1.3.6.1.4.1.19376.1.5.3.1.1

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CDA Document Content Modules

This section contains document content modules using the CDA Release 2.0 standard.

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

Final.gif Medical Documents Specification 1.3.6.1.4.1.19376.1.5.3.1.1.1

This section defines the base set of constraints used by almost all medical document profiles described the PCC Technical Framework.



Standards
CDAR2 HL7 CDA Release 2.0
CDTHP CDA for Common Document Types History and Physical Notes (DSTU)
XMLXSL Associating Style Sheets with XML documents



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 Medical Documents Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Medical Documents</title>
  <effectiveTime value='20240424012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
       
  </structuredBody></component>
</ClinicalDocument>

  

   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Medical Documents must be {{{LOINC}}}
   </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>
Specification

The constraints for encoding of the CDA Header (Level 1) can be found in the CDA for Common Document Types History and Physical Implementation Guide, in the section 2. CDA Header -- General Constraints.

  • IHE Medical Documents shall follow all constraints found in that section with the exception of the constraint on realmcode found in CONF-HP-15:.
  • IHE Medical Documents which are implemented for the US Realm shall follow ALL constraints found in that section, and shall use both the IHE Medical Document templateId (1.3.6.1.4.1.19376.1.5.3.1.1.1) and the HL7 General Header Constraints templateId (2.16.840.1.113883.10.20.3).}}
Realm Constraints Template IDs Required
Universal CONF-HP-1 through CONF-HP-14
CONF-HP-16 through CONF-HP-52		 1.3.6.1.4.1.19376.1.5.3.1.1.1
US CONF-HP-1 through CONF-HP-52 1.3.6.1.4.1.19376.1.5.3.1.1.1
2.16.840.1.113883.10.20.3
Style Sheets

Document sources should provide an XML style sheet to render the content of the Medical Summary document. The output of this style sheet shall be an XHTML Basic (see http://www.w3.org/TR/xhtml-basic/) document that renders the clinical content of a Medical Summary Document as closely as possible as the sending provider viewed the completed document. When a style sheet is provided, at least one processing instruction shall be included in the document that including a link to the URL for the XML style sheet. To ensure that the style sheet is available to all receivers, more than one stylesheet link may be included.

When a stylesheet is used within an XDS Affinity domain, the link to it shall be provided using an HTTPS or HTTP URL. 

<?xml-stylesheet href='https://foobar:8080/mystylesheet.xsl' type='text/xsl'?>


When using XDM or XDR to exchange documents, the stylesheet shall also be exchanged on the media. The link to the stylesheet shall be recorded as a relative URL. 

<?xml-stylesheet href='../../stylesheets/mystylesheet.xsl' type='text/xsl'?>


Style sheets should not rely on graphic or other media resources. If graphics other media resources are used, these shall be accessible in the same way as the stylesheet. The Content Creator need not be the provider of the resources (stylesheet or graphcs).

When a Content Creator provides a style sheet, Content Consumers must provide a mechanism to render the document with that style sheet. Content Consumers may view the document with their own style sheet.

To record the stylesheet within a CDA Document that might be used in both an XDS and XDM environment, more than one stylesheet processing instruction is required. In this case, all style sheet processing instructions included must include the alternate='yes' attribute. 

<?xml-stylesheet href='https://foobar:8080/mystylesheet.xsl' type='text/xsl' alternate='yes'?>
<?xml-stylesheet href='../../stylesheets/mystylesheet.xsl' type='text/xsl' alternate='yes'?>

A Content Consumer that is attempting to render a document using the document supplied stylesheet may use the first style sheet processing instruction for which it is able to obtain the style sheet content, and shall not report any errors if it is able to find at least one stylesheet to render with.

Distinctions of None

Information that is sent must clearly identify distinctions between

None
It is known with complete confidence that there are none. Used in the context of problem and medication lists, this indicates that the sender knows that there is no relevant information that can be sent.
None Known
None are known at this time, but it is not known with complete confidence than none exist. Used in the context of allergy lists, where essentially, it is impossible to prove the negative that no allergies exist, it is only possible to assert that none have been found to date.
None Known Did Ask
None are known at this time, and it is not known with complete confidence than none exist, but the information was requested. Also used in the context of allergy lists, where essentially, it is impossible to prove the negative that no allergies exist, it is only possible to assert that none have been found to date.
Unknown
The information is not known, or is otherwise unavailable.

In the context of CDA, sections that are required to be present but have no information should use one of the above phrases where appropriate.

An appropriate machine readable entry shall be present for problems, medications and allergies to indicate the reason that no information. Codes for recording unknown or no information are provided in the section on the Problem, Allergy and Medications Entry.

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

Trial.gif Medical Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.2

A medical summary contains a snapshot of the patient's medical information, including at the very least, a list of the patients problems, medications and allergies. A Medical Summary is an abstract template that is expected to be further refined by additional document templates.


Parent Template

This document is an instance of the Medical Document template.

Standards
CDAR2 HL7 CDA Release 2.0


Specification
Data Element Name Opt Template ID
Problem Concern Entry R 1.3.6.1.4.1.19376.1.5.3.1.4.5.2
Allergy Concern Entry R 1.3.6.1.4.1.19376.1.5.3.1.4.5.3
Medications R 1.3.6.1.4.1.19376.1.5.3.1.4.7


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. A CDA Document may conform to more than one template. This content module inherits from the Medical Document content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Medical Summary Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Medical Summary</title>
  <effectiveTime value='20240424012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
       
  </structuredBody></component>
</ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.2'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Medical Summary can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'>
     Error: The parent template identifier for Medical Summary is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Medical Summary must be {{{LOINC}}}
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.5.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Medical Summary Document must contain a(n) Problem Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.2
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.5.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Medical Summary Document must contain a(n) Allergy Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.2
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.7"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Medical Summary Document must contain a(n) Medications Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.2
   </assert> 
 </rule>
</pattern>
Document Specification

A medical summary is a type of medical document, and incorporates the constraints defined for Medical Documents, and requires the recording of Problems, Allergies and Medications.

