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 3 concepts | ||||||||||||
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| Used by 0 transactions and 1 template, Uses 5 templates | ||||||||||||||||||||||||||||||||
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CDA Author (Body)ref
ch-pcc-
| Example |
| <observation classCode="OBS" moodCode="EVN" negationInd=" false|true "> <templateId root="2.16.840.1.113883.10.20.1.28"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/> <id root=" " extension=" "/> <code code=" " displayName=" " codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/> <text> <reference value=" "/> </text> <statusCode code="completed"/> <effectiveTime> <low value=" "/> <high value=" "/> </effectiveTime> <value xsi:type="CD" code=" " codeSystem=" " displayName=" " codeSystemName=" "> <originalText> <reference value=" "/> </originalText> </value> <!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements identifying the health status of concern --> <!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements containing clinical status --> <!-- zero to many <entryRelationship typeCode='REFR' inversionInd='true'> elements containing comments --> </observation> |
| Item | DT | Card | Conf | Description | Label | ||||
|---|---|---|---|---|---|---|---|---|---|
| hl7:observation | R | VPSP tion | |||||||
| @classCode | cs | 0 … 1 | F | OBS | |||||
| @moodCode | cs | 1 … 1 | F | EVN | |||||
| hl7:templateId | II | 1 … 1 | M | VPSPtion | |||||
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.2.9.10.1.6.61 | |||||
| hl7:id | II | 0 … * | R | VPSPtion | |||||
| hl7:code | CD.EPSOS | 1 … 1 | R |  This element describes the type of condition this observation is referring to. | VPSPtion | ||||
| 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. | VPSPtion | ||||
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| hl7:reference | TEL | 1 … 1 | M | VPSPtion | |||||
| @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 <statusCode> shall always have code='completed'. | VPSPtion | ||||
| @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. | VPSPtion | ||||
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| hl7:low | IVXB_TS | 1 … 1 | R | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. | VPSPtion | ||||
| 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". | VPSPtion | ||||
| Constraint | If this condition is known to be resolved, then the effectiveTime/high would be present. | ||||||||
| hl7:value | CD.EPSOS | 1 … 1 | M | The <value> is the condition that was found. This element is required. While the value may be a coded or an un-coded string, the type is always a coded value (xsi:type='CD'). If uncoded, all attributes other than xsi:type='CD' must be absent and - in this case - shall contain a <reference> to the <originalText> in the narrative where the allergy is described. The coded form shall be used to indicate known absent conditions or the nonavailability of information about them. | VPSPtion | ||||
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| CONF |
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| 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. | VPSPtion | ||||||
| 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. | VPSPtion | |||||
| Example | <reference value="#eP_as_text"/> | ||||||||
| hl7:translation | CD.EPSOS | 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. | VPSPtion | |||||
| hl7:author | 0 … * | Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC) | VPSPtion | ||||||
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| hl7:informant | 0 … * | Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC) | VPSPtion | ||||||
| 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
| VPSPtion | |||||
| @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
| VPSPtion | |||||
| @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
| VPSPtion | |||||
| @typeCode | cs | 1 … 1 | F | REFR | |||||
| @inversionInd | bl | 0 … 1 | F | false | |||||
