Current Smoking Status

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Example metadata last updated 2017-12-11 19:21:12.731000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 6/26/2014
  • SDWG: 7/3/2014
  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

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Comments:

  • This is an example of current smoking status. This example also includes a coordinating social history observation to convey the amount of smoking using a SNOMED code. This SNOMED code in the accompanying observation is not acceptable since smoking status, which is constrained by HL7 and Meaningful Use value set requirements. Each social history section shall only include a single smoking status.

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

Full sample: Social history in empty CCD

Example: download example view on GitHub

<section>
	<templateId root="2.16.840.1.113883.10.20.22.2.17"/>
	<templateId root="2.16.840.1.113883.10.20.22.2.17" extension="2015-08-01"/>
	<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social History"/>
	<title>Social History</title>
	<text>
		<list>
			<caption>Smoking Status</caption>
			<item>
				<content>Status: Current every day smoker</content>
				<content ID="SmokingDetail1">Detail: Moderate smoker (10-19 cigs/day)</content>
				<content>Started: 1992</content>
				<content>Stopped:</content>
				<content>Recorded June 6, 2014 10:32am</content>
			</item>
		</list>
	</text>
	<!-- Only include one smoking status per patient. -->
	<entry>
		<observation classCode="OBS" moodCode="EVN">
			<templateId root="2.16.840.1.113883.10.20.22.4.78"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.78"  extension="2014-06-09"/>
			<id extension="123456789" root="2.16.840.1.113883.19" />
			<code code="72166-2" codeSystem="2.16.840.1.113883.6.1" displayName="Tobacco smoking status NHIS"/>
			<statusCode code="completed"/>
			<effectiveTime value="201406061032+0500"/>
			<!--Note: This template represents a “snapshot in time” observation, simply reflecting what the patient’s 
					current smoking status is at the time of the observation. As a result, the effectiveTime is constrained 
					to just a time stamp, and will approximately correspond with the author/time. -->			
			<value xsi:type="CD" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="449868002" displayName="Current every day smoker"/>
			<author>
				<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
				<time value="201406061032+0500"/>
				<assignedAuthor>
					<id root="2.16.840.1.113883.4.6" extension="99999999"/>
					<!-- Root means NPI number. -->
					<code code="200000000X" codeSystem="2.16.840.1.113883.6.101"
						displayName="Allopathic and Osteopathic Physicians"/>
					<telecom use="WP" value="tel:+1(555)555-1002"/>
					<assignedPerson>
						<name>
							<given>Henry</given>
							<family>Seven</family>
						</name>
					</assignedPerson>
				</assignedAuthor>
			</author>
		</observation>
	</entry>
	<!--- You can use a social history observation template entry for additional smoking detail, such as smoking quantity-->
	<entry>
		<observation classCode="OBS" moodCode="EVN">
			<!-- ** Tobacco use ** -->
            <templateId root="2.16.840.1.113883.10.20.22.4.85"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.85" extension="2014-06-09" />
			<id root="45efb604-7049-4a2e-ad33-d38556c9636c" />
			<code code="11367-0" codeSystem="2.16.840.1.113883.6.1" displayName="History of tobacco use" />
			<statusCode code="completed" />
			<effectiveTime>
				<!-- To record a current smoker, the effectiveTime/low will define the time the patient started 
					smoking and will have no effectiveTime/high to indicated that the patient is still smoking. -->
				<low value="1992" />
			</effectiveTime>
			<value xsi:type="CD" code="160604004" displayName="Moderate cigarette smoker, 10-19/day" codeSystem="2.16.840.1.113883.6.96" />
			<author>
				<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
				<time value="201406061032+0500"/>
				<assignedAuthor>
					<id root="2.16.840.1.113883.4.6" extension="99999999"/>
					<!-- Root means NPI number. -->
					<code code="200000000X" codeSystem="2.16.840.1.113883.6.101"
						displayName="Allopathic and Osteopathic Physicians"/>
					<telecom use="WP" value="tel:+1(555)555-1002"/>
					<assignedPerson>
						<name>
							<given>Henry</given>
							<family>Seven</family>
						</name>
					</assignedPerson>
				</assignedAuthor>
			</author>
		</observation>
	</entry>
</section>
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