Family History two individuals same relationship to the patient

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Example metadata last updated 2017-08-06 10:15:50.434000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 2/12/2015
  • SDWG: 2/12/2015
  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

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Certification

Comments:

  • Example shows two brothers with multiple conditions. Though they have the same relationship to the patient, they can be identified by their separation into two family history organizers as well as by their subject ID's.

Custodian: Benjamin Flessner, benjamin@epic.com (GitHub: benjaminflessner)

Full sample: Family history in empty CCD

Example: download example view on GitHub

<section>
	<!-- C-CDAR2 Example Family History Section for two siblings -->
	<templateId root="2.16.840.1.113883.10.20.22.2.15"/>
	<templateId root="2.16.840.1.113883.10.20.22.2.15" extension="2015-08-01"/>
	<code code="10157-6" codeSystem="2.16.840.1.113883.6.1" displayName="Family History"/>
	<title>Family History</title>
	<text>
		<paragraph>James, <content ID="FamHist1rel">brother</content>, born 1982</paragraph>
		<list>
			<item ID="FamHist1prob1">High blood pressure</item>
			<item ID="FamHist1prob2">Diabetes</item>
		</list>
		<paragraph>Gerald, <content ID="FamHist2rel">brother</content>, born 1985</paragraph>
		<list>
			<item ID="FamHist2prob1">Asthma</item>
		</list>
	</text>
	<!-- James' history -->
	<entry> 
		<organizer classCode="CLUSTER" moodCode="EVN">
			<templateId root="2.16.840.1.113883.10.20.22.4.45"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.45" extension="2015-08-01"/>
			<!-- Unique identifier for this family member's HISTORY (not the individual) -->
			<id root="01faa204-0000-4610-864f-cb50b650d0fa" />
			<statusCode code="completed"/>
			<subject>
				<relatedSubject classCode="PRS">
					<!-- Identifies relationship; though there are two brothers, the separation into 
					     two different organizers with their own subject identifies these as two 
					     distinct individuals. The subject/@sdtc:id can also futher identify the individuals.-->
					<code code="BRO" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 RoleCode" displayName="Brother">
						<originalText>
							<reference value="#FamHist1rel"/>
						</originalText>
					</code>
					<subject>
						<!-- Unique ID for the brother as an individual -->
						<sdtc:id extension="98765432-1" root="1.3.6.1.4.1.16517.1" xmlns:sdtc="urn:hl7-org:sdtc" />
						<name>James</name>
						<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
						<birthTime value="1982" />
					</subject>
				</relatedSubject>
			</subject>
			<!-- High Blood Pressure observation -->
			<component>
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.46"/>
					<templateId root="2.16.840.1.113883.10.20.22.4.46" extension="2015-08-01"/>
					<!-- Unique ID for this individual observation -->
					<id root="02faa204-0000-4610-864f-cb50b650d0fa" />
					<code code="64572001" codeSystem="2.16.840.1.113883.6.96" displayName="Condition" >
						<translation code="75315-2" codeSystem="2.16.840.1.113883.6.1" displayName="Condition Family Member" />
					</code>
					<statusCode code="completed"/>
					<!-- Since we do not know when the brother was diagnosed with High Blood pressure, the effective time is UNKown -->
					<effectiveTime nullFlavor="UNK" />
					<!-- SNOMED code for High Blood Pressure -->
					<value xsi:type="CD" code="59621000" codeSystem="2.16.840.1.113883.6.96" displayName="Essential Hypertension">
						<originalText>
							<reference value="#FamHist1prob1"/>
						</originalText>
					</value>
				</observation>
			</component>
			<!-- Diabetes observation -->
			<component>
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.46"/>
					<templateId root="2.16.840.1.113883.10.20.22.4.46" extension="2015-08-01"/>
					<!-- Unique ID for this individual observation -->
					<id root="03faa204-0000-4610-864f-cb50b650d0fa" />
					<code code="64572001" codeSystem="2.16.840.1.113883.6.96" displayName="Condition" >
						<translation code="75315-2" codeSystem="2.16.840.1.113883.6.1" displayName="Condition Family Member" />
					</code>
					<statusCode code="completed"/>
					<!-- Since we do not know when the brother was diagnosed with Diabetes, the effective time is UNKown -->
					<effectiveTime nullFlavor="UNK" />
					<!-- SNOMED code for Diabetes -->
					<value xsi:type="CD" code="73211009" codeSystem="2.16.840.1.113883.6.96" displayName="Diabetes Mellitus">
						<originalText>
							<reference value="#FamHist1prob2"/>
						</originalText>
					</value>
				</observation>
			</component>
		</organizer>
	</entry>
	<!-- Gerald's History-->
	<entry>
		<organizer classCode="CLUSTER" moodCode="EVN">
			<templateId root="2.16.840.1.113883.10.20.22.4.45"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.45" extension="2015-08-01"/>
			<!-- Unique identifier for this family member's HISTORY (not the individual) -->
			<id root="01faa204-1111-4610-864f-cb50b650d0fa" />
			<statusCode code="completed"/>
			<subject>
				<relatedSubject classCode="PRS">
					<!-- Identifies relationship; though there are two brothers, the separation into 
						two different organizers with their own subject identifies these as two 
						distinct individuals. The subject/@sdtc:id can also futher identify the individuals.-->
					<code code="BRO" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 RoleCode" displayName="Brother">
						<originalText>
							<reference value="#FamHist2rel"/>
						</originalText>
					</code>
					<subject>
						<!-- Unique ID for the brother as an individual; note the extension is different from James's id -->
						<sdtc:id extension="98765432-2" root="1.3.6.1.4.1.16517.1" xmlns:sdtc="urn:hl7-org:sdtc" />
						<name>Gerald</name>
						<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" />
						<birthTime value="1985" />
					</subject>
				</relatedSubject>
			</subject>
			<!-- Asthma observation -->
			<component>
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.46"/>
					<templateId root="2.16.840.1.113883.10.20.22.4.46" extension="2015-08-01"/>
					<!-- Unique ID for this individual observation -->
					<id root="03faa204-1111-4610-864f-cb50b650d0fa" />
					<code code="64572001" codeSystem="2.16.840.1.113883.6.96" displayName="Condition" >
						<translation code="75315-2" codeSystem="2.16.840.1.113883.6.1" displayName="Condition Family Member" />
					</code>
					<statusCode code="completed"/>
					<!-- Since we do not know when the brother was diagnosed with asthma, the effective time is UNKown -->
					<effectiveTime nullFlavor="UNK" />
					<!-- SNOMED code for Asthma -->
					<value xsi:type="CD" code="195967001" codeSystem="2.16.840.1.113883.6.96" displayName="Asthma (disorder)">
						<originalText>
							<reference value="#FamHist2prob1"/>
						</originalText>
					</value>
				</observation>
			</component>
		</organizer>
	</entry>
</section>
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