CDA Entry Content Modules

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Entry Content Modules

This section describes the HL7 Version 3 structures used as entries in CDA documents and found in other HL7 Version 3 messaging standards. These entries describe information such as conditions, problems, medications, and references to external documents, as well as several common components that may be used by these entries, including:

  • Severity observations allow practitioners to indicate the severity of a condition.
  • Unstructured comments allow practitioners to specify additional information that they feel is relevant.
  • Medication instructions allow practitioners to specify additional instructions for the use of a medication.

These common structures are included in the target act using the <entryRelationship> element defined in the CDA Schema, or the appropriate act relationship structure when used in an HL7 Version 3 message. This allows for arbitrary act relationships to be described.

The normal containment structure includes the target of the related act inside an act relationship element that is contained in the source act. To invert the direction of the relationship the inversionInd attribute of act relationship element is set to true (inversionInd='true') in the samples below.

Linking Narrative and Coded Entries

This section defines a linking mechanism that allows entries or portions thereof to be connected to the text of the clinical document.

Standards
RIM HL7 Version 3 Reference Information Model
CDAR2 HL7 Clinical Document Architecture Release 2.0
Constraints for CDA

Elements within the narrative <text> will use the ID attribute to provide a destination for links. Elements within an <entry> will be linked to the text via a URI reference using this attribute as the fragment identifier. This links the coded entry to the specific narrative text it is related to within the CDA instance, and can be traversed in either direction. This serves three purposes:

  1. It supports diagnostics during software development and testing.
  2. It provides a mechanism to enrich the markup that can be supported in the viewing application.
  3. It eliminates the need to duplicate content in two places, which prevents a common source of error, and eliminates steps needed to validate that content that should be identical in fact is.

Each narrative content element within CDA may have an ID attribute. This attribute is of type xs:ID. This means that each ID in the document must be unique within that document. Within an XML document, an attribute of type xs:ID must start with a letter, and may be followed one or more letters, digits, hyphens or underscores . Three different examples showing the use of the ID attribute, and references to it appear below:

Example Uses of ID
Use of ID References to ID
<tr ID='foo'>
<td ID='bar'>Table Cell 1</td>
<td>Table Cell 2</td>

</tr>

<code>
<originalText>​<reference value='#foo'>​</originalText>

</code>
<code>

<originalText>​<reference value='#bar'>​</originalText>

</code>

<list>
<item ID='baz'>List item 1</item>

</list>

<code>
<originalText>​<reference value='#baz'>​</originalText>

</code>

<paragraph ID='p-1'>A paragraph
<content ID='c-1'>with content</content>

</paragraph>

<code>
<originalText>​<reference value='#p-1'>​</originalText>

</code>
<code>

<originalText>​<reference value='#c-1'>​</originalText>

</code>

This allows the text to be located with a special type of URI reference, which simply contains a fragment identifier. This URI is local to the document and so just begins with a hash mark (#), and is followed by the value of the ID being referenced. Given one of these URIs stored in a variable named theURI, the necessary text value can be found via the following XPath expression:

string(//*[@ID=substring-after('#',$theURI)])

The table below shows the result of this expression using the examples above:

URI Dereference Result
$theURI Returned Value
"#bar" "Table Cell 1"
"#foo" "Table Cell 1Table Cell 2" (note the spacing issue between 1 and T)
"#p-1" "A paragraph with content"
"#c-1" "with content"

If your XSLT processor is schema aware, even more efficient mechanisms exist to locate the element than the above expression.

Having identified the critical text in the narrative, any elements using the HL7 CD datatype (e.g., <code>) can then contain a <reference> to the <originalText> found in the narrative. That is why, although CDA allows <value> to be of any type in <entry> elements, this profile restricts them to always be of xsi:type='CD'.

Now, given an item with an ID stored in a variable named theID all <reference> elements referring to it can be found via the following XPath expression:

//cda:reference[@URI=concat('#',$theID)]
Constraints for HL7 Version 3 Messages

Unlike CDA entries, structured statements in HL7 Version 3 Messages do not have a related narrative text section. Therefore full text representations should be included in the <text> element care statement acts.

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Trial.gif Severity 1.3.6.1.4.1.19376.1.5.3.1.4.1

Any condition or allergy may be the subject of a severity observation. This structure is included in the target act using the <entryRelationship> element defined in the CDA Schema.

The example below shows the recording the condition or allergy severity, and is used as the context for the following sections.

Standards
PatCareStruct HL7 Care Provision Domain (DSTU)
CCD ASTM/HL7 Continuity of Care Document
Uses

See Templates using Severity

Specification
Severity Example

  <observation classCode='COND' moodCode='EVN'>

<entryRelationship typeCode='SUBJ' inversionInd='true'> <observation classCode='OBS' moodCode='EVN'> <templateId root='2.16.840.1.113883.10.20.1.55'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1'/> <code code='SEV' displayName='Severity' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode' /> <text><reference value='#severity-2'/></text> <statusCode code='completed'/> <value xsi:type='CD' code='H|M|L' codeSystem='2.16.840.1.113883.5.1063' codeSystemName='ObservationValue' /> </observation> </entryRelationship>

</observation>


This specification models a severity observation as a separate observation from the condition. While this model is different from work presently underway by various organizations (i.e., SNOMED, HL7, TermInfo), it is not wholly incompatible with that work. In that work, qualifiers may be used to identify severity in the coded condition observation, and a separate severity observation is no longer necessary. The use of qualifiers is not precluded by this specification. However, to support semantic interoperability between EMR systems using different vocabularies, this specification does require that severity information also be provided in a separate observation. This ensures that all EMR systems have equal access to the information, regardless of the vocabularies they support.

<entryRelationship typeCode='SUBJ' inversionInd='true'>

The related statement is made about the severity of the condition (or allergy). For CDA, this observation is recorded inside an <entryRelationship> element occurring in the condition, allergy or medication entry. The containing <entry> is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'. For HL7 Version 3 Messages this relationship is represented with a <sourceOf> element, however the semantics, typeCode, and inversionInd is unchanged.

<observation moodCode='EVN' classCode='OBS'>

The related statement is another event (moodCode='EVN') observing (<observation classCode='OBS'>) the severity of the (surrounding) related entry (e.g., a condition or allergy).

<templateId root='2.16.840.1.113883.10.20.1.55'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1'/>

The <templateId> elements identifies this <observation> as a severity observation, allowing for validation of the content. As a side effect, readers of the CDA can quickly locate and identify severity observations. The templateId elements shown above must be present.

<code code='SEV' codeSystem='2.16.840.1.113883.5.4' displayName='Severity' codeSystemName='ActCode' />

This observation is of severity, as indicated by the <code> element listed above. This element is required. The code and codeSystem attributes shall be recorded exactly as shown above.

<text><reference value='#severity-2'/></text>

The <observation> element shall contain a <text> element. For CDA, the <text> elements shall contain a <reference> element pointing to the narrative where the severity is recorded, rather than duplicate text to avoid ambiguity. For HL7 Version 3 Messages, the <text> element should contain the full narrative text.

<statusCode code='completed'/>

The code attribute of <statusCode> for all severity observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

<value xsi:type='CD' code='H|M|L' codeSystem='2.16.840.1.113883.5.1063' codeSystemName='SeverityObservation'>

The <value> element contains the level of severity. It is always represented using the CD datatype (xsi:type='CD'), even though the value may be a coded or uncoded string. If coded, it should use the HL7 SeverityObservation vocabulary (codeSystem='2.16.840.1.113883.5.1063') containing three values (H, M, and L), representing high, moderate and low severity depending upon whether the severity is life threatening, presents noticeable adverse consequences, or is unlikely substantially effect the situation of the subject.

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Trial.gif Problem Status Observation 1.3.6.1.4.1.19376.1.5.3.1.4.1.1

Any problem or allergy observation may reference a problem status observation. This structure is included in the target observation using the <entryRelationship> element defined in the CDA Schema. The clinical status observation records information about the current status of the problem or allergy, for example, whether it is active, in remission, resolved, et cetera. The example below shows the recording of clinical status of a condition or allergy, and is used as the context for the following sections.

Standards
CCD ASTM/HL7 Continuity of Care Document
Uses

See Templates using Problem Status Observation

Specification
Problem Status Observation Example

 <entry>
   <observation classCode='OBS' moodCode='EVN'>
<entryRelationship typeCode='REFR' inversionInd='false'> <observation classCode='OBS' moodCode='EVN'> <templateId root='2.16.840.1.113883.10.20.1.57'/> <templateId root='2.16.840.1.113883.10.20.1.50'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1.1'/> <code code='33999-4' displayName='Status' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <text><reference value='#cstatus-2'/></text> <statusCode code='completed'/> <value xsi:type='CE' code=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/> </observation> </entryRelationship>
</observation> </entry>


This CCD models a problem status observation as a separate observation from the problem, allergy or medication observation. While this model is different from work presently underway by various organizations (i.e., SNOMED, HL7, TermInfo), it is not wholly incompatible with that work. In that work, qualifiers may be used to identify problem status in the coded condition observation, and a separate clinical status observation is no longer necessary. The use of qualifiers in the problem observation is not precluded by this specification or by CCD. However, to support semantic interoperability between EMR systems using different vocabularies, this specification does require that problem status information also be provided in a separate observation. This ensures that all EMR systems have equal access to the information, regardless of the vocabularies they support.

<entryRelationship typeCode='REFR' inversionInd='false'>

The related statement is made about the clinical status of the problem or allergy. For CDA, this observation is recorded inside an <entryRelationship> element occurring in the problem or allergy. For HL7 Version 3 Messages, the <entryRelationship> tag name is <sourceOf>, though the typeCode and inversionInd attributes and other semantics remain the same. The containing observation refers to (typeCode='REFR') this new observation.

<observation moodCode='EVN' classCode='OBS'>

The related statement is another event (moodCode='EVN') observing (<observation classCode='OBS'>) the clinical status of the (surrounding) related observation (e.g., a problem or allergy).

<templateId root='2.16.840.1.113883.10.20.1.57'/>
<templateId root='2.16.840.1.113883.10.20.1.50'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1.1'/>

These <templateId> elements identify this <observation> as a problem status observation, allowing for validation of the content.

<code code='33999-4' codeSystem='2.16.840.1.113883.6.1' displayName='Status' codeSystemName='LOINC' />

This observation is of clinical status, as indicated by the <code> element. This element must be present. The code and codeSystem shall be recorded exactly as shown above.

<text><reference value='#cstatus-2'/></text>

The <observation> element shall contain a <text> element that points to the narrative text describing the clinical status. For CDA, the <text> elements shall contain a <reference> element pointing to the narrative section (see Linking Narrative and Coded Entries), rather than duplicate text to avoid ambiguity. For HL7 Version 3 Messages, the <text> element SHALL contain the full narrative text.

<statusCode code='completed'/>

The code attribute of <statusCode> for all clinical status observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

<value xsi:type='CE' code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'>

The <value> element contains the clinical status. It is always represented using the CE datatype (xsi:type='CE'). It shall contain a code from the following set of values from SNOMED CT.

Clinical Status Values
Code Description
55561003 Active
73425007 Inactive
90734009 Chronic
7087005 Intermittent
255227004 Recurrent
415684004 Rule out
410516002 Ruled out
413322009 Resolved

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Trial.gif Health Status 1.3.6.1.4.1.19376.1.5.3.1.4.1.2

A problem observation may reference a health status observation. This structure is included in the target observation using the <entryRelationship> element defined in the CDA Schema. The health status observation records information about the current health status of the patient. The example below shows the recording the health status, and is used as the context for the following sections.


Uses

See Templates using Health Status

Specification
Health Status Example

<entry>
 <observation classCode='OBS' moodCode='EVN'>
<entryRelationship typeCode='REFR' inversionInd='false'> <observation classCode='OBS' moodCode='EVN'> <templateId root='2.16.840.1.113883.10.20.1.51'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1.2'/> <code code='11323-3' displayName='Health Status' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <text><reference value='#hstatus-2'/></text> <statusCode code='completed'/> </value> <value xsi:type='CE' code=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/> </observation> </entryRelationship>
</observation> </entry>


This specification models a health status observation as a separate observation about the patient.

<entryRelationship typeCode='REFR'>

The related statement is made about the health status of the patient. For CDA, this observation is recorded inside an <entryRelationship> element occurring in the observation. The contained observersation is referenced (typeCode='REFR') by the observation entry. For HL7 Version 3 Messages, the entryRelationship tagName is sourceOf, though the typeCode and inversionInd attributes and other semantics remain the same.

<observation moodCode='EVN' classCode='OBS'>

The related statement is another event (moodCode='EVN') observing (<observation classCode='OBS'>) the health status of the patient.

<templateId root='2.16.840.1.113883.10.20.1.51'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1.2'/>

The <templateId> element identifies this <observation> as a health status observation, allowing for validation of the content.

<code code='11323-3'
displayName='Health Status'
codeSystem='2.16.840.1.113883.6.1'
codeSystemName='LOINC' />

This observation is of health status, as indicated by the <code> element. This element must be present. The code and codeSystem attributes shall be recorded exactly as shown above.

<text><reference value='#hstatus-2'/></text>

The <observation> element shall contain a <text> element that contains the narrative text describing the clinical status. For CDA, the <text> elements shall contain a <reference> element pointing to the narrative section (see Linking Narrative and Coded Entries, rather than duplicate text to avoid ambiguity. For HL7 Version 3 Messages, the <text> element shall contain the full narrative text.

<statusCode code='completed'/>

The code attribute of <statusCode> for all health status observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

<value xsi:type='CE' code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'>

The <value> element contains the clinical status. It is always represented using the CE datatype (xsi:type='CE').

Health Status Codes
Code Description
81323004 Alive and well
313386006 In remission
162467007 Symptom free
161901003 Chronically ill
271593001 Severely ill
21134002 Disabled
161045001 Severely disabled
419099009 Deceased

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Trial.gif Comments 1.3.6.1.4.1.19376.1.5.3.1.4.2

This entry allows for a comment to be supplied with each entry. For CDA this structure is usually included in the target act using the <entryRelationship> element defined in the CDA Schema, but can also be used in the <component> element when the comment appears within an <organizer>. The example below shows recording a comment for an <entry>, and is used as context for the following sections. For HL7 Version 3 Messages, this relationship is represented with the element <sourceOf>, although the remainder of the typecodes and semantics are unchanged.

Any condition or allergy may be the subject of a comment.

Standards
CareStruct HL7 Care Provision Care Structures (DSTU)
CCD ASTM/HL7 Continuity of Care Document
Uses

See Templates using Comments

Specification
Comments Example
<entry>
  <observation classCode='OBS' moodCode='EVN'>
          ∶
    <entryRelationship typeCode='SUBJ' inversionInd='true'>
      <act classCode='ACT' moodCode='EVN'>
        <templateId root='2.16.840.1.113883.10.20.1.40'/>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>
        <code code='48767-8' displayName='Annotation Comment'
          codeSystem='2.16.840.1.113883.6.1'
          codeSystemName='LOINC' />
        <text><reference value='#comment-2'/></text>
        <statusCode code='completed' />
        <author>
          <time value=''/>
          <assignedAuthor>
            <id root='' extension=''>
            <addr></addr>
            <telecom value='' use=''>
            <assignedPerson><name></name></assignedPerson>
            <representedOrganization><name></name></representedOrganization>
          </assignedAuthor>
        </author>
      </act>
    </entryRelationship>
          ∶
  </observation>
</entry>
<entry>
  <organizer>
    <component typeCode='COMP'>
      <act classCode='ACT' moodCode='EVN'>
        <templateId root='2.16.840.1.113883.10.20.1.40'/>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>
        <code code='48767-8' displayName='Annotation Comment'
          codeSystem='2.16.840.1.113883.6.1'
          codeSystemName='LOINC' />
            :
      </act>
    </component>
  </organizer>
</entry>


<entryRelationship typeCode='SUBJ' inversionInd='true'> or <component typeCode='COMP'/>

A related statement is made about an act, or a cluster or battery of results. In CDA the former shall be recorded inside an <entryRelationship> element occurring at the end of the entry. The containing act is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'.

For HL7 Version 3 Messages, the relationship element is <sourceOf>, however the typeCode and inversionInd remain the same.

In the latter case, the comment shall be recorded inside a <commponent> element contained within the <organizer> element.

