1.3.6.1.4.1.19376.1.5.3.1.1.19.1

Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

Prehospital Patient Care Report Specification 1.3.6.1.4.1.19376.1.5.3.1.1.19.1

Explain rationale for mapping to DEEDS is to show progression of information from NEMSIS to ED

Note 1

Either the Injury Incident Description or the History of Present Illness section shall be present. Both are permitted to be present. A content creator must demonstrate the ability to complete both, though not necessarily in the same report.

Note 2

The content creator must demonstrate the ability to complete these sections. If no data is available, the recommended behavior is to send indication that the data is not known, but this is not required.

LOINC Code

The LOINC code for this document is X-EMS EMS Report

Standards

CDAR2	HL7 CDA Release 2.0
CCD	ASTM/HL7 Continuity of Care Document
NEMCIS	http://www.nemsis.org/softwareDevelopers/datasetComponentsRequirements.html
DEEDS	http://www.cdc.gov/ncipc/pub-res/deedspage.htm
ASTM 1744	http://www.astm.org/Standards/E1744.htm

Data Element Index

Data Element	LOINC	DEEDS	NEMSIS
Chief Complaint	10154-3 CHIEF COMPLAINT	4.06 Chief Complaint	E09_05 Chief Complaint
Injury Incident Description	11374-6 INJURY INCIDENT DESCRIPTION	???	???
History of Present Illness	10164-2 HISTORY OF PRESENT ILLNESS	5.15 ED Clinical Finding
Acuity Assessment	11283-9 ACUITY ASSESSMENT	4.08 First ED Acuity Assessment
Active Problems	11450-4 PROBLEM LIST	5.15 ED Clinical Finding	E12_10 Medical/Surgical History
Current Medications	10160-0 CURRENT MEDICATIONS	5.09 Current Therapeutic Medication	E12_14 Current Medications
Allergies	48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS	5.15 ED Clinical Finding	E12_08 Medication Allergies, E12_09 Environmental/Food Allergies
Immunizations	11369-6 HISTORY OF IMMUNIZATIONS	5.15 ED Clinical Finding	E12_12 Immunization History
History of Past Illness	11348-0 HISTORY OF PAST ILLNESS	5.15 ED Clinical Finding	E12_10 Medical/Surgical History
History of Pregnancies	10162-6 HISTORY OF PREGNANCIES	5.15 ED Clinical Finding	E12_20 Pregnancy
Advance Directives	42348-3 ADVANCE DIRECTIVES	5.15 ED Clinical Finding	E12_07 Advanced Directives
Family History	10157-6 HISTORY OF FAMILY MEMBER DISEASES	5.15 ED Clinical Finding	E12_10 Medical/Surgical History
Social History	29762-2 SOCIAL HISTORY	5.15 ED Clinical Finding	E12_10 Medical/Surgical History
Vital Signs	8716-3 VITAL SIGNS	5.15 ED Clinical Finding	E14 Assessment/ Vital Signs
Pertinent ROS	10187-3 REVIEW OF SYSTEMS	5.15 ED Clinical Finding	E09_13 Primary Symptom
Physical Examination	29545-1 PHYSICAL EXAMINATION	5.15 ED Clinical Finding	E16 Assessment/ Exam
Assessment	X-ASSESS ASSESSMENTS	8.30 Patient Problem Assessed	E09_15 Providers Primary Impression
Intravenous Fluids Administered	X-IVFLU INTRAVENOUS FLUID ADMINISTERED	6.02 ED Procedure
Medications Administered	18610-6 MEDICATION ADMINISTERED (COMPOSITE)	7.04 ED Medication	E18_03 Medication Given
Procedures Performed	X-PROC PROCEDURES PERFORMED	6.02 ED Procedure	E19_03 Procedure
Transport Mode	11459-5 TRANSPORT MODE	4.02 Mode of Transport	E20 Disposition

