1.3.6.1.4.1.19376.1.5.3.1.4.1.2

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Trial.gif Health Status 1.3.6.1.4.1.19376.1.5.3.1.4.1.2

A problem observation may reference a health status observation. This structure is included in the target observation using the <entryRelationship> element defined in the CDA Schema. The health status observation records information about the current health status of the patient. The example below shows the recording the health status, and is used as the context for the following sections.


Uses

See Templates using Health Status

Specification
Health Status Example 

<entry>
 <observation classCode='OBS' moodCode='EVN'>

   <entryRelationship typeCode='REFR' inversionInd='false'>
     <observation classCode='OBS' moodCode='EVN'>
       <templateId root='2.16.840.1.113883.10.20.1.51'/>
       <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1.2'/>
       <code code='11323-3' displayName='Health Status' 
         codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />
       <text><reference value='#hstatus-2'/></text>
       <statusCode code='completed'/>
       </value>
       <value xsi:type='CE' code=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
     </observation>
   </entryRelationship>

 </observation>
</entry>


This specification models a health status observation as a separate observation about the patient.

<entryRelationship typeCode='REFR'>

The related statement is made about the health status of the patient. For CDA, this observation is recorded inside an <entryRelationship> element occurring in the observation. The contained observersation is referenced (typeCode='REFR') by the observation entry. For HL7 Version 3 Messages, the entryRelationship tagName is sourceOf, though the typeCode and inversionInd attributes and other semantics remain the same.

<observation moodCode='EVN' classCode='OBS'>

The related statement is another event (moodCode='EVN') observing (<observation classCode='OBS'>) the health status of the patient.

<templateId root='2.16.840.1.113883.10.20.1.51'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1.2'/>

The <templateId> element identifies this <observation> as a health status observation, allowing for validation of the content.

<code code='11323-3'
displayName='Health Status'
codeSystem='2.16.840.1.113883.6.1'
codeSystemName='LOINC' />

This observation is of health status, as indicated by the <code> element. This element must be present. The code and codeSystem attributes shall be recorded exactly as shown above.

<text><reference value='#hstatus-2'/></text>

The <observation> element shall contain a <text> element that contains the narrative text describing the clinical status. For CDA, the <text> elements shall contain a <reference> element pointing to the narrative section (see Linking Narrative and Coded Entries, rather than duplicate text to avoid ambiguity. For HL7 Version 3 Messages, the <text> element shall contain the full narrative text.

<statusCode code='completed'/>

The code attribute of <statusCode> for all health status observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

<value xsi:type='CE' code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'>

The <value> element contains the clinical status. It is always represented using the CE datatype (xsi:type='CE').

Health Status Codes
Code Description
81323004 Alive and well
313386006 In remission
162467007 Symptom free
161901003 Chronically ill
271593001 Severely ill
21134002 Disabled
161045001 Severely disabled
419099009 Deceased
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