<act classCode='ACT' moodCode='EVN'>

The related statement is an event (moodCode='EVN') describing the act (classCode='ACT') of making an arbitrary comment or providing instruction on the related entry.

<templateId root='2.16.840.1.113883.10.20.1.40'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>

These <templateId> elements identify this <act> as a comment, allowing for validation of the content.

<code code='48767-8' displayName='Annotation Comment' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />

The <code> element indicates that this is a comment and shall be recorded as shown above. The codeSystem and code attributes shall use the values specified above.

<text><reference value='#comment-2'/></text>

The <text> element provides a way to represent the <reference> to the text of the comment in the narrative portion of the document. For CDA, this SHALL be represented as a <reference> element that points to the narrative text section of the CDA. The comment itself is not the act being coded, so it appears in the <text> of the <observation>, not as part of the <code>. For HL7 Version 3 Messages, the <text> element SHALL contain the full narrative text.

<statusCode code='completed' />

The code attribute of <statusCode> for all comments must be completed.

<author>

The comment may have an author.

<time value=' '/>

The time of the comment creation shall be recorded in the

<assignedAuthor>
 <id root=' ' extension=' '>
 <addr></addr>
 <telecom value=' ' use=' '>

The identifier of the author, and their address and telephone number must be present inside the <id>, <addr> and <telecom> elements when the <author> element is present.

<assignedPerson><name></name></assignedPerson>
<representedOrganization><name></name></representedOrganization>

The author's and/or the organization's name must be present when the <author> element is present.

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Trial.gif Patient Medication Instructions 1.3.6.1.4.1.19376.1.5.3.1.4.3

Any medication may be the subject of further instructions to the patient, for example to indicate that it should be taken with food, et cetera.

This structure is included in the target substance administration or supply act using the <entryRelationship> element defined in the CDA Schema. The example below shows the recording of patient medication instruction for an <entry>, and is used as context for the following section.

Standards
Pharmacy HL7 Pharmacy Domain (Normative)
Uses

See Templates using Patient Medication Instructions

Specification
Patient Medication Instructions Example

<entry>
 <substanceAdministration classCode='SBADM' moodCode='EVN'>
         ∶
   <entryRelationship typeCode='SUBJ' inversionInd='true'>
     <act classCode='ACT' moodCode='INT'>
       <templateId root='2.16.840.1.113883.10.20.1.49'/>
       <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.3'/>
       <code code='PINSTRUCT' codeSystem='1.3.6.1.4.1.19376.1.5.3.2'
         codeSystemName='IHEActCode' />
       <text><reference value='#comment-2'/></text>
       <statusCode code='completed' />
     </act>
   </entryRelationship>
         ∶
 </substanceAdministration>
</entry>


<entryRelationship typeCode='SUBJ' inversionInd='true'>

Again, a related statement is made about the medication or immunization. This observation is recorded inside an <entryRelationship> element occurring at the end of the substance administration or supply entry. The containing <entry> is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'.

<act classCode='ACT' moodCode='INT'>

The related statement is the intent (moodCode='INT') on how the related entry is to be performed. .

<templateId root='2.16.840.1.113883.10.20.1.49'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.3'/>

These <templateId> elements identify this <act> as a medication instruction, allowing for validation of the content. As a side effect, readers of the CDA can quickly locate and identify medication instructions.

<code code='PINSTRUCT' codeSystem='1.3.6.1.4.1.19376.1.5.3.2' codeSystemName='IHEActCode' />

The <code> element indicates that this is a patient medication instruction. This element shall be recorded exactly as specified above.

Note: These values will be sent to HL7 for harmonization with the HL7 Act Vocabulary.
<text><reference value='#comment-2'/></text>

The <text> element indicates the text of the comment. For CDA, this SHALL be represented as a <reference> element that points at the narrative portion of the document. The comment itself is not the act being coded, so it appears in the <text> of the <observation>, not as part of the <code>. For HL7 Version 3 Messages, the full text SHALL be represented here.

<statusCode code='completed' />

The code attribute of <statusCode> for all comments must be completed.

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Trial.gif Medication Fulfillment Instructions 1.3.6.1.4.1.19376.1.5.3.1.4.3.1

Any medication may be the subject of further instructions to the pharmacist, for example to indicate that it should be labeled in Spanish, et cetera.

This structure is included in the target substance administration or supply act using the <entryRelationship> element defined in the CDA Schema. The figure below is an example of recording an instruction for an <entry>, and is used as context for the following sections.

Standards
Pharmacy HL7 Pharmacy Domain (Normative)
Uses

See Templates using Medication Fulfillment Instructions

Specification
Medication Fulfillment Instructions Example

<entry>
 <supply classCode='SPLY' moodCode='EVN'>
         ∶
   <entryRelationship typeCode='SUBJ' inversionInd='true'>
     <act classCode='ACT' moodCode='INT'>
       <templateId root='2.16.840.1.113883.10.20.1.43'/>
       <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.3.1'/>
       <code code='FINSTRUCT' codeSystem='1.3.6.1.4.1.19376.1.5.3.2'
         codeSystemName='IHEActCode' />
       <text><reference value='#comment-2'/></text>
       <statusCode code='completed' />
     </act>
   </entryRelationship>
         ∶
 </supply>
</entry>


<entryRelationship typeCode='SUBJ' inversionInd='true'>

Again, a related statement is made about the medication or immunization. In CDA, this observation is recorded inside an <entryRelationship> element occurring at the end of the substance administration or supply entry. The containing <act> is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'. For HL7 Version 3 Messages, this relationship is represented with the <sourceOf> element however the semantics, typeCode, and inversionInd remain the same.

<act classCode='ACT' moodCode='INT'>

The related statement is the intent (moodCode='INT') on how the related entry is to be performed.

<templateId root='2.16.840.1.113883.10.20.1.43'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.3.1'/>

These <templateId> elements identify this <act> as a medication fulfillment instruction, allowing for validation of the content.

<code code='FINSTRUCT' codeSystem='1.3.6.1.4.1.19376.1.5.3.2' codeSystemName='IHEActCode' />

The <code> element indicates that this is a medication fulfillment instruction. This element shall be recorded exactly as specified above.

Note: These values will be sent to HL7 for harmonization with the HL7 Act Vocabulary.
<text><reference value='#comment-2'/></text>

The <text> element contains a free text representation of the instruction. For CDA this SHALL contain a provides a <reference>element to thelink text of the comment in the narrative portion of the document. The comment itself is not the act being coded, so it appears in the <text> of the <observation>, not as part of the <code>. For HL7 Version 3 Messages, the full text SHALL be represented here.

<statusCode code='completed' />

The code attribute of <statusCode> for all comments must be completed.

References

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 External References 1.3.6.1.4.1.19376.1.5.3.1.4.4

CDA Documents may reference information contained in other documents. While CDA Release 2.0 supports references in content via the <linkHtml> element, this is insufficient for many EMR systems as the link is assumed to be accessible via a URL, which is often not the case. In order to link an external reference, one needs the document identifier, and access to the clinical system wherein the document resides. For a variety of reasons, it is desirable to refer to the document by its identity, rather than by linking through a URL.

  1. The identity of a document does not change, but the URLs used to access it may vary depending upon location, implementation, or other factors.
  2. Referencing clinical documents by identity does not impose any implementation specific constraints on the mechanism used to resolve these references, allowing the content to be implementation neutral. For example, in the context of an XDS Affinity domain the clinical system used to access documents would be an XDS Registry and one or more XDS Repositories where documents are stored. In other contexts, access might be through a Clincial Data Repository (CDR), or Document Content Management System (DCMS). Each of these may have different mechanisms to resolve a document identifier to the document resource.
  3. The identity of a document is known before the document is published (e.g., in an XDS Repository, Clincial Data Repository, or Document Content Management System), but its URL is often not known. Using the document identity allows references to existing documents to be created before those documents have been published to a URL. This is important to document creators, as it does not impose workflow restrictions on how links are created during the authoring process.

Fortunately, CDA Release 2.0 also provides a mechanism to refer to external documents in an entry, as shown below.


Uses

See Templates using External References

Specification
External References Example
<entry>
  <act classCode='ACT' moodCode='EVN'> 
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
    <id root='' extension=''/>
    <code nullFlavor='NA' />
    <text><reference value='#study-1'/></text>
    <!-- For CDA -->
    <reference typeCode='REFR|SPRT'>
      <externalDocument classCode='DOC' moodCode='EVN'>
        <id extension='' root=''/>
        <text><reference value='http://foo..'/></text>
      </externalDocument>
    </reference>
    <!-- For HL7 Version 3 Messages
    <sourceOf typeCode='REFR|SPRT'>
       <act classCode='DOC' moodCode='EVN'>
          <id extension='' root=''/>
          <text><reference value='http://foo…'</text>
       </act>
    </sourceOf>
     -->
  </act>
</entry>


<act classCode='ACT' moodCode='EVN'>

The external reference is an act that refers to documentation of an <act> (classCode='ACT'), that previously occurred (moodCode='EVN').

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>

The <templateId> element identifies this <act> as a reference act, allowing for validation of the content. As a side effect, readers of the CDA can quickly locate and identify reference acts. The templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.4.1.4.4'.

<id root=' ' extension=' '/>

The reference is an act of itself, and must be uniquely identified. If there is no explicit identifier for this act in the source EMR system, a GUID may be used for the root attribute, and the extension may be omitted. Although HL7 allows for multiple identifiers, this profile requires that one and only one be used.

<code nullFlavor='NA'/>

The reference act has no code associated with it.

<text><reference value='#study-1'/></text>

In order to connect this external reference to the narrative text which it refers, the value of the <reference> element in the <text> element is a URI to an element in the CDA narrative of this document.

<reference typeCode='SPRT|REFR'>
<externalDocument classCode='DOC' moodCode='EVN'>

External references are listed as either supporting documentation (typeCode='SPRT') or simply reference material (typeCode='REFR') for the reader. If this distinction is not supported by the source EMR system, the value of typeCode should be REFR. For CDA, the reference is indicated by a <reference> element containing an <externalDocument> element which documents (classCode='DOC') the event (moodCode='EVN'). For HL7 Version 3 Messages, the reference is represented with the element <sourceOf> and the external document is representated with a <act> element, however semantics, and attributes remain otherwise without change.

<id extension=' ' root=' '/>

The identifier of the document is supplied in the <id> element.

<text><reference value=' '/></text>

A link to the original document may be provided here. This shall be a URL where the referenced document can be located. For CDA, the link should also be present in the narrative inside the CDA Narrative in a <linkHTML> 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 Internal References 1.3.6.1.4.1.19376.1.5.3.1.4.4.1

CDA and HL7 Version 3 Entries may reference (point to) information contained in other entries within the same document or message as shown below.


Uses

See Templates using Internal References

Specification
Internal References Example
          ∶
  <entryRelationship typeCode='' inversionInd='true|false'>
      <act classCode='' moodCode=''>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
        <id root='' extension=''/>
        <code code='' displayName='' codeSystem='' codeSystemName=''/>
      </act>
  </entryRelationship>


<entryRelationship typeCode=' ' inversionInd='true|false'>

For CDA the act being referenced appears inside a related entryRelationship. The type (typeCode) and direction (inversionInd) attributes will be specified in the entry content module that contains the reference. For HL7 Version 3 Messages, the relationship is indicated with a <sourceOf> element, however typeCodes and semantics remain unchanged.

<act classCode=' ' moodCode=' '>

The act being referred to can be any CDA Clinical Statement element type (act, procedure, observation, substanceAdministration, supply, et cetera). For compatibility with the Clinical Statement model the internal reference shall always use the <act> class, regardless of the XML element type of the act it refers to.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>

The <templateId> element identifies this as an internal reference that conforms to all rules specified in this section.

<id root=' ' extension=' '/>

This element shall be present. The root and extension attributes shall identify an element defined elsewhere in the same document.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

This element shall be present. It shall be valued when the internal reference is to element that has a <code> element, and shall have the same attributes as the <code> element in the act it references. If the element it references does not have a <code> element, then the nullFlavor attribute should be set to "NA".

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 Concern Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5.1

This event (moodCode='EVN') represents an act (<act classCode='ACT') of being concerned about a problem, allergy or other issue. The <effectiveTime> element describes the period of concern. The subject of concern is one or more observations about related problems (see 1.3.6.1.4.1.19376.1.5.3.1.4.5.2) or allergies and intolerances (see 1.3.6.1.4.1.19376.1.5.3.1.4.5.3). Additional references can be provided having additional information related to the concern. The concern entry allows related acts to be grouped. This allows representing the history of a problem as a series of observation over time, for example.

Standards
CCD ASTM/HL7 Continuity of Care Document
CareStruct HL7 Care Provision Care Structures (DSTU)
ClinStat ClinStat HL7 Clinical Statement (DRAFT)
Uses

See Templates using Concern Entry

Specification
Concern Entry Example
<act classCode='ACT' moodCode='EVN'>
  <templateId root='2.16.840.1.113883.10.20.1.27'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
  <id root='' extension=''/>
  <code nullFlavor='NA'/>
  <statusCode code='active|suspended|aborted|completed'/>
  <effectiveTime>
    <low value=''/>
    <high value=''/>
  </effectiveTime>
  <!-- one or more entry relationships identifying problems of concern -->
  <entryRelationship typeCode='SUBJ' inversionInd='false'>
     :
  </entryRelationship>
  <!-- For HL7 Version 3 Messages 
  <sourceOf typeCode='SUBJ' inversionInd='false'>
     :
  </sourceOf>
  -->
  <!-- optional entry relationship providing more information about the concern -->
  <entryRelationship typeCode='REFR'>
     :
  </entryRelationship>
  <!-- For HL7 Version 3 Messages 
  <sourceOf typeCode='REFR' inversionInd='false'>
     :
  </sourceOf>
  -->

</act>


<act classCode='ACT' moodCode='EVN'>

All concerns reflect the act of recording (<act classCode='ACT'>) the event (moodCode='EVN') of being concerned about a problem, allergy or other issue about the patient condition.

<templateId root='2.16.840.1.113883.10.20.1.27'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>

These template identifiers indicates this entry conforms to the concern content module. This content module inherits constraints from the HL7 CCD Template for problem acts, and so also includes that template identifier.

<id root=' ' extension=' '/>

This required element identifies the concern.

<code nullFlavor='NA'/>

The code is not applicable to a concern act, and so shall be recorded as shown above.

<statusCode code='active|suspended|aborted|completed'/>

The statusCode associated with any concern must be one of the following values:

Status Code Values
Value Description
active A concern that is still being tracked.
suspended A concern that is active, but which may be set aside. For example, this value might be used to suspend concern about a patient problem after some period of remission, but before assumption that the concern has been resolved.
aborted A concern that is no longer actively being tracked, but for reasons other than because the problem was resolved. This value might be used to mark a concern as being aborted after a patient leaves care against medical advice.
completed The problem, allergy or medical state has been resolved and the concern no longer needs to be tracked except for historical purposes.
Note: A concern in the "active" state represents one for which some ongoing clinical activity is expected, and that no activity is expected in other states. Specific uses of the suspended and aborted states are left to the implementation.
<effectiveTime><low value=' '/><high value=' '/></effectiveTime>

The <effectiveTime> element records the starting and ending times during which the concern was active. The <low> element shall be present. The <high> element shall be present for concerns in the completed or aborted state, and shall not be present otherwise.

<!-- 1..* entry relationships identifying problems of concern -->
<entryRelationship type='SUBJ' inversionInd='false'>

Each concern is about one or more related problems or allergies. This entry shall contain one or more problem or allergy entries that conform to the specification in section Problem Entry or Allergies and Intolerances. This is how a series of related observations can be grouped as a single concern.

For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element. The typeCode SHALL be ‘SUBJ’ for both HL7 Version 3 and CDA. HL7 Version 3 additionally requires that inversionInd SHALL be ‘false’.


Note: The Allergy and Intolerances entry is a refinement of the Problem entry.
<!-- 0..n optional entry relationship providing more information about the concern -->
<entryRelationship type='REFR' inversionInd='false'>

Each concern may have 0 or more related references. These may be used to represent related statements such related visits. This may be any valid CDA clinical statement, and SHOULD be an IHE entry template. For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <subjectOf> element. The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘false’

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 Problem Concern Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5.2

This entry is a specialization of the Concern Entry, wherein the subject of the concern is focused on a problem. Elements shown in the example below in gray are explained in the Concern Entry.

