No Known Allergies

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Example metadata last updated 2017-08-06 10:15:50.695000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 1/9/2014
  • SDWG: 1/16/2014
  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

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Comments:

  • This is an example of how an author can record a patient has no known allergies.

Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)

Full sample: Allergies in empty CCD

Example: download example view on GitHub

<section>
    <!-- *** Allergies and Intolerances Section (entries required) (V3) *** -->
    <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"/>
    <code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
    <title>ALLERGIES AND ADVERSE REACTIONS</title>
    <text>No Known Allergies</text>
    <entry typeCode="DRIV">
        <!-- Allergy Concern Act -->
        <act classCode="ACT" moodCode="EVN">
            <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="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
            <!-- SDWG supports 48765-2 or CONC in the code element -->
            <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
            <statusCode code="active"/>
            <!--currently tracked concerns are active concerns-->
            <effectiveTime>
                <low value="20100103"/>
                <!--show time when the concern first began being tracked-->
            </effectiveTime>
            <author>
                <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
                <time value="20100103"/>
                <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="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">
                <!-- No Known Allergies -->
                <!-- The negationInd = true negates the observation/value -->
                <!-- The use of negationInd corresponds with the newer Observation.valueNegationInd -->
                <observation classCode="OBS" moodCode="EVN" negationInd="true">
                    <!-- allergy - intolerance 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="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
                    <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
                    <statusCode code="completed"/>
                    <!-- N/A - author/time records when this assertion was made -->
                    <effectiveTime>
                        <low nullFlavor="NA"/>
                    </effectiveTime>
                    <value xsi:type="CD" code="419199007"
                        displayName="Allergy 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="20100103"/>
                        <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="Family Medicine"/>
                            <telecom use="WP" value="tel:555-555-1002"/>
                            <assignedPerson>
                                <name>
                                    <given>Henry</given>
                                    <family>Seven</family>
                                </name>
                            </assignedPerson>
                        </assignedAuthor>
                    </author>
                    <!-- In C-CDA R2.1 the participant is required. -->
                    <participant typeCode="CSM">
                        <participantRole classCode="MANU">
                            <playingEntity classCode="MMAT">
                                <code nullFlavor="NA"/>
                            </playingEntity>
                        </participantRole>
                    </participant>
                </observation>
            </entryRelationship>
        </act>
    </entry>
</section>
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