PCC Vocabulary Registry and Data Dictionary/zh: Difference between revisions
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== ''PCC模板标识符'' == | == ''PCC模板标识符'' == | ||
{|border="2" cellspacing="0" cellpadding="4" width="100%" | {|border="2" cellspacing="0" cellpadding="4" width="100%" | ||
|align = "center" bgcolor = "#D9D9D9"|''' | |align = "center" bgcolor = "#D9D9D9"|'''模板标识符''' | ||
|align = "center" bgcolor = "#D9D9D9"|''' | |align = "center" bgcolor = "#D9D9D9"|'''英文描述''' | ||
|align = "center" bgcolor = "#D9D9D9"|'''中文描述''' | |||
|- | |- | ||
|style="background-color:#D9D9D9; font-weight:bold" | 1.3.6.1.4.1.19376.1.5.3.1.1 | |style="background-color:#D9D9D9; font-weight:bold" | 1.3.6.1.4.1.19376.1.5.3.1.1 | ||
|style="background-color:#D9D9D9; font-weight:bold" | CDA Document Template Identifiers | |style="background-color:#D9D9D9; font-weight:bold" | CDA Document Template Identifiers | ||
|style="background-color:#D9D9D9; font-weight:bold" | CDA文档模板标识符 | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.1 | ||
|Medical Document | |Medical Document | ||
|医疗文档 | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.2 | ||
|Medical Summary Template Identifier and XDS-MS formatCode | |Medical Summary Template Identifier and XDS-MS formatCode | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.3 | |1.3.6.1.4.1.19376.1.5.3.1.1.3 | ||
|Referral Summary | |Referral Summary | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.4 | |1.3.6.1.4.1.19376.1.5.3.1.1.4 | ||
|Discharge Summary | |Discharge Summary | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 | |1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 | ||
|History and Physical | |History and Physical | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.5 | |1.3.6.1.4.1.19376.1.5.3.1.1.5 | ||
|PHR Extract | |PHR Extract | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.6 | |1.3.6.1.4.1.19376.1.5.3.1.1.6 | ||
|PHR Update | |PHR Update | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.7 | |1.3.6.1.4.1.19376.1.5.3.1.1.7 | ||
|Basic Patient Privacy Consent (BPPC) | |Basic Patient Privacy Consent (BPPC) | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.10 | |1.3.6.1.4.1.19376.1.5.3.1.1.10 | ||
|Emergency Department Referral (EDR) | |Emergency Department Referral (EDR) | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.11.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.11.2 | ||
|Antepartum Summary | |Antepartum Summary | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 | ||
|Triage Note | |Triage Note | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2 | ||
|Nursing Note | |Nursing Note | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 | ||
|Composite Triage and Nursing Note | |Composite Triage and Nursing Note | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 | ||
|ED Physician Note | |ED Physician Note | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 | ||
|Antepartum History and Physical | |Antepartum History and Physical | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.16.1.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.16.1.2 | ||
|Antepartum Laboratory | |Antepartum Laboratory | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.16.1.3 | |1.3.6.1.4.1.19376.1.5.3.1.1.16.1.3 | ||
|Antepartum Education | |Antepartum Education | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2 | ||
|Immunization Detail | |Immunization Detail | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.19.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.19.1 | ||
|Prehospital Patient Care Report | |Prehospital Patient Care Report | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 | ||
|Care Plan | |Care Plan | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.20.1.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.20.1.2 | ||
|Subsequent Evaluation Note | |Subsequent Evaluation Note | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.21.1.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.21.1.1 | ||
|Labor and Delivery Admission History and Physical | |Labor and Delivery Admission History and Physical | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.21.1.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.21.1.2 | ||
|Labor and Delivery Summary | |Labor and Delivery Summary | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.21.1.3 | |1.3.6.1.4.1.19376.1.5.3.1.1.21.1.3 | ||
|Maternal Discharge Summary | |Maternal Discharge Summary | ||
| | |||
|- | |- | ||
|style="background-color:#D9D9D9; font-weight:bold" | 1.3.6.1.4.1.19376.1.5.3.1.2 | |style="background-color:#D9D9D9; font-weight:bold" | 1.3.6.1.4.1.19376.1.5.3.1.2 | ||
|style="background-color:#D9D9D9; font-weight:bold" | CDA Header Template Identifiers | |style="background-color:#D9D9D9; font-weight:bold" | CDA Header Template Identifiers | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.2.1 | |1.3.6.1.4.1.19376.1.5.3.1.2.1 | ||
