CDA Section Content Modules

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Section Content Modules

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

Reasons for Care

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

Reason for Referral

Development Only

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

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



Sample Reason for Referral Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
    <id root=' ' extension=' '/>
    <code code='42349-1' displayName='REASON FOR REFERRAL'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.1'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.1"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Reason for Referral can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "42349-1"]'> 
     Error: The section type code of a Reason for Referral must be 42349-1 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Reason for Referral Section


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

Development Only

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

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



Parent Template

The parent of this template is Reason for Referral.

Sample Coded Reason for Referral Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.2'/>
    <id root=' ' extension=' '/>
    <code code='42349-1' displayName='REASON FOR REFERRAL'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Simple Observations element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
         :
    </entry> 
    <entry>
         :
      <!-- Required Conditions Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Coded Reason for Referral can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.1"]'> 
     Error: The parent template identifier for Coded Reason for Referral is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "42349-1"]'> 
     Error: The section type code of a Coded Reason for Referral must be 42349-1 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded Reason for Referral Section must contain a(n) Simple Observations Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.2
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.5"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded Reason for Referral Section must contain a(n) Conditions Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.2
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Coded Reason for Referral Section


TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.2 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.1 General Description This section shall include at least one entry describing the reason for referral as described in the Entry Content Module. Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.13 R 5.4.4.18 Simple Observations 1.3.6.1.4.1.19376.1.5.3.1.4.5 5.4.4.9 Conditions Entry


Hospital Admission Diagnosis

Development Only

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

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



Sample Hospital Admission Diagnosis Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.3'/>
    <id root=' ' extension=' '/>
    <code code='46241-6' displayName='HOSPITAL ADMISSION DX'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Problem Concern Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.3'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.3"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Hospital Admission Diagnosis can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "46241-6"]'> 
     Error: The section type code of a Hospital Admission Diagnosis must be 46241-6 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.5.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Hospital Admission Diagnosis Section must contain a(n) Problem Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.3
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Hospital Admission Diagnosis Section


TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.3 General Description The hospital admitting diagnosis section shall contain a narrative description of the primary reason for admission to a hospital facility. It shall include entries for observations as described in the Entry Content Modules. Valid LOINC CODES Opt Description 46241-6 R HOSPITAL ADMISSION DX Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.5 R 5.4.4.9 Conditions Entry

Proposed Procedure

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.1 Parent Template NONE General Description The proposed procedure section shall contain a description of the procedures for which a risk assessment is required including procedure names and codes, patient position, dates, and names of surgeons. It shall include entries for procedures as described in the Entry Content Modules and the required and optional subsections. Valid LOINC CODES Opt Description 29554-3 R PROCEDURE Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.16 R 5.4.4.30 Procedure Entry Sub-sections Description 1.3.6.1.4.1.19376.1.5.3.1.1.9.4 R 5.4.3.1.6 Reason for Procedure 1.3.6.1.4.1.19376.1.5.3.1.1.9.3 R 5.4.3.1.5 Proposed Anesthesia 1.3.6.1.4.1.19376.1.5.3.1.1.9.2 R2 5.4.3.1.4 Expected Blood Loss 1.3.6.1.4.1.19376.1.5.3.1.1.9.40 R2 5.4.3.6.5 Procedure Care Plan

Expected Blood Loss

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.2 Parent Template NONE General Description The expected blood loss section shall contain a description of the blood loss for the procedure for which a risk assessment is required. Valid LOINC CODES Opt Description 8717-1 R OPERATIVE NOTE ESTIMATED BLOOD LOSS Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.13 R 5.4.4.18 Simple Observations

Proposed Anesthesia

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.3 Parent Template NONE General Description The proposed anesthesia section shall contain a description of the anesthetic techniques for which a risk assessment is required. It shall include entries for anesthetic procedures as described in the Entry Content Modules. Valid LOINC CODES Opt Description 10213-7 R OPERATIVE NOTE ANESTHESIA Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.16 R 5.4.4.30 Procedure Entry The procedure entries shall be in INT mood.

