1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3: Difference between revisions
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Index={{T|Data Element|LOINC|Rows= | Index={{T|Data Element|LOINC|Rows= | ||
{{R|Referral Source||}} | {{R|Referral Source|11293-8 ED REFERRAL SOURCE|}} | ||
{{R|Mode of Arrival||}} | {{R|Mode of Arrival|11459-5 TRANSPORT MODE|}} | ||
{{R|Chief Complaint||}} | {{R|Chief Complaint|10154-3 CHIEF COMPLAINT FIND|}} | ||
{{R|History of Present Illness||}} | {{R|History of Present Illness|10164-2 HISTORY OF PRESENT ILLNESS|}} | ||
{{R|Active Problems||}} | {{R|Active Problems|10160-0 HISTORY OF MEDICATION USE|}} | ||
{{R|Current Medications||}} | {{R|Current Medications||}} | ||
{{R| | {{R|Allergies|X-AARA ALLERGIES, ADVERSE REACTIONS, ALERTS|}} | ||
{{R|List of Surgeries||}} | {{R|List of Surgeries|10167-5 HISTORY OF SURGICAL PROCEDURES|}} | ||
{{R|Immunizations||}} | {{R|Immunizations|11369-6 HISTORY OF IMMUNIZATIONS|}} | ||
{{R|Family History||}} | {{R|Family History|10157-6 HISTORY OF FAMILY MEMBER DISEASES|}} | ||
{{R|Social History||}} | {{R|Social History|29762-2 SOCIAL HISTORY|}} | ||
{{R|History of Pregnancies||}} | {{R|History of Pregnancies|10162-6 HISTORY OF PREGNANCIES|}} | ||
{{R|LMP||}} | {{R|LMP|8665-2 DATE LAST MENSTRUAL PERIOD|}} | ||
{{R|Pertinent ROS||}} | {{R|Pertinent ROS|10187-3 REVIEW OF SYSTEMS|}} | ||
{{R|Vital Signs||}} | {{R|Vital Signs||}} | ||
{{R|Physical Examination||}} | {{R|Physical Examination|22029-3 PHYSICAL EXAM.TOTAL|}} | ||
{{R|Assessment||}} | {{R|Assessment|X-AAPLN ASSESSMENT AND PLAN|}} | ||
{{R|Medications Administered||}} | {{R|Medications Administered|18610-6 MEDICATION ADMINISTERED (COMPOSITE)|}} | ||
{{R|Intravenous Fluids Administered||}} | {{R|Intravenous Fluids Administered||}} | ||
{{R|Procedures Performed||}} | {{R|Procedures Performed|XXXXX-X PROCEDURE PERFORMED|}} | ||
{{R|Test Results: Lab, ECG, Radiology||}} | {{R|Test Results: Lab, ECG, Radiology|30954-2 STUDIES SUMMARY|}} | ||
{{R|Consultations||}} | {{R|Consultations|11488-4 CONSULTATION NOTE {SETTING} ATTACH.CLINRPT|}} | ||
{{R|Progress Note||}} | {{R|Progress Note|18733-6 SUBSEQUENT EVALUATION NOTE (ATTENDING PHYSICIAN)|}} | ||
{{R|ED Diagnoses||}} | {{R|ED Diagnoses|11301-9 ED DIAGNOSIS|}} | ||
{{R|ED Disposition||}} | {{R|ED Disposition|11302-7 ED DISPOSITION|}} | ||
Revision as of 21:22, 29 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 | LOINC |
|---|---|
| Referral Source | 11293-8 ED REFERRAL SOURCE |
| Mode of Arrival | 11459-5 TRANSPORT MODE |
| Chief Complaint | 10154-3 CHIEF COMPLAINT FIND |
| History of Present Illness | 10164-2 HISTORY OF PRESENT ILLNESS |
| Active Problems | 10160-0 HISTORY OF MEDICATION USE |
| Current Medications | |
| Allergies | X-AARA ALLERGIES, ADVERSE REACTIONS, ALERTS |
| List of Surgeries | 10167-5 HISTORY OF SURGICAL PROCEDURES |
| Immunizations | 11369-6 HISTORY OF IMMUNIZATIONS |
| Family History | 10157-6 HISTORY OF FAMILY MEMBER DISEASES |
| Social History | 29762-2 SOCIAL HISTORY |
| History of Pregnancies | 10162-6 HISTORY OF PREGNANCIES |
| LMP | 8665-2 DATE LAST MENSTRUAL PERIOD |
| Pertinent ROS | 10187-3 REVIEW OF SYSTEMS |
| Vital Signs | |
| Physical Examination | 22029-3 PHYSICAL EXAM.TOTAL |
| Assessment | X-AAPLN ASSESSMENT AND PLAN |
| Medications Administered | 18610-6 MEDICATION ADMINISTERED (COMPOSITE) |
| Intravenous Fluids Administered | |
| Procedures Performed | XXXXX-X PROCEDURE PERFORMED |
| Test Results: Lab, ECG, Radiology | 30954-2 STUDIES SUMMARY |
| Consultations | 11488-4 CONSULTATION NOTE {SETTING} ATTACH.CLINRPT |
| Progress Note | 18733-6 SUBSEQUENT EVALUATION NOTE (ATTENDING PHYSICIAN) |
| ED Diagnoses | 11301-9 ED DIAGNOSIS |
| ED Disposition | 11302-7 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 | 1.3.6.1.4.1.19376.1.5.3.1.1.9.15 |
| 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>