Difference between revisions of "PCC Vocabulary Registry and Data Dictionary"

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Revision as of 13:44, 30 May 2008

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.



Volume 1, Sections and Appendices

Chapter Description OID Space
3 Cross-Enterprise Sharing of Medical Summaries (XDS-MS)
4 Reserved for Exchange of Personal Health Record Content (XPHR)
5 Reserved for Basic Patient Privacy Consents (BPPC)
6 Reserved for ED Referral (EDR)
7 Reserved for Preprocedure History and Physical (PPHP)
8 Reserved for Antepartum Summary (APS) 1.3.6.1.4.1.19376.1.5.3.1.1.11
9 Reserved for Functional Status Assessments (FSA) 1.3.6.1.4.1.19376.1.5.3.1.1.12
10 Reserved for Emergency Department Encounter Record (EDER) 1.3.6.1.4.1.19376.1.5.3.1.1.13
11 Reserved for Query for Existing Data (QED) 1.3.6.1.4.1.19376.1.5.3.1.1.14
12 Laboratory Public Health Reporting 1.3.6.1.4.1.19376.1.5.3.1.1.15
13 Antepartum Record 1.3.6.1.4.1.19376.1.5.3.1.1.16
14 Care Management 1.3.6.1.4.1.19376.1.5.3.1.1.17
15 Immunization Content 1.3.6.1.4.1.19376.1.5.3.1.1.18
16 Cancer Registry Content 1.3.6.1.4.1.19376.1.5.3.1.1.19
A Actor Descriptions
B Transaction Descriptions
C How to Prepare and IHE Integration Statement

Volume 2, Transaction and Section Numbers

Number Section Name and Transaction Name
PCC-1 Query Existing DataQuery Vital Signs
PCC-2 Query Problems and Allergies
PCC-3 Query Lab Results
PCC-4 Query Medications
PCC-5 Query Immunizations
PCC-6 Query Professional Services
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


Chapter Description
5.3.1 Folder Content Module Reserved for APS
5.4.1.10 - 13 Document Content Modules Reserved for APS

This text needs to be fixed-->>Update this page<<--

PCC Template Identifiers

Template Identifier Description
1.3.6.1.4.1.19376.1.5.3.1.1 CDA Document Template Identifiers
1.3.6.1.4.1.19376.1.5.3.1.1.1 Medical Document Template
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 Template
1.3.6.1.4.1.19376.1.5.3.1.1.4 Discharge Summary Template
1.3.6.1.4.1.19376.1.5.3.1.1.5 The template identifier used to indicate that a CDA document conforms to the PHR Extract Module Specification.
1.3.6.1.4.1.19376.1.5.3.1.1.6 The template identifier used to indicate that a CDA document conforms to the PHR Update Module Specification.
1.3.6.1.4.1.19376.1.5.3.1.1.7 The template identifier used to indicate that a CDA document conforms to the Basic Patient Privacy Consent to Share Information Module.
1.3.6.1.4.1.19376.1.5.3.1.1.9 The template identifier used to indicate that a CDA document conforms to the Pre-procedure History and Physical Module Specification.
1.3.6.1.4.1.19376.1.5.3.1.1.10 The template identifier used to indicate that a CDA document conforms to the ED Referral Module Specification.
1.3.6.1.4.1.19376.1.5.3.1.2 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, School or other affiliated organization contact
1.3.6.1.4.1.19376.1.5.3.1.2.3 Pharmacy Contact
1.3.6.1.4.1.19376.1.5.3.1.3 CDA Section Template Identifiers
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 (Structured)
1.3.6.1.4.1.19376.1.5.3.1.3.3 Hospital Admission Diagnosis
1.3.6.1.4.1.19376.1.5.3.1.3.4 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 Problems
1.3.6.1.4.1.19376.1.5.3.1.3.8 Resolved Problems
1.3.6.1.4.1.19376.1.5.3.1.3.9 History of Outpatient Visits
1.3.6.1.4.1.19376.1.5.3.1.3.10 History of Inpatient Admissions
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 List of Surgeries (structured)
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 Family Medical History (structured)
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
1.3.6.1.4.1.19376.1.5.3.1.3.19 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 Hospital Medications
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
1.3.6.1.4.1.19376.1.5.3.1.3.24 Physical Exam
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1 History of Occupational Exposure
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 Vital Signs (Coded)
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3 History of Encounters
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 History of Pregnancies
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 History of Foreign Travel
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7 Payers
1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1 The template identifier for the CARE PLAN Section
1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 The template identifier for the TRANSPORT MODE Section
1.3.6.1.4.1.19376.1.5.3.1.4 CDA Entry Template Identifiers
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.
1.3.6.1.4.1.19376.1.5.3.1.4.4 The template identifier used to identify references to external documents.
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.
1.3.6.1.4.1.19376.1.5.3.1.4.6.1 The template identifier used to identify observation elements that describe manifestations of an allergy; the symptom, sign, or diagnosis observation, e.g. rash, weal (hive), or urticaria.
1.3.6.1.4.1.19376.1.5.3.1.4.7 The template identifier for a <substanceAdministration> event that records medication administration events or requests. This is the root template for all medications.
1.3.6.1.4.1.19376.1.5.3.1.4.7.1 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 <substanceAdministration> event that records tapered dose information in subordinate <substanceAdministration> events.
1.3.6.1.4.1.19376.1.5.3.1.4.9 The template identifier for a <substanceAdministration> event that records split dose information in subordinate <substanceAdministration> events.
1.3.6.1.4.1.19376.1.5.3.1.4.10 The template identifier for a <substanceAdministration> event that records conditional dose information in subordinate <substanceAdministration> events.
1.3.6.1.4.1.19376.1.5.3.1.4.11 The template identifier for a <substanceAdministration> event that records combination medication component information in subordinate <substanceAdministration> events.
1.3.6.1.4.1.19376.1.5.3.1.4.12 Immunization
1.3.6.1.4.1.19376.1.5.3.1.4.13 Simple Observation
1.3.6.1.4.1.19376.1.5.3.1.4.14 Encounter
1.3.6.1.4.1.19376.1.5.3.1.4.15 Family History Observation
1.3.6.1.4.1.19376.1.5.3.1.4.16 Procedure Entry
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 Policy Entry
1.3.6.1.4.1.19376.1.5.3.1.4.19 Payer Entry
1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1 The template identifier for the Transport Entry.
1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2 The template identifier for the Intended Disposition Entry.

Volume 2, Appendices

Chapter Description
A Examples
B Validating CDA Documents
C Extensions to CDA Release 2.0


See Also

The PCC Technical Framework is the official master document.