Reason for Procedure

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.4 Parent Template NONE General Description The reason for procedure section shall contain a description of the reason that the patient is receiving the procedure. It shall include entries for conditions as described in the Entry Content Module. Valid LOINC CODES Opt Description 10217-8 R OPERATIVE NOTE INDICATIONS Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.5 R2 5.4.4.9 Conditions Entry


Other Condition Histories

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

History of Present Illness

TemplateID 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. Valid LOINC CODES Opt Description 10164-2 R HISTORY OF PRESENT ILLNESS

Hospital Course

TemplateID 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. Valid LOINC CODES Opt Description 8648-8 R HOSPITAL COURSE

Active Problems

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.6 Parent Template 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. Valid LOINC CODES Opt Description 11450-4 R PROBLEM LIST Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.5 R 5.4.4.9 Conditions Entry

Discharge Diagnosis

TemplateID 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. Valid LOINC CODES Opt Description 11535-2 R HOSPITAL DISCHARGE DX Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.5 R 5.4.4.9 Conditions Entry

Resolved Problems

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.8 General Description The resolved problems 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. Valid LOINC CODES Opt Description 11348-0 R HISTORY OF PAST ILLNESS Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.5 R 5.4.4.9 Conditions Entry

Encounter Histories

TemplateID 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 Section Title Encounter Histories General Description The encounter history section contains coded entries describing the patient history of encounters. Valid LOINC CODES Opt Description 46240-8 R HISTORY OF ENCOUNTERS Valid Entries Opt Description 1.3.6.1.4.1.19376.1.5.3.1.4.14 R 5.4.4.28 Encounters

History of Outpatient Visits

TemplateID 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. Valid LOINC CODES Opt Description 11346-4 R HISTORY OF OUTPATIENT VISITS 5.4.3.2.8 History of Inpatient Admissions TemplateID 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. Valid LOINC CODES Opt Description 11336-5 R HISTORY OF HOSPITALIZATIONS

List of Surgeries

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.11 Parent Template 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. Valid LOINC CODES Opt Description 47519-4 R HISTORY OF PROCEDURES

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.12 Parent Template 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.

Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.16 R 5.4.4.30 Procedure Entry 1.3.6.1.4.1.19376.1.5.3.1.4.4 R2 5.4.4.8 References Entry

Allergies and Other Adverse Reactions

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.13 Parent Template 2.16.840.1.113883.10.20.1.2 General Description The adverse 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. Valid LOINC CODES Opt Description 48765-2 R Allergies, adverse reactions, alerts Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.5.3 R 5.4.4.11 Allergies and Intolerances Concern

Family Medical History

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.14 Parent Template 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. Valid LOINC CODES Opt Description 10157-6 R HISTORY OF FAMILY MEMBER DISEASES

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.15 Parent Template 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. Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.15 R 5.4.4.22 Family History Organizer

Pre-procedure Family Medical History

TemplateID 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 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.

Social History

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.16 Parent Template 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. Valid LOINC CODES Opt Description 29762-2 R SOCIAL HISTORY

Functional Status

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.17 Parent Template 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. Valid LOINC CODES Opt Description 47420-5 R FUNCTIONAL STATUS ASSESSMENT

Review of Systems

TemplateID 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. Valid LOINC CODES Opt Description 10187-3 R REVIEW OF SYSTEMS

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.13 Parent Template 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. Valid LOINC CODES Opt Description 10187-3 R REVIEW OF SYSTEMS Entries Description No Entries Sub-sections 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


Hazardous Working Conditions

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1 General Description Hazardous working conditions only a narrative description of the patient's hazardous risks. Valid LOINC CODES Description 10161-8 HISTORY OF OCCUPATIONAL EXPOSURE 5.4.3.2.17 Pregnancy History TemplateID 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. Valid LOINC CODES Opt Description 10162-6 R HISTORY OF PREGNANCIES Valid Entries Opt Description 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 R 5.4.4.25 Pregnancy Observation

Medical Devices

TemplateID 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 General Description The medical devices section contains narrative text describing the patient history of medical device use. Valid LOINC CODES Opt Description 46264-8 R HISTORY OF MEDICAL DEVICE USE

