Health Concerns Link to Problems Section

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 12/15/2015
  • SDWG: 2/11/2016
  • SDWG C-CDA R2.1 Upgrade: 2/2/2017

C-CDA 2.1 Example:

  • 2.16.840.1.113883.10.20.22.2.58:2015-08-01
  • 2.16.840.1.113883.10.20.22.4.132:2015-08-01
  • 2.16.840.1.113883.10.20.22.4.4:2015-08-01
  • 2.16.840.1.113883.10.20.22.4.122
  • 2.16.840.1.113883.10.20.22.2.5.1:2015-08-01
  • 2.16.840.1.113883.10.20.22.4.3:2015-08-01

Reference to full CDA sample:

  • Empty CCD

Validation location

Comments

  • This is an example of how to link a concern to a problem in the problem list section.

Custodian

  • Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)

Certification

  • ONC

Keywords

  • entry reference

Permalink

Links

 

Example: download example view on GitHub 

<ClinicalDocument>
    <!-- This ClinicalDocument's structure is stubbed with the minimum elements necessary
       to demonstrate the locations of the entries across multiple different sections;
       however, required content like the document header and section LOINC codes
       has been omitted. -->
    <component>
        <structuredBody>
            <component>
                <section>
                    <!-- Health Concerns Section (V2)-->
                    <templateId root="2.16.840.1.113883.10.20.22.2.58" extension="2015-08-01"/>
                    <templateId root="2.16.840.1.113883.10.20.22.2.58"/>
                    <code code="75310-3" displayName="Health Concerns Document" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
                    <title>Health Concerns Section</title>
                    <text>
                        <table border="1" width="100%">
                            <thead>
                                <tr>
                                    <th>Health Concern</th>
                                    <th>Date</th>
                                    <th>Related Problem</th>
                                </tr>
                            </thead>
                            <tbody>
                                <tr ID="Concern1">
                                    <td ID="Concern1Issue1">Patient is concerned about being contagious and infecting roommate.</td>
                                    <td>Concern from 03/02/2014</td>
                                    <!-- Providing this as a link to the related problem in problem list is an option using base CDA implementation guidance. -->
                                    <td>Community Acquired Pneumonia</td>
                                </tr>
                            </tbody>
                        </table>
                    </text>
                    <entry>
                        <!-- Health Concern Act -->
                        <act classCode="ACT" moodCode="EVN">
                            <templateId root="2.16.840.1.113883.10.20.22.4.132" extension="2015-08-01"/>
                            <templateId root="2.16.840.1.113883.10.20.22.4.132"/>
                            <id root="63c5e137-3024-46cc-951f-885ec69d9030"/>
                            <code code="75310-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Health Concern"/>
                            <!-- This Health Concern has a statusCode of active because it is an active concern -->
                            <statusCode code="active"/>
                            <!-- The effective time is the date that the Health Concern started being followed - 
            							 this does not necessarily correlate to the onset date of the contained health issues-->
                            <effectiveTime value="20140302"/>
                            <entryRelationship typeCode="REFR">
                                <observation classCode="OBS" moodCode="EVN">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
                                    <templateId root="2.16.840.1.113883.10.20.22.4.4"/>
                                    <id root="59c5ca3e-662f-4e33-943f-2777ebc6227e"/>
                                    <code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="55607006" displayName="Problem">
                                        <translation codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="75326-9" displayName="Problem"/>
                                    </code>
                                    <text>
                                        <reference value="#Concern1" />
                                    </text>
                                    <statusCode code="completed"/>
                                    <effectiveTime>
                                        <low value="20140302"/>
                                    </effectiveTime>
                                    <value xsi:type="CD" nullFlavor="OTH">
            			<originalText>
            				<reference value="#Concern1Issue1" />
            			</originalText>
                                    </value>						
                                </observation>
                            </entryRelationship>
                            <!-- Health Concern Problem: Community Acquired Pneumonia -->
                            <!-- This Entry Reference refers to a problem observation present in Problem List 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 Community Acquired Pneumonia problem -->
                                    <id root="49c5ca3e-662f-4e33-948f-2777ebc6727e" />
                                    <!-- The code is nulled to "NP" Not Present" -->
                                    <code nullFlavor="NP"/>
                                    <statusCode code="completed" />
                                </act>
                            </entryRelationship>
                        </act>
                    </entry>
                </section>
            </component>
            <component> 
                <section>
                    <!-- Located elsewhere in the document -->
                    <!-- Taken directly (changed observation/id) from prior example https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Problem_List_Active_Problem.xml -->
                    <templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
                    <templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
                    <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" displayName="Problem List"/>
                    <title>Problem List</title>
                    <text>
                        <table>
                            <thead>
                                <tr>
                                    <th>Name</th>
                                    <th>Dates</th>
                                    <th>Status</th>
                                </tr>
                            </thead>
                            <tbody>
                                <tr ID="Problem1">
                                    <td>Community Acquired Pneumonia</td>
                                    <td>
                                        <content>Onset: 02/27/2014</content>
                                    </td>
                                    <td>Active</td>
                                </tr>
                            </tbody>
                        </table>
                    </text>
                    <entry>
                        <act classCode="ACT" moodCode="EVN">
                            <templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01"/>
                            <templateId root="2.16.840.1.113883.10.20.22.4.3"/>
                            <id root="102ca2e9-884c-4523-a2b4-1b6c3469c397" />
                            <code code="CONC" codeSystem="2.16.840.1.113883.5.6" />
                            <!-- Since this is an active problem, the concern status is active. -->
                            <!-- While clinicians can track resolved problems, generally active problems will have active concern status and resolved concerns will be completed -->
                            <statusCode code="active" />
                            <effectiveTime>
                                <!-- This equates to the time the concern was authored in the patient's chart. This may frequently be an EHR timestamp-->
                                <low value="20140302124536-0500" />
                            </effectiveTime>
                            <entryRelationship typeCode="SUBJ">
                                <observation classCode="OBS" moodCode="EVN">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
                                    <templateId root="2.16.840.1.113883.10.20.22.4.4"/>
                                    <id root="49c5ca3e-662f-4e33-948f-2777ebc6727e"/>
                                    <code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="55607006" displayName="Problem">
                                        <translation codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="75326-9" displayName="Problem"/>
                                    </code>
                                    <text>
                                        <reference value="#Problem1" />
                                    </text>
                                    <statusCode code="completed"/>
                                    <effectiveTime>
                                        <!-- This represents the date of biological onset. -->
                                        <low value="20140227"/>
                                    </effectiveTime>
                                    <!-- This is a SNOMED code as the primary vocabulary for problem lists-->
                                    <value xsi:type="CD" code="385093006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Community acquired pneumonia"/>							
                                </observation>
                            </entryRelationship>
                        </act>
                    </entry>
                </section>
            </component>
        </structuredBody>
    </component>
</ClinicalDocument>

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