SampleDocumentOID
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
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-->>Data<<--
Specification
| Data Element Name | Opt | Template ID |
|---|---|---|
| Chief Complaint | R | |
| History of Present Illness | R | |
| Acuity | R | |
| Vital Signs | R | |
| Assessment | 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.
<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='20240715012005'/> <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>
Instructions
This is a sample document demonstrating the use of the Template:CDA Document, Template:CDA Document Code and Template:CDA Document Content templates. To create a new document specification for an IHE PCC Profile, you simply create a new page, and enter the following wiki text and save it:
{{subst:Sample Document}}
This will include this Sample Document page. Change the content so that everywhere "Sample Document" appears, it now contains the name of the page you just created. Then update the rows appearing in the {{CDA Document Code| and {{CDA Document Content| rows to list the sections or entries that should appear in the document.
Update the description, and you have now created a CDA Document specification for the profile.
Click on the links within the table after you are finished editing the CDA Document Specification specification to begin work on each of the section or entry specifications in your folder. See Sample Section for an example section from which to work.