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

Trial.gif Referral Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.3

The use case is described fully in PCC_TF-1 for the Ambulatory Specialist Referral. Briefly, it involves a "collaborative" transfer of care for the referral of a patient from a primary care provider (PCP) to a specialist. The important document data elements identified by physicians and nurses for this use case are listed in the table below under the column "Data Elements". These were then mapped to the categories given HL7 Care Record Summary Implementation Guide, and HL7 CDA Release 2.0. These mappings are provided in the next two columns.

A referral summary is a type of Medical Summary, and incorporates the constraints defined for a Medical Summary(1.3.6.1.4.1.19376.1.5.3.1.1.2) above. This section defines additional constraints for Medical Summary Content used in a Referral summary. These tables present the Categories, as defined in Section 3 of CRS. In no case are these IHE requirements less strict than those defined by CRS.


Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:xds-ms:2007

Parent Template

This document is an instance of the Medical Summary template.

Standards
CDAR2 HL7 CDA Release 2.0
CRS HL7 Care Record Summary
CCD ASTM/HL7 Continuity of Care Document
Data Element Index
Data Elements HL7 Care Record Summary CDA Release 2.0
Reason for Referral Reason for Referral REASON FOR REFERRAL
History Present Illness History of Present Illness HISTORY OF PRESENT ILLNESS
Active Problems Conditions PROBLEM LIST
Current Meds Medications HISTORY OF MEDICATION USE
Allergies Allergies and Adverse Reactions HISTORY OF ALLERGIES
History of Past Illness Conditions HISTORY OF PAST ILLNESS
List of Surgeries Past Surgical History HISTORY OF PRIOR SURGERIES
Immunizations Immunizations HISTORY OF IMMUNIZATIONS
Family History Family History HISTORY OF FAMILY ILLNESS
Social History Social History SOCIAL HISTORY
Pertinent Review of Systems Review of Systems REVIEW OF SYSTEMS
Vital Signs Physical Exam VITAL SIGNS
Physical Exam Physical Exam GENERAL STATUS, PHYSICAL FINDINGS
Relevant Diagnostic Surgical Procedures / Clinical Reports (including links) Studies and Reports RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Relevant Diagnostic Test and Reports (Lab, Imaging, EKG's, etc.) including links. Studies and Reports RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Plan of Care (new meds labs, or x-rays ordered) Care Plan TREATMENT PLAN
Advance Directives Advance Directives ADVANCE DIRECTIVES
Patient Administrative Identifiers Header patientRole/id
Pertinent Insurance Information Participant participant[@classCode='HLD']
Data needed for state and local referral forms, if different than above Optional Sections section
Specification
Data Element Name Opt Template ID
Reason for Referral R 1.3.6.1.4.1.19376.1.5.3.1.3.1
History Present Illness R 1.3.6.1.4.1.19376.1.5.3.1.3.4
Active Problems R 1.3.6.1.4.1.19376.1.5.3.1.3.6
Current Meds R 1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies R 1.3.6.1.4.1.19376.1.5.3.1.3.13
History of Past Illness R2 1.3.6.1.4.1.19376.1.5.3.1.3.8
List of Surgeries R2 1.3.6.1.4.1.19376.1.5.3.1.3.11
Immunizations R2 1.3.6.1.4.1.19376.1.5.3.1.3.23
Family History R2 1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History R2 1.3.6.1.4.1.19376.1.5.3.1.3.16
Pertinent Review of Systems O 1.3.6.1.4.1.19376.1.5.3.1.3.18
Vital Signs R2 1.3.6.1.4.1.19376.1.5.3.1.3.25
Physical Exam R2 1.3.6.1.4.1.19376.1.5.3.1.3.24
Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports
(Lab, Imaging, EKG's, etc.) including links. 		R2 1.3.6.1.4.1.19376.1.5.3.1.3.27
Plan of Care (new meds, labs, or x-rays ordered) R2 1.3.6.1.4.1.19376.1.5.3.1.3.31
Advance Directives R2 1.3.6.1.4.1.19376.1.5.3.1.3.34
Patient Administrative Identifiers
Handled by the Medical Documents Content Profile by reference to constraints in HL7 CRS. 		R
Pertinent Insurance Information
Refer to Appropriate Payers Section -- TBD 		R2
Data needed for state and local referral forms, if different than above
These are handed by including additional sections within the summary.


R2


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. A CDA Document may conform to more than one template. This content module inherits from the Medical Summary content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Referral Summary Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.3'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Referral Summary</title>
  <effectiveTime value='20240424012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
        <!-- Required Reason for Referral Section content -->
      </section>
    </component>

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

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Current Meds Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required if known History of Past Illness Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
        <!-- Required if known List of Surgeries Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
        <!-- Required if known Immunizations Section content -->
      </section>
    </component>

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

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Optional Pertinent Review of Systems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
        <!-- Required if known Vital Signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
        <!-- Required if known Physical Exam Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.27'/>
        <!-- Required if known Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
        <!-- Required if known Plan of Care (new meds, labs, or x-rays ordered) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required if known Advance Directives Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.3'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.3"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Referral Summary can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
     Error: The parent template identifier for Referral Summary is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Referral Summary must be {{{LOINC}}}
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.3.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Referral Summary Document must contain a(n) Reason for Referral Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Referral Summary Document must contain a(n) History Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Referral Summary Document must contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Referral Summary Document must contain a(n) Current Meds Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Referral Summary Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) History of Past Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) List of Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Referral Summary Document does not contain a(n) Pertinent Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.24"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Physical Exam Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.27"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Plan of Care (new meds, labs, or x-rays ordered) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Referral Summary Document must contain a(n) Patient Administrative Identifiers Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Pertinent Insurance Information Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Data needed for state and local referral forms, if different than above Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 
   </assert> 
 </rule>
</pattern>

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

Trial.gif Discharge Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.4

This use case is described fully in the XDS-MS profile found in PCC TF-1. Briefly, it involves an episodic transfer of care in the form of a patient discharge from a hospital to home. The important data elements identified by physicians and nurses for this use case are listed in the table below under the column "Data Elements". These are mapped to the categories given HL7 Care Record Summary Implementation Guide, and HL7 CDA Release 2.0 in the next two columns.

A discharge summary is a type of medical summary, and incorporates the constraints defined for Medical Summaries.

