Aps vol2 content-modules cda-r2-content-modules: Difference between revisions

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|Data=
|Data=
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.13|Allergies|R||Must include observation of Latex Allergy}}
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.13|Allergies|R||Must include observation of Latex Allergy}}
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.39|Advance Directives|R||Must include observation of blood transfusion acceptable?}}}}
  {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.39|Advance Directives|R||Must include observation of blood transfusion acceptable?}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.31|Plan of Care|R||Must include observation stating if an anesthesia consult is planned}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.19|Medications|R||}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.3.6|Problems|R||}}
}}
{{CDA Document|docname2|did2|draft|desc2|
{{CDA Document|docname2|did2|draft|desc2|
|Data=
|Data=
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====CDA Section Content Modules====
====CDA Section Content Modules====
{{CDA Section|sectionname|oid|draft|desc1
{{CDA Section|Estimated Due Dates|1.2.6.1.4.1.19376.1.5.3.1.1.11.2.1|draft|This section houses the physicians best estimate of the patients due date.  This is generally done both on an initial evaluation, and later confirmed at 18-20 weeks.  The date is supported by evidence such as the patients history of last menstral period, a physical examination, or ultrasound measurements.  If an gestational age based on ultrasound is present, it is generally considered the most accurate measurement and so that date would be chosen.
|Parent=ParentOID
|Code={{CDA Section Code|Estimated Due Dates|EntryName1|R|(LOINC-requested)|}}
|ParentName=ParentName
|Entry={{CDA Section Content|Estimated Due Date Observation|entN|R|1.2.6.1.4.1.19376.1.5.3.1.1.11.2.1|if one observation is present, then it is to be interpreted as the initial EDD.  If observations dates indicate the EDD is within 20 weeks, the most recent observation will also be interpreted as the 18-20 week update.}}
|Code={{CDA Section Code|sectionName|EntryName1|R|loinc|comment1}}
|Entry={{CDA Section Content|secN|entN|R2|oidN|comN}}
}}
}}


====CDA Entry Content Modules====
====CDA Entry Content Modules====

Revision as of 10:44, 26 May 2007

CDA Release 2 Content Modules

CDA Document Content Modules

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

Antepartum Summary Form C, F & G Specification 1.3.6.1.4.1.19376.1.5.3.1.1.11.2

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

Specification
Data Element Name Opt Template ID
Allergies
Must include observation of Latex Allergy 		R
Advance Directives
Must include observation of blood transfusion acceptable? 		R
Plan of Care
Must include observation stating if an anesthesia consult is planned 		R
Medications R
Problems 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 Antepartum Summary Form C, F & G Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Antepartum Summary Form C, F & G</title>
  <effectiveTime value='20260408012005'/>
  <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 Antepartum Summary Form C, F & G 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>

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

docname2 Specification did2

desc2



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

Specification
Data Element Name Opt Template ID
sect1 R sid1


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 docname2 Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='did2'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>docname2</title>
  <effectiveTime value='20260408012005'/>
  <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 docname2 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>

CDA Header Content Modules

CDA Section Content Modules

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 Due Dates Section
Template ID 1.2.6.1.4.1.19376.1.5.3.1.1.11.2.1
General Description This section houses the physicians best estimate of the patients due date. This is generally done both on an initial evaluation, and later confirmed at 18-20 weeks. The date is supported by evidence such as the patients history of last menstral period, a physical examination, or ultrasound measurements. If an gestational age based on ultrasound is present, it is generally considered the most accurate measurement and so that date would be chosen.
LOINC Codes Opt Description
(LOINC-requested) R EntryName1
Entries Opt Description
1.2.6.1.4.1.19376.1.5.3.1.1.11.2.1 R entN
if one observation is present, then it is to be interpreted as the initial EDD. If observations dates indicate the EDD is within 20 weeks, the most recent observation will also be interpreted as the 18-20 week update.



Sample Estimated Due Dates Section 
<component>
  <section>
    <templateId root='1.2.6.1.4.1.19376.1.5.3.1.1.11.2.1'/>
    <id root=' ' extension=' '/>
    <code code=' ' displayName=' '
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
    <entry>
      Required and optional entries as described above
    </entry>

       
  </section>
</component>


Uses

See Templates using the Estimated Due Dates Section



CDA Entry Content Modules

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