1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1: Difference between revisions

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{{R|Vital Signs|8716-3 VITAL SIGNS|}}
{{R|Vital Signs|8716-3 VITAL SIGNS|}}
{{R|Assessments|XASSES-X|}}
{{R|Assessments|XASSES-X|}}
{{R|Level of Consciousness|XLOC-X LEVEL OF CONSCIOUSNESS}}
{{R|Pain Scale Assessment|38212-7 PAIN ASSESSMENT PANEL}}
{{R|Interventions Performed|NURIN-T NURSING INTERVENTIONS}}
{{R|Interventions|29554-3 PROCEDURE}}
{{R|Medications Administered|18610-6 MEDICATION ADMINISTERED (COMPOSITE)}}
{{R|Intravenous Fluids Administered|XIVFLU-X INTRAVENOUS FLUID ADMINISTERED (COMPOSITE)}}
}}
}}
|LOINC=X-TRIAGE|LOINCName=TriageNote
|LOINC=X-TRIAGE|LOINCName=TriageNote
Line 34: Line 40:
|Section|Vital Signs|R|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2|
|Section|Vital Signs|R|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2|
|Section|Nursing Assessments|R2|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4|
|Section|Nursing Assessments|R2|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4|
|Section|Level of Consciousness|O|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9|
|Section|Pain Scale Assessment|O|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10|
|Section|Interventions|R2|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5|This section is used to record interventions performed 
|Section|Procedures Performed|R2|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7|
|Section|Medications Administered|R2|1.3.6.1.4.1.19376.1.5.3.1.3.21|
|Section|Intravenous Fluids Administered|R2|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6|
}}
}}
==Sections==
==Sections==
{{:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1}}
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{{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7}}
{{:1.3.6.1.4.1.19376.1.5.3.1.3.21}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6}}

Revision as of 00:52, 1 June 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

The triage note specification includes sections for data commonly captured during the initial triage assessment of the patient. It includes historical information about the patient, vital signs, and assessments.


LOINC Code

The LOINC code for this document is X-TRIAGE TriageNote

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 XASSES-X
Level of Consciousness XLOC-X LEVEL OF CONSCIOUSNESS
Pain Scale Assessment 38212-7 PAIN ASSESSMENT PANEL
Interventions Performed NURIN-T NURSING INTERVENTIONS
Interventions 29554-3 PROCEDURE
Medications Administered 18610-6 MEDICATION ADMINISTERED (COMPOSITE)
Intravenous Fluids Administered XIVFLU-X INTRAVENOUS FLUID ADMINISTERED (COMPOSITE)
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
This section should contain one entry containing the date (TS) of last menstrual period for women of childbearing age, using LOINC Code 8665-2 DATE LAST MENSTRUAL PERIOD 		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
Nursing Assessments R2 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
Level of Consciousness O 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9
Pain Scale Assessment O 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10
Interventions
This section is used to record interventions performed 		R2 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5
Procedures Performed R2 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7
Medications Administered R2 1.3.6.1.4.1.19376.1.5.3.1.3.21
Intravenous Fluids Administered R2 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6


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='X-TRIAGE' displayName='TriageNote'
    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>
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/>
        <!-- Required Chief Complaint Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/>
        <!-- Required Mode of Arrival Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Required History of Present Illness Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required Active Problems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required if known Resolved Problems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
        <!-- Required if known List of Surgeries Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
        <!-- Required if known Immunizations Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/>
        <!-- Required if known Family History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/>
        <!-- Required if known Social History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/>
        <!-- Required History of Pregnancies Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Current Medications Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
        <!-- Required Allergies Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2'/>
        <!-- Required Acuity Assessment Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
        <!-- Required Vital Signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'/>
        <!-- Required if known Nursing Assessments Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9'/>
        <!-- Optional Level of Consciousness Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'/>
        <!-- Optional Pain Scale Assessment Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5'/>
        <!-- Required if known Interventions Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7'/>
        <!-- Required if known Procedures Performed Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/>
        <!-- Required if known Medications Administered Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6'/>
        <!-- Required if known Intravenous Fluids Administered Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Triage Note can only be used on Clinical Documents.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "X-TRIAGE"]'>
     Error: The document type code of a Triage Note must be X-TRIAGE
   </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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) Chief Complaint Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) Mode of Arrival Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) History of Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) Resolved Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) List of Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) History of Pregnancies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) Current Medications Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) Acuity Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) Nursing Assessments Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9"]'> 
     <!-- Note any missing optional elements -->
     Note: This Triage Note Document does not contain a(n) Level of Consciousness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10"]'> 
     <!-- Note any missing optional elements -->
     Note: This Triage Note Document does not contain a(n) Pain Scale Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) Interventions Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) Procedures Performed Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.21"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) Medications Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) Intravenous Fluids Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
 </rule>
</pattern>

