Difference between revisions of "CDA Release 2.0 Content Modules"

Revision as of 14:57, 11 May 2007

CDA Release 2.0 Content Modules

This section contains content modules based upon the HL7 CDA Release 2.0 Standard, and related standards and/or implementation guides.

CDA Document Content Modules

This section contains document content modules using the CDA Release 2.0 standard.

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

Medical Documents Specification 1.3.6.1.4.1.19376.1.5.3.1.1.1

This section defines the base set of constraints used by almost all medical document profiles described the PCC Technical Framework.

Standards

CDAR2	HL7 CDA Release 2.0
CDTHP	CDA for Common Document Types History and Physical Notes (DSTU)
XMLXSL	Associating Style Sheets with XML documents

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 Medical Documents Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Medical Documents</title>
  <effectiveTime value='20240424012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
       
  </structuredBody></component>
</ClinicalDocument>

   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Medical Documents must be {{{LOINC}}}
   </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>

Specification

The constraints for encoding of the CDA Header (Level 1) can be found in the CDA for Common Document Types History and Physical Implementation Guide, in the section 2. CDA Header -- General Constraints.

IHE Medical Documents shall follow all constraints found in that section with the exception of the constraint on realmcode found in CONF-HP-15:.
IHE Medical Documents which are implemented for the US Realm shall follow ALL constraints found in that section, and shall use both the IHE Medical Document templateId (1.3.6.1.4.1.19376.1.5.3.1.1.1) and the HL7 General Header Constraints templateId (2.16.840.1.113883.10.20.3).}}

Realm	Constraints	Template IDs Required
Universal	CONF-HP-1 through CONF-HP-14 CONF-HP-16 through CONF-HP-52	1.3.6.1.4.1.19376.1.5.3.1.1.1
US	CONF-HP-1 through CONF-HP-52	1.3.6.1.4.1.19376.1.5.3.1.1.1 2.16.840.1.113883.10.20.3

Style Sheets

Document sources should provide an XML style sheet to render the content of the Medical Summary document. The output of this style sheet shall be an XHTML Basic (see http://www.w3.org/TR/xhtml-basic/) document that renders the clinical content of a Medical Summary Document as closely as possible as the sending provider viewed the completed document. When a style sheet is provided, at least one processing instruction shall be included in the document that including a link to the URL for the XML style sheet. To ensure that the style sheet is available to all receivers, more than one stylesheet link may be included.

When a stylesheet is used within an XDS Affinity domain, the link to it shall be provided using an HTTPS or HTTP URL.

<?xml-stylesheet href='https://foobar:8080/mystylesheet.xsl' type='text/xsl'?>

When using XDM or XDR to exchange documents, the stylesheet shall also be exchanged on the media. The link to the stylesheet shall be recorded as a relative URL.

<?xml-stylesheet href='../../stylesheets/mystylesheet.xsl' type='text/xsl'?>

Style sheets should not rely on graphic or other media resources. If graphics other media resources are used, these shall be accessible in the same way as the stylesheet. The Content Creator need not be the provider of the resources (stylesheet or graphcs).

When a Content Creator provides a style sheet, Content Consumers must provide a mechanism to render the document with that style sheet. Content Consumers may view the document with their own style sheet.

To record the stylesheet within a CDA Document that might be used in both an XDS and XDM environment, more than one stylesheet processing instruction is required. In this case, all style sheet processing instructions included must include the alternate='yes' attribute.

<?xml-stylesheet href='https://foobar:8080/mystylesheet.xsl' type='text/xsl' alternate='yes'?>
<?xml-stylesheet href='../../stylesheets/mystylesheet.xsl' type='text/xsl' alternate='yes'?>

A Content Consumer that is attempting to render a document using the document supplied stylesheet may use the first style sheet processing instruction for which it is able to obtain the style sheet content, and shall not report any errors if it is able to find at least one stylesheet to render with.

Distinctions of None

Information that is sent must clearly identify distinctions between

None: It is known with complete confidence that there are none. Used in the context of problem and medication lists, this indicates that the sender knows that there is no relevant information that can be sent.
None Known: None are known at this time, but it is not known with complete confidence than none exist. Used in the context of allergy lists, where essentially, it is impossible to prove the negative that no allergies exist, it is only possible to assert that none have been found to date.
None Known Did Ask: None are known at this time, and it is not known with complete confidence than none exist, but the information was requested. Also used in the context of allergy lists, where essentially, it is impossible to prove the negative that no allergies exist, it is only possible to assert that none have been found to date.
Unknown: The information is not known, or is otherwise unavailable.

In the context of CDA, sections that are required to be present but have no information should use one of the above phrases where appropriate.

An appropriate machine readable entry shall be present for problems, medications and allergies to indicate the reason that no information. Codes for recording unknown or no information are provided in the section on the Problem, Allergy and Medications Entry.

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

Medical Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.2

A medical summary contains a snapshot of the patient's medical information, including at the very least, a list of the patients problems, medications and allergies. A Medical Summary is an abstract template that is expected to be further refined by additional document templates.

Parent Template

This document is an instance of the Medical Document template.

Standards

CDAR2

HL7 CDA Release 2.0

Specification

Data Element Name	Opt	Template ID
Problem Concern Entry	R	1.3.6.1.4.1.19376.1.5.3.1.4.5.2
Allergy Concern Entry	R	1.3.6.1.4.1.19376.1.5.3.1.4.5.3
Medications	R	1.3.6.1.4.1.19376.1.5.3.1.4.7

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 Document 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 Medical Summary Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Medical Summary</title>
  <effectiveTime value='20240424012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.2'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Medical Summary can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'>
     Error: The parent template identifier for Medical Summary is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Medical Summary must be {{{LOINC}}}
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.5.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Medical Summary Document must contain a(n) Problem Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.2
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.5.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Medical Summary Document must contain a(n) Allergy Concern Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.2
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.7"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Medical Summary Document must contain a(n) Medications Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.2
   </assert> 
 </rule>
</pattern>

Document Specification

A medical summary is a type of medical document, and incorporates the constraints defined for Medical Documents, and requires the recording of Problems, Allergies and Medications.

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

Referral Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.3

The use case is described fully in PCC_TF-1 for the Ambulatory Specialist Referral. Briefly, it involves a "collaborative" transfer of care for the referral of a patient from a primary care provider (PCP) to a specialist. The important document data elements identified by physicians and nurses for this use case are listed in the table below under the column "Data Elements". These were then mapped to the categories given HL7 Care Record Summary Implementation Guide, and HL7 CDA Release 2.0. These mappings are provided in the next two columns.

A referral summary is a type of Medical Summary, and incorporates the constraints defined for a Medical Summary(1.3.6.1.4.1.19376.1.5.3.1.1.2) above. This section defines additional constraints for Medical Summary Content used in a Referral summary. These tables present the Categories, as defined in Section 3 of CRS. In no case are these IHE requirements less strict than those defined by CRS.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:xds-ms:2007

Parent Template

This document is an instance of the Medical Summary template.

Standards

CDAR2	HL7 CDA Release 2.0
CRS	HL7 Care Record Summary
CCD	ASTM/HL7 Continuity of Care Document

Data Element Index

Data Elements	HL7 Care Record Summary	CDA Release 2.0
Reason for Referral	Reason for Referral	REASON FOR REFERRAL
History Present Illness	History of Present Illness	HISTORY OF PRESENT ILLNESS
Active Problems	Conditions	PROBLEM LIST
Current Meds	Medications	HISTORY OF MEDICATION USE
Allergies	Allergies and Adverse Reactions	HISTORY OF ALLERGIES
History of Past Illness	Conditions	HISTORY OF PAST ILLNESS
List of Surgeries	Past Surgical History	HISTORY OF PRIOR SURGERIES
Immunizations	Immunizations	HISTORY OF IMMUNIZATIONS
Family History	Family History	HISTORY OF FAMILY ILLNESS
Social History	Social History	SOCIAL HISTORY
Pertinent Review of Systems	Review of Systems	REVIEW OF SYSTEMS
Vital Signs	Physical Exam	VITAL SIGNS
Physical Exam	Physical Exam	GENERAL STATUS, PHYSICAL FINDINGS
Relevant Diagnostic Surgical Procedures / Clinical Reports (including links)	Studies and Reports	RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Relevant Diagnostic Test and Reports (Lab, Imaging, EKG's, etc.) including links.	Studies and Reports	RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Plan of Care (new meds labs, or x-rays ordered)	Care Plan	TREATMENT PLAN
Advance Directives	Advance Directives	ADVANCE DIRECTIVES
Patient Administrative Identifiers	Header	patientRole/id
Pertinent Insurance Information	Participant	participant[@classCode='HLD']
Data needed for state and local referral forms, if different than above	Optional Sections	section

Specification

Data Element Name	Opt	Template ID
Reason for Referral	R	1.3.6.1.4.1.19376.1.5.3.1.3.1
History Present Illness	R	1.3.6.1.4.1.19376.1.5.3.1.3.4
Active Problems	R	1.3.6.1.4.1.19376.1.5.3.1.3.6
Current Meds	R	1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies	R	1.3.6.1.4.1.19376.1.5.3.1.3.13
History of Past Illness	R2	1.3.6.1.4.1.19376.1.5.3.1.3.8
List of Surgeries	R2	1.3.6.1.4.1.19376.1.5.3.1.3.11
Immunizations	R2	1.3.6.1.4.1.19376.1.5.3.1.3.23
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
Pertinent Review of Systems	O	1.3.6.1.4.1.19376.1.5.3.1.3.18
Vital Signs	R2	1.3.6.1.4.1.19376.1.5.3.1.3.25
Physical Exam	R2	1.3.6.1.4.1.19376.1.5.3.1.3.24
Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports (Lab, Imaging, EKG's, etc.) including links.	R2	1.3.6.1.4.1.19376.1.5.3.1.3.27
Plan of Care (new meds, labs, or x-rays ordered)	R2	1.3.6.1.4.1.19376.1.5.3.1.3.31
Advance Directives	R2	1.3.6.1.4.1.19376.1.5.3.1.3.34
Patient Administrative Identifiers Handled by the Medical Documents Content Profile by reference to constraints in HL7 CRS.	R
Pertinent Insurance Information Refer to Appropriate Payers Section -- TBD	R2
Data needed for state and local referral forms, if different than above These are handed by including additional sections within the summary.	R2

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 Referral Summary 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='1.3.6.1.4.1.19376.1.5.3.1.1.3'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Referral Summary</title>
  <effectiveTime value='20240424012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
        <!-- Required Reason for Referral Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Required History Present Illness Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required Active Problems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Current Meds Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
        <!-- Required Allergies 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='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
        <!-- Required if known List of Surgeries 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='1.3.6.1.4.1.19376.1.5.3.1.3.14'/>
        <!-- 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='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Optional Pertinent Review of Systems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
        <!-- Required if known Vital Signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
        <!-- Required if known Physical Exam Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.27'/>
        <!-- Required if known Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
        <!-- Required if known Plan of Care (new meds, labs, or x-rays ordered) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required if known Advance Directives Section content -->
      </section>
    </component>

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

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.3'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.3"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Referral Summary 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 Referral Summary is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Referral Summary must be {{{LOINC}}}
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.3.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Referral Summary Document must contain a(n) Reason for Referral Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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 Referral Summary Document must contain a(n) History Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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 Referral Summary Document must contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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 Referral Summary Document must contain a(n) Current Meds Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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 Referral Summary Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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  Referral Summary Document should contain a(n) History of Past Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) List of Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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  Referral Summary Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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  Referral Summary Document should contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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  Referral Summary Document should contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Referral Summary Document does not contain a(n) Pertinent Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.24"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Physical Exam Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.27"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Plan of Care (new meds, labs, or x-rays ordered) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </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  Referral Summary Document should contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Referral Summary Document must contain a(n) Patient Administrative Identifiers Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Pertinent Insurance Information Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Referral Summary Document should contain a(n) Data needed for state and local referral forms, if different than above Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 
   </assert> 
 </rule>
</pattern>

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

Discharge Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.4

This use case is described fully in the XDS-MS profile found in PCC TF-1. Briefly, it involves an episodic transfer of care in the form of a patient discharge from a hospital to home. The important data elements identified by physicians and nurses for this use case are listed in the table below under the column "Data Elements". These are mapped to the categories given HL7 Care Record Summary Implementation Guide, and HL7 CDA Release 2.0 in the next two columns.

A discharge summary is a type of medical summary, and incorporates the constraints defined for Medical Summaries.

This section defines additional constraints for Medical Summary Content used in a Discharge Summary. These tables present the data elements described above, along with their optionality, and references to the section and template where these sections or header data elements are further defined.

In no case are these IHE requirements less strict than those defined by the HL7 Care Record Summary.

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:xds-ms:2007

Parent Template

This document is an instance of the Medical Summary template.

Standards

CDAR2	HL7 CDA Release 2.0
CRS	HL7 Care Record Summary
CCD	ASTM/HL7 Continuity of Care Document

Data Element Index

Data Elements	HL7 Care Record Summary	CDA Release 2.0
Date of Admission	Header	encompassingEncounter/effectiveTime
Date of Discharge	Header	encompassingEncounter/effectiveTime
Participating Providers and Roles	Header	documentationOf/serviceEvent/performer
Discharge Disposition (who, how, where)	Care Plan	DISCHARGE DISPOSITION
Admitting Diagnosis	Conditions	HOSPITAL ADMISSION DX
History of Present Illness	History of Present Illness	HISTORY OF PRESENT ILLNESS
Hospital Course	Hospital Course	HOSPITAL COURSE
Discharge Diagnosis (including active and resolved problems)	Conditions	HOSPITAL DISCHARGE DX
Selected Medicine Administered during Hospitalization	Medications	HISTORY OF MEDICATION USE
Discharge Medications	Medications	HOSPITAL DISCHARGE MEDICATIONS
Allergies and adverse reactions	Allergies and Adverse Reactions	HISTORY OF ALLERGIES
Discharge Diet	Optionally found in Care Plan	DISCHARGE DIET
Review of Systems	Review of Systems	REVIEW OF SYSTEMS
Vital Signs (most recent, high/low/average)	Physical Exam	VITAL SIGNS
Functional Status	Functional Status	HISTORY OF FUNCTIONAL STATUS
Relevant Procedures and Reports (including links)	Studies and Reports	HOSPITAL DISCHARGE STUDIES
Relevant Diagnostic Tests and Reports (including links)	Studies and Reports	HOSPITAL DISCHARGE STUDIES
Plan of Care	Care Plan	TREATMENT PLAN
Administrative Identifiers	Header	patient/id
Pertinent Insurance Information	Header	participant[@classCode='HLD']

Specification

Data Element Name	Opt	Template ID
Active Problems	R	1.3.6.1.4.1.19376.1.5.3.1.3.6
Resolved Problems	R	1.3.6.1.4.1.19376.1.5.3.1.3.8
Discharge Diagnosis	R	1.3.6.1.4.1.19376.1.5.3.1.3.7
Admitting Diagnosis	R	1.3.6.1.4.1.19376.1.5.3.1.3.3
Selected Meds Administered	R2	1.3.6.1.4.1.19376.1.5.3.1.3.21
Discharge Meds	R	1.3.6.1.4.1.19376.1.5.3.1.3.22
Admission Medications	R2	1.3.6.1.4.1.19376.1.5.3.1.3.20
Allergies	R	1.3.6.1.4.1.19376.1.5.3.1.3.13
Hospital Course	R	1.3.6.1.4.1.19376.1.5.3.1.3.5
Advance Directives	O	1.3.6.1.4.1.19376.1.5.3.1.3.34
History of Present Illness	R2	1.3.6.1.4.1.19376.1.5.3.1.3.4
Functional Status	O	1.3.6.1.4.1.19376.1.5.3.1.3.17
Review of Systems	O	1.3.6.1.4.1.19376.1.5.3.1.3.18
Physical Examination	O	1.3.6.1.4.1.19376.1.5.3.1.3.24
Vital Signs	O	1.3.6.1.4.1.19376.1.5.3.1.3.25
Discharge Procedures Tests, Reports	O	1.3.6.1.4.1.19376.1.5.3.1.3.29
Plan of Care	R	1.3.6.1.4.1.19376.1.5.3.1.3.31
Discharge Diet	O	1.3.6.1.4.1.19376.1.5.3.1.3.33

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 Discharge Summary 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='1.3.6.1.4.1.19376.1.5.3.1.1.4'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Discharge Summary</title>
  <effectiveTime value='20240424012005'/>
  <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 Active Problems Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.7'/>
        <!-- Required Discharge Diagnosis Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.3'/>
        <!-- Required Admitting Diagnosis Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/>
        <!-- Required if known Selected Meds Administered Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.22'/>
        <!-- Required Discharge Meds Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.20'/>
        <!-- Required if known Admission Medications Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.5'/>
        <!-- Required Hospital Course Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Optional Advance Directives Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Required if known History of Present Illness 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>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Optional Review of Systems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
        <!-- Optional Physical Examination Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
        <!-- Optional Vital Signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.29'/>
        <!-- Optional Discharge Procedures Tests, Reports Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.33'/>
        <!-- Optional Discharge Diet Section content -->
      </section>
    </component>

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

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.4'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.4"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Discharge Summary 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 Discharge Summary is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Discharge Summary must be {{{LOINC}}}
   </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"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </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 Discharge Summary Document must contain a(n) Resolved Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.7"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Discharge Diagnosis Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Admitting Diagnosis Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </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  Discharge Summary Document should contain a(n) Selected Meds Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.22"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Discharge Meds Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.20"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Discharge Summary Document should contain a(n) Admission Medications Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </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 Discharge Summary Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.5"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Hospital Course Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Discharge Summary Document should contain a(n) History of Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </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 Discharge Summary Document does not contain a(n) Functional Status Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.24"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Physical Examination Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.29"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Discharge Procedures Tests, Reports Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Plan of Care Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.33"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Discharge Diet Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
 </rule>
</pattern>

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='20240424012005'/>
  <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.

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 Update Specification 1.3.6.1.4.1.19376.1.5.3.1.1.6

The PHR Update Content Module is similar to the PHR Extract content module, except that it has a number of different constraints. First of all, it is not required to contain all of the information that the PHR Extract content module does. The reason for this is because the purpose of this module is to reflect the changes that should be made to a PHR based on a previously existing PHR Extract content module. So, while it makes use of the same data element index, almost all of the data elements are optional. The purpose of this module is to make it easier for an EHR to create content that can be used to update a PHR.

Format Code

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

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 PHR Update Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.6'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>PHR Update</title>
  <effectiveTime value='20240424012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
       
  </structuredBody></component>
</ClinicalDocument>

   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a PHR Update must be {{{LOINC}}}
   </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>

Requirements

The requirements of this module are that it support recording updates to the original PHR Extract. The PHR Extract is made up of a header, and several sections, each of which may contain one or more entries. Suggestions to add, remove or update a section or entry are described in more detail below.

Adding a New Section or Appending to an Existing Section

A PHR Reviewer Actor may suggest additional material for an existing or new section by simply adding that section to the PHR Update document.

Replacing a Section

A PHR Reviewer Actor may suggest a revision to a section in the PHR Extract by replacing that section. To replace a section, the PHR Reviewer Actor creates a section in the PHR Update document that is of the same type as the section to be replaced in the PHR Extract document, and adds a <ppc:replacementOf> element to that section to indicate the section that it replaces.

The replacementOf element is an extension to the CDA Release 2.0 standard, and is further described below in Appendix C Extensions to CDA Release 2.0.

Adding an Entry

A PHR Reviewer Actor may suggest a new entry be added to a section by simply including that entry in a like section in the PHR Update document.

Replacing or Removing an Entry

The PHR Review Actor can replace an existing entry by adding an entry of the same type with new or modified information, and including in that entry a <reference> element that has an <externalAct> element. The <id> element of the <externalAct> shall be that of the act that is being replaced

Removing an Entry

The PHR Reviewer Actor can suggest that an entry be removed by replacing it with an act who <statusCode> element has been set to nullified.

Constraints

The LOINC document type code is the same as for the PHR Extract content module. The PHR Update Content module must record the PHR Extract which it is updating

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

Consent to Share Information Specification 1.3.6.1.4.1.19376.1.5.3.1.1.7

Consents to share information are documents that contain both a human and machine readable description of how a patient has chosen to share their information.

Format Code

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

Parent Template

This document is an instance of the Medical Document template.

Standards

CDAR2	HL7 CDA Release 2.0
XDS-SD	Scanned Documents

Specification

Data Element Name	Opt	Template ID
Consent Service Event At least one, and possibly more than one, consent can be provided within the document.	R	1.3.6.1.4.1.19376.1.5.3.1.2.6
Authorization Consents may also be protected under a sharing policity.	O	1.3.6.1.4.1.19376.1.5.3.1.2.5

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 Document 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 Consent to Share Information Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.7'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Consent to Share Information</title>
  <effectiveTime value='20240424012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.7'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.7"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Consent to Share Information can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'>
     Error: The parent template identifier for Consent to Share Information is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Consent to Share Information must be {{{LOINC}}}
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.2.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Consent to Share Information Document must contain a(n) Consent Service Event Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.7 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.5"]'> 
     <!-- Note any missing optional elements -->
     Note: This Consent to Share Information Document does not contain a(n) Authorization Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.7 
   </assert> 
 </rule>
</pattern>

Constraints

A consent shall contain a text description of what the patient consented to, a list of codes indicating the policy(s) agreed to, a time range indicating the effective time of the consent, and shall contain a signature signifying the patient agreement to those policy(s) stated in the text description. Finally, consents may be attested to using an electronic digital signature, conforming to the ITI Digital Signature Profile.

The text description and signature may appear as a scanned image. When the consent contains a scanned image, it shall also conform to the constraints of the ITI Scanned Document profile.

A consent shall have one or more <serviceEvent> elements in the header identifying the policies authorized by the document (see Section 4.2.3.4 of CDAR2). Each <serviceEvent> element indicates informed consent to one and only one XDS Affinity Domain policy. More than one policy may be agreed to within a given consent document.

Consent documents should be attested to by either the patient and/or legal guardian, or a third party assigned by the XDS Affinity Domain or its member organizations. The attestation, if present, should be performed using the ITI Digital Signature profile. The signer may be the patient, or a third party.

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

Preprocedure History and Physical Specification 1.3.6.1.4.1.19376.1.5.3.1.1.9

A Pre-procedure History and Physical is a type of medical document, and incorporates the constraints defined for Medical Documents(1.3.6.1.4.1.19376.1.5.3.1.1.1) .

This use case is described fully in in the PPHP Profile described in PCC TF-1. Briefly, this use case involves a sequence of events leading up to the patient’s admission to the operating room in a surgical center. Included in these events is the creation and communication of the pre-procedure history and physical document required by quality review organizations prior to most surgeries. Using this use case, the contents of documents used in collaborative transfers of care were discussed with physicians and nurses in detail to identify major sections. The sections identified by physicians during the use case exercise as important are listed in the table below under the column “Use Case Documentation Section??.

Using this information from the use case, the following mappings were made to existing standards and implementation guides. As illustrated, there is quite a bit of overlap between sections in this integration profile and in sections specified in the HL7 Care Record Summary CDA implementation guide.

Format Code

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

Parent Template

This document is an instance of the Medical Document template.

