Stream: CDA
Topic: Encounter
Kajal (Jan 28 2021 at 06:09):
Hi All,
I have question related to Encounter .
How inside the Encounter entryRelationship's Observation are related to Encounter,what meaning they reflect ?
in the below Example encounter is having entryRelationship ,Observation is appearing .
<encounter classCode="ENC" moodCode="EVN">
<!-- Encounter Activity (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code code="99221" displayName="Initial hospital care, per day, for the evaluation and management of a patient - 50 minutes" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12">
<entryRelationship typeCode="RSON">
<!-- Indivcation (V2) -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.19" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/>
<!-- code is required; MAY be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2014-09-02 (CONF:1098-31229) -->
<code code="404684003" displayName="Finding" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96">
<!-- of course this MAY be present
<translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Clinical finding"/>
-->
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="201209251130-0500"/>
</effectiveTime>
<value xsi:type="CD" code="233604007" displayName="Pneumonia" codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entryRelationship>
</encounter>
While converting to FHIR resource , this observation map to Condition FHIR resource so how we identify this is Discharge Diagnosis or Chief complaint role for diagnosis?
Looking for some help on this . Thanks.
Er.Madhav Adhikari (Mar 31 2022 at 15:39):
Hello, as per the hl7 release document(https://vico.org/CDAR22005_HL7SP/infrastructure/cda/cda.htm#link) , we come to know that narrative block and entry block consists same level of data structure , however, my vendor sent file where some narrative data were missed in the entry tag. Could you please help me ? how this work narrative and entry section?
René Spronk (Apr 01 2022 at 07:04):
Please create a new topic if your question isn't related to an existing topic (Encounter, in this case).
As for your question: the CDA R2 specification doesn't mandate the use of explicit links between the narrative and the entries. Both narrative and entries are contained in a section, so one knows that the entries (all of them jointly) express 'the same' information as the section narrative.
Er.Madhav Adhikari (Apr 01 2022 at 08:18):
@René Spronk I have created new stream for this https://chat.fhir.org/#narrow/stream/229921-CDA/topic/Hl7.20v3.28.20CDA.29.20xml.20files/near/277383300
Last updated: Apr 12 2022 at 19:14 UTC
