PCC Public Comment Drafts/7

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Revision as of 00:12, 20 June 2007 by Kboone (talk | contribs) (New page: ====Medications==== This section contains section content modules that describe activities surrounding the use of medication. {{:1.3.6.1.4.1.19376.1.5.3.1.3.19|Medications|XDS-MS|XPHR|EDR|...)
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Medications

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

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

Medications Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.19
Parent Template CCD 3.9 (2.16.840.1.113883.10.20.1.8)
General Description The medications section shall contain a description of the relevant medications for the patient, e.g. an ambulatory prescription list. It shall include entries for medications as described in the Entry Content Module.
LOINC Code Opt Description
10160-0 R HISTORY OF MEDICATION USE
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.7 R Medications



Parent Template

The parent of this template is CCD 3.9.

Sample Medications Section 
<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.8'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
    <id root=' ' extension=' '/>
    <code code='10160-0' displayName='HISTORY OF MEDICATION USE'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Medications element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.19'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Medications can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.8"]'> 
     Error: The parent template identifier for Medications is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10160-0"]'> 
     Error: The section type code of a Medications must be 10160-0 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.7"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Medications Section must contain a(n) Medications Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.19
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Medications Section



Note: this LOINC code is typically used to record the current medication list found in an EHR.

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

Admission Medication History Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.20
General Description The admission medication history section shall contain a narrative description of the relevant medications administered to a patient prior to admission to a facility. It shall include entries for medication administration as described in the Entry Content Module.
LOINC Code Opt Description
42346-7 R MEDICATIONS ON ADMISSION
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.7 R Medications



Sample Admission Medication History Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.20'/>
    <id root=' ' extension=' '/>
    <code code='42346-7' displayName='MEDICATIONS ON ADMISSION'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Medications element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.20'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.20"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Admission Medication History can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "42346-7"]'> 
     Error: The section type code of a Admission Medication History must be 42346-7 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.7"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Admission Medication History Section must contain a(n) Medications Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.20
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Admission Medication 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

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



Sample Medications Administered Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/>
    <id root=' ' extension=' '/>
    <code code='18610-6' displayName='MEDICATION ADMINISTERED'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Medications element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.21'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.21"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Medications Administered can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "18610-6"]'> 
     Error: The section type code of a Medications Administered must be 18610-6 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.7"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Medications Administered Section must contain a(n) Medications Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.21
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Medications Administered 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 Discharge Medications Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.22
General Description The hospital discharge medications section shall contain a narrative description of the medications requested (ordered) to be administered to the patient after discharge from the hospital. It shall include entries for medication requests as described in the Entry Content Module.
LOINC Code Opt Description
10183-2 R HOSPITAL DISCHARGE MEDICATIONS
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.7 R Medications



Sample Hospital Discharge Medications Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.22'/>
    <id root=' ' extension=' '/>
    <code code='10183-2' displayName='HOSPITAL DISCHARGE MEDICATIONS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Medications element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.22'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.22"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Hospital Discharge Medications can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10183-2"]'> 
     Error: The section type code of a Hospital Discharge Medications must be 10183-2 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.7"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Hospital Discharge Medications Section must contain a(n) Medications Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.22
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Hospital Discharge Medications Section



Note: All medications in this section must have sustanceAdministration/@moodCode = "INT"

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

Immunizations Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.23
Parent Template CCD 3.11 (2.16.840.1.113883.10.20.1.6)
General Description The immunizations section shall contain a narrative description of the immunizations administered to the patient in the past. It shall include entries for medication administration as described in the Entry Content Modules.
LOINC Code Opt Description
11369-6 R HISTORY OF IMMUNIZATIONS
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.12 R Immunization



Parent Template

The parent of this template is CCD 3.11.

Sample Immunizations Section 
<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.6'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
    <id root=' ' extension=' '/>
    <code code='11369-6' displayName='HISTORY OF IMMUNIZATIONS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Immunization element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.23'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Immunizations can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.6"]'> 
     Error: The parent template identifier for Immunizations is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11369-6"]'> 
     Error: The section type code of a Immunizations must be 11369-6 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.12"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Immunizations Section must contain a(n) Immunization Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.23
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Immunizations Section


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