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draft Template  Problem Observation

Id 1.2.276.0.76.10.4075
ref
hl7de-
 		Gültigkeit 2015‑12‑06
Status draft Entwurf Versions-Label
Name ProblemObservation Anzeigename Problem Observation
Beschreibung
en-US 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".
Kontext Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4075
Klassifikation CDA Entry Level Template
Offen/Geschlossen Offen (auch andere als die definierten Elemente sind erlaubt)
Benutzt von / Benutzt
Benutzt von 0 Transactions und 5 Templates, Benutzt 6 Templates
Benutzt von als Name Version
1.2.276.0.76.10.4074 Containment draft Problem Concern Act 2015‑12‑06
1.2.276.0.76.10.3023 link draft Frühere Erkrankungen 2017‑04‑09
1.2.276.0.76.10.1013 link retired Arztbrief (v2.01) 2013‑12‑30
1.2.276.0.76.10.1020 link draft Arztbrief Plus (v3.00) 2017‑02‑01
1.2.276.0.76.10.3079 link draft Gesundheitsprobleme 2017‑03‑01
Benutzt als Name Version
1.2.276.0.76.10.90025 Inklusion draft Author (Body) DYNAMIC
1.2.276.0.76.10.4077 Containment draft Alter Beobachtung DYNAMIC
1.2.276.0.76.10.4078 Containment draft Prognose Observation DYNAMIC
1.2.276.0.76.10.4076 Containment draft Priorität Präferenz DYNAMIC
1.2.276.0.76.10.4093 Containment draft Manifestation Observation DYNAMIC
1.2.276.0.76.10.4094 Containment draft Etiology Observation DYNAMIC
Beziehung Spezialisierung: Template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 Problem Observation (V3) (2015‑08‑01)
ref
ccda-
Beispiel
Beispiel
<observation classCode="OBS" moodCode="EVN">
  <!-- Problem Observation -->
  <templateId root="1.2.276.0.76.10.4075"/>  <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>  <code code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis"/>  <!-- The statusCode reflects the status of the observation itself -->
  <statusCode code="completed"/>  <effectiveTime>
    <!-- Das low Element gibt das Datum an, seit wann der Patient dieses Problem hat -->
    <low value="20130703"/>    <!-- Das high Element gibt das Datum an, seit wann der Patient dieses Problem nicht mehr hat -->
    <high value="20130721"/>  </effectiveTime>  <!-- Im value Element wird das Problem angegeben. Dies kann ein ICD 10 Code oder ein anderer Code sein. -->
  <value xsi:type="CD" code="J11.1" codeSystem="1.2.276.0.76.5.430" displayName="Grippe mit sonstigen Manifestationen an den Atemwegen, Viren nicht nachgewiesen"/>  <author typeCode="AUT">
    <!-- optional: Autor des Problem -->
  </author></observation>
Item DT Kard Konf Beschreibung Label
hl7:observation
 (Prodotsion)
@classCode
 cs 1 … 1 F OBS
@moodCode
 cs 1 … 1 F EVN
@negationInd
 bl 0 … 1  
hl7:templateId
 1 … 1 M (Prodotsion)
@root
 uid 1 … 1 F 1.2.276.0.76.10.4075
hl7:id
 1 … * (Prodotsion)
hl7:code
 1 … 1 M (Prodotsion)
  CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.3.88.12.3221.7.2 Problem Type (DYNAMIC)
hl7:statusCode
 1 … 1 M (Prodotsion)
@code
 CONF 1 … 1 F completed
hl7:effectiveTime
 1 … 1 M en-US 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. (Prodotsion)
hl7:low
 1 … 1 M Das low Element gibt das Datum an, seit wann der Patient diese Problem hat (Prodotsion)
hl7:high
 0 … 1 Das high Element gibt das Datum an, seit wann der Patient diese Problem nicht mehr hat (Prodotsion)
hl7:value
 CD 1 … 1 R (Prodotsion)
  CONF
muss aus der Konzeptdomäne "Problemcodes" gewählt werden
hl7:qualifier
 0 … * en-US 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.		 (Prodotsion)
hl7:translation
 0 … * (Prodotsion)
@code
 0 … 1   en-US MAY contain zero or one [0..1] @code (CodeSystem: ICD10CM urn:oid:2.16.840.1.113883.6.90 STATIC) (CONF:1198-16750).
