9.8.4 Complications

9.8.4 Complications (Current)
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Template ID	2.16.840.1.113883.10.20.22.2.37
Name	Complications
Effective Date	2012-07
Version Label	DICOM-20150324
Status	Active
Description	The Complications section records problems that occurred during the procedure or other activity. The complications may have been known risks or unanticipated problems.
Classification	CDA Section Level
Relationships	Included in 9.3 Imaging Procedure Description
Context	parent node
Open/Closed	Open
Revision History	From Consolidated CDA r1.1 DICOM-20150324: Addition of optional entries

Business Name	Nest Level	Element/Attribute	Card	Elem/Attr Conf	Data Type	Value Conf	Value	Subsidiary Template
Complications		section	1..1	SHALL
	>	templateId	1..1	SHALL	II
	>@	@root	1..1	SHALL	UID	SHALL	2.16.840.1.113883.10.20.22.2.37
	>	id	1..*	SHALL	II
	>	code	1..1	SHALL	CD	SHALL	(55109-3, LOINC, "Complications")
Title	>	title	1..1	SHALL	ST
Text	>	text	1..1	COND	ED			9.1.1 Section Text 1.2.840.10008.9.19
	>	entry	0..*	MAY
CodedObservation[*]	>>	observation						10.1 Coded Observation 2.16.840.1.113883.10.20.6.2.13

Example 9.8.4-1. Complications section example

<section classCode="DOCSECT" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.20.22.2.37"/>
    <id root="1.2.840.10213.2.62.70444786655528.11428987524546666"/>
    <code code="55109-3"
        codeSystem="2.16.840.1.113883.6.1"
        codeSystemName="LOINC"
        displayName="Complications"/>
    <title>Complications</title>
    <text>Immediately following IV contrast injection, the patient reporting itching "all over".
        Dr. Smith examined the patient and found multiple urticaria. The patient denied difficulty
        breathing or swallowing. The patient was given Benadryl 50 mg PO and was followed for
        30 minutes, during which time the symptoms subsided.</text>
    <entry>
        <observation classCode="OBS" moodCode="EVN">
            <templateId root="2.16.840.1.113883.10.20.6.2.13"/>
            <!-- Coded Observation -->
            ...
        </observation>
    </entry>
</section>

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