1.3.6.1.4.1.19376.1.5.3.1.1.19.1

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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 NEMSIS
Chief Complaint 10154-3 CHIEF COMPLAINT 4.06 Chief Complaint E09_05 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 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
Past Medical History 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
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='20240416012005'/>
  <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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