CDA+-+Problems+Section

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Problems-1: statusCode
//This issue was discussed on 2/22 Harmonization call. The proposal below was accepted.// (Back to the top)
 * **Element [clinicalDocument/component**
 * /structuredBody/component/section/]** || **cda:entry/cda:act/statusCode** ||
 * || CCD: Not mentioned ||
 * || C83: Not mentioned ||
 * || IHE: PCC Requires status code with values: active, suspended, aborted or completed IHE {nolink:PCC-6}  .3.4.11.7 ||
 * **proposal** || **SHALL [1..1] statusCode**
 * SHALL [1..1] statusCode/@code from value set TEMP-OID-PROBLEM-STATUS-CODE**
 * ProblemStatusCode (values active, suspended, aborted or completed)** ||

Problems-2: effectiveTime
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 * **Element [clinicalDocument/component**
 * /structuredBody/component/section/]** || **cda:entry /cda:act/effectiveTime** ||
 * || CCD: MAY ||
 * || C83: Not Mentioned ||
 * || IHE: requires low element and high element if statusCode @code is completed or aborted ||
 * **proposal** || **SHALL [1..1] low element**
 * SHALL [1..1] high element if statusCode@code=completed or aborted**
 * SHALL NOT [1..1] high element if statusCode@code=active or suspended** ||

Problems-3: Patient Awareness
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 * **Element [clinicalDocument/component**
 * /structuredBody/component/section/]** || **Patient Awareness template**
 * 2.16.840.1.113883.10.20.1.48** ||
 * || CCD: Mentioned in CCD but no explicit requirement to include in document ||
 * || C83: Not mentioned ||
 * || IHE: Not mentioned ||
 * **proposal** || **Omit from Consolidated Guide** ||

Problems-4: inversionInd containing Problem Observation
//This issue was discussed on 2/22 Harmonization call. The proposal below was accepted.// (Back to the top)
 * **Element [clinicalDocument/component**
 * /structuredBody/component/section/]** || **cda:entryRelationship@inversionInd**
 * containing Problem Observation (2.16.840.1.113883.10.20.1.28)** ||
 * || CCD: Not mentioned ||
 * || C83: Not mentioned ||
 * || IHE: SHALL @inversionInd=’False’ ||
 * **proposal** || **SHALL [1..1] @inversionInd=’False’** ||

Problems-5: Linking Narrative to Entries
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Problems-6: performer
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 * **Element [clinicalDocument/component**
 * /structuredBody/component/section/]** || **cda:entry /cda:act/cda:performer** ||
 * || CCD: not mentioned ||
 * || C83: MAY [0..1] performer HITSP Table 2-11 Data Element 7.05 Treating Provider ||
 * || IHE: not mentioned ||
 * **proposal** || **MAY [0..1] performer**
 * SHALL [1..*] performer/id**
 * The performer/id SHALL link to a provider in the header under cda:ClinicalDocument/cda:documentationOf/cda:serviceEvent/cda:performer.**
 * (Additional prose: Using a link between provider in the problems entry and the provider in the header eliminates duplicate information.)** ||

Problems-7: entryRelationship
SHALL [1..*] entryRelationship @typeCode="SUBJ", entryRelationship SHALL [1..1] Problem Observation or Allergy Observation || (Back to the top)
 * **Element [clinicalDocument/component**
 * /structuredBody/component/section/]** || **cda:entry /cda:act/cda:entryRelationship** ||
 * || CCD: SHOULD ({nolink:CCD-153} ) ||
 * || C83: Not mentioned ||
 * || IHE PCC 6.3.4.11.9:
 * **proposal** || **SHALL [1..*] entryRelationship @typeCode="SUBJ", entryRelationship SHALL [1..1] Problem Observation or Allergy Observation** ||

Problems-8: observation
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 * **Element [clinicalDocument/component**
 * /structuredBody/component/section/]** || **cda:entry /cda:act/cda:entryRelationship/cda:observation** ||
 * || CCD: Not mentioned ||
 * || C83: Not mentioned ||
 * || SHALL [1..*] id IHE PCC 6.3.4.14.6 ||
 * **proposal** || **SHALL [1..*] id** ||

