Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4"
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|Section|Consultations|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8| | |Section|Consultations|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8| | ||
|Section|Progress Note|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7| | |Section|Progress Note|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7| | ||
− | |Section|ED Diagnoses|R| | | + | |Section|ED Diagnoses|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9| |
|Section|ED Disposition|R| | | |Section|ED Disposition|R| | | ||
|Section|(Admission) Inpatient Facility|C| | | |Section|(Admission) Inpatient Facility|C| | |
Revision as of 22:00, 2 June 2007
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 http://www.ihe.net/Technical_Framework/index.cfm#PCC
ED Physician Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
The ED Physician note specification includes sections for data commonly reported by the physician as part of an ED encounter. It includes relevant historical information about the patient, pertinent arrival information, vital signs, history and physical examination findings, assessment and plan, interventions including medications, fluids and procedures, diagnosis and disposition.
LOINC Code
The LOINC code for this document is X-EDPHYSNT ED Physician Note
Data Element Index
Data Element | LOINC |
---|---|
Referral Source | 11293-8 ED REFERRAL SOURCE |
Mode of Arrival | 11459-5 TRANSPORT MODE |
Chief Complaint | 10154-3 CHIEF COMPLAINT FIND |
History of Present Illness | 10164-2 HISTORY OF PRESENT ILLNESS |
Active Problems | 11450-4 PROBLEM LIST |
Resolved Problems | 11348-0 HISTORY OF PAST ILLNESS |
Current Medications | 10160-0 CURRENT MEDICATIONS |
Allergies | 48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS |
List of Surgeries | 10167-5 HISTORY OF SURGICAL PROCEDURES |
Immunizations | 11369-6 HISTORY OF IMMUNIZATIONS |
Family History | 10157-6 HISTORY OF FAMILY MEMBER DISEASES |
Social History | 29762-2 SOCIAL HISTORY |
History of Pregnancies | 10162-6 HISTORY OF PREGNANCIES |
Pertinent ROS | 10187-3 REVIEW OF SYSTEMS |
Vital Signs | 8716-3 VITAL SIGNS |
Physical Examination | 22029-3 PHYSICAL EXAM.TOTAL |
Plan of Care | XXXXX-X ASSESSMENT AND PLAN |
Medications Administered | 18610-6 MEDICATION ADMINISTERED (COMPOSITE) |
Intravenous Fluids Administered | XIVFLU-X INTRAVENOUS FLUID ADMINISTERED (COMPOSITE) |
Procedures Performed | XXXXX-X PROCEDURE PERFORMED |
Test Results: Lab, ECG, Radiology | 30954-2 STUDIES SUMMARY |
Consultations | 18693-2 ED CONSULTANT PRACTITIONER |
Progress Note | 18733-6 SUBSEQUENT EVALUATION NOTE (ATTENDING PHYSICIAN) |
ED Diagnoses | 11301-9 ED DIAGNOSIS |
ED Disposition | 11302-7 ED DISPOSITION |
(Admission) Inpatient Facility | LOINC??? |
(Admission) Inpatient Practitioner | 18774-0 STAFF PRACTITIONER NAME ??? |
(Discharge) Discharge Medications | 18617-1 MEDICATION DISCHARGE ??? |
(Discharge) Discharge Instructions | 8653-8 HOSPITAL DISCHARGE INSTRUCTIONS ??? |
(Discharge) Referral at ED Disposition | 11303-5 ED DISPOSITION CONSULT/REFERRAL |
(Discharge) ED Referral Practitioner | 39266-2 FOLLOW-UP (REFERRED TO) PROVIDER/SPECIALIST |
(Transfer) Facility Receiving ED Patient | 11453-8 RECEIVING FACILITY |
(Transfer) Accepting Practitioner | 11303-5 ED DISPOSITION CONSULT/REFERRAL ??? |
Advanced Directives | 42348-3 ADVANCE DIRECTIVES |
Specification
Data Element Name | Opt | Template ID |
---|---|---|
Referral Source | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3 |
Mode of Arrival | R | 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 |
Chief Complaint | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 |
History of Present Illness | R | 1.3.6.1.4.1.19376.1.5.3.1.3.4 |
Active Problems | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.6 |
Resolved Problems | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.8 |
Current Medications | R | 1.3.6.1.4.1.19376.1.5.3.1.3.19 |
Allergies | R | 1.3.6.1.4.1.19376.1.5.3.1.3.13 |
List of Surgeries | R | 1.3.6.1.4.1.19376.1.5.3.1.3.11 |
Immunizations | R | 1.3.6.1.4.1.19376.1.5.3.1.3.23 |
Family History | R | 1.3.6.1.4.1.19376.1.5.3.1.3.14 |
Social History | R | 1.3.6.1.4.1.19376.1.5.3.1.3.16 |
History of Pregnancies This section should contain one entry containing the date (TS) of last menstrual period for women of childbearing age, using LOINC Code 8665-2 DATE LAST MENSTRUAL PERIOD |
R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 |
Pertinent ROS | R | 1.3.6.1.4.1.19376.1.5.3.1.3.18 |
Vital Signs | R | 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 |
Physical Examination | R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.15 |
Plan of Care | R | 1.3.6.1.4.1.19376.1.5.3.1.3.31 |
Medications Administered | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.21 |
IV Fluids Administered | R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6 |
Procedures Performed | R | 1.3.6.1.4.1.19376.1.5.3.1.4.19 |
Test Results: Lab, ECG, Radiology | R | 1.3.6.1.4.1.19376.1.5.3.1.3.27 |
Consultations | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8 |
Progress Note | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7 |
ED Diagnoses | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9 |
ED Disposition | R | |
(Admission) Inpatient Facility | C | |
(Admission) Inpatient Practitioner | C | |
(Discharge) Discharge Medications | C | |
(Discharge) Discharge Instructions | C | |
(Discharge) Referral at ED Disposition | C | |
(Discharge) ED Referral Practitioner | C | |
(Transfer) Facility Receiving ED Patient | C | |
(Transfer) Accepting Practitioner | C | |
Advanced Directives | R | 1.3.6.1.4.1.19376.1.5.3.1.3.34 |
Conformance
CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below.
