Id1.3.6.1.4.1.19376.1.5.3.1.4.6
ref
epsos-
Effective Date2018‑11‑19 09:27:03
Statusretired RetiredVersion Label
NameEntryAllergyAndIntoleranceDisplay NameAllergies And Intolerances
Description

Allergies and intolerances are special kinds of problems, and so are also recorded in the CDA <observation> element, with classCode='OBS'. They follow the same pattern as the problem entry, with exceptions noted below.

Parent Template

This is a specialization of the IHE PCC Problem Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5 and of the CCD alert observation template 2.16.840.1.113883.10.20.1.18

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.6
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 3 templates
Uses as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.4.1Containmentretired eHDSI SeverityDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.5ContainmentDYNAMIC
2.16.840.1.113883.3.1937.777.11.10.134Containmentactive eHDSI Participant (Body)DYNAMIC
RelationshipVersion: template 1.3.6.1.4.1.19376.1.5.3.1.4.6 Allergies And Intolerances (2013‑12‑20)
ref
epsos-

Specialization: template 2.16.840.1.113883.10.20.1.18 (DYNAMIC)
ref
epsos-

Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 (DYNAMIC)
ref
epsos-
Example
Example
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="2.16.840.1.113883.10.20.1.18"/>  <templateId root="2.16.840.1.113883.10.20.1.28"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.6"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>  <id root=" " extension=" "/>  <!-- This is the code that shows what kind of allergy or intolerance derived from the epSOSAdverseEventType Value Set-->
  <code code="" codeSystem="2.16.840.1.113883.6.96"/>  <text>
    <reference value=" "/>  </text>  <statusCode code="completed"/>  <effectiveTime>
    <low value=" "/>    <high value=" "/>  </effectiveTime>  <!-- value element is present only to indicate no known allergies, in all other cases is used for referenicng text in the narrative -->
  <value xsi:type="CD"/>  <!-- This is the allergen - the substance that caused the allergy -->
  <participant typeCode="CSM">
    <participantRole classCode="MANU">
      <playingEntity classCode="MMAT">
        <code code=" " codeSystem=" ">
          <originalText>
            <reference value="#substance"/>          </originalText>        </code>        <name/>      </playingEntity>    </participantRole>  </participant>  <!-- This is how the allergy manifests itself -->
  <entryRelationship typeCode="MFST">
    <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.6.1"/>    <!-- a problem entry -->
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.1.54"/>      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>      <!-- The code tells us that the observation is a symptom -->
      <code code="418799008" codeSystem="2.16.840.1.113883.6.96" displayName="Finding reported by subject or history provider" codeSystemName="SNOMED CT"/>      <text>
        <reference value="#manifest-1"/>      </text>      <statusCode code="completed"/>      <!-- The value tells us what the symptom (i.e. allergy manifestation) is -->
      <!-- This is where anaphylaxy or angiooedema will be coded -->
      <value xsi:type="CD" code=" " codeSystem=" " displayName=" " codeSystemName=" "/>    </observation>  </entryRelationship>  <!-- This is how the severity of the allergy is described (Optional)-->
  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.1.55"/>      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1"/>      <!-- This code is from HL7 and indicates that the observation is about severity -->
      <code code="SEV" displayName="Severity" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>      <text>
        <reference value="#severity-1"/>      </text>      <statusCode code="completed"/>      <!-- This code is from SNOMED, according to the epSOS value set-->
      <value xsi:type="CD" code="" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>    </observation>  </entryRelationship></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
R

This entry has a template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.6, and is a subtype of the Problem Entry, and so must also conform to the rules of the problem entry, which has the template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5. These elements are required and shall be recorded exactly as shown above.

Note: the 1.3.6.1.4.1.19376.1.5.3.1.4.5 requires that also the template ID '2.16.840.1.113883.10.20.1.28' is included.