Sections

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

Transport Mode Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
General Description The transport mode section contains a description of the mode of transport and the time of departure or arrival of the patient to a facility.
LOINC Code Opt Description
11459-5 R TRANSPORT MODE
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1 R Transport
This entry provides coded values giving the mode and time of departure or arrival of the patient to a facility.



Sample Transport Mode Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/>
    <id root=' ' extension=' '/>
    <code code='11459-5' displayName='TRANSPORT MODE'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Transport element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Transport Mode can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11459-5"]'> 
     Error: The section type code of a Transport Mode must be 11459-5 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Transport Mode Section must contain a(n) Transport Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Transport Mode 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

History of Present Illness Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.4
General Description The history of present illness section shall contain a narrative description of the sequence of events preceding the patient’s current complaints.
LOINC Code Opt Description
10164-2 R HISTORY OF PRESENT ILLNESS



Sample History of Present Illness Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
    <id root=' ' extension=' '/>
    <code code='10164-2' displayName='HISTORY OF PRESENT ILLNESS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.4'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The History of Present Illness can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10164-2"]'> 
     Error: The section type code of a History of Present Illness must be 10164-2 
   </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 History of Present Illness 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

Active Problems Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.6
Parent Template CCD 3.5 (2.16.840.1.113883.10.20.1.11)
General Description The active problem section shall contain a narrative description of the conditions currently being monitored for the patient. It shall include entries for patient conditions as described in the Entry Content Module.
LOINC Code Opt Description
11450-4 R PROBLEM LIST
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.5.2 R Problem Concern Entry



Parent Template

The parent of this template is CCD 3.5.

Sample Active Problems Section 
<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.11'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
    <id root=' ' extension=' '/>
    <code code='11450-4' displayName='PROBLEM LIST'
      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_1.3.6.1.4.1.19376.1.5.3.1.3.6'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Active Problems can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.11"]'> 
     Error: The parent template identifier for Active Problems is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11450-4"]'> 
     Error: The section type code of a Active Problems must be 11450-4 
   </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 Active Problems Section must contain a(n) Problem Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.6
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Active Problems 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

History of Past Illness Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.8
General Description The History of Past Illness section shall contain a narrative description of the conditions the patient suffered in the past. It shall include entries for problems as described in the Entry Content Modules.
LOINC Code Opt Description
11348-0 R HISTORY OF PAST ILLNESS
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.5.2 R Problem Concern Entry



Sample History of Past Illness Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
    <id root=' ' extension=' '/>
    <code code='11348-0' displayName='HISTORY OF PAST ILLNESS'
      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_1.3.6.1.4.1.19376.1.5.3.1.3.8'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The History of Past Illness can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11348-0"]'> 
     Error: The section type code of a History of Past Illness must be 11348-0 
   </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 History of Past Illness Section must contain a(n) Problem Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.8
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the History of Past Illness 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

List of Surgeries Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.11
Parent Template CCD 3.14 (2.16.840.1.113883.10.20.1.12)
General Description The list of surgeries section shall contain a narrative description of the diagnostic and therapeutic operative procedures and associated anesthetic techniques the patient received in the past.
LOINC Code Opt Description
47519-4 R HISTORY OF PROCEDURES



Parent Template

The parent of this template is CCD 3.14.