<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4'/> <id root=' ' extension=' '/> <code code='X-EDPHYSNT' displayName='ED Physician Note' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>ED Physician Note</title> <effectiveTime value='20240423012005'/> <confidentialityCode code='N' displayName='Normal' codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' /> <languageCode code='en-US'/> : <component><structuredBody> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3'/> <!-- Required Referral Source Section content --> </section> </component> |
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4'> <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4"]'> <!-- Verify that the template id is used on the appropriate type of object --> <assert test='../cda:ClinicalDocument'> Error: The ED Physician Note can only be used on Clinical Documents. </assert> <!-- Verify the document type code --> <assert test='cda:code[@code = "X-EDPHYSNT"]'> Error: The document type code of a ED Physician Note must be X-EDPHYSNT </assert> <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> Error: The document type code must come from the LOINC code system (2.16.840.1.113883.6.1). </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Referral Source Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </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 ED Physician Note Document must contain a(n) Mode of Arrival Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Chief Complaint Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) History of Present Illness Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> <!-- Alert on any missing required if known elements --> Warning: The ED Physician Note Document should contain a(n) Active Problems Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> <!-- Alert on any missing required if known elements --> Warning: The ED Physician Note Document should contain a(n) Resolved Problems Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Current Medications Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Allergies Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) List of Surgeries Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Immunizations Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Family History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Social History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> <!-- Alert on any missing required if known elements --> Warning: The ED Physician Note Document should contain a(n) History of Pregnancies Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Pertinent ROS Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Vital Signs Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Physical Examination Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Plan of Care Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.21"]'> <!-- Alert on any missing required if known elements --> Warning: The ED Physician Note Document should contain a(n) Medications Administered Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6"]'> <!-- Alert on any missing required if known elements --> Warning: The ED Physician Note Document should contain a(n) IV Fluids Administered Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </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 ED Physician Note Document must contain a(n) Procedures Performed Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.27"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Test Results: Lab, ECG, Radiology Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Consultations Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Progress Note Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) ED Diagnoses Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = " "]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) ED Disposition Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = " "]'> <!-- Manually verify condtional elements --> Manual: This ED Physician Note Document does not contain a(n) (Admission) Inpatient Facility Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = " "]'> <!-- Manually verify condtional elements --> Manual: This ED Physician Note Document does not contain a(n) (Admission) Inpatient Practitioner Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = " "]'> <!-- Manually verify condtional elements --> Manual: This ED Physician Note Document does not contain a(n) (Discharge) Discharge Medications Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = " "]'> <!-- Manually verify condtional elements --> Manual: This ED Physician Note Document does not contain a(n) (Discharge) Discharge Instructions Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = " "]'> <!-- Manually verify condtional elements --> Manual: This ED Physician Note Document does not contain a(n) (Discharge) Referral at ED Disposition Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = " "]'> <!-- Manually verify condtional elements --> Manual: This ED Physician Note Document does not contain a(n) (Discharge) ED Referral Practitioner Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = " "]'> <!-- Manually verify condtional elements --> Manual: This ED Physician Note Document does not contain a(n) (Transfer) Facility Receiving ED Patient Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = " "]'> <!-- Manually verify condtional elements --> Manual: This ED Physician Note Document does not contain a(n) (Transfer) Accepting Practitioner Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> <!-- Verify that all required data elements are present --> Error: The ED Physician Note Document must contain a(n) Advanced Directives Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 </assert> </rule> </pattern>
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