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| ==== Reasons for Care ==== | | ==== Reasons for Care ==== |
| The sections described below describe various reasons why healthcare is being provided to the patient.
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| ===== Reason for Referral=====
| | Technical Framework Volume 2: 6.3.3.1 '''Reasons for Care''' |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.1}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.1
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| General Description The reason for referral section shall contain a narrative description of the reason that the patient is being referred.
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| Valid LOINC CODES Opt Description
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| 42349-1 R REASON FOR REFERRAL
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| | |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.2}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.2
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| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.1
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| General Description This section shall include at least one entry describing the reason for referral as described in the Entry Content Module.
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| Entries Description
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| 1.3.6.1.4.1.19376.1.5.3.1.4.13 R 5.4.4.18 Simple Observations
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| 1.3.6.1.4.1.19376.1.5.3.1.4.5 5.4.4.9 Conditions Entry
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|
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|
| | The sections described below describe various reasons why healthcare is being provided to the patient. |
|
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|
| =====Hospital Admission Diagnosis=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.3.3}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.3
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| General Description The hospital admitting diagnosis section shall contain a narrative description of the primary reason for admission to a hospital facility. It shall include entries for observations as described in the Entry Content Modules.
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| Valid LOINC CODES Opt Description
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| 46241-6 R HOSPITAL ADMISSION DX
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| Entries Description
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| 1.3.6.1.4.1.19376.1.5.3.1.4.5 R 5.4.4.9 Conditions Entry
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|
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|
| =====Proposed Procedure=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.1}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.1
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| Parent Template NONE
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| General Description The proposed procedure section shall contain a description of the procedures for which a risk assessment is required including procedure names and codes, patient position, dates, and names of surgeons. It shall include entries for procedures as described in the Entry Content Modules and the required and optional subsections.
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| Valid LOINC CODES Opt Description
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| 29554-3 R PROCEDURE
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| Entries Description
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| 1.3.6.1.4.1.19376.1.5.3.1.4.16 R 5.4.4.30 Procedure Entry
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| Sub-sections Description
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| 1.3.6.1.4.1.19376.1.5.3.1.1.9.4 R 5.4.3.1.6 Reason for Procedure
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| 1.3.6.1.4.1.19376.1.5.3.1.1.9.3 R 5.4.3.1.5 Proposed Anesthesia
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| 1.3.6.1.4.1.19376.1.5.3.1.1.9.2 R2 5.4.3.1.4 Expected Blood Loss
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| 1.3.6.1.4.1.19376.1.5.3.1.1.9.40 R2 5.4.3.6.5 Procedure Care Plan
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|
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| =====Expected Blood Loss=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.2}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.2
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| Parent Template NONE
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| General Description The expected blood loss section shall contain a description of the blood loss for the procedure for which a risk assessment is required.
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| Valid LOINC CODES Opt Description
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| 8717-1 R OPERATIVE NOTE ESTIMATED BLOOD LOSS
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| Entries Description
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| 1.3.6.1.4.1.19376.1.5.3.1.4.13 R 5.4.4.18 Simple Observations
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|
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| =====Proposed Anesthesia=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.3}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.3
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| Parent Template NONE
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| General Description The proposed anesthesia section shall contain a description of the anesthetic techniques for which a risk assessment is required. It shall include entries for anesthetic procedures as described in the Entry Content Modules.
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| Valid LOINC CODES Opt Description
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| 10213-7 R OPERATIVE NOTE ANESTHESIA
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| Entries Description
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| 1.3.6.1.4.1.19376.1.5.3.1.4.16 R 5.4.4.30 Procedure Entry The procedure entries shall be in INT mood.
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|
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| =====Reason for Procedure=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.4}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.4
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| Parent Template NONE
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| General Description The reason for procedure section shall contain a description of the reason that the patient is receiving the procedure. It shall include entries for conditions as described in the Entry Content Module.
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| Valid LOINC CODES Opt Description
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| 10217-8 R OPERATIVE NOTE INDICATIONS
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| Entries Description
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| 1.3.6.1.4.1.19376.1.5.3.1.4.5 R2 5.4.4.9 Conditions Entry
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|
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|
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.1|PCC 2:6.3.3.1.1 Reason for Referral}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.2|PCC 2:6.3.3.1.2 Coded Reason for Referral}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.3|PCC 2:6.3.3.1.4 Hospital Admission Diagnosis}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.1|Proposed Procedure}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.2|Expected Blood Loss}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.3|Proposed Anesthesia}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.4|Reason for Procedure}} |
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| ====Other Condition Histories==== | | ====Other Condition Histories==== |
| The sections defined below provide historical information about the patient's conditions. | | The sections defined below provide historical information about the patient's conditions. |
| =====History of Present Illness=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.3.4}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.4
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| General Description The history of present illness section shall contain a narrative description of the sequence of events preceding the patient’s current complaints.
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| Valid LOINC CODES Opt Description
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| 10164-2 R HISTORY OF PRESENT ILLNESS
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| =====Hospital Course=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.3.5}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.5
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| General Description The hospital course section shall contain a narrative description of the sequence of events from admission to discharge in a hospital facility.
