Volume 2

HIMSS and RSNA
Integrating the Healthcare Enterprise

IHE Patient Care Coordination

Technical Framework
Volume 2

Revision 2.0
2006-2007

Comment

Preface to Volume 2

Intended Audience

The intended audience of this document is:

Technical staff of vendors planning to participate in the IHE initiative
IT departments of healthcare institutions
Experts involved in standards development
Anyone interested in the technical aspects of integrating healthcare information systems

Copyright Permissions

Material drawn from these documents is credited where used.

How to Contact Us

IHE Sponsors welcome comments on this document and the IHE initiative. They should be directed to the discussion server at http://forums.rsna.org or to:

Didi Davis
Director of Integrating the Healthcare Enterprise
230 East Ohio St., Suite 500
Chicago, IL 60611
Email: ihe@himss.org

Introduction

This document, the IHE Patient Care Coordination Technical Framework (PCC TF), defines specific implementations of established standards. These are intended to achieve integration goals that promote appropriate exchange of medical information to coordinate the optimal patient care among care providers in different care settings. It is expanded annually, after a period of public review, and maintained regularly through the identification and correction of errata. The latest version of the document is always available via the Internet at http://www.ihe.net/Technical_Framework/index.cfm , where the technical framework volumes specific to the various healthcare domains addressed by IHE may be found.

The IHE Patient Care Coordination Technical Framework identifies a subset of the functional components of the healthcare enterprises and health information networks, called IHE actors, and specifies their interactions in terms of a set of coordinated, standards-based transactions.

The other domains within the IHE initiative also produce Technical Frameworks within their respective areas that together form the IHE Technical Framework. Currently, the following IHE Technical Framework(s) are available:

IHE IT Infrastructure Technical Framework
IHE Cardiology Technical Framework
IHE Laboratory Technical framework
IHE Radiology Technical Framework
IHE Patient Care Coordination Technical Framework

Where applicable, references are made to other technical frameworks. For the conventions on referencing other frameworks, see the preface of this volume.

Relationship to Standards

The IHE Technical Framework identifies functional components of a distributed healthcare environment (referred to as IHE actors), solely from the point of view of their interactions in the healthcare enterprise. At its current level of development, it defines a coordinated set of transactions based on standards (such as HL7, IETF, ASTM, DICOM, ISO, OASIS, etc.) in order to accomplish a particular use case. As the scope of the IHE initiative expands, transactions based on other standards may be included as required.

Each transaction may have as its payload one or more forms of content, as well as specific metadata describing that content within the transaction. The specification of the payload and metadata about it are the components of a Content Integration Profile. The payload is specified in a Content Module, and the impacts of any particular payload on a transaction are described within a content binding. The payloads of each transaction are also based on standards (such as HL7, IETF, ASTM, DICOM, ISO, OASIS, etc.), again, in order to meet the needs of a specific use case.

In some cases, IHE recommends selection of specific options supported by these standards. However, IHE does not introduce technical choices that contradict conformance to these standards. If errors in or extensions to existing standards are identified, IHE's policy is to report them to the appropriate standards bodies for resolution within their conformance and standards evolution strategy.

IHE is therefore an implementation framework, not a standard. Conformance claims for products must still be made in direct reference to specific standards. In addition, vendors who have implemented IHE integration capabilities in their products may publish IHE Integration Statements to communicate their products' capabilities. Vendors publishing IHE Integration Statements accept full responsibility for their content. By comparing the IHE Integration Statements from different products, a user familiar with the IHE concepts of actors and integration profiles can determine the level of integration between them. See PCC TF-1: Appendix C for the format of IHE Integration Statements.

Relationship to Product Implementations

The IHE actors and transactions described in the IHE Technical Framework are abstractions of the real-world healthcare information system environment. While some of the transactions are traditionally performed by specific product categories (e.g. HIS, Clinical Data Repository, Electronic Health record systems, Radiology Information Systems, Clinical Information Systems or Cardiology Information Systems), the IHE Technical Framework intentionally avoids associating functions or actors with such product categories. For each actor, the IHE Technical Framework defines only those functions associated with integrating information systems. The IHE definition of an actor should therefore not be taken as the complete definition of any product that might implement it, nor should the framework itself be taken to comprehensively describe the architecture of a healthcare information system.

The reason for defining actors and transactions is to provide a basis for defining the interactions among functional components of the healthcare information system environment. In situations where a single physical product implements multiple functions, only the interfaces between the product and external functions in the environment are considered to be significant by the IHE initiative. Therefore, the IHE initiative takes no position as to the relative merits of an integrated environment based on a single, all-encompassing information system versus one based on multiple systems that together achieve the same end.

Relation of this Volume to the Technical Framework

The IHE Technical Framework is based on actors that interact through transactions using some form of content.

Actors are information systems or components of information systems that produce, manage, or act on information associated with operational activities in the enterprise.

Transactions are interactions between actors that transfer the required information through standards-based messages.

The implementation of the transactions described in this PCC TF-2 support the specification of Integration Profiles defined in PCC TF-1. The role and implementation of these transactions require the understanding of the Integration profile they support.

There is often a very clear distinction between the transactions in a messaging framework used to package and transmit information, and the information content actually transmitted in those messages. This is especially true when the messaging framework begins to move towards mainstream computing infrastructures being adopted by the healthcare industry.

In these cases, the same transactions may be used to support a wide variety of use cases in healthcare, and so more and more the content and use of the message also needs to be profiled, sometimes separately from the transaction itself. Towards this end IHE has developed the concept of a Content Integration Profile.

Content Integration Profiles specify how the payload of a transaction fits into a specific use of that transaction. A content integration profile has three main parts. The first part describes the use case. The second part is binding to a specific IHE transaction, which describes how the content affects the transaction. The third part is a Content Module, which describes the payload of the transaction. A content module is specified so as to be independent of the transaction in which it appears.

Content Modules

The Patient Care Coordination Technical Framework organizes content modules categorically by the base standard. At present, the PCC Technical Framework uses only one base standard, CDA Release 2.0, but this is expected to change over time. Underneath each standard, the content modules are organized using a very coarse hierarchy inherent to the standard. So for CDA Release 2.0 the modules are organized by document, section, entry, and header elements.

Each content module can be viewed as the definition of a "class" in software design terms, and has associated with it a name. Like "class" definitions in software design, a content module is a "contract", and the PCC Technical Framework defines that contract in terms of constraints that must be obeyed by instances of that content module. Each content module has a name, also known as its template identifier. The template identifiers are used to identify the contract agreed to by the content module. The PCC Technical Committee is responsible for assigning the template identifiers to each content module.

Like classes, content modules may inherit features of other content modules of the same type (Document, Section or Entry) by defining the parent content module that they inherit from. They may not inherit features from a different type. Although information in the CDA Header is in a different location that information in a CDA Entry, these two content modules are considered to be of the same type, and so may inherit from each other when necessary.

The PCC Technical Framework uses the convention that a content module cannot have more than one parent (although it may have several ancestors). This is similar to the constraint in the Java™ programming language, where classes can derive from only one parent. This convention is not due to any specific technical limitation of the technical framework, but does make it easier for software developers to implement content modules.

Each content module has a list of data elements that are required (R), required if known (R2), and optional (O). The presentation of this information varies with the type of content module, and is described in more detail below. Additional data elements may be provided by the sender that are not defined by a specific content module, but the receiver is not required to interpret them.

Required data elements must always be sent. Data elements that are required may under exceptional circumstances have an unknown value (e.g., the name of an unconscious patient). In these cases the sending application is required to indicate the reason that the data is not available.

Data elements that are marked required if known (R2) must be sent when the sending application has that data available. The sending application must be able to demonstrate that it can send all required if known elements, unless it does not in fact gather that data. When the information is not available, the sending application may indicate the reason that the data is not available.

Data elements that are marked optional (O) may be sent at the choice of the sending application. Since a content module may include data elements not specified by the profile, some might ask why these are specified in a content module. The reason for specifying the optional data elements is to ensure that both sender and receiver use the appropriate semantic interpretation of these elements. Thus, an optional element need not be sent, but when it is sent, the content module defines the meaning of that data element, and a receiver can always be assured of what that data element represents when it is present. Senders should not send an optional data element with an unknown value. If the value is not known, simply do not send the data element.

Other data elements may be included in an instance of a content module over what is defined by the PCC Technical Framework. Receivers are not required to process these elements, and if they do not understand them, must ignore them. Thus, it is not an error to include more than is asked for, but it is an error to reject a content module because it contains more than is defined by the framework. This allows value to be added to the content modules delivered in this framework, through extensions to it that are not defined or profiled by IHE. It further allows content modules to be defined later by IHE that are refinements or improvements over previous content modules.

For example, there is a Referral Summary content module defined in this framework. In later years an ED Referral content module can be created that inherits the constraints of the Referral Summary content module, with a few more use case specific constraints added. Systems that do not understand the ED Referral content module but do understand the Referral Summary content module will be able to interoperate with systems that send instances of documents that conform to the ED Referral content module. This interoperability, albeit at a reduced level of functionality, is by virtue of the fact that ED Referrals are simply a refinement of the Referral Summary.

In order to retain this capability, there are a few rules about how the PCC Technical Committee creates constraints. Constraints that apply to any content module will always apply to any content modules that inherit from it. Thus, the "contracts" are always valid down the inheritance hierarchy. Secondly, data elements of a content module will rarely be deprecated. This will usually occur only in the cases where they have been deprecated by the base standard. While any specific content module has a limited scope and set of use cases, deprecating the data element prevents any future content module from taking advantage of what has already been defined when a particular data element has been deprecated simply because it was not necessary in the original use case.

Document Content Module Constraints

Each document content module will define the appropriate codes used to classify the document, and will also describe the specific data elements that are included. The code used to classify it is specified using an external vocabulary, typically LOINC in the case of CDA Release 2.0 documents. The set of data elements that make up the document are defined, including the whether these data elements must, should or may be included in the document. Each data element is typically a section within the document, but may also describe information that is contained elsewhere within of the document (e.g., in the header). Each data element is mapped into a content module via a template identifier, and the document content module will further indicate whether these are data elements are required, required if known or optional.

Thus, a document content module shall contain as constraints:

The template identifier of the parent content module when there is one.
The LOINC code or codes that shall be used to classify the document.
A possibly empty set of required, required if known, and optional section content modules, and their template identifiers.
A possibly empty set of required, required if known, and optional header content modules, and their template identifiers.
Other constraints as necessary.

The template identifier for the document will be provided in the narrative, as will the legal LOINC document type codes and if present, any parent template identifier.

The remaining constraints are presented in two tables. The first table identifies the relevant data elements as determined during the technical analysis, and maps these data elements to one or more standards. The second table actually provides the constraints, wherein each data element identified in the first table is repeated, along with whether it is required, required if known, or optional. Following this column is a reference to the specification for the content module that encodes that data element, and the template identifier assigned to it. The simple example below completes the content specification described above. A simplified example is shown below.

== 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

Sample Document Specification SampleDocumentOID

Sample Document has one required section, and one entry that is required if known

Specification

Data Element Name	Opt	Template ID
Sample Section Comment on section	R	SampleSectionOID
Sample Entry Comment on entry	R2	SampleEntryOID

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 Sample Document Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='SampleDocumentOID'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Sample Document</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='SampleSectionOID'/>
        <!-- Required Sample Section Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_SampleDocumentOID'>
 <rule context='*[cda:templateId/@root="SampleDocumentOID"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Sample Document can only be used on Clinical Documents.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Sample Document 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> 
   <assert test='.//cda:templateId[@root = "SampleSectionOID"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Sample Document Document must contain a(n) Sample Section Section.
     See http://wiki.ihe.net/index.php?title=SampleDocumentOID 
   </assert> 
   <assert test='.//cda:templateId[@root = "SampleEntryOID"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Sample Document Document should contain a(n) Sample Entry Entry.
     See http://wiki.ihe.net/index.php?title=SampleDocumentOID 
   </assert> 
 </rule>
</pattern>

}}

Section Content Module Constraints

Section content modules will define the content of a section of a clinical document. Sections will usually contain narrative text, and so this definition will often describe the information present in the narrative, although sections may be wholly comprised of subsections.

Sections may contain various subsections, and these may be required, required if known or optional. Sections may also contain various entries, and again, these may be required, required if known, or optional. A section may not contain just entries; it must have at least some narrative text or subsections to be considered to be valid content.

Again, sections can inherit features from other section content modules. Once again, sections are classified using an external vocabulary (again typically this would be LOINC), and so the list of possible section codes is also specified. Sections that inherit from other sections will not specify a LOINC code unless it is to restrict the type of section to smaller set of LOINC codes specified by one of its ancestors.

Thus, a section content module will contain as constraints:

The template identifier of the parent content module when there is one.
The LOINC code or codes that shall be used to classify the section.
A possibly empty set of required, required if known, and optional section content modules, and their template identifiers for the subsections of this section.
A possibly empty set of required, required if known, and optional entry content modules, and their template identifiers.
Other constraints as necessary.

These constraints are presented in this document using a table for each section content module, as shown below.

Sample Section Content Module

== 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

Sample Section

LOINC Codes	Opt	Description
Template ID	SampleSectionOID
Parent Template	foo (SampleParentOID)
General Description	Desription of this section
XXXXX-X	R	SECTION NAME
Entries	Opt	Description
OID	R	Sample Entry
Subsections	Opt	Description
OID	R	Sample Subsection

Parent Template

The parent of this template is foo.

Sample Sample Section

<component>
  <section>
    <templateId root='SampleParentOID'/>
    <templateId root='SampleSectionOID'/>
    <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>

    <component>
      Required and optional subsections as described above
    </component>
       
  </section>
</component>

Uses

See Templates using the Sample Section

Entry and Header Content Modules Constraints

Entry and Header content modules are the lowest level of content for which content modules are defined. These content modules are associated with classes from the HL7 Reference Information Model (RIM). These "RIM" content modules will constrain a single RIM class. Entry content modules typically constrain an "Act" class or one of its subtypes, while header content modules will normally constrain "Participation", "Role" or "Entity" classes, but may also constrain an "Act" class.

Entry and Header content modules will describe the required, required if known, and optional XML elements and attributes that are present in the CDA Release 2.0 instance. Header and Entry content modules may also be built up using other Header and Entry content modules.

An entry or header content module may also specify constraints on the vocabularies used for codes found in the entry, or data types for the values found in the entry.

Thus, an entry or header content module will contain as constraints:

The template identifier of the parent content module when there is one.
A description of the XML elements and attributes used in the entry, along with explanations of their meaning.
An indication of those XML elements or attributes that are required, required if known, or optional.
Vocabulary domains to use when coding the entry.
Data types used to specify the value of the entry.
Other constraints as necessary.

An example is shown below:

==== Sample Entry ====

Some text describing the entry.

<observation classCode='OBS' moodCode='EVN'>
   <templateId root='foo'/>
</observation>

<observation classCode='OBS' moodCode='EVN'>

Some details about the observation element

<templateId root='foo'/>

Some details about the template id element

IHE Transactions

This section defines each IHE transaction in detail, specifying the standards used, and the information transferred.

IHE Patient Care Coordination Bindings

This section describes how the payload used in a transaction of an IHE profile is related to and/or constrains the data elements sent or received in those transactions. This section is where any specific dependencies between the content and transaction are defined.

A content integration profile can define multiple bindings. Each binding should identify the transactions and content to which it applies.

The source for all required and optional attributes have been defined in the bindings below. Three tables describe the three main XDS object types: XDSDocumentEntry, XDSSubmissionSet, and XDSFolder. XDSSubmissionSet and XDSDocumentEntry are required. Use of XDSFolder is optional. These concepts are universal to XDS, XDR and XDM.

The columns of the following tables are:

<XXX> attribute – name of an XDS attribute, followed by any discussion of the binding detail.
Optional? - Indicates the required status of the XDS attribute, and is one of R, R2, or O (optional). This column is filled with the values specified in the XDS Profile as a convenience.
Source Type – Will contain one of the following values:

Source Type	Description
SA	Source document Attribute – value is copied directly from source document. The Source/Value column identifies where in the source document this attribute comes from. Specify the location in XPath when possible.
SAT	Source document Attribute with Transformation – value is copied from source document and transformed. The Source/Value column identifies where in the source document this attribute comes from. Specify the location in XPath when possible. Extended Discussion column must not be empty and the transform must be defined in the extended discussion
FM	Fixed (constant) by Mapping - for all source documents. Source/Value column contains the value to be used in all documents.
FAD	Fixed by Affinity Domain – value configured into Affinity Domain, all documents will use this value.
CAD	Coded in Affinity Domain – a list of acceptable codes are to be configured into Affinity Domain. The value for this attribute shall be taken from this list.
CADT	Coded in Affinity Domain with Transform - a list of acceptable codes are to be configured into Affinity Domain. The value for this attribute shall be taken from this list.
n/a	Not Applicable – may be used with an optionality R2 or O attribute to indicate it is not to be used.
DS	Document Source – value comes from the Document Source actor. Use Source/Value column or Extended Discussion to give details.
O	Other – Extended Discussion must be 'yes' and details given in an Extended Discussion.

Source/Value – This column indicates the source or the value used.

The following tables are intended to be summaries of the mapping and transforms. The accompanying sections labeled 'Extended Discussion' are to contain the details as necessary.

Medical Document Binding to XDS, XDM and XDR

This binding defines a transformation that generates metadata for the XDSDocumentEntry element of appropriate transactions from the XDS, XDM and XDR profiles given a medical document and information from other sources. The medical document refers to the document being stored in a repository that will be referenced in the registry. The other sources of information include the configuration of the Document Source actor, the Affinity Domain, the site or facility, local agreements, other documents in the registry/repository, and this Content Profile.

In many cases, the CDA document is created for the purposes of sharing within an affinity domain. In these cases the context of the CDA and the context of the affinity domain are the same, in which case the following mappings shall apply.

In other cases, the CDA document may have been created for internal use, and are subsequentyly being shared. In these cases the context of the CDA document would not neccessarily coincide with that of the affinity domain, and the mappings below would not necessarily apply.

Please note the specifics given in the table below.

