1.3.6.1.4.1.19376.1.5.3.1.4.5

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The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

Trial.gif Problem Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5

This section makes use of the linking, severity, clinical status and comment content specifications defined elsewhere in the technical framework. In HL7 RIM parlance, observations about a problem, complaint, symptom, finding, diagnosis, or functional limitation of a patient is the event (moodCode='EVN') of observing (<observation classCode='OBS'>) that problem. The <value> of the observation comes from a controlled vocabulary representing such things. The <code> contained within the <observation> describes the method of determination from yet another controlled vocabulary. An example appears below in the figure below.

Standards
CCD ASTM/HL7 Continuity of Care Document
CareStruct HL7 Care Provision Care Structures (DSTU)
ClinStat HL7 Clinical Statement Pattern (Draft)
Parent Template

This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.28

Uses

See Templates using Problem Entry

Specification
Problem Entry 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>


<observation classCode='OBS' moodCode='EVN' negationInd='false|true'>

The basic pattern for reporting a problem uses the CDA <observation> element, setting the classCode='OBS' to represent that this is an observation of a problem, and the moodCode='EVN', to represent that this is an observation that has in fact taken place. The negationInd attribute, if true, specifies that the problem indicated was observed to not have occurred (which is subtly but importantly different from having not been observed). The value of negationInd should not normally be set to true. Instead, to record that there is "no prior history of chicken pox", one would use a coded value indicated exactly that. However, it is not always possible to record problems in this manner, especially if using a controlled vocabulary that does not supply pre-coordinated negations , or which do not allow the negation to be recorded with post-coordinated coded terminology.

<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'/>

These <templateId> elements identify this <observation> as a problem, under both IHE and CCD specifications. This SHALL be included as shown above.

<id root=' ' extension=' '/>

The specific observation being recorded must have an identifier (<id>) that shall be provided for tracking purposes. If the source EMR does not or cannot supply an intrinsic identifier, then a GUID shall be provided as the root, with no extension (e.g., <id root='CE1215CD-69EC-4C7B-805F-569233C5E159'/>). While CDA allows for more than one identifier element to be provided, this profile requires that only one be used.

<code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'>

The <code> describes the process of establishing a problem. The code element should be used, as the process of determining the value is important to clinicians (e.g., a diagnosis is a more advanced statement than a symptom). The recommended vocabulary for describing problems is shown in the table below. Subclasses of this content module may specify other vocabularies. When the list below is used, the codeSystem is '2.16.840.1.113883.6.96' and codeSystemName is SNOMED CT.

Problem Codes
Code Description
64572001 Condition
418799008 Symptom
404684003 Finding
409586006 Complaint
248536006 Functional limitation
55607006 Problem
282291009 Diagnosis
<text><reference value=' '/></text>

The <text> element is required and 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.

<statusCode code='completed'/>

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'.

<effectiveTime><low value=' '/><high value=' '/></effectiveTime>

The <effectiveTime> of this <observation> is the time interval over which the <observation> is known to be true. The <low> and <high> values should be no more precise than known, but as precise as possible. While CDA allows for multiple mechanisms to record this time interval (e.g. by low and high values, low and width, high and width, or center point and width), we are constraining Medical summaries to use only the low/high form. The <low> value is the earliest point for which the condition is known to have existed. The <high> value, when present, indicates the time at which the observation was no longer known to be true. Thus, the implication is made that if the <high> value is specified, that the observation was no longer seen after this time, and it thus represents the date of resolution of the problem. Similarly, the <low> value may seem to represent onset of the problem. Neither of these statements is necessarily precise, as the <low> and <high> values may represent only an approximation of the true onset and resolution (respectively) times. For example, it may be the case that onset occurred prior to the <low> value, but no observation may have been possible before that time to discern whether the condition existed prior to that time. The <low> value should normally be present. There are exceptions, such as for the case where the patient may be able to report that they had chicken pox, but are unsure when. In this case, the <effectiveTime> element shall have a <low> element with a nullFlavor attribute set to 'UNK'. The <high> value need not be present when the observation is about a state of the patient that is unlikely to change (e.g., the diagnosis of an incurable disease).

<value xsi:type='CD' code=' ' codeSystem=' ' codeSystemName=' ' displayName=' '>

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 coded, the code and codeSystem attributes shall be present. The codeSystem should reference a controlled vocabulary describing problems, complaints, symptoms, findings, diagnoses, or functional limitations, e.g., ICD-9, SNOMED-CT or MEDCIN, or others. The table below is an incomplete listing of acceptable values for the codeSystem attribute, along with the codeSystemName.

Example Problem Vocabularies
CodeSystem codeSystemName Description
2.16.840.1.113883.6.96 SNOMED-CT SNOMED Controlled Terminology
2.16.840.1.113883.6.103 ICD-9CM (diagnoses) International Classification of Diseases, Clinical Modifiers, Version 9
2.16.840.1.113883.6.26 MEDCIN A classification system from MEDICOMP Systems.

It is recommended that the codeSystemName associated with the codeSystem, and the displayName for the code also be provided for diagnostic and human readability purposes, but this is not required by this profile.

If uncoded, all attributes other than xsi:type='CD' must be absent.

In cases where information about a problem or allergy is unknown or where there are no problems or allergies, an entry shall use codes from the table below to record this fact:

Entry Type Code Display Name Description
Problem 396782006 Past Medical History Unknown To indicate unknown medical history
Problem 407559004 Family History Unknown To indicate that the patient's family history is not known.
Problem 160243008 No Significant Medical History To indicate no relevant medical history
Problem 160245001 No current problems or disability To indicate that the patient has no current problems (as distinct from no history).
Allergy 409137002 No Known Drug Allergies To indicate that there are no known Drug allergies for this patient.
Allergy 160244002 No Known Allergies To indicate that there are no known allergies for this patient.
Allergy 64970000 Substance Type Unknown To indicate the state where there is a known allergy or intollerance to an unknown substance
<originalText><reference value=' '/></originalText>

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.

<!-- zero or one <entryRelationship typeCode='SUBJ' inversionInd='true'> elements containing severity -->

An optional <entryRelationship> element may be present indicating the severity of the problem. When present, this <entryRelationship> element shall contain a severity observation conforming to the Severity entry template (1.3.6.1.4.1.19376.1.5.3.1.4.1).

For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <subjectOf> element. The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘true’.

<!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements containing clinical status -->

An optional <entryRelationship> may be present indicating the clinical status of the problem, e.g., resolved, in remission, active. When present, this <entryRelationship> element shall contain a clinical status observation conforming to the Problem Status Observation template (1.3.6.1.4.1.19376.1.5.3.1.4.1.1).

For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element. The typeCode SHALL be ‘REFR’ and inversionInd SHALL be ‘false’.

<!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements identifying the health status of concern -->

An optional <entryRelationship> may be present referencing the health status of the patient, e.g., resolved, in remission, active. When present, this <entryRelationship> element shall contain a clinical status observation conforming to the Health Status Observation template (1.3.6.1.4.1.19376.1.5.3.1.4.1.2). The typeCode SHALL be ‘REFR’ and inversionInd SHALL be ‘false’.

For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element.

<!-- zero to many <entryRelationship typeCode='SUBJ' inversionInd='true'> element containing comments -->

One or more optional <entryRelationship> elements may be present providing an additional comments (annotations) for the condition. When present, this <entryRelationship> element shall contain a comment observation conforming to the Comment entry template (1.3.6.1.4.1.19376.1.5.3.1.4.2). The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘true’.

For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element.