Foreign Travel

TemplateID 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. Valid LOINC CODES Opt Description 10182-4 R HISTORY OF TRAVEL

History of Tobacco Use

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.8 Parent Template None 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. Valid LOINC CODES Opt Description 11366-2 R HISTORY OF TOBACCO USE

Current Alcohol/Substance Abuse

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.10 Parent Template None 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. Valid LOINC CODES Opt Description 18663-5 R HISTORY OF PRESENT ALCOHOL AND/OR SUBSTANCE ABUSE

Transfusion History

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.12 Parent Template None 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. Valid LOINC CODES Opt Description TBD R BLOOD PRODUCTS ADMINISTRATION

Anesthesia Risk Review of Systems

TemplateID 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 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. Valid LOINC CODES Opt Description


Implanted Medical Device Review

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.46 Parent Template None 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. Valid LOINC CODES Opt Description


Pregnancy Status Review

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.47 Parent Template None 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. Valid LOINC CODES Opt Description



Medications

This section contains section content modules that describe activities surrounding the use of medication.

Medications

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.19 Parent Template 2.16.840.1.113883.10.20.1.8 General Description The medications section shall contain a description of the relevant medications for the patient, e.g. an ambulatory prescription list. It shall include entries for medications as described in the Entry Content Module. Valid LOINC CODES Opt Description 10160-0 R HISTORY OF MEDICATION USE Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.7 R 5.4.4.14 Medications 5.4.3.3.2 Admission Medication History TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.20 General Description The admission medication history section shall contain a narrative description of the relevant medications administered to a patient prior to admission to a facility. It shall include entries for medication administration as described in the Entry Content Module. Valid LOINC CODES Opt Description 42346-7 R MEDICATIONS ON ADMISSION Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.7 R 5.4.4.14 Medications

Medications Administered

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.21 General Description The medications administered section shall contain a narrative description of the relevant medications administered to a patient during the course of an encounter. It shall include entries for medication administration as described in the Entry Content Module. Valid LOINC CODES Opt Description 18610-6 R MEDICATION ADMINISTERED Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.7 R 5.4.4.14 Medications

Hospital Discharge Medications

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.22 General Description The hospital discharge medications section shall contain a narrative description of the medications requested (ordered) to be administered to the patient after discharge from the hospital. It shall include entries for medication requests as described in the Entry Content Module. Valid LOINC CODES Opt Description 10183-2 R HOSPITAL DISCHARGE MEDICATIONS Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.7 R 5.4.4.14 MedicationsNote: All medications in this section must have sustanceAdministration/@moodCode = "INT"

Immunizations

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.23 Parent Template 2.16.840.1.113883.10.20.1.6 General Description The immunizations section shall contain a narrative description of the immunizations administered to the patient in the past. It shall include entries for medication administration as described in the Entry Content Modules. Valid LOINC CODES Opt Description 11369-6 R HISTORY OF IMMUNIZATIONS Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.12 R 5.4.4.15 Immunization

Physical Exams

Physical Exam

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.24 General Description The physical exam section shall contain a narrative description of the patient’s physical findings. Valid LOINC CODES Opt Description 22029-3 R PHYSICAL EXAM.TOTAL


TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.15 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.24 General Description The physical exam section shall contain only the required and optional subsections performed. Valid LOINC CODES Opt Description 22029-3 R PHYSICAL EXAM.TOTAL Sub-sections Description 1.3.6.1.4.1.19376.1.5.3.1.3.49 R 5.4.3.4.3 Vital Signs 1.3.6.1.4.1.19376.1.5.3.1.1.9.16 O 5.4.3.4.4 General Appearance 1.3.6.1.4.1.19376.1.5.3.1.1.9.48 O 5.4.3.4.5 Visible Implanted Medical Devices 1.3.6.1.4.1.19376.1.5.3.1.1.9.17 O 5.4.3.4.6Integumentary System 1.3.6.1.4.1.19376.1.5.3.1.1.9.18 O 5.4.3.4.7 Head 1.3.6.1.4.1.19376.1.5.3.1.1.9.19 O 5.4.3.4.8 Eyes 1.3.6.1.4.1.19376.1.5.3.1.1.9.20 O 5.4.3.4.9 Ears, Nose, Mouth and Throat 1.3.6.1.4.1.19376.1.5.3.1.1.9.21 O 5.4.3.4.10 Ears 1.3.6.1.4.1.19376.1.5.3.1.1.9.22 O 5.4.3.4.11 Nose 1.3.6.1.4.1.19376.1.5.3.1.1.9.23 O 5.4.3.4.12 Mouth, Throat, and Teeth 1.3.6.1.4.1.19376.1.5.3.1.1.9.24 O 5.4.3.4.13 Neck 1.3.6.1.4.1.19376.1.5.3.1.1.9.25 O 5.4.3.4.14 Endocrine System 1.3.6.1.4.1.19376.1.5.3.1.1.9.26 O 5.4.3.4.15 Thorax and Lungs 1.3.6.1.4.1.19376.1.5.3.1.1.9.27 O 5.4.3.4.16 Chest Wall 1.3.6.1.4.1.19376.1.5.3.1.1.9.28 O 5.4.3.4.17 Breasts 1.3.6.1.4.1.19376.1.5.3.1.1.9.29 O 5.4.3.4.18 Heart 1.3.6.1.4.1.19376.1.5.3.1.1.9.30 O 5.4.3.4.19 Respiratory System 1.3.6.1.4.1.19376.1.5.3.1.1.9.31 O 5.4.3.4.20 Abdomen 1.3.6.1.4.1.19376.1.5.3.1.1.9.32 O 5.4.3.4.21 Lymphatic System 1.3.6.1.4.1.19376.1.5.3.1.1.9.33 O 5.4.3.4.22 Vessels 1.3.6.1.4.1.19376.1.5.3.1.1.9.34 O 5.4.3.4.23 Musculoskeletal System 1.3.6.1.4.1.19376.1.5.3.1.1.9.35 O 5.4.3.4.24 Neurologic System 1.3.6.1.4.1.19376.1.5.3.1.1.9.36 O 5.4.3.4.25 Genitalia 1.3.6.1.4.1.19376.1.5.3.1.1.9.37 O 5.4.3.4.26 Rectum


Hospital Discharge Physical Exam

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.26 General Description The hospital discharge physical exam section shall contain a narrative description of the patient’s physical findings at discharge from a hospital facility. Valid LOINC CODES Opt Description 10184-0 R HOSPITAL DISCHARGE PHYSICAL

Vital Signs

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.25 Parent Template ID 2.16.840.1.113883.10.20.1.16 General Description The vital signs section shall contain a narrative description of the measurement results of a patient’s vital signs. Valid LOINC CODES Opt Description 8716-3 R VITAL SIGNS

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.25 General Description The vital signs section contains coded measurement results of a patient’s vital signs. Valid LOINC CODES Opt Description 8716-3 R VITAL SIGNS Valid Entries Opt Description 1.3.6.1.4.1.19376.1.5.3.1.4.13.1 R 5.4.4.19 Vital Signs Organizer

General Appearance

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.16 Parent Template None General Description The general appearance section shall contain a description of the overall, visibly-apparent condition of the patient. Valid LOINC CODES Opt Description 10210-3 R GENERAL STATUS

Visible Implanted Medical Devices

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.48 Parent Template None General Description The visible implanted medical devices section shall contain a description of the medical devices apparent on physical exam that have been inserted into the patient, whether internal or partially external. Valid LOINC CODES Opt Description TBD R VISIBLE IMPLANTED MEDICAL DEVICES

Integumentary System

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.17 Parent Template None General Description The integumentary system section shall contain a description of any type of integumentary system exam. Valid LOINC CODES Opt Description 29302-7 R INTEGUMENTARY SYSTEM

Head

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.18 Parent Template None General Description The head section shall contain a description of any type of head exam. Valid LOINC CODES Opt Description 10199-8 R HEAD

Eyes

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.19 Parent Template None General Description The eyes section shall contain a description of any type of eye exam. Valid LOINC CODES Opt Description 10197-2 R EYE

