Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.19.1"

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|Description
 
|Description
 
|Index=
 
|Index=
−
{{T|Data Element|Description|Title=Immunization Detail Data Elements|Rows=
+
{{T|Data Element|LOINC|DEEDS|Title=Immunization Detail Data Elements|Rows=
−
{{R|Chief Complaint|10154-3 CHIEF COMPLAINT}}
+
{{R|Chief Complaint|10154-3 CHIEF COMPLAINT|4.06 Chief Complaint}}
−
{{R|History of Present Illness|10164-2 HISTORY OF PRESENT ILLNESS}}
+
{{R|History of Present Illness|10164-2 HISTORY OF PRESENT ILLNESS|5.15 ED Clinical Finding}}
−
{{R|Acuity Assessment|11283-9 ACUITY ASSESSMENT}}
+
{{R|Acuity Assessment|11283-9 ACUITY ASSESSMENT|4.08 First ED Acuity Assessment}}
−
{{R|Active Problems|11450-4 PROBLEM LIST}}
+
{{R|Active Problems|11450-4 PROBLEM LIST|5.15 ED Clinical Finding}}
−
{{R|Current Medications|10160-0 CURRENT MEDICATIONS}}
+
{{R|Current Medications|10160-0 CURRENT MEDICATIONS|5.09 Current Therapeutic Medication}}
−
{{R|Allergies|48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS}}
+
{{R|Allergies|48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS|5.15 ED Clinical Finding}}
−
{{R|Immunizations|11369-6 HISTORY OF IMMUNIZATIONS}}
+
{{R|Immunizations|11369-6 HISTORY OF IMMUNIZATIONS|5.15 ED Clinical Finding}}
−
{{R|Past Medical History|11348-0 HISTORY OF PAST ILLNESS}}
+
{{R|Past Medical History|11348-0 HISTORY OF PAST ILLNESS|5.15 ED Clinical Finding}}
−
{{R|History of Pregnancies|10162-6 HISTORY OF PREGNANCIES}}
+
{{R|History of Pregnancies|10162-6 HISTORY OF PREGNANCIES|5.15 ED Clinical Finding}}
−
{{R|Advance Directives|42348-3 ADVANCE DIRECTIVES}}
+
{{R|Advance Directives|42348-3 ADVANCE DIRECTIVES|5.15 ED Clinical Finding}}
−
{{R|Family History|10157-6 HISTORY OF FAMILY MEMBER DISEASES}}
+
{{R|Family History|10157-6 HISTORY OF FAMILY MEMBER DISEASES|5.15 ED Clinical Finding}}
−
{{R|Social History|29762-2 SOCIAL HISTORY}}
+
{{R|Social History|29762-2 SOCIAL HISTORY|5.15 ED Clinical Finding}}
−
{{R|Vital Signs|8716-3 VITAL SIGNS}}
+
{{R|Vital Signs|8716-3 VITAL SIGNS|5.15 ED Clinical Finding}}
−
{{R|Pertinent ROS|10187-3 REVIEW OF SYSTEMS}}
+
{{R|Pertinent ROS|10187-3 REVIEW OF SYSTEMS|5.15 ED Clinical Finding}}
−
{{R|Physical Examination|29545-1 PHYSICAL EXAMINATION}}
+
{{R|Physical Examination|29545-1 PHYSICAL EXAMINATION|5.15 ED Clinical Finding}}
−
{{R|Assessment|X-ASSESS ASSESSMENTS}}
+
{{R|Assessment|X-ASSESS ASSESSMENTS|8.30 Patient Problem Assessed}}
−
{{R|Intravenous Fluids Administered|X-IVFLU INTRAVENOUS FLUID ADMINISTERED}}
+
{{R|Intravenous Fluids Administered|X-IVFLU INTRAVENOUS FLUID ADMINISTERED|6.02 ED Procedure}}
−
{{R|Medications Administered|18610-6 MEDICATION ADMINISTERED (COMPOSITE)}}
+
{{R|Medications Administered|18610-6 MEDICATION ADMINISTERED (COMPOSITE)|7.04 ED Medication}}
−
{{R|Procedures Performed|X-PROC PROCEDURES PERFORMED}}
+
{{R|Procedures Performed|X-PROC PROCEDURES PERFORMED|6.02 ED Procedure}}
−
{{R|Transport Mode|11459-5 TRANSPORT MODE}}
+
{{R|Transport Mode|11459-5 TRANSPORT MODE|4.02 Mode of Transport}}
 
}}
 
}}
 
|Section|Chief Complaint|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1|
 
|Section|Chief Complaint|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1|

Revision as of 14:03, 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 LOINC DEEDS
Chief Complaint 10154-3 CHIEF COMPLAINT 4.06 Chief Complaint
History of Present Illness 10164-2 HISTORY OF PRESENT ILLNESS 5.15 ED Clinical Finding
Acuity Assessment 11283-9 ACUITY ASSESSMENT 4.08 First ED Acuity Assessment
Active Problems 11450-4 PROBLEM LIST 5.15 ED Clinical Finding
Current Medications 10160-0 CURRENT MEDICATIONS 5.09 Current Therapeutic Medication
Allergies 48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS 5.15 ED Clinical Finding
Immunizations 11369-6 HISTORY OF IMMUNIZATIONS 5.15 ED Clinical Finding
Past Medical History 11348-0 HISTORY OF PAST ILLNESS 5.15 ED Clinical Finding
History of Pregnancies 10162-6 HISTORY OF PREGNANCIES 5.15 ED Clinical Finding
Advance Directives 42348-3 ADVANCE DIRECTIVES 5.15 ED Clinical Finding
Family History 10157-6 HISTORY OF FAMILY MEMBER DISEASES 5.15 ED Clinical Finding
Social History 29762-2 SOCIAL HISTORY 5.15 ED Clinical Finding
Vital Signs 8716-3 VITAL SIGNS 5.15 ED Clinical Finding
Pertinent ROS 10187-3 REVIEW OF SYSTEMS 5.15 ED Clinical Finding
Physical Examination 29545-1 PHYSICAL EXAMINATION 5.15 ED Clinical Finding
Assessment X-ASSESS ASSESSMENTS 8.30 Patient Problem Assessed
Intravenous Fluids Administered X-IVFLU INTRAVENOUS FLUID ADMINISTERED 6.02 ED Procedure
Medications Administered 18610-6 MEDICATION ADMINISTERED (COMPOSITE) 7.04 ED Medication
Procedures Performed X-PROC PROCEDURES PERFORMED 6.02 ED Procedure
Transport Mode 11459-5 TRANSPORT MODE 4.02 Mode of Transport
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 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2


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='20240420012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/>
        <!-- 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 = "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 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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