Specification

Data Element Name	Opt	Template ID
Service Times Times for relevant events prior to or after the encounter may appear as service events in the CDA header (e.g., dispatch, arrival at scene).	O	1.3.6.1.4.1.19376.1.5.3.1.1.19.3.1
Encounter Data The EMS encounter identifier shall appear in the componentOf/encompassingEncounter element of the CDA header. The effective time of the encounter starts when the patient is contacted by the emergency responder.	R
Chief Complaint This section shall contain a condition entry describing the chief complaint in coded form. The effective time of the chief complaint should be the best estimate or actual time of occurence of the incident or onset leading to emergency care. It may contain a simple observation describing the cause of the injury.	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
Injury Incident Description See note 1. This section shall include a description of the incident leading to the injury, including status of relevant safety equipment in use (e.g., safety belts, air bag, helmet).	C	1.3.6.1.4.1.19376.1.5.3.1.1.19.2.1
History of Present Illness See note 1	C	1.3.6.1.4.1.19376.1.5.3.1.3.4
Acuity Assessment	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2
Active Problems See note 2	C	1.3.6.1.4.1.19376.1.5.3.1.3.6
Current Medications See note 2	C	1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies See note 2	C	1.3.6.1.4.1.19376.1.5.3.1.3.13
Immunizations	O	1.3.6.1.4.1.19376.1.5.3.1.3.23
Past Medical History See note 2	C	1.3.6.1.4.1.19376.1.5.3.1.3.8
History of Pregnancies See note 2	C	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Advanced Directives See note 2	C	1.3.6.1.4.1.19376.1.5.3.1.3.34
Family History	O	1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History Drug use?	O	1.3.6.1.4.1.19376.1.5.3.1.3.16
Vital Signs	R	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Pertinent ROS See note 2	C	1.3.6.1.4.1.19376.1.5.3.1.3.18
Physical Examination See note 2	C	1.3.6.1.4.1.19376.1.5.3.1.1.9.15
Assessement	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
Intravenous Fluids Administered See note 2	C	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
Medications Administered See note 2	C	1.3.6.1.4.1.19376.1.5.3.1.3.21
Procedures Performed See note 2. The procedures section shall contain procedure entries describing the type and timing of each intervention performed (e.g., CPR)	C	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11
Transport Mode The transport mode entry contains the time of departure from the scene with the patient and the time of arrival at the treatment facility, along with the mode of transport of the patient.	R	1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2

Conformance

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below.

Sample Prehospital Patient Care Report Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.19.1'/>
  <id root=' ' extension=' '/>
  <code code='X-EMS' displayName='EMS Report'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Prehospital Patient Care Report</title>
  <effectiveTime value='20240419012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/>
        <!-- Required Chief Complaint Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.19.2.1'/>
        <!-- Conditional Injury Incident Description Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Conditional History of Present Illness Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2'/>
        <!-- Required Acuity Assessment Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Conditional Active Problems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Conditional Current Medications Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
        <!-- Conditional Allergies Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
        <!-- Optional Immunizations Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Conditional Past Medical History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/>
        <!-- Conditional History of Pregnancies Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Conditional Advanced Directives Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/>
        <!-- Optional Family History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/>
        <!-- Optional Social History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
        <!-- Required Vital Signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Conditional Pertinent ROS Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/>
        <!-- Conditional Physical Examination Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'/>
        <!-- Required Assessement Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6'/>
        <!-- Conditional Intravenous Fluids Administered Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/>
        <!-- Conditional Medications Administered Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'/>
        <!-- Conditional Procedures Performed Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/>
        <!-- Required Transport Mode Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.19.1'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.19.1"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Prehospital Patient Care Report can only be used on Clinical Documents.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "X-EMS"]'>
     Error: The document type code of a Prehospital Patient Care Report must be X-EMS
   </assert>
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
     Error: The document type code must come from the LOINC code 
     system (2.16.840.1.113883.6.1).
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.19.3.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This Prehospital Patient Care Report Document does not contain a(n) Service Times Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Prehospital Patient Care Report Document must contain a(n) Encounter Data Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Prehospital Patient Care Report Document must contain a(n) Chief Complaint Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.19.2.1"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Prehospital Patient Care Report Document does not contain a(n) Injury Incident Description Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Prehospital Patient Care Report Document does not contain a(n) History of Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Prehospital Patient Care Report Document must contain a(n) Acuity Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Prehospital Patient Care Report Document does not contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Prehospital Patient Care Report Document does not contain a(n) Current Medications Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Prehospital Patient Care Report Document does not contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Note any missing optional elements -->
     Note: This Prehospital Patient Care Report Document does not contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Prehospital Patient Care Report Document does not contain a(n) Past Medical History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Prehospital Patient Care Report Document does not contain a(n) History of Pregnancies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Prehospital Patient Care Report Document does not contain a(n) Advanced Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> 
     <!-- Note any missing optional elements -->
     Note: This Prehospital Patient Care Report Document does not contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Note any missing optional elements -->
     Note: This Prehospital Patient Care Report Document does not contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Prehospital Patient Care Report Document must contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Prehospital Patient Care Report Document does not contain a(n) Pertinent ROS Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Prehospital Patient Care Report Document does not contain a(n) Physical Examination Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Prehospital Patient Care Report Document must contain a(n) Assessement Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Prehospital Patient Care Report Document does not contain a(n) Intravenous Fluids Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.21"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Prehospital Patient Care Report Document does not contain a(n) Medications Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Prehospital Patient Care Report Document does not contain a(n) Procedures Performed Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Prehospital Patient Care Report Document must contain a(n) Transport Mode Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1 
   </assert> 
 </rule>
</pattern>