View source for PCC Vocabulary Registry and Data Dictionary

''PCC Vocabulary Registry and Data Dictionary''



This page lists various vocabularies and data dictionaries that are under the control of the PCC Committee.  Please do not edit this without coordinating your activity with the PCC Committee.  It is supposed to be a safe reference for currently assigned terms, etc.  Some terms should not be assigned permanent values here until after the PCC profile documentation is complete.


__TOC__

== How to Acquire a new PCC Template Id ==
* add new row to section and Appendices for each new profile 
* IHE PCC Template Id root: 1.3.6.1.4.1.19376.1.5.3.1
* .1 is for doc content modules 
* .2 is for sections
* .3 is for entries and header elements
* .4 is for entries
* .5 is for workflow

==''Volume 1, Sections and Appendices ''==

{| class="wikitable"
!Chapter !! Description !! Status !! OID Space
|-
| 3 || [[PCC_TF-1/XDS-MS|Cross-Enterprise Sharing of Medical Summaries (XDS-MS)]] || Final Text ||1.3.6.1.4.1.19376.1.5.3.1.1.2
|-
| 4 || [[PCC_TF-1/XPHR|Exchange of Personal Health Record Content (XPHR)]] || Final Text
|-
| 5 || [[PCC_TF-1/EDR|ED Referral (EDR)]] || Final Text ||1.3.6.1.4.1.19376.1.5.3.1.1.10
|-
| 6 || [[PCC_TF-1/FSA|Reserved for Functional Status Assessments (FSA)]] || Under Revision || 1.3.6.1.4.1.19376.1.5.3.1.1.12
|-
| 7 || [[PCC_TF-1/EDES|Reserved for Emergency Department Encounter Summary (EDES)]] || Under Revision ||1.3.6.1.4.1.19376.1.5.3.1.1.13
|-
| 8 || [[PCC_TF-1/QED|Reserved for Query for Existing Data (QED)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.14
|-
| 9 || [[PCC_TF-1/APR|Antepartum Record (APR)]] || Under Revision || 1.3.6.1.4.1.19376.1.5.3.1.1.16
|-
| 10 || [[PCC_TF-1/CM|Care Management (CM)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.17
|-
| 11 || [[PCC_TF-1/IC|Immunization Content (IC)]] || Final Text || 1.3.6.1.4.1.19376.1.5.3.1.1.18
|-
| 12 || [[PCC_TF-1/CND|Patient Plan of Care (PPOC)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.20
|-
| 13 || [[PCC_TF-1/QCG|Request for Clincal Guidance (QCG)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.??
|-
| 13 || [[PCC_TF-1/PPCR|EMS Transfer of Care (ETC)]] || Trial Implementation || 1.3.6.1.4.1.19376.1.5.3.1.1.19
|-
| 13 || Labor and Delivery Record (LDR) || || 1.3.6.1.4.1.19376.1.5.3.1.1.21
|-
| 14 || Newborn Delivery Record  || || 1.3.6.1.4.1.19376.1.5.3.1.1.22
|-
| 15 || Patient Centerd Coordination Plan (PCCP) || || 1.3.6.1.4.1.19376.1.5.3.1.1.23
|-
| 16 || eReferral Workflow (XBeR-WD) || || 1.3.6.1.4.1.19376.1.5.3.1.5.1
|-
| 17 || Telehome Monitoring Workflow (XTHM-WD) || || 1.3.6.1.4.1.19376.1.5.3.1.5.2
|-
| 18 || Tumour Board Workflow (XTB-WD) || || 1.3.6.1.4.1.19376.1.5.3.1.5.3
|-
| 19 || Family Planning || || 1.3.6.1.4.1.19376.1.5.3.1.1.24
|-
|    || EHDI Workflow (EHDI) || || 1.3.6.1.4.1.19376.1.5.3.1.5.4
|-
|    || Mutliple Content View (MCV) || || 1.3.6.1.4.1.19376.1.5.3.1.5.5
|-
| A || Actor Descriptions
|-
| B || Transaction Descriptions
|-
| C || How to Prepare and IHE Integration Statement
|}

