Section Code |
LOINC: 48765-2 (Allergies, adverse reactions, alerts) |
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Description |
The Allergies and Other Adverse reactions section (in CCD known as the Alerts section) contains information related to current allergies and intolerances that are of concern when delivering care to the patient. |
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CDA Level |
Level 3 Only |
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Template IDs |
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Level / Spec |
Template ID |
Standards Reference |
3 / CCD |
2.16.840.1.113883.10.20.1.2 |
HL7 CCD 3.8 |
3 / IHE |
1.3.6.1.4.1.19376.1.5.3.1.3.13 |
IHE PCC TF-2: 6.3.3.2.11 |
Expected Entries / Sub-Sections |
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Entry |
Template ID |
Reference |
Allergy and Intolerances Concern |
1.3.6.1.4.1.19376.1.5.3.1.4.5.3
2.16.840.1.113883.10.20.1.27 |
3.4.2.3 |
OpenSHR Implementation Notes |
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Data Model |
Obs |
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Code File |
AllergiesAndOtherAdverseReactionsSectionProcessor.java |
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Additional Constraints |
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Notes |
The allergies and intolerances section SHOULD contain a concern entry related to an allergy to latex. This allergy can be negated through a negation indicator to indicate a non-allergy. |
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Specification |
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<section classCode="DOCSECT" moodCode="EVN">
<!-- CCD Alerts Section Template -->
<templateId root="2.16.840.1.113883.10.20.1.2"/>
<!-- IHE PCC Allergies and Intolerances Section Template -->
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.13"/>
<!-- Code for section must be 48765-2 -->
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts"/>
<title language="en-US">Allergies and Intolerances</title>
<!-- Text as described in general implementation notes -->
<text mediaType="text/x-hl7-text+xml">
...
</text>
<!-- 0..n Allergy and Intolerance Concerns -->
<entry typeCode="DRIV" contextConductionInd="true">
<act classCode="ACT" moodCode="EVN">
...
</act>
</entry>
</section> |
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Examples |
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This example illustrates an active, severe allergy to penicillin with a reaction of anaphylaxis. |
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<section classCode="DOCSECT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.2"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.13"/>
<id root="9c659a8c-d93f-4627-a37c-46b50744699b"/>
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts"/>
<title language="en-US">Allergies and Intolerances</title>
<text mediaType="text/x-hl7-text+xml">
...
</text>
<entry typeCode="DRIV" contextConductionInd="true">
<act classCode="ACT" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.3"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.1"/>
<templateId root="2.16.840.1.113883.10.20.1.27"/>
<id root="1.2.3.4.5.6.9.5" extension="1"/>
<code nullFlavor="NA"/>
<statusCode code="active"/>
<effectiveTime>
<low value="20070115141530"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="false"
contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28"/>
<templateId root="2.16.840.1.113883.10.20.1.18"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.6"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>
<id root="7aea1b00-b972-48e8-acb6-adc0e9cef77b"/>
<code code="DALG" codeSystem="2.16.840.1.113883.5.4"
codeSystemName="ObservationIntoleranceType" displayName="Drug Allergy"/>
<text representation="TXT" language="en-US">
<reference value="#obs1afe29b3"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20140609102005.000-0600"/>
<value xsi:type="CD" code="373270004" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="PENICILLIN">
</value>
<participant typeCode="CSM" contextControlCode="OP">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT" determinerCode="INSTANCE">
<code code="373270004" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="PENICILLIN"/>
<name>PENICILLIN</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ" inversionInd="true"
contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1"/>
<templateId root="2.16.840.1.113883.10.20.1.55"/>
<id root="514826d8-6ad8-4618-a7f8-f1f50547bac1"/>
<code code="SEV" codeSystem="2.16.840.1.113883.5.4"
codeSystemName="ActCode" displayName="Severity"/>
<text representation="TXT" language="en-US">
<reference value="#obs619f7149"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="H" codeSystem="2.16.840.1.113883.5.1063"
codeSystemName="ObservationValue" displayName="Severe"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="MFST" contextConductionInd="true">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.6.1"/>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.54"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>
<templateId root="2.16.840.1.113883.10.20.1.28"/>
<id root="853845cb-9f28-4185-a452-96153137e59b"/>
<id root="1.2.3.4.5.6.9.3" extension="33"/>
<code code="PROBLEM" codeSystem="1.3.6.1.4.1.19376.1.5.3.2"
codeSystemName="1.3.6.1.4.1.19376.1.5.3.2"/>
<text representation="TXT" language="en-US">
<reference value="#obs6b1be129"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20070115141530"/>
</effectiveTime>
<value xsi:type="CD" code="39579001" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Anaphylaxis"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section> |
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