CDA On FHIR England - End of Life Care Document

COFE-AllergicOrAdverseReactions-AllergyIntolerance-1

Records information of a known allergy or adverse reaction relating to the patient.

NameCard.TypeDescription & Constraints
..AllergyIntoleranceAllergyIntoleranceAllergy or Intolerance (generally: Risk Of Adverse reaction to a substance)

...Probability of Recurrence0..1ExtensionAn extension to represent the probability of recurrence of an allergy or intolerence.
Extension http://fhir.nhs.net/StructureDefinition/extension-cofe-probability-of-recurrence-1

...identifier1..1IdentifierExternal ids for this item

....value1..1StringShall contain a DCE UUID
Example Value c541803c-d575-4c57-bee0-cfbcd748626d

...onset0..1DateTimeDate(/time) when manifestations showed

...recordedDate0..1DateTimeWhen recorded

...recorder0..1Reference (cofe-practitioner-1)Who recorded the sensitivity

...patient1..1Reference (cofe-patient-1)Who the sensitivity is for

....reference1..1StringRelative URL reference

....display0..1StringText alternative for the resource

...substance (Causative Agent)1..1CodeableConceptSubstance, (or class) considered to be responsible for risk
Binding An agent such as food, drug or substances that has caused, or many cause an allergy, intolerance or adverse reaction in a patient. (http://fhir.nhs.net/ValueSet/causative-agent-snct-1)
Binding Strength Required

....coding0..1CodingCode defined by a terminology system
Binding A subset of the Snomed-CT clinical terminology (i.e. coding system) intended for use in the UK, previously named SnomedCTUK, that describes an agent such as food, drug or substances that has caused, or may cause an allergy, intolerance or adverse reaction in a patient. (http://fhir.nhs.net/ValueSet/causative-agent-snct-1)
Binding Strength Required

.....system1..1UriIdentity of the terminology system
Fixed Value http://fhir.nhs.net/ValueSet/causative-agent-snct-1

.....code1..1CodeSymbol in syntax defined by the system
Binding An agent such as food, drug or substances that has caused, or may cause an allergy, intolerance or adverse reaction in a patient. (http://fhir.nhs.net/ValueSet/causative-agent-snct-1)
Binding Strength Required

.....display1..1StringRepresentation defined by the system

....text0..1StringPlain text representation of the concept. If there are no known allergies or adverse reactions then text should be used to carry the string "No known drug allergies or adverse reactions" or the string "Information not available".

...status1..1Codeactive | unconfirmed | confirmed | inactive | resolved | refuted | entered-in-error
Binding Assertion about certainty associated with a propensity, or potential risk, of a reaction to the identified Substance. (http://hl7.org/fhir/ValueSet/allergy-intolerance-status)
Binding Strength Required

...criticality0..1CodeCRITL | CRITH | CRITU
Binding Estimate of the potential clinical harm, or seriousness, of a reaction to an identified Substance. (http://hl7.org/fhir/ValueSet/allergy-intolerance-criticality)
Binding Strength Required

...type0..1Codeallergy | intolerance - Underlying mechanism (if known)
Binding Identification of the underlying physiological mechanism for a Reaction Risk. (http://hl7.org/fhir/ValueSet/allergy-intolerance-type)
Binding Strength Required

...category0..1Codefood | medication | environment | other - Category of Substance
Binding Category of an identified Substance. (http://hl7.org/fhir/ValueSet/allergy-intolerance-category)
Binding Strength Required

...note0..1AnnotationAdditional text not captured in other fields

....text1..1StringThe annotation - text content

...reaction0..*BackboneElementAdverse Reaction Events linked to exposure to substance

....substance0..1CodeableConceptSpecific substance considered to be responsible for event
Binding An agent such as food, drug or substances that has caused, or may cause an allergy, intolerance or adverse reaction in a patient. (http://fhir.nhs.net/ValueSet/causative-agent-snct-1)
Binding Strength Required

