Family History Generic

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Example metadata last updated 2017-08-06 10:15:50.438000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 2/12/2015
  • SDWG: 2/19/2015
  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

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Comments:

  • Example shows generic "family history of x" and "no family history of x" with commentary suggesting better options.

Custodian: Benjamin Flessner, benjamin@epic.com (GitHub: benjaminflessner)

Full sample: Family history in empty CCD

Example: download example view on GitHub

<section>
	<!-- C-CDAR2 Example Family History Section (Generic Family History)-->
	<templateId root="2.16.840.1.113883.10.20.22.2.15"/>
	<templateId root="2.16.840.1.113883.10.20.22.2.15" extension="2015-08-01"/>
	<code code="10157-6" codeSystem="2.16.840.1.113883.6.1" displayName="Family History"/>
	<title>Family History</title>
	<text>
		<!-- Family history is intended to convery information about discrete family members' health conditions.
			The best way to convey "Family history of heart disease" would be to identify which family members
			actually HAD heart disease.
			The best way to convey "No family history of asthma" would be to explicitly state:
			The father did not have asthma.
			The mother did not have asthma.
			The grandfather did not have asthma.
		    ...and so on.
		
			An alternative to using this section to convey generic family history would be to add
			codes from the SNOMED 416471007: Family Medical History hierarchy to the patient's problem list.
			
			This example, however, shows how to convey generic family history in the Family History
			section in the absence of any known discrete family relationships.
		-->
		
		<paragraph>Patient has a family history of <content ID="FHGeneric1prob">heart disease</content>.</paragraph>
		<paragraph>Patient has no known family history of <content ID="FHGeneric2prob">asthma</content>.</paragraph>
	</text>
	<!-- Generic family member's history -->
	<entry>
		<organizer classCode="CLUSTER" moodCode="EVN">
			<templateId root="2.16.840.1.113883.10.20.22.4.45"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.45" extension="2015-08-01"/>
			<!-- Unique ID for the collection of observations about "generic family member" -->
			<id root="01faa204-3333-4610-864f-cb50b650d0fa" />
			<statusCode code="completed"/>
			<subject>
				<relatedSubject classCode="PRS">
					<!-- Identifies this subject as a generic 'Family Member' -->
					<code code="FAMMEMB" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 RoleCode" displayName="Family Member" />
					<!-- No additional subject information is necessary, since we are not talking about an individual person -->
				</relatedSubject>
			</subject>
			<!-- Heart Disease observation -->
			<component>
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.46"/>
					<templateId root="2.16.840.1.113883.10.20.22.4.46" extension="2015-08-01"/>
					<!-- Unique ID for this individual observation -->
					<id root="02faa204-3333-4610-864f-cb50b650d0fa" />
					<code code="64572001" codeSystem="2.16.840.1.113883.6.96" displayName="Condition" >
						<translation code="75315-2" codeSystem="2.16.840.1.113883.6.1" displayName="Condition Family Member" />
					</code>
					<statusCode code="completed"/>
					<!-- Since no date is given, effectiveTime is UNKnown -->
					<effectiveTime nullFlavor="UNK" />
					<!-- SNOMED for Heart Disease
						 Note: explicitly NOT using 266894000: FH Cardiovascular disease, since we are scoped by the "family member"
						 The family member has 'Heart Disease', not a 'Family History of Heart Disease'
						-->
					<value xsi:type="CD" code="56265001" codeSystem="2.16.840.1.113883.6.96" displayName="Heart Disease (Disorder)">
						<originalText>
							<reference value="#FHGeneric1prob"/>
						</originalText>
					</value>
				</observation>
			</component>
			<!-- Asthma negative observation -->
			<component>
				<!-- Similar to Problem Observation, negationInd here represents Observation.ValueNegation,
				     stating the relative does NOT have asthma-->
				<observation classCode="OBS" moodCode="EVN" negationInd="true">
					<templateId root="2.16.840.1.113883.10.20.22.4.46"/>
					<templateId root="2.16.840.1.113883.10.20.22.4.46" extension="2015-08-01"/>
					<!-- Unique ID for this individual observation -->
					<id root="04faa204-3333-4610-864f-cb50b650d0fa" />
					<code code="64572001" codeSystem="2.16.840.1.113883.6.96" displayName="Condition" >
						<translation code="75315-2" codeSystem="2.16.840.1.113883.6.1" displayName="Condition Family Member" />
					</code>
					<statusCode code="completed"/>
					<!-- Since no date is given, effectiveTime is UNKnown -->
					<effectiveTime nullFlavor="UNK" />
					<!-- SNOMED for Asthma 
						Again, not using 160377001: Family History of Asthma. That code would be 
					    appropriate for the patient's own problem list. -->
					<value xsi:type="CD" code="195967001" codeSystem="2.16.840.1.113883.6.96" displayName="Asthma">
						<originalText>
							<reference value="#FHGeneric2prob"/>
						</originalText>
					</value>
				</observation>
			</component>
		</organizer>
	</entry>
</section>
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