XDSDocumentEntry Metadata

XDSDocumentEntry Attribute	Optional?	Source Type	Source/ Value
availabilityStatus	R	DS
authorInstitution	R2	SAT	$inst <= /ClinicalDocument/author /assignedAuthor /representedOrganization The authorInstitution can be formated using the following XPath expression, where $inst in the expression below represents the representedOrganization. concat($inst/name)
authorPerson	R2	SAT	$person <= /ClinicalDocument/author The author can be formatted using the following XPath expression, where $person in the expression below represents the author. concat( $person/id/@extension,"^", $person/assignedPerson/name/family,"^", $person/assignedPerson/name/given[1],"^", $person/assignedPerson/name/given[2],"^", $person/assignedPerson/name/suffix,"^", $person/assignedPerson/name/prefix,"^", "^^^&", $person/id/@root,"&ISO")
authorRole	R2	SAT	This metadata element should be based on a mapping of the participation function defined in the CDA document to the set of author roles configured for the affinity domain. If the context of the CDA coincides with that of the affinity domain, then the following x-path may be appropriate: /ClincicalDocument/author/ participationFunction
authorSpecialty	R2	SAT	This metadata element should be based on a mapping of the code associated with the assignedAuthor to detailed defined classification system for healthcare providers such configured in the affinitity domain. Possible classifications include those found in SNOMED-CT, or the HIPAA Healthcare Provider Taxonomy. If the context of the CDA coincides with that of the affinity domain, then the following x-path may be appropriate: /ClinicalDocument/author/ assignedAuthor/code
classCode	R	CADT	Derived from a mapping of /ClinicalDocument/code/@code to an Affinity Domain specified coded value to use and coding system. Affinity Domains are encouraged to use the appropriate value for Type of Service, based on the LOINC Type of Service (see Page 53 of the LOINC User's Manual). Must be consistent with /ClinicalDocument/code/@code
classCodeDisplayName	R	CADT	DisplayName of the classCode derived. Derived from a mapping of /ClinicalDocument/code/@code to the appropriate Display Name based on the Type of Service. Must be Consitent with /ClinicalDocument/code/@code
confidentialityCode	R	CADT	Derived from a mapping of /ClinicalDocument/confidentialityCode/@code to an Affinity Domain specified coded value and coding system. When using the BPPC profile, the confidentialyCode may also be obtained from the <authorization> element. /ClinicalDocument/ confidentialityCode/@code -AND/OR- /ClinicalDocument/authorization/ consent[ templateId/@root= '1.3.6.1.4.1.19376.1.5.3.1.2.5' ] /code/@code
comments	O	DS
creationTime	R	SAT	/ClinicalDocument/effectiveTime Times specified in clinical documents may be specified with a precision in fractional sections, and may contain a time zone offset. In the XDS Metadata, it can be precise to the second, and is always given in UTC, so the timezone offset if present must be added to the current time to obtain the UTC time.
entryUUID	R	DS
eventCodeList	O	CADT	These values express a collection of keywords that may be relevant to the consumer of the documents in the registry. They may come from anywhere in the CDA document, according to its purpose.
eventCodeDisplayNameList	R (if event Code is valued)	CADT	These are the display names for the collection of keywords described above.
formatCode	R	FM	The format code for each PCC Document content profile is provided within the document specifications.
healthcareFacilityTypeCode	R	CAD	A fixed value assigned to the Document Source and configured form a set of Affinity Domain defined values. Must be concistent with /clinicalDocument/code
healthcareFacility TypeCodeDisplay Name	R	CAD	Must be concistent with /clinicalDocument/code
intendedRecipient (for XDR, XDM)	O	SAT	$person <= /ClinicalDocument/intendedRecipient and/or $inst <= /ClinicalDocument/intendedRecipient/receivedOrganization The intendedRecipient can be formated using the following XPath expression, where $inst in the expression below represents the receivedOrganization and where $person in the expression below represents the intendedRecipient. concat( $person/id/@extension,"^", $person/informationRecipient/name/family,"^", $person/informationRecipient/name/given[1],"^", $person/informationRecipient/name/given[2],"^", $person/informationRecipient/name/suffix,"^", $person/informationRecipient/name/prefix,"^", "^^^&", $person/id/@root,"&ISO", "\|" $inst/name) "^^^^^&", $inst/id/@root, "&ISO", "^^^^", $inst/id/@extension) -->
languageCode	R	SA	/ClinicalDocument/languageCode
legalAuthenticator	O	SAT	$person <= /ClinicalDocument/ legalAuthenticator The legalAuthenticator can be formatted using the following XPath expression, where $person in the expression below represents the legalAuthenticator. concat( $person/id/@extension,"^", $person/assignedPerson/name/family,"^", $person/assignedPerson/name/given[1],"^", $person/assignedPerson/name/given[2],"^", $person/assignedPerson/name/suffix,"^", $person/assignedPerson/name/prefix,"^", "^^^&", $person/id/@root,"&ISO")
mimeType	R	FM	text/xml
parentDocumentRelationship	R (when applicable)	DS	Local document versions need not always be published, and so no exact mapping can be determined from the content of the CDA document. The parentDocumentRelationship may be determined in some configurations from the relatedDocument element present in the CDA dsocument. If the context of the CDA coincides with that of the affinity domain, then the following x-path may be appropriate: /ClinicalDocument/relatedDocument/@typeCode
parentDocumentId	R (when parent Document Relationship is present)	DS	Local document versions need not always be published, and so no exact mapping can be determined from the content of the CDA document. The parentDocumentId may be determined in some configurations from the relatedDocument element present in the CDA dsocument. If the context of the CDA coincides with that of the affinity domain, then the following x-path may be appropriate: $docID <= /ClinicalDocument/ relatedDocument/parentDocument/id The parentDocumentId can be formatted using the following XPath expression, where $docID in the expression below represents the identifier. concat($docID/@root,"^", $docID/@extension)
patientId	R	DS	The XDS Affinity Domain patient ID can be mapped from the patientRole/id element using transactions from the ITI PIX or PDQ profiles. See sourcePatientId below. If the context of the CDA coincides with that of the affinity domain, then the following x-path may be appropriate: $patID <= /ClinicalDocument/recordTarget/ patientRole/id
practiceSettingCode	R	CAD	This elements should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC.
practiceSettingCodeDisplayName	R	CAD	This element shall contain the display names associated with the codes described above.
serviceStartTime	R2	SAT	/ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/low/ @value Times specified in clinical documents may be specified with a precision in fractional sections, and may contain a time zone offset. In the XDS Metadata, it can be precise to the second, and is always given in UTC, so the timezone offset if present must be added to the current time to obtain the UTC time.
serviceStopTime	R2	SAT	/ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/high/ @value Times specified in clinical documents may be specified with a precision in fractional sections, and may contain a time zone offset. In the XDS Metadata, it can be precise to the second, and is always given in UTC, so the timezone offset if present must be added to the current time to obtain the UTC time.
sourcePatientId	R	SAT	$patID <= /ClinicalDocument/recordTarget/ patientRole/id The patientId can be formatted using the following XPath expression, where $patID in the expression below represents the appropriate identifier. concat($patID/@extension,"^^^&", $patID/@root, "&ISO")
sourcePatientInfo	R	SAT	/ClinicalDocument/recordTarget/ patientRole The sourcePatientInfo metadata element can be assembled from various components of the patientRole element in the clinical document.
title	O	SA	/ClinicalDocument/title
typeCode	R	CADT	/ClinicalDocument/code/@code The typeCode should be mapped from the ClinicalDocument/code element to a set of document type codes configured in the affinity domain. One suggested coding system to use for typeCode is LOINC, in which case the mapping step can be omitted.
typeCodeDisplay Name	R	CADT	/ClinicalDocument/code/@displayName
uniqueId	R	SAT	$docID <= /ClinicalDocument/id The uniqueId can be formatted using the following XPath expression, where $docID in the expression below represents the identifier. concat($docID/@root,"^", $docID/@extension)

XDSSubmissionSet Metadata

The submission set metadata is as defined for XDS, and is not necessarily affected by the content of the clinical document. Metadata values in an XDSSubmissionSet with names identical to those in the XDSDocumentEntry may be inherited from XDSDocumentEntry metadata, but this is left to affinity domain policy and/or application configuration.

Use of XDS Submission Set

This content format uses the XDS Submission Set to create a package of information to send from one provider to another. All documents referenced by the Medical Summary in this Package must be in the submission set.

Use of XDS Folders

No specific requirements identified.

Configuration

IHE Content Profiles using this binding require that Content Creators and Content Consumers be configurable with institution and other specific attributes or parameters. Implementers should be aware of these requirements to make such attributes easily configurable. There shall be a mechanism for the publishing and distribution of style sheets used to view clinical documents.

Extensions from other Domains

Scanned Documents (XDS-SD)

XDS-SD is a CDA R2 document and thus conforms to the XDS Metadata requirements in the PCC-TF, volume 2, Section 5 unless otherwise specified below.

XDSDocumentEntry

XDS-SD leverages the XDS DocumentEntry Metadata requirements in the PCC-TF, volume 2, Section 5.1.1.1.1 and in PCC_TF-2/Bindings unless otherwise specified below

XDSDocumentEntry.formatCode

The XDSDocumentEntry.formatCode shall be urn:ihe:iti:xds-sd:pdf:2008 when the document is scanned pdf and urn:ihe:iti:xds-sd:text:2008 when the document is scanned text. The formatCode codeSystem shall be 1.3.6.1.4.1.19376.1.2.3.

XDSDocumentEntry.uniqueId

This value shall be the ClinicalDocument/id in the HL7 CDA R2 header. The root attribute is required, and the extension attribute is optional. In accordance with the XDS.a profile, total length is limited to 128 characters; for XDS.b the limit is 256 characters. Additionally see PCC-TF, volume 2, Section 5.1.1.1.1 or PCC_TF-2/Bindings for further content specification.

Relating instances of XDS-SD documents

In general, most instances of XDS-SD will not have parent documents. It is possible, however, in some specific use cases that instances of XDS-SD documents are related. For example, for a particular document it may be the case that both the PDF scanned content and somewhat equivalent plaintext need to be wrapped and submitted. Each document would correspond to separate XDSDocumentEntries linked via an XFRM Association that indicates one document is a transform of the other. These can be submitted in a single submission set, or in separate ones. Other specific examples may exist and this profile does not preclude the notion of a parent document for these cases.

XDSSubmissionSet

No additional constraints. Particular to this profile, a legitimate use of submission sets would be to maintain a logical grouping of multiple XDS-SD documents. We encourage such usage. For more information, see PCC-TF-2 Section 5.1.1.1.2 or PCC_TF-2/Bindings.

XDSFolder

No additional requirements. For more information, see PCC-TF-2 Section 5.1.1.1.3 or PCC_TF-2/Bindings.

Basic Patient Privacy Consents (BPPC)

Laboratory Reports (XD-LAB)

XD-Lab is a CDA R2 document and thus conforms to the XDS Metadata requirements in the PCC-TF, volume 2, Section 5 unless otherwise specified below.

XDSDocumentEntry

XD-Lab leverages the XDS DocumentEntry Metadata requirements in the PCC-TF, volume 2, Section 5.1.1.1.1 and in PCC_TF-2/Bindings unless otherwise specified below

XDSDocumentEntry.eventCodeList

XD-Lab documents further constrain the the XDSDocumentEntry.eventCodeList to the following.

XDSDocumentEntry
Attribute	Optional?	Source Type	Source/ Value
eventCodeList	R2	SAT	ClinicalDocument / component / structuredBody / component / section / entry / act / entryRelationship / organizer (templateId="1.3.6.1.4.1.19376.1.3.1.1")/ component / observation(templateId="1.3.6.1.4.1.19376.1.3.1.1.1")/code AND ClinicalDocument / component / structuredBody / component / section / entry / act / subject / code If the document has Reportable Condition, then this code shall be among those listed in the eventCodeList. Additionally, if the document contains information about a Non-Human Subject, then the code that indicates what this subject is shall be among those listed in the eventCodeList. Thus, this attribute has been enhanced from the XDS profile from O to R2.

XDSDocumentEntry.formatCode

The XDSDocumentEntry.formatCode shall be urn:ihe:lab:xd-lab:2008 The formatCode codeSystem shall be 1.3.6.1.4.1.19376.1.2.3.

XDSSubmissionSet

No additional constraints. For more information, see PCC-TF-2 Section 5.1.1.1.2 or PCC_TF-2/Bindings.

XDSFolder

No additional requirements. For more information, see PCC-TF-2 Section 5.1.1.1.3 or PCC_TF-2/Bindings.

Namespaces and Vocabularies

This section lists the namespaces and identifiers defined or referenced by the IHE PCC Technical Framework, and the vocabularies defined or referenced herein.

The following vocabularies are referenced in this document. An extensive list of registered vocabularies can be found at http://www.hl7.org/oid/.

Vocabularies Used
codeSystem	codeSystemName	Description
1.3.6.1.4.1.19376.1.5.3.1	IHE PCC Template Identifiers	This is the root OID for all IHE PCC Templates. A list of PCC templates can be found below in CDA Release 2.0 Content Modules.
1.3.6.1.4.1.19376.1.5.3.2	IHEActCode	See IHEActCode Vocabulary below
1.3.6.1.4.1.19376.1.5.3.3	IHE PCC RoleCode	See IHERoleCode Vocabulary below
1.3.6.1.4.1.19376.1.5.3.4		Namespace OID used for IHE Extensions to CDA Release 2.0
2.16.840.1.113883.10.20.1	CCD Root OID	Root OID used for by ASTM/HL7 Continuity of Care Document
2.16.840.1.113883.5.112	RouteOfAdministration	See the HL7 RouteOfAdministration Vocabulary
2.16.840.1.113883.5.1063	SeverityObservation	See the HL7 SeverityObservation Vocabulary
2.16.840.1.113883.5.7	ActPriority	See the HL7 ActPriority Vocabulary
2.16.840.1.113883.6.1	LOINC	Logical Observation Identifier Names and Codes
2.16.840.1.113883.6.96	SNOMED-CT	SNOMED Controlled Terminology
2.16.840.1.113883.6.103	ICD-9CM (diagnosis codes)	International Classification of Diseases, Clinical Modifiers, Version 9
2.16.840.1.113883.6.104	ICD-9CM (procedure codes)	International Classification of Diseases, Clinical Modifiers, Version 9
2.16.840.1.113883.6.26	MEDCIN	A classification system from MEDICOMP Systems.
2.16.840.1.113883.6.88	RxNorm	RxNorm
2.16.840.1.113883.6.63	FDDC	First DataBank Drug Codes
2.16.840.1.113883.6.12	C4	Current Procedure Terminology 4 (CPT-4) codes.
2.16.840.1.113883.6.257	Minimum Data Set for Long Term Care	The root OID for Minimum Data Set Answer Lists
1.2.840.10008.2.16.4	DCM	DICOM Controlled Terminology; PS 3.16 Content Mapping Resource, Annex D
2.16.840.1.113883.6.24	MDC	ISO/IEEE 11073 Medical Device Nomenclature
2.16.840.1.113883.3.26.1.5	NDF-RT	National Drug File Reference Terminology (NCI version)
2.16.840.1.113883.11.19465	nuccProviderCodes	National Uniform Codes Council Healthcare Provider Terminology
2.16.840.1.113883.6.255.1336	X12DE1336	Insurance Type Code (ASC X12 Data Element 1336)
2.16.840.1.113883.6.256	RadLex	RadLex (Radiological Society of North America)
1.3.6.1.4.1.19376.1.5.3.1.3.43	PCC.ODH	Vocabulary OID used in ODH IG

The IHE FormatCode vocabulary is now managed in an Implementation Guide published using FHIR.

formal canonical URI https://profiles.ihe.net/fhir/ihe.formatcode.fhir/ValueSet-formatcode.html
formal publication URL https://profiles.ihe.net/fhir/ihe.formatcode.fhir/
FormatCode gitHub repository for source of the Implementation Guide can be used to register issues, or create pull requests for modifications. Formal governance is managed by ITI Technical Committee.

This FormatCode vocabulary represents:

Code System 1.3.6.1.4.1.19376.1.2.3
Value Set 1.3.6.1.4.1.19376.1.2.7.1

IHEActCode Vocabulary

CCD		ASTM/HL7 Continuity of Care Document
CCR		ASTM CCR Implementation Guide

The IHEActCode vocabulary is a small vocabulary of clinical acts that are not presently supported by the HL7 ActCode vocabulary. The root namespace (OID) for this vocabulary is 1.3.6.1.4.1.19376.1.5.3.2. These vocabulary terms are based on the vocabulary and concepts used in the CCR and CCD standards listed above.

Code	Description
COMMENT	This is the act of commenting on another act.
PINSTRUCT	This is the act of providing instructions to a patient regarding the use of medication.
FINSTRUCT	This is the act of providing instructions to the supplier regarding the fulfillment of the medication order.
IMMUNIZ	The act of immunization of a patient using a particular substance or class of substances identified using a specified vocabulary. Use of this vocabulary term requires the use of either the SUBSTANCE or SUBSTCLASS qualifier described below, along with an identified substance or class of substances.
DRUG	The act of treating a patient with a particular substance or class of substances identified using a specified vocabulary. Use of this vocabulary term requires the use of either the SUBSTANCE or SUBSTCLASS qualifier described below, along with an identified substance or class of substances.
INTOL	An observation that a patient is somehow intollerant of (e.g., allergic to) a particular substance or class of substances using a specified vocabulary. Use of this vocabulary term requires the use of either the SUBSTANCE or SUBSTCLASS qualifier described below, along with an identified substance or class of substances.
SUBSTANCE	A qualifier that identifies the substance used to treat a patient in an immunization or drug treatment act. The substance is expected to be identified using a vocabulary such as RxNORM, SNOMED CT or other similar vocabulary and should be specific enough to identify the ingredients of the substance used.
SUBSTCLASS	A qualifier that identifies the class of substance used to treat a patient in an immunization or drug treatment act. The class of substances is expected to be identified using a vocabulary such as NDF-RT, SNOMED CT or other similar vocabulary, and should be broad enough to classify substances by mechanism of action (e.g., Beta Blocker), intended effect (Dieuretic, antibiotic) or ...

For Public Comment

What else needs to appear above for SUBSTCLASS?

IHERoleCode Vocabulary

The IHERoleCode vocabulary is a small vocabulary of role codes that are not presently supported by the HL7 Role Code vocabulary. The root namespace (OID) for this vocabulary is 1.3.6.1.4.1.19376.1.5.3.3.

IHERoleCode Vocabulary
Code	Description
EMPLOYER	The employer of a person.
SCHOOL	The school in which a person is enrolled.
AFFILIATED	An organization with which a person is affiliated (e.g., a volunteer organization).
PHARMACY	The pharmacy a person uses.

Conventions

Various tables used in this section will further constrain the content. Within this volume, the follow conventions are used.

R: A "Required" data element is one that shall always be provided. If there is information available, the data element must be present. If there is no information available, or it cannot be transmitted, the data element must contain a value indicating the reason for omission of the data. (See PCC TF-2: 5.3.4.2 for a list of appropriate statements).

R2: A "Required if data present" data element is one that shall be provided when a value exists. If the information cannot be transmitted, the data element shall contain a value indicating the reason for omission of the data. If no such information is available to the creator or if such information is not available in a well identified manner (e.g. buried in a free form narrative that contains additional information relevant to other sections) or if the creator requires that information be absent, the R2 section shall be entirely absent. (See section PCC TF-2: 5.3.4.2 for a list of appropriate statements).

O: An optional data element is one that may be provided, irrespective of whether the information is available or not. If the implementation elects to support this optional section, then its support shall meet the requirement set forth for the "Required if data present" or R2.

C: A conditional data element is one that is required, required if known or optional depending upon other conditions. These will have further notes explaining when the data element is required, et cetera.

Note:

The definitions of R, R2, and O differ slightly from other IHE profiles. This is due in part to the fact that local regulations and policies may in fact prohibit the transmission of certain information, and that a human decision to transmit the information may be required in many cases.

Folder Content Modules

This section contains modules that describe the content requirements of XDS Folders. At present, the IHE PCC Technical Framework has not defined any Folder Modules.

CDA Release 2.0 Content Modules

This section contains content modules based upon the HL7 CDA Release 2.0 Standard, and related standards and/or implementation guides.

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

Medical Documents Specification 1.3.6.1.4.1.19376.1.5.3.1.1.1

This section defines the base set of constraints used by almost all medical document profiles described the PCC Technical Framework.

Standards

CDAR2	HL7 CDA Release 2.0
CDTHP	CDA for Common Document Types History and Physical Notes (DSTU)
XMLXSL	Associating Style Sheets with XML documents

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 Medical Documents Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Medical Documents</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 Medical Documents 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>

Specification

The constraints for encoding of the CDA Header (Level 1) can be found in the CDA for Common Document Types History and Physical Implementation Guide, in the section 2. CDA Header -- General Constraints.

