1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7

From IHE Wiki
(Redirected from Progress Note)
Jump to: navigation, search

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 Progress Note Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7
General Description The Progress Note section shall contain a narrative description of the sequence of events from initial assessment to discharge for an encounter.
LOINC Code Opt Description
18733-6 R SUBSEQUENT EVALUATION NOTE (ATTENDING PHYSICIAN)



Sample Progress Note Section
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7'/>
    <id root=' ' extension=' '/>
    <code code='18733-6' displayName='SUBSEQUENT EVALUATION NOTE (ATTENDING PHYSICIAN)'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Progress Note can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "18733-6"]'> 
     Error: The section type code of a Progress Note must be 18733-6 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Progress Note Section