Draft| 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". |
| Associated with 12 concepts | |||||||||||||||||||||||||||||||||||||||
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| Used by 0 transactions and 2 templates, Uses 3 templates | ||||||||||||||||||||||||||||
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IPS Problem Concern Entry (STU1)ref
IHE-PCC-
| 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> |
| 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> |
| 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> |
| Item | DT | Card | Conf | Description | Label | ||||||||||
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| hl7:observation | R | IPSP ntry | |||||||||||||
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| @classCode | cs | 0 … 1 | F | OBS | |||||||||||
| @moodCode | cs | 1 … 1 | F | EVN | |||||||||||
| hl7:templateId | II | 1 … 1 | M | IPSPntry | |||||||||||
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.22.4.8 | |||||||||||
| hl7:id | II | 0 … * | R | IPSPntry | |||||||||||
| hl7:code | CD.IPS | 1 … 1 | R | This element describes the type of condition this observation is referring to. | IPSPntry | ||||||||||
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| CONF |
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| Example | <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/> | ||||||||||||||
| hl7:text | ED | 0 … 1 | R | The | IPSPntry | ||||||||||
| Example | <text> <reference value="#problem-1"/></text> | ||||||||||||||
| hl7:reference | TEL | 1 … 1 | M | IPSPntry | |||||||||||
| @value | 1 … 1 | R | When used it shall refer to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1 | ||||||||||||
| hl7:statusCode | CS | 1 … 1 | M | A clinical document normally records only those condition observation events that have been completed, not observations that are in any other state. Therefore, the | IPSPntry | ||||||||||
| @code | CONF | 1 … 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. | IPSPntry | ||||||||||
| 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_TS | 1 … 1 | R | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | IPSPntry | ||||||||||
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| 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". | IPSPntry | ||||||||||
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| Constraint | If this condition is known to be resolved, then the effectiveTime/high would be present. | ||||||||||||||
| hl7:value | CD.IPS (preferred) | 1 … 1 | M | The <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. | IPSPntry | ||||||||||
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| @xsi:type | 0 … 1 | F | CD | ||||||||||||
| CONF |
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| 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. | IPSPntry | ||||||||||||
| hl7:reference | 0 … 1 | R | The URI given in the value attribute of the | IPSPntry | |||||||||||
| Example | <reference value="#value_as_text"/> | ||||||||||||||
| hl7:qualifier | CR | 0 … * | IPSPntry | ||||||||||||
| hl7:translation | CD.IPS | 0 … * | 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. | IPSPntry | |||||||||||
| 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) | IPSPntry | |||||||||||
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| @typeCode | cs | 1 … 1 | F | SUBJ | |||||||||||
| @inversionInd | bl | 1 … 1 | F | true | |||||||||||
| hl7:entryRelationship | 0 … 1 | R | 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) | IPSPntry | |||||||||||
| @typeCode | cs | 1 … 1 | F | SUBJ | |||||||||||
| @inversionInd | bl | 1 … 1 | F | true | |||||||||||
| hl7:entryRelationship | 0 … 1 | R | Status of the Problem The contained entry describes the current status of the condition, for example, whether it is active, in remission, resolved, and so on ... Contains 2.16.840.1.113883.10.22.4.20 IPS Problem Status Observation (2017‑03‑29) | IPSPntry | |||||||||||
| @typeCode | cs | 1 … 1 | F | REFR | |||||||||||
| @inversionInd | bl | 0 … 1 | F | false | |||||||||||
