PCC Vocabulary Registry and Data Dictionary

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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.

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 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

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
7 Reserved for Emergency Department Encounter Summary (EDES) Under Revision
8 Reserved for Query for Existing Data (QED) Trial Implementation
9 Antepartum Record (APR) Under Revision
10 Care Management (CM) Trial Implementation
11 Immunization Content (IC) Final Text
12 Patient Plan of Care (PPOC) Trial Implementation
13 Request for Clincal Guidance (QCG) Trial Implementation
13 EMS Transfer of Care (ETC) Trial Implementation
13 Labor and Delivery Record (LDR)
14 Newborn Delivery Record
15 Patient Centerd Coordination Plan (PCCP)
16 eReferral Workflow (XBeR-WD)
17 Telehome Monitoring Workflow (XTHM-WD)
18 Tumour Board Workflow (XTB-WD)
19 Family Planning
EHDI Workflow (EHDI)
Mutliple Content View (MCV)
Cross-Enterprise Cardiovascular Heart Team Workflow (XCHT-WD)
A Actor Descriptions
B Transaction Descriptions
C How to Prepare and IHE Integration Statement

Volume 2, Transaction and Section Numbers

Number Section and Transaction Name
PCC-1 Share Content
PCC-2 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

Transaction 12 is already defined in the Request for Clinical Guidance (RCG) supplement and is not related to the requirements in the RPM supplement. Transactions 13 and 14 are already defined in the RCK supplement.

PCC-12 Reserved for RCG
PCC-13 Reserved for RCK
PCC-14 Reserved for RCK
PCC-15 Communicate PCHA Data Transaction (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)
PCC-21 Communicate PCD Data-hData (RPM)
PCC-22 Communicate PCD Data-SOAP (RPM)
PCC-23 Reserved for BED
PCC-24 Reserved for BED
PCC-25 Reserved for BED
PCC-26 Submit and assign HT Management
PCC-27 Accept/Reject HT Activity
PCC-28 Assign HT Participation
PCC-29 Add Request of more clinical information
PCC-30 Add more clinical information
PCC-31 Complete individual preparation
PCC-32 Plan HT Discussion
PCC-33 Complete HT
PCC-34 Finalization
PCC-35 Cancel HT
PCC-36 Cancel HT assignment
PCC-37 Update Care Plan
PCC-38 Retrieve Care Plan
PCC-39 Subscribe to Care Plan Updates
PCC-40 Provide Care Plan
PCC-41 Search for Care Plan
PCC-42 Communicate FHIR Data-hData (RPM)
PCC-43 Share FHIR Resources (RPM)
Chapter Description
5.3.1 Folder Content Module Reserved for APS - 13 Document Content Modules Reserved for APS
6.6 HL7 FHIR® Content Module
Chapter PCC FHIR Profiled IHE PCC Profile Used in
6.6.1 CarePlan DCP
6.6.2 Subscription DCP
6.6.3 Transport Content RIPT
6.6.4 careTeam DCTM
6.6.5 subscription DCTM

Sections, Appendices and Transactions that have been Removed, Deprecated, Withdrawn From Volume 1 and 2