Standards
CCD ASTM/HL7 Continuity of Care Document
CareStruct HL7 Care Provision Care Structures (DSTU)
ClinStat HL7 Clinical Statement Pattern (Draft)
Parent Template

The parent of this template is Concern Entry. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.27

Uses

See Templates using Problem Concern Entry

Specification
Problem Concern Entry Example

<act classCode='ACT' moodCode='EVN'>
 <templateId root='2.16.840.1.113883.10.20.1.27'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/>
 <id root=' ' extension=' '/>
 <code nullFlavor='NA'/>
 <statusCode code='active|suspended|aborted|completed'/>
 <effectiveTime>
   <low value=' '/>
   <high value=' '/>
 </effectiveTime>
 <!-- 1..* entry relationships identifying problems of concern -->
 <entryRelationship type='SUBJ'>
   <observation classCode='OBS' moodCode='EVN'/>
      <templateID root='1.3.6.1.4.1.19376.1.5.3.1.4.5'>
        :
   </observation>
 </entryRelationship>
 <!-- optional entry relationship providing more information about the concern -->
 <entryRelationship type='REFR'>
 </entryRelationship>
</act>


<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/>

This entry has a template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5.2, and is a subtype of the Concern Entry, and so must also conform to that specification, with the template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5.1. These elements are required and shall be recorded exactly as shown above.

<!-- 1..* entry relationships identifying problems of concern -->
 <observation classCode='OBS' moodCode='EVN'>
  <templateID root=' 1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
   …
 </observation>
<entryRelationship type='SUBJ'>

This entry shall contain one or more problem entries that conform to the Problem Entry template 1.3.6.1.4.1.19376.1.5.3.1.4.5. For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <subjectOf> element. The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘false’

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 Allergy and Intolerance Concern 1.3.6.1.4.1.19376.1.5.3.1.4.5.3

This entry is a specialization of the Concern Entry, wherein the subject of the concern is focused on an allergy or intolerance. Elements shown in the example below in gray are explained in that entry.

Standards
CCD ASTM/HL7 Continuity of Care Document
CareStruct HL7 Care Provision Care Structures (DSTU)
ClinStat HL7 Clinical Statement Pattern (Draft)
Parent Template

The parent of this template is Concern Entry. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.27

Uses

See Templates using Allergy and Intolerance Concern

Specification
Allergy and Intolerance Concern Example

<act classCode='ACT' moodCode='EVN'>
 <templateId root='2.16.840.1.113883.10.20.1.27'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.3'/>
 <id root=' ' extension=' '/>
 <code nullFlavor='NA'/>
 <statusCode code='active|suspended|aborted|completed'/>
 <effectiveTime>
   <low value=' '/>
   <high value=' '/>
 </effectiveTime>
 <!-- 1..* entry relationships identifying allergies of concern -->
 <entryRelationship typeCode='SUBJ'>
   <observation classCode='OBS' moodCode='EVN'/>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6'/>
        :
   </observation> 
 </entryRelationship>
 <!-- optional entry relationship providing more information about the concern -->
 <entryRelationship type='REFR'>
 </entryRelationship>
</act>


<templateId root='2.16.840.1.113883.10.20.1.27'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.3'/>

This entry has a template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5.3, and is a subtype of the Concern entry, and so must also conform to the rules of the Concern Entry. These elements are required and shall be recorded exactly as shown above.

<!-- 1..* entry relationships identifying allergies of concern -->
 <observation classCode='OBS' moodCode='EVN'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6'/>
   :
</observation>
<entryRelationship typeCode='SUBJ'>

This entry shall contain one or more allergy or intolerance entries that conform to the Allergy and Intolerance Entry. For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element. The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘false’

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 Problem Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5

This section makes use of the linking, severity, clinical status and comment content specifications defined elsewhere in the technical framework. In HL7 RIM parlance, observations about a problem, complaint, symptom, finding, diagnosis, or functional limitation of a patient is the event (moodCode='EVN') of observing (<observation classCode='OBS'>) that problem. The <value> of the observation comes from a controlled vocabulary representing such things. The <code> contained within the <observation> describes the method of determination from yet another controlled vocabulary. An example appears below in the figure below.

Standards
CCD ASTM/HL7 Continuity of Care Document
CareStruct HL7 Care Provision Care Structures (DSTU)
ClinStat HL7 Clinical Statement Pattern (Draft)
Parent Template

This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.28

Uses

See Templates using Problem Entry

Specification
Problem Entry Example

<observation classCode='OBS' moodCode='EVN' negationInd=' false|true '>
 <templateId root='2.16.840.1.113883.10.20.1.28'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
 <id root=' ' extension=' '/>
 <code code=' ' displayName=' '
   codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
 <text><reference value=' '/></text>
 <statusCode code='completed'/>
 <effectiveTime><low value=' '/><high value=' '/></effectiveTime>
 <value xsi:type='CD' code=' ' 
   codeSystem=' ' displayName=' ' codeSystemName=' '>
   <originalText><reference value=' '/></originalText>
 </value>
 <
 <!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements
      identifying the health status of concern -->
 <!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements
      containing clinical status -->
 <!-- zero to many <entryRelationship typeCode='REFR' inversionInd='true'> elements
      containing comments -->
</observation>


<observation classCode='OBS' moodCode='EVN' negationInd='false|true'>

The basic pattern for reporting a problem uses the CDA <observation> element, setting the classCode='OBS' to represent that this is an observation of a problem, and the moodCode='EVN', to represent that this is an observation that has in fact taken place. The negationInd attribute, if true, specifies that the problem indicated was observed to not have occurred (which is subtly but importantly different from having not been observed). The value of negationInd should not normally be set to true. Instead, to record that there is "no prior history of chicken pox", one would use a coded value indicated exactly that. However, it is not always possible to record problems in this manner, especially if using a controlled vocabulary that does not supply pre-coordinated negations , or which do not allow the negation to be recorded with post-coordinated coded terminology.

<templateId root='2.16.840.1.113883.10.20.1.28'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>

These <templateId> elements identify this <observation> as a problem, under both IHE and CCD specifications. This SHALL be included as shown above.

<id root=' ' extension=' '/>

The specific observation being recorded must have an identifier (<id>) that shall be provided for tracking purposes. If the source EMR does not or cannot supply an intrinsic identifier, then a GUID shall be provided as the root, with no extension (e.g., <id root='CE1215CD-69EC-4C7B-805F-569233C5E159'/>). While CDA allows for more than one identifier element to be provided, this profile requires that only one be used.

<code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'>

The <code> describes the process of establishing a problem. The code element should be used, as the process of determining the value is important to clinicians (e.g., a diagnosis is a more advanced statement than a symptom). The recommended vocabulary for describing problems is shown in the table below. Subclasses of this content module may specify other vocabularies. When the list below is used, the codeSystem is '2.16.840.1.113883.6.96' and codeSystemName is SNOMED CT.

Problem Codes
Code Description
64572001 Condition
418799008 Symptom
404684003 Finding
409586006 Complaint
248536006 Functional limitation
55607006 Problem
282291009 Diagnosis
<text><reference value=' '/></text>

The <text> element is required and points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.

<statusCode code='completed'/>

A clinical document normally records only those condition observation events that have been completed, not observations that are in any other state. Therefore, the <statusCode> shall always have code='completed'.

<effectiveTime><low value=' '/><high value=' '/></effectiveTime>

The <effectiveTime> of this <observation> is the time interval over which the <observation> is known to be true. The <low> and <high> values should be no more precise than known, but as precise as possible. While CDA allows for multiple mechanisms to record this time interval (e.g. by low and high values, low and width, high and width, or center point and width), we are constraining Medical summaries to use only the low/high form. The <low> value is the earliest point for which the condition is known to have existed. The <high> value, when present, indicates the time at which the observation was no longer known to be true. Thus, the implication is made that if the <high> value is specified, that the observation was no longer seen after this time, and it thus represents the date of resolution of the problem. Similarly, the <low> value may seem to represent onset of the problem. Neither of these statements is necessarily precise, as the <low> and <high> values may represent only an approximation of the true onset and resolution (respectively) times. For example, it may be the case that onset occurred prior to the <low> value, but no observation may have been possible before that time to discern whether the condition existed prior to that time. The <low> value should normally be present. There are exceptions, such as for the case where the patient may be able to report that they had chicken pox, but are unsure when. In this case, the <effectiveTime> element shall have a <low> element with a nullFlavor attribute set to 'UNK'. The <high> value need not be present when the observation is about a state of the patient that is unlikely to change (e.g., the diagnosis of an incurable disease).

<value xsi:type='CD' code=' ' codeSystem=' ' codeSystemName=' ' displayName=' '>

The <value> is the condition that was found. This element is required. While the value may be a coded or an un-coded string, the type is always a coded value (xsi:type='CD'). If coded, the code and codeSystem attributes shall be present. The codeSystem should reference a controlled vocabulary describing problems, complaints, symptoms, findings, diagnoses, or functional limitations, e.g., ICD-9, SNOMED-CT or MEDCIN, or others. The table below is an incomplete listing of acceptable values for the codeSystem attribute, along with the codeSystemName.

Example Problem Vocabularies
CodeSystem codeSystemName Description
2.16.840.1.113883.6.96 SNOMED-CT SNOMED Controlled Terminology
2.16.840.1.113883.6.103 ICD-9CM (diagnoses) International Classification of Diseases, Clinical Modifiers, Version 9
2.16.840.1.113883.6.26 MEDCIN A classification system from MEDICOMP Systems.

It is recommended that the codeSystemName associated with the codeSystem, and the displayName for the code also be provided for diagnostic and human readability purposes, but this is not required by this profile.

If uncoded, all attributes other than xsi:type='CD' must be absent.

In cases where information about a problem or allergy is unknown or where there are no problems or allergies, an entry shall use codes from the table below to record this fact:

Entry Type Code Display Name Description
Problem 396782006 Past Medical History Unknown To indicate unknown medical history
Problem 407559004 Family History Unknown To indicate that the patient's family history is not known.
Problem 160243008 No Significant Medical History To indicate no relevant medical history
Problem 160245001 No current problems or disability To indicate that the patient has no current problems (as distinct from no history).
Allergy 409137002 No Known Drug Allergies To indicate that there are no known Drug allergies for this patient.
Allergy 160244002 No Known Allergies To indicate that there are no known allergies for this patient.
Allergy 64970000 Substance Type Unknown To indicate the state where there is a known allergy or intollerance to an unknown substance
<originalText><reference value=' '/></originalText>

The <value> contains a <reference> to the <originalText> in order to link the coded value to the problem narrative text (minus any dates, comments, et cetera). The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.

<!-- zero or one <entryRelationship typeCode='SUBJ' inversionInd='true'> elements containing severity -->

An optional <entryRelationship> element may be present indicating the severity of the problem. When present, this <entryRelationship> element shall contain a severity observation conforming to the Severity entry template (1.3.6.1.4.1.19376.1.5.3.1.4.1).

For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <subjectOf> element. The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘true’.

<!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements containing clinical status -->

An optional <entryRelationship> may be present indicating the clinical status of the problem, e.g., resolved, in remission, active. When present, this <entryRelationship> element shall contain a clinical status observation conforming to the Problem Status Observation template (1.3.6.1.4.1.19376.1.5.3.1.4.1.1).

For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element. The typeCode SHALL be ‘REFR’ and inversionInd SHALL be ‘false’.

<!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements identifying the health status of concern -->

An optional <entryRelationship> may be present referencing the health status of the patient, e.g., resolved, in remission, active. When present, this <entryRelationship> element shall contain a clinical status observation conforming to the Health Status Observation template (1.3.6.1.4.1.19376.1.5.3.1.4.1.2). The typeCode SHALL be ‘REFR’ and inversionInd SHALL be ‘false’.

For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element.

<!-- zero to many <entryRelationship typeCode='SUBJ' inversionInd='true'> element containing comments -->

One or more optional <entryRelationship> elements may be present providing an additional comments (annotations) for the condition. When present, this <entryRelationship> element shall contain a comment observation conforming to the Comment entry template (1.3.6.1.4.1.19376.1.5.3.1.4.2). The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘true’.

For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> 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 Allergies and Intolerances 1.3.6.1.4.1.19376.1.5.3.1.4.6

Allergies and intolerances are special kinds of problems, and so are also recorded in the CDA <observation> element, with classCode='OBS'. They follow the same pattern as the problem entry, with exceptions noted below.

Standards
CCD ASTM/HL7 Continuity of Care Document
CareStruct HL7 Care Provision Care Structures (DSTU)
ClinStat HL7 Clinical Statement Pattern (Draft)
Uses

See Templates using Allergies and Intolerances

Specification
Allergies and Intolerances Example

<observation classCode='OBS' moodCode='EVN' negationInd='false'>
 <templateId root='2.16.840.1.113883.10.20.1.18'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
 <id root=' ' extension=' '/>
 <code 
   code='ALG|OINT|DALG|EALG|FALG|DINT|EINT|FINT|DNAINT|ENAINT|FNAINT' 
   codeSystem='2.16.840.1.113883.5.4' 
   codeSystemName='ObservationIntoleranceType'/>
 <text><reference value=' '/></text>
 <statusCode code='completed'/>
 <effectiveTime>
   <low value=' '/>
   <high value=' '/>
 </effectiveTime>
 <value xsi:type='CD' code=' ' codeSystem=' ' displayName=' ' codeSystemName=' '/>
 <participant typeCode='CSM'>
   <participantRole classCode='MANU'>
     <playingEntity classCode='MMAT'>
       <code  code=' ' codeSystem=' '>
         <originalText><reference value='#substance'/></originalText>
       </code>
       <name></name>
     </playingEntity>
   </participantRole>
 </participant>
 <!-- zero to many <entryRelationship> elements containing reactions -->
 <!-- zero or one <entryRelationship> elements containing severity -->
 <!-- zero or one <entryRelationship> elements containing clinical status -->
 <!-- zero to many <entryRelationship> elements containing comments -->
</observation>


<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6'/>

This entry has a template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.6, and is a subtype of the Problem Entry, and so must also conform to the rules of the problem entry, which has the template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5. These elements are required and shall be recorded exactly as shown above.

<code code='ALG|OINT|DINT|EINT|FINT|DALG|EALG|FALG|DNAINT|ENAINT|FNAINT' displayName=' ' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ObservationIntoleranceType'/>

The <code> element represents the kind of allergy observation made, to a drug, food or environmental agent, and whether it is an allergy, non-allergy intolerance, or unknown class of intolerance (not known to be allergy or intolerance). The <code> element of an allergy entry shall be provided, and a code and codeSystem attribute shall be present. The example above uses the HL7 ObservationIntoleranceType vocabulary domain, which does provide suitable observation codes. Other vocabularies may be used, such as SNOMED-CT or MEDCIN. The displayName and codeSystemName attributes should be present.

<value xsi:type='CD' code=' ' codeSystem=' ' codeSystemName=' ' displayName=' '>

The <value> is a description of the allergy or adverse reaction. While the value may be a coded or an uncoded string, the type is always a coded value (xsi:type='CD'). If coded, the code and codeSystem attributes must be present. The codingSystem should reference a controlled vocabulary describing allergies and adverse reactions, see Table 5.4 12Table 5.4 12 above . If uncoded, all attributes other than xsi:type='CD' must be absent. The allergy or intolerance may not be known, in which case that fact shall be recorded appropriately. This might occur in the case where a patient experiences an allergic reaction to an unknown substance.

<participant typeCode='CSM'>
 <participantRole classCode='MANU'>
  <playingEntity classCode='MMAT'>

The substance that causes the allergy or intolerance may be specified in the <participant> element.

<code code=' ' codeSystem=' '>
 <originalText><reference value=' '/></originalText>
  </code>

The <code> element shall be present. It may contain a code and codeSystem attribute to indicate the code for the substance causing the allergy or intolerance. It shall contain a <reference> to the <originalText> in the narrative where the substance is named.

<!-- zero to many <entryRelationship> elements containing reactions -->

An allergy entry can record the reactions that are manifestations of the allergy or intolerance as shown below.

Adverse Reaction Example
<entryRelationship typeCode='MFST'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6.1'/>
  <!-- a problem entry  -->
  <observation classCode='OBS' moodCode='EVN'>
    <templateId root='2.16.840.1.113883.10.20.1.54'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
      ∶
  </observation>
</entryRelationship>
<entryRelationship typeCode='MFST'>

This is a related entry (<entryRelationship>) that indicates the manifestations (typeCode='MFST') the reported allergy or intolerance. These are events that may occur, or have occurred in the past as a reaction to the allergy or intolerance.

