1.3.6.1.4.1.19376.1.5.3.1.1.9
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 http://www.ihe.net/Technical_Framework/index.cfm#PCC
Preprocedure History and Physical Specification 1.3.6.1.4.1.19376.1.5.3.1.1.9
A Pre-procedure History and Physical is a type of medical document, and incorporates the constraints defined for Medical Documents(1.3.6.1.4.1.19376.1.5.3.1.1.1) .
CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown below. Note that a Preprocedure History and Physical is a Medical Document, and so includes that <templateId> element as well.
<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.1"/> :
A CDA Document may conform to more than one template, and can therefore have more that one <templateId> element. The <templateId> elements shown above must be present in the document.
This use case is described fully in PCC TF-1: 7.4. Briefly, this use case involves a sequence of events leading up to the patient’s admission to the operating room in a surgical center. Included in these events is the creation and communication of the pre-procedure history and physical document required by quality review organizations prior to most surgeries. Using this use case, the contents of documents used in collaborative transfers of care were discussed with physicians and nurses in detail to identify major sections. The sections identified by physicians during the use case exercise as important are listed in the table below under the column “Use Case Documentation Section”.
Using this information from the use case, the following mappings were made to existing standards and implementation guides. As illustrated, there is quite a bit of overlap between sections in this integration profile and in sections specified in the HL7 Care Record Summary CDA implementation guide.
Standards
CDAR2 | HL7 CDA Release 2.0 |
CAREPROV | HL7 Care Provision DSTU |
CRS | HL7 Care Record Summary |
CCD | ASTM/HL7 Continuity of Care Document |
Data Element Index
Data Element Requirements | Sections in HL7 CDA-R2/ | LOINC Descriptions |
---|---|---|
Proposed Procedure: (coded procedure) | PROCEDURE | |
Expected Blood Loss | OPERATIVE NOTE ESTIMATED BLOOD LOSS | |
Proposed Anesthesia | OPERATIVE NOTE ANESTHESIA | |
Reason for Procedure: (coded diagnosis) | OPERATIVE NOTE INDICATIONS | |
HPI—(free text leading up to procedure) | History of Present Illness | HISTORY OF PRESENT ILLNESS |
Current Problem List | Conditions | PROBLEM LIST |
Past Medical History | Conditions | HISTORY OF PAST ILLNESS |
Past Surgical-Anesthesia History | Past Surgical History | HISTORY OF SURGICAL PROCEDURES |
Medication List | Medications | HISTORY OF MEDICATION USE |
Allergy List | Allergies and Adverse Reactions | HISTORY OF ALLERGIES |
Immunizations | Immunizations | HISTORY OF IMMUNIZATIONS |
History of Tobacco Use | HISTORY OF TOBACCO USE | |
Current Alcohol/Substance Abuse | HISTORY OF PRESENT ALCOHOL AND/OR SUBSTANCE ABUSE | |
Transfusion History | TBD | |
Family History (specifically includes): | Family History | HISTORY OF FAMILY MEMBER DISEASES |
Social History | SOCIAL HISTORY | |
Advance Directives | Advance Directives | ADVANCE DIRECTIVES |
Functional Capacity | Functional Status | HISTORY OF FUNCTIONAL STATUS |
Review of Systems (specifically includes): | Review of Systems | REVIEW OF SYSTEMS |
Physical Exam (specifically includes): | Physical Examination | PHYSICAL EXAM.TOTAL |
Studies and Reports | Studies and Reports | STUDIES SUMMARY |
Health Maintenance Status | TREATMENT PLAN | |
Pre-procedure Care Plan Status Report | TREATMENT PLAN | |
Pre-procedure Impressions (specifically includes): | DIAGNOSIS | |
-Updated Problem List | Conditions | PROBLEM LIST |
-Pre-Procedure Risk Assessment | OPERATIVE NOTE COMPLICATIONS | |
Pre-procedure Care Plan | Plan of Care | TREATMENT PLAN |
Patient Education/Consents | EDUCATION NOTE |
Specification
Data Element Name | Opt | Template ID |
---|---|---|
Proposed Procedure: (coded procedure) includes: Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.1 |
-Reason for Procedure: (coded diagnosis) Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.4 |
-Proposed Anesthesia Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.3 |
-Expected Blood Loss Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. Needs narrative LOINC code |
R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.9.2 |
-Procedure Care Plan Care Plan generated by the surgeon or surgical coordinator prior to the H&P |
R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.9.40 |
HPI—(free text leading up to procedure) | R | 1.3.6.1.4.1.19376.1.5.3.1.3.4 |
Current Problem List Problem List (if known) is represented as current at beginning of H&P encounter. |
R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.6 |
Past Medical History | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.8 |
Past Surgical-Anesthesia History | R | 1.3.6.1.4.1.19376.1.5.3.1.3.11 |
