1.3.6.1.4.1.19376.1.5.3.1.1.19.1
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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
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 |
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.
<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='20240329012005'/> <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 = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> <!-- 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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