BH_CDA_IG_D1_SEPT_2012

Axis II

[Observation: templateId 2.16.840.1.113883.3.2852.1.7]

Up to two diagnoses from the DSM-IV Axis II category may be reported in a single encounter.  See definition for the principalDiagnosis attribute below.  principalDiagnosis is constrained to a value from either the DSM-IV Axis I or Axis II category, so the implementation of Axis-II-problem and principalDiagnosis may require consideration if there is a limit to reporting only DSM-IV Axis II codes.

  1. SHALL conform to Consol Problem Observation template (templateId: 2.16.840.1.113883.10.20.22.4.4)
  2. SHALL conform to Behavioral Health Problem template (templateId: 2.16.840.1.113883.3.2852.1.9)
  3. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:10578)
  4. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: 2.16.840.1.113883.5.1001 HL7ActMood) (CONF:9042)
  5. MAY contain zero or one [0..1] @negationInd (CONF:10139)
    • Use negationInd="true" to indicate that the problem was not observed (CONF:16880)

  6. SHALL contain at least one [1..*] id (CONF:9043)
  7. SHOULD contain exactly one [1..1] code, where the @code SHALL be selected from ValueSet Problem Type 2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2008-12-18 (CONF:9045)
    • The behavioral health problems are encoded using DSM-IV codes.

  8. SHOULD contain zero or one [0..1] text (CONF:9185)
  9. SHALL contain exactly one [1..1] statusCode/@code="completed" Completed (CodeSystem: 2.16.840.1.113883.5.14 ActStatus) (CONF:9049)
  10. SHALL contain exactly one [1..1] effectiveTime (CONF:10601)
    • This is the date of onset and, if applicable, the date of resolution. The implementers are expected to use the "low" and "high" elements to specify the onset and resolution dates respectively. This attribute corresponds to the date of onset and date of resolution of a problem specified in the domain analysis model.

  11. SHALL contain exactly one [1..1] value (CONF:10585), where the @code SHALL be selected from (CodeSystem: 2.16.840.1.113883.6.126 DSM-IV-TR) (CONF:10691)
  12. MAY contain zero or more [0..*] interpretationCode
    • To assess the degree of severity (high, medium, low).

  13. SHOULD contain zero or more [0..*] author (CONF:15450)
    • This association is used to specify who recorded the problem and it may be used to establish the provenance of the data once it is exchanged across organizational boundaries.

  14. SHOULD contain zero or one [0..1] healthStatusObservation (CONF:15451)
  15. SHOULD contain zero or one [0..1] ageObservation (CONF:15452)
  16. MAY contain zero or one [0..1] entryRelationship (CONF:9059, CONF:9060, CONF:15590)
    1. Contains @typeCode="SUBJ" SUBJ
    2. Contains exactly one [1..1] Age Observation (templateId: 2.16.840.1.113883.10.20.22.4.31)
  17. MAY contain zero or one [0..1] entryRelationship (CONF:9063, CONF:9068, CONF:15591)
    1. Contains @typeCode="REFR" REFR
    2. Contains exactly one [1..1] Problem Status (templateId: 2.16.840.1.113883.10.20.22.4.6)
  18. MAY contain zero or one [0..1] entryRelationship (CONF:9067, CONF:9064, CONF:15592)
    1. Contains @typeCode="REFR" REFR
    2. Contains exactly one [1..1] Health Status Observation (templateId: 2.16.840.1.113883.10.20.22.4.5)
  19. The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15587)
  20. reference, if present, SHALL contain exactly one [1..1] @value (CONF:15588)
  21. reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15589)
  22. The effectiveTime element , if present, SHALL contain exactly one [1..1] low (CONF:15603)
  23. effectiveTime, if present, SHOULD contain zero or one [0..1] high (CONF:15604)
  24. 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 (CONF:16881)
  25. value MAY contain zero or one [0..1] @nullFlavor (CONF:10141)
  26. If the diagnosis is unknown 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:10142)
  27. entryRelationship with target entry Age Observation SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:9069)
  28. value MAY contain zero or more [0..*] translation (CONF:16749)
  29. translation, if present, MAY contain zero or one [0..1] @code (CodeSystem: ICD10 2.16.840.1.113883.6.3) (CONF:16750)

Axis II example

<observation xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3">
  <id root="MDHT" extension="360144316"/>
  <code code="17726814"/>
  <text>Text Value</text>
  <effectiveTime>
    <low value="2013"/>
    <high value="2013"/>
  </effectiveTime>
  <value xsi:type="CE" code="1048128727"/>
  <interpretationCode code="468770593"/>
  <author>
    <time/>
    <assignedAuthor/>
  </author>
</observation>