Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.5"

Latest revision as of 14:03, 2 October 2008

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

PHR Extract Specification 1.3.6.1.4.1.19376.1.5.3.1.1.5

The PHR Extract module describes the document content that summarizes information contained within a Personal Health Record. While a PHR can contain a great deal more information (including clinical documents, lab reported, images, trend data, monitoring data) et cetera, this content module only deals with the format of the summary information from the PHR.

An PHR Extract Module is a type of medical summary, and incorporates the constraints defined for Medical Summaries. While mappings have been provided to various standards, this content module conforms to the ASTM/HL7 Continuity of Care Document as well as this guide.

The following table describes the data elements that may be present in a PHR Extract. The first column of this table is drawn from the Common Data Elements in the PHR found in Appendix B of the AHIMA Report: The Role of the Personal Health Record in the EHR. Indented items in this column of the table provide more detail for the item they appear underneath.

These data elements were then mapped to the ASTM CCR, HL7 CDA, CRS and CCD and the implicit data elements referenced by the HL7 PHR Conformance Criteria.

A further requirement of transfers of information between PHR and EHR systems is that authorship of the information stored within the PHR shall be tracable through the various import/export cycles. PHR Manager Actors must be secure nodes, which requires logging of any updates to or accesses of PHR information. The DSG profile should be used to ensure that information coming into, or exiting these systems is verifiably authored.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:xphr:2007

Parent Template

This document is an instance of the Medical Summary template.

LOINC Code

The LOINC code for this document is 34133-9 Summary of Episode Note

Standards

AHIMA-PHR	AHIMA PHR Common Data Elements
CDAR2	HL7 CDA Release 2.0
CRS	HL7 Care Record Summary
CCD	ASTM/HL7 Continuity of Care Document
HL7-PHR	HL7 PHR Functional Model (Draft)
LOINC	Logical Observation Identifier Names and Codes

Data Element Index

AHIMA Common Data Elements	ASTM Continuity of Care Record	HL7 Clincial Document Architecture, Care Record Summary or Continuity of Care Document	HL7 PHR Conformance Criteria
Personal Information	Patient	patientRole	Demographic Information
Name	Patient	patient/name	Demographic Information
Address	Patient	patientRole/addr	Contact Information
Contact Information	Patient	patientRole/telecom	Contact Information
Personal Identification Information	Patient	patientRole/id	Demographic Information
Gender	Patient	patient/administrativeGenderCode	Demographic Information
Date of Birth	Patient	patient/birthTime	Demographic Information
Marital Status	Patient	patient/maritalStatusCode
Race	Patient	patient/raceCode
Ethnicity	Patient	patient/ethnicGroupCode	Demographic Information
(Religious Affiliation[1])	Patient	patient/religiousAffiliationCode	Spiritual Affiliation / Considerations
Languages Spoken	Patient	patient/languageCommunication
Employer and School Contacts	Social History
Hazardous Working Conditions	Social History	HISTORY OF OCCUPATIONAL EXPOSURE
Emergency Contacts	Support
Healthcare Providers	Practitioners	serviceEvent/performer	Healthcare Providers
Insurance Providers	Insurance	Health Insurance or Pharmacy Insurance
Pharamacy		performer
Legal Documents and Medical Directives	Advance Directives	ADVANCE DIRECTIVES	Advance Directive
General Medical Information Height, Weight	Vital Signs	VITAL SIGNS
Blood Type	Results	RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Last Physical or Checkup	Encounters	HISTORY OF OUTPATIENT VISITS	Clinical Encounters and Procedures List
Allergies and Drug Sensitivies	Alerts	HISTORY OF ALLERGIES	Allergy and Reaction List
Conditions	Problems	HISTORY OF PAST ILLNESS - or - PROBLEM LIST	Problem List
Surgeries	Procedures	HISTORY OF SURGICAL PROCEDURES	Clinical Encounters and Procedures List
Medications – Prescription and Non-Prescription	Medications	HISTORY OF MEDICATION USE	Medication List
Immunizations	Immunizations	HISTORY OF IMMUNIZATIONS	Immunizations List
Doctor Visits	Encounters	HISTORY OF OUTPATIENT VISITS	Clinical Encounters and Procedures List
Hospitalizations	Encounters	HISTORY OF HOSPITALIZATIONS	Clinical Encounters and Procedures List
Other Healthcare Visits	Encounters	HISTORY OF OUTPATIENT VISITS	Clinical Encounters and Procedures List
Clinical Tests	Results	RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA	Laboratory and Test Results
Pregnancies		HISTORY OF PREGNANCIES
Medical Devices	Medical Devices	HISTORY OF MEDICAL DEVICE USE
Family Member History	Family History	HISTORY OF FAMILY MEMBER DISEASES	Family History
Foreign Travel		HISTORY OF TRAVEL
Therapy	Plan of Care	TREATMENT PLAN	Care Plans, Goals and Disease Management
Vital Signs	Vital signs	VITAL SIGNS
(Functional Status[2])	Functional Status	FUNCTIONAL STATUS

