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pending Template  Allergy - Intolerance Observation

Template 2.16.840.1.113883.10.20.22.4.7 - Allergy-IntoleranceObservation
Id 2.16.840.1.113883.10.20.22.4.7
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 2.16.840.1.113883.10.20.22.4.7
Open/Closed Open (other than defined elements are allowed)
Description This clinical statement represents that an allergy or adverse reaction exists or does not exist. The agent that is the cause of the allergy or adverse reaction is represented as a manufactured material participant playing entity in the allergy observation. While the agent is often implicit in the alert observation (e.g. ""allergy to penicillin""), it should also be asserted explicitly as an entity. The manufactured material participant is used to represent natural and non-natural occurring substances. NOTE: 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.
Used by / Uses
Used by / Uses 12 templates
Used by Template id as Name Version
2.16.840.1.113883.10.20.22.4.30 Containment 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
2.16.840.1.113883.10.20.22.1.3 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
2.16.840.1.113883.10.20.22.1.9 link ProgressNote Progress Note 2013‑01‑31
2.16.840.1.113883.10.20.22.2.6.1 link AllergiesSectionentriesrequired Allergies Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.22.1.2 link ContinuityofCareDocumentCCD Continuity of Care Document (CCD) 2013‑01‑31
Uses Template id as Name Version
2.16.840.1.113883.10.20.22.4.28 Containment AllergyStatusObservation DYNAMIC
2.16.840.1.113883.10.20.22.4.9 Containment ReactionObservation DYNAMIC
2.16.840.1.113883.10.20.22.4.8 Containment SeverityObservation DYNAMIC
Item DT Card Conf Description Label
cda:observation
(Allergy-IntoleranceObservation)
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:7381) such that it conf‑7381
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.7
treetree cda:id
1 .. * M SHALL contain at least one [1..*] id (CONF:7382). conf‑7382
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:15947). conf‑15947
treeblank treetree @code
1 .. 1 F ASSERTION
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.5.4 (Act Code)
treetree cda:statusCode
1 .. 1 M SHALL contain exactly one [1..1] statusCode (CONF:19084). conf‑19084
treeblank treetree @code
1 .. 1 F completed
  Schematron assert role red error
  test count(cda:statusCode)=1
  Message SHALL contain exactly one [1..1] statusCode (CONF:19084).
treetree cda:effectiveTime
1 .. 1 M SHALL contain exactly one [1..1] effectiveTime (CONF:7387).

If it is unknown when the allergy began, this effectiveTime SHALL contain low/@nullFLavor="UNK"

If the allergy is no longer a concern, this effectiveTime MAY contain zero or one [0..1] high
conf‑7387
treetree cda:value
CD 1 .. 1 M SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:7390). conf‑7390
treeblank treetree @code
1 .. 1 R
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.6.2 Allergy/Adverse Event Type (DYNAMIC)
treeblank treetree cda:originalText
0 .. 1 R This value SHOULD contain zero or one [0..1] originalText (CONF:7422). conf‑7422
treeblank treeblank treetree cda:reference
0 .. 1 The originalText, if present, MAY contain zero or one [0..1] reference (CONF:15949).

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‑15949
treeblank treeblank treeblank treetree @value
0 .. 1  
  Schematron assert role red error
  test count(cda:value/cda:originalText/cda:reference[@value])=0 or starts-with(cda:value/cda:originalText/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:participant
0 .. 1 R SHOULD contain zero or one [0..1] participant (CONF:7402) such that it conf‑7402
treeblank treetree @typeCode
1 .. 1 F CSM
treeblank treetree cda:participantRole
1 .. 1 M SHALL contain exactly one [1..1] participantRole (CONF:7404). conf‑7404
treeblank treeblank treetree @classCode
1 .. 1 F MANU
treeblank treeblank treetree cda:playingEntity
1 .. 1 M This participantRole SHALL contain exactly one [1..1] playingEntity (CONF:7406). conf‑7406
treeblank treeblank treeblank treetree @classCode
1 .. 1 F MMAT
treeblank treeblank treeblank treetree cda:code
1 .. 1 M This playingEntity SHALL contain exactly one [1..1] code (CONF:7419). conf‑7419
treeblank treeblank treeblank treeblank treetree cda:originalText
0 .. 1 R This code SHOULD contain zero or one [0..1] originalText (CONF:7424). conf‑7424
treeblank treeblank treeblank treeblank treeblank treetree cda:reference
0 .. 1 R The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:7425).

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‑7425
treeblank treeblank treeblank treeblank treeblank treeblank treetree @value
0 .. 1  
  Schematron assert role red error
  test count(cda:participant/cda:participantRole/cda:playingEntity/cda:code/cda:originalText/cda:reference[@value])=0 or starts-with(cda:participant/cda:participantRole/cda:playingEntity/cda:code/cda:originalText/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)
treeblank treeblank treeblank treeblank treetree cda:translation
PQR 0 .. * This code MAY contain zero or more [0..*] translation (CONF:7431). conf‑7431
treetree cda:entryRelationship
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.28']]
0 .. 1 conf‑7440
treeblank treetree @typeCode
1 .. 1 F SUBJ
treeblank treetree @inversionInd
1 .. 1 F true
  Contains 2.16.840.1.113883.10.20.22.4.28 Allergy Status Observation (DYNAMIC)
treetree cda:entryRelationship
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.9']]
0 .. * R conf‑7447
treeblank treetree @typeCode
1 .. 1 F MFST
treeblank treetree @inversionInd
1 .. 1 F true
  Contains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (DYNAMIC)
treetree cda:entryRelationship
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.8']]
0 .. 1 conf‑9961
treeblank treetree @typeCode
1 .. 1 F SUBJ
treeblank treetree @inversionInd
1 .. 1 F true
  Contains 2.16.840.1.113883.10.20.22.4.8 Severity Observation (DYNAMIC)