PCC Public Comment Drafts/12

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Revision as of 00:34, 20 June 2007 by Kboone (talk | contribs) (New page: ====Plans of Care==== This section provides content modules for sections that describe the plan of care intended for the patient. {{:1.3.6.1.4.1.19376.1.5.3.1.3.31|Care Plan|XDS-MS|XPHR|ED...)
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Plans of Care

This section provides content modules for sections that describe the plan of care intended for 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

Care Plan Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.31
Parent Template CCD 3.16 (2.16.840.1.113883.10.20.1.10)
General Description The care plan section shall contain a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient.
LOINC Code Opt Description
61145-9 R TREATMENT PLAN
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.20.3.1 O Observation Requests
The care plan may include observation requests in intent, goal or proposal mood to identify intended observations that are part of the care plan, goals of the plan, or proposed observations (e.g., from clinical decision support).
1.3.6.1.4.1.19376.1.5.3.1.4.7 O Medication
The care plan may include medication entries to identify those medications that are or are proposed to be part of the care plan.
1.3.6.1.4.1.19376.1.5.3.1.4.12 O Immunization
The care plan may include immunization entries to identify those immunizations that are or are proposed to be part of the care plan.
1.3.6.1.4.1.19376.1.5.3.1.4.19 O Procedure
The care plan may include procedure entries to identify those procedures that are or are proposed to be part of the care plan.
1.3.6.1.4.1.19376.1.5.3.1.4.14 O Encounter
The care plan may include encounter entries in to identify those encounters that are or are proposed to be part of the care plan.



Parent Template

The parent of this template is CCD 3.16.

Sample Care Plan Section
<component>
  <section>
<templateId root='2.16.840.1.113883.10.20.1.10'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/> <id root=' ' extension=' '/> <code code='61145-9' displayName='TREATMENT PLAN' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text>   <entry>  : <!-- Optional Observation Requests element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.20.3.1'/>  : </entry>  <entry>  : <!-- Optional Medication element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/>  : </entry>  <entry>  : <!-- Optional Immunization element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12'/>  : </entry>  <entry>  : <!-- Optional Procedure element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>  : </entry>  <entry>  : <!-- Optional Encounter element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.14'/>  : </entry>     </section> </component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.31'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Care Plan can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.10"]'> 
     Error: The parent template identifier for Care Plan is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "61145-9"]'> 
     Error: The section type code of a Care Plan must be 61145-9 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.20.3.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This Care Plan Section does not contain a(n) Observation Requests Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.31 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.7"]'> 
     <!-- Note any missing optional elements -->
     Note: This Care Plan Section does not contain a(n) Medication Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.31 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.12"]'> 
     <!-- Note any missing optional elements -->
     Note: This Care Plan Section does not contain a(n) Immunization Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.31 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.19"]'> 
     <!-- Note any missing optional elements -->
     Note: This Care Plan Section does not contain a(n) Procedure Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.31 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.14"]'> 
     <!-- Note any missing optional elements -->
     Note: This Care Plan Section does not contain a(n) Encounter Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.31 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Care Plan 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

Care Plan Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1
Parent Template Care Plan (1.3.6.1.4.1.19376.1.5.3.1.3.31)
General Description The plan of care section contains descriptions of the expectations for care including proposals, order requests, the intended transporation mode and estimated time of arrival to the ED, as well as intended disposition from the ED.
LOINC Code Opt Description
18776-5 R TREATMENT PLAN
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2 R2 Intended Encounter Disposition
This required entry describes the expected disposition of the patient after the emergency department encounter has been completed.
Subsections Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 R Transport Mode
This required entry describes the expected disposition of the patient after the emergency department encounter has been completed.



Parent Template

The parent of this template is Care Plan.

Sample Care Plan Section
<component>
  <section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1'/> <id root=' ' extension=' '/> <code code='18776-5' displayName='TREATMENT PLAN' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text>   <entry>  : <!-- Required if known Intended Encounter Disposition element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2'/>  : </entry>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/> <!-- Required Transport Mode Section content --> </section> </component>
    </section> </component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Care Plan can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     Error: The parent template identifier for Care Plan is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "18776-5"]'> 
     Error: The section type code of a Care Plan must be 18776-5 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Care Plan Section should contain a(n) Intended Encounter Disposition Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Care Plan Section must contain a(n) Transport Mode Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Care Plan 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 Diet Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.33
General Description The discharge diet section shall contain a narrative description of the expectations for diet including proposals, goals, and order requests for monitoring, tracking, or improving the dietary control of the patient, specifically used in a discharge from a facility such as an emergency department, hospital, or nursing home.
LOINC Code Opt Description
42344-2 R DISCHARGE DIET



Sample Discharge Diet Section
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.33'/>
    <id root=' ' extension=' '/>
    <code code='42344-2' displayName='DISCHARGE DIET'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.33'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.33"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Discharge Diet can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "42344-2"]'> 
     Error: The section type code of a Discharge Diet must be 42344-2 
   </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 Discharge Diet 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

