PCC Public Comment Drafts/8

From IHE Wiki
Revision as of 00:14, 20 June 2007 by Kboone (talk | contribs) (New page: ====Physical Exams==== {{:1.3.6.1.4.1.19376.1.5.3.1.3.24|Physical Exam|XDS-MS|EDR|EDER}} {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Physical Exam (with subsections)|XDS-MS|EDR|EDER}} {{:1.3.6.1.4...)
(diff) ← Older revision | Latest revision (diff) | Newer revision → (diff)
Jump to navigation Jump to search

Physical Exams

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 Exam Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.24
General Description The physical exam section shall contain a narrative description of the patient’s physical findings.
LOINC Code Opt Description
29545-1 R PHYSICAL EXAMINATION



Sample Physical Exam Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
    <id root=' ' extension=' '/>
    <code code='29545-1' displayName='PHYSICAL EXAMINATION'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.24'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.24"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Physical Exam can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "29545-1"]'> 
     Error: The section type code of a Physical Exam must be 29545-1 
   </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 Physical Exam 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 Exam Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.15
Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.24 (1.3.6.1.4.1.19376.1.5.3.1.3.24)
General Description The physical exam section shall contain only the required and optional subsections performed.
LOINC Code Opt Description
29545-1 R PHYSICAL EXAMINATION
Entries Opt Description
Subsections Opt Description
1.3.6.1.4.1.19376.1.5.3.1.3.25 O Vital Signs
Vital signs may be a subsection of the physical exam or they may stand alone
1.3.6.1.4.1.19376.1.5.3.1.1.9.16 O General Appearance
1.3.6.1.4.1.19376.1.5.3.1.1.9.48 O Visible Implanted Medical Devices
1.3.6.1.4.1.19376.1.5.3.1.1.9.17 O Integumentary System
1.3.6.1.4.1.19376.1.5.3.1.1.9.18 O Head
1.3.6.1.4.1.19376.1.5.3.1.1.9.19 O Eyes
1.3.6.1.4.1.19376.1.5.3.1.1.9.20 O Ears, Nose, Mouth and Throat
1.3.6.1.4.1.19376.1.5.3.1.1.9.21 O Ears
1.3.6.1.4.1.19376.1.5.3.1.1.9.22 O Nose
1.3.6.1.4.1.19376.1.5.3.1.1.9.23 O Mouth, Throat, and Teeth
1.3.6.1.4.1.19376.1.5.3.1.1.9.24 O Neck
1.3.6.1.4.1.19376.1.5.3.1.1.9.25 O Endocrine System
1.3.6.1.4.1.19376.1.5.3.1.1.9.26 O Thorax and Lungs
1.3.6.1.4.1.19376.1.5.3.1.1.9.27 O Chest Wall
1.3.6.1.4.1.19376.1.5.3.1.1.9.28 O Breasts
1.3.6.1.4.1.19376.1.5.3.1.1.9.29 O Heart
1.3.6.1.4.1.19376.1.5.3.1.1.9.30 O Respiratory System
1.3.6.1.4.1.19376.1.5.3.1.1.9.31 O Abdomen
1.3.6.1.4.1.19376.1.5.3.1.1.9.32 O Lymphatic System
1.3.6.1.4.1.19376.1.5.3.1.1.9.33 O Vessels
1.3.6.1.4.1.19376.1.5.3.1.1.9.34 O Musculoskeletal System
1.3.6.1.4.1.19376.1.5.3.1.1.9.35 O Neurologic System
1.3.6.1.4.1.19376.1.5.3.1.1.9.36 O Genitalia
1.3.6.1.4.1.19376.1.5.3.1.1.9.37 O Rectum
1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1 O Extremeties



Parent Template

The parent of this template is 1.3.6.1.4.1.19376.1.5.3.1.3.24.

Sample Physical Exam Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/>
    <id root=' ' extension=' '/>
    <code code='29545-1' displayName='PHYSICAL EXAMINATION'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
        <!-- Optional Vital Signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.16'/>
        <!-- Optional General Appearance Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.48'/>
        <!-- Optional Visible Implanted Medical Devices Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.17'/>
        <!-- Optional Integumentary System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.18'/>
        <!-- Optional Head Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.19'/>
        <!-- Optional Eyes Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.20'/>
        <!-- Optional Ears, Nose, Mouth and Throat Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.21'/>
        <!-- Optional Ears Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.22'/>
        <!-- Optional Nose Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.23'/>
        <!-- Optional Mouth, Throat, and Teeth Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.24'/>
        <!-- Optional Neck Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.25'/>
        <!-- Optional Endocrine System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.26'/>
        <!-- Optional Thorax and Lungs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.27'/>
        <!-- Optional Chest Wall Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.28'/>
        <!-- Optional Breasts Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.29'/>
        <!-- Optional Heart Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.30'/>
        <!-- Optional Respiratory System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.31'/>
        <!-- Optional Abdomen Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.32'/>
        <!-- Optional Lymphatic System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.33'/>
        <!-- Optional Vessels Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.34'/>
        <!-- Optional Musculoskeletal System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.35'/>
        <!-- Optional Neurologic System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.36'/>
        <!-- Optional Genitalia Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.37'/>
        <!-- Optional Rectum Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1'/>
        <!-- Optional Extremeties Section content -->
      </section>
    </component>

