Specification - Extended

HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes DSTU Release 2.1 - US Realm

Document Description

extended per extended per TSC tracker 12437, again with 14128 and jira.hl7.org/browse/TSC-38

Existing Wording

The C-CDA 2.1 Problem Value Set (urn:oid:2.16.840.1.113883.3.88.12.3221.7.4) allows only terms descending from the Clinical Findings (404684003) or Situation with Explicit Context (243796009) hierarchies. The FHIR US Core profile equivalent value set starts with the identical set of terms, but also adds the concept "No current problems or disability" (160245001) The approved C-CDA Example for "No Known Problems" requires a term outside of the accepted Value Set (55607006 "Problem") used with Negation. http://hl7-c-cda-examples.herokuapp.com/examples/view/Problems/No%20Known%20Problems

Proposed Wording

To align implementations of C-CDA and FHIR, rather than require a complex negation-based modelling with a normally disallowed term, we should add the "No current problems or disability" (160245001) term to the Problem Value Set (urn:oid:2.16.840.1.113883.3.88.12.3221.7.4)