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.
Volume 1, Sections and Appendices
| Chapter | Description | Status | OID Space |
|---|---|---|---|
| 3 | Cross-Enterprise Sharing of Medical Summaries (XDS-MS) | Final Text | |
| 4 | Exchange of Personal Health Record Content (XPHR) | Final Text | |
| 5 | ED Referral (EDR) | Final Text | |
| 6 | Reserved for Functional Status Assessments (FSA) | Under Revision | 1.3.6.1.4.1.19376.1.5.3.1.1.12 |
| 7 | Reserved for Emergency Department Encounter Summary (EDES) | Trial Implementation | 1.3.6.1.4.1.19376.1.5.3.1.1.13 |
| 8 | Reserved for Query for Existing Data (QED) | Trial Implementation | 1.3.6.1.4.1.19376.1.5.3.1.1.14 |
| 9 | Antepartum Record (APR) | Under Revision | 1.3.6.1.4.1.19376.1.5.3.1.1.16 |
| 10 | Care Management (CM) | Trial Implementation | 1.3.6.1.4.1.19376.1.5.3.1.1.17 |
| 11 | Immunization Content (IC) | Trial Implementation | 1.3.6.1.4.1.19376.1.5.3.1.1.18 |
| 12 | Patient Plan of Care (PPOC) | Draft | 1.3.6.1.4.1.19376.1.5.3.1.1.20 |
| 13 | Query for Clincal Guidance (QCG) | Draft | 1.3.6.1.4.1.19376.1.5.3.1.1.21 |
| 13 | Prehosptial Care Report (PPCR) | Draft | 1.3.6.1.4.1.19376.1.5.3.1.1.22 |
| 13 | Labor and Delivery Record (LDR) | Draft | 1.3.6.1.4.1.19376.1.5.3.1.1.23 |
| A | Actor Descriptions | ||
| B | Transaction Descriptions | ||
| C | How to Prepare and IHE Integration Statement |
Removed, Deprecated, Withdrawn From Volume 1, Sections and Appendices
| Chapter | Description | Status/Location | OID Space |
|---|---|---|---|
| X | Now in ITI | ||
| X | Withdrawn | 1.3.6.1.4.1.19376.1.5.3.1.1.9 | |
| X | Moved to APR | 1.3.6.1.4.1.19376.1.5.3.1.1.11 | |
| X | Added as CP to XD-LAB | 1.3.6.1.4.1.19376.1.5.3.1.1.15 | |
| X | Transferred to Pathology | 1.3.6.1.4.1.19376.1.5.3.1.1.19 |
Volume 2, Transaction and Section Numbers
| Number | Section and Transaction Name |
|---|---|
| PCC-1 | Query Existing Data |
| 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 |
Removed, Deprecated, Withdrawn From Volume 2, Transaction and Section Numbers
| Number | Section and Transaction Name |
|---|---|
| PCC-1 | |
| PCC-2 | |
| PCC-3 | |
| PCC-4 | |
| PCC-5 | |
| PCC-6 |
| Chapter | Description |
|---|---|
| 5.3.1 | Folder Content Module Reserved for APS |
| 5.4.1.10 - 13 | Document Content Modules Reserved for APS |
-->>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 |
| 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 |
| 1.3.6.1.4.1.19376.1.5.3.1.2 | 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 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 |
| 1.3.6.1.4.1.19376.1.5.3.1.3 | CDA Section Template Identifiers |
| 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 |
| 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 Dates 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 | 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 |
| 1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1 | APR|- |
| 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 |
| 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 |
| 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 |
| 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 |
| 1.3.6.1.4.1.19376.1.5.3.1.3.32 | Discharge Disposition |
| 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 |
| 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 | Transport Mode |
| Procedures Performed | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.38 | Patient Education and Consents |
| 1.3.6.1.4.1.19376.1.5.3.1.1.9.39 | Coded Patient Education and Consents |
|
Procedures Performed | |
| 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6 | Intravenous Fluids Administered |
| 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 |
| 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 |
| 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.