Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.19.1"
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|LOINC=X-EMS|LOINCName=EMS Report | |LOINC=X-EMS|LOINCName=EMS Report | ||
|Explain rationale for mapping to DEEDS is to show progression of information from NEMSIS to ED | |Explain rationale for mapping to DEEDS is to show progression of information from NEMSIS to ED | ||
+ | {{Note|Either the Injury Incident Description or the History of Present Illness section shall be present. Both are permitted to be present. A content creator must demonstrate the ability to complete both, though not necessarily in the same report.|Note 1}} | ||
+ | {{Note|The content creator must demonstrate the ability to complete these sections. If no data is available, the recommended behavior is to send indication that the data is not known, but this is not required.|Note 2}} | ||
|Index= | |Index= | ||
{{T|Data Element|LOINC|DEEDS|NEMSIS|Title=Prehospital Patient Care Report|Rows= | {{T|Data Element|LOINC|DEEDS|NEMSIS|Title=Prehospital Patient Care Report|Rows= | ||
{{R|Chief Complaint|10154-3 CHIEF COMPLAINT|4.06 Chief Complaint|E09_05 Chief Complaint}} | {{R|Chief Complaint|10154-3 CHIEF COMPLAINT|4.06 Chief Complaint|E09_05 Chief Complaint}} | ||
+ | {{R|Injury Incident Description|11374-6 INJURY INCIDENT DESCRIPTION|???|???}} | ||
{{R|History of Present Illness|10164-2 HISTORY OF PRESENT ILLNESS|5.15 ED Clinical Finding|}} | {{R|History of Present Illness|10164-2 HISTORY OF PRESENT ILLNESS|5.15 ED Clinical Finding|}} | ||
{{R|Acuity Assessment|11283-9 ACUITY ASSESSMENT|4.08 First ED Acuity Assessment}} | {{R|Acuity Assessment|11283-9 ACUITY ASSESSMENT|4.08 First ED Acuity Assessment}} | ||
Line 34: | Line 37: | ||
}} | }} | ||
|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| | ||
− | |Section|History of Present Illness| | + | |Section|Injury Incident Description|C|1.3.6.1.4.1.19376.1.5.3.1.1.19.2.1|See note 1 |
+ | |Section|History of Present Illness|C|1.3.6.1.4.1.19376.1.5.3.1.3.4|See note 1 | ||
|Section|Acuity Assessment|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2| | |Section|Acuity Assessment|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2| | ||
− | |Section|Active Problems| | + | |Section|Active Problems|C|1.3.6.1.4.1.19376.1.5.3.1.3.6|See note 2 |
− | |Section|Current Medications| | + | |Section|Current Medications|C|1.3.6.1.4.1.19376.1.5.3.1.3.19|See note 2 |
− | |Section|Allergies| | + | |Section|Allergies|C|1.3.6.1.4.1.19376.1.5.3.1.3.13|See note 2 |
|Section|Immunizations|O|1.3.6.1.4.1.19376.1.5.3.1.3.23| | |Section|Immunizations|O|1.3.6.1.4.1.19376.1.5.3.1.3.23| | ||
− | |Section|Past Medical History| | + | |Section|Past Medical History|C|1.3.6.1.4.1.19376.1.5.3.1.3.8|See note 2 |
− | |Section|History of Pregnancies| | + | |Section|History of Pregnancies|C|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4|See note 2 |
− | |Section|Advanced Directives| | + | |Section|Advanced Directives|C|1.3.6.1.4.1.19376.1.5.3.1.3.34|See note 2 |
− | |Section|Family History| | + | |Section|Family History|O|1.3.6.1.4.1.19376.1.5.3.1.3.14| |
− | |Section|Social History| | + | |Section|Social History|O|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|Vital Signs|R|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2| | ||
− | |Section|Pertinent ROS| | + | |Section|Pertinent ROS|C|1.3.6.1.4.1.19376.1.5.3.1.3.18|See note 2 |
− | |Section|Physical Examination| | + | |Section|Physical Examination|C|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|See note 2 |
|Section|Assessement|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4| | |Section|Assessement|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4| | ||
− | |Section|Intravenous Fluids Administered| | + | |Section|Intravenous Fluids Administered|C|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6|See note 2 |
− | |Section|Medications Administered| | + | |Section|Medications Administered|C|1.3.6.1.4.1.19376.1.5.3.1.3.21|See note 2 |
− | |Section|Procedures Performed| | + | |Section|Procedures Performed|C|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11|See note 2 |
|Section|Transport Mode|R|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2| | |Section|Transport Mode|R|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2| | ||
}} | }} |
Revision as of 02:43, 5 May 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
Prehospital Patient Care Report Specification 1.3.6.1.4.1.19376.1.5.3.1.1.19.1
Explain rationale for mapping to DEEDS is to show progression of information from NEMSIS to ED
Note 1 | Either the Injury Incident Description or the History of Present Illness section shall be present. Both are permitted to be present. A content creator must demonstrate the ability to complete both, though not necessarily in the same report. |
Note 2 | The content creator must demonstrate the ability to complete these sections. If no data is available, the recommended behavior is to send indication that the data is not known, but this is not required. |
LOINC Code
The LOINC code for this document is X-EMS EMS Report
Standards
Data Element Index
Data Element | LOINC | DEEDS | NEMSIS |
---|---|---|---|
Chief Complaint | 10154-3 CHIEF COMPLAINT | 4.06 Chief Complaint | E09_05 Chief Complaint |
Injury Incident Description | 11374-6 INJURY INCIDENT DESCRIPTION | ??? | ??? |
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 | E12_10 Medical/Surgical History |
Current Medications | 10160-0 CURRENT MEDICATIONS | 5.09 Current Therapeutic Medication | E12_14 Current Medications |
Allergies | 48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS | 5.15 ED Clinical Finding | E12_08 Medication Allergies, E12_09 Environmental/Food Allergies |
