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ref Template  Problem Observation

Id 2.16.840.1.113883.10.20.22.4.4 ref (from repository: ccda-) Effective Date valid from 2013‑01‑31
Status pending Under pre-publication review Version Label 1.1
Name ProblemObservation Display Name Problem Observation
Description 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 of template element with id 2.16.840.1.113883.10.20.22.4.4
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 4 templates, Uses 3 templates
Used by Template id as Name Version
2.16.840.1.113883.10.20.22.2.37 Containment Complications Section 2016‑10‑09 02:01:42
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
2.16.840.1.113883.10.20.22.2.2 link Encounters Section (entries optional) 2016‑10‑09 02:21:23
Uses Template id as Name Version
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 Description Label
cda:observation
(ProblemObservation)
treetree @classCode
1 … 1 F OBS conf‑9041
treetree @moodCode
1 … 1 F EVN conf‑9042
treetree @negationInd
0 … 1   conf‑10139
treetree cda:templateId
II 1 … 1 M 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 conf‑14927
treetree cda:id
II 1 … * SHALL contain at least one [1..*] id (CONF:9043). conf‑9043
treetree cda:code
CD 1 … 1 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
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.7.2 Problem Type (2012‑06‑01)
treetree cda:text
0 … 1 R SHOULD contain zero or one [0..1] text (CONF:9185). conf‑9185
treeblank treetree cda:reference
0 … 1 R 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 conf‑15588
  Schematron assert role red error  
  test not(@value) or starts-with(@value, '#')  
  Message 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 SHALL contain exactly one [1..1] statusCode (CONF:9049). conf‑9049
treeblank treetree @code
1 … 1 F completed
treetree cda:effectiveTime
IVL_TS 0 … 1 R SHOULD contain zero or one [0..1] effectiveTime (CONF:9050). conf‑9050
treeblank treetree cda:low
1 … 1 M The effectiveTime, if present, SHALL contain exactly one [1..1] low (CONF:15603). conf‑15603
treeblank treetree cda:high
0 … 1 The effectiveTime, if present, MAY contain zero or one [0..1] high (CONF:15604). conf‑15604
treetree cda:value
CD 1 … 1 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‑10141
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.7.4 Problem (DYNAMIC)
treeblank treetree cda:translation
0 … * This value MAY contain zero or more [0..*] translation (CONF:16749). conf‑16749
treeblank treeblank treetree @code
0 … 1   conf‑16750
treetree cda:entryRelationship
0 … 1 Contains 2.16.840.1.113883.10.20.22.4.31 Age Observation (2013‑01‑31) conf‑9059
where [cda:observation [hl7:templateId/@root='2.16.840.1.113883.10.20.22.4.31']]
treeblank treetree @typeCode
1 … 1 F SUBJ conf‑9060
treeblank treetree @inversionInd
1 … 1 F true conf‑9069
treetree cda:entryRelationship
0 … 1 Contains 2.16.840.1.113883.10.20.22.4.6 Problem Status (2013‑01‑31) conf‑9063
where [cda:observation [hl7:templateId/@root='2.16.840.1.113883.10.20.22.4.6']]
treeblank treetree @typeCode
1 … 1 F REFR conf‑9068
treetree cda:entryRelationship
0 … 1 Contains 2.16.840.1.113883.10.20.22.4.5 Health Status Observation (2013‑01‑31) conf‑9067
where [cda:observation [hl7:templateId/@root='2.16.840.1.113883.10.20.22.4.5']]
treeblank treetree @typeCode
1 … 1 F REFR conf‑9064