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Indication

[Observation: templateId 2.16.840.1.113883.10.20.22.4.19]

The Indication Observation documents the rationale for an activity. It can do this with the id element to reference a problem recorded elsewhere in the document or with a code and value to record the problem type and problem within the Indication. For example, the indication for a prescription of a painkiller might be a headache that is documented in the Problems Section

  1. SHALL contain exactly one [1..1] templateId ( CONF:7482, CONF:10502 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.19"
  2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:7480)
  3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: 2.16.840.1.113883.5.1001 HL7ActMood) (CONF:7481)
  4. SHALL contain exactly one [1..1] id (CONF:7483)
  5. SHALL contain exactly one [1..1] code, where the @code SHOULD be selected from ValueSet Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2008-12-18 (CONF:16886)
  6. SHALL contain exactly one [1..1] statusCode/@code="completed" (CodeSystem: 2.16.840.1.113883.5.14 ActStatus) (CONF:7487)
  7. SHOULD contain zero or one [0..1] effectiveTime (CONF:7488)
  8. SHOULD contain zero or one [0..1] value with data type CD (CONF:7489), where the @code SHOULD be selected from ValueSet Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:CONF:15985)
  9. MAY satisfy: Set the observation/id equal to an ID on the problem list to signify that problem as an indication (CONF:16885)
  10. The value element MAY contain @nullFlavor (CONF:15990)
  11. If the diagnosis is unkown or the SNOMED code is unknown, @nullFlavor SHOULD be "UNK". If the code is something other than SNOMED, @nullFlavor SHOULD be "OTH" and the other code SHOULD be placed in the translation element. (CONF:15991)

Indication example

<observation xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3">
  <id root="MDHT" extension="1010247872"/>
  <code code="1756382149"/>
  <effectiveTime>
    <low value="2013"/>
    <high value="2013"/>
  </effectiveTime>
  <value xsi:type="CD" code="953859576"/>
</observation>