PCC Public Comment Drafts/2: Difference between revisions

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{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.4|Reason for Procedure|PPHP}}
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Revision as of 22:27, 19 June 2007

CDA Section Content Modules

This list defines the sections that may appear in a medical document. It is intended to be a comprehensive list of all document sections that are used by any content profile defined in the Patient Care Coordination Technical Framework. All sections shall have a narrative component that may be freely formatted into normal text, lists, tables, or other appropriate human-readable presentations. Additional subsections or entry content modules may be required.

Reasons for Care

The sections described below describe various reasons why healthcare is being provided to the patient.

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 https://www.ihe.net/resources/technical_frameworks/#pcc

Reason for Referral Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.1
General Description The reason for referral section shall contain a narrative description of the reason that the patient is being referred.
LOINC Code Opt Description
42349-1 R REASON FOR REFERRAL



Sample Reason for Referral Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
    <id root=' ' extension=' '/>
    <code code='42349-1' displayName='REASON FOR REFERRAL'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.1'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.1"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Reason for Referral can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "42349-1"]'> 
     Error: The section type code of a Reason for Referral must be 42349-1 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Reason for Referral Section


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 https://www.ihe.net/resources/technical_frameworks/#pcc

Coded Reason for Referral Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.2
Parent Template Reason for Referral (1.3.6.1.4.1.19376.1.5.3.1.3.1)
General Description This section shall include at least one entry describing the reason for referral as described in the Entry Content Module.
LOINC Code Opt Description
42349-1 R REASON FOR REFERRAL
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.13 R Simple Observations
1.3.6.1.4.1.19376.1.5.3.1.4.5 R Conditions Entry



Parent Template

The parent of this template is Reason for Referral.

Sample Coded Reason for Referral Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.2'/>
    <id root=' ' extension=' '/>
    <code code='42349-1' displayName='REASON FOR REFERRAL'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Simple Observations element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
         :
    </entry> 
    <entry>
         :
      <!-- Required Conditions Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Coded Reason for Referral can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.1"]'> 
     Error: The parent template identifier for Coded Reason for Referral is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "42349-1"]'> 
     Error: The section type code of a Coded Reason for Referral must be 42349-1 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded Reason for Referral Section must contain a(n) Simple Observations Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.2
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.5"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded Reason for Referral Section must contain a(n) Conditions Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.2
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Coded Reason for Referral Section


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 https://www.ihe.net/resources/technical_frameworks/#pcc

Chief Complaint Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
General Description This contains a narrative description of the patient's chief complaint.
LOINC Code Opt Description
10154-3 R CHIEF COMPLAINT



Sample Chief Complaint Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/>
    <id root=' ' extension=' '/>
    <code code='10154-3' displayName='CHIEF COMPLAINT'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Chief Complaint can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10154-3"]'> 
     Error: The section type code of a Chief Complaint must be 10154-3 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Chief Complaint Section


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 https://www.ihe.net/resources/technical_frameworks/#pcc

Hospital Admission Diagnosis Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.3
General Description The hospital admitting diagnosis section shall contain a narrative description of the primary reason for admission to a hospital facility. It shall include entries for observations as described in the Entry Content Modules.
LOINC Code Opt Description
46241-6 R HOSPITAL ADMISSION DX
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.5.2 R Problem Concern Entry



Sample Hospital Admission Diagnosis Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.3'/>
    <id root=' ' extension=' '/>
    <code code='46241-6' displayName='HOSPITAL ADMISSION DX'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Problem Concern Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.3'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.3"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Hospital Admission Diagnosis can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "46241-6"]'> 
     Error: The section type code of a Hospital Admission Diagnosis must be 46241-6 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.5.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Hospital Admission Diagnosis Section must contain a(n) Problem Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.3
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Hospital Admission Diagnosis Section


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 https://www.ihe.net/resources/technical_frameworks/#pcc