Specification

Data Element Name	Opt	Template ID
Personal Information Name Address Contact Information Personal Identification Gender Date of Birth Thes components are required of all Medical Documents	R	1.3.6.1.4.1.19376.1.5.3.1.1.1
Personal Information Marital Status This commponent is optional in Medical Documents, but required if known in this specification.	R2	1.3.6.1.4.1.19376.1.5.3.1.1.1
Personal Information Race Ethnicity Religious Affiliation [2] These components are optional in Medical Documents	O	1.3.6.1.4.1.19376.1.5.3.1.1.1
Languages Spoken	R2	1.3.6.1.4.1.19376.1.5.3.1.2.1
Employer and School Contacts	O	1.3.6.1.4.1.19376.1.5.3.1.2.2
Hazardous Working Conditions	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1
Patient Contacts	R2	1.3.6.1.4.1.19376.1.5.3.1.2.4
Healthcare Providers	R	1.3.6.1.4.1.19376.1.5.3.1.2.3
Insurance Providers	R2	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7
Pharamacy	R2	1.3.6.1.4.1.19376.1.5.3.1.2.3
Legal Documents and Medical Directives	R2	1.3.6.1.4.1.19376.1.5.3.1.3.34
Allergies and Drug Sensitivities	R	1.3.6.1.4.1.19376.1.5.3.1.3.13
Conditions	R	1.3.6.1.4.1.19376.1.5.3.1.3.8
Conditions (cont)	R	1.3.6.1.4.1.19376.1.5.3.1.3.6
Surgeries	R2	1.3.6.1.4.1.19376.1.5.3.1.3.12
Medications – Prescription and Non-Prescription	R	1.3.6.1.4.1.19376.1.5.3.1.3.19
Immunizations	R2	1.3.6.1.4.1.19376.1.5.3.1.3.23
Doctor Visits / Last Physical or Checkup	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
Hospitalizations	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
Other Healthcare Visits	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
Clinical Tests / Blood Type	O	1.3.6.1.4.1.19376.1.5.3.1.3.28
Pregnancies	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Medical Devices	R2	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5
Family Member History	O	1.3.6.1.4.1.19376.1.5.3.1.3.15
Foreign Travel	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6
Plan of Care	O	1.3.6.1.4.1.19376.1.5.3.1.3.31
Coded Vital signs	O	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Functional Status	O	1.3.6.1.4.1.19376.1.5.3.1.3.17

