SDOH Problem

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 6/6/2024
  • SDWG C-CDA R2.1: 6/6/2024

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
  • 2.16.840.1.113883.10.20.22.4.4:2022-06-01

Reference to full CDA sample:

  • Problems in empty CCD

Validation location

Comments

  • This example illustrates how to structure an Active SDOH problem with a translation to ICD10.
  • Some systems may document active SDOH issues in the Social History Section or the Health Concerns Section. Gravity and other industry initiatives may provide additional guidance on best practices.

Custodian

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

Certification

  • SDOH, ICD10

Keywords

  • SDOH Goal

 

Example: download example view on GitHub 

<?xml version="1.0" encoding="UTF-8"?>

<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="ProblemObs1">
					<td ID="Problem1">Nutrition impaired due to limited access to healthful
						foods</td>
					<td>
						<content>Onset: March 21 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"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01"/>
			<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 -->
			<text>
				<reference value="#ProblemObs1"/>
			</text>
			<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="2014032124536-0500"/>
			</effectiveTime>
			<entryRelationship typeCode="SUBJ">
				<!-- SDOH Problem -->
				<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"/>
					<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2022-06-01"/>
					<id extension="68993" root="1.2.840.114350.1.13.6289.1.7.2.768076"/>
					<id root="093A5380-00CE-11E6-B4C5-0050568B000B" extension="1.1"/>
					<code code="55607006" codeSystem="2.16.840.1.113883.6.96"
						codeSystemName="SNOMED CT" displayName="Problem">
						<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1"
							codeSystemName="LOINC" displayName="Problem"/>
					</code>

					<statusCode code="completed"/>
					<effectiveTime>
						<low value="2014032124536-0500"/>
					</effectiveTime>
					<value xsi:type="CD" code="445281000124101"
						displayName="Nutrition impaired due to limited access to healthful foods (finding)"
						codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
						<originalText>
							<reference value="#Problem1"/>
						</originalText>
						<translation code="Z59.48" codeSystem="2.16.840.1.113883.6.90"
							codeSystemName="ICD-10-CM"
							displayName="Other specified lack of adequate food"/>
					</value>
					<!-- Optional Author Element-->
					<author>
						<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
						<time value="20140302124536-0500"/>
						<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="Physician Assistants &amp; Advanced Practice Nursing Providers; 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>
							<!-- Optional Organization Element-->
							<representedOrganization>
								<id root="2.16.840.1.113883.19.5"/>
								<name>Neighborhood Physicians Practice</name>
							</representedOrganization>
						</assignedAuthor>
					</author>
				</observation>
			</entryRelationship>
		</act>
	</entry>
</section>

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