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| Valid LOINC CODES Opt Description
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| 8648-8 R HOSPITAL COURSE
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| =====Active Problems=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.3.6}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.6
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| Parent Template 2.16.840.1.113883.10.20.1.11
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| General Description The active problem section shall contain a narrative description of the conditions currently being monitored for the patient. It shall include entries for patient conditions as described in the Entry Content Module.
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| Valid LOINC CODES Opt Description
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| 11450-4 R PROBLEM LIST
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| Entries Description
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| 1.3.6.1.4.1.19376.1.5.3.1.4.5 R 5.4.4.9 Conditions Entry
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| =====Discharge Diagnosis=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.3.7}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.7
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| General Description The discharge diagnosis section shall contain a narrative description of the conditions that need to be monitored after discharge from the hospital and those that were resolved during the hospital course. It shall include entries for patient conditions as described in the Entry Content Module.
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| Valid LOINC CODES Opt Description
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| 11535-2 R HOSPITAL DISCHARGE DX
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| Entries Description
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| 1.3.6.1.4.1.19376.1.5.3.1.4.5 R 5.4.4.9 Conditions Entry
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| =====Resolved Problems=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.3.8}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.8
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| General Description The resolved problems section shall contain a narrative description of the conditions the patient suffered in the past. It shall include entries for problems as described in the Entry Content Modules.
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| Valid LOINC CODES Opt Description
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| 11348-0 R HISTORY OF PAST ILLNESS
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| Entries Description
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| 1.3.6.1.4.1.19376.1.5.3.1.4.5 R 5.4.4.9 Conditions Entry
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| =====Encounter Histories=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
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| Parent Template 2.16.840.1.113883.10.20.1.3
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| Section Title Encounter Histories
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| General Description The encounter history section contains coded entries describing the patient history of encounters.
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| Valid LOINC CODES Opt Description
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| 46240-8 R HISTORY OF ENCOUNTERS
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| Valid Entries Opt Description
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| 1.3.6.1.4.1.19376.1.5.3.1.4.14 R 5.4.4.28 Encounters
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| =====History of Outpatient Visits=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.3.9}}
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|
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| {{:1.3.6.1.4.1.19376.1.5.3.1.3.10}}
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|
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| =====List of Surgeries=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.3.11}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.11
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| Parent Template 2.16.840.1.113883.10.20.1.12
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| General Description The list of surgeries section shall contain a narrative description of the diagnostic and therapeutic operative procedures and associated anesthetic techniques the patient received in the past.
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| Valid LOINC CODES Opt Description
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| 47519-4 R HISTORY OF PROCEDURES
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|
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| {{:1.3.6.1.4.1.19376.1.5.3.1.3.12}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.12
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| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.11
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| General Description The list of surgeries section shall include entries for procedures and references to procedure reports when known as described in the Entry Content Modules.
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|
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| Entries Description
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| 1.3.6.1.4.1.19376.1.5.3.1.4.16 R 5.4.4.30 Procedure Entry
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| 1.3.6.1.4.1.19376.1.5.3.1.4.4 R2 5.4.4.8 References Entry
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| =====Allergies and Other Adverse Reactions=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.3.13}}
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|
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.13
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| Parent Template 2.16.840.1.113883.10.20.1.2
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| General Description The adverse and other adverse reactions section shall contain a narrative description of the substance intolerances and the associated adverse reactions suffered by the patient. It shall include entries for intolerances and adverse reactions as described in the Entry Content Modules.
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| Valid LOINC CODES Opt Description
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| 48765-2 R Allergies, adverse reactions, alerts
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| Entries Description
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| 1.3.6.1.4.1.19376.1.5.3.1.4.5.3 R 5.4.4.11 Allergies and Intolerances Concern
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| =====Family Medical History=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.3.14}}
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|
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|
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.14
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.4|History of Present Illness }} |
| Parent Template 2.16.840.1.113883.10.20.1.4
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.5|Hospital Course}} |
| General Description The family history section shall contain a narrative description of the genetic family members, to the extent that they are known, the diseases they suffered from, their ages at death, and other relevant genetic information.
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.6|Active Problems}} |
| Valid LOINC CODES Opt Description
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.7|Discharge Diagnosis}} |
| 10157-6 R HISTORY OF FAMILY MEMBER DISEASES
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.8|Resolved Problems}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3|Encounter Histories}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.9|History of Outpatient Visits}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.10|History of Inpatient Visits}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.11|List of Surgeries}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.12|Coded List of Surgeries }} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.13|Allergies and Other Adverse Reactions}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.14|Family Medical History}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.15|Coded Family Medical History }} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.5|Pre-procedure Family Medical History}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.16|Social History}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.17|Functional Status}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.18|Review of Systems}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.13|Preprocedure Review of Systems}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1|Hazardous Working Conditions}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4|Pregnancy History}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5|Medical Devices }} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6|Foreign Travel}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.8|History of Tobacco Use}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.10|Current Alcohol/Substance Abuse }} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.12|Transfusion History}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.14|Anesthesia Risk Review of Systems}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.46|Implanted Medical Device Review}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.47|Pregnancy Status Review}} |
|
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|
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.15}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.15
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| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.14
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| General Description The family history section shall include entries for family history as described in the Entry Content Modules.