|Language Communication | |Language Communication | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.2.2 | |1.3.6.1.4.1.19376.1.5.3.1.2.2 | ||
|Employer and School Contacts | |Employer and School Contacts | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.2.3 | |1.3.6.1.4.1.19376.1.5.3.1.2.3 | ||
|Healthcare Providers and Pharmacies | |Healthcare Providers and Pharmacies | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.2.4 | |1.3.6.1.4.1.19376.1.5.3.1.2.4 | ||
|Patient Contacts | |Patient Contacts | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.2.4.1 | |1.3.6.1.4.1.19376.1.5.3.1.2.4.1 | ||
|Spouse | |Spouse | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.2.4.2 | |1.3.6.1.4.1.19376.1.5.3.1.2.4.2 | ||
|Natural Father of Fetus | |Natural Father of Fetus | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.2.5 | |1.3.6.1.4.1.19376.1.5.3.1.2.5 | ||
|Authorization | |Authorization | ||
| | |||
|- | |- | ||
|style="background-color:#D9D9D9; font-weight:bold" | 1.3.6.1.4.1.19376.1.5.3.1.3 | |style="background-color:#D9D9D9; font-weight:bold" | 1.3.6.1.4.1.19376.1.5.3.1.3 | ||
|style="background-color:#D9D9D9; font-weight:bold" | CDA Section Template Identifiers | |style="background-color:#D9D9D9; font-weight:bold" | CDA Section Template Identifiers | ||
| | |||
|- | |- | ||
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Reasons For Care | |style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Reasons For Care | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.1 | |1.3.6.1.4.1.19376.1.5.3.1.3.1 | ||
|Reason for Referral | |Reason for Referral | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.2 | |1.3.6.1.4.1.19376.1.5.3.1.3.2 | ||
|Reason for Referral (coded) | |Reason for Referral (coded) | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 | ||
|Chief Complaint | |Chief Complaint | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.3 | |1.3.6.1.4.1.19376.1.5.3.1.3.3 | ||
|Hospital Admission Diagnosis | |Hospital Admission Diagnosis | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.1 | ||
|Proposed Procedure | |Proposed Procedure | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.2 | ||
|Estimated Blood Loss | |Estimated Blood Loss | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.3 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.3 | ||
|Proposed Anesthesia | |Proposed Anesthesia | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.4 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.4 | ||
|Reason for Procedure | |Reason for Procedure | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1 | ||
|Reason for Visit | |Reason for Visit | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 | ||
|Mode of Arrival | |Mode of Arrival | ||
| | |||
|- | |- | ||
|style="background-color:#EFEFEF; font-weight:bold;padding-left:60px" colspan="2" | Other Condition Histories | |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 | |1.3.6.1.4.1.19376.1.5.3.1.3.4 | ||
|History of Present Illness | |History of Present Illness | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.5 | |1.3.6.1.4.1.19376.1.5.3.1.3.5 | ||
|Hospital Course | |Hospital Course | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.6 | |1.3.6.1.4.1.19376.1.5.3.1.3.6 | ||
|Active Problems | |Active Problems | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.7 | |1.3.6.1.4.1.19376.1.5.3.1.3.7 | ||
|Discharge Diagnosis | |Discharge Diagnosis | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.8 | |1.3.6.1.4.1.19376.1.5.3.1.3.8 | ||
|History of Past Illness | |History of Past Illness | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3 | |1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3 | ||
|Encounter Histories | |Encounter Histories | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.9 | |1.3.6.1.4.1.19376.1.5.3.1.3.9 | ||
|History of Outpatient Visits | |History of Outpatient Visits | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.10 | |1.3.6.1.4.1.19376.1.5.3.1.3.10 | ||
|History of Inpatient Visits | |History of Inpatient Visits | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.11 | |1.3.6.1.4.1.19376.1.5.3.1.3.11 | ||
|List of Surgeries | |List of Surgeries | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.12 | |1.3.6.1.4.1.19376.1.5.3.1.3.12 | ||
|Coded List of Surgeries | |Coded List of Surgeries | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.13 | |1.3.6.1.4.1.19376.1.5.3.1.3.13 | ||
|Allergies and Other Adverse Reactions | |Allergies and Other Adverse Reactions | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.14 | |1.3.6.1.4.1.19376.1.5.3.1.3.14 | ||
|Family Medical History | |Family Medical History | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.15 | |1.3.6.1.4.1.19376.1.5.3.1.3.15 | ||
