Template 2.16.840.1.113883.10.20.22.4.4

Template Problem Observation (V3)

2.16.840.1.113883.10.20.22.4.4 ref (van repository: ccda-)

Geldigheid

geldig vanaf 2015‑08‑01

Er zijn versies van templates met dit id:

ProblemObservationV3 van 2015‑08‑01
ProblemObservation van 2013‑01‑31

Status Onder revisie vóór de publicatie Versielabel 2.1

Naam ProblemObservationV3 Weergavenaam Problem Observation (V3)

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".

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 5 templates

Gebruikt door Template-id	als	Naam	Versie
2.16.840.1.113883.10.20.22.4.80	Containment	Encounter Diagnosis (V3)	2015‑08‑01
2.16.840.1.113883.10.20.22.4.49		Encounter Activity (V3)	2015‑08‑01
Gebruikt Template-id	als	Naam	Versie
2.16.840.1.113883.10.20.22.4.119	Containment	AuthorParticipation	2015‑08‑13
2.16.840.1.113883.10.20.22.4.31	Containment	AgeObservation	2015‑08‑13
2.16.840.1.113883.10.20.22.4.113	Containment	PrognosisObservation	2015‑08‑13
2.16.840.1.113883.10.20.22.4.143	Containment	PriorityPreference	2015‑08‑13
2.16.840.1.113883.10.20.22.4.6	Containment	ProblemStatusDEPRECATED	2014‑06‑09

Relatie Specialisatie: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Versie: template 2.16.840.1.113883.10.20.22.4.4 (2013‑01‑31)

Item DT Card Conf Omschrijving Label

cda:observation (ProblemObservationV3)

@classCode 1 … 1 F OBS

SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-9041).

@moodCode 1 … 1 F EVN

SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1198-9042).

@negationInd 0 … 1 MAY contain zero or one [0..1] @negationInd (CONF:1198-10139).

cda:templateId II 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 II 1 … * SHALL contain at least one [1..*] id (CONF:1198-9043). CONF:1198‑9043

cda:code CD 1 … 1 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). CONF:1198‑9045

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:translation 1 … * M 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). CONF:1198‑32848

CONF

De waarde van @code moet komen uit waardelijst 2.16.840.1.113883.3.88.12.3221.7.2 Problem Type (2014‑09‑02)

cda:statusCode CS 1 … 1 M SHALL contain exactly one [1..1] statusCode (CONF:1198-9049). CONF:1198‑9049

@code 1 … 1 F completed

cda:effectiveTime

IVL_TS

1 … 1

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

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).

CONF

De waarde van @code moet komen uit waardelijst 2.16.840.1.113883.3.88.12.3221.7.4 Problem (DYNAMISCH)

cda:qualifier

0 … *

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 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).
Bevat 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13) CONF:1198‑31147

waar [hl7:templateId/@root='2.16.840.1.113883.10.20.22.4.119']

cda:entryRelationship 0 … 1 Bevat 2.16.840.1.113883.10.20.22.4.31 Age Observation (2015‑08‑13) CONF:1198‑9059

waar [cda:observation [hl7:templateId/@root='2.16.840.1.113883.10.20.22.4.31']]

@typeCode 1 … 1 F SUBJ

SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1198-9060).

@inversionInd 1 … 1 F true

SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1198-9069).

cda:entryRelationship 0 … 1 Bevat 2.16.840.1.113883.10.20.22.4.113 Prognosis Observation (2015‑08‑13) CONF:1198‑29951

waar [cda:observation [hl7:templateId/@root='2.16.840.1.113883.10.20.22.4.113']]

@typeCode 1 … 1 F REFR

SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31531).

cda:entryRelationship 0 … * Bevat 2.16.840.1.113883.10.20.22.4.143 Priority Preference (2015‑08‑13) CONF:1198‑31063

waar [cda:observation [hl7:templateId/@root='2.16.840.1.113883.10.20.22.4.143']]

@typeCode 1 … 1 F REFR

SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31532).

cda:entryRelationship 0 … 1 Bevat 2.16.840.1.113883.10.20.22.4.6 Problem Status (DEPRECATED) (2014‑06‑09) CONF:1198‑9063

waar [cda:observation [hl7:templateId/@root='2.16.840.1.113883.10.20.22.4.6']]

@typeCode 1 … 1 F REFR

SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-9068).

Template Problem Observation (V3)