Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.10"

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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Physical Exam|R2|1.3.6.1.4.1.19376.1.5.3.1.3.24|}}
 
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Physical Exam|R2|1.3.6.1.4.1.19376.1.5.3.1.3.24|}}
 
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports (Lab, Imaging, EKG’s, etc.) including links.|R2|1.3.6.1.4.1.19376.1.5.3.1.3.27|}}
 
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports (Lab, Imaging, EKG’s, etc.) including links.|R2|1.3.6.1.4.1.19376.1.5.3.1.3.27|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Plan of Care (new meds, labs, or x-rays ordered)|R2|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1|{{Ref|edrvms}} }}
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|<u>''Plan of Care (new meds, labs, or x-rays ordered)''</u>|<u>''R2''</u>|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Mode of Transport to the Emergency Department|R|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2|{{Ref|edrvms}} }}
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|<u>''Mode of Transport to the Emergency Department''</u>|<u>''R''</u>|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 }}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Estimated Time of Arrival|R2|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1|{{Ref|edrvms}} }}
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|<u>''Estimated Time of Arrival''</u>|<u>''R2''</u>|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Proposed disposition|R2|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2|{{Ref|edrvms}}}}
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|<u>''Proposed disposition''</u>|<u>''R2''</u>|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Advance Directives|R|1.3.6.1.4.1.19376.1.5.3.1.3.34|{{Ref|edrvms}} The availability of information about Advance Directives must provided.  A common concern among ED providers is over situations where patients presented to the ED require extensive resuscitative efforts, only later to discover that the patient had a DNR order.}}
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|<u>''Advance Directives''</u>|<u>''R''</u>|1.3.6.1.4.1.19376.1.5.3.1.3.34|The availability of information about Advance Directives must provided.  A common concern among ED providers is over situations where patients presented to the ED require extensive resuscitative efforts, only later to discover that the patient had a DNR order.}}
 
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Patient Administrative Identifiers|R||These are handed by the Medical Documents Content Profile by reference to constraints in HL7 CRS.|}}
 
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Patient Administrative Identifiers|R||These are handed by the Medical Documents Content Profile by reference to constraints in HL7 CRS.|}}
 
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Pertinent Insurance Information|R2|TBD|}}
 
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.10|Pertinent Insurance Information|R2|TBD|}}
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# {{EndNote|edrvms}}These data elements are different from what appears in the XDS-MS profile.  All other data elements have identical definitions.
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{{Note|<u>''Highlighted''</u> items in the table above are different from what appears in the XDS-MS profile.  All other data elements have identical definitions.}}

Revision as of 12:20, 15 May 2007

Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

Draft.gif Emergency Department Referral Specification 1.3.6.1.4.1.19376.1.5.3.1.1.10

An ED Referral is a type of Referral Summary, and incorporates the constraints defined for Referral Summaries(1.3.6.1.4.1.19376.1.5.3.1.1.3) .

Conformance

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown below in Figure 5.4 4. Note that an ED Referral is a Referral Summary, and so includes that <templateId> element as well.

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.10"/>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.3"/>
    :

A CDA Document may conform to more than one template, and can therefore have more that one <templateId> element. Both of the <templateId> elements shown above must be present in the document.

This use case is described fully in Link TBD. Briefly, it involves a collaborative transfer of care for the referral of a patient from a care provider to an emergency department. Using this use case the contents of documents used in collaborative transfers of care were discussed with physicians and nurses in detail to identify major sections. The sections identified by physicians during the use case exercise as important are listed in the table below under the column “Use Case Documentation Section”.

Using this information from the use case, the following mappings were made to existing standards.




