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draft Template  Problem Observation (V3)

Id 2.16.840.1.113883.10.20.22.4.4
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ccda-
 		Effective Date 2015‑08‑01
Status draft Draft Version Label 2.1
Name ProblemObservationV3 Display Name 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 2.16.840.1.113883.10.20.22.4.4
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 5 templates
Used by as Name Version
2.16.840.1.113883.10.20.22.2.37 Containment draft Complications Section (V3) (2.1) 2015‑08‑01
1.2.840.10008.9.3 link draft Imaging Procedure Description (DICOM-20150324) 2021‑06‑22 11:48:00
2.16.840.1.113883.2.51.10.1.9.1 link cancelled XeH Imaging Report 2021‑06‑22 14:23:06
2.16.840.1.113883.2.51.10.2 link draft XeH Diagnostic Imaging Report (0.1) 2021‑06‑21 14:23:14
2.16.840.1.113883.2.51.10.45 link cancelled XeH Diagnostic Imaging Report2 (DICOM-20150324) 2021‑11‑08 15:59:54
2.16.840.1.113883.2.51.10.63 link draft XeH Imaging Procedure Description (DICOM-20150324) 2022‑03‑21 16:08:00
Uses as Name Version
2.16.840.1.113883.10.20.22.4.119 Containment draft Author Participation (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.31 Containment draft Age Observation (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.113 Containment draft Prognosis Observation (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.143 Containment draft Priority Preference (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.6 Containment draft Problem Status (2.1-OLD) 2014‑06‑09
Relationship Specialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
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ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.4.4 Problem Observation (2013‑01‑31)
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ccda-
Item DT Card Conf Description Label
cda:observation
 		(ProdotsnV3)
@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).
@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).
@negationInd
 		bl 0 … 1   MAY contain zero or one [0..1] @negationInd (CONF:1198-10139). CONFdots0139
cda:templateId
 		II 1 … 1 M C-CDA R1.1 templateId root without an extension CONFdots2936
@root
 		uid 1 … 1 F 2.16.840.1.113883.10.20.22.4.4
cda:templateId
 		II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:1198-14926) such that it CONFdots4926
@root
 		uid 1 … 1 F 2.16.840.1.113883.10.20.22.4.4 CONFdots4927
  SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.4" (CONF:1198-14927).
@extension
 		st 1 … 1 F 2015-08-01 CONFdots2508
  SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32508).
cda:id
 		II 1 … * SHALL contain at least one [1..*] id (CONF:1198-9043). CONFdots9043
cda:code
 		CD (extensible) 1 … 1 SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Problem Type (SNOMEDCT) 2.16.840.1.113883.3.88.12.3221.7.2 DYNAMIC (CONF:1198-9045).

a. If code is selected from ValueSet Problem Type (SNOMEDCT) 2.16.840.1.113883.3.88.12.3221.7.2 DYNAMIC, then it SHALL have at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) 2.16.840.1.113762.1.4.1099.28 DYNAMIC (CONF:1198-32950). 		CONFdots9045
  CONF
The value of @code should be drawn from value set 2.16.840.1.113883.3.88.12.3221.7.2 Problem Type (DYNAMIC)
hl7:translation
 		CD (extensible) 0 … * C If code is selected from ValueSet Problem Type (SNOMEDCT) 2.16.840.1.113883.3.88.12.3221.7.2 DYNAMIC, then it SHALL have at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) 2.16.840.1.113762.1.4.1099.28 DYNAMIC (CONF:1198-32950). (CONF:1198-32950)
CONFdots9045
  CONF
The value of @code should be drawn from value set 2.16.840.1.113762.1.4.1099.28 Problem Type LOINC (DYNAMIC)
  Schematron assert role orange warning  
  test not(../cda:code/@codeSystem='2.16.840.1.113883.6.96') or cda:translation  
  Message If code is selected from ValueSet Problem Type (SNOMEDCT) 2.16.840.1.113883.3.88.12.3221.7.2 DYNAMIC, then it SHALL have at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) 2.16.840.1.113762.1.4.1099.28 DYNAMIC (CONF:1198-32950).  
cda:statusCode
 		CS 1 … 1 M SHALL contain exactly one [1..1] statusCode (CONF:1198-9049). CONFdots9049
@code
 		CONF 1 … 1 F completed
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
cda:low
 		1 … 1 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
cda:high
 		0 … 1 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
cda:value
 		CD (extensible) 1 … 1 CONFdots9058
@code
 		0 … 1   This value MAY contain zero or one [0..1] @code (CONF:1198-31871). CONFdots1871
  CONF
The value of @code should be drawn from value set 2.16.840.1.113883.3.88.12.3221.7.4 Problem (DYNAMIC)
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
cda:translation
 		0 … * This value MAY contain zero or more [0..*] translation (CONF:1198-16749) such that it CONFdots6749
@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
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 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13) 		CONFdots1147
cda:entryRelationship
 		0 … 1 Contains 2.16.840.1.113883.10.20.22.4.31 Age Observation (2015‑08‑13) CONFdots9059
@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).
@inversionInd
 		bl 1 … 1 F true CONFdots9069
  SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1198-9069).
cda:entryRelationship
 		0 … 1 Contains 2.16.840.1.113883.10.20.22.4.113 Prognosis Observation (2015‑08‑13) CONFdots9951
@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).
cda:entryRelationship
 		0 … * Contains 2.16.840.1.113883.10.20.22.4.143 Priority Preference (2015‑08‑13) CONFdots1063
@typeCode
 		cs 1 … 1 F REFR CONFdots1532
  SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31532).
cda:entryRelationship
 		0 … 1 MAY contain zero or one [0..1] entryRelationship (CONF:1198-9063) such that it

SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-9068).

SHALL contain exactly one [1..1] Problem Status (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.6) (CONF:1198-15591).
Contains 2.16.840.1.113883.10.20.22.4.6 Problem Status (2014‑06‑09) 		CONFdots9063
@typeCode
 		cs 1 … 1 F REFR CONFdots9068
  SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-9068).