Ears, Nose, Mouth and Throat

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.20 Parent Template None General Description The ears, nose, mouth, and throat section shall contain a description of any type of ears, nose, mouth, or throat exam. Valid LOINC CODES Opt Description 11393-6 R EARS & NOSE & MOUTH & THROAT

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.20 General Description The ears, nose, mouth, and throat section shall contain a description of any type of ears, nose, mouth, or throat exam. It shall contain sub-sections on ears, nose, mouth, throat, and teeth. Valid LOINC CODES Opt Description 11393-6 R EARS & NOSE & MOUTH & THROAT Sub-sections Description 1.3.6.1.4.1.19376.1.5.3.1.1.9.21 R Ears 1.3.6.1.4.1.19376.1.5.3.1.1.9.22 R Nose 1.3.6.1.4.1.19376.1.5.3.1.1.9.23 R Mouth, Throat, and Teeth


Ears

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.21 Parent Template None General Description The ears section shall contain a description of any type of ear exam. Valid LOINC CODES Opt Description 10195-6 R EAR

Nose

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.22 Parent Template None General Description The nose section shall contain a description of any type of nose exam. Valid LOINC CODES Opt Description 10203-8 R NOSE


Mouth, Throat and Teeth

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.23 Parent Template None General Description The mouth, throat, and teeth section shall contain a description of any type of mouth, throat, or teeth exam. Valid LOINC CODES Opt Description 10201-2 R MOUTH & THROAT & TEETH


Neck

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.24 Parent Template None General Description The neck section shall contain a description of any type of neck exam. Valid LOINC CODES Opt Description 11411-6 R NECK

Endocrine System

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.25 Parent Template None General Description The endocrine system section shall contain a description of any type of endocrine system exam. Valid LOINC CODES Opt Description 29307-6 R ENDOCRINE SYSTEM

Thorax and Lungs

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.26 Parent Template None General Description The thorax and lungs section shall contain a description of any type of thoracic or lung exams. Valid LOINC CODES Opt Description 10207-9 R THORAX+LUNGS

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.26 General Description The thorax and lungs section shall contain a description of any type of thoracic or lung exams. Valid LOINC CODES Opt Description 10207-9 R THORAX+LUNGS Sub-sections Description 1.3.6.1.4.1.19376.1.5.3.1.1.9.27 O Chest Wall 1.3.6.1.4.1.19376.1.5.3.1.1.9.28 O Breasts 1.3.6.1.4.1.19376.1.5.3.1.1.9.29 O Heart 1.3.6.1.4.1.19376.1.5.3.1.1.9.30 O Respiratory System

Chest Wall

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.27 Parent Template None General Description The chest wall section shall contain a description of any type of chest wall exam. Valid LOINC CODES Opt Description 11392-8 R CHEST WALL

Breast

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.28 Parent Template None General Description The breast section shall contain a description of any type of breast exam. Valid LOINC CODES Opt Description 10193-1 R BREASTS

Heart

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.29 Parent Template None Section Title Heart General Description The heart section shall contain a description of any type of heart exam. Valid LOINC CODES Opt Description 10200-4 R HEART

Respiratory System

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.30 Parent Template None General Description The respiratory system section shall contain a description of any type of respiratory exam. Valid LOINC CODES Opt Description 11412-4 R RESPIRATORY SYSTEM

Abdomen

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.31 Parent Template None General Description The abdomen system section shall contain a description of any type of abdominal exam. Valid LOINC CODES Opt Description 10191-5 R ABDOMEN

Lymphatic System

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.32 Parent Template None General Description The lymphatic system section shall contain a description of any type of lymphatic exam. Valid LOINC CODES Opt Description 11447-0 R HEMATOLOGIC+LYMPHATIC+IMMUNOLOGIC SYSTEM

Vessels

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.33 Parent Template None General Description The vessels section shall contain a description of any type of vessels exam. Valid LOINC CODES Opt Description 10208-7 R VESSELS