       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.15'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Physical Exam can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.24"]'> 
     Error: The parent template identifier for Physical Exam is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "29545-1"]'> 
     Error: The section type code of a Physical Exam must be 29545-1 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.16"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) General Appearance Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.48"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Visible Implanted Medical Devices Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.17"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Integumentary System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Head Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.19"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Eyes Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.20"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Ears, Nose, Mouth and Throat Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.21"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Ears Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.22"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Nose Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.23"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Mouth, Throat, and Teeth Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.24"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Neck Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.25"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Endocrine System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.26"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Thorax and Lungs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.27"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Chest Wall Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.28"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Breasts Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.29"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Heart Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.30"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Respiratory System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.31"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Abdomen Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.32"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Lymphatic System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.33"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Vessels Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.34"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Musculoskeletal System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.35"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Neurologic System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.36"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Genitalia Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.37"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Rectum Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Extremeties Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Physical Exam 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 Physical Exam Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.26
General Description The hospital discharge physical exam section shall contain a narrative description of the patient’s physical findings at discharge from a hospital facility.
LOINC Code Opt Description
10184-0 R HOSPITAL DISCHARGE PHYSICAL



Sample Hospital Discharge Physical Exam Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.26'/>
    <id root=' ' extension=' '/>
    <code code='10184-0' displayName='HOSPITAL DISCHARGE PHYSICAL'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.26'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.26"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Hospital Discharge Physical Exam can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10184-0"]'> 
     Error: The section type code of a Hospital Discharge Physical Exam must be 10184-0 
   </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> 
 </rule> 
</pattern>
Uses

See Templates using the Hospital Discharge Physical Exam 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

Vital Signs Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.25
Parent Template CCD 3.12 (2.16.840.1.113883.10.20.1.16)
General Description The vital signs section shall contain a narrative description of the measurement results of a patient’s vital signs.
LOINC Code Opt Description
8716-3 R VITAL SIGNS



Parent Template

The parent of this template is CCD 3.12.

Sample Vital Signs Section 
<component>
  <section>
    <templateId root='2.16.840.1.113883.10.20.1.16'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
    <id root=' ' extension=' '/>
    <code code='8716-3' displayName='VITAL SIGNS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.25'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Vital Signs can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.16"]'> 
     Error: The parent template identifier for Vital Signs is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "8716-3"]'> 
     Error: The section type code of a Vital Signs must be 8716-3 
   </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 Vital Signs 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 Vital Signs Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Parent Template Vital Signs (1.3.6.1.4.1.19376.1.5.3.1.3.25)
General Description The vital signs section contains coded measurement results of a patient’s vital signs.
LOINC Code Opt Description
8716-3 R VITAL SIGNS
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.13.1 R Vital Signs Organizer



Parent Template

The parent of this template is Vital Signs.

Sample Coded Vital Signs Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
    <id root=' ' extension=' '/>
    <code code='8716-3' displayName='VITAL SIGNS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Vital Signs Organizer element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.1'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Coded Vital Signs can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     Error: The parent template identifier for Coded Vital Signs is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "8716-3"]'> 
     Error: The section type code of a Coded Vital Signs must be 8716-3 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.13.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded Vital Signs Section must contain a(n) Vital Signs Organizer Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Coded Vital Signs 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

General Appearance Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.16
General Description The general appearance section shall contain a description of the overall, visibly-apparent condition of the patient.
LOINC Code Opt Description
10210-3 R GENERAL STATUS



Sample General Appearance Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.16'/>
    <id root=' ' extension=' '/>
    <code code='10210-3' displayName='GENERAL STATUS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.16'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.16"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The General Appearance can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10210-3"]'> 
     Error: The section type code of a General Appearance must be 10210-3 
   </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 General Appearance 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

Visible Implanted Medical Devices Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.48
General Description The visible implanted medical devices section shall contain a description of the medical devices apparent on physical exam that have been inserted into the patient, whether internal or partially external.
LOINC Code Opt Description
TBD R TBD



Sample Visible Implanted Medical Devices Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.48'/>
    <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_1.3.6.1.4.1.19376.1.5.3.1.1.9.48'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.48"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Visible Implanted Medical Devices 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 Visible Implanted Medical Devices 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 Visible Implanted 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

Integumentary System Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.17
General Description The integumentary system section shall contain a description of any type of integumentary system exam.
LOINC Code Opt Description
29302-7 R INTEGUMENTARY SYSTEM



Sample Integumentary System Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.17'/>
    <id root=' ' extension=' '/>
    <code code='29302-7' displayName='INTEGUMENTARY SYSTEM'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.17'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.17"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Integumentary System can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "29302-7"]'> 
     Error: The section type code of a Integumentary System must be 29302-7 
   </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> 
 </rule> 
</pattern>
Uses

See Templates using the Integumentary System 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

Head Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.18
General Description The head section shall contain a description of any type of head exam.
LOINC Code Opt Description
10199-8 R HEAD



Sample Head Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.18'/>
    <id root=' ' extension=' '/>
    <code code='10199-8' displayName='HEAD'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.18'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.18"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Head can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10199-8"]'> 
     Error: The section type code of a Head must be 10199-8 
   </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 Head Section


Retrieved from "http://wiki.ihe.net/index.php?title=PCC_Public_Comment_Drafts/8&oldid=7886"