Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4"
Tsoutherland (talk | contribs) |
Tsoutherland (talk | contribs) |
||
(7 intermediate revisions by 2 users not shown) | |||
Line 1: | Line 1: | ||
− | + | {{CDA Document|History and Physical|1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4|Comment| | |
− | + | The intention of this work is to provide a parent template for the Antepartum History and Physical specifications. Future work in IHE may create an integration profile for a history and physical. | |
− | The intention of this work is to provide a parent template for the History and Physical specifications | + | |LOINC=34117-2|LOINCName=HISTORY AND PHYSICAL |
− | + | |Parent=1.3.6.1.4.1.19376.1.5.3.1.1.2|ParentName=Medical Summaries | |
− | + | |formatCode=urn:ihe:pcc:handp:2008 | |
− | + | |Standards={{Std|CDAR2}} | |
− | + | {{Std|CDTHP}} | |
− | + | |Section|Chief Complaint|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1| | |
− | + | |Section|History of Present Illness|R|1.3.6.1.4.1.19376.1.5.3.1.3.4| | |
− | + | |Section|History of Past Illness|R|1.3.6.1.4.1.19376.1.5.3.1.3.8| | |
− | + | |Section|Medications|R|1.3.6.1.4.1.19376.1.5.3.1.3.19| | |
− | + | |Section|Allergies and Other Adverse Reactions Section|R|1.3.6.1.4.1.19376.1.5.3.1.3.13| | |
− | + | |Section|Social History|R|1.3.6.1.4.1.19376.1.5.3.1.3.16| | |
− | + | |Section|Family History|R|1.3.6.1.4.1.19376.1.5.3.1.3.14| | |
− | + | |Section|Review of Systems|R|1.3.6.1.4.1.19376.1.5.3.1.3.18| | |
− | + | |Section|Physical Examination|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.15| | |
− | + | |Section|Vital Signs|R|1.3.6.1.4.1.19376.1.5.3.1.3.25| | |
− | + | |Section|Results|R|1.3.6.1.4.1.19376.1.5.3.1.3.27|Diagnostic Findings; use this OR Coded Results | |
− | | | + | |Section|Coded Results|R|1.3.6.1.4.1.19376.1.5.3.1.3.28|Diagnostic Findings; use this OR Results |
− | + | |Section|Assessment and Plan|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5| | |
− | + | }} | |
− | | | ||
− | |||
− | |||
− | | | ||
− | |||
− | |||
− | | | ||
− | |||
− | |||
− | |||
− | | | ||
− | |||
− | |||
− | | | ||
− | |||
− | |||
− | | | ||
− | |||
− | |||
− | | | ||
− | |||
− | |||
− | | | ||
− | |||
− | |||
− | | | ||
− | |||
− | |||
− | | | ||
− | |||
− | |||
− | | | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− |
Latest revision as of 17:41, 16 September 2008
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
History and Physical Specification 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4
The intention of this work is to provide a parent template for the Antepartum History and Physical specifications. Future work in IHE may create an integration profile for a history and physical.
Format Code
The XDSDocumentEntry format code for this content is urn:ihe:pcc:handp:2008
Parent Template
This document is an instance of the Medical Summaries template.
LOINC Code
The LOINC code for this document is 34117-2 HISTORY AND PHYSICAL
Standards
CDAR2 | HL7 CDA Release 2.0 |
CDTHP | CDA for Common Document Types History and Physical Notes (DSTU) |
Specification
Data Element Name | Opt | Template ID |
---|---|---|
Chief Complaint | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 |
History of Present Illness | R | 1.3.6.1.4.1.19376.1.5.3.1.3.4 |
History of Past Illness | R | 1.3.6.1.4.1.19376.1.5.3.1.3.8 |
Medications | R | 1.3.6.1.4.1.19376.1.5.3.1.3.19 |
Allergies and Other Adverse Reactions Section | R | 1.3.6.1.4.1.19376.1.5.3.1.3.13 |
Social History | R | 1.3.6.1.4.1.19376.1.5.3.1.3.16 |
Family History | R | 1.3.6.1.4.1.19376.1.5.3.1.3.14 |
Review of Systems | R | 1.3.6.1.4.1.19376.1.5.3.1.3.18 |
Physical Examination | R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.15 |
Vital Signs | R | 1.3.6.1.4.1.19376.1.5.3.1.3.25 |
Results Diagnostic Findings; use this OR Coded Results |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.27 |
Coded Results Diagnostic Findings; use this OR Results |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.28 |
Assessment and Plan | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5 |
Conformance
CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below. A CDA Document may conform to more than one template. This content module inherits from the Medical Summaries content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.
<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/> |
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4'> <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4"]'> <!-- Verify that the template id is used on the appropriate type of object --> <assert test='../cda:ClinicalDocument'> Error: The History and Physical can only be used on Clinical Documents. </assert> <!-- Verify that the parent templateId is also present. --> <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'> Error: The parent template identifier for History and Physical is not present. </assert> <!-- Verify the document type code --> <assert test='cda:code[@code = "34117-2"]'> Error: The document type code of a History and Physical must be 34117-2 </assert> <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> Error: The document type code must come from the LOINC code system (2.16.840.1.113883.6.1). </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> <!-- Verify that all required data elements are present --> Error: The History and Physical Document must contain a(n) Chief Complaint Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> <!-- Verify that all required data elements are present --> Error: The History and Physical Document must contain a(n) History of Present Illness Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> <!-- Verify that all required data elements are present --> Error: The History and Physical Document must contain a(n) History of Past Illness Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> <!-- Verify that all required data elements are present --> Error: The History and Physical Document must contain a(n) Medications Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> <!-- Verify that all required data elements are present --> Error: The History and Physical Document must contain a(n) Allergies and Other Adverse Reactions Section Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> <!-- Verify that all required data elements are present --> Error: The History and Physical Document must contain a(n) Social History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> <!-- Verify that all required data elements are present --> Error: The History and Physical Document must contain a(n) Family History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> <!-- Verify that all required data elements are present --> Error: The History and Physical Document must contain a(n) Review of Systems Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> <!-- Verify that all required data elements are present --> Error: The History and Physical Document must contain a(n) Physical Examination Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> <!-- Verify that all required data elements are present --> Error: The History and Physical Document must contain a(n) Vital Signs Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.27"]'> <!-- Verify that all required data elements are present --> Error: The History and Physical Document must contain a(n) Results Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.28"]'> <!-- Verify that all required data elements are present --> Error: The History and Physical Document must contain a(n) Coded Results Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"]'> <!-- Verify that all required data elements are present --> Error: The History and Physical Document must contain a(n) Assessment and Plan Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 </assert> </rule> </pattern>
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.4
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.8
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.19
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.13
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.16
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.14
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.18
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.9.15
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.25
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.27
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.28
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5
- CDA Document Templates