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

: Value Set: Problem Severity urn:oid:2.16.840.1.113883.3.88.12.3221.6.8 This is a description of the level of the severity of the problem. Value Set Source: https://vsac.nlm.nih.gov CURRENT SNOMED CT CODES: 1.Mild – 255604002 2.Mild to moderate – 371923003 3.Moderate – 6736007 4.Moderate to severe – 371924009 5.Severe – 24484000 6.Fatal – 399166001

Proposed Wording

Value Set: REACTION Severity 2.16.840.1.113883.3.88.12.3221.6.8 This is a description of the level of the severity of the REACTION. CURRENT SNOMED-CT CODES: 1.Mild – 255604002 (SUGGEST FOR USE) 2. Mild to moderate – 371923003 (DO NOT SUGGEST FOR USE) 3.Moderate – 6736007 (SUGGEST FOR USE)(include mild to moderate) 4.Moderate to severe – 371924009 (DO NOT SUGGEST FOR USE) 5.Severe – 24484000 (SUGGEST FOR USE)(Include moderate to severe) 6. Fatal – 399166001 (DO NOT SUGGEST FOR USE)) REASON: Criticality is now available to use in looking at the propensity for an adverse reaction. Having fatal as a severity code will create a patient safety issue. Also, if using reaction severity for decision support, can not use an ambiguous scale of mild to moderate. Implementation should provide a mapping from six codes to three codes. Suggested mapping as follows If used fatal, map to severe; if used moderate to severe, map to severe; if your mild to moderate, map to moderate. NOTE: New LOINC concept for reaction severity