<observation classCode='OBS' moodCode='EVN'>
 <templateId root='2.16.840.1.113883.10.20.1.54'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
  ∶
 </observation>

The entry contained with this entry relationship is some sort of problem that is a manifestation of the allergy. It is recorded using the Problem Entry structure, with the additional template identifier (2.16.840.1.113883.10.20.1.54) indicating that this problem is a reaction.

<!-- zero or one <entryRelationship typeCode='SUBJ' inversionInd='true'> elements containing severity -->

An optional <entryRelationship> element may be present indicating the severity of the problem. When present, this <entryRelationship> element shall contain a severity observation conforming to the Severity entry template (1.3.6.1.4.1.19376.1.5.3.1.4.1). For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element. The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘true’.

<!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements containing clinical status -->

An optional <entryRelationship> may be present indicating the clinical status of the allergy, e.g., resolved, in remission, active. When present, this <entryRelationship> element shall contain a clinical status observation conforming to the Problem Status Observation template (1.3.6.1.4.1.19376.1.5.3.1.4.1.1). The typeCode SHALL be ‘REFR’ and inversionInd SHALL be ‘false’. For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element.

<!-- zero to many <entryRelationship typeCode='SUBJ' inversionInd='true'> element containing comments -->

One or more optional <entryRelationship> elements may be present providing an additional comments (annotations) for the allergy. When present, this <entryRelationship> element shall contain an entry conforming to the Comment entry template (1.3.6.1.4.1.19376.1.5.3.1.4.2). The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘true’.

For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> 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 Medications 1.3.6.1.4.1.19376.1.5.3.1.4.7

This content module describes the general structure for a medication. All medication administration acts will be derived from this content module.

Standards
Pharmacy HL7 Pharmacy Domain (Normative)
CCD ASTM/HL7 Continuity of Care Document
Uses

See Templates using Medications

Specification
Medications Example
<substanceAdministration classCode='SBADM' moodCode='INT|EVN'>
  <templateId root='2.16.840.1.113883.10.20.1.24'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/>
  <templateId root=''/>
  <id root='' extension=''/>
  <code code='' codeSystem='' displayName='' codeSystemName=''/>
  <text><reference value='#med-1'/></text>
  <statusCode code='completed'/>
  <effectiveTime xsi:type='IVL_TS'>
      <low value=''/>
      <high value=''/>
  </effectiveTime>
  <effectiveTime operator='A' xsi:type='TS|PIVL_TS|EIVL_TS|PIVL_PPD_TS|SXPR_TS'>
    :
  </effectiveTime>
  <routeCode code='' codeSystem='' displayName='' codeSystemName=''/>
  <doseQuantity value='' unit=''/>
  <approachSiteCode code='' codeSystem='' displayName='' codeSystemName=''/>
  <rateQuantity value='' unit=''/>
  <consumable>
    :
    .
  </consumable>
  <!-- 0..* entries describing the components -->
  <entryRelationship typeCode='COMP' >
      <sequenceNumber value=''/>
  </entryRelationship>
  <!-- An optional entry relationship that indicates the the reason for use -->
  <entryRelationship typeCode='RSON'>
    <act classCode='ACT' moodCode='EVN'>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
      <id root='' extension=''/>
    </act>
  </entryRelationship>
  <!-- An optional entry relationship that provides prescription activity -->
  <entryRelationship typeCode='REFR'>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>
      :
      .
  </entryRelationship>
  <precondition>
    <criterion>
      <text><reference value=''></text>
    </criterion>
  </precondition>
</substanceAdministation>


This section makes use of the linking, severity and instruction entries.

Medications are perhaps the most difficult data elements to model due to variations in the ways that medications are prescribed.

This profile identifies the following relevant fields of a medication as being important to be able to generate in a medical summary. The table below identifies and describes these fields, and indicates the constraints on whether or not they are required to be sent. The fields are listed in the order that they appear in the CDA XML content.

Medication Fields
Medication Fields
Field Opt. CDA Tag Description
Start and Stop Date R2 <effectiveTime> The date (and time if available) when the medication regimen began and is expected to finish. The first component of the <effectiveTime> encodes the lower and upper bounds over which the <substanceAdministration> occurs, and the start time is determined from the lower bound. If the medication has been known to be stopped, the high value must be present, but expressed as a flavor of null (e.g., Unknown).
Frequency R2 <effectiveTime> The frequency indicates how often the medication is to be administered. It is often expressed as the number of times per day, but which may also include information such as 1 hour before/after meals, or in the morning, or evening.The second <effectiveTime> element encodes the frequency. In cases where split or tapered doses are used, these may be found in subordinate <substanceAdministration> elements.
Route R2 <routeCode> The route is a coded value, and indicates how the medication is received by the patient (by mouth, intravenously, topically, et cetera).
Dose R2 <doseQuantity> The amount of the medication given. This should be in some known and measurable unit, such as grams, milligrams, et cetera. It may be measured in "administration" units (such as tablets or each), for medications where the strength is relevant. In this case, only the unit count is specified , no units are specified. It may be a range.
Site O <approachSiteCode> The site where the medication is administered, usually used with IV or topical drugs.
Rate R2 <rateQuantity> The rate is a measurement of how fast the dose is given to the patient over time (e.g., .5 liter / 1 hr), and is often used with IV drugs.
Product R1 <consumable>
 <name>
</consumable>
The name of the substance or product. This should be sufficient for a provider to identify the kind of medication. It may be a trade name or a generic name. This information is required in all medication entries. If the name of the medication is unknown, the type, purpose or other description may be supplied. The name should not include packaging, strength or dosing information. Note: Due to restrictions of the CDA schema, there is no way to explicitly link the name to the narrative text.
Strength R2 <consumable>
 <code>
  <originalText/>
 </code>
</consumable>
The name and strength of the medication. This information is only relevant for some medications, as the dose of the medication is often sufficient to indicate how much medication the patient receives. For example, the medication Percocet comes in a variety of strengths, which indicate specific amounts of two different medications being received in single tablet. Another example is eye-drops, where the medication is in a solution of a particular strength, and the dose quantity is some number of drops. The originalText referenced by the <code> element in the consumable should refer to the name and strength of the medication in the narrative text.Note: Due to restrictions of the CDA schema, there is no way to separately record the strength.
Code R2 <consumable>
 <code/>
</consumable>
A code describing the product from a controlled vocabulary, such as RxNorm, First DataBank, et cetera.
Instructions R2 <entryRelationship> A place to put free text comments to support additional relevant information, or to deal with specialized dosing instructions. For example, "take with food", or tapered dosing.
Indication O <entryRelationship> A link to supporting clinical information about the reason for providing the medication (e.g., a link to the relevant diagnosis).


1 A consumable is not neccessary when the substanceAdministration code indicates none or unknown medications.


<substanceAdministration classCode='SBADM' moodCode='INT|EVN'>

The general model is to record each prescribed medication in a <substanceAdministration> intent (moodCode='INT'). Medications that have been reported by the patient or administered (instead of prescribed ), are recorded in the same element, except that this is now an event (moodCode='EVN'). The <substanceAdministration> element may contain subordinate <substanceAdministration> elements in a related component entry to deal with special cases (see the section below on Special Cases). These cases include split, tapered, or conditional dosing, or combination medications. The use of subordinate <substanceAdministration> elements to deal with these cases is optional. The comment field should always be used in these cases to provide the same information as free text in the top level <substanceAdministration> element. There are a variety of special cases for dosing that need to be accounted for. These are described below. Most of these special cases involve changing the dosage or frequency over time, or based on some measurement. When the dosage changes, then additional entries are required for each differing dosage. The last case deals with combination medications.

Normal Dosing 1.3.6.1.4.1.19376.1.5.3.1.4.7.1

This template identifier is used to identify medication administration events that do not require any special processing. The parent template is 1.3.6.1.4.1.19376.1.5.3.1.4.7. Medications that use this template identifier shall not use subordinate <substanceAdministation> acts.

Tapered Doses 1.3.6.1.4.1.19376.1.5.3.1.4.8

This template identifier is used to identify medication administration events that require special processing to handle tapered dosing. The parent template is 1.3.6.1.4.1.19376.1.5.3.1.4.7. A tapered dose is often used for certain medications where abrupt termination of the medication can have negative consequences. Tapered dosages may be done by adjusting the dose frequency, the dose amount, or both.

When merely the dose frequency is adjusted, (e.g., Prednisone 5mg b.i.d. for three days, then 5mg. daily for three days, and then 5mg every other day), then only one medication entry is needed, multiple frequency specifications recorded in <effectiveTime> elements. When the dose varies (eg. Prednisone 15mg daily for three days, then 10 mg daily for three days, the 5 mg daily for three days), subordinate medication entries should be created for each distinct dosage.

Split Dosing 1.3.6.1.4.1.19376.1.5.3.1.4.9

This template identifier is used to identify medication administration events that require special processing to handle split dosing. The parent template is 1.3.6.1.4.1.19376.1.5.3.1.4.7. A split dose is often used when different dosages are given at different times (e.g., at different times of day, or on different days). This may be to account for different metabolism rates at different times of day, or to simply address drug packaging deficiencies (e.g., and order for Coumadin 2mg on even days, 2.5mg on odd days is used because Coumadin does not come in a 2.25mg dose form).

In this case a subordinate <substanceAdministration> entry is required for each separate dosage.

Conditional Dosing 1.3.6.1.4.1.19376.1.5.3.1.4.10

This template identifier is used to identify medication administration events that require special processing to handle conditional dosing. The parent template is 1.3.6.1.4.1.19376.1.5.3.1.4.7. A conditional dose is often used when the dose amount differs based on some measurement (e.g., an insulin sliding scale dose based on blood sugar level). In this case a subordinate <substanceAdministration> entry is required for each different dose, and the condition should be recorded.

Combination Medications 1.3.6.1.4.1.19376.1.5.3.1.4.11

This template identifier is used to identify medication administration events that require special processing to handle combination medications. The parent template is 1.3.6.1.4.1.19376.1.5.3.1.4.7. A combination medication is made up of two or more other medications. These may be prepackaged, such as Percocet, which is a combination of Acetaminophen and oxycodone in predefined ratios, or prepared by a pharmacist, such as a GI cocktail.

In the case of the prepackaged combination, it is sufficient to supply the name of the combination drug product, and its strength designation in a single <substanceAdministation> entry. The dosing information should then be recorded as simply a count of administration units.

In the latter case of a prepared mixture, the description of the mixture should be provided as the product name (e.g., "GI Cocktail") , in the <substanceAdministration> entry. That entry may, but is not required, to have subordinate <substanceAdministration> entries included beneath it to record the components of the mixture.

<templateId root='2.16.840.1.113883.10.20.1.24'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7' />

All medications entries use the <templateId> elements specified above to indicate that they are medication acts. This element is required. In addition, a medication entry shall further identify itself using one of the template identifiers detailed in the next section.

<templateId root=' ' />

The <templateId> element identifies this <entry> as a particular type of medication event, allowing for validation of the content. As a side effect, readers of the CDA can quickly locate and identify medication events. The templateId must use one of the values in the table below for the root attribute.

Extension values for <templateId> in <substanceAdministration>
root Description
1.3.6.1.4.1.19376.1.5.3.1.4.7.1 A "normal" <substanceAdministration> act that may not contain any subordinate <substanceAdministration> acts.
1.3.6.1.4.1.19376.1.5.3.1.4.8 A <substanceAdministration> act that records tapered dose information in subordinate <substanceAdministration> act.
1.3.6.1.4.1.19376.1.5.3.1.4.9 A <substanceAdministration> act that records split dose information in subordinate <substanceAdministration> acts.
1.3.6.1.4.1.19376.1.5.3.1.4.10 A <substanceAdministration> act that records conditional dose information in subordinate <substanceAdministration> acts.
1.3.6.1.4.1.19376.1.5.3.1.4.11 A <substanceAdministration> act that records combination medication component information in subordinate <substanceAdministration> acts.
<id root=' ' extension=' '/>

A top level <substanceAdministration> element must be uniquely identified. If there is no explicit identifier for this observation in the source EMR system, a GUID may be used for the root attribute, and the extension may be omitted. Although HL7 allows for multiple identifiers, this profile requires that one and only one be used. Subordinate <substanceAdministration> elements may, but need not be uniquely identified.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '>

The <code> element is used to supply a code that describes the <substanceAdminstration> act, not the medication being administered or prescribed. This may be a procedure code, such as those found in CPT-4 (and often used for billing), or may describe the method of medication administration, such as by intravenous injection. The type of medication is coded in the consumable, do not supply the code for the medication in this element. This element is optional.

One of the following values from SNOMED CT shall be used in the <code> element to record that a patient is either not on medications, or that medications are not known.

Entry Type Code Display Name Description
Medication 182904002 Drug Treatment Unknown To indicate lack of knowledge about drug therapy
Medication 182849000 No Drug Therapy Prescribed To indicate the absense of any prescribed medications
Medication 408350003 Patient Not On Self-Medications To indicate no treatment
<text><reference value=' '/></text>

The URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the medication. In a CDA document, the URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the medication. In an HL7 message, the content of the text element shall contain the complete text describing the medication.

<statusCode code='completed'/>

The status of all <substanceAdministration> elements must be "completed". The act has either occurred, or the request or order has been placed.

<effectiveTime xsi:type='IVL_TS'>

The first <effectiveTime> element encodes the start and stop time of the medication regimen. This an interval of time (xsi:type='IVL_TS'), and must be specified as shown. This is an additional constraint placed upon CDA Release 2.0 by this profile, and simplifies the exchange of start/stop and frequency information between EMR systems.

<low value=' '/><high value=' '/>

The <low> and <high> values of the first <effectiveTime> element represent the start and stop times for the medication. The <low> value represents the start time, and the <high> value represents the stop time. If either the <low> or the <high> value is unknown, this shall be recorded by setting the nullFlavor attribute to UNK. The <high> value records the end of the medication regime according to the information provided in the prescription or order. For example, if the prescription is for enough medication to last 30 days, then the high value should contain a date that is 30 days later then the <low> value. The rationale is that a provider, seeing an un-refilled prescription would normally assume that the medication is no longer being taken, even if the intent of the treatment plan is to continue the medication indefinitely.

<effectiveTime operator='A' xsi:type='TS|PIVL_TS|EIVL_TS|PIVL_PPD_TS|SXPR_TS' />

The second <effectiveTime> element records the frequency of administration. This <effectiveTime> element must be intersected with the previous time specification (operator='A'), producing the bounded set containing only those time specifications that fall within the start and stop time of the medication regimen. Several common frequency expressions appear in the table below, along with their XML representations.

Specifying Medication Frequency
Sample Frequency Specifications
Freq Description XML Representation
b.i.d. Twice a day <effectiveTime xsi:type='PIVL_TS' institutionSpecified='true' operator='A'> <period value='12' unit='h' /></effectiveTime>
q12h Every 12 hours <effectiveTime xsi:type='PIVL_TS' institutionSpecified='false' operator='A'> <period value='12' unit='h' /></effectiveTime>
Once Once, on 2005-09-01 at 1:18am. <effectiveTime xsi:type='TS' value='200509010118'/>
t.i.d. Three times a day, at times determined by the person administering the medication . <effectiveTime xsi:type='PIVL_TS' institutionSpecified='true' operator='A'> <period value='8' unit='h' /></effectiveTime>
q8h Every 8 hours <effectiveTime xsi:type='PIVL_TS' institutionSpecified='false' operator='A'> <period value='8' unit='h' /></effectiveTime>
qam In the morning <effectiveTime xsi:type='EIVL' operator='A'> <event code='ACM'/></effectiveTime>
  Every day at 8 in the morning for 10 minutes <effectiveTime xsi:type='PIVL_TS' operator='A'> <phase> <low value="198701010800" inclusive="true"/> <width value="10" unit="min"/> </phase> <period value='1' unit='d'/></effectiveTime>
q4-6h Every 4 to 6 hours. <effectiveTime xsi:type='PIVL_PPD_TS' institutionSpecified='false' operator='A'> <period value='5' unit='h' /> <standardDeviation value='1' unit='h'></effectiveTime>

The last frequency specification is about as bad as it gets, but can still be represented accurately within the HL7 V3 datatypes. The mean (average) of the low and high values is specified for the period. The mean of 4 and 6 is 5. The standard deviation is recorded as one half the difference between the high and low values, with an unspecified distribution. The type attribute of the <effectiveTime> element describes the kind of frequency specification it contains. More detail is given for each type in the table below.