This section defines additional constraints for Medical Summary Content used in a Discharge Summary. These tables present the data elements described above, along with their optionality, and references to the section and template where these sections or header data elements are further defined.

In no case are these IHE requirements less strict than those defined by the HL7 Care Record Summary.


Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:xds-ms:2007

Parent Template

This document is an instance of the Medical Summary template.

Standards
CDAR2 HL7 CDA Release 2.0
CRS HL7 Care Record Summary
CCD ASTM/HL7 Continuity of Care Document
Data Element Index
Data Elements HL7 Care Record Summary CDA Release 2.0
Date of Admission Header encompassingEncounter/effectiveTime
Date of Discharge Header encompassingEncounter/effectiveTime
Participating Providers and Roles Header documentationOf/serviceEvent/performer
Discharge Disposition (who, how, where) Care Plan DISCHARGE DISPOSITION
Admitting Diagnosis Conditions HOSPITAL ADMISSION DX
History of Present Illness History of Present Illness HISTORY OF PRESENT ILLNESS
Hospital Course Hospital Course HOSPITAL COURSE
Discharge Diagnosis (including active and resolved problems) Conditions HOSPITAL DISCHARGE DX
Selected Medicine Administered during Hospitalization Medications HISTORY OF MEDICATION USE
Discharge Medications Medications HOSPITAL DISCHARGE MEDICATIONS
Allergies and adverse reactions Allergies and Adverse Reactions HISTORY OF ALLERGIES
Discharge Diet Optionally found in Care Plan DISCHARGE DIET
Review of Systems Review of Systems REVIEW OF SYSTEMS
Vital Signs (most recent, high/low/average) Physical Exam VITAL SIGNS
Functional Status Functional Status HISTORY OF FUNCTIONAL STATUS
Relevant Procedures and Reports (including links) Studies and Reports HOSPITAL DISCHARGE STUDIES
Relevant Diagnostic Tests and Reports (including links) Studies and Reports HOSPITAL DISCHARGE STUDIES
Plan of Care Care Plan TREATMENT PLAN
Administrative Identifiers Header patient/id
Pertinent Insurance Information Header participant[@classCode='HLD']
Specification
Data Element Name Opt Template ID
Active Problems R 1.3.6.1.4.1.19376.1.5.3.1.3.6
Resolved Problems R 1.3.6.1.4.1.19376.1.5.3.1.3.8
Discharge Diagnosis R 1.3.6.1.4.1.19376.1.5.3.1.3.7
Admitting Diagnosis R 1.3.6.1.4.1.19376.1.5.3.1.3.3
Selected Meds Administered R2 1.3.6.1.4.1.19376.1.5.3.1.3.21
Discharge Meds R 1.3.6.1.4.1.19376.1.5.3.1.3.22
Admission Medications R2 1.3.6.1.4.1.19376.1.5.3.1.3.20
Allergies R 1.3.6.1.4.1.19376.1.5.3.1.3.13
Hospital Course R 1.3.6.1.4.1.19376.1.5.3.1.3.5
Advance Directives O 1.3.6.1.4.1.19376.1.5.3.1.3.34
History of Present Illness R2 1.3.6.1.4.1.19376.1.5.3.1.3.4
Functional Status O 1.3.6.1.4.1.19376.1.5.3.1.3.17
Review of Systems O 1.3.6.1.4.1.19376.1.5.3.1.3.18
Physical Examination O 1.3.6.1.4.1.19376.1.5.3.1.3.24
Vital Signs O 1.3.6.1.4.1.19376.1.5.3.1.3.25
Discharge Procedures Tests, Reports O 1.3.6.1.4.1.19376.1.5.3.1.3.29
Plan of Care R 1.3.6.1.4.1.19376.1.5.3.1.3.31
Discharge Diet O 1.3.6.1.4.1.19376.1.5.3.1.3.33


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. A CDA Document may conform to more than one template. This content module inherits from the Medical Summary content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Discharge Summary Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.4'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Discharge Summary</title>
  <effectiveTime value='20240424012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required Active Problems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required Resolved Problems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.7'/>
        <!-- Required Discharge Diagnosis Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.3'/>
        <!-- Required Admitting Diagnosis Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/>
        <!-- Required if known Selected Meds Administered Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.22'/>
        <!-- Required Discharge Meds Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.20'/>
        <!-- Required if known Admission Medications Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.5'/>
        <!-- Required Hospital Course Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Optional Advance Directives Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/>
        <!-- Optional Functional Status Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Optional Review of Systems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
        <!-- Optional Physical Examination Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
        <!-- Optional Vital Signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.29'/>
        <!-- Optional Discharge Procedures Tests, Reports Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
        <!-- Required Plan of Care Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.33'/>
        <!-- Optional Discharge Diet Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.4'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.4"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Discharge Summary can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
     Error: The parent template identifier for Discharge Summary is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Discharge Summary must be {{{LOINC}}}
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Resolved Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.7"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Discharge Diagnosis Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Admitting Diagnosis Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.21"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Discharge Summary Document should contain a(n) Selected Meds Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.22"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Discharge Meds Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.20"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Discharge Summary Document should contain a(n) Admission Medications Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.5"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Hospital Course Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Discharge Summary Document should contain a(n) History of Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.17"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Functional Status Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.24"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Physical Examination Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.29"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Discharge Procedures Tests, Reports Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Plan of Care Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.33"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Discharge Diet Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
 </rule>
</pattern>

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

Trial.gif PHR Extract Specification 1.3.6.1.4.1.19376.1.5.3.1.1.5

The PHR Extract module describes the document content that summarizes information contained within a Personal Health Record. While a PHR can contain a great deal more information (including clinical documents, lab reported, images, trend data, monitoring data) et cetera, this content module only deals with the format of the summary information from the PHR.

An PHR Extract Module is a type of medical summary, and incorporates the constraints defined for Medical Summaries. While mappings have been provided to various standards, this content module conforms to the ASTM/HL7 Continuity of Care Document as well as this guide.

The following table describes the data elements that may be present in a PHR Extract. The first column of this table is drawn from the Common Data Elements in the PHR found in Appendix B of the AHIMA Report: The Role of the Personal Health Record in the EHR. Indented items in this column of the table provide more detail for the item they appear underneath.