PCC Template Identifiers

Template Identifier Description CDA Document Template Identifiers Medical Document Medical Summary Template Identifier and XDS-MS formatCode Referral Summary Discharge Summary History and Physical PHR Extract PHR Update Basic Patient Privacy Consent (BPPC) Emergency Department Referral (EDR) Antepartum Summary Triage Note Nursing Note Composite Triage and Nursing Note ED Physician Note Antepartum History and Physical Antepartum Laboratory Antepartum Education Immunization Detail Prehospital Patient Care Report Care Plan Subsequent Evaluation Note Labor and Delivery Admission History and Physical Labor and Delivery Summary Maternal Discharge Summary Postpartum Visit Summary e-Nursing Summary Newborn Discharge Summary Patient Centered Coordination Plan Patient Centered Coordination Task Patient Centered Coordination Task Report Reconciliation Document Transport Document Patient Care Plan Document Patient Care Plan Document (CCDA version) CDA Header Template Identifiers Language Communication Employer and School Contacts Healthcare Providers and Pharmacies Patient Contacts Spouse Natural Father of Fetus Authorization Consent Service Events Related Document Order Fulfillment CDA Section Template Identifiers
Reasons For Care Reason for Referral Reason for Referral (coded) Chief Complaint Hospital Admission Diagnosis Proposed Procedure Estimated Blood Loss Proposed Anesthesia Reason for Procedure Reason for Visit Mode of Arrival
Other Condition Histories History of Present Illness Hospital Course Active Problems Discharge Diagnosis History of Past Illness Encounter Histories History of Outpatient Visits History of Inpatient Visits List of Surgeries Coded List of Surgeries Allergies and Other Adverse Reactions Family Medical History Coded Family Medical History Pre-procedure Family Medical History Social History Functional Status Coded Functional Status Pain Scale Assessment Braden Score Assessment Geriatric Depression Scale Physical Function Review of Systems Preprocedure Review of Systems Hazardous Working Conditions Pregnancy History Estimated Delivery Date Section Medical Devices Foreign Travel History of Tobacco Use Current Alcohol/Substance Abuse History of Blood Transfusion Anesthesia Risk Review of Systems Implanted Medical Device Review Pregnancy Status Review History of Infection Coded History of Infection Coded Social History Occupational Data for Health Prenatal Events Labor and Delivery Events Newborn Delivery Information Postpartum Treatment Newborn Status at Maternal Discharge Event Outcomes History of Cognitive Function History of Surgical Procedures Operation Note Section Pain Assessment Panel Discharge Status Occupational Data for Health Section
Medications Medications Admission Medication History Medications Administered Hospital Discharge Medications Immunizations
Physical Exams Physical Exam Physical Exam (with subsections) Hospital Discharge Physical Exam Vital Signs Coded Vital Signs General Appearance Visible Implanted Medical Devices Integumentary System Head Eyes Ears, Nose, Mouth and Throat Ears Nose Mouth, Throat, and Teeth Neck Endocrine System Thorax and Lungs Chest Wall Breasts Heart Respiratory System Abdomen Lymphatic System Vessels Musculoskeletal System Neurologic System Genitalia Rectum Extremeties Coded Physical Exam Pelvis Admission Physical Exam
Relevant Studies Results Coded Results Hospital Studies Summary Coded Hospital Studies Summary Consultations Antenatal Testing and Surveillance Coded Antenatal Testing and Surveillance
Plans of Care Care Plan Assessment and Plan Discharge Diet Advance Directives Coded Advance Directives Procedure Care Plan Procedure Care Plan Status Report Health Maintenance Care Plan Health Maintenance Care Plan Status Report Provider Orders Transport Mode History of Cognitive Function Birth Plan Immunization Recommendations Patient Education Diet and Nutrition Intake and Output Goals Expected Outcomes Treatment Plan Coded Care Plan Patient Care Plan Hospital Discharge Instructions Patient Goals Reconciled Plan of Care Reconciled Patient Goals Reconciled Interventions
Procedures Performed Procedures and Interventions Intravenous Fluids Administered
Impressions Pre-procedure Impressions Pre-procedure Risk Assessment Visit Summary Flowsheet Section Progress Note ED Diagnoses Acuity Assessment Assessments
Administrative and Other Information Payers Referral Source Mode of Arrival ED Disposition CDA Entry Template Identifiers Severity Problem Status Observation The template identifier used to identify a health status observation. The template identifier used to identify a comment on an observation. The template identifier used to identify instructions in medication order. Medication Fulfillment Instructions The template identifier used to identify references to external documents. Internal References The template identifier used to identify observation elements that indicate a concern. The template identifier used to identify observation elements that indicate a problem of concern. The template identifier used to identify observation elements that indicate an allergy or adverse reaction of concern. The template identifier used to identify observation elements that describe patient problem. The template identifier used to identify observation elements that describe patient allergy or adverse reaction. The template identifier for a <substanceAdministration> event that records medication administration events or requests. This is the root template for all medications. Immunizations Supply Entry Product Entry Simple Observations Vital Signs Organizer Vital Signs Observation Family History Organizer Family History Observation Social History Observation Pregnancy Observation Estimated Delivery Date Observation Antepartum Visit Summary Battery Advance Directive Observation Blood Type Observation Encounters Update Entry Procedure Entry Transport Intended Encounter Disposition Coverage Entry Payer Entry Pain Score Observation Braden Score Observation Braden Score Component Geriatric Depression Score Observation Geriatric Depression Score Component Survey Panel Survey Observation Acuity Intravenous Fluids Administered Nursing Assessments Battery Antenatal Testing and Surveillance Battery This template identifier identifies medications that do not require complex processing for dose (e.g., split, tapered, conditional dosing or combination medications). The template identifier for a <substanceAdministration> event that records tapered dose information in subordinate <substanceAdministration> events. The template identifier for a <substanceAdministration> event that records split dose information in subordinate <substanceAdministration> events. The template identifier for a <substanceAdministration> event that records conditional dose information in subordinate <substanceAdministration> events. The template identifier for a <substanceAdministration> event that records combination medication component information in subordinate <substanceAdministration> events. The template identifier for a <substanceAdministration> event that records delayed start medication component information in subordinate <substanceAdministration> events. Patient Transfer Occupational Data for Health Organizer Employment Status Organizer Entry Usual Occupation and Industry Organizer Entry History of Occupation Organizer Entry Employment Status Observation Entry Usual Occupation and Industry Observation Entry Past and Present Occupation Observation Entry Work Schedule Observation Entry Weekly Work Hours Observation Entry Usual Occupation Duration Entry Usual Industry Duration Entry Weekly Work Days Observation Entry Past and Present Industry Observation Entry Job Employment Type Observation Entry Usual Occupation Observation Entry Usual Industry Observation Entry Pregnancy Status Review Organizer Pregnancy Status Review Observation

Volume 2, Appendices

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

See Also