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|Comment| | {{CDA Document|Emergency Department Referral|1.3.6.1.4.1.19376.1.5.3.1.1.10|Comment| | ||
− | An ED Referral is a type of Referral Summary, and incorporates the constraints defined for {{ | + | An ED Referral is a type of Referral Summary, and incorporates the constraints defined for {{ILink|1.3.6.1.4.1.19376.1.5.3.1.1.3|1.3.6.1.4.1.19376.1.5.3.1.1.10|Referral Summaries}}. |
− | + | This use case is described fully in the EDR Profile in PCC TF-1. 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. | |
− | |||
− | This use case is described fully in | ||
Using this information from the use case, the following mappings were made to existing standards. | Using this information from the use case, the following mappings were made to existing standards. | ||
+ | |Note={{Note|<u>''Highlighted''</u> items in the table above are different from what appears in the XDS-MS profile. All other data elements have identical definitions.}} | ||
|Parent=1.3.6.1.4.1.19376.1.5.3.1.1.3 | |Parent=1.3.6.1.4.1.19376.1.5.3.1.1.3 | ||
|Index= | |Index= | ||
Line 53: | Line 52: | ||
|Section|<u>''Proposed disposition''</u>|R2|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2| | |Section|<u>''Proposed disposition''</u>|R2|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2| | ||
|Section|<u>''Advance Directives''</u>|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. | |Section|<u>''Advance Directives''</u>|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. | ||
− | |Section|Patient Administrative Identifiers|R||These are handed by the Medical Documents Content Profile by reference to constraints in HL7 CRS. | + | |Section|Patient Administrative Identifiers|R||These are handed by the Medical Documents Content Profile by reference to constraints in HL7 CRS. |
|Section|Pertinent Insurance Information|R2|| | |Section|Pertinent Insurance Information|R2|| | ||
|Section|Data needed for state and local referral forms, if different than above|R2||These are handed by including additional sections within the summary.}} | |Section|Data needed for state and local referral forms, if different than above|R2||These are handed by including additional sections within the summary.}} | ||
− | |||
− |
Revision as of 12:06, 5 June 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.
This use case is described fully in the EDR Profile in PCC TF-1. 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.
Using this information from the use case, the following mappings were made to existing standards.
Parent Template
This document is an instance of the {{{ParentName}}} template.
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 Results and/or Clinical Reports Includes Diagnostic Surgical Procedures, Clinical Reports and Diagnostic Tests and Results (Lab, Imaging, EKG’s, etc.) including links to relevant documents. |
R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.27 |
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 |
Mode of Transport to the Emergency Department | R | 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 |
Estimated Time of Arrival | R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1 |
Proposed disposition | R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2 |
Advance Directives 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 | |
Data needed for state and local referral forms, if different than above These are handed by including additional sections within the summary. |
R2 |
Note: | Highlighted items in the table above are different from what appears in the XDS-MS profile. All other data elements have identical definitions. |
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 1.3.6.1.4.1.19376.1.5.3.1.1.3 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='1.3.6.1.4.1.19376.1.5.3.1.1.3'/> |
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.10'> <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.10"]'> <!-- Verify that the template id is used on the appropriate type of object --> <assert test='../cda:ClinicalDocument'> Error: The Emergency Department Referral can only be used on Clinical Documents. </assert> <!-- Verify that the parent templateId is also present. --> <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.3"]'> Error: The parent template identifier for Emergency Department Referral is not present. </assert> <!-- 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> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.1"]'> <!-- Verify that all required data elements are present --> Error: The Emergency Department Referral Document must contain a(n) Reason for Referral Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </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 Emergency Department Referral Document must contain a(n) History Present Illness Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> <!-- Verify that all required data elements are present --> Error: The Emergency Department Referral Document must contain a(n) Active Problems Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </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 Emergency Department Referral Document must contain a(n) Current Meds Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </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 Emergency Department Referral Document must contain a(n) Allergies Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> <!-- Alert on any missing required if known elements --> Warning: The Emergency Department Referral Document should contain a(n) Resolved Problems Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> <!-- Alert on any missing required if known elements --> Warning: The Emergency Department Referral Document should contain a(n) List of Surgeries Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> <!-- Alert on any missing required if known elements --> Warning: The Emergency Department Referral Document should contain a(n) Immunizations Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> <!-- Alert on any missing required if known elements --> Warning: The Emergency Department Referral Document should contain a(n) Family History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> <!-- Alert on any missing required if known elements --> Warning: The Emergency Department Referral Document should contain a(n) Social History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> <!-- Note any missing optional elements --> Note: This Emergency Department Referral Document does not contain a(n) Pertinent Review of Systems Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> <!-- Alert on any missing required if known elements --> Warning: The Emergency Department Referral Document should contain a(n) Vital Signs Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.24"]'> <!-- Alert on any missing required if known elements --> Warning: The Emergency Department Referral Document should contain a(n) Physical Exam Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.27"]'> <!-- Alert on any missing required if known elements --> Warning: The Emergency Department Referral Document should contain a(n) Relevant Diagnostic Results and/or Clinical Reports Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1"]'> <!-- Alert on any missing required if known elements --> Warning: The Emergency Department Referral Document should contain a(n) Plan of Care Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2"]'> <!-- Verify that all required data elements are present --> Error: The Emergency Department Referral Document must contain a(n) Mode of Transport to the Emergency Department Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1"]'> <!-- Alert on any missing required if known elements --> Warning: The Emergency Department Referral Document should contain a(n) Estimated Time of Arrival Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2"]'> <!-- Alert on any missing required if known elements --> Warning: The Emergency Department Referral Document should contain a(n) Proposed disposition Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> <!-- Verify that all required data elements are present --> Error: The Emergency Department Referral Document must contain a(n) Advance Directives Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = ""]'> <!-- Verify that all required data elements are present --> Error: The Emergency Department Referral Document must contain a(n) Patient Administrative Identifiers Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = ""]'> <!-- Alert on any missing required if known elements --> Warning: The Emergency Department Referral Document should contain a(n) Pertinent Insurance Information Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> <assert test='.//cda:templateId[@root = ""]'> <!-- Alert on any missing required if known elements --> Warning: The Emergency Department Referral Document should contain a(n) Data needed for state and local referral forms, if different than above Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert> </rule> </pattern>
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