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.


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Removed, Deprecated, Withdrawn From Volume 1, Sections and Appendices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 Reserved for Basic Patient Privacy Consents (BPPC) Now in ITI
X Reserved for Preprocedure History and Physical (PPHP) Withdrawn 1.3.6.1.4.1.19376.1.5.3.1.1.9
X Reserved for Antepartum Summary (APS) Moved to APR 1.3.6.1.4.1.19376.1.5.3.1.1.11
X Laboratory Public Health Reporting Added as CP to XD-LAB 1.3.6.1.4.1.19376.1.5.3.1.1.15
X Cancer Registry Content 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Removed, Deprecated, Withdrawn From Volume 2, Transaction and Section Numbers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 Query 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


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
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
Other Condition Histories
Medications
Physical Exams
Relevant Studies
Plans of Care
Procedures Performed
Impressions
Administrative and Other Information


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
1.3.6.1.4.1.19376.1.5.3.1.3.4 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 (coded)
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 (coded)
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.