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ref Template  Problem Observation

Id 2.16.840.1.113883.10.20.22.4.4 ref (van repository: ccda-) Geldigheid geldig vanaf 2013‑01‑31

Er zijn versies van templates met dit id:
  • ProblemObservationV3 van 2015‑08‑01
  • ProblemObservation van 2013‑01‑31
Status pending Onder revisie vóór de publicatie Versielabel 1.1
Naam ProblemObservation Weergavenaam Problem Observation
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”.
Context Parent nodes van template element met id 2.16.840.1.113883.10.20.22.4.4
Classificatie CDA entry level template
Open/gesloten Open (ook andere dan gedefinieerde elementen zijn toegestaan)
Gebruikt door / Gebruikt
Gebruikt door 2 templates, Gebruikt 3 templates
Gebruikt door Template-id als Naam Versie
2.16.840.1.113883.10.20.22.4.80 Containment Encounter Diagnosis 2013‑01‑31
2.16.840.1.113883.10.20.22.4.49 link 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)
@classCode
 1 … 1 F OBS
@moodCode
 1 … 1 F EVN
@negationInd
 0 … 1  
cda:templateId
 II 1 … 1 M en-US SHALL contain exactly one [1..1] templateId (CONF:14926) such that it conf‑14926
@root
 1 … 1 F 2.16.840.1.113883.10.20.22.4.4
cda:id
 II 1 … * en-US SHALL contain at least one [1..*] id (CONF:9043). conf‑9043
cda:code
 CD 1 … 1 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)
cda:text
 0 … 1 R en-US SHOULD contain zero or one [0..1] text (CONF:9185). conf‑9185
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
@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)  
cda:statusCode
 CS 1 … 1 M en-US SHALL contain exactly one [1..1] statusCode (CONF:9049). conf‑9049
@code
 1 … 1 F completed
cda:effectiveTime
 IVL_TS 0 … 1 R en-US SHOULD contain zero or one [0..1] effectiveTime (CONF:9050). conf‑9050
cda:low
 1 … 1 M en-US The effectiveTime, if present, SHALL contain exactly one [1..1] low (CONF:15603). conf‑15603
cda:high
 0 … 1 en-US The effectiveTime, if present, MAY contain zero or one [0..1] high (CONF:15604). conf‑15604
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
@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)
cda:translation
 0 … * en-US This value MAY contain zero or more [0..*] translation (CONF:16749). conf‑16749
@code
 0 … 1  
cda:entryRelationship
 0 … 1 Bevat 2.16.840.1.113883.10.20.22.4.31 Age Observation (2013‑01‑31) conf‑9059
waar [cda:observation [hl7:templateId/@root='2.16.840.1.113883.10.20.22.4.31']]
@typeCode
 1 … 1 F SUBJ
@inversionInd
 1 … 1 F true
cda:entryRelationship
 0 … 1 Bevat 2.16.840.1.113883.10.20.22.4.6 Problem Status (2013‑01‑31) conf‑9063
waar [cda:observation [hl7:templateId/@root='2.16.840.1.113883.10.20.22.4.6']]
@typeCode
 1 … 1 F REFR
cda:entryRelationship
 0 … 1 Bevat 2.16.840.1.113883.10.20.22.4.5 Health Status Observation (2013‑01‑31) conf‑9067
waar [cda:observation [hl7:templateId/@root='2.16.840.1.113883.10.20.22.4.5']]
@typeCode
 1 … 1 F REFR