Standards

CDAR2	HL7 CDA Release 2.0
CRS	HL7 Care Record Summary
CCD	ASTM/HL7 Continuity of Care Document

Data Element Index

Data Element Requirements	Sections in HL7 CDA-R2/	LOINC Descriptions
Proposed Procedure: (coded procedure)		PROCEDURE
Expected Blood Loss		OPERATIVE NOTE ESTIMATED BLOOD LOSS
Proposed Anesthesia		OPERATIVE NOTE ANESTHESIA
Reason for Procedure: (coded diagnosis)		OPERATIVE NOTE INDICATIONS
HPI—(free text leading up to procedure)	History of Present Illness	HISTORY OF PRESENT ILLNESS
Current Problem List	Conditions	PROBLEM LIST
Past Medical History	Conditions	HISTORY OF PAST ILLNESS
Past Surgical-Anesthesia History	Past Surgical History	HISTORY OF SURGICAL PROCEDURES
Medication List	Medications	HISTORY OF MEDICATION USE
Allergy List	Allergies and Adverse Reactions	HISTORY OF ALLERGIES
Immunizations	Immunizations	HISTORY OF IMMUNIZATIONS
History of Tobacco Use		HISTORY OF TOBACCO USE
Current Alcohol/Substance Abuse		HISTORY OF PRESENT ALCOHOL AND/OR SUBSTANCE ABUSE
Transfusion History		TBD
Family History (specifically includes):	Family History	HISTORY OF FAMILY MEMBER DISEASES
Social History		SOCIAL HISTORY
Advance Directives	Advance Directives	ADVANCE DIRECTIVES
Functional Capacity	Functional Status	HISTORY OF FUNCTIONAL STATUS
Review of Systems (specifically includes):	Review of Systems	REVIEW OF SYSTEMS
Physical Exam (specifically includes):	Physical Examination	PHYSICAL EXAM.TOTAL
Studies and Reports	Studies and Reports	STUDIES SUMMARY
Health Maintenance Status		TREATMENT PLAN
Pre-procedure Care Plan Status Report		TREATMENT PLAN
Pre-procedure Impressions (specifically includes):		DIAGNOSIS
-Updated Problem List	Conditions	PROBLEM LIST
-Pre-Procedure Risk Assessment		OPERATIVE NOTE COMPLICATIONS
Pre-procedure Care Plan	Plan of Care	TREATMENT PLAN
Patient Education/Consents		EDUCATION NOTE

Specification

Data Element Name	Opt	Template ID
Proposed Procedure: (coded procedure) includes: Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.1
-Reason for Procedure: (coded diagnosis) Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.4
-Proposed Anesthesia Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.3
-Expected Blood Loss Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. Needs narrative LOINC code	R2	1.3.6.1.4.1.19376.1.5.3.1.1.9.2
-Procedure Care Plan Care Plan generated by the surgeon or surgical coordinator prior to the H&P	R2	1.3.6.1.4.1.19376.1.5.3.1.1.9.40
HPI—(free text leading up to procedure)	R	1.3.6.1.4.1.19376.1.5.3.1.3.4
Current Problem List Problem List (if known) is represented as current at beginning of H&P encounter.	R2	1.3.6.1.4.1.19376.1.5.3.1.3.6
Past Medical History	R2	1.3.6.1.4.1.19376.1.5.3.1.3.8
Past Surgical-Anesthesia History	R	1.3.6.1.4.1.19376.1.5.3.1.3.11
Medication List	R	1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergy List	R	1.3.6.1.4.1.19376.1.5.3.1.3.13
Immunizations	R2	1.3.6.1.4.1.19376.1.5.3.1.3.23
History of Tobacco Use	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.8
Current Alcohol/Substance Abuse	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.10
Transfusion History	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.12
Pre-procedure Family History	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.5
Social History	R2	1.3.6.1.4.1.19376.1.5.3.1.3.16
Advance Directives	R2	1.3.6.1.4.1.19376.1.5.3.1.3.34
Functional Capacity	R	1.3.6.1.4.1.19376.1.5.3.1.3.17
Review of Systems (specifically includes):	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.13
-General Review	R	1.3.6.1.4.1.19376.1.5.3.1.3.18
-Implanted Medical Devices	R2	1.3.6.1.4.1.19376.1.5.3.1.1.9.46
-Pregnancy Status (if female)	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.47
-Anesthesia Review of Systems	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.14
Physical Exam (specifically includes):	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.15
-Vitals	R	1.3.6.1.4.1.19376.1.5.3.1.9.49
-General Appearance	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.16
-Visible Implanted Medical Devices	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.48
-Integumentary System	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.17
-Head	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.18
-Eyes	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.19
-Ears, Nose, Mouth and Throat (may include):	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1
--Ears	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.21
--Nose	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.22
--Mouth, Throat, and Teeth	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.23
-Neck	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.24
-Endocrine System	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.25
-Thorax and Lungs (may include):	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1
--Chest Wall	O	1.3.6.1.4.1.19376.1.5.3.1.1.9.27

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 Document 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 Preprocedure History and Physical Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Preprocedure History and Physical</title>
  <effectiveTime value='20240424012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.1.9.1'/>
        <!-- Required Proposed Procedure: (coded procedure) includes: Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.4'/>
        <!-- Required -Reason for Procedure: (coded diagnosis) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.3'/>
        <!-- Required -Proposed Anesthesia Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.2'/>
        <!-- Required if known -Expected Blood Loss Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.40'/>
        <!-- Required if known -Procedure Care Plan Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Required HPI—(free text leading up to procedure) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required if known Current 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 Past Medical History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
        <!-- Required Past Surgical-Anesthesia History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Medication List Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
        <!-- Required Allergy List 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='1.3.6.1.4.1.19376.1.5.3.1.1.9.8'/>
        <!-- Required History of Tobacco Use Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.10'/>
        <!-- Required Current Alcohol/Substance   Abuse Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.12'/>
        <!-- Required Transfusion History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.5'/>
        <!-- Required Pre-procedure 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='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required if known Advance Directives Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/>
        <!-- Required Functional Capacity Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.13'/>
        <!-- Required Review of Systems (specifically includes): Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Required   -General Review Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.46'/>
        <!-- Required if known -Implanted Medical Devices Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.47'/>
        <!-- Required -Pregnancy Status (if female) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.14'/>
        <!-- Required   -Anesthesia Review of Systems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/>
        <!-- Required Physical Exam (specifically includes): Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.9.49'/>
        <!-- Required -Vitals Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.16'/>
        <!-- Optional -General Appearance Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.48'/>
        <!-- Optional -Visible Implanted Medical Devices Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.17'/>
        <!-- Optional -Integumentary System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.18'/>
        <!-- Optional -Head Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.19'/>
        <!-- Optional -Eyes Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1'/>
        <!-- Optional -Ears, Nose, Mouth and Throat (may include): Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.21'/>
        <!-- Optional --Ears Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.22'/>
        <!-- Optional --Nose Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.23'/>
        <!-- Optional --Mouth, Throat, and Teeth Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.24'/>
        <!-- Optional -Neck Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.25'/>
        <!-- Optional -Endocrine System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1'/>
        <!-- Optional -Thorax and Lungs (may include): Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.27'/>
        <!-- Optional --Chest Wall Section content -->
      </section>
    </component>

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

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Preprocedure History and Physical can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'>
     Error: The parent template identifier for Preprocedure History and Physical is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Preprocedure History and Physical must be {{{LOINC}}}
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.9.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Proposed Procedure: (coded procedure) includes: Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) -Reason for Procedure: (coded diagnosis) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) -Proposed Anesthesia Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.2"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) -Expected Blood Loss Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.40"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) -Procedure Care Plan Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </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 Preprocedure History and Physical Document must contain a(n) HPI—(free text leading up to procedure) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </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  Preprocedure History and Physical Document should contain a(n) Current Problem List Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </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  Preprocedure History and Physical Document should contain a(n) Past Medical History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Past Surgical-Anesthesia History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </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 Preprocedure History and Physical Document must contain a(n) Medication List Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </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 Preprocedure History and Physical Document must contain a(n) Allergy List Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </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  Preprocedure History and Physical Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.8"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) History of Tobacco Use Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.10"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Current Alcohol/Substance   Abuse Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.12"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Transfusion History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.5"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Pre-procedure Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </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  Preprocedure History and Physical Document should contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </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  Preprocedure History and Physical Document should contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.17"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Functional Capacity Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Review of Systems (specifically includes): Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n)   -General Review Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.46"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) -Implanted Medical Devices Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.47"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) -Pregnancy Status (if female) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.14"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n)   -Anesthesia Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Physical Exam (specifically includes): Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.9.49"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) -Vitals Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.16"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -General Appearance Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.48"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Visible Implanted Medical Devices Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.17"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Integumentary System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Head Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.19"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Eyes Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Ears, Nose, Mouth and Throat (may include): Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.21"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) --Ears Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.22"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) --Nose Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.23"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) --Mouth, Throat, and Teeth Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.24"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Neck Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.25"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Endocrine System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Thorax and Lungs (may include): Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.27"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) --Chest Wall Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
 </rule>
</pattern>

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

Emergency Department Referral Specification 1.3.6.1.4.1.19376.1.5.3.1.1.10

An ED Referral is a type of Referral Summary, and incorporates the constraints defined for Referral Summaries.

This use case is described fully in the EDR Profile in PCC TF-1. Briefly, it involves a collaborative transfer of care for the referral of a patient from a care provider to an emergency department. Using this use case the contents of documents used in collaborative transfers of care were discussed with physicians and nurses in detail to identify major sections. The sections identified by physicians during the use case exercise as important are listed in the table below.

Using this information from the use case, the following mappings were made to existing standards.

Format Code

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

Parent Template

This document is an instance of the Medical Summary template.

Data Element Index

Data Elements	HL7 Care Record Summary	CDA Release 2.0
Reason for Referral	Reason for Referral	REASON FOR REFERRAL
History Present Illness	History of Present Illness	HISTORY OF PRESENT ILLNESS
Active Problems	Conditions	PROBLEM LIST
Current Meds	Medications	HISTORY OF MEDICATION USE
Allergies	Allergies and Adverse Reactions	HISTORY OF ALLERGIES
Resolved Problems	Conditions	HISTORY OF PAST ILLNESS
List of Surgeries	Past Surgical History	HISTORY OF PRIOR SURGERIES
Immunizations	Immunizations	HISTORY OF IMMUNIZATIONS
Family History	Family History	HISTORY OF FAMILY ILLNESS
Social History	Social History	SOCIAL HISTORY
Pertinent Review of Systems	Review of Systems	REVIEW OF SYSTEMS
Vital Signs	Physical Exam	VITAL SIGNS
Physical Exam	Physical Exam	GENERAL STATUS, PHYSICAL FINDINGS
Relevant Surgical Procedures / Clinical Reports (including links)	Studies and Reports	RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Relevant Diagnostic Test and Reports (Lab, Imaging, EKG’s, etc.) including links.	Studies and Reports	RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Care Plan (new meds labs, or x-rays ordered)	Care Plan	TREATMENT PLAN
Proposed ED Disposition	ED DISPOSITION
Mode of Transport to the Emergency Department	Care Plan	MODE OF TRANSPORT
Estimated Time of Arrival to the ED	Care Plan	MODE OF TRANSPORT
Advance Directives	Advance Directives	ADVANCE DIRECTIVES
Patient Administrative Identifiers	Header	patientRole/id
Pertinent Insurance Information	Participant	participant[@roleCode='HLD']
Data needed for state and local referral forms, if different than above	Optional Sections	section

Specification

Data Element Name	Opt	Template ID
Reason for Referral	R	1.3.6.1.4.1.19376.1.5.3.1.3.1
History Present Illness	R	1.3.6.1.4.1.19376.1.5.3.1.3.4
Active Problems	R	1.3.6.1.4.1.19376.1.5.3.1.3.6
Current Meds	R	1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies	R	1.3.6.1.4.1.19376.1.5.3.1.3.13
Resolved Problems	R2	1.3.6.1.4.1.19376.1.5.3.1.3.8
List of Surgeries	R2	1.3.6.1.4.1.19376.1.5.3.1.3.11
Immunizations	R2	1.3.6.1.4.1.19376.1.5.3.1.3.23
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
Pertinent Review of Systems	O	1.3.6.1.4.1.19376.1.5.3.1.3.18
Vital Signs	R2	1.3.6.1.4.1.19376.1.5.3.1.3.25
Physical Exam	R2	1.3.6.1.4.1.19376.1.5.3.1.3.24
Relevant Diagnostic Results and/or Clinical Reports Includes Diagnostic Surgical Procedures, Clinical Reports and Diagnostic Tests and Results (Lab, Imaging, EKG’s, etc.) including links to relevant documents.	R2	1.3.6.1.4.1.19376.1.5.3.1.3.27
Care Plan (new meds, labs, or x-rays ordered)	R2	1.3.6.1.4.1.19376.1.5.3.1.3.31
Mode of Transport to the Emergency Department (includes ETA)	R	1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
Proposed ED Disposition	R2	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10
Advance Directives The availability of information about Advance Directives must provided. A common concern among ED providers is over situations where patients presented to the ED require extensive resuscitative efforts, only later to discover that the patient had a DNR order.	R	1.3.6.1.4.1.19376.1.5.3.1.3.34
Patient Administrative Identifiers These are handed by the Medical Documents Content Profile by reference to constraints in HL7 CRS.	R
Pertinent Insurance Information	R2
Data needed for state and local referral forms, if different than above These are handed by including additional sections within the summary.	R2

Note:

Highlighted items in the table above are different from what appears in the XDS-MS profile. All other data elements have identical definitions.

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 Emergency Department Referral Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.3'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Emergency Department Referral</title>
  <effectiveTime value='20240424012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
        <!-- Required Reason for Referral Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Required History Present Illness Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required Active Problems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Current Meds Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required if known Resolved Problems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
        <!-- Required if known List of Surgeries 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='1.3.6.1.4.1.19376.1.5.3.1.3.14'/>
        <!-- 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='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Optional Pertinent Review of Systems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
        <!-- Required if known Vital Signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
        <!-- Required if known Physical Exam Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.27'/>
        <!-- Required if known Relevant Diagnostic Results and/or Clinical Reports Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
        <!-- Required if known Care Plan Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/>
        <!-- Required Mode of Transport to the Emergency Department
(includes ETA)  Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'/>
        <!-- Required if known Proposed ED Disposition Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required Advance Directives Section content -->
      </section>
    </component>

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

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.10'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.10"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Emergency Department Referral can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.3"]'>
     Error: The parent template identifier for Emergency Department Referral is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Emergency Department Referral must be {{{LOINC}}}
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.3.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Reason for Referral Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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 Emergency Department Referral Document must contain a(n) History Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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 Emergency Department Referral Document must contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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 Emergency Department Referral Document must contain a(n) Current Meds Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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 Emergency Department Referral Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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  Emergency Department Referral Document should contain a(n) Resolved Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) List of Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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  Emergency Department Referral Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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  Emergency Department Referral Document should contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </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  Emergency Department Referral Document should contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Emergency Department Referral Document does not contain a(n) Pertinent Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.24"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Physical Exam Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.27"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Relevant Diagnostic Results and/or Clinical Reports Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Care Plan Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </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 Emergency Department Referral Document must contain a(n) Mode of Transport to the Emergency Department
(includes ETA)  Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Proposed ED Disposition Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Patient Administrative Identifiers Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Pertinent Insurance Information Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Data needed for state and local referral forms, if different than above Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </assert> 
 </rule>
</pattern>

CDA Header Content Modules

The following content modules define the structure of elements in the header of CDA Release 2.0 document.

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

Language Communication 1.3.6.1.4.1.19376.1.5.3.1.2.1

Languages spoken shall be recorded using the languageCommunication infrastructure class associated with the patient. The <languageCommunication> element describes the primary and secondary languages of communication for a person. When used, these shall be described using the languageCommunication element as follows.

Uses

See Templates using Language Communication

Specification

Language Communication Example

<languageCommunication>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.1'/>
  <languageCode code='en-US'/>
  <modeCode code='' codeSystem='2.16.840.1.113883.5.60'
    codeSystemName='LanguageAbilityMode'/>
  <preferenceInd value='true|false'/>
</languageCommunication>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.1'/>

The <templateId> element identifies this <languageCommunication> element for validation of the content. The templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.2.1'.

<languageCode code=' '/>

This element describes the language code. It uses the same vocabulary described for the ClinicalDocument/languageCode element described in more detail in HL7 CRS: 2.1.1. This element is required.

<modeCode code=' ' codeSystem='2.16.840.1.113883.5.60' codeSystemName='LanguageAbilityMode'/>

This element describes the mode of use, and is only necessary when there are differences between expressive and receptive abilities. This element is optional. When not present, the assumption is that any further detail provided within the languageCommunication element refers to all common modes of communication. The coding system used shall be the HL7 LanguageAbilityMode vocabulary when this element is communicated.

<proficiencyLevelCode code=' ' codeSystem='2.16.840.1.113883.5.61' codeSystemName='LanguageProficiencyCode' />

This element describes the proficiency of the patient (with respect to the mode if specified). This element is optional. The coding system used shall be the HL7 LanguageProficiencyCode vocabulary when this element is communicated.

<preferenceInd value=' '/>

This element shall be present on all languageCommunication elements when more than one is provided. It shall be valued "true" if this language is the patient’s preferred language for communication, or "false" if this is not the patient’s preferred language. More than one language may be preferred, and at least one must be preferred.

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

Employer and School Contacts 1.3.6.1.4.1.19376.1.5.3.1.2.2

Employer and school informational contacts shall be recorded as participants in the CDA Header as demonstrated in the figure below. These contacts shall conform to the General Constraints found in HL7 CRS: 2.1.1 with respect to the requirements for name, address, telephone numbers and other contact information.

The figure below shows how the information for this element is coded, and further constraints are provided in the following sections.

Uses

See Templates using Employer and School Contacts

Specification

Employer and School Contacts Example

<participant typeCode='IND'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.2'/>
  <time>
    <low value=''/>
    <high value=''/>
  </time>
  <associatedEntity classCode='CON'>
    <id root='' extension=''/>
    <code code='EMPLOYER|SCHOOL|AFFILIATED' codeSystem='1.3.5.1.4.1.19376.1.5.3.3' codeSystemName='IHERoleCode'/>
    <associatedPerson><name>…</name></associatedPerson>
    <scopingOrganization>
      <name>…</name>
      <telecom value='' use=''/>
      <addr>…</addr>
    </scopingOrganization>
  </associatedEntity>
</participant>

<participant typeCode='IND'>

The typeCode of the participant shall be IND.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.2'/>

The <templateId> element identifies this <participant> as a school or employer contact for validation of the content. The templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.2.2'.

<time><low value=' '/><high value=' '/>

The time element indicates the start and stop time range for this contact. These dates shall correspond to the start and stop dates for employment, enrollment, or other affiliation with the organization described.

<associatedEntity classCode='CON'>

The <associatedEntity> element provides the contact information (classCode='CON') for the school, employer or affiliated organization.

<code code='EMPLOYER|SCHOOL|AFFILIATED' codeSystem='1.3.5.1.4.1.19376.1.5.3.3' codeSystemName='IHERoleCode'/>

The code value shall indicate whether the participant is the employer, school or other affiliated (e.g., volunteer) organization. See also the IHE Role Code Vocabulary(1.3.5.1.4.1.19376.1.5.3.3)

<associatedPerson><name>…</name></associatedPerson>

This element should be present. When present is shall provide the name of a contact person within the organization.

<scopingOrganization><name>…</name><telecom value= use=/><addr>…</addr></scopingOrganization>

This element shall be present, and shall provide the name, address and telephone number of the organization.

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

Healthcare Providers and Pharmacies 1.3.6.1.4.1.19376.1.5.3.1.2.3

Healthcare providers (including pharmacies) shall be recorded as described in CCD: 3.17. The identifier that the patient is known by to these providers may be included using the Patient Identifier extension described in Extensions to HL7 CDA Release 2.0. See the example shown in for use of this extension element.

Uses

See Templates using Healthcare Providers and Pharmacies

Specification

Healthcare Providers and Pharmacies Example

<documentationOf>
  <serviceEvent classCode="PCPR">
    <effectiveTime><low value=""/><high value=""/></effectiveTime>
    <performer typeCode="PRF">
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.3'/>
      <functionCode code='' displayName='' codeSystem='' codeSystemName=''/>
      <time>
        <low value=''/>
        <high value=''/>
      </time>
      <assignedEntity>
        <id root='' extension=''/>
        <code code='' displayName='' codeSystem='' codeSystemName=''/>
        <addr></addr>
        <telecom value='' use=''/>
        <assignedPerson><name></name></assignedPerson>
        <representedOrganization><name></name></representedOrganization>
        <sdtc:patient>
          <sdtc:id root='' extension=''/>
        </sdtc:patient>
      </assignedEntity>
    </performer>
  </serviceEvent>
<documentationOf>

<documentationOf>

The <documentationOf> element records the service events that were performed. This element shall be present.

<serviceEvent classCode="PCPR">

The <serviceEvent> element describes the activity being documented. This element shall be present, and shall have a classCode attribute of 'PCPR'.

<effectiveTime><low value=""/><high value=""/></effectiveTime>

The <effectiveTime> element records the time over which care provision activities are recorded in the document. There shall be a <low> element which records the starting date of care provision, and a <high> element which records the ending date of care provision. The ending date may extend into the future in the document describes care that is intended to be provided, but that has not actually occurred.

<performer typeCode="PRF">

The <performer> elements in the <serviceEvent> identify the providers of care. At least one <performer> element should be present. When a provider gives care over two distinct time intervals (e.g., as in the case of a specialist who treats the patient for short periods of time in different years), the provider may be recorded multiple times as a performer.

<functionCode code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The function of the provider in the care of the patient should be present, and will be described in the <functionCode> element. This may be used for example, to identify the primary care provider.

<time><low value=' '/><high value=' '/>

The element is used to show the time period over which the provider gave care to the patient. The <low> and <high> elements must be present, and indicate the time over which care was (or is to be) provided.

<assignedEntity classCode='ASSIGNED'>

The <assignedEntity> element contains elements that identify the individual provider, and shall be present.

<id root=' ' extension=' '/>

The <id> element may be present and identifies the provider.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The <code> element describes the type of provider and can be used to distinguish pharmacies from other providers.

<addr></addr>

The <addr> element gives the address of the provider.

<telecom value=' ' use=' '/>

The <telecom> element gives the telephone number of the provider.

<assignedPerson><name></name></assignedPerson>

The providers name should be present. If not present, then the <scopingOrganization> shall be present (see below).

<representedOrganization><name></name></representedOrganization>

This element should be present, and shall provide the name of the organization.

<sdtc:patient><sdtc:id root=' ' extension=' '/></sdtc:patient>

The <sdtc:patient> element may be present to represent the patient's medical record number with the given provider. The root attribute of <sdtc:id> element shall be present and identifies the namespace used for the identifier. The extension attribute shall be present and is the patient's medical record or account number with the provider. This element is an HL7 extension to CDA Release 2.0.

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

Patient Contacts 1.3.6.1.4.1.19376.1.5.3.1.2.4

Patient contacts are recorded as described in HL7 CCD: 3.3

Uses

See Templates using Patient Contacts

Specification

Patient Contacts Example

<guardian classCode='GUARD'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.4'/>
  <code code='' displayName='' codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
  <addr></addr>
  <telecom />
  <guardianPerson>
    <name></name>
  </guardianPerson>
</guardian>

Guardians

<participant typeCode='IND'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.4'/>
  <time value='20070213'/>
  <associatedEntity classCode='AGNT|CAREGIVER|ECON|NOK|PRS'>
    <code code='' displayName='' codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
    <addr></addr>
    <telecom value='' use=''/>
    <assignedPerson><name></name></assignedPerson>
  </associatedEntity>
</participant>

<guardian classCode='GUARD'>

The guardians of a patient shall be recorded in the <guardian> element beneath the <patient> element.

<participant typeCode='IND'>

Other contacts are recorded as <participant> elements appearing in the document header. The classCode attribute shall be set to 'IND'.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.4'/>

The <templateId> element identifies this person as a patient contact and must be recorded exactly as shown above.

<time value=' '>

The element may be present and indicates the time of the participation.

<associatedEntity classCode='AGNT|CAREGIVER|ECON|NOK|PRS'>

The <associatedEntity> element identifies the type of contact. The classCode attribute shall be present, and contains a value from the set AGNT, CAREGIVER, ECON, NOK, or PRS to identify contacts that are agents of the patient, care givers, emergency contacts, next of kin, or other relations respectively.

