Allergy to food egg

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Example metadata last updated 2017-08-06 10:15:50.683000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 4/17/2014
  • Example Task Force (2nd review): 3/12/2015
  • SDWG: 3/19/2015
  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

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Certification

Comments:

  • This is an example of a food allergy with information on both allergic reaction and reaction severity. It was based upon discussion with Russ Leftwich and Lisa Nelson in coordination with Patient Care Committee. See DSTU 219 for update regarding act/code.

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

Full sample: Allergies in empty CCD

Example: download example view on GitHub

<section>
	<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"/>
	<!-- Allergies (entries required) section template -->
	<code code="48765-2" codeSystem="2.16.840.1.113883.6.1"/>
	<title>Allergies, Adverse Reactions and Alerts</title>
	<text>
		<table>
			<thead>
				<tr>
					<th>Allergen</th>
					<th>Reaction</th>
					<th>Reaction Severity</th>
					<th>Documentation Date</th>
					<th>Start Date</th>
				</tr>
			</thead>
			<tbody>
				<tr ID="allergy5">
					<td ID="allergy5allergen">Egg</td>
					<td ID="allergy5reaction">Hives</td>
					<td ID="allergy5reactionseverity">Moderate</td>
					<td>Jan 4 2014</td>
					<td>1998</td>
				</tr>
			</tbody>
		</table>
	</text>
	<entry typeCode="DRIV">
		<act classCode="ACT" moodCode="EVN">
			<!-- ** Allergy problem act ** -->
			<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="0fffb34f-c1e0-47c2-92af-c414a3ff21ec"/>
			<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
			<statusCode code="active"/>
			<!-- This is the time stamp for when the allergy was first documented as a concern-->
			<effectiveTime>
				<low value="20140104123506-0500"/>
			</effectiveTime>
			<author>
				<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
				<time value="20140104"/>
				<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">
				<observation classCode="OBS" moodCode="EVN">
					<!-- allergy 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="0fffb34f-c1e0-47c2-92af-c414a3ff21ec"/>
					<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
					<statusCode code="completed"/>
					<!-- This is the time stamp for the biological onset of the allergy. -->
					<!-- Just the year is shown since a specific month and date was not reported -->
					<effectiveTime>
						<low value="1998"/>
					</effectiveTime>
					<!-- This specifies that the allergy is to a food in contrast to other allergies (drug) -->
					<value xsi:type="CD" code="414285001" displayName="Food allergy (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"></value>
					<author>
						<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
						<time value="20140104"/>
						<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">
								<!-- The agent responsible for an allergy or adverse reaction is not always a manufactured material (for example, food allergies), 
													nor is it necessarily consumed. The following constraints reflect limitations in the base CDA R2 specification, 
													and should be used to represent any type of responsible agent, i.e., use playingEntity classCode = "MMAT" for all agents, 
													manufactured or not. -->
								<!-- 
													... the expectation for use is that the chosen concept identifier for a substance should be appropriately specific and 
													drawn from the available code systems in the following priority order: NDFRT, then RXNORM, then UNII, then SNOMED CT. 
													This overarching grouping value set is intended to support identification of drug classes, individual medication 
													ingredients, foods, general substances and environmental entities. Value set intensionally defined as a GROUPING made 
													up of: Value Set: Medication Drug Class (2.16.840.1.113883.3.88.12.80.18) (NDFRT drug class codes); 
													Value Set: Clinical Drug Ingredient (2.16.840.1.113762.1.4.1010.7) (RxNORM ingredient codes); 
													Value Set: Unique Ingredient Identifier - Complete Set (2.16.840.1.113883.3.88.12.80.20) (UNII ingredient codes); 
													Value Set: Substance Other Than Clinical Drug (2.16.840.1.113762.1.4.1010.9) (SNOMED CT substance codes).
												
												-->
								<code code="102263004" displayName="Eggs (edible)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
									<originalText>
										<reference value="#allergy5allergen"/>
									</originalText>
								</code>
							</playingEntity>
						</participantRole>
					</participant>
					<entryRelationship typeCode="MFST" inversionInd="true">
						<observation classCode="OBS" moodCode="EVN">
							<!-- Reaction Observation template -->
							<templateId root="2.16.840.1.113883.10.20.22.4.9"/>
							<templateId root="2.16.840.1.113883.10.20.22.4.9" extension="2014-06-09"/>
							<id root="d89ce431-e0f1-4f8d-a81f-489b6ed91f09"/>
							<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
							<text>
								<reference value="#allergy5reaction"/>
							</text>
							<statusCode code="completed"/>
							<effectiveTime>
								<low value="1998"/>
								<high nullFlavor="NA"/>
							</effectiveTime>
							<value xsi:type="CD" code="247472004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hives"/>
							<entryRelationship typeCode="SUBJ" inversionInd="true">
								<observation classCode="OBS" moodCode="EVN">
									<!-- Severity Observation template -->
									<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
									<templateId root="2.16.840.1.113883.10.20.22.4.8"
 extension="2014-06-09"/>
									<code code="SEV" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
									<text>
										<reference value="#allergy5reactionseverity"/>
									</text>
									<statusCode code="completed"/>
									<value xsi:type="CD" code="6736007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="moderate"/>
								</observation>
							</entryRelationship>
						</observation>
					</entryRelationship>
				</observation>
			</entryRelationship>
		</act>
	</entry>
</section>
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