Sample List of Surgeries Section 
<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.12'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
    <id root=' ' extension=' '/>
    <code code='47519-4' displayName='HISTORY OF PROCEDURES'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.11'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The List of Surgeries can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.12"]'> 
     Error: The parent template identifier for List of Surgeries is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "47519-4"]'> 
     Error: The section type code of a List of Surgeries must be 47519-4 
   </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 List of Surgeries 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

Immunizations Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.23
Parent Template CCD 3.11 (2.16.840.1.113883.10.20.1.6)
General Description The immunizations section shall contain a narrative description of the immunizations administered to the patient in the past. It shall include entries for medication administration as described in the Entry Content Modules.
LOINC Code Opt Description
11369-6 R HISTORY OF IMMUNIZATIONS
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.12 R Immunization



Parent Template

The parent of this template is CCD 3.11.

Sample Immunizations Section 
<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.6'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
    <id root=' ' extension=' '/>
    <code code='11369-6' displayName='HISTORY OF IMMUNIZATIONS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Immunization element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.23'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Immunizations can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.6"]'> 
     Error: The parent template identifier for Immunizations is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11369-6"]'> 
     Error: The section type code of a Immunizations must be 11369-6 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.12"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Immunizations Section must contain a(n) Immunization Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.23
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Immunizations 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

Family Medical History Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.14
Parent Template CCD 3.6 (2.16.840.1.113883.10.20.1.4)
General Description The family history section shall contain a narrative description of the genetic family members, to the extent that they are known, the diseases they suffered from, their ages at death, and other relevant genetic information.
LOINC Code Opt Description
10157-6 R HISTORY OF FAMILY MEMBER DISEASES



Parent Template

The parent of this template is CCD 3.6.

Sample Family Medical History Section 
<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.4'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/>
    <id root=' ' extension=' '/>
    <code code='10157-6' displayName='HISTORY OF FAMILY MEMBER DISEASES'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.14'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Family Medical History can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.4"]'> 
     Error: The parent template identifier for Family Medical History is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10157-6"]'> 
     Error: The section type code of a Family Medical History must be 10157-6 
   </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> 
 </rule> 
</pattern>
Uses

See Templates using the Family Medical History 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

Social History Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.16
Parent Template CCD 3.7 (2.16.840.1.113883.10.20.1.15)
General Description The social history section shall contain a narrative description of the person’s beliefs, home life, community life, work life, hobbies, and risky habits.
LOINC Code Opt Description
29762-2 R SOCIAL HISTORY



Parent Template

The parent of this template is CCD 3.7.

Sample Social History Section 
<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.15'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/>
    <id root=' ' extension=' '/>
    <code code='29762-2' displayName='SOCIAL HISTORY'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.16'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Social History can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.15"]'> 
     Error: The parent template identifier for Social History is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "29762-2"]'> 
     Error: The section type code of a Social History must be 29762-2 
   </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 Social History 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

Pregnancy History Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
General Description The pregnancy history section contains coded entries describing the patient history of pregnancies.
LOINC Code Opt Description
10162-6 R HISTORY OF PREGNANCIES
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.13.5 R Pregnancy Observation



Sample Pregnancy History Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/>
    <id root=' ' extension=' '/>
    <code code='10162-6' displayName='HISTORY OF PREGNANCIES'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Pregnancy Observation  element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Pregnancy History can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10162-6"]'> 
     Error: The section type code of a Pregnancy History must be 10162-6 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.13.5"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Pregnancy History Section must contain a(n) Pregnancy Observation  Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Pregnancy History 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

Medications Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.19
Parent Template CCD 3.9 (2.16.840.1.113883.10.20.1.8)
General Description The medications section shall contain a description of the relevant medications for the patient, e.g. an ambulatory prescription list. It shall include entries for medications as described in the Entry Content Module.
LOINC Code Opt Description
10160-0 R HISTORY OF MEDICATION USE
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.7 R Medications



Parent Template

The parent of this template is CCD 3.9.

