1.3.6.1.4.1.19376.1.5.3.1.1.2

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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='20191015012005'/> <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.