Data types used in Frequency Specifications
<effectiveTime> types used in Frequency Specifications
xsi:type Description
TS An xsi:type of TS represents a single point in time, and is the simplest of all to represent. The value attribute of the <effectiveTime> element specifies the point in time in HL7 date-time format (CCYYMMDDHHMMSS)
PIVL_TS An xsi:type of PIVL_TS is the most commonly used, representing a periodic interval of time. The <low> element of <phase> may be present. If so it specifies the starting point, and only the lower order components of this value are relevant with respect to the <period>. The <width> element represents the duration of the dose administration (e.g., for IV administration). The <period> indicates how often the dose is given. Legal values for the unit attribute of <period> are s, min, h, d, wk and mo representing seconds, minutes, hours, days, weeks, and months respectively.
EIVL_TS An xsi:type of EIVL_TS represents an event based time interval, where the event is not a precise time, but is often used for timing purposes (e.g. with meals, between meals, before breakfast, before sleep). Refer to the HL7 TimingEvent vocabulary for the codes to use for the <event> element. This interval may specify an <offset> which provides information about the time offset from the specified event (e.g., <offset><low value='-1' unit='h'/><width value='10' unit='min'/></offset> means 1 hour before the event. In that same example, the <width> element indicates the duration for the dose to be given.
PIVL_PPD_TS An xsi:type of PIVL_PPD_TS represents an probabilistic time interval and is used to represent dosing frequencies like q4-6h. This profile requires that the distributionType of this interval be left unspecified. The <period> element specifies the average of the time interval, and the value of the <standardDeviation> shall be computed as half the width of the interval. The unit attributes of the <period> and <standardDeviation> elements shall be the same.
SXPR_TS An xsi:type of SXPR_TS represents a parenthetical set of time expressions. This type is used when the frequency varies over time (e.g., for some cases of tapered dosing, or to handle split dosing). The <comp> elements of this <effectiveTime> element are themselves time expressions (using any of the types listed above). Each <comp> element may specify an operator (e.g. to intersect or form the union of two sets).
<routeCode code=' ' displayName=' ' codeSystem='2.16.840.1.113883.5.112' codeSystemName='RouteOfAdministration'>

The <routeCode> element specifies the route of administration using the HL7 RouteOfAdministration vocabulary. A code must be specified if the route is known, and the displayName attribute should be specified. If the route is unknown, this element shall not be sent.

<approachSiteCode code=' ' codeSystem=' '>
 originalText><reference value=' '/></originalText>
</approachSiteCode>

The <approachSiteCode> element describes the site of medication administrion. It may be coded to a controlled vocabulary that lists such sites (e.g., SNOMED-CT). In CDA documents, this element contains a URI in the value attribute of the <reference> that points to the text in the narrative identifying the site. In a message, the <originalText> element shall contain the text identifying the site.

<doseQuantity> <low value=' ' unit=' '/><high value=' ' unit=' '/> </doseQuantity>

The dose is specified if the <doseQuantity> element. If a dose range is given (e.g., 1-2 tablets, or 325-750mg), then the <low> and <high> bounds are specified in their respective elements, otherwise both <low> and <high> have the same value. If the dose is in countable units (tablets, caplets, "eaches"), then the unit attribute is not sent. Otherwise the units are sent. The unit attribute should be derived from the HL7 UnitsOfMeasureCaseSensitive vocabulary .

<low|high value=' '> <translation> <originalText><reference value=' '/></originalText> </translation></low|high >

Any <low> and <high> elements used for <doseQuantity> or <rateQuantity> should contain a <translation> element that provides a <reference> to the <originalText> found in the narrative body of the document. In a CDA document, any <low> and <high> elements used for <doseQuantity> or <rateQuantity> should contain a <translation> element that provides a <reference> to the <originalText> found in the narrative body of the document. In a message, the <originalText> may contain the original text used to describe dose quantity.

<rateQuantity><low value=' ' unit=' '/><high value=' ' unit=' '/></rateQuantity>

The rate is specified in the <rateQuantity> element. The rate is given in units that have measure over time. In this case, the units should be specified as a string made up of a unit of measure (see doseQuantity above), followed by a slash (/), followed by a time unit (s, min, h or d).

Again, if a range is given, then the <low> and <high> elements contain the lower and upper bound of the range, otherwise, they contain the same value.

<consumable>

The <consumable> element shall be present, and shall contain a <manufacturedProduct> entry conforming to the Product Entry template

<entryRelationship typeCode='REFR'>
&nsbp;<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>

The top level <substanceAdministration> element may contain a reference (typeCode='REFR') to related prescription activity as described in the Supply Entry.

<entryRelationship typeCode='COMP'>
 <sequenceNumber value=' '>

A top level <substanceAdministration> element may contain one or more related components, either to handle split, tapered or conditional dosing, or to support combination medications.

In the first three cases, the subordinate components shall specify only the changed <frequency> and/or <doseAmount> elements. For conditional dosing, each subordinate component shall have a <precondition> element that specifies the <observation> that must be obtained before administration of the dose. The value of the <sequenceNumber> shall be an ordinal number, starting at 1 for the first component, and increasing by 1 for each subsequent component. Components shall be sent in <sequenceNumber> order.

<entryRelationship typeCode='SUBJ' inversionInd='true'/>

At most one instruction may be provided for each <substanceAdministration> entry. If provided, it shall conform to the requirements listed for Patient Medication Instructions. The instructions shall contain any special case dosing instructions (e.g., split, tapered, or conditional dosing), and may contain other information (take with food, et cetera).

<entryRelationship typeCode='RSON'>
 <act classCode='ACT' moodCode='EVN'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
  <id root=' ' extension=' '/>
 </act>
</entryRelationship>

A <substanceAdministration> event may indicate one or more reasons for the use of the medication. These reasons identify the concern that was the reason for use via the Internal Reference entry content module.

The extension and root of each observation present must match the identifier of a concern entry contained elsewhere within the CDA document.

A consumer of the Medical Summary is encouraged, but not required to maintain these links on import.

<precondition><criterion>
 <text><reference value=' '></text>
</criterion></precondition>

In a CDA document, the preconditions for use of the medication are recorded in the <precondition> element. The value attribute of the <reference> element is a URL that points to the CDA narrative describing those preconditions.

<condition typeCode='PRCN'>
 <criterion>
  <text></text>
  <value nullFlavor='UNK'/>
  <interpretationCode nullFlavor='UNK'/>
 </criterion>
</condition>

In a message, the preconditions for use of the medication are recorded in the <condition> element. The typeCode shall be PRCN. The <text> element of the criterion shall contain a text description of the precondition. The <value> element is required, and may be recorded in a structured data type if known, and if not, may be recorded using a nullFlavor as shown above. The same is true for <interpretationCode>.

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 Immunizations 1.3.6.1.4.1.19376.1.5.3.1.4.12

An immunizations entry is used to record the patient's immunization history.


Uses

See Templates using Immunizations

Specification
Immunizations Example
<substanceAdministration typeCode='SBADM' moodCode='EVN{{!}}INT' negationInd='true{{!}}false'>
  <templateId root='2.16.840.1.113883.10.20.1.24'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12'/>

  <id root='' extension=''/>
  <code code='IMMUNIZ' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode'/>
  <text><reference value='#xxx'/></text>
  <statusCode code='completed'/>
  <effectiveTime value=''/>
  <!-- The reasonCode would normally provide a reason why the immunization was
    not performed.  It isn't supported by CDA R2, and so comments will have to suffice.
    <reasonCode code='' codeSystem='' codeSystemName='ActNoImmunizationReasonIndicator'/>
  -->
  <routeCode code='' codeSystem='' codeSystemName='RouteOfAdministration'/>
  <approachSiteCode code='' codeSystem='' codeSystemName='HumanSubstanceAdministrationSite'/>
  <doseQuantity value='' units=''/>
  <consumable typeCode='CSM'>
    <manufacturedProduct classCode='MANU'>
      <manufacturedLabeledDrug classCode='MMAT' determinerCode='KIND'>
        <code code='' codeSystem='' codeSystemName=''>
          <originalText><reference value='#yyy'/></originalText>
        </code>
      </manufacturedLabeledDrug>
    </manufacturedProduct>
  </consumable>
  <!-- An optional entry relationship that provides prescription activity -->
  <entryRelationship typeCode='REFR'>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>
      :
      .
  </entryRelationship>
  <!-- An optional entry relationship that identifies the immunization series number -->
  <entryRelationship typeCode='SUBJ'>
    <observation classCode='OBS' moodCode='EVN'>
      <templateId root='2.16.840.1.113883.10.20.1.46'/>
      <code code='30973-2' displayName='Dose Number' 
        codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
      <statusCode code='completed'/>
      <value xsi:type='INT' value=''/>
    </observation>
  </entryRelationship>

  <entryRelationship inversionInd='false' typeCode='CAUS'>
    <observation classCode='OBS' moodCode='EVN'>
      <templateId root='2.16.840.1.113883.10.20.1.28'/>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
      <templateId root='2.16.840.1.113883.10.20.1.54'/>
      <id root='' extension=''/>
    </observation> 
  </entryRelationship>
  <!-- Optional <entryRelationship> element containing comments -->
</substanceAdministration>


<substanceAdministration typeCode='SBADM' moodCode='EVN|INT' negationInd='true|false'>

To record an immunization that has been given, use a substance administration event, with moodCode='EVN'. An immunization entry may also be a record of why a specific immunization was not performed. In this case, negationInd shall be set to "true", otherwise, it shall be false.

To record (e.g., in a care plan), the intent to give an immunization at a future time, use the intent mood (moodCode='INT').

<templateId root='2.16.840.1.113883.10.20.1.24'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12'/>

The <templateId> elements identifies this <substanceAdministration> as an immunization. Both elements shall be present as shown above.

<id root=' ' extension=' '/>

This shall be the identifier for the immunization event.

<code code='IMMUNIZ' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode'/>

This required element records that the act was an immunization. The substance administration act must have a <code> element with code and codeSystem attributes present. If no coding system is used by the source, then simply record the code exactly as shown above. Another coding system that may be used for codes for immunizations are the CPT-4 codes for immunization procedures. This <code> element shall not be used to record the type of vaccine used from a vocabulary of drug names.

Vaccination Codes
codeSystem codeSystemName Description
2.16.840.1.113883.5.4 IMMUNIZ The IMMUNIZ term from the HL7 ActCode vocabulary.
2.16.840.1.113883.6.12 C4 Current Procedure Terminology 4 (CPT-4) codes.
<text><reference value='#xxx'/></text>

In a CDA document, the URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the immunization activity. In an HL7 message, the content of the text element shall contain the complete text describing the immunization activity.

<statusCode code='completed'/>

The statusCode shall be set to "completed" for all immunizations.

<effectiveTime value=' '/>

The effectiveTime element shall be present and should contain a time value that indicates the date of the substance administration. If the date is unkown, this shall be recorded using the nullFlavor attribute, with the reason that the information is unknown being specified. Otherwise, the date shall be recorded, and should have precision of at least the day.

<routeCode code=' ' codeSystem=' ' codeSystemName='RouteOfAdministration'/>

See routeCode under Medications.

<approachSiteCode code=' ' codeSystem=' ' codeSystemName='HumanSubstanceAdministrationSite'/>

See approachSiteCode under Medications.

<doseQuantity value=' ' units=' '/>

See doseQuantity under Medications.

<consumable typeCode='CSM'>

See consumable under Medications.

<entryRelationship typeCode='REFR'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>

The top level <substanceAdministration> element may contain a reference (typeCode='REFR') to related Supply entry

<entryRelationship typeCode='SUBJ'>
 <observation classCode='OBS' moodCode='EVN'>
  <templateId root='2.16.840.1.113883.10.20.1.46'/>

This optional entry relationship may be present to indicate that position of this immunization in a series of immunizations.

<code code='30973-2' displayName='Dose Number' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

The <code> element shall be present and must be recorded with the code and codeSystem attributes shown above. This element indicates that the observation describes the dose number for the immunization.

<statusCode code='completed'/>

The <statusCode> element shall be present, and must be recorded exactly as shown above. This element indicates that the observation has been completed.

<value xsi:type='INT' value=' '/>

The <value> element shall be present, and shall indicate the immunization series number in the value attribute.

<entryRelationship inversionInd='false' typeCode='CAUS'>

This repeatable element should be used to identify adverse reactions caused by the immunization.

<observation classCode='OBS' moodCode='EVN'>

This element is required, and provides a pointer to the the adverse reaction caused by the immunization.

<templateId root='2.16.840.1.113883.10.20.1.28'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
<templateId root='2.16.840.1.113883.10.20.1.54'/>

It shall contain a conforming Problem Entry that also conform to the CCD Reaction template.

<id root=' ' extension=' '/>

This element is required, and gives the identifier of the adverse reaction. The adverse reaction pointed to by this element shall be described in more detail using the Allergies entry, elsewhere in the document where this element was found.

<!-- Optional <entryRelationship> element containing comments -->

An immunization entry can have negationInd set to true to indicate that an immunization did not occur. In this case, it shall have at least one comment that provides an explaination for why the immunization did not take place . Other comments may also be present.

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 Supply Entry 1.3.6.1.4.1.19376.1.5.3.1.4.7.3

The supply entry describes a prescription activity.


Uses

See Templates using Supply Entry

Specification
Supply Entry Example
<substanceAdministration classCode='SBADM' moodCode='INT|EVN'>
    :
    .
  <entryRelationship typeCode='REFR' inversionInd='false'>
    <sequenceNumber value=''/>
    <supply classCode='SPLY' moodCode='INT|EVN'>
      <templateId root='2.16.840.1.113883.10.20.1.34'/>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>
      <id root='' extension=''/>
      <repeatNumber value=''/>
      <quantity value='' unit=''/>
      <author>
        <time value=''/>
        <assignedAuthor>
          <id root='' extension=''/>
          <addr></addr>
          <telecom use='' value=''/>
          <assignedPerson><name></name></assignedPerson>
          <representedOrganization><name></name></representedOrganization>
        </assignedAuthor>
      </author>
      <performer typeCode='PRF'>
        <time value=''/>
        <assignedEntity>
          <id root='' extension=''/>
          <addr></addr>
          <telecom use='' value=''/>
          <assignedPerson><name></name></assignedPerson>
          <representedOrganization><name></name></representedOrganization>
        </assignedEntity>
      </performer>
      <!-- Optional Fulfillment instrctions -->
      <entryRelationship typeCode='SUBJ'>
      </entryRelationship>
    </supply>
  </entryRelationship>
</substanceAdministration>


<entryRelationship typeCode='REFR' inversionInd='false'>

A <substanceAdministration> act may reference (typeCode='REFR') a prescription activity in an <entryRelationship> element in a CDA document. In a message, the relationship is recorded using a <sourceOf> element instead of the <entryRelationship> element. The typeCode and inversionInd attributes, and the semantics remain identical.

<sequenceNumber value=' '/>

The prescription activity may have a <sequenceNumber> element to indicate the fill number. A value of 1, 2 or N indicates that it is the first, second, or Nth fill respectively of a specific prescription. This element should be present when the embedded <supply> element has a moodCode attribute of EVN.

<supply classCode='SPLY' moodCode='INT|EVN'>

The <supply> element shall be present. The moodCode attribute shall be INT to reflect that a medication has been prescribed, or EVN to indicate that the prescription has been filled.

<templateId root='2.16.840.1.113883.10.20.1.34'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>

The <templateId> elements shown above shall be present, and identify this supply act as a Supply Entry.

<id root=' ' extension=' '/>

Each supply act shall have an identifier to uniquely identify the supply entry.

<repeatNumber value=' '/>

Each supply entry should have a <repeatNumber> element that indicates the number of times the prescription can be filled.

<quantity value=' ' unit=' '/>

The supply entry should indicate the quantity supplied. The value attribute shall be present and indicates the quantity of medication supplied. If the medication is supplied in dosing units (tablets or capsules), then the unit attribute need not be present (and should be set to 1 if present). Otherwise, the unit element shall be present to indicate the quantity (e.g., volume or mass) of medication supplied.

