PCC Public Comment Drafts/13

From IHE Wiki
Revision as of 00:47, 20 June 2007 by Kboone (talk | contribs) (New page: {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.41|Health Maintenance Care Plan Status Report|PPHP}} {{:1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2|Transport Mode|EDR|EDER}} ==== Procedures Performed ==== {{:1.3...)
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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 Status Report Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.41
Parent Template 1.3.6.1.4.1.19376.1.5.3.1.1.9.50 (1.3.6.1.4.1.19376.1.5.3.1.1.9.50)
General Description The health maintenance 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.
LOINC Code Opt Description
18776-5 R TREATMENT PLAN



Parent Template

The parent of this template is 1.3.6.1.4.1.19376.1.5.3.1.1.9.50.

Sample Health Maintenance Care Plan Status Report Section
<component>
  <section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.50'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.41'/> <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_1.3.6.1.4.1.19376.1.5.3.1.1.9.41'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.41"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Health Maintenance Care Plan Status Report can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.50"]'> 
     Error: The parent template identifier for Health Maintenance 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 Health Maintenance 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 Health Maintenance 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

Transport Mode Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
General Description The transport mode section contains a description of the mode of transport and the time of departure or arrival of the patient to a facility.
LOINC Code Opt Description
11459-5 R TRANSPORT MODE
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1 R Transport
This entry provides coded values giving the mode and time of departure or arrival of the patient to a facility.



Sample Transport Mode Section
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/>
    <id root=' ' extension=' '/>
    <code code='11459-5' displayName='TRANSPORT MODE'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Transport element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Transport Mode can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11459-5"]'> 
     Error: The section type code of a Transport Mode must be 11459-5 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Transport Mode Section must contain a(n) Transport Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Transport Mode Section



Procedures Performed

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

Patient Education and Consents Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.38
General Description The patient education and consents section shall contain a description of the patient education the patient received, the results of the education, and the consents the patient signed.
LOINC Code Opt Description
34895-3 R EDUCATION NOTE



Sample Patient Education and Consents Section
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.38'/>
    <id root=' ' extension=' '/>
    <code code='34895-3' displayName='EDUCATION NOTE'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.38'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.38"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Patient Education and Consents can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "34895-3"]'> 
     Error: The section type code of a Patient Education and Consents must be 34895-3 
   </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 Patient Education and Consents 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

Patient Education and Consents Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.39
Parent Template Patient Education and Consents Section (1.3.6.1.4.1.19376.1.5.3.1.1.9.38)
General Description The patient education and consents section shall contain a description of the patient education the patient received, the results of the education, and references to the consents the patient signed. It shall include entries for procedures and references to consent documents as described in the Entry Content Modules.
LOINC Code Opt Description
34895-3 R EDUCATION NOTE
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.19 R Procedure Entry
The procedures shall be in INT mood
1.3.6.1.4.1.19376.1.5.3.1.4.13 R2 Simple Observations
1.3.6.1.4.1.19376.1.5.3.1.4.4 R2 External References



Parent Template

The parent of this template is Patient Education and Consents Section.

Sample Patient Education and Consents Section
<component>
  <section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.38'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.39'/> <id root=' ' extension=' '/> <code code='34895-3' displayName='EDUCATION NOTE' 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 Simple Observations element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>  : </entry>  <entry>  : <!-- Required if known External References element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>  : </entry>     </section> </component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.39'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.39"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Patient Education and Consents can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.38"]'> 
     Error: The parent template identifier for Patient Education and Consents is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "34895-3"]'> 
     Error: The section type code of a Patient Education and Consents must be 34895-3 
   </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 Patient Education and Consents Section must contain a(n) Procedure Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.39 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.13"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Patient Education and Consents Section should contain a(n) Simple Observations Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.39
   </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  Patient Education and Consents Section should contain a(n) External References Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.39
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Patient Education and Consents 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

Procedures and Interventions Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11
General Description This section contains a narrative description of the actions performed by a clinician.
LOINC Code Opt Description
29544-3 R PROCEDURES
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.19 R Procedures
This entry provides coded values for actions performed during the encounter.



Sample Procedures and Interventions Section
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'/>
    <id root=' ' extension=' '/>
    <code code='29544-3' displayName='PROCEDURES'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Procedures element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Procedures and Interventions can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "29544-3"]'> 
     Error: The section type code of a Procedures and Interventions must be 29544-3 
   </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 Procedures and Interventions Section must contain a(n) Procedures Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Procedures and Interventions Section


Impressions

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 Impressions Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.42
Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.6 (1.3.6.1.4.1.19376.1.5.3.1.3.6)
General Description The Impressions section shall contain only the required and optional subsections dealing with the updated problem list, the general risks the patient faces from the procedures, and the fixed and modifiable risks the patient faces because of specific patient findings.
LOINC Code Opt Description
34895-3 R EDUCATION NOTE
Subsections Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.9.44 R Pre-procedure Risk Assessment



Parent Template

The parent of this template is 1.3.6.1.4.1.19376.1.5.3.1.3.6.

