1.3.6.1.4.1.19376.1.5.3.1.4.1.1

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Trial.gif Problem Status Observation 1.3.6.1.4.1.19376.1.5.3.1.4.1.1

Any problem or allergy observation may reference a problem status observation. This structure is included in the target observation using the <entryRelationship> element defined in the CDA Schema. The clinical status observation records information about the current status of the problem or allergy, for example, whether it is active, in remission, resolved, et cetera. The example below shows the recording of clinical status of a condition or allergy, and is used as the context for the following sections.

Standards
CCD ASTM/HL7 Continuity of Care Document
Uses

See Templates using Problem Status Observation

Specification
Problem Status Observation Example 

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

     <entryRelationship typeCode='REFR' inversionInd='false'>
       <observation classCode='OBS' moodCode='EVN'>
         <templateId root='2.16.840.1.113883.10.20.1.57'/>
         <templateId root='2.16.840.1.113883.10.20.1.50'/>
         <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1.1'/>
         <code code='33999-4' displayName='Status' 
           codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />
         <text><reference value='#cstatus-2'/></text>
         <statusCode code='completed'/>
         <value xsi:type='CE' code=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
       </observation>
     </entryRelationship>

   </observation>
 </entry>


This CCD models a problem status observation as a separate observation from the problem, allergy or medication observation. While this model is different from work presently underway by various organizations (i.e., SNOMED, HL7, TermInfo), it is not wholly incompatible with that work. In that work, qualifiers may be used to identify problem status in the coded condition observation, and a separate clinical status observation is no longer necessary. The use of qualifiers in the problem observation is not precluded by this specification or by CCD. However, to support semantic interoperability between EMR systems using different vocabularies, this specification does require that problem status information also be provided in a separate observation. This ensures that all EMR systems have equal access to the information, regardless of the vocabularies they support.

<entryRelationship typeCode='REFR' inversionInd='false'>

The related statement is made about the clinical status of the problem or allergy. For CDA, this observation is recorded inside an <entryRelationship> element occurring in the problem or allergy. For HL7 Version 3 Messages, the <entryRelationship> tag name is <sourceOf>, though the typeCode and inversionInd attributes and other semantics remain the same. The containing observation refers to (typeCode='REFR') this new observation.

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

The related statement is another event (moodCode='EVN') observing (<observation classCode='OBS'>) the clinical status of the (surrounding) related observation (e.g., a problem or allergy).

<templateId root='2.16.840.1.113883.10.20.1.57'/>
<templateId root='2.16.840.1.113883.10.20.1.50'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1.1'/>

These <templateId> elements identify this <observation> as a problem status observation, allowing for validation of the content.

<code code='33999-4' codeSystem='2.16.840.1.113883.6.1' displayName='Status' codeSystemName='LOINC' />

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

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

The <observation> element shall contain a <text> element that points to 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 clinical 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'). It shall contain a code from the following set of values from SNOMED CT.

Clinical Status Values
Code Description
55561003 Active
73425007 Inactive
90734009 Chronic
7087005 Intermittent
255227004 Recurrent
415684004 Rule out
410516002 Ruled out
413322009 Resolved
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