.....coding0..1CodingCode defined by a terminology system
Binding An agent such as food, drug or substances that has caused, or may cause an allergy, intolerance or adverse reaction in a patient. (http://fhir.nhs.net/ValueSet/causative-agent-snct-1)
Binding Strength Required

......system1..1UriIdentity of the terminology system
Fixed Value http://fhir.nhs.net/ValueSet/causative-agent-snct-1

......code1..1CodeSymbol in syntax defined by the system

......display1..1StringRepresentation defined by the system

.....text0..1StringPlain text representation of the concept

....certainty0..1Codeunlikely | likely | confirmed - clinical certainty about the specific substance
Binding Statement about the degree of clinical certainty that a Specific Substance was the cause of the Manifestation in an reaction event. (http://hl7.org/fhir/ValueSet/reaction-event-certainty)
Binding Strength Required

....manifestation1..*CodeableConceptClinical symptoms/signs associated with the Event
Binding A description of the manifestation of the reaction experienced by the patient. (http://fhir.nhs.net/ValueSet/finding-snct-1)
Binding Strength Example

.....coding1..1CodingCode defined by a terminology system
Binding A description of the manifestation of the reaction experienced by the patient. (http://fhir.nhs.net/ValueSet/finding-snct-1)
Binding Strength Required

......system1..1UriIdentity of the terminology system
Fixed Value http://fhir.nhs.net/ValueSet/finding-snct-1

......code1..1CodeSymbol in syntax defined by the system
Binding A description of the manifestation of the reaction experienced by the patient. (http://fhir.nhs.net/ValueSet/finding-snct-1)
Binding Strength Required

......display1..1StringRepresentation defined by the system

.....text0..1StringPlain text representation of the concept

....onset0..1DateTimeDate(/time) when manifestations showed

....severity0..1Codemild | moderate | severe (of event as a whole)
Binding Clinical assessment of the severity of a reaction event as a whole, potentially considering multiple different manifestations. (http://hl7.org/fhir/ValueSet/reaction-event-severity)
Binding Strength Required

....note0..1AnnotationText about event not captured in other fields

.....text1..1StringThe annotation - text content

Name Type Description & Constraints
. . Extension-COFE-Probability-Of-Recurrence-1 Extension An extension to represent the probability of recurrence of an allergy or intolerance.
Path Name Binding Strength ValueSet
.AllergyIntolerance.substance Causative Agent Required http://fhir.nhs.net/ValueSet/causative-agent-snct-1
.AllergyIntolerance.substance.coding coding Required http://fhir.nhs.net/ValueSet/causative-agent-snct-1
.AllergyIntolerance.substance.coding.code code Required http://fhir.nhs.net/ValueSet/causative-agent-snct-1
.AllergyIntolerance.status status Required http://hl7.org/fhir/ValueSet/allergy-intolerance-status
.AllergyIntolerance.reaction.substance substance Required http://fhir.nhs.net/ValueSet/causative-agent-snct-1
.AllergyIntolerance.reaction.manifestation manifestation Example http://fhir.nhs.net/ValueSet/finding-snct-1
.AllergyIntolerance.reaction.manifestation.coding coding Required http://fhir.nhs.net/ValueSet/finding-snct-1
.AllergyIntolerance.reaction.manifestation.coding.code code Required http://fhir.nhs.net/ValueSet/finding-snct-1

COFE-AllergicOrAdverseReactions-AllergyIntolerance-1

Examples Description XML File JSON File
COFE-AllergicOrAdverseReactions-AllergyIntolerence-Example-1 Patient Allergy - Sticking Plaster
COFE-AllergicOrAdverseReactions-AllergyIntolerence-Example-2 Patient Allergy - Penicillin
COFE-AllergicOrAdverseReactions-AllergyIntolerence-Example-3 Patient Allergy - Lanolin Oil
COFE-AllergicOrAdverseReactions-AllergyIntolerence-Example-4 Patient Allergy - Cat Dander
COFE-AllergicOrAdverseReactions-AllergyIntolerence-Example-5 Patient Allergy - Mazindol
COFE-AllergicOrAdverseReactions-AllergyIntolerence-Example-6 Patient Allergy - Aspirin