Complete or Resolved Problem

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 5/30/2014

  • SDWG: 6/5/2014

  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

C-CDA 2.1 Example:

  • 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
  • 2.16.840.1.113883.10.20.22.4.119
  • 2.16.840.1.113883.10.20.22.4.4:2015-08-01

Reference to full CDA sample:

  • Problems in empty CCD

Validation location

Comments

  • This example illustrates how to structure a resolved problem, both by having a biological resolution date and a completed status of the concern.

    Custodian

  • John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)

Keywords

  • problems

Permalink

Links

 

Example: download example view on GitHub 

<section>
	<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
	<templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
	<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 ID="ProblemDescription1">Acute pharyngitis</td>
					<td>
						<content>Onset: Apr 2 2014</content>
						<br />
						<content>Resolution: Apr 5 2014</content>
					</td>
					<td>Resolved</td>
				</tr>
			</tbody>
		</table>
	</text>
	<entry>
		<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="e5fbc288-659f-4aeb-a5e1-eb7cc8fcdfaf" />
			<code code="CONC" codeSystem="2.16.840.1.113883.5.6" />
			<!-- Since this is a resolved problem, the concern status has been changed to completed. -->
			<!-- While clinicians can track resolved problems, generally active problems will have active concern status and resolved concerns will be completed -->
			<statusCode code="completed" />
			<effectiveTime>
				<!-- This represents the time that the clinician began tracking the concern. This may frequently be an EHR timestamp-->
				<low value="20140403124536-0500" />
				<!-- This represents the time that the clinician stopped actively the concern. This may frequently be an EHR timestamp-->
				<high value="20140407102516-0500" />
			</effectiveTime>
			<entryRelationship typeCode="SUBJ">
				<observation classCode="OBS" moodCode="EVN">
					<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 extension="10241108" root="1.3.6.1.4.1.22812.4.111.0.4.1.2.1" />
					<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="#Problem1" />
					</text>
					<statusCode code="completed" />
					<effectiveTime>
						<!-- This represents the date of biological onset. This can be before the patient vistited the clinician, as illustrated in this example-->
						<low value="20140402" />
						<!-- This represents the date of resolution. Since this a boundary condition, if you wish to include the full day, the boundary should be padded or be the start of next day -->
						<!-- This reflects a common confusion point since people often consider dates to include the day at the boundary, but this ia RIM-related boundary constraint-->
						<high value="20140405235959-0500"/>
					</effectiveTime>
					<!-- This is a SNOMED code as the primary vocabulary for problem lists-->
					<value xsi:type="CD" code="363746003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Acute pharyngitis">
						<originalText>
							<reference value="#ProblemDescription1" />
						</originalText>
						<!-- These are common translations of the SNOMED code, ICd-9 and ICd-10 are often used in billing-->
						<translation xsi:type="CD" code="462" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD-9" displayName="Acute pharyngitis" />
						<translation xsi:type="CD" code="J02.9" codeSystem="2.16.840.1.113883.6.90" codeSystemName="ICD-10" displayName="Acute pharyngitis" />
					</value>
					<author>
						<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
						<time value="20140407"/>
						<assignedAuthor>
							<id extension="66666" root="2.16.840.1.113883.4.6"/>
							<code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101"
								codeSystemName="NUCC" displayName="Allopathic &amp; Osteopathic Physicians; Internal Medicine, Cardiovascular Disease"/>
							<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>Heartly</given>
									<family>Sixer</family>
									<suffix>MD</suffix>
								</name>
							</assignedPerson>
						</assignedAuthor>
					</author>
				</observation>
			</entryRelationship>
		</act>
	</entry>
</section>

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