These data elements were then mapped to the ASTM CCR, HL7 CDA, CRS and CCD and the implicit data elements referenced by the HL7 PHR Conformance Criteria.

A further requirement of transfers of information between PHR and EHR systems is that authorship of the information stored within the PHR shall be tracable through the various import/export cycles. PHR Manager Actors must be secure nodes, which requires logging of any updates to or accesses of PHR information. The DSG profile should be used to ensure that information coming into, or exiting these systems is verifiably authored.


Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:xphr:2007

Parent Template

This document is an instance of the Medical Summary template.

LOINC Code

The LOINC code for this document is 34133-9 Summary of Episode Note

Standards
AHIMA-PHR AHIMA PHR Common Data Elements
CDAR2 HL7 CDA Release 2.0
CRS HL7 Care Record Summary
CCD ASTM/HL7 Continuity of Care Document
HL7-PHR HL7 PHR Functional Model (Draft)
LOINC Logical Observation Identifier Names and Codes
Data Element Index
AHIMA Common Data Elements ASTM Continuity of Care Record HL7 Clincial Document Architecture, Care Record Summary or Continuity of Care Document HL7 PHR Conformance Criteria
Personal Information Patient patientRole Demographic Information
Name Patient patient/name Demographic Information
Address Patient patientRole/addr Contact Information
Contact Information Patient patientRole/telecom Contact Information
Personal Identification Information Patient patientRole/id Demographic Information
Gender Patient patient/administrativeGenderCode Demographic Information
Date of Birth Patient patient/birthTime Demographic Information
Marital Status Patient patient/maritalStatusCode  
Race Patient patient/raceCode  
Ethnicity Patient patient/ethnicGroupCode Demographic Information
(Religious Affiliation[1]) Patient patient/religiousAffiliationCode Spiritual Affiliation / Considerations
Languages Spoken Patient patient/languageCommunication  
Employer and School Contacts Social History  
Hazardous Working Conditions Social History HISTORY OF OCCUPATIONAL EXPOSURE  
Emergency Contacts Support  
Healthcare Providers Practitioners serviceEvent/performer Healthcare Providers
Insurance Providers Insurance Health Insurance or Pharmacy Insurance
Pharamacy   performer
Legal Documents and Medical Directives Advance Directives ADVANCE DIRECTIVES Advance Directive
General Medical Information
Height, Weight		 Vital Signs VITAL SIGNS  
Blood Type Results RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA  
Last Physical or Checkup Encounters HISTORY OF OUTPATIENT VISITS Clinical Encounters and Procedures List
Allergies and Drug Sensitivies Alerts HISTORY OF ALLERGIES Allergy and Reaction List
Conditions Problems HISTORY OF PAST ILLNESS
- or -
PROBLEM LIST		 Problem List
Surgeries Procedures HISTORY OF SURGICAL PROCEDURES Clinical Encounters and Procedures List
Medications – Prescription and Non-Prescription Medications HISTORY OF MEDICATION USE Medication List
Immunizations Immunizations HISTORY OF IMMUNIZATIONS Immunizations List
Doctor Visits Encounters HISTORY OF OUTPATIENT VISITS Clinical Encounters and Procedures List
Hospitalizations Encounters HISTORY OF HOSPITALIZATIONS Clinical Encounters and Procedures List
Other Healthcare Visits Encounters HISTORY OF OUTPATIENT VISITS Clinical Encounters and Procedures List
Clinical Tests Results RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA Laboratory and Test Results
Pregnancies   HISTORY OF PREGNANCIES  
Medical Devices Medical Devices HISTORY OF MEDICAL DEVICE USE  
Family Member History Family History HISTORY OF FAMILY MEMBER DISEASES Family History
Foreign Travel   HISTORY OF TRAVEL  
Therapy Plan of Care TREATMENT PLAN Care Plans, Goals and Disease Management
Vital Signs Vital signs VITAL SIGNS  
(Functional Status[2]) Functional Status FUNCTIONAL STATUS  
Specification
Data Element Name Opt Template ID
Personal Information
 
Name
Address
Contact Information
Personal Identification
Gender
Date of Birth

Thes components are required of all Medical Documents

R 1.3.6.1.4.1.19376.1.5.3.1.1.1
Personal Information
 
Marital Status

This commponent is optional in Medical Documents, but required if known in this specification.

R2 1.3.6.1.4.1.19376.1.5.3.1.1.1
Personal Information
 
Race
Ethnicity
Religious Affiliation [2]

These components are optional in Medical Documents

O 1.3.6.1.4.1.19376.1.5.3.1.1.1
Languages Spoken R2 1.3.6.1.4.1.19376.1.5.3.1.2.1
Employer and School Contacts O 1.3.6.1.4.1.19376.1.5.3.1.2.2
Hazardous Working Conditions O 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1
Patient Contacts R2 1.3.6.1.4.1.19376.1.5.3.1.2.4
Healthcare Providers R 1.3.6.1.4.1.19376.1.5.3.1.2.3
Insurance Providers R2 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7
Pharamacy R2 1.3.6.1.4.1.19376.1.5.3.1.2.3
Legal Documents and Medical Directives R2 1.3.6.1.4.1.19376.1.5.3.1.3.34
Allergies and Drug Sensitivities R 1.3.6.1.4.1.19376.1.5.3.1.3.13
Conditions R 1.3.6.1.4.1.19376.1.5.3.1.3.8
Conditions (cont) R 1.3.6.1.4.1.19376.1.5.3.1.3.6
Surgeries R2 1.3.6.1.4.1.19376.1.5.3.1.3.12
Medications – Prescription and Non-Prescription R 1.3.6.1.4.1.19376.1.5.3.1.3.19
Immunizations R2 1.3.6.1.4.1.19376.1.5.3.1.3.23
Doctor Visits / Last Physical or Checkup O 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
Hospitalizations O 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
Other Healthcare Visits O 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
Clinical Tests / Blood Type O 1.3.6.1.4.1.19376.1.5.3.1.3.28
Pregnancies O 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Medical Devices R2 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5
Family Member History O 1.3.6.1.4.1.19376.1.5.3.1.3.15
Foreign Travel O 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6
Plan of Care O 1.3.6.1.4.1.19376.1.5.3.1.3.31
Coded Vital signs O 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Functional Status O 1.3.6.1.4.1.19376.1.5.3.1.3.17


