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draft Template  BC CDA Problem Observation (V3)

Id 2.16.840.1.113883.10.20.22.2.53 Effective Date 2019‑03‑15 13:27:10
Status draft Draft Version Label 2.1
Name BCCDAProblemObservationV3 Display Name BC CDA 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 2.16.840.1.113883.10.20.22.2.53
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 6 templates, Uses 4 templates
Used by as Name Version
2.16.840.1.113883.10.20.22.2.49 Containment draft BC CDA Complications DS Section (V3) (2.1) 2019‑03‑26 10:19:55
2.16.840.1.113883.3.51.60.2.4.1 link draft BC CDA ClinicalDocumentDischargeSummary (V3) (2.1) 2019‑03‑19 14:15:51
2.16.840.1.113883.10.20.22.2.54 Containment draft BC CDA Problem Concern Act (V3) (2.1) 2019‑03‑20 11:24:34
2.16.840.1.113883.10.20.22.2.55 link draft BC CDA Problem Section (entries optional) (V3) (2.1) 2019‑03‑16 21:22:30
2.16.840.1.113883.10.20.22.2.93 Containment draft Hospital Discharge Diagnosis (V3) (2.1) 2019‑04‑01 08:04:31
2.16.840.1.113883.10.20.22.2.24 link draft BC CDA Discharge Diagnosis Section (V3) (2.1) 2019‑03‑15 13:34:11
Uses as Name Version
2.16.840.1.113883.10.20.22.2.81 Containment draft BC CDA Author (Body) DYNAMIC
2.16.840.1.113883.10.20.22.2.63 Containment draft Age Observation (2.1) DYNAMIC
2.16.840.1.113883.10.20.22.2.75 Containment draft Prognosis Observation (2.1) DYNAMIC
2.16.840.1.113883.10.20.22.2.98 Containment draft Principle Diagnosis (2.1) DYNAMIC
Relationship Adaptation: template 2.16.840.1.113883.10.20.22.2.53 (2019‑03‑09 13:22:49)
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Specialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
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Version: template 2.16.840.1.113883.10.20.22.2.53 (2013‑01‑31)
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Item DT Card Conf Description Label
cda:observation
(BCCdotsnV3)
treetree @classCode
cs 1 … 1 F OBS CONFdots9041
  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
cs 1 … 1 F EVN CONFdots9042
  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
bl 0 … 1   MAY contain zero or one [0..1] @negationInd (CONF:1198-10139). CONFdots0139
treetree hl7:templateId
II 1 … 1 M (BCCdotsnV3)
treeblank treetree @root
uid 1 … 1 F 2.16.840.1.113883.10.20.22.2.53
treetree hl7:templateId
II 1 … 1 M (BCCdotsnV3)
treeblank treetree @root
uid 1 … 1 F 2.16.840.1.113883.10.20.22.2.53
treetree cda:templateId
II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:1198-14926) such that it CONFdots4926
treeblank treetree @root
uid 1 … 1 F 2.16.840.1.113883.10.20.22.2.53 CONFdots4927
  SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.4" (CONF:1198-14927).
treeblank treetree @extension
st 1 … 1 F 2015-08-01 CONFdots2508
  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). CONFdots9043
treetree cda:code
CD 1 … 1 SHOULD 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 DYNAMIC  (CONF:1198-9045) or MAY be selected from Code System ICD-10 urn:oid 2.16.840.1.113883.6.3 or MAY be selected from a value set defined by the local jurisdiction


 CONFdots9045
  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). CONFdots2848
  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). CONFdots9049
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.

CONFdots9050
treeblank treetree cda:low
1 … 1 R 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.

CONFdots5603
treeblank treetree cda:high
0 … 1 R 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.

CONFdots5604
treetree cda:value
CD 1 … 1 M CONFdots9058
treeblank treetree @code
0 … 1   This value MAY contain zero or one [0..1] @code (CONF:1198-31871). CONFdots1871
  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.

CONFdots1870
treeblank treetree cda:translation
0 … * This value MAY contain zero or more [0..*] translation (CONF:1198-16749) such that it CONFdots6749
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). CONFdots6750
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 2.16.840.1.113883.10.20.22.2.81 BC CDA Author (Body) (DYNAMIC) 		CONFdots1147
treeblank where [hl7:assignedAuthor [@classCode = 'ASSIGNED']]
treetree cda:entryRelationship
0 … 1 Contains 2.16.840.1.113883.10.20.22.2.63 Age Observation (DYNAMIC) CONFdots9059
treeblank where [cda:observation [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.63'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.63']]]
treeblank treetree @typeCode
cs 1 … 1 F SUBJ CONFdots9060
  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
bl 1 … 1 F true CONFdots9069
  SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1198-9069).
treetree cda:entryRelationship
0 … 1 Contains 2.16.840.1.113883.10.20.22.2.75 Prognosis Observation (DYNAMIC) CONFdots9951
treeblank where [cda:observation [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.75'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.75']]]
treeblank treetree @typeCode
cs 1 … 1 F REFR CONFdots1531
  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 … 1 Contains 2.16.840.1.113883.10.20.22.2.98 Principle Diagnosis (DYNAMIC) CONFdots9951
treeblank where [cda:observation [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.98'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.98']]]
treeblank treetree @typeCode
cs 1 … 1 F REFR CONFdots1531
  SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31531).