hl7:observation
|
|
|
R |
|
(XeH sis) |
@classCode
|
cs |
0 … 1 |
F |
OBS |
@moodCode
|
cs |
1 … 1 |
F |
EVN |
hl7:templateId
|
II |
1 … 1 |
M |
|
(XeHsis) |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.2.51.10.27 |
hl7:templateId
|
II |
1 … 1 |
M |
|
(XeHsis) |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.3.1937.99.61.67.10.21 |
hl7:id
|
II |
0 … * |
R |
|
(XeHsis) |
hl7:code
|
CD.IPS |
1 … 1 |
R |
This element describes the type of condition this observation is referring to. |
(XeHsis) |
| |
CONF |
| @code shall be "8646-2" |
| @codeSystem shall be "2.16.840.1.113883.6.1" |
| or |
| @code shall be "8651-2" |
| @codeSystem shall be "2.16.840.1.113883.6.1" |
|
| |
Example |
<hl7:code code="8646-2" codeSystem="2.16.840.1.113883.6.1" displayName=""/> |
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.
|
(XeHsis) |
| |
Example |
<text>
<reference value="#problem-1"/></text> |
hl7:reference
|
TEL |
1 … 1 |
M |
|
(XeHsis) |
@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'.
|
(XeHsis) |
@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.
|
(XeHsis) |
| |
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.
|
(XeHsis) |
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".
|
(XeHsis) |
| |
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.
|
(XeHsis) |
@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.
|
(XeHsis) |
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.
|
(XeHsis) |
| |
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.
|
(XeHsis) |
hl7:qualifier
|
CR |
0 … * |
|
|
(XeHsis) |
hl7:entryRelationship
|
|
0 … 1 |
|
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)
|
(XeHsis) |
@typeCode
|
cs |
1 … 1 |
F |
SUBJ |
@inversionInd
|
bl |
1 … 1 |
F |
true |
hl7:entryRelationship
|
|
0 … 1 |
|
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)
|
(XeHsis) |
@typeCode
|
cs |
1 … 1 |
F |
SUBJ |
@inversionInd
|
bl |
1 … 1 |
F |
true |
hl7:entryRelationship
|
|
0 … 1 |
|
Prognosis
The contained entry describes the prognosis associated with this diagnosis.
Contains 2.16.840.1.113883.2.51.10.51 XeH Prognosis Observation (DYNAMIC)
|
(XeHsis) |
@typeCode
|
cs |
1 … 1 |
F |
REFR |
Template XeH Admission / Discharge Diagnosis
IPS Severity Observation (STU1)