PCC Public Comment Drafts/2

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CDA 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.

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


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


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

Chief Complaint Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
General Description This contains a narrative description of the patient's chief complaint.
LOINC Code Opt Description
10154-3 R CHIEF COMPLAINT



Sample Chief Complaint Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/>
    <id root=' ' extension=' '/>
    <code code='10154-3' displayName='CHIEF COMPLAINT'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Chief Complaint can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10154-3"]'> 
     Error: The section type code of a Chief Complaint must be 10154-3 
   </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 Chief Complaint 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

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


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

Proposed Procedure Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.1
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.
LOINC Code Opt Description
29554-3 R PROCEDURE
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.19 R Procedure Entry
Subsections Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.9.4 R Reason for Procedure
1.3.6.1.4.1.19376.1.5.3.1.1.9.3 R Proposed Anesthesia
1.3.6.1.4.1.19376.1.5.3.1.1.9.2 R2 Expected Blood Loss
1.3.6.1.4.1.19376.1.5.3.1.1.9.40 R2 Procedure Care Plan



Sample Proposed Procedure Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.1'/>
    <id root=' ' extension=' '/>
    <code code='29554-3' displayName='PROCEDURE'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Procedure Entry  element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
         :
    </entry>
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.4'/>
        <!-- Required Reason for Procedure Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.3'/>
        <!-- Required Proposed Anesthesia Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.2'/>
        <!-- Required if known Expected Blood Loss Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.40'/>
        <!-- Required if known Procedure Care Plan Section content -->
      </section>
    </component>

       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.1'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.1"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Proposed Procedure can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "29554-3"]'> 
     Error: The section type code of a Proposed Procedure must be 29554-3 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Proposed Procedure Section must contain a(n) Procedure Entry  Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Proposed Procedure Section must contain a(n) Reason for Procedure Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Proposed Procedure Section must contain a(n) Proposed Anesthesia Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.2"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Proposed Procedure Section should contain a(n) Expected Blood Loss Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.40"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Proposed Procedure Section should contain a(n) Procedure Care Plan Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.1
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Proposed Procedure 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 Blood Loss Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.2
General Description The estimated blood loss section shall contain a description of the blood loss for the procedure.
LOINC Code Opt Description
8717-1 R OPERATIVE NOTE ESTIMATED BLOOD LOSS
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.13 R Simple Observations



Sample Estimated Blood Loss Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.2'/>
    <id root=' ' extension=' '/>
    <code code='8717-1' displayName='OPERATIVE NOTE ESTIMATED BLOOD LOSS'
      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>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Estimated Blood Loss can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "8717-1"]'> 
     Error: The section type code of a Estimated Blood Loss must be 8717-1 
   </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 Estimated Blood Loss Section must contain a(n) Simple Observations Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.2
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Estimated Blood Loss 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

Proposed Anesthesia Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.3
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.
LOINC Code Opt Description
10213-7 R OPERATIVE NOTE ANESTHESIA
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.19 R Procedure Entry
The procedure entries shall be in INT mood.



Sample Proposed Anesthesia Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.3'/>
    <id root=' ' extension=' '/>
    <code code='10213-7' displayName='OPERATIVE NOTE ANESTHESIA'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Procedure Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.3'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.3"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Proposed Anesthesia can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10213-7"]'> 
     Error: The section type code of a Proposed Anesthesia must be 10213-7 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Proposed Anesthesia Section must contain a(n) Procedure Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.3 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Proposed Anesthesia 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

Reason for Procedure Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.4
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.
LOINC Code Opt Description
10217-8 R OPERATIVE NOTE INDICATIONS
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.5 R2 Conditions Entry



Sample Reason for Procedure Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.4'/>
    <id root=' ' extension=' '/>
    <code code='10217-8' displayName='OPERATIVE NOTE INDICATIONS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required if known 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_1.3.6.1.4.1.19376.1.5.3.1.1.9.4'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.4"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Reason for Procedure can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10217-8"]'> 
     Error: The section type code of a Reason for Procedure must be 10217-8 
   </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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.5"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Reason for Procedure Section should contain a(n) Conditions Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.4
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Reason for Procedure Section


Other Condition Histories

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

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 Present Illness Section
Template ID 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.
LOINC Code Opt Description
10164-2 R HISTORY OF PRESENT ILLNESS