|Coded Family Medical History | |Coded Family Medical History | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.5 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.5 | ||
|Pre-procedure Family Medical History | |Pre-procedure Family Medical History | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.16 | |1.3.6.1.4.1.19376.1.5.3.1.3.16 | ||
|Social History | |Social History | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.17 | |1.3.6.1.4.1.19376.1.5.3.1.3.17 | ||
|Functional Status | |Functional Status | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1 | ||
|Coded Functional Status | |Coded Functional Status | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2 | ||
|Pain Scale Assessment | |Pain Scale Assessment | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3 | |1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3 | ||
|Braden Score Assessment | |Braden Score Assessment | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4 | |1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4 | ||
|Geriatric Depression Scale | |Geriatric Depression Scale | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5 | |1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5 | ||
|Physical Function | |Physical Function | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.18 | |1.3.6.1.4.1.19376.1.5.3.1.3.18 | ||
|Review of Systems | |Review of Systems | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.13 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.13 | ||
|Preprocedure Review of Systems | |Preprocedure Review of Systems | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1 | ||
|Hazardous Working Conditions | |Hazardous Working Conditions | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 | |1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 | ||
|Pregnancy History | |Pregnancy History | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1 | ||
|Estimated Delivery Dates Section | |Estimated Delivery Dates Section | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5 | |1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5 | ||
|Medical Devices | |Medical Devices | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6 | |1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6 | ||
|Foreign Travel | |Foreign Travel | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.8 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.8 | ||
|History of Tobacco Use | |History of Tobacco Use | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.10 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.10 | ||
|Current Alcohol/Substance Abuse | |Current Alcohol/Substance Abuse | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.12 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.12 | ||
|Transfusion History | |Transfusion History | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.14 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.14 | ||
|Anesthesia Risk Review of Systems | |Anesthesia Risk Review of Systems | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.46 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.46 | ||
|Implanted Medical Device Review | |Implanted Medical Device Review | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.47 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.47 | ||
|Pregnancy Status Review | |Pregnancy Status Review | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1 | ||
|History of Infection | |History of Infection | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1.1 | ||
|Coded History of Infection | |Coded History of Infection | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.16.1 | |1.3.6.1.4.1.19376.1.5.3.1.3.16.1 | ||
|Coded Social History | |Coded Social History | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.21.2.2 | ||
|Prenatal Events | |Prenatal Events | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 | |1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3 | ||
|Labor and Delivery | |Labor and Delivery | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 | |1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4 | ||
|Newborn Delivery Information | |Newborn Delivery Information | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.7 | |1.3.6.1.4.1.19376.1.5.3.1.1.21.2.7 | ||
|Post-partum Treatment | |Post-partum Treatment | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.8 | |1.3.6.1.4.1.19376.1.5.3.1.1.21.2.8 | ||
|Newborn Status at Maternal Discharge | |Newborn Status at Maternal Discharge | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.9 | |1.3.6.1.4.1.19376.1.5.3.1.1.21.2.9 | ||
|Event Outcomes | |Event Outcomes | ||
| | |||
|- | |- | ||
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Medications | |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 | |1.3.6.1.4.1.19376.1.5.3.1.3.19 | ||
|Medications | |Medications | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.20 | |1.3.6.1.4.1.19376.1.5.3.1.3.20 | ||