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| Entries Description
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| 1.3.6.1.4.1.19376.1.5.3.1.4.15 R 5.4.4.22 Family History Organizer
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|
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| =====Pre-procedure Family Medical History=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.5}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.5
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| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.15
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| General Description The pre-procedure family history section shall contain a description of the genetic family members who have suffered complications during anesthesia such as malignant hyperthermia, bleeding, etc. It shall include entries for family history as described in the Entry Content Modules.
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|
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| =====Social History=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.3.16}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.16
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| Parent Template 2.16.840.1.113883.10.20.1.15
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| General Description The social history section shall contain a narrative description of the person’s beliefs, home life, community life, work life, hobbies, and risky habits.
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| Valid LOINC CODES Opt Description
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| 29762-2 R SOCIAL HISTORY
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| =====Functional Status=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.3.17}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.17
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| Parent Template 2.16.840.1.113883.10.20.1.5
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| General Description The functional status section shall contain a narrative description of capability of the patient to perform acts of daily living.
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| Valid LOINC CODES Opt Description
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| 47420-5 R FUNCTIONAL STATUS ASSESSMENT
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| =====Review of Systems=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.3.18}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.18
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| General Description The review of systems section shall contain a narrative description of the responses the patient gave to a set of routine questions on the functions of each anatomic body system.
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| Valid LOINC CODES Opt Description
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| 10187-3 R REVIEW OF SYSTEMS
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|
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.13}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.13
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| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.18
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| General Description The pre-procedure review of systems section shall contain only required and optional subsections dealing with the responses the patient gave to a set of routine questions on body systems in general and specific risks of anesthesia not covered in general review of systems.
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| Valid LOINC CODES Opt Description
| |
| 10187-3 R REVIEW OF SYSTEMS
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| Entries Description
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| No Entries
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| Sub-sections Description
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|
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| 1.3.6.1.4.1.19376.1.5.3.1.1.9.46 R History of Implanted Medical Devices
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| 1.3.6.1.4.1.19376.1.5.3.1.1.9.47 R2 Pregnancy Status History
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| 1.3.6.1.4.1.19376.1.5.3.1.1.9.14 R Anesthesia Risk Review of Systems
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|
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|
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| =====Hazardous Working Conditions=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1
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| General Description Hazardous working conditions only a narrative description of the patient's hazardous risks.
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| Valid LOINC CODES Description
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| 10161-8 HISTORY OF OCCUPATIONAL EXPOSURE
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| =====Pregnancy History=====
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| {{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4}}
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
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| General Description The pregnancy history section contains coded entries describing the patient history of pregnancies.
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| Valid LOINC CODES Opt Description
| |
| 10162-6 R HISTORY OF PREGNANCIES
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| Valid Entries Opt Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 R 5.4.4.25 Pregnancy Observation
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|
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| =====Medical Devices=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5}}
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5
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| Parent Template 2.16.840.1.11383.10.20.1.7
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| General Description The medical devices section contains narrative text describing the patient history of medical device use.
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| Valid LOINC CODES Opt Description
| |
| 46264-8 R HISTORY OF MEDICAL DEVICE USE
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| =====Foreign Travel=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6}}
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|
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| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6
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| General Description The foreign travel section contains only narrative text describing the patient's travel history.
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| Valid LOINC CODES Opt Description
| |
| 10182-4 R HISTORY OF TRAVEL
| |
| =====History of Tobacco Use=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.8}}
| |
|
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.8
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| Parent Template None
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| General Description The history of tobacco use section shall contain a description of the responses the patient gave to a set of routine questions on the history of tobacco use.
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| Valid LOINC CODES Opt Description
| |
| 11366-2 R HISTORY OF TOBACCO USE
| |
| =====Current Alcohol/Substance Abuse=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.10}}
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.10
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| Parent Template None
| |
| General Description The history of alcohol/substance abuse section shall contain a description of the responses the patient gave to a set of routine questions on the current abuse of alcohol or other substances.
| |
| Valid LOINC CODES Opt Description
| |
| 18663-5 R HISTORY OF PRESENT ALCOHOL AND/OR SUBSTANCE ABUSE
| |
| =====Transfusion History=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.12}}
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.12
| |
| Parent Template None
| |
| General Description The transfusion history section shall contain a description of the blood products the patient has received in the past, including any reactions to blood products. It shall include entries for substance administration as described in the Entry Content Modules.
| |
| Valid LOINC CODES Opt Description
| |
| TBD R BLOOD PRODUCTS ADMINISTRATION
| |
|
| |
| =====Anesthesia Risk Review of Systems=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.14}}
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.14
| |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.18
| |
| General Description The anethesia review of systems section shall contain a description of the responses the patient gave to a set of routine questions on specific risks of anesthesia not covered in general review of systems such as broken teeth, airway limitations, positioning limitations, recent infections, and history of personal anethesia problems.