IHE Medical Documents shall follow all constraints found in that section with the exception of the constraint on realmcode found in CONF-HP-15:.
IHE Medical Documents which are implemented for the US Realm shall follow ALL constraints found in that section, and shall use both the IHE Medical Document templateId (1.3.6.1.4.1.19376.1.5.3.1.1.1) and the HL7 General Header Constraints templateId (2.16.840.1.113883.10.20.3).}}

Realm	Constraints	Template IDs Required
Universal	CONF-HP-1 through CONF-HP-14 CONF-HP-16 through CONF-HP-52	1.3.6.1.4.1.19376.1.5.3.1.1.1
US	CONF-HP-1 through CONF-HP-52	1.3.6.1.4.1.19376.1.5.3.1.1.1 2.16.840.1.113883.10.20.3

Style Sheets

Document sources should provide an XML style sheet to render the content of the Medical Summary document. The output of this style sheet shall be an XHTML Basic (see http://www.w3.org/TR/xhtml-basic/) document that renders the clinical content of a Medical Summary Document as closely as possible as the sending provider viewed the completed document. When a style sheet is provided, at least one processing instruction shall be included in the document that including a link to the URL for the XML style sheet. To ensure that the style sheet is available to all receivers, more than one stylesheet link may be included.

When a stylesheet is used within an XDS Affinity domain, the link to it shall be provided using an HTTPS or HTTP URL.

<?xml-stylesheet href='https://foobar:8080/mystylesheet.xsl' type='text/xsl'?>

When using XDM or XDR to exchange documents, the stylesheet shall also be exchanged on the media. The link to the stylesheet shall be recorded as a relative URL.

<?xml-stylesheet href='../../stylesheets/mystylesheet.xsl' type='text/xsl'?>

Style sheets should not rely on graphic or other media resources. If graphics other media resources are used, these shall be accessible in the same way as the stylesheet. The Content Creator need not be the provider of the resources (stylesheet or graphcs).

When a Content Creator provides a style sheet, Content Consumers must provide a mechanism to render the document with that style sheet. Content Consumers may view the document with their own style sheet.

To record the stylesheet within a CDA Document that might be used in both an XDS and XDM environment, more than one stylesheet processing instruction is required. In this case, all style sheet processing instructions included must include the alternate='yes' attribute.

<?xml-stylesheet href='https://foobar:8080/mystylesheet.xsl' type='text/xsl' alternate='yes'?>
<?xml-stylesheet href='../../stylesheets/mystylesheet.xsl' type='text/xsl' alternate='yes'?>

A Content Consumer that is attempting to render a document using the document supplied stylesheet may use the first style sheet processing instruction for which it is able to obtain the style sheet content, and shall not report any errors if it is able to find at least one stylesheet to render with.

Distinctions of None

Information that is sent must clearly identify distinctions between

None: It is known with complete confidence that there are none. Used in the context of problem and medication lists, this indicates that the sender knows that there is no relevant information that can be sent.
None Known: None are known at this time, but it is not known with complete confidence than none exist. Used in the context of allergy lists, where essentially, it is impossible to prove the negative that no allergies exist, it is only possible to assert that none have been found to date.
None Known Did Ask: None are known at this time, and it is not known with complete confidence than none exist, but the information was requested. Also used in the context of allergy lists, where essentially, it is impossible to prove the negative that no allergies exist, it is only possible to assert that none have been found to date.
Unknown: The information is not known, or is otherwise unavailable.

In the context of CDA, sections that are required to be present but have no information should use one of the above phrases where appropriate.

An appropriate machine readable entry shall be present for problems, medications and allergies to indicate the reason that no information. Codes for recording unknown or no information are provided in the section on the Problem, Allergy and Medications Entry.

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

Medical Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.2

A medical summary contains a snapshot of the patient's medical information, including at the very least, a list of the patients problems, medications and allergies. A Medical Summary is an abstract template that is expected to be further refined by additional document templates.

Parent Template

This document is an instance of the Medical Document template.

Standards

CDAR2

HL7 CDA Release 2.0

Specification

Data Element Name	Opt	Template ID
Problem Concern Entry	R	1.3.6.1.4.1.19376.1.5.3.1.4.5.2
Allergy Concern Entry	R	1.3.6.1.4.1.19376.1.5.3.1.4.5.3
Medications	R	1.3.6.1.4.1.19376.1.5.3.1.4.7

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. A CDA Document may conform to more than one template. This content module inherits from the Medical Document content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Medical Summary Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Medical Summary</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>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.2'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Medical Summary can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'>
     Error: The parent template identifier for Medical Summary is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Medical Summary 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> 
   <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 Medical Summary Document must contain a(n) Problem Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.2
   </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 Medical Summary Document must contain a(n) Allergy Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.2
   </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 Medical Summary Document must contain a(n) Medications Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.2
   </assert> 
 </rule>
</pattern>

Document Specification

A medical summary is a type of medical document, and incorporates the constraints defined for Medical Documents, and requires the recording of Problems, Allergies and Medications.

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

Referral Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.3

The use case is described fully in PCC_TF-1 for the Ambulatory Specialist Referral. Briefly, it involves a "collaborative" transfer of care for the referral of a patient from a primary care provider (PCP) to a specialist. The important document data elements identified by physicians and nurses for this use case are listed in the table below under the column "Data Elements". These were then mapped to the categories given HL7 Care Record Summary Implementation Guide, and HL7 CDA Release 2.0. These mappings are provided in the next two columns.

A referral summary is a type of Medical Summary, and incorporates the constraints defined for a Medical Summary(1.3.6.1.4.1.19376.1.5.3.1.1.2) above. This section defines additional constraints for Medical Summary Content used in a Referral summary. These tables present the Categories, as defined in Section 3 of CRS. In no case are these IHE requirements less strict than those defined by CRS.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:xds-ms:2007

Parent Template

This document is an instance of the Medical Summary template.

Standards

CDAR2	HL7 CDA Release 2.0
CRS	HL7 Care Record Summary
CCD	ASTM/HL7 Continuity of Care Document

Data Element Index

Data Elements	HL7 Care Record Summary	CDA Release 2.0
Reason for Referral	Reason for Referral	REASON FOR REFERRAL
History Present Illness	History of Present Illness	HISTORY OF PRESENT ILLNESS
Active Problems	Conditions	PROBLEM LIST
Current Meds	Medications	HISTORY OF MEDICATION USE
Allergies	Allergies and Adverse Reactions	HISTORY OF ALLERGIES
History of Past Illness	Conditions	HISTORY OF PAST ILLNESS
List of Surgeries	Past Surgical History	HISTORY OF PRIOR SURGERIES
Immunizations	Immunizations	HISTORY OF IMMUNIZATIONS
Family History	Family History	HISTORY OF FAMILY ILLNESS
Social History	Social History	SOCIAL HISTORY
Pertinent Review of Systems	Review of Systems	REVIEW OF SYSTEMS
Vital Signs	Physical Exam	VITAL SIGNS
Physical Exam	Physical Exam	GENERAL STATUS, PHYSICAL FINDINGS
Relevant Diagnostic Surgical Procedures / Clinical Reports (including links)	Studies and Reports	RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Relevant Diagnostic Test and Reports (Lab, Imaging, EKG's, etc.) including links.	Studies and Reports	RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Plan of Care (new meds labs, or x-rays ordered)	Care Plan	TREATMENT PLAN
Advance Directives	Advance Directives	ADVANCE DIRECTIVES
Patient Administrative Identifiers	Header	patientRole/id
Pertinent Insurance Information	Participant	participant[@classCode='HLD']
Data needed for state and local referral forms, if different than above	Optional Sections	section

Specification

Data Element Name	Opt	Template ID
Reason for Referral	R	1.3.6.1.4.1.19376.1.5.3.1.3.1
History 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
Current Meds	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
History of Past Illness	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
Pertinent Review of Systems	O	1.3.6.1.4.1.19376.1.5.3.1.3.18
Vital Signs	R2	1.3.6.1.4.1.19376.1.5.3.1.3.25
Physical Exam	R2	1.3.6.1.4.1.19376.1.5.3.1.3.24
Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports (Lab, Imaging, EKG's, etc.) including links.	R2	1.3.6.1.4.1.19376.1.5.3.1.3.27
Plan of Care (new meds, labs, or x-rays ordered)	R2	1.3.6.1.4.1.19376.1.5.3.1.3.31
Advance Directives	R2	1.3.6.1.4.1.19376.1.5.3.1.3.34
Patient Administrative Identifiers Handled by the Medical Documents Content Profile by reference to constraints in HL7 CRS.	R
Pertinent Insurance Information Refer to Appropriate Payers Section -- TBD	R2
Data needed for state and local referral forms, if different than above These are handed by including additional sections within the summary.	R2

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. A CDA Document may conform to more than one template. This content module inherits from the Medical Summary content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Referral Summary Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.3'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Referral Summary</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='1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
        <!-- Required Reason for Referral Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Required History 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='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Current Meds 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='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required if known History of Past Illness 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='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Optional Pertinent Review of Systems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
        <!-- Required if known Vital Signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
        <!-- Required if known Physical Exam Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.27'/>
        <!-- Required if known Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
        <!-- Required if known Plan of Care (new meds, labs, or x-rays ordered) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required if known Advance Directives Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.3'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.3"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Referral Summary can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
     Error: The parent template identifier for Referral Summary is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Referral Summary 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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Referral Summary Document must contain a(n) Reason for Referral Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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 Referral Summary Document must contain a(n) History Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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 Referral Summary Document must contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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 Referral Summary Document must contain a(n) Current Meds Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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 Referral Summary Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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  Referral Summary Document should contain a(n) History of Past Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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  Referral Summary Document should contain a(n) List of Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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  Referral Summary Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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  Referral Summary Document should contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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  Referral Summary Document should contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Referral Summary Document does not contain a(n) Pertinent Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.24"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Physical Exam Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.27"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Plan of Care (new meds, labs, or x-rays ordered) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Referral Summary Document must contain a(n) Patient Administrative Identifiers Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Pertinent Insurance Information Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Data needed for state and local referral forms, if different than above Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 
   </assert> 
 </rule>
</pattern>

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

Discharge Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.4

This use case is described fully in the XDS-MS profile found in PCC TF-1. Briefly, it involves an episodic transfer of care in the form of a patient discharge from a hospital to home. The important data elements identified by physicians and nurses for this use case are listed in the table below under the column "Data Elements". These are mapped to the categories given HL7 Care Record Summary Implementation Guide, and HL7 CDA Release 2.0 in the next two columns.

A discharge summary is a type of medical summary, and incorporates the constraints defined for Medical Summaries.

This section defines additional constraints for Medical Summary Content used in a Discharge Summary. These tables present the data elements described above, along with their optionality, and references to the section and template where these sections or header data elements are further defined.

In no case are these IHE requirements less strict than those defined by the HL7 Care Record Summary.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:xds-ms:2007

Parent Template

This document is an instance of the Medical Summary template.

Standards

CDAR2	HL7 CDA Release 2.0
CRS	HL7 Care Record Summary
CCD	ASTM/HL7 Continuity of Care Document

Data Element Index

Data Elements	HL7 Care Record Summary	CDA Release 2.0
Date of Admission	Header	encompassingEncounter/effectiveTime
Date of Discharge	Header	encompassingEncounter/effectiveTime
Participating Providers and Roles	Header	documentationOf/serviceEvent/performer
Discharge Disposition (who, how, where)	Care Plan	DISCHARGE DISPOSITION
Admitting Diagnosis	Conditions	HOSPITAL ADMISSION DX
History of Present Illness	History of Present Illness	HISTORY OF PRESENT ILLNESS
Hospital Course	Hospital Course	HOSPITAL COURSE
Discharge Diagnosis (including active and resolved problems)	Conditions	HOSPITAL DISCHARGE DX
Selected Medicine Administered during Hospitalization	Medications	HISTORY OF MEDICATION USE
Discharge Medications	Medications	HOSPITAL DISCHARGE MEDICATIONS
Allergies and adverse reactions	Allergies and Adverse Reactions	HISTORY OF ALLERGIES
Discharge Diet	Optionally found in Care Plan	DISCHARGE DIET
Review of Systems	Review of Systems	REVIEW OF SYSTEMS
Vital Signs (most recent, high/low/average)	Physical Exam	VITAL SIGNS
Functional Status	Functional Status	HISTORY OF FUNCTIONAL STATUS
Relevant Procedures and Reports (including links)	Studies and Reports	HOSPITAL DISCHARGE STUDIES
Relevant Diagnostic Tests and Reports (including links)	Studies and Reports	HOSPITAL DISCHARGE STUDIES
Plan of Care	Care Plan	TREATMENT PLAN
Administrative Identifiers	Header	patient/id
Pertinent Insurance Information	Header	participant[@classCode='HLD']

Specification

Data Element Name	Opt	Template ID
Active Problems	R	1.3.6.1.4.1.19376.1.5.3.1.3.6
Resolved Problems	R	1.3.6.1.4.1.19376.1.5.3.1.3.8
Discharge Diagnosis	R	1.3.6.1.4.1.19376.1.5.3.1.3.7
Admitting Diagnosis	R	1.3.6.1.4.1.19376.1.5.3.1.3.3
Selected Meds Administered	R2	1.3.6.1.4.1.19376.1.5.3.1.3.21
Discharge Meds	R	1.3.6.1.4.1.19376.1.5.3.1.3.22
Admission Medications	R2	1.3.6.1.4.1.19376.1.5.3.1.3.20
Allergies	R	1.3.6.1.4.1.19376.1.5.3.1.3.13
Hospital Course	R	1.3.6.1.4.1.19376.1.5.3.1.3.5
Advance Directives	O	1.3.6.1.4.1.19376.1.5.3.1.3.34
History of Present Illness	R2	1.3.6.1.4.1.19376.1.5.3.1.3.4
Functional Status	O	1.3.6.1.4.1.19376.1.5.3.1.3.17
Review of Systems	O	1.3.6.1.4.1.19376.1.5.3.1.3.18
Physical Examination	O	1.3.6.1.4.1.19376.1.5.3.1.3.24
Vital Signs	O	1.3.6.1.4.1.19376.1.5.3.1.3.25
Discharge Procedures Tests, Reports	O	1.3.6.1.4.1.19376.1.5.3.1.3.29
Plan of Care	R	1.3.6.1.4.1.19376.1.5.3.1.3.31
Discharge Diet	O	1.3.6.1.4.1.19376.1.5.3.1.3.33

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. A CDA Document may conform to more than one template. This content module inherits from the Medical Summary content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Discharge Summary Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.4'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Discharge Summary</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='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- 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 Resolved Problems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.7'/>
        <!-- Required Discharge Diagnosis Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.3'/>
        <!-- Required Admitting Diagnosis Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.22'/>
        <!-- Required Discharge Meds Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.20'/>
        <!-- Required if known Admission 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='1.3.6.1.4.1.19376.1.5.3.1.3.5'/>
        <!-- Required Hospital Course Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Optional Advance Directives Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/>
        <!-- Optional Functional Status Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Optional Review of Systems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
        <!-- Optional Physical Examination Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
        <!-- Optional Vital Signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.29'/>
        <!-- Optional Discharge Procedures Tests, Reports Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
        <!-- Required Plan of Care Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.33'/>
        <!-- Optional Discharge Diet Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.4'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.4"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Discharge Summary can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
     Error: The parent template identifier for Discharge Summary is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Discharge Summary 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> 
   <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 Discharge Summary Document must contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Resolved Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.7"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Discharge Diagnosis Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Admitting Diagnosis Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </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  Discharge Summary Document should contain a(n) Selected Meds Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.22"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Discharge Meds Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.20"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Discharge Summary Document should contain a(n) Admission Medications Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </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 Discharge Summary Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.5"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Hospital Course Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Discharge Summary Document should contain a(n) History of Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.17"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Functional Status Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.24"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Physical Examination Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.29"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Discharge Procedures Tests, Reports Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Plan of Care Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.33"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Discharge Diet Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
 </rule>
</pattern>

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

PHR Extract Specification 1.3.6.1.4.1.19376.1.5.3.1.1.5

The PHR Extract module describes the document content that summarizes information contained within a Personal Health Record. While a PHR can contain a great deal more information (including clinical documents, lab reported, images, trend data, monitoring data) et cetera, this content module only deals with the format of the summary information from the PHR.

An PHR Extract Module is a type of medical summary, and incorporates the constraints defined for Medical Summaries. While mappings have been provided to various standards, this content module conforms to the ASTM/HL7 Continuity of Care Document as well as this guide.

The following table describes the data elements that may be present in a PHR Extract. The first column of this table is drawn from the Common Data Elements in the PHR found in Appendix B of the AHIMA Report: The Role of the Personal Health Record in the EHR. Indented items in this column of the table provide more detail for the item they appear underneath.

These data elements were then mapped to the ASTM CCR, HL7 CDA, CRS and CCD and the implicit data elements referenced by the HL7 PHR Conformance Criteria.

A further requirement of transfers of information between PHR and EHR systems is that authorship of the information stored within the PHR shall be tracable through the various import/export cycles. PHR Manager Actors must be secure nodes, which requires logging of any updates to or accesses of PHR information. The DSG profile should be used to ensure that information coming into, or exiting these systems is verifiably authored.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:xphr:2007

Parent Template

This document is an instance of the Medical Summary template.

