Allergy to specific drug Codeine

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Example metadata last updated 2017-12-11 19:21:14.814000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 4/17/2014
  • SDWG: 4/16/2015
  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

SITE C-CDA Validator

Comments:

  • This is an example of a propensity to drug adverse event with information on multiple allergic reactions each with reaction severity. It was based upon discussion with Rob Hausam and John D'Amore and Russ Leftwich in coordination with Patient Care Committee. This sample replaces the Epinephrine sample which had less clinical accuracy/relevance. See DSTU 219 for update regarding act/code.

Custodian: Lisa R. Nelson LisaRNelson@cox.net (GitHub: lisarnelson)

Full sample: Allergies in empty CCD

Example: download example view on GitHub

<!-- Allergies Section -->
<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>
		<list>
			<item ID="AllergyIntoleranceObservation_1.1">
				<table>
					<thead>
						<tr>
							<th ID="AllergyIntolerance_1.1Label">Allergy or Intolerance</th>
							<th ID="AllergyIntolerance_1.1Data">Data</th>
						</tr>
					</thead>
					<tbody>
						<tr>
							<th ID="AllergyType_1.1L">Type:</th>
							<td ID="AllergyType_1.1D">Drug intolerance (disorder)</td>
						</tr>
						<tr>
							<th ID="AllergyAgent_1.1L">Agent:</th>
							<td ID="AllergyAgent_1.1D">Codeine</td>
						</tr>
						<tr>
							<th>Allergy Start Date:</th>
							<td>03/15/2010</td>
						</tr>
						<tr>
							<th>Allergy End Date:</th>
							<td/>
						</tr>
						<tr>
							<th ID="Reactions_1.1Label">Reactions:</th>
							<td>
								<list>
									<item>
										<table>
											<thead>
												<tr>
												<th>Start Date</th>
												<th>End Date</th>
												<th ID="REACT_1.1.0L">Reaction</th>
												<th ID="SEV_1.1.0L">Severity</th>
												</tr>
											</thead>
											<tbody>
												<tr>
												<td>01/29/2012</td>
												<td>01/29/2012</td>
												<td ID="REACT_1.1.1D">Nausea</td>
												<td ID="SEV_1.1.1D">Severe</td>
												</tr>
												<tr>
												<td>03/15/2010</td>
												<td>03/15/2010</td>
												<td ID="REACT_1.1.2D">Nausea</td>
												<td ID="SEV_1.1.2D">Mild</td>
												</tr>
											</tbody>
										</table>
									</item>
								</list>
							</td>
						</tr>
					</tbody>
				</table>
			</item>
		</list>
	</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="4a2ac5fc-0c85-4223-baee-c2e254803974"/>
			<code code="CONC" codeSystem="2.16.840.1.113883.5.6"
				displayName="Allergies, adverse reactions, alerts" codeSystemName="LOINC">
				<originalText>
					<reference value="#AllergyIntoleranceObservation_1.1"/>
				</originalText>
			</code>
			<text>
				<reference value="#AllergyIntoleranceObservation_1.1"/>
			</text>
			<statusCode code="active"/>
			<!-- This is the time stamp for when the allergy was first documented as a concern-->
			<effectiveTime>
				<low value="20140103"/>
				<!--show time when this author's concern about the allergy became active. -->
				<high nullFlavor="NA"/>
			</effectiveTime>

			<author>
				<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
				<time value="20140103102500-0500"/>
				<assignedAuthor>
					<id extension="99999999" root="2.16.840.1.113883.4.6"/>
					<!-- Root means NPI number. -->
					<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="4a2ac5fc-0c85-4223-baee-c2e254803974"/>
					<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
					<statusCode code="completed"/>
					<effectiveTime>
						<low value="20100315"/>
					</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. -->
					<value xsi:type="CD" code="59037007" displayName="Drug intolerance (disorder)"
						codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
						<originalText>
							<reference value="#AllergyType_1.1D"/>
						</originalText>
					</value>
			<author>
				<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
				<time value="20140103102500-0500"/>
				<assignedAuthor>
					<id extension="99999999" root="2.16.840.1.113883.4.6"/>
					<!-- Root means NPI number. -->
					<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>
					<informant>
						<assignedEntity>
							<!-- This is a fictional OID and identifier for the patient. This should be adapted to local implementation -->
							<id root="2.16.840.1.113883.3.3208.101.2"
								extension="20130607100800-Patient1"/>
							<addr use="HP">
								<streetAddressLine>1111 StreetName St.</streetAddressLine>
								<city>Silver Spring</city>
								<state>MD</state>
								<postalCode>20901</postalCode>
								<country>US</country>
							</addr>
							<telecom value="tel:+1(301)111-1111" use="HP"/>
							<assignedPerson>
								<name>
									<given>Patient</given>
									<family>One</family>
								</name>
							</assignedPerson>
						</assignedEntity>
					</informant>
					<participant typeCode="CSM">
						<participantRole classCode="MANU">
							<playingEntity classCode="MMAT">
								<code code="2670" displayName="Codeine"
									codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
									<originalText>
										<reference value="#AllergyAgent_1.1D"/>
									</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="0506c036-adfb-4e6e-b9e1-eea76177ead5"/>
							<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
							<statusCode code="completed"/>
							<effectiveTime>
								<low value="20120129"/>
								<!-- Not sure about the effectiveTime for reaction -->
								<high value="20120129"/>
							</effectiveTime>
							<value xsi:type="CD" code="422587007"
								codeSystem="2.16.840.1.113883.6.96" displayName="Nausea">
								<originalText>
									<reference value="#REACT_1.1.1D"/>
								</originalText>
							</value>
							<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"/>
									<statusCode code="completed"/>
									<value xsi:type="CD" code="24484000" displayName="Severe"
										codeSystem="2.16.840.1.113883.6.96"
										codeSystemName="SNOMED CT">
										<originalText>
											<reference value="#SEV_1.1.1D"/>
										</originalText>
									</value>
								</observation>
							</entryRelationship>
						</observation>
					</entryRelationship>
				</observation>
			</entryRelationship>
			<!-- Note that multiple reactions may be recorded to the same substance ([0..*] -->
			<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="fea0b775-f3fe-4e0a-9c4f-4a5c235c2af0"/>
					<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>

					<statusCode code="completed"/>
					<effectiveTime>
						<low value="20100315"/>
						<!-- Not sure about the effectiveTime for reaction -->
						<high value="20100315"/>
					</effectiveTime>
					<value xsi:type="CD" code="422587007" codeSystem="2.16.840.1.113883.6.96"
						displayName="Nausea">
						<originalText>
							<reference value="#REACT_1.1.2D"/>
						</originalText>
					</value>
					<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"/>
							<statusCode code="completed"/>
							<value xsi:type="CD" code="255604002" displayName="Mild"
								codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
								<originalText>
									<reference value="#SEV_1.1.2D"/>
								</originalText>
							</value>
						</observation>
					</entryRelationship>
				</observation>
			</entryRelationship>
		</act>
	</entry>
</section>
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