2.1 geldig vanaf 2015‑08‑01 status 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
This template reflects a discrete observation about a patient's problem. Because it
is a discrete observation, it will have a statusCode of "completed". The effectiveTime,
also referred to as the “biologically relevant time” is the time at which the observation
holds for the patient. For a provider seeing a patient in the clinic today, observing
a history of
heart attack that occurred five years ago, the effectiveTime is five years ago. The
effectiveTime of the Problem Observation is the definitive indication of whether or
not the underlying condition is resolved. If the problem is known to be resolved,
then an effectiveTime/high would be present. If the date of resolution is not known,
then effectiveTime/high will be present with a
nullFlavor of "UNK".
MAY contain zero or one [0..1] @negationInd (CONF:1198-10139).
cda:templateId
1 .. 1
M
SHALL contain exactly one [1..1] templateId (CONF:1198-14926) such that it
CONF:1198‑14926
@root
1 .. 1
F
2.16.840.1.113883.10.20.22.4.4
SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.4" (CONF:1198-14927).
@extension
1 .. 1
F
2015-08-01
SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32508).
cda:id
1 .. *
M
SHALL contain at least one [1..*] id (CONF:1198-9043).
CONF:1198‑9043
cda:code
1 .. 1
M
SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Problem
Type urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2012-06-01 (CONF:1198-9045).
This code SHALL contain at least one [1..*] translation, which SHOULD be selected
from ValueSet Problem Type urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 2014-09-02 (CONF:1198-32848).
SHALL contain exactly one [1..1] statusCode (CONF:1198-9049).
CONF:1198‑9049
@code
1 .. 1
F
completed
cda:effectiveTime
1 .. 1
M
SHALL contain exactly one [1..1] effectiveTime (CONF:1198-9050).
If the problem is known to be resolved, but the date of resolution is not known, then
the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'.
Therefore, the existence of an high element within a problem does indicate that the
problem has been
resolved.
CONF:1198‑9050
cda:low
1 .. 1
M
This effectiveTime SHALL contain exactly one [1..1] low (CONF:1198-15603).
The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically
active.
CONF:1198‑15603
cda:high
0 .. 1
This effectiveTime MAY contain zero or one [0..1] high (CONF:1198-15604).
The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became
biologically resolved.
CONF:1198‑15604
cda:value
CD
1 .. 1
M
CONF:1198‑9058
@code
0 .. 1
This value MAY contain zero or one [0..1] @code (CONF:1198-31871).
This value MAY contain zero or more [0..*] qualifier (CONF:1198-31870).
The observation/value and all the qualifiers together (often referred to as a post-coordinated
expression) make up one concept. Qualifiers constrain the meaning of the primary code,
and cannot negate it or change its meaning. Qualifiers can only be used according
to
well-defined rules of post-coordination and only if the underlying code system defines
the use of such qualifiers or if there is a third code system that specifies how other
code systems may be combined. For example, SNOMED CT allows constructing concepts
as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)"
(233604007) an attribute
"finding site" (363698007) and another concept "left lower lobe of lung (body structure)"
(41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown
in the sample XML.
CONF:1198‑31870
cda:translation
0 .. *
This value MAY contain zero or more [0..*] translation (CONF:1198-16749) such that
it
CONF:1198‑16749
@code
0 .. 1
MAY contain zero or one [0..1] @code (CodeSystem: ICD10CM urn:oid:2.16.840.1.113883.6.90
STATIC) (CONF:1198-16750).
cda:author waar [hl7:templateId/@root='2.16.840.1.113883.10.20.22.4.119']
0 .. *
R
SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119)
(CONF:1198-31147).
Template Problem Observation (V3)
Onder revisie vóór de publicatie
Er zijn versies van templates met dit id:
This template reflects a discrete observation about a patient's problem. Because it
is a discrete observation, it will have a statusCode of "completed". The effectiveTime,
also referred to as the “biologically relevant time” is the time at which the observation
holds for the patient. For a provider seeing a patient in the clinic today, observing
a history of
heart attack that occurred five years ago, the effectiveTime is five years ago. The
effectiveTime of the Problem Observation is the definitive indication of whether or
not the underlying condition is resolved. If the problem is known to be resolved,
then an effectiveTime/high would be present. If the date of resolution is not known,
then effectiveTime/high will be present with a
nullFlavor of "UNK".
