1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3: Difference between revisions
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{{R|Physical Examination||}} | {{R|Physical Examination||}} | ||
{{R|Assessment||}} | {{R|Assessment||}} | ||
{{R|Medications Administered||}} | |||
{{R|Intravenous Fluids Administered||}} | |||
{{R|Procedures Performed||}} | |||
{{R|Test Results: Lab, ECG, Radiology||}} | |||
{{R|Consultations||}} | |||
{{R|Progress Note||}} | |||
{{R|ED Diagnoses||}} | |||
{{R|ED Disposition||}} | |||
}} | }} | ||
|Data= | |Data= | ||
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{{CDA Document Content| |Physical Examination|R| |}} | {{CDA Document Content| |Physical Examination|R| |}} | ||
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Assessment|R||}} | {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Assessment|R||}} | ||
{{CDA Document Content| |Medications Administered|R| |}} | |||
{{CDA Document Content| |Intravenous Fluids Administered|R| |}} | |||
{{CDA Document Content| |Procedures Performed|R| |}} | |||
{{CDA Document Content| |Test Results: Lab, ECG, Radiology|R| |}} | |||
{{CDA Document Content| |Consultations|R| |}} | |||
{{CDA Document Content| |Progress Note|R| |}} | |||
{{CDA Document Content| |ED Diagnoses|R| |}} | |||
{{CDA Document Content| |ED Disposition|R| |}} | |||
}} | }} | ||
Revision as of 21:14, 23 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
ED Physician Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
Fill this in
Data Element Index
| Data Element | A | B |
|---|---|---|
| Referral Source | ||
| Mode of Arrival | ||
| Chief Complaint | ||
| History of Present Illness | ||
| Active Problems | ||
| Current Medications | ||
| Alergies | ||
| List of Surgeries | ||
| Immunizations | ||
| Family History | ||
| Social History | ||
| History of Pregnancies | ||
| LMP | ||
| Pertinent ROS | ||
| Vital Signs | ||
| Physical Examination | ||
| Assessment | ||
| Medications Administered | ||
| Intravenous Fluids Administered | ||
| Procedures Performed | ||
| Test Results: Lab, ECG, Radiology | ||
| Consultations | ||
| Progress Note | ||
| ED Diagnoses | ||
| ED Disposition |
-->>Data<<--
Specification
| Data Element Name | Opt | Template ID |
|---|---|---|
| Referral Source | R | |
| Mode of Arrival | R | |
| Chief Complaint | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 |
| History of Present Illness | R | |
| Active Problems | R | |
| Current Medications | R | |
| Alergies | R | |
| List of Surgeries | R | |
| Immunizations | R | |
| Family History | R | |
| Social History | R | |
| History of Pregnancies | R | |
| LMP | R | |
| Pertinent ROS | R | |
| Vital Signs | R | |
| Physical Examination | R | |
| Assessment | R | |
| Medications Administered | R | |
| Intravenous Fluids Administered | R | |
| Procedures Performed | R | |
| Test Results: Lab, ECG, Radiology | R | |
| Consultations | R | |
| Progress Note | R | |
| ED Diagnoses | R | |
| ED Disposition | R |
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.
<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>ED Physician Note</title> <effectiveTime value='20260407012005'/> <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 ED Physician Note 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>