| |
| Valid LOINC CODES Opt Description
| |
|
| |
|
| |
| =====Implanted Medical Device Review=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.46}}
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.46
| |
| Parent Template None
| |
| General Description The implanted medical device review section shall contain a description of the medical devices that are inserted into the patient, whether internal or partially external.
| |
| Valid LOINC CODES Opt Description
| |
|
| |
|
| |
| =====Pregnancy Status Review=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.47}}
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.47
| |
| Parent Template None
| |
| General Description The pregnancy status review section shall contain a description of the responses the patient gave to a set of routine questions regarding potential pregnancy in females of child-bearing-age.
| |
| Valid LOINC CODES Opt Description
| |
|
| |
| ====Medications==== | | ====Medications==== |
| This section contains section content modules that describe activities surrounding the use of medication. | | This section contains section content modules that describe activities surrounding the use of medication. |
| =====Medications=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.19}}
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.19
| |
| Parent Template 2.16.840.1.113883.10.20.1.8
| |
| General Description The medications section shall contain a description of the relevant medications for the patient, e.g. an ambulatory prescription list. It shall include entries for medications as described in the Entry Content Module.
| |
| Valid LOINC CODES Opt Description
| |
| 10160-0 R HISTORY OF MEDICATION USE
| |
| Entries Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.7 R 5.4.4.14 Medications
| |
|
| |
|
| =====Admission Medication History=====
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.19|Medications}} |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.20}} | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.20|Admission Medication History}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.21|Medications Administered}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.22|Hospital Discharge Medications}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.23|Immunizations}} |
|
| |
|
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.20
| |
| General Description The admission medication history section shall contain a narrative description of the relevant medications administered to a patient prior to admission to a facility. It shall include entries for medication administration as described in the Entry Content Module.
| |
| Valid LOINC CODES Opt Description
| |
| 42346-7 R MEDICATIONS ON ADMISSION
| |
| Entries Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.7 R 5.4.4.14 Medications
| |
| =====Medications Administered=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.21}}
| |
|
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.21
| |
| General Description The medications administered section shall contain a narrative description of the relevant medications administered to a patient during the course of an encounter. It shall include entries for medication administration as described in the Entry Content Module.
| |
| Valid LOINC CODES Opt Description
| |
| 18610-6 R MEDICATION ADMINISTERED
| |
| Entries Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.7 R 5.4.4.14 Medications
| |
| =====Hospital Discharge Medications=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.22}}
| |
|
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.22
| |
| General Description The hospital discharge medications section shall contain a narrative description of the medications requested (ordered) to be administered to the patient after discharge from the hospital. It shall include entries for medication requests as described in the Entry Content Module.
| |
| Valid LOINC CODES Opt Description
| |
| 10183-2 R HOSPITAL DISCHARGE MEDICATIONS
| |
| Entries Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.7 R 5.4.4.14 MedicationsNote: All medications in this section must have sustanceAdministration/@moodCode = "INT"
| |
| =====Immunizations=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.23}}
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.23
| |
| Parent Template 2.16.840.1.113883.10.20.1.6
| |
| General Description The immunizations section shall contain a narrative description of the immunizations administered to the patient in the past. It shall include entries for medication administration as described in the Entry Content Modules.
| |
| Valid LOINC CODES Opt Description
| |
| 11369-6 R HISTORY OF IMMUNIZATIONS
| |
| Entries Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.12 R 5.4.4.15 Immunization
| |
| ====Physical Exams==== | | ====Physical Exams==== |
| =====Physical Exam=====
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.24|Physical Exam}} |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.24}} | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Physical Exam (with subsections)}} |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.24
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.26|Hospital Discharge Physical Exam}} |
| General Description The physical exam section shall contain a narrative description of the patient’s physical findings.
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.25|Vital Signs}} |
| Valid LOINC CODES Opt Description
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2|Coded Vital Signs}} |
| 22029-3 R PHYSICAL EXAM.TOTAL
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.16|General Appearance}} |
| | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.48|Visible Implanted Medical Devices}} |
| | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.17|Integumentary System}} |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.15}} | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.18|Head}} |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.15
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.19|Eyes}} |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.24
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.20|Ears, Nose, Mouth and Throat}} |
| General Description The physical exam section shall contain only the required and optional subsections performed.
