A_AllergiesAndAdverseReactionIdent Tabular View

This CMET is used to record that a patient has a propensity of an allergic reaction or adverse reaction to a substance, food or drug.

This clinical statement is used to populate the patient's Allergy and Adverse Reaction list. If a patient's record has an AllergyOrAdverseReactionDE-UKCT_MT144048UK02 statement then they should also have one corresponding AllergyOrAdverseReactionIdent-UKCT_MT144053UK02 statement.
However if a patient's record has a AllergyOrAdverseReactionIdent-UKCT_MT144053UK02 statement it is not required for there to be a corresponding AllergyOrAdverseReactionDE-UKCT_MT144048UK02 statement.
A patient's record should only have one AllergyOrAdverseReactionIdent-UKCT_MT144053UK02 statement to the same drug, food or substance.
A patient's record may have more than one AllergyOrAdverseReactionDE-UKCT_MT144048UK02 statement to the same drug, food or substance.
In a GP Summary message then the patient's record equates to the GP Summary.

For example.
If a patient had a clinical statement which stated that he had an allergic reaction to penicillin on the 3rd April 2005 (AllergyOrAdverseReactionDE-UKCT_MT144048UK02), then his PSIS (Personal Spine Information Services) record should also contain a statement that he has propensity to allergy to penicillin statement (AllergyOrAdverseReactionIdent-UKCT_MT144053UK02). In a GP Summary both these statement should appear in the same message.

For back ground to this please refer to the document "Representation in Electronic Patient Records of Allergic Reactions, Adverse Reactions, and Intolerance of Pharmaceutical Products (NPFIT-EP-DB-0007.03)"

N.B. this document is scoped to look at Allergies and Adverse Reactions to pharmaceutical products however the principles hold for Allergies and Adverse Reactions to foods and substances.

Used by:

[1..1] [M] classCode (CS {CNE:ActClass } ) { Fixed="OBS" }

Indicates that this is an Observation.

[1..1] [M] moodCode (CS {CNE:ActMood } ) { Fixed="EVN" }

Indicates this is an Event.

[1..1] [M] code (CD {CNE:AllergyOrAdverseReactionIdentSnCT } )

A SNOMED CT code taken from the vocabulary shown.

The Concept Descriptor (CD) datatype shall be used to carry this information as follows:

The code attribute shall contain acode from the relevant vocabulary.
The code System attribute shall containthe OID for SnomedCT.
The displaytext shall carry a description associated with the codein SnomedCT.
the original text attribute may be used if required.
qualifier (s) may be used if required.

Codes from the above should be used as the object codes for a post coordinated phrase.

These should be post coordinated to the causative agent constraints as described.

The causative agent subsets are for guidance purposes only. No Codes outside this subset may be used. There will be codes in the subset which are unsuitable.

[1..1] [R] effectiveTime (IVL<TS>)

The time during/at which the allergy or adverse reaction propensity was present.

The date range shall be carried as follows:

If both a start date and an end date are present the Date or Time Interval Complete datatype shall be used:

The low attribute shall contain the start date
The high attribute shall contain the end date.

If only a start date is present the Date or Time Interval After datatype shall be used:

The low attribute shall contain the start date

[1..1] [M] id (II)

This is a unique identifier for this instance of an Allergy or Adverse Reaction.

The Identifier Global datatype flavour is used to carry the identifier as follows:

The root attribute shall contain a DCE UUID.

[1..1] [M] statusCode (CS {CNE:ActStatus } ) { Default="completed" }

The status of the Allergy or Adverse Reaction.

The Coded Only datatype flavour is used to carry this information as follows:

The code attribute will contain a one of the following codes from the Act Status vocabulary:

normal
nullified
active
completed

[0..1] author

Refers to the person who is the author of the act.

Constraint: This author is only required if the author or author time is different from the inherited author.

[1..1] [M] typeCode (CS {CNE:ParticipationType } ) { Fixed="AUT" }

Indicates that the role is that ofauthor.

[1..1] [M] contextControlCode (CS {CNE:ContextControl } ) { Fixed="OP" }

Specifies how this participation contributes to the context of the current act and whether it may be propagated to descendent acts whose association allows such propagation.

"O" (Overriding)- the association replaces any context of the same or more specific type that has been conducted from the parent act.

"P" (Propagating)- the association is conducted to all child acts where the ActRelationship.contextConductionInd is set to "true."

[1..1] [R] time (TS)

The time at which the author participated.

[1..1] participant (RoleChoice)

The agent/non-agent who participates in the role of author.

[0..1] informant

Information about the person acting in the role of informant to the author.

Note: This is only required if the Informant or Informant time is different from the inherited Informant.

[1..1] [M] typeCode (CS {CNE:ParticipationType } ) { Fixed="INF" }

Indicates that the role is that of informant.

