hl7:observation
|
|
|
R |
|
(IPS…nce) |
@classCode
|
cs |
1 … 1 |
F |
OBS |
@moodCode
|
cs |
1 … 1 |
F |
EVN |
hl7:templateId
|
II |
1 … 1 |
M |
|
(IPS…nce) |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.10.22.4.1 |
hl7:id
|
II |
0 … * |
R |
|
(IPS…nce) |
hl7:code
|
CD.IPS |
1 … 1 |
M |
Thus element describes whether this condition refers to an allergy, non-allergy intolerance,
or unknown class of intolerance (not known to be allergy or intolerance).
|
(IPS…nce) |
| |
CONF |
|
hl7:text
|
ED |
0 … 1 |
R |
The <text> element if present points to the text describing the problem being recorded;
including any dates, comments, et cetera. The <reference> contains a URI in value
attribute. This URI points to the free text description of the problem in the document
that is being described.
|
(IPS…nce) |
hl7:reference
|
TEL |
1 … 1 |
M |
|
(IPS…nce) |
@value
|
|
1 … 1 |
R |
When used it shall refer to the narrative, typically #{label}-{generated-id}, e.g.
#xxx-1
|
hl7:statusCode
|
CS |
1 … 1 |
M |
A clinical document normally records only those condition observation events that
have been completed, not observations that are in any other state. Therefore, the
<statusCode> shall always have code='completed'.
|
(IPS…nce) |
@code
|
cs |
1 … 1 |
F |
completed |
hl7:effectiveTime
|
IVL_TS |
1 … 1 |
M |
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 penicillin allergy that developed five years
ago, the effectiveTime is five years ago. The effectiveTime of the Allergy - Intolerance
Observation may give an indication of whether or not the underlying allergy/intolerance
is resolved.
The <low> and <high> values should be no more precise than known, but as precise as
possible.
|
(IPS…nce) |
hl7:low
|
IVXB_TS |
1 … 1 |
R |
The effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became
biologically active.
|
(IPS…nce) |
hl7:high
|
IVXB_TS |
0 … 1 |
C |
The effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance
became biologically resolved.
If the date of resolution is not known, then effectiveTime/high will be present with
a nullFlavor of "UNK".
|
(IPS…nce) |
| |
Constraint |
If this condition is known to be resolved, then the effectiveTime/high would be present. |
hl7:value
|
CD.IPS CWE |
0 … 1 |
C |
While the value may be a coded or an uncoded string, the type is always a coded value
(xsi:type='CD'). If uncoded, all attributes other than xsi:type='CD' must be absent and
may contain a <reference> to the <originalText> in the narrative where the allergy
is described.
The coded form shall be used to indicate known absent conditions (e.g. NKA) or the
nonavailability of infos about them; or in some cases the allergy to specific substances
(e.g. allergy to nuts).
When the value is present in a coded form, no allergy agent is expected to be provided.
|
(IPS…nce) |
| |
CONF |
|
hl7:participant
|
|
0 … 1 |
C |
The substance that causes the allergy or intolerance should be specified in the <participant>
structure.
This is the preferred way an allergy is supposed to be expressed.
However it is recognized that in some contexts a controlled vocabulary is used for
describing the allergy to a substance; or for asserting known absence or unavailability
of information.
In this case the <participant> structure shall be omitted.
The agent responsible for an allergy or adverse reaction is not always a manufactured
material (for example, food allergies), nor is it necessarily consumed. The following
constraints reflect limitations in the base CDA R2 specification, and should be used
to represent any type of responsible agent, i.e., use playingEntity classCode = "MMAT"
for all agents, manufactured or not.
|
(IPS…nce) |
@typeCode
|
cs |
1 … 1 |
F |
CSM |
| |
Constraint |
IF the observation/value element is present and coded then the observation/participant
element SHALL be omitted.
Conditional: Omit if Observation.value is SNOMED-CT 160244002 No known Allergies
|
hl7:participantRole
|
|
0 … 1 |
C |
|
(IPS…nce) |
@classCode
|
cs |
1 … 1 |
F |
MANU |
hl7:playingEntity
|
|
1 … 1 |
R |
|
(IPS…nce) |
@classCode
|
cs |
1 … 1 |
F |
MMAT |
hl7:code
|
CD.IPS |
1 … 1 |
R |
Code for the substance causing the allergy or intolerance.
|
(IPS…nce) |
| |
CONF |
|
| |
Schematron assert |
role |
 error
|
|
| |
test |
hl7:value[@code] or hl7:participantRole |
|
| |
Message |
IF the observation/value element is present and coded then the observation/participant
element SHALL be omitted |
|
hl7:entryRelationship
|
|
0 … * |
R |
The contained entry describes the reactions that are manifestations (typeCode='MFST') of
the reported allergy or intolerance.
Contains 2.16.840.1.113883.10.22.4.6 IPS Reaction Manifestation (DYNAMIC)
|
(IPS…nce) |
 |
where [hl7:observation [hl7:templateId [@root='2.16.840.1.113883.10.22.4.6']]] |
|
|
@typeCode
|
cs |
1 … 1 |
F |
MFST |
@inversionInd
|
cs |
1 … 1 |
F |
true |
hl7:entryRelationship
|
|
0 … 1 |
R |
Criticality
The contained entry describes the gravity of the potential risk for future life-threatening
adverse reactions when exposed to a substance known to cause an adverse reaction in
that individual.
Contains 2.16.840.1.113883.10.22.4.18 IPS Criticality Observation (DYNAMIC)
|
(IPS…nce) |
|
where [hl7:observation [hl7:templateId [@root='2.16.840.1.113883.10.22.4.18']]] |
|
|
@typeCode
|
cs |
1 … 1 |
F |
SUBJ |
@inversionInd
|
cs |
1 … 1 |
F |
true |
hl7:entryRelationship
|
|
0 … 1 |
R |
Certainty or Verification Status
The contained entry describes the certainty associated with a propensity, or potential
risk, of a reaction to the identified substance.
Contains 2.16.840.1.113883.10.22.4.19 IPS Certainty Observation (DYNAMIC)
|
(IPS…nce) |
|
where [hl7:observation [hl7:templateId [@root='2.16.840.1.113883.10.22.4.19']]] |
|
|
@typeCode
|
cs |
1 … 1 |
F |
SUBJ |
@inversionInd
|
cs |
1 … 1 |
F |
true |
hl7:entryRelationship
|
|
0 … 1 |
R |
Status of the Allergy or Intolerance
The contained entry describes the current status of the allergy or intolerance, for
example, whether it is active, in remission, resolved, and so on ...
Contains 2.16.840.1.113883.10.22.4.21 IPS Allergy Status Observation (DYNAMIC)
|
(IPS…nce) |
|
where [hl7:observation [hl7:templateId [@root='2.16.840.1.113883.10.22.4.21']] [hl7:templateId
[@root='2.16.840.1.113883.10.22.4.20']]] |
|
|
@typeCode
|
cs |
1 … 1 |
F |
REFR |
@inversionInd
|
cs |
1 … 1 |
F |
false |
Template IPS Allergy or Intolerance
Draft
