Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.19.1"

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m (New page: {{CDA Document|Prehospital Patient Care Report|1.3.6.1.4.1.19376.1.5.3.1.1.19.1|Comment| Standards= {{Std|CDAR2}} {{Std|CCD}} {{Std|NEMCIS}} {{Std|DEEDS}} |LOINC=11369-6|LOINCName=HISTORY ...)
 
m
Line 9: Line 9:
 
|Index=
 
|Index=
 
{{T|Data Element|Description|Title=Immunization Detail Data Elements|Rows=
 
{{T|Data Element|Description|Title=Immunization Detail Data Elements|Rows=
−
{{R|Data Element Name|Descriptin}}
+
{{R|Chief Complaint|10154-3 CHIEF COMPLAINT}}
−
{{R|Authors and Informants|The source of the information must be able to be recorded, including information obtained from a patient, parent or guardian, another provider, immunization registry, et cetera.  Within the IHE PCC technical framework, all coded entries may include the author or informant that provided the information being recorded.}}
+
{{R|History of Present Illness|10164-2 HISTORY OF PRESENT ILLNESS}}
−
{{R|History of Past Illness|The history of past illnesses is where clinical diagnoses relevant.}}
+
{{R|Acuity Assessment|11283-9 ACUITY ASSESSMENT}}
−
{{R|Problem List|The problem list must be able to include problems that are relevant.}}
+
{{R|Active Problems|11450-4 PROBLEM LIST}}
−
{{R|Allergies and Intolerances|This information includes a list of allergies or intolerances.}}
+
{{R|Current Medications|10160-0 CURRENT MEDICATIONS}}
−
{{R|Medications|The list of medications should include the list of relevant medications for the patient.}}
+
{{R|Allergies|48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS}}
−
{{R|Vital Signs|Vital signs such as height and weight should be able to be reported to enable dosing calculations to be performed.  Other vital signs such as tempurature may be included to enable a clinical decision support to identify potential situations such as fever that may be a contraindication for immunization.}}
+
{{R|Immunizations|11369-6 HISTORY OF IMMUNIZATIONS}}
−
{{R|Pregnancy Observation|The pregnancy history section would include information relevant to the current pregnancy status for the patient.}}
+
{{R|Past Medical History|11348-0 HISTORY OF PAST ILLNESS}}
−
{{R|Advance Directive Observation|Advance directives.}}
+
{{R|History of Pregnancies|10162-6 HISTORY OF PREGNANCIES}}
−
{{R|Comments|Additional text comments should be supported in the content to enable providers to comment}}
+
{{R|Advance Directives|42348-3 ADVANCE DIRECTIVES}}
 +
{{R|Family History|10157-6 HISTORY OF FAMILY MEMBER DISEASES}}
 +
{{R|Social History|29762-2 SOCIAL HISTORY}}
 +
{{R|Vital Signs|8716-3 VITAL SIGNS}}
 +
{{R|Pertinent ROS|10187-3 REVIEW OF SYSTEMS}}
 +
{{R|Physical Examination|29545-1 PHYSICAL EXAMINATION}}
 +
{{R|Assessment|X-ASSESS ASSESSMENTS}}
 +
{{R|Intravenous Fluids Administered|X-IVFLU INTRAVENOUS FLUID ADMINISTERED}}
 +
{{R|Medications Administered|18610-6 MEDICATION ADMINISTERED (COMPOSITE)}}
 +
{{R|Procedures Performed|X-PROC PROCEDURES PERFORMED}}
 +
{{R|Transport Mode|11459-5 TRANSPORT MODE}}
 
}}
 
}}
−
|Section|Problem List|R2|1.3.6.1.4.1.19376.1.5.3.1.3.6|
+
|Section|Chief Complaint|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1|
−
|Section|History of Past Illness|R2|1.3.6.1.4.1.19376.1.5.3.1.3.8|
+
|Section|History of Present Illness|R|1.3.6.1.4.1.19376.1.5.3.1.3.4|
−
|Section|Allergies and Intolerances|R2|1.3.6.1.4.1.19376.1.5.3.1.3.13|
+
|Section|Acuity Assessment|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2|
−
|Section|Medications|R2|1.3.6.1.4.1.19376.1.5.3.1.3.19|
+
|Section|Active Problems|R2|1.3.6.1.4.1.19376.1.5.3.1.3.6|
−
|Section|Coded Vital Signs|R2|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2|
+
|Section|Current Medications|R2|1.3.6.1.4.1.19376.1.5.3.1.3.19|
−
|Section|Pregnancy History|R2|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4|When present, the pregnancy history section shall contain a {{ILink|1.3.6.1.4.1.19376.1.5.3.1.4.13.5|Pregnancy Observation}} using the 11449-6 PREGNANCY STATUS code from LOINC to indicate whether the patient is pregnant.
+
|Section|Allergies|R2|1.3.6.1.4.1.19376.1.5.3.1.3.13|
−
|Section|Coded Advance Directives|R2|1.3.6.1.4.1.19376.1.5.3.1.3.35|
+
|Section|Immunizations|O|1.3.6.1.4.1.19376.1.5.3.1.3.23|
 +
|Section|Past Medical History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.8|
 +
|Section|History of Pregnancies|R2|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4|
 +
|Section|Advanced Directives|R2|1.3.6.1.4.1.19376.1.5.3.1.3.34|
 +
|Section|Family History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.14|
 +
|Section|Social History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.16|
 +
|Section|Vital Signs|R|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2|
 +
|Section|Pertinent ROS|R2|1.3.6.1.4.1.19376.1.5.3.1.3.18|
 +
|Section|Physical Examination|R2|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|
 +
|Section|Assessement|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4|
 +
|Section|Intravenous Fluids Administered|R2|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6|
 +
|Section|Medications Administered|R2|1.3.6.1.4.1.19376.1.5.3.1.3.21|
 +
|Section|Procedures Performed|R2|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11|
 +
|Section|Transport Mode|R|.3.6.1.4.1.19376.1.5.3.1.1.10.3.2|
 
