hl7:observation
|
|
|
R |
|
(XeH try) |
@classCode
|
cs |
0 … 1 |
F |
OBS |
@moodCode
|
cs |
1 … 1 |
F |
EVN |
hl7:templateId
|
II |
1 … 1 |
M |
|
(XeHtry) |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.2.51.10.25 |
hl7:id
|
II |
0 … * |
R |
|
(XeHtry) |
hl7:code
|
CD.IPS |
1 … 1 |
R |
This element describes the type of condition this observation is referring to. |
(XeHtry) |
| |
CONF |
|
| |
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.
|
(XeHtry) |
| |
Example |
<text>
<reference value="#problem-1"/></text> |
hl7:reference
|
TEL |
1 … 1 |
M |
|
(XeHtry) |
@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'.
|
(XeHtry) |
@code
|
CONF |
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 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.
|
(XeHtry) |
| |
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.
|
(XeHtry) |
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".
|
(XeHtry) |
| |
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.
|
(XeHtry) |
@xsi:type
|
|
0 … 1 |
F |
CD |
| |
CONF |
|
| |
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
|
|
|
R |
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.
|
(XeHtry) |
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.
|
(XeHtry) |
| |
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.
|
(XeHtry) |
hl7:qualifier
|
CR |
0 … * |
|
|
(XeHtry) |
hl7:targetSiteCode
|
CD |
0 … * |
|
|
(XeHtry) |
hl7:author
|
|
0 … * |
|
Contains 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
|
(XeHtry) |
hl7:participant
|
|
0 … * |
|
|
(XeHtry) |
hl7:participant
|
|
0 … * |
|
Contact Person or Organization
Patient contacts or the Preferred Health Professional to contact in case of emergency.
Contains 2.16.840.1.113883.2.51.10.35 XeH Patient Contact [body] (DYNAMIC)
|
(XeHtry) |
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)
|
(XeHtry) |
@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)
|
(XeHtry) |
@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 (DYNAMIC)
|
(XeHtry) |
@typeCode
|
cs |
1 … 1 |
F |
REFR |
@inversionInd
|
bl |
0 … 1 |
F |
false |
hl7:entryRelationship
|
|
0 … 1 |
|
Trend
The contained entry describes the current trend of the condition, for example, whether
it is improving, worsening, stable and so on ...
Contains 2.16.840.1.113883.2.51.10.32 XeH Problem Status Trend (DYNAMIC)
|
(XeHtry) |
@typeCode
|
cs |
1 … 1 |
F |
REFR |
@inversionInd
|
bl |
0 … 1 |
F |
false |
hl7:entryRelationship
|
|
0 … * |
|
Comments
Free text data that cannot otherwise be recorded using data elements already defined
by this specification. They are not to be used to record information that can be recorded
elsewhere. For example, a free text description of the severity of an allergic reaction
would not be recorded in a comment.
Contains 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC)
|
(XeHtry) |
@typeCode
|
cs |
1 … 1 |
F |
COMP |
hl7:entryRelationship
|
|
0 … * |
|
Reference Center/Practitioner
The contained entry describes the care provision act performed by the reference center
and practictioner.
Contains 2.16.840.1.113883.2.51.10.37 XeH Care Team Act (DYNAMIC)
|
(XeHtry) |
@typeCode
|
cs |
1 … 1 |
F |
REFR |
@inversionInd
|
bl |
0 … 1 |
F |
false |
hl7:reference
|
|
0 … |
|
This element may be used to indicate the url to relevant information on this particular disease, including CPGs, emergency and anesthesia guidelines.
|
(XeHtry) |
@typeCode
|
cs |
1 … 1 |
F |
REFR |
hl7:externalDocument
|
|
0 … 1 |
|
|
(XeHtry) |
hl7:id
|
|
0 … |
|
identifier of the document/guideline referred |
(XeHtry) |
hl7:code
|
|
0 … |
|
type of document/guideline referred |
(XeHtry) |
hl7:text
|
|
0 … 1 |
|
|
(XeHtry) |
hl7:reference
|
|
1 … 1 |
|
Url to relevant information on this particular disease, including CPGs, emergency and anesthesia guidelines.
|
(XeHtry) |
Template XeH Problem Entry
IPS Body Author (STU1)