<author>

A supply entry that describes an intent (<supply classCode='SPLY' moodCode='INT'>) may include an <author> element to identify the prescribing provider.

<time value=' '/>

The <time> element must be present to indicate when the author created the prescription. If this information is unknown, it shall be recorded by setting the nullFlavor attribute to UNK.

<assignedAuthor>

The <assignedAuthor> element shall be present, and identifies the author.

<id root=' ' extension=' '/>

One or more <id> elements should be present. These identifiers identify the author of the act. When the author is the prescribing physician they may include local identifiers or regional identifiers necessary for prescribing.

<assignedPerson><name/></assignedPerson>
<representedOrganization><name/></ representedOrganization>

An <assignedPerson> and/or <representedOriganization> element shall be present. This element shall contain a <name> element to identify the prescriber or their organization.

<performer typeCode='PRF'>

The <performer> element may be present to indicate who is intended (moodCode='INT'), or actually filled (moodCode='EVN') the prescription.

<time value=' '/>

The <time> element shall be present to indicate when the prescription was filled (moodCode='EVN'). If this information is unknown, it shall be recorded by setting the nullFlavor attribute to UNK.

The <time> element should be present to indicate when the prescription is intended to be filled (moodCode='INT').

<assignedEntity>

The < assignedEntity> element shall be present, and identifies the filler of the prescription.

<id root=' ' extension=' '/>

One or more <id> elements should be present. These identify the performer.

<assignedPerson><name/></assignedPerson>
<representedOrganization><name/></ representedOrganization>

An <assignedPerson> and/or <representedOriganization> element shall be present. This element shall contain a <name> element to identify the filler or their organization.

<!-- Optional Fulfillment instrctions -->
 <entryRelationship typeCode='SUBJ'>
</entryRelationship>

An entry relationship may be present to provide the fulfillment instructions. When present, this entry relationship shall contain a Medication Fulfillment Instructions 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 Product Entry 1.3.6.1.4.1.19376.1.5.3.1.4.7.2

The product entry describes a medication or immunization used in a <substanceAdministration> or <supply> act. It adopts the constraints of the ASTM/HL7 Continuity of Care Document.


Uses

See Templates using Product Entry

Specification
Product Entry Example
<!-- Within a CDA Document -->
<manufacturedProduct>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.2'/>
  <templateId root='2.16.840.1.113883.10.20.1.53'/>
  <manufacturedMaterial>
    <code code='' displayName='' codeSystem='' codeSystemName=''>
      <originalText><reference value=''/></originalText>
    </code>
    <name></name>
  </manufacturedMaterial>
</manufacturedProduct>
<!-- Within a message -->
<administerableMaterial>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.2'/>
  <templateId root='2.16.840.1.113883.10.20.1.53'/>
  	<administerableMaterial>
    	<code></code>
		<desc></desc>
	</administerableMaterial>
</administerableMaterial>


<manufacturedProduct> -OR- <administerableMaterial>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.2'/>
 <templateId root='2.16.840.1.113883.10.20.1.53'/>
 <manufacturedMaterial> -OR- <administerableMaterial>

In a CDA document, the name and strength of the medication are specified in the elements under the <manufacturedMaterial> element. In a message, the are contained within the <administeredMaterial> element, inside another <administerableMaterial> element1. The templateId elements are required and identify this as a product entry.

1 This duplication of element names is an artifact of the standard.
<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '>
 <originalText><reference value=' '/></originalText>
</code>

The <code> element of the <manufacturedMaterial> describes the medication. This may be coded using a controlled vocabulary, such as RxNorm, First Databank, or other vocabulary system for medications, and should be the code that represents the generic medication name and strength (e.g., acetaminophen and oxycodone -5/325), or just the generic medication name alone if strength is not relevant (Acetaminophen).

In a CDA document, the <originalText> shall contain a <reference> whose URI value points to the generic name and strength of the medication, or just the generic name alone if strength is not relevant. Inside a message, the <originalText> may contain the actual text that describes the medication in similar fashion.


Note: When the text is supplied from the narrative, the implication is that if you supply the components of a combination medication in an entry, you must also display these in the narrative text, otherwise you would not be able to break the combination medication down into its component parts. This is entirely consistent with the CDA Release 2.0 requirements that the narrative supply the necessary and relevant human readable information content.

The <code> element is also used to support coding of the medication. If coded, it must provide a code and codeSystem attribute using a controlled vocabulary for medications. The displayName for the code and codeSystemName should be provided as well for diagnostic and human readability purposes, but are not required. The table below provides the codeSystem and codeSystemName for several controlled terminologies that may be used to encode medications and/or immunizations.

codeSystem codeSystemName Description
2.16.840.1.113883.6.88 RxNorm RxNorm
2.16.840.1.113883.6.69 NDC National Drug Codes
2.16.840.1.113883.6.63 FDDC First DataBank Drug Codes
2.16.840.1.113883.6.96 SNOMED-CT SNOMED Controlled Terminology
2.16.840.1.113883.6.59 CVX CDC Vaccine Codes
Example Medication and Immunization Vocabularies

The code used for an immunization may use code systems other than what might be used for other medications, such as the CDC maintained CVX codes. Code systems that describe vaccination procedures (such as CPT-4) shall not be used to describe the vaccine entry.

<name> -OR- <desc>

In a CDA document, the <name> element should contain the brand name of the medication (or active ingredient in the case of subordinate <substanceAdministration> elements used to record components of a medication). Within a message, this information shall be provided in the <desc> 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 Simple Observations 1.3.6.1.4.1.19376.1.5.3.1.4.13

The simple observation entry is meant to be an abstract representation of many of the observations used in this specification. It can be made concrete by the specification of a few additional constraints, namely the vocabulary used for codes, and the value representation. A simple observation may also inherit constraints from other specifications (e.g., ASTM/HL7 Continuity of Care Document).


Uses

See Templates using Simple Observations

Specification
Simple Observations Example
<observation classCode='OBS' moodCode='EVN'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
  <id root='' extension=''/>
  <code code='' displayName='' codeSystem='' codeSystemName=''/>
  <!-- for CDA -->
  <text><reference value='#xxx'/></text>
  <!-- For HL7 Version 3 Messages
  <text>text</text> 
  -->
  <statusCode code='completed'/>
  <effectiveTime value=''/>
  <repeatNumber value=''/>
  <value xsi:type='' …/>
  <interpretationCode code='' codeSystem='' codeSystemName=''/>
  <methodCode code='' codeSystem='' codeSystemName=''/>
  <targetSiteCode code='' codeSystem='' codeSystemName=''/>
	<author typeCode='AUT'>
    <assignedAuthor typeCode='ASSIGNED'><id ... /></assignedAuthor> <!-- for CDA -->
    <!-- For HL7 Version 3 Messages 
    <assignedEntity typeCode='ASSIGNED'>
       <Person classCode='PSN'>
          <determinerCode root=''>
          <name>…</name>
       </Person>
    <assignedEntity>
     -->
  </author>
</observation>


<observation classCode='OBS' moodCode='EVN'>

These acts are simply observations that have occurred, and so are recored using the <observation> element as shown above.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>

The <templateId> element identifies this <observation> as a simple observation, allowing for validation of the content. The templateId must appear as shown above.

<id root=' ' extension=' '/>

Each observation shall have an identifier.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

Observations shall have a code describing what was measured. The code system used is determined by the vocabulary constraints on the types of measurements that might be recorded in a section. Content modules that are derived from the Simple Observation content module may restrict the code system and code values used for the observation.

<text><reference value='#xxx'/></text> -OR- <text>text</text>

Each observation measurement entry may contain a <text> element providing the free text that provides the same information as the observation within the narrative portion of the document with a <text> element. For CDA based uses of Simple Observations, this element SHALL be present, and SHALL contain a <reference> element that points to the related string in the narrative portion of the document. For HL7 Version 3 based uses, the <text> element MAY be included.

<statusCode code='completed'/>

The status code of all observations shall be completed.

<effectiveTime value=' '/>

The <effectiveTime> element shall be present in standalone observations , and shall record the date and time when the measurement was taken. This element should be precise to the day. If the date and time is unknown, this element should record that using the nullFlavor attribute.

<value xsi:type=' ' …/>

The value of the observation shall be recording using a data type appropriate to the observation. Content modules derived from the Simple Observation content module may restrict the allowable data types used for the observation.

<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>

If there is an interpretation that can be performed using an observation result (e.g., high, borderline, normal, low), these may be recorded within the interpretationCode element.

<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>

The methodCode element may be used to record the specific method used to make an observation when this information is not already pre-coordinated with the observation code .

<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The targetSiteCode may be used to record the target site where an observation is made when this information is not already pre-coordinated with the observation code.

<author><assignedAuthor classCode='ASSIGNED'>...<assignedAuthor></author>

In CDA uses, SimpleObservations are assumed to be authored by the same author as the document through context conduction. However specific authorship of observation may be represented by listing the author in the header and referencing the author in a <author> relationship. If authors are explicitly listed in documents, an <id> element SHOULD reference the ID of the author in the header through an assignedAuthor Role. If the author of the observation is not an author of the document the <person> object including a name and ID SHALL be included.

For HL7 Version 3 purposes, the <author> element SHOULD be present unless it can be determined by conduction from organizers or higher level structures. When used for HL7 Version 3 the role element name is <assignedEntity> and the author is represented a <assignedPerson> 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 Vital Signs Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.13.1

A vital signs organizer collects vital signs observations.


Uses

See Templates using Vital Signs Organizer

Specification
Vital Signs Organizer Example
<organizer classCode='CLUSTER' moodCode='EVN'>
  <templateId root='2.16.840.1.113883.10.20.1.32'/>
  <templateId root='2.16.840.1.113883.10.20.1.35'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.1'/>
  <id root='' extension=''/>
  <code code='46680005' displayName='Vital signs' 
    codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
  <statusCode code='completed'/>
  <effectiveTime value=''/>
  <!-- For HL7 Version 3 Messages
  <author classCode='AUT'>
     <assignedEntity1 typeCode='ASSIGNED'>
        :
     <assignedEntity1>
  </author>
  -->
  <!-- one or more vital signs observations -->
  <component typeCode='COMP'>
    <observation classCode='OBS' moodCode='EVN'>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.2'/>
        :
    </observation>
  </component>
</organizer>


<organizer classCode='CLUSTER' moodCode='EVN'>

The vital signs organizer is a cluster of vital signs observations.

<templateId root='2.16.840.1.113883.10.20.1.32'/>
 <templateId root='2.16.840.1.113883.10.20.1.35'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.1'/>

The vital signs organizer shall have the <templateId> elements shown above to indicate that it inherits constraints from the ASTM/HL7 CCD Specification for Vital signs, and the constraints of this specification.

<id root=' ' extension=' '/>

The organizer shall have an <id> element.

<code code='46680005' displayName='Vital signs'
   codeSystem='2.16.840.1.113883.6.96'
   codeSystemName='SNOMED CT'/>

The <code> element shall be recorded as shown above to indicate that this organizer captures information about patient vital signs.

<statusCode code='completed'/>

The observations have all been completed.

<effectiveTime value=' '/>

The effective time element shall be present to indicate when the measurement was taken.

<author typeCode='AUT'><assignedEntity1 typeCode='ASSIGNED'>...</assignedEntity1></author>

For use with HL7 Version 3, Vital Sign organizers SHALL contain an <author> element to represent the person or device.

<!-- one or more vital signs observations -->
  <component typeCode='COMP'>

The organizer shall have one or more <component> elements that are <observation> elements using the Vital Signs Observation template.

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 Vital Signs Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.2

A vital signs observation is a simple observation that uses a specific vocabulary, and inherits constraints from CCD.


Uses

See Templates using Vital Signs Observation

Specification
Vital Signs Observation Example

<observation classCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='2.16.840.1.113883.10.20.1.31'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.2'/>
 <id root=' ' extension=' '/>
 <code code=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type='PQ' value=' ' unit=' '/>
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>


<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
  <templateId root='2.16.840.1.113883.10.20.1.31'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.2'/>

A vital signs observation shall have the <templateId> elements shown above to indicate that it inherits constraints from the ASTM/HL7 CCD Specification for Vital signs, and the constraints of this specification.

<code code=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

A vital signs observation entry shall use one of the following LOINC codes, with the specified data types and units.

Vital Signs Codes
LOINC Description Units Type
9279-1 RESPIRATION RATE /min PQ
8867-4 HEART BEAT
2710-2 OXYGEN SATURATION %
8480-6 INTRAVASCULAR SYSTOLIC mm[Hg]
8462-4 INTRAVASCULAR DIASTOLIC
8310-5 BODY TEMPERATURE Cel or [degF]
8302-2 BODY HEIGHT (MEASURED) m, cm,[in_us] or [in_uk]
8306-3 BODY HEIGHT^LYING
8287-5 CIRCUMFRENCE.OCCIPITAL-FRONTAL (TAPE MEASURE)
3141-9 BODY WEIGHT (MEASURED) kg, g, [lb_av] or [oz_av]
<value xsi:type='PQ' value=' ' unit=' '/>

The <value> element shall be present, and shall be of the appropriate data type specified for measure in the table above.

<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>

The interpretation code may be present to provide an interpretation of the vital signs measure (e.g., High, Normal, Low, et cetera).

<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <methodCode> element may be present to indicate the method used to obtain the measure. Note that method used is distinct from, but possibly related to the target site.

<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The target site of the measure may be identified in the <targetSiteCode> element (e.g., Left arm [blood pressure], oral [temperature], et cetera).

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 Family History Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.15

The family history organizer collects the problems of a patient's family member.


Uses

See Templates using Family History Organizer

Specification
Family History Organizer Example
<entry>
  <organizer classCode='CLUSTER' moodCode='EVN'>
    <templateId root='2.16.840.1.113883.10.20.1.23'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.15'/>
    <subject typeCode='SBJ'>
      <relatedSubject classCode='PRS'>
        <code code='' displayName='' 
          codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
        <subject>
          <sdtc:id root='' extension=''/>
          <administrativeGenderCode code='' displayName='' 
            codeSystem='' codeSystemName=''/>
        </subject>
      </relatedSubject>
    </subject>
    <!-- zero or more participants linking to other relations -->
    <participant typeCode='IND'>
      <participantRole classCode='PRS'>
        <code code='' displayName='' 
          codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
        <playingEntity classCode='PSN'>
          <sdtc:id root='' extension=''/>
        </playingEntity>
      </participantRole>
    </participant>
    <!-- one or more entry relationships for family history observations -->
    <component typeCode='COMP'>
      <observation classCode='OBS' moodCode='EVN'>
        <templateId root='2.16.840.1.113883.10.20.1.22'/>
      </observation>
    </component>
  </organizer>
</entry>


<organizer classCode='CLUSTER' moodCode='EVN'>

Each family history entry is organized (classCode='CLUSTER') into a group of observations about a family member.

<templateId root='2.16.840.1.113883.10.20.1.23'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.15'/>

The organizer is identified by the <templateId> elements, which shall be present as shown above.

<subject typeCode='SUBJ'>
    <relatedSubject classCode='PRS'>

The <subject> element shall be present and relates the subject of the observations to the patient. It shall contain a <relatedSubject> element that is a personal relation of the patient (classCode='PRS').

<code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>

The <code> element shall be present, and give the relationship of the subject to the patient. The code attribute shall be present, and shall contain a value from the HL7 FamilyMember vocabulary. The codeSystem attribute shall be present and shall use the value shown above.

<subject>

The <subject> element contains information about the relation.

<sdtc:id root=' ' extension=' '/>

The <sdtc:id> element should be present. It is used to identify the patient relation to create a pedigree graph.

<administrativeGenderCode code=' ' />

The <administrativeGenderCode> element should be present. It gives the gender of the relation.

<participant typeCode='IND'>
 <participantRole classCode='PRS'>

The <participant> element may be present to record the relationship of the subject to other family members to create a pedigree graph. It shall contain a <participantRole> element showing the relationship of the subject to other family members (classCode='PRS').

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The <code> element shall be present, and gives the relationship of the participant to the subject. The code attribute shall be present, and shall contain a value from the HL7 FamilyMember vocabulary. The codeSystem attribute shall be present and shall use the value shown above.

<playingEntity classCode='PSN'>

The <playingEntity> element identifies the related person. It shall be recorded as shown above.

<sdtc:id root=' ' extension=' '/>

The <sdtc:id> element shall be present. It must have the same root and extension attributes of the <subject> of a separate family history organizer. See Appendix C of PCC-TF for definition of this extension to CDA.