==''Volume 2, Transaction and Section Numbers''==

{| class="wikitable"
! Number
! Section and Transaction Name
|-
| [[PCC-1]]
| Share Content
|-
| [[PCC-2]]
| <ins>Query Existing Data</ins>
|-
| [[PCC-7]]
| Guideline Notification
|-
| [[PCC-8]]
| Request Guideline Data 
|-
| [[PCC-9]]
| Care Management Data Query 
|-
| [[PCC-10]]
| V3 Care Management Update 
|-
| [[PCC-11]]
| V2 Care Management Update 
|-
| [[PCC-12]]
| Reserved for RPM
|-
| [[PCC-13]]
| Reserved for RPM
|-
| [[PCC-14]]
| Reserved for RPM
|-
| [[PCC-15]]
| Reserved for RPM
|-
| [[PCC-16]]
| Share List (RECON on FHIR)
|-
| [[PCC-17]]
| Translate Code (CMAP)
|-
| [[PCC-18]]
| Retrieve Code Mappings (CMAP)
|-
| [[PCC-19]]
| Evaluate Order (GAO)
|-
| [[PCC-20]]
| Invoke Questionnaire (GAO)
|}

{| class="wikitable"
! Chapter !! Description
|-
| 5.3.1 || Folder Content Module Reserved for APS 
|-
| 5.4.1.10 - 13 || Document Content Modules Reserved for APS 
|-
|}

'''[[PCC_Vocabulary_Registry_and_Data_Dictionary_Removed | Sections, Appendices and Transactions that have been Removed, Deprecated, Withdrawn From Volume 1 and 2]]'''

== ''PCC Template Identifiers'' ==
{|border="2" cellspacing="0" cellpadding="4" width="100%"
|align = "center" bgcolor = "#D9D9D9"|'''Template Identifier'''
|align = "center" bgcolor = "#D9D9D9"|'''Description'''
|-
|style="background-color:#D9D9D9; font-weight:bold" | 1.3.6.1.4.1.19376.1.5.3.1.1
|style="background-color:#D9D9D9; font-weight:bold" | CDA Document Template Identifiers
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.1
|Medical Document
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.2
|Medical Summary Template Identifier and XDS-MS formatCode
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.3
|Referral Summary
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.4
|Discharge Summary
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4
|History and Physical
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.5
|PHR Extract
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.6
|PHR Update
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.7 
|Basic Patient Privacy Consent (BPPC)
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.10
|Emergency Department Referral (EDR)
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.11.2
|Antepartum Summary
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
|Triage Note
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2
|Nursing Note
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
|Composite Triage and Nursing Note
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
|ED Physician Note
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1
|Antepartum History and Physical
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.16.1.2
|Antepartum Laboratory
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.16.1.3
|Antepartum Education
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2
|Immunization Detail
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.19.1
|Prehospital Patient Care Report
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1
|Care Plan
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.20.1.2
|Subsequent Evaluation Note
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.1.1
|Labor and Delivery Admission History and Physical
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.1.2
|Labor and Delivery Summary
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.1.3
|Maternal Discharge Summary
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.1.4
|Postpartum Visit Summary
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.20.1.3
|e-Nursing Summary
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.22.1.1
|Newborn Discharge Summary
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.23.1.1
|Patient Centered Coordination Plan
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.23.1.2
|Patient Centered Coordination Task
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.23.1.3
|Patient Centered Coordination Task Report
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.24.1
|Reconciliation Document
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.25.1
|Transport Document
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.26.1
|Patient Care Plan Document
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.27.1
|Patient Care Plan Document (CCDA version)
|-
|style="background-color:#D9D9D9; font-weight:bold" | 1.3.6.1.4.1.19376.1.5.3.1.2
|style="background-color:#D9D9D9; font-weight:bold" | CDA Header Template Identifiers
|-
|1.3.6.1.4.1.19376.1.5.3.1.2.1
|Language Communication
|-
|1.3.6.1.4.1.19376.1.5.3.1.2.2
|Employer and School Contacts
|-
|1.3.6.1.4.1.19376.1.5.3.1.2.3
|Healthcare Providers and Pharmacies
|-
|1.3.6.1.4.1.19376.1.5.3.1.2.4
|Patient Contacts
|-
|1.3.6.1.4.1.19376.1.5.3.1.2.4.1
|Spouse
|-
|1.3.6.1.4.1.19376.1.5.3.1.2.4.2
|Natural Father of Fetus
|-
|1.3.6.1.4.1.19376.1.5.3.1.2.5
|Authorization
|-
|1.3.6.1.4.1.19376.1.5.3.1.2.6
|Consent Service Events
|-
|1.3.6.1.4.1.19376.1.5.3.1.2.7
|Related Document
|-
|1.3.6.1.4.1.19376.1.5.3.1.2.8
|Order Fulfillment
|-
|style="background-color:#D9D9D9; font-weight:bold" | 1.3.6.1.4.1.19376.1.5.3.1.3
|style="background-color:#D9D9D9; font-weight:bold" | CDA Section Template Identifiers
|-
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Reasons For Care
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.1
|Reason for Referral
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.2
|Reason for Referral (coded)
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
|Chief Complaint
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.3
|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
|Estimated 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
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1
|Reason for Visit
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
|Mode of Arrival

