Entry Reference_2.16.840.1.113883.10.20.22.4.122

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SDWG Supported Sample from Implementation Guide

The initial load of this repository in January 2021 includes all examples (figures) from the June 2019 Errata published PDF of C-CDA 2.1 and 2019 release of C-CDA Companion Guide.

These examples were reviewed through the HL7 ballot process. They have not been formally reviewed/approved by the examples task force.

Keywords:

Entry Reference

2.16.840.1.113883.10.20.22.4.122

 

Example: Entry Reference Example.xml download example view on GitHub

<!-- 
  ********************************************************
  Health Concern section
  ********************************************************
-->
<act classCode="ACT" moodCode="EVN">
  <!-- Health Concern Act of a pneumonia diagnosis -->
  <templateId root="2.16.840.1.113883.10.20.22.4.132" />
  <id root="4eab0e52-dd7d-4285-99eb-72d32ddb195c" />
  <code code="75310-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Health Concern" />
  <statusCode code="active" />
  <effectiveTime value="20130616" />
  <entryRelationship typeCode="REFR">
    <!-- Problem Observation (V2) -->
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2014-06-09" />
      <id root="8dfacd73-1682-4cc4-9351-e54ccea83612" />
      <code code="29308-4" 
            codeSystem="2.16.840.1.113883.6.1" 
            codeSystemName="LOINC" 
            displayName="Diagnosis"/>
      <statusCode code="completed" />
      <effectiveTime>
        <!-- Date of diagnosis -->
        <low value="20130616" />
      </effectiveTime>
      <value xsi:type="CD" code="233604007" 
            codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED" 
            displayName="Pneumonia" />
      <!-- This Entry Reference refers to a goal, intervention, actual 
         outcome, or some other entry present in the Care Plan
         that the Health Concern is related to-->
      <entryRelationship typeCode="REFR">
        <act classCode="ACT" moodCode="EVN">
          <templateId root="2.16.840.1.113883.10.20.22.4.122" />
          <!-- This ID equals the ID of the goal of a pulse 
                        ox greater than 92% -->
          <id root="3700b3b0-fbed-11e2-b778-0800200c9a66" />
          <!-- The code is nulled to "NP" Not Present" -->
          <code nullFlavor="NP" />
          <statusCode code="completed" />
        </act>
      </entryRelationship>
    </observation>
  </entryRelationship>
</act>

...


<!-- 
  ********************************************************
  Expected Outcomes/Goals section
  ********************************************************
-->

...


<entry>
  <!-- This is an observation about the expected outcome of a pulse ox reading
       of 92 or greater.  The Id is the same as the ID as the ID of the 
       pneumonia problem above  -->
  <observation classCode="OBS" moodCode="GOL">
    <id root="3700b3b0-fbed-11e2-b778-0800200c9a66" />
    <code code="59408-5" 
          codeSystem="2.16.840.1.113883.6.1" 
          codeSystemName="LOINC" 
          displayName="Oxygen saturation in Arterial blood by Pulse oximetry"/>
    <statusCode code="active" />
    <value xsi:type="IVL_PQ">
      <low value="92" unit="%" />
    </value>
    <!-- There could be another Entry Reference here referring to the 
            related health concern, actual outcome, or intervention -->
    ...
    
  
  </observation>
</entry>
...

Example: Diagnosis Reference Example.xml download example view on GitHub

<!-- Show how an encounter can include a discharge diagnosis which references an 
       item on the problem list using the Entry Reference template -->
<!-- Problem Section -->
<observation>
  <id root="1234567" />
  <code code="123" codeSystem="1.2.3" displayName="asthma" />
</observation>
<!-- Encounter Section -->
<encounter>
  <entryRelationship typeCode="COMP">
    <act>
      <code code="145" codeSystem="4.5.6" displayName="discharge diagnosis" />
      <templateId root="2.16.840.1.113883.10.20.22.4.33" extension="2014-06-09" />
      <!-- this is for illustrative purposes only. In this particular 
                  case, the template requires a nested Problem 
                  Observation (V2). In the Health Concern template, 
                  we'd need a constraint that says it's allowable to 
                  include the Entry Reference template. -->
      <entryRelationship typeCode="SUBJ">
        <act classCode="ACT" moodCode="XXX">
          <templateId root="2.16.840.1.113883.10.20.22.4.122" />
          <id root="1234567" />
          <code nullFlavor="NP" />
        </act>
      </entryRelationship>
    </act>
  </entryRelationship>
</encounter>
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