[1..1] [M] contextControlCode (CS {CNE:ContextControl } ) { Fixed="OP" }

Specifies how this participation contributes to the context of the current act and whether it may be propagated to descendent acts whose association allows such propagation.

"O" (Overriding)- the association replaces any context of the same or more specific type that has been conducted from the parent act.

"P" (Propagating)- the association is conducted to all child acts where the ActRelationship.contextConductionInd is set to "true."

[1..1] [R] time (TS)

The time during /at which the informant participated.

[1..1] participant (RoleChoice)

The person who participates in the role of informant.

[0..1] performer

Refers to a performer of the act.

Where performer participation is used, then all performers must be stated, even if they authored the act.

Where the author did not perform the act then the performer(s) should be explicitly stated.

[1..1] [M] typeCode (CS {CNE:ParticipationType } ) { Fixed="PRF" }

Indicates that this is a performer.

[1..1] [M] contextControlCode (CS {CNE:ContextControl } ) { Fixed="OP" }

Specifies how this participation contributes to the context of the current act and whether it may be propagated to descendent acts whose association allows such propagation.

"O" (Overriding)- the association replaces any context of the same or more specific type that has been conducted from the parent act.

"P" (Propagating)- the association is conducted to all child acts where the ActRelationship.contextConductionInd is set to "true."

[0..1] modeCode (CS {CNE:ParticipationMode } )

The mode in which the participant participated in the Allergy or Adverse Reaction.

The Coded Only datatype flavour is used to carry this information as follows:

The code attribute will contain a value from the list of codes in theParticipationMode vocabulary.

[1..1] [R] time (TS)

The time at/during which the performer participated.

[1..1] participant (RoleChoice)

The person who participates in the role of performer.

[0..1] pertinentInformation

Indicates pertinent supporting information.

[1..1] [M] typeCode (CS {CNE:ActRelationshipType } ) { Fixed="PERT" }

Indicates pertinent information.

[1..1] [M] contextConductionInd (BL) { Fixed="true" }

Indicates that the associations in the source act are conducted across the ActRelationship to the target act.

[1..1] [M] seperatableInd (BL) { Fixed="false" }

Indicates that the source act and the target act are not meant to be interpreted independently.

[1..1] pertinentSupportingInfo (SupportingInfo)

Link to the details of SupportingInformation.

RoleChoice

The person performing this participation.

Used by: Allergy

[1..1] either : UKCT_MT160018UK01

A CMET to identify a person on SDS or provides detailed information for a person not registered on SDS.

... or ... : NonAgentRole

The participating person.

NonAgentRole

A role played by a person who is not an agent (i.e. not a care professional).

Used by: Allergy,RoleChoice

[1..1] [M] classCode (CS {CNE:RoleClass } ) { Fixed="ROL" }

Indicates this is a role.

[1..1] [M] code (CV {CNE:PersonRelationshipType } )

A code identifying the relationship of the non-agent person to the patient, e.g. parent or carer.

The Coded Plain flavour of the Coded Value (CV) datatype shall be used to carry this information as follows:

The code attribute shall contain a value from the list of codes in the vocabulary
The code System attribute shall contain the OID for the vocabulary
The display text attribute will carry a description for the code from the vocabulary.

[0..1] id (II)

An optional unique identifier of the role-player. May be used to convey the NHS number of a patient who is playing a role. It shall be an OID for the identification scheme and the identifier within that scheme (e.g. for patient NHS number).

[0..1] playingNonAgentPerson (NonAgentPerson)

A link to the person playing the non-agent role.

NonAgentPerson

Details of the non-agent person (i.e. not a care professional).

Used by: NonAgentRole

[1..1] [M] classCode (CS {CNE:EntityClass } ) { Fixed="PSN" }

Indicates this is a person.

[1..1] [M] determinerCode (CS {CNE:EntityDeterminer } ) { Fixed="INSTANCE" }

Indicates that the entity is a single identifiable person.

[1..1] [M] name (SET<PN>)

The name(s) of the person.

SupportingInfo

An Act holding overflow information from the Act acting as the root of the clinical statement . Supporting informationshall not contradict the content of the source act, only add to it or explain it.

Used by: Allergy

[1..1] [M] classCode (CS {CNE:ActClass } ) { Fixed="OBS" }

Indicates that this is an Observation.

[1..1] [M] moodCode (CS {CNE:ActMood } ) { Fixed="EVN" }

Indicates this is an Event.

[1..1] [M] code (CV {CNE:TextType } ) { Fixed="SupportingText" }

A code from the shown vocabulary indicating the nature of the supporting information.

The Coded Plain flavour of the Coded Value (CV) datatype shall be used to carry this information.

