Oh good health – how can a medical record shout out good fortune? Here’s how …

     :finding snomed:160245001; # No current problems or disability
     :finding snomed:160244002; # No known allergies
     :finding snomed:182850000; # Drugs not issued
or the more general ...
     :finding snomed:408350003; # Patient not on self medications

and such an explicit endorsement of health is very different from saying you don’t know about a person’s health …

      :finding snomed:396782006; # medical history unknown
or the precise
      :finding snomed:182904002 # drug treatment unknown

I suppose I don’t know is one step better than leaving a record empty: it snuffs out any hope of something being found in some out of the way filing cabinet.

Meaningful-use doesn’t like empty records. A CCD without at least one allergy, one medication and one problem entry is not conformant. To make a CCD for the healthy, we need to put our “findings of absence” to work, though it’s a little counter-intuitive …

Our one problem is a diagnosis of no problems …

     <code code="282291009" displayName="Diagnosis" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
                  ...
     <value xsi:type="CD" code="160245001" codeSystem="2.16.840.1.113883.6.96" displayName="No current problems or disability" codeSystemName="SNOMED CT">

but our one allergy is a stretch: we’re saying ‘Propensity to an adverse reaction’ is ‘No reactions’. The simpler ‘Diagnosis’ is ‘No known allergies’ makes more sense but allergy markup won’t allow it …

     <code code="420134006" codeSystem="2.16.840.1.113883.6.96" displayName="Propensity to adverse reactions (disorder)" codeSystemName="SNOMED CT"/>
                  ...
     <value xsi:type="CD" code="160244002" codeSystem="2.16.840.1.113883.6.96" displayName="No Known allergies" codeSystemName="SNOMED CT">

and our one medication? Normally medications are all about declaring the drug, the substance administered and the markup doesn’t start with a code like “Drugs Issued”, but as we need to declare absence, in comes a code …

     <code code="182850000" codeSystem="2.16.840.1.113883.6.96" displayName="Drugs not issued" codeSystemName="SNOMED CT"/>

Of course, all this means that no man, not even the healthiest, gets an empty medical record.