|Admission Medication History | |Admission Medication History | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.21 | |1.3.6.1.4.1.19376.1.5.3.1.3.21 | ||
|Medications Administered | |Medications Administered | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.22 | |1.3.6.1.4.1.19376.1.5.3.1.3.22 | ||
|Hospital Discharge Medications | |Hospital Discharge Medications | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.23 | |1.3.6.1.4.1.19376.1.5.3.1.3.23 | ||
|Immunizations | |Immunizations | ||
| | |||
|- | |- | ||
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Physical Exams | |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 | |1.3.6.1.4.1.19376.1.5.3.1.3.24 | ||
|Physical Exam | |Physical Exam | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.15 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.15 | ||
|Physical Exam (with subsections) | |Physical Exam (with subsections) | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.26 | |1.3.6.1.4.1.19376.1.5.3.1.3.26 | ||
|Hospital Discharge Physical Exam | |Hospital Discharge Physical Exam | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.25 | |1.3.6.1.4.1.19376.1.5.3.1.3.25 | ||
|Vital Signs | |Vital Signs | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 | ||
|Coded Vital Signs | |Coded Vital Signs | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.16 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.16 | ||
|General Appearance | |General Appearance | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.48 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.48 | ||
|Visible Implanted Medical Devices | |Visible Implanted Medical Devices | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.17 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.17 | ||
|Integumentary System | |Integumentary System | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.18 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.18 | ||
|Head | |Head | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.19 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.19 | ||
|Eyes | |Eyes | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.20 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.20 | ||
|Ears, Nose, Mouth and Throat | |Ears, Nose, Mouth and Throat | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.21 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.21 | ||
|Ears | |Ears | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.22 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.22 | ||
|Nose | |Nose | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.23 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.23 | ||
|Mouth, Throat, and Teeth | |Mouth, Throat, and Teeth | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.24 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.24 | ||
|Neck | |Neck | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.25 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.25 | ||
|Endocrine System | |Endocrine System | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.26 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.26 | ||
|Thorax and Lungs | |Thorax and Lungs | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.27 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.27 | ||
|Chest Wall | |Chest Wall | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.28 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.28 | ||
|Breasts | |Breasts | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.29 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.29 | ||
|Heart | |Heart | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.30 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.30 | ||
|Respiratory System | |Respiratory System | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.31 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.31 | ||
|Abdomen | |Abdomen | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.32 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.32 | ||
|Lymphatic System | |Lymphatic System | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.33 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.33 | ||
|Vessels | |Vessels | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.34 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.34 | ||
|Musculoskeletal System | |Musculoskeletal System | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.35 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.35 | ||
|Neurologic System | |Neurologic System | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.36 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.36 | ||
|Genitalia | |Genitalia | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.37 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.37 | ||
|Rectum | |Rectum | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1 | ||
