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pending Template  Indication

Template 2.16.840.1.113883.10.20.22.4.19 - Indication
Id 2.16.840.1.113883.10.20.22.4.19
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Entry Level Template
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.19
Open/Closed Open (other than defined elements are allowed)
Description The Indication Observation documents the rationale for an activity. It can do this with the id element to reference a problem recorded elsewhere in the document or with a code and value to record the problem type and problem within the Indication. For example, the indication for a prescription of a painkiller might be a headache that is documented in the Problems Section.
Used by / Uses
Used by / Uses 246 templates
Used by Template id as Name Version
2.16.840.1.113883.10.20.22.2.29 Containment ProcedureIndicationsSection Procedure Indications Section 2013‑01‑31
2.16.840.1.113883.10.20.22.1.6 link ProcedureNote Procedure Note 2013‑01‑31
2.16.840.1.113883.10.20.22.1.7 link OperativeNote Operative Note 2013‑01‑31
2.16.840.1.113883.10.20.22.4.12 Containment ProcedureActivityAct Procedure Activity Act 2013‑01‑31
2.16.840.1.113883.10.20.22.2.7 link ProceduresSectionentriesoptional Procedures Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.1.3 link HistoryandPhysical History and Physical 2013‑01‑31
2.16.840.1.113883.10.20.22.1.4 link ConsultationNote Consultation Note 2013‑01‑31
2.16.840.1.113883.10.20.22.1.8 link DischargeSummary Discharge Summary 2013‑01‑31
2.16.840.1.113883.10.20.22.2.7.1 link ProceduresSectionentriesrequired Procedures Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.22.1.2 link ContinuityofCareDocumentCCD Continuity of Care Document (CCD) 2013‑01‑31
2.16.840.1.113883.10.20.22.4.13 Containment ProcedureActivityObservation Procedure Activity Observation 2013‑01‑31
2.16.840.1.113883.10.20.22.4.14 Containment ProcedureActivityProcedure Procedure Activity Procedure 2013‑01‑31
2.16.840.1.113883.10.20.22.2.25 link AnesthesiaSection Anesthesia Section 2013‑01‑31
2.16.840.1.113883.10.20.22.4.9 link ReactionObservation Reaction Observation 2013‑01‑31
2.16.840.1.113883.10.20.22.4.16 link MedicationActivity Medication Activity 2013‑01‑31
2.16.840.1.113883.10.20.22.2.1 link MedicationsSectionentriesoptional Medications Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.1.9 link ProgressNote Progress Note 2013‑01‑31
2.16.840.1.113883.10.20.22.2.1.1 link MedicationsSectionentriesrequired Medications Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.22.2.38 link MedicationsAdministeredSection Medications Administered Section 2013‑01‑31
2.16.840.1.113883.10.20.22.4.35 link DischargeMedication Discharge Medication 2013‑01‑31
2.16.840.1.113883.10.20.22.2.11 link HospitalDischargeMedicationsSectionentriesoptional Hospital Discharge Medications Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.2.11.1 link HospitalDischargeMedicationsSectionentriesrequired Hospital Discharge Medications Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.22.4.36 link AdmissionMedication Admission Medication 2013‑01‑31
2.16.840.1.113883.10.20.22.2.44 link HospitalAdmissionMedicationsSectionentriesoptional Hospital Admission Medications Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.4.52 link ImmunizationActivity Immunization Activity 2013‑01‑31
2.16.840.1.113883.10.20.22.2.2 link ImmunizationsSectionentriesoptional Immunizations Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.2.2.1 link ImmunizationsSectionentriesrequired Immunizations Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.22.4.7 link Allergy-IntoleranceObservation Allergy - Intolerance Observation 2013‑01‑31
2.16.840.1.113883.10.20.22.4.30 link AllergyProblemAct Allergy Problem Act 2013‑01‑31
2.16.840.1.113883.10.20.22.2.6 link AllergiesSectionentriesoptional Allergies Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.2.6.1 link AllergiesSectionentriesrequired Allergies Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.24.3.90 link SubstanceorDeviceAllergy-IntoleranceObservation Substance or Device Allergy - Intolerance Observation 2013‑01‑31
2.16.840.1.113883.10.20.22.4.49 Containment EncounterActivities Encounter Activities 2013‑01‑31
2.16.840.1.113883.10.20.22.2.22 link EncountersSectionentriesoptional Encounters Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.2.22.1 link EncountersSectionentriesrequired Encounters Section (entries required) 2013‑01‑31
Item DT Card Conf Description Label
cda:observation
(Indication)
treetree @classCode
1 .. 1 F OBS
treetree @moodCode
1 .. 1 F EVN
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:7482) such that it conf‑7482
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.19
treetree cda:id
1 .. 1 M SHALL contain exactly one [1..1] id (CONF:7483).

Set the observation/id equal to an ID on the problem list to signify that problem as an indication.
conf‑7483
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2012-06-01 (CONF:16886). conf‑16886
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.7.2 Problem Type (DYNAMIC)
treetree cda:statusCode
1 .. 1 M SHALL contain exactly one [1..1] statusCode (CONF:7487). conf‑7487
treeblank treetree @code
1 .. 1 F completed
treetree cda:effectiveTime
0 .. 1 R SHOULD contain zero or one [0..1] effectiveTime (CONF:7488). conf‑7488
treetree cda:value
CD 0 .. 1 R SHOULD contain zero or one [0..1] value with @xsi:type="CD" (CONF:7489).

If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the code is something other than SNOMED, @nullFlavor SHOULD be “OTH” and the other code SHOULD be placed in the translation element
conf‑7489
treeblank treetree @nullFlavor
0 .. 1  
treeblank treetree @code
0 .. 1  
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.7.4 Problem (DYNAMIC)