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. A CDA Document may conform to more than one template. This content module inherits from the Medical Summary content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample PHR Extract Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5'/>
  <id root=' ' extension=' '/>
  <code code='34133-9' displayName='Summary of Episode Note'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>PHR Extract</title>
  <effectiveTime value='20240419012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1'/>
        <!-- Optional Hazardous Working Conditions Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required if known Legal Documents and Medical Directives Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
        <!-- Required Allergies and Drug Sensitivities Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required Conditions Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required Conditions (cont) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.12'/>
        <!-- Required if known Surgeries Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Medications – Prescription and Non-Prescription Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
        <!-- Required if known Immunizations Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'/>
        <!-- Optional Doctor Visits / Last Physical or Checkup Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'/>
        <!-- Optional Hospitalizations Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'/>
        <!-- Optional Other Healthcare Visits Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.28'/>
        <!-- Optional Clinical Tests / Blood Type Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/>
        <!-- Optional Pregnancies Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5'/>
        <!-- Required if known Medical Devices Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.15'/>
        <!-- Optional Family Member History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6'/>
        <!-- Optional Foreign Travel Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
        <!-- Optional Plan of Care Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
        <!-- Optional Coded Vital signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/>
        <!-- Optional Functional Status Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.5'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.5"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The PHR Extract can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
     Error: The parent template identifier for PHR Extract is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "34133-9"]'>
     Error: The document type code of a PHR Extract must be 34133-9
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The PHR Extract Document must contain a(n) Personal Information Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.1"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Personal Information Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Personal Information Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.1"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Languages Spoken Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.2"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Employer and School Contacts Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Hazardous Working Conditions Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Patient Contacts Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The PHR Extract Document must contain a(n) Healthcare Providers Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Insurance Providers Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.3"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Pharamacy Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </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  PHR Extract Document should contain a(n) Legal Documents and Medical Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The PHR Extract Document must contain a(n) Allergies and Drug Sensitivities Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The PHR Extract Document must contain a(n) Conditions Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The PHR Extract Document must contain a(n) Conditions (cont) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.12"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The PHR Extract Document must contain a(n) Medications – Prescription and Non-Prescription Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Doctor Visits / Last Physical or Checkup Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Hospitalizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Other Healthcare Visits Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.28"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Clinical Tests / Blood Type Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Pregnancies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  PHR Extract Document should contain a(n) Medical Devices Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.15"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Family Member History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Foreign Travel Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Plan of Care Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Coded Vital signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.17"]'> 
     <!-- Note any missing optional elements -->
     Note: This PHR Extract Document does not contain a(n) Functional Status Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5
   </assert> 
 </rule>
</pattern>

Additional Constraints

The assignedAuthoring device shall be populated with information about the EHR and/or PHR which assisted in creation of the document.

All sections and entries within the document shall contain an <id> element.