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. A CDA Document may conform to more than one template. This content module inherits from the Medical Summary content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample PHR Extract Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5'/>
  <id root=' ' extension=' '/>
  <code code='34133-9' displayName='Summary of Episode Note'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>PHR Extract</title>
  <effectiveTime value='20240424012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1'/>
        <!-- Optional Hazardous Working Conditions Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required if known Legal Documents and Medical Directives Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
        <!-- Required Allergies and Drug Sensitivities Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required Conditions Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required Conditions (cont) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.12'/>
        <!-- Required if known Surgeries Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Medications – Prescription and Non-Prescription Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
        <!-- Required if known Immunizations Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'/>
        <!-- Optional Doctor Visits / Last Physical or Checkup Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'/>
        <!-- Optional Hospitalizations Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'/>
        <!-- Optional Other Healthcare Visits Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.28'/>
        <!-- Optional Clinical Tests / Blood Type Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/>
        <!-- Optional Pregnancies Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5'/>
        <!-- Required if known Medical Devices Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.15'/>
        <!-- Optional Family Member History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6'/>
        <!-- Optional Foreign Travel Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
        <!-- Optional Plan of Care Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
        <!-- Optional Coded Vital signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/>
        <!-- Optional Functional Status Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.5'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.5"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The PHR Extract can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
     Error: The parent template identifier for PHR Extract is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "34133-9"]'>
     Error: The document type code of a PHR Extract must be 34133-9
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The PHR Extract Document must contain a(n) Personal Information Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.1"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Personal Information Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Personal Information Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.1"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Languages Spoken Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.2"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Employer and School Contacts Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Hazardous Working Conditions Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Patient Contacts Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The PHR Extract Document must contain a(n) Healthcare Providers Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Insurance Providers Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.3"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Pharamacy Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Legal Documents and Medical Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The PHR Extract Document must contain a(n) Allergies and Drug Sensitivities Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The PHR Extract Document must contain a(n) Conditions Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The PHR Extract Document must contain a(n) Conditions (cont) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.12"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The PHR Extract Document must contain a(n) Medications – Prescription and Non-Prescription Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Doctor Visits / Last Physical or Checkup Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Hospitalizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Other Healthcare Visits Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.28"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Clinical Tests / Blood Type Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Pregnancies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Medical Devices Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.15"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Family Member History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Foreign Travel Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Plan of Care Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Coded Vital signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.17"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Functional Status Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
 </rule>
</pattern>
Additional Constraints

The assignedAuthoring device shall be populated with information about the EHR and/or PHR which assisted in creation of the document.

All sections and entries within the document shall contain an <id> element.

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

Trial.gif PHR Update Specification 1.3.6.1.4.1.19376.1.5.3.1.1.6

The PHR Update Content Module is similar to the PHR Extract content module, except that it has a number of different constraints. First of all, it is not required to contain all of the information that the PHR Extract content module does. The reason for this is because the purpose of this module is to reflect the changes that should be made to a PHR based on a previously existing PHR Extract content module. So, while it makes use of the same data element index, almost all of the data elements are optional. The purpose of this module is to make it easier for an EHR to create content that can be used to update a PHR.


Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:xphr:2007




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 PHR Update Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.6'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>PHR Update</title>
  <effectiveTime value='20240424012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
       
  </structuredBody></component>
</ClinicalDocument>

  

   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a PHR Update must be {{{LOINC}}}
   </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>
Requirements

The requirements of this module are that it support recording updates to the original PHR Extract. The PHR Extract is made up of a header, and several sections, each of which may contain one or more entries. Suggestions to add, remove or update a section or entry are described in more detail below.

Adding a New Section or Appending to an Existing Section

A PHR Reviewer Actor may suggest additional material for an existing or new section by simply adding that section to the PHR Update document.

Replacing a Section

A PHR Reviewer Actor may suggest a revision to a section in the PHR Extract by replacing that section. To replace a section, the PHR Reviewer Actor creates a section in the PHR Update document that is of the same type as the section to be replaced in the PHR Extract document, and adds a <ppc:replacementOf> element to that section to indicate the section that it replaces.

The replacementOf element is an extension to the CDA Release 2.0 standard, and is further described below in Appendix C Extensions to CDA Release 2.0.

Adding an Entry

A PHR Reviewer Actor may suggest a new entry be added to a section by simply including that entry in a like section in the PHR Update document.

Replacing or Removing an Entry

The PHR Review Actor can replace an existing entry by adding an entry of the same type with new or modified information, and including in that entry a <reference> element that has an <externalAct> element. The <id> element of the <externalAct> shall be that of the act that is being replaced

Removing an Entry

The PHR Reviewer Actor can suggest that an entry be removed by replacing it with an act who <statusCode> element has been set to nullified.

Constraints

The LOINC document type code is the same as for the PHR Extract content module. The PHR Update Content module must record the PHR Extract which it is updating

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

Trial.gif Consent to Share Information Specification 1.3.6.1.4.1.19376.1.5.3.1.1.7

Consents to share information are documents that contain both a human and machine readable description of how a patient has chosen to share their information.


Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:bppc:2007

Parent Template

This document is an instance of the Medical Document template.

Standards
CDAR2 HL7 CDA Release 2.0
XDS-SD Scanned Documents


Specification
Data Element Name Opt Template ID
Consent Service Event
At least one, and possibly more than one, consent can be provided within the document. 		R 1.3.6.1.4.1.19376.1.5.3.1.2.6
Authorization
Consents may also be protected under a sharing policity. 		O 1.3.6.1.4.1.19376.1.5.3.1.2.5


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. A CDA Document may conform to more than one template. This content module inherits from the Medical Document content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Consent to Share Information Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.7'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Consent to Share Information</title>
  <effectiveTime value='20240424012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
       
  </structuredBody></component>
</ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.7'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.7"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Consent to Share Information can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'>
     Error: The parent template identifier for Consent to Share Information is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Consent to Share Information must be {{{LOINC}}}
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.2.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Consent to Share Information Document must contain a(n) Consent Service Event Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.7 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.5"]'> 
     <!-- Note any missing optional elements -->
     Note: This Consent to Share Information Document does not contain a(n) Authorization Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.7 
   </assert> 
 </rule>
</pattern>
Constraints

A consent shall contain a text description of what the patient consented to, a list of codes indicating the policy(s) agreed to, a time range indicating the effective time of the consent, and shall contain a signature signifying the patient agreement to those policy(s) stated in the text description. Finally, consents may be attested to using an electronic digital signature, conforming to the ITI Digital Signature Profile.

