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draft Template  Problem Concern Act

Id 1.2.276.0.76.10.4074
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hl7de-
Gültigkeit 2015‑12‑06
Status draft Entwurf Versions-Label
Name ProblemConcernAct Bezeichnung Problem Concern Act
Beschreibung
en-US This template reflects an ongoing concern on behalf of the provider that placed the concern on a patient’s problem list. So long as the underlying condition is of concern to the provider (i.e., as long as the condition, whether active or resolved, is of ongoing concern and interest to the provider), the statusCode is “active”. Only when the underlying condition is no longer of concern is the statusCode set to “completed”. The effectiveTime reflects the time that the underlying condition was felt to be a concern; it may or may not correspond to the effectiveTime of the condition (e.g., even five years later, the clinician may remain concerned about a prior heart attack). The statusCode of the Problem Concern Act is the definitive indication of the status of the concern, whereas the effectiveTime of the nested Problem Observation is the definitive indication of whether or not the underlying condition is resolved. The effectiveTime/low of the Problem Concern Act asserts when the concern became active. This equates to the time the concern was authored in the patient's chart. The effectiveTime/high asserts when the concern was completed (e.g., when the clinician deemed there is no longer any need to track the underlying condition). A Problem Concern Act can contain many Problem Observations (templateId 2.16.840.1.113883.10.20.22.4.4). Each Problem Observation is a discrete observation of a condition, and therefore will have a statusCode of “completed”. The many Problem Observations nested under a Problem Concern Act reflect the change in the clinical understanding of a condition over time. For instance, a Concern may initially contain a Problem Observation of “chest pain”: - Problem Concern 1 --- Problem Observation: Chest Pain Later, a new Problem Observation of “esophagitis” will be added, reflecting a better understanding of the nature of the chest pain. The later problem observation will have a more recent author time stamp. - Problem Concern 1 --- Problem Observation (author/time Jan 3, 2012): Chest Pain --- Problem Observation (author/time Jan 6, 2012): Esophagitis Many systems display the nested Problem Observation with the most recent author time stamp, and provide a mechanism for viewing prior observations.
Kontext Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4074
Klassifikation CDA Entry Level Template
Offen/Geschlossen Offen (auch andere als die definierten Elemente sind erlaubt)
Benutzt von / Benutzt
Benutzt von 0 Transactions und 2 Templates, Benutzt 3 Templates
Benutzt von als Name Version
1.2.276.0.76.10.3079 Containment draft Gesundheitsprobleme 2017‑03‑01
2.16.840.1.113883.3.1937.777.26.10.16 link draft Nephrologische Konsilanfrage 2018‑08‑02 12:52:50
Benutzt als Name Version
1.2.276.0.76.10.90025 Inklusion draft Author (Body) DYNAMIC
1.2.276.0.76.10.4075 Containment draft Problem Observation DYNAMIC
1.2.276.0.76.10.4076 Containment draft Priorität Präferenz DYNAMIC
Beziehung Spezialisierung: Template 2.16.840.1.113883.10.12.301 CDA Act (2005‑09‑07)
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ad1bbr-

