1.3.6.1.4.1.19376.1.5.3.1.1.5

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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 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='20190920012005'/> <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.