Template 2.16.840.1.113883.10.22.4.8

Template IPS Problem Entry

Id 2.16.840.1.113883.10.22.4.8 Effective Date 2017‑02‑15

Status Draft Version Label

Name IPSProblemEntry Display Name IPS Problem Entry

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 2.16.840.1.113883.10.22.4.8

Classification CDA Entry Level Template

Open/Closed Open (other than defined elements are allowed)

Associated with

Associated with 12 concepts

Id	Name	Data Set
hl7ips-dataelement-136	Severity	CEN/TC 251 prEN 17269
hl7ips-dataelement-36	Diagnosis	CEN/TC 251 prEN 17269
hl7ips-dataelement-115	Problem content status	CEN/TC 251 prEN 17269
hl7ips-dataelement-210	Problem Type	CEN/TC 251 prEN 17269
hl7ips-dataelement-34	Date resolved	CEN/TC 251 prEN 17269
hl7ips-dataelement-131	Diagnosis	CEN/TC 251 prEN 17269
hl7ips-dataelement-128	Severity	CEN/TC 251 prEN 17269
hl7ips-dataelement-32	Onset Date	CEN/TC 251 prEN 17269
hl7ips-dataelement-101	Problem type	CEN/TC 251 prEN 17269
hl7ips-dataelement-209	Health condition / Problem	CEN/TC 251 prEN 17269
hl7ips-dataelement-140	Problem	CEN/TC 251 prEN 17269
hl7ips-dataelement-127	Onset date	CEN/TC 251 prEN 17269

Used by / Uses

Used by 0 transactions and 4 templates, Uses 3 templates

Used by	as	Name	Version
2.16.840.1.113883.10.22.4.7	Containment	IPS Problem Concern Entry	2017‑02‑15
2.16.840.1.113883.10.22.3.3		IPS Problems Section	2017‑02‑15
2.16.840.1.113883.10.22.1.1		International Patient Summary	2017‑04‑11
2.16.840.1.113883.10.22.3.7		IPS History of Past Illness Section	2017‑04‑12
Uses	as	Name	Version
2.16.840.1.113883.10.22.4.25	Containment	IPS Severity Observation	DYNAMIC
2.16.840.1.113883.10.22.4.19	Containment	IPS Certainty Observation	DYNAMIC
2.16.840.1.113883.10.22.4.20	Containment	IPS Problem Status Observation	2017‑03‑29

Relationship Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 (DYNAMIC)

Example

Active Problem

Example

Closed Problem (resolution date known)

Example

Known absent problems

<observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.22.4.8"/> <id root="1.2.3.999" extension="__example only__"/> <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/> <statusCode code="completed"/> <effectiveTime> <low nullFlavor="NI"/> </effectiveTime> <value code="no-known-problems" displayName="No known problems" codeSystem="2.16.840.1.113883.5.1150.1"/></observation>

Item DT Card Conf Description Label

hl7:observation R (IPStry)


hl7ips-dataelement-209	Health condition / Problem	CEN/TC 251 prEN 17269
hl7ips-dataelement-140	Problem	CEN/TC 251 prEN 17269

@classCode cs 0 … 1 F OBS

@moodCode cs 1 … 1 F EVN

hl7:templateId II 1 … 1 M (IPStry)

@root uid 1 … 1 F 2.16.840.1.113883.10.22.4.8

hl7:id II 0 … * R (IPStry)

hl7:code CD.IPS 1 … 1 R This element describes the type of condition this observation is referring to. (IPStry)


hl7ips-dataelement-210	Problem Type	CEN/TC 251 prEN 17269
hl7ips-dataelement-101	Problem type	CEN/TC 251 prEN 17269

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.16 Problem Type (DYNAMIC)

Example <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>

hl7:text ED 0 … 1 R The element if present points to the text describing the problem being recorded; including any dates, comments, et cetera. The contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described. (IPStry)

Example <text> <reference value="#problem-1"/></text>

hl7:reference TEL 1 … 1 M (IPStry)

@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 shall always have code='completed'. (IPStry)

@code CONF 1 … 1 F completed

hl7:effectiveTime

IVL_TS

1 … 1

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 <low> and <high> values should be no more precise than known, but as precise as possible.

