2.16.840.1.113883.10.22.4.8

Weitere Informationen sind zusammengefasst im Hilfe-Beitrag Templates.

1 Template IPSProblemEntry

1.1 Aktuelle Version

Id	2.16.840.1.113883.10.22.4.8	Gültigkeit ab	2024‑08‑04 11:06:03
Status	Entwurf	Versions-Label	2021
Name	IPSProblemEntry	Bezeichnung	IPS Problem Entry
Beschreibung This template reflects a discrete observation about a patient's problem. 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 heart attack that occurred five years ago, the effectiveTime is five years ago. The effectiveTime of the Problem Observation is the definitive indication of whether or not the underlying condition is resolved. If the problem is 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".
Kontext	Elternknoten des Template-Element mit Id 2.16.840.1.113883.10.22.4.8
Klassifikation	CDA Entry Level Template
Offen/Geschlossen	Offen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit	Assoziiert mit 12 Konzepte Id Name Datensatz hl7ips-data​element-101  Problem type  CEN/TC 251 prEN 17269 hl7ips-data​element-115  Problem content status  CEN/TC 251 prEN 17269 hl7ips-data​element-127  Onset date  CEN/TC 251 prEN 17269 hl7ips-data​element-128  Severity  CEN/TC 251 prEN 17269 hl7ips-data​element-131  Diagnosis  CEN/TC 251 prEN 17269 hl7ips-data​element-136  Severity  CEN/TC 251 prEN 17269 hl7ips-data​element-140  Problem  CEN/TC 251 prEN 17269 hl7ips-data​element-209  Health condition / Problem  CEN/TC 251 prEN 17269 hl7ips-data​element-210  Problem Type  CEN/TC 251 prEN 17269 hl7ips-data​element-32  Onset Date  CEN/TC 251 prEN 17269 hl7ips-data​element-34  Date resolved  CEN/TC 251 prEN 17269 hl7ips-data​element-36  Diagnosis  CEN/TC 251 prEN 17269
Benutzt	Benutzt 3 Templates Benutzt als Name Version 2.16.840.1.113883.10.22.4.25 Containment IPS Severity Observation (STU1) DYNAMIC 2.16.840.1.113883.10.22.4.19 Containment IPS Certainty Observation (STU1) DYNAMIC 2.16.840.1.113883.10.22.4.20 Containment IPS Problem Status Observation (STU1) 2017‑03‑29
Beziehung	Spezialisierung: Template 2.16.840.1.113883.10.22.4.8 IPS Problem Entry (2021‑08‑04 08:52:52) ref hl7ips- Adaptation: Template 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (DYNAMIC) ref ch-pcc-
Beispiel	Active Problem <observation classCode="OBS" moodCode="EVN">   <templateId root="2.16.840.1.113883.10.22.4.8"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">     <text>       <reference value="#problem-1"/>    </text>    <statusCode code="completed"/>    <effectiveTime>       <low value="20100507"/>    </effectiveTime>    <value code="38341003" displayName="Hypertensive disorder, systemic arterial (disorder)" codeSystem="2.16.840.1.113883.6.96"/>    <entryRelationship typeCode="SUBJ" inversionInd="true">       <!-- template 2.16.840.1.113883.10.22.4.25 'IPS Severity 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 2.16.840.1.113883.10.22.4.20 'IPS Problem Status Observation' (2017-03-29T00:00:00) -->       <!-- this referred observation should report that the condition is still active -->     </entryRelationship>  </code></observation>
Beispiel	Closed Problem (resolution date known) <observation classCode="OBS" moodCode="EVN">   <templateId root="2.16.840.1.113883.10.22.4.8"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">     <statusCode code="completed"/>    <effectiveTime>       <low value="2010"/>      <high value="2015"/>    </effectiveTime>    <value code="38341003" displayName="Hypertensive disorder, systemic arterial (disorder)" codeSystem="2.16.840.1.113883.6.96"/>    <entryRelationship typeCode="SUBJ" inversionInd="true">       <!-- template 2.16.840.1.113883.10.22.4.25 'IPS Severity 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 2.16.840.1.113883.10.22.4.20 'IPS Problem Status Observation' (2017-03-29T00:00:00) -->       <!-- this referred observation should report that the condition is resolved -->     </entryRelationship>  </code></observation>
Beispiel	Known absent problems <observation classCode="OBS" moodCode="EVN">   <templateId root="2.16.840.1.113883.10.22.4.8"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">     <statusCode code="completed"/>    <effectiveTime>       <low nullFlavor="NI"/>    </effectiveTime>    <value code="no-known-problems" displayName="No known problems" codeSystem="2.16.840.1.113883.5.1150.1"/>  </code></observation>
