PCC Public Comment Drafts/11

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Revision as of 00:33, 20 June 2007 by Kboone (talk | contribs) (New page: {{:1.3.6.1.4.1.19376.1.5.3.1.1.9.37|Rectum|XDS-MS|EDR|EDER|PPHP}} ====Relevant Studies==== {{:1.3.6.1.4.1.19376.1.5.3.1.3.27|Results|XDS-MS|EDR|EDER|PPHP}} {{:1.3.6.1.4.1.19376.1.5.3.1.3.2...)
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Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at https://www.ihe.net/resources/technical_frameworks/#pcc

Trial.gif Rectum Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.37
General Description The rectum section shall contain a description of any type of rectal exam.
LOINC Code Opt Description
10205-3 R RECTUM



Sample Rectum Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.37'/>
    <id root=' ' extension=' '/>
    <code code='10205-3' displayName='RECTUM'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.37'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.37"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Rectum can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "10205-3"]'> 
     Error: The section type code of a Rectum must be 10205-3 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Rectum Section


Relevant Studies

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 https://www.ihe.net/resources/technical_frameworks/#pcc

Trial.gif Results Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.27
General Description The results section shall contain a narrative description of the patient’s relevant studies.
LOINC Code Opt Description
30954-2 R STUDIES SUMMARY



Sample Results Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.27'/>
    <id root=' ' extension=' '/>
    <code code='30954-2' displayName='STUDIES SUMMARY'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.27'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.27"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Results can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "30954-2"]'> 
     Error: The section type code of a Results must be 30954-2 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Results Section


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 https://www.ihe.net/resources/technical_frameworks/#pcc

Trial.gif Coded Results Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.28
General Description The results section shall contain a narrative description of the relevant diagnostic procedures the patient received in the past. It shall include entries for procedures and references to procedure reports when known as described in the Entry Content Modules.
LOINC Code Opt Description
30954-2 R STUDIES SUMMARY
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.19 R Procedure Entry
1.3.6.1.4.1.19376.1.5.3.1.4.4 R2 References Entry
1.3.6.1.4.1.19376.1.5.3.1.4.13 O Simple Observation



Sample Coded Results Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.28'/>
    <id root=' ' extension=' '/>
    <code code='30954-2' displayName='STUDIES SUMMARY'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Procedure Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
         :
    </entry> 
    <entry>
         :
      <!-- Required if known References Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
         :
    </entry> 
    <entry>
         :
      <!-- Optional Simple Observation element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.28'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.28"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Coded Results can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "30954-2"]'> 
     Error: The section type code of a Coded Results must be 30954-2 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded Results Section must contain a(n) Procedure Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.28
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Coded Results Section should contain a(n) References Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.28
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.13"]'> 
     <!-- Note any missing optional elements -->
     Note: This Coded Results Section does not contain a(n) Simple Observation Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.28
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Coded Results Section


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 https://www.ihe.net/resources/technical_frameworks/#pcc

Trial.gif Hospital Studies Summary Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.29
General Description The hospital studies summary section shall contain a narrative description of the relevant diagnostic procedures the patient received during the hospital admission.
LOINC Code Opt Description
11493-4 R HOSPITAL DISCHARGE STUDIES SUMMARY



Sample Hospital Studies Summary Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.29'/>
    <id root=' ' extension=' '/>
    <code code='11493-4' displayName='HOSPITAL DISCHARGE STUDIES SUMMARY'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.29'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.29"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Hospital Studies Summary can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11493-4"]'> 
     Error: The section type code of a Hospital Studies Summary must be 11493-4 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Hospital Studies Summary Section


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 https://www.ihe.net/resources/technical_frameworks/#pcc

Trial.gif Coded Hospital Studies Summary Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.30
Parent Template Hospital Studies Summary (1.3.6.1.4.1.19376.1.5.3.1.3.29)
General Description The hospital studies summary section shall include entries for diagnostic procedures and references to procedure reports when known as described in the Entry Content Modules.
LOINC Code Opt Description
11493-4 R HOSPITAL DISCHARGE STUDIES SUMMARY
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.19 R Procedure Entry
1.3.6.1.4.1.19376.1.5.3.1.4.4 R2 References Entry



Parent Template

The parent of this template is Hospital Studies Summary.

Sample Coded Hospital Studies Summary Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.29'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.30'/>
    <id root=' ' extension=' '/>
    <code code='11493-4' displayName='HOSPITAL DISCHARGE STUDIES SUMMARY'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Procedure Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
         :
    </entry> 
    <entry>
         :
      <!-- Required if known References Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.30'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.30"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Coded Hospital Studies Summary can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.29"]'> 
     Error: The parent template identifier for Coded Hospital Studies Summary is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11493-4"]'> 
     Error: The section type code of a Coded Hospital Studies Summary must be 11493-4 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded Hospital Studies Summary Section must contain a(n) Procedure Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.30
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Coded Hospital Studies Summary Section should contain a(n) References Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.30
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Coded Hospital Studies Summary Section


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 https://www.ihe.net/resources/technical_frameworks/#pcc

Trial.gif ED Consultations Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8
General Description The ED Consultations section shall contain a narrative description of the consultations obtained during an encounter of care. Consultations themselves may be placed in the consultation section of the EDES folder.
LOINC Code Opt Description
18693-2 R ED CONSULTANT PRACTITIONER



Sample ED Consultations Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8'/>
    <id root=' ' extension=' '/>
    <code code='18693-2' displayName='ED CONSULTANT PRACTITIONER'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The ED Consultations can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "18693-2"]'> 
     Error: The section type code of a ED Consultations must be 18693-2 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the ED Consultations Section


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