@@ Line 1: / Line 1: @@
-{{CDA Document|PHR Extract|1.3.6.1.4.1.19376.1.5.3.1.1.5|Draft|
+{{CDA Document|PHR Extract|1.3.6.1.4.1.19376.1.5.3.1.1.5|Trial|formatCode=urn:ihe:pcc:xphr:2007|
 The PHR Extract module describes the document content that summarizes information contained within a Personal Health Record.  While a PHR can contain a great deal more information (including clinical documents, lab reported, images, trend data, monitoring data) et cetera, this content module only deals with the format of the summary information from the PHR.
-An PHR Extract Module is a type of medical summary, and incorporates the constraints defined for medical summaries found in PCC TF-2: 5.4.1.2 Medical Summary Content.  While mappings have been provided to various standards, this content module conforms to the ASTM/HL7 Continuity of Care Document as well as this guide.
+An PHR Extract Module is a type of medical summary, and incorporates the constraints defined for {{ILink|1.3.6.1.4.1.19376.1.5.3.1.1.5|1.3.6.1.4.1.19376.1.5.3.1.1.2|Medical Summaries}}.  While mappings have been provided to various standards, this content module conforms to the ASTM/HL7 Continuity of Care Document as well as this guide.
-CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <nowiki><</nowiki>templateId<nowiki>></nowiki> elements in the header of the document.  This is shown below:
-<pre>
-  <ClinicalDocument xmlns='urn:hl7-org:v3'>
-    <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
-      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.2"/>
-      <templateId root="2.16.840.1.113883.10.20.1"/><!—conformance to HL7 CCD -->
-      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.5"/>
-        :
-</pre>
-A CDA Document may conform to more than one template, and can therefore have more that one <templateId> element.  The <templateId> elements shown above must be present.
-Furthermore, a clinical document conforming to this guide must use the LOINC Code 34133-9 SUMMARIZATION OF EPISODE note as shown below.
-<pre>
-       :
-      <code code='34133-9' displayName='SUMMARIZATION OF EPISODE'
-        codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
-       :
-</pre>
 The following table describes the data elements that may be present in a PHR Extract.  The first column of this table is drawn from the Common Data Elements in the PHR found in Appendix B of the AHIMA Report: The Role of the Personal Health Record in the EHR.  Indented items in this column of the table provide more detail for the item they appear underneath.
@@ Line 30: / Line 10: @@
 A further requirement of transfers of information between PHR and EHR systems is that authorship of the information stored within the PHR shall be tracable through the various import/export cycles.  PHR Manager Actors must be secure nodes, which requires logging of any updates to or accesses of PHR information.
 The DSG profile should be used to ensure that information coming into, or exiting these systems is verifiably authored.
+|Parent=1.3.6.1.4.1.19376.1.5.3.1.1.2|ParentName=Medical Summary|CCD=2.16.840.1.113883.10.20.1
 |Standards=
-{{Std|AHIMA-PHR|AHIMA PHR Common Data Elements|}}
+{{Std|AHIMA-PHR|AHIMA PHR Common Data Elements|http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_027456.pdf}}
-{{Std|CDAR2|Clinical Document Architecture, Release 2.0, 2005, HL7}}
+{{Std|CDAR2}}
-{{Std|CRS|Implementation Guide for CDA Release 2 – Level 1 and 2 – Care Record Summary (US realm), 2006, HL7.}}
+{{Std|CRS}}
-{{Std|CCD|ASTM/HL7 Continuity of Care Document}}
+{{Std|CCD}}
-{{Std|HL7-PHR|HL7 PHR Functional Model (Draft)}}
+{{Std|HL7-PHR|HL7 PHR Functional Model (Draft)|http://www.hl7.org/documentcenter/ballots/2007NOV/downloads/EHR_PHRSFM_R1_D1_2007NOV.zip}}
 {{Std|LOINC|Logical Observation Identifier Names and Codes|http://www.loinc.org}}
 |Index={{T|AHIMA Common Data Elements|ASTM Continuity of Care Record|HL7 Clincial Document Architecture, Care Record Summary or Continuity of Care Document|HL7 PHR Conformance Criteria|
@@ Line 44: / Line 24: @@
 {{R|Contact Information|Patient|patientRole/telecom|Contact Information}}
 {{R|Personal Identification Information|Patient|patientRole/id|Demographic Information}}
-{{R|Gender|Patient|patient/genderCode|Demographic Information}}
+{{R|Gender|Patient|patient/administrativeGenderCode|Demographic Information}}
-{{R|Date of Birth|Patient|patient/dateOfBirth|Demographic Information}}
+{{R|Date of Birth|Patient|patient/birthTime|Demographic Information}}
-{{R|Marital Status|Patient|patient/martitalStatusCode|&nbsp;}}
+{{R|Marital Status|Patient|patient/maritalStatusCode|&nbsp;}}
 {{R|Race|Patient|patient/raceCode|&nbsp;}}
-{{R|Ethnicity|Patient|patient/ethnicityCode|Demographic Information}}
+{{R|Ethnicity|Patient|patient/ethnicGroupCode|Demographic Information}}
 {{R|(Religious Affiliation[1])|Patient|patient/religiousAffiliationCode|Spiritual Affiliation / Considerations}}
 {{R|Languages Spoken|Patient|patient/languageCommunication|&nbsp;}}
@@ Line 78: / Line 58: @@
 {{R|(Functional Status[2])|Functional Status|FUNCTIONAL STATUS|&nbsp;}}
 }}
-|Data=
+|LOINC=34133-9|LOINCName=Summary of Episode Note
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Personal Information|R|See Personal Information}}
+|Entry|Personal Information|R|1.3.6.1.4.1.19376.1.5.3.1.1.1|&nbsp;
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Name|R|See Personal Information}}
+:Name
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Address|R2|See Personal Information}}
+:Address
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Contact Information|R2|See Personal Information}}
+:Contact Information
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Personal Identification Information|R2|See Personal Information}}
