Draft| Associated with 3 concepts | ||||||||||||
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| Used by 0 transactions and 0 templates, Uses 2 templates | ||||||||||||
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CDA Author (Body)Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (DYNAMIC)
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 | HL7I tion | |||||||
| @classCode | cs | 0 … 1 | F | OBS | |||||
| @moodCode | cs | 1 … 1 | F | EVN | |||||
| hl7:templateId | II | 1 … 1 | M | HL7Ition | |||||
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.2.9.10.1.6.83 | |||||
| hl7:id | II | 0 … * | R | HL7Ition | |||||
| hl7:code | CD.EPSOS | 1 … 1 | R | HL7Ition | |||||
| @code | CONF | 0 … 1 | F | 8661-1 | |||||
| @codeSystem | 0 … 1 | F | 2.16.840.1.113883.6.1 | ||||||
| @codeSystemName | 0 … 1 | F | LOINC | ||||||
| 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'. | HL7Ition | ||||
| @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. | HL7Ition | ||||
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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. | HL7Ition | ||||
| 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". | HL7Ition | ||||
| 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. | HL7Ition | ||||
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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. | HL7Ition | ||||||
| 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. | HL7Ition | |||||
| Example | <reference value="#eP_as_text"/> | ||||||||
| hl7:author | 0 … * | Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC) | HL7Ition | ||||||
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| hl7:informant | 0 … * | Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC) | HL7Ition | ||||||