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.21|Ears}} |
| Valid LOINC CODES Opt Description
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.22|Nose}} |
| 22029-3 R PHYSICAL EXAM.TOTAL
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.23|Mouth, Throat, and Teeth}} |
| Sub-sections Description
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.24|Neck}} |
| 1.3.6.1.4.1.19376.1.5.3.1.3.49 R 5.4.3.4.3 Vital Signs | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.25|Endocrine System}} |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.16 O 5.4.3.4.4 General Appearance | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.26|Thorax and Lungs}} |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.48 O 5.4.3.4.5 Visible Implanted Medical Devices | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.27|Chest Wall}} |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.17 O 5.4.3.4.6Integumentary System
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.28|Breasts}} |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.18 O 5.4.3.4.7 Head | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.29|Heart}} |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.19 O 5.4.3.4.8 Eyes | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.30|Respiratory System}} |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.20 O 5.4.3.4.9 Ears, Nose, Mouth and Throat | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.31|Abdomen}} |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.21 O 5.4.3.4.10 Ears | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.32|Lymphatic System}} |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.22 O 5.4.3.4.11 Nose | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.33|Vessels}} |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.23 O 5.4.3.4.12 Mouth, Throat, and Teeth | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.34|Musculoskeletal System}} |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.24 O 5.4.3.4.13 Neck | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.35|Neurologic System}} |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.25 O 5.4.3.4.14 Endocrine System
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.36|Genitalia}} |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.26 O 5.4.3.4.15 Thorax and Lungs | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.37|Rectum}} |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.27 O 5.4.3.4.16 Chest Wall | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.28 O 5.4.3.4.17 Breasts | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.29 O 5.4.3.4.18 Heart | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.30 O 5.4.3.4.19 Respiratory System | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.31 O 5.4.3.4.20 Abdomen | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.32 O 5.4.3.4.21 Lymphatic System
| |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.33 O 5.4.3.4.22 Vessels | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.34 O 5.4.3.4.23 Musculoskeletal System | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.35 O 5.4.3.4.24 Neurologic System
| |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.36 O 5.4.3.4.25 Genitalia
| |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.37 O 5.4.3.4.26 Rectum
| |
| | |
| | |
| =====Hospital Discharge Physical Exam=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.26}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.26
| |
| General Description The hospital discharge physical exam section shall contain a narrative description of the patient’s physical findings at discharge from a hospital facility.
| |
| Valid LOINC CODES Opt Description
| |
| 10184-0 R HOSPITAL DISCHARGE PHYSICAL
| |
| =====Vital Signs=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.25}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.25
| |
| Parent Template ID 2.16.840.1.113883.10.20.1.16
| |
| General Description The vital signs section shall contain a narrative description of the measurement results of a patient’s vital signs.
| |
| Valid LOINC CODES Opt Description
| |
| 8716-3 R VITAL SIGNS
| |
| | |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2}}
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
| |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.25
| |
| General Description The vital signs section contains coded measurement results of a patient’s vital signs.
| |
| Valid LOINC CODES Opt Description
| |
| 8716-3 R VITAL SIGNS
| |
| Valid Entries Opt Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.13.1 R 5.4.4.19 Vital Signs Organizer
| |
| | |
| =====General Appearance=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.16}}
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.16
| |
| Parent Template None
| |
| General Description The general appearance section shall contain a description of the overall, visibly-apparent condition of the patient.
| |
| Valid LOINC CODES Opt Description
| |
| 10210-3 R GENERAL STATUS
| |
| | |
| =====Visible Implanted Medical Devices=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.48}}
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.48
| |
| Parent Template None
| |
| General Description The visible implanted medical devices section shall contain a description of the medical devices apparent on physical exam that have been inserted into the patient, whether internal or partially external.
| |
| Valid LOINC CODES Opt Description
| |
| TBD R VISIBLE IMPLANTED MEDICAL DEVICES
| |
| | |
| =====Integumentary System=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.17}}
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.17
| |
| Parent Template None
| |
| General Description The integumentary system section shall contain a description of any type of integumentary system exam.
| |
| Valid LOINC CODES Opt Description
| |
| 29302-7 R INTEGUMENTARY SYSTEM
| |
| | |
| =====Head=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.18}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.18
| |
| Parent Template None
| |
| General Description The head section shall contain a description of any type of head exam.
| |
| Valid LOINC CODES Opt Description
| |
| 10199-8 R HEAD
| |
| | |
| =====Eyes=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.19}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.19
| |
| Parent Template None
| |
| General Description The eyes section shall contain a description of any type of eye exam.
| |
| Valid LOINC CODES Opt Description
| |
| 10197-2 R EYE
| |
| | |
| =====Ears, Nose, Mouth and Throat=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.20}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.20
| |
| Parent Template None
| |
| General Description The ears, nose, mouth, and throat section shall contain a description of any type of ears, nose, mouth, or throat exam.
| |
| Valid LOINC CODES Opt Description
| |
| 11393-6 R EARS & NOSE & MOUTH & THROAT
| |
| | |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1
| |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.20
| |
| General Description The ears, nose, mouth, and throat section shall contain a description of any type of ears, nose, mouth, or throat exam. It shall contain sub-sections on ears, nose, mouth, throat, and teeth.
| |
| Valid LOINC CODES Opt Description
| |
| 11393-6 R EARS & NOSE & MOUTH & THROAT
| |
| Sub-sections Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.21 R Ears
| |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.22 R Nose
| |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.23 R Mouth, Throat, and Teeth
| |
| | |
| | |
| =====Ears=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.21}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.21
| |
| Parent Template None
| |
| General Description The ears section shall contain a description of any type of ear exam.