|Extremeties | |Extremeties | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1 | ||
|Coded Physical Exam | |Coded Physical Exam | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.10 | |1.3.6.1.4.1.19376.1.5.3.1.1.21.2.10 | ||
|Pelvis | |Pelvis | ||
| | |||
|- | |- | ||
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Relevant Studies | |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 | |1.3.6.1.4.1.19376.1.5.3.1.3.27 | ||
|Results | |Results | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.28 | |1.3.6.1.4.1.19376.1.5.3.1.3.28 | ||
|Coded Results | |Coded Results | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.29 | |1.3.6.1.4.1.19376.1.5.3.1.3.29 | ||
|Hospital Studies Summary | |Hospital Studies Summary | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.30 | |1.3.6.1.4.1.19376.1.5.3.1.3.30 | ||
|Coded Hospital Studies Summary | |Coded Hospital Studies Summary | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8 | ||
|Consultations | |Consultations | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.5 | |1.3.6.1.4.1.19376.1.5.3.1.1.21.2.5 | ||
|Antenatal Testing and Surveillance | |Antenatal Testing and Surveillance | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.5.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.21.2.5.1 | ||
|Coded Antenatal Testing and Surveillance | |Coded Antenatal Testing and Surveillance | ||
| | |||
|- | |- | ||
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Plans of Care | |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 | |1.3.6.1.4.1.19376.1.5.3.1.3.31 | ||
|Care Plan | |Care Plan | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5 | ||
|Assessment and Plan | |Assessment and Plan | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.33 | |1.3.6.1.4.1.19376.1.5.3.1.3.33 | ||
|Discharge Diet | |Discharge Diet | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.34 | |1.3.6.1.4.1.19376.1.5.3.1.3.34 | ||
|Advance Directives | |Advance Directives | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.3.35 | |1.3.6.1.4.1.19376.1.5.3.1.3.35 | ||
|Coded Advance Directives | |Coded Advance Directives | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.40 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.40 | ||
|Procedure Care Plan | |Procedure Care Plan | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.45 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.45 | ||
|Procedure Care Plan Status Report | |Procedure Care Plan Status Report | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.50 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.50 | ||
|Health Maintenance Care Plan | |Health Maintenance Care Plan | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.41 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.41 | ||
|Health Maintenance Care Plan Status Report | |Health Maintenance Care Plan Status Report | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 | ||
|Transport Mode | |Transport Mode | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.21.2.1 | ||
|Birth Plan | |Birth Plan | ||
| | |||
|- | |- | ||
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Procedures Performed | |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 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.38 | ||
|Patient Education and Consents | |Patient Education and Consents | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.39 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.39 | ||
|Coded Patient Education and Consents | |Coded Patient Education and Consents | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11| | |1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11| | ||
Procedures Performed | Procedures Performed | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6 | ||
|Intravenous Fluids Administered | |Intravenous Fluids Administered | ||
| | |||
|- | |- | ||
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Impressions | |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 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.42 | ||
|Pre-procedure Impressions | |Pre-procedure Impressions | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.9.44 | |1.3.6.1.4.1.19376.1.5.3.1.1.9.44 | ||
|Pre-procedure Risk Assessment | |Pre-procedure Risk Assessment | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2 | ||
|Visit Summary Flowsheet Section | |Visit Summary Flowsheet Section | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7 | ||
|Progress Note | |Progress Note | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9 | ||
|ED Diagnoses | |ED Diagnoses | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2 | ||
|Acuity Assessment | |Acuity Assessment | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4 | ||
|Assessments | |Assessments | ||
| | |||
|- | |- | ||
