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Health Concerns Section

Template ID: 2.16.840.1.113883.10.20.22.2.58 Version: 2015-08-01 (R2.1 | R2.0) Badge: Extended Section

Overview

The Health Concerns Section (V2) contains data that describes an interest or worry about a health state or process that could possibly require attention, intervention, or management. A Health Concern is a health-related matter that is of interest, importance, or worry to someone who may be the patient, patient's family or patient's health care provider.

Health concerns are more comprehensive than problems. A health concern can include: - Current problems (e.g., diabetes, hypertension) - Past problems that continue to require monitoring - Risk factors (e.g., family history of breast cancer) - Social determinants of health (e.g., food insecurity, housing instability) - Patient worries (e.g., fear of falling, anxiety about diagnosis)

This section enables a holistic view of factors affecting patient health beyond traditional diagnoses.

Template Details

Identifiers

  • Root: 2.16.840.1.113883.10.20.22.2.58
  • Extension: 2015-08-01
  • LOINC Code: 75310-3 (Health concerns document)

Conformance Requirements

  • MAY contain @nullFlavor="NI" if no information available (CONF:1198-32802)
  • SHALL contain exactly one [1..1] templateId (CONF:1198-28804)
  • SHALL contain exactly one [1..1] code with code="75310-3" from LOINC (CONF:1198-28806)
  • SHALL contain exactly one [1..1] title (CONF:1198-28809)
  • SHALL contain exactly one [1..1] text (narrative block) (CONF:1198-28810)
  • If @nullFlavor is not present, SHALL contain at least one [1..*] entry (CONF:1198-30768)
  • Each entry SHALL contain exactly one [1..1] Health Concern Act (V2) (CONF:1198-30768)

Cardinality

  • Section: Optional
  • Entries: Required if not using nullFlavor (1..*)
  • Health Concern Acts: One per entry

Protocol Requirements

The section uses the HealthConcernProtocol from ccdakit.protocols.health_concern:

Required Properties

@property
def name(self) -> str:
    """Human-readable health concern name/description"""

@property
def status(self) -> str:
    """Status: 'active', 'suspended', 'aborted', 'completed'"""

Optional Properties

@property
def effective_time_low(self) -> Optional[date]:
    """Date when concern started"""

@property
def effective_time_high(self) -> Optional[date]:
    """Date when concern ended (None if ongoing)"""

@property
def persistent_id(self) -> Optional[PersistentIDProtocol]:
    """Persistent ID across document versions"""

@property
def observations(self) -> Sequence[HealthConcernObservationProtocol]:
    """Related observations (problems, allergies, etc.)"""

@property
def author_is_patient(self) -> bool:
    """Whether this is a patient concern (vs. provider concern)"""

@property
def observation_type(self) -> str:
    """Type: 'problem', 'allergy', 'social_history', etc."""

@property
def code(self) -> str:
    """Observation code (SNOMED, LOINC, etc.)"""

@property
def code_system(self) -> str:
    """Code system identifier"""

@property
def display_name(self) -> str:
    """Human-readable display name"""

Code Example

Basic Usage

from datetime import date
from ccdakit import HealthConcernsSection, CDAVersion

# Define health concerns
concerns = [
    {
        "name": "Risk of falls due to balance issues",
        "status": "active",
        "effective_time_low": date(2024, 1, 15),
        "observations": [
            {
                "observation_type": "problem",
                "code": "282299006",
                "code_system": "SNOMED",
                "display_name": "Difficulty walking",
            }
        ],
        "author_is_patient": False,
    },
    {
        "name": "Food insecurity affecting diabetes management",
        "status": "active",
        "effective_time_low": date(2023, 11, 1),
        "observations": [
            {
                "observation_type": "social_history",
                "code": "733423003",
                "code_system": "SNOMED",
                "display_name": "Food insecurity",
            }
        ],
        "author_is_patient": True,
    },
]

# Create section
section = HealthConcernsSection(
    health_concerns=concerns,
    version=CDAVersion.R2_1
)

# Generate XML
xml_element = section.to_element()

Empty Section (No Health Concerns)

# Create section with no concerns
section = HealthConcernsSection(
    health_concerns=[],
    version=CDAVersion.R2_1
)

# Generates section with narrative: "No health concerns"

Section with Null Flavor

# When no information is available
section = HealthConcernsSection(
    health_concerns=[],
    null_flavor="NI",  # No information
    version=CDAVersion.R2_1
)

Complex Health Concern with Multiple Observations

concerns = [
    {
        "name": "Cardiovascular risk management",
        "status": "active",
        "effective_time_low": date(2024, 1, 1),
        "observations": [
            {
                "observation_type": "problem",
                "code": "38341003",
                "code_system": "SNOMED",
                "display_name": "Hypertension",
            },
            {
                "observation_type": "problem",
                "code": "44054006",
                "code_system": "SNOMED",
                "display_name": "Type 2 Diabetes Mellitus",
            },
            {
                "observation_type": "social_history",
                "code": "77176002",
                "code_system": "SNOMED",
                "display_name": "Smoker",
            }
        ],
        "author_is_patient": False,
    }
]

section = HealthConcernsSection(health_concerns=concerns)

Resolved Health Concern

concerns = [
    {
        "name": "Post-surgical infection risk",
        "status": "completed",  # No longer a concern
        "effective_time_low": date(2023, 8, 15),
        "effective_time_high": date(2023, 9, 30),
        "observations": [],
        "author_is_patient": False,
    }
]

section = HealthConcernsSection(health_concerns=concerns)

With Custom Protocol Implementation

from dataclasses import dataclass
from datetime import date
from typing import Optional, Sequence