hl7:author
 0 … * R (Prodotsion)
Eingefügt von 1.2.276.0.76.10.90025 Author (Body) (DYNAMIC)
@typeCode
 0 … 1 F AUT
@contextControlCode
 0 … 1 F OP
hl7:functionCode
 CE 0 … 1 (Prodotsion)
  CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
hl7:time
 TS 1 … 1 R (Prodotsion)
hl7:assignedAuthor
 1 … 1 R (Prodotsion)
@classCode
 0 … 1 F ASSIGNED
hl7:id
 II 1 … * R (Prodotsion)
hl7:code
 CE 0 … 1 (Prodotsion)
@codeSystem
 CONF 0 … 1 F 2.16.840.1.113883.5.111 (Role Code)
hl7:addr
 AD 0 … * (Prodotsion)
hl7:telecom
 TEL 0 … * (Prodotsion)
hl7:assignedPerson
 0 … 1 (Prodotsion)
Eingefügt von 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC)
@classCode
 0 … 1 F PSN
@determinerCode
 0 … 1 F INSTANCE
hl7:name
 PN 1 … 1 M (Prodotsion)
hl7:representedOrganization
 0 … 1 (Prodotsion)
Eingefügt von 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC)
@classCode
 0 … 1 F ORG
@determinerCode
 0 … 1 F INSTANCE
hl7:id
 II 0 … * (Prodotsion)
hl7:name
 ON 1 … 1 M (Prodotsion)
hl7:telecom
 TEL 0 … * (Prodotsion)
hl7:addr
 AD 0 … 1 (Prodotsion)
hl7:entryRelationship
 0 … 1 Alter des Patienten
Beinhaltet 1.2.276.0.76.10.4077 Alter Beobachtung (DYNAMIC) 		(Prodotsion)
treeblank wo [hl7:observation [hl7:templateId [@root = '1.2.276.0.76.10.4077']]]
@typeCode
 cs 1 … 1 F SUBJ
@inversionInd
 bl 1 … 1 F true
hl7:entryRelationship
 0 … 1 Prognose des Problems
Beinhaltet 1.2.276.0.76.10.4078 Prognose Observation (DYNAMIC) 		(Prodotsion)
treeblank wo [hl7:observation [hl7:templateId [@root = '1.2.276.0.76.10.4078']]]
@typeCode
 cs 1 … 1 F REFR
hl7:entryRelationship
 0 … * Schweregrad des Problems laut Einschätzung des Gesundheitsdienstleisters
Beinhaltet 1.2.276.0.76.10.4076 Priorität Präferenz (DYNAMIC) 		(Prodotsion)
treeblank wo [hl7:observation [hl7:templateId [@root = '1.2.276.0.76.10.4076']]]
@typeCode
 cs 1 … 1 F REFR
hl7:entryRelationship
 0 … * Manifestations-Beobachtung
Beinhaltet 1.2.276.0.76.10.4093 Manifestation Observation (DYNAMIC) 		(Prodotsion)
treeblank wo [hl7:observation [hl7:templateId [@root = '1.2.276.0.76.10.4093']]]
@typeCode
 cs 1 … 1 F MFST
hl7:entryRelationship
 0 … * Ätiologie-Beobachtung
Beinhaltet 1.2.276.0.76.10.4094 Etiology Observation (DYNAMIC) 		(Prodotsion)
treeblank wo [hl7:observation [hl7:templateId [@root = '1.2.276.0.76.10.4094']]]
@typeCode
 cs 1 … 1 F CAUS