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1 Template IPSEntryAllergyOrIntolerance

1.1 Aktuelle Version

Id2.16.840.1.113883.10.22.4.1Gültigkeit ab2024‑08‑04 09:48:50
Status  EntwurfVersions-LabelSTU2
NameIPSEntryAllergyOrIntoleranceBezeichnungIPS Allergy or Intolerance
Beschreibung
  This template reflects a discrete observation about a patient's allergy or intolerance.
Because it is a discrete observation, it will have a statusCode of "completed".
The effectiveTime, also referred to as the "biologically relevant time" is the time at which the observation holds for the patient.
For a provider seeing a patient in the clinic today, observing a history of penicillin allergy that developed five years ago, the effectiveTime is five years ago.
The effectiveTime of the Allergy - Intolerance Observation gives an indication of whether or not the underlying allergy/intolerance is resolved. If known to be resolved, then an effectiveTime/high would be present. 
If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK". 
It is recommended that the agent responsible for an allergy or adverse reaction would be used for describing the allergy, however the possibility that pre-coordinate codes (e.g. "allergy to nuts") will be used has been here also considered.
The agent responsible for  an allergy or adverse reaction it is not always a manufactured material (for example, food allergies), nor is it necessarily consumed; however  the playingEntity classCode = "MMAT" for all agents, manufactured or not is expected to be used. This choice depends on thecharacteristics of the base CDA R2 specification.
KontextElternknoten des Template-Element mit Id 2.16.840.1.113883.10.22.4.1
KlassifikationCDA Entry Level Template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit
Assoziiert mit 12 Konzepte
IdNameDatensatz
hl7ips-data​element-173  Agent   CEN/TC 251 prEN 17269
hl7ips-data​element-182  Allergies/Intolerances Content Status   CEN/TC 251 prEN 17269
hl7ips-data​element-184  Allergy/Intolerance   CEN/TC 251 prEN 17269
hl7ips-data​element-185  Diagnosis   CEN/TC 251 prEN 17269
hl7ips-data​element-186  Clinical Status   CEN/TC 251 prEN 17269
hl7ips-data​element-187  Onset date   CEN/TC 251 prEN 17269
hl7ips-data​element-188  End Date   CEN/TC 251 prEN 17269
hl7ips-data​element-189  Criticality   CEN/TC 251 prEN 17269
hl7ips-data​element-190  Certainty   CEN/TC 251 prEN 17269
hl7ips-data​element-191  Type of propensity   CEN/TC 251 prEN 17269
hl7ips-data​element-192  Reaction   CEN/TC 251 prEN 17269
hl7ips-data​element-196  Agent code   CEN/TC 251 prEN 17269
Benutzt
Benutzt 4 Templates
Benutzt als NameVersion
2.16.840.1.113883.10.22.4.6Containment  IPS Reaction Manifestation (STU2)DYNAMIC
2.16.840.1.113883.10.22.4.18Containment  IPS Criticality Observation (STU1)DYNAMIC
2.16.840.1.113883.10.22.10Containment  IPS Allergy Certainty Observation (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.21Containment  IPS Allergy Status Observation (STU1)DYNAMIC
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.22.4.1 IPS Allergy or Intolerance (2016‑11‑10)
ref
hl7ips-

Adaptation: Template 2.16.840.1.113883.10.20.1.18 Alert observation (DYNAMIC)
ref
ccd1-

Adaptation: Template 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (DYNAMIC)
ref
ch-pcc-