(IPS

try)

Example

Known onset date (active condition)

<effectiveTime> <low value="20100507"/></effectiveTime>

Example

Unknown onset date (active condition)

<effectiveTime> <low nullFlavor="UNK"/></effectiveTime>

Example

Unknown resolution date

<effectiveTime> <low value="2010"/> <high nullFlavor="UNK"/></effectiveTime>

Example

Known resolution date

<effectiveTime> <low value="201007"/> <high value="201703"/></effectiveTime>

hl7:low IVXB_TS 1 … 1 R The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. (IPStry)


hl7ips-dataelement-32	Onset Date	CEN/TC 251 prEN 17269
hl7ips-dataelement-127	Onset date	CEN/TC 251 prEN 17269

hl7:high IVXB_TS 0 … 1 C The effectiveTime/high (a.k.a. "resolution date") asserts when the condition e became biologically resolved.
If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK". (IPStry)


	hl7ips-dataelement-34	Date resolved	CEN/TC 251 prEN 17269

Constraint If this condition is known to be resolved, then the effectiveTime/high would be present.

hl7:value CD.IPS (preferred) 1 … 1 M The <value> is the condition that was found.
It may a coded or an un-coded string, but its type is always coded.
The coded form shall be used also to indicate known absent conditions or the nonavailability of information about them. (IPStry)


hl7ips-dataelement-36	Diagnosis	CEN/TC 251 prEN 17269
hl7ips-dataelement-115	Problem content status	CEN/TC 251 prEN 17269
hl7ips-dataelement-131	Diagnosis	CEN/TC 251 prEN 17269

@xsi:type 0 … 1 F CD

CONF

The value of @code comes preferably from value set 2.16.840.1.113883.11.22.5 CORE Problem List Disorders (DYNAMIC)

The value of @code comes preferably from value set 2.16.840.1.113883.11.22.17 Absent or Unknown Problems (DYNAMIC)

Example

Multiple Coding

<value code="302231008" displayName="Salmonella infection" codeSystem="2.16.840.1.113883.6.96"> <translate code="A02.9" displayName="Infezioni da Salmonella non specificate" codeSystem="2.16.840.1.113883.6.3"/></value>

Example

Local code not mappable in the reference terminology

<value nullFlavor="OTH"> <translate code="12345" displayName="Not in the reference value set" codeSystem="1.2.3.999" codeSystemName="--example only--"/></value>

Example

Textual Information

<value nullFlavor="NI"> <originalText> <reference value="#value_as_text"/> </originalText></value>

Example

Known absent problems

<value code="160245001" displayName="No current problems or disability" codeSystem="2.16.840.1.113883.6.96"/>

hl7:originalText

The <originalText> element within the <code> element described above is used as follows: the <value> contains a <reference> to the <originalText> in order to link the coded value to the problem narrative text (minus 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

try)

hl7:reference 0 … 1 R The URI given in the value attribute of the element points to an element in the narrative content that contains the complete text describing the medication. In a CDA document, the URI given in the value attribute of the element points to an element in the narrative content that contains the complete text describing the medication. (IPStry)

Example <reference value="#value_as_text"/>

hl7:translation CD.IPS 0 … * The translation element may be used to transmit a set of other concept descriptors, using for example ICD-10 or other international or jurisdictional code systems. (IPStry)

hl7:qualifier CR 0 … * (IPStry)

hl7:entryRelationship 0 … 1 R Severity
The contained entry describes a subjective assessment of the severity of the condition as evaluated by the clinician.
Contains 2.16.840.1.113883.10.22.4.25 IPS Severity Observation (DYNAMIC) (IPStry)

where [hl7:observation [hl7:templateId [@root = '2.16.840.1.113883.10.22.4.25']]]


hl7ips-dataelement-136	Severity	CEN/TC 251 prEN 17269
hl7ips-dataelement-128	Severity	CEN/TC 251 prEN 17269

@typeCode cs 1 … 1 F SUBJ

@inversionInd bl 1 … 1 F true

hl7:entryRelationship 0 … 1 R Certainty or Verification Status
The contained entry describes the certainty associated with a condition.
Contains 2.16.840.1.113883.10.22.4.19 IPS Certainty Observation (DYNAMIC) (IPStry)

where [hl7:observation [hl7:templateId [@root = '2.16.840.1.113883.10.22.4.19']]]

@typeCode cs 1 … 1 F SUBJ

@inversionInd bl 1 … 1 F true

hl7:entryRelationship 0 … 1 R Status of the Problem
The contained entry describes the current status of the condition, for example, whether it is active, in remission, resolved, and so on ...
Contains 2.16.840.1.113883.10.22.4.20 IPS Problem Status Observation (2017‑03‑29) (IPStry)

where [hl7:observation [hl7:templateId [@root = '2.16.840.1.113883.10.22.4.20']]]

@typeCode cs 1 … 1 F REFR

@inversionInd bl 0 … 1 F false

Template IPS Problem Entry