| |
| Valid LOINC CODES Opt Description
| |
| 10195-6 R EAR
| |
| | |
| =====Nose=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.22}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.22
| |
| Parent Template None
| |
| General Description The nose section shall contain a description of any type of nose exam.
| |
| Valid LOINC CODES Opt Description
| |
| 10203-8 R NOSE
| |
| | |
| | |
| =====Mouth, Throat and Teeth=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.23}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.23
| |
| Parent Template None
| |
| General Description The mouth, throat, and teeth section shall contain a description of any type of mouth, throat, or teeth exam.
| |
| Valid LOINC CODES Opt Description
| |
| 10201-2 R MOUTH & THROAT & TEETH
| |
| | |
| | |
| =====Neck=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.24}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.24
| |
| Parent Template None
| |
| General Description The neck section shall contain a description of any type of neck exam.
| |
| Valid LOINC CODES Opt Description
| |
| 11411-6 R NECK
| |
| | |
| =====Endocrine System=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.25}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.25
| |
| Parent Template None
| |
| General Description The endocrine system section shall contain a description of any type of endocrine system exam.
| |
| Valid LOINC CODES Opt Description
| |
| 29307-6 R ENDOCRINE SYSTEM
| |
| | |
| =====Thorax and Lungs=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.26}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.26
| |
| Parent Template None
| |
| General Description The thorax and lungs section shall contain a description of any type of thoracic or lung exams.
| |
| Valid LOINC CODES Opt Description
| |
| 10207-9 R THORAX+LUNGS
| |
| | |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1}}
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1
| |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.26
| |
| General Description The thorax and lungs section shall contain a description of any type of thoracic or lung exams.
| |
| Valid LOINC CODES Opt Description
| |
| 10207-9 R THORAX+LUNGS
| |
| Sub-sections Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.27 O Chest Wall
| |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.28 O Breasts
| |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.29 O Heart
| |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.30 O Respiratory System
| |
| | |
| =====Chest Wall=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.27}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.27
| |
| Parent Template None
| |
| General Description The chest wall section shall contain a description of any type of chest wall exam.
| |
| Valid LOINC CODES Opt Description
| |
| 11392-8 R CHEST WALL
| |
| | |
| =====Breast=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.28}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.28
| |
| Parent Template None
| |
| General Description The breast section shall contain a description of any type of breast exam.
| |
| Valid LOINC CODES Opt Description
| |
| 10193-1 R BREASTS
| |
| | |
| =====Heart=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.29}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.29
| |
| Parent Template None
| |
| Section Title Heart
| |
| General Description The heart section shall contain a description of any type of heart exam.
| |
| Valid LOINC CODES Opt Description
| |
| 10200-4 R HEART
| |
| | |
| =====Respiratory System=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.30}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.30
| |
| Parent Template None
| |
| General Description The respiratory system section shall contain a description of any type of respiratory exam.
| |
| Valid LOINC CODES Opt Description
| |
| 11412-4 R RESPIRATORY SYSTEM
| |
| | |
| =====Abdomen=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.31}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.31
| |
| Parent Template None
| |
| General Description The abdomen system section shall contain a description of any type of abdominal exam.
| |
| Valid LOINC CODES Opt Description
| |
| 10191-5 R ABDOMEN
| |
| | |
| =====Lymphatic System=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.32}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.32
| |
| Parent Template None
| |
| General Description The lymphatic system section shall contain a description of any type of lymphatic exam.
| |
| Valid LOINC CODES Opt Description
| |
| 11447-0 R HEMATOLOGIC+LYMPHATIC+IMMUNOLOGIC SYSTEM
| |
| | |
| =====Vessels=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.33}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.33
| |
| Parent Template None
| |
| General Description The vessels section shall contain a description of any type of vessels exam.
| |
| Valid LOINC CODES Opt Description
| |
| 10208-7 R VESSELS
| |
| | |
| =====Musculoskeletal System=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.34}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.34
| |
| Parent Template None
| |
| General Description The musculoskeletal system section shall contain a description of any type of musculoskeletal exam.
| |
| Valid LOINC CODES Opt Description
| |
| 11410-8 R MUSCULOSKELETAL SYSTEM
| |
| | |
| =====Neurologic System=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.35}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.35
| |
| Parent Template None
| |
| General Description The neurologic system section shall contain a description of any type of neurologic exam.
| |
| Valid LOINC CODES Opt Description
| |
| 10202-0 R NEUROLOGIC SYSTEM
| |
| | |
| =====Genitalia=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.36}}
| |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.36
| |
| Parent Template None
| |
| General Description The genitalia section shall contain a description of any type of genital exam.
| |
| Valid LOINC CODES Opt Description
| |
| 11400-9 R GENITALIA
| |
| | |
| =====Rectum=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.37}}
| |
| | |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.37
| |
| Parent Template None
| |
| General Description The rectum section shall contain a description of any type of rectal exam.
| |
| Valid LOINC CODES Opt Description
| |
| 10205-3 R RECTUM
| |
| | |
|
| |
|
| ====Relevant Studies==== | | ====Relevant Studies==== |
| =====Results=====
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.27|Results }} |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.27}} | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.28}} |
| | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.29}} |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.27
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.30}} |
| General Description The results section shall contain a narrative description of the patient’s relevant studies.
