1.3.6.1.4.1.19376.1.5.3.1.4.5.1

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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 Concern Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5.1

This event (moodCode='EVN') represents an act (<act classCode='ACT') of being concerned about a problem, allergy or other issue. The <effectiveTime> element describes the period of concern. The subject of concern is one or more observations about related problems (see 1.3.6.1.4.1.19376.1.5.3.1.4.5.2) or allergies and intolerances (see 1.3.6.1.4.1.19376.1.5.3.1.4.5.3). Additional references can be provided having additional information related to the concern. The concern entry allows related acts to be grouped. This allows representing the history of a problem as a series of observation over time, for example.

Standards
CCD ASTM/HL7 Continuity of Care Document
CareStruct HL7 Care Provision Care Structures (DSTU)
ClinStat ClinStat HL7 Clinical Statement (DRAFT)
Uses

See Templates using Concern Entry

Specification
Concern Entry Example
<act classCode='ACT' moodCode='EVN'>
  <templateId root='2.16.840.1.113883.10.20.1.27'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
  <id root='' extension=''/>
  <code nullFlavor='NA'/>
  <statusCode code='active|suspended|aborted|completed'/>
  <effectiveTime>
    <low value=''/>
    <high value=''/>
  </effectiveTime>
  <!-- one or more entry relationships identifying problems of concern -->
  <entryRelationship typeCode='SUBJ' inversionInd='false'>
     :
  </entryRelationship>
  <!-- For HL7 Version 3 Messages 
  <sourceOf typeCode='SUBJ' inversionInd='false'>
     :
  </sourceOf>
  -->
  <!-- optional entry relationship providing more information about the concern -->
  <entryRelationship typeCode='REFR'>
     :
  </entryRelationship>
  <!-- For HL7 Version 3 Messages 
  <sourceOf typeCode='REFR' inversionInd='false'>
     :
  </sourceOf>
  -->

</act>


<act classCode='ACT' moodCode='EVN'>

All concerns reflect the act of recording (<act classCode='ACT'>) the event (moodCode='EVN') of being concerned about a problem, allergy or other issue about the patient condition.

<templateId root='2.16.840.1.113883.10.20.1.27'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>

These template identifiers indicates this entry conforms to the concern content module. This content module inherits constraints from the HL7 CCD Template for problem acts, and so also includes that template identifier.

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

This required element identifies the concern.

<code nullFlavor='NA'/>

The code is not applicable to a concern act, and so shall be recorded as shown above.

<statusCode code='active|suspended|aborted|completed'/>

The statusCode associated with any concern must be one of the following values:

Status Code Values
Value Description
active A concern that is still being tracked.
suspended A concern that is active, but which may be set aside. For example, this value might be used to suspend concern about a patient problem after some period of remission, but before assumption that the concern has been resolved.
aborted A concern that is no longer actively being tracked, but for reasons other than because the problem was resolved. This value might be used to mark a concern as being aborted after a patient leaves care against medical advice.
completed The problem, allergy or medical state has been resolved and the concern no longer needs to be tracked except for historical purposes.
Note: A concern in the "active" state represents one for which some ongoing clinical activity is expected, and that no activity is expected in other states. Specific uses of the suspended and aborted states are left to the implementation.
<effectiveTime><low value=' '/><high value=' '/></effectiveTime>

The <effectiveTime> element records the starting and ending times during which the concern was active. The <low> element shall be present. The <high> element shall be present for concerns in the completed or aborted state, and shall not be present otherwise.

<!-- 1..* entry relationships identifying problems of concern -->
<entryRelationship type='SUBJ' inversionInd='false'>

Each concern is about one or more related problems or allergies. This entry shall contain one or more problem or allergy entries that conform to the specification in section Problem Entry or Allergies and Intolerances. This is how a series of related observations can be grouped as a single concern.

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 ‘SUBJ’ for both HL7 Version 3 and CDA. HL7 Version 3 additionally requires that inversionInd SHALL be ‘false’.


Note: The Allergy and Intolerances entry is a refinement of the Problem entry.
<!-- 0..n optional entry relationship providing more information about the concern -->
<entryRelationship type='REFR' inversionInd='false'>

Each concern may have 0 or more related references. These may be used to represent related statements such related visits. This may be any valid CDA clinical statement, and SHOULD be an IHE entry template. 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 ‘false’