Sample Medications Section 
<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.8'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
    <id root=' ' extension=' '/>
    <code code='10160-0' displayName='HISTORY OF MEDICATION USE'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Medications element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.19'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Medications can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.8"]'> 
     Error: The parent template identifier for Medications is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10160-0"]'> 
     Error: The section type code of a Medications must be 10160-0 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.7"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Medications Section must contain a(n) Medications Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.19
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Medications Section



Note: this LOINC code is typically used to record the current medication list found in an EHR.

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

Allergies and Other Adverse Reactions Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.13
Parent Template CCD 3.8 (2.16.840.1.113883.10.20.1.2)
General Description The allergies and other adverse reactions section shall contain a narrative description of the substance intolerances and the associated adverse reactions suffered by the patient. It shall include entries for intolerances and adverse reactions as described in the Entry Content Modules.
LOINC Code Opt Description
48765-2 R Allergies, adverse reactions, alerts
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.5.3 R Allergies and Intolerances Concern



Parent Template

The parent of this template is CCD 3.8. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.2

Sample Allergies and Other Adverse Reactions Section 
<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.2'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
    <id root=' ' extension=' '/>
    <code code='48765-2' displayName='Allergies, adverse reactions, alerts'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Allergies and Intolerances Concern element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.3'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.13'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Allergies and Other Adverse Reactions can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.2"]'> 
     Error: The parent template identifier for Allergies and Other Adverse Reactions is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "48765-2"]'> 
     Error: The section type code of a Allergies and Other Adverse Reactions must be 48765-2 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.5.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Allergies and Other Adverse Reactions Section must contain a(n) Allergies and Intolerances Concern Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.13
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Allergies and Other Adverse Reactions 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

Acuity Assessment Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2
General Description The Acuity Assessment section contains a description of the acuity of the patient upon presentation to the Emergency department.
LOINC Code Opt Description
11283-9 R ACUITY ASSESSMENT
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1 R Acuity
This entry provides coded values giving the triage acuity.



Sample Acuity Assessment Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2'/>
    <id root=' ' extension=' '/>
    <code code='11283-9' displayName='ACUITY ASSESSMENT'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Acuity element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Acuity Assessment can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11283-9"]'> 
     Error: The section type code of a Acuity Assessment must be 11283-9 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Acuity Assessment Section must contain a(n) Acuity Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Acuity Assessment 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 Vital Signs Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Parent Template Vital Signs (1.3.6.1.4.1.19376.1.5.3.1.3.25)
General Description The vital signs section contains coded measurement results of a patient’s vital signs.
LOINC Code Opt Description
8716-3 R VITAL SIGNS
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.13.1 R Vital Signs Organizer



Parent Template

The parent of this template is Vital Signs.

Sample Coded Vital Signs Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
    <id root=' ' extension=' '/>
    <code code='8716-3' displayName='VITAL SIGNS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Vital Signs Organizer element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.1'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Coded Vital Signs can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     Error: The parent template identifier for Coded Vital Signs is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "8716-3"]'> 
     Error: The section type code of a Coded Vital Signs must be 8716-3 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.13.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded Vital Signs Section must contain a(n) Vital Signs Organizer Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Coded Vital Signs 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

Assessments Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
General Description The assessments section contains narrative assessments of the patient status.
LOINC Code Opt Description
X-ASSESS R ASSESSMENTS
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.13.3.4 O Nursing Assessments Battery



Sample Assessments Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'/>
    <id root=' ' extension=' '/>
    <code code='X-ASSESS' displayName='ASSESSMENTS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Optional Nursing Assessments Battery element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.3.4'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Assessments can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "X-ASSESS"]'> 
     Error: The section type code of a Assessments must be X-ASSESS 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.3.4"]'> 
     <!-- Note any missing optional elements -->
     Note: This Assessments Section does not contain a(n) Nursing Assessments Battery Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Assessments 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

ED Diagnosis Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9
General Description The ED diagnosis section shall contain a narrative description of the conditions that were diagnosed or addressed during the ED course, as well as those active conditions that modify the complexity of the patient encounter. It should include entries for patient conditions as described in the Entry Content Module.
LOINC Code Opt Description
11301-9 R ED DIAGNOSIS
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.5 R Conditions Entry