Sample History of Present Illness Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
    <id root=' ' extension=' '/>
    <code code='10164-2' displayName='HISTORY OF PRESENT ILLNESS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.4'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The History of Present Illness can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10164-2"]'> 
     Error: The section type code of a History of Present Illness must be 10164-2 
   </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 Present Illness 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

Hospital Course Section
Template ID 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.
LOINC Code Opt Description
8648-8 R HOSPITAL COURSE



Sample Hospital Course Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.5'/>
    <id root=' ' extension=' '/>
    <code code='8648-8' displayName='HOSPITAL COURSE'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.5'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.5"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Hospital Course can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "8648-8"]'> 
     Error: The section type code of a Hospital Course must be 8648-8 
   </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 Hospital Course 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

Active Problems Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.6
Parent Template CCD 3.5 (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.
LOINC Code Opt Description
11450-4 R PROBLEM LIST
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.5.2 R Problem Concern Entry



Parent Template

The parent of this template is CCD 3.5.

Sample Active Problems Section 
<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.11'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
    <id root=' ' extension=' '/>
    <code code='11450-4' displayName='PROBLEM LIST'
      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_1.3.6.1.4.1.19376.1.5.3.1.3.6'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Active Problems can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.11"]'> 
     Error: The parent template identifier for Active Problems is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11450-4"]'> 
     Error: The section type code of a Active Problems must be 11450-4 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.5.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Active Problems Section must contain a(n) Problem Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.6
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Active Problems 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

Discharge Diagnosis Section
Template ID 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.
LOINC Code Opt Description
11535-2 R HOSPITAL DISCHARGE DX
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.5.2 R Problem Concern Entry



Sample Discharge Diagnosis Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.7'/>
    <id root=' ' extension=' '/>
    <code code='11535-2' displayName='HOSPITAL DISCHARGE 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_1.3.6.1.4.1.19376.1.5.3.1.3.7'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.7"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Discharge Diagnosis can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11535-2"]'> 
     Error: The section type code of a Discharge Diagnosis must be 11535-2 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.5.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Diagnosis Section must contain a(n) Problem Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.7
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Discharge Diagnosis 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 Past Illness Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.8
General Description The History of Past Illness 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.
LOINC Code Opt Description
11348-0 R HISTORY OF PAST ILLNESS
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.5.2 R Problem Concern Entry



Sample History of Past Illness Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
    <id root=' ' extension=' '/>
    <code code='11348-0' displayName='HISTORY OF PAST ILLNESS'
      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_1.3.6.1.4.1.19376.1.5.3.1.3.8'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The History of Past Illness can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11348-0"]'> 
     Error: The section type code of a History of Past Illness must be 11348-0 
   </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 History of Past Illness Section must contain a(n) Problem Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.8
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the History of Past Illness 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

Encounter Histories Section
Template ID 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 (2.16.840.1.113883.10.20.1.3)
General Description The encounter history section contains coded entries describing the patient history of encounters.
LOINC Code Opt Description
46240-8 R HISTORY OF ENCOUNTERS
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.14 R Encounters



Parent Template

The parent of this template is 2.16.840.1.113883.10.20.1.3.

Sample Encounter Histories Section 
<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.3'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'/>
    <id root=' ' extension=' '/>
    <code code='46240-8' displayName='HISTORY OF ENCOUNTERS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Encounters element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.14'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Encounter Histories can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.3"]'> 
     Error: The parent template identifier for Encounter Histories is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "46240-8"]'> 
     Error: The section type code of a Encounter Histories must be 46240-8 
   </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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.14"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Encounter Histories Section must contain a(n) Encounters Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Encounter Histories 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 Outpatient Visits Section
Template ID 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.
LOINC Code Opt Description
11346-4 R HISTORY OF OUTPATIENT VISITS



Sample History of Outpatient Visits Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.9'/>
    <id root=' ' extension=' '/>
    <code code='11346-4' displayName='HISTORY OF OUTPATIENT VISITS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.9'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.9"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The History of Outpatient Visits can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11346-4"]'> 
     Error: The section type code of a History of Outpatient Visits must be 11346-4 
   </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 History of Outpatient Visits 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 Inpatient Visits Section
Template ID 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.
LOINC Code Opt Description
11336-5 R HISTORY OF HOSPITALIZATIONS



Sample History of Inpatient Visits Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.10'/>
    <id root=' ' extension=' '/>
    <code code='11336-5' displayName='HISTORY OF HOSPITALIZATIONS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.10'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.10"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The History of Inpatient Visits can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11336-5"]'> 
     Error: The section type code of a History of Inpatient Visits must be 11336-5 
   </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 History of Inpatient Visits 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

List of Surgeries Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.11
Parent Template CCD 3.14 (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.
LOINC Code Opt Description
47519-4 R HISTORY OF PROCEDURES



Parent Template

The parent of this template is CCD 3.14.

