PCC Public Comment Drafts/6

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Revision as of 23:53, 19 June 2007 by Kboone (talk | contribs) (New page: {{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5|Medical Devices|XPHR}} {{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6|Foreign Travel|XPHR}} {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.8|History of Tobacco Use|PPHP}} {{: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

Medical Devices Section
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.
LOINC Code Opt Description
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
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.
LOINC Code Opt Description
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
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.
LOINC Code Opt Description
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
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.
LOINC Code Opt Description
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
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.
LOINC Code Opt Description
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
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.
LOINC Code Opt Description
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


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

Implanted Medical Device Review Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.46
General Description The implanted medical device review section shall contain a description of the medical devices that are inserted into the patient, whether internal or partially external.
LOINC Code Opt Description
TBD R TBD



Sample Implanted Medical Device Review Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.46'/>
    <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_1.3.6.1.4.1.19376.1.5.3.1.1.9.46'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.46"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Implanted Medical Device Review 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 Implanted Medical Device Review 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 Implanted Medical Device Review 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 Status Review Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.47
General Description The pregnancy status review section shall contain a description of the responses the patient gave to a set of routine questions regarding potential pregnancy in females of child-bearing-age.
LOINC Code Opt Description
TBD R TBD



Sample Pregnancy Status Review Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.47'/>
    <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_1.3.6.1.4.1.19376.1.5.3.1.1.9.47'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.47"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Pregnancy Status Review 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 Pregnancy Status Review 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 Pregnancy Status Review Section


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