1.3.6.1.4.1.19376.1.5.3.1.1.9

From IHE Wiki
Revision as of 10:34, 15 May 2007 by Kboone (talk | contribs)
(diff) ← Older revision | Latest revision (diff) | Newer revision → (diff)
Jump to navigation Jump to search

Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

Draft.gif Preprocedure History and Physical Specification 1.3.6.1.4.1.19376.1.5.3.1.1.9

A Pre-procedure History and Physical is a type of medical document, and incorporates the constraints defined for Medical Documents(1.3.6.1.4.1.19376.1.5.3.1.1.1) .

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown below. Note that a Preprocedure History and Physical is a Medical Document, and so includes that <templateId> element as well. 

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9"/>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.1"/>
    :

A CDA Document may conform to more than one template, and can therefore have more that one <templateId> element. The <templateId> elements shown above must be present in the document.

This use case is described fully in PCC TF-1: 7.4. Briefly, this use case involves a sequence of events leading up to the patient’s admission to the operating room in a surgical center. Included in these events is the creation and communication of the pre-procedure history and physical document required by quality review organizations prior to most surgeries. Using this use case, the contents of documents used in collaborative transfers of care were discussed with physicians and nurses in detail to identify major sections. The sections identified by physicians during the use case exercise as important are listed in the table below under the column “Use Case Documentation Section”.

Using this information from the use case, the following mappings were made to existing standards and implementation guides. As illustrated, there is quite a bit of overlap between sections in this integration profile and in sections specified in the HL7 Care Record Summary CDA implementation guide.



Standards
CDAR2 HL7 CDA Release 2.0
CAREPROV HL7 Care Provision DSTU
CRS HL7 Care Record Summary
CCD ASTM/HL7 Continuity of Care Document
Data Element Index
Data Element Requirements Sections in HL7 CDA-R2/ LOINC Descriptions
Proposed Procedure: (coded procedure)   PROCEDURE
Expected Blood Loss   OPERATIVE NOTE ESTIMATED BLOOD LOSS
Proposed Anesthesia   OPERATIVE NOTE ANESTHESIA
Reason for Procedure: (coded diagnosis)   OPERATIVE NOTE INDICATIONS
HPI—(free text leading up to procedure) History of Present Illness HISTORY OF PRESENT ILLNESS
Current Problem List Conditions PROBLEM LIST
Past Medical History Conditions HISTORY OF PAST ILLNESS
Past Surgical-Anesthesia History Past Surgical History HISTORY OF SURGICAL PROCEDURES
Medication List Medications HISTORY OF MEDICATION USE
Allergy List Allergies and Adverse Reactions HISTORY OF ALLERGIES
Immunizations Immunizations HISTORY OF IMMUNIZATIONS
History of Tobacco Use   HISTORY OF TOBACCO USE
Current Alcohol/Substance Abuse   HISTORY OF PRESENT ALCOHOL AND/OR SUBSTANCE ABUSE
Transfusion History   TBD
Family History (specifically includes): Family History HISTORY OF FAMILY MEMBER DISEASES
Social History   SOCIAL HISTORY
Advance Directives Advance Directives ADVANCE DIRECTIVES
Functional Capacity Functional Status HISTORY OF FUNCTIONAL STATUS
Review of Systems (specifically includes): Review of Systems REVIEW OF SYSTEMS
Physical Exam (specifically includes): Physical Examination PHYSICAL EXAM.TOTAL
Studies and Reports Studies and Reports STUDIES SUMMARY
Health Maintenance Status   TREATMENT PLAN
Pre-procedure Care Plan Status Report   TREATMENT PLAN
Pre-procedure Impressions (specifically includes):   DIAGNOSIS
-Updated Problem List Conditions PROBLEM LIST
-Pre-Procedure Risk Assessment   OPERATIVE NOTE COMPLICATIONS
Pre-procedure Care Plan Plan of Care TREATMENT PLAN
Patient Education/Consents   EDUCATION NOTE