Sample Pre-procedure Impressions Section
<component>
  <section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.42'/> <id root=' ' extension=' '/> <code code='34895-3' displayName='EDUCATION NOTE' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.44'/> <!-- Required Pre-procedure Risk Assessment Section content --> </section> </component>
    </section> </component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.42'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.42"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Pre-procedure Impressions can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     Error: The parent template identifier for Pre-procedure Impressions is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "34895-3"]'> 
     Error: The section type code of a Pre-procedure Impressions must be 34895-3 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.9.44"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Pre-procedure Impressions Section must contain a(n) Pre-procedure Risk Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.42
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Pre-procedure Impressions 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 Risk Assessment Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.44
Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.6 (1.3.6.1.4.1.19376.1.5.3.1.3.6)
General Description The pre-procedure risk section shall contain a description of the risks the patient faces because of the planned procedure and associated anethesia, especially in the context of modifiable risks identified by patient findings. It shall include entries for patient risks 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 R Conditions Entry



Parent Template

The parent of this template is 1.3.6.1.4.1.19376.1.5.3.1.3.6.

Sample Pre-procedure Risk Assessment Section
<component>
  <section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.44'/> <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 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_1.3.6.1.4.1.19376.1.5.3.1.1.9.44'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.44"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Pre-procedure Risk Assessment can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     Error: The parent template identifier for Pre-procedure Risk Assessment is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11450-4"]'> 
     Error: The section type code of a Pre-procedure Risk Assessment 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"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Pre-procedure Risk Assessment Section must contain a(n) Conditions Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.44
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Pre-procedure Risk 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

Visit Summary Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2
General Description

This section is a running history of the most important elements noted for a pregnant woman.

LOINC Code Opt Description
(xx-acog-visit-sum-section) R PREGNANCY VISIT SUMMARY-^PATIENT-FIND-PT-NAR
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.13 R Simple Observation
The flowsheet contains one simple observation to represent the Prepregancy Weight. This observation SHALL be valued with the LOINC code 8348-5, BODY WEIGHT^PRE PREGNANCY-MASS-PT-QN-MEASURED. The value SHALL be of type PQ. The units may be either "lb_av" or "kg".
1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2 R Antepartum Flowsheet Panel
Other entries on the flowsheet are "batteries" which represent a single visit.



Sample Visit Summary Section
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2'/>
    <id root=' ' extension=' '/>
    <code code='(xx-acog-visit-sum-section)' displayName='PREGNANCY VISIT SUMMARY-^PATIENT-FIND-PT-NAR'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Simple Observation element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
         :
    </entry> 
    <entry>
         :
      <!-- Required Antepartum Flowsheet Panel element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Visit Summary can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "(xx-acog-visit-sum-section)"]'> 
     Error: The section type code of a Visit Summary must be (xx-acog-visit-sum-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 = "1.3.6.1.4.1.19376.1.5.3.1.4.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Visit Summary Section must contain a(n) Simple Observation Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Visit Summary Section must contain a(n) Antepartum Flowsheet Panel Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2 
   </assert> 
   <assert test='.//cda:observation/cda:code[@code="8348-5"]'>
     Error: The Visit Summary must have at least one simple observation with the LOINC
     code 8348-5 to represent the prepregnancy weight.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2
   </assert>
   <assert test='.//cda:observation[cda:code/@code='8348-5']/cda:value[@unit='kg' or @unit='lb_av']">
     Error: The prepregnancy weight shall record the units in kg or lbs
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Visit Summary 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

Progress Note Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7
General Description The Progress Note section shall contain a narrative description of the sequence of events from initial assessment to discharge for an encounter.
LOINC Code Opt Description
18733-6 R SUBSEQUENT EVALUATION NOTE (ATTENDING PHYSICIAN)



Sample Progress Note Section
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7'/>
    <id root=' ' extension=' '/>
    <code code='18733-6' displayName='SUBSEQUENT EVALUATION NOTE (ATTENDING PHYSICIAN)'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Progress Note can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "18733-6"]'> 
     Error: The section type code of a Progress Note must be 18733-6 
   </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 Progress Note Section