CDA Release 2.0 Content Modules
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.
<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='20240425012005'/> <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.
<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'/> |
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.
<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'/> |
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.
<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'/> |
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
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
Thes components are required of all Medical Documents |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.1 |
Personal Information
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
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.
<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'/> |
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.
<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='20240425012005'/> <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
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.
<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'/> |
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.
<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'/> |
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.
<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'/> |
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
<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
<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
<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
<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
<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> <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
<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 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
<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
Related Document 1.3.6.1.4.1.19376.1.5.3.1.2.7
The relatedDocument element using this templateId shall refer to a document conforming to the PHR Extract Content module. All XML content with the exception of the <id> element must appear exactly as shown below.
Uses
See Templates using Related Document
Specification
<relatedDocument typeCode='APND'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.7'/> <parentDocument classCode='DOCCLIN' moodCode='EVN'> <id root=' ' extension=' '/> </parentDocument> </relatedDocument> |
Indicates that this CDA document is an addendum to a preceeding CDA document. The typeCode
attribute shall have the value APND.
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.7'/>
This template identifier indicates that the <relatedDocument> entry conforms to the rules of this specification.
<parentDocument classCode='DOCCLIN' moodCode='EVN'>
<id root=' ' extension=' '/>
The related document shall be recorded in the <parentDocument> document element by identifying the the PHR Extract that is being updated in the <id> element.
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
Plans of Care
This section provides content modules for sections that describe the plan of care intended for the patient.
- (1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1)ED Care Plan
- (1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2)Transport Mode
Procedures Performed
Impressions
Administrative and Other Information
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:
</tr>
Use of ID | References to ID |
---|---|
<tr ID='foo'>
|
<code>
</code>
</code> |
<list>
</list> |
<code>
</code> |
<paragraph ID='p-1'>A paragraph
</paragraph> |
<code>
</code>
</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:
$theURI | Returned Value |
---|---|
"#bar" | "Table Cell 1" |
"#foo" | "Table Cell 1Table Cell 2" (note the spacing issue between 1 and T) |
"#p-1" | "A paragraph with content" |
"#c-1" | "with content" |
If your XSLT processor is schema aware, even more efficient mechanisms exist to locate the element than the above expression.
Having identified the critical text in the narrative, any elements using the HL7 CD datatype (e.g., <code>) can then contain a <reference> to the <originalText> found in the narrative. That is why, although CDA allows <value> to be of any type in <entry> elements, this profile restricts them to always be of xsi:type='CD'.
Now, given an item with an ID stored in a variable named theID all <reference> elements referring to it can be found via the following XPath expression:
//cda:reference[@URI=concat('#',$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
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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
Specification
<observation classCode='COND' moodCode='EVN'> |
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
<entry> <observation classCode='OBS' moodCode='EVN'> |
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.
Code | Description |
---|---|
55561003 | Active |
73425007 | Inactive |
90734009 | Chronic |
7087005 | Intermittent |
255227004 | Recurrent |
415684004 | Rule out |
410516002 | Ruled out |
413322009 | Resolved |
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
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
<entry> <observation classCode='OBS' moodCode='EVN'> |
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'
).
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
Specification
<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
<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
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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
<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
<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.
Development Only
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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
<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.
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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
∶ <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
<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:
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.
<!-- 1..* entry relationships identifying problems of concern -->
<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. |
<!-- 0..n optional entry relationship providing more information about the concern -->
<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
<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.
<!-- 1..* entry relationships identifying problems of concern -->
<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’
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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
<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.
<!-- 1..* entry relationships identifying allergies of concern -->
<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’
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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
<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.
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.
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.
<!-- zero or one <entryRelationship typeCode='SUBJ' inversionInd='true'> elements containing severity -->
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’.
<!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements containing clinical status -->
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’.
<!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements identifying the health status of concern -->
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.
<!-- zero to many <entryRelationship typeCode='SUBJ' inversionInd='true'> element containing comments -->
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
<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.
<!-- zero to many <entryRelationship> elements containing reactions -->
An allergy entry can record the reactions that are manifestations of the allergy or intolerance as shown below.
<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.
<!-- zero or one <entryRelationship typeCode='SUBJ' inversionInd='true'> elements containing severity -->
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’.
<!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements containing clinical status -->
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.
<!-- zero to many <entryRelationship typeCode='SUBJ' inversionInd='true'> element containing comments -->
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
<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
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.
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
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
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>.
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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
<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.
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.
<!-- Optional <entryRelationship> element containing comments -->
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
<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
<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
The
<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.
<!-- Optional Fulfillment instrctions -->
<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.
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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
<!-- 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.
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
<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
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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
<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.
<!-- one or more vital signs observations -->
<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
<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.
LOINC | Description | Units | Type |
---|---|---|---|
9279-1 | RESPIRATION RATE | /min | PQ |
8867-4 | HEART BEAT | ||
2710-2 | OXYGEN SATURATION | % | |
8480-6 | INTRAVASCULAR SYSTOLIC | mm[Hg] | |
8462-4 | INTRAVASCULAR DIASTOLIC | ||
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
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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
<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.
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
<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.
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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
<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=' '/> |
<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.
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 | |
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=' '/>
<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
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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
<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=' '/> |
<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.
LOINC CODE | Description | Type | Units or Vocabulary | |
---|---|---|---|---|
Summary over All Pregnancies | ||||
11636-8 | BIRTHS LIVE (REPORTED) | INT | ||
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 | SNOMED CT | ||
8665-2 | DATE LAST MENSTRUAL PERIOD | TS | ||
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=' '/>
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
The <interpretationCode>, <methodCode>, and <targetSiteCode> should not be present in a pregnancy observation.
Development Only
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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
<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=' '/> |
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.
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.
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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
<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=' '/> |
<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.
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=' '/>
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
The <interpretationCode>, <methodCode>, and <targetSiteCode> should not be present in a blood type observation.
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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
<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'> <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
<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.
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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
<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.
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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 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.
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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
Specification
<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.
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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
<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'>
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.
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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
<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.
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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
<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:
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.
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.
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