Section Code |
LOINC: 11450-4 (PROBLEM LIST) |
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Description |
Used to capture the current list of problems associated with the patient in either a coded or un-coded manner. The problem list is comprised of problem concern acts which identify when the particular was/is of concern. |
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CDA Level |
Level 3 Section Only |
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Template IDs |
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Level / Spec |
Template ID |
Standards Reference |
3 / CCD |
2.16.840.1.113883.10.20.1.11 |
HL7 CCD 3.5 |
3 / IHE |
1.3.6.1.4.1.19376.1.5.3.1.3.6 |
IHE PCC TF-2 : 6.3.3.2.3 |
Expected Entries / Sub-Sections |
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Entry |
Template ID |
Reference |
Problem Concern |
1.3.6.1.4.1.19376.1.5.3.1.4.5.2 |
3.4.2.18 |
OpenSHR Implementation Notes |
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Data Model |
Obs |
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Code File |
ActiveProblemSectionProcessor.java |
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Additional Constraints |
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Notes |
Content creators may produce an Active Problems section at CDA Level 2 conformance, however this is not recommended as Level 2 entries will not be produced on ODD instances when Level 3 problems exist. |
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Specification |
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<section>
<!-- IHE PCC Template ID -->
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.6"/>
<!-- HL7 CCD Template ID -->
<templateId root="2.16.840.1.113883.10.20.1.11"/>
<!--Problems section template -->
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Problem list" />
<title>Problems</title>
<text>
<!-- Text as described in general notes -->
</text>
<!-- 0 .. n Problem Concern Entries -->
<entry>
<act classCode="ACT" moodCode="EVN">
...
</act>
</entry>
</section> |
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Example |
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An example illustrating a patient who has had Asthma whereby the condition started sometime in 1990. The condition is currently a concern. |
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<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.6"/>
<templateId root="2.16.840.1.113883.10.20.1.11"/>
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Problem list" />
<title>Problems</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Problem</th>
<th>Effective Dates</th>
<th>Problem Status</th>
</tr>
</thead>
<tbody>
<tr ID="PROBSUMMARY_1">
<td ID="PROBKIND_1">Asthma</td>
<td>1990</td>
<td ID="PROBSTATUS_1">Active</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.27"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.1"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.2"/>
<id root="6a2fa88d-4174-4909-aece-db44b60a3abb" />
<code nullFlavor="NA" />
<statusCode code="active" />
<effectiveTime>
<low value="1990" />
<high nullFlavor="UNK" />
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>
<id root="d11275e7-67ae-11db-bd13-0800200c9a66" />
<code code="64572001" displayName="Condition"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT" />
<text>
<reference value="#PROBSUMMARY_1" />
</text>
<statusCode code="completed" />
<effectiveTime>
<low value="1990" />
</effectiveTime>
<value xsi:type="CD" displayName="Asthma" code="195967001"
codeSystemName="SNOMED" codeSystem="2.16.840.1.113883.6.96" />
</observation>
</entryRelationship>
</act>
</entry>
</section> |
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