PCC Public Comment Drafts/3

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



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

See Templates using the History of Present Illness Section


Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at https://www.ihe.net/resources/technical_frameworks/#pcc

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



Parent Template

The parent of this template is CCD 3.5.

Sample Active Problems Section 
<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.11'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
    <id root=' ' extension=' '/>
    <code code='11450-4' displayName='PROBLEM LIST'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Problem Concern Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.6'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Active Problems can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.11"]'> 
     Error: The parent template identifier for Active Problems is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11450-4"]'> 
     Error: The section type code of a Active Problems must be 11450-4 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.5.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Active Problems Section must contain a(n) Problem Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.6
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Active Problems Section


Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at https://www.ihe.net/resources/technical_frameworks/#pcc

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



Sample History of Past Illness Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
    <id root=' ' extension=' '/>
    <code code='11348-0' displayName='HISTORY OF PAST ILLNESS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Problem Concern Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.8'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The History of Past Illness can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11348-0"]'> 
     Error: The section type code of a History of Past Illness must be 11348-0 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.5.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The History of Past Illness Section must contain a(n) Problem Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.8
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the History of Past Illness Section


Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at https://www.ihe.net/resources/technical_frameworks/#pcc

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



Parent Template

The parent of this template is CCD 3.14.

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

See Templates using the List of Surgeries Section


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