Allergy to latex

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 4/17/2014
  • Example Task Force (review 2): 3/12/2015

  • SDWG: 3/19/2015

  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

C-CDA 2.1 Example:

  • 2.16.840.1.113883.10.20.22.2.6.1:2015-08-01

  • Allergy Concern Act 2.16.840.1.113883.10.20.22.4.30:2015-08-01

  • Allergy Intolerance Observation 2.16.840.1.113883.10.20.22.4.7:2014-06-09

  • Reaction Observation 2.16.840.1.113883.10.20.22.4.9:2014-06-09
  • Severity Observation 2.16.840.1.113883.10.20.22.4.8:2014-06-09

Reference to full CDA sample:

  • Allergies in empty CCD

Validation location

Comments

  • This is an example of a propensity to substance allergy with information on both allergic reaction and reaction severity. It was based upon discussion with Russ Leftwich and Lisa Nelson in coordination with Patient Care Committee. See DSTU 219 for update regarding act/code.

    Custodian

  • John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)

Keywords

  • substance, allergies, allergy

Permalink

Links

 

Example: download example view on GitHub 

<section>
	<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
	<templateId root="2.16.840.1.113883.10.20.22.2.6.1" extension="2015-08-01"/>
	<!-- Allergies (entries required) section template -->
	<code code="48765-2" codeSystem="2.16.840.1.113883.6.1"/>
	<title>Allergies, Adverse Reactions and Alerts</title>
	<text>
		<table>
			<thead>
				<tr>
					<th>Allergen</th>
					<th>Reaction</th>
					<th>Reaction Severity</th>
					<th>Documentation Date</th>
					<th>Start Date</th>
				</tr>
			</thead>
			<tbody>
				<tr ID="allergy4">
					<td ID="allergy4allergen">Latex</td>
					<td ID="allergy4reaction">Anaphylaxis</td>
					<td ID="allergy4reactionseverity">Severe</td>
					<td>Jan 4 2014</td>
					<td>Jan 3 2014</td>
				</tr>
			</tbody>
		</table>
	</text>
	<entry typeCode="DRIV">
		<act classCode="ACT" moodCode="EVN">
			<!-- ** Allergy problem act ** -->
			<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.30" extension="2015-08-01"/>
			<id root="4a2ac5fc-0c85-4223-baee-c2e254803974"/>
			<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
			<text>
				<reference value="#allergy4" />
			</text>
			<statusCode code="active"/>
			<!-- This is the time stamp for when the allergy was first documented as a concern-->
			<effectiveTime>
				<low value="20140104123506-0500"/>
			</effectiveTime>
			<author>
				<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
				<time value="20140104"/>
				<assignedAuthor>
					<id extension="99999999" root="2.16.840.1.113883.4.6"/>
					<code code="207Q00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Health Care Provider Taxonomy" displayName="Allopathic &amp; Osteopathic Physicians; Family Medicine" />
					<telecom use="WP" value="tel:555-555-1002"/>
					<assignedPerson>
						<name>
							<given>Henry</given>
							<family>Seven</family>
						</name>
					</assignedPerson>
				</assignedAuthor>
			</author>
			<entryRelationship typeCode="SUBJ">
				<observation classCode="OBS" moodCode="EVN">
					<!-- allergy observation template -->
					<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
					<templateId root="2.16.840.1.113883.10.20.22.4.7" extension="2014-06-09"/>
					<id root="4a2ac5fc-0c85-4223-baee-c2e254803974"/>
					<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
					<text>
						<reference value="#allergy4" />
					</text>
					<statusCode code="completed"/>
					<!-- This is the time stamp for the biological onset of the allergy. -->
					<!-- This documents that the allergy began at given year month and day, although hour and minute not specified-->
					<effectiveTime>
						<low value="20140103"/>
					</effectiveTime>
					<!-- This specifies that the allergy is a propensity to adverse reactions to substance -->
					<value xsi:type="CD" code="418038007" displayName="Propensity to adverse reactions to substance (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" />
					<author>
						<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
						<time value="20140104"/>
						<assignedAuthor>
							<id extension="99999999" root="2.16.840.1.113883.4.6"/>
							<code code="207Q00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Health Care Provider Taxonomy" displayName="Allopathic &amp; Osteopathic Physicians; Family Medicine" />
							<telecom use="WP" value="tel:555-555-1002"/>
							<assignedPerson>
								<name>
									<given>Henry</given>
									<family>Seven</family>
								</name>
							</assignedPerson>
						</assignedAuthor>
					</author>
					<participant typeCode="CSM">
						<participantRole classCode="MANU">
							<playingEntity classCode="MMAT">
								<!-- SNOMED or UNII may be used for allergies in both C-CDA 1.1 and 2.0 -->
								<!-- SNOMED was added to C-CDA 1.1 by DSTU  381 and illustrated below -->
								<!-- Note that the SNOMED code for 'latex allergy' is not appropriate since the allergy is conveyed elsewhere in the observation -->
								<code code="111088007" displayName="Latex" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
									<originalText>
										<reference value="#allergy4allergen"/>
									</originalText>
								</code>
							</playingEntity>
						</participantRole>
					</participant>
					<entryRelationship typeCode="MFST" inversionInd="true">
						<observation classCode="OBS" moodCode="EVN">
							<!-- Reaction Observation template -->
							<templateId root="2.16.840.1.113883.10.20.22.4.9"/>
							<templateId root="2.16.840.1.113883.10.20.22.4.9" extension="2014-06-09"/>
							<id root="0506c036-adfb-4e6e-b9e1-eea76177ead5"/>
							<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
							<text>
								<reference value="#allergy4reaction"/>
							</text>
							<statusCode code="completed"/>
							<effectiveTime>
								<low value="20140103"/>
							</effectiveTime>
							<value xsi:type="CD" code="39579001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Anaphylaxis"/>
                        	<!-- The Severity observation is no longer recommended, use criticality observation in future exchanges -->							
                            <entryRelationship typeCode="SUBJ" inversionInd="true">
								<observation classCode="OBS" moodCode="EVN">
									<!-- Severity Observation template -->
									<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
									<templateId root="2.16.840.1.113883.10.20.22.4.8" extension="2014-06-09"/>
									<code code="SEV" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
									<text>
										<reference value="#allergy4reactionseverity"/>
									</text>
									<statusCode code="completed"/>
									<value xsi:type="CD" code="24484000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Severe"/>
								</observation>
							</entryRelationship>
						</observation>
					</entryRelationship>
				</observation>
			</entryRelationship>
		</act>
	</entry>
</section>

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