LOINC Code

The LOINC code for this document is 34133-9 Summary of Episode Note

Standards

AHIMA-PHR	AHIMA PHR Common Data Elements
CDAR2	HL7 CDA Release 2.0
CRS	HL7 Care Record Summary
CCD	ASTM/HL7 Continuity of Care Document
HL7-PHR	HL7 PHR Functional Model (Draft)
LOINC	Logical Observation Identifier Names and Codes

Data Element Index

AHIMA Common Data Elements	ASTM Continuity of Care Record	HL7 Clincial Document Architecture, Care Record Summary or Continuity of Care Document	HL7 PHR Conformance Criteria
Personal Information	Patient	patientRole	Demographic Information
Name	Patient	patient/name	Demographic Information
Address	Patient	patientRole/addr	Contact Information
Contact Information	Patient	patientRole/telecom	Contact Information
Personal Identification Information	Patient	patientRole/id	Demographic Information
Gender	Patient	patient/administrativeGenderCode	Demographic Information
Date of Birth	Patient	patient/birthTime	Demographic Information
Marital Status	Patient	patient/maritalStatusCode
Race	Patient	patient/raceCode
Ethnicity	Patient	patient/ethnicGroupCode	Demographic Information
(Religious Affiliation[1])	Patient	patient/religiousAffiliationCode	Spiritual Affiliation / Considerations
Languages Spoken	Patient	patient/languageCommunication
Employer and School Contacts	Social History
Hazardous Working Conditions	Social History	HISTORY OF OCCUPATIONAL EXPOSURE
Emergency Contacts	Support
Healthcare Providers	Practitioners	serviceEvent/performer	Healthcare Providers
Insurance Providers	Insurance	Health Insurance or Pharmacy Insurance
Pharamacy		performer
Legal Documents and Medical Directives	Advance Directives	ADVANCE DIRECTIVES	Advance Directive
General Medical Information Height, Weight	Vital Signs	VITAL SIGNS
Blood Type	Results	RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Last Physical or Checkup	Encounters	HISTORY OF OUTPATIENT VISITS	Clinical Encounters and Procedures List
Allergies and Drug Sensitivies	Alerts	HISTORY OF ALLERGIES	Allergy and Reaction List
Conditions	Problems	HISTORY OF PAST ILLNESS - or - PROBLEM LIST	Problem List
Surgeries	Procedures	HISTORY OF SURGICAL PROCEDURES	Clinical Encounters and Procedures List
Medications – Prescription and Non-Prescription	Medications	HISTORY OF MEDICATION USE	Medication List
Immunizations	Immunizations	HISTORY OF IMMUNIZATIONS	Immunizations List
Doctor Visits	Encounters	HISTORY OF OUTPATIENT VISITS	Clinical Encounters and Procedures List
Hospitalizations	Encounters	HISTORY OF HOSPITALIZATIONS	Clinical Encounters and Procedures List
Other Healthcare Visits	Encounters	HISTORY OF OUTPATIENT VISITS	Clinical Encounters and Procedures List
Clinical Tests	Results	RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA	Laboratory and Test Results
Pregnancies		HISTORY OF PREGNANCIES
Medical Devices	Medical Devices	HISTORY OF MEDICAL DEVICE USE
Family Member History	Family History	HISTORY OF FAMILY MEMBER DISEASES	Family History
Foreign Travel		HISTORY OF TRAVEL
Therapy	Plan of Care	TREATMENT PLAN	Care Plans, Goals and Disease Management
Vital Signs	Vital signs	VITAL SIGNS
(Functional Status[2])	Functional Status	FUNCTIONAL STATUS

Specification

Data Element Name	Opt	Template ID
Personal Information Name Address Contact Information Personal Identification Gender Date of Birth Thes components are required of all Medical Documents	R	1.3.6.1.4.1.19376.1.5.3.1.1.1
Personal Information Marital Status This commponent is optional in Medical Documents, but required if known in this specification.	R2	1.3.6.1.4.1.19376.1.5.3.1.1.1
Personal Information Race Ethnicity Religious Affiliation [2] These components are optional in Medical Documents	O	1.3.6.1.4.1.19376.1.5.3.1.1.1
Languages Spoken	R2	1.3.6.1.4.1.19376.1.5.3.1.2.1
Employer and School Contacts	O	1.3.6.1.4.1.19376.1.5.3.1.2.2
Hazardous Working Conditions	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1
Patient Contacts	R2	1.3.6.1.4.1.19376.1.5.3.1.2.4
Healthcare Providers	R	1.3.6.1.4.1.19376.1.5.3.1.2.3
Insurance Providers	R2	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7
Pharamacy	R2	1.3.6.1.4.1.19376.1.5.3.1.2.3
Legal Documents and Medical Directives	R2	1.3.6.1.4.1.19376.1.5.3.1.3.34
Allergies and Drug Sensitivities	R	1.3.6.1.4.1.19376.1.5.3.1.3.13
Conditions	R	1.3.6.1.4.1.19376.1.5.3.1.3.8
Conditions (cont)	R	1.3.6.1.4.1.19376.1.5.3.1.3.6
Surgeries	R2	1.3.6.1.4.1.19376.1.5.3.1.3.12
Medications – Prescription and Non-Prescription	R	1.3.6.1.4.1.19376.1.5.3.1.3.19
Immunizations	R2	1.3.6.1.4.1.19376.1.5.3.1.3.23
Doctor Visits / Last Physical or Checkup	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
Hospitalizations	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
Other Healthcare Visits	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
Clinical Tests / Blood Type	O	1.3.6.1.4.1.19376.1.5.3.1.3.28
Pregnancies	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Medical Devices	R2	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5
Family Member History	O	1.3.6.1.4.1.19376.1.5.3.1.3.15
Foreign Travel	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6
Plan of Care	O	1.3.6.1.4.1.19376.1.5.3.1.3.31
Coded Vital signs	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Functional Status	O	1.3.6.1.4.1.19376.1.5.3.1.3.17

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. A CDA Document may conform to more than one template. This content module inherits from the Medical Summary content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample PHR Extract Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5'/>
  <id root=' ' extension=' '/>
  <code code='34133-9' displayName='Summary of Episode Note'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>PHR Extract</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='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1'/>
        <!-- Optional Hazardous Working Conditions Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required if known Legal Documents and Medical Directives Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required Conditions Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required Conditions (cont) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.12'/>
        <!-- Required if known Surgeries Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Medications – Prescription and Non-Prescription 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='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'/>
        <!-- Optional Doctor Visits / Last Physical or Checkup Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'/>
        <!-- Optional Hospitalizations Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'/>
        <!-- Optional Other Healthcare Visits Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.28'/>
        <!-- Optional Clinical Tests / Blood Type Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/>
        <!-- Optional Pregnancies Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5'/>
        <!-- Required if known Medical Devices Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.15'/>
        <!-- Optional Family Member History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6'/>
        <!-- Optional Foreign Travel Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
        <!-- Optional Plan of Care Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
        <!-- Optional Coded Vital signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/>
        <!-- Optional Functional Status Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.5'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.5"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The PHR Extract can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
     Error: The parent template identifier for PHR Extract is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "34133-9"]'>
     Error: The document type code of a PHR Extract must be 34133-9
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The PHR Extract Document must contain a(n) Personal Information Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.1"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Personal Information Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Personal Information Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.1"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Languages Spoken Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.2"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Employer and School Contacts Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Hazardous Working Conditions Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Patient Contacts Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The PHR Extract Document must contain a(n) Healthcare Providers Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Insurance Providers Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.3"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Pharamacy Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Legal Documents and Medical Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </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 PHR Extract Document must contain a(n) Allergies and Drug Sensitivities Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The PHR Extract Document must contain a(n) Conditions Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </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 PHR Extract Document must contain a(n) Conditions (cont) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.12"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </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 PHR Extract Document must contain a(n) Medications – Prescription and Non-Prescription Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </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  PHR Extract Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Doctor Visits / Last Physical or Checkup Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Hospitalizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Other Healthcare Visits Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.28"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Clinical Tests / Blood Type Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Pregnancies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Medical Devices Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.15"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Family Member History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Foreign Travel Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Plan of Care Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Coded Vital signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.17"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Functional Status Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
 </rule>
</pattern>

Additional Constraints

The assignedAuthoring device shall be populated with information about the EHR and/or PHR which assisted in creation of the document.

All sections and entries within the document shall contain an <id> element.

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

PHR Update Specification 1.3.6.1.4.1.19376.1.5.3.1.1.6

The PHR Update Content Module is similar to the PHR Extract content module, except that it has a number of different constraints. First of all, it is not required to contain all of the information that the PHR Extract content module does. The reason for this is because the purpose of this module is to reflect the changes that should be made to a PHR based on a previously existing PHR Extract content module. So, while it makes use of the same data element index, almost all of the data elements are optional. The purpose of this module is to make it easier for an EHR to create content that can be used to update a PHR.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:xphr:2007

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 PHR Update Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.6'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>PHR Update</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 PHR Update 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>

Requirements

The requirements of this module are that it support recording updates to the original PHR Extract. The PHR Extract is made up of a header, and several sections, each of which may contain one or more entries. Suggestions to add, remove or update a section or entry are described in more detail below.

Adding a New Section or Appending to an Existing Section

A PHR Reviewer Actor may suggest additional material for an existing or new section by simply adding that section to the PHR Update document.

Replacing a Section

A PHR Reviewer Actor may suggest a revision to a section in the PHR Extract by replacing that section. To replace a section, the PHR Reviewer Actor creates a section in the PHR Update document that is of the same type as the section to be replaced in the PHR Extract document, and adds a <ppc:replacementOf> element to that section to indicate the section that it replaces.

The replacementOf element is an extension to the CDA Release 2.0 standard, and is further described below in Appendix C Extensions to CDA Release 2.0.

Adding an Entry

A PHR Reviewer Actor may suggest a new entry be added to a section by simply including that entry in a like section in the PHR Update document.

Replacing or Removing an Entry

The PHR Review Actor can replace an existing entry by adding an entry of the same type with new or modified information, and including in that entry a <reference> element that has an <externalAct> element. The <id> element of the <externalAct> shall be that of the act that is being replaced

Removing an Entry

The PHR Reviewer Actor can suggest that an entry be removed by replacing it with an act who <statusCode> element has been set to nullified.

Constraints

The LOINC document type code is the same as for the PHR Extract content module. The PHR Update Content module must record the PHR Extract which it is updating

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

Consent to Share Information Specification 1.3.6.1.4.1.19376.1.5.3.1.1.7

Consents to share information are documents that contain both a human and machine readable description of how a patient has chosen to share their information.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:bppc:2007

Parent Template

This document is an instance of the Medical Document template.

Standards

CDAR2	HL7 CDA Release 2.0
XDS-SD	Scanned Documents

Specification

Data Element Name	Opt	Template ID
Consent Service Event At least one, and possibly more than one, consent can be provided within the document.	R	1.3.6.1.4.1.19376.1.5.3.1.2.6
Authorization Consents may also be protected under a sharing policity.	O	1.3.6.1.4.1.19376.1.5.3.1.2.5

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. A CDA Document may conform to more than one template. This content module inherits from the Medical Document content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Consent to Share Information Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.7'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Consent to Share Information</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>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.7'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.7"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Consent to Share Information can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'>
     Error: The parent template identifier for Consent to Share Information is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Consent to Share Information 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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Consent to Share Information Document must contain a(n) Consent Service Event Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.7 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.5"]'> 
     <!-- Note any missing optional elements -->
     Note: This Consent to Share Information Document does not contain a(n) Authorization Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.7 
   </assert> 
 </rule>
</pattern>

Constraints

A consent shall contain a text description of what the patient consented to, a list of codes indicating the policy(s) agreed to, a time range indicating the effective time of the consent, and shall contain a signature signifying the patient agreement to those policy(s) stated in the text description. Finally, consents may be attested to using an electronic digital signature, conforming to the ITI Digital Signature Profile.

The text description and signature may appear as a scanned image. When the consent contains a scanned image, it shall also conform to the constraints of the ITI Scanned Document profile.

A consent shall have one or more <serviceEvent> elements in the header identifying the policies authorized by the document (see Section 4.2.3.4 of CDAR2). Each <serviceEvent> element indicates informed consent to one and only one XDS Affinity Domain policy. More than one policy may be agreed to within a given consent document.

Consent documents should be attested to by either the patient and/or legal guardian, or a third party assigned by the XDS Affinity Domain or its member organizations. The attestation, if present, should be performed using the ITI Digital Signature profile. The signer may be the patient, or a third party.

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

Preprocedure History and Physical Specification 1.3.6.1.4.1.19376.1.5.3.1.1.9

A Pre-procedure History and Physical is a type of medical document, and incorporates the constraints defined for Medical Documents(1.3.6.1.4.1.19376.1.5.3.1.1.1) .

This use case is described fully in in the PPHP Profile described in PCC TF-1. Briefly, this use case involves a sequence of events leading up to the patient’s admission to the operating room in a surgical center. Included in these events is the creation and communication of the pre-procedure history and physical document required by quality review organizations prior to most surgeries. Using this use case, the contents of documents used in collaborative transfers of care were discussed with physicians and nurses in detail to identify major sections. The sections identified by physicians during the use case exercise as important are listed in the table below under the column “Use Case Documentation Section??.

Using this information from the use case, the following mappings were made to existing standards and implementation guides. As illustrated, there is quite a bit of overlap between sections in this integration profile and in sections specified in the HL7 Care Record Summary CDA implementation guide.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:pphp:2007

Parent Template

This document is an instance of the Medical Document template.

Standards

CDAR2	HL7 CDA Release 2.0
CRS	HL7 Care Record Summary
CCD	ASTM/HL7 Continuity of Care Document

Data Element Index

Data Element Requirements	Sections in HL7 CDA-R2/	LOINC Descriptions
Proposed Procedure: (coded procedure)		PROCEDURE
Expected Blood Loss		OPERATIVE NOTE ESTIMATED BLOOD LOSS
Proposed Anesthesia		OPERATIVE NOTE ANESTHESIA
Reason for Procedure: (coded diagnosis)		OPERATIVE NOTE INDICATIONS
HPI—(free text leading up to procedure)	History of Present Illness	HISTORY OF PRESENT ILLNESS
Current Problem List	Conditions	PROBLEM LIST
Past Medical History	Conditions	HISTORY OF PAST ILLNESS
Past Surgical-Anesthesia History	Past Surgical History	HISTORY OF SURGICAL PROCEDURES
Medication List	Medications	HISTORY OF MEDICATION USE
Allergy List	Allergies and Adverse Reactions	HISTORY OF ALLERGIES
Immunizations	Immunizations	HISTORY OF IMMUNIZATIONS
History of Tobacco Use		HISTORY OF TOBACCO USE
Current Alcohol/Substance Abuse		HISTORY OF PRESENT ALCOHOL AND/OR SUBSTANCE ABUSE
Transfusion History		TBD
Family History (specifically includes):	Family History	HISTORY OF FAMILY MEMBER DISEASES
Social History		SOCIAL HISTORY
Advance Directives	Advance Directives	ADVANCE DIRECTIVES
Functional Capacity	Functional Status	HISTORY OF FUNCTIONAL STATUS
Review of Systems (specifically includes):	Review of Systems	REVIEW OF SYSTEMS
Physical Exam (specifically includes):	Physical Examination	PHYSICAL EXAM.TOTAL
Studies and Reports	Studies and Reports	STUDIES SUMMARY
Health Maintenance Status		TREATMENT PLAN
Pre-procedure Care Plan Status Report		TREATMENT PLAN
Pre-procedure Impressions (specifically includes):		DIAGNOSIS
-Updated Problem List	Conditions	PROBLEM LIST
-Pre-Procedure Risk Assessment		OPERATIVE NOTE COMPLICATIONS
Pre-procedure Care Plan	Plan of Care	TREATMENT PLAN
Patient Education/Consents		EDUCATION NOTE

Specification

Data Element Name	Opt	Template ID
Proposed Procedure: (coded procedure) includes: Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.1
-Reason for Procedure: (coded diagnosis) Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.4
-Proposed Anesthesia Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.3
-Expected Blood Loss Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. Needs narrative LOINC code	R2	1.3.6.1.4.1.19376.1.5.3.1.1.9.2
-Procedure Care Plan Care Plan generated by the surgeon or surgical coordinator prior to the H&P	R2	1.3.6.1.4.1.19376.1.5.3.1.1.9.40
HPI—(free text leading up to procedure)	R	1.3.6.1.4.1.19376.1.5.3.1.3.4
Current Problem List Problem List (if known) is represented as current at beginning of H&P encounter.	R2	1.3.6.1.4.1.19376.1.5.3.1.3.6
Past Medical History	R2	1.3.6.1.4.1.19376.1.5.3.1.3.8
Past Surgical-Anesthesia History	R	1.3.6.1.4.1.19376.1.5.3.1.3.11
Medication List	R	1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergy List	R	1.3.6.1.4.1.19376.1.5.3.1.3.13
Immunizations	R2	1.3.6.1.4.1.19376.1.5.3.1.3.23
History of Tobacco Use	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.8
Current Alcohol/Substance Abuse	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.10
Transfusion History	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.12
Pre-procedure Family History	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.5
Social History	R2	1.3.6.1.4.1.19376.1.5.3.1.3.16
Advance Directives	R2	1.3.6.1.4.1.19376.1.5.3.1.3.34
Functional Capacity	R	1.3.6.1.4.1.19376.1.5.3.1.3.17
Review of Systems (specifically includes):	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.13
-General Review	R	1.3.6.1.4.1.19376.1.5.3.1.3.18
-Implanted Medical Devices	R2	1.3.6.1.4.1.19376.1.5.3.1.1.9.46
-Pregnancy Status (if female)	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.47
-Anesthesia Review of Systems	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.14
Physical Exam (specifically includes):	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.15
-Vitals	R	1.3.6.1.4.1.19376.1.5.3.1.9.49
-General Appearance	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.16
-Visible Implanted Medical Devices	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.48
-Integumentary System	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.17
-Head	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.18
-Eyes	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.19
-Ears, Nose, Mouth and Throat (may include):	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1
--Ears	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.21
--Nose	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.22
--Mouth, Throat, and Teeth	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.23
-Neck	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.24
-Endocrine System	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.25
-Thorax and Lungs (may include):	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1
--Chest Wall	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.27

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. A CDA Document may conform to more than one template. This content module inherits from the Medical Document content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Preprocedure History and Physical Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Preprocedure History and Physical</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='1.3.6.1.4.1.19376.1.5.3.1.1.9.1'/>
        <!-- Required Proposed Procedure: (coded procedure) includes: Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.4'/>
        <!-- Required -Reason for Procedure: (coded diagnosis) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.3'/>
        <!-- Required -Proposed Anesthesia Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.2'/>
        <!-- Required if known -Expected Blood Loss Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.40'/>
        <!-- Required if known -Procedure Care Plan Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Required HPI—(free text leading up to procedure) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required if known Current Problem List Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required if known Past Medical History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
        <!-- Required Past Surgical-Anesthesia History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Medication List Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
        <!-- Required Allergy List 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='1.3.6.1.4.1.19376.1.5.3.1.1.9.8'/>
        <!-- Required History of Tobacco Use Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.10'/>
        <!-- Required Current Alcohol/Substance   Abuse Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.12'/>
        <!-- Required Transfusion History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.5'/>
        <!-- Required Pre-procedure 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='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required if known Advance Directives Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/>
        <!-- Required Functional Capacity Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.13'/>
        <!-- Required Review of Systems (specifically includes): Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Required   -General Review Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.46'/>
        <!-- Required if known -Implanted Medical Devices Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.47'/>
        <!-- Required -Pregnancy Status (if female) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.14'/>
        <!-- Required   -Anesthesia Review of Systems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/>
        <!-- Required Physical Exam (specifically includes): Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.9.49'/>
        <!-- Required -Vitals Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.16'/>
        <!-- Optional -General Appearance Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.48'/>
        <!-- Optional -Visible Implanted Medical Devices Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.17'/>
        <!-- Optional -Integumentary System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.18'/>
        <!-- Optional -Head Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.19'/>
        <!-- Optional -Eyes Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1'/>
        <!-- Optional -Ears, Nose, Mouth and Throat (may include): Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.21'/>
        <!-- Optional --Ears Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.22'/>
        <!-- Optional --Nose Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.23'/>
        <!-- Optional --Mouth, Throat, and Teeth Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.24'/>
        <!-- Optional -Neck Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.25'/>
        <!-- Optional -Endocrine System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1'/>
        <!-- Optional -Thorax and Lungs (may include): Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.27'/>
        <!-- Optional --Chest Wall Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Preprocedure History and Physical can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'>
     Error: The parent template identifier for Preprocedure History and Physical is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Preprocedure History and Physical 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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Proposed Procedure: (coded procedure) includes: Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) -Reason for Procedure: (coded diagnosis) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) -Proposed Anesthesia Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.2"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) -Expected Blood Loss Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.40"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) -Procedure Care Plan Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </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 Preprocedure History and Physical Document must contain a(n) HPI—(free text leading up to procedure) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) Current Problem List Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </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  Preprocedure History and Physical Document should contain a(n) Past Medical History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Past Surgical-Anesthesia History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </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 Preprocedure History and Physical Document must contain a(n) Medication List Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </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 Preprocedure History and Physical Document must contain a(n) Allergy List Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </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  Preprocedure History and Physical Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.8"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) History of Tobacco Use Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.10"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Current Alcohol/Substance   Abuse Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.12"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Transfusion History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.5"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Pre-procedure Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </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  Preprocedure History and Physical Document should contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.17"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Functional Capacity Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Review of Systems (specifically includes): Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n)   -General Review Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.46"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) -Implanted Medical Devices Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.47"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) -Pregnancy Status (if female) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.14"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n)   -Anesthesia Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Physical Exam (specifically includes): Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.9.49"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) -Vitals Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.16"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -General Appearance Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.48"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Visible Implanted Medical Devices Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.17"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Integumentary System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Head Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.19"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Eyes Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Ears, Nose, Mouth and Throat (may include): Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.21"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) --Ears Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.22"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) --Nose Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.23"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) --Mouth, Throat, and Teeth Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.24"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Neck Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.25"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Endocrine System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Thorax and Lungs (may include): Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.27"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) --Chest Wall Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
 </rule>
</pattern>

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

Emergency Department Referral Specification 1.3.6.1.4.1.19376.1.5.3.1.1.10

An ED Referral is a type of Referral Summary, and incorporates the constraints defined for Referral Summaries.