[1..1] [M] value (ST)

The supporting text.


UKCT_RM144053UK02

Allergy		This CMET is used to record that a patient has a propensity of an allergic reaction or adverse reaction to a substance, food or drug. This clinical statement is used to populate the patient's Allergy and Adverse Reaction list. If a patient's record has an AllergyOrAdverseReactionDE-UKCT_MT144048UK02 statement then they should also have one corresponding AllergyOrAdverseReactionIdent-UKCT_MT144053UK02 statement. However if a patient's record has a AllergyOrAdverseReactionIdent-UKCT_MT144053UK02 statement it is not required for there to be a corresponding AllergyOrAdverseReactionDE-UKCT_MT144048UK02 statement. A patient's record should only have one AllergyOrAdverseReactionIdent-UKCT_MT144053UK02 statement to the same drug, food or substance. A patient's record may have more than one AllergyOrAdverseReactionDE-UKCT_MT144048UK02 statement to the same drug, food or substance. In a GP Summary message then the patient's record equates to the GP Summary. For example. If a patient had a clinical statement which stated that he had an allergic reaction to penicillin on the 3rd April 2005 (AllergyOrAdverseReactionDE-UKCT_MT144048UK02), then his PSIS (Personal Spine Information Services) record should also contain a statement that he has propensity to allergy to penicillin statement (AllergyOrAdverseReactionIdent-UKCT_MT144053UK02). In a GP Summary both these statement should appear in the same message. For back ground to this please refer to the document "Representation in Electronic Patient Records of Allergic Reactions, Adverse Reactions, and Intolerance of Pharmaceutical Products (NPFIT-EP-DB-0007.03)" N.B. this document is scoped to look at Allergies and Adverse Reactions to pharmaceutical products however the principles hold for Allergies and Adverse Reactions to foods and substances.

	Used by:

[1..1] [M] classCode (CS {CNE:ActClass } ) { Fixed="OBS" }		Indicates that this is an Observation.

[1..1] [M] moodCode (CS {CNE:ActMood } ) { Fixed="EVN" }		Indicates this is an Event.

[1..1] [M] code (CD {CNE:AllergyOrAdverseReactionIdentSnCT } )		A SNOMED CT code taken from the vocabulary shown. The Concept Descriptor (CD) datatype shall be used to carry this information as follows: The code attribute shall contain acode from the relevant vocabulary. The code System attribute shall containthe OID for SnomedCT. The displaytext shall carry a description associated with the codein SnomedCT. the original text attribute may be used if required. qualifier (s) may be used if required. Codes from the above should be used as the object codes for a post coordinated phrase. These should be post coordinated to the causative agent constraints as described. The causative agent subsets are for guidance purposes only. No Codes outside this subset may be used. There will be codes in the subset which are unsuitable.

[1..1] [R] effectiveTime (IVL<TS>)		The time during/at which the allergy or adverse reaction propensity was present. The date range shall be carried as follows: If both a start date and an end date are present the Date or Time Interval Complete datatype shall be used: The low attribute shall contain the start date The high attribute shall contain the end date. If only a start date is present the Date or Time Interval After datatype shall be used: The low attribute shall contain the start date

[1..1] [M] id (II)		This is a unique identifier for this instance of an Allergy or Adverse Reaction. The Identifier Global datatype flavour is used to carry the identifier as follows: The root attribute shall contain a DCE UUID.

[1..1] [M] statusCode (CS {CNE:ActStatus } ) { Default="completed" }		The status of the Allergy or Adverse Reaction. The Coded Only datatype flavour is used to carry this information as follows: The code attribute will contain a one of the following codes from the Act Status vocabulary: normal nullified active completed

[0..1] author		Refers to the person who is the author of the act. Constraint: This author is only required if the author or author time is different from the inherited author.


[1..1] [M] typeCode (CS {CNE:ParticipationType } ) { Fixed="AUT" }		Indicates that the role is that ofauthor.

[1..1] [M] contextControlCode (CS {CNE:ContextControl } ) { Fixed="OP" }		Specifies how this participation contributes to the context of the current act and whether it may be propagated to descendent acts whose association allows such propagation. "O" (Overriding)- the association replaces any context of the same or more specific type that has been conducted from the parent act. "P" (Propagating)- the association is conducted to all child acts where the ActRelationship.contextConductionInd is set to "true."

[1..1] [R] time (TS)		The time at which the author participated.

[1..1] participant (RoleChoice)		The agent/non-agent who participates in the role of author.

[0..1] informant		Information about the person acting in the role of informant to the author. Note: This is only required if the Informant or Informant time is different from the inherited Informant.


[1..1] [M] typeCode (CS {CNE:ParticipationType } ) { Fixed="INF" }		Indicates that the role is that of informant.

