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ref Template  Problem Observation (V3)

Id 2.16.840.1.113883.10.20.22.4.4
ref
(from repository: ccda-)		 Effective Date valid from 2015‑08‑01
Status pending Under pre-publication review Version Label 2.1
Name ProblemObservationV3 Display Name Problem Observation (V3)
Description 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 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 2 templates, Uses 5 templates
Used by Template id as Name Version
2.16.840.1.113883.10.20.22.2.37.2 Containment draft BC CDA Complications Section (V3) (2.1) 2017‑03‑29 12:32:13
2.16.840.1.113883.3.51.60.2.5.1 link draft BC CDA ClinicalDocumentMedicalImaging 2016‑10‑09 02:16:30
Uses Template id as Name Version
2.16.840.1.113883.10.20.22.4.119 Containment pending Author Participation (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.31 Containment draft Age Observation (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.113 Containment pending Prognosis Observation (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.143 Containment pending Priority Preference (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.6 Containment retired Problem Status (DEPRECATED) (2.1) 2014‑06‑09
Relationship Specialization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Version: template 2.16.840.1.113883.10.20.22.4.4 (2013‑01‑31)
Item DT Card Conf Description Label
cda:observation
(ProblemObservationV3)
treetree @classCode
1 … 1 F OBS CONF:1198‑9041
  SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-9041).
treetree @moodCode
1 … 1 F EVN CONF:1198‑9042
  SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1198-9042).
treetree @negationInd
0 … 1   MAY contain zero or one [0..1] @negationInd (CONF:1198-10139). CONF:1198‑10139
treetree cda:templateId
II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:1198-14926) such that it CONF:1198‑14926
treeblank treetree @root
1 … 1 F 2.16.840.1.113883.10.20.22.4.4 CONF:1198‑14927
  SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.4" (CONF:1198-14927).
treeblank treetree @extension
1 … 1 F 2015-08-01 CONF:1198‑32508
  SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32508).
treetree cda:id
II 1 … * SHALL contain at least one [1..*] id (CONF:1198-9043). CONF:1198‑9043
treetree 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
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)
treeblank treetree 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
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.7.2 Problem Type (2014‑09‑02)
treetree cda:statusCode
CS 1 … 1 M SHALL contain exactly one [1..1] statusCode (CONF:1198-9049). CONF:1198‑9049
treeblank treetree @code
CONF 1 … 1 F completed
treetree cda:effectiveTime
IVL_TS 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
treeblank treetree 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
treeblank treetree 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
treetree cda:value
CD 1 … 1 M CONF:1198‑9058
treeblank treetree @code
0 … 1   This value MAY contain zero or one [0..1] @code (CONF:1198-31871). CONF:1198‑31871
  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: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
treeblank treetree cda:translation
0 … * This value MAY contain zero or more [0..*] translation (CONF:1198-16749) such that it CONF:1198‑16749
treeblank treeblank treetree @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). CONF:1198‑16750
treetree 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).
Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13) 		CONF:1198‑31147
treeblank where [hl7:templateId [@root='2.16.840.1.113883.10.20.22.4.119']]
treetree cda:entryRelationship
0 … 1 Contains 2.16.840.1.113883.10.20.22.4.31 Age Observation (2015‑08‑13) CONF:1198‑9059
treeblank where [cda:observation [hl7:templateId [@root='2.16.840.1.113883.10.20.22.4.31']]]
treeblank treetree @typeCode
1 … 1 F SUBJ CONF:1198‑9060
  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).
treeblank treetree @inversionInd
1 … 1 F true CONF:1198‑9069
  SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1198-9069).
treetree cda:entryRelationship
0 … 1 Contains 2.16.840.1.113883.10.20.22.4.113 Prognosis Observation (2015‑08‑13) CONF:1198‑29951
treeblank where [cda:observation [hl7:templateId [@root='2.16.840.1.113883.10.20.22.4.113']]]
treeblank treetree @typeCode
1 … 1 F REFR CONF:1198‑31531
  SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31531).
treetree cda:entryRelationship
0 … * Contains 2.16.840.1.113883.10.20.22.4.143 Priority Preference (2015‑08‑13) CONF:1198‑31063
treeblank where [cda:observation [hl7:templateId [@root='2.16.840.1.113883.10.20.22.4.143']]]
treeblank treetree @typeCode
1 … 1 F REFR CONF:1198‑31532
  SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31532).
treetree cda:entryRelationship
0 … 1 Contains 2.16.840.1.113883.10.20.22.4.6 Problem Status (DEPRECATED) (2014‑06‑09) CONF:1198‑9063
treeblank where [cda:observation [hl7:templateId [@root='2.16.840.1.113883.10.20.22.4.6']]]
treeblank treetree @typeCode
1 … 1 F REFR CONF:1198‑9068
  SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-9068).