Talk:1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4

Fixed: 08:03, 2 October 2008 (CDT) Kboone

Changed the LOINC Code

In the table listing LOINC codes, "List of Surgeries" is shown as having a LOINC code of "10167-5 HISTORY OF SURGICAL PROCEDURES".

In the table listing template IDs, "List of Surgeries" is shown as having a template ID of "1.3.6.1.4.1.19376.1.5.3.1.3.11".

However, on the page describing template ID 1.3.6.1.4.1.19376.1.5.3.1.3.11, the requisite LOINC code is given as: 47519-4 HISTORY OF PROCEDURES.

There is a conflict between two differing LOINC codes.

The CCD parent of 1.3.6.1.4.1.19376.1.5.3.1.3.11 gives us a clue as to which LOINC code was probably intended. The CCD parent template ID is 2.16.840.1.113883.10.20.1.12. According to CCD 3.14 Procedures (pg 54): "The template identifier for the procedures section is 2.16.840.1.113883.10.20.1.12." And by CONF-424 we see: 'The value for "Section / code" SHALL be "47519-4" "History of procedures" 2.16.840.1.113883.6.1 LOINC STATIC.'

Therefore the solution to this conflict would be to choose the LOINC code specified by CCD and change the LOINC in the table for List of Surgeries to 47519-4.

Fixed: 08:03, 2 October 2008 (CDT) Kboone

Added schematron

This is not really an error report, rather it's something I'm passing along in case it is helpful for anyone.

There are three sections which are listed as "conditional": "Assessements", "Care Plan" and "Assessment and Plan".

The rules are the following:

"Assessements: This section shall be present when assessments and plans are recorded separately."

"Care Plan: This section shall be present when assessments and plans are recorded separately."

"Assessment and Plan: This section shall be present when assessments and plans are recorded together."

Currently, the schematron rules check for the existence of all three and if any are not present, it flags this as something that must be checked manually.

My interpretation (which may be incorrect) of the above three rules (and considering the structure of the rest of the ED Physician Note) was as follows:

Either "Assessments" AND "Care Plan" shall be present OR "Assessment and Plan" shall be present. All three sections shall not exist at the same time. If "Assessment and Plan" exists then neither "Assessments" or "Care Plan" shall exist.

My schematron to implement that interpretation replaced the three manual checks with:

<assert test='((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"])
               and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"])
              or (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"]))
             and
               not((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"])
                and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"])
                and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"]))
             and
               not((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"])
                and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]))
             and
               not((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"])
                and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"]))
'>
   Error:  A(n) ED Physician Note shall contain either Assessments AND Care
   Plan OR Assessment and Plan. See
   http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
</assert>

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