1.3.6.1.4.1.19376.1.5.3.1.4.5
Development Only
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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
<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.
| 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).
<confidentialityCode code=' '/>
While CDA allows for a condition to specify a <confidentialtyCode> for an observation, in practice there is no way to enforce consistent use of this information across institutions to secure confidential patient information. Therefore, it is recommended that this element not be sent. If there are confidentiality issues that need to be addressed other mechanisms should be negotiated within the affinity domain.
<uncertaintyCode code=' '/>
CDA allows a condition to be specified with an <uncertaintyCode>. Such conditions can also be recorded as a possible condition (e.g. possible ear infection). There is no present consensus on the best use of this element; therefore, it is recommended that this element not be sent.
<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.
| 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.
<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 (1.3.6.1.4.1.19376.1.5.3.1.4.1.1). 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.