1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3: Difference between revisions

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{{R|Social History|29762-2 SOCIAL HISTORY|}}
{{R|Social History|29762-2 SOCIAL HISTORY|}}
{{R|History of Pregnancies|10162-6 HISTORY OF PREGNANCIES|}}
{{R|History of Pregnancies|10162-6 HISTORY OF PREGNANCIES|}}
{{R|LMP|8665-2 DATE LAST MENSTRUAL PERIOD|}}
{{R|Current Medications|10160-0 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|}}
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Social History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.16|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Social History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.16|}}
{{CDA Document Content| |History of Pregnancies|R|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4|}}
{{CDA Document Content| |History of Pregnancies|R|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4|}}
{{CDA Document Content| |LMP|R| |}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Current Medications|R|1.3.6.1.4.1.19376.1.5.3.1.3.19|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Current Medications|R|1.3.6.1.4.1.19376.1.5.3.1.3.19|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Allergies|R|1.3.6.1.4.1.19376.1.5.3.1.3.13|}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Allergies|R|1.3.6.1.4.1.19376.1.5.3.1.3.13|}}
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|ED Disposition|R| |}}
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|ED Disposition|R| |}}
}}
}}
{{Fixme|Clean this up to same as other notes}}

Revision as of 17:55, 31 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

Composite Triage and Nursing Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3

The Composite Triage and Nursing Note specification may be employed where the ED triage note and nursing notes exist as a single document type.



Data Element Index
Data Element LOINC
Chief Complaint 10154-3 CHIEF COMPLAINT
Mode of Arrival 11459-5 TRANSPORT MODE
History of Present Illness 10164-2 HISTORY OF PRESENT ILLNESS
Active Problems 11450-4 PROBLEM LIST
Resolved Problems 11348-0 HISTORY OF PAST ILLNESS
List of Surgeries 47519-4 HISTORY OF PRIOR SURGERIES
Immunizations 11369-6 HISTORY OF IMMUNIZATIONS
Family History 10157-6 HISTORY OF FAMILY ILLNESS
Social History 29762-2 SOCIAL HISTORY
History of Pregnancies 10162-6 HISTORY OF PREGNANCIES
Current Medications 10160-0 CURRENT MEDICATIONS
Allergies X-AARA ALLERGIES, ADVERSE REACTIONS, ALERTS
Acuity Assessment 11283-9 ACUITY ASSESSMENT
Vital Signs 8716-3 VITAL SIGNS
Assessments
Level of Consciousness
Pain Scale Assessment 38212-7 Pain assessment panel
Interventions 29554-3 Procedure
Medications Administered 18610-6 MEDICATION ADMINISTERED (COMPOSITE)
Intravenous Fluids Administered
ED Disposition 11302-7 ED DISPOSITION

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 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
History of Present Illness R 1.3.6.1.4.1.19376.1.5.3.1.3.4
Active Problems R 1.3.6.1.4.1.19376.1.5.3.1.3.6
Resolved Problems R2 1.3.6.1.4.1.19376.1.5.3.1.3.8
List of Surgeries R2 1.3.6.1.4.1.19376.1.5.3.1.3.11
Immunizations R2 1.3.6.1.4.1.19376.1.5.3.1.3.23
Family History R2 1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History R2 1.3.6.1.4.1.19376.1.5.3.1.3.16
History of Pregnancies R 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Current Medications R 1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies R 1.3.6.1.4.1.19376.1.5.3.1.3.13
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 R2 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3
Level of Consciousness O 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
Pain Scale Assessment O 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
Interventions
Record the interventions performed 		R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5
Medications Administered R
Intravenous Fluids Administered R
Procedures Performed 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 Composite Triage and Nursing 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>Composite Triage and Nursing 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 Composite Triage and Nursing 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>


This text needs to be fixed-->>Clean this up to same as other notes<<--

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