}}
 
}}

Revision as of 13:44, 10 April 2009

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 Prehospital Patient Care Report Specification 1.3.6.1.4.1.19376.1.5.3.1.1.19.1

Description



LOINC Code

The LOINC code for this document is 11369-6 HISTORY OF IMMUNIZATIONS

Standards
CDAR2 HL7 CDA Release 2.0
CCD ASTM/HL7 Continuity of Care Document
NEMCIS [ ]
DEEDS [ ]
Data Element Index
Data Element Description
Chief Complaint 10154-3 CHIEF COMPLAINT
History of Present Illness 10164-2 HISTORY OF PRESENT ILLNESS
Acuity Assessment 11283-9 ACUITY ASSESSMENT
Active Problems 11450-4 PROBLEM LIST
Current Medications 10160-0 CURRENT MEDICATIONS
Allergies 48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS
Immunizations 11369-6 HISTORY OF IMMUNIZATIONS
Past Medical History 11348-0 HISTORY OF PAST ILLNESS
History of Pregnancies 10162-6 HISTORY OF PREGNANCIES
Advance Directives 42348-3 ADVANCE DIRECTIVES
Family History 10157-6 HISTORY OF FAMILY MEMBER DISEASES
Social History 29762-2 SOCIAL HISTORY
Vital Signs 8716-3 VITAL SIGNS
Pertinent ROS 10187-3 REVIEW OF SYSTEMS
Physical Examination 29545-1 PHYSICAL EXAMINATION
Assessment X-ASSESS ASSESSMENTS
Intravenous Fluids Administered X-IVFLU INTRAVENOUS FLUID ADMINISTERED
Medications Administered 18610-6 MEDICATION ADMINISTERED (COMPOSITE)
Procedures Performed X-PROC PROCEDURES PERFORMED
Transport Mode 11459-5 TRANSPORT MODE
Specification
Data Element Name Opt Template ID
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
Acuity Assessment R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2
Active Problems R2 1.3.6.1.4.1.19376.1.5.3.1.3.6
Current Medications R2 1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies R2 1.3.6.1.4.1.19376.1.5.3.1.3.13
Immunizations O 1.3.6.1.4.1.19376.1.5.3.1.3.23
Past Medical History R2 1.3.6.1.4.1.19376.1.5.3.1.3.8
History of Pregnancies R2 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Advanced Directives R2 1.3.6.1.4.1.19376.1.5.3.1.3.34
Family History R2 1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History R2 1.3.6.1.4.1.19376.1.5.3.1.3.16
Vital Signs R 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Pertinent ROS R2 1.3.6.1.4.1.19376.1.5.3.1.3.18
Physical Examination R2 1.3.6.1.4.1.19376.1.5.3.1.1.9.15
Assessement R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
Intravenous Fluids Administered R2 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
Medications Administered R2 1.3.6.1.4.1.19376.1.5.3.1.3.21
Procedures Performed R2 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11
Transport Mode R .3.6.1.4.1.19376.1.5.3.1.1.10.3.2


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 Prehospital Patient Care Report Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.19.1'/>
  <id root=' ' extension=' '/>
  <code code='11369-6' displayName='HISTORY OF IMMUNIZATIONS'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Prehospital Patient Care Report</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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/>
        <!-- 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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2'/>
        <!-- Required Acuity Assessment 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='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required if known Current Medications Section content -->
      </section>
    </component>

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

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required if known Past Medical 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='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required if known Advanced Directives Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/>
        <!-- Required if known Social History 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='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Required if known Pertinent ROS Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'/>
        <!-- Required Assessement 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 Intravenous Fluids Administered 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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'/>
        <!-- Required if known Procedures Performed Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/>
        <!-- Required Transport Mode Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.19.1'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.19.1"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Prehospital Patient Care Report can only be used on Clinical Documents.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "11369-6"]'>
     Error: The document type code of a Prehospital Patient Care Report must be 11369-6
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Prehospital Patient Care Report Document must contain a(n) Chief Complaint Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </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 Prehospital Patient Care Report Document must contain a(n) History of Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Prehospital Patient Care Report Document must contain a(n) Acuity Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </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  Prehospital Patient Care Report Document should contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Prehospital Patient Care Report Document should contain a(n) Current Medications Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Prehospital Patient Care Report Document should contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Note any missing optional elements -->
     Note: This Prehospital Patient Care Report Document does not contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </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  Prehospital Patient Care Report Document should contain a(n) Past Medical History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </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  Prehospital Patient Care Report Document should contain a(n) History of Pregnancies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Prehospital Patient Care Report Document should contain a(n) Advanced Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Prehospital Patient Care Report Document should contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Prehospital Patient Care Report Document should contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </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 Prehospital Patient Care Report Document must contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Prehospital Patient Care Report Document should contain a(n) Pertinent ROS Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Prehospital Patient Care Report Document should contain a(n) Physical Examination Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Prehospital Patient Care Report Document must contain a(n) Assessement Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </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  Prehospital Patient Care Report Document should contain a(n) Intravenous Fluids Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </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  Prehospital Patient Care Report Document should contain a(n) Medications Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Prehospital Patient Care Report Document should contain a(n) Procedures Performed Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
   <assert test='.//cda:templateId[@root = ".3.6.1.4.1.19376.1.5.3.1.1.10.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Prehospital Patient Care Report Document must contain a(n) Transport Mode Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.19.1
   </assert> 
 </rule>
</pattern>
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