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2}} |
| Valid LOINC CODES Opt Description
| |
| 30954-2 R STUDIES SUMMARY
| |
| | |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.28}} | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.28
| |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.27
| |
| General Description The results section shall contain a narrative description of the relevant diagnostic procedures the patient received in the past. It shall include entries for procedures and references to procedure reports when known as described in the Entry Content Modules.
| |
| Valid LOINC CODES Opt Description
| |
| 30954-2 R STUDIES SUMMARY
| |
| Entries Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.16 R 5.4.4.30 Procedure Entry
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.4 R2 5.4.4.8 References Entry
| |
| =====Hospital Studies Summary=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.29}} | |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.29
| |
| General Description The hospital studies summary section shall contain a narrative description of the relevant diagnostic procedures the patient received during the hospital admission.
| |
| Valid LOINC CODES Opt Description
| |
| 11493-4 R HOSPITAL DISCHARGE STUDIES SUMMARY
| |
| | |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.30}} | |
| | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.30
| |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.29
| |
| General Description The hospital studies summary section shall include entries for diagnostic procedures and references to procedure reports when known as described in the Entry Content Modules.
| |
| Valid LOINC CODES Opt Description
| |
| 11493-4 R HOSPITAL DISCHARGE STUDIES SUMMARY
| |
| Entries Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.16 R 5.4.4.30 Procedure Entry
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.4 R2 5.4.4.8 References Entry
| |
| =====Blood Type =====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2}} | |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
| |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.27
| |
| General Description The results section shall contain an observation of the patients blood type.
| |
| Entries Description
| |
|
| |
| Move to PCC TF-3
| |
| LOINC CODE Description Type Units or Vocabulary
| |
| 882-1 ABO+RH GROUP CE SNOMED CT, ISBT 129
| |
|
| |
|
| ====Plans of Care==== | | ====Plans of Care==== |
| This section provides content modules for sections that describe the plan of care intended for the patient. | | This section provides content modules for sections that describe the plan of care intended for the patient. |
| =====Care Plan=====
| |
| Note: specific templates for entries within plans of care may be found in other categories such as the medications category.
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.31}}
| |
|
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.31
| |
| General Description The care plan section shall contain a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient.
| |
| Valid LOINC CODES Opt Description
| |
| 18776-5 R TREATMENT PLAN
| |
|
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1}}
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1
| |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.31
| |
| General Description The plan of care section contains descriptions of the expectations for care including proposals, order requests, the intended transporation mode and estimated time of arrival to the ED, as well as intended disposition from the ED.
| |
| Valid LOINC CODES Opt Description
| |
| 18776-5 R2 TREATMENT PLAN
| |
| Sub-sections Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 R 5.4.3.6.9 Transport ModeThis required subsection describes the expected mode and time of arrival of the patient to the emergency department.
| |
| Valid Entries Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2 R2 5.4.4.32 Intended Encounter DispositionThis required entry describes the expected disposition of the patient after the emergency department encounter has been completed.
| |
| =====Discharge Disposition=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.32}}
| |
|
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.32
| |
| General Description The plan of care section shall contain a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient, specifically used in a discharge from a facility such as an emergency department, hospital, or nursing home.
| |
| Valid LOINC CODES Opt Description
| |
| 18776-5 R TREATMENT PLAN
| |
| =====Discharge Diet=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.33}}
| |
|
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.33
| |
| General Description The discharge diet section shall contain a narrative description of the expectations for diet including proposals, goals, and order requests for monitoring, tracking, or improving the dietary control of the patient, specifically used in a discharge from a facility such as an emergency department, hospital, or nursing home.
| |
| Valid LOINC CODES Opt Description
| |
| 42344-2 R DISCHARGE DIET
| |
| =====Advance Directives=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.34}}
| |
|
| |
|
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.34
| |
| Parent Template 2.16.840.1.113883.10.20.1.1
| |
| General Description The advance directive section shall contain a narrative description of the list of documents that define the patient’s expectations and requests for care along with the locations of the documents.
| |
| Valid LOINC CODES Opt Description
| |
| 42348-3 R ADVANCE DIRECTIVES
| |
|
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.3.35}}
| |
|
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.35
| |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.34
| |
| General Description The advance directive section shall include entries for references to consent and advance directive documents when known as described in the Entry Content Modules.
| |
| Entries Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.13.3 R2 5.4.4.26 Advance Directive Observation
| |
| =====Procedure Care Plan=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.40}}
| |
|
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.40
| |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.31
| |
| General Description The procedure care plan section shall contain a description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient prior, during and after a procedure with goals of educating the patient, reducing the modifiable risks of the procedure and anethesia and otherwise optimizing the outcomes. The care plan will often be updated immediately following the addition of new impressions during the course of pre-procedure evaluation.