This use case is described fully in the EDR Profile in PCC TF-1. Briefly, it involves a collaborative transfer of care for the referral of a patient from a care provider to an emergency department. Using this use case the contents of documents used in collaborative transfers of care were discussed with physicians and nurses in detail to identify major sections. The sections identified by physicians during the use case exercise as important are listed in the table below.

Using this information from the use case, the following mappings were made to existing standards.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:edr:2007

Parent Template

This document is an instance of the Medical Summary template.

Data Element Index

Data Elements	HL7 Care Record Summary	CDA Release 2.0
Reason for Referral	Reason for Referral	REASON FOR REFERRAL
History Present Illness	History of Present Illness	HISTORY OF PRESENT ILLNESS
Active Problems	Conditions	PROBLEM LIST
Current Meds	Medications	HISTORY OF MEDICATION USE
Allergies	Allergies and Adverse Reactions	HISTORY OF ALLERGIES
Resolved Problems	Conditions	HISTORY OF PAST ILLNESS
List of Surgeries	Past Surgical History	HISTORY OF PRIOR SURGERIES
Immunizations	Immunizations	HISTORY OF IMMUNIZATIONS
Family History	Family History	HISTORY OF FAMILY ILLNESS
Social History	Social History	SOCIAL HISTORY
Pertinent Review of Systems	Review of Systems	REVIEW OF SYSTEMS
Vital Signs	Physical Exam	VITAL SIGNS
Physical Exam	Physical Exam	GENERAL STATUS, PHYSICAL FINDINGS
Relevant Surgical Procedures / Clinical Reports (including links)	Studies and Reports	RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Relevant Diagnostic Test and Reports (Lab, Imaging, EKG’s, etc.) including links.	Studies and Reports	RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Care Plan (new meds labs, or x-rays ordered)	Care Plan	TREATMENT PLAN
Proposed ED Disposition	ED DISPOSITION
Mode of Transport to the Emergency Department	Care Plan	MODE OF TRANSPORT
Estimated Time of Arrival to the ED	Care Plan	MODE OF TRANSPORT
Advance Directives	Advance Directives	ADVANCE DIRECTIVES
Patient Administrative Identifiers	Header	patientRole/id
Pertinent Insurance Information	Participant	participant[@roleCode='HLD']
Data needed for state and local referral forms, if different than above	Optional Sections	section

Specification

Data Element Name	Opt	Template ID
Reason for Referral	R	1.3.6.1.4.1.19376.1.5.3.1.3.1
History 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
Current Meds	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
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
Pertinent Review of Systems	O	1.3.6.1.4.1.19376.1.5.3.1.3.18
Vital Signs	R2	1.3.6.1.4.1.19376.1.5.3.1.3.25
Physical Exam	R2	1.3.6.1.4.1.19376.1.5.3.1.3.24
Relevant Diagnostic Results and/or Clinical Reports Includes Diagnostic Surgical Procedures, Clinical Reports and Diagnostic Tests and Results (Lab, Imaging, EKG’s, etc.) including links to relevant documents.	R2	1.3.6.1.4.1.19376.1.5.3.1.3.27
Care Plan (new meds, labs, or x-rays ordered)	R2	1.3.6.1.4.1.19376.1.5.3.1.3.31
Mode of Transport to the Emergency Department (includes ETA)	R	1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
Proposed ED Disposition	R2	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10
Advance Directives The availability of information about Advance Directives must provided. A common concern among ED providers is over situations where patients presented to the ED require extensive resuscitative efforts, only later to discover that the patient had a DNR order.	R	1.3.6.1.4.1.19376.1.5.3.1.3.34
Patient Administrative Identifiers These are handed by the Medical Documents Content Profile by reference to constraints in HL7 CRS.	R
Pertinent Insurance Information	R2
Data needed for state and local referral forms, if different than above These are handed by including additional sections within the summary.	R2

Note:

Highlighted items in the table above are different from what appears in the XDS-MS profile. All other data elements have identical definitions.

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. A CDA Document may conform to more than one template. This content module inherits from the Medical Summary content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Emergency Department Referral Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.3'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Emergency Department Referral</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='1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
        <!-- Required Reason for Referral Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Required History 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='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Current Meds 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='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- 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='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Optional Pertinent Review of Systems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
        <!-- Required if known Vital Signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
        <!-- Required if known Physical Exam Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.27'/>
        <!-- Required if known Relevant Diagnostic Results and/or Clinical Reports Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
        <!-- Required if known Care Plan 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 Transport to the Emergency Department
(includes ETA)  Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'/>
        <!-- Required if known Proposed ED Disposition Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required Advance Directives Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.10'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.10"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Emergency Department Referral can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.3"]'>
     Error: The parent template identifier for Emergency Department Referral is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Emergency Department Referral 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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Reason for Referral Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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 Emergency Department Referral Document must contain a(n) History Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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 Emergency Department Referral Document must contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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 Emergency Department Referral Document must contain a(n) Current Meds Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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 Emergency Department Referral Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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  Emergency Department Referral Document should contain a(n) Resolved Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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  Emergency Department Referral Document should contain a(n) List of Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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  Emergency Department Referral Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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  Emergency Department Referral Document should contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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  Emergency Department Referral Document should contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Emergency Department Referral Document does not contain a(n) Pertinent Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.24"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Physical Exam Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.27"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Relevant Diagnostic Results and/or Clinical Reports Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Care Plan Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </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 Emergency Department Referral Document must contain a(n) Mode of Transport to the Emergency Department
(includes ETA)  Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Proposed ED Disposition Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Patient Administrative Identifiers Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Pertinent Insurance Information Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Data needed for state and local referral forms, if different than above Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </assert> 
 </rule>
</pattern>

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 Specification 1.3.6.1.4.1.19376.1.5.3.1.1.11.2

The Antepartum Summary represents a summary of the most critical information to an antepartum care provider regarding the status of a patients pregnancy.

The APS document is a medical summary and inherits all header constraints from Medical Summaries.

The use case for this document is described fully in the APS Profile in PCC TF-1.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:aps:2007

Parent Template

This document is an instance of the Medical Summary template.

LOINC Code

The LOINC code for this document is XX-APS Antepartum Summary

Standards

CCD	ASTM/HL7 Continuity of Care Document
CDAR2	HL7 CDA Release 2.0
ACOGAR	American College of Obstretricians and Gynecologists (ACOG), Antepartum Record
LOINC	Logical Observation Identifiers, Names and Codes
SNOMED	Systemized Nomenclature for Medicine

Data Element Index

This section maps the ACOG Antepartum Record to corresponding CDA sections as constrained by IHE.

ACOG Antepartum Record Datum	CDA Section	Trial
Drug Allergy/Latex Allergy	Allergies
Is Blood Transfusion Acceptable	Advance Directives
Antepartum Anesthesia Consult Planned	Plan of Care
Problems/Plans	Problems	Related plans should be listed in Plan of Care
Medication List	Active Medications
EDD Confirmation/18-20 Week EDD Update	Estimated Delivery Dates
Prepregnancy Weight	Visit Summary Flowsheet
Visit Flowsheet	Visit Summary Flowsheet

Specification

Data Element Name	Opt	Template ID
Allergies This section is the same as for Medical Summary, however it SHALL include one observation of Latex Allergy which may be negated through the negationInd attribute. Latex Allergy is particularly relevant for Obstetrics because of the frequency of vaginal exams that might involve the use of latex gloves. The observation value code for Latex Allergy is '300916003'. The codeSystem is '2.16.840.1.113883.6.96'. The codeSystemName is 'SNOMED CT'	R	1.3.6.1.4.1.19376.1.5.3.1.3.13
Advance Directives APS includes an explicit check of patients preference for blood transfusion because the risk of massive hemorrhage during delivery is much higher. This observation SHALL be recorded in the Advance Directives section. APS Form C documents SHALL include a simple observation of "blood transfusion acceptable?" The observation value for this observation is '(xx-bld-transf-ok)'. The codeSystem is '2.16.840.1.113883.6.1'. The codeSystemName is 'LOINC'	R	1.3.6.1.4.1.19376.1.5.3.1.3.34
Plan of Care APS forms SHOULD include an observation stating if an anesthesia consult is planned. When present, the observation value for this observation is '(xx-anest-cons-pland)'. The codeSystem is '2.16.840.1.113883.6.1'. The codeSystemName is 'LOINC'. If the type of anesthesia planned is known, systems SHOULD include an observation to represent that data using the LOINC code '(xx-type-of-anesth-pland)' with a CD value including one of the following values: ( General \| Epidural \| Spinal ) or a Null flavor to represent unknown or not listed.	R	1.3.6.1.4.1.19376.1.5.3.1.3.31
Medications Medications should include start and stop date if known.	R	1.3.6.1.4.1.19376.1.5.3.1.3.19
Problems Related Plans should be included in the Plan of Care section.	R	1.3.6.1.4.1.19376.1.5.3.1.3.6
Estimated Delivery Dates	R	1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1
Antepartum Visit Summary Flowsheet	R	1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2

Note:

The Antepartum summary is typically used as a 'living document' where the latest information is added to the end of the flowsheet at each visit. This is different than a typical Medical Summary which typically would not share information until document is complete. Although this pattern of updates is not prohibited by Medical Summary, it is also not typical. For APS documents may be published at the end of each visit, but subsequent updates with a pregnancy SHALL be represented as document replacement by including a <relatedDocument typeCode='REPL'> element as below.

<ClinicalDocument xmlns='urn:hl7-org:v3'>
    :
  <relatedDocument typeCode='REPL'>
    <parentDocument>
      <id root=' ' extension=' '/>
    </parentDocument>
  </relatedDocument>
    :
</ClinicalDocument>

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. A CDA Document may conform to more than one template. This content module inherits from the Medical Summary content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Antepartum Summary Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2'/>
  <id root=' ' extension=' '/>
  <code code='XX-APS' displayName='Antepartum Summary'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Antepartum Summary</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='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
        <!-- Required Allergies Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required Advance Directives Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
        <!-- Required Plan of Care Section content -->
      </section>
    </component>

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

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1'/>
        <!-- Required Estimated Delivery Dates Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2'/>
        <!-- Required Antepartum Visit Summary Flowsheet Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.11.2'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.11.2"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Antepartum Summary can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
     Error: The parent template identifier for Antepartum Summary is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "XX-APS"]'>
     Error: The document type code of a Antepartum Summary must be XX-APS
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Document must contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Document must contain a(n) Plan of Care Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2 
   </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 Antepartum Summary Document must contain a(n) Medications Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2 
   </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 Antepartum Summary Document must contain a(n) Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Document must contain a(n) Estimated Delivery Dates Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum Summary Document must contain a(n) Antepartum Visit Summary Flowsheet Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2
   </assert> 
   <assert test="cda:entry/cda:observation/cda:value[@code='300916003']">
     Antepartum Summary Requires an observation of Latex Allergy to be
     asserted.  This may be negated via the negationInd attribute.
   </assert>
   <assert test="cda:entry/cda:observation/cda:value[@code='(xx-bld-transf-ok)']">
     Antepartum Summary Requires an observation of blood transfusion
     acceptability to be asserted.  This may be negated via the negationInd attribute.
   </assert>
   <assert test="cda:entry/cda:observation/cda:value[@code='(xx-anest-cons-pland)']">
     Antepartum Summary Requires an observation of anesthesia consult 
     planned to be asserted.  This may be negated via the negationInd attribute.
   </assert> 
 </rule>
</pattern>

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 arrival data, historical information about the patient, vital signs, assessments, and interventions.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:edes:2007

Parent Template

This document is an instance of the Medical Document template.

LOINC Code

The LOINC code for this document is X-TRIAGE Triage Note

Data Element Index

Data Element	LOINC
Chief Complaint	10154-3 CHIEF COMPLAINT
Reason for Visit	29299-6 REASON FOR VISIT
Mode of Arrival	11459-5 TRANSPORT MODE
History of Present Illness	10164-2 HISTORY OF PRESENT ILLNESS
History of Past Illness	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	48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS
Acuity Assessment	11283-9 ACUITY ASSESSMENT
Vital Signs	8716-3 VITAL SIGNS
Assessments	X-ASSESS ASSESSMENTS
Procedures and Interventions	29544-3 PROCEDURE
Medications Administered	18610-6 MEDICATION ADMINISTERED (COMPOSITE)
Intravenous Fluids Administered	8975-5 INTRAVASCULAR FLUID INTAKE

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
Reason for Visit	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1
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
History of Past Illness	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	R2	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	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
Procedures and Interventions	R2	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11
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. A CDA Document may conform to more than one template. This content module inherits from the Medical Document content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Triage Note Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <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='Triage Note'
    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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1'/>
        <!-- Required Reason for Visit 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='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required if known History of Past Illness 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 if known 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 Assessments Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'/>
        <!-- Required if known Procedures and Interventions 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 that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'>
     Error: The parent template identifier for Triage Note is not present.
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) Reason for Visit 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 = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) History of Past 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 = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- 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"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should 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) 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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) Procedures and 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 = "1.3.6.1.4.1.19376.1.5.3.1.3.21"]'> 
     <!-- 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>

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

ED Nursing Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2

The ED Nursing Note specification includes sections for data commonly captured during the ongoing care of the ED patient. It includes vital signs, ongoing assessments, and interventions.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:edes:2007

Parent Template

This document is an instance of the Medical Document template.

LOINC Code

The LOINC code for this document is X-NN Nursing Note

Data Element Index

Data Element	LOINC
Vital Signs	8716-3 VITAL SIGNS
Assessments	X-ASSESS ASSESSMENTS
Functional Status Assessments	47420-5
Procedures and Interventions	29544-3 PROCEDURE
Medications Administered	18610-6 MEDICATION ADMINISTERED (COMPOSITE)
Intravenous Fluids Administered	X-IVFLU INTRAVENOUS FLUID ADMINISTERED (COMPOSITE)
ED Disposition	11302-7 ED DISPOSITION

Specification

Data Element Name	Opt	Template ID
Vital Signs	R	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Assessments Record of assessments of the patient's condition	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
Functional Status Assessments Record of assessments of patient's functional status	O	1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
Procedures and Interventions This section is used to record interventions or nursing procedures performed	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11
Medications Administered	R	1.3.6.1.4.1.19376.1.5.3.1.3.21
Intravenous Fluids Administered	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
ED Disposition	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10

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. A CDA Document may conform to more than one template. This content module inherits from the Medical Document content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample ED Nursing Note Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2'/>
  <id root=' ' extension=' '/>
  <code code='X-NN' displayName='Nursing Note'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>ED 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>
    <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 Assessments Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1'/>
        <!-- Optional Functional Status Assessments Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'/>
        <!-- Required Procedures and Interventions Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/>
        <!-- Required 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 Intravenous Fluids Administered Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'/>
        <!-- Required ED Disposition Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The ED Nursing Note can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'>
     Error: The parent template identifier for ED Nursing Note is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "X-NN"]'>
     Error: The document type code of a ED Nursing Note must be X-NN
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Nursing Note Document must contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Nursing Note Document must contain a(n) Assessments Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This ED Nursing Note Document does not contain a(n) Functional Status Assessments Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Nursing Note Document must contain a(n) Procedures and Interventions Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.21"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Nursing Note Document must contain a(n) Medications Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Nursing Note Document must contain a(n) Intravenous Fluids Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Nursing Note Document must contain a(n) ED Disposition Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2
   </assert> 
 </rule>
</pattern>

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 ED Nursing Note specification may be employed where the ED Triage Note and ED Nursing Notes exist within a single document. The elements below are an exact composite of the elements from the Triage Note specification and the ED Nursing Note specification.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:edes:2007

Parent Template

This document is an instance of the Medical Document template.

LOINC Code

The LOINC code for this document is X-TRIAGE Triage Note

Data Element Index

Data Element	LOINC
Chief Complaint	10154-3 CHIEF COMPLAINT
Reason for Visit	29299-6 REASON FOR VISIT
Mode of Arrival	11459-5 TRANSPORT MODE
History of Present Illness	10164-2 HISTORY OF PRESENT ILLNESS
Past Medical History	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	48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS
Acuity Assessment	11283-9 ACUITY ASSESSMENT
Vital Signs	8716-3 VITAL SIGNS
Assessments	X-ASSESS ASSESSMENTS
Functional Status Assessments	47420-5
Procedures and Interventions	29544-3 PROCEDURE
Medications Administered	18610-6 MEDICATION ADMINISTERED (COMPOSITE)
Intravenous Fluids Administered	X-IVFLU INTRAVENOUS FLUID ADMINISTERED (COMPOSITE)
ED Disposition	11302-7 ED DISPOSITION

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
Reason for Visit	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1
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
Past Medical History	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	R2	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	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
Functional Status Assessments Record of assessments of patient's functional status	O	1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
Procedures and Interventions This section is used to record interventions or nursing procedures performed	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11
Medications Administered	R2	1.3.6.1.4.1.19376.1.5.3.1.3.21
IV Fluids Administered	R2	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
ED Disposition The ED Disposition shall have a Mode of Transport entry describing how the patient departed.	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10

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. A CDA Document may conform to more than one template. This content module inherits from the Medical Document content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

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='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3'/>
  <id root=' ' extension=' '/>
  <code code='X-TRIAGE' displayName='Triage Note'
    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>
    <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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1'/>
        <!-- Required Reason for Visit 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='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required if known Past Medical History 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 if known 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 Assessments  Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1'/>
        <!-- Optional Functional Status Assessments Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'/>
        <!-- Required Procedures and Interventions 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 IV Fluids Administered Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'/>
        <!-- Required ED Disposition Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Composite Triage and Nursing Note can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'>
     Error: The parent template identifier for Composite Triage and Nursing Note is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "X-TRIAGE"]'>
     Error: The document type code of a Composite Triage and Nursing 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 Composite Triage and Nursing Note Document must contain a(n) Chief Complaint Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Composite Triage and Nursing Note Document must contain a(n) Reason for Visit Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </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 Composite Triage and Nursing Note Document must contain a(n) Mode of Arrival Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </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 Composite Triage and Nursing Note Document must contain a(n) History of Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </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  Composite Triage and Nursing Note Document should contain a(n) Past Medical History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </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  Composite Triage and Nursing Note Document should contain a(n) List of Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </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  Composite Triage and Nursing Note Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </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  Composite Triage and Nursing Note Document should contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </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  Composite Triage and Nursing Note Document should contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Composite Triage and Nursing Note Document should contain a(n) History of Pregnancies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 
   </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 Composite Triage and Nursing Note Document must contain a(n) Current Medications Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </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 Composite Triage and Nursing Note Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </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 Composite Triage and Nursing Note Document must contain a(n) Acuity Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </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 Composite Triage and Nursing Note Document must contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </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  Composite Triage and Nursing Note Document should contain a(n) Assessments  Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This Composite Triage and Nursing Note Document does not contain a(n) Functional Status Assessments Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Composite Triage and Nursing Note Document must contain a(n) Procedures and Interventions Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 
   </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  Composite Triage and Nursing Note Document should contain a(n) Medications Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </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  Composite Triage and Nursing Note Document should contain a(n) IV Fluids Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Composite Triage and Nursing Note Document must contain a(n) ED Disposition Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 
   </assert> 
 </rule>
</pattern>

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

ED Physician Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4

The ED Physician note specification includes sections for data commonly reported by the physician as part of an ED encounter. It includes relevant historical information about the patient, pertinent arrival information, vital signs, history and physical examination findings, assessment and plan, interventions including medications, fluids and procedures, diagnosis and disposition.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:edes:2007

Parent Template

This document is an instance of the Medical Document template.