Advance Directives Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.34
Parent Template CCD 3.2 (2.16.840.1.113883.10.20.1.1)
General Description The advance directive section shall contain a narrative description of the list of documents that define the patient’s expectations and requests for care along with the locations of the documents.
LOINC Code Opt Description
42348-3 R ADVANCE DIRECTIVES



Parent Template

The parent of this template is CCD 3.2. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.1

Sample Advance Directives Section
<component>
  <section>
<templateId root='2.16.840.1.113883.10.20.1.1'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/> <id root=' ' extension=' '/> <code code='42348-3' displayName='ADVANCE DIRECTIVES' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text>     </section> </component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.34'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Advance Directives can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="2.16.840.1.113883.10.20.1.1"]'> 
     Error: The parent template identifier for Advance Directives is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "42348-3"]'> 
     Error: The section type code of a Advance Directives must be 42348-3 
   </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 Advance Directives 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 Advance Directives Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.35
Parent Template Advance Directives (1.3.6.1.4.1.19376.1.5.3.1.3.34)
General Description The advance directive section shall include entries for references to consent and advance directive documents when known as described in the Entry Content Modules.
LOINC Code Opt Description
42348-3 R ADVANCE DIRECTIVES
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.13.7 R2 Advance Directive Observation



Parent Template

The parent of this template is Advance Directives.

Sample Coded Advance Directives Section
<component>
  <section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.35'/> <id root=' ' extension=' '/> <code code='42348-3' displayName='ADVANCE DIRECTIVES' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text>   <entry>  : <!-- Required if known Advance Directive Observation element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.7'/>  : </entry>     </section> </component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.35'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.35"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Coded Advance Directives can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     Error: The parent template identifier for Coded Advance Directives is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "42348-3"]'> 
     Error: The section type code of a Coded Advance Directives must be 42348-3 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.13.7"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Coded Advance Directives Section should contain a(n) Advance Directive Observation Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.35
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Coded Advance Directives 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

Procedure Care Plan Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.40
Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.31 (1.3.6.1.4.1.19376.1.5.3.1.3.31)
General Description The procedure care plan section shall contain a description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient prior, during and after a procedure with goals of educating the patient, reducing the modifiable risks of the procedure and anethesia and otherwise optimizing the outcomes. The care plan will often be updated immediately following the addition of new impressions during the course of pre-procedure evaluation.
LOINC Code Opt Description
18776-5 R TREATMENT PLAN



Parent Template

The parent of this template is 1.3.6.1.4.1.19376.1.5.3.1.3.31.

Sample Procedure Care Plan Section
<component>
  <section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.40'/> <id root=' ' extension=' '/> <code code='18776-5' displayName='TREATMENT PLAN' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text>     </section> </component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.40'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.40"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Procedure Care Plan can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     Error: The parent template identifier for Procedure Care Plan is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "18776-5"]'> 
     Error: The section type code of a Procedure Care Plan must be 18776-5 
   </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 Procedure Care Plan 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

Procedure Care Plan Status Report Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.45
Parent Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.40 (1.3.6.1.4.1.19376.1.5.3.1.1.9.40)
General Description The procedure care plan status report section shall contain a description of the progress towards completing expectations for care including actions completed in fulfilment of proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient prior to the procedure.
LOINC Code Opt Description
18776-5 R TREATMENT PLAN



Parent Template

The parent of this template is 1.3.6.1.4.1.19376.1.5.3.1.1.9.40.

Sample Procedure Care Plan Status Report Section
<component>
  <section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.40'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.45'/> <id root=' ' extension=' '/> <code code='18776-5' displayName='TREATMENT PLAN' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text>     </section> </component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.45'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.45"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Procedure Care Plan Status Report can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.40"]'> 
     Error: The parent template identifier for Procedure Care Plan Status Report is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "18776-5"]'> 
     Error: The section type code of a Procedure Care Plan Status Report must be 18776-5 
   </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 Procedure Care Plan Status Report 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

Health Maintenance Care Plan Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.50
Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.31 (1.3.6.1.4.1.19376.1.5.3.1.3.31)
General Description The health maintenance care plan section shall contain a description of the expectations for wellness care including proposals, goals, and order requests for monitoring, tracking, or improving the lifetime condition of the patient with goals of educating the patient on how to reduce the modifiable risks of the patient’s genetic, behavioral, and environmental pre-conditions and otherwise optimizing lifetime outcomes.
LOINC Code Opt Description
18776-5 R TREATMENT PLAN



Parent Template

The parent of this template is 1.3.6.1.4.1.19376.1.5.3.1.3.31.

Sample Health Maintenance Care Plan Section
<component>
  <section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.50'/> <id root=' ' extension=' '/> <code code='18776-5' displayName='TREATMENT PLAN' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text>     </section> </component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.50'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.50"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Health Maintenance Care Plan can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     Error: The parent template identifier for Health Maintenance Care Plan is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "18776-5"]'> 
     Error: The section type code of a Health Maintenance Care Plan must be 18776-5 
   </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 Health Maintenance Care Plan Section