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pending Template  Problem Observation

Template 2.16.840.1.113883.10.20.22.4.4 - ProblemObservation
Id 2.16.840.1.113883.10.20.22.4.4
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 2.16.840.1.113883.10.20.22.4.4
Open/Closed Open (other than defined elements are allowed)
Description A problem is a clinical statement that a clinician has noted. In health care it is a condition that requires monitoring or diagnostic, therapeutic, or educational action. It also refers to any unmet or partially met basic human need. A Problem Observation is required to be wrapped in an act wrapper in locations such as the Problem Section, Allergies Section, and Hospital Discharge Diagnosis Section, where the type of problem needs to be identified or the condition tracked. A Problem Observation can be a valid “standalone” template instance in cases where a simple problem observation is to be sent. The negationInd attribute, if true, specifies that the problem indicated was observed to not have occurred (which is subtly but importantly different from having not been observed). NegationInd='true' is an acceptable way to make a clinical assertion that something did not occur, for example, “no diabetes”.
Used by / Uses
Used by / Uses 41 templates
Used by Template id as Name Version
2.16.840.1.113883.10.20.22.2.20 Containment HistoryofPastIllnessSection History of Past Illness Section 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
2.16.840.1.113883.10.20.22.1.6 link ProcedureNote Procedure Note 2013‑01‑31
2.16.840.1.113883.10.20.22.1.8 link DischargeSummary Discharge Summary 2013‑01‑31
2.16.840.1.113883.10.20.22.2.28 Containment ProcedureFindingsSection Procedure Findings Section 2013‑01‑31
2.16.840.1.113883.10.20.22.1.7 link OperativeNote Operative Note 2013‑01‑31
2.16.840.1.113883.10.20.22.2.32 Containment ComplicationsOpNote Complications (OpNote) 2013‑01‑31
2.16.840.1.113883.10.20.22.2.37 Containment ComplicationsSection Complications Section 2013‑01‑31
2.16.840.1.113883.10.20.22.4.3 Containment ProblemConcernActCondition Problem Concern Act (Condition) 2013‑01‑31
2.16.840.1.113883.10.20.22.2.5 link ProblemSectionentriesoptional Problem Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.1.9 link ProgressNote Progress Note 2013‑01‑31
2.16.840.1.113883.10.20.22.2.5.1 link ProblemSectionentriesrequired Problem 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
2.16.840.1.113883.10.20.22.4.33 Containment HospitalDischargeDiagnosis Hospital Discharge Diagnosis 2013‑01‑31
2.16.840.1.113883.10.20.22.2.24 link HospitalDischargeDiagnosisSection Hospital Discharge Diagnosis Section 2013‑01‑31
2.16.840.1.113883.10.20.22.4.34 Containment HospitalAdmissionDiagnosis Hospital Admission Diagnosis 2013‑01‑31
2.16.840.1.113883.10.20.22.2.43 link HospitalAdmissionDiagnosisSection Hospital Admission Diagnosis Section 2013‑01‑31
2.16.840.1.113883.10.20.22.4.51 Containment PostprocedureDiagnosis Postprocedure Diagnosis 2013‑01‑31
2.16.840.1.113883.10.20.22.2.36 link PostprocedureDiagnosisSection Postprocedure Diagnosis Section 2013‑01‑31
2.16.840.1.113883.10.20.22.4.65 Containment PreoperativeDiagnosis Preoperative Diagnosis 2013‑01‑31
2.16.840.1.113883.10.20.22.2.34 link PreoperativeDiagnosisSection Preoperative Diagnosis Section 2013‑01‑31
2.16.840.1.113883.10.20.22.4.79 Containment DeceasedObservation Deceased Observation 2013‑01‑31
2.16.840.1.113883.10.20.22.4.80 Containment EncounterDiagnosis Encounter Diagnosis 2013‑01‑31
2.16.840.1.113883.10.20.22.4.49 link 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
Uses Template id as Name Version
2.16.840.1.113883.10.20.22.4.31 Containment AgeObservation DYNAMIC
2.16.840.1.113883.10.20.22.4.6 Containment ProblemStatus DYNAMIC
2.16.840.1.113883.10.20.22.4.5 Containment HealthStatusObservation DYNAMIC
Item DT Card Conf Description Label
cda:observation
(ProblemObservation)
treetree @classCode
1 .. 1 F OBS
treetree @moodCode
1 .. 1 F EVN
treetree @negationInd
0 .. 1  
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:14926) such that it conf‑14926
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.4
treetree cda:id
1 .. * M SHALL contain at least one [1..*] id (CONF:9043). conf‑9043
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:9045). conf‑9045
  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:text
0 .. 1 R SHOULD contain zero or one [0..1] text (CONF:9185). conf‑9185
treeblank treetree cda:reference
0 .. 1 R The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15587).

This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)
conf‑15587
treeblank treeblank treetree @value
1 .. 1 R
  Schematron assert role red error
  test count(cda:text/cda:reference[@value])=0 or starts-with(cda:text/cda:reference/@value, '#')
  Message This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)
treetree cda:statusCode
1 .. 1 M SHALL contain exactly one [1..1] statusCode (CONF:9049). conf‑9049
treeblank treetree @code
1 .. 1 F completed
treetree cda:effectiveTime
0 .. 1 R SHOULD contain zero or one [0..1] effectiveTime (CONF:9050). conf‑9050
treeblank treetree cda:low
1 .. 1 M The effectiveTime, if present, SHALL contain exactly one [1..1] low (CONF:15603). conf‑15603
treeblank treetree cda:high
0 .. 1 The effectiveTime, if present, MAY contain zero or one [0..1] high (CONF:15604). conf‑15604
treetree cda:value
CD 1 .. 1 SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:9058).

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‑9058
treeblank treetree @nullFlavor
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)
  Schematron assert role red error
  test count(cda:value[@xsi:type='CD' or @xsi:type='CE' or @xsi:type='CV' or @xsi:type='CS' or @xsi:type='CO' or @xsi:type='PQR' or @xsi:type='event' or @xsi:type='SXCM_CD' or @xsi:type='HXIT_CE' or @xsi:type='BXIT_CD'])=1
  Message SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:9058).
treeblank treetree cda:translation
0 .. * This value MAY contain zero or more [0..*] translation (CONF:16749). conf‑16749
treeblank treeblank treetree @code
0 .. 1  
treetree cda:entryRelationship
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.31']]
0 .. 1 conf‑9059
treeblank treetree @typeCode
1 .. 1 F SUBJ
treeblank treetree @inversionInd
1 .. 1 F true
  Contains 2.16.840.1.113883.10.20.22.4.31 Age Observation (DYNAMIC)
treetree cda:entryRelationship
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.6']]
0 .. 1 conf‑9063
treeblank treetree @typeCode
1 .. 1 F REFR
  Contains 2.16.840.1.113883.10.20.22.4.6 Problem Status (DYNAMIC)
treetree cda:entryRelationship
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.5']]
0 .. 1 conf‑9067
treeblank treetree @typeCode
1 .. 1 F REFR
  Contains 2.16.840.1.113883.10.20.22.4.5 Health Status Observation (DYNAMIC)