LOINC Code

The LOINC code for this document is 28568-4 ED Visit Note

Data Element Index

Data Element	LOINC
Referral Source	11293-8 ED REFERRAL SOURCE
Mode of Arrival	11459-5 TRANSPORT MODE
Chief Complaint	10154-3 CHIEF COMPLAINT
Reason for Visit	29299-6 REASON FOR VISIT
History of Present Illness	10164-2 HISTORY OF PRESENT ILLNESS
Advance Directives	42348-3 ADVANCE DIRECTIVES
Active Problems	11450-4 PROBLEM LIST
Past Medical History	11348-0 HISTORY OF PAST ILLNESS
Current Medications	10160-0 CURRENT MEDICATIONS
Allergies	48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS
List of Surgeries	47519-4 History of procedures
Immunizations	11369-6 HISTORY OF IMMUNIZATIONS
Family History	10157-6 HISTORY OF FAMILY MEMBER DISEASES
Social History	29762-2 SOCIAL HISTORY
History of Pregnancies	10162-6 HISTORY OF PREGNANCIES
Pertinent ROS	10187-3 REVIEW OF SYSTEMS
Vital Signs	8716-3 VITAL SIGNS
Physical Examination	29545-1 PHYSICAL EXAMINATION
Assessment and Plan	X-AANDP ASSESSMENT AND PLAN X-ASSESS ASSESSMENT 18776-5 TREATMENT PLAN
Medications Administered	18610-6 MEDICATION ADMINISTERED (COMPOSITE)
Intravenous Fluids Administered	X-IVFLU INTRAVENOUS FLUID ADMINISTERED
Procedures Performed	29544-3 PROCEDURE
Test Results - Lab, ECG, Radiology	30954-2 STUDIES SUMMARY
Consultations	18693-2 ED CONSULTANT PRACTITIONER
Progress Note	18733-6 SUBSEQUENT EVALUATION NOTE (ATTENDING PHYSICIAN)
ED Diagnoses	11301-9 ED DIAGNOSIS
Medications at Discharge	10183-2 HOSPITAL DISCHARGE MEDICATIONS
ED Disposition	11302-7 ED DISPOSITION

Specification

Data Element Name	Opt	Template ID
Referral Source	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3
Mode of Arrival	R	1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
Chief Complaint	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
Reason for Visit	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1
History of Present Illness	R	1.3.6.1.4.1.19376.1.5.3.1.3.4
Advanced Directives	R	1.3.6.1.4.1.19376.1.5.3.1.3.34
Active Problems	R2	1.3.6.1.4.1.19376.1.5.3.1.3.6
Past Medical History	R2	1.3.6.1.4.1.19376.1.5.3.1.3.8
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
List of Surgeries	R	1.3.6.1.4.1.19376.1.5.3.1.3.11
Immunizations	R	1.3.6.1.4.1.19376.1.5.3.1.3.23
Family History	R	1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History	R	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	R2	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Pertinent ROS	R2	1.3.6.1.4.1.19376.1.5.3.1.3.18
Vital Signs	R	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Physical Examination	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.15
Assessements This section shall be present when assessments and plans are recorded separately.	C	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
Care Plan This section shall be present when assessments and plans are recorded separately.	C	1.3.6.1.4.1.19376.1.5.3.1.3.31
Assessment and Plan This section shall be present when assessments and plans are recorded together.	C	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5
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
Procedures Performed	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11
Test Results Lab, ECG, Radiology	R	1.3.6.1.4.1.19376.1.5.3.1.3.27
Consultations	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8
Progress Note	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7
ED Diagnoses	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9
Medications at Discharge	R2	1.3.6.1.4.1.19376.1.5.3.1.3.22
ED Disposition The ED Disposition shall contain a mode of transport entry describing how the patient departed.	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10

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. A CDA Document may conform to more than one template. This content module inherits from the Medical Document content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample ED Physician Note Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4'/>
  <id root=' ' extension=' '/>
  <code code='28568-4' displayName='ED Visit Note'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>ED Physician 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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3'/>
        <!-- Required Referral Source 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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/>
        <!-- Required Chief Complaint Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1'/>
        <!-- Required Reason for Visit 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='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required Advanced Directives Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required if known 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 Past Medical History 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='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
        <!-- Required 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 Immunizations Section content -->
      </section>
    </component>

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

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Required if known Pertinent ROS 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='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/>
        <!-- Required Physical Examination Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'/>
        <!-- Conditional Assessements Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
        <!-- Conditional Care Plan Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5'/>
        <!-- Conditional Assessment and Plan 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>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'/>
        <!-- Required Procedures Performed Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.27'/>
        <!-- Required Test Results Lab, ECG, Radiology Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8'/>
        <!-- Required Consultations Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7'/>
        <!-- Required Progress Note Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9'/>
        <!-- Required ED Diagnoses Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.22'/>
        <!-- Required if known Medications at Discharge Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'/>
        <!-- Required ED Disposition Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The ED Physician Note can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'>
     Error: The parent template identifier for ED Physician Note is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "28568-4"]'>
     Error: The document type code of a ED Physician Note must be 28568-4
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Referral Source Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </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 ED Physician Note Document must contain a(n) Mode of Arrival Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </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 ED Physician Note Document must contain a(n) Chief Complaint Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Reason for Visit Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </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 ED Physician Note Document must contain a(n) History of Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Advanced Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  ED Physician Note Document should contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </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  ED Physician Note Document should contain a(n) Past Medical History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </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 ED Physician Note Document must contain a(n) Current Medications Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </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 ED Physician Note Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) List of Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  ED Physician Note Document should contain a(n) History of Pregnancies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  ED Physician Note Document should contain a(n) Pertinent ROS Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </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 ED Physician Note Document must contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Physical Examination Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </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  ED Physician Note Document should contain a(n) Medications Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </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  ED Physician Note Document should contain a(n) Intravenous Fluids Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Procedures Performed Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.27"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Test Results Lab, ECG, Radiology Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Consultations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Progress Note Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) ED Diagnoses Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.22"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  ED Physician Note Document should contain a(n) Medications at Discharge Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) ED Disposition Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 
   </assert> 
   <assert test='((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"])
              and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"])
               or (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"]))
             and
              not((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"])
               and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"])
               and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"]))
             and
               not((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"])
               and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]))
             and
               not((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"])
               and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"]))'>
     Error:  A(n) ED Physician Note shall contain either Assessments AND Care
     Plan OR Assessment and Plan. See
     http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
 </rule>
</pattern>

CDA Header 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

Language Communication 1.3.6.1.4.1.19376.1.5.3.1.2.1

Languages spoken shall be recorded using the languageCommunication infrastructure class associated with the patient. The <languageCommunication> element describes the primary and secondary languages of communication for a person. When used, these shall be described using the languageCommunication element as follows.

Uses

See Templates using Language Communication

Specification

Language Communication Example

<languageCommunication>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.1'/>
  <languageCode code='en-US'/>
  <modeCode code='' codeSystem='2.16.840.1.113883.5.60'
    codeSystemName='LanguageAbilityMode'/>
  <preferenceInd value='true|false'/>
</languageCommunication>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.1'/>

The <templateId> element identifies this <languageCommunication> element for validation of the content. The templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.2.1'.

<languageCode code=' '/>

This element describes the language code. It uses the same vocabulary described for the ClinicalDocument/languageCode element described in more detail in HL7 CRS: 2.1.1. This element is required.

<modeCode code=' ' codeSystem='2.16.840.1.113883.5.60' codeSystemName='LanguageAbilityMode'/>

This element describes the mode of use, and is only necessary when there are differences between expressive and receptive abilities. This element is optional. When not present, the assumption is that any further detail provided within the languageCommunication element refers to all common modes of communication. The coding system used shall be the HL7 LanguageAbilityMode vocabulary when this element is communicated.

<proficiencyLevelCode code=' ' codeSystem='2.16.840.1.113883.5.61' codeSystemName='LanguageProficiencyCode' />

This element describes the proficiency of the patient (with respect to the mode if specified). This element is optional. The coding system used shall be the HL7 LanguageProficiencyCode vocabulary when this element is communicated.

<preferenceInd value=' '/>

This element shall be present on all languageCommunication elements when more than one is provided. It shall be valued "true" if this language is the patient’s preferred language for communication, or "false" if this is not the patient’s preferred language. More than one language may be preferred, and at least one must be preferred.

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

Employer and School Contacts 1.3.6.1.4.1.19376.1.5.3.1.2.2

Employer and school informational contacts shall be recorded as participants in the CDA Header as demonstrated in the figure below. These contacts shall conform to the General Constraints found in HL7 CRS: 2.1.1 with respect to the requirements for name, address, telephone numbers and other contact information.

The figure below shows how the information for this element is coded, and further constraints are provided in the following sections.

Uses

See Templates using Employer and School Contacts

Specification

Employer and School Contacts Example

<participant typeCode='IND'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.2'/>
  <time>
    <low value=''/>
    <high value=''/>
  </time>
  <associatedEntity classCode='CON'>
    <id root='' extension=''/>
    <code code='EMPLOYER|SCHOOL|AFFILIATED' codeSystem='1.3.5.1.4.1.19376.1.5.3.3' codeSystemName='IHERoleCode'/>
    <associatedPerson><name>…</name></associatedPerson>
    <scopingOrganization>
      <name>…</name>
      <telecom value='' use=''/>
      <addr>…</addr>
    </scopingOrganization>
  </associatedEntity>
</participant>

<participant typeCode='IND'>

The typeCode of the participant shall be IND.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.2'/>

The <templateId> element identifies this <participant> as a school or employer contact for validation of the content. The templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.2.2'.

<time><low value=' '/><high value=' '/>

The time element indicates the start and stop time range for this contact. These dates shall correspond to the start and stop dates for employment, enrollment, or other affiliation with the organization described.

<associatedEntity classCode='CON'>

The <associatedEntity> element provides the contact information (classCode='CON') for the school, employer or affiliated organization.

<code code='EMPLOYER|SCHOOL|AFFILIATED' codeSystem='1.3.5.1.4.1.19376.1.5.3.3' codeSystemName='IHERoleCode'/>

The code value shall indicate whether the participant is the employer, school or other affiliated (e.g., volunteer) organization. See also the IHE Role Code Vocabulary(1.3.5.1.4.1.19376.1.5.3.3)

<associatedPerson><name>…</name></associatedPerson>

This element should be present. When present is shall provide the name of a contact person within the organization.

<scopingOrganization><name>…</name><telecom value= use=/><addr>…</addr></scopingOrganization>

This element shall be present, and shall provide the name, address and telephone number of the organization.

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

Healthcare Providers and Pharmacies 1.3.6.1.4.1.19376.1.5.3.1.2.3

Healthcare providers (including pharmacies) shall be recorded as described in CCD: 3.17. The identifier that the patient is known by to these providers may be included using the Patient Identifier extension described in Extensions to HL7 CDA Release 2.0. See the example shown in for use of this extension element.

Uses

See Templates using Healthcare Providers and Pharmacies

Specification

Healthcare Providers and Pharmacies Example

<documentationOf>
  <serviceEvent classCode="PCPR">
    <effectiveTime><low value=""/><high value=""/></effectiveTime>
    <performer typeCode="PRF">
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.3'/>
      <functionCode code='' displayName='' codeSystem='' codeSystemName=''/>
      <time>
        <low value=''/>
        <high value=''/>
      </time>
      <assignedEntity>
        <id root='' extension=''/>
        <code code='' displayName='' codeSystem='' codeSystemName=''/>
        <addr></addr>
        <telecom value='' use=''/>
        <assignedPerson><name></name></assignedPerson>
        <representedOrganization><name></name></representedOrganization>
        <sdtc:patient>
          <sdtc:id root='' extension=''/>
        </sdtc:patient>
      </assignedEntity>
    </performer>
  </serviceEvent>
<documentationOf>

<documentationOf>

The <documentationOf> element records the service events that were performed. This element shall be present.

<serviceEvent classCode="PCPR">

The <serviceEvent> element describes the activity being documented. This element shall be present, and shall have a classCode attribute of 'PCPR'.

<effectiveTime><low value=""/><high value=""/></effectiveTime>

The <effectiveTime> element records the time over which care provision activities are recorded in the document. There shall be a <low> element which records the starting date of care provision, and a <high> element which records the ending date of care provision. The ending date may extend into the future in the document describes care that is intended to be provided, but that has not actually occurred.

<performer typeCode="PRF">

The <performer> elements in the <serviceEvent> identify the providers of care. At least one <performer> element should be present. When a provider gives care over two distinct time intervals (e.g., as in the case of a specialist who treats the patient for short periods of time in different years), the provider may be recorded multiple times as a performer.

<functionCode code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The function of the provider in the care of the patient should be present, and will be described in the <functionCode> element. This may be used for example, to identify the primary care provider.

<time><low value=' '/><high value=' '/>

The element is used to show the time period over which the provider gave care to the patient. The <low> and <high> elements must be present, and indicate the time over which care was (or is to be) provided.

<assignedEntity classCode='ASSIGNED'>

The <assignedEntity> element contains elements that identify the individual provider, and shall be present.

<id root=' ' extension=' '/>

The <id> element may be present and identifies the provider.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The <code> element describes the type of provider and can be used to distinguish pharmacies from other providers.

<addr></addr>

The <addr> element gives the address of the provider.

<telecom value=' ' use=' '/>

The <telecom> element gives the telephone number of the provider.

<assignedPerson><name></name></assignedPerson>

The providers name should be present. If not present, then the <scopingOrganization> shall be present (see below).

<representedOrganization><name></name></representedOrganization>

This element should be present, and shall provide the name of the organization.

<sdtc:patient><sdtc:id root=' ' extension=' '/></sdtc:patient>

The <sdtc:patient> element may be present to represent the patient's medical record number with the given provider. The root attribute of <sdtc:id> element shall be present and identifies the namespace used for the identifier. The extension attribute shall be present and is the patient's medical record or account number with the provider. This element is an HL7 extension to CDA Release 2.0.

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

Patient Contacts 1.3.6.1.4.1.19376.1.5.3.1.2.4

Patient contacts are recorded as described in HL7 CCD: 3.3

Uses

See Templates using Patient Contacts

Specification

Patient Contacts Example

<guardian classCode='GUARD'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.4'/>
  <code code='' displayName='' codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
  <addr></addr>
  <telecom />
  <guardianPerson>
    <name></name>
  </guardianPerson>
</guardian>

Guardians

<participant typeCode='IND'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.4'/>
  <time value='20070213'/>
  <associatedEntity classCode='AGNT|CAREGIVER|ECON|NOK|PRS'>
    <code code='' displayName='' codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
    <addr></addr>
    <telecom value='' use=''/>
    <assignedPerson><name></name></assignedPerson>
  </associatedEntity>
</participant>

<guardian classCode='GUARD'>

The guardians of a patient shall be recorded in the <guardian> element beneath the <patient> element.

<participant typeCode='IND'>

Other contacts are recorded as <participant> elements appearing in the document header. The classCode attribute shall be set to 'IND'.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.4'/>

The <templateId> element identifies this person as a patient contact and must be recorded exactly as shown above.

<time value=' '>

The element may be present and indicates the time of the participation.

<associatedEntity classCode='AGNT|CAREGIVER|ECON|NOK|PRS'>

The <associatedEntity> element identifies the type of contact. The classCode attribute shall be present, and contains a value from the set AGNT, CAREGIVER, ECON, NOK, or PRS to identify contacts that are agents of the patient, care givers, emergency contacts, next of kin, or other relations respectively.

<code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>

The relationship between the patient and the guardian or other contact should be recorded in the <code> element. The code attribute is required and comes from the HL7 PersonalRelationshipRoleType vocabulary. The codeSystem attribute is required and shall be represented exactly as shown above.

<addr>

The address of the guardian or other contact should be present, and shall be represented as any other address would be in CDA.

<telecom>

The phone number of the guardian or other contact should be present, and shall be represented as any other phone number would be in CDA.

<guardianPerson><name/> or <assignedPerson><name/>

The name of the guardian or other contact shall be present, and shall be represented as any other name would be in CDA.

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

Authorization 1.3.6.1.4.1.19376.1.5.3.1.2.5

Each <authorization> element in the CDA Header represents an informed consent. When the document being shared represents the informed consent to a policy expressed by the XDS Affinity Domain within the document, it shall do so in an <authorization> element. More than one <authorization> element may be present. The consent to share informaiton shall have a unique identifier contained in the <id> element, representing the patient consent to that policy. The policy being consented to shall be represented in the <code> element. Note that other <authorization> elements may be present representing other sorts of consents associated with the document.

Uses

See Templates using Authorization

Specification

Authorization Example

<authorization typeCode='AUTH'>
  <consent classCode='CONS' moodCode='EVN'>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.5'/>
    <id root=''/>
    <code code='' codeSystem='' codeSystemName='' displayName=''/>
    <statusCode code='completed'/>
  </consent>
</authorization>

Policies are identified using an Affinity Domain specified coding system. Each coded value in that vocabulary represents one affinity domain specific policy.

<authorization typeCode='AUTH'>

At least one <authorization> element must be present in a consent medical document in documents shared by Document Source actors that implement the privacy option. The typeCode attribute shall be present and be valued with AUTH, indicating that this is an authorization act related to the document.

<consent classCode='CONS' moodCode='EVN'>

Each authorization element shall have one <consent> element. The classCode shall be present and be valued with CONS, indicating that the related act is an informed consent. The moodCode shall be EVN, indicating that this element represents and act that has occurred.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.5'/>

The <templateId> element shall be recorded as shown above and identifies this consent as an authorization entry.

<id root=' '/>

The <consent> element shall have one identifier that is used to uniquely identify the consent act. This identifier shall contain a root attribute, and shall not contain an extension attribute.

<code code=' ' codeSystem=' ' codeSystemName=' ' displayName=' '/>

The <consent> element shall have one <code> element that is used to identify the consent policy that was agreed to by the patient.

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

Consent Service Events 1.3.6.1.4.1.19376.1.5.3.1.2.6

Within a consent document, the effective time of the consent shall be specified within the documentationOf/serviceEvent element.

Uses

See Templates using Consent Service Events

Specification

Consent Service Events Example

<documentationOf typeCode='DOC'>
  <serviceEvent classCode='ACT' moodCode='EVN'>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.6'/>
    <id root=''/>
    <code code='' displayName='' codeSystem='' codeSystemName=''/>
    <effectiveTime>
      <low value=''/>
      <high value=''/>
    </effectiveTime>
  </serviceEvent>
</documentationOf>

<documentationOf typeCode='DOC'>

At least one <documentationOf> element shall exist within a consent to share information, describing the service event of provision of consent. This element shall have a typeCode attribute with the value DOC.

<serviceEvent classCode='ACT' moodCode='EVN'>

One <serviceEvent> shall exist for each consent to share information given, describing the duration of the provision of consent. This element shall have a classCode attribute set to ACT, and a moodCode attribute of EVN.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.6'/>

The <templateId> element shall be recorded exactly as shown above, and identifies this <serviceEvent> as recording consent to share information.

<id root=' ' />

The service event shall have one <id> element, providing an identifier for the service event. The root attribute of this element shall be present, and shall be a GUID or OID. The extension attribute shall not be present.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The <code> element shall be present, and shall indicate the consent given. The code attribute indicates the consent given, and the codeSystem attribute indicates the code system from which this consent is given. The displayName attribute may be present, and describes the consent given. The codeSystemName attribute may be present, and describes the code system.

<effectiveTime><low value=' '/><high value=' '/></effectiveTime>

The <effectiveTime> element shall be present, and shall indicated the effective time range over which consent is given. The low value must be provided . The high value may be present. If present, is shall indicate the maximum effective time of the consent.