Adaptation: Template 1.3.6.1.4.1.19376.1.5.3.1.4.6 eHDSI Allergies And Intolerances (DYNAMIC)
ref
epsos-
Beispiel
Beispiel
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.1"/>  <id root=" " extension=" "/>  <!-- This is the code that shows what kind of allergy or intolerance -->
  <code code="OINT" displayName="Allergy or Intolerance" codeSystem="2.16.840.1.113883.5.4">
    <text>
      <reference value="#ref1"/>    </text>    <statusCode code="completed"/>    <effectiveTime>
      <low value="20170701"/>    </effectiveTime>    <!-- This is the allergen - the substance that caused the allergy -->
    <participant typeCode="CSM">
      <participantRole classCode="MANU">
        <playingEntity classCode="MMAT">
          <code code=" " codeSystem=" ">
            <originalText>
              <reference value="#substance"/>            </originalText>          </code>          <name>...</name>        </playingEntity>      </participantRole>    </participant>    <!-- This is how the allergy manifests itself -->
    <entryRelationship typeCode="MFST" inversionInd="true">
      <!-- template 2.16.840.1.113883.10.22.4.6 'IPS Reaction Manifestation' (dynamic) -->
    </entryRelationship>    <entryRelationship typeCode="SUBJ" inversionInd="true">
      <!-- template 2.16.840.1.113883.10.22.4.18 'IPS Criticality Observation' (dynamic) -->
    </entryRelationship>    <entryRelationship typeCode="SUBJ" inversionInd="true">
      <!-- template 2.16.840.1.113883.10.22.4.19 'IPS Certainty Observation' (dynamic) -->
    </entryRelationship>    <entryRelationship typeCode="REFR" inversionInd="false">
      <!-- template 2.16.840.1.113883.10.22.4.21 'IPS Allergy Status Observation' (dynamic) -->
    </entryRelationship>  </code></observation>
Beispiel
No Known Allergies
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.1"/>  <code code="allergy" displayName="Allergy" codeSystem="2.16.840.1.113883.4.642.1.122">
    <statusCode code="completed"/>    <effectiveTime>
      <low nullFlavor="UNK"/>    </effectiveTime>    <value code="X-NoKnownAllergy" displayName="No known allergy" codeSystem="2.16.840.1.113883.5.1150.2"/>  </code></observation>
Beispiel
No Information available about allergies or intolerances
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.1"/>  <code code="OINT" displayName="Allergy or Intolerance" codeSystem="2.16.840.1.113883.5.4">
    <statusCode code="completed"/>    <effectiveTime>
      <low nullFlavor="NA"/>    </effectiveTime>    <value code="no-allergy-info" displayName="No information about allergies" codeSystem="2.16.840.1.113883.5.1150.1"/>  </code></observation>
Beispiel
Minimum Set (active propensity; agent known)
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.1"/>  <code code="OINT" displayName="Allergy or Intolerance" codeSystem="2.16.840.1.113883.5.4">
    <statusCode code="completed"/>    <effectiveTime>
      <low nullFlavor="UNK"/>    </effectiveTime>    <participant typeCode="CSM">
      <participantRole classCode="MANU">
        <playingEntity classCode="MMAT">
          <code code="13577000" codeSystem="2.16.840.1.113883.6.96" displayName="Nut"/>        </playingEntity>      </participantRole>    </participant>  </code></observation>
ItemDTKardKonfBeschreibungLabel
hl7:observation
R
 
 
hl7ips-data​element-184  Allergy/Intolerance   CEN/TC 251 prEN 17269
 @classCode
cs1 … 1FOBS
 @moodCode
cs1 … 1FEVN
 hl7:templateId
II1 … 1M
  @root
uid1 … 1F2.16.840.1.113883.10.22.4.1
 hl7:id
II0 … *R
 hl7:code
CD.IPS1 … 1M  This element describes whether this condition refers to an allergy, non-allergy intolerance, or unknown class of intolerance (not known to be allergy or intolerance).
 
 
hl7ips-data​element-191  Type of propensity   CEN/TC 251 prEN 17269
 CONF
Der Wert von @code MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.11.22.2 Allergy or Intolerance Type (DYNAMIC)
 hl7:text
ED0 … 1R  The text element if present points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.</reference>
  hl7:reference
TEL1 … 1M
   @value
url1 … 1R  When used it shall refer to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
 hl7:statusCode
CS1 … 1M  A clinical document normally records only those condition observation events that have been completed, not observations that are in any other state. Therefore, the <statusCode> shall always have code='completed'.</statusCode>
  @code
cs1 … 1Fcompleted
 hl7:effectiveTime
IVL_TS1 … 1M  The effectiveTime, also referred to as the "biologically relevant time" is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of penicillin allergy that developed five years ago, the effectiveTime is five years ago. The effectiveTime of the Allergy - Intolerance  Observation may give an indication of whether or not the underlying allergy/intolerance is resolved. 
The <low> and <high> values should be no more precise than known, but as precise as possible.
  hl7:low
IVXB_TS1 … 1R  The effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became biologically active.
 