Immunizations | 11369-6 HISTORY OF IMMUNIZATIONS | 5.15 ED Clinical Finding | E12_12 Immunization History |
History of Past Illness | 11348-0 HISTORY OF PAST ILLNESS | 5.15 ED Clinical Finding | E12_10 Medical/Surgical History |
History of Pregnancies | 10162-6 HISTORY OF PREGNANCIES | 5.15 ED Clinical Finding | E12_20 Pregnancy |
Advance Directives | 42348-3 ADVANCE DIRECTIVES | 5.15 ED Clinical Finding | E12_07 Advanced Directives |
Family History | 10157-6 HISTORY OF FAMILY MEMBER DISEASES | 5.15 ED Clinical Finding | E12_10 Medical/Surgical History |
Social History | 29762-2 SOCIAL HISTORY | 5.15 ED Clinical Finding | E12_10 Medical/Surgical History |
Vital Signs | 8716-3 VITAL SIGNS | 5.15 ED Clinical Finding | E14 Assessment/ Vital Signs |
Pertinent ROS | 10187-3 REVIEW OF SYSTEMS | 5.15 ED Clinical Finding | E09_13 Primary Symptom |
Physical Examination | 29545-1 PHYSICAL EXAMINATION | 5.15 ED Clinical Finding | E16 Assessment/ Exam |
Assessment | X-ASSESS ASSESSMENTS | 8.30 Patient Problem Assessed | E09_15 Providers Primary Impression |
Intravenous Fluids Administered | X-IVFLU INTRAVENOUS FLUID ADMINISTERED | 6.02 ED Procedure | |
Medications Administered | 18610-6 MEDICATION ADMINISTERED (COMPOSITE) | 7.04 ED Medication | E18_03 Medication Given |
Procedures Performed | X-PROC PROCEDURES PERFORMED | 6.02 ED Procedure | E19_03 Procedure |
Transport Mode | 11459-5 TRANSPORT MODE | 4.02 Mode of Transport | E20 Disposition |
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 |
Injury Incident Description See note 1 |
C | 1.3.6.1.4.1.19376.1.5.3.1.1.19.2.1 |
History of Present Illness See note 1 |
C | 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 See note 2 |
C | 1.3.6.1.4.1.19376.1.5.3.1.3.6 |
Current Medications See note 2 |
C | 1.3.6.1.4.1.19376.1.5.3.1.3.19 |
Allergies See note 2 |
C | 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 See note 2 |
C | 1.3.6.1.4.1.19376.1.5.3.1.3.8 |
History of Pregnancies See note 2 |
C | 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 |
Advanced Directives See note 2 |
C | 1.3.6.1.4.1.19376.1.5.3.1.3.34 |
Family History | O | 1.3.6.1.4.1.19376.1.5.3.1.3.14 |
Social History | O | 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 See note 2 |
C | 1.3.6.1.4.1.19376.1.5.3.1.3.18 |
Physical Examination See note 2 |
C | 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 See note 2 |
C | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6 |
Medications Administered See note 2 |
C | 1.3.6.1.4.1.19376.1.5.3.1.3.21 |
Procedures Performed See note 2 |
C | 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.
<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='X-EMS' displayName='EMS Report' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Prehospital Patient Care Report</title> <effectiveTime value='20240328012005'/> <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> |
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 = "X-EMS"]'> Error: The document type code of a Prehospital Patient Care Report must be X-EMS </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.19.2.1"]'> <!-- Manually verify condtional elements --> Manual: This Prehospital Patient Care Report Document does not contain a(n) Injury Incident Description 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"]'> <!-- Manually verify condtional elements --> Manual: This Prehospital Patient Care Report Document does not 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"]'> <!-- Manually verify condtional elements --> Manual: This Prehospital Patient Care Report Document does not 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"]'> <!-- Manually verify condtional elements --> Manual: This Prehospital Patient Care Report Document does not 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"]'> <!-- Manually verify condtional elements --> Manual: This Prehospital Patient Care Report Document does not 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"]'> <!-- Manually verify condtional elements --> Manual: This Prehospital Patient Care Report Document does not 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"]'> <!-- Manually verify condtional elements --> Manual: This Prehospital Patient Care Report Document does not 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"]'> <!-- Manually verify condtional elements --> Manual: This Prehospital Patient Care Report Document does not 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"]'> <!-- Note any missing optional elements --> Note: This Prehospital Patient Care Report Document does not 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"]'> <!-- Note any missing optional elements --> Note: This Prehospital Patient Care Report Document does not 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"]'> <!-- Manually verify condtional elements --> Manual: This Prehospital Patient Care Report Document does not 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"]'> <!-- Manually verify condtional elements --> Manual: This Prehospital Patient Care Report Document does not 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"]'> <!-- Manually verify condtional elements --> Manual: This Prehospital Patient Care Report Document does not 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"]'> <!-- Manually verify condtional elements --> Manual: This Prehospital Patient Care Report Document does not 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"]'> <!-- Manually verify condtional elements --> Manual: This Prehospital Patient Care Report Document does not 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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