<code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>

The relationship between the patient and the guardian or other contact should be recorded in the <code> element. The code attribute is required and comes from the HL7 PersonalRelationshipRoleType vocabulary. The codeSystem attribute is required and shall be represented exactly as shown above.

<addr>

The address of the guardian or other contact should be present, and shall be represented as any other address would be in CDA.

<telecom>

The phone number of the guardian or other contact should be present, and shall be represented as any other phone number would be in CDA.

<guardianPerson><name/> or <assignedPerson><name/>

The name of the guardian or other contact shall be present, and shall be represented as any other name would be in CDA.

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

Authorization 1.3.6.1.4.1.19376.1.5.3.1.2.5

Each <authorization> element in the CDA Header represents an informed consent. When the document being shared represents the informed consent to a policy expressed by the XDS Affinity Domain within the document, it shall do so in an <authorization> element. More than one <authorization> element may be present. The consent to share informaiton shall have a unique identifier contained in the <id> element, representing the patient consent to that policy. The policy being consented to shall be represented in the <code> element. Note that other <authorization> elements may be present representing other sorts of consents associated with the document.

Uses

See Templates using Authorization

Specification

Authorization Example

<authorization typeCode='AUTH'>
  <consent classCode='CONS' moodCode='EVN'>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.5'/>
    <id root=''/>
    <code code='' codeSystem='' codeSystemName='' displayName=''/>
    <statusCode code='completed'/>
  </consent>
</authorization>

Policies are identified using an Affinity Domain specified coding system. Each coded value in that vocabulary represents one affinity domain specific policy.

<authorization typeCode='AUTH'>

At least one <authorization> element must be present in a consent medical document in documents shared by Document Source actors that implement the privacy option. The typeCode attribute shall be present and be valued with AUTH, indicating that this is an authorization act related to the document.

<consent classCode='CONS' moodCode='EVN'>

Each authorization element shall have one <consent> element. The classCode shall be present and be valued with CONS, indicating that the related act is an informed consent. The moodCode shall be EVN, indicating that this element represents and act that has occurred.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.5'/>

The <templateId> element shall be recorded as shown above and identifies this consent as an authorization entry.

<id root=' '/>

The <consent> element shall have one identifier that is used to uniquely identify the consent act. This identifier shall contain a root attribute, and shall not contain an extension attribute.

<code code=' ' codeSystem=' ' codeSystemName=' ' displayName=' '/>

The <consent> element shall have one <code> element that is used to identify the consent policy that was agreed to by the patient.

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

Consent Service Events 1.3.6.1.4.1.19376.1.5.3.1.2.6

Within a consent document, the effective time of the consent shall be specified within the documentationOf/serviceEvent element.

Uses

See Templates using Consent Service Events

Specification

Consent Service Events Example

<documentationOf typeCode='DOC'>
  <serviceEvent classCode='ACT' moodCode='EVN'>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.6'/>
    <id root=''/>
    <code code='' displayName='' codeSystem='' codeSystemName=''/>
    <effectiveTime>
      <low value=''/>
      <high value=''/>
    </effectiveTime>
  </serviceEvent>
</documentationOf>

<documentationOf typeCode='DOC'>

At least one <documentationOf> element shall exist within a consent to share information, describing the service event of provision of consent. This element shall have a typeCode attribute with the value DOC.

<serviceEvent classCode='ACT' moodCode='EVN'>

One <serviceEvent> shall exist for each consent to share information given, describing the duration of the provision of consent. This element shall have a classCode attribute set to ACT, and a moodCode attribute of EVN.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.6'/>

The <templateId> element shall be recorded exactly as shown above, and identifies this <serviceEvent> as recording consent to share information.

<id root=' ' />

The service event shall have one <id> element, providing an identifier for the service event. The root attribute of this element shall be present, and shall be a GUID or OID. The extension attribute shall not be present.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The <code> element shall be present, and shall indicate the consent given. The code attribute indicates the consent given, and the codeSystem attribute indicates the code system from which this consent is given. The displayName attribute may be present, and describes the consent given. The codeSystemName attribute may be present, and describes the code system.

<effectiveTime><low value=' '/><high value=' '/></effectiveTime>

The <effectiveTime> element shall be present, and shall indicated the effective time range over which consent is given. The low value must be provided . The high value may be present. If present, is shall indicate the maximum effective time of the consent.

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

Section Content Modules

This list defines the sections that may appear in a medical document. It is intended to be a comprehensive list of all document sections that are used by any content profile defined in the Patient Care Coordination Technical Framework. All sections shall have a narrative component that may be freely formatted into normal text, lists, tables, or other appropriate human-readable presentations. Additional subsections or entry content modules may be required.

Reasons for Care

Technical Framework Volume 2: 6.3.3.1 Reasons for Care

The sections described below describe various reasons why healthcare is being provided to the patient.

(1.3.6.1.4.1.19376.1.5.3.1.3.1)PCC 2:6.3.3.1.1 Reason for Referral

(1.3.6.1.4.1.19376.1.5.3.1.3.2)PCC 2:6.3.3.1.2 Coded Reason for Referral

(1.3.6.1.4.1.19376.1.5.3.1.3.3)PCC 2:6.3.3.1.4 Hospital Admission Diagnosis

(1.3.6.1.4.1.19376.1.5.3.1.1.9.1)Proposed Procedure

(1.3.6.1.4.1.19376.1.5.3.1.1.9.2)Expected Blood Loss

(1.3.6.1.4.1.19376.1.5.3.1.1.9.3)Proposed Anesthesia

(1.3.6.1.4.1.19376.1.5.3.1.1.9.4)Reason for Procedure

Other Condition Histories

The sections defined below provide historical information about the patient's conditions.

(1.3.6.1.4.1.19376.1.5.3.1.3.4)History of Present Illness

(1.3.6.1.4.1.19376.1.5.3.1.3.5)Hospital Course

(1.3.6.1.4.1.19376.1.5.3.1.3.6)Active Problems

(1.3.6.1.4.1.19376.1.5.3.1.3.7)Discharge Diagnosis

(1.3.6.1.4.1.19376.1.5.3.1.3.8)Resolved Problems

(1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3)Encounter Histories

(1.3.6.1.4.1.19376.1.5.3.1.3.9)History of Outpatient Visits

(1.3.6.1.4.1.19376.1.5.3.1.3.10)History of Inpatient Visits

(1.3.6.1.4.1.19376.1.5.3.1.3.11)List of Surgeries

(1.3.6.1.4.1.19376.1.5.3.1.3.12)Coded List of Surgeries

(1.3.6.1.4.1.19376.1.5.3.1.3.13)Allergies and Other Adverse Reactions

(1.3.6.1.4.1.19376.1.5.3.1.3.14)Family Medical History

(1.3.6.1.4.1.19376.1.5.3.1.3.15)Coded Family Medical History

(1.3.6.1.4.1.19376.1.5.3.1.1.9.5)Pre-procedure Family Medical History

(1.3.6.1.4.1.19376.1.5.3.1.3.16)Social History

(1.3.6.1.4.1.19376.1.5.3.1.3.17)Functional Status

(1.3.6.1.4.1.19376.1.5.3.1.3.18)Review of Systems

(1.3.6.1.4.1.19376.1.5.3.1.1.9.13)Preprocedure Review of Systems

(1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1)Hazardous Working Conditions

(1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4)Pregnancy History

(1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5)Medical Devices

(1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6)Foreign Travel

(1.3.6.1.4.1.19376.1.5.3.1.1.9.8)History of Tobacco Use

(1.3.6.1.4.1.19376.1.5.3.1.1.9.10)Current Alcohol/Substance Abuse

(1.3.6.1.4.1.19376.1.5.3.1.1.9.12)Transfusion History

(1.3.6.1.4.1.19376.1.5.3.1.1.9.14)Anesthesia Risk Review of Systems

(1.3.6.1.4.1.19376.1.5.3.1.1.9.46)Implanted Medical Device Review

(1.3.6.1.4.1.19376.1.5.3.1.1.9.47)Pregnancy Status Review

Medications

This section contains section content modules that describe activities surrounding the use of medication.

(1.3.6.1.4.1.19376.1.5.3.1.3.19)Medications

(1.3.6.1.4.1.19376.1.5.3.1.3.20)Admission Medication History

(1.3.6.1.4.1.19376.1.5.3.1.3.21)Medications Administered

(1.3.6.1.4.1.19376.1.5.3.1.3.22)Hospital Discharge Medications

(1.3.6.1.4.1.19376.1.5.3.1.3.23)Immunizations

Physical Exams

(1.3.6.1.4.1.19376.1.5.3.1.3.24)Physical Exam

(1.3.6.1.4.1.19376.1.5.3.1.1.9.15)Physical Exam (with subsections)

(1.3.6.1.4.1.19376.1.5.3.1.3.26)Hospital Discharge Physical Exam

(1.3.6.1.4.1.19376.1.5.3.1.3.25)Vital Signs

(1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2)Coded Vital Signs

(1.3.6.1.4.1.19376.1.5.3.1.1.9.16)General Appearance

(1.3.6.1.4.1.19376.1.5.3.1.1.9.48)Visible Implanted Medical Devices

(1.3.6.1.4.1.19376.1.5.3.1.1.9.17)Integumentary System

(1.3.6.1.4.1.19376.1.5.3.1.1.9.18)Head

(1.3.6.1.4.1.19376.1.5.3.1.1.9.19)Eyes

(1.3.6.1.4.1.19376.1.5.3.1.1.9.20)Ears, Nose, Mouth and Throat

(1.3.6.1.4.1.19376.1.5.3.1.1.9.21)Ears

(1.3.6.1.4.1.19376.1.5.3.1.1.9.22)Nose

(1.3.6.1.4.1.19376.1.5.3.1.1.9.23)Mouth, Throat, and Teeth

(1.3.6.1.4.1.19376.1.5.3.1.1.9.24)Neck

(1.3.6.1.4.1.19376.1.5.3.1.1.9.25)Endocrine System

(1.3.6.1.4.1.19376.1.5.3.1.1.9.26)Thorax and Lungs

(1.3.6.1.4.1.19376.1.5.3.1.1.9.27)Chest Wall

(1.3.6.1.4.1.19376.1.5.3.1.1.9.28)Breasts

(1.3.6.1.4.1.19376.1.5.3.1.1.9.29)Heart

(1.3.6.1.4.1.19376.1.5.3.1.1.9.30)Respiratory System

(1.3.6.1.4.1.19376.1.5.3.1.1.9.31)Abdomen

(1.3.6.1.4.1.19376.1.5.3.1.1.9.32)Lymphatic System

(1.3.6.1.4.1.19376.1.5.3.1.1.9.33)Vessels

(1.3.6.1.4.1.19376.1.5.3.1.1.9.34)Musculoskeletal System

(1.3.6.1.4.1.19376.1.5.3.1.1.9.35)Neurologic System

(1.3.6.1.4.1.19376.1.5.3.1.1.9.36)Genitalia

(1.3.6.1.4.1.19376.1.5.3.1.1.9.37)Rectum

Relevant Studies

(1.3.6.1.4.1.19376.1.5.3.1.3.27)Results

1.3.6.1.4.1.19376.1.5.3.1.3.28

1.3.6.1.4.1.19376.1.5.3.1.3.29

1.3.6.1.4.1.19376.1.5.3.1.3.30

1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2

Plans of Care

This section provides content modules for sections that describe the plan of care intended for the patient.

1.3.6.1.4.1.19376.1.5.3.1.3.31

(1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1)ED Care Plan

1.3.6.1.4.1.19376.1.5.3.1.3.32

1.3.6.1.4.1.19376.1.5.3.1.3.33

1.3.6.1.4.1.19376.1.5.3.1.3.34

1.3.6.1.4.1.19376.1.5.3.1.3.35

1.3.6.1.4.1.19376.1.5.3.1.1.9.40

1.3.6.1.4.1.19376.1.5.3.1.1.9.45

1.3.6.1.4.1.19376.1.5.3.1.1.9.50

1.3.6.1.4.1.19376.1.5.3.1.1.9.41

(1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2)Transport Mode

Entry Content Modules

This section describes the HL7 Version 3 structures used as entries in CDA documents and found in other HL7 Version 3 messaging standards. These entries describe information such as conditions, problems, medications, and references to external documents, as well as several common components that may be used by these entries, including:

Severity observations allow practitioners to indicate the severity of a condition.
Unstructured comments allow practitioners to specify additional information that they feel is relevant.
Medication instructions allow practitioners to specify additional instructions for the use of a medication.

These common structures are included in the target act using the <entryRelationship> element defined in the CDA Schema, or the appropriate act relationship structure when used in an HL7 Version 3 message. This allows for arbitrary act relationships to be described.

The normal containment structure includes the target of the related act inside an act relationship element that is contained in the source act. To invert the direction of the relationship the inversionInd attribute of act relationship element is set to true (inversionInd='true') in the samples below.

Linking Narrative and Coded Entries

This section defines a linking mechanism that allows entries or portions thereof to be connected to the text of the clinical document.

Standards

RIM	HL7 Version 3 Reference Information Model
CDAR2	HL7 Clinical Document Architecture Release 2.0

Constraints for CDA

Elements within the narrative <text> will use the ID attribute to provide a destination for links. Elements within an <entry> will be linked to the text via a URI reference using this attribute as the fragment identifier. This links the coded entry to the specific narrative text it is related to within the CDA instance, and can be traversed in either direction. This serves three purposes:

It supports diagnostics during software development and testing.
It provides a mechanism to enrich the markup that can be supported in the viewing application.
It eliminates the need to duplicate content in two places, which prevents a common source of error, and eliminates steps needed to validate that content that should be identical in fact is.

Each narrative content element within CDA may have an ID attribute. This attribute is of type xs:ID. This means that each ID in the document must be unique within that document. Within an XML document, an attribute of type xs:ID must start with a letter, and may be followed one or more letters, digits, hyphens or underscores . Three different examples showing the use of the ID attribute, and references to it appear below:

<td>Table Cell 2

</tr>

Example Uses of ID
Use of ID	References to ID
<tr ID='foo'> <td ID='bar'>Table Cell 1	<code> <originalText><reference value='#foo'></originalText> </code> <code> <originalText><reference value='#bar'></originalText> </code>
<list> <item ID='baz'>List item 1</item> </list>	<code> <originalText><reference value='#baz'></originalText> </code>
<paragraph ID='p-1'>A paragraph <content ID='c-1'>with content</content> </paragraph>	<code> <originalText><reference value='#p-1'></originalText> </code> <code> <originalText><reference value='#c-1'></originalText> </code>

This allows the text to be located with a special type of URI reference, which simply contains a fragment identifier. This URI is local to the document and so just begins with a hash mark (#), and is followed by the value of the ID being referenced. Given one of these URIs stored in a variable named theURI, the necessary text value can be found via the following XPath expression:

string(//*[@ID=substring-after('#',$theURI)])

The table below shows the result of this expression using the examples above:

URI Dereference Result
$theURI	Returned Value
"#bar"	"Table Cell 1"
"#foo"	"Table Cell 1Table Cell 2" (note the spacing issue between 1 and T)
"#p-1"	"A paragraph with content"
"#c-1"	"with content"

If your XSLT processor is schema aware, even more efficient mechanisms exist to locate the element than the above expression.

Having identified the critical text in the narrative, any elements using the HL7 CD datatype (e.g., <code>) can then contain a <reference> to the <originalText> found in the narrative. That is why, although CDA allows <value> to be of any type in <entry> elements, this profile restricts them to always be of xsi:type='CD'.

Now, given an item with an ID stored in a variable named theID all <reference> elements referring to it can be found via the following XPath expression:

//cda:reference[@URI=concat('#',$theID)]

Constraints for HL7 Version 3 Messages

Unlike CDA entries, structured statements in HL7 Version 3 Messages do not have a related narrative text section. Therefore full text representations should be included in the <text> element care statement acts.

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

Severity 1.3.6.1.4.1.19376.1.5.3.1.4.1

Any condition or allergy may be the subject of a severity observation. This structure is included in the target act using the <entryRelationship> element defined in the CDA Schema.

The example below shows the recording the condition or allergy severity, and is used as the context for the following sections.

Standards

PatCareStruct	HL7 Care Provision Domain (DSTU)
CCD	ASTM/HL7 Continuity of Care Document

Uses

See Templates using Severity

Specification

Severity Example

  <observation classCode='COND' moodCode='EVN'>


    <entryRelationship typeCode='SUBJ' inversionInd='true'>
      <observation classCode='OBS' moodCode='EVN'>
        <templateId root='2.16.840.1.113883.10.20.1.55'/>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1'/>
        <code code='SEV' displayName='Severity' 
          codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode' />
        <text><reference value='#severity-2'/></text>
        <statusCode code='completed'/>
        <value xsi:type='CD' code='H|M|L' 
          codeSystem='2.16.840.1.113883.5.1063' 
          codeSystemName='ObservationValue' />
      </observation>
    </entryRelationship>


  </observation>

This specification models a severity observation as a separate observation from the condition. While this model is different from work presently underway by various organizations (i.e., SNOMED, HL7, TermInfo), it is not wholly incompatible with that work. In that work, qualifiers may be used to identify severity in the coded condition observation, and a separate severity observation is no longer necessary. The use of qualifiers is not precluded by this specification. However, to support semantic interoperability between EMR systems using different vocabularies, this specification does require that severity information also be provided in a separate observation. This ensures that all EMR systems have equal access to the information, regardless of the vocabularies they support.

<entryRelationship typeCode='SUBJ' inversionInd='true'>

The related statement is made about the severity of the condition (or allergy). For CDA, this observation is recorded inside an <entryRelationship> element occurring in the condition, allergy or medication entry. The containing <entry> is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'. For HL7 Version 3 Messages this relationship is represented with a <sourceOf> element, however the semantics, typeCode, and inversionInd is unchanged.

<observation moodCode='EVN' classCode='OBS'>

The related statement is another event (moodCode='EVN') observing (<observation classCode='OBS'>) the severity of the (surrounding) related entry (e.g., a condition or allergy).

<templateId root='2.16.840.1.113883.10.20.1.55'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1'/>

The <templateId> elements identifies this <observation> as a severity observation, allowing for validation of the content. As a side effect, readers of the CDA can quickly locate and identify severity observations. The templateId elements shown above must be present.

<code code='SEV' codeSystem='2.16.840.1.113883.5.4' displayName='Severity' codeSystemName='ActCode' />

This observation is of severity, as indicated by the <code> element listed above. This element is required. The code and codeSystem attributes shall be recorded exactly as shown above.

<text><reference value='#severity-2'/></text>

The <observation> element shall contain a <text> element. For CDA, the <text> elements shall contain a <reference> element pointing to the narrative where the severity is recorded, rather than duplicate text to avoid ambiguity. For HL7 Version 3 Messages, the <text> element should contain the full narrative text.

<statusCode code='completed'/>

The code attribute of <statusCode> for all severity observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

<value xsi:type='CD' code='H|M|L' codeSystem='2.16.840.1.113883.5.1063' codeSystemName='SeverityObservation'>

The <value> element contains the level of severity. It is always represented using the CD datatype (xsi:type='CD'), even though the value may be a coded or uncoded string. If coded, it should use the HL7 SeverityObservation vocabulary (codeSystem='2.16.840.1.113883.5.1063') containing three values (H, M, and L), representing high, moderate and low severity depending upon whether the severity is life threatening, presents noticeable adverse consequences, or is unlikely substantially effect the situation of the subject.

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

Problem Status Observation 1.3.6.1.4.1.19376.1.5.3.1.4.1.1

Any problem or allergy observation may reference a problem status observation. This structure is included in the target observation using the <entryRelationship> element defined in the CDA Schema. The clinical status observation records information about the current status of the problem or allergy, for example, whether it is active, in remission, resolved, et cetera. The example below shows the recording of clinical status of a condition or allergy, and is used as the context for the following sections.

Standards

CCD	ASTM/HL7 Continuity of Care Document

Uses

See Templates using Problem Status Observation

Specification

Problem Status Observation Example

 <entry>
   <observation classCode='OBS' moodCode='EVN'>

     <entryRelationship typeCode='REFR' inversionInd='false'>
       <observation classCode='OBS' moodCode='EVN'>
         <templateId root='2.16.840.1.113883.10.20.1.57'/>
         <templateId root='2.16.840.1.113883.10.20.1.50'/>
         <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1.1'/>
         <code code='33999-4' displayName='Status' 
           codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />
         <text><reference value='#cstatus-2'/></text>
         <statusCode code='completed'/>
         <value xsi:type='CE' code=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
       </observation>
     </entryRelationship>

   </observation>
 </entry>

This CCD models a problem status observation as a separate observation from the problem, allergy or medication observation. While this model is different from work presently underway by various organizations (i.e., SNOMED, HL7, TermInfo), it is not wholly incompatible with that work. In that work, qualifiers may be used to identify problem status in the coded condition observation, and a separate clinical status observation is no longer necessary. The use of qualifiers in the problem observation is not precluded by this specification or by CCD. However, to support semantic interoperability between EMR systems using different vocabularies, this specification does require that problem status information also be provided in a separate observation. This ensures that all EMR systems have equal access to the information, regardless of the vocabularies they support.

<entryRelationship typeCode='REFR' inversionInd='false'>

The related statement is made about the clinical status of the problem or allergy. For CDA, this observation is recorded inside an <entryRelationship> element occurring in the problem or allergy. For HL7 Version 3 Messages, the <entryRelationship> tag name is <sourceOf>, though the typeCode and inversionInd attributes and other semantics remain the same. The containing observation refers to (typeCode='REFR') this new observation.

<observation moodCode='EVN' classCode='OBS'>

The related statement is another event (moodCode='EVN') observing (<observation classCode='OBS'>) the clinical status of the (surrounding) related observation (e.g., a problem or allergy).

<templateId root='2.16.840.1.113883.10.20.1.57'/>
<templateId root='2.16.840.1.113883.10.20.1.50'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1.1'/>

These <templateId> elements identify this <observation> as a problem status observation, allowing for validation of the content.

<code code='33999-4' codeSystem='2.16.840.1.113883.6.1' displayName='Status' codeSystemName='LOINC' />

This observation is of clinical status, as indicated by the <code> element. This element must be present. The code and codeSystem shall be recorded exactly as shown above.

<text><reference value='#cstatus-2'/></text>

The <observation> element shall contain a <text> element that points to the narrative text describing the clinical status. For CDA, the <text> elements shall contain a <reference> element pointing to the narrative section (see Linking Narrative and Coded Entries), rather than duplicate text to avoid ambiguity. For HL7 Version 3 Messages, the <text> element SHALL contain the full narrative text.

<statusCode code='completed'/>

The code attribute of <statusCode> for all clinical status observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

<value xsi:type='CE' code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'>

The <value> element contains the clinical status. It is always represented using the CE datatype (xsi:type='CE'). It shall contain a code from the following set of values from SNOMED CT.

Clinical Status Values
Code	Description
55561003	Active
73425007	Inactive
90734009	Chronic
7087005	Intermittent
255227004	Recurrent
415684004	Rule out
410516002	Ruled out
413322009	Resolved

Development Only

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Health Status 1.3.6.1.4.1.19376.1.5.3.1.4.1.2

A problem observation may reference a health status observation. This structure is included in the target observation using the <entryRelationship> element defined in the CDA Schema. The health status observation records information about the current health status of the patient. The example below shows the recording the health status, and is used as the context for the following sections.