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Administrative and Other Information | |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 | |1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7 | ||
|Payers | |Payers | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3 | ||
|Referral Source | |Referral Source | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 | ||
|Mode of Arrival | |Mode of Arrival | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10 | ||
|ED Disposition | |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" | 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 | |1.3.6.1.4.1.19376.1.5.3.1.4.1 | ||
|Severity | |Severity | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.1.1 | |1.3.6.1.4.1.19376.1.5.3.1.4.1.1 | ||
|Problem Status Observation | |Problem Status Observation | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.1.2 | |1.3.6.1.4.1.19376.1.5.3.1.4.1.2 | ||
|The template identifier used to identify a health status observation. | |The template identifier used to identify a health status observation. | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.2 | |1.3.6.1.4.1.19376.1.5.3.1.4.2 | ||
|The template identifier used to identify a comment on an observation. | |The template identifier used to identify a comment on an observation. | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.3 | |1.3.6.1.4.1.19376.1.5.3.1.4.3 | ||
|The template identifier used to identify instructions in medication order. | |The template identifier used to identify instructions in medication order. | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.3.1 | |1.3.6.1.4.1.19376.1.5.3.1.4.3.1 | ||
|Medication Fulfillment Instructions | |Medication Fulfillment Instructions | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.4 | |1.3.6.1.4.1.19376.1.5.3.1.4.4 | ||
|The template identifier used to identify references to external documents. | |The template identifier used to identify references to external documents. | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.4.1 | |1.3.6.1.4.1.19376.1.5.3.1.4.4.1 | ||
|Internal References | |Internal References | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.5.1 | |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. | |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 | |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. | |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 | |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. | |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 | |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. | |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 | |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. | |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 | |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. | |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 | |1.3.6.1.4.1.19376.1.5.3.1.4.12 | ||
|Immunizations | |Immunizations | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.7.3 | |1.3.6.1.4.1.19376.1.5.3.1.4.7.3 | ||
|Supply Entry | |Supply Entry | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.7.2 | |1.3.6.1.4.1.19376.1.5.3.1.4.7.2 | ||
|Product Entry | |Product Entry | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.13 | |1.3.6.1.4.1.19376.1.5.3.1.4.13 | ||
|Simple Observations | |Simple Observations | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.13.1 | |1.3.6.1.4.1.19376.1.5.3.1.4.13.1 | ||
|Vital Signs Organizer | |Vital Signs Organizer | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.13.2 | |1.3.6.1.4.1.19376.1.5.3.1.4.13.2 | ||
|Vital Signs Observation | |Vital Signs Observation | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.15 | |1.3.6.1.4.1.19376.1.5.3.1.4.15 | ||
|Family History Organizer | |Family History Organizer | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.13.3 | |1.3.6.1.4.1.19376.1.5.3.1.4.13.3 | ||
|Family History Observation | |Family History Observation | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.13.4 | |1.3.6.1.4.1.19376.1.5.3.1.4.13.4 | ||
|Social History Observation | |Social History Observation | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.13.5 | |1.3.6.1.4.1.19376.1.5.3.1.4.13.5 | ||
|Pregnancy Observation | |Pregnancy Observation | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1 | ||
|Estimated Delivery Date Observation | |Estimated Delivery Date Observation | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2 | ||
|Antepartum Visit Summary Battery | |Antepartum Visit Summary Battery | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.13.7 | |1.3.6.1.4.1.19376.1.5.3.1.4.13.7 | ||
|Advance Directive Observation | |Advance Directive Observation | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.13.6 | |1.3.6.1.4.1.19376.1.5.3.1.4.13.6 | ||
|Blood Type Observation | |Blood Type Observation | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.14 | |1.3.6.1.4.1.19376.1.5.3.1.4.14 | ||
