Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.1"
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| − | + | ===== [[Image:Draft.gif]] <span id='1.3.6.1.4.1.19376.1.5.3.1.1.1'>Medical Documents Specification</span> 1.3.6.1.4.1.19376.1.5.3.1.1.1 ===== | |
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This section defines the base set of constraints used by almost all medical document profiles described the PCC Technical Framework. | This section defines the base set of constraints used by almost all medical document profiles described the PCC Technical Framework. | ||
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| − | + | {|class='wikitable' style='border-collapse: collapse; border: 1px solid black; width: 100%' | |
| − | {{ | + | |-style='background-color: lightgrey; border: 1px solid black;' |
| − | + | ! style='border: 1px solid black; width: 70%'| Data Element Name | |
| − | + | ! style='border: 1px solid black; width: 10%'| Opt | |
| + | ! style='border: 1px solid black; width: 20%'| Template ID | ||
| + | |- | ||
| + | {{{Data|}}} | ||
| + | |} | ||
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| + | [[Category:CDA Document Templates]] | ||
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| + | ====Specification==== | ||
| + | The constraints for encoding of the CDA Header (Level 1), and codes for sections within the section body follow all Level 1 constraints found in the HL7 Care Record Summary Implementation Guide, with the exception that the constraints on the type of document and its narrative content are not adopted by this content profile. | ||
| + | |||
| + | ===== Style Sheets===== | ||
| + | Document sources should provide an XML style sheet to render the content of the Medical Summary document. The output of this style sheet shall be an XHTML Basic (see [http://www.w3.org/TR/xhtml-basic/ http://www.w3.org/TR/xhtml-basic/]) document that renders the clinical content of a Medical Summary Document as closely as possible as the sending provider viewed the completed document. When a style sheet is provided a processing instruction including a link to the URL for the XML style sheet must be included in the document, and the style sheet must be available to all receivers. Within an XDS Affinity domain this shall be via an HTTP or HTTPS GET. When using XDM or XDR to exchange documents, the stylesheet must also be exchanged. The style sheet should not rely on graphic or other media resources. If graphics other media resources are used, these shall be accessible in the same way. The content creator need not be the provider of the resources. | ||
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| + | When a Content Creator provides a style sheet, Content Consumers must provide a mechanism to render the document with that style sheet. Content Consumers may view the document with their own style sheet. | ||
| + | |||
| + | =====Distinctions of None===== | ||
| + | Information that is sent must clearly identify distinctions between | ||
| + | |||
| + | * None<br>It is known with complete confidence that there are none. Used in the context of problem and medication lists, this indicates that the sender knows that there is no relevant information that can be sent. | ||
| + | * None Known<br>None are known at this time, but it is not known with complete confidence than none exist. Used in the context of allergy lists, where essentially, it is impossible to prove the negative that no allergies exist, it is only possible to assert that none have been found to date. | ||
| + | * None Known Did Ask (NKDA)<br>None are known at this time, and it is not known with complete confidence than none exist, but the information was requested. Also used in the context of allergy lists, where essentially, it is impossible to prove the negative that no allergies exist, it is only possible to assert that none have been found to date. | ||
| + | * Unknown<br>The information is not known, or is otherwise unavailable. | ||
| + | In the context of CDA, sections that are required to be present but have no information should use one of the above phrases where appropriate. | ||
Revision as of 15:10, 11 May 2007
Medical Documents Specification 1.3.6.1.4.1.19376.1.5.3.1.1.1
This section defines the base set of constraints used by almost all medical document profiles described the PCC Technical Framework.
| Data Element Name | Opt | Template ID |
|---|
Specification
The constraints for encoding of the CDA Header (Level 1), and codes for sections within the section body follow all Level 1 constraints found in the HL7 Care Record Summary Implementation Guide, with the exception that the constraints on the type of document and its narrative content are not adopted by this content profile.
Style Sheets
Document sources should provide an XML style sheet to render the content of the Medical Summary document. The output of this style sheet shall be an XHTML Basic (see http://www.w3.org/TR/xhtml-basic/) document that renders the clinical content of a Medical Summary Document as closely as possible as the sending provider viewed the completed document. When a style sheet is provided a processing instruction including a link to the URL for the XML style sheet must be included in the document, and the style sheet must be available to all receivers. Within an XDS Affinity domain this shall be via an HTTP or HTTPS GET. When using XDM or XDR to exchange documents, the stylesheet must also be exchanged. The style sheet should not rely on graphic or other media resources. If graphics other media resources are used, these shall be accessible in the same way. The content creator need not be the provider of the resources.
When a Content Creator provides a style sheet, Content Consumers must provide a mechanism to render the document with that style sheet. Content Consumers may view the document with their own style sheet.
Distinctions of None
Information that is sent must clearly identify distinctions between
- None
It is known with complete confidence that there are none. Used in the context of problem and medication lists, this indicates that the sender knows that there is no relevant information that can be sent. - None Known
None are known at this time, but it is not known with complete confidence than none exist. Used in the context of allergy lists, where essentially, it is impossible to prove the negative that no allergies exist, it is only possible to assert that none have been found to date. - None Known Did Ask (NKDA)
None are known at this time, and it is not known with complete confidence than none exist, but the information was requested. Also used in the context of allergy lists, where essentially, it is impossible to prove the negative that no allergies exist, it is only possible to assert that none have been found to date. - Unknown
The information is not known, or is otherwise unavailable.
In the context of CDA, sections that are required to be present but have no information should use one of the above phrases where appropriate.