PCC Public Comment Drafts/5

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Revision as of 23:30, 19 June 2007 by Kboone (talk | contribs) (New page: {{:1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2|Pain Scale Assessment|XDS-MS|XPHR|FSA}} {{:1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3|Braden Score Assessment|XDS-MS|XPHR|FSA}} {{:1.3.6.1.4.1.19376.1.5.3.1.1...)
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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


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



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

See Templates using the Pregnancy History Section


Development Only

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

Estimated Delivery Dates Section
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.

LOINC Code Opt Description
(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


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