|Encounters | |Encounters | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.16 | |1.3.6.1.4.1.19376.1.5.3.1.4.16 | ||
|Update Entry | |Update Entry | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.19 | |1.3.6.1.4.1.19376.1.5.3.1.4.19 | ||
|Procedure Entry | |Procedure Entry | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1 | ||
|Transport | |Transport | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2 | ||
|Intended Encounter Disposition | |Intended Encounter Disposition | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.17 | |1.3.6.1.4.1.19376.1.5.3.1.4.17 | ||
|Coverage Entry | |Coverage Entry | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.18 | |1.3.6.1.4.1.19376.1.5.3.1.4.18 | ||
|Payer Entry | |Payer Entry | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1 | ||
|Pain Score Observation | |Pain Score Observation | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2 | ||
|Braden Score Observation | |Braden Score Observation | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3 | |1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3 | ||
|Braden Score Component | |Braden Score Component | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.4 | |1.3.6.1.4.1.19376.1.5.3.1.1.12.3.4 | ||
|Geriatric Depression Score Observation | |Geriatric Depression Score Observation | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.5 | |1.3.6.1.4.1.19376.1.5.3.1.1.12.3.5 | ||
|Geriatric Depression Score Component | |Geriatric Depression Score Component | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7 | |1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7 | ||
|Survey Panel | |Survey Panel | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6 | |1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6 | ||
|Survey Observation | |Survey Observation | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1 | ||
|Acuity | |Acuity | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.3.2 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.3.2 | ||
|Intravenous Fluids Administered | |Intravenous Fluids Administered | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.13.3.4 | |1.3.6.1.4.1.19376.1.5.3.1.1.13.3.4 | ||
|Nursing Assessments Battery | |Nursing Assessments Battery | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.1.21.3.10 | |1.3.6.1.4.1.19376.1.5.3.1.1.21.3.10 | ||
|Antenatal Testing and Surveillance Battery | |Antenatal Testing and Surveillance Battery | ||
| | |||
|- | |- | ||
|1.3.6.1.4.1.19376.1.5.3.1.4.7.1 | |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). | |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 | |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. | |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 | |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. | |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 | |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. | |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 | |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. | |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. | ||
| | |||
|- | |- | ||
| | | | ||
Revision as of 08:40, 3 March 2010
PCC词表注册库与数据字典（PCC Vocabulary Registry and Data Dictionary）
本页面列出的是PCC委员会所掌控的各种词表和数据字典。在没有与PCC委员会进行协调的情况下，请勿编辑此页面。本页面旨在作为现行指定术语等的可靠参考。在PCC概貌文档记录尚未完善之前，不应当对某些术语赋予永久取值。
第1卷：小节与附录
| Chapter | Description | Status | OID Space |
|---|---|---|---|
| 3 | Cross-Enterprise Sharing of Medical Summaries (XDS-MS) | Final Text | 1.3.6.1.4.1.19376.1.5.3.1.1.2 |
| 4 | Exchange of Personal Health Record Content (XPHR) | Final Text | |
| 5 | ED Referral (EDR) | Final Text | 1.3.6.1.4.1.19376.1.5.3.1.1.10 |
| 6 | Reserved for Functional Status Assessments (FSA) | Under Revision | 1.3.6.1.4.1.19376.1.5.3.1.1.12 |
| 7 | Reserved for Emergency Department Encounter Summary (EDES) | Under Revision | 1.3.6.1.4.1.19376.1.5.3.1.1.13 |
| 8 | Reserved for Query for Existing Data (QED) | Trial Implementation | 1.3.6.1.4.1.19376.1.5.3.1.1.14 |
| 9 | Antepartum Record (APR) | Under Revision | 1.3.6.1.4.1.19376.1.5.3.1.1.16 |
| 10 | Care Management (CM) | Trial Implementation | 1.3.6.1.4.1.19376.1.5.3.1.1.17 |
| 11 | Immunization Content (IC) | Trial Implementation | 1.3.6.1.4.1.19376.1.5.3.1.1.18 |
| 12 | Patient Plan of Care (PPOC) | Trial Implementation | 1.3.6.1.4.1.19376.1.5.3.1.1.20 |
| 13 | Request for Clincal Guidance (QCG) | Trial Implementation | 1.3.6.1.4.1.19376.1.5.3.1.1.?? |
| 13 | EMS Transfer of Care (ETC) | Trial Implementation | 1.3.6.1.4.1.19376.1.5.3.1.1.19 |
| 13 | Labor and Delivery Record (LDR) | Under Revision | 1.3.6.1.4.1.19376.1.5.3.1.1.21 |
| A | Actor Descriptions | ||
| B | Transaction Descriptions | ||
| C | How to Prepare and IHE Integration Statement |
第2卷：交易与小节编号
| Number | Section and Transaction Name |
|---|---|
| PCC-1 | Query Existing Data |
