehr4cr2ehsdi-dataelement-241draft Pack years draft Test
ehr4cr2ehsdi-dataelement-243draft Substance Use Start Date Time draft Test
ehr4cr2ehsdi-dataelement-244draft Substance Use End Date Time draft Test
ehr4cr2ehsdi-dataelement-240draft Years Smoked draft Test
ehr4cr2ehsdi-dataelement-694draft Substance Abuse draft Test
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.14 eHDSISocialHistory (DYNAMIC)
hl7:text
ED1 … 1M

Since a Social History Observation is fulfilling the rules of a Simple Observation pattern, each Social History Observation shall have a text element.

Entrdotstion
hl7:statusCode
CS1 … 1REntrdotstion
@code
CONF0 … 1Fcompleted
hl7:effectiveTime
IVL_TS1 … 1R

The effectiveTime element contains a required low and an optional high subelement representing the start date and potential end date of the smoking habit, alcohol consumption or diet.
The low subelement represents the start date of the habit/consumption.
The high subelement represents the date the patient stopped the habit/consumption if applicable. This element shall not be present when observation is still active.

Entrdotstion
 
target
ehr4cr2ehsdi-dataelement-240draft Years Smoked draft Test
ehr4cr2ehsdi-dataelement-241draft Pack years draft Test
hl7:low
1 … 1RThe element shall be present. Entrdotstion
 
target
ehr4cr2ehsdi-dataelement-243draft Substance Use Start Date Time draft Test
hl7:high
0 … 1CThe element shall be present for completed or stopped habits/consumptions, and shall not be present otherwise. Entrdotstion
 
target
ehr4cr2ehsdi-dataelement-238draft Last Smoked draft Test
ehr4cr2ehsdi-dataelement-244draft Substance Use End Date Time draft Test
hl7:repeatNumber
NP

The <repeatNumber> element should not be used in a social history observation.

Entrdotstion
hl7:value
ANY1 … *R

The <value> element reports the value associated with the social history observation. The data type to use for each observation should be drawn from the table above.

Observations in the table above using the PQ data type have a unit in the form {xxx}/d, {xxx}/wk or {xxx}/a represent the number of items per day, week or year respectively. The value attribute indicates the number of times of the act performed, and the units represent the frequency. The example below shows how to represent 1 drink per day. 

    :
  <code code='160573003' displayName='ETOH Use' 
        codeSystem='2.16.840.1.113883.6.96' 
        codeSystemName='SNOMED CT'/>
    :
  <value xsi:type='PQ' value='1' unit='{drink}/d'/>
    :
 
 
 
Observations in the table using the CD data type should include coded values from an appropriate vocabulary to represent the social history item. The example below shows the encoding to indicate drug use of cannabis. 
 
 
    :
 
  <code code='363908000' displayName='Drug Use' 
 
        codeSystem='2.16.840.1.113883.6.96' 
 
        codeSystemName='SNOMED CT'/>
 
    :
 
  <value xsi:type='CD' code='398705004' displayName='cannabis' 
 
         codeSystem='2.16.840.1.113883.6.96' 
 
         codeSystemName='SNOMED CT'/>
 
    :
 
 
 
 
Other social history observations may use any appropriate data type.
Entrdotstion
 
target
ehr4cr2ehsdi-dataelement-241draft Pack years draft Test
ehr4cr2ehsdi-dataelement-239draft Cigarettes Smoked Per Day draft Test
ehr4cr2ehsdi-dataelement-242draft Alcohol Consumption draft Test
ehr4cr2ehsdi-dataelement-237draft Smoking History draft Test
ehr4cr2ehsdi-dataelement-694draft Substance Abuse draft Test
hl7:interpretationCode
NP

The <interpretationCode>, <methodCode>, and <targetSiteCode> elements should not be used in a social history observation.

Entrdotstion
hl7:methodCode
NP

The <interpretationCode>, <methodCode>, and <targetSiteCode> elements should not be used in a social history observation.

Entrdotstion
hl7:targetSiteCode
NP

The <interpretationCode>, <methodCode>, and <targetSiteCode> elements should not be used in a social history observation.

Entrdotstion