1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2

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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 Visit Summary Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2
General Description

This section is a running history of the most important elements noted for a pregnant woman.

LOINC Code Opt Description
(xx-acog-visit-sum-section) R PREGNANCY VISIT SUMMARY-^PATIENT-FIND-PT-NAR
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.13 R Simple Observation
The flowsheet contains one simple observation to represent the Prepregancy Weight. This observation SHALL be valued with the LOINC code 8348-5, BODY WEIGHT^PRE PREGNANCY-MASS-PT-QN-MEASURED. The value SHALL be of type PQ. The units may be either "lb_av" or "kg".
1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2 R Antepartum Flowsheet Panel
Other entries on the flowsheet are "batteries" which represent a single visit.



Sample Visit Summary Section
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2'/>
    <id root=' ' extension=' '/>
    <code code='(xx-acog-visit-sum-section)' displayName='PREGNANCY VISIT SUMMARY-^PATIENT-FIND-PT-NAR'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Simple Observation element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
         :
    </entry> 
    <entry>
         :
      <!-- Required Antepartum Flowsheet Panel element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Visit Summary can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "(xx-acog-visit-sum-section)"]'> 
     Error: The section type code of a Visit Summary must be (xx-acog-visit-sum-section) 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Visit Summary Section must contain a(n) Simple Observation Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Visit Summary Section must contain a(n) Antepartum Flowsheet Panel Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2 
   </assert> 
   <assert test='.//cda:observation/cda:code[@code="8348-5"]'>
     Error: The Visit Summary must have at least one simple observation with the LOINC
     code 8348-5 to represent the prepregnancy weight.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2
   </assert>
   <assert test='.//cda:observation[cda:code/@code='8348-5']/cda:value[@unit='kg' or @unit='lb_av']">
     Error: The prepregnancy weight shall record the units in kg or lbs
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Visit Summary Section