|-
|style="background-color:#EFEFEF; font-weight:bold;padding-left:60px" colspan="2" | Other Condition Histories
|-
|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
|History of Past Illness
|-
|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
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
|Coded Functional Status
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2
|Pain Scale Assessment
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3
|Braden Score Assessment
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4
|Geriatric Depression Scale
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5
|Physical Function
|-
|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
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1
|Estimated Delivery Date Section
|-
|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
|History of Blood Transfusion
|-
|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
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1
|History of Infection
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1.1
|Coded History of Infection
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.16.1
|Coded Social History
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.37
|Occupational Data for Health
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.2
|Prenatal Events
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.3
|Labor and Delivery Events
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.4
|Newborn Delivery Information
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.7
|Postpartum Treatment
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.8
|Newborn Status at Maternal Discharge
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.9
|Event Outcomes
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.20.2.1
|History of Cognitive Function
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.16.2.2
|History of Surgical Procedures
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.6
|Operation Note Section
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.20.2.4
|Pain Assessment Panel
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.12
|Discharge Status
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.37
|Occupational Data for Health Section
|-
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Medications
|-
|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

|-
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | 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
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1
|Extremeties
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.15.1
|Coded Physical Exam
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.10
|Pelvis
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.22.1.1.2.1
|Admission Physical Exam

|-
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Relevant Studies
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.27
|Results
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.28
|Coded Results
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.29
|Hospital Studies Summary
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.30
|Coded Hospital Studies Summary
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8
|Consultations
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.5
|Antenatal Testing and Surveillance
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.5.1
|Coded Antenatal Testing and Surveillance

|-
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Plans of Care
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.31
|Care Plan
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5
|Assessment and Plan
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.33
|Discharge Diet
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.34
|Advance Directives
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.35
|Coded Advance Directives
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.40
|Procedure Care Plan
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.45
|Procedure Care Plan Status Report
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.50
|Health Maintenance Care Plan
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.41
|Health Maintenance Care Plan Status Report
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.20.2.1
|Provider Orders
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
|Transport Mode
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.11
|History of Cognitive Function
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.2.1
|Birth Plan
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.18.3.1
|Immunization Recommendations
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.38
|Patient Education
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.20.2.2
|Diet and Nutrition
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.20.2.3
|Intake and Output
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.20.1.3.2.1
|Goals
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.20.1.3.2.2
|Expected Outcomes
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.20.1.3.2.3
|Treatment Plan
|-
|1.3.6.1.4.1.19376.1.5.3.1.3.36
|Coded Care Plan
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.26.1.1
|Patient Care Plan
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.26.1.2
|Hospital Discharge Instructions
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.26.1.3
|Patient Goals
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.26.1.4
|Reconciled Plan of Care
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.26.1.5
|Reconciled Patient Goals
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.26.1.6
|Reconciled Interventions

|-
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Procedures Performed
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11
|Procedures and Interventions
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
|Intravenous Fluids Administered

|-
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Impressions
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.42
|Pre-procedure Impressions
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.9.44
|Pre-procedure Risk Assessment
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2
|Visit Summary Flowsheet Section
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7
|Progress Note
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9
|ED Diagnoses
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2
|Acuity Assessment
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
|Assessments

|-
|style="background-color:#EFEFEF; font-weight:bold; padding-left:60px" colspan="2" | Administrative and Other Information
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7
|Payers
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3
|Referral Source
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
|Mode of Arrival
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10
|ED Disposition

