Allergy to specific drug Penicillin

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Approval Status

  • Approval Status: Approved

  • Example Task Force: 4/10/2014

  • SDWG: 4/24/2014

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

C-CDA 2.1 Example:

  • 2.16.840.1.113883.10.20.22.2.6.1:2015-08-01

  • Allergy Concern Act 2.16.840.1.113883.10.20.22.4.30:2015-08-01

  • Allergy Intolerance Observation 2.16.840.1.113883.10.20.22.4.7:2014-06-09

  • Reaction Observation 2.16.840.1.113883.10.20.22.4.9:2014-06-09
  • Severity Observation 2.16.840.1.113883.10.20.22.4.8:2014-06-09

Reference to full CDA sample:

  • Allergies in empty CCD

Validation location

Comments

  • This is an example of an allergy to a specific drug (penicillin) using RxNorm as terminology with information on both allergic reaction and reaction severity. For drug allergies, this example illustrates a good practice of encoding the allergen at the ingredient level (penicillin) not administration level (10 mg tablet). See DSTU 219 for update regarding act/code.

  • Multiple reactions are listed in some examples

    Custodian

  • John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)

Keywords

  • substance, allergies, allergy

Permalink

Links

 

Example: download example view on GitHub 

<section>
	<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
	<templateId root="2.16.840.1.113883.10.20.22.2.6.1" extension="2015-08-01"/>
	<!-- Allergies (entries required) section template -->
	<code code="48765-2" codeSystem="2.16.840.1.113883.6.1"/>
	<title>Allergies, Adverse Reactions and Alerts</title>
	<text>
		<table>
			<thead>
				<tr>
					<th>Allergen</th>
					<th>Reaction</th>
					<th>Reaction Severity</th>
					<th>Documentation Date</th>
					<th>Start Date</th>
				</tr>
			</thead>
			<tbody>
				<tr ID="allergy2">
					<td ID="allergy2allergen">Penicillin</td>
					<td ID="allergy2reaction">Anaphylaxis</td>
					<td ID="allergy2reactionseverity">Severe</td>
					<td>Jan 4 2014</td>
					<td>2006</td>
				</tr>
			</tbody>
		</table>
	</text>
	<entry typeCode="DRIV">
		<act classCode="ACT" moodCode="EVN">
			<!-- ** Allergy problem act ** -->
			<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.30" extension="2015-08-01"/>
			<id root="4a2ac5fc-0c85-4223-baee-c2e254803974"/>
			<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
			<text>
				<reference value="#allergy2" />
			</text>
			<statusCode code="active"/>
			<!-- This is the time stamp for when the allergy was first documented as a concern-->
			<effectiveTime>
				<low value="20140104123506-0500"/>
			</effectiveTime>
			<author>
				<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
				<time value="20140104"/>
				<assignedAuthor>
					<id extension="99999999" root="2.16.840.1.113883.4.6"/>
					<code code="207Q00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Health Care Provider Taxonomy" displayName="Allopathic &amp; Osteopathic Physicians; Family Medicine" />
					<telecom use="WP" value="tel:555-555-1002"/>
					<assignedPerson>
						<name>
							<given>Henry</given>
							<family>Seven</family>
						</name>
					</assignedPerson>
				</assignedAuthor>
			</author>
			<entryRelationship typeCode="SUBJ">
				<observation classCode="OBS" moodCode="EVN">
					<!-- allergy observation template -->
					<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
					<templateId root="2.16.840.1.113883.10.20.22.4.7" extension="2014-06-09"/>
					<id root="4a2ac5fc-0c85-4223-baee-c2e254803974"/>
					<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
					<text>
						<reference value="#allergy2" />
					</text>
					<statusCode code="completed"/>
					<!-- This is the time stamp for the biological onset of the allergy. -->
					<!-- Just the year is shown since a specific month and date was not reported -->
					<effectiveTime>
						<low value="2006"/>
					</effectiveTime>
					<!-- This specifies that the allergy is to a medication in contrast to other allergies (substance) -->
					<value xsi:type="CD" code="416098002" displayName="Allergy to drug" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
					<author>
						<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
						<time value="20140104"/>
						<assignedAuthor>
							<id extension="99999999" root="2.16.840.1.113883.4.6"/>
							<code code="207Q00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Health Care Provider Taxonomy" displayName="Allopathic &amp; Osteopathic Physicians; Family Medicine" />
							<telecom use="WP" value="tel:555-555-1002"/>
							<assignedPerson>
								<name>
									<given>Henry</given>
									<family>Seven</family>
								</name>
							</assignedPerson>
						</assignedAuthor>
					</author>
					<participant typeCode="CSM">
						<participantRole classCode="MANU">
							<playingEntity classCode="MMAT">
								<!-- RxNorm is used to report specific drug allergies. Note to use SNOMED CT for drug classes -->
								<!-- Best practice is to report drug allergies at ingredient level (e.g. penicillin) not at the adminsitration level (e.g. 10mg tablet)-->
								<code code="7980" displayName="penicillin G" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
									<originalText>
										<reference value="#allergy2allergen"/>
									</originalText>
								</code>
							</playingEntity>
						</participantRole>
					</participant>
					<entryRelationship typeCode="MFST" inversionInd="true">
						<observation classCode="OBS" moodCode="EVN">
							<!-- Reaction Observation template -->
							<templateId root="2.16.840.1.113883.10.20.22.4.9"/>
							<templateId root="2.16.840.1.113883.10.20.22.4.9" extension="2014-06-09"/>
							<id root="0506c036-adfb-4e6e-b9e1-eea76177ead5"/>
							<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
							<text>
								<reference value="#allergy2reaction"/>
							</text>
							<statusCode code="completed"/>
							<effectiveTime>
								<low value="2006"/>
								<high nullFlavor="UNK"/>
							</effectiveTime>
							<value xsi:type="CD" code="39579001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Anaphylaxis"/>
							<!-- The Severity observation is no longer recommended, use criticality observation in future exchanges -->
							<entryRelationship typeCode="SUBJ" inversionInd="true">
								<observation classCode="OBS" moodCode="EVN">
									<!-- Severity Observation template -->
									<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
									<templateId root="2.16.840.1.113883.10.20.22.4.8"
 extension="2014-06-09"/>
									<code code="SEV" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
									<text>
										<reference value="#allergy2reactionseverity"/>
									</text>
									<statusCode code="completed"/>
									<value xsi:type="CD" code="24484000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Severe"/>
								</observation>
							</entryRelationship>
						</observation>
					</entryRelationship>
				</observation>
			</entryRelationship>
		</act>
	</entry>
</section>

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