| PCC-7 | Guideline Notification |
| PCC-8 | Request Guideline Data |
| PCC-9 | Care Management Data Query |
| PCC-10 | V3 Care Management Update |
| PCC-11 | V2 Care Management Update |
| Chapter | Description |
|---|---|
| 5.3.1 | Folder Content Module Reserved for APS |
| 5.4.1.10 - 13 | Document Content Modules Reserved for APS |
PCC模板标识符
| 模板标识符 | 英文描述 | 中文描述 |
| 1.3.6.1.4.1.19376.1.5.3.1.1 | CDA Document Template Identifiers | CDA文档模板标识符 |
| 1.3.6.1.4.1.19376.1.5.3.1.1.1 | Medical Document | 医疗文档 |
| 1.3.6.1.4.1.19376.1.5.3.1.1.2 | Medical Summary Template Identifier and XDS-MS formatCode | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.3 | Referral Summary | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.4 | Discharge Summary | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4 | History and Physical | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.5 | PHR Extract | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.6 | PHR Update | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.7 | Basic Patient Privacy Consent (BPPC) | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.10 | Emergency Department Referral (EDR) | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.11.2 | Antepartum Summary | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 | Triage Note | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2 | Nursing Note | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 | Composite Triage and Nursing Note | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 | ED Physician Note | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 | Antepartum History and Physical | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.2 | Antepartum Laboratory | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.3 | Antepartum Education | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2 | Immunization Detail | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.19.1 | Prehospital Patient Care Report | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 | Care Plan | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.20.1.2 | Subsequent Evaluation Note | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.1.1 | Labor and Delivery Admission History and Physical | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.1.2 | Labor and Delivery Summary | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.21.1.3 | Maternal Discharge Summary | |
| 1.3.6.1.4.1.19376.1.5.3.1.2 | CDA Header Template Identifiers | |
| 1.3.6.1.4.1.19376.1.5.3.1.2.1 | Language Communication | |
| 1.3.6.1.4.1.19376.1.5.3.1.2.2 | Employer and School Contacts | |
| 1.3.6.1.4.1.19376.1.5.3.1.2.3 | Healthcare Providers and Pharmacies | |
| 1.3.6.1.4.1.19376.1.5.3.1.2.4 | Patient Contacts | |
| 1.3.6.1.4.1.19376.1.5.3.1.2.4.1 | Spouse | |
| 1.3.6.1.4.1.19376.1.5.3.1.2.4.2 | Natural Father of Fetus | |
| 1.3.6.1.4.1.19376.1.5.3.1.2.5 | Authorization | |
| 1.3.6.1.4.1.19376.1.5.3.1.3 | CDA Section Template Identifiers | |
| Reasons For Care | ||
| 1.3.6.1.4.1.19376.1.5.3.1.3.1 | Reason for Referral | |
| 1.3.6.1.4.1.19376.1.5.3.1.3.2 | Reason for Referral (coded) | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 | 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 | |
| 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 | |
| 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 | |
| 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 | |
| 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 | |
| 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 | |
| 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 | |
|
Procedures Performed |
||
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6 | Intravenous Fluids Administered | |
| 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 | |
| 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 | |
| 1.3.6.1.4.1.19376.1.5.3.1.4 | 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 <substanceAdministration> 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 <substanceAdministration> event that records tapered dose information in subordinate <substanceAdministration> events. | |
| 1.3.6.1.4.1.19376.1.5.3.1.4.9 | The template identifier for a <substanceAdministration> event that records split dose information in subordinate <substanceAdministration> events. | |
| 1.3.6.1.4.1.19376.1.5.3.1.4.10 | The template identifier for a <substanceAdministration> event that records conditional dose information in subordinate <substanceAdministration> events. | |
| 1.3.6.1.4.1.19376.1.5.3.1.4.11 | The template identifier for a <substanceAdministration> event that records combination medication component information in subordinate <substanceAdministration> events. | |
第2卷：附录
| Chapter | Description |
|---|---|
| A | Examples |
| B | Validating CDA Documents |
| C | Extensions to CDA Release 2.0 |
参见
- PCC技术框架乃是正式的主文档。
- PCC名称空间与词表