Transition to new CDA Document template to support schematron-->>Data<<--

Specification
Data Element Name Opt Template ID
Proposed Procedure: (coded procedure) includes:
Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. 		R 1.3.6.1.4.1.19376.1.5.3.1.1.9.1
-Reason for Procedure: (coded diagnosis)
Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. 		R 1.3.6.1.4.1.19376.1.5.3.1.1.9.4
-Proposed Anesthesia
Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. 		R 1.3.6.1.4.1.19376.1.5.3.1.1.9.3
-Expected Blood Loss
Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.
Needs narrative LOINC code 		R2 1.3.6.1.4.1.19376.1.5.3.1.1.9.2
-Procedure Care Plan
Care Plan generated by the surgeon or surgical coordinator prior to the H&P 		R2 1.3.6.1.4.1.19376.1.5.3.1.1.9.40
HPI—(free text leading up to procedure) R 1.3.6.1.4.1.19376.1.5.3.1.3.4
Current Problem List
Problem List (if known) is represented as current at beginning of H&P encounter. 		R2 1.3.6.1.4.1.19376.1.5.3.1.3.6
Past Medical History R2 1.3.6.1.4.1.19376.1.5.3.1.3.8
Past Surgical-Anesthesia History R 1.3.6.1.4.1.19376.1.5.3.1.3.11
Medication List R 1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergy List R 1.3.6.1.4.1.19376.1.5.3.1.3.13
Immunizations R2 1.3.6.1.4.1.19376.1.5.3.1.3.23
History of Tobacco Use R 1.3.6.1.4.1.19376.1.5.3.1.1.9.8
Current Alcohol/Substance Abuse R 1.3.6.1.4.1.19376.1.5.3.1.1.9.10
Transfusion History R 1.3.6.1.4.1.19376.1.5.3.1.1.9.12
Pre-procedure Family History R 1.3.6.1.4.1.19376.1.5.3.1.1.9.5
Social History R2 1.3.6.1.4.1.19376.1.5.3.1.3.16
Advance Directives R2 1.3.6.1.4.1.19376.1.5.3.1.3.34
Functional Capacity R 1.3.6.1.4.1.19376.1.5.3.1.3.17
Review of Systems (specifically includes): R 1.3.6.1.4.1.19376.1.5.3.1.1.9.13
-General Review R 1.3.6.1.4.1.19376.1.5.3.1.3.18
-Implanted Medical Devices R2 1.3.6.1.4.1.19376.1.5.3.1.1.9.46
-Pregnancy Status (if female) R 1.3.6.1.4.1.19376.1.5.3.1.1.9.47
-Anesthesia Review of Systems R 1.3.6.1.4.1.19376.1.5.3.1.1.9.14
Physical Exam (specifically includes): R 1.3.6.1.4.1.19376.1.5.3.1.1.9.15
-Vitals R 1.3.6.1.4.1.19376.1.5.3.1.9.49
-General Appearance O 1.3.6.1.4.1.19376.1.5.3.1.1.9.16
-Visible Implanted Medical Devices O 1.3.6.1.4.1.19376.1.5.3.1.1.9.48
-Integumentary System O 1.3.6.1.4.1.19376.1.5.3.1.1.9.17
-Head O 1.3.6.1.4.1.19376.1.5.3.1.1.9.18
-Eyes O 1.3.6.1.4.1.19376.1.5.3.1.1.9.19
-Ears, Nose, Mouth and Throat (may include): O 1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1
--Ears O 1.3.6.1.4.1.19376.1.5.3.1.1.9.21
--Nose O 1.3.6.1.4.1.19376.1.5.3.1.1.9.22
--Mouth, Throat, and Teeth O 1.3.6.1.4.1.19376.1.5.3.1.1.9.23
-Neck O 1.3.6.1.4.1.19376.1.5.3.1.1.9.24
-Endocrine System O 1.3.6.1.4.1.19376.1.5.3.1.1.9.25
-Thorax and Lungs (may include): O 1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1
--Chest Wall O 1.3.6.1.4.1.19376.1.5.3.1.1.9.27
--Breasts O 1.3.6.1.4.1.19376.1.5.3.1.1.9.28
--Heart O 1.3.6.1.4.1.19376.1.5.3.1.1.9.29
--Respiratory System O 1.3.6.1.4.1.19376.1.5.3.1.1.9.30
-Abdomen O 1.3.6.1.4.1.19376.1.5.3.1.1.9.31
-Lymphatic System O 1.3.6.1.4.1.19376.1.5.3.1.1.9.32
-Vessels O 1.3.6.1.4.1.19376.1.5.3.1.1.9.33
-Musculoskeletal System O 1.3.6.1.4.1.19376.1.5.3.1.1.9.34
-Neurologic System O 1.3.6.1.4.1.19376.1.5.3.1.1.9.35
-Genitalia O 1.3.6.1.4.1.19376.1.5.3.1.1.9.36
-Rectum O 1.3.6.1.4.1.19376.1.5.3.1.1.9.37
Studies and Reports R2 1.3.6.1.4.1.19376.1.5.3.1.3.28
Health Maintenance Care Plan Status Report
Actions completed to date 		R2 1.3.6.1.4.1.19376.1.5.3.1.1.9.41
Procedure Care Plan Status Report
Actions completed to date 		R2 1.3.6.1.4.1.19376.1.5.3.1.1.9.45
Pre-procedure Impressions (specifically includes): R 1.3.6.1.4.1.19376.1.5.3.1.1.9.42
- Problems
Updated at completion of encounter 		R 1.3.6.1.4.1.19376.1.5.3.1.3.6
-Pre-Procedure Risk Assessment
Content same as corresponding Op Note section except that this section describes what is at risk of happening instead of what happened. 		R 1.3.6.1.4.1.19376.1.5.3.1.1.9.44
Procedure Care Plan
Updated with additional or modified actions to be executed in future 		R 1.3.6.1.4.1.19376.1.5.3.1.1.9.40
Patient Education/Consents
Performed during H&P encounter 		R 1.3.6.1.4.1.19376.1.5.3.1.1.9.38


Conformance

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below.

Sample Preprocedure History and Physical Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Preprocedure History and Physical</title>
  <effectiveTime value='20240915012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
       
  </structuredBody></component>
</ClinicalDocument>

  

   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Preprocedure History and Physical must be {{{LOINC}}}
   </assert>
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
     Error: The document type code must come from the LOINC code 
     system (2.16.840.1.113883.6.1).
   </assert>
Retrieved from "http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9&oldid=4987"