Uses

See Templates using Health Status

Specification

Health Status Example

<entry>
 <observation classCode='OBS' moodCode='EVN'>

   <entryRelationship typeCode='REFR' inversionInd='false'>
     <observation classCode='OBS' moodCode='EVN'>
       <templateId root='2.16.840.1.113883.10.20.1.51'/>
       <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1.2'/>
       <code code='11323-3' displayName='Health Status' 
         codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />
       <text><reference value='#hstatus-2'/></text>
       <statusCode code='completed'/>
       </value>
       <value xsi:type='CE' code=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
     </observation>
   </entryRelationship>

 </observation>
</entry>

This specification models a health status observation as a separate observation about the patient.

<entryRelationship typeCode='REFR'>

The related statement is made about the health status of the patient. For CDA, this observation is recorded inside an <entryRelationship> element occurring in the observation. The contained observersation is referenced (typeCode='REFR') by the observation entry. For HL7 Version 3 Messages, the entryRelationship tagName is sourceOf, though the typeCode and inversionInd attributes and other semantics remain the same.

<observation moodCode='EVN' classCode='OBS'>

The related statement is another event (moodCode='EVN') observing (<observation classCode='OBS'>) the health status of the patient.

<templateId root='2.16.840.1.113883.10.20.1.51'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1.2'/>

The <templateId> element identifies this <observation> as a health status observation, allowing for validation of the content.

<code code='11323-3'
displayName='Health Status'
codeSystem='2.16.840.1.113883.6.1'
codeSystemName='LOINC' />

This observation is of health status, as indicated by the <code> element. This element must be present. The code and codeSystem attributes shall be recorded exactly as shown above.

<text><reference value='#hstatus-2'/></text>

The <observation> element shall contain a <text> element that contains the narrative text describing the clinical status. For CDA, the <text> elements shall contain a <reference> element pointing to the narrative section (see Linking Narrative and Coded Entries, rather than duplicate text to avoid ambiguity. For HL7 Version 3 Messages, the <text> element shall contain the full narrative text.

<statusCode code='completed'/>

The code attribute of <statusCode> for all health status observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

<value xsi:type='CE' code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'>

The <value> element contains the clinical status. It is always represented using the CE datatype (xsi:type='CE').

Health Status Codes
Code	Description
81323004	Alive and well
313386006	In remission
162467007	Symptom free
161901003	Chronically ill
271593001	Severely ill
21134002	Disabled
161045001	Severely disabled
419099009	Deceased

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

Comments 1.3.6.1.4.1.19376.1.5.3.1.4.2

This entry allows for a comment to be supplied with each entry. For CDA this structure is usually included in the target act using the <entryRelationship> element defined in the CDA Schema, but can also be used in the <component> element when the comment appears within an <organizer>. The example below shows recording a comment for an <entry>, and is used as context for the following sections. For HL7 Version 3 Messages, this relationship is represented with the element <sourceOf>, although the remainder of the typecodes and semantics are unchanged.

Any condition or allergy may be the subject of a comment.

Standards

CareStruct	HL7 Care Provision Care Structures (DSTU)
CCD	ASTM/HL7 Continuity of Care Document

Uses

See Templates using Comments

Specification

Comments Example

<entry>
  <observation classCode='OBS' moodCode='EVN'>
          ∶
    <entryRelationship typeCode='SUBJ' inversionInd='true'>
      <act classCode='ACT' moodCode='EVN'>
        <templateId root='2.16.840.1.113883.10.20.1.40'/>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>
        <code code='48767-8' displayName='Annotation Comment'
          codeSystem='2.16.840.1.113883.6.1'
          codeSystemName='LOINC' />
        <text><reference value='#comment-2'/></text>
        <statusCode code='completed' />
        <author>
          <time value=''/>
          <assignedAuthor>
            <id root='' extension=''>
            <addr></addr>
            <telecom value='' use=''>
            <assignedPerson><name></name></assignedPerson>
            <representedOrganization><name></name></representedOrganization>
          </assignedAuthor>
        </author>
      </act>
    </entryRelationship>
          ∶
  </observation>
</entry>
<entry>
  <organizer>
    <component typeCode='COMP'>
      <act classCode='ACT' moodCode='EVN'>
        <templateId root='2.16.840.1.113883.10.20.1.40'/>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>
        <code code='48767-8' displayName='Annotation Comment'
          codeSystem='2.16.840.1.113883.6.1'
          codeSystemName='LOINC' />
            :
      </act>
    </component>
  </organizer>
</entry>

<entryRelationship typeCode='SUBJ' inversionInd='true'> or <component typeCode='COMP'/>

A related statement is made about an act, or a cluster or battery of results. In CDA the former shall be recorded inside an <entryRelationship> element occurring at the end of the entry. The containing act is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'.

For HL7 Version 3 Messages, the relationship element is <sourceOf>, however the typeCode and inversionInd remain the same.

In the latter case, the comment shall be recorded inside a <commponent> element contained within the <organizer> element.

<act classCode='ACT' moodCode='EVN'>

The related statement is an event (moodCode='EVN') describing the act (classCode='ACT') of making an arbitrary comment or providing instruction on the related entry.

<templateId root='2.16.840.1.113883.10.20.1.40'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>

These <templateId> elements identify this <act> as a comment, allowing for validation of the content.

<code code='48767-8' displayName='Annotation Comment' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />

The <code> element indicates that this is a comment and shall be recorded as shown above. The codeSystem and code attributes shall use the values specified above.

<text><reference value='#comment-2'/></text>

The <text> element provides a way to represent the <reference> to the text of the comment in the narrative portion of the document. For CDA, this SHALL be represented as a <reference> element that points to the narrative text section of the CDA. The comment itself is not the act being coded, so it appears in the <text> of the <observation>, not as part of the <code>. For HL7 Version 3 Messages, the <text> element SHALL contain the full narrative text.

<statusCode code='completed' />

The code attribute of <statusCode> for all comments must be completed.

<author>

The comment may have an author.

The time of the comment creation shall be recorded in the element when the <author> element is present.

<assignedAuthor>
<id root=' ' extension=' '>
<addr></addr>
<telecom value=' ' use=' '>

The identifier of the author, and their address and telephone number must be present inside the <id>, <addr> and <telecom> elements when the <author> element is present.

<assignedPerson><name></name></assignedPerson>
<representedOrganization><name></name></representedOrganization>

The author's and/or the organization's name must be present when the <author> element is present.

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

Patient Medication Instructions 1.3.6.1.4.1.19376.1.5.3.1.4.3

Any medication may be the subject of further instructions to the patient, for example to indicate that it should be taken with food, et cetera.

This structure is included in the target substance administration or supply act using the <entryRelationship> element defined in the CDA Schema. The example below shows the recording of patient medication instruction for an <entry>, and is used as context for the following section.

Standards

Pharmacy

HL7 Pharmacy Domain (Normative)

Uses

See Templates using Patient Medication Instructions

Specification

Patient Medication Instructions Example

<entry>
 <substanceAdministration classCode='SBADM' moodCode='EVN'>
         ∶
   <entryRelationship typeCode='SUBJ' inversionInd='true'>
     <act classCode='ACT' moodCode='INT'>
       <templateId root='2.16.840.1.113883.10.20.1.49'/>
       <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.3'/>
       <code code='PINSTRUCT' codeSystem='1.3.6.1.4.1.19376.1.5.3.2'
         codeSystemName='IHEActCode' />
       <text><reference value='#comment-2'/></text>
       <statusCode code='completed' />
     </act>
   </entryRelationship>
         ∶
 </substanceAdministration>
</entry>

<entryRelationship typeCode='SUBJ' inversionInd='true'>

Again, a related statement is made about the medication or immunization. This observation is recorded inside an <entryRelationship> element occurring at the end of the substance administration or supply entry. The containing <entry> is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'.

<act classCode='ACT' moodCode='INT'>

The related statement is the intent (moodCode='INT') on how the related entry is to be performed. .

<templateId root='2.16.840.1.113883.10.20.1.49'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.3'/>

These <templateId> elements identify this <act> as a medication instruction, allowing for validation of the content. As a side effect, readers of the CDA can quickly locate and identify medication instructions.

<code code='PINSTRUCT' codeSystem='1.3.6.1.4.1.19376.1.5.3.2' codeSystemName='IHEActCode' />

The <code> element indicates that this is a patient medication instruction. This element shall be recorded exactly as specified above.

Note:

These values will be sent to HL7 for harmonization with the HL7 Act Vocabulary.

<text><reference value='#comment-2'/></text>

The <text> element indicates the text of the comment. For CDA, this SHALL be represented as a <reference> element that points at the narrative portion of the document. The comment itself is not the act being coded, so it appears in the <text> of the <observation>, not as part of the <code>. For HL7 Version 3 Messages, the full text SHALL be represented here.

<statusCode code='completed' />

The code attribute of <statusCode> for all comments must be completed.

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Medication Fulfillment Instructions 1.3.6.1.4.1.19376.1.5.3.1.4.3.1

Any medication may be the subject of further instructions to the pharmacist, for example to indicate that it should be labeled in Spanish, et cetera.

This structure is included in the target substance administration or supply act using the <entryRelationship> element defined in the CDA Schema. The figure below is an example of recording an instruction for an <entry>, and is used as context for the following sections.

Standards

Pharmacy

HL7 Pharmacy Domain (Normative)

Uses

See Templates using Medication Fulfillment Instructions

Specification

Medication Fulfillment Instructions Example

<entry>
 <supply classCode='SPLY' moodCode='EVN'>
         ∶
   <entryRelationship typeCode='SUBJ' inversionInd='true'>
     <act classCode='ACT' moodCode='INT'>
       <templateId root='2.16.840.1.113883.10.20.1.43'/>
       <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.3.1'/>
       <code code='FINSTRUCT' codeSystem='1.3.6.1.4.1.19376.1.5.3.2'
         codeSystemName='IHEActCode' />
       <text><reference value='#comment-2'/></text>
       <statusCode code='completed' />
     </act>
   </entryRelationship>
         ∶
 </supply>
</entry>

<entryRelationship typeCode='SUBJ' inversionInd='true'>

Again, a related statement is made about the medication or immunization. In CDA, this observation is recorded inside an <entryRelationship> element occurring at the end of the substance administration or supply entry. The containing <act> is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'. For HL7 Version 3 Messages, this relationship is represented with the <sourceOf> element however the semantics, typeCode, and inversionInd remain the same.

<act classCode='ACT' moodCode='INT'>

The related statement is the intent (moodCode='INT') on how the related entry is to be performed.

<templateId root='2.16.840.1.113883.10.20.1.43'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.3.1'/>

These <templateId> elements identify this <act> as a medication fulfillment instruction, allowing for validation of the content.

<code code='FINSTRUCT' codeSystem='1.3.6.1.4.1.19376.1.5.3.2' codeSystemName='IHEActCode' />

The <code> element indicates that this is a medication fulfillment instruction. This element shall be recorded exactly as specified above.

Note:

These values will be sent to HL7 for harmonization with the HL7 Act Vocabulary.

<text><reference value='#comment-2'/></text>

The <text> element contains a free text representation of the instruction. For CDA this SHALL contain a provides a <reference>element to thelink text of the comment in the narrative portion of the document. The comment itself is not the act being coded, so it appears in the <text> of the <observation>, not as part of the <code>. For HL7 Version 3 Messages, the full text SHALL be represented here.

<statusCode code='completed' />

The code attribute of <statusCode> for all comments must be completed.

References

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External References 1.3.6.1.4.1.19376.1.5.3.1.4.4

CDA Documents may reference information contained in other documents. While CDA Release 2.0 supports references in content via the <linkHtml> element, this is insufficient for many EMR systems as the link is assumed to be accessible via a URL, which is often not the case. In order to link an external reference, one needs the document identifier, and access to the clinical system wherein the document resides. For a variety of reasons, it is desirable to refer to the document by its identity, rather than by linking through a URL.

The identity of a document does not change, but the URLs used to access it may vary depending upon location, implementation, or other factors.
Referencing clinical documents by identity does not impose any implementation specific constraints on the mechanism used to resolve these references, allowing the content to be implementation neutral. For example, in the context of an XDS Affinity domain the clinical system used to access documents would be an XDS Registry and one or more XDS Repositories where documents are stored. In other contexts, access might be through a Clincial Data Repository (CDR), or Document Content Management System (DCMS). Each of these may have different mechanisms to resolve a document identifier to the document resource.
The identity of a document is known before the document is published (e.g., in an XDS Repository, Clincial Data Repository, or Document Content Management System), but its URL is often not known. Using the document identity allows references to existing documents to be created before those documents have been published to a URL. This is important to document creators, as it does not impose workflow restrictions on how links are created during the authoring process.

Fortunately, CDA Release 2.0 also provides a mechanism to refer to external documents in an entry, as shown below.

Uses

See Templates using External References

Specification

External References Example

<entry>
  <act classCode='ACT' moodCode='EVN'> 
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
    <id root='' extension=''/>
    <code nullFlavor='NA' />
    <text><reference value='#study-1'/></text>
    <!-- For CDA -->
    <reference typeCode='REFR|SPRT'>
      <externalDocument classCode='DOC' moodCode='EVN'>
        <id extension='' root=''/>
        <text><reference value='http://foo..'/></text>
      </externalDocument>
    </reference>
    <!-- For HL7 Version 3 Messages
    <sourceOf typeCode='REFR|SPRT'>
       <act classCode='DOC' moodCode='EVN'>
          <id extension='' root=''/>
          <text><reference value='http://foo…'</text>
       </act>
    </sourceOf>
     -->
  </act>
</entry>

<act classCode='ACT' moodCode='EVN'>

The external reference is an act that refers to documentation of an <act> (classCode='ACT'), that previously occurred (moodCode='EVN').

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>

The <templateId> element identifies this <act> as a reference act, allowing for validation of the content. As a side effect, readers of the CDA can quickly locate and identify reference acts. The templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.4.1.4.4'.

<id root=' ' extension=' '/>

The reference is an act of itself, and must be uniquely identified. If there is no explicit identifier for this act in the source EMR system, a GUID may be used for the root attribute, and the extension may be omitted. Although HL7 allows for multiple identifiers, this profile requires that one and only one be used.

<code nullFlavor='NA'/>

The reference act has no code associated with it.

<text><reference value='#study-1'/></text>

In order to connect this external reference to the narrative text which it refers, the value of the <reference> element in the <text> element is a URI to an element in the CDA narrative of this document.

<reference typeCode='SPRT|REFR'>
<externalDocument classCode='DOC' moodCode='EVN'>

External references are listed as either supporting documentation (typeCode='SPRT') or simply reference material (typeCode='REFR') for the reader. If this distinction is not supported by the source EMR system, the value of typeCode should be REFR. For CDA, the reference is indicated by a <reference> element containing an <externalDocument> element which documents (classCode='DOC') the event (moodCode='EVN'). For HL7 Version 3 Messages, the reference is represented with the element <sourceOf> and the external document is representated with a <act> element, however semantics, and attributes remain otherwise without change.

<id extension=' ' root=' '/>

The identifier of the document is supplied in the <id> element.

<text><reference value=' '/></text>

A link to the original document may be provided here. This shall be a URL where the referenced document can be located. For CDA, the link should also be present in the narrative inside the CDA Narrative in a <linkHTML> element.

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

Internal References 1.3.6.1.4.1.19376.1.5.3.1.4.4.1

CDA and HL7 Version 3 Entries may reference (point to) information contained in other entries within the same document or message as shown below.

Uses

See Templates using Internal References

Specification

Internal References Example

          ∶
  <entryRelationship typeCode='' inversionInd='true|false'>
      <act classCode='' moodCode=''>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
        <id root='' extension=''/>
        <code code='' displayName='' codeSystem='' codeSystemName=''/>
      </act>
  </entryRelationship>

<entryRelationship typeCode=' ' inversionInd='true|false'>

For CDA the act being referenced appears inside a related entryRelationship. The type (typeCode) and direction (inversionInd) attributes will be specified in the entry content module that contains the reference. For HL7 Version 3 Messages, the relationship is indicated with a <sourceOf> element, however typeCodes and semantics remain unchanged.

<act classCode=' ' moodCode=' '>

The act being referred to can be any CDA Clinical Statement element type (act, procedure, observation, substanceAdministration, supply, et cetera). For compatibility with the Clinical Statement model the internal reference shall always use the <act> class, regardless of the XML element type of the act it refers to.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>

The <templateId> element identifies this as an internal reference that conforms to all rules specified in this section.

<id root=' ' extension=' '/>

This element shall be present. The root and extension attributes shall identify an element defined elsewhere in the same document.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

This element shall be present. It shall be valued when the internal reference is to element that has a <code> element, and shall have the same attributes as the <code> element in the act it references. If the element it references does not have a <code> element, then the nullFlavor attribute should be set to "NA".

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Concern Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5.1

This event (moodCode='EVN') represents an act (<act classCode='ACT') of being concerned about a problem, allergy or other issue. The <effectiveTime> element describes the period of concern. The subject of concern is one or more observations about related problems (see 1.3.6.1.4.1.19376.1.5.3.1.4.5.2) or allergies and intolerances (see 1.3.6.1.4.1.19376.1.5.3.1.4.5.3). Additional references can be provided having additional information related to the concern. The concern entry allows related acts to be grouped. This allows representing the history of a problem as a series of observation over time, for example.

Standards

CCD	ASTM/HL7 Continuity of Care Document
CareStruct	HL7 Care Provision Care Structures (DSTU)
ClinStat	ClinStat HL7 Clinical Statement (DRAFT)

Uses

See Templates using Concern Entry

Specification

Concern Entry Example

<act classCode='ACT' moodCode='EVN'>
  <templateId root='2.16.840.1.113883.10.20.1.27'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
  <id root='' extension=''/>
  <code nullFlavor='NA'/>
  <statusCode code='active|suspended|aborted|completed'/>
  <effectiveTime>
    <low value=''/>
    <high value=''/>
  </effectiveTime>
  <!-- one or more entry relationships identifying problems of concern -->
  <entryRelationship typeCode='SUBJ' inversionInd='false'>
     :
  </entryRelationship>
  <!-- For HL7 Version 3 Messages 
  <sourceOf typeCode='SUBJ' inversionInd='false'>
     :
  </sourceOf>
  -->
  <!-- optional entry relationship providing more information about the concern -->
  <entryRelationship typeCode='REFR'>
     :
  </entryRelationship>
  <!-- For HL7 Version 3 Messages 
  <sourceOf typeCode='REFR' inversionInd='false'>
     :
  </sourceOf>
  -->

</act>

<act classCode='ACT' moodCode='EVN'>

All concerns reflect the act of recording (<act classCode='ACT'>) the event (moodCode='EVN') of being concerned about a problem, allergy or other issue about the patient condition.

<templateId root='2.16.840.1.113883.10.20.1.27'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>

These template identifiers indicates this entry conforms to the concern content module. This content module inherits constraints from the HL7 CCD Template for problem acts, and so also includes that template identifier.

<id root=' ' extension=' '/>

This required element identifies the concern.

<code nullFlavor='NA'/>

The code is not applicable to a concern act, and so shall be recorded as shown above.

<statusCode code='active|suspended|aborted|completed'/>

The statusCode associated with any concern must be one of the following values:

Status Code Values
Value	Description
active	A concern that is still being tracked.
suspended	A concern that is active, but which may be set aside. For example, this value might be used to suspend concern about a patient problem after some period of remission, but before assumption that the concern has been resolved.
aborted	A concern that is no longer actively being tracked, but for reasons other than because the problem was resolved. This value might be used to mark a concern as being aborted after a patient leaves care against medical advice.
completed	The problem, allergy or medical state has been resolved and the concern no longer needs to be tracked except for historical purposes.

Note:

A concern in the "active" state represents one for which some ongoing clinical activity is expected, and that no activity is expected in other states. Specific uses of the suspended and aborted states are left to the implementation.

<effectiveTime><low value=' '/><high value=' '/></effectiveTime>

The <effectiveTime> element records the starting and ending times during which the concern was active. The <low> element shall be present. The <high> element shall be present for concerns in the completed or aborted state, and shall not be present otherwise.

<entryRelationship type='SUBJ' inversionInd='false'>

Each concern is about one or more related problems or allergies. This entry shall contain one or more problem or allergy entries that conform to the specification in section Problem Entry or Allergies and Intolerances. This is how a series of related observations can be grouped as a single concern.

For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element. The typeCode SHALL be ‘SUBJ’ for both HL7 Version 3 and CDA. HL7 Version 3 additionally requires that inversionInd SHALL be ‘false’.

Note:

The Allergy and Intolerances entry is a refinement of the Problem entry.

<entryRelationship type='REFR' inversionInd='false'>

Each concern may have 0 or more related references. These may be used to represent related statements such related visits. This may be any valid CDA clinical statement, and SHOULD be an IHE entry template. For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <subjectOf> element. The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘false’

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Problem Concern Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5.2

This entry is a specialization of the Concern Entry, wherein the subject of the concern is focused on a problem. Elements shown in the example below in gray are explained in the Concern Entry.

Standards

CCD	ASTM/HL7 Continuity of Care Document
CareStruct	HL7 Care Provision Care Structures (DSTU)
ClinStat	HL7 Clinical Statement Pattern (Draft)

Parent Template

The parent of this template is Concern Entry. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.27

Uses

See Templates using Problem Concern Entry

Specification

Problem Concern Entry Example

<act classCode='ACT' moodCode='EVN'>
 <templateId root='2.16.840.1.113883.10.20.1.27'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/>
 <id root=' ' extension=' '/>
 <code nullFlavor='NA'/>
 <statusCode code='active|suspended|aborted|completed'/>
 <effectiveTime>
   <low value=' '/>
   <high value=' '/>
 </effectiveTime>
 <!-- 1..* entry relationships identifying problems of concern -->
 <entryRelationship type='SUBJ'>
   <observation classCode='OBS' moodCode='EVN'/>
      <templateID root='1.3.6.1.4.1.19376.1.5.3.1.4.5'>
        :
   </observation>
 </entryRelationship>
 <!-- optional entry relationship providing more information about the concern -->
 <entryRelationship type='REFR'>
 </entryRelationship>
</act>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/>

This entry has a template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5.2, and is a subtype of the Concern Entry, and so must also conform to that specification, with the template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5.1. These elements are required and shall be recorded exactly as shown above.

<observation classCode='OBS' moodCode='EVN'>
<templateID root=' 1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
…
</observation>
<entryRelationship type='SUBJ'>

This entry shall contain one or more problem entries that conform to the Problem Entry template 1.3.6.1.4.1.19376.1.5.3.1.4.5. For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <subjectOf> element. The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘false’

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

Allergy and Intolerance Concern 1.3.6.1.4.1.19376.1.5.3.1.4.5.3

This entry is a specialization of the Concern Entry, wherein the subject of the concern is focused on an allergy or intolerance. Elements shown in the example below in gray are explained in that entry.

Standards

CCD	ASTM/HL7 Continuity of Care Document
CareStruct	HL7 Care Provision Care Structures (DSTU)
ClinStat	HL7 Clinical Statement Pattern (Draft)

Parent Template

The parent of this template is Concern Entry. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.27

Uses

See Templates using Allergy and Intolerance Concern

Specification

Allergy and Intolerance Concern Example

<act classCode='ACT' moodCode='EVN'>
 <templateId root='2.16.840.1.113883.10.20.1.27'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.3'/>
 <id root=' ' extension=' '/>
 <code nullFlavor='NA'/>
 <statusCode code='active|suspended|aborted|completed'/>
 <effectiveTime>
   <low value=' '/>
   <high value=' '/>
 </effectiveTime>
 <!-- 1..* entry relationships identifying allergies of concern -->
 <entryRelationship typeCode='SUBJ'>
   <observation classCode='OBS' moodCode='EVN'/>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6'/>
        :
   </observation> 
 </entryRelationship>
 <!-- optional entry relationship providing more information about the concern -->
 <entryRelationship type='REFR'>
 </entryRelationship>
</act>

<templateId root='2.16.840.1.113883.10.20.1.27'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.3'/>

This entry has a template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5.3, and is a subtype of the Concern entry, and so must also conform to the rules of the Concern Entry. These elements are required and shall be recorded exactly as shown above.

