No Known Problems

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Example metadata last updated 2017-12-11 19:21:12.238000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 2/27/2015
  • SDWG: 3/6/2015
  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

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Comments:

  • This is an example of no known problems.

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

Full sample: Problems in empty CCD

Example: download example view on GitHub

<section>
    <templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
    <!-- Problem Section with Coded Entries Required -->
    <templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
    <!-- Problem Section with Coded Entries Required -->
    <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
        displayName="Problem List"/>
    <title>PROBLEMS</title>
    <text ID="Concern_1"> Problem Concern:<br/> Concern Tracker Start Date: 06/07/2013 16:05:06<br/>
        Concern Tracker End Date: <br/> Concern Status: Active<br/>
        <content ID="problems1">No known <content ID="problemType1">problems.</content></content>
    </text>
    <entry typeCode="DRIV">
        <!-- Problem Concern Act -->
        <act classCode="ACT" moodCode="EVN">
            <templateId root="2.16.840.1.113883.10.20.22.4.3"/>
            <templateId root="2.16.840.1.113883.10.20.22.4.3" 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"/>
            <text>
                <reference value="#Concern_1"/>
            </text>
            <statusCode code="active"/>
            <!-- So long as the underlying condition is of concern to the provider (i.e., as long as the condition, 
                    whether active or resolved, is of ongoing concern and interest to the provider), the statusCode is “active”. 
                    Only when the underlying condition is no longer of concern is the statusCode set to “completed”. -->
            <effectiveTime>
                <low value="20130607160506"/>
                <!-- The effectiveTime reflects the time that the underlying condition was felt to be a concern; 
                        it may or may not correspond to the effectiveTime of the condition (e.g., even five years later, the clinician may remain concerned about a prior heart attack).-->
            </effectiveTime>
            <!-- status is active so high is not applicable. If high is present it should have nullFlavor of NA-->

            <author>
                <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
                <time value="20130607160506"/>
                <assignedAuthor>
                    <id extension="66666" root="2.16.840.1.113883.4.6"/>
                    <code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101"
                        codeSystemName="NUCC" displayName="Cardiovascular Disease"/>
                    <addr>
                        <streetAddressLine>6666 StreetName St.</streetAddressLine>
                        <city>Silver Spring</city>
                        <state>MD</state>
                        <postalCode>20901</postalCode>
                        <country>US</country>
                    </addr>
                    <telecom value="tel:+1(301)666-6666" use="WP"/>
                    <assignedPerson>
                        <name>
                            <given>Heartly</given>
                            <family>Sixer</family>
                            <suffix>MD</suffix>
                        </name>
                    </assignedPerson>
                </assignedAuthor>
            </author>
            <entryRelationship typeCode="SUBJ">
                <observation classCode="OBS" moodCode="EVN" negationInd="true">
                    <!-- The negationInd is used to indicate the absence of the condition in observation/value (Observation.ValueNegationInd). 
                            A negationInd of "true" coupled with an observation/value of SNOMED code 55607006 "Problem" 
                            indicates that the patient has no known conditions. -->
                    <!-- problem observation template -->
                    <templateId root="2.16.840.1.113883.10.20.22.4.4"/>
                    <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
                    <id root="4adc1021-7b14-11db-9fe1-0800200c9a67"/>
                    <code code="64572001" displayName="Disease" codeSystem="2.16.840.1.113883.6.96"
                        codeSystemName="SNOMED CT">
                        <translation code="75323-6" codeSystem="2.16.840.1.113883.6.1"
                            codeSystemName="LOINC" displayName="Condition"/>
                    </code>
                    <text>
                        <reference value="#problems1"/>
                    </text>
                    <statusCode code="completed"/>
                    <effectiveTime>
                        <low value="20130607160506"/>
                    </effectiveTime>
                    <!-- The time when this was biologically relevant ie True for the patient. -->
                    <!-- As a minimum time interval over which this is true, populate the effectiveTime/low with the current time. -->
                    <!-- It would be equally valid to have a longer range of time over which this statement was represented as being true. -->
                    <!-- As a maximum, you would never indicate an effectiveTime/high that was greater than the current point in time. -->

                    <!-- This idea assumes that the value element could come from the Problem value set, or-->
                    <!-- when negationInd was true, is could also come from the ProblemType value set (and code would be ASSERTION). -->
                    <value xsi:type="CD" code="55607006" displayName="Problem"
                        codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
                        <originalText>
                            <reference value="#problemType1"/>
                        </originalText>
                    </value>
                </observation>
            </entryRelationship>
        </act>
    </entry>
</section>
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