CDA Section Content Modules

This list defines the sections that may appear in a medical document. It is intended to be a comprehensive list of all document sections that are used by any content profile defined in the Patient Care Coordination Technical Framework. All sections shall have a narrative component that may be freely formatted into normal text, lists, tables, or other appropriate human-readable presentations. Additional subsections or entry content modules may be required.

Reasons for Care

The sections described below describe various reasons why healthcare is being provided to the patient.

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

Reason for Referral Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.3.1
General Description	The reason for referral section shall contain a narrative description of the reason that the patient is being referred.
42349-1	R	REASON FOR REFERRAL

Sample Reason for Referral Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
    <id root=' ' extension=' '/>
    <code code='42349-1' displayName='REASON FOR REFERRAL'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.1'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.1"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Reason for Referral can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "42349-1"]'> 
     Error: The section type code of a Reason for Referral must be 42349-1 
   </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> 
 </rule> 
</pattern>

Uses

See Templates using the Reason for Referral 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 Reason for Referral Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.3.2
Parent Template	Reason for Referral (1.3.6.1.4.1.19376.1.5.3.1.3.1)
General Description	This section shall include at least one entry describing the reason for referral as described in the Entry Content Module.
42349-1	R	REASON FOR REFERRAL
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.4.13	R	Simple Observations
1.3.6.1.4.1.19376.1.5.3.1.4.5	R	Conditions Entry

Parent Template

The parent of this template is Reason for Referral.

Sample Coded Reason for Referral Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.2'/>
    <id root=' ' extension=' '/>
    <code code='42349-1' displayName='REASON FOR REFERRAL'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Simple Observations element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
         :
    </entry> 
    <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_1.3.6.1.4.1.19376.1.5.3.1.3.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Coded Reason for Referral can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.1"]'> 
     Error: The parent template identifier for Coded Reason for Referral is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "42349-1"]'> 
     Error: The section type code of a Coded Reason for Referral must be 42349-1 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded Reason for Referral Section must contain a(n) Simple Observations Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.2
   </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 Coded Reason for Referral Section must contain a(n) Conditions Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.2
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Coded Reason for Referral 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

Chief Complaint Section

LOINC Code	Opt	Description
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.
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

Hospital Admission Diagnosis Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.3.3
General Description	The hospital admitting diagnosis section shall contain a narrative description of the primary reason for admission to a hospital facility. It shall include entries for observations as described in the Entry Content Modules.
46241-6	R	HOSPITAL ADMISSION DX
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.4.5.2	R	Problem Concern Entry

Sample Hospital Admission Diagnosis Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.3'/>
    <id root=' ' extension=' '/>
    <code code='46241-6' displayName='HOSPITAL ADMISSION DX'
      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_1.3.6.1.4.1.19376.1.5.3.1.3.3'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.3"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Hospital Admission Diagnosis can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "46241-6"]'> 
     Error: The section type code of a Hospital Admission Diagnosis must be 46241-6 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.5.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Hospital Admission Diagnosis Section must contain a(n) Problem Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.3
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Hospital Admission 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

Proposed Procedure Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.9.1
General Description	The proposed procedure section shall contain a description of the procedures for which a risk assessment is required including procedure names and codes, patient position, dates, and names of surgeons. It shall include entries for procedures as described in the Entry Content Modules and the required and optional subsections.
29554-3	R	PROCEDURE
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.4.19	R	Procedure Entry
Subsections	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.1.9.4	R	Reason for Procedure
1.3.6.1.4.1.19376.1.5.3.1.1.9.3	R	Proposed Anesthesia
1.3.6.1.4.1.19376.1.5.3.1.1.9.2	R2	Expected Blood Loss
1.3.6.1.4.1.19376.1.5.3.1.1.9.40	R2	Procedure Care Plan

Sample Proposed Procedure Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.1'/>
    <id root=' ' extension=' '/>
    <code code='29554-3' displayName='PROCEDURE'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Procedure Entry  element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
         :
    </entry>
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.4'/>
        <!-- Required Reason for Procedure Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.3'/>
        <!-- Required Proposed Anesthesia Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.2'/>
        <!-- Required if known Expected Blood Loss Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.40'/>
        <!-- Required if known Procedure Care Plan Section content -->
      </section>
    </component>

       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.1'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.1"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Proposed Procedure can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "29554-3"]'> 
     Error: The section type code of a Proposed Procedure must be 29554-3 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Proposed Procedure Section must contain a(n) Procedure Entry  Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Proposed Procedure Section must contain a(n) Reason for Procedure Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Proposed Procedure Section must contain a(n) Proposed Anesthesia Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.2"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Proposed Procedure Section should contain a(n) Expected Blood Loss Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.40"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Proposed Procedure Section should contain a(n) Procedure Care Plan Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.1
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Proposed Procedure 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

Estimated Blood Loss Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.9.2
General Description	The estimated blood loss section shall contain a description of the blood loss for the procedure.
8717-1	R	OPERATIVE NOTE ESTIMATED BLOOD LOSS
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.4.13	R	Simple Observations

Sample Estimated Blood Loss Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.2'/>
    <id root=' ' extension=' '/>
    <code code='8717-1' displayName='OPERATIVE NOTE ESTIMATED BLOOD LOSS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Simple Observations element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
         :
    </entry>
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Estimated Blood Loss can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "8717-1"]'> 
     Error: The section type code of a Estimated Blood Loss must be 8717-1 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Estimated Blood Loss Section must contain a(n) Simple Observations Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.2
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Estimated Blood Loss 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

Proposed Anesthesia Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.9.3
General Description	The proposed anesthesia section shall contain a description of the anesthetic techniques for which a risk assessment is required. It shall include entries for anesthetic procedures as described in the Entry Content Modules.
10213-7	R	OPERATIVE NOTE ANESTHESIA
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.4.19	R	Procedure Entry The procedure entries shall be in INT mood.

Sample Proposed Anesthesia Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.3'/>
    <id root=' ' extension=' '/>
    <code code='10213-7' displayName='OPERATIVE NOTE ANESTHESIA'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Procedure Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
         :
    </entry>
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.3'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.3"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Proposed Anesthesia can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10213-7"]'> 
     Error: The section type code of a Proposed Anesthesia must be 10213-7 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Proposed Anesthesia Section must contain a(n) Procedure Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.3 
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Proposed Anesthesia 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

Reason for Procedure Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.9.4
General Description	The reason for procedure section shall contain a description of the reason that the patient is receiving the procedure. It shall include entries for conditions as described in the Entry Content Module.
10217-8	R	OPERATIVE NOTE INDICATIONS
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.4.5	R2	Conditions Entry

Sample Reason for Procedure Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.4'/>
    <id root=' ' extension=' '/>
    <code code='10217-8' displayName='OPERATIVE NOTE INDICATIONS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required if known 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_1.3.6.1.4.1.19376.1.5.3.1.1.9.4'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.4"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Reason for Procedure can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10217-8"]'> 
     Error: The section type code of a Reason for Procedure must be 10217-8 
   </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"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Reason for Procedure Section should contain a(n) Conditions Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.4
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Reason for Procedure Section

Other Condition Histories

The sections defined below provide historical information about the patient's conditions.

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

LOINC Code	Opt	Description
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.
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

Hospital Course Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.3.5
General Description	The hospital course section shall contain a narrative description of the sequence of events from admission to discharge in a hospital facility.
8648-8	R	HOSPITAL COURSE

Sample Hospital Course Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.5'/>
    <id root=' ' extension=' '/>
    <code code='8648-8' displayName='HOSPITAL COURSE'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.5'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.5"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Hospital Course can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "8648-8"]'> 
     Error: The section type code of a Hospital Course must be 8648-8 
   </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 Hospital Course 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

LOINC Code	Opt	Description
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.
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

Discharge Diagnosis Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.3.7
General Description	The discharge diagnosis section shall contain a narrative description of the conditions that need to be monitored after discharge from the hospital and those that were resolved during the hospital course. It shall include entries for patient conditions as described in the Entry Content Module.
11535-2	R	HOSPITAL DISCHARGE DX
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.4.5.2	R	Problem Concern Entry

Sample Discharge Diagnosis Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.7'/>
    <id root=' ' extension=' '/>
    <code code='11535-2' displayName='HOSPITAL DISCHARGE DX'
      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_1.3.6.1.4.1.19376.1.5.3.1.3.7'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.7"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Discharge Diagnosis can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11535-2"]'> 
     Error: The section type code of a Discharge Diagnosis must be 11535-2 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.5.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Diagnosis Section must contain a(n) Problem Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.7
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Discharge 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

History of Past Illness Section

LOINC Code	Opt	Description
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.
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

Encounter Histories Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
Parent Template	2.16.840.1.113883.10.20.1.3 (2.16.840.1.113883.10.20.1.3)
General Description	The encounter history section contains coded entries describing the patient history of encounters.
46240-8	R	HISTORY OF ENCOUNTERS
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.4.14	R	Encounters

Parent Template

The parent of this template is 2.16.840.1.113883.10.20.1.3.

Sample Encounter Histories Section

<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.3'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'/>
    <id root=' ' extension=' '/>
    <code code='46240-8' displayName='HISTORY OF ENCOUNTERS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Encounters element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.14'/>
         :
    </entry>
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Encounter Histories can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.3"]'> 
     Error: The parent template identifier for Encounter Histories is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "46240-8"]'> 
     Error: The section type code of a Encounter Histories must be 46240-8 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.14"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Encounter Histories Section must contain a(n) Encounters Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Encounter Histories 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 Outpatient Visits Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.3.9
General Description	The outpatients visit section shall contain a narrative description of the completed visits to ambulatory facilities.
11346-4	R	HISTORY OF OUTPATIENT VISITS

Sample History of Outpatient Visits Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.9'/>
    <id root=' ' extension=' '/>
    <code code='11346-4' displayName='HISTORY OF OUTPATIENT VISITS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.9'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.9"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The History of Outpatient Visits can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11346-4"]'> 
     Error: The section type code of a History of Outpatient Visits must be 11346-4 
   </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 History of Outpatient Visits 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 Inpatient Visits Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.3.10
General Description	The inpatient admissions section shall contain a narrative description of the admissions and discharges to inpatient facilities.
11336-5	R	HISTORY OF HOSPITALIZATIONS

Sample History of Inpatient Visits Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.10'/>
    <id root=' ' extension=' '/>
    <code code='11336-5' displayName='HISTORY OF HOSPITALIZATIONS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.10'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.10"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The History of Inpatient Visits can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11336-5"]'> 
     Error: The section type code of a History of Inpatient Visits must be 11336-5 
   </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> 
 </rule> 
</pattern>

Uses

See Templates using the History of Inpatient Visits 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

LOINC Code	Opt	Description
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.
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

Coded List of Surgeries Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.3.12
Parent Template	List of Surgeries (1.3.6.1.4.1.19376.1.5.3.1.3.11)
General Description	The list of surgeries section shall include entries for procedures and references to procedure reports when known as described in the Entry Content Modules.
47519-4	R	HISTORY OF PROCEDURES
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.4.19	R	Procedure Entry
1.3.6.1.4.1.19376.1.5.3.1.4.4	R2	References Entry

Parent Template

The parent of this template is List of Surgeries.

Sample Coded List of Surgeries Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.12'/>
    <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>   
    <entry>
         :
      <!-- Required Procedure Entry  element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
         :
    </entry> 
    <entry>
         :
      <!-- Required if known References Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
         :
    </entry>
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.12'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.12"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Coded List of Surgeries can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     Error: The parent template identifier for Coded 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 Coded 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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded List of Surgeries Section must contain a(n) Procedure Entry  Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.12
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Coded List of Surgeries Section should contain a(n) References Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.12
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Coded 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

Allergies and Other Adverse Reactions Section

LOINC Code	Opt	Description
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.
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

Family Medical History Section

LOINC Code	Opt	Description
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.
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

Coded Family Medical History Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.3.15
Parent Template	Family Medical History (1.3.6.1.4.1.19376.1.5.3.1.3.14)
General Description	The family history section shall include entries for family history as described in the Entry Content Modules.
10157-6	R	HISTORY OF FAMILY MEMBER DISEASES
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.4.15	R	Family History Organizer

Parent Template

The parent of this template is Family Medical History.

Sample Coded Family Medical History Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.15'/>
    <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>   
    <entry>
         :
      <!-- Required Family History Organizer element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.15'/>
         :
    </entry>
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.15'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.15"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Coded Family Medical History can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> 
     Error: The parent template identifier for Coded 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 Coded 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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.15"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded Family Medical History Section must contain a(n) Family History Organizer Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.15
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Coded 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

Pre-procedure Family Medical History Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.9.5
Parent Template	1.3.6.1.4.1.19376.1.5.3.1.3.15 (1.3.6.1.4.1.19376.1.5.3.1.3.15)
General Description	The pre-procedure family history section shall contain a description of the genetic family members who have suffered complications during anesthesia such as malignant hyperthermia, bleeding, etc. It shall include entries for family history as described in the Entry Content Modules.
10157-6	R	HISTORY OF FAMILY MEMBER DISEASES

Parent Template

The parent of this template is 1.3.6.1.4.1.19376.1.5.3.1.3.15.

Sample Pre-procedure Family Medical History Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.15'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.5'/>
    <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_1.3.6.1.4.1.19376.1.5.3.1.1.9.5'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.5"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Pre-procedure Family Medical History can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.15"]'> 
     Error: The parent template identifier for Pre-procedure 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 Pre-procedure 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 Pre-procedure 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

LOINC Code	Opt	Description
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.
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

Functional Status Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.3.17
Parent Template	CCD 3.4 (2.16.840.1.113883.10.20.1.5)
General Description	The functional status section shall contain a narrative description of capability of the patient to perform acts of daily living.
47420-5	R	FUNCTIONAL STATUS ASSESSMENT

Parent Template

The parent of this template is CCD 3.4.

Sample Functional Status Section

<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.5'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/>
    <id root=' ' extension=' '/>
    <code code='47420-5' displayName='FUNCTIONAL STATUS ASSESSMENT'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.17'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.17"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Functional Status can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.5"]'> 
     Error: The parent template identifier for Functional Status is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "47420-5"]'> 
     Error: The section type code of a Functional Status must be 47420-5 
   </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> 
 </rule> 
</pattern>

Uses

See Templates using the Functional Status 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 Functional Status Assessment Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
Parent Template	Functional Status (1.3.6.1.4.1.19376.1.5.3.1.3.17)
General Description	The coded functional status assessment section provided a machine readable and narrative description of the patient’s status of normal functioning at the time the document was created. Functional status includes information concerning: Ambulatory ability Mental status or competency Activities of Daily Living (ADL’s) including bathing, dressing, feeding, grooming Home/living situation having an effect on the health status of the patient Ability to care for self Social activity, including issues with social cognition, participation with friends and acquaintances other than family members Occupation activity, including activities partly or directly related to working, housework or volunteering, family and home responsibilities or activities related to home and family Communication ability, including issues with speech, writing or cognition required for communication Perception, including sight, hearing, taste, skin sensation, kinesthetic sense, proprioception, or balance
47420-5	R	Functional Status Assessment
Subsections	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2	R	Pain Scale Assessment
1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3	O	Braden Score Assessment
1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4	O	Geriatric Depression Scale
1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5	O	Minimum Data Set

At least one of the above optional subsections shall be present

Standards

CDAR2	HL7 CDA Release 2.0
CRS	HL7 Care Record Summary
CCD	ASTM/HL7 Continuity of Care Document
LOINC	Logical Observation Identifier Names and Codes
SNOMED	Systemitized Nomenclature of Medicine Clinical Terminology

Parent Template

The parent of this template is Functional Status.

Sample Coded Functional Status Assessment Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1'/>
    <id root=' ' extension=' '/>
    <code code='47420-5' displayName='Functional Status Assessment'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2'/>
        <!-- Required Pain Scale Assessment Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3'/>
        <!-- Optional Braden Score Assessment Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4'/>
        <!-- Optional Geriatric Depression Scale Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5'/>
        <!-- Optional Minimum Data Set Section content -->
      </section>
    </component>

       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Coded Functional Status Assessment can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.17"]'> 
     Error: The parent template identifier for Coded Functional Status Assessment is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "47420-5"]'> 
     Error: The section type code of a Coded Functional Status Assessment must be 47420-5 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded Functional Status Assessment Section must contain a(n) Pain Scale Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3"]'> 
     <!-- Note any missing optional elements -->
     Note: This Coded Functional Status Assessment Section does not contain a(n) Braden Score Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4"]'> 
     <!-- Note any missing optional elements -->
     Note: This Coded Functional Status Assessment Section does not contain a(n) Geriatric Depression Scale Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5"]'> 
     <!-- Note any missing optional elements -->
     Note: This Coded Functional Status Assessment Section does not contain a(n) Minimum Data Set Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
   </assert> 
   <assert test="./cda:component/cda:section/cda:templateId[
                   @root = '1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3' or
                   @root = '1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4' or
                   @root = '1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5']">
     At least one of the optional subsections must be in a coded functional assessment.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Coded Functional Status 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

Pain Scale Assessment Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2
General Description	The Pain Scale Assessment contains a coded observation reflecting the patient's reported intensity of pain on a scale from 0 to 10.
38208-5	R	Pain severity
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1	R	Pain Score Observation

Sample Pain Scale Assessment Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2'/>
    <id root=' ' extension=' '/>
    <code code='38208-5' displayName='Pain severity'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Pain Score Observation element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1'/>
         :
    </entry>
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Pain Scale Assessment can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "38208-5"]'> 
     Error: The section type code of a Pain Scale Assessment must be 38208-5 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Pain Scale Assessment Section must contain a(n) Pain Score Observation Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Pain Scale 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

Braden Score Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3
General Description	This section reports the braden score and its related assessments in machine and human readable form.
38228-3	R	BRADEN SCALE SKIN ASSESSMENT PANEL
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2	R	Braden Score Observation

Sample Braden Score Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3'/>
    <id root=' ' extension=' '/>
    <code code='38228-3' displayName='BRADEN SCALE SKIN ASSESSMENT PANEL'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Braden Score Observation element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2'/>
         :
    </entry>
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Braden Score can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "38228-3"]'> 
     Error: The section type code of a Braden Score must be 38228-3 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Braden Score Section must contain a(n) Braden Score Observation Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Braden Score 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

Geriatric Depression Scale Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4
General Description	This section reports the Geriatric Depression Scale score and its related assessments in machine and human readable form.
48542-5	R	Geriatric Depression Scale (GDS) Panel
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.1.12.3.4	R	Geriatric Depression Score Observation

Sample Geriatric Depression Scale Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4'/>
    <id root=' ' extension=' '/>
    <code code='48542-5' displayName='Geriatric Depression Scale (GDS) Panel'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Geriatric Depression Score Observation element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.4'/>
         :
    </entry>
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Geriatric Depression Scale can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "48542-5"]'> 
     Error: The section type code of a Geriatric Depression Scale must be 48542-5 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.12.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Geriatric Depression Scale Section must contain a(n) Geriatric Depression Score Observation Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Geriatric Depression Scale 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

Physical Function Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5
General Description	This section reports scores from section G of the Minimum Data Set.
46006-3	R	Physical functioning and structural problems
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7	O	Survey Panel At least one Survey Panel or Survey Observation shall be present.
1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6	O	Survey Observations At least one Survey Panel or Survey Observation shall be present.