Sample List of Surgeries Section 
<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.12'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
    <id root=' ' extension=' '/>
    <code code='47519-4' displayName='HISTORY OF PROCEDURES'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.11'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The List of Surgeries can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.12"]'> 
     Error: The parent template identifier for List of Surgeries is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "47519-4"]'> 
     Error: The section type code of a List of Surgeries must be 47519-4 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the List of Surgeries Section


Development Only

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

Coded List of Surgeries Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.12
Parent Template List of Surgeries (1.3.6.1.4.1.19376.1.5.3.1.3.11)
General Description The list of surgeries section shall include entries for procedures and references to procedure reports when known as described in the Entry Content Modules.
LOINC Code Opt Description
47519-4 R HISTORY OF PROCEDURES
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.19 R Procedure Entry
1.3.6.1.4.1.19376.1.5.3.1.4.4 R2 References Entry



Parent Template

The parent of this template is List of Surgeries.

Sample Coded List of Surgeries Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.12'/>
    <id root=' ' extension=' '/>
    <code code='47519-4' displayName='HISTORY OF PROCEDURES'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Procedure Entry  element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
         :
    </entry> 
    <entry>
         :
      <!-- Required if known References Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.12'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.12"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Coded List of Surgeries can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     Error: The parent template identifier for Coded List of Surgeries is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "47519-4"]'> 
     Error: The section type code of a Coded List of Surgeries must be 47519-4 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded List of Surgeries Section must contain a(n) Procedure Entry  Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.12
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Coded List of Surgeries Section should contain a(n) References Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.12
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Coded List of Surgeries Section


Development Only

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

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



Parent Template

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

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

See Templates using the Allergies and Other Adverse Reactions Section


Development Only

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

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



Parent Template

The parent of this template is CCD 3.6.

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

See Templates using the Family Medical History Section


Development Only

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

Coded Family Medical History Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.15
Parent Template Family Medical History (1.3.6.1.4.1.19376.1.5.3.1.3.14)
General Description The family history section shall include entries for family history as described in the Entry Content Modules.
LOINC Code Opt Description
10157-6 R HISTORY OF FAMILY MEMBER DISEASES
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.15 R Family History Organizer



Parent Template

The parent of this template is Family Medical History.

Sample Coded Family Medical History Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.15'/>
    <id root=' ' extension=' '/>
    <code code='10157-6' displayName='HISTORY OF FAMILY MEMBER DISEASES'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Family History Organizer element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.15'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.15'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.15"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Coded Family Medical History can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> 
     Error: The parent template identifier for Coded Family Medical History is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10157-6"]'> 
     Error: The section type code of a Coded Family Medical History must be 10157-6 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.15"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded Family Medical History Section must contain a(n) Family History Organizer Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.15
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Coded Family Medical History Section


Development Only

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

Pre-procedure Family Medical History Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.5
Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.15 (1.3.6.1.4.1.19376.1.5.3.1.3.15)
General Description The pre-procedure family history section shall contain a description of the genetic family members who have suffered complications during anesthesia such as malignant hyperthermia, bleeding, etc. It shall include entries for family history as described in the Entry Content Modules.
LOINC Code Opt Description
10157-6 R HISTORY OF FAMILY MEMBER DISEASES



Parent Template

The parent of this template is 1.3.6.1.4.1.19376.1.5.3.1.3.15.

Sample Pre-procedure Family Medical History Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.15'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.5'/>
    <id root=' ' extension=' '/>
    <code code='10157-6' displayName='HISTORY OF FAMILY MEMBER DISEASES'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.5'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.5"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Pre-procedure Family Medical History can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.15"]'> 
     Error: The parent template identifier for Pre-procedure Family Medical History is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10157-6"]'> 
     Error: The section type code of a Pre-procedure Family Medical History must be 10157-6 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Pre-procedure Family Medical History Section


Development Only

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

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



Parent Template

The parent of this template is CCD 3.7.