Item DT Kard Konf Beschreibung Label hl7:observation R   hl7ips-data​element-140  Problem  CEN/TC 251 prEN 17269 hl7ips-data​element-209  Health condition / Problem  CEN/TC 251 prEN 17269 @classCode cs 0 … 1 F OBS @moodCode cs 1 … 1 F EVN hl7:templateId II 1 … 1 M @root uid 1 … 1 F 2.16.840.1.113883.10.22.4.8 hl7:id II 0 … * R hl7:code CD.IPS 1 … 1 R This element describes the type of condition this observation is referring to.   hl7ips-data​element-101  Problem type  CEN/TC 251 prEN 17269 hl7ips-data​element-210  Problem Type  CEN/TC 251 prEN 17269   CONF Der Wert von @code MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.11.22.16 IPS Problem Type (DYNAMIC)   Beispiel <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/> hl7:text ED 0 … 1 R 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> </text>   Beispiel <text>   <reference value="#problem-1"/></text> hl7:reference TEL 1 … 1 M @value url 1 … 1 R When used it shall refer to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1 hl7:statusCode CS 1 … 1 M 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 CONF 1 … 1 F completed hl7:effectiveTime IVL_TS 1 … 1 M 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 heart attack that occurred five years ago, the effectiveTime is five years ago. The <low> and <high> values should be no more precise than known, but as precise as possible.   Beispiel Known onset date (active condition) <effectiveTime>   <low value="20100507"/></effectiveTime>   Beispiel Unknown onset date (active condition) <effectiveTime>   <low nullFlavor="UNK"/></effectiveTime>   Beispiel Unknown resolution date <effectiveTime>   <low value="2010"/>  <high nullFlavor="UNK"/></effectiveTime>   Beispiel Known resolution date <effectiveTime>   <low value="201007"/>  <high value="201703"/></effectiveTime> hl7:low IVXB_TS 1 … 1 R The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.   hl7ips-data​element-127  Onset date  CEN/TC 251 prEN 17269 hl7ips-data​element-32  Onset Date  CEN/TC 251 prEN 17269 hl7:high IVXB_TS 0 … 1 C The effectiveTime/high (a.k.a. "resolution date") asserts when the condition e 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-34  Date resolved  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) 1 … 1 M The <value> is the condition that was found. It may a coded or an un-coded string, but its type is always coded. The coded form shall be used also to indicate known absent conditions or the nonavailability of information about them.   hl7ips-data​element-115  Problem content status  CEN/TC 251 prEN 17269 hl7ips-data​element-131  Diagnosis  CEN/TC 251 prEN 17269 hl7ips-data​element-36  Diagnosis  CEN/TC 251 prEN 17269 @xsi:type 0 … 1 F CD   CONF Der Wert von @code kommt vorzugsweise aus dem Value Set 2.16.840.1.113883.11.22.73 IPS Problems (DYNAMIC)   Beispiel Multiple Coding <value code="302231008" displayName="Salmonella infection" codeSystem="2.16.840.1.113883.6.96">   <translate code="A02.9" displayName="Infezioni da Salmonella non specificate" codeSystem="2.16.840.1.113883.6.3"/></value>   Beispiel Local code not mappable in the reference terminology <value nullFlavor="OTH">   <translate code="12345" displayName="Not in the reference value set" codeSystem="1.2.3.999" codeSystemName="--example only--"/></value>   Beispiel Textual Information <value nullFlavor="NI">   <originalText>     <reference value="#value_as_text"/>  </originalText></value>   Beispiel Known absent problems <value code="160245001" displayName="No current problems or disability" codeSystem="2.16.840.1.113883.6.96"/> hl7:originalText ED R The <originalText> element within the <code> element described above is used as follows: the <value> contains a <reference> to the <originalText> in order to link the coded value to the problem narrative text (minus 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. hl7:reference TEL 0 … 1 R The URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the medication. In a CDA document, the URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the medication. </reference> </reference>   Beispiel <reference value="#value_as_text"/> hl7:qualifier CR 0 … * hl7:translation CD.IPS 0 … * The translation element may be used to transmit a set of other concept descriptors, using for example ICD-10 or other international or jurisdictional code systems. hl7:entryRelationship 0 … 1 R Severity The contained entry describes a subjective assessment of the severity of the condition as evaluated by the clinician. Beinhaltet 2.16.840.1.113883.10.22.4.25 IPS Severity Observation (DYNAMIC)   hl7ips-data​element-128  Severity  CEN/TC 251 prEN 17269 hl7ips-data​element-136  Severity  CEN/TC 251 prEN 17269 @typeCode cs 1 … 1 F SUBJ @inversionInd bl 1 … 1 F true hl7:entryRelationship 0 … 1 R Certainty or Verification Status  The contained entry describes the certainty associated with a condition. Beinhaltet 2.16.840.1.113883.10.22.4.19 IPS Certainty Observation (DYNAMIC) @typeCode cs 1 … 1 F SUBJ @inversionInd bl 1 … 1 F true hl7:entryRelationship 0 … 1 R Status of the Problem    The contained entry describes the current status of the condition, for example, whether it is active, in remission, resolved, and so on ... Beinhaltet 2.16.840.1.113883.10.22.4.20 IPS Problem Status Observation (2017‑03‑29) @typeCode cs 1 … 1 F REFR @inversionInd bl 0 … 1 F false

1.2 Zusammenstellung aller Versionen dieses Templates

• 2024-08-04 11:06:03 (In Entwicklung)