Sample Physical Function Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5'/>
    <id root=' ' extension=' '/>
    <code code='46006-3' displayName='Physical functioning and structural problems'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Optional Survey Panel element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7'/>
         :
    </entry> 
    <entry>
         :
      <!-- Optional Survey Observations element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6'/>
         :
    </entry>
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Physical Function can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "46006-3"]'> 
     Error: The section type code of a Physical Function must be 46006-3 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Function Section does not contain a(n) Survey Panel Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Function Section does not contain a(n) Survey Observations Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6"] or 
                 .//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7"]'>
     At least one Survey Panel or Survey Observation shall be present.
     See http://www.ihe.net/index.php/1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Physical Function Section

Constraints

Survey Panels found in this section shall be identified using the panel codes found in the table below, and shall contain one or more survey observations from that panel.

Survey Observations found in this section shall use the LOINC codes from the table below to express the answer to one or more questions from the Minimum Data Set Section G. The Survey Observations shall not contain a <methodCode> or <targetSiteCode> element, as these are not appropriate to the MDS Survey instrument.

Panel Code	Observation Code	Description	Data Type	Value Set
46007-1	Panel	ADL self performance or support
	45588-1	Bed mobility - self-performance	CO	2.16.840.1.113883.6.257.755
	45589-9	Bed mobility - support provided	CO	2.16.840.1.113883.6.257.768
	45590-7	Transfer - self-performance	CO	2.16.840.1.113883.6.257.755
	45591-5	Transfer - support provided	CO	2.16.840.1.113883.6.257.768
	45592-3	Walk in room - self-performance	CO	2.16.840.1.113883.6.257.755
	45593-1	Walk in room - support provided	CO	2.16.840.1.113883.6.257.768
	45594-9	Walk in corridor - self-performance	CO	2.16.840.1.113883.6.257.755
	45595-6	Walk in corridor - support provided	CO	2.16.840.1.113883.6.257.768
	45596-4	Locomotion on unit - self-performance	CO	2.16.840.1.113883.6.257.755
	45597-2	Locomotion on unit - support provided	CO	2.16.840.1.113883.6.257.768
	45598-0	Locomotion off unit - self-performance	CO	2.16.840.1.113883.6.257.755
	45599-8	Locomotion off unit - support provided	CO	2.16.840.1.113883.6.257.768
	45600-4	Dressing - self-performance	CO	2.16.840.1.113883.6.257.755
	45601-2	Dressing - support provided	CO	2.16.840.1.113883.6.257.768
	45602-0	Eating - self-performance	CO	2.16.840.1.113883.6.257.755
	45603-8	Eating - support provided	CO	2.16.840.1.113883.6.257.768
	45604-6	Toilet use - self-performance	CO	2.16.840.1.113883.6.257.755
	45605-3	Toilet use - support provided	CO	2.16.840.1.113883.6.257.768
	45606-1	Personal hygiene - self-performance	CO	2.16.840.1.113883.6.257.755
	45607-9	Personal hygiene - support provided	CO	2.16.840.1.113883.6.257.768
46008-9	Panel	Bathing
	45608-7	Bathing - self-performance	CO	2.16.840.1.113883.6.257.860
	45609-5	Bathing - support provided	CO	2.16.840.1.113883.6.257.768
46009-7	Panel	Test for balance
	45610-3	Balance while standing	CO	2.16.840.1.113883.6.257.876
	45523-8	Balance while sitting	CO	2.16.840.1.113883.6.257.876
46010-5	Panel	Functional limitation in range of motion
	45524-6	Range of motion^Neck	CO	2.16.840.1.113883.6.257.889
	45525-3	Voluntary movement^Neck	CO	2.16.840.1.113883.6.257.898
	45526-1	Range of motion^Upper Extremity	CO	2.16.840.1.113883.6.257.889
	45527-9	Voluntary movement^Upper Extremity	CO	2.16.840.1.113883.6.257.898
	45528-7	Range of motion^Hand	CO	2.16.840.1.113883.6.257.889
	45529-5	Voluntary movement^Hand	CO	2.16.840.1.113883.6.257.898
	45530-3	Range of motion^Lower Extremity	CO	2.16.840.1.113883.6.257.889
	45531-1	Voluntary movement^Lower Extremity	CO	2.16.840.1.113883.6.257.898
	45532-9	Range of motion^Foot	CO	2.16.840.1.113883.6.257.889
	45533-7	Voluntary movement^Foot	CO	2.16.840.1.113883.6.257.898
	45534-5	Other - range of motion	CO	2.16.840.1.113883.6.257.889
	45535-2	Other - voluntary movement	CO	2.16.840.1.113883.6.257.898
46011-3	Panel	Modes of locomotion
	45536-0	Uses cane, walker or crutch	CO	2.16.840.1.113883.6.257.117
	45537-8	Wheeled self	CO	2.16.840.1.113883.6.257.117
	45538-6	Other person wheeled	CO	2.16.840.1.113883.6.257.117
	45539-4	Uses wheelchair for primary locomotion	CO	2.16.840.1.113883.6.257.117
	45540-2	No modes of locomotion	CO	2.16.840.1.113883.6.257.117
46012-1	Panel	Modes of transfer
	45541-0	Bedfast all or most of the time	CO	2.16.840.1.113883.6.257.117
	45542-8	Bed rails for bed mobility or transfer	CO	2.16.840.1.113883.6.257.117
	45543-6	Lifted manually	CO	2.16.840.1.113883.6.257.117
	45544-4	Lifted mechanically	CO	2.16.840.1.113883.6.257.117
	45545-1	Transfer aid	CO	2.16.840.1.113883.6.257.117
	45546-9	No mode of transfer	CO	2.16.840.1.113883.6.257.117
No Panel	45611-1	Task segmentation	CO	2.16.840.1.113883.6.257.117
46013-9	Panel	ADL functional rehabilitation potential
	45612-9	Resident sees increased independence capability	CO	2.16.840.1.113883.6.257.117
	45613-7	Staff sees increased independence capability	CO	2.16.840.1.113883.6.257.117
	45614-5	Resident slow performing tasks or activity	CO	2.16.840.1.113883.6.257.117
	45615-2	Difference in morning to evening activities of daily living	CO	2.16.840.1.113883.6.257.117
	45616-0	Activities of daily living rehabilitation potential - none of above	CO	2.16.840.1.113883.6.257.117
	45617-8	Change in activities of daily living function	CO	2.16.840.1.113883.6.257.464

The coded orginal values used in the observations above are described in more detail in the table below.

Explanation	Coded Value
2.16.840.1.113883.6.257.755
INDEPENDENT-No help or oversight -OR- Help/oversight provided only 1 or 2 times during last 7 days	0
SUPERVISION-Oversight, encouragement or cueing provided 3 or more times during last7 days -OR- Supervision (3 or more times) plus physical assistance provided only 1 or 2 times during last 7 days	1
LIMITED ASSISTANCE-Resident highly involved in activity; received physical help in guided maneuvering of limbs or other nonweight bearing assistance 3 or more times - OR-More help provided only 1 or 2 times during last 7 days	2
EXTENSIVE ASSISTANCE-While resident performed part of activity, over last 7-day period, help of following type(s) provided 3 or more times: - Weight-bearing support - Full staff performance during part (but not all) of last 7 days	3
TOTAL DEPENDENCE-Full staff performance of activity during entire 7 days	4
ACTIVITY DID NOT OCCUR during entire 7 days	8
2.16.840.1.113883.6.257.768
No setup or physical help from staff	0
Setup help only	1
One person physical assist	2
ADL activity itself did not occur during entire 7 days	8
2.16.840.1.113883.6.257.860
Independent-No help provided	0
Supervision-Oversight help only	1
Physical help limited to transfer only	2
Physical help in part of bathing activity	3
Total dependence	4
Activity itself did not occur during entire 7 days	8
2.16.840.1.113883.6.257.876
Maintained position as required in test	0
Unsteady, but able to rebalance self without physical support	1
Partial physical support during test; or stands (sits) but does not follow directions for test	2
Not able to attempt test without physical help	3
2.16.840.1.113883.6.257.889
No limitation	0
Limitation on one side	1
Limitation on both sides	2
2.16.840.1.113883.6.257.898
No loss	0
Partial loss	1
Full loss	2
2.16.840.1.113883.6.257.117
No	0
Yes	1
UTD	-
2.16.840.1.113883.6.257.464
No change	0
Improved	1
Deteriorated	2

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

Review of Systems Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.3.18
General Description	The review of systems section shall contain a narrative description of the responses the patient gave to a set of routine questions on the functions of each anatomic body system.
10187-3	R	REVIEW OF SYSTEMS

Sample Review of Systems Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
    <id root=' ' extension=' '/>
    <code code='10187-3' displayName='REVIEW OF SYSTEMS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.18'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Review of Systems can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10187-3"]'> 
     Error: The section type code of a Review of Systems must be 10187-3 
   </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 Review of Systems 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

Preprocedure Review of Systems Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.9.13
Parent Template	Review of Systems (1.3.6.1.4.1.19376.1.5.3.1.3.18)
General Description	The pre-procedure review of systems section shall contain only required and optional subsections dealing with the responses the patient gave to a set of routine questions on body systems in general and specific risks of anesthesia not covered in general review of systems.
10187-3	R	REVIEW OF SYSTEMS
Subsections	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.1.9.46	R	History of Implanted Medical Devices
1.3.6.1.4.1.19376.1.5.3.1.1.9.47	R2	Pregnancy Status History
1.3.6.1.4.1.19376.1.5.3.1.1.9.14	R	Anesthesia Risk Review of Systems

Parent Template

The parent of this template is Review of Systems.

Sample Preprocedure Review of Systems Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.13'/>
    <id root=' ' extension=' '/>
    <code code='10187-3' displayName='REVIEW OF SYSTEMS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.46'/>
        <!-- Required History of Implanted Medical Devices Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.47'/>
        <!-- Required if known Pregnancy Status History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.14'/>
        <!-- Required Anesthesia Risk Review of Systems Section content -->
      </section>
    </component>

       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.13'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.13"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Preprocedure Review of Systems can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     Error: The parent template identifier for Preprocedure Review of Systems is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10187-3"]'> 
     Error: The section type code of a Preprocedure Review of Systems must be 10187-3 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.9.46"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure Review of Systems Section must contain a(n) History of Implanted Medical Devices Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.13
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.47"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure Review of Systems Section should contain a(n) Pregnancy Status History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.13
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.14"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure Review of Systems Section must contain a(n) Anesthesia Risk Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.13
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Preprocedure Review of Systems 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

Hazardous Working Conditions Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1
General Description	Hazardous working conditions contains a narrative description of the patient's hazardous risks.
10161-8	R	HISTORY OF OCCUPATIONAL EXPOSURE

Sample Hazardous Working Conditions Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1'/>
    <id root=' ' extension=' '/>
    <code code='10161-8' displayName='HISTORY OF OCCUPATIONAL EXPOSURE'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Hazardous Working Conditions can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10161-8"]'> 
     Error: The section type code of a Hazardous Working Conditions must be 10161-8 
   </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 Hazardous Working Conditions 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

LOINC Code	Opt	Description
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.
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

Estimated Delivery Dates Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1
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.
(xx-edd-section)	R	ESTIMATED DELIVERY DATE-^PATIENT-FIND-PT-NAR-
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1	R	Estimated Due Date Observation This is a simple observation to represent the estimated due date with a supporting observation or observations that state the method used and date implied by that method. If one observation is present, then it is to be interpreted as the initial EDD. If the initial observation dates indicate the EDD is within the 18 to 20 weeks completed gestation, that observation will also populate the 18-20 week update. If the initial observation indicates an EDD of more than 20 weeks EGA, then no value will be placed in the 18-20 week update field.

Sample Estimated Delivery Dates Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1'/>
    <id root=' ' extension=' '/>
    <code code='(xx-edd-section)' displayName='ESTIMATED DELIVERY DATE-^PATIENT-FIND-PT-NAR-'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Estimated Due Date Observation element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1'/>
         :
    </entry>
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Estimated Delivery Dates can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "(xx-edd-section)"]'> 
     Error: The section type code of a Estimated Delivery Dates must be (xx-edd-section) 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Estimated Delivery Dates Section must contain a(n) Estimated Due Date Observation Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1 
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Estimated Delivery Dates 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

Medical Devices Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5
Parent Template	2.16.840.1.11383.10.20.1.7 (2.16.840.1.11383.10.20.1.7)
General Description	The medical devices section contains narrative text describing the patient history of medical device use.
46264-8	R	HISTORY OF MEDICAL DEVICE USE

Parent Template

The parent of this template is 2.16.840.1.11383.10.20.1.7.

Sample Medical Devices Section

<component>
  <section>
    <templateId root='2.16.840.1.11383.10.20.1.7'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5'/>
    <id root=' ' extension=' '/>
    <code code='46264-8' displayName='HISTORY OF MEDICAL DEVICE USE'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Medical Devices can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.11383.10.20.1.7"]'> 
     Error: The parent template identifier for Medical Devices is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "46264-8"]'> 
     Error: The section type code of a Medical Devices must be 46264-8 
   </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 Medical Devices 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

Foreign Travel Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6
General Description	The foreign travel section contains only narrative text describing the patient's travel history.
10182-4	R	HISTORY OF TRAVEL

Sample Foreign Travel Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6'/>
    <id root=' ' extension=' '/>
    <code code='10182-4' displayName='HISTORY OF TRAVEL'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Foreign Travel can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10182-4"]'> 
     Error: The section type code of a Foreign Travel must be 10182-4 
   </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 Foreign Travel 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 Tobacco Use Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.9.8
General Description	The history of tobacco use section shall contain a description of the responses the patient gave to a set of routine questions on the history of tobacco use.
11366-2	R	HISTORY OF TOBACCO USE

Sample History of Tobacco Use Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.8'/>
    <id root=' ' extension=' '/>
    <code code='11366-2' displayName='HISTORY OF TOBACCO USE'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.8'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.8"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The History of Tobacco Use can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11366-2"]'> 
     Error: The section type code of a History of Tobacco Use must be 11366-2 
   </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 Tobacco Use 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

Current Alcohol/Substance Abuse Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.9.10
General Description	The history of alcohol/substance abuse section shall contain a description of the responses the patient gave to a set of routine questions on the current abuse of alcohol or other substances.
18663-5	R	HISTORY OF PRESENT ALCOHOL AND/OR SUBSTANCE ABUSE

Sample Current Alcohol/Substance Abuse Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.10'/>
    <id root=' ' extension=' '/>
    <code code='18663-5' displayName='HISTORY OF PRESENT ALCOHOL AND/OR SUBSTANCE ABUSE'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.10'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.10"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Current Alcohol/Substance Abuse can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "18663-5"]'> 
     Error: The section type code of a Current Alcohol/Substance Abuse must be 18663-5 
   </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> 
 </rule> 
</pattern>

Uses

See Templates using the Current Alcohol/Substance Abuse Section

__________

gregorysmith

Alcohol abuse affects millions. This site has a lot of useful information. Alcohol Abuse

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

Transfusion History Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.9.12
General Description	The transfusion history section shall contain a description of the blood products the patient has received in the past, including any reactions to blood products. It shall include entries for substance administration as described in the Entry Content Modules.
TBD	R	BLOOD PRODUCTS ADMINISTRATION

Sample Transfusion History Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.12'/>
    <id root=' ' extension=' '/>
    <code code='TBD' displayName='BLOOD PRODUCTS ADMINISTRATION'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.12'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.12"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Transfusion History can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "TBD"]'> 
     Error: The section type code of a Transfusion History must be TBD 
   </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 Transfusion 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

Anesthesia Risk Review of Systems Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.9.14
Parent Template	1.3.6.1.4.1.19376.1.5.3.1.3.18 (1.3.6.1.4.1.19376.1.5.3.1.3.18)
General Description	The anethesia review of systems section shall contain a description of the responses the patient gave to a set of routine questions on specific risks of anesthesia not covered in general review of systems such as broken teeth, airway limitations, positioning limitations, recent infections, and history of personal anethesia problems.
TBD	R	TBD

Parent Template

The parent of this template is 1.3.6.1.4.1.19376.1.5.3.1.3.18.

Sample Anesthesia Risk Review of Systems Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.14'/>
    <id root=' ' extension=' '/>
    <code code='TBD' displayName='TBD'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.14'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.14"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Anesthesia Risk Review of Systems can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     Error: The parent template identifier for Anesthesia Risk Review of Systems is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "TBD"]'> 
     Error: The section type code of a Anesthesia Risk Review of Systems must be TBD 
   </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 Anesthesia Risk Review of Systems Section

1.3.6.1.4.1.19376.1.5.3.1.1.9.46 Template:CDA Section

Medications

This section contains section content modules that describe activities surrounding the use of medication. 1.3.6.1.4.1.19376.1.5.3.1.3.19 1.3.6.1.4.1.19376.1.5.3.1.3.20 1.3.6.1.4.1.19376.1.5.3.1.3.21 1.3.6.1.4.1.19376.1.5.3.1.3.22 1.3.6.1.4.1.19376.1.5.3.1.3.23

Physical Exams

Relevant Studies

1.3.6.1.4.1.19376.1.5.3.1.3.27 1.3.6.1.4.1.19376.1.5.3.1.3.28 1.3.6.1.4.1.19376.1.5.3.1.3.29 1.3.6.1.4.1.19376.1.5.3.1.3.30 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8

Plans of Care

This section provides content modules for sections that describe the plan of care intended for the patient. 1.3.6.1.4.1.19376.1.5.3.1.3.31 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1

1.3.6.1.4.1.19376.1.5.3.1.3.33 1.3.6.1.4.1.19376.1.5.3.1.3.34 1.3.6.1.4.1.19376.1.5.3.1.3.35 1.3.6.1.4.1.19376.1.5.3.1.1.9.40 1.3.6.1.4.1.19376.1.5.3.1.1.9.45 1.3.6.1.4.1.19376.1.5.3.1.1.9.50 1.3.6.1.4.1.19376.1.5.3.1.1.9.41 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2

PCC Public Comment Drafts

Volume 2

Preface to Volume 2

Intended Audience

Related Information for the Reader

How this Document is Organized

Conventions Used in this Volume

The Generic IHE Transaction Model

Copyright Permissions

How to Contact Us

Introduction

Relationship to Standards

Relationship to Product Implementations

Relation of this Volume to the Technical Framework

Content Modules

Document Content Module Constraints

Sample Document Specification SampleDocumentOID

Specification

Conformance

Schematron

Section Content Module Constraints

Sample Section

Parent Template

Uses

Entry and Header Content Modules Constraints

<observation classCode='OBS' moodCode='EVN'>

<templateId root='foo'/>

IHE Transactions

IHE Patient Care Coordination Bindings

Medical Document Binding to XDS, XDM and XDR

XDSDocumentEntry Metadata

XDSSubmissionSet Metadata

Use of XDS Submission Set

Use of XDS Folders

Configuration

Extensions from other Domains

Scanned Documents (XDS-SD)

XDSDocumentEntry

XDSDocumentEntry.formatCode

XDSDocumentEntry.uniqueId

Relating instances of XDS-SD documents

XDSSubmissionSet

XDSFolder

Basic Patient Privacy Consents (BPPC)

Laboratory Reports (XD-LAB)

XDSDocumentEntry

XDSDocumentEntry.eventCodeList

XDSDocumentEntry.formatCode

XDSSubmissionSet

XDSFolder

Namespaces and Vocabularies

IHEActCode Vocabulary

IHERoleCode Vocabulary

Conventions

Folder Content Modules

CDA Release 2.0 Content Modules

CDA Document Content Modules

Development Only

Medical Documents Specification 1.3.6.1.4.1.19376.1.5.3.1.1.1

Standards

Conformance

Specification

Style Sheets

Distinctions of None

Development Only

Medical Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.2

Parent Template

Standards

Specification

Conformance

Schematron

Document Specification

Development Only

Referral Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.3

Format Code

Parent Template

Standards

Data Element Index

Specification

Conformance