Medication List | R | 1.3.6.1.4.1.19376.1.5.3.1.3.19 |
Allergy List | R | 1.3.6.1.4.1.19376.1.5.3.1.3.13 |
Immunizations | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.23 |
History of Tobacco Use | R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.8 |
Current Alcohol/Substance Abuse | R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.10 |
Transfusion History | R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.12 |
Pre-procedure Family History | R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.5 |
Social History | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.16 |
Advance Directives | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.34 |
Functional Capacity | R | 1.3.6.1.4.1.19376.1.5.3.1.3.17 |
Review of Systems (specifically includes): | R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.13 |
-General Review | R | 1.3.6.1.4.1.19376.1.5.3.1.3.18 |
-Implanted Medical Devices | R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.9.46 |
-Pregnancy Status (if female) | R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.47 |
-Anesthesia Review of Systems | R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.14 |
Physical Exam (specifically includes): | R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.15 |
-Vitals | R | 1.3.6.1.4.1.19376.1.5.3.1.9.49 |
-General Appearance | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.16 |
-Visible Implanted Medical Devices | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.48 |
-Integumentary System | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.17 |
-Head | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.18 |
-Eyes | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.19 |
-Ears, Nose, Mouth and Throat (may include): | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1 |
--Ears | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.21 |
--Nose | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.22 |
--Mouth, Throat, and Teeth | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.23 |
-Neck | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.24 |
-Endocrine System | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.25 |
-Thorax and Lungs (may include): | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1 |
--Chest Wall | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.27 |
--Breasts | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.28 |
--Heart | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.29 |
--Respiratory System | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.30 |
-Abdomen | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.31 |
-Lymphatic System | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.32 |
-Vessels | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.33 |
-Musculoskeletal System | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.34 |
-Neurologic System | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.35 |
-Genitalia | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.36 |
-Rectum | O | 1.3.6.1.4.1.19376.1.5.3.1.1.9.37 |
Studies and Reports | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.28 |
Health Maintenance Care Plan Status Report Actions completed to date |
R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.9.41 |
Procedure Care Plan Status Report Actions completed to date |
R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.9.45 |
Pre-procedure Impressions (specifically includes): | R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.42 |
- Problems Updated at completion of encounter |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.6 |
-Pre-Procedure Risk Assessment Content same as corresponding Op Note section except that this section describes what is at risk of happening instead of what happened. |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.44 |
Procedure Care Plan Updated with additional or modified actions to be executed in future |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.40 |
Patient Education/Consents Performed during H&P encounter |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.38 |
Conformance
CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below.
<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Preprocedure History and Physical</title> <effectiveTime value='20241017012005'/> <confidentialityCode code='N' displayName='Normal' codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' /> <languageCode code='en-US'/> : <component><structuredBody> </structuredBody></component> </ClinicalDocument> |
<!-- Verify the document type code --> <assert test='cda:code[@code = "{{{LOINC}}}"]'> Error: The document type code of a Preprocedure History and Physical must be {{{LOINC}}} </assert> <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> Error: The document type code must come from the LOINC code system (2.16.840.1.113883.6.1). </assert>
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