Sample ED Diagnosis Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9'/>
    <id root=' ' extension=' '/>
    <code code='11301-9' displayName='ED DIAGNOSIS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <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_1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The ED Diagnosis can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11301-9"]'> 
     Error: The section type code of a ED Diagnosis must be 11301-9 
   </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"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Diagnosis Section must contain a(n) Conditions Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the ED 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

ED Disposition Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10
General Description The ED Disposition section contains descriptions of the various components of ED Disposition, including disposition from the ED, time of disposition, intended transportation mode, time of transport, and the non-ED practitioner the patient's care will be transferred to.
LOINC Code Opt Description
11302-7 R ED DISPOSITION
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2 R Encounter Disposition
This required entry describes the expected or actual disposition of the patient after the emergency department encounter has been completed.



Sample ED Disposition Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'/>
    <id root=' ' extension=' '/>
    <code code='11302-7' displayName='ED DISPOSITION'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Encounter Disposition element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The ED Disposition can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11302-7"]'> 
     Error: The section type code of a ED Disposition must be 11302-7 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Disposition Section must contain a(n) Encounter Disposition Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the ED Disposition 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

Assessment and Plan Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5
General Description The assessment and plan section shall contain a narrative description of the assessment of the patient condition and expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient.
LOINC Code Opt Description
51847-2 R ASSESSMENT AND PLAN



Sample Assessment and Plan Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5'/>
    <id root=' ' extension=' '/>
    <code code='51847-2' displayName='ASSESSMENT AND PLAN'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Assessment and Plan can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "51847-2"]'> 
     Error: The section type code of a Assessment and Plan must be 51847-2 
   </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 Assessment and Plan 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

Progress Note Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7
General Description The Progress Note section shall contain a narrative description of the sequence of events from initial assessment to discharge for an encounter.
LOINC Code Opt Description
18733-6 R SUBSEQUENT EVALUATION NOTE (ATTENDING PHYSICIAN)



Sample Progress Note Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7'/>
    <id root=' ' extension=' '/>
    <code code='18733-6' displayName='SUBSEQUENT EVALUATION NOTE (ATTENDING PHYSICIAN)'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Progress Note can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "18733-6"]'> 
     Error: The section type code of a Progress Note must be 18733-6 
   </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> 
 </rule> 
</pattern>
Uses

See Templates using the Progress Note 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

Medications Administered Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.21
General Description The medications administered section shall contain a narrative description of the relevant medications administered to a patient during the course of an encounter. It shall include entries for medication administration as described in the Entry Content Module.
LOINC Code Opt Description
18610-6 R MEDICATION ADMINISTERED
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.7 R Medications



Sample Medications Administered Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/>
    <id root=' ' extension=' '/>
    <code code='18610-6' displayName='MEDICATION ADMINISTERED'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Medications element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.21'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.21"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Medications Administered can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "18610-6"]'> 
     Error: The section type code of a Medications Administered must be 18610-6 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.7"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Medications Administered Section must contain a(n) Medications Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.21
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Medications Administered 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

Intravenous Fluids Administered Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
General Description The intravenous fluids administered section shall contain a narrative description of fluids administered to a patient during the course of an encounter. It may include entries for IV fluid administration as described in the Entry Content Module.
LOINC Code Opt Description
57072-1 R INTRAVASCULAR FLUID INTAKE
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.13.3.2 R Intravenous Fluids



Sample Intravenous Fluids Administered Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6'/>
    <id root=' ' extension=' '/>
    <code code='57072-1' displayName='INTRAVASCULAR FLUID INTAKE'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Intravenous Fluids element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.3.2'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Intravenous Fluids Administered can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "57072-1"]'> 
     Error: The section type code of a Intravenous Fluids Administered must be 57072-1 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Intravenous Fluids Administered Section must contain a(n) Intravenous Fluids Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Intravenous Fluids Administered Section


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