Musculoskeletal System

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.34 Parent Template None General Description The musculoskeletal system section shall contain a description of any type of musculoskeletal exam. Valid LOINC CODES Opt Description 11410-8 R MUSCULOSKELETAL SYSTEM

Neurologic System

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.35 Parent Template None General Description The neurologic system section shall contain a description of any type of neurologic exam. Valid LOINC CODES Opt Description 10202-0 R NEUROLOGIC SYSTEM

Genitalia

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.36 Parent Template None General Description The genitalia section shall contain a description of any type of genital exam. Valid LOINC CODES Opt Description 11400-9 R GENITALIA

Rectum

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.37 Parent Template None General Description The rectum section shall contain a description of any type of rectal exam. Valid LOINC CODES Opt Description 10205-3 R RECTUM


Relevant Studies

Results

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.27 General Description The results section shall contain a narrative description of the patient’s relevant studies. Valid LOINC CODES Opt Description 30954-2 R STUDIES SUMMARY

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.28 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.27 General Description The results section shall contain a narrative description of the relevant diagnostic procedures the patient received in the past. It shall include entries for procedures and references to procedure reports when known as described in the Entry Content Modules. Valid LOINC CODES Opt Description 30954-2 R STUDIES SUMMARY Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.16 R 5.4.4.30 Procedure Entry 1.3.6.1.4.1.19376.1.5.3.1.4.4 R2 5.4.4.8 References Entry

Hospital Studies Summary

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.29 General Description The hospital studies summary section shall contain a narrative description of the relevant diagnostic procedures the patient received during the hospital admission. Valid LOINC CODES Opt Description 11493-4 R HOSPITAL DISCHARGE STUDIES SUMMARY

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.30 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.29 General Description The hospital studies summary section shall include entries for diagnostic procedures and references to procedure reports when known as described in the Entry Content Modules. Valid LOINC CODES Opt Description 11493-4 R HOSPITAL DISCHARGE STUDIES SUMMARY Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.16 R 5.4.4.30 Procedure Entry 1.3.6.1.4.1.19376.1.5.3.1.4.4 R2 5.4.4.8 References Entry

Blood Type

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.27 General Description The results section shall contain an observation of the patients blood type. Entries Description

Move to PCC TF-3 LOINC CODE Description Type Units or Vocabulary 882-1 ABO+RH GROUP CE SNOMED CT, ISBT 129

Plans of Care

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

Care Plan

Note: specific templates for entries within plans of care may be found in other categories such as the medications category. TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.31 General Description The care plan section shall contain a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. Valid LOINC CODES Opt Description 18776-5 R TREATMENT PLAN

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.31 General Description The plan of care section contains descriptions of the expectations for care including proposals, order requests, the intended transporation mode and estimated time of arrival to the ED, as well as intended disposition from the ED. Valid LOINC CODES Opt Description 18776-5 R2 TREATMENT PLAN Sub-sections Description 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 R 5.4.3.6.9 Transport ModeThis required subsection describes the expected mode and time of arrival of the patient to the emergency department. Valid Entries Description 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2 R2 5.4.4.32 Intended Encounter DispositionThis required entry describes the expected disposition of the patient after the emergency department encounter has been completed.

Discharge Disposition

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.32 General Description The plan of care section shall contain a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient, specifically used in a discharge from a facility such as an emergency department, hospital, or nursing home. Valid LOINC CODES Opt Description 18776-5 R TREATMENT PLAN

Discharge Diet

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.33 General Description The discharge diet section shall contain a narrative description of the expectations for diet including proposals, goals, and order requests for monitoring, tracking, or improving the dietary control of the patient, specifically used in a discharge from a facility such as an emergency department, hospital, or nursing home. Valid LOINC CODES Opt Description 42344-2 R DISCHARGE DIET

Advance Directives

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.34 Parent Template 2.16.840.1.113883.10.20.1.1 General Description The advance directive section shall contain a narrative description of the list of documents that define the patient’s expectations and requests for care along with the locations of the documents. Valid LOINC CODES Opt Description 42348-3 R ADVANCE DIRECTIVES

