Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4"

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Revision as of 20:34, 4 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

Comment.gif 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
Advanced Directives 42348-3 ADVANCE DIRECTIVES
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
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
Advanced Directives R 1.3.6.1.4.1.19376.1.5.3.1.3.34
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 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10


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.

Sample ED Physician Note Document 
<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='20240419012005'/>
  <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>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/>
        <!-- Required Mode of Arrival Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/>
        <!-- Required Chief Complaint Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Required History of Present Illness Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required Advanced Directives Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required if known Active Problems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required if known Resolved Problems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Current Medications Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
        <!-- Required Allergies Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
        <!-- Required List of Surgeries Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
        <!-- Required Immunizations Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/>
        <!-- Required Family History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/>
        <!-- Required Social History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/>
        <!-- Required if known History of Pregnancies Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Required Pertinent ROS Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
        <!-- Required Vital Signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/>
        <!-- Required Physical Examination Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
        <!-- Required Plan of Care Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/>
        <!-- Required if known Medications Administered Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6'/>
        <!-- Required if known IV Fluids Administered Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
        <!-- Required Procedures Performed Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.27'/>
        <!-- Required Test Results: Lab, ECG, Radiology Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8'/>
        <!-- Required Consultations Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7'/>
        <!-- Required Progress Note Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9'/>
        <!-- Required ED Diagnoses Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'/>
        <!-- Required ED Disposition Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>
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 = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- 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> 
   <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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10"]'> 
     <!-- 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> 
 </rule>
</pattern>

Sections

1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3
1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
1.3.6.1.4.1.19376.1.5.3.1.3.4
1.3.6.1.4.1.19376.1.5.3.1.3.34
1.3.6.1.4.1.19376.1.5.3.1.3.6
1.3.6.1.4.1.19376.1.5.3.1.3.8
1.3.6.1.4.1.19376.1.5.3.1.3.19
1.3.6.1.4.1.19376.1.5.3.1.3.13
1.3.6.1.4.1.19376.1.5.3.1.3.11
1.3.6.1.4.1.19376.1.5.3.1.3.23
1.3.6.1.4.1.19376.1.5.3.1.3.14
1.3.6.1.4.1.19376.1.5.3.1.3.16
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
1.3.6.1.4.1.19376.1.5.3.1.3.18
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
1.3.6.1.4.1.19376.1.5.3.1.1.9.15
1.3.6.1.4.1.19376.1.5.3.1.3.31
1.3.6.1.4.1.19376.1.5.3.1.3.21
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
1.3.6.1.4.1.19376.1.5.3.1.4.19
1.3.6.1.4.1.19376.1.5.3.1.3.27
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10

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