Problem TargetSiteCode Qualifier

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Example metadata last updated 2017-08-06 10:15:50.539000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 2/2/2017
  • SDWG: 5/18/2017

SITE C-CDA Validator

Certification

Comments:

  • This is an example of adding a SNOMED qualifier to an ambiguous ICD-9 which could be used in qualifying patients related to QRDA/eCQM measure

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

Full sample: Problems in empty CCD

Example: download example view on GitHub

<!-- An example of how to use a qualifier. This example shows presence of a problem/value/translation, although it could also be used to refine the problem/value -->
<!-- The use of qualifiers could also be used on other sections, such as qualifying a procedure -->
<section>
    <templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
    <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" displayName="Problem List"/>
    <title>Problem List</title>
    <text>
        <table>
            <thead>
                <tr>
                    <th>Name</th>
                    <th>Dates</th>
                    <th>Location/Qualifier</th>
                    <th>Status</th>
                </tr>
            </thead>
            <tbody>
                <tr ID="Problem1">
                    <td ID="ProblemDescription1">Below Knee Amputation</td>
                    <td>
                        <content>Onset: Apr 2 2014</content>
                    </td>
                    <td>Left</td>
                    <td>Active</td>
                </tr>
            </tbody>
        </table>
    </text>
    <entry>
        <act classCode="ACT" moodCode="EVN">
            <templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01"/>
            <id root="e5fbc288-659f-4aeb-a5e1-eb7cc8fcdfaf" />
            <code code="CONC" codeSystem="2.16.840.1.113883.5.6" />
            <!-- While clinicians can track resolved problems, generally active problems will have active concern status and resolved concerns will be completed -->
            <statusCode code="active" />
            <effectiveTime>
                <!-- This represents the time that the clinician began tracking the concern. This may frequently be an EHR timestamp-->
                <low value="20140403124536-0500" />
            </effectiveTime>
            <entryRelationship typeCode="SUBJ">
                <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
                    <id root="ac416033-3cc1-4485-ab31-36ce7669f55c" />
                    <code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="55607006" displayName="Problem" >
                        <translation code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem"/>
                    </code>
                    <text>
                        <reference value="#Problem1" />
                    </text>
                    <statusCode code="completed" />
                    <effectiveTime>
                        <!-- This represents the date of biological onset. This can be before the patient vistited the clinician, as illustrated in this example-->
                        <low value="20140402" />
                    </effectiveTime>
                    <!-- This is a SNOMED code as the primary vocabulary for problem lists. It would be preferable to have a SNOMED code but no direct translation is available here. -->
                    <value xsi:type="CD" nullFlavor="OTH">
                        <originalText>
                            <reference value="#ProblemDescription1" />
                        </originalText>
                        <translation xsi:type="CD" code="V49.75" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD-9" displayName="Below Knee Amputation Status" />
                    </value>
                    <!-- Recommendation of task force that laterality on problems should be in targetSiteCode rather than on the value or value/translation elements -->
                    <targetSiteCode xsi:type="CD" code="30021000" codeSystem="2.16.840.1.113883.6.96" displayName="Lower leg structure">
                        <!-- This is an example of a qualifer which would affect a quality measure (e.g. cms 123 Diabetes Foot Exam) -->
                        <qualifier>
                            <name code="272741003" codeSystem="2.16.840.1.113883.6.96" displayName="Laterality" />
                            <value code="7771000" codeSystem="2.16.840.1.113883.6.96" displayName="Left"/>
                        </qualifier>
                    </targetSiteCode>
                </observation>
            </entryRelationship>
        </act>
    </entry>
</section>
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