<observation classCode='OBS' moodCode='EVN'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6'/>
:
</observation>
<entryRelationship typeCode='SUBJ'>

This entry shall contain one or more allergy or intolerance entries that conform to the Allergy and Intolerance Entry. For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element. The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘false’

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

Problem Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5

This section makes use of the linking, severity, clinical status and comment content specifications defined elsewhere in the technical framework. In HL7 RIM parlance, observations about a problem, complaint, symptom, finding, diagnosis, or functional limitation of a patient is the event (moodCode='EVN') of observing (<observation classCode='OBS'>) that problem. The <value> of the observation comes from a controlled vocabulary representing such things. The <code> contained within the <observation> describes the method of determination from yet another controlled vocabulary. An example appears below in the figure below.

Standards

CCD	ASTM/HL7 Continuity of Care Document
CareStruct	HL7 Care Provision Care Structures (DSTU)
ClinStat	HL7 Clinical Statement Pattern (Draft)

Parent Template

This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.28

Uses

See Templates using Problem Entry

Specification

Problem Entry Example

<observation classCode='OBS' moodCode='EVN' negationInd=' false|true '>
 <templateId root='2.16.840.1.113883.10.20.1.28'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
 <id root=' ' extension=' '/>
 <code code=' ' displayName=' '
   codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
 <text><reference value=' '/></text>
 <statusCode code='completed'/>
 <effectiveTime><low value=' '/><high value=' '/></effectiveTime>
 <value xsi:type='CD' code=' ' 
   codeSystem=' ' displayName=' ' codeSystemName=' '>
   <originalText><reference value=' '/></originalText>
 </value>
 <
 <!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements
      identifying the health status of concern -->
 <!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements
      containing clinical status -->
 <!-- zero to many <entryRelationship typeCode='REFR' inversionInd='true'> elements
      containing comments -->
</observation>

<observation classCode='OBS' moodCode='EVN' negationInd='false|true'>

The basic pattern for reporting a problem uses the CDA <observation> element, setting the classCode='OBS' to represent that this is an observation of a problem, and the moodCode='EVN', to represent that this is an observation that has in fact taken place. The negationInd attribute, if true, specifies that the problem indicated was observed to not have occurred (which is subtly but importantly different from having not been observed). The value of negationInd should not normally be set to true. Instead, to record that there is "no prior history of chicken pox", one would use a coded value indicated exactly that. However, it is not always possible to record problems in this manner, especially if using a controlled vocabulary that does not supply pre-coordinated negations , or which do not allow the negation to be recorded with post-coordinated coded terminology.

<templateId root='2.16.840.1.113883.10.20.1.28'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>

These <templateId> elements identify this <observation> as a problem, under both IHE and CCD specifications. This SHALL be included as shown above.

<id root=' ' extension=' '/>

The specific observation being recorded must have an identifier (<id>) that shall be provided for tracking purposes. If the source EMR does not or cannot supply an intrinsic identifier, then a GUID shall be provided as the root, with no extension (e.g., <id root='CE1215CD-69EC-4C7B-805F-569233C5E159'/>). While CDA allows for more than one identifier element to be provided, this profile requires that only one be used.

<code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'>

The <code> describes the process of establishing a problem. The code element should be used, as the process of determining the value is important to clinicians (e.g., a diagnosis is a more advanced statement than a symptom). The recommended vocabulary for describing problems is shown in the table below. Subclasses of this content module may specify other vocabularies. When the list below is used, the codeSystem is '2.16.840.1.113883.6.96' and codeSystemName is SNOMED CT.

Problem Codes
Code	Description
64572001	Condition
418799008	Symptom
404684003	Finding
409586006	Complaint
248536006	Functional limitation
55607006	Problem
282291009	Diagnosis

<text><reference value=' '/></text>

The <text> element is required and points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.

<statusCode code='completed'/>

A clinical document normally records only those condition observation events that have been completed, not observations that are in any other state. Therefore, the <statusCode> shall always have code='completed'.

<effectiveTime><low value=' '/><high value=' '/></effectiveTime>

The <effectiveTime> of this <observation> is the time interval over which the <observation> is known to be true. The <low> and <high> values should be no more precise than known, but as precise as possible. While CDA allows for multiple mechanisms to record this time interval (e.g. by low and high values, low and width, high and width, or center point and width), we are constraining Medical summaries to use only the low/high form. The <low> value is the earliest point for which the condition is known to have existed. The <high> value, when present, indicates the time at which the observation was no longer known to be true. Thus, the implication is made that if the <high> value is specified, that the observation was no longer seen after this time, and it thus represents the date of resolution of the problem. Similarly, the <low> value may seem to represent onset of the problem. Neither of these statements is necessarily precise, as the <low> and <high> values may represent only an approximation of the true onset and resolution (respectively) times. For example, it may be the case that onset occurred prior to the <low> value, but no observation may have been possible before that time to discern whether the condition existed prior to that time. The <low> value should normally be present. There are exceptions, such as for the case where the patient may be able to report that they had chicken pox, but are unsure when. In this case, the <effectiveTime> element shall have a <low> element with a nullFlavor attribute set to 'UNK'. The <high> value need not be present when the observation is about a state of the patient that is unlikely to change (e.g., the diagnosis of an incurable disease).

<value xsi:type='CD' code=' ' codeSystem=' ' codeSystemName=' ' displayName=' '>

The <value> is the condition that was found. This element is required. While the value may be a coded or an un-coded string, the type is always a coded value (xsi:type='CD'). If coded, the code and codeSystem attributes shall be present. The codeSystem should reference a controlled vocabulary describing problems, complaints, symptoms, findings, diagnoses, or functional limitations, e.g., ICD-9, SNOMED-CT or MEDCIN, or others. The table below is an incomplete listing of acceptable values for the codeSystem attribute, along with the codeSystemName.

Example Problem Vocabularies
CodeSystem	codeSystemName	Description
2.16.840.1.113883.6.96	SNOMED-CT	SNOMED Controlled Terminology
2.16.840.1.113883.6.103	ICD-9CM (diagnoses)	International Classification of Diseases, Clinical Modifiers, Version 9
2.16.840.1.113883.6.26	MEDCIN	A classification system from MEDICOMP Systems.

It is recommended that the codeSystemName associated with the codeSystem, and the displayName for the code also be provided for diagnostic and human readability purposes, but this is not required by this profile.

If uncoded, all attributes other than xsi:type='CD' must be absent.

In cases where information about a problem or allergy is unknown or where there are no problems or allergies, an entry shall use codes from the table below to record this fact:

Entry Type	Code	Display Name	Description
Problem	396782006	Past Medical History Unknown	To indicate unknown medical history
Problem	407559004	Family History Unknown	To indicate that the patient's family history is not known.
Problem	160243008	No Significant Medical History	To indicate no relevant medical history
Problem	160245001	No current problems or disability	To indicate that the patient has no current problems (as distinct from no history).
Allergy	409137002	No Known Drug Allergies	To indicate that there are no known Drug allergies for this patient.
Allergy	160244002	No Known Allergies	To indicate that there are no known allergies for this patient.
Allergy	64970000	Substance Type Unknown	To indicate the state where there is a known allergy or intollerance to an unknown substance

<originalText><reference value=' '/></originalText>

The <value> contains a <reference> to the <originalText> in order to link the coded value to the problem narrative text (minus any dates, comments, et cetera). The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.

An optional <entryRelationship> element may be present indicating the severity of the problem. When present, this <entryRelationship> element shall contain a severity observation conforming to the Severity entry template (1.3.6.1.4.1.19376.1.5.3.1.4.1).

For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <subjectOf> element. The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘true’.

An optional <entryRelationship> may be present indicating the clinical status of the problem, e.g., resolved, in remission, active. When present, this <entryRelationship> element shall contain a clinical status observation conforming to the Problem Status Observation template (1.3.6.1.4.1.19376.1.5.3.1.4.1.1).

For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element. The typeCode SHALL be ‘REFR’ and inversionInd SHALL be ‘false’.

An optional <entryRelationship> may be present referencing the health status of the patient, e.g., resolved, in remission, active. When present, this <entryRelationship> element shall contain a clinical status observation conforming to the Health Status Observation template (1.3.6.1.4.1.19376.1.5.3.1.4.1.2). The typeCode SHALL be ‘REFR’ and inversionInd SHALL be ‘false’.

For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element.

One or more optional <entryRelationship> elements may be present providing an additional comments (annotations) for the condition. When present, this <entryRelationship> element shall contain a comment observation conforming to the Comment entry template (1.3.6.1.4.1.19376.1.5.3.1.4.2). The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘true’.

For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element.

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

Allergies and Intolerances 1.3.6.1.4.1.19376.1.5.3.1.4.6

Allergies and intolerances are special kinds of problems, and so are also recorded in the CDA <observation> element, with classCode='OBS'. They follow the same pattern as the problem entry, with exceptions noted below.

Standards

CCD	ASTM/HL7 Continuity of Care Document
CareStruct	HL7 Care Provision Care Structures (DSTU)
ClinStat	HL7 Clinical Statement Pattern (Draft)

Uses

See Templates using Allergies and Intolerances

Specification

Allergies and Intolerances Example

<observation classCode='OBS' moodCode='EVN' negationInd='false'>
 <templateId root='2.16.840.1.113883.10.20.1.18'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
 <id root=' ' extension=' '/>
 <code 
   code='ALG|OINT|DALG|EALG|FALG|DINT|EINT|FINT|DNAINT|ENAINT|FNAINT' 
   codeSystem='2.16.840.1.113883.5.4' 
   codeSystemName='ObservationIntoleranceType'/>
 <text><reference value=' '/></text>
 <statusCode code='completed'/>
 <effectiveTime>
   <low value=' '/>
   <high value=' '/>
 </effectiveTime>
 <value xsi:type='CD' code=' ' codeSystem=' ' displayName=' ' codeSystemName=' '/>
 <participant typeCode='CSM'>
   <participantRole classCode='MANU'>
     <playingEntity classCode='MMAT'>
       <code  code=' ' codeSystem=' '>
         <originalText><reference value='#substance'/></originalText>
       
       <name></name>
     </playingEntity>
   </participantRole>
 </participant>
 <!-- zero to many <entryRelationship> elements containing reactions -->
 <!-- zero or one <entryRelationship> elements containing severity -->
 <!-- zero or one <entryRelationship> elements containing clinical status -->
 <!-- zero to many <entryRelationship> elements containing comments -->
</observation>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6'/>

This entry has a template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.6, and is a subtype of the Problem Entry, and so must also conform to the rules of the problem entry, which has the template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5. These elements are required and shall be recorded exactly as shown above.

<code code='ALG|OINT|DINT|EINT|FINT|DALG|EALG|FALG|DNAINT|ENAINT|FNAINT' displayName=' ' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ObservationIntoleranceType'/>

The <code> element represents the kind of allergy observation made, to a drug, food or environmental agent, and whether it is an allergy, non-allergy intolerance, or unknown class of intolerance (not known to be allergy or intolerance). The <code> element of an allergy entry shall be provided, and a code and codeSystem attribute shall be present. The example above uses the HL7 ObservationIntoleranceType vocabulary domain, which does provide suitable observation codes. Other vocabularies may be used, such as SNOMED-CT or MEDCIN. The displayName and codeSystemName attributes should be present.

<value xsi:type='CD' code=' ' codeSystem=' ' codeSystemName=' ' displayName=' '>

The <value> is a description of the allergy or adverse reaction. While the value may be a coded or an uncoded string, the type is always a coded value (xsi:type='CD'). If coded, the code and codeSystem attributes must be present. The codingSystem should reference a controlled vocabulary describing allergies and adverse reactions, see Table 5.4 12Table 5.4 12 above . If uncoded, all attributes other than xsi:type='CD' must be absent. The allergy or intolerance may not be known, in which case that fact shall be recorded appropriately. This might occur in the case where a patient experiences an allergic reaction to an unknown substance.

<participant typeCode='CSM'>
<participantRole classCode='MANU'>
<playingEntity classCode='MMAT'>

The substance that causes the allergy or intolerance may be specified in the <participant> element.

<code code=' ' codeSystem=' '>
<originalText><reference value=' '/></originalText>

The <code> element shall be present. It may contain a code and codeSystem attribute to indicate the code for the substance causing the allergy or intolerance. It shall contain a <reference> to the <originalText> in the narrative where the substance is named.

An allergy entry can record the reactions that are manifestations of the allergy or intolerance as shown below.

Adverse Reaction Example

<entryRelationship typeCode='MFST'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6.1'/>
  <!-- a problem entry  -->
  <observation classCode='OBS' moodCode='EVN'>
    <templateId root='2.16.840.1.113883.10.20.1.54'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
      ∶
  </observation>
</entryRelationship>

<entryRelationship typeCode='MFST'>

This is a related entry (<entryRelationship>) that indicates the manifestations (typeCode='MFST') the reported allergy or intolerance. These are events that may occur, or have occurred in the past as a reaction to the allergy or intolerance.

<observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.54'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
∶
</observation>

The entry contained with this entry relationship is some sort of problem that is a manifestation of the allergy. It is recorded using the Problem Entry structure, with the additional template identifier (2.16.840.1.113883.10.20.1.54) indicating that this problem is a reaction.

An optional <entryRelationship> element may be present indicating the severity of the problem. When present, this <entryRelationship> element shall contain a severity observation conforming to the Severity entry template (1.3.6.1.4.1.19376.1.5.3.1.4.1). For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element. The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘true’.

An optional <entryRelationship> may be present indicating the clinical status of the allergy, e.g., resolved, in remission, active. When present, this <entryRelationship> element shall contain a clinical status observation conforming to the Problem Status Observation template (1.3.6.1.4.1.19376.1.5.3.1.4.1.1). The typeCode SHALL be ‘REFR’ and inversionInd SHALL be ‘false’. For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element.

One or more optional <entryRelationship> elements may be present providing an additional comments (annotations) for the allergy. When present, this <entryRelationship> element shall contain an entry conforming to the Comment entry template (1.3.6.1.4.1.19376.1.5.3.1.4.2). The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘true’.

For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element.

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

Medications 1.3.6.1.4.1.19376.1.5.3.1.4.7

This content module describes the general structure for a medication. All medication administration acts will be derived from this content module.

Standards

Pharmacy	HL7 Pharmacy Domain (Normative)
CCD	ASTM/HL7 Continuity of Care Document

Uses

See Templates using Medications

Specification

Medications Example

<substanceAdministration classCode='SBADM' moodCode='INT|EVN'>
  <templateId root='2.16.840.1.113883.10.20.1.24'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/>
  <templateId root=''/>
  <id root='' extension=''/>
  <code code='' codeSystem='' displayName='' codeSystemName=''/>
  <text><reference value='#med-1'/></text>
  <statusCode code='completed'/>
  <effectiveTime xsi:type='IVL_TS'>
      <low value=''/>
      <high value=''/>
  </effectiveTime>
  <effectiveTime operator='A' xsi:type='TS|PIVL_TS|EIVL_TS|PIVL_PPD_TS|SXPR_TS'>
    :
  </effectiveTime>
  <routeCode code='' codeSystem='' displayName='' codeSystemName=''/>
  <doseQuantity value='' unit=''/>
  <approachSiteCode code='' codeSystem='' displayName='' codeSystemName=''/>
  <rateQuantity value='' unit=''/>
  <consumable>
    :
    .
  </consumable>
  <!-- 0..* entries describing the components -->
  <entryRelationship typeCode='COMP' >
      <sequenceNumber value=''/>
  </entryRelationship>
  <!-- An optional entry relationship that indicates the the reason for use -->
  <entryRelationship typeCode='RSON'>
    <act classCode='ACT' moodCode='EVN'>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
      <id root='' extension=''/>
    </act>
  </entryRelationship>
  <!-- An optional entry relationship that provides prescription activity -->
  <entryRelationship typeCode='REFR'>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>
      :
      .
  </entryRelationship>
  <precondition>
    <criterion>
      <text><reference value=''></text>
    </criterion>
  </precondition>
</substanceAdministation>

This section makes use of the linking, severity and instruction entries.

Medications are perhaps the most difficult data elements to model due to variations in the ways that medications are prescribed.

This profile identifies the following relevant fields of a medication as being important to be able to generate in a medical summary. The table below identifies and describes these fields, and indicates the constraints on whether or not they are required to be sent. The fields are listed in the order that they appear in the CDA XML content.

Medication Fields

Medication Fields
Field	Opt.	CDA Tag	Description
Start and Stop Date	R2	<effectiveTime>	The date (and time if available) when the medication regimen began and is expected to finish. The first component of the <effectiveTime> encodes the lower and upper bounds over which the <substanceAdministration> occurs, and the start time is determined from the lower bound. If the medication has been known to be stopped, the high value must be present, but expressed as a flavor of null (e.g., Unknown).
Frequency	R2	<effectiveTime>	The frequency indicates how often the medication is to be administered. It is often expressed as the number of times per day, but which may also include information such as 1 hour before/after meals, or in the morning, or evening.The second <effectiveTime> element encodes the frequency. In cases where split or tapered doses are used, these may be found in subordinate <substanceAdministration> elements.
Route	R2	<routeCode>	The route is a coded value, and indicates how the medication is received by the patient (by mouth, intravenously, topically, et cetera).
Dose	R2	<doseQuantity>	The amount of the medication given. This should be in some known and measurable unit, such as grams, milligrams, et cetera. It may be measured in "administration" units (such as tablets or each), for medications where the strength is relevant. In this case, only the unit count is specified , no units are specified. It may be a range.
Site	O	<approachSiteCode>	The site where the medication is administered, usually used with IV or topical drugs.
Rate	R2	<rateQuantity>	The rate is a measurement of how fast the dose is given to the patient over time (e.g., .5 liter / 1 hr), and is often used with IV drugs.
Product	R¹	<consumable> <name> </consumable>	The name of the substance or product. This should be sufficient for a provider to identify the kind of medication. It may be a trade name or a generic name. This information is required in all medication entries. If the name of the medication is unknown, the type, purpose or other description may be supplied. The name should not include packaging, strength or dosing information. Note: Due to restrictions of the CDA schema, there is no way to explicitly link the name to the narrative text.
Strength	R2	<consumable> <code> <originalText/> </consumable>	The name and strength of the medication. This information is only relevant for some medications, as the dose of the medication is often sufficient to indicate how much medication the patient receives. For example, the medication Percocet comes in a variety of strengths, which indicate specific amounts of two different medications being received in single tablet. Another example is eye-drops, where the medication is in a solution of a particular strength, and the dose quantity is some number of drops. The originalText referenced by the <code> element in the consumable should refer to the name and strength of the medication in the narrative text.Note: Due to restrictions of the CDA schema, there is no way to separately record the strength.
Code	R2	<consumable> <code/> </consumable>	A code describing the product from a controlled vocabulary, such as RxNorm, First DataBank, et cetera.
Instructions	R2	<entryRelationship>	A place to put free text comments to support additional relevant information, or to deal with specialized dosing instructions. For example, "take with food", or tapered dosing.
Indication	O	<entryRelationship>	A link to supporting clinical information about the reason for providing the medication (e.g., a link to the relevant diagnosis).

¹	A consumable is not neccessary when the substanceAdministration code indicates none or unknown medications.

<substanceAdministration classCode='SBADM' moodCode='INT|EVN'>

The general model is to record each prescribed medication in a <substanceAdministration> intent (moodCode='INT'). Medications that have been reported by the patient or administered (instead of prescribed ), are recorded in the same element, except that this is now an event (moodCode='EVN'). The <substanceAdministration> element may contain subordinate <substanceAdministration> elements in a related component entry to deal with special cases (see the section below on Special Cases). These cases include split, tapered, or conditional dosing, or combination medications. The use of subordinate <substanceAdministration> elements to deal with these cases is optional. The comment field should always be used in these cases to provide the same information as free text in the top level <substanceAdministration> element. There are a variety of special cases for dosing that need to be accounted for. These are described below. Most of these special cases involve changing the dosage or frequency over time, or based on some measurement. When the dosage changes, then additional entries are required for each differing dosage. The last case deals with combination medications.

Normal Dosing 1.3.6.1.4.1.19376.1.5.3.1.4.7.1

This template identifier is used to identify medication administration events that do not require any special processing. The parent template is 1.3.6.1.4.1.19376.1.5.3.1.4.7. Medications that use this template identifier shall not use subordinate <substanceAdministation> acts.

Tapered Doses 1.3.6.1.4.1.19376.1.5.3.1.4.8

This template identifier is used to identify medication administration events that require special processing to handle tapered dosing. The parent template is 1.3.6.1.4.1.19376.1.5.3.1.4.7. A tapered dose is often used for certain medications where abrupt termination of the medication can have negative consequences. Tapered dosages may be done by adjusting the dose frequency, the dose amount, or both.

When merely the dose frequency is adjusted, (e.g., Prednisone 5mg b.i.d. for three days, then 5mg. daily for three days, and then 5mg every other day), then only one medication entry is needed, multiple frequency specifications recorded in <effectiveTime> elements. When the dose varies (eg. Prednisone 15mg daily for three days, then 10 mg daily for three days, the 5 mg daily for three days), subordinate medication entries should be created for each distinct dosage.

Split Dosing 1.3.6.1.4.1.19376.1.5.3.1.4.9

This template identifier is used to identify medication administration events that require special processing to handle split dosing. The parent template is 1.3.6.1.4.1.19376.1.5.3.1.4.7. A split dose is often used when different dosages are given at different times (e.g., at different times of day, or on different days). This may be to account for different metabolism rates at different times of day, or to simply address drug packaging deficiencies (e.g., and order for Coumadin 2mg on even days, 2.5mg on odd days is used because Coumadin does not come in a 2.25mg dose form).

In this case a subordinate <substanceAdministration> entry is required for each separate dosage.

Conditional Dosing 1.3.6.1.4.1.19376.1.5.3.1.4.10

This template identifier is used to identify medication administration events that require special processing to handle conditional dosing. The parent template is 1.3.6.1.4.1.19376.1.5.3.1.4.7. A conditional dose is often used when the dose amount differs based on some measurement (e.g., an insulin sliding scale dose based on blood sugar level). In this case a subordinate <substanceAdministration> entry is required for each different dose, and the condition should be recorded.

Combination Medications 1.3.6.1.4.1.19376.1.5.3.1.4.11

This template identifier is used to identify medication administration events that require special processing to handle combination medications. The parent template is 1.3.6.1.4.1.19376.1.5.3.1.4.7. A combination medication is made up of two or more other medications. These may be prepackaged, such as Percocet, which is a combination of Acetaminophen and oxycodone in predefined ratios, or prepared by a pharmacist, such as a GI cocktail.

In the case of the prepackaged combination, it is sufficient to supply the name of the combination drug product, and its strength designation in a single <substanceAdministation> entry. The dosing information should then be recorded as simply a count of administration units.

In the latter case of a prepared mixture, the description of the mixture should be provided as the product name (e.g., "GI Cocktail") , in the <substanceAdministration> entry. That entry may, but is not required, to have subordinate <substanceAdministration> entries included beneath it to record the components of the mixture.

<templateId root='2.16.840.1.113883.10.20.1.24'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7' />

All medications entries use the <templateId> elements specified above to indicate that they are medication acts. This element is required. In addition, a medication entry shall further identify itself using one of the template identifiers detailed in the next section.

