1.3.6.1.4.1.19376.1.5.3.1.1.19.1

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

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
Data Element Name	Descriptin
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.
History of Past Illness	The history of past illnesses is where clinical diagnoses relevant.
Problem List	The problem list must be able to include problems that are relevant.
Allergies and Intolerances	This information includes a list of allergies or intolerances.
Medications	The list of medications should include the list of relevant medications for the patient.
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.
Pregnancy Observation	The pregnancy history section would include information relevant to the current pregnancy status for the patient.
Advance Directive Observation	Advance directives.
Comments	Additional text comments should be supported in the content to enable providers to comment

Specification

Data Element Name	Opt	Template ID
Problem List	R2	1.3.6.1.4.1.19376.1.5.3.1.3.6
History of Past Illness	R2	1.3.6.1.4.1.19376.1.5.3.1.3.8
Allergies and Intolerances	R2	1.3.6.1.4.1.19376.1.5.3.1.3.13
Medications	R2	1.3.6.1.4.1.19376.1.5.3.1.3.19
Coded Vital Signs	R2	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Pregnancy History When present, the pregnancy history section shall contain a Pregnancy Observation using the 11449-6 PREGNANCY STATUS code from LOINC to indicate whether the patient is pregnant.	R2	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Coded Advance Directives	R2	1.3.6.1.4.1.19376.1.5.3.1.3.35

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='20240425012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required if known Problem List Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required if known History of Past Illness 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 and Intolerances Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
        <!-- Required if known Coded Vital Signs 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 Pregnancy History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.35'/>
        <!-- Required if known Coded Advance Directives 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 = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Prehospital Patient Care Report Document should contain a(n) Problem List 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) History of Past 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 = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Prehospital Patient Care Report Document should contain a(n) Allergies and Intolerances 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) 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 = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Prehospital Patient Care Report Document should contain a(n) Coded 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 = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Prehospital Patient Care Report Document should contain a(n) Pregnancy 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 = "1.3.6.1.4.1.19376.1.5.3.1.3.35"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Prehospital Patient Care Report Document should contain a(n) Coded Advance 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> 
 </rule>
</pattern>