Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.10"
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{{CDA Document|Emergency Department Referral|1.3.6.1.4.1.19376.1.5.3.1.1.10|Draft| | {{CDA Document|Emergency Department Referral|1.3.6.1.4.1.19376.1.5.3.1.1.10|Draft| | ||
An ED Referral is a type of Referral Summary, and incorporates the constraints defined for {{ITmpRef|1.3.6.1.4.1.19376.1.5.3.1.1.3|Referral Summaries|1.3.6.1.4.1.19376.1.5.3.1.1.10}}. | An ED Referral is a type of Referral Summary, and incorporates the constraints defined for {{ITmpRef|1.3.6.1.4.1.19376.1.5.3.1.1.3|Referral Summaries|1.3.6.1.4.1.19376.1.5.3.1.1.10}}. | ||
− | + | ||
======Conformance====== | ======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 below in Figure 5.4 4. Note that an ED Referral is a Referral Summary, and so includes that <templateId> element as well. | 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 below in Figure 5.4 4. Note that an ED Referral is a Referral Summary, and so includes that <templateId> element as well. | ||
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{{R|Advance Directives|Advance Directives|ADVANCE DIRECTIVES}} | {{R|Advance Directives|Advance Directives|ADVANCE DIRECTIVES}} | ||
{{R|Patient Administrative Identifiers|Header|patientRole/id}} | {{R|Patient Administrative Identifiers|Header|patientRole/id}} | ||
− | {{R|Pertinent Insurance Information|Participant|participant[@roleCode='HLD']}} | + | {{R|Pertinent Insurance Information|Participant|participant<nowiki>[@roleCode='HLD']</nowiki>}} |
{{R|Data needed for state and local referral forms, if different than above|Optional Sections|section}} | {{R|Data needed for state and local referral forms, if different than above|Optional Sections|section}} | ||
}} | }} | ||
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Physical Exam|R2|1.3.6.1.4.1.19376.1.5.3.1.3.24|}} | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Physical Exam|R2|1.3.6.1.4.1.19376.1.5.3.1.3.24|}} | ||
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports (Lab, Imaging, EKG’s, etc.) including links.|R2|1.3.6.1.4.1.19376.1.5.3.1.3.27|}} | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports (Lab, Imaging, EKG’s, etc.) including links.|R2|1.3.6.1.4.1.19376.1.5.3.1.3.27|}} | ||
− | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Plan of Care (new meds, labs, or x-rays ordered)|R2|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1|}} | + | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Plan of Care (new meds, labs, or x-rays ordered)|R2|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1|{{Ref|edrvms}} }} |
− | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Mode of Transport to the Emergency Department|R|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2|}} | + | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Mode of Transport to the Emergency Department|R|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2|{{Ref|edrvms}} }} |
− | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Estimated Time of Arrival|R2|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1|}} | + | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Estimated Time of Arrival|R2|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1|{{Ref|edrvms}} }} |
− | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Proposed disposition|R2|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2|}} | + | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Proposed disposition|R2|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2|{{Ref|edrvms}}}} |
− | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Advance Directives|R|1.3.6.1.4.1.19376.1.5.3.1.3.34|The availability of information about Advance Directives must provided. A common concern among ED providers is over situations where patients presented to the ED require extensive resuscitative efforts, only later to discover that the patient had a DNR order.}} | + | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Advance Directives|R|1.3.6.1.4.1.19376.1.5.3.1.3.34|{{Ref|edrvms}} The availability of information about Advance Directives must provided. A common concern among ED providers is over situations where patients presented to the ED require extensive resuscitative efforts, only later to discover that the patient had a DNR order.}} |
− | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Patient Administrative Identifiers|R|These are handed by the Medical Documents Content Profile by reference to constraints in HL7 CRS.|}} | + | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Patient Administrative Identifiers|R||These are handed by the Medical Documents Content Profile by reference to constraints in HL7 CRS.|}} |
− | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Pertinent Insurance Information|R2||}} | + | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Pertinent Insurance Information|R2|TBD|}} |
− | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Data needed for state and local referral forms, if different than above|R2|These are handed by including additional sections within the summary.|}} | + | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Data needed for state and local referral forms, if different than above|R2||These are handed by including additional sections within the summary.|}} |
}} | }} | ||
− | # These data elements are different from what appears in the XDS-MS profile. All other data elements have identical definitions. | + | # {{EndNote|edrvms}}These data elements are different from what appears in the XDS-MS profile. All other data elements have identical definitions. |
Revision as of 11:25, 15 May 2007
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
Emergency Department Referral Specification 1.3.6.1.4.1.19376.1.5.3.1.1.10
An ED Referral is a type of Referral Summary, and incorporates the constraints defined for Referral Summaries(1.3.6.1.4.1.19376.1.5.3.1.1.3) .