[1..1] [M] contextControlCode (CS {CNE:ContextControl } ) { Fixed="OP" }		Specifies how this participation contributes to the context of the current act and whether it may be propagated to descendent acts whose association allows such propagation. "O" (Overriding)- the association replaces any context of the same or more specific type that has been conducted from the parent act. "P" (Propagating)- the association is conducted to all child acts where the ActRelationship.contextConductionInd is set to "true."

[1..1] [R] time (TS)		The time during /at which the informant participated.

[1..1] participant (RoleChoice)		The person who participates in the role of informant.

[0..1] performer		Refers to a performer of the act. Where performer participation is used, then all performers must be stated, even if they authored the act. Where the author did not perform the act then the performer(s) should be explicitly stated.


[1..1] [M] typeCode (CS {CNE:ParticipationType } ) { Fixed="PRF" }		Indicates that this is a performer.

[1..1] [M] contextControlCode (CS {CNE:ContextControl } ) { Fixed="OP" }		Specifies how this participation contributes to the context of the current act and whether it may be propagated to descendent acts whose association allows such propagation. "O" (Overriding)- the association replaces any context of the same or more specific type that has been conducted from the parent act. "P" (Propagating)- the association is conducted to all child acts where the ActRelationship.contextConductionInd is set to "true."

[0..1] modeCode (CS {CNE:ParticipationMode } )		The mode in which the participant participated in the Allergy or Adverse Reaction. The Coded Only datatype flavour is used to carry this information as follows: The code attribute will contain a value from the list of codes in theParticipationMode vocabulary.

[1..1] [R] time (TS)		The time at/during which the performer participated.

[1..1] participant (RoleChoice)		The person who participates in the role of performer.

[0..1] pertinentInformation		Indicates pertinent supporting information.


[1..1] [M] typeCode (CS {CNE:ActRelationshipType } ) { Fixed="PERT" }		Indicates pertinent information.

[1..1] [M] contextConductionInd (BL) { Fixed="true" }		Indicates that the associations in the source act are conducted across the ActRelationship to the target act.

[1..1] [M] seperatableInd (BL) { Fixed="false" }		Indicates that the source act and the target act are not meant to be interpreted independently.

[1..1] pertinentSupportingInfo (SupportingInfo)		Link to the details of SupportingInformation.

RoleChoice		The person performing this participation.

	Used by: Allergy

[1..1] either : UKCT_MT160018UK01		A CMET to identify a person on SDS or provides detailed information for a person not registered on SDS.

... or ... : NonAgentRole		The participating person.

NonAgentRole		A role played by a person who is not an agent (i.e. not a care professional).

	Used by: Allergy,RoleChoice

[1..1] [M] classCode (CS {CNE:RoleClass } ) { Fixed="ROL" }		Indicates this is a role.

[1..1] [M] code (CV {CNE:PersonRelationshipType } )		A code identifying the relationship of the non-agent person to the patient, e.g. parent or carer. The Coded Plain flavour of the Coded Value (CV) datatype shall be used to carry this information as follows: The code attribute shall contain a value from the list of codes in the vocabulary The code System attribute shall contain the OID for the vocabulary The display text attribute will carry a description for the code from the vocabulary.

[0..1] id (II)		An optional unique identifier of the role-player. May be used to convey the NHS number of a patient who is playing a role. It shall be an OID for the identification scheme and the identifier within that scheme (e.g. for patient NHS number).

[0..1] playingNonAgentPerson (NonAgentPerson)		A link to the person playing the non-agent role.

NonAgentPerson		Details of the non-agent person (i.e. not a care professional).

	Used by: NonAgentRole

[1..1] [M] classCode (CS {CNE:EntityClass } ) { Fixed="PSN" }		Indicates this is a person.

[1..1] [M] determinerCode (CS {CNE:EntityDeterminer } ) { Fixed="INSTANCE" }		Indicates that the entity is a single identifiable person.

[1..1] [M] name (SET<PN>)		The name(s) of the person.

SupportingInfo		An Act holding overflow information from the Act acting as the root of the clinical statement . Supporting informationshall not contradict the content of the source act, only add to it or explain it.

	Used by: Allergy

[1..1] [M] classCode (CS {CNE:ActClass } ) { Fixed="OBS" }		Indicates that this is an Observation.

[1..1] [M] moodCode (CS {CNE:ActMood } ) { Fixed="EVN" }		Indicates this is an Event.

[1..1] [M] code (CV {CNE:TextType } ) { Fixed="SupportingText" }		A code from the shown vocabulary indicating the nature of the supporting information. The Coded Plain flavour of the Coded Value (CV) datatype shall be used to carry this information.

[1..1] [M] value (ST)		The supporting text.

A_AllergiesAndAdverseReactionIdent - tabular view