Problem TargetSiteCode Qualifier

back to homepage

Approval Status

  • Approval Status: Approved
  • Example Task Force: 2/2/2017
  • SDWG: 5/18/2017

C-CDA 2.1 Example:

  • 2.16.840.1.113883.10.20.22.2.6.1:2015-08-01
  • Problem Section: 2.16.840.1.113883.10.20.22.2.5.1:2015-08-01
  • Problem Act: 2.16.840.1.113883.10.20.22.4.3:2015-08-01
  • Problem Observation: 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 is an example of adding a SNOMED qualifier to an ambiguous ICD-9 which could be used in qualifying patients related to QRDA/eCQM measure

Custodian

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

Keywords

  • problem, qualifier, QRDA, eCQM, laterality, targetSiteCod

Permalink

Links

 

Example: download example view on GitHub 

<!-- An example of how to use a qualifier. This example shows presence of a problem/value/translation, although it could also be used to refine the problem/value -->
<!-- The use of qualifiers could also be used on other sections, such as qualifying a procedure -->
<section>
    <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>Location/Qualifier</th>
                    <th>Status</th>
                </tr>
            </thead>
            <tbody>
                <tr ID="Problem1">
                    <td ID="ProblemDescription1">Below Knee Amputation</td>
                    <td>
                        <content>Onset: Apr 2 2014</content>
                    </td>
                    <td>Left</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" extension="2015-08-01"/>
            <id root="e5fbc288-659f-4aeb-a5e1-eb7cc8fcdfaf" />
            <code code="CONC" codeSystem="2.16.840.1.113883.5.6" />
            <!-- 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 represents the time that the clinician began tracking the concern. This may frequently be an EHR timestamp-->
                <low value="20140403124536-0500" />
            </effectiveTime>
            <entryRelationship typeCode="SUBJ">
                <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
                    <id root="ac416033-3cc1-4485-ab31-36ce7669f55c" />
                    <code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="55607006" displayName="Problem">
                        <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. This can be before the patient vistited the clinician, as illustrated in this example-->
                        <low value="20140402" />
                    </effectiveTime>
                    <!-- This is a SNOMED code as the primary vocabulary for problem lists. It would be preferable to have a SNOMED code but no direct translation is available here. -->
                    <value xsi:type="CD" nullFlavor="OTH">
                        <originalText>
                            <reference value="#ProblemDescription1" />
                        </originalText>
                        <translation xsi:type="CD" code="V49.75" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD-9" displayName="Below Knee Amputation Status" />
                    </value>
                    <!-- Recommendation of task force that laterality on problems should be in targetSiteCode rather than on the value or value/translation elements -->
                    <targetSiteCode xsi:type="CD" code="30021000" codeSystem="2.16.840.1.113883.6.96" displayName="Structure of lower extremity from knee to ankle">
                        <!-- This is an example of a qualifer which would affect a quality measure (e.g. cms 123 Diabetes Foot Exam) -->
                        <qualifier>
                            <name code="272741003" codeSystem="2.16.840.1.113883.6.96" displayName="Laterality" />
                            <value code="7771000" codeSystem="2.16.840.1.113883.6.96" displayName="Left"/>
                        </qualifier>
                    </targetSiteCode>
                </observation>
            </entryRelationship>
        </act>
    </entry>
</section>

  1. C-CDA Example Search Help

    C-CDA Example Search Results
    This screen displays the results of executing the example search criteria against the existing examples recorded in the example database.

  2. Search Criteria Panel

    This panel allow you to further refine your queries and narrow the results

  3. Text Search Words

    Use this field to enter words related to your search. These words can appear in the title, the comments or as part of a special list of keywords associated with the example. The search words should be entered with spaces separating the items.

  4. Filter by example status

    By selecting the various statuses, the search results can be limited to only the example that are set to the selected status(es). By removing all status selections, the filtering is removed and examples from all statuses will be returned (based on any other filtering).

  5. Select only ONC Certified examples

    These are samples referenced in a government rule or certification companion guide.

  6. Execute the search based on the criteria entered (or retrieve all examples if no criteria specified).

  7. The number of results that match the query parameters can be found here.

  8. Use this link to jump back to the initial page of the application (that lists the sections).

  9. This columns list the names of the examples that match the criteria (and the comment for each example).

  10. This columns lists the area in the C-CDA specification (the specification is broken into distinct topics for the various exchangeable documents, the common header, and the sections that occur within the exchangeable documents) that the example demonstrates.

  11. This columns lists the state of the example in the example verification and approval process.

  12. You can select to download the examples directly or navigate to page with the full detailed description of the example.

  13. Tour Complete

    Return to the C-CDA Example Search Results page.