<component typeCode='COMP'>
    <observation classCode='OBS' moodCode='EVN'>
     <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.3'/>

The family history organizer shall contain one or more components using the <component> element shown above. These components must conform the Family History Observation template.

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 Family History Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.3

A family history observation is a Simple Observation that uses a specific vocabulary, and inherits constraints from CCD. Family history observations are found inside Family History Organizers.

Standards
CCD ASTM/HL7 Continuity of Care Document
Parent Template

The parent of this template is Simple Observation. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.22

Uses

See Templates using Family History Observation

Specification
Family History Observation Example

<observation typeCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='2.16.840.1.113883.10.20.1.22'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.3'/>
 <id root=' ' extension=' '/>
 <code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type='CD' .../>
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>


<templateId root='2.16.840.1.113883.10.20.1.22'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.3'/>

The <templateId> elements identify this observation as a family history observation, and shall be present as shown above.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The <code> indicates the type of observation made (e.g., Diagnosis, et cetera). See the code element in the Problem Entry entry for suggested values.

<value xsi:type='CD' code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The <value> element indicates the information (e.g., diagnosis) of the family member. See the value element in the Problem Entry for suggested values.

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 Social History Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.4

A social history observation is a simple observation that uses a specific vocabulary, and inherits constraints from CCD.

Standards
CCD ASTM/HL7 Continuity of Care Document
Parent Template

The parent of this template is Simple Observation. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.33

Uses

See Templates using Social History Observation

Specification
Social History Observation Example

<observation typeCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='2.16.840.1.113883.10.20.1.33'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.4'/>
 <id root=' ' extension=' '/>
 <code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type=' ' />
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>


<templateId root='2.16.840.1.113883.10.20.1.33'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.4'/>

These <templateId> elements identify this as a Social History observation.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The <code> element identifies the type social history observation.

Social History Codes
Code Description Data Type Units
229819007 Smoking PQ {pack}/d or {pack}/wk or {pack}/a
256235009 Exercise {times}/wk
160573003 ETOH (Alcohol) Use {drink}/d or {drink}/wk
364393001 Diet CD
N/A
364703007 Employment
425400000 Toxic Exposure
363908000 Drug Use
228272008 Other Social History ANY
<repeatNumber value=' '/>

The <repeatNumber> element should not be used in a social history observation.

<value xsi:type=' ' ... />

The <value> element reports the value associated with the social history observation. The data type to use for each observation should be drawn from the table above.

Observations in the table above using the PQ data type have a unit in the form {xxx}/d, {xxx}/wk or {xxx}/a represent the number of items per day, week or year respectively. The value attribute indicates the number of times of the act performed, and the units represent the frequency. The example below shows how to represent 1 drink per day.

    :
  <code code='160573003' displayName='ETOH Use' 
        codeSystem='2.16.840.1.113883.6.96' 
        codeSystemName='SNOMED CT'/>
    :
  <value xsi:type='PQ' value='1' unit='{drink}/d'/>
    :

Observations in the table using the CD data type should include coded values from an appropriate vocabulary to represent the social history item. The example below shows the encoding to indicate drug use of cannabis.

    :
  <code code='363908000' displayName='Drug Use' 
        codeSystem='2.16.840.1.113883.6.96' 
        codeSystemName='SNOMED CT'/>
    :
  <value xsi:type='CD' code='398705004' displayName='cannabis' 
         codeSystem='2.16.840.1.113883.6.96' 
         codeSystemName='SNOMED CT'/>
    :

Other social history observations may use any appropriate data type.


<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <interpretationCode>, <methodCode>, and <targetSiteCode> elements should not be used in a social history observation.

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 Pregnancy Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.5

A pregnancy observation is a Simple Observation that uses a specific vocabulary to record observations about a patient's pregnancy history.


Parent Template

The parent of this template is Simple Observation.

Uses

See Templates using Pregnancy Observation

Specification
Pregnancy Observation Example

<observation classCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5'/>
 <id root=' ' extension=' '/>
 <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type=' ' .../>
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>


<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5'/>

These <templateId> elements identify this <observation> as a pregnancy observation, allowing for validation of the content. The <templateId> elements shall be recorded as shown above.

<code code=' ' displayName=' '
  codeSystem='2.16.840.1.113883.6.1'
  codeSystemName='LOINC'/>

A pregnancy observation shall have a code describing what facet of patient's pregnancy history is being recorded. These codes should come from the list of codes shown below. Additional codes may be used to reflect additional information about the pregnancy history.

Pregnancy Observation Codes
LOINC CODE Description Type Units or Vocabulary
Summary over All Pregnancies
11636-8 BIRTHS LIVE (REPORTED) INT
N/A
11637-6 BIRTHS PRETERM (REPORTED)
11638-4 BIRTHS STILL LIVING (REPORTED)
11639-2 BIRTHS TERM (REPORTED)
11640-0 BIRTHS TOTAL (REPORTED)
11612-9 ABORTIONS (REPORTED)
11613-7 ABORTIONS INDUCED (REPORTED)
11614-5 ABORTIONS SPONTANEOUS (REPORTED)
33065-4 ECTOPIC PREGNANCY (REPORTED)
Detailed Pregnancy Data
11449-6 PREGNANCY STATUS CE SNOMED CT, ICD-9-CM (V22)
8678-5 MENSTRUAL STATUS SNOMED CT
8665-2 DATE LAST MENSTRUAL PERIOD TS
N/A
11778-8 DELIVERY DATE (CLINICAL ESTIMATE) TS
11779-6 DELIVERY DATE (ESTIMATED FROM LAST MENSTRUAL PERIOD)
11780-4 DELIVERY DATE (ESTIMATED FROM OVULATION DATE)
11884-4 FETUS, GESTATIONAL AGE (CLINICAL ESTIMATE) PQ d, wk or mo
11885-1 FETUS, GESTATIONAL AGE (ESTIMATED FROM LAST MENSTRUAL PERIOD)
11886-9 FETUS, GESTATIONAL AGE (ESTIMATED FROM OVULATION DATE)
11887-7 FETUS, GESTATIONAL AGE (ESTIMATED FROM SELECTED DELIVERY DATE)
45371‑2 MULTIPLE PREGNANCY
<repeatNumber value=' '/>

The <repeatNumber> element should not be present in a pregancy observation.

<value xsi:type=' ' .../>

The value of the observation shall be recording using a data type appropriate to the coded observation according to the table above.

<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <interpretationCode>, <methodCode>, and <targetSiteCode> should not be present in a pregnancy observation.

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 Advance Directive Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.7

An advance directive observation is a simple observation that uses a specific vocabulary, and inherits constraints from CCD.

Standards
CCD ASTM/HL7 Continuity of Care Document
Uses

See Templates using Advance Directive Observation

Specification
Advance Directive Observation Example

<observation typeCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='2.16.840.1.113883.10.20.1.17'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.7'/>
 <id root=' ' extension=' '/>
 <code code=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type='BL' value='true|false'/>
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <reference typeCode='REFR'>
   <templateId root='2.16.840.1.113883.10.20.1.36'/>
   <externalDocument classCode='DOC' moodCode='EVN'>
     <id root=' ' extension=' '/>
     <text><reference value=' '/></text>
   </externalDocument>
 </reference>
</observation>


An advanced directive <observation> shall be represented as shown above. They shall not contain any <repeatNumber>, <interpretationCode>, <methodCode> or <targetSiteCode> elements.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
  <templateId root='2.16.840.1.113883.10.20.1.17'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.7'/>

The <templateId> elements shown above shall be present, and indicated that this is an Advance Directive entry.

<code code=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>

The <code> element records the type of advance directive. It should use one of the following SNOMED codes in the table below.

Advance Directive Type Codes
Code Description Data Type
304251008 Resuscitation BL
52765003 Intubation
225204009 IV Fluid and Support
89666000 CPR
281789004 Antibiotics
78823007 Life Support
61420007 Tube Feedings
116859006 Transfusion of blood product
71388002 Other Directive <value> not permitted
<value xsi:type='BL' value='true|false'/>

The advance directive observation may include a <value> element using the Boolean (xsi:type='BL') data type to indicate simply whether the procedure described is permitted. Absence of the the <value> element indicates that an advance directive of the specified type has been recorded, and must be examined to determine what type of treatment should be performed. The value element is not permitted when the <code> element describes an Other directive.

<reference typeCode='REFR'>
  <templateId root='2.16.840.1.113883.10.20.1.36'/>
  <externalDocument classCode='DOC' moodCode='EVN'>
   <id root=' ' extension=' '/>
   <text><reference value=' '/></text>

The advanced directive observation may contain a single reference to an external document. That reference shall be recorded as shown above. The <id> element shall contain the appropriate root and extension attributes to identify the document. The <text> element may be present to provide a URL link to the document in the value attribute of the <reference> element. If the <reference> element is present, the Advance Directive in the narrative shall contain a <linkHTML> element to the same URL found in the value attribute.

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 Blood Type Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.6

The blood type observation is a Simple Observation of the patient's blood type. It conforms to the CCD Result observation template.

Standards
CCD ASTM/HL7 Continuity of Care Document
Parent Template

The parent of this template is Simple Observation.

Uses

See Templates using Blood Type Observation

Specification
Blood Type Observation Example

<observation typeCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.6'/>
 <templateId root='2.16.840.1.113883.10.20.1.31'/>
 <id root=' ' extension=' '/>
 <code code='882-1' displayName='ABO+RH GROUP' 
   codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type='CE' code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
<observation>


<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.6'/>
  <templateId root='2.16.840.1.113883.10.20.1.31'/>

These <templateId> elements identify this as a blood type observation. They shall be present in the <observation> element as shown above.

<code code='882-1' displayName='ABO+RH GROUP'
   codeSystem='2.16.840.1.113883.6.1'
   codeSystemName='LOINC'/>

The <code> element shall be present to represent this as a finding of the patient's composite blood type. It shall use the code and codeSystem attributes shown above.

<repeatNumber value=' '/>

The <repeatNumber> element should not be present in a blood type observation.

<value xsi:type='CE' code=' ' displayName=' '
   codeSystem=' ' codeSystemName=' '/>

The <value> element shall be present and shall use the CE data type. The code attribute should be valued using a vocabulary that supports encoding of blood types. The table below shows some coding systems that may be used to encode blood type.

Blood Type Coding Systems
Coding System OID
ISBT 128 2.16.840.1.113883.6.18
SNOMED CT 2.16.840.1.113883.6.96
<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <interpretationCode>, <methodCode>, and <targetSiteCode> should not be present in a blood type observation.

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 Encounters 1.3.6.1.4.1.19376.1.5.3.1.4.14

Standards
CCD ASTM/HL7 Continuity of Care Document
Uses

See Templates using Encounters

Specification
Encounters Example

<encounter classCode='ENC' moodCode='PRMS|ARQ|EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.14'/>
 <templateId root='2.16.840.1.113883.10.20.1.21'/>
 <templateId root='2.16.840.1.113883.10.20.1.25'/>
 <id root=' ' extension=' '/>
 <code code=' ' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActEncounterCode' />
 <text><reference value='#xxx'/></text>
 <effectiveTime>
   <low value=' '/>
   <high value=' '/>
 </effectiveTime>
 <priorityCode code=' '/>
 <performer typeCode='PRF'>
   <time><low value=' '/><high value=' '/>
   <assignedEntity>...</assignedEntity>
 </performer>
 <author />
 <informant />
 <participant typeCode='LOC'>
   <participantRole classCode='SDLOC'>
     <id/>
     <code/>
     <addr>...</addr>
     <telecom value=' ' use=' '/>
     <playingEntity classCode='PLC' determinerCode='INST'>
       <name></name>
     </playingEntity>
   </participantRole>
 </participant>
</encounter>


<encounter classCode='ENC' moodCode='PRMS|ARQ|EVN'>

This element is an encounter. The classCode shall be 'ENC'. The moodCode may be PRMS to indicated a scheduled appointment, ARQ to describe a request for an appointment that has been made but not yet scheduled by a provider, or EVN, to describe an encounter that has already occurred.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.14'/>

The templateId indicates that this <encounter> entry conforms to the constraints of this content module. NOTE: When the encounter is in event mood (moodCode='EVN'), this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.21, and when in other moods, this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.25.

<id root=' ' extension=' '/>

This required element shall contain an identifier for the encounter. More than one encounter identifier may be present.

<code code=' ' codeSystem='2.16.840.1.113883.5.4'
  codeSystemName='ActEncounterCode' />

This required element should contain a code from the HL7 ActEncounterCode vocabulary describing the type of encounter (e.g., inpatient, ambulatory, emergency, et cetera). Developers should take care to check that rational combinations of encounter.code and encounter.moodCode are used , but this profile does not restrict any combination.

<text><reference value='#xxx'/></text>

The <text> element shall contain a reference to the narrative text describing the encounter.

<effectiveTime><low value=' '/><high value=' '/></effectiveTime>

This element records the time over which the encounter occurred (in EVN mood), or the desired time of the encounter in ARQ or APT mood. In EVN or APT mood, the effectiveTime element should be present. In ARQ mood, the effectiveTime element may be present, and if not, the priorityCode may be present to indicate that a callback is required to schedule the appointment.

<priorityCode code='CS'/>

This element may be present in ARQ mood to indicate a callback is requested to schedule the appointment.

<performer>

For encounters in EVN mood, at least one performer should be present that identifies the provider of the service given during the encounter. More than one performer may be present. The

<participant typeCode='LOC'>
 <participantRole classCode='SDLOC'>

A <participant> element with typeCode='LOC' may be present to provide information about the location where the encounter is to be or was performed. This element shall have a <participantRole> element with classCode='SDLOC' that describes the service delivery location.

<id/>

The <id> element may be present to identify the service delivery location.

<code/>

The <code> element may be present to classify the service delivery location.

<addr>...</addr>

The <addr> element should be present, and gives the address of the location.

<telecom value=' ' use=' '/>

The <telecom> element should be present, and gives the telephone number of the location.

<playingEntity classCode='PLC'>
 <name>...</name>
</playingEntity>

The <playingEntity> shall be present, and gives the name of the location in the required <name> 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 Update Entry 1.3.6.1.4.1.19376.1.5.3.1.4.16

The update entry shall contain references to the entries or sections which are being replaced or updated. This reference shall not be present when the update entry is adding a new entries or sections.

Entries and sections can be added, updated, or removed from a PHR. An update entry indicates the entry in the original PHR Extract that should be replaced or updated with new information contained within the entry. Only one organizer of this type is allowed in a section, and if present, it must be the first entry in the section.


Uses

See Templates using Update Entry

Specification
Update Entry Example
<entry>
  <organizer classCode='BATTERY' moodCode='EVN'>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.16'/>
    <reference typeCode='RPLC'>
      <externalAct classCode='ACT' moodCode='EVN'>
        <id root='' extension=''/>
      </externalAct>
    </reference>
  </organizer>
</entry>


<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.16'/>

This templateId indicates that the organizer is used to update a PHR Extract.

<reference typeCode='RPLC'>

A reference element shall be present with typeCode RPLC. The reference element lists the acts that are affected by the update. It indicates that any referenced act is being replaced with new information. This element must be present, and may be repeated to replace more than one act at a time.

<externalAct classCode='ACT' moodCode='EVN'>

This element must appear as shown above. It indicates that the reference is to an external act (a section or entry contained in the parent document).

<id root=' ' extension=' '/>

This element identifies the information being replaced or updated. The identifer is of the entry or section being replaced. If the identifier is to a section being replaced, only one reference element is permitted.

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 Procedure Entry 1.3.6.1.4.1.19376.1.5.3.1.4.19

The procedure entry is used to record procedures that have occured, or which are planned for in the future.