<templateId root=' ' />

The <templateId> element identifies this <entry> as a particular type of medication event, allowing for validation of the content. As a side effect, readers of the CDA can quickly locate and identify medication events. The templateId must use one of the values in the table below for the root attribute.

Extension values for <templateId> in <substanceAdministration>
root	Description
1.3.6.1.4.1.19376.1.5.3.1.4.7.1	A "normal" <substanceAdministration> act that may not contain any subordinate <substanceAdministration> acts.
1.3.6.1.4.1.19376.1.5.3.1.4.8	A <substanceAdministration> act that records tapered dose information in subordinate <substanceAdministration> act.
1.3.6.1.4.1.19376.1.5.3.1.4.9	A <substanceAdministration> act that records split dose information in subordinate <substanceAdministration> acts.
1.3.6.1.4.1.19376.1.5.3.1.4.10	A <substanceAdministration> act that records conditional dose information in subordinate <substanceAdministration> acts.
1.3.6.1.4.1.19376.1.5.3.1.4.11	A <substanceAdministration> act that records combination medication component information in subordinate <substanceAdministration> acts.

<id root=' ' extension=' '/>

A top level <substanceAdministration> element must be uniquely identified. If there is no explicit identifier for this observation in the source EMR system, a GUID may be used for the root attribute, and the extension may be omitted. Although HL7 allows for multiple identifiers, this profile requires that one and only one be used. Subordinate <substanceAdministration> elements may, but need not be uniquely identified.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '>

The <code> element is used to supply a code that describes the <substanceAdminstration> act, not the medication being administered or prescribed. This may be a procedure code, such as those found in CPT-4 (and often used for billing), or may describe the method of medication administration, such as by intravenous injection. The type of medication is coded in the consumable, do not supply the code for the medication in this element. This element is optional.

One of the following values from SNOMED CT shall be used in the <code> element to record that a patient is either not on medications, or that medications are not known.

Entry Type	Code	Display Name	Description
Medication	182904002	Drug Treatment Unknown	To indicate lack of knowledge about drug therapy
Medication	182849000	No Drug Therapy Prescribed	To indicate the absense of any prescribed medications
Medication	408350003	Patient Not On Self-Medications	To indicate no treatment

<text><reference value=' '/></text>

The URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the medication. In a CDA document, the URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the medication. In an HL7 message, the content of the text element shall contain the complete text describing the medication.

<statusCode code='completed'/>

The status of all <substanceAdministration> elements must be "completed". The act has either occurred, or the request or order has been placed.

<effectiveTime xsi:type='IVL_TS'>

The first <effectiveTime> element encodes the start and stop time of the medication regimen. This an interval of time (xsi:type='IVL_TS'), and must be specified as shown. This is an additional constraint placed upon CDA Release 2.0 by this profile, and simplifies the exchange of start/stop and frequency information between EMR systems.

<low value=' '/><high value=' '/>

The <low> and <high> values of the first <effectiveTime> element represent the start and stop times for the medication. The <low> value represents the start time, and the <high> value represents the stop time. If either the <low> or the <high> value is unknown, this shall be recorded by setting the nullFlavor attribute to UNK. The <high> value records the end of the medication regime according to the information provided in the prescription or order. For example, if the prescription is for enough medication to last 30 days, then the high value should contain a date that is 30 days later then the <low> value. The rationale is that a provider, seeing an un-refilled prescription would normally assume that the medication is no longer being taken, even if the intent of the treatment plan is to continue the medication indefinitely.

<effectiveTime operator='A' xsi:type='TS|PIVL_TS|EIVL_TS|PIVL_PPD_TS|SXPR_TS' />

The second <effectiveTime> element records the frequency of administration. This <effectiveTime> element must be intersected with the previous time specification (operator='A'), producing the bounded set containing only those time specifications that fall within the start and stop time of the medication regimen. Several common frequency expressions appear in the table below, along with their XML representations.

Specifying Medication Frequency

Sample Frequency Specifications
Freq	Description	XML Representation
b.i.d.	Twice a day	<effectiveTime xsi:type='PIVL_TS' institutionSpecified='true' operator='A'> <period value='12' unit='h' /></effectiveTime>
q12h	Every 12 hours	<effectiveTime xsi:type='PIVL_TS' institutionSpecified='false' operator='A'> <period value='12' unit='h' /></effectiveTime>
Once	Once, on 2005-09-01 at 1:18am.	<effectiveTime xsi:type='TS' value='200509010118'/>
t.i.d.	Three times a day, at times determined by the person administering the medication .	<effectiveTime xsi:type='PIVL_TS' institutionSpecified='true' operator='A'> <period value='8' unit='h' /></effectiveTime>
q8h	Every 8 hours	<effectiveTime xsi:type='PIVL_TS' institutionSpecified='false' operator='A'> <period value='8' unit='h' /></effectiveTime>
qam	In the morning	<effectiveTime xsi:type='EIVL' operator='A'> <event code='ACM'/></effectiveTime>
	Every day at 8 in the morning for 10 minutes	<effectiveTime xsi:type='PIVL_TS' operator='A'> <phase> <low value="198701010800" inclusive="true"/> <width value="10" unit="min"/> </phase> <period value='1' unit='d'/></effectiveTime>
q4-6h	Every 4 to 6 hours.	<effectiveTime xsi:type='PIVL_PPD_TS' institutionSpecified='false' operator='A'> <period value='5' unit='h' /> <standardDeviation value='1' unit='h'></effectiveTime>

The last frequency specification is about as bad as it gets, but can still be represented accurately within the HL7 V3 datatypes. The mean (average) of the low and high values is specified for the period. The mean of 4 and 6 is 5. The standard deviation is recorded as one half the difference between the high and low values, with an unspecified distribution. The type attribute of the <effectiveTime> element describes the kind of frequency specification it contains. More detail is given for each type in the table below.

Data types used in Frequency Specifications

<effectiveTime> types used in Frequency Specifications
xsi:type	Description
TS	An xsi:type of TS represents a single point in time, and is the simplest of all to represent. The value attribute of the <effectiveTime> element specifies the point in time in HL7 date-time format (CCYYMMDDHHMMSS)
PIVL_TS	An xsi:type of PIVL_TS is the most commonly used, representing a periodic interval of time. The <low> element of <phase> may be present. If so it specifies the starting point, and only the lower order components of this value are relevant with respect to the <period>. The <width> element represents the duration of the dose administration (e.g., for IV administration). The <period> indicates how often the dose is given. Legal values for the unit attribute of <period> are s, min, h, d, wk and mo representing seconds, minutes, hours, days, weeks, and months respectively.
EIVL_TS	An xsi:type of EIVL_TS represents an event based time interval, where the event is not a precise time, but is often used for timing purposes (e.g. with meals, between meals, before breakfast, before sleep). Refer to the HL7 TimingEvent vocabulary for the codes to use for the <event> element. This interval may specify an <offset> which provides information about the time offset from the specified event (e.g., <offset><low value='-1' unit='h'/><width value='10' unit='min'/></offset> means 1 hour before the event. In that same example, the <width> element indicates the duration for the dose to be given.
PIVL_PPD_TS	An xsi:type of PIVL_PPD_TS represents an probabilistic time interval and is used to represent dosing frequencies like q4-6h. This profile requires that the distributionType of this interval be left unspecified. The <period> element specifies the average of the time interval, and the value of the <standardDeviation> shall be computed as half the width of the interval. The unit attributes of the <period> and <standardDeviation> elements shall be the same.
SXPR_TS	An xsi:type of SXPR_TS represents a parenthetical set of time expressions. This type is used when the frequency varies over time (e.g., for some cases of tapered dosing, or to handle split dosing). The <comp> elements of this <effectiveTime> element are themselves time expressions (using any of the types listed above). Each <comp> element may specify an operator (e.g. to intersect or form the union of two sets).

<routeCode code=' ' displayName=' ' codeSystem='2.16.840.1.113883.5.112' codeSystemName='RouteOfAdministration'>

The <routeCode> element specifies the route of administration using the HL7 RouteOfAdministration vocabulary. A code must be specified if the route is known, and the displayName attribute should be specified. If the route is unknown, this element shall not be sent.

<approachSiteCode code=' ' codeSystem=' '>
originalText><reference value=' '/></originalText>
</approachSiteCode>

The <approachSiteCode> element describes the site of medication administrion. It may be coded to a controlled vocabulary that lists such sites (e.g., SNOMED-CT). In CDA documents, this element contains a URI in the value attribute of the <reference> that points to the text in the narrative identifying the site. In a message, the <originalText> element shall contain the text identifying the site.

<doseQuantity> <low value=' ' unit=' '/><high value=' ' unit=' '/> </doseQuantity>

The dose is specified if the <doseQuantity> element. If a dose range is given (e.g., 1-2 tablets, or 325-750mg), then the <low> and <high> bounds are specified in their respective elements, otherwise both <low> and <high> have the same value. If the dose is in countable units (tablets, caplets, "eaches"), then the unit attribute is not sent. Otherwise the units are sent. The unit attribute should be derived from the HL7 UnitsOfMeasureCaseSensitive vocabulary .

<low|high value=' '> <translation> <originalText><reference value=' '/></originalText> </translation></low|high >

Any <low> and <high> elements used for <doseQuantity> or <rateQuantity> should contain a <translation> element that provides a <reference> to the <originalText> found in the narrative body of the document. In a CDA document, any <low> and <high> elements used for <doseQuantity> or <rateQuantity> should contain a <translation> element that provides a <reference> to the <originalText> found in the narrative body of the document. In a message, the <originalText> may contain the original text used to describe dose quantity.

<rateQuantity><low value=' ' unit=' '/><high value=' ' unit=' '/></rateQuantity>

The rate is specified in the <rateQuantity> element. The rate is given in units that have measure over time. In this case, the units should be specified as a string made up of a unit of measure (see doseQuantity above), followed by a slash (/), followed by a time unit (s, min, h or d).

Again, if a range is given, then the <low> and <high> elements contain the lower and upper bound of the range, otherwise, they contain the same value.

<consumable>

The <consumable> element shall be present, and shall contain a <manufacturedProduct> entry conforming to the Product Entry template

<entryRelationship typeCode='REFR'>
&nsbp;<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>

The top level <substanceAdministration> element may contain a reference (typeCode='REFR') to related prescription activity as described in the Supply Entry.

<entryRelationship typeCode='COMP'>
<sequenceNumber value=' '>

A top level <substanceAdministration> element may contain one or more related components, either to handle split, tapered or conditional dosing, or to support combination medications.

In the first three cases, the subordinate components shall specify only the changed <frequency> and/or <doseAmount> elements. For conditional dosing, each subordinate component shall have a <precondition> element that specifies the <observation> that must be obtained before administration of the dose. The value of the <sequenceNumber> shall be an ordinal number, starting at 1 for the first component, and increasing by 1 for each subsequent component. Components shall be sent in <sequenceNumber> order.

<entryRelationship typeCode='SUBJ' inversionInd='true'/>

At most one instruction may be provided for each <substanceAdministration> entry. If provided, it shall conform to the requirements listed for Patient Medication Instructions. The instructions shall contain any special case dosing instructions (e.g., split, tapered, or conditional dosing), and may contain other information (take with food, et cetera).

<entryRelationship typeCode='RSON'>
<act classCode='ACT' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
<id root=' ' extension=' '/>
</act>
</entryRelationship>

A <substanceAdministration> event may indicate one or more reasons for the use of the medication. These reasons identify the concern that was the reason for use via the Internal Reference entry content module.

The extension and root of each observation present must match the identifier of a concern entry contained elsewhere within the CDA document.

A consumer of the Medical Summary is encouraged, but not required to maintain these links on import.

<precondition><criterion>
<text><reference value=' '></text>
</criterion></precondition>

In a CDA document, the preconditions for use of the medication are recorded in the <precondition> element. The value attribute of the <reference> element is a URL that points to the CDA narrative describing those preconditions.

<condition typeCode='PRCN'>
<criterion>
  <text></text>
  <value nullFlavor='UNK'/>
  <interpretationCode nullFlavor='UNK'/>
</criterion>
</condition>

In a message, the preconditions for use of the medication are recorded in the <condition> element. The typeCode shall be PRCN. The <text> element of the criterion shall contain a text description of the precondition. The <value> element is required, and may be recorded in a structured data type if known, and if not, may be recorded using a nullFlavor as shown above. The same is true for <interpretationCode>.

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

Immunizations 1.3.6.1.4.1.19376.1.5.3.1.4.12

An immunizations entry is used to record the patient's immunization history.

Uses

See Templates using Immunizations

Specification

Immunizations Example

<substanceAdministration typeCode='SBADM' moodCode='EVN{{!}}INT' negationInd='true{{!}}false'>
  <templateId root='2.16.840.1.113883.10.20.1.24'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12'/>

  <id root='' extension=''/>
  <code code='IMMUNIZ' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode'/>
  <text><reference value='#xxx'/></text>
  <statusCode code='completed'/>
  <effectiveTime value=''/>
  <!-- The reasonCode would normally provide a reason why the immunization was
    not performed.  It isn't supported by CDA R2, and so comments will have to suffice.
    <reasonCode code='' codeSystem='' codeSystemName='ActNoImmunizationReasonIndicator'/>
  -->
  <routeCode code='' codeSystem='' codeSystemName='RouteOfAdministration'/>
  <approachSiteCode code='' codeSystem='' codeSystemName='HumanSubstanceAdministrationSite'/>
  <doseQuantity value='' units=''/>
  <consumable typeCode='CSM'>
    <manufacturedProduct classCode='MANU'>
      <manufacturedLabeledDrug classCode='MMAT' determinerCode='KIND'>
        <code code='' codeSystem='' codeSystemName=''>
          <originalText><reference value='#yyy'/></originalText>
        </code>
      </manufacturedLabeledDrug>
    </manufacturedProduct>
  </consumable>
  <!-- An optional entry relationship that provides prescription activity -->
  <entryRelationship typeCode='REFR'>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>
      :
      .
  </entryRelationship>
  <!-- An optional entry relationship that identifies the immunization series number -->
  <entryRelationship typeCode='SUBJ'>
    <observation classCode='OBS' moodCode='EVN'>
      <templateId root='2.16.840.1.113883.10.20.1.46'/>
      <code code='30973-2' displayName='Dose Number' 
        codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
      <statusCode code='completed'/>
      <value xsi:type='INT' value=''/>
    </observation>
  </entryRelationship>

  <entryRelationship inversionInd='false' typeCode='CAUS'>
    <observation classCode='OBS' moodCode='EVN'>
      <templateId root='2.16.840.1.113883.10.20.1.28'/>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
      <templateId root='2.16.840.1.113883.10.20.1.54'/>
      <id root='' extension=''/>
    </observation> 
  </entryRelationship>
  <!-- Optional <entryRelationship> element containing comments -->
</substanceAdministration>

<substanceAdministration typeCode='SBADM' moodCode='EVN|INT' negationInd='true|false'>

To record an immunization that has been given, use a substance administration event, with moodCode='EVN'. An immunization entry may also be a record of why a specific immunization was not performed. In this case, negationInd shall be set to "true", otherwise, it shall be false.

To record (e.g., in a care plan), the intent to give an immunization at a future time, use the intent mood (moodCode='INT').

<templateId root='2.16.840.1.113883.10.20.1.24'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12'/>

The <templateId> elements identifies this <substanceAdministration> as an immunization. Both elements shall be present as shown above.

<id root=' ' extension=' '/>

This shall be the identifier for the immunization event.

<code code='IMMUNIZ' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode'/>

This required element records that the act was an immunization. The substance administration act must have a <code> element with code and codeSystem attributes present. If no coding system is used by the source, then simply record the code exactly as shown above. Another coding system that may be used for codes for immunizations are the CPT-4 codes for immunization procedures. This <code> element shall not be used to record the type of vaccine used from a vocabulary of drug names.

Vaccination Codes
codeSystem	codeSystemName	Description
2.16.840.1.113883.5.4	IMMUNIZ	The IMMUNIZ term from the HL7 ActCode vocabulary.
2.16.840.1.113883.6.12	C4	Current Procedure Terminology 4 (CPT-4) codes.

<text><reference value='#xxx'/></text>

In a CDA document, the URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the immunization activity. In an HL7 message, the content of the text element shall contain the complete text describing the immunization activity.

<statusCode code='completed'/>

The statusCode shall be set to "completed" for all immunizations.

<effectiveTime value=' '/>

The effectiveTime element shall be present and should contain a time value that indicates the date of the substance administration. If the date is unkown, this shall be recorded using the nullFlavor attribute, with the reason that the information is unknown being specified. Otherwise, the date shall be recorded, and should have precision of at least the day.

<routeCode code=' ' codeSystem=' ' codeSystemName='RouteOfAdministration'/>

See routeCode under Medications.

<approachSiteCode code=' ' codeSystem=' ' codeSystemName='HumanSubstanceAdministrationSite'/>

See approachSiteCode under Medications.

<doseQuantity value=' ' units=' '/>

See doseQuantity under Medications.

<consumable typeCode='CSM'>

See consumable under Medications.

<entryRelationship typeCode='REFR'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>

The top level <substanceAdministration> element may contain a reference (typeCode='REFR') to related Supply entry

<entryRelationship typeCode='SUBJ'>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.46'/>

This optional entry relationship may be present to indicate that position of this immunization in a series of immunizations.

<code code='30973-2' displayName='Dose Number' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

The <code> element shall be present and must be recorded with the code and codeSystem attributes shown above. This element indicates that the observation describes the dose number for the immunization.

<statusCode code='completed'/>

The <statusCode> element shall be present, and must be recorded exactly as shown above. This element indicates that the observation has been completed.

<value xsi:type='INT' value=' '/>

The <value> element shall be present, and shall indicate the immunization series number in the value attribute.

<entryRelationship inversionInd='false' typeCode='CAUS'>

This repeatable element should be used to identify adverse reactions caused by the immunization.

<observation classCode='OBS' moodCode='EVN'>

This element is required, and provides a pointer to the the adverse reaction caused by the immunization.

<templateId root='2.16.840.1.113883.10.20.1.28'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
<templateId root='2.16.840.1.113883.10.20.1.54'/>

It shall contain a conforming Problem Entry that also conform to the CCD Reaction template.

<id root=' ' extension=' '/>

This element is required, and gives the identifier of the adverse reaction. The adverse reaction pointed to by this element shall be described in more detail using the Allergies entry, elsewhere in the document where this element was found.

An immunization entry can have negationInd set to true to indicate that an immunization did not occur. In this case, it shall have at least one comment that provides an explaination for why the immunization did not take place . Other comments may also be present.

Development Only

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Supply Entry 1.3.6.1.4.1.19376.1.5.3.1.4.7.3

The supply entry describes a prescription activity.

Uses

See Templates using Supply Entry

Specification

Supply Entry Example

<substanceAdministration classCode='SBADM' moodCode='INT|EVN'>
    :
    .
  <entryRelationship typeCode='REFR' inversionInd='false'>
    <sequenceNumber value=''/>
    <supply classCode='SPLY' moodCode='INT|EVN'>
      <templateId root='2.16.840.1.113883.10.20.1.34'/>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>
      <id root='' extension=''/>
      <repeatNumber value=''/>
      <quantity value='' unit=''/>
      <author>
        <time value=''/>
        <assignedAuthor>
          <id root='' extension=''/>
          <addr></addr>
          <telecom use='' value=''/>
          <assignedPerson><name></name></assignedPerson>
          <representedOrganization><name></name></representedOrganization>
        </assignedAuthor>
      </author>
      <performer typeCode='PRF'>
        <time value=''/>
        <assignedEntity>
          <id root='' extension=''/>
          <addr></addr>
          <telecom use='' value=''/>
          <assignedPerson><name></name></assignedPerson>
          <representedOrganization><name></name></representedOrganization>
        </assignedEntity>
      </performer>
      <!-- Optional Fulfillment instrctions -->
      <entryRelationship typeCode='SUBJ'>
      </entryRelationship>
    </supply>
  </entryRelationship>
</substanceAdministration>

<entryRelationship typeCode='REFR' inversionInd='false'>

A <substanceAdministration> act may reference (typeCode='REFR') a prescription activity in an <entryRelationship> element in a CDA document. In a message, the relationship is recorded using a <sourceOf> element instead of the <entryRelationship> element. The typeCode and inversionInd attributes, and the semantics remain identical.

<sequenceNumber value=' '/>

The prescription activity may have a <sequenceNumber> element to indicate the fill number. A value of 1, 2 or N indicates that it is the first, second, or Nth fill respectively of a specific prescription. This element should be present when the embedded <supply> element has a moodCode attribute of EVN.

<supply classCode='SPLY' moodCode='INT|EVN'>

The <supply> element shall be present. The moodCode attribute shall be INT to reflect that a medication has been prescribed, or EVN to indicate that the prescription has been filled.

<templateId root='2.16.840.1.113883.10.20.1.34'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>

The <templateId> elements shown above shall be present, and identify this supply act as a Supply Entry.

<id root=' ' extension=' '/>

Each supply act shall have an identifier to uniquely identify the supply entry.

<repeatNumber value=' '/>

Each supply entry should have a <repeatNumber> element that indicates the number of times the prescription can be filled.

<quantity value=' ' unit=' '/>

The supply entry should indicate the quantity supplied. The value attribute shall be present and indicates the quantity of medication supplied. If the medication is supplied in dosing units (tablets or capsules), then the unit attribute need not be present (and should be set to 1 if present). Otherwise, the unit element shall be present to indicate the quantity (e.g., volume or mass) of medication supplied.

<author>

A supply entry that describes an intent (<supply classCode='SPLY' moodCode='INT'>) may include an <author> element to identify the prescribing provider.

The element must be present to indicate when the author created the prescription. If this information is unknown, it shall be recorded by setting the nullFlavor attribute to UNK.

<assignedAuthor>

The <assignedAuthor> element shall be present, and identifies the author.

<id root=' ' extension=' '/>

One or more <id> elements should be present. These identifiers identify the author of the act. When the author is the prescribing physician they may include local identifiers or regional identifiers necessary for prescribing.

<assignedPerson><name/></assignedPerson>
<representedOrganization><name/></ representedOrganization>

An <assignedPerson> and/or <representedOriganization> element shall be present. This element shall contain a <name> element to identify the prescriber or their organization.

<performer typeCode='PRF'>

The <performer> element may be present to indicate who is intended (moodCode='INT'), or actually filled (moodCode='EVN') the prescription.

The element shall be present to indicate when the prescription was filled (moodCode='EVN'). If this information is unknown, it shall be recorded by setting the nullFlavor attribute to UNK.

The element should be present to indicate when the prescription is intended to be filled (moodCode='INT').

<assignedEntity>

The < assignedEntity> element shall be present, and identifies the filler of the prescription.

<id root=' ' extension=' '/>

One or more <id> elements should be present. These identify the performer.

<assignedPerson><name/></assignedPerson>
<representedOrganization><name/></ representedOrganization>

An <assignedPerson> and/or <representedOriganization> element shall be present. This element shall contain a <name> element to identify the filler or their organization.

<entryRelationship typeCode='SUBJ'>
</entryRelationship>

An entry relationship may be present to provide the fulfillment instructions. When present, this entry relationship shall contain a Medication Fulfillment Instructions entry.

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

Product Entry 1.3.6.1.4.1.19376.1.5.3.1.4.7.2

The product entry describes a medication or immunization used in a <substanceAdministration> or <supply> act. It adopts the constraints of the ASTM/HL7 Continuity of Care Document.