Proposed Procedure Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.1
General Description The proposed procedure section shall contain a description of the procedures for which a risk assessment is required including procedure names and codes, patient position, dates, and names of surgeons. It shall include entries for procedures as described in the Entry Content Modules and the required and optional subsections.
LOINC Code Opt Description
29554-3 R PROCEDURE
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.19 R Procedure Entry
Subsections Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.9.4 R Reason for Procedure
1.3.6.1.4.1.19376.1.5.3.1.1.9.3 R Proposed Anesthesia
1.3.6.1.4.1.19376.1.5.3.1.1.9.2 R2 Expected Blood Loss
1.3.6.1.4.1.19376.1.5.3.1.1.9.40 R2 Procedure Care Plan



Sample Proposed Procedure Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.1'/>
    <id root=' ' extension=' '/>
    <code code='29554-3' displayName='PROCEDURE'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Procedure Entry  element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
         :
    </entry>
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.4'/>
        <!-- Required Reason for Procedure Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.3'/>
        <!-- Required Proposed Anesthesia Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.2'/>
        <!-- Required if known Expected Blood Loss Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.40'/>
        <!-- Required if known Procedure Care Plan Section content -->
      </section>
    </component>

       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.1'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.1"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Proposed Procedure can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "29554-3"]'> 
     Error: The section type code of a Proposed Procedure must be 29554-3 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Proposed Procedure Section must contain a(n) Procedure Entry  Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Proposed Procedure Section must contain a(n) Reason for Procedure Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Proposed Procedure Section must contain a(n) Proposed Anesthesia Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.2"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Proposed Procedure Section should contain a(n) Expected Blood Loss Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.40"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Proposed Procedure Section should contain a(n) Procedure Care Plan Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.1
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Proposed Procedure Section


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 https://www.ihe.net/resources/technical_frameworks/#pcc

Estimated Blood Loss Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.2
General Description The estimated blood loss section shall contain a description of the blood loss for the procedure.
LOINC Code Opt Description
8717-1 R OPERATIVE NOTE ESTIMATED BLOOD LOSS
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.13 R Simple Observations



Sample Estimated Blood Loss Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.2'/>
    <id root=' ' extension=' '/>
    <code code='8717-1' displayName='OPERATIVE NOTE ESTIMATED BLOOD LOSS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Simple Observations element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Estimated Blood Loss can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "8717-1"]'> 
     Error: The section type code of a Estimated Blood Loss must be 8717-1 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Estimated Blood Loss Section must contain a(n) Simple Observations Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.2
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Estimated Blood Loss Section


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 https://www.ihe.net/resources/technical_frameworks/#pcc

Proposed Anesthesia Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.3
General Description The proposed anesthesia section shall contain a description of the anesthetic techniques for which a risk assessment is required. It shall include entries for anesthetic procedures as described in the Entry Content Modules.
LOINC Code Opt Description
10213-7 R OPERATIVE NOTE ANESTHESIA
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.19 R Procedure Entry
The procedure entries shall be in INT mood.



Sample Proposed Anesthesia Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.3'/>
    <id root=' ' extension=' '/>
    <code code='10213-7' displayName='OPERATIVE NOTE ANESTHESIA'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Procedure Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.3'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.3"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Proposed Anesthesia can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10213-7"]'> 
     Error: The section type code of a Proposed Anesthesia must be 10213-7 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Proposed Anesthesia Section must contain a(n) Procedure Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.3 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Proposed Anesthesia Section


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 https://www.ihe.net/resources/technical_frameworks/#pcc

Reason for Procedure Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.4
General Description The reason for procedure section shall contain a description of the reason that the patient is receiving the procedure. It shall include entries for conditions as described in the Entry Content Module.
LOINC Code Opt Description
10217-8 R OPERATIVE NOTE INDICATIONS
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.5 R2 Conditions Entry



Sample Reason for Procedure Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.4'/>
    <id root=' ' extension=' '/>
    <code code='10217-8' displayName='OPERATIVE NOTE INDICATIONS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required if known Conditions Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.4'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.4"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Reason for Procedure can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10217-8"]'> 
     Error: The section type code of a Reason for Procedure must be 10217-8 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.5"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Reason for Procedure Section should contain a(n) Conditions Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.4
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Reason for Procedure Section



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