MS-PCC-CP-0018

Change Proposal MS-PCC-CP-0018

Official Change Proposal Template is a WORD document found at ftp://ftp.ihe.net/Document_templates/IHE_Change_Proposal-Template-V10.doc

The Change Proposal Template that you use is dependent on the committee.

Tracking Information

Domain

Patient Care Coordination

Change Proposal Number

MS-PCC-CP-0018

Status

incoming

Last Updated

11:51, 3 March 2008 (CST)

Assigned

Change Proposal Summary

Title

Entries for Unknown or No Known Medications, Problems and Allergies

Submission Date

11:51, 3 March 2008 (CST)

Profile Affected

TF

TF Version

3.0

Volume and Section

II

Rationale

When no information is present, or is otherwise unknown, there is no present way to represent this in medication, problem and allergy entries in the current technical framework.

Content

Add the following text to "Distinctions of None" under the Medical Documents Specification.

An appropriate machine readable entry must also be present to indicate the reason that no information is present.

The table below provides some thoughts in this direction.

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	???	Allergies Unknown	To indicate a true unknown state for allergies
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
Medication	182904002	Drug Treatment Unknown	To indicate lack of knowledge about drug therapy
Medication	182849000	No Drug Therapy Prescribed	To indicate the absense of any prescribed medications
Medication	408350003	Patient Not On Self-Medications	To indicate no treatment

Add appropriate references to the Active Problems, Resolved Problems, Allergies and Other Adverse Reactions, and Medications sections.

Open Issues

1. How should unknown allergies be represented, vs. allergy to unknown substance? These should be perfectly clear and distinct entries.
2. Should examples for "unknown" or "no known" and/or "none" be provided under the appropriate level 3 entry using the same template identifier? Should these be a separate template or templates? In that case, how should the cardinality of the entries should be changed? I would suggest in this case to use Conditional (either 1-N of standard entry, or 1 from unknown/none entry), so that we can ensure that a machine readable entry is present providing the same information as in the text.
3. What other text changes are necessary?

See also: MS-PCC-CP-0017

1. Needs to be harmonized with HL7 Patient Care
2. Needs to be different template, (e.g., no frequency and route for a negative)

Accepted

Assigned to Keith and Larry to come up with proposed text.