TEMPLATE epSOS Active Problems Section 1.3.6.1.4.1.19376.1.5.3.1.3.6 (epSOS Active Problems Section 1.3.6.1.4.1.19376.1.5.3.1.3.6)

TEMPLATE IDepSOS Active Problems Section 1.3.6.1.4.1.19376.1.5.3.1.3.6
ConceptepSOS Active Problems Section 1.3.6.1.4.1.19376.1.5.3.1.3.6
DescriptionRepesents openEHR equivalent of epSOS CDA History of Past Illness Section.
PurposeRepesents openEHR equivalent of epSOS CDA History of Past Illness Section.
References
Other Details (Language Independent)
  • MetaDataSet:Sample Set : Template metadata sample set
Language useden
Citeable Identifier1013.26.12
Root archetype idopenEHR-EHR-SECTION.adhoc.v1
Active ProblemsActive Problems: A generic section header.

Annotations

  • CDA Mappings.CDA Implementation Document: epSos Patient Summary
  • CDA Mappings.CDA Template Name: Active Problems Section
  • CDA Mappings.CDA Template Name OID: 1.3.6.1.4.1.19376.1.5.3.1.3.6
  • CDA Mappings.Template Node Name Valueset: LOINC::11450-4::PROBLEM LIST
Problem/DiagnosisProblem/Diagnosis: An issue or obstacle which adversely impacts on the physical, mental and/or social well-being of an individual. The definition of a problem is deliberately kept rather loose and inclusive of a formal biomedical diagnosis so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree.

Annotations

  • CDA Mappings.CDA Template Name: Problem Concern Entry
  • CDA Mappings.CDA Template Name OID: 1.3.6.1.4.1.19376.1.5.3.1.4.5.2
  • CDA Mappings.CDA Template XML Skeleton:
Problem DescriptionProblem Description: Identification of the index problem, issue or diagnosis.
Value set: terminology:epSOS?subset=IllnessesandDisorders&language=en-GB

Annotations

  • CDA Mappings.Template Node Name: R7.1 Problem Description
  • CDA Mappings.Template Node Value Valueset: epSOSCodeProb, OID 1.3.6.1.4.1.12559.11.10.1.3.1.42.23
  • CDA Mappings.Template Node Path: entry/act[templateId/@root=‘1.3.6.1.4.1.19376.1.5.3.1.4.5.2’]/entryRelationship[@type='SUBJ']/observation[templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.5']/value/@code
  • CDA Mappings.CDA Template XML Skeleton:
CommentsComments: A narrative description of the issue, problem or diagnosis.

Annotations

  • CDA Mappings.CDA Template Name: Comment Entry
  • CDA Mappings.CDA Template Name OID: 1.3.6.1.4.1.19376.1.5.3.1.4.2
  • CDA Mappings.Template Node Path: /text
  • CDA Mappings.CDA Template XML Skeleton:
SeveritySeverity: The assessed overall severity of the index problem.
Coding of the severity with a terminology is preferred, where possible.
  •  

Annotations

  • CDA Mappings.Template Node Value Valueset: epSOSSeverity::1.3.6.1.4.1.12559.11.10.1.3.1.42.13
  • CDA Mappings.CDA Template Name: Severity Entry
  • CDA Mappings.CDA Template Name OID: 1.3.6.1.4.1.19376.1.5.3.1.4.1
  • CDA Mappings.Template Node Name: Severity
Problem Onset DateProblem Onset Date: The date / time when the problem was first identified by the individual.

Annotations

  • CDA Mappings.Template Node Name: R7.3 Problem Onset Time
  • CDA Mappings.Template Node Path: entry/act[templateId/@root=‘1.3.6.1.4.1.19376.1.5.3.1.4.5.2’]/effectiveTime/low
Problem End DateProblem End Date: The date that the problem resolved or went into remission.

Annotations

  • CDA Mappings.Template Node Name: R7.4 Problem End Date
  • CDA Mappings.Template Node Path: Template Node Path entry/act[templateId/@root=‘1.3.6.1.4.1.19376.1.5.3.1.4.5.2’]/effectiveTime/high
  • CDA Mappings.CDA Template Name: Problem Concern Entry
  • CDA Mappings.CDA Template Name OID: 1.3.6.1.4.1.19376.1.5.3.1.4.5.2
CategoryCategory: Cateories of problem/ diagnosis/issue.
  • Condition 
  • Symptom 
  • Finding 
  • Complaint 
  • Functional limitation 
  • Problem 
  • Diagnosis 
Clinical statusClinical status: The degree to which the problem is active and relevant within the current clinical context.
  • Active 
  • Inactive 
  • Resolved 
  • In remission 
Resolution CircumstancesResolution Circumstances: A text comment on the active status e.g describing the circumstances or evidence for resolution of a problem.

Annotations

  • CDA Mappings.Template Node Name: R 7.5 Resolution Circumstances
  • CDA Mappings.Template Node Path: entry/act[templateId/@root=‘1.3.6.1.4.1.19376.1.5.3.1.4.5.2’]/entryRelationship[@type='REFR']/observation[templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.1.2']/value/@code
  • CDA Mappings.Template Node Value Valueset: 2.16.840.1.113883.6.96::epSOSResolutionOutcome