1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1: Difference between revisions

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Index={{T|Data Element|A|B|Rows=
Index={{T|Data Element|A|B|Rows=
{{R|Chief Complaint||}}
{{R|Chief Complaint||}}
{{R|Mode of Arrival||}}
{{R|History of Present Illness||}}
{{R|History of Present Illness||}}
{{R|Acuity||}}
{{R|Active Problems - may need PMH LOINC||}}
{{R|Current Medications||}}
{{R|Allergies||}}
{{R|Acuity Assessment||}}
{{R|Vital Signs||}}
{{R|Vital Signs||}}
{{R|Assessment||}}
{{R|Assessments||}}
}}
}}
|Data=
|Data=
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Chief Complaint|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Chief Complaint|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1|}}
{{CDA Document Content| |Mode of Arrival|R| |}}
{{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|Acuity|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2|}}
{{CDA Document Content| |Active Problems - may need PMH LOINC|R| |}}
{{CDA Document Content| |Current Medications|R| |}}
{{CDA Document Content| |Allergies|R| |}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Acuity Assessment|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Vital Signs|R|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Vital Signs|R|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Assessment|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Assessments|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3|}}
}}
}}

Revision as of 21:28, 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

Triage Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1

Fill this in



Data Element Index
Data Element A B
Chief Complaint
Mode of Arrival
History of Present Illness
Active Problems - may need PMH LOINC
Current Medications
Allergies
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
History of Present Illness R 1.3.6.1.4.1.19376.1.5.3.1.3.4
Active Problems - may need PMH LOINC R
Current Medications R
Allergies R
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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