The text description and signature may appear as a scanned image. When the consent contains a scanned image, it shall also conform to the constraints of the ITI Scanned Document profile.

A consent shall have one or more <serviceEvent> elements in the header identifying the policies authorized by the document (see Section 4.2.3.4 of CDAR2). Each <serviceEvent> element indicates informed consent to one and only one XDS Affinity Domain policy. More than one policy may be agreed to within a given consent document.

Consent documents should be attested to by either the patient and/or legal guardian, or a third party assigned by the XDS Affinity Domain or its member organizations. The attestation, if present, should be performed using the ITI Digital Signature profile. The signer may be the patient, or a third party.

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

Trial.gif Preprocedure History and Physical Specification 1.3.6.1.4.1.19376.1.5.3.1.1.9

A Pre-procedure History and Physical is a type of medical document, and incorporates the constraints defined for Medical Documents(1.3.6.1.4.1.19376.1.5.3.1.1.1) .

This use case is described fully in in the PPHP Profile described in PCC TF-1. Briefly, this use case involves a sequence of events leading up to the patient’s admission to the operating room in a surgical center. Included in these events is the creation and communication of the pre-procedure history and physical document required by quality review organizations prior to most surgeries. Using this use case, the contents of documents used in collaborative transfers of care were discussed with physicians and nurses in detail to identify major sections. The sections identified by physicians during the use case exercise as important are listed in the table below under the column “Use Case Documentation Section??.

Using this information from the use case, the following mappings were made to existing standards and implementation guides. As illustrated, there is quite a bit of overlap between sections in this integration profile and in sections specified in the HL7 Care Record Summary CDA implementation guide.


Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:pphp:2007

Parent Template

This document is an instance of the Medical Document template.

Standards
CDAR2 HL7 CDA Release 2.0
CRS HL7 Care Record Summary
CCD ASTM/HL7 Continuity of Care Document
Data Element Index
Data Element Requirements Sections in HL7 CDA-R2/ LOINC Descriptions
Proposed Procedure: (coded procedure)   PROCEDURE
Expected Blood Loss   OPERATIVE NOTE ESTIMATED BLOOD LOSS
Proposed Anesthesia   OPERATIVE NOTE ANESTHESIA
Reason for Procedure: (coded diagnosis)   OPERATIVE NOTE INDICATIONS
HPI—(free text leading up to procedure) History of Present Illness HISTORY OF PRESENT ILLNESS
Current Problem List Conditions PROBLEM LIST
Past Medical History Conditions HISTORY OF PAST ILLNESS
Past Surgical-Anesthesia History Past Surgical History HISTORY OF SURGICAL PROCEDURES
Medication List Medications HISTORY OF MEDICATION USE
Allergy List Allergies and Adverse Reactions HISTORY OF ALLERGIES
Immunizations Immunizations HISTORY OF IMMUNIZATIONS
History of Tobacco Use   HISTORY OF TOBACCO USE
Current Alcohol/Substance Abuse   HISTORY OF PRESENT ALCOHOL AND/OR SUBSTANCE ABUSE
Transfusion History   TBD
Family History (specifically includes): Family History HISTORY OF FAMILY MEMBER DISEASES
Social History   SOCIAL HISTORY
Advance Directives Advance Directives ADVANCE DIRECTIVES
Functional Capacity Functional Status HISTORY OF FUNCTIONAL STATUS
Review of Systems (specifically includes): Review of Systems REVIEW OF SYSTEMS
Physical Exam (specifically includes): Physical Examination PHYSICAL EXAM.TOTAL
Studies and Reports Studies and Reports STUDIES SUMMARY
Health Maintenance Status   TREATMENT PLAN
Pre-procedure Care Plan Status Report   TREATMENT PLAN
Pre-procedure Impressions (specifically includes):   DIAGNOSIS
-Updated Problem List Conditions PROBLEM LIST
-Pre-Procedure Risk Assessment   OPERATIVE NOTE COMPLICATIONS
Pre-procedure Care Plan Plan of Care TREATMENT PLAN
Patient Education/Consents   EDUCATION NOTE
Specification
Data Element Name Opt Template ID
Proposed Procedure: (coded procedure) includes:
Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. 		R 1.3.6.1.4.1.19376.1.5.3.1.1.9.1
-Reason for Procedure: (coded diagnosis)
Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. 		R 1.3.6.1.4.1.19376.1.5.3.1.1.9.4
-Proposed Anesthesia
Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. 		R 1.3.6.1.4.1.19376.1.5.3.1.1.9.3
-Expected Blood Loss
Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.
Needs narrative LOINC code 		R2 1.3.6.1.4.1.19376.1.5.3.1.1.9.2
-Procedure Care Plan
Care Plan generated by the surgeon or surgical coordinator prior to the H&P 		R2 1.3.6.1.4.1.19376.1.5.3.1.1.9.40
HPI—(free text leading up to procedure) R 1.3.6.1.4.1.19376.1.5.3.1.3.4
Current Problem List
Problem List (if known) is represented as current at beginning of H&P encounter. 		R2 1.3.6.1.4.1.19376.1.5.3.1.3.6
Past Medical History R2 1.3.6.1.4.1.19376.1.5.3.1.3.8
Past Surgical-Anesthesia History R 1.3.6.1.4.1.19376.1.5.3.1.3.11
Medication List R 1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergy List R 1.3.6.1.4.1.19376.1.5.3.1.3.13
Immunizations R2 1.3.6.1.4.1.19376.1.5.3.1.3.23
History of Tobacco Use R 1.3.6.1.4.1.19376.1.5.3.1.1.9.8
Current Alcohol/Substance Abuse R 1.3.6.1.4.1.19376.1.5.3.1.1.9.10
Transfusion History R 1.3.6.1.4.1.19376.1.5.3.1.1.9.12
Pre-procedure Family History R 1.3.6.1.4.1.19376.1.5.3.1.1.9.5
Social History R2 1.3.6.1.4.1.19376.1.5.3.1.3.16
Advance Directives R2 1.3.6.1.4.1.19376.1.5.3.1.3.34
Functional Capacity R 1.3.6.1.4.1.19376.1.5.3.1.3.17
Review of Systems (specifically includes): R 1.3.6.1.4.1.19376.1.5.3.1.1.9.13
-General Review R 1.3.6.1.4.1.19376.1.5.3.1.3.18
-Implanted Medical Devices R2 1.3.6.1.4.1.19376.1.5.3.1.1.9.46
-Pregnancy Status (if female) R 1.3.6.1.4.1.19376.1.5.3.1.1.9.47
-Anesthesia Review of Systems R 1.3.6.1.4.1.19376.1.5.3.1.1.9.14
Physical Exam (specifically includes): R 1.3.6.1.4.1.19376.1.5.3.1.1.9.15
-Vitals R 1.3.6.1.4.1.19376.1.5.3.1.9.49
-General Appearance O 1.3.6.1.4.1.19376.1.5.3.1.1.9.16
-Visible Implanted Medical Devices O 1.3.6.1.4.1.19376.1.5.3.1.1.9.48
-Integumentary System O 1.3.6.1.4.1.19376.1.5.3.1.1.9.17
-Head O 1.3.6.1.4.1.19376.1.5.3.1.1.9.18
-Eyes O 1.3.6.1.4.1.19376.1.5.3.1.1.9.19
-Ears, Nose, Mouth and Throat (may include): O 1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1
--Ears O 1.3.6.1.4.1.19376.1.5.3.1.1.9.21
--Nose O 1.3.6.1.4.1.19376.1.5.3.1.1.9.22
--Mouth, Throat, and Teeth O 1.3.6.1.4.1.19376.1.5.3.1.1.9.23
-Neck O 1.3.6.1.4.1.19376.1.5.3.1.1.9.24
-Endocrine System O 1.3.6.1.4.1.19376.1.5.3.1.1.9.25
-Thorax and Lungs (may include): O 1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1
--Chest Wall O 1.3.6.1.4.1.19376.1.5.3.1.1.9.27