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 below in Figure 5.4 4. Note that an ED Referral is a Referral Summary, and so includes that <templateId> element as well.
<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.10"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.3"/> :
A CDA Document may conform to more than one template, and can therefore have more that one <templateId> element. Both of the <templateId> elements shown above must be present in the document.
This use case is described fully in Link TBD. Briefly, it involves a collaborative transfer of care for the referral of a patient from a care provider to an emergency department. Using this use case the contents of documents used in collaborative transfers of care were discussed with physicians and nurses in detail to identify major sections. The sections identified by physicians during the use case exercise as important are listed in the table below under the column “Use Case Documentation Section”.
Using this information from the use case, the following mappings were made to existing standards.
Data Element Index
Data Elements | HL7 Care Record Summary | CDA Release 2.0 |
---|---|---|
Reason for Referral | Reason for Referral | REASON FOR REFERRAL |
History Present Illness | History of Present Illness | HISTORY OF PRESENT ILLNESS |
Active Problems | Conditions | PROBLEM LIST |
Current Meds | Medications | HISTORY OF MEDICATION USE |
Allergies | Allergies and Adverse Reactions | HISTORY OF ALLERGIES |
Resolved Problems | Conditions | HISTORY OF PAST ILLNESS |
List of Surgeries | Past Surgical History | HISTORY OF PRIOR SURGERIES |
Immunizations | Immunizations | HISTORY OF IMMUNIZATIONS |
Family History | Family History | HISTORY OF FAMILY ILLNESS |
Social History | Social History | SOCIAL HISTORY |
Pertinent Review of Systems | Review of Systems | REVIEW OF SYSTEMS |
Vital Signs | Physical Exam | VITAL SIGNS |
Physical Exam | Physical Exam | GENERAL STATUS, PHYSICAL FINDINGS |
Relevant Surgical Procedures / Clinical Reports (including links) | Studies and Reports | RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA |
Relevant Diagnostic Test and Reports (Lab, Imaging, EKG’s, etc.) including links. | Studies and Reports | RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA |
Plan of Care (new meds labs, or x-rays ordered) | Care Plan | TREATMENT PLAN |
Proposed disposition | Care Plan | TREATMENT PLAN |
Mode of Transport to the Emergency Department | Care Plan | MODE OF TRANSPORT |
Estimated Time of Arrival to the ED | Care Plan | MODE OF TRANSPORT |
Advance Directives | Advance Directives | ADVANCE DIRECTIVES |
Patient Administrative Identifiers | Header | patientRole/id |
Pertinent Insurance Information | Participant | participant[@roleCode='HLD'] |
Data needed for state and local referral forms, if different than above | Optional Sections | section |
Specification
Data Element Name | Opt | Template ID |
---|---|---|
Reason for Referral | R | 1.3.6.1.4.1.19376.1.5.3.1.3.1 |
History Present Illness | R | 1.3.6.1.4.1.19376.1.5.3.1.3.4 |
Active Problems | R | 1.3.6.1.4.1.19376.1.5.3.1.3.6 |
Current Meds | R | 1.3.6.1.4.1.19376.1.5.3.1.3.19 |
Allergies | R | 1.3.6.1.4.1.19376.1.5.3.1.3.13 |
Resolved Problems | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.8 |
List of Surgeries | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.11 |
Immunizations | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.23 |
Family History | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.14 |
Social History | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.16 |
Pertinent Review of Systems | O | 1.3.6.1.4.1.19376.1.5.3.1.3.18 |
Vital Signs | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.25 |
Physical Exam | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.24 |
Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports (Lab, Imaging, EKG’s, etc.) including links. | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.27 |
Plan of Care (new meds, labs, or x-rays ordered) [1] |
R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1 |
Mode of Transport to the Emergency Department [2] |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 |
Estimated Time of Arrival [3] |
R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1 |
Proposed disposition [4] |
R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2 |
Advance Directives [5] The availability of information about Advance Directives must provided. A common concern among ED providers is over situations where patients presented to the ED require extensive resuscitative efforts, only later to discover that the patient had a DNR order. |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.34 |
Patient Administrative Identifiers These are handed by the Medical Documents Content Profile by reference to constraints in HL7 CRS. |
R | |
Pertinent Insurance Information | R2 | TBD |
Data needed for state and local referral forms, if different than above These are handed by including additional sections within the summary. |
R2 |
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.
<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Emergency Department Referral</title> <effectiveTime value='20240915012005'/> <confidentialityCode code='N' displayName='Normal' codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' /> <languageCode code='en-US'/> : <component><structuredBody> </structuredBody></component> </ClinicalDocument> |
<!-- Verify the document type code --> <assert test='cda:code[@code = "{{{LOINC}}}"]'> Error: The document type code of a Emergency Department Referral must be {{{LOINC}}} </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>
- Template:EndNoteThese data elements are different from what appears in the XDS-MS profile. All other data elements have identical definitions.
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