@dataclass
class HealthConcernObservation:
    """Custom observation implementation."""
    observation_type: str
    code: str
    code_system: str
    display_name: str

@dataclass
class HealthConcern:
    """Custom health concern implementation."""
    name: str
    status: str
    effective_time_low: Optional[date] = None
    effective_time_high: Optional[date] = None
    persistent_id: Optional[object] = None
    observations: Sequence[HealthConcernObservation] = None
    author_is_patient: bool = False

    def __post_init__(self):
        if self.observations is None:
            self.observations = []

# Create concerns
concerns = [
    HealthConcern(
        name="Concern about medication adherence",
        status="active",
        effective_time_low=date(2024, 2, 1),
        observations=[
            HealthConcernObservation(
                observation_type="social_history",
                code="182834008",
                code_system="SNOMED",
                display_name="Drug compliance poor"
            )
        ],
        author_is_patient=True,
    )
]

section = HealthConcernsSection(health_concerns=concerns)

Patient-Identified Concerns

# Patient's own worries and concerns
concerns = [
    {
        "name": "Worried about memory problems",
        "status": "active",
        "effective_time_low": date(2024, 1, 5),
        "observations": [],
        "author_is_patient": True,  # Patient-identified
    },
    {
        "name": "Concerned about family history of cancer",
        "status": "active",
        "effective_time_low": date(2023, 6, 1),
        "observations": [],
        "author_is_patient": True,
    }
]

section = HealthConcernsSection(health_concerns=concerns)

Official Reference

For complete specification details, refer to: - C-CDA Online: Health Concerns Section (V2) - Local Reference: references/C-CDA_2.1/templates/2.16.840.1.113883.10.20.22.2.58.html

Best Practices

1. Distinguish from Problem List

# Problem List: Diagnosed conditions
problems = ["Type 2 Diabetes Mellitus", "Hypertension"]

# Health Concerns: Broader issues requiring attention
concerns = [
    "Diabetes management complicated by food insecurity",
    "Fall risk due to multiple medications",
    "Depression affecting diabetes self-care"
]

2. Include Social Determinants

# Document social factors affecting health
concerns = [
    {
        "name": "Housing instability affecting medication storage",
        "status": "active",
        "observations": [
            {
                "observation_type": "social_history",
                "code": "32911000",
                "code_system": "SNOMED",
                "display_name": "Homeless",
            }
        ],
        "author_is_patient": False,
    }
]

3. Patient vs Provider Concerns

# Provider-identified concern
{
    "name": "Declining renal function requiring monitoring",
    "author_is_patient": False,  # Provider concern
}

# Patient-identified concern
{
    "name": "Anxiety about upcoming surgery",
    "author_is_patient": True,  # Patient concern
}

4. Status Management

# Active: Current concern requiring attention
{"status": "active"}

# Completed: No longer a concern
{"status": "completed", "effective_time_high": date(2024, 3, 1)}

# Suspended: Temporarily not being addressed
{"status": "suspended"}

# Aborted: Abandoned or invalidated
{"status": "aborted"}

# Connect concern to specific clinical findings
{
    "name": "Cardiovascular disease risk",
    "status": "active",
    "observations": [
        {"observation_type": "problem", "display_name": "Hypertension", ...},
        {"observation_type": "problem", "display_name": "Hyperlipidemia", ...},
        {"observation_type": "social_history", "display_name": "Current smoker", ...},
    ]
}

6. Temporal Clarity

# Document when concern started
{
    "effective_time_low": date(2024, 1, 15),  # When identified
    "effective_time_high": None,  # Ongoing
}

# Document when concern resolved
{
    "effective_time_low": date(2023, 6, 1),
    "effective_time_high": date(2024, 2, 15),  # No longer concerning
}

7. Narrative Generation

The section automatically generates an HTML table with: - Health concern name with unique ID reference - Status (capitalized) - Effective time range - Related observations (as a list) - Concern type (Patient or Provider)

8. Comprehensive Care Planning

# Link concerns to goals and plans
health_concerns = [
    {
        "name": "Risk of diabetic foot ulcer",
        "status": "active",
        ...
    }
]

goals = [
    {"description": "Maintain intact skin on feet", ...}
]

plan = [
    {"text": "Daily foot inspections", ...}
]

9. Risk Factors

# Document risk factors as concerns
concerns = [
    {
        "name": "High risk for osteoporotic fracture",
        "status": "active",
        "observations": [
            {
                "observation_type": "problem",
                "display_name": "Osteoporosis",
                "code": "64859006",
                "code_system": "SNOMED",
            }
        ],
        "author_is_patient": False,
    }
]

10. Family History Concerns

# Include family history concerns
concerns = [
    {
        "name": "Family history of breast cancer - requires surveillance",
        "status": "active",
        "effective_time_low": date(2024, 1, 1),
        "observations": [],
        "author_is_patient": False,
    }
]

Common Pitfalls

  1. Confusing with Problem List: Health concerns are broader than diagnoses
  2. Missing Context: Always link concerns to specific observations when applicable
  3. Ignoring Patient Input: Include patient-identified concerns alongside clinical ones
  4. Incomplete Status: Update status when concerns are resolved or change
  5. Missing Social Factors: Don't overlook social determinants of health
  6. No Timeline: Document when concerns were identified
  7. Too Granular: Focus on overarching concerns, not individual symptoms
  8. Disconnected from Care Plan: Link concerns to goals and interventions
  9. Author Attribution: Clearly identify whether concern is patient- or provider-identified
  10. Static Documentation: Update health concerns as patient situation changes