|-
|style="background-color:#D9D9D9; font-weight:bold" | 1.3.6.1.4.1.19376.1.5.3.1.4
|style="background-color:#D9D9D9; font-weight:bold" | CDA Entry Template Identifiers

|-
|1.3.6.1.4.1.19376.1.5.3.1.4.1
|Severity
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.1.1
|Problem Status Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.1.2
|The template identifier used to identify a health status observation.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.2
|The template identifier used to identify a comment on an observation.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.3
|The template identifier used to identify instructions in medication order.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.3.1
|Medication Fulfillment Instructions
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.4
|The template identifier used to identify references to external documents.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.4.1
|Internal References
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.5.1
|The template identifier used to identify observation elements that indicate a concern.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.5.2
|The template identifier used to identify observation elements that indicate a problem of concern.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.5.3
|The template identifier used to identify observation elements that indicate an allergy or adverse reaction of concern.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.5
|The template identifier used to identify observation elements that describe patient problem.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.6
|The template identifier used to identify observation elements that describe patient allergy or adverse reaction.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.7
|The template identifier for a <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> event that records medication administration events or requests.  This is the root template for all medications.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.12
|Immunizations
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.7.3
|Supply Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.7.2
|Product Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.13
|Simple Observations
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.13.1
|Vital Signs Organizer
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.13.2
|Vital Signs Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.15
|Family History Organizer
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.13.3
|Family History Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.13.4
|Social History Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.13.5
|Pregnancy Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1
|Estimated Delivery Date Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2
|Antepartum Visit Summary Battery  
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.13.7
|Advance Directive Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.13.6
|Blood Type Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.14
|Encounters
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.16
|Update Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.19
|Procedure Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1
|Transport
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2
|Intended Encounter Disposition
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.17
|Coverage Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.18
|Payer Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1
|Pain Score Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2
|Braden Score Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3
|Braden Score Component
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.4
|Geriatric Depression Score Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.5
|Geriatric Depression Score Component
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7
|Survey Panel
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6
|Survey Observation
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1
|Acuity
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.3.2
|Intravenous Fluids Administered
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.13.3.4
|Nursing Assessments Battery
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.21.3.10
|Antenatal Testing and Surveillance Battery
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.7.1
|This template identifier identifies medications that do not require complex processing for dose (e.g., split, tapered, conditional dosing or combination medications).
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.8
|The template identifier for a <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> event that records tapered dose information in subordinate <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> events.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.9
|The template identifier for a <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> event that records split dose information in subordinate <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> events.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.10
|The template identifier for a <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> event that records conditional dose information in subordinate <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> events.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.11
|The template identifier for a <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> event that records combination medication component information in subordinate <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> events.
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.21
|The template identifier for a <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> event that records delayed start medication component information in subordinate <nowiki><</nowiki>substanceAdministration<nowiki>></nowiki> events.
|-
|1.3.6.1.4.1.19376.1.5.3.1.1.25.1.4.1
|Patient Transfer
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.20 
|Occupational Data for Health Organizer
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.20.1
|Employment Status Organizer Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.20.2
|Usual Occupation and Industry Organizer Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.20.3
|History of Occupation Organizer Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.20.4
|Employment Status Observation Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.20.5
|Usual Occupation and Industry Observation Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.20.6
|Occupation Observation Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.20.7 
|Work Schedule Observation Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.20.8 
|Weekly Work Hours Observation Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.20.9
|Usual Occupation Duration Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.20.10
|Usual Industry Duration Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.20.11 
|Weekly Work Days Observation Entry
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.22 
|Pregnancy Status Review Organizer
|-
|1.3.6.1.4.1.19376.1.5.3.1.4.22.1 
|Pregnancy Status Review Observation
|-

|}

==''Volume 2, Appendices''==

{| class="wikitable"
! Chapter !! Description
|-
| A || Examples
|-
| B || Validating CDA Documents
|-
| C || Extensions to CDA Release 2.0
|}


==See Also==

*The [[Frameworks#IHE Patient Care Coordination Technical Framework| PCC Technical Framework]] is the official master document.<br/>
*[[PCC_TF-2/Namespaces_and_Vocabularies | PCC Namespaces and Vocabularies]]
*[[PCC Vocabulary Registry and Data Dictionary/zh|A Simplified Chinese version of this page]]