Problem - tabular view

No Current Link To VocabularyCoded With ExtensionsCoded No Extensions

Fri Nov 09 12:57:42 GMT 2007

COCD_TP146006UK04
Problem

An abstract problem and issue node which indicates the a coded entry has been catergorised as a problem and issue.

A Problem and Issue is created by Creating a condition node and relating this to the coded entry which is the Problem and Issue. This will, usually but not always, be a Diagnosis or a Clinical Observation and Finding.

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

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

Indicates that this is an event.
[1..1] [M] code (CV {CNE:SnomedCT } ) { Fixed="181301000000103" }

A fixed SnomedCT code.

The Coded Value (CV) with CDA URL datatype/flavour shall be used to carry this information as follows:

  • The code attribute shall contain a code from the relevant vocabulary
  • The codeSystem attribute shall contain the OID for SnomedCT
  • The displayName attribute shall carry a description associated with the code in SnomedCT
  • The originalText element can be used to carry a reference element. This can link the coded item to the relevant text in the CDA section
Note the implementation guidance for the domain where this template is used should be consulted regarding correct usage of the originalText element.
[1..1] [M] effectiveTime (IVL<TS>)

The effective date carries the start and end date/time of the problem.

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
This is required to indicate that the problem is no longer active along with a status code of completed.

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.
This should be used along with an status code of active to indicate the problem is still ongoing.
[1..1] [M] id (II)

This is a unique identifier for this instance of a Problem.

The Identifier Global data type flavour is used to carry the identifier follows:

  • The root attribute shall contain a DCE UUID.
[1..1] [M] statusCode (CS {CNE:ActStatus } ) { Default="active" }
The status of the Problem.

The Coded Only data type 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:
    • nullified
    • active
    • completed.
[1..1] [M] templateId (II) { Fixed="COCD_TP146006UK04#Problem" }

The fixed value of this attribute provides a unique identifier for the template and the classname within that template.

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

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The extension attribute shall contain the fixed value.
[0..1] author

Refers to the author of the problem.

Note :- This is the person who highlighted the information represented by the coded entry as a problem.

Only required if different to inherited author or no author is inherited.

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

Indicates this is an author.
[1..1] [M] contextControlCode (CS {CNE:ContextControl } ) { Fixed="OP" }

Specifies how this author contributes to the context of the problem 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] [M] contentId (II) { "NPFIT-000001#Role" }

This attribute, when valued in an instance, provides a unique forward pointing identifier for a template which constrains the classes and attributes which follow.

The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning.

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

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.16"
  • The extension attribute shall contain the template artifact Id.
[1..1] [M] functionCode (CV {CNE:AuthorFunctionType } ) { Fixed="OA" }

A code from the vocabulary shown indicating the function of the document author

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

  • The code attribute shall contain the value.
  • The codeSystem attribute shall contain the OID for the vocabulary concerned.
  • The displayName attribute shall contain the text associated with the code
[1..1] [M] templateId (II) { Fixed="COCD_TP146006UK04#author" }

The fixed value of this attribute provides a unique identifier for the template and the classname within that template.

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

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The extension attribute shall contain the fixed value.
[1..1] [R] time (TS)

When the author authored the problem act.
[1..1] participant (AuthorChoice)

A link to choice of authors.
[1..1] [M] entryRelationship

Refers to the coded entry which has been highlighted as a problem.

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

Indicates that the coded entry is the subject of the problem assertion.
[1..1] [M] contextConductionInd (BL) { Fixed="false" }

If true, associations in the parent act are conducted across the ActRelationship to the child act.
[1..1] [M] contentId (II) { "NPFIT-000002#ActRef" }

This attribute, when valued in an instance, provides a unique forward pointing identifier for a template which constrains the classes and attributes which follow.

The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning.

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

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.16"
  • The extension attribute shall contain the template artifact Id.
[1..1] [M] seperatableInd (BL) { Fixed="false" }

Indicates if the source Act is to be interpreted independently of the target Act.
[1..1] [M] templateId (II) { Fixed="COCD_TP146006UK04#entryRelationship" }

The fixed value of this attribute provides a unique identifier for the template and the classname within that template.

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

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The extension attribute shall contain the fixed value.
[1..1] [M] codedEntryReference (CodedEntryReference)

A link to a coded entry reference.
CodedEntryReference
Refers to the choice of coded entry references.
Used by: Problem
[1..1] either : Template

A link to the choice of coded entry reference templates.
AuthorChoice

Refers to the choice of authors

Used by: Problem
[1..1] either : Template1

A link to the author templates.