1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1: Difference between revisions

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{{R|History of Present Illness|10164-2 HISTORY OF PRESENT ILLNESS|}}
{{R|History of Present Illness|10164-2 HISTORY OF PRESENT ILLNESS|}}
{{R|Active Problems|11450-4 PROBLEM LIST|}}
{{R|Active Problems|11450-4 PROBLEM LIST|}}
{{R|Resolved Problems|HISTORY OF PAST ILLNESS|}}
{{R|List of Surgeries|HISTORY OF PRIOR SURGERIES|}}
{{R|Immunizations|HISTORY OF IMMUNIZATIONS|}}
{{R|Family History|HISTORY OF FAMILY ILLNESS|}}
{{R|Social History|SOCIAL HISTORY|}}
{{R|Current Medications|10160-0 CURRENT MEDICATIONS|}}
{{R|Current Medications|10160-0 CURRENT MEDICATIONS|}}
{{R|Allergies|X-AARA ALLERGIES, ADVERSE REACTIONS, ALERTS|}}
{{R|Allergies|X-AARA ALLERGIES, ADVERSE REACTIONS, ALERTS|}}
Line 17: Line 22:
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|History of Present Illness|R|1.3.6.1.4.1.19376.1.5.3.1.3.4|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|History of Present Illness|R|1.3.6.1.4.1.19376.1.5.3.1.3.4|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Active Problems|R|1.3.6.1.4.1.19376.1.5.3.1.3.6|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Active Problems|R|1.3.6.1.4.1.19376.1.5.3.1.3.6|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Resolved Problems|R2|1.3.6.1.4.1.19376.1.5.3.1.3.8|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|List of Surgeries|R2|1.3.6.1.4.1.19376.1.5.3.1.3.11|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Immunizations|R2|1.3.6.1.4.1.19376.1.5.3.1.3.23|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Family History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.14|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Social History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.16|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Current Medications|R|1.3.6.1.4.1.19376.1.5.3.1.3.19|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Current Medications|R|1.3.6.1.4.1.19376.1.5.3.1.3.19|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Allergies|R|1.3.6.1.4.1.19376.1.5.3.1.3.13|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Allergies|R|1.3.6.1.4.1.19376.1.5.3.1.3.13|}}

Revision as of 13:30, 28 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

Triage Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1

The triage note specification includes sections for data commonly captured during the initial triage assessment of the patient. It includes historical information about the patient, vital signs, and assessments.



Data Element Index
Data Element LOINC
Chief Complaint 10154-3 CHIEF COMPLAINT
Mode of Arrival 11459-5 TRANSPORT MODE
History of Present Illness 10164-2 HISTORY OF PRESENT ILLNESS
Active Problems 11450-4 PROBLEM LIST
Resolved Problems HISTORY OF PAST ILLNESS
List of Surgeries HISTORY OF PRIOR SURGERIES
Immunizations HISTORY OF IMMUNIZATIONS
Family History HISTORY OF FAMILY ILLNESS
Social History SOCIAL HISTORY
Current Medications 10160-0 CURRENT MEDICATIONS
Allergies X-AARA ALLERGIES, ADVERSE REACTIONS, ALERTS
Acuity Assessment 11283-9 ACUITY ASSESSMENT
Vital Signs
Assessments

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

Specification
Data Element Name Opt Template ID
Chief Complaint R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
Mode of Arrival R 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
History of 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
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
Current Medications 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
Acuity Assessment R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2
Vital Signs R 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Assessments R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3


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 in the sample document below.

Sample Triage Note Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Triage 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 Triage 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>
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