Ambulance
Domain Message Specification

Problem Tabular View

COCD_TP146306GB01
Problem

An abstract problem and issue node which indicates the a coded entry has been catergorised as a problem and issue.

A Problem and Issue is created by Creating a condition node and relating this to the coded entry which is the Problem and Issue. This will, usually but not always, be a Diagnosis or a Clinical Observation and Finding.

Used by:
[1..1] [M] classCode (CS { CNE: ActClass } )
{ Fixed="ACT" }

Indicates that this is a act.

[1..1] [M] moodCode (CS { CNE: ActMood } )
{ Fixed="EVN" }

Indicates that this is an event.

[1..1] [M] code (CD { CWE:CodedEntryCode } )

A code to identify a problem.

The Concept Descriptor (CD) with CDA URL datatype/flavour shall be used to carry this information as follows:
  • The code attribute shall contain a code from the relevant vocabulary.
  • The codeSystem attribute shall contain the OID for vocabulary.
  • The displayName attribute shall carry a description associated with the code in the vocabulary.
  • The originalText element can be used to carry a reference element. This can link the coded item to the relevant text in the CDA section.
  • qualifier (s) may be used if required.
[1..1] [M] effectiveTime (IVL<TS>)

The effective date carries the start and end date/time of the problem.

The date range shall be carried as follows:

If both a start date and an end date are present the Date or Time Interval Complete datatype shall be used:

  • The low attribute shall contain the start date
  • The high attribute shall contain the end date
This is required to indicate that the problem is no longer active along with a status code of completed.

If only a start date is present the Date or Time Interval After datatype shall be used:

  • The low attribute shall contain the start date.
This should be used along with an status code of active to indicate the problem is still ongoing.
[1..1] [M] id (II)

This is a unique identifier for this instance of a Problem.

The Identifier Global data type flavour is used to carry the identifier follows:

  • The root attribute shall contain a DCE UUID.
[1..1] [M] statusCode (CS { CNE:ActStatus } )
{ Default="active" }
The status of the Problem.

The Coded Only data type flavour is used to carry this information as follows:

  • The code attribute will contain a one of the following codes from the Act Status vocabulary:
    • nullified
    • active
    • completed.
[1..1] [M] templateId (II)
{ Fixed="COCD_TP146306GB01#Problem" }

The fixed value of this attribute provides a unique identifier for the template and the classname within that template.

The IdentifierExternal datatype flavour is used to carry this information as follows:

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The extension attribute shall contain the fixed value.
[0..1] author

Refers to the author of the problem.

Note :- This is the person who highlighted the information represented by the coded entry as a problem.

Only required if different to inherited author or no author is inherited.

[1..1] [M] typeCode (CS { CNE: ParticipationType } )
{ Fixed="AUT" }

Indicates this is an author.

[1..1] [M] contextControlCode (CS { CNE: ContextControl } )
{ Fixed="OP" }

Specifies how this author contributes to the context of the problem act and whether it may be propagated to descendent acts whose association allows such propagation.

"O" (Overriding)- the association replaces any context of the same or more specific type that has been conducted from the parent act.

"P" (Propagating)- the association is conducted to all child acts where the ActRelationship.contextConductionInd is set to "true".
[1..1] [M] contentId (II) { "NPFIT-000001#Role" }

This attribute, when valued in an instance, provides a unique forward pointing identifier for a template which constrains the classes and attributes which follow.

The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning.

The IdentifierExternal datatype flavour is used to carry this information as follows:

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.16"
  • The extension attribute shall contain the template artifact Id.
[1..1] [M] functionCode (CV { CNE:AuthorFunctionType } )
{ Fixed="OA" }

A code from the vocabulary shown indicating the function of the document author

The Coded Plain flavour of Coded Value (CV) datatype shall be used to carry this information as follows:

  • The code attribute shall contain the value.
  • The codeSystem attribute shall contain the OID for the vocabulary concerned.
  • The displayName attribute shall contain the text associated with the code
[1..1] [M] templateId (II)
{ Fixed="COCD_TP146306GB01#author" }

The fixed value of this attribute provides a unique identifier for the template and the classname within that template.

The IdentifierExternal datatype flavour is used to carry this information as follows:

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The extension attribute shall contain the fixed value.
[1..1] [R] time (TS)

When the author authored the problem act.

[1..1] participant (AuthorChoice)

A link to choice of authors.

[1..1] [M] entryRelationship

Refers to the coded entry which has been highlighted as a problem.

[1..1] [M] typeCode (CS { CNE: ActRelationshipType } )
{ Fixed="SUBJ" }

Indicates that the coded entry is the subject of the problem assertion.

[1..1] [M] contextConductionInd (BL)
{ Fixed="false" }

If true, associations in the parent act are conducted across the ActRelationship to the child act.

[1..1] [M] contentId (II) { "NPFIT-000302#ActRef" }

This attribute, when valued in an instance, provides a unique forward pointing identifier for a template which constrains the classes and attributes which follow.

The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning.

The IdentifierExternal datatype flavour is used to carry this information as follows:

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.16"
  • The extension attribute shall contain the template artifact Id.
[1..1] [M] seperatableInd (BL)
{ Fixed="false" }

Indicates if the source Act is to be interpreted independently of the target Act.

[1..1] [M] templateId (II)
{ Fixed="COCD_TP146306GB01#entryRelationship" }

The fixed value of this attribute provides a unique identifier for the template and the classname within that template.

The IdentifierExternal datatype flavour is used to carry this information as follows:

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The extension attribute shall contain the fixed value.
[1..1] [M] codedEntryReference (CodedEntryReference)

A link to a coded entry reference.

CodedEntryReference
Refers to the choice of coded entry references.
Used by: Problem
[1..1] : Template

A link to the choice of coded entry reference templates.

AuthorChoice

Refers to the choice of authors

Used by: Problem
[1..1] : Template1

A link to the author templates.