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. A CDA Document may conform to more than one template. This content module inherits from the Medical Document content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Preprocedure History and Physical Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Preprocedure History and Physical</title>
  <effectiveTime value='20240424012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.1.9.1'/>
        <!-- Required Proposed Procedure: (coded procedure) includes: Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.4'/>
        <!-- Required -Reason for Procedure: (coded diagnosis) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.3'/>
        <!-- Required -Proposed Anesthesia Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.2'/>
        <!-- Required if known -Expected Blood Loss Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.40'/>
        <!-- Required if known -Procedure Care Plan Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Required HPI—(free text leading up to procedure) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required if known Current Problem List Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
        <!-- Required Past Surgical-Anesthesia History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Medication List Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
        <!-- Required Allergy List Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
        <!-- Required if known Immunizations Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.8'/>
        <!-- Required History of Tobacco Use Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.10'/>
        <!-- Required Current Alcohol/Substance   Abuse Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.12'/>
        <!-- Required Transfusion History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.5'/>
        <!-- Required Pre-procedure Family History Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required if known Advance Directives Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/>
        <!-- Required Functional Capacity Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.13'/>
        <!-- Required Review of Systems (specifically includes): Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Required   -General Review Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.46'/>
        <!-- Required if known -Implanted Medical Devices Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.47'/>
        <!-- Required -Pregnancy Status (if female) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.14'/>
        <!-- Required   -Anesthesia Review of Systems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/>
        <!-- Required Physical Exam (specifically includes): Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.9.49'/>
        <!-- Required -Vitals Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.16'/>
        <!-- Optional -General Appearance Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.48'/>
        <!-- Optional -Visible Implanted Medical Devices Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.17'/>
        <!-- Optional -Integumentary System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.18'/>
        <!-- Optional -Head Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.19'/>
        <!-- Optional -Eyes Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1'/>
        <!-- Optional -Ears, Nose, Mouth and Throat (may include): Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.21'/>
        <!-- Optional --Ears Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.22'/>
        <!-- Optional --Nose Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.23'/>
        <!-- Optional --Mouth, Throat, and Teeth Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.24'/>
        <!-- Optional -Neck Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.25'/>
        <!-- Optional -Endocrine System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1'/>
        <!-- Optional -Thorax and Lungs (may include): Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.27'/>
        <!-- Optional --Chest Wall Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Preprocedure History and Physical can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'>
     Error: The parent template identifier for Preprocedure History and Physical is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Preprocedure History and Physical must be {{{LOINC}}}
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.9.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Proposed Procedure: (coded procedure) includes: Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) -Reason for Procedure: (coded diagnosis) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) -Proposed Anesthesia Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.2"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) -Expected Blood Loss Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.40"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) -Procedure Care Plan Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) HPI—(free text leading up to procedure) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) Current Problem List Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) Past Medical History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Past Surgical-Anesthesia History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Medication List Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Allergy List Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.8"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) History of Tobacco Use Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.10"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Current Alcohol/Substance   Abuse Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.12"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Transfusion History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.5"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Pre-procedure Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.17"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Functional Capacity Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Review of Systems (specifically includes): Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n)   -General Review Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.46"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) -Implanted Medical Devices Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.47"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) -Pregnancy Status (if female) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.14"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n)   -Anesthesia Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Physical Exam (specifically includes): Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.9.49"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) -Vitals Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.16"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -General Appearance Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.48"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Visible Implanted Medical Devices Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.17"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Integumentary System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Head Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.19"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Eyes Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Ears, Nose, Mouth and Throat (may include): Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.21"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) --Ears Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.22"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) --Nose Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.23"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) --Mouth, Throat, and Teeth Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.24"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Neck Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.25"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Endocrine System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Thorax and Lungs (may include): Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.27"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) --Chest Wall Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
 </rule>
</pattern>

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

Trial.gif Emergency Department Referral Specification 1.3.6.1.4.1.19376.1.5.3.1.1.10

An ED Referral is a type of Referral Summary, and incorporates the constraints defined for Referral Summaries.

