FamilyHistory - tabular view

No Current Link To VocabularyCoded With ExtensionsCoded No Extensions

Fri Nov 09 12:57:43 GMT 2007

COCD_TP146018UK04
FamilyHistory

Family History releates to a previous event or condition in a family relative deemed to be significant to the care or health of the patient.

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 that this is an event.

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

A SNOMED CT code taken from the vocabulary shown.

The Concept Descriptor (CD) 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
  • qualifier (s) may be used if required
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 time for Family History relates to the disease as it occurred in family member. So the date of diagnosis of breast cancer in the mother would be appropriate. It is acceptable to have a low attribute only, a low and a high, and a centre.

The clinically relevant time or duration that the Family History observation was applicable.

The date range shall be carried as follows:

If a single point in time is to be carried the Date or Time Point data type shall be used:

  • The center attribute shall contain the date.

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

  • The low attribute shall contain the start date.

If only an end date is present the Date or Time Interval Before data type shall be used:

  • The high attribute shall contain the end date.
[1..1] [M] id (II)

This is a unique identifier for this instance of a Family History observation.

The Identifier Global datatype flavour is used to carry the first identifiers follows:

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

The status of the observation.

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
    • completed
[1..1] [M] templateId (II) { Fixed="COCD_TP146018UK04#FamilyHistory" }

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

The person who authored the recording of the family history observation.

Only required if different to inherited author or no author is inherited.
[1..1] [M] typeCode (CS {CNE:ParticipationType } ) { Fixed="AUT" }

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

Specifies how this author contributes to the context of the family history observation 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_TP146018UK04#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)

The time the author authoured the family history observation.
[1..1] participant (AuthorChoice)

A link to the choice of author templates.
[0..1] informant

Refers to who informed about the family history event or condition.

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

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

Specifies how the informant contributes to the context of the family history observation and whether they 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-000002#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] templateId (II) { Fixed="COCD_TP146018UK04#informant" }

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] participant (InformantChoice)
A link to the choice of informant templates.
AuthorChoice

Refers to the choice of author of the family history observation.

Used by: FamilyHistory
[1..1] either : Template

A link to the author templates.
InformantChoice

Refers to the choice of informants of the family history observation.

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

A link to the choice of informant templates.