Difference between revisions of "MS-PCC-CP-0018"
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# Should examples for "unknown" or "no known" and/or "none" be provided under the appropriate level 3 entry using the same template identifier? Should these be a separate template or templates? In that case, how should the cardinality of the entries should be changed? I would suggest in this case to use Conditional (either 1-N of standard entry, or 1 from unknown/none entry), so that we can ensure that a machine readable entry is present providing the same information as in the text. | # Should examples for "unknown" or "no known" and/or "none" be provided under the appropriate level 3 entry using the same template identifier? Should these be a separate template or templates? In that case, how should the cardinality of the entries should be changed? I would suggest in this case to use Conditional (either 1-N of standard entry, or 1 from unknown/none entry), so that we can ensure that a machine readable entry is present providing the same information as in the text. | ||
# What other text changes are necessary? | # What other text changes are necessary? | ||
+ | |||
+ | See also: [[MS-PCC-CP-0017]] | ||
[[Category:Change Proposal]] | [[Category:Change Proposal]] | ||
[[Category:Patient Care Coordination]] | [[Category:Patient Care Coordination]] |
Revision as of 13:28, 3 March 2008
Change Proposal MS-PCC-CP-0018
Official Change Proposal Template is a WORD document found at ftp://ftp.ihe.net/Document_templates/IHE_Change_Proposal-Template-V10.doc
The Change Proposal Template that you use is dependent on the committee.
Tracking Information
- Domain
- Patient Care Coordination
- Change Proposal Number
- MS-PCC-CP-0018
- Status
- incoming
- Last Updated
- 11:51, 3 March 2008 (CST)
- Assigned
Change Proposal Summary
- Title
- Entries for Unknown or No Known Medications, Problems and Allergies
- Submission Date
- 11:51, 3 March 2008 (CST)
- Profile Affected
- TF
- TF Version
- 3.0
- Volume and Section
- II
Rationale
When no information is present, or is otherwise unknown, there is no present way to represent this in medication, problem and allergy entries in the current technical framework.
Content
Add the following text to "Distinctions of None" under the Medical Documents Specification.
An appropriate machine readable entry must also be present to indicate the reason that no information is present.
The table below provides some thoughts in this direction.
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 | ??? | Allergies Unknown | To indicate a true unknown state for allergies |
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 |
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 |
Add appropriate references to the Active Problems, Resolved Problems, Allergies and Other Adverse Reactions, and Medications sections.
Open Issues
- How should unknown allergies be represented, vs. allergy to unknown substance? These should be perfectly clear and distinct entries.
- Should examples for "unknown" or "no known" and/or "none" be provided under the appropriate level 3 entry using the same template identifier? Should these be a separate template or templates? In that case, how should the cardinality of the entries should be changed? I would suggest in this case to use Conditional (either 1-N of standard entry, or 1 from unknown/none entry), so that we can ensure that a machine readable entry is present providing the same information as in the text.
- What other text changes are necessary?
See also: MS-PCC-CP-0017