Uses

See Templates using Product Entry

Specification

Product Entry Example

<!-- Within a CDA Document -->
<manufacturedProduct>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.2'/>
  <templateId root='2.16.840.1.113883.10.20.1.53'/>
  <manufacturedMaterial>
    <code code='' displayName='' codeSystem='' codeSystemName=''>
      <originalText><reference value=''/></originalText>
    </code>
    <name></name>
  </manufacturedMaterial>
</manufacturedProduct>
<!-- Within a message -->
<administerableMaterial>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.2'/>
  <templateId root='2.16.840.1.113883.10.20.1.53'/>
  	<administerableMaterial>
    	<code></code>
		<desc></desc>
	</administerableMaterial>
</administerableMaterial>

<manufacturedProduct> -OR- <administerableMaterial>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.2'/>
<templateId root='2.16.840.1.113883.10.20.1.53'/>
<manufacturedMaterial> -OR- <administerableMaterial>

In a CDA document, the name and strength of the medication are specified in the elements under the <manufacturedMaterial> element. In a message, the are contained within the <administeredMaterial> element, inside another <administerableMaterial> element¹. The templateId elements are required and identify this as a product entry.

¹	This duplication of element names is an artifact of the standard.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '>
<originalText><reference value=' '/></originalText>

The <code> element of the <manufacturedMaterial> describes the medication. This may be coded using a controlled vocabulary, such as RxNorm, First Databank, or other vocabulary system for medications, and should be the code that represents the generic medication name and strength (e.g., acetaminophen and oxycodone -5/325), or just the generic medication name alone if strength is not relevant (Acetaminophen).

In a CDA document, the <originalText> shall contain a <reference> whose URI value points to the generic name and strength of the medication, or just the generic name alone if strength is not relevant. Inside a message, the <originalText> may contain the actual text that describes the medication in similar fashion.

Note:

When the text is supplied from the narrative, the implication is that if you supply the components of a combination medication in an entry, you must also display these in the narrative text, otherwise you would not be able to break the combination medication down into its component parts. This is entirely consistent with the CDA Release 2.0 requirements that the narrative supply the necessary and relevant human readable information content.

The <code> element is also used to support coding of the medication. If coded, it must provide a code and codeSystem attribute using a controlled vocabulary for medications. The displayName for the code and codeSystemName should be provided as well for diagnostic and human readability purposes, but are not required. The table below provides the codeSystem and codeSystemName for several controlled terminologies that may be used to encode medications and/or immunizations.

Example Medication and Immunization Vocabularies
codeSystem	codeSystemName	Description
2.16.840.1.113883.6.88	RxNorm	RxNorm
2.16.840.1.113883.6.69	NDC	National Drug Codes
2.16.840.1.113883.6.63	FDDC	First DataBank Drug Codes
2.16.840.1.113883.6.96	SNOMED-CT	SNOMED Controlled Terminology
2.16.840.1.113883.6.59	CVX	CDC Vaccine Codes

The code used for an immunization may use code systems other than what might be used for other medications, such as the CDC maintained CVX codes. Code systems that describe vaccination procedures (such as CPT-4) shall not be used to describe the vaccine entry.

<name> -OR- <desc>

In a CDA document, the <name> element should contain the brand name of the medication (or active ingredient in the case of subordinate <substanceAdministration> elements used to record components of a medication). Within a message, this information shall be provided in the <desc> element.

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

Simple Observations 1.3.6.1.4.1.19376.1.5.3.1.4.13

The simple observation entry is meant to be an abstract representation of many of the observations used in this specification. It can be made concrete by the specification of a few additional constraints, namely the vocabulary used for codes, and the value representation. A simple observation may also inherit constraints from other specifications (e.g., ASTM/HL7 Continuity of Care Document).

Uses

See Templates using Simple Observations

Specification

Simple Observations Example

<observation classCode='OBS' moodCode='EVN'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
  <id root='' extension=''/>
  <code code='' displayName='' codeSystem='' codeSystemName=''/>
  <!-- for CDA -->
  <text><reference value='#xxx'/></text>
  <!-- For HL7 Version 3 Messages
  <text>text</text> 
  -->
  <statusCode code='completed'/>
  <effectiveTime value=''/>
  <repeatNumber value=''/>
  <value xsi:type='' …/>
  <interpretationCode code='' codeSystem='' codeSystemName=''/>
  <methodCode code='' codeSystem='' codeSystemName=''/>
  <targetSiteCode code='' codeSystem='' codeSystemName=''/>
	<author typeCode='AUT'>
    <assignedAuthor typeCode='ASSIGNED'><id ... /></assignedAuthor> <!-- for CDA -->
    <!-- For HL7 Version 3 Messages 
    <assignedEntity typeCode='ASSIGNED'>
       <Person classCode='PSN'>
          <determinerCode root=''>
          <name>…</name>
       </Person>
    <assignedEntity>
     -->
  </author>
</observation>

<observation classCode='OBS' moodCode='EVN'>

These acts are simply observations that have occurred, and so are recored using the <observation> element as shown above.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>

The <templateId> element identifies this <observation> as a simple observation, allowing for validation of the content. The templateId must appear as shown above.

<id root=' ' extension=' '/>

Each observation shall have an identifier.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

Observations shall have a code describing what was measured. The code system used is determined by the vocabulary constraints on the types of measurements that might be recorded in a section. Content modules that are derived from the Simple Observation content module may restrict the code system and code values used for the observation.

<text><reference value='#xxx'/></text> -OR- <text>text</text>

Each observation measurement entry may contain a <text> element providing the free text that provides the same information as the observation within the narrative portion of the document with a <text> element. For CDA based uses of Simple Observations, this element SHALL be present, and SHALL contain a <reference> element that points to the related string in the narrative portion of the document. For HL7 Version 3 based uses, the <text> element MAY be included.

<statusCode code='completed'/>

The status code of all observations shall be completed.

<effectiveTime value=' '/>

The <effectiveTime> element shall be present in standalone observations , and shall record the date and time when the measurement was taken. This element should be precise to the day. If the date and time is unknown, this element should record that using the nullFlavor attribute.

<value xsi:type=' ' …/>

The value of the observation shall be recording using a data type appropriate to the observation. Content modules derived from the Simple Observation content module may restrict the allowable data types used for the observation.

<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>

If there is an interpretation that can be performed using an observation result (e.g., high, borderline, normal, low), these may be recorded within the interpretationCode element.

<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>

The methodCode element may be used to record the specific method used to make an observation when this information is not already pre-coordinated with the observation code .

<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The targetSiteCode may be used to record the target site where an observation is made when this information is not already pre-coordinated with the observation code.

<author><assignedAuthor classCode='ASSIGNED'>...<assignedAuthor></author>

In CDA uses, SimpleObservations are assumed to be authored by the same author as the document through context conduction. However specific authorship of observation may be represented by listing the author in the header and referencing the author in a <author> relationship. If authors are explicitly listed in documents, an <id> element SHOULD reference the ID of the author in the header through an assignedAuthor Role. If the author of the observation is not an author of the document the <person> object including a name and ID SHALL be included.

For HL7 Version 3 purposes, the <author> element SHOULD be present unless it can be determined by conduction from organizers or higher level structures. When used for HL7 Version 3 the role element name is <assignedEntity> and the author is represented a <assignedPerson> element.

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

Vital Signs Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.13.1

A vital signs organizer collects vital signs observations.

Uses

See Templates using Vital Signs Organizer

Specification

Vital Signs Organizer Example

<organizer classCode='CLUSTER' moodCode='EVN'>
  <templateId root='2.16.840.1.113883.10.20.1.32'/>
  <templateId root='2.16.840.1.113883.10.20.1.35'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.1'/>
  <id root='' extension=''/>
  <code code='46680005' displayName='Vital signs' 
    codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
  <statusCode code='completed'/>
  <effectiveTime value=''/>
  <!-- For HL7 Version 3 Messages
  <author classCode='AUT'>
     <assignedEntity1 typeCode='ASSIGNED'>
        :
     <assignedEntity1>
  </author>
  -->
  <!-- one or more vital signs observations -->
  <component typeCode='COMP'>
    <observation classCode='OBS' moodCode='EVN'>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.2'/>
        :
    </observation>
  </component>
</organizer>

<organizer classCode='CLUSTER' moodCode='EVN'>

The vital signs organizer is a cluster of vital signs observations.

<templateId root='2.16.840.1.113883.10.20.1.32'/>
<templateId root='2.16.840.1.113883.10.20.1.35'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.1'/>

The vital signs organizer shall have the <templateId> elements shown above to indicate that it inherits constraints from the ASTM/HL7 CCD Specification for Vital signs, and the constraints of this specification.

<id root=' ' extension=' '/>

The organizer shall have an <id> element.

<code code='46680005' displayName='Vital signs'
codeSystem='2.16.840.1.113883.6.96'
codeSystemName='SNOMED CT'/>

The <code> element shall be recorded as shown above to indicate that this organizer captures information about patient vital signs.

<statusCode code='completed'/>

The observations have all been completed.

<effectiveTime value=' '/>

The effective time element shall be present to indicate when the measurement was taken.

<author typeCode='AUT'><assignedEntity1 typeCode='ASSIGNED'>...</assignedEntity1></author>

For use with HL7 Version 3, Vital Sign organizers SHALL contain an <author> element to represent the person or device.

<component typeCode='COMP'>

The organizer shall have one or more <component> elements that are <observation> elements using the Vital Signs Observation template.

Development Only

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Vital Signs Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.2

A vital signs observation is a simple observation that uses a specific vocabulary, and inherits constraints from CCD.

Uses

See Templates using Vital Signs Observation

Specification

Vital Signs Observation Example

<observation classCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='2.16.840.1.113883.10.20.1.31'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.2'/>
 <id root=' ' extension=' '/>
 <code code=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type='PQ' value=' ' unit=' '/>
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='2.16.840.1.113883.10.20.1.31'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.2'/>

A vital signs observation shall have the <templateId> elements shown above to indicate that it inherits constraints from the ASTM/HL7 CCD Specification for Vital signs, and the constraints of this specification.

<code code=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

A vital signs observation entry shall use one of the following LOINC codes, with the specified data types and units.

Vital Signs Codes
LOINC	Description	Units	Type
9279-1	RESPIRATION RATE	/min	PQ
8867-4	HEART BEAT	/min
2710-2	OXYGEN SATURATION	%
8480-6	INTRAVASCULAR SYSTOLIC	mm[Hg]
8462-4	INTRAVASCULAR DIASTOLIC	mm[Hg]
8310-5	BODY TEMPERATURE	Cel or [degF]
8302-2	BODY HEIGHT (MEASURED)	m, cm,[in_us] or [in_uk]
8306-3	BODY HEIGHT^LYING
8287-5	CIRCUMFRENCE.OCCIPITAL-FRONTAL (TAPE MEASURE)
3141-9	BODY WEIGHT (MEASURED)	kg, g, [lb_av] or [oz_av]

<value xsi:type='PQ' value=' ' unit=' '/>

The <value> element shall be present, and shall be of the appropriate data type specified for measure in the table above.

<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>

The interpretation code may be present to provide an interpretation of the vital signs measure (e.g., High, Normal, Low, et cetera).

<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <methodCode> element may be present to indicate the method used to obtain the measure. Note that method used is distinct from, but possibly related to the target site.

<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The target site of the measure may be identified in the <targetSiteCode> element (e.g., Left arm [blood pressure], oral [temperature], et cetera).

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

Family History Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.15

The family history organizer collects the problems of a patient's family member.

Uses

See Templates using Family History Organizer

Specification

Family History Organizer Example

<entry>
  <organizer classCode='CLUSTER' moodCode='EVN'>
    <templateId root='2.16.840.1.113883.10.20.1.23'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.15'/>
    <subject typeCode='SBJ'>
      <relatedSubject classCode='PRS'>
        <code code='' displayName='' 
          codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
        <subject>
          <sdtc:id root='' extension=''/>
          <administrativeGenderCode code='' displayName='' 
            codeSystem='' codeSystemName=''/>
        </subject>
      </relatedSubject>
    </subject>
    <!-- zero or more participants linking to other relations -->
    <participant typeCode='IND'>
      <participantRole classCode='PRS'>
        <code code='' displayName='' 
          codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
        <playingEntity classCode='PSN'>
          <sdtc:id root='' extension=''/>
        </playingEntity>
      </participantRole>
    </participant>
    <!-- one or more entry relationships for family history observations -->
    <component typeCode='COMP'>
      <observation classCode='OBS' moodCode='EVN'>
        <templateId root='2.16.840.1.113883.10.20.1.22'/>
      </observation>
    </component>
  </organizer>
</entry>

<organizer classCode='CLUSTER' moodCode='EVN'>

Each family history entry is organized (classCode='CLUSTER') into a group of observations about a family member.

<templateId root='2.16.840.1.113883.10.20.1.23'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.15'/>

The organizer is identified by the <templateId> elements, which shall be present as shown above.

<subject typeCode='SUBJ'>
<relatedSubject classCode='PRS'>

The <subject> element shall be present and relates the subject of the observations to the patient. It shall contain a <relatedSubject> element that is a personal relation of the patient (classCode='PRS').

<code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>

The <code> element shall be present, and give the relationship of the subject to the patient. The code attribute shall be present, and shall contain a value from the HL7 FamilyMember vocabulary. The codeSystem attribute shall be present and shall use the value shown above.

<subject>

The <subject> element contains information about the relation.

<sdtc:id root=' ' extension=' '/>

The <sdtc:id> element should be present. It is used to identify the patient relation to create a pedigree graph.

<administrativeGenderCode code=' ' />

The <administrativeGenderCode> element should be present. It gives the gender of the relation.

<participant typeCode='IND'>
<participantRole classCode='PRS'>

The <participant> element may be present to record the relationship of the subject to other family members to create a pedigree graph. It shall contain a <participantRole> element showing the relationship of the subject to other family members (classCode='PRS').

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The <code> element shall be present, and gives the relationship of the participant to the subject. The code attribute shall be present, and shall contain a value from the HL7 FamilyMember vocabulary. The codeSystem attribute shall be present and shall use the value shown above.

<playingEntity classCode='PSN'>

The <playingEntity> element identifies the related person. It shall be recorded as shown above.

<sdtc:id root=' ' extension=' '/>

The <sdtc:id> element shall be present. It must have the same root and extension attributes of the <subject> of a separate family history organizer. See Appendix C of PCC-TF for definition of this extension to CDA.

<component typeCode='COMP'>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.3'/>

The family history organizer shall contain one or more components using the <component> element shown above. These components must conform the Family History Observation template.

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Family History Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.3

A family history observation is a Simple Observation that uses a specific vocabulary, and inherits constraints from CCD. Family history observations are found inside Family History Organizers.

Standards

CCD	ASTM/HL7 Continuity of Care Document

Parent Template

The parent of this template is Simple Observation. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.22

Uses

See Templates using Family History Observation

Specification

Family History Observation Example

<observation typeCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='2.16.840.1.113883.10.20.1.22'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.3'/>
 <id root=' ' extension=' '/>
 <code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type='CD' .../>
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>

<templateId root='2.16.840.1.113883.10.20.1.22'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.3'/>

The <templateId> elements identify this observation as a family history observation, and shall be present as shown above.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The <code> indicates the type of observation made (e.g., Diagnosis, et cetera). See the code element in the Problem Entry entry for suggested values.

<value xsi:type='CD' code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The <value> element indicates the information (e.g., diagnosis) of the family member. See the value element in the Problem Entry for suggested values.

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

Social History Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.4

A social history observation is a simple observation that uses a specific vocabulary, and inherits constraints from CCD.

Standards

CCD	ASTM/HL7 Continuity of Care Document

Parent Template

The parent of this template is Simple Observation. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.33

Uses

See Templates using Social History Observation

Specification

Social History Observation Example

<observation typeCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='2.16.840.1.113883.10.20.1.33'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.4'/>
 <id root=' ' extension=' '/>
 <code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type=' ' />
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>

<templateId root='2.16.840.1.113883.10.20.1.33'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.4'/>

These <templateId> elements identify this as a Social History observation.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

The <code> element identifies the type social history observation.

Social History Codes
Code	Description	Data Type	Units
229819007	Smoking	PQ	{pack}/d or {pack}/wk or {pack}/a
256235009	Exercise		{times}/wk
160573003	ETOH (Alcohol) Use		{drink}/d or {drink}/wk
364393001	Diet	CD	N/A
364703007	Employment
425400000	Toxic Exposure
363908000	Drug Use
228272008	Other Social History	ANY

<repeatNumber value=' '/>

The <repeatNumber> element should not be used in a social history observation.

<value xsi:type=' ' ... />

The <value> element reports the value associated with the social history observation. The data type to use for each observation should be drawn from the table above.

Observations in the table above using the PQ data type have a unit in the form {xxx}/d, {xxx}/wk or {xxx}/a represent the number of items per day, week or year respectively. The value attribute indicates the number of times of the act performed, and the units represent the frequency. The example below shows how to represent 1 drink per day.

    :
  <code code='160573003' displayName='ETOH Use' 
        codeSystem='2.16.840.1.113883.6.96' 
        codeSystemName='SNOMED CT'/>
    :
  <value xsi:type='PQ' value='1' unit='{drink}/d'/>
    :

Observations in the table using the CD data type should include coded values from an appropriate vocabulary to represent the social history item. The example below shows the encoding to indicate drug use of cannabis.

    :
  <code code='363908000' displayName='Drug Use' 
        codeSystem='2.16.840.1.113883.6.96' 
        codeSystemName='SNOMED CT'/>
    :
  <value xsi:type='CD' code='398705004' displayName='cannabis' 
         codeSystem='2.16.840.1.113883.6.96' 
         codeSystemName='SNOMED CT'/>
    :

Other social history observations may use any appropriate data type.

<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <interpretationCode>, <methodCode>, and <targetSiteCode> elements should not be used in a social history observation.

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

Pregnancy Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.5

A pregnancy observation is a Simple Observation that uses a specific vocabulary to record observations about a patient's pregnancy history.

Parent Template

The parent of this template is Simple Observation.

Uses

See Templates using Pregnancy Observation

Specification

Pregnancy Observation Example

<observation classCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5'/>
 <id root=' ' extension=' '/>
 <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type=' ' .../>
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5'/>

These <templateId> elements identify this <observation> as a pregnancy observation, allowing for validation of the content. The <templateId> elements shall be recorded as shown above.

<code code=' ' displayName=' '
codeSystem='2.16.840.1.113883.6.1'
codeSystemName='LOINC'/>

A pregnancy observation shall have a code describing what facet of patient's pregnancy history is being recorded. These codes should come from the list of codes shown below. Additional codes may be used to reflect additional information about the pregnancy history.

Pregnancy Observation Codes
LOINC CODE	Description	Type	Units or Vocabulary
Summary over All Pregnancies
11636-8	BIRTHS LIVE (REPORTED)	INT	N/A
11637-6	BIRTHS PRETERM (REPORTED)
11638-4	BIRTHS STILL LIVING (REPORTED)
11639-2	BIRTHS TERM (REPORTED)
11640-0	BIRTHS TOTAL (REPORTED)
11612-9	ABORTIONS (REPORTED)
11613-7	ABORTIONS INDUCED (REPORTED)
11614-5	ABORTIONS SPONTANEOUS (REPORTED)
33065-4	ECTOPIC PREGNANCY (REPORTED)
Detailed Pregnancy Data
11449-6	PREGNANCY STATUS	CE	SNOMED CT, ICD-9-CM (V22)
8678-5	MENSTRUAL STATUS	CE	SNOMED CT
8665-2	DATE LAST MENSTRUAL PERIOD	TS	N/A
11778-8	DELIVERY DATE (CLINICAL ESTIMATE)	TS
11779-6	DELIVERY DATE (ESTIMATED FROM LAST MENSTRUAL PERIOD)
11780-4	DELIVERY DATE (ESTIMATED FROM OVULATION DATE)
11884-4	FETUS, GESTATIONAL AGE (CLINICAL ESTIMATE)	PQ	d, wk or mo
11885-1	FETUS, GESTATIONAL AGE (ESTIMATED FROM LAST MENSTRUAL PERIOD)
11886-9	FETUS, GESTATIONAL AGE (ESTIMATED FROM OVULATION DATE)
11887-7	FETUS, GESTATIONAL AGE (ESTIMATED FROM SELECTED DELIVERY DATE)
45371‑2	MULTIPLE PREGNANCY

<repeatNumber value=' '/>

The <repeatNumber> element should not be present in a pregancy observation.

<value xsi:type=' ' .../>

The value of the observation shall be recording using a data type appropriate to the coded observation according to the table above.

<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <interpretationCode>, <methodCode>, and <targetSiteCode> should not be present in a pregnancy observation.

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

Advance Directive Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.7

An advance directive observation is a simple observation that uses a specific vocabulary, and inherits constraints from CCD.

Standards

CCD	ASTM/HL7 Continuity of Care Document

Uses

See Templates using Advance Directive Observation

Specification

Advance Directive Observation Example

<observation typeCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='2.16.840.1.113883.10.20.1.17'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.7'/>
 <id root=' ' extension=' '/>
 <code code=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type='BL' value='true|false'/>
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <reference typeCode='REFR'>
   <templateId root='2.16.840.1.113883.10.20.1.36'/>
   <externalDocument classCode='DOC' moodCode='EVN'>
     <id root=' ' extension=' '/>
     <text><reference value=' '/></text>
   </externalDocument>
 </reference>
</observation>

An advanced directive <observation> shall be represented as shown above. They shall not contain any <repeatNumber>, <interpretationCode>, <methodCode> or <targetSiteCode> elements.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='2.16.840.1.113883.10.20.1.17'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.7'/>

The <templateId> elements shown above shall be present, and indicated that this is an Advance Directive entry.

<code code=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>

The <code> element records the type of advance directive. It should use one of the following SNOMED codes in the table below.

Advance Directive Type Codes
Code	Description	Data Type
304251008	Resuscitation	BL
52765003	Intubation
225204009	IV Fluid and Support
89666000	CPR
281789004	Antibiotics
78823007	Life Support
61420007	Tube Feedings
116859006	Transfusion of blood product
71388002	Other Directive	<value> not permitted

<value xsi:type='BL' value='true|false'/>

The advance directive observation may include a <value> element using the Boolean (xsi:type='BL') data type to indicate simply whether the procedure described is permitted. Absence of the the <value> element indicates that an advance directive of the specified type has been recorded, and must be examined to determine what type of treatment should be performed. The value element is not permitted when the <code> element describes an Other directive.

<reference typeCode='REFR'>
  <templateId root='2.16.840.1.113883.10.20.1.36'/>
  <externalDocument classCode='DOC' moodCode='EVN'>
   <id root=' ' extension=' '/>
   <text><reference value=' '/></text>

The advanced directive observation may contain a single reference to an external document. That reference shall be recorded as shown above. The <id> element shall contain the appropriate root and extension attributes to identify the document. The <text> element may be present to provide a URL link to the document in the value attribute of the <reference> element. If the <reference> element is present, the Advance Directive in the narrative shall contain a <linkHTML> element to the same URL found in the value attribute.

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

Blood Type Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.6

The blood type observation is a Simple Observation of the patient's blood type. It conforms to the CCD Result observation template.

Standards

CCD	ASTM/HL7 Continuity of Care Document

Parent Template

The parent of this template is Simple Observation.

Uses

See Templates using Blood Type Observation

Specification

Blood Type Observation Example

<observation typeCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.6'/>
 <templateId root='2.16.840.1.113883.10.20.1.31'/>
 <id root=' ' extension=' '/>
 <code code='882-1' displayName='ABO+RH GROUP' 
   codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type='CE' code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
<observation>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.6'/>
<templateId root='2.16.840.1.113883.10.20.1.31'/>

These <templateId> elements identify this as a blood type observation. They shall be present in the <observation> element as shown above.

<code code='882-1' displayName='ABO+RH GROUP'
codeSystem='2.16.840.1.113883.6.1'
codeSystemName='LOINC'/>

The <code> element shall be present to represent this as a finding of the patient's composite blood type. It shall use the code and codeSystem attributes shown above.