Entrdotsance
@classCode
cs1 … 1FOBS
@moodCode
cs1 … 1FEVN
@negationInd
bl0 … 1 
hl7:templateId
II.EPSOS1 … 1RIHE PCC Problem EntryEntrdotsance
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.5
hl7:templateId
II.EPSOS1 … 1RCCD Alert ObservationEntrdotsance
@root
uid1 … 1F2.16.840.1.113883.10.20.1.18
hl7:templateId
II.EPSOS1 … 1REntrdotsance
@root
uid1 … 1F2.16.840.1.113883.10.20.1.28
hl7:templateId
II.EPSOS1 … 1REntrdotsance
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.6
hl7:id
II.EPSOS1 … 1MEntrdotsance
hl7:code
CD1 … 1R

The <code> element represents the kind of allergy observation made, to a drug, food or environmental agent, and whether it is an allergy, non-allergy intolerance, or unknown class of intolerance (not known to be allergy or intolerance). The <code> element of an allergy entry shall be provided, and a code and codeSystem attribute shall be present.

Entrdotsance
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.18 eHDSIAdverseEventType (DYNAMIC)
hl7:text
ED1 … 1REntrdotsance
hl7:reference
TEL1 … 1MEntrdotsance
@value
1 … 1RReference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
CS1 … 1REntrdotsance
@code
CONF0 … 1Fcompleted
hl7:effectiveTime
IVL_TS0 … 1REntrdotsance
hl7:value
CD0 … *R

The value element shall be present in a coded or uncoded form. In both cases the type shall be set to xsi:type='CD'. The coded form shall be used to indicate "No known allergy" (code='716186003' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'). In all other cases it shall be in its uncoded form and may contain a <reference> to the <originalText> in the narrative where the allergy is described.

Entrdotsance
hl7:participant
0 … *C

The substance that causes the allergy or intolerance shall be specified in the <participant> structure.

The <code> element shall be present. It may contain a code and codeSystem attribute to indicate the code for the substance causing the allergy or intolerance. It shall contain a <reference> to the <originalText> in the narrative where the substance is named.


Contains 2.16.840.1.113883.3.1937.777.11.10.134 eHDSI Participant (Body) (DYNAMIC)		Entrdotsance
 ConstraintConditional: Omit if Observation.value is SNOMED-CT 716186003 No known allergy
hl7:entryRelationship
0 … *R

An allergy entry can record the reactions that are manifestations of the allergy or intolerance as shown below. It uses a related entry (<entryRelationship>) that indicates the manifestations (typeCode='MFST') the reported allergy or intolerance. These are events that may occur, or have occurred in the past as a reaction to the allergy or intolerance<entryRelationship typeCode='MFST'>

The entry contained with this entry relationship is some sort of problem that is a manifestation of the allergy. It is recorded using the Problem Entry structure.

Note: the 1.3.6.1.4.1.19376.1.5.3.1.4.5 requires that also the template ID '2.16.840.1.113883.10.20.1.28' is included.


Contains
alertError: Cannot find template "1.3.6.1.4.1.19376.1.5.3.1.4.5" (DYNAMIC)
Entrdotsance
hl7:entryRelationship
0 … 1R

An optional <entryRelationship> element may be present indicating the severity of the problem. If present, this <entryRelationship> element shall contain a severity observation conforming to the Severity entry template (1.3.6.1.4.1.19376.1.5.3.1.4.1).

The related statement is made about the severity of the condition, concern, or allergy). This observation is recorded inside an <entryRelationship> element occurring in the containing entry. The containing <entry> is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'.

The related statement is another event (moodCode='EVN') observing (<observation classCode='OBS'>) the severity of the (surrounding) related entry (e.g., a condition or allergy).


Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1 eHDSI Severity (DYNAMIC)		Entrdotsance
 Example<!-- The encompasing condition or allergy observation -->
<observation classCode="COND" moodCode="EVN">
  <!-- ... -->
  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.1.55"/>      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1"/>      <code code="SEV" displayName="Severity" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>      <text>
        <reference value="#severity-2"/>      </text>      <statusCode code="completed"/>      <!-- This code is from SNOMED, according to the epSOS value set-->
      <value xsi:type="CD" code="" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>    </observation>  </entryRelationship>  <!-- ... -->
</observation>