 
hl7ips-data​element-187  Onset date   CEN/TC 251 prEN 17269
  hl7:high
IVXB_TS0 … 1C  The effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance became biologically resolved.
If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".
 
 
hl7ips-data​element-188  End Date   CEN/TC 251 prEN 17269
 Constraint  If this condition is known to be resolved, then the effectiveTime/high would be present.
 hl7:value
CD.IPS (preferred)0 … 1
 
 
hl7ips-data​element-185  Diagnosis   CEN/TC 251 prEN 17269
 CONF
Der Wert von @code kommt vorzugsweise aus dem Value Set 2.16.840.1.113883.11.22.10 IPS Allergy or Intolerance Conditions (DYNAMIC)
 hl7:participant
0 … 1C  The substance that causes the allergy or intolerance should be specified in the <participant> structure. 
This is the preferred way an allergy is supposed to be expressed.
However it is recognized that in some contexts a controlled vocabulary is used for describing the allergy to a substance; or for asserting known absence or unavailability of information. 
In this case the <participant> structure shall be omitted.
The agent responsible for an allergy or adverse reaction is not always a manufactured material (for example, food allergies), nor is it necessarily consumed. The following constraints reflect limitations in the base CDA R2 specification, and should be used to represent any type of responsible agent, i.e., use playingEntity classCode = "MMAT" for all agents, manufactured or not.
 
 
hl7ips-data​element-173  Agent   CEN/TC 251 prEN 17269
  @typeCode
cs1 … 1FCSM
 Constraint  IF the observation/value element is present and valued with a code derived form the  2.16.840.1.113883.11.22.9 Absent or Unknown Allergies value set THEN the  observation/participant element used to describe the agent SHALL be omitted.
  hl7:participantRole
1 … 1R
   @classCode
cs1 … 1FMANU
   hl7:playingEntity
1 … 1R
    @classCode
cs1 … 1FMMAT
    hl7:code
CD.IPS (preferred)1 … 1R  Code for the substance causing the allergy or intolerance.
 
 
hl7ips-data​element-196  Agent code   CEN/TC 251 prEN 17269
 CONF
Der Wert von @code kommt vorzugsweise aus dem Value Set 2.16.840.1.113883.11.22.65 IPS Allergy or Intolerance Substances (DYNAMIC)
 hl7:entryRelationship
0 … *R  The contained entry describes the reactions that are manifestations (typeCode='MFST') of the reported allergy or intolerance.
Beinhaltet 2.16.840.1.113883.10.22.4.6 IPS Reaction Manifestation (DYNAMIC)
 
 
hl7ips-data​element-192  Reaction   CEN/TC 251 prEN 17269
  @typeCode
cs1 … 1FMFST
  @inversionInd
bl1 … 1Ftrue
 hl7:entryRelationship
0 … 1R  Criticality
The contained entry describes the gravity of the potential risk for future life-threatening adverse reactions when exposed to a substance known to cause an adverse reaction in that individual.
Beinhaltet 2.16.840.1.113883.10.22.4.18 IPS Criticality Observation (DYNAMIC)
 
 
hl7ips-data​element-189  Criticality   CEN/TC 251 prEN 17269
  @typeCode
cs1 … 1FSUBJ
  @inversionInd
bl1 … 1Ftrue
 hl7:entryRelationship
0 … 1R  Certainty or Verification Status
The contained entry describes the certainty associated with a propensity, or potential risk, of a reaction to the identified substance.
Beinhaltet 2.16.840.1.113883.10.22.10 IPS Allergy Certainty Observation (DYNAMIC)
 
 
hl7ips-data​element-190  Certainty   CEN/TC 251 prEN 17269
  @typeCode
cs1 … 1FSUBJ
  @inversionInd
bl1 … 1Ftrue
 hl7:entryRelationship
0 … 1R  Status of the Allergy or Intolerance 
The contained entry describes the current status of the allergy or intolerance, for example, whether it is active, in remission, resolved, and so on ...
Beinhaltet 2.16.840.1.113883.10.22.4.21 IPS Allergy Status Observation (DYNAMIC)
 
 
hl7ips-data​element-186  Clinical Status   CEN/TC 251 prEN 17269
  @typeCode
cs1 … 1FREFR
  @inversionInd
bl1 … 1Ffalse


1.2 Zusammenstellung aller Versionen dieses Templates

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