QRPH Registry: Difference between revisions

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| 
|-
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
|style="background-color:#D9D9D9; font-weight:bold" | 1.3.6.1.4.1.19376.1.7.3.1.4
|Chief Complaint
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.3
|Hospital Admission Diagnosis
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.1
|Proposed Procedure
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.2
|Estimated Blood Loss
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.3
|Proposed Anesthesia
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.4
|Reason for Procedure
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1
|Reason for Visit
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
|Mode of Arrival
 
|-
|style="background-color:#EFEFEF; font-weight:bold;padding-left:60px" colspan="2" | Other Condition Histories
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.4
|History of Present Illness
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.5
|Hospital Course
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.6
|Active Problems
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.7
|Discharge Diagnosis
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.8
|History of Past Illness
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
|Encounter Histories
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.9
|History of Outpatient Visits
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.10
|History of Inpatient Visits
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.11
|List of Surgeries
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.12
|Coded List of Surgeries
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.13
|Allergies and Other Adverse Reactions
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.14
|Family Medical History
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.15
|Coded Family Medical History
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.5
|Pre-procedure Family Medical History
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.16
|Social History
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.17
|Functional Status
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
|Coded Functional Status
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2
|Pain Scale Assessment
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3
|Braden Score Assessment
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4
|Geriatric Depression Scale
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5
|Physical Function
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.18
|Review of Systems
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.13
|Preprocedure Review of Systems
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1
|Hazardous Working Conditions
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
|Pregnancy History
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1
|Estimated Delivery Dates Section
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5
|Medical Devices
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6
|Foreign Travel
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.8
|History of Tobacco Use
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.10
|Current Alcohol/Substance Abuse
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.12
|Transfusion History
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.14
|Anesthesia Risk Review of Systems
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.46
|Implanted Medical Device Review
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.47
|Pregnancy Status Review
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1
|History of Infection
 
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1.1
|Coded History of Infection
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.16.1
|Coded Social History
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.2
|Prenatal Events
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3
|Labor and Delivery
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4
|Newborn Delivery Information
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.7
|Post-partum Treatment
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.8
|Newborn Status at Maternal Discharge
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.9
|Event Outcomes
 
|-
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Medications
|-
|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
|Admission Medication History
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.21
|Medications Administered
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.22
|Hospital Discharge Medications
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.23
|Immunizations
 
|-
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Physical Exams
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.24
|Physical Exam
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.15
|Physical Exam (with subsections)
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.26
|Hospital Discharge Physical Exam
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.25
|Vital Signs
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
|Coded Vital Signs
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.16
|General Appearance
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.48
|Visible Implanted Medical Devices
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.17
|Integumentary System
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.18
|Head
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.19
|Eyes
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.20
|Ears, Nose, Mouth and Throat
|-
|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
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.23
|Mouth, Throat, and Teeth
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.24
|Neck
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.25
|Endocrine System
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.26
|Thorax and Lungs
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.27
|Chest Wall
|-
|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
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.30
|Respiratory System
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.31
|Abdomen
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.32
|Lymphatic System
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.33
|Vessels
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.34
|Musculoskeletal System
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.35
|Neurologic System
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.36
|Genitalia
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.37
|Rectum
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1
|Extremeties
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1
|Coded Physical Exam
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.10
|Pelvis
 
|-
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Relevant Studies
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.27
|Results
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.28
|Coded Results
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.29
|Hospital Studies Summary
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.30
|Coded Hospital Studies Summary
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8
|Consultations
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.5
|Antenatal Testing and Surveillance
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.5.1
|Coded Antenatal Testing and Surveillance
 
|-
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Plans of Care
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.31
|Care Plan
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5
|Assessment and Plan
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.33
|Discharge Diet
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.34
|Advance Directives
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.35
|Coded Advance Directives
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.40
|Procedure Care Plan
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.45
|Procedure Care Plan Status Report
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.50
|Health Maintenance Care Plan
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.41
|Health Maintenance Care Plan Status Report
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
|Transport Mode
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.1
|Birth Plan
 
|-
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Procedures Performed
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.38
|Patient Education and Consents
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.39
|Coded Patient Education and Consents
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11|
Procedures Performed
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
|Intravenous Fluids Administered
 
|-
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Impressions
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.42
|Pre-procedure Impressions
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.44
|Pre-procedure Risk Assessment
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2
|Visit Summary Flowsheet Section
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7
|Progress Note
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9
|ED Diagnoses
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2
|Acuity Assessment
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
|Assessments
 
|-
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Administrative and Other Information
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7
|Payers
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3
|Referral Source
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
|Mode of Arrival
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10
|ED Disposition
 