+:Personal Identification
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Gender|R|See Personal Information}}
+:Gender
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Date of Birth|R2|See Personal Information}}
+:Date of Birth<br/>
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Marital Status|R2|See Personal Information}}
+Thes components are required of all {{ILink|1.3.6.1.4.1.19376.1.5.3.1.1.5|1.3.6.1.4.1.19376.1.5.3.1.1.1|Medical Documents}}
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Race|O|See Personal Information}}
+|Entry|Personal Information|R2|1.3.6.1.4.1.19376.1.5.3.1.1.1|&nbsp;
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Ethnicity|O|See Personal Information}}
+:Marital Status<br/>
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|(Religious Affiliation[2])|O|See Personal Information}}
+This commponent is optional in {{ILink|1.3.6.1.4.1.19376.1.5.3.1.1.5|1.3.6.1.4.1.19376.1.5.3.1.1.1|Medical Documents}}, but required if known in this specification.
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Languages Spoken|R2|1.3.6.1.4.1.19376.1.5.3.1.2.1}}
+|Entry|Personal Information|O|1.3.6.1.4.1.19376.1.5.3.1.1.1|&nbsp;
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Employer and School Contacts|O|1.3.6.1.4.1.19376.1.5.3.1.2.2}}
+:Race
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Hazardous Working Conditions|O|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1}}
+:Ethnicity
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Emergency Contacts|R2|1.3.6.1.4.1.19376.1.5.3.1.2.3.1}}
+:Religious Affiliation [2]<br/>
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Healthcare Providers|R|1.3.6.1.4.1.19376.1.5.3.1.2.3}}
+These components are optional in {{ILink|1.3.6.1.4.1.19376.1.5.3.1.1.5|1.3.6.1.4.1.19376.1.5.3.1.1.1|Medical Documents}}
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Insurance Providers|R2|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7}}
+|Entry|Languages Spoken|R2|1.3.6.1.4.1.19376.1.5.3.1.2.1|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Pharamacy|R2|1.3.6.1.4.1.19376.1.5.3.1.2.3}}
+|Entry|Employer and School Contacts|O|1.3.6.1.4.1.19376.1.5.3.1.2.2|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Legal Documents and Medical Directives|R2|1.3.6.1.4.1.19376.1.5.3.1.3.34}}
+|Section|Hazardous Working Conditions|O|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Allergies and Drug Sensitivities|R|1.3.6.1.4.1.19376.1.5.3.1.3.13}}
+|Entry|Patient Contacts|R2|1.3.6.1.4.1.19376.1.5.3.1.2.4|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Conditions|R|1.3.6.1.4.1.19376.1.5.3.1.3.8}}
+|Entry|Healthcare Providers|R|1.3.6.1.4.1.19376.1.5.3.1.2.3|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Conditions (cont)|R|1.3.6.1.4.1.19376.1.5.3.1.3.6}}
+|Entry|Insurance Providers|R2|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Surgeries|R2|1.3.6.1.4.1.19376.1.5.3.1.3.12}}
+|Entry|Pharamacy|R2|1.3.6.1.4.1.19376.1.5.3.1.2.3|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Medications – Prescription and Non-Prescription|R|1.3.6.1.4.1.19376.1.5.3.1.3.19}}
+|Section|Legal Documents and Medical Directives|R2|1.3.6.1.4.1.19376.1.5.3.1.3.34|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Immunizations|R2|1.3.6.1.4.1.19376.1.5.3.1.3.23}}
+|Section|Allergies and Drug Sensitivities|R|1.3.6.1.4.1.19376.1.5.3.1.3.13|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Doctor Visits / Last Physical or Checkup|O|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3}}
+|Section|Conditions|R|1.3.6.1.4.1.19376.1.5.3.1.3.8|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Hospitalizations|O|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3}}
+|Section|Conditions (cont)|R|1.3.6.1.4.1.19376.1.5.3.1.3.6|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Other Healthcare Visits|O|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3}}
+|Section|Surgeries|R2|1.3.6.1.4.1.19376.1.5.3.1.3.12|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Clinical Tests / Blood Type|O|1.3.6.1.4.1.19376.1.5.3.1.3.28}}
+|Section|Medications – Prescription and Non-Prescription|R|1.3.6.1.4.1.19376.1.5.3.1.3.19|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Pregnancies|O|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4}}
+|Section|Immunizations|R2|1.3.6.1.4.1.19376.1.5.3.1.3.23|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Medical Devices|R2|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5}}
+|Section|Doctor Visits / Last Physical or Checkup|O|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Family Member History|O|1.3.6.1.4.1.19376.1.5.3.1.3.15}}
+|Section|Hospitalizations|O|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Foreign Travel|O|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6}}
+|Section|Other Healthcare Visits|O|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Therapy|O|1.3.6.1.4.1.19376.1.5.3.1.3.31}}
+|Section|Clinical Tests / Blood Type|O|1.3.6.1.4.1.19376.1.5.3.1.3.28|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Vital Signs|R|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2}}
+|Section|Pregnancies|O|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.5|Functional Status|O|1.3.6.1.4.1.19376.1.5.3.1.3.17}}
+|Section|Medical Devices|R2|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5|
+|Section|Family Member History|O|1.3.6.1.4.1.19376.1.5.3.1.3.15|
+|Section|Foreign Travel|O|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6|
+|Section|Plan of Care|O|1.3.6.1.4.1.19376.1.5.3.1.3.31|
+|Section|Coded Vital signs|O|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2|
+|Section|Functional Status|O|1.3.6.1.4.1.19376.1.5.3.1.3.17|
 }}
 ====== Additional Constraints ======