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ref Template  Problem Observation

Template 2.16.840.1.113883.10.20.22.4.4 - ProblemObservation ref (van repository: ccda-)
Id 2.16.840.1.113883.10.20.22.4.4
Versie 1.1 geldig vanaf 2013‑01‑31 status pending Onder revisie vóór de publicatie

Er zijn versies van templates met dit id:
  • ProblemObservationV3 van 2015‑08‑01
  • ProblemObservation van 2013‑01‑31
Classificatie CDA entry level template
Context Parent nodes van template element met id 2.16.840.1.113883.10.20.22.4.4
Open/gesloten Open (ook andere dan gedefinieerde elementen zijn toegestaan)
Omschrijving en-US A problem is a clinical statement that a clinician has noted. In health care it is a condition that requires monitoring or diagnostic, therapeutic, or educational action. It also refers to any unmet or partially met basic human need. A Problem Observation is required to be wrapped in an act wrapper in locations such as the Problem Section, Allergies Section, and Hospital Discharge Diagnosis Section, where the type of problem needs to be identified or the condition tracked. A Problem Observation can be a valid “standalone” template instance in cases where a simple problem observation is to be sent. 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). NegationInd='true' is an acceptable way to make a clinical assertion that something did not occur, for example, “no diabetes”.
Gebruikt door / Gebruikt
Gebruikt door / Gebruikt 5 templates
Gebruikt door Template-id als Naam Versie
2.16.840.1.113883.10.20.22.4.80 Containment EncounterDiagnosis Encounter Diagnosis 2013‑01‑31
2.16.840.1.113883.10.20.22.4.49 link EncounterActivities Encounter Activities 2013‑01‑31
Gebruikt Template-id als Naam Versie
2.16.840.1.113883.10.20.22.4.31 Containment AgeObservation 2013‑01‑31
2.16.840.1.113883.10.20.22.4.6 Containment ProblemStatus 2013‑01‑31
2.16.840.1.113883.10.20.22.4.5 Containment HealthStatusObservation 2013‑01‑31
Item DT Card Conf Omschrijving Label
cda:observation
(ProblemObservation)
treetree @classCode
1 .. 1 F OBS
treetree @moodCode
1 .. 1 F EVN
treetree @negationInd
0 .. 1  
treetree cda:templateId
1 .. 1 M en-US SHALL contain exactly one [1..1] templateId (CONF:14926) such that it conf‑14926
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.4
treetree cda:id
1 .. * M en-US SHALL contain at least one [1..*] id (CONF:9043). conf‑9043
treetree cda:code
1 .. 1 M en-US SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2012-06-01 (CONF:9045). conf‑9045
  CONF
De waarde van @code moet komen uit waardelijst 2.16.840.1.113883.3.88.12.3221.7.2 Problem Type (2012‑06‑01)
treetree cda:text
0 .. 1 R en-US SHOULD contain zero or one [0..1] text (CONF:9185). conf‑9185
treeblank treetree cda:reference
0 .. 1 R en-US The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15587).

This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)		 conf‑15587
treeblank treeblank treetree @value
1 .. 1 R
  Schematron assert role red error
  test not(@value) or starts-with(@value, '#')
  Melding This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)
treetree cda:statusCode
CS 1 .. 1 M en-US SHALL contain exactly one [1..1] statusCode (CONF:9049). conf‑9049
treeblank treetree @code
1 .. 1 F completed
treetree cda:effectiveTime
0 .. 1 R en-US SHOULD contain zero or one [0..1] effectiveTime (CONF:9050). conf‑9050
treeblank treetree cda:low
1 .. 1 M en-US The effectiveTime, if present, SHALL contain exactly one [1..1] low (CONF:15603). conf‑15603
treeblank treetree cda:high
0 .. 1 en-US The effectiveTime, if present, MAY contain zero or one [0..1] high (CONF:15604). conf‑15604
treetree cda:value
CD 1 .. 1 en-US SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:9058).

If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the code is something other than SNOMED, @nullFlavor SHOULD be “OTH” and the other code SHOULD be placed in the translation element		 conf‑9058
treeblank treetree @nullFlavor
0 .. 1  
  CONF
De waarde van @code moet komen uit waardelijst 2.16.840.1.113883.3.88.12.3221.7.4 Problem (DYNAMISCH)
treeblank treetree cda:translation
0 .. * en-US This value MAY contain zero or more [0..*] translation (CONF:16749). conf‑16749
treeblank treeblank treetree @code
0 .. 1  
treetree cda:entryRelationship
waar
[cda:observation [hl7:templateId/@root='2.16.840.1.113883.10.20.22.4.31']]
0 .. 1 conf‑9059
treeblank treetree @typeCode
1 .. 1 F SUBJ
treeblank treetree @inversionInd
1 .. 1 F true
  Bevat 2.16.840.1.113883.10.20.22.4.31 Age Observation (2013‑01‑31)
treetree cda:entryRelationship
waar
[cda:observation [hl7:templateId/@root='2.16.840.1.113883.10.20.22.4.6']]
0 .. 1 conf‑9063
treeblank treetree @typeCode
1 .. 1 F REFR
  Bevat 2.16.840.1.113883.10.20.22.4.6 Problem Status (2013‑01‑31)
treetree cda:entryRelationship
waar
[cda:observation [hl7:templateId/@root='2.16.840.1.113883.10.20.22.4.5']]
0 .. 1 conf‑9067
treeblank treetree @typeCode
1 .. 1 F REFR
  Bevat 2.16.840.1.113883.10.20.22.4.5 Health Status Observation (2013‑01‑31)