1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3: Difference between revisions

From IHE Wiki
Jump to navigation Jump to search
← Older editNewer edit →
Trothenh (talk | contribs)
364 edits
No edit summary
Trothenh (talk | contribs)
364 edits
No edit summary
Line 7: Line 7:
{{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|10160-0 HISTORY OF MEDICATION USE|}}
{{R|Active Problems|10160-0 HISTORY OF MEDICATION USE|}}
{{R|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|}}
{{R|List of Surgeries|10167-5 HISTORY OF SURGICAL PROCEDURES|}}
{{R|List of Surgeries|10167-5 HISTORY OF SURGICAL PROCEDURES|}}

Revision as of 21:33, 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 10160-0 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

Transition to new CDA Document template to support schematron-->>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.

Sample ED Physician Note Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3'/>
  <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>
Retrieved from "http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3&oldid=6337"