CDA Section Content Modules: Difference between revisions

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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.


{{:1.3.6.1.4.1.19376.1.5.3.1.3.1}}
Technical Framework Volume 2: 6.3.3.1 '''Reasons for Care'''


{{:1.3.6.1.4.1.19376.1.5.3.1.3.2}}
The sections described below describe various reasons why healthcare is being provided to the patient.
 
{{:1.3.6.1.4.1.19376.1.5.3.1.3.3}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.1}}


{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.2}}


{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.3}}


{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.4}}
{{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}}


====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.


{{:1.3.6.1.4.1.19376.1.5.3.1.3.4}}
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.4|History of Present Illness }}
 
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.5|Hospital Course}}
{{:1.3.6.1.4.1.19376.1.5.3.1.3.5}}
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.6|Active Problems}}
 
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.7|Discharge Diagnosis}}
{{:1.3.6.1.4.1.19376.1.5.3.1.3.6}}
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.8|Resolved Problems}}
 
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3|Encounter Histories}}
{{:1.3.6.1.4.1.19376.1.5.3.1.3.7}}
{{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}}
{{:1.3.6.1.4.1.19376.1.5.3.1.3.8}}
{{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 }}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3}}
{{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}}
{{:1.3.6.1.4.1.19376.1.5.3.1.3.9}}
{{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}}
{{:1.3.6.1.4.1.19376.1.5.3.1.3.10}}
{{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}}
{{:1.3.6.1.4.1.19376.1.5.3.1.3.11}}
{{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}}
{{:1.3.6.1.4.1.19376.1.5.3.1.3.12}}
{{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}}
{{:1.3.6.1.4.1.19376.1.5.3.1.3.13}}
{{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}}
{{:1.3.6.1.4.1.19376.1.5.3.1.3.14}}
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.8|History of Tobacco Use}}
 
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.10|Current Alcohol/Substance Abuse }}
{{:1.3.6.1.4.1.19376.1.5.3.1.3.15}}
{{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}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.5}}
{{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}}
{{:1.3.6.1.4.1.19376.1.5.3.1.3.16}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.3.17}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.3.18}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.13}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.8}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.10}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.12}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.14}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.46}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.47}}


====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.


{{:1.3.6.1.4.1.19376.1.5.3.1.3.19}}
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.19|Medications}}
 
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.20|Admission Medication History}}
{{:1.3.6.1.4.1.19376.1.5.3.1.3.20}}
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.21|Medications Administered}}
 
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.22|Hospital Discharge Medications}}
{{:1.3.6.1.4.1.19376.1.5.3.1.3.21}}
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.23|Immunizations}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.3.22}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.3.23}}


====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

Latest revision as of 22:12, 22 July 2009

Section Content Modules

This list defines the sections that may appear in a medical document. It is intended to be a comprehensive list of all document sections that are used by any content profile defined in the Patient Care Coordination Technical Framework. All sections shall have a narrative component that may be freely formatted into normal text, lists, tables, or other appropriate human-readable presentations. Additional subsections or entry content modules may be required.

Reasons for Care

Technical Framework Volume 2: 6.3.3.1 Reasons for Care

The sections described below describe various reasons why healthcare is being provided to the patient.


Other Condition Histories

The sections defined below provide historical information about the patient's conditions.

Medications

This section contains section content modules that describe activities surrounding the use of medication.

Physical Exams

  • (1.3.6.1.4.1.19376.1.5.3.1.1.9.18)Head
  • (1.3.6.1.4.1.19376.1.5.3.1.1.9.19)Eyes
  • (1.3.6.1.4.1.19376.1.5.3.1.1.9.21)Ears
  • (1.3.6.1.4.1.19376.1.5.3.1.1.9.22)Nose
  • (1.3.6.1.4.1.19376.1.5.3.1.1.9.24)Neck
  • (1.3.6.1.4.1.19376.1.5.3.1.1.9.28)Breasts
  • (1.3.6.1.4.1.19376.1.5.3.1.1.9.29)Heart
  • (1.3.6.1.4.1.19376.1.5.3.1.1.9.31)Abdomen
  • (1.3.6.1.4.1.19376.1.5.3.1.1.9.33)Vessels
  • (1.3.6.1.4.1.19376.1.5.3.1.1.9.37)Rectum

Relevant Studies

  • (1.3.6.1.4.1.19376.1.5.3.1.3.27)Results

Plans of Care

This section provides content modules for sections that describe the plan of care intended for the patient.

Procedures Performed

Impressions

Administrative and Other Information

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