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draft Template  Allergy / Intolerance Observation

Template 1.2.276.0.76.10.4066 - Allergyintoleranceobservation
Id 1.2.276.0.76.10.4066
Klassifikation CDA entry level template
Kontext Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4066
Version gültig ab 2014‑06‑09 Status In Entwicklung
Offen/Geschlossen Offen (auch andere als die definierten Elemente sind erlaubt)
Benutzt von / Benutzt
Benutzt von / Benutzt 3 Templates
Benutzt von Template-Id als Name Version
1.2.276.0.76.10.4065 Containment Allergyconcernact Allergy Concern Act 2015‑03‑27
1.2.276.0.76.10.3051 link AllergienUnvertraeglichkeiten Allergien und Unverträglichkeiten 2015‑03‑26
1.2.276.0.76.10.1015 link EmergencymedicineNoteCDAdocument Emergency medicine Note CDA document 2014‑09‑18
Beziehung Spezialisierung: Template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Adaptation: Template 2.16.840.1.113883.10.20.22.4.7 (2014‑06‑09)
Beispiel
Antibiotika-Allergie bekannt seit 2010
<observation classCode="OBS" moodCode="EVN">
  <templateId root="1.2.276.0.76.10.4066"/>
  <id root="1.2.276.0.76.4.17.9814184919" extension="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
  <statusCode code="completed"/>
  <effectiveTime>
    <low value="2010"/>
  </effectiveTime>  <value xsi:type="CD" code="419199007" displayName="Allergy to substance (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
  <participant typeCode="CSM">
    <participantRole classCode="MANU">
      <playingEntity classCode="MMAT">
        <code code="250428009" codeSystem="2.16.840.1.113883.6.96" displayName="Antimicrobial substance (substance)">
          <originalText>
            <reference value="#alg-1"/>
          </originalText>        </code>      </playingEntity>    </participantRole>  </participant></observation>
Beispiel
Keine Kontrastmittel-Allergie bekannt (negationInd=true)
<observation classCode="OBS" moodCode="EVN" negationInd="true">
  <templateId root="1.2.276.0.76.10.4066"/>
  <id root="1.2.276.0.76.4.17.9814184919" extension="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
  <statusCode code="completed"/>
  <effectiveTime nullFlavor="NA"/>
  <value xsi:type="CD" code="419199007" displayName="Allergy to substance (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
  <participant typeCode="CSM">
    <participantRole classCode="MANU">
      <playingEntity classCode="MMAT">
        <code code="385420005" codeSystem="2.16.840.1.113883.6.96" displayName="Contrast media (substance)">
          <originalText>
            <reference value="#alg-2"/>
          </originalText>        </code>      </playingEntity>    </participantRole>  </participant></observation>
Beispiel
Sonstige Allergie: Hühnereiweiss (Der Freitext steht im zugehörigen Section.text, hier referenziert durch #alg-4)
<observation classCode="OBS" moodCode="EVN">
  <templateId root="1.2.276.0.76.10.4066"/>
  <id root="1.2.276.0.76.4.17.9814184919" extension="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
  <statusCode code="completed"/>
  <effectiveTime nullFlavor="NA"/>
  <value xsi:type="CD" code="419199007" displayName="Allergy to substance (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
  <participant typeCode="CSM">
    <participantRole classCode="MANU">
      <playingEntity classCode="MMAT">
        <code nullFlavor="OTH">
          <originalText>
            <reference value="#alg-4"/>
          </originalText>        </code>      </playingEntity>    </participantRole>  </participant></observation>
Beispiel
Keine Allergie bekannt (negationInd=true)
<observation classCode="OBS" moodCode="EVN" negationInd="true">
  <templateId root="1.2.276.0.76.10.4066"/>
  <id root="1.2.276.0.76.4.17.9814184919" extension="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
  <statusCode code="completed"/>
  <!-- N/A - author/time records when this assertion was made -->
  <effectiveTime nullFlavor="NA"/>
  <value xsi:type="CD" code="419199007" displayName="Allergy to substance (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
Item DT Kard Konf Beschreibung Label
hl7:observation
(Allergyintoleranceobservation)
treetree @classCode
1 .. 1 F OBS
treetree @moodCode
1 .. 1 F EVN
treetree @negationInd
bl 0 .. 1  
treetree hl7:templateId
II 1 .. 1 M (Allergyintoleranceobservation)
treeblank treetree @root
1 .. 1 F 1.2.276.0.76.10.4066
treetree hl7:id
II 1 .. * M (Allergyintoleranceobservation)
treetree hl7:code
CV 1 .. 1 M (Allergyintoleranceobservation)
treeblank treetree @code
1 .. 1 F ASSERTION
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.5.4 (Act Code)
treetree hl7:statusCode
CS 1 .. 1 M (Allergyintoleranceobservation)
treetree hl7:effectiveTime
IVL_TS 1 .. 1 R (Allergyintoleranceobservation)
treeblank treetree hl7:low
TS 0 .. 1 R (Allergyintoleranceobservation)
treeblank treetree hl7:high
TS 0 .. 1 R (Allergyintoleranceobservation)
treetree hl7:value
CV 1 .. 1 M (Allergyintoleranceobservation)
  CONF
@code muss "419199007" sein
@codeSystem muss "2.16.840.1.113883.6.96" sein
oder
@code muss "420134006" sein
@codeSystem muss "2.16.840.1.113883.6.96" sein
treetree hl7:participant
0 .. 1 R (Allergyintoleranceobservation)
treeblank treetree @typeCode
1 .. 1 F CSM
treeblank treetree hl7:participantRole
1 .. 1 M (Allergyintoleranceobservation)
treeblank treeblank treetree @classCode
1 .. 1 F MANU
treeblank treeblank treetree hl7:playingEntity
1 .. 1 M (Allergyintoleranceobservation)
treeblank treeblank treeblank treetree @classCode
1 .. 1 F MMAT
treeblank treeblank treeblank treetree hl7:code
CE 1 .. 1 R (Allergyintoleranceobservation)
  CONF
Der Wert von @code muss gewählt werden aus dem Value Set 1.2.276.0.76.11.52 Allergy / intolerance substances (DYNAMIC)