<repeatNumber value=' '/>

The <repeatNumber> element should not be present in a blood type observation.

<value xsi:type='CE' code=' ' displayName=' '
codeSystem=' ' codeSystemName=' '/>

The <value> element shall be present and shall use the CE data type. The code attribute should be valued using a vocabulary that supports encoding of blood types. The table below shows some coding systems that may be used to encode blood type.

Blood Type Coding Systems
Coding System	OID
ISBT 128	2.16.840.1.113883.6.18
SNOMED CT	2.16.840.1.113883.6.96

<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <interpretationCode>, <methodCode>, and <targetSiteCode> should not be present in a blood type observation.

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

Encounters 1.3.6.1.4.1.19376.1.5.3.1.4.14

Standards

CCD	ASTM/HL7 Continuity of Care Document

Uses

See Templates using Encounters

Specification

Encounters Example

<encounter classCode='ENC' moodCode='PRMS|ARQ|EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.14'/>
 <templateId root='2.16.840.1.113883.10.20.1.21'/>
 <templateId root='2.16.840.1.113883.10.20.1.25'/>
 <id root=' ' extension=' '/>
 <code code=' ' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActEncounterCode' />
 <text><reference value='#xxx'/></text>
 <effectiveTime>
   <low value=' '/>
   <high value=' '/>
 </effectiveTime>
 <priorityCode code=' '/>
 <performer typeCode='PRF'>
   <low value=' '/><high value=' '/>
   <assignedEntity>...</assignedEntity>
 </performer>
 <author />
 <informant />
 <participant typeCode='LOC'>
   <participantRole classCode='SDLOC'>
     <id/>
     <code/>
     <addr>...</addr>
     <telecom value=' ' use=' '/>
     <playingEntity classCode='PLC' determinerCode='INST'>
       <name></name>
     </playingEntity>
   </participantRole>
 </participant>
</encounter>

<encounter classCode='ENC' moodCode='PRMS|ARQ|EVN'>

This element is an encounter. The classCode shall be 'ENC'. The moodCode may be PRMS to indicated a scheduled appointment, ARQ to describe a request for an appointment that has been made but not yet scheduled by a provider, or EVN, to describe an encounter that has already occurred.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.14'/>

The templateId indicates that this <encounter> entry conforms to the constraints of this content module. NOTE: When the encounter is in event mood (moodCode='EVN'), this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.21, and when in other moods, this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.25.

<id root=' ' extension=' '/>

This required element shall contain an identifier for the encounter. More than one encounter identifier may be present.

<code code=' ' codeSystem='2.16.840.1.113883.5.4'
codeSystemName='ActEncounterCode' />

This required element should contain a code from the HL7 ActEncounterCode vocabulary describing the type of encounter (e.g., inpatient, ambulatory, emergency, et cetera). Developers should take care to check that rational combinations of encounter.code and encounter.moodCode are used , but this profile does not restrict any combination.

<text><reference value='#xxx'/></text>

The <text> element shall contain a reference to the narrative text describing the encounter.

<effectiveTime><low value=' '/><high value=' '/></effectiveTime>

This element records the time over which the encounter occurred (in EVN mood), or the desired time of the encounter in ARQ or APT mood. In EVN or APT mood, the effectiveTime element should be present. In ARQ mood, the effectiveTime element may be present, and if not, the priorityCode may be present to indicate that a callback is required to schedule the appointment.

<priorityCode code='CS'/>

This element may be present in ARQ mood to indicate a callback is requested to schedule the appointment.

<performer>

For encounters in EVN mood, at least one performer should be present that identifies the provider of the service given during the encounter. More than one performer may be present. The element should be used to indicate the duration of the participation of the performer when it is substantially different from that of the effectiveTime of the encounter. In ARQ mood, the performer may be present to indicate a preference for a specific provider. In APT mood, the performer may be present to indicate which provider is scheduled to perform the service.

<participant typeCode='LOC'>
<participantRole classCode='SDLOC'>

A <participant> element with typeCode='LOC' may be present to provide information about the location where the encounter is to be or was performed. This element shall have a <participantRole> element with classCode='SDLOC' that describes the service delivery location.

<id/>

The <id> element may be present to identify the service delivery location.

<code/>

The <code> element may be present to classify the service delivery location.

<addr>...</addr>

The <addr> element should be present, and gives the address of the location.

<telecom value=' ' use=' '/>

The <telecom> element should be present, and gives the telephone number of the location.

<playingEntity classCode='PLC'>
<name>...</name>
</playingEntity>

The <playingEntity> shall be present, and gives the name of the location in the required <name> element.

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

Update Entry 1.3.6.1.4.1.19376.1.5.3.1.4.16

The update entry shall contain references to the entries or sections which are being replaced or updated. This reference shall not be present when the update entry is adding a new entries or sections.

Entries and sections can be added, updated, or removed from a PHR. An update entry indicates the entry in the original PHR Extract that should be replaced or updated with new information contained within the entry. Only one organizer of this type is allowed in a section, and if present, it must be the first entry in the section.

Uses

See Templates using Update Entry

Specification

Update Entry Example

<entry>
  <organizer classCode='BATTERY' moodCode='EVN'>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.16'/>
    <reference typeCode='RPLC'>
      <externalAct classCode='ACT' moodCode='EVN'>
        <id root='' extension=''/>
      </externalAct>
    </reference>
  </organizer>
</entry>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.16'/>

This templateId indicates that the organizer is used to update a PHR Extract.

<reference typeCode='RPLC'>

A reference element shall be present with typeCode RPLC. The reference element lists the acts that are affected by the update. It indicates that any referenced act is being replaced with new information. This element must be present, and may be repeated to replace more than one act at a time.

<externalAct classCode='ACT' moodCode='EVN'>

This element must appear as shown above. It indicates that the reference is to an external act (a section or entry contained in the parent document).

<id root=' ' extension=' '/>

This element identifies the information being replaced or updated. The identifer is of the entry or section being replaced. If the identifier is to a section being replaced, only one reference element is permitted.

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

Procedure Entry 1.3.6.1.4.1.19376.1.5.3.1.4.19

The procedure entry is used to record procedures that have occured, or which are planned for in the future.

Standards

CCD	ASTM/HL7 Continuity of Care Document

Uses

See Templates using Procedure Entry

Specification

Procedure Entry Example

<procedure classCode='PROC' moodCode='EVN|INT'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
  <templateId root='2.16.840.1.113883.10.20.1.29'/><!-- see text of section 0 -->
  <templateId root='2.16.840.1.113883.10.20.1.25'/><!-- see text of section 0 -->
  <id root='' extension=''/>
  <code code='' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode' />
  <text><reference value='#xxx'/></text>
  <statusCode code='completed|active|aborted|cancelled'/>
  <effectiveTime>
    <low value=''/>
    <high value=''/>
  </effectiveTime>
  <priorityCode code=''/>
  <approachSiteCode code='' displayName='' codeSystem='' codeSystemName=''/>
  <targetSiteCode code='' displayName='' codeSystem='' codeSystemName=''/>
  <author />
  <informant />
  <entryRelationship typeCode='COMP' inversionInd='true'>
    <act classCode='ACT' moodCode=''>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
      <id root='' extension=''/>
    </act>
  </entryRelationship>
  <entryRelationship typeCode='RSON'>
    <act classCode='ACT' moodCode='EVN'>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
      <id root='' extension=''/>
    </act>
  </entryRelationship>
</procedure>

<procedure classCode='PROC' moodCode='EVN|INT'>

This element is a procedure. The classCode shall be 'PROC'. The moodCode may be INT to indicated a planned procedure or EVN, to describe a procedure that has already occurred.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>

The templateId indicates that this <procedure> entry conforms to the constraints of this content module. NOTE: When the procedure is in event mood (moodCode='EVN'), this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.29, and when in intent mood, this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.25.

<id root=' ' extension=' '/>

This required element shall contain an identifier for the procedure. More than one procedure identifier may be present.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' ' />

This element shall be present, and should contain a code describing the type of procedure.

<text><reference value='#xxx'/></text>

The <text> element shall contain a reference to the narrative text describing the procedure.

<statusCode code='completed|active|aborted|cancelled'/>

The <statusCode> element shall be present when used to describe a procedure event. It shall have the value 'completed' for procedures that have been completed, and 'active' for procedures that are still in progress. Procedures that were stopped prior to completion shall use the value 'aborted', and procedures that were cancelled before being started shall use the value 'cancelled'.

<effectiveTime><low value=' '/><high value=' '/></effectiveTime>

This element should be present, and records the time at which the procedure occurred (in EVN mood), or the desired time of the procedure in INT mood.

<priorityCode code=' '/>

This element shall be present in INT mood when effectiveTime is not provided, it may be present in other moods. It indicates the priority of the procedure.

<approachSiteCode code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

This element may be present to indicate the procedure approach.

<targetSiteCode code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

This element may be present to indicate the target site of the procedure.

<entryRelationship typeCode='COMP' inversionInd='true'>

This element may be present to point the encounter in which the procedure was performed, and shall contain an internal reference to the encounter. See Internal References for more details.

<entryRelationship typeCode='RSON'>

A <procedure> act may indicate one or more reasons for the procedure. These reasons identify the concern that was the reason for the procedure via an Internal Reference to the concern. The extension and root of each observation present must match the identifier of a concern entry contained elsewhere within the CDA document.

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

Transport 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1

A transport entry indicates the intended or actual mode of transport and time of departure and/or arrival of the patient.

Uses

See Templates using Transport

Specification

Transport Example

<entry>
 <act classCode='ACT' moodCode='INT|EVN'>
   <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'/>
   <id root=' ' extension=' '/>
   <code code=' ' displayName=' '
         codeSystem='2.16.840.1.113883.6.102.4.2' 
         codeSystemName='DEEDS4.02'>
     <originalText><reference value='#(ID of text coded)/></orginalText>
   
   <text><reference value='#text/></text>
     <high value=/>
   </effectiveTime>
 </act>
</entry>

<act classCode='ACT' moodCode='INT|EVN'>

This element indicates that the entry is an act (of transporting the patient, as indicated by the code below). This entry records the mode, and intended or actual ending time of transportation. In intent mood (moodCode='INT') this is how the estimated time of departure or arrival is indicated. In event mood (moodCode='EVN') this is how the actual departure or arrival of the patient is recorded.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'/>

The <templateId> element identifies this <act> as about the tranportation of the patient. The templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'.

<id root=' ' extension=' '/>

The entry must have an identifier.

<code code=' ' displayName=' '
codeSystem='2.16.840.1.113883.6.102.4.2' codeSystemName='DEEDS4.02'>

The code describes the intented mode of transport. For transport between facilities, IHE recommends the use of a code system based on the DEEDS Mode of Transportation data element value set. However, the vocabulary used within an affinity domain should be determined by a policy agreement within the domain.

<originalText><reference value='#xxx'/><orginalText>

This is a reference to the narrative text within the section that describes the mode of transportation.

<text><reference value='#text/></text>

This is a reference to the narrative text cooresponding to the transport act.

<effectiveTime>

The effectiveTime element shall be sent. It records the interval of time over which transport occurs.

<low value=' '/>

This element records the time of departure. This element shall be sent using the TS data type, as shown above.

<high value=' '/>

This element records the time of arrival. If unknown, it must be recorded using a flavor of null. This element shall be sent using the TS data type as shown above.

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

Encounter Disposition 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2

This element records the intended or actual disposition for the patient (e.g., admit, discharge home after treatment, et cetera).

Uses

See Templates using Encounter Disposition

Specification

Encounter Disposition Example

<act classCode='ACT' moodCode='INT|EVN'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2'/>
  <id root='' extension=''/>
  <code code='' displayName='' codeSystem='' codeSystemName='' />
  <text><reference value='#xxx'/></text>
  <statusCode code='normal|completed'/>
  <effectiveTime value=''/> 
  <performer typeCode='PRF'>
    <assignedEntity>
      <id root='' extension=''/>
      <addr></addr>
      <telecom value='' use=''/>
      <assignedPerson>
        <name></name>
      </assignedPerson>
    </assignedEntity>
  </performer>
  <participant typeCode='RCV'>
    <time value=''/> 
    <participantRole classCode='ROL'>
      <id root='' extension=''/>
      <addr></addr>
      <telecom value='' use=''/>
      <playingEntity>
        <name></name>
      </playingEntity>
    </participantRole>
  </participant>
  <entryRelationship typeCode='COMP'>
    <act classCode='ACT'>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'/>
        :
    </act>
  </entryRelationship>
</act>

<act classCode='ACT' moodCode='INT|EVN'>

The disposition is recorded in an act element, to describe the disposition action taken during the encounter¹ . In intent mood (moodCode='INT'), this records the expected disposition of the patient. In event mood (moodCode='EVN'), this records the actual disposition.

¹	The HL7 RIM allows this portion of the encounter to be recorded in the dischargeDispositionCode RIM Attribute of the Encounter class, but the Encounter class is constrained within CDA. To record the disposition act therefore requires the use of the Act class.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2'/>

The templateId indicates that this <encounter> entry conforms to the constraints of this content module.

<id root=' ' extension=' '/>

This required element shall contain an identifier.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' ' />

This required element indicates the disposition of the patient. The code shall come from a coding system that is able to record common patient dispositions (e.g., Discharged, Transferred, Admitted). The "Administrative Procedure" concept (14734007) of SNOMED CT contains several code values that cover a wide variety of dispositions routinely recorded. Other vocabularies that are commonly in use to describe discharge disposition codes are DEEDS (See section 8.02), and in the US, the Uniform National Billing Code.

<text><reference value='#xxx'/></text>

The <text> element shall contain a reference to the narrative text describing the disposition of the patient. <statusCode code='normal|completed'/> When the disposition act has occurred (moodCode='EVN'), the statusCode element shall be present, and shall contain the value 'completed'. When the disposition act is intended (moodCode='EVN') the statusCode element shall contain the value 'normal'.

<effectiveTime><low value=' '/><high value=' '/><effectiveTime/>

When the disposition has occurred, this element shall be sent, and indicates the effective time for the disposition process. This element may be sent to record when the disposition act is intended to occur. The <low> element records the time at which the disposition process was started. The <high> value records the time at which the disposition process was completed.

<performer typeCode='PRF'>

The <performer> element provides information about the person that performs the discharge, admission or transfer of the patient. When the disposition is in intent mood, this element describes any expectations with respect to the performer, and is optional. When the disposition is in event mood, this element is required.

<assignedEntity>

The <assignedEntity> element identifies the performer of the disposition.

<id root=' ' extension=' '/>

The <id> element shall be sent when the disponsition has occurred, and identifies the performer of the act.

<addr></addr>

The <addr> element may be sent to provide a contact postal address for the performer of the disposition.

<telecom value=' ' use=' '/>

The <telecom> element may be sent to provide a contact postal address for the performer of the disposition.

<assignedPerson><name/></assignedPerson>

The <assignedPerson> element shall be sent to identify the person who performed the disposition of the patient.

<participant typeCode='RCV'>

<participantRole classCode='ROL'>
  <id root=' ' extension=' '/>
  <addr></addr>
  <telecom value=' ' use=' '/>
  <playingEntity><name/></playingEntity>

This element identifies the person or organization that is receiving the patient.

<entryRelationship typeCode='COMP'>
<act classCode='ACT'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'/>

If the disposition of the patient requires transport to another location, this information shall be recorded in a subordinate act that conforms to the Transport template described above.

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

Coverage Entry 1.3.6.1.4.1.19376.1.5.3.1.4.17

Payers shall be recorded as described in CCD: 3.1.2.1.2.

Standards

CCD	ASTM/HL7 Continuity of Care Document

Uses

See Templates using Coverage Entry

Specification

Coverage Entry Example

<act classCode='ACT' moodCode='DEF'>
  <templateId root='2.16.840.1.113883.10.20.1.20'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.17'/>
  <id root='' extension='' />
  <code code='35525-4' displayName='FINANCING AND INSURANCE' 
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <statusCode code='completed'/>
  <entryRelationship typeCode='COMP'>
    <sequenceNumber value=''/>
      :
  </entryRelationship>
</act>

<act classCode='ACT' moodCode='DEF'>

Coverage shall be recorded in an <act> that groups all patient coverage together, and defines (moodCode='DEF') the payers.

<templateId root='2.16.840.1.113883.10.20.1.20'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.17'/>

The <act> conforms to CCD: 3.1.2.1.1 as well as this specification. This shall be reflected by including the <templateId> elements shown above.

<id root=' ' extension=' '/>

The <id> element shall be present.

<code code='35525-4' displayName='FINANCING AND INSURANCE' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

The <code> element shall be recorded exactly as shown above.

<statusCode code='completed'/>

The <statusCode> element shall be present exactly as shown above.

<entryRelationship typeCode='COMP'>

The coverage <act> shall have one or more <entryRelationship> elements. These elements define the coverage. The entry relationships must contain Payer Entries.

<sequenceNumber value=' '/>

The <sequenceNumber> element may be present. If present, it shall contain a value attribute that indicates the priority of the payment source.

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

Payer Entry 1.3.6.1.4.1.19376.1.5.3.1.4.18

The payer entry allows information about the patient's sources of payment to be recorded.

Standards

CCD	ASTM/HL7 Continuity of Care Document

Uses

See Templates using Payer Entry

Specification

Payer Entry Example

<act classCode='ACT' moodCode='EVN'>
  <templateId root='2.16.840.1.113883.10.20.1.26'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.18'/>
  <id root='' extension=''/>
  <code code='' displayName='' codeSystem='' codeSystemName=''/>
  <statusCode code='completed'/>
  <performer typeCode='PRF'><!-- payer -->
    <assignedEntity classCode='ASSIGNED'>
      <id root='' extension=''/>
      <code code='PAYOR|GUAR|PAT' displayName=''
        codeSystem='2.16.840.1.113883.5.110' codeSystemName='RoleClass'/>
      <addr></addr>
      <telecom value='' use=''/>
      <representedOrganization typeCode='ORG'>
        <name></name>
      </representedOrganization>
    </assignedEntity>
  </performer>
  <participant typeCode='COV'><!-- member -->
    <participantRole classCode='PAT'>
      <id root='' extension=''/>
      <code code='' displayName='' 
        codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
      <addr></addr>
      <telecom value='' use=''/>
      <playingEntity><name></name></playingEntity>
    </participantRole>
  </participant>
  <participant typeCode='HLD'><!-- subscriber -->
    <participantRole classCode='PAT'>
      <id root='' extension=''/>
      <playingEntity><name></name></playingEntity>
    </participantRole>
  </participant>
  <entryRelationship typeCode='REFR'>
    <act classCode='ACT' moodCode='DEF'>
      <id root='' extension=''/>
      <code code='' displayName='' codeSystem='' codeSystemName=''/>
      <text><reference value=''/></text>
    </act>
  </entryRelationship>
</act>

<act classCode='ACT' moodCode='EVN'>

The policy entry <act> describes the policy or program that has agreed to pay (moodCode='EVN') for the patient's treatment.

<templateId root='2.16.840.1.113883.10.20.1.26'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.18'/>

The <act> conforms to CCD: 3.1.2.1.2 and this guide. This shall be reflected by including the <templateId> elements shown above.

<id root=' ' extension=' '/>

The <act> shall contain at least one <id> element that represents the policy or group number of the coverage. That identifier shall appear in the extension attribute.

<code code=' ' displayName=' '
codeSystem=' ' codeSystemName=' '/>

The <code> element should be present, and represents the type of coverage provided by the payer. Potential vocabularies to use include:

Payer Type Vocabularies
Vocabulary	Description	OID
HL7 ActCoverageType	The HL7 ActCoverageType vocabulary describes payers and programs. Note that HL7 does not have a specific code to identify an individual payer, e.g., in the role of a guarantor or patient.	2.16.840.1.113883.5.4
X12 Data Element 1336	The X12N 271 implementation guide includes various types of payers. This code set does include a code to identify individual payers.	2.16.840.1.113883.6.255.1336

<statusCode code='completed'/>

The <statusCode> element shall be present, and should be recorded exactly as shown above.

<performer typeCode='PRF'>
<assignedEntity classCode='ASSIGNED'>

The <performer> element shall be present to represent the payer of the coverage.

<id root=' ' extension=' '/>

The identity of the performer should be recorded in the <id> element.

<code code='PAYOR|GUAR|PAT' displayName=' '
codeSystem='2.16.840.1.113883.5.110'
codeSystemName='RoleClass'/>

The <code> element describes the role of the payer. It shall contain one of the values listed in the table below.

Payer Role Codes
Code	Description
PAYOR	Used to indicate that the payer is a payor for a policy or program.
GUAR	Used to indicate that the payer is a guarantor for the patient.
PAT	Used to indicate that the payer is the patient.

<addr></addr>

The <addr> element shall be used to record the address of the payer. This information will usually come from the back of an insurance card.

<telecom value=' ' use=' '/>

The <telecom> element shall be used to record the phone number of the payer. This information will usually come from the back of an insurance card.

<representedOrganization typeCode='ORG'>
<name></name>

The name of the payer organization shall be provided in the <name> element contained within the <representedOrganization> element.

<participant typeCode='COV'>
<participantRole classCode='PAT'>

Information about the patient with respect to the policy or program shall be recorded in the <participantRole> element shown above. This element shall be present when the patient is a member of a policy or program.

<id root=' ' extension=' '/>

The <id> element should contain the identifier of the patient with respect to the payer (the subscriber or member id).

<code code= displayName= codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>

The <code> element shall indicate the covered parties relationship to the subscriber, and should come from the HL7 CoverageRoleType value set.

<addr></addr>

The <addr> element should be used to record the address of the patient as known to the payer when different from that recorded in the <patientRole> element.

<telecom value=' ' use=' '/>

The <telecom> element should be used to record the phone number of the patient when different from that recorded in the <patientRole> element.

<playingEntity><name></name></playingEntity>

The <name> element should be used to record the member name when it is different from that recorded in the <patient> element.

<participant typeCode='HLD'>
<participantRole classCode='IND'>

Information about subscriber to the policy or program shall be recorded in the <participantRole> element shown above. This element shall be present when the subscriber is different from the patient.

<id root=' ' extension=' '/>

The <id> element shall contain the identifier of the subscriber when the subscriber is not the patient.

<addr></addr>

The <addr> element shall be used to record the address of the subscriber when the subscriber is not the patient.

<telecom value=' ' use=' '/>

The <telecom> element shall be used to record the phone number of the subscriber when the subscriber is not the patient.

<playingEntity><name></name></playingEntity>

The name of the subscriber shall be recorded in the <name> element of the <playingEntity>.

<entryRelationship typeCode='REFR'>
<act classCode='ACT' moodCode='DEF'>

The plan information may be provided in the elements described above.

<id root=' ' extension=' '/>

The health plan identifier is recorded in the <id> element.

<text><reference value=' '/></text>

This <reference> element shown above should be present and the value attribute should point to the name of the plan contained in the narrative of the document.

Revision as of 14:56, 11 May 2007 (view source) Kboone (talk \| contribs) m (→‎CDA Release 2.0 Content Modules) ← Older edit		Revision as of 14:57, 11 May 2007 (view source) Kboone (talk \| contribs) m (→‎CDA Release 2.0 Content Modules) Newer edit →
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−	== CDA Release 2.0 Content Modules ==	+	== <span ID='1.3.6.1.4.1.19376.1.5.3.1.1'/>CDA Release 2.0 Content Modules</span> ==
	This section contains content modules based upon the HL7 CDA Release 2.0 Standard, and related standards and/or implementation guides.		This section contains content modules based upon the HL7 CDA Release 2.0 Standard, and related standards and/or implementation guides.