Problems-9: observation/code
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 * **Element [clinicalDocument/component**
 * /structuredBody/component/section/]** || **cda:entry /cda:act/cda:entryRelationship/cda:observation/cda:code** ||
 * || CCD: SHALL [1..1] code and MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.14 ProblemTypeCode {nolink:CCD-159} ||
 * || C83: SHALL [1..1] code and SHALL be selected from C83 2.2.3.1.2 Problem Type (HITSP 7.02) ||
 * || IHE: The value for “Observation / code” in a problem observation SHOULD be selected from ValueSet 2.16.840.1.113883.1.11.20.14 ProblemTypeCode STATIC 20061017 (IHE 6.3.4.14.7) ||
 * **proposal** || **SHALL [1..1] code and**
 * SHOULD be selected from HITSP C80 ValueSet 2.16.840.1.113883.3.88.12.3221.7.2 ProblemTypeCode** ||

Problems-10: observation/value
If present, **SHALL** be coded as specified in HITSP/C80 Section 2.2.3.1.1 Problem || If coded value, @code and @codeSystem SHALL be present If uncoded, all attributes other than xsi:type='CD' SHALL NOT be present. || (Back to the top)
 * **Element [clinicalDocument/component**
 * /structuredBody/component/section/]** || **cda:entry /cda:act/cda:entryRelationship/cda:observation/cda:value** ||
 * || CCD: Not mentioned ||
 * || HITSP: MAY [0..1] value be present.
 * || IHE: SHALL [1..1] value be present. xsi:type=’CD’
 * **proposal** || **SHALL [1..1] value be present. xsi:type=’CD’**
 * SHALL be coded as specified in HITSP/C80 Section 2.2.3.1.1 Problem** ||

Problems-11: observation/value/[xsi:type=’CD’]originalText
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 * **Element [clinicalDocument/component**
 * /structuredBody/component/section/]** || **cda:entry /cda:act/cda:entryRelationship/cda:observation/cda:value[xsi:type=’CD’]/cda:originalText** ||
 * || CCD: Not mentioned ||
 * || HITSP: Not Mentioned ||
 * || IHE: Unclear conformance. 6.3.4.14.12 ||
 * **proposal** || **Omit from Consolidated Guide** ||

Problems-12: observation/entryRelationship
MAY [0..1] severity, @typeCode=’SUBJ’, @inversionInd=’true’, if present conformant to Severity template (1.3.6.1.4.1.19376.1.5.3.1.4.1) IHE 6.3.4.14.13 (_if included, update to new template if changed during allergy analysis_) MAY [0..1] clinical status, if present conformant to Problem Status Observation template (1.3.6.1.4.1.19376.1.5.3.1.4.1.1) (_ONLY DIFFERENCE FROM CCD IS NARRATIVE-ENTRY REQUIREMENT_) MAY [0..1] health status, @typeCode=’REFR’, if present conformant to Health Status Observation template (1.3.6.1.4.1.19376.1.5.3.1.4.1.1) (_DIFFERENCE FROM CCD IS NARRATIVE-ENTRY REQUIREMENT_) MAY [0..1] comments template, @typeCode=’SUBJ’, @inversionInd=’true’, if present conformant to Comment entry template (1.3.6.1.4.1.19376.1.5.3.1.4.2) || (Back to the top)
 * **Element [clinicalDocument/component**
 * /structuredBody/component/section/]** || **cda:entry /cda:act/cda:entryRelationship/cda:observation/cda:entryRelationship** ||
 * || CCD: Not mentioned ||
 * || HITSP: Not Mentioned ||
 * || IHE:
 * **proposal** || **Omit Severity Observation in Problem Observation**
 * Omit Comment template**
 * Update Problem Status Observation and Problem Health Status Observation after decision narrative-entry link requirement** ||