This use case is described fully in the EDR Profile in PCC TF-1. Briefly, it involves a collaborative transfer of care for the referral of a patient from a care provider to an emergency department. Using this use case the contents of documents used in collaborative transfers of care were discussed with physicians and nurses in detail to identify major sections. The sections identified by physicians during the use case exercise as important are listed in the table below.

Using this information from the use case, the following mappings were made to existing standards.


Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:edr:2007

Parent Template

This document is an instance of the Medical Summary template.


Data Element Index
Data Elements HL7 Care Record Summary CDA Release 2.0
Reason for Referral Reason for Referral REASON FOR REFERRAL
History Present Illness History of Present Illness HISTORY OF PRESENT ILLNESS
Active Problems Conditions PROBLEM LIST
Current Meds Medications HISTORY OF MEDICATION USE
Allergies Allergies and Adverse Reactions HISTORY OF ALLERGIES
Resolved Problems Conditions HISTORY OF PAST ILLNESS
List of Surgeries Past Surgical History HISTORY OF PRIOR SURGERIES
Immunizations Immunizations HISTORY OF IMMUNIZATIONS
Family History Family History HISTORY OF FAMILY ILLNESS
Social History Social History SOCIAL HISTORY
Pertinent Review of Systems Review of Systems REVIEW OF SYSTEMS
Vital Signs Physical Exam VITAL SIGNS
Physical Exam Physical Exam GENERAL STATUS, PHYSICAL FINDINGS
Relevant Surgical Procedures / Clinical Reports (including links) Studies and Reports RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Relevant Diagnostic Test and Reports (Lab, Imaging, EKG’s, etc.) including links. Studies and Reports RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Care Plan (new meds labs, or x-rays ordered) Care Plan TREATMENT PLAN
Proposed ED Disposition ED DISPOSITION
Mode of Transport to the Emergency Department Care Plan MODE OF TRANSPORT
Estimated Time of Arrival to the ED Care Plan MODE OF TRANSPORT
Advance Directives Advance Directives ADVANCE DIRECTIVES
Patient Administrative Identifiers Header patientRole/id
Pertinent Insurance Information Participant participant[@roleCode='HLD']
Data needed for state and local referral forms, if different than above Optional Sections section
Specification
Data Element Name Opt Template ID
Reason for Referral R 1.3.6.1.4.1.19376.1.5.3.1.3.1
History Present Illness R 1.3.6.1.4.1.19376.1.5.3.1.3.4
Active Problems R 1.3.6.1.4.1.19376.1.5.3.1.3.6
Current Meds R 1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies R 1.3.6.1.4.1.19376.1.5.3.1.3.13
Resolved Problems R2 1.3.6.1.4.1.19376.1.5.3.1.3.8
List of Surgeries R2 1.3.6.1.4.1.19376.1.5.3.1.3.11
Immunizations R2 1.3.6.1.4.1.19376.1.5.3.1.3.23
Family History R2 1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History R2 1.3.6.1.4.1.19376.1.5.3.1.3.16
Pertinent Review of Systems O 1.3.6.1.4.1.19376.1.5.3.1.3.18
Vital Signs R2 1.3.6.1.4.1.19376.1.5.3.1.3.25
Physical Exam R2 1.3.6.1.4.1.19376.1.5.3.1.3.24
Relevant Diagnostic Results and/or Clinical Reports
Includes Diagnostic Surgical Procedures, Clinical Reports and Diagnostic Tests and Results (Lab, Imaging, EKG’s, etc.) including links to relevant documents. 		R2 1.3.6.1.4.1.19376.1.5.3.1.3.27
Care Plan
(new meds, labs, or x-rays ordered) 		R2 1.3.6.1.4.1.19376.1.5.3.1.3.31
Mode of Transport to the Emergency Department
(includes ETA) 		R 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
Proposed ED Disposition R2 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10
Advance Directives
The availability of information about Advance Directives must provided. A common concern among ED providers is over situations where patients presented to the ED require extensive resuscitative efforts, only later to discover that the patient had a DNR order. 		R 1.3.6.1.4.1.19376.1.5.3.1.3.34
Patient Administrative Identifiers
These are handed by the Medical Documents Content Profile by reference to constraints in HL7 CRS. 		R
Pertinent Insurance Information R2
Data needed for state and local referral forms, if different than above
These are handed by including additional sections within the summary. 		R2


Note: Highlighted items in the table above are different from what appears in the XDS-MS profile. All other data elements have identical definitions.
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. A CDA Document may conform to more than one template. This content module inherits from the Medical Summary content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Emergency Department Referral Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.3'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Emergency Department Referral</title>
  <effectiveTime value='20240424012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
        <!-- Required Reason for Referral Section content -->
      </section>
    </component>

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

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Current Meds Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required if known Resolved Problems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
        <!-- Required if known List of Surgeries Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
        <!-- Required if known Immunizations Section content -->
      </section>
    </component>

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

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Optional Pertinent Review of Systems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
        <!-- Required if known Vital Signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
        <!-- Required if known Physical Exam Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.27'/>
        <!-- Required if known Relevant Diagnostic Results and/or Clinical Reports Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
        <!-- Required if known Care Plan Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/>
        <!-- Required Mode of Transport to the Emergency Department
(includes ETA)  Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'/>
        <!-- Required if known Proposed ED Disposition Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required Advance Directives Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.10'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.10"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Emergency Department Referral can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.3"]'>
     Error: The parent template identifier for Emergency Department Referral is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Emergency Department Referral must be {{{LOINC}}}
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.3.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Reason for Referral Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) History Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Current Meds Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Resolved Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) List of Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Emergency Department Referral Document does not contain a(n) Pertinent Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.24"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Physical Exam Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.27"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Relevant Diagnostic Results and/or Clinical Reports Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Care Plan Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </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 Emergency Department Referral Document must contain a(n) Mode of Transport to the Emergency Department
(includes ETA)  Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Proposed ED Disposition Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Patient Administrative Identifiers Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Pertinent Insurance Information Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Data needed for state and local referral forms, if different than above Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </assert> 
 </rule>
</pattern>
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