|-
|style="background-color:#D9D9D9; font-weight:bold" | 1.3.6.1.4.1.19376.1.5.3.1.4
|style="background-color:#D9D9D9; font-weight:bold" | CDA Entry Template Identifiers
|style="background-color:#D9D9D9; font-weight:bold" | CDA Entry Template Identifiers
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.1
|Severity
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.1.1
|Problem Status Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.1.2
|The template identifier used to identify a health status observation.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.2
|The template identifier used to identify a comment on an observation.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.3
|The template identifier used to identify instructions in medication order.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.3.1
|Medication Fulfillment Instructions
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.4
|The template identifier used to identify references to external documents.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.4.1
|Internal References
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.5.1
|The template identifier used to identify observation elements that indicate a concern.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.5.2
|The template identifier used to identify observation elements that indicate a problem of concern.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.5.3
|The template identifier used to identify observation elements that indicate an allergy or adverse reaction of concern.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.5
|The template identifier used to identify observation elements that describe patient problem.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.6
|The template identifier used to identify observation elements that describe patient allergy or adverse reaction.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.7
|The template identifier for a <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> event that records medication administration events or requests.  This is the root template for all medications.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.12
|Immunizations
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.7.3
|Supply Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.7.2
|Product Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.13
|Simple Observations
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.13.1
|Vital Signs Organizer
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.13.2
|Vital Signs Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.15
|Family History Organizer
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.13.3
|Family History Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.13.4
|Social History Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.13.5
|Pregnancy Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1
|Estimated Delivery Date Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2
|Antepartum Visit Summary Battery 
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.13.7
|Advance Directive Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.13.6
|Blood Type Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.14
|Encounters
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.16
|Update Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.19
|Procedure Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1
|Transport
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2
|Intended Encounter Disposition
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.17
|Coverage Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.18
|Payer Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1
|Pain Score Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2
|Braden Score Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3
|Braden Score Component
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.4
|Geriatric Depression Score Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.5
|Geriatric Depression Score Component
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7
|Survey Panel
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6
|Survey Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1
|Acuity
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.3.2
|Intravenous Fluids Administered
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.3.4
|Nursing Assessments Battery
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.3.10
|Antenatal Testing and Surveillance Battery
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.7.1
|This template identifier identifies medications that do not require complex processing for dose (e.g., split, tapered, conditional dosing or combination medications).
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.8
|The template identifier for a <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> event that records tapered dose information in subordinate <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> events.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.9
|The template identifier for a <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> event that records split dose information in subordinate <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> events.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.10
|The template identifier for a <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> event that records conditional dose information in subordinate <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> events.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.11
|The template identifier for a <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> event that records combination medication component information in subordinate <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> events.
|-
|-
|
|&nbsp;
|
|&nbsp;
 
|}
|}


Revision as of 22:04, 20 July 2009

QRPH Vocabulary Registry and Data Dictionary


This page lists various vocabularies and data dictionaries that are under the control of the QRPH Committee. Please do not edit this without coordinating your activity with the QRPH Committee. It is supposed to be a safe reference for currently assigned terms, etc. Some terms should not be assigned permanent values here until after the QRPH profile documentation is complete.


Profiles

Description Status OID Space
Clinical Research Document (CRD) Trial Implementation 1.3.6.1.4.1.19376.1.7.3.1.1.10
Drug Safety Content (DSC) Trial Implementation 1.3.6.1.4.1.19376.1.7.3.1.1.11
Retrieve Protocol for Execution (RPE) Trial Implementation 1.3.6.1.4.1.19376.1.7.3.1.1.12
Maternal and Child Health (MCH) Trial Implementation 1.3.6.1.4.1.19376.1.7.3.1.1.13

Transactions

Number Transaction Name
QRPH-10 RetrieveProtocolDef
QRPH-11 EnterPatientRequest
QRPH-12 PatientScreeningVisitsScheduled
QRPH-13 RecordPatientScreeningVisit
QRPH-14 EnrollPatientRequest
QRPH-15 PatientStudyVisitsScheduled
QRPH-16 RecordPatientStudyVisit
QRPH-17 AmendProtocolDef
QRPH-18 AlertProtocolState

QRPH Template Identifiers

Template Identifier Description
1.3.6.1.4.1.19376.1.7.3.1.1 CDA Document Template Identifiers
1.3.6.1.4.1.19376.1.7.3.1.1.10 Clinical Research Document (CRD)
1.3.6.1.4.1.19376.1.7.3.1.1.11 Drug Safety Content (DSC)
1.3.6.1.4.1.19376.1.7.3.1.1.12 Retrieve Protocol for Execution (RPE)
1.3.6.1.4.1.19376.1.7.3.1.1.13 Maternal and Child Health (MCH)
1.3.6.1.4.1.19376.1.7.3.1.2 CDA Header Template Identifiers
   
1.3.6.1.4.1.19376.1.7.3.1.3 CDA Section Template Identifiers
   
1.3.6.1.4.1.19376.1.7.3.1.4 CDA Entry Template Identifiers
   

Volume 2, Appendices

Chapter Description
A Examples
B Validating CDA Documents
C Extensions to CDA Release 2.0


See Also

The PCC Technical Framework is the official master document.

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