1.3.6.1.4.1.19376.1.5.3.1.4.13.4

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Social History Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.4

A social history observation is a simple observation that uses a specific vocabulary, and inherits constraints from CCD.

Standards

CCD	ASTM/HL7 Continuity of Care Document

Parent Template

The parent of this template is Simple Observation. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.33

Uses

See Templates using Social History Observation

Specification

Social History Observation Example

<observation typeCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <templateId root='2.16.840.1.113883.10.20.1.33'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.4'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/> <text><reference value='#xxx'/></text> <statusCode code='completed'/> <effectiveTime value=' '/> <repeatNumber value=' '/> <value xsi:type=' ' /> <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/> <methodCode code=' ' codeSystem=' ' codeSystemName=' '/> <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/> </observation>

<templateId root='2.16.840.1.113883.10.20.1.33'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.4'/>

These <templateId> elements identify this as a Social History observation.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The <code> element identifies the type social history observation.

Social History Codes

Code	Description	Data Type	Units
229819007	Smoking	PQ	{pack}/d or {pack}/wk or {pack}/a
256235009	Exercise		{times}/wk
160573003	ETOH (Alcohol) Use		{drink}/d or {drink}/wk
364393001	Diet	CD	N/A
364703007	Employment
425400000	Toxic Exposure
363908000	Drug Use
228272008	Other Social History	ANY

<repeatNumber value=' '/>

The <repeatNumber> element should not be used in a social history observation.

<value xsi:type=' ' ... />

The <value> element reports the value associated with the social history observation. The data type to use for each observation should be drawn from the table above.

Observations in the table above using the PQ data type have a unit in the form {xxx}/d, {xxx}/wk or {xxx}/a represent the number of items per day, week or year respectively. The value attribute indicates the number of times of the act performed, and the units represent the frequency. The example below shows how to represent 1 drink per day.

    :
  <code code='160573003' displayName='ETOH Use' 
        codeSystem='2.16.840.1.113883.6.96' 
        codeSystemName='SNOMED CT'/>
    :
  <value xsi:type='PQ' value='1' unit='{drink}/d'/>
    :

Observations in the table using the CD data type should include coded values from an appropriate vocabulary to represent the social history item. The example below shows the encoding to indicate drug use of cannabis.

    :
  <code code='363908000' displayName='Drug Use' 
        codeSystem='2.16.840.1.113883.6.96' 
        codeSystemName='SNOMED CT'/>
    :
  <value xsi:type='CD' code='398705004' displayName='cannabis' 
         codeSystem='2.16.840.1.113883.6.96' 
         codeSystemName='SNOMED CT'/>
    :

Other social history observations may use any appropriate data type.

<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <interpretationCode>, <methodCode>, and <targetSiteCode> elements should not be used in a social history observation.