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Condition

Reference:2.2.2.7
Definition:Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.5 for constraints applicable to these data elements.
OID:2.16.840.1.113883.3.88.11.83.7
CDA Data Location HITSP Data Element Identifier and Name O/R Additional Specification
cda:act[cda:templateId/@root= '2.16.840.1.113883.10.20.1.27']/ cda:entryRelationship[@typeCode='SUBJ']/ Problem Entry See Note18
cda:sequenceNumber 7.10 Diagnosis Priority R2/N
cda:observation[ cda:templateId/@root= '2.16.840.1.113883.10.20.1.28']
cda:effectiveTime 7.01 - Problem Date R2/N 2.2.2.7.2
cda:code/@code 7.02 - Problem Type R2/N 2.2.2.7.3
cda:text 7.03 - Problem Name R/N 2.2.2.7.4
cda:value/@code 7.04 - Problem Code O/N 2.2.2.7.5
cda:act[cda:templateId/@root= '2.16.840.1.113883.10.20.1.27']/ cda:performer 7.05 - Treating Provider O/Y 2.2.2.7.6
cda:assignedEntity/cda:id 7.11 - Treating Provider ID R2/N 2.2.2.7.6
cda:entryRelationship/cda:observation [cda:templateId/@root = '2.16.840.1.113883.10.20.1.38'] 7.06 - Age (at Onset) O/N 2.2.2.18.11
cda:entryRelationship[ @typeCode='CAUS']/ cda:observation 7.07 - Cause of Death O/N 2.2.2.18.12
cda:effectiveTime 7.09 - Time of Death O/N See 2.2.2.18.12 for example
cda:entryRelationship/ cda:observation [cda:templateId/@root = '2.16.840.1.113883.10.20.1.38'] 7.08 - Age (at Death) O/N 2.2.2.18.11
cda:entryRelationship/cda:observation [cda:templateId/@root = '2.16.840.1.113883.10.20.1.50']/ value/@code 7.12 - Problem Status O/N 2.2.2.18.17

Optionality Legend: “R” for Required, “R2” for Required if known, “O” for Optional and Repeat = “Y” for Yes or “N” for No


Section ID Constraint ID Definition
2.2.2.7.1 Condition Module Constraints Not Provided
C83-[DE-7-CDA-1] A CDA Document SHALL declare conformance for the Condition Module by including a <templateID> element with the root attribute set to the value 2.16.840.1.113883.3.88.11.83.7
C83-[DE-7-CDA-2] Problem Entries SHALL also declare conformance to the IHE Problem Concern by including a <templateID> element with the root attribute set to the value 1.3.6.1.4.1.19376.1.5.3.1.4.5.2
2.2.2.7.2 Problem Date Constraints The problem date constraints include the onset and resolution dates for the problem. These dates represent the clinically effective time span over which the problem existed.
C83-[DE-7.01-1] The onset date SHALL be recorded in the <low> element of the <effectiveTime> when known (see example 1 below).
C83-[DE-7.01-2] The resolution data SHALL be recorded in the element <high> element of the <effectiveTime> element when known.
C83-[DE-7.01-3] If the problem is known to be resolved, but the date of resolution is not known, then the <high> element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. Therefore, the existence of an <high> element within a problem does indicate that the problem has been resolved.

Problem Date Constraints Example:

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<!-- example 1 -->
<effectiveTime>
<low value='20070209'/>
<high value='20070210'/>
</effectiveTime>
<!-- example 2 -->
<effectiveTime>
<low value='20070209'/>
<high nullFlavor='UNK'/>
</effectiveTime>
2.2.2.7.3 Problem Type Constraints Not Provided
C154-[DE-7.02-1] The problem type SHALL be coded as specified in HITSP/C80 Section 2.2.3.1.2 Problem Type

Problem Type Constraints Example:

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.28'/>
...
<code code='404684003' displayName='Finding'
codeSystem='2.16.840.1.113883.96' codeSystemName='SNOMED CT'/>
2.2.2.7.4 Problem Name Constraints Not Provided
C83-[DE-7.04-1] The problem name SHALL be recorded in the entry by recording a <reference> where the value attribute points to the narrative text containing the name of the problem.

Problem Name Constraints Example:

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<text><p ID='problem-1'>migraine</p><text>
<entry>
<act classCode='ACT' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.27'/>
<templateId root='2.16.840.1.113883.3.88.11.83.7'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/>
<id root='...'/>
<code nullFlavor='NA'/>
<entryRelationship typeCode='SUBJ'>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.28'/>
...
<text><reference value='#problem-1'/></text>
</observation>
</entryRelationship>
</act>
</entry>
2.2.2.7.5 Problem Code Constraints Not Provided
C154-[DE-7.04-1] If the code attribute is present, the problem SHALL be coded as specified in HITSP/C80 Section 2.2.3.1.1 Problem

Problem Code Constraints Example:

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.28'/>
...
<value xsi:type='CD' code='37796009' displayName='Migraine'
codeSystem='2.16.840.1.113883.96' codeSystemName='SNOMED CT'/>
</observation>
2.2.2.7.6 Treating Provider Constraints Not Provided
C83-[DE-7.05-CDA-1] The time over which this provider treated the condition MAY be recorded in the <time> element beneath the <performer> element
C83-[DE-7.05-CDA-2] The identifier of the treating provider SHALL be present in the <id> element beneath the <assignedEntity>2.2.2.4. This identifier SHALL be the identifier of one of the providers listed in the healthcare providers module described in Section
C83-[DE-7.05-CDA-3] The treating provider or providers SHALL be recorded in a <performer> element under the <act> that describes the condition of concern

Treating Provider Constraints Example:

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<text><p ID='problem-1'>Migraine</p><text>
<entry>
<act classCode='ACT' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.27'/>
<templateId root='2.16.840.1.113883.3.88.11.83.7'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/>
<id root='...'/>
<code nullFlavor='NA'/> <performer typeCode='PRF'>
<time><low value='...'/><high value='...'/></time>
<assignedEntity>
<id root='...' extension='...'/>
</assignedEntity>
</performer>
...
</act>
</entry>
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