| |
| Valid LOINC CODES Opt Description
| |
| 18776-5 R TREATMENT PLAN
| |
|
| |
| =====Procedure Care Plan Status Report=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.45}}
| |
|
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.45
| |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.40
| |
| General Description The procedure care plan status report section shall contain a description of the progress towards completing expectations for care including actions completed in fulfilment of proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient prior to the procedure.
| |
| Valid LOINC CODES Opt Description
| |
| 18776-5 R TREATMENT PLAN
| |
|
| |
| =====Health Maintenance Care Plan=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.50}}
| |
|
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.50
| |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.31
| |
| General Description The health maintenance care plan section shall contain a description of the expectations for wellness care including proposals, goals, and order requests for monitoring, tracking, or improving the lifetime condition of the patient with goals of educating the patient on how to reduce the modifiable risks of the patient’s genetic, behavioral, and environmental pre-conditions and otherwise optimizing lifetime outcomes.
| |
| Valid LOINC CODES Opt Description
| |
| 18776-5 R TREATMENT PLAN
| |
|
| |
| =====Health Maintenance Care Plan Status Report=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.41}}
| |
|
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.41
| |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.50
| |
| General Description The health maintenance status report section shall contain a description of the progress towards completing expectations for care including actions completed in fulfilment of proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient.
| |
| Valid LOINC CODES Opt Description
| |
| 18776-5 R TREATMENT PLAN
| |
|
| |
| =====Transport Mode=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2}}
| |
|
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
| |
| Parent Template None
| |
| General Description The transport mode section contains a description of the expected mode of transport and estimated time of arrival.to the Emergency department.
| |
| Valid LOINC CODES Opt Description
| |
| 11459-5 R TRANSPORT MODE
| |
| Valid Entries Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1 R 5.4.4.31 Transport This entry provides coded values giving the expected mode and time of arrival of the patient to the emergency department.
| |
| 5.4.3.7 Procedures Performed
| |
|
| |
| =====Patient Education and Consents=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.38}}
| |
|
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.38
| |
| Parent Template None
| |
| General Description The patient education and consents section shall contain a description of the patient education the patient received, the results of the education, and the consents the patient signed.
| |
| Valid LOINC CODES Opt Description
| |
| 34895-3 R EDUCATION NOTE
| |
|
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.38}}
| |
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.39
| |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.38
| |
| General Description The patient education and consents section shall contain a description of the patient education the patient received, the results of the education, and references to the consents the patient signed. It shall include entries for procedures and references to consent documents as described in the Entry Content Modules.
| |
| Valid LOINC CODES Opt Description
| |
| 34895-3 R EDUCATION NOTE
| |
| Entries Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.16 R 5.4.4.30 Procedure Entry The procedures shall be in INT mood
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.13 R2 5.4.4.18 Simple Observations
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.4 R2 5.4.4.8.1 External References
| |
|
| |
| ====Impressions====
| |
|
| |
|
| |
|
| =====Pre-procedure Impressions=====
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.31}} |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.42}} | | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1|ED Care Plan}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.32}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.33}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.34}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.35}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.40}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.45}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.50}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.41}} |
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2|Transport Mode}} |
|
| |
|
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.42
| | ==== Procedures Performed ==== |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.6
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.38}} |
| General Description The Impressions section shall contain only the required and optional subsections dealing with the updated problem list, the general risks the patient faces from the procedures, and the fixed and modifiable risks the patient faces because of specific patient findings.
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.38}} |
| Sub-sections Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.44 R Pre-procedure Risk Assessment | |
|
| |
|
| =====Pre-procedure Risk Assessment===== | | ==== Impressions==== |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.44}}
| |
|
| |
|
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.44
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.42}} |
| Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.6
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.44}} |
| General Description The pre-procedure risk section shall contain a description of the risks the patient faces because of the planned procedure and associated anethesia, especially in the context of modifiable risks identified by patient findings. It shall include entries for patient risks as described in the Entry Content Module.
| |
| Valid LOINC CODES Opt Description
| |
| 11450-4 R PROBLEM LIST
| |
| Entries Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.5 R 5.4.4.9 Conditions Entry
| |
|
| |
|
| ====Administrative and Other Information==== | | ====Administrative and Other Information==== |
| =====Payers=====
| |
| {{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7}}
| |
|
| |
|
| TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7
| | {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7}} |
| Parent TemplateID 2.16.840.1.113883.10.20.1.9
| |
| General Description The Payers section contains data on the patient’s payers, whether a ‘third party’ insurance, self-pay, other payer or guarantor, or some combination.
| |
| Valid LOINC CODES Opt Description
| |
| 48768-6 R PAYMENT SOURCES
| |
| Entries Description
| |
| 1.3.6.1.4.1.19376.1.5.3.1.4.17 R2 5.4.4.33 Coverage Entry
| |