Patient Does Not Have Diabetes

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Example metadata last updated 2017-08-06 10:15:50.550000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 11/5/2015
  • SDWG: 11/12/2015
  • SDWG C-CDA R2.1 Upgrade: 2/2/2017

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Certification

Comments:

  • This is an example of an author asserting a patient does not have diabetes.

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">
        <table>
            <thead>
                <tr>
                    <td>Start Time:</td>
                    <td>End Time:</td>
                    <td>Status:</td>
                    <td>Problem:</td>
                </tr>
            </thead>
            <tbody>
                <tr ID="problems1">
                    <td>12/01/2015 16:05:06</td>
                    <td></td>
                    <td>Active</td>
                    <td ID="problem1">No Diabetes (ruled out)</td>
                </tr>
            </tbody>
        </table>
        <!-- The statement above and the associated problem observation could be placed in the History of Past Illness Section -->
    </text>
    <entry typeCode="COMP">
        <!-- 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"/>
            <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
            <text><reference value="#Concern_1"></reference></text>
            <statusCode code="completed"/> <!-- The concern is not active, in terms of there being an active condition to be managed.-->
            <effectiveTime>
                <low value="20151201071605"/> <!-- Time at which THIS “concern” began being tracked.-->
                <high nullFlavor="NA"/>
            </effectiveTime> <!-- status is active so high is not applicable. If high is present it should have nullFlavor of NA-->
            <!-- Optional Author Element-->
            <author>
                <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
                <time value="2015120171605"/>
                <assignedAuthor>
                    <id extension="666545666" root="2.16.840.1.113883.4.6"/>
                    <code code="363LA2100X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"
                        displayName="Nurse Practitioner - Acute Care"/>
                    <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>Jenheartly</given>
                            <family>Sixer</family>
                            <suffix>NP</suffix>
                        </name>
                    </assignedPerson>
                </assignedAuthor>
            </author>
            <entryRelationship typeCode="SUBJ">
                <!-- This problem observation could be placed in the History of Past Illness Section -->
                <!-- Or, in future, in the Health Concerns Section -->
                <observation classCode="OBS" moodCode="EVN" negationInd="true">
                    <!-- Model of Meaning for No Diabetes -->
                    <!-- The use of negationInd corresponds with the newer Observation.ValueNegationInd -->
                    <!-- The negationInd = true negates the value element. --> 
                    <!-- 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-9fe1-0800200c9a69"/>
                    <code code="55607006" displayName="Problem"
                        codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
                        <translation code="75326-9" codeSystem="2.16.840.1.113883.6.1"
                            codeSystemName="LOINC" displayName="Problem"/>
                    </code>
                    <text><reference value="#problems1"></reference></text>
                    <statusCode code="completed"/>
                    <effectiveTime>
                        <low value="20151201160506"/>
                    </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="44054006"
                        displayName="Diabetes Mellitus Type 2 (Disorder)"
                        codeSystem="2.16.840.1.113883.6.96"
                        codeSystemName="SNOMED CT">
                        <originalText><reference value="#problem1"></reference></originalText>
                    </value>
                </observation>
            </entryRelationship>
        </act>
    </entry>
</section>
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