Id1.3.182.11.10.3.7Effective Date2018‑06‑18 11:53:22
Statusdraft DraftVersion Label
NameProblemStatusObservationDisplay NameeHDSI Problem Status Observation Entry
Description

Any problem or allergy observation may reference a problem status observation. This structure is included in the target observation using the <entryRelationship> element defined in the CDA Schema. The clinical status observation records information about the current status of the problem or allergy, for example, whether it is active, in remission, resolved, et cetera. The example below shows the recording of clinical status of a condition or allergy, and is used as the context for the following sections.

ContextPathname /
ClassificationCDA Entry Level Template
Open/ClosedClosed (only defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 0 templates
Used by as NameVersion
1.3.182.11.10.3.2Containmentdraft eHDSI Problem Entry2018‑02‑27 15:18:44
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="1.3.182.11.10.3.7"/>  <code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <text>
    <reference value="#cstatus-2"/>  </text>  <statusCode code="completed"/>  <value xsi:type="CE" code="413322009" codeSystem="2.16.840.1.113883.6.96"/></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
Probdotstion
@classCode
cs0 … 1FOBS
@moodCode
cs0 … 1FEVN
hl7:templateId
II1 … 1MProbdotstion
@root
uid1 … 1F1.3.182.11.10.3.7
hl7:code
CD1 … 1R

This observation is of clinical status, as indicated by the <code> element. This element must be present.

Probdotstion
@code
CONF0 … 1F33999-4
@codeSystem
0 … 1F2.16.840.1.113883.6.1
@codeSystemName
0 … 1FLOINC
@displayName
0 … 1FStatus
hl7:text
ED1 … 1M

The <text> element is required and points to the text describing the problem being recorded; including 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.

Probdotstion
hl7:reference
TEL1 … 1MProbdotstion
@value
1 … 1RReference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
CS1 … 1M

The code attribute of <statusCode> for all clinical status observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

Probdotstion
@code
cs1 … 1Fcompleted
hl7:value
CE.EPSOS1 … 1RThe element contains the clinical status. It is always represented using the CE datatype (xsi:type='CE'). It shall contain a code from the following set of values from SNOMED CT.Probdotstion
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.15 epSOSStatusCode (DYNAMIC)