PCC Public Comment Drafts/4

From IHE Wiki
Revision as of 23:03, 19 June 2007 by Kboone (talk | contribs) (New page: {{:1.3.6.1.4.1.19376.1.5.3.1.3.12|Coded List of Surgeries|XDS-MS|XPHR|EDER}} {{:1.3.6.1.4.1.19376.1.5.3.1.3.13|Allergies and Other Adverse Reactions|XDS-MS|XPHR|APS|EDR|EDER}} {{:1.3.6.1.4...)
(diff) ← Older revision | Latest revision (diff) | Newer revision → (diff)
Jump to navigation Jump to search

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



Parent Template

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

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

See Templates using the Allergies and Other Adverse Reactions Section


Development Only

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

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



Parent Template

The parent of this template is CCD 3.6.

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

See Templates using the Family Medical History Section


Development Only

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

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



Parent Template

The parent of this template is CCD 3.7.

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

See Templates using the Social History Section


Development Only

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

Functional Status Section
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.
LOINC Code Opt Description
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
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
LOINC Code Opt Description
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
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.
LOINC Code Opt Description
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


Retrieved from "http://wiki.ihe.net/index.php?title=PCC_Public_Comment_Drafts/4&oldid=7881"