Under pre-publication review| Description |
This clinical statement represents the response to an undesired symptom, finding, etc. due to administered or exposed substance. This reaction may be an undesired symptom, finding, etc. or it could be a desired response to a treatment. A reaction can be defined with respect to its severity, and can have been treated by one or more interventions. |
| Associated with 2 concepts | |||||||||
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Manifestation of the reaction | Used by 0 transactions and 1 template, Uses 1 template | ||||||||||||||||
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ref
IHE-PCC-
| Example |
| <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.22.4.6"/> <id root="1.2.3.999" extension="__example only__"/> <code code="404684003" displayName="Clinical finding" codeSystem="2.16.840.1.113883.6.96"/> <text> <reference value="#ref1"/> </text> <statusCode code="completed"/> <effectiveTime> <low value="201611"/> </effectiveTime> <value xsi:type="CD" code="1985008" displayName="Vomitus" codeSystem="2.16.840.1.113883.6.96"> <originalText> <reference value="#ref2"/> </originalText> </value> <entryRelationship typeCode="SUBJ" inversionInd="true"> <!-- template 2.16.840.1.113883.10.22.4.25 'IPS Severity Observation' (dynamic) --> </entryRelationship></observation> |
| Item | DT | Card | Conf | Description | Label | ||||
|---|---|---|---|---|---|---|---|---|---|
| hl7:observation | R | IPSA MFST | |||||||
| @classCode | cs | 0 … 1 | F | OBS | |||||
| @moodCode | cs | 1 … 1 | F | EVN | |||||
| hl7:templateId | II | 1 … 1 | M | IPSAMFST | |||||
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.22.4.6 | |||||
| hl7:id | II | 0 … * | R | IPSAMFST | |||||
| hl7:code | CD.IPS | 1 … 1 | R | This element describes the type of condition this observation is referring to. | IPSAMFST | ||||
| CONF |
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| hl7:text | ED | 0 … 1 | R | The <text> element if present 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. | IPSAMFST | ||||
| hl7:reference | TEL | 1 … 1 | M | IPSAMFST | |||||
| @value | 1 … 1 | R | When used it shall refer to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1 | ||||||
| hl7:statusCode | CS (required) | 0 … 1 | R | A clinical document normally records only those condition observation events that have been completed, not observations that are in any other state. Therefore, the <statusCode> shall always have code='completed'. | IPSAMFST | ||||
| @code | CONF | 0 … 1 | F | completed | |||||
| hl7:effectiveTime | IVL_TS | 1 … 1 | M | 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. | IPSAMFST | ||||
| hl7:low | IVXB_TS | 1 … 1 | R | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | IPSAMFST | ||||
| hl7:high | IVXB_TS | 0 … 1 | C | The 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". | IPSAMFST | ||||
| Constraint | If this condition is known to be resolved, then the effectiveTime/high would be present. | ||||||||
| hl7:value | CD.IPS (preferred) | 1 … 1 | R | The <value> is the condition that was found. While the value may be a coded or an un-coded string, the type is always a coded value. If uncoded, it shall contain a <reference> to the <originalText> in the narrative where the reaction is described. | IPSAMFST | ||||
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| @xsi:type | 1 … 1 | F | CD | ||||||
| CONF |
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| hl7:originalText | 0 … 1 | 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. | IPSAMFST | |||||
| hl7:reference | 0 … 1 | R | The URI given in the value attribute of the <reference> 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 <reference> element points to an element in the narrative content that contains the complete text describing the medication. | IPSAMFST | |||||
| Example | <reference value="#AdvReaction_1"/> | ||||||||
| hl7:translation | CD | 0 … * | IPSAMFST | ||||||
| hl7:entryRelationship | 0 … 1 | R | Severity 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) | IPSAMFST | |||||
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| @typeCode | cs | 1 … 1 | F | SUBJ | |||||
| @inversionInd | bl | 1 … 1 | F | true | |||||