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.35 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.34 General Description The advance directive section shall include entries for references to consent and advance directive documents when known as described in the Entry Content Modules. Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.13.3 R2 5.4.4.26 Advance Directive Observation

Procedure Care Plan

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.40 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.31 General Description The procedure care plan section shall contain a description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient prior, during and after a procedure with goals of educating the patient, reducing the modifiable risks of the procedure and anethesia and otherwise optimizing the outcomes. The care plan will often be updated immediately following the addition of new impressions during the course of pre-procedure evaluation. Valid LOINC CODES Opt Description 18776-5 R TREATMENT PLAN

Procedure Care Plan Status Report

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.45 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.40 General Description The procedure care plan status report section shall contain a description of the progress towards completing expectations for care including actions completed in fulfilment of proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient prior to the procedure. Valid LOINC CODES Opt Description 18776-5 R TREATMENT PLAN

Health Maintenance Care Plan

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.50 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.31 General Description The health maintenance care plan section shall contain a description of the expectations for wellness care including proposals, goals, and order requests for monitoring, tracking, or improving the lifetime condition of the patient with goals of educating the patient on how to reduce the modifiable risks of the patient’s genetic, behavioral, and environmental pre-conditions and otherwise optimizing lifetime outcomes. Valid LOINC CODES Opt Description 18776-5 R TREATMENT PLAN

Health Maintenance Care Plan Status Report

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.41 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.50 General Description The health maintenance status report section shall contain a description of the progress towards completing expectations for care including actions completed in fulfilment of proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. Valid LOINC CODES Opt Description 18776-5 R TREATMENT PLAN

Transport Mode

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 Parent Template None General Description The transport mode section contains a description of the expected mode of transport and estimated time of arrival.to the Emergency department. Valid LOINC CODES Opt Description 11459-5 R TRANSPORT MODE Valid Entries Description 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1 R 5.4.4.31 Transport This entry provides coded values giving the expected mode and time of arrival of the patient to the emergency department. 5.4.3.7 Procedures Performed

Patient Education and Consents

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.38 Parent Template None General Description The patient education and consents section shall contain a description of the patient education the patient received, the results of the education, and the consents the patient signed. Valid LOINC CODES Opt Description 34895-3 R EDUCATION NOTE

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.39 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.38 General Description The patient education and consents section shall contain a description of the patient education the patient received, the results of the education, and references to the consents the patient signed. It shall include entries for procedures and references to consent documents as described in the Entry Content Modules. Valid LOINC CODES Opt Description 34895-3 R EDUCATION NOTE Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.16 R 5.4.4.30 Procedure Entry The procedures shall be in INT mood 1.3.6.1.4.1.19376.1.5.3.1.4.13 R2 5.4.4.18 Simple Observations 1.3.6.1.4.1.19376.1.5.3.1.4.4 R2 5.4.4.8.1 External References

Impressions

Pre-procedure Impressions

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.42 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.6 General Description The Impressions section shall contain only the required and optional subsections dealing with the updated problem list, the general risks the patient faces from the procedures, and the fixed and modifiable risks the patient faces because of specific patient findings. Sub-sections Description 1.3.6.1.4.1.19376.1.5.3.1.1.9.44 R Pre-procedure Risk Assessment

Pre-procedure Risk Assessment

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.9.44 Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.6 General Description The pre-procedure risk section shall contain a description of the risks the patient faces because of the planned procedure and associated anethesia, especially in the context of modifiable risks identified by patient findings. It shall include entries for patient risks as described in the Entry Content Module. Valid LOINC CODES Opt Description 11450-4 R PROBLEM LIST Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.5 R 5.4.4.9 Conditions Entry

Administrative and Other Information

Payers 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7

TemplateID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7 Parent TemplateID 2.16.840.1.113883.10.20.1.9 General Description The Payers section contains data on the patient’s payers, whether a ‘third party’ insurance, self-pay, other payer or guarantor, or some combination. Valid LOINC CODES Opt Description 48768-6 R PAYMENT SOURCES Entries Description 1.3.6.1.4.1.19376.1.5.3.1.4.17 R2 5.4.4.33 Coverage Entry

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