Standards
CCD ASTM/HL7 Continuity of Care Document
Uses

See Templates using Procedure Entry

Specification
Procedure Entry Example
<procedure classCode='PROC' moodCode='EVN|INT'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
  <templateId root='2.16.840.1.113883.10.20.1.29'/><!-- see text of section 0 -->
  <templateId root='2.16.840.1.113883.10.20.1.25'/><!-- see text of section 0 -->
  <id root='' extension=''/>
  <code code='' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode' />
  <text><reference value='#xxx'/></text>
  <statusCode code='completed|active|aborted|cancelled'/>
  <effectiveTime>
    <low value=''/>
    <high value=''/>
  </effectiveTime>
  <priorityCode code=''/>
  <approachSiteCode code='' displayName='' codeSystem='' codeSystemName=''/>
  <targetSiteCode code='' displayName='' codeSystem='' codeSystemName=''/>
  <author />
  <informant />
  <entryRelationship typeCode='COMP' inversionInd='true'>
    <act classCode='ACT' moodCode=''>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
      <id root='' extension=''/>
    </act>
  </entryRelationship>
  <entryRelationship typeCode='RSON'>
    <act classCode='ACT' moodCode='EVN'>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
      <id root='' extension=''/>
    </act>
  </entryRelationship>
</procedure>


<procedure classCode='PROC' moodCode='EVN|INT'>

This element is a procedure. The classCode shall be 'PROC'. The moodCode may be INT to indicated a planned procedure or EVN, to describe a procedure that has already occurred.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>

The templateId indicates that this <procedure> entry conforms to the constraints of this content module. NOTE: When the procedure is in event mood (moodCode='EVN'), this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.29, and when in intent mood, this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.25.

<id root=' ' extension=' '/>

This required element shall contain an identifier for the procedure. More than one procedure identifier may be present.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' ' />

This element shall be present, and should contain a code describing the type of procedure.

<text><reference value='#xxx'/></text>

The <text> element shall contain a reference to the narrative text describing the procedure.

<statusCode code='completed|active|aborted|cancelled'/>

The <statusCode> element shall be present when used to describe a procedure event. It shall have the value 'completed' for procedures that have been completed, and 'active' for procedures that are still in progress. Procedures that were stopped prior to completion shall use the value 'aborted', and procedures that were cancelled before being started shall use the value 'cancelled'.

<effectiveTime><low value=' '/><high value=' '/></effectiveTime>

This element should be present, and records the time at which the procedure occurred (in EVN mood), or the desired time of the procedure in INT mood.

<priorityCode code=' '/>

This element shall be present in INT mood when effectiveTime is not provided, it may be present in other moods. It indicates the priority of the procedure.

<approachSiteCode code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

This element may be present to indicate the procedure approach.

<targetSiteCode code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

This element may be present to indicate the target site of the procedure.

<entryRelationship typeCode='COMP' inversionInd='true'>

This element may be present to point the encounter in which the procedure was performed, and shall contain an internal reference to the encounter. See Internal References for more details.

<entryRelationship typeCode='RSON'>

A <procedure> act may indicate one or more reasons for the procedure. These reasons identify the concern that was the reason for the procedure via an Internal Reference to the concern. The extension and root of each observation present must match the identifier of a concern entry contained elsewhere within the CDA document.

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 Transport 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1

A transport entry indicates the intended or actual mode of transport and time of departure and/or arrival of the patient.


Uses

See Templates using Transport

Specification
Transport Example
 
<entry>
 <act classCode='ACT' moodCode='INT|EVN'>
   <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'/>
   <id root=' ' extension=' '/>
   <code code=' ' displayName=' '
         codeSystem='2.16.840.1.113883.6.102.4.2' 
         codeSystemName='DEEDS4.02'>
     <originalText><reference value='#(ID of text coded)/></orginalText>
   </code>
   <text><reference value='#text/></text>
     <high value=/>
   </effectiveTime>
 </act>
</entry>


<act classCode='ACT' moodCode='INT|EVN'>

This element indicates that the entry is an act (of transporting the patient, as indicated by the code below). This entry records the mode, and intended or actual ending time of transportation. In intent mood (moodCode='INT') this is how the estimated time of departure or arrival is indicated. In event mood (moodCode='EVN') this is how the actual departure or arrival of the patient is recorded.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'/>

The <templateId> element identifies this <act> as about the tranportation of the patient. The templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'.

<id root=' ' extension=' '/>

The entry must have an identifier.

<code code=' ' displayName=' '
 codeSystem='2.16.840.1.113883.6.102.4.2'  codeSystemName='DEEDS4.02'>

The code describes the intented mode of transport. For transport between facilities, IHE recommends the use of a code system based on the DEEDS Mode of Transportation data element value set. However, the vocabulary used within an affinity domain should be determined by a policy agreement within the domain.

<originalText><reference value='#xxx'/><orginalText>

This is a reference to the narrative text within the section that describes the mode of transportation.

<text><reference value='#text/></text>

This is a reference to the narrative text cooresponding to the transport act.

<effectiveTime>

The effectiveTime element shall be sent. It records the interval of time over which transport occurs.

<low value=' '/>

This element records the time of departure. This element shall be sent using the TS data type, as shown above.

<high value=' '/>

This element records the time of arrival. If unknown, it must be recorded using a flavor of null. This element shall be sent using the TS data type as shown above.

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 Encounter Disposition 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2

This element records the intended or actual disposition for the patient (e.g., admit, discharge home after treatment, et cetera).


Uses

See Templates using Encounter Disposition

Specification
Encounter Disposition Example
<act classCode='ACT' moodCode='INT|EVN'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2'/>
  <id root='' extension=''/>
  <code code='' displayName='' codeSystem='' codeSystemName='' />
  <text><reference value='#xxx'/></text>
  <statusCode code='normal|completed'/>
  <effectiveTime value=''/> 
  <performer typeCode='PRF'>
    <assignedEntity>
      <id root='' extension=''/>
      <addr></addr>
      <telecom value='' use=''/>
      <assignedPerson>
        <name></name>
      </assignedPerson>
    </assignedEntity>
  </performer>
  <participant typeCode='RCV'>
    <time value=''/> 
    <participantRole classCode='ROL'>
      <id root='' extension=''/>
      <addr></addr>
      <telecom value='' use=''/>
      <playingEntity>
        <name></name>
      </playingEntity>
    </participantRole>
  </participant>
  <entryRelationship typeCode='COMP'>
    <act classCode='ACT'>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'/>
        :
    </act>
  </entryRelationship>
</act>


<act classCode='ACT' moodCode='INT|EVN'>

The disposition is recorded in an act element, to describe the disposition action taken during the encounter1 . In intent mood (moodCode='INT'), this records the expected disposition of the patient. In event mood (moodCode='EVN'), this records the actual disposition.


1 The HL7 RIM allows this portion of the encounter to be recorded in the dischargeDispositionCode RIM Attribute of the Encounter class, but the Encounter class is constrained within CDA. To record the disposition act therefore requires the use of the Act class.
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2'/>

The templateId indicates that this <encounter> entry conforms to the constraints of this content module.

<id root=' ' extension=' '/>

This required element shall contain an identifier.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' ' />

This required element indicates the disposition of the patient. The code shall come from a coding system that is able to record common patient dispositions (e.g., Discharged, Transferred, Admitted). The "Administrative Procedure" concept (14734007) of SNOMED CT contains several code values that cover a wide variety of dispositions routinely recorded. Other vocabularies that are commonly in use to describe discharge disposition codes are DEEDS (See section 8.02), and in the US, the Uniform National Billing Code.

<text><reference value='#xxx'/></text>

The <text> element shall contain a reference to the narrative text describing the disposition of the patient. <statusCode code='normal|completed'/> When the disposition act has occurred (moodCode='EVN'), the statusCode element shall be present, and shall contain the value 'completed'. When the disposition act is intended (moodCode='EVN') the statusCode element shall contain the value 'normal'.

<effectiveTime><low value=' '/><high value=' '/><effectiveTime/>

When the disposition has occurred, this element shall be sent, and indicates the effective time for the disposition process. This element may be sent to record when the disposition act is intended to occur. The <low> element records the time at which the disposition process was started. The <high> value records the time at which the disposition process was completed.

<performer typeCode='PRF'>

The <performer> element provides information about the person that performs the discharge, admission or transfer of the patient. When the disposition is in intent mood, this element describes any expectations with respect to the performer, and is optional. When the disposition is in event mood, this element is required.

<assignedEntity>

The <assignedEntity> element identifies the performer of the disposition.

<id root=' ' extension=' '/>

The <id> element shall be sent when the disponsition has occurred, and identifies the performer of the act.

<addr></addr>

The <addr> element may be sent to provide a contact postal address for the performer of the disposition.

<telecom value=' ' use=' '/>

The <telecom> element may be sent to provide a contact postal address for the performer of the disposition.

<assignedPerson><name/></assignedPerson>

The <assignedPerson> element shall be sent to identify the person who performed the disposition of the patient.

<participant typeCode='RCV'>
 <time value=' '/>
 <participantRole classCode='ROL'>
  <id root=' ' extension=' '/>
  <addr></addr>
  <telecom value=' ' use=' '/>
  <playingEntity><name/></playingEntity>

This element identifies the person or organization that is receiving the patient.

<entryRelationship typeCode='COMP'>
 <act classCode='ACT'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'/>

If the disposition of the patient requires transport to another location, this information shall be recorded in a subordinate act that conforms to the Transport template described above.

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 Coverage Entry 1.3.6.1.4.1.19376.1.5.3.1.4.17

Payers shall be recorded as described in CCD: 3.1.2.1.2.

Standards
CCD ASTM/HL7 Continuity of Care Document
Uses

See Templates using Coverage Entry

Specification
Coverage Entry Example
<act classCode='ACT' moodCode='DEF'>
  <templateId root='2.16.840.1.113883.10.20.1.20'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.17'/>
  <id root='' extension='' />
  <code code='35525-4' displayName='FINANCING AND INSURANCE' 
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <statusCode code='completed'/>
  <entryRelationship typeCode='COMP'>
    <sequenceNumber value=''/>
      :
  </entryRelationship>
</act>


<act classCode='ACT' moodCode='DEF'>

Coverage shall be recorded in an <act> that groups all patient coverage together, and defines (moodCode='DEF') the payers.

<templateId root='2.16.840.1.113883.10.20.1.20'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.17'/>

The <act> conforms to CCD: 3.1.2.1.1 as well as this specification. This shall be reflected by including the <templateId> elements shown above.

<id root=' ' extension=' '/>

The <id> element shall be present.

<code code='35525-4' displayName='FINANCING AND INSURANCE' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

The <code> element shall be recorded exactly as shown above.

<statusCode code='completed'/>

The <statusCode> element shall be present exactly as shown above.

<entryRelationship typeCode='COMP'>

The coverage <act> shall have one or more <entryRelationship> elements. These elements define the coverage. The entry relationships must contain Payer Entries.

<sequenceNumber value=' '/>

The <sequenceNumber> element may be present. If present, it shall contain a value attribute that indicates the priority of the payment source.

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 Payer Entry 1.3.6.1.4.1.19376.1.5.3.1.4.18

The payer entry allows information about the patient's sources of payment to be recorded.

Standards
CCD ASTM/HL7 Continuity of Care Document
Uses

See Templates using Payer Entry

Specification
Payer Entry Example
<act classCode='ACT' moodCode='EVN'>
  <templateId root='2.16.840.1.113883.10.20.1.26'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.18'/>
  <id root='' extension=''/>
  <code code='' displayName='' codeSystem='' codeSystemName=''/>
  <statusCode code='completed'/>
  <performer typeCode='PRF'><!-- payer -->
    <assignedEntity classCode='ASSIGNED'>
      <id root='' extension=''/>
      <code code='PAYOR|GUAR|PAT' displayName=''
        codeSystem='2.16.840.1.113883.5.110' codeSystemName='RoleClass'/>
      <addr></addr>
      <telecom value='' use=''/>
      <representedOrganization typeCode='ORG'>
        <name></name>
      </representedOrganization>
    </assignedEntity>
  </performer>
  <participant typeCode='COV'><!-- member -->
    <participantRole classCode='PAT'>
      <id root='' extension=''/>
      <code code='' displayName='' 
        codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
      <addr></addr>
      <telecom value='' use=''/>
      <playingEntity><name></name></playingEntity>
    </participantRole>
  </participant>
  <participant typeCode='HLD'><!-- subscriber -->
    <participantRole classCode='PAT'>
      <id root='' extension=''/>
      <playingEntity><name></name></playingEntity>
    </participantRole>
  </participant>
  <entryRelationship typeCode='REFR'>
    <act classCode='ACT' moodCode='DEF'>
      <id root='' extension=''/>
      <code code='' displayName='' codeSystem='' codeSystemName=''/>
      <text><reference value=''/></text>
    </act>
  </entryRelationship>
</act>


<act classCode='ACT' moodCode='EVN'>

The policy entry <act> describes the policy or program that has agreed to pay (moodCode='EVN') for the patient's treatment.

<templateId root='2.16.840.1.113883.10.20.1.26'/>
   <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.18'/>

The <act> conforms to CCD: 3.1.2.1.2 and this guide. This shall be reflected by including the <templateId> elements shown above.

<id root=' ' extension=' '/>

The <act> shall contain at least one <id> element that represents the policy or group number of the coverage. That identifier shall appear in the extension attribute.

<code code=' ' displayName=' '
    codeSystem=' ' codeSystemName=' '/>

The <code> element should be present, and represents the type of coverage provided by the payer. Potential vocabularies to use include:

Vocabulary Description OID
HL7 ActCoverageType The HL7 ActCoverageType vocabulary describes payers and programs. Note that HL7 does not have a specific code to identify an individual payer, e.g., in the role of a guarantor or patient. 2.16.840.1.113883.5.4
X12 Data Element 1336 The X12N 271 implementation guide includes various types of payers. This code set does include a code to identify individual payers. 2.16.840.1.113883.6.255.1336
Payer Type Vocabularies
<statusCode code='completed'/>

The <statusCode> element shall be present, and should be recorded exactly as shown above.

<performer typeCode='PRF'>
    <assignedEntity classCode='ASSIGNED'>

The <performer> element shall be present to represent the payer of the coverage.

<id root=' ' extension=' '/>

The identity of the performer should be recorded in the <id> element.

<code code='PAYOR|GUAR|PAT' displayName=' '
      codeSystem='2.16.840.1.113883.5.110'
      codeSystemName='RoleClass'/>

The <code> element describes the role of the payer. It shall contain one of the values listed in the table below.

Payer Role Codes
Code Description
PAYOR Used to indicate that the payer is a payor for a policy or program.
GUAR Used to indicate that the payer is a guarantor for the patient.
PAT Used to indicate that the payer is the patient.
<addr></addr>

The <addr> element shall be used to record the address of the payer. This information will usually come from the back of an insurance card.

<telecom value=' ' use=' '/>

The <telecom> element shall be used to record the phone number of the payer. This information will usually come from the back of an insurance card.

<representedOrganization typeCode='ORG'>
 <name></name>

The name of the payer organization shall be provided in the <name> element contained within the <representedOrganization> element.

<participant typeCode='COV'>
 <participantRole classCode='PAT'>

Information about the patient with respect to the policy or program shall be recorded in the <participantRole> element shown above. This element shall be present when the patient is a member of a policy or program.

<id root=' ' extension=' '/>

The <id> element should contain the identifier of the patient with respect to the payer (the subscriber or member id).

<code code= displayName= codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>

The <code> element shall indicate the covered parties relationship to the subscriber, and should come from the HL7 CoverageRoleType value set.

<addr></addr>

The <addr> element should be used to record the address of the patient as known to the payer when different from that recorded in the <patientRole> element.

<telecom value=' ' use=' '/>

The <telecom> element should be used to record the phone number of the patient when different from that recorded in the <patientRole> element.

<playingEntity><name></name></playingEntity>

The <name> element should be used to record the member name when it is different from that recorded in the <patient> element.

<participant typeCode='HLD'>
 <participantRole classCode='IND'>

Information about subscriber to the policy or program shall be recorded in the <participantRole> element shown above. This element shall be present when the subscriber is different from the patient.

<id root=' ' extension=' '/>

The <id> element shall contain the identifier of the subscriber when the subscriber is not the patient.

<addr></addr>

The <addr> element shall be used to record the address of the subscriber when the subscriber is not the patient.

<telecom value=' ' use=' '/>

The <telecom> element shall be used to record the phone number of the subscriber when the subscriber is not the patient.

<playingEntity><name></name></playingEntity>

The name of the subscriber shall be recorded in the <name> element of the <playingEntity>.

<entryRelationship typeCode='REFR'>
 <act classCode='ACT' moodCode='DEF'>

The plan information may be provided in the elements described above.

<id root=' ' extension=' '/>

The health plan identifier is recorded in the <id> element.

<text><reference value=' '/></text>

This <reference> element shown above should be present and the value attribute should point to the name of the plan contained in the narrative of the document.