Data Element Index
Data Elements HL7 Care Record Summary CDA Release 2.0
Reason for Referral Reason for Referral REASON FOR REFERRAL
History Present Illness History of Present Illness HISTORY OF PRESENT ILLNESS
Active Problems Conditions PROBLEM LIST
Current Meds Medications HISTORY OF MEDICATION USE
Allergies Allergies and Adverse Reactions HISTORY OF ALLERGIES
Resolved Problems Conditions HISTORY OF PAST ILLNESS
List of Surgeries Past Surgical History HISTORY OF PRIOR SURGERIES
Immunizations Immunizations HISTORY OF IMMUNIZATIONS
Family History Family History HISTORY OF FAMILY ILLNESS
Social History Social History SOCIAL HISTORY
Pertinent Review of Systems Review of Systems REVIEW OF SYSTEMS
Vital Signs Physical Exam VITAL SIGNS
Physical Exam Physical Exam GENERAL STATUS, PHYSICAL FINDINGS
Relevant Surgical Procedures / Clinical Reports (including links) Studies and Reports RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Relevant Diagnostic Test and Reports (Lab, Imaging, EKG’s, etc.) including links. Studies and Reports RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Plan of Care (new meds labs, or x-rays ordered) Care Plan TREATMENT PLAN
Proposed disposition Care Plan TREATMENT PLAN
Mode of Transport to the Emergency Department Care Plan MODE OF TRANSPORT
Estimated Time of Arrival to the ED Care Plan MODE OF TRANSPORT
Advance Directives Advance Directives ADVANCE DIRECTIVES
Patient Administrative Identifiers Header patientRole/id
Pertinent Insurance Information Participant participant[@roleCode='HLD']
Data needed for state and local referral forms, if different than above Optional Sections section

Transition to new CDA Document template to support schematron-->>Data<<--

Specification
Data Element Name Opt Template ID
Reason for Referral R 1.3.6.1.4.1.19376.1.5.3.1.3.1
History Present Illness R 1.3.6.1.4.1.19376.1.5.3.1.3.4
Active Problems R 1.3.6.1.4.1.19376.1.5.3.1.3.6
Current Meds R 1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies R 1.3.6.1.4.1.19376.1.5.3.1.3.13
Resolved Problems R2 1.3.6.1.4.1.19376.1.5.3.1.3.8
List of Surgeries R2 1.3.6.1.4.1.19376.1.5.3.1.3.11
Immunizations R2 1.3.6.1.4.1.19376.1.5.3.1.3.23
Family History R2 1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History R2 1.3.6.1.4.1.19376.1.5.3.1.3.16
Pertinent Review of Systems O 1.3.6.1.4.1.19376.1.5.3.1.3.18
Vital Signs R2 1.3.6.1.4.1.19376.1.5.3.1.3.25
Physical Exam R2 1.3.6.1.4.1.19376.1.5.3.1.3.24
Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports (Lab, Imaging, EKG’s, etc.) including links. R2 1.3.6.1.4.1.19376.1.5.3.1.3.27
Plan of Care (new meds, labs, or x-rays ordered) C 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1
Mode of Transport to the Emergency Department C 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
Estimated Time of Arrival C 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1
Proposed disposition C 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2
Advance Directives
The availability of information about Advance Directives must provided. A common concern among ED providers is over situations where patients presented to the ED require extensive resuscitative efforts, only later to discover that the patient had a DNR order.
C 1.3.6.1.4.1.19376.1.5.3.1.3.34
Patient Administrative Identifiers
These are handed by the Medical Documents Content Profile by reference to constraints in HL7 CRS.
R
Pertinent Insurance Information R2 TBD
Data needed for state and local referral forms, if different than above
These are handed by including additional sections within the summary.
R2


Conformance

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below.

Sample Emergency Department Referral Document
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Emergency Department Referral</title>
  <effectiveTime value='20240915012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
       
  </structuredBody></component>
</ClinicalDocument>

 

   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Emergency Department Referral must be {{{LOINC}}}
   </assert>
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
     Error: The document type code must come from the LOINC code 
     system (2.16.840.1.113883.6.1).
   </assert>


Note: Highlighted items in the table above are different from what appears in the XDS-MS profile. All other data elements have identical definitions.