1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
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
ED Physician Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
The ED Physician note specification includes sections for data commonly reported by the physician as part of an ED encounter. It includes relevant historical information about the patient, pertinent arrival information, vital signs, history and physical examination findings, assessment and plan, interventions including medications, fluids and procedures, diagnosis and disposition.
Format Code
The XDSDocumentEntry format code for this content is urn:ihe:pcc:edes:2007
Parent Template
This document is an instance of the Medical Document template.
LOINC Code
The LOINC code for this document is 28568-4 ED Visit Note
Data Element Index
Data Element | LOINC |
---|---|
Referral Source | 11293-8 ED REFERRAL SOURCE |
Mode of Arrival | 11459-5 TRANSPORT MODE |
Chief Complaint | 10154-3 CHIEF COMPLAINT |
Reason for Visit | 29299-6 REASON FOR VISIT |
History of Present Illness | 10164-2 HISTORY OF PRESENT ILLNESS |
Advance Directives | 42348-3 ADVANCE DIRECTIVES |
Active Problems | 11450-4 PROBLEM LIST |
Past Medical History | 11348-0 HISTORY OF PAST ILLNESS |
Current Medications | 10160-0 CURRENT MEDICATIONS |
Allergies | 48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS |
List of Surgeries | 47519-4 History of procedures |
Immunizations | 11369-6 HISTORY OF IMMUNIZATIONS |
Family History | 10157-6 HISTORY OF FAMILY MEMBER DISEASES |
Social History | 29762-2 SOCIAL HISTORY |
History of Pregnancies | 10162-6 HISTORY OF PREGNANCIES |
Pertinent ROS | 10187-3 REVIEW OF SYSTEMS |
Vital Signs | 8716-3 VITAL SIGNS |
Physical Examination | 29545-1 PHYSICAL EXAMINATION |
Assessment and Plan | X-AANDP ASSESSMENT AND PLAN X-ASSESS ASSESSMENT 18776-5 TREATMENT PLAN |
Medications Administered | 18610-6 MEDICATION ADMINISTERED (COMPOSITE) |
Intravenous Fluids Administered | X-IVFLU INTRAVENOUS FLUID ADMINISTERED |
Procedures Performed | 29544-3 PROCEDURE |
Test Results - Lab, ECG, Radiology | 30954-2 STUDIES SUMMARY |
Consultations | 18693-2 ED CONSULTANT PRACTITIONER |
Progress Note | 18733-6 SUBSEQUENT EVALUATION NOTE (ATTENDING PHYSICIAN) |
ED Diagnoses | 11301-9 ED DIAGNOSIS |
Medications at Discharge | 10183-2 HOSPITAL DISCHARGE MEDICATIONS |
ED Disposition | 11302-7 ED DISPOSITION |
Specification
Data Element Name | Opt | Template ID |
---|---|---|
Referral Source | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3 |
Mode of Arrival | R | 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 |
Chief Complaint | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 |
Reason for Visit | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1 |
History of Present Illness | R | 1.3.6.1.4.1.19376.1.5.3.1.3.4 |
Advanced Directives | R | 1.3.6.1.4.1.19376.1.5.3.1.3.34 |
Active Problems | 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 |
Current Medications | 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 |
List of Surgeries | R | 1.3.6.1.4.1.19376.1.5.3.1.3.11 |
Immunizations | R | 1.3.6.1.4.1.19376.1.5.3.1.3.23 |
Family History | R | 1.3.6.1.4.1.19376.1.5.3.1.3.14 |
Social History | R | 1.3.6.1.4.1.19376.1.5.3.1.3.16 |
History of Pregnancies This section should contain one entry containing the date (TS) of last menstrual period for women of childbearing age, using LOINC Code 8665-2 DATE LAST MENSTRUAL PERIOD |
R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 |
Pertinent ROS | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.18 |
Vital Signs | R | 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 |
Physical Examination | R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.15 |
Assessements This section shall be present when assessments and plans are recorded separately. |
C | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4 |
Care Plan This section shall be present when assessments and plans are recorded separately. |
C | 1.3.6.1.4.1.19376.1.5.3.1.3.31 |
Assessment and Plan This section shall be present when assessments and plans are recorded together. |
C | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5 |
Medications Administered | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.21 |
Intravenous Fluids Administered | R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6 |
Procedures Performed | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 |
Test Results Lab, ECG, Radiology | R | 1.3.6.1.4.1.19376.1.5.3.1.3.27 |
Consultations | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8 |
Progress Note | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7 |
ED Diagnoses | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9 |
Medications at Discharge | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.22 |
ED Disposition The ED Disposition shall contain a mode of transport entry describing how the patient departed. |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10 |
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.
<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'/> |
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4'> <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4"]'> <!-- Verify that the template id is used on the appropriate type of object --> <assert test='../cda:ClinicalDocument'> Error: The ED Physician Note 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 ED Physician Note is not present. </assert> <!-- Verify the document type code --> <assert test='cda:code[@code = "28568-4"]'> Error: The document type code of a ED Physician Note must be 28568-4 </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Referral Source Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </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 ED Physician Note Document must contain a(n) Mode of Arrival Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Chief Complaint Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Reason for Visit Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </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 ED Physician Note Document must contain a(n) History of Present Illness Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </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 ED Physician Note Document must contain a(n) Advanced Directives Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </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 ED Physician Note Document should contain a(n) Active Problems Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </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 ED Physician Note Document should contain a(n) Past Medical History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </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 ED Physician Note Document must contain a(n) Current Medications Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </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 ED Physician Note Document must contain a(n) Allergies Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </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 ED Physician Note Document must contain a(n) List of Surgeries Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Immunizations Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Family History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Social History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> <!-- Alert on any missing required if known elements --> Warning: The ED Physician Note Document should contain a(n) History of Pregnancies Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> <!-- Alert on any missing required if known elements --> Warning: The ED Physician Note Document should contain a(n) Pertinent ROS Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Vital Signs Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </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 ED Physician Note Document must contain a(n) Physical Examination Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </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 ED Physician Note Document should contain a(n) Medications Administered Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6"]'> <!-- Alert on any missing required if known elements --> Warning: The ED Physician Note Document should contain a(n) Intravenous Fluids Administered Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Procedures Performed Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.27"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Test Results Lab, ECG, Radiology Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Consultations Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Progress Note Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) ED Diagnoses Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.22"]'> <!-- Alert on any missing required if known elements --> Warning: The ED Physician Note Document should contain a(n) Medications at Discharge Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) ED Disposition Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]) and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"]) or (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"])) and not((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]) and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"]) and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"])) and not((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"]) and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"])) and not((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"]) and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"]))'> Error: A(n) ED Physician Note shall contain either Assessments AND Care Plan OR Assessment and Plan. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> </rule> </pattern>
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