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
Adaptation: Template 2.16.840.1.113883.10.20.22.4.3 Problem Concern Act (V3) (2015‑08‑01)
ref
ccda-
Beispiel
Beispiel
<actclassCode="ACT"moodCode="EVN"> <templateIdroot="1.2.276.0.76.10.4074"/><idroot="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7"/><codecode="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 --> <statusCodecode="active"/><effectiveTime> <!-- Das low Element gibt an, wann das Problem zum ersten Male dokumentiert worden ist
--> <lowvalue="201307061145-0800"/></effectiveTime><authortypeCode="AUT"> <!-- dasselbe wie Concern effectiveTime/low --> <timevalue="201307061145-0800"/><assignedAuthor> <!-- Autor des Problems mit id und code --> </assignedAuthor></author><entryRelationshiptypeCode="SUBJ"> <observationclassCode="OBS"moodCode="EVN"> <!-- Problem Observation 1.2.276.0.76.10.4076 --> </observation></entryRelationship></act>
Template Problem Concern Act
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.
Act)