Active Problem

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 10/2/2014

  • SDWG: 11/6/2014

  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

C-CDA 2.1 Example:

  • 2.16.840.1.113883.10.20.22.2.5.1:2015-08-01
  • 2.16.840.1.113883.10.20.22.4.3:2015-08-01
  • 2.16.840.1.113883.10.20.22.4.119
  • 2.16.840.1.113883.10.20.22.4.4:2015-08-01

Reference to full CDA sample:

  • Problems in empty CCD

Validation location

Comments

  • This example illustrates how to structure an active problem.

    Custodian

  • Brett Marquard brett@riverrockassociates.com (GitHub: brettmarquard)

    Keywords

  • problems

Permalink

Links

 

Example: download example view on GitHub 

<section>
	<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
	<templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
	<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" displayName="Problem List"/>
	<title>Problem List</title>
	<text>
		<table>
			<thead>
				<tr>
					<th>Name</th>
					<th>Dates</th>
					<th>Status</th>
				</tr>
			</thead>
			<tbody>
				<tr ID="Problem1">
					<td>Community Acquired Pneumonia</td>
					<td>
						<content>Onset: February 27 2014</content>
					</td>
					<td>Active</td>
				</tr>
			</tbody>
		</table>
	</text>
	<entry>
		<act classCode="ACT" moodCode="EVN">
			<templateId root="2.16.840.1.113883.10.20.22.4.3" />
			<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01"/>
			<id root="102ca2e9-884c-4523-a2b4-1b6c3469c397"/>
			<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
			<!-- Since this is an active problem, the concern status is active. -->
			<!-- While clinicians can track resolved problems, generally active problems will have active concern status and resolved concerns will be completed -->
			<statusCode code="active"/>
			<effectiveTime>
				<!-- This equates to the time the concern was authored in the patient's chart. This may frequently be an EHR timestamp-->
				<low value="20140302124536-0500"/>
			</effectiveTime>
			<entryRelationship typeCode="SUBJ">
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.4" />
					<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
					<id extension="10241104348" root="1.3.6.1.4.1.22812.4.111.0.4.1.2.1"/>
					<code code="55607006" displayName="Problem"
						codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
						<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1"
							codeSystemName="LOINC" displayName="Problem"/>
					</code>
					<text>
						<reference value="#Problem1"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime>
						<!-- This represents the date of biological onset. -->
						<low value="20140227"/>
					</effectiveTime>
					<!-- This is a SNOMED code as the primary vocabulary for problem lists-->
					<value xsi:type="CD" code="385093006" codeSystem="2.16.840.1.113883.6.96"
						codeSystemName="SNOMED CT" displayName="Community acquired pneumonia"/>
					<author>
						<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
						<time value="20140302124536"/>
						<assignedAuthor>
							<id extension="66666" root="2.16.840.1.113883.4.6"/>
							<code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101"
								codeSystemName="NUCC" displayName="Allopathic &amp; Osteopathic Physicians; Internal Medicine, Cardiovascular Disease"/>
							<addr>
								<streetAddressLine>6666 StreetName St.</streetAddressLine>
								<city>Silver Spring</city>
								<state>MD</state>
								<postalCode>20901</postalCode>
								<country>US</country>
							</addr>
							<telecom value="tel:+1(301)666-6666" use="WP"/>
							<assignedPerson>
								<name>
									<given>Heartly</given>
									<family>Sixer</family>
									<suffix>MD</suffix>
								</name>
							</assignedPerson>
						</assignedAuthor>
					</author>
				</observation>
			</entryRelationship>
		</act>
	</entry>
</section>

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