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

See Templates using the Social History Section


Development Only

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

Functional Status Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.17
Parent Template CCD 3.4 (2.16.840.1.113883.10.20.1.5)
General Description The functional status section shall contain a narrative description of capability of the patient to perform acts of daily living.
LOINC Code Opt Description
47420-5 R FUNCTIONAL STATUS ASSESSMENT



Parent Template

The parent of this template is CCD 3.4.

Sample Functional Status Section 
<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.5'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/>
    <id root=' ' extension=' '/>
    <code code='47420-5' displayName='FUNCTIONAL STATUS ASSESSMENT'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.17'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.17"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Functional Status can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.5"]'> 
     Error: The parent template identifier for Functional Status is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "47420-5"]'> 
     Error: The section type code of a Functional Status must be 47420-5 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Functional Status Section


Development Only

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

Coded Functional Status Assessment Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
Parent Template Functional Status (1.3.6.1.4.1.19376.1.5.3.1.3.17)
General Description The coded functional status assessment section provided a machine readable and narrative description of the patient’s status of normal functioning at the time the document was created.

Functional status includes information concerning:

  • Ambulatory ability
  • Mental status or competency
  • Activities of Daily Living (ADL’s) including bathing, dressing, feeding, grooming
  • Home/living situation having an effect on the health status of the patient
  • Ability to care for self
  • Social activity, including issues with social cognition, participation with friends and acquaintances other than family members
  • Occupation activity, including activities partly or directly related to working, housework or volunteering, family and home responsibilities or activities related to home and family
  • Communication ability, including issues with speech, writing or cognition required for communication
  • Perception, including sight, hearing, taste, skin sensation, kinesthetic sense, proprioception, or balance
LOINC Code Opt Description
47420-5 R Functional Status Assessment
Subsections Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2 R Pain Scale Assessment
1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3 O Braden Score Assessment
1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4 O Geriatric Depression Scale
1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5 O Minimum Data Set


At least one of the above optional subsections shall be present

Standards
CDAR2 HL7 CDA Release 2.0
CRS HL7 Care Record Summary
CCD ASTM/HL7 Continuity of Care Document
LOINC Logical Observation Identifier Names and Codes
SNOMED Systemitized Nomenclature of Medicine Clinical Terminology
Parent Template

The parent of this template is Functional Status.

Sample Coded Functional Status Assessment Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1'/>
    <id root=' ' extension=' '/>
    <code code='47420-5' displayName='Functional Status Assessment'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2'/>
        <!-- Required Pain Scale Assessment Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3'/>
        <!-- Optional Braden Score Assessment Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4'/>
        <!-- Optional Geriatric Depression Scale Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5'/>
        <!-- Optional Minimum Data Set Section content -->
      </section>
    </component>

       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Coded Functional Status Assessment can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.17"]'> 
     Error: The parent template identifier for Coded Functional Status Assessment is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "47420-5"]'> 
     Error: The section type code of a Coded Functional Status Assessment must be 47420-5 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded Functional Status Assessment Section must contain a(n) Pain Scale Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3"]'> 
     <!-- Note any missing optional elements -->
     Note: This Coded Functional Status Assessment Section does not contain a(n) Braden Score Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4"]'> 
     <!-- Note any missing optional elements -->
     Note: This Coded Functional Status Assessment Section does not contain a(n) Geriatric Depression Scale Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5"]'> 
     <!-- Note any missing optional elements -->
     Note: This Coded Functional Status Assessment Section does not contain a(n) Minimum Data Set Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
   </assert> 
   <assert test="./cda:component/cda:section/cda:templateId[
                   @root = '1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3' or
                   @root = '1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4' or
                   @root = '1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5']">
     At least one of the optional subsections must be in a coded functional assessment.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Coded Functional Status Assessment Section


Development Only

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

Pain Scale Assessment Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2
General Description The Pain Scale Assessment contains a coded observation reflecting the patient's reported intensity of pain on a scale from 0 to 10.
LOINC Code Opt Description
38208-5 R Pain severity
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1 R Pain Score Observation



Sample Pain Scale Assessment Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2'/>
    <id root=' ' extension=' '/>
    <code code='38208-5' displayName='Pain severity'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Pain Score Observation element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Pain Scale Assessment can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "38208-5"]'> 
     Error: The section type code of a Pain Scale Assessment must be 38208-5 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Pain Scale Assessment Section must contain a(n) Pain Score Observation Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Pain Scale Assessment Section


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


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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