Adaptation: Template 2.16.840.1.113883.10.20.22.4.3 Problem Concern Act (V3) (2015‑08‑01)
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ccda-
Beispiel
Beispiel
<act classCode="ACT" moodCode="EVN">
  <templateId root="1.2.276.0.76.10.4074"/>  <id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7"/>  <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>  <!-- Der statusCode besagt, dass das Problem noch besteht (aktuell/aktiv) und verfolgt werden muss -->
  <statusCode code="active"/>  <effectiveTime>
    <!-- Das low Element gibt an, wann das Problem zum ersten Male dokumentiert worden ist -->
    <low value="201307061145-0800"/>  </effectiveTime>
  <author typeCode="AUT">
    <!-- dasselbe wie Concern effectiveTime/low -->
    <time value="201307061145-0800"/>    <assignedAuthor>
      <!-- Autor des Problems mit id und code -->
    </assignedAuthor>
  </author>
  <entryRelationship typeCode="SUBJ">
    <observation classCode="OBS" moodCode="EVN">
      <!-- Problem Observation 1.2.276.0.76.10.4076 -->
    </observation>
  </entryRelationship>
</act>
Item DT Kard Konf Beschreibung Label
hl7:act
(ProdotsAct)
@classCode
cs 1 … 1 F ACT
@moodCode
cs 1 … 1 F EVN
hl7:templateId
1 … 1 M (ProdotsAct)
@root
uid 1 … 1 F 1.2.276.0.76.10.4074
hl7:id
1 … * (ProdotsAct)
hl7:code
1 … 1 M (ProdotsAct)
@code
CONF 1 … 1 F CONC
@codeSystem
1 … 1 F 2.16.840.1.113883.5.6 (HL7ActClass)
hl7:statusCode
1 … 1 M (ProdotsAct)
hl7:effectiveTime
1 … 1 M (ProdotsAct)
hl7:low
1 … 1 M (ProdotsAct)
hl7:high
0 … 1 (ProdotsAct)
hl7:author
0 … * R (ProdotsAct)
Eingefügt von 1.2.276.0.76.10.90025 Author (Body) (DYNAMIC)
@typeCode
0 … 1 F AUT
@contextControlCode
0 … 1 F OP
hl7:functionCode
CE 0 … 1 (ProdotsAct)
  CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
hl7:time
TS 1 … 1 R (ProdotsAct)
 
target
konsab-dataelement-133 draft Zeitpunkt Bildaufnahme draft Datensatz
konsab-dataelement-132 draft Zeitpunkt Bildaufnahme draft Datensatz
konsab-dataelement-82 draft Zeitpunkt Konsilrückfrage draft Datensatz
konsab-dataelement-83 draft Zeitpunkt Konsilanfrage draft Datensatz
konsab-dataelement-84 draft Zeitpunkt Antwort auf Konsilrückfrage draft Datensatz
konsab-dataelement-85 draft Zeitpunkt Konsiliarbericht draft Datensatz
konsab-dataelement-92 draft Zeitpunkt Konsilabschluss draft Datensatz
hl7:assignedAuthor
1 … 1 R (ProdotsAct)
@classCode
0 … 1 F ASSIGNED
hl7:id
II 1 … * R (ProdotsAct)
hl7:code
CE 0 … 1 (ProdotsAct)
@codeSystem
CONF 0 … 1 F 2.16.840.1.113883.5.111 (Role Code)
hl7:addr
AD 0 … * (ProdotsAct)
hl7:telecom
TEL 0 … * (ProdotsAct)
hl7:assignedPerson
0 … 1 (ProdotsAct)
Eingefügt von 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC)
@classCode
0 … 1 F PSN
@determinerCode
0 … 1 F INSTANCE
hl7:name
PN 1 … 1 M (ProdotsAct)
 
target
konsab-dataelement-128 draft Name draft Datensatz
hl7:representedOrganization
0 … 1 (ProdotsAct)
Eingefügt von 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC)
@classCode
0 … 1 F ORG
@determinerCode
0 … 1 F INSTANCE
hl7:id
II 0 … * (ProdotsAct)
 
target
konsab-dataelement-90 draft BSNR draft Datensatz
konsab-dataelement-89 draft BSNR draft Datensatz
hl7:name
ON 1 … 1 M (ProdotsAct)
hl7:telecom
TEL 0 … * (ProdotsAct)
 
target
konsab-dataelement-93 draft Telefonnummer draft Datensatz
konsab-dataelement-94 draft Faxnummer draft Datensatz
konsab-dataelement-145 draft Telefonnummer draft Datensatz
konsab-dataelement-146 draft Faxnummer draft Datensatz
hl7:addr
AD 0 … 1 (ProdotsAct)
hl7:entryRelationship
1 … * M Liste der Probleme
Beinhaltet 1.2.276.0.76.10.4075 Problem Observation (DYNAMIC)
(ProdotsAct)
@typeCode
cs 1 … 1 F SUBJ
hl7:entryRelationship
0 … * Priorität des Problem laut Einschätzung des Gesundheitsdienstleisters
Beinhaltet 1.2.276.0.76.10.4076 Priorität Präferenz (DYNAMIC)
(ProdotsAct)
@typeCode
cs 1 … 1 F REFR