IHE Patient Care Coordination Technical Framework Supplement Pre-procedure History and Physical (PPHP)

Transcription

1 ACC, HIMSS and RSNA Integrating the Healthcare Enterprise 5 IHE Patient Care Coordination Technical Framework Supplement Pre-procedure History and Physical (PPHP) 15 Draft for Trial Implementation August 15, Copyright 2006: ACC/HIMSS/RSNA

2 Contents Foreword... 3 GLOSSARY Introduction Open Issues and Questions Closed Issues... 7 Changes to Sections 1 1.X History of Annual Changes... 7 Y <XYZ> Integration Profile Dependencies PPHP Integration Profile PPHP Process Flow Use Case 1: Pre-procedure H&P to Surgical Center PPHP Binding PPHP Document Content Module Content Profile Namespaces and Vocabularies CDA Release 2.0 Content Modules Header Content Modules Section Content Modules Entry Modules

3 Foreword Integrating the Healthcare Enterprise (IHE) is an initiative designed to stimulate the integration of the information systems that support modern healthcare institutions. Its fundamental objective is to ensure that in the care of patients all required information for medical decisions is both correct and available to healthcare professionals. The IHE initiative is both a process and a forum for encouraging integration efforts. It defines a technical framework for the implementation of established messaging standards to achieve specific clinical goals. It includes a rigorous testing process for the implementation of this framework. And it organizes educational sessions and exhibits at major meetings of medical professionals to demonstrate the benefits of this framework and encourage its adoption by industry and users. The approach employed in the IHE initiative is not to define new integration standards, but rather to support the use of existing standards, HL7, DICOM, IETF, and others, as appropriate in their respective domains in an integrated manner, defining configuration choices when necessary. IHE maintain formal relationships with several standards bodies including HL7, DICOM and refers recommendations to them when clarifications or extensions to existing standards are necessary. This initiative has numerous sponsors and supporting organizations in different medical specialty domains and geographical regions. In North America the primary sponsors are the American College of Cardiology (ACC), the Healthcare Information and Management Systems Society (HIMSS) and the Radiological Society of North America (RSNA). IHE Canada has also been formed. IHE Europe (IHE-EUR) is supported by a large coalition of organizations including the European Association of Radiology (EAR) and European Congress of Radiologists (ECR), the Coordination Committee of the Radiological and Electromedical Industries (COCIR), Deutsche Röntgengesellschaft (DRG), the EuroPACS Association, Groupement pour la Modernisation du Système d'information Hospitalier (GMSIH), Société Francaise de Radiologie (SFR), Società Italiana di Radiologia Medica (SIRM), the European Institute for health Records (EuroRec), and the European Society of Cardiology (ESC). In Japan IHE-J is sponsored by the Ministry of Economy, Trade, and Industry (METI); the Ministry of Health, Labor, and Welfare; and MEDIS-DC; cooperating organizations include the Japan Industries Association of Radiological Systems (JIRA), the Japan Association of Healthcare Information Systems Industry (JAHIS), Japan Radiological Society (JRS), Japan Society of Radiological Technology (JSRT), and the Japan Association of Medical Informatics (JAMI). Other organizations representing healthcare professionals are invited to join in the expansion of the IHE process across disciplinary and geographic boundaries. The IHE Technical Frameworks for the various domains (IT Infrastructure, Cardiology, Laboratory, Radiology, etc.) defines specific implementations of established standards to achieve integration goals that promote appropriate sharing of medical information to support optimal patient care. It is expanded annually, after a period of public review, and 3

4 maintained regularly through the identification and correction of errata. The current version for these Technical Frameworks may be found at The IHE Technical Framework identifies a subset of the functional components of the healthcare enterprise, called IHE Actors, and specifies their interactions in terms of a set of coordinated, standards-based transactions. It describes this body of transactions in progressively greater depth. The volume I provides a high-level view of IHE functionality, showing the transactions organized into functional units called Integration Profiles that highlight their capacity to address specific clinical needs. The subsequent volumes provide detailed technical descriptions of each IHE transaction. This supplement to the IHE Patient Care Coordination Technical Framework V1.0 is submitted for Public Comment between June 15, 2006 and July 15, 2006, per the schedule announced in February 2006 Comments shall be submitted before July 15, 2006 to: under the IHE forum Select the IHE Patient Care Coordination Supplements for Public Review sub-forum. The IHE Patient Care Coordination Technical Committee will address these comments and publish the Trial Implementation version in August of

5 105 Date: August 15, 2006 Author(s): Dan Russler, M.D., McKesson Huong Bach, M.D. M.B.A., University of California-Davis, Surgical Admissions Center Davera Gabriel, R.N., University of California-Davis 110 These boxed instructions for the author to indicate to the Volume Editor how to integrate the relevant section(s) into the overall Technical Framework 5

6 115 GLOSSARY Procedure In the context of a Pre-procedure History and Physical, the procedure is a surgery or an invasive examination of a patient that is required by quality review organizations to be preceded by a pre-procedure assessment of procedure risk and anesthesia risk. This assessment is typically referred to as a Pre-operative or Preprocedure History and Physical. 6

7 Volume I Integration Profiles <This section describes the changes required in Volume I of the Technical Framework that result form including this Integration Profile.> 1 Introduction Volume 1: Volume 1:. Volume 1: Volume 1:3.2.X Place Use Case description into 1.5 Open Issues and Questions 1. Use of coded vocabulary/terminologies in new elements in this round. 1.6 Closed Issues 130 Changes to Sections 1 1.X <Include a subsection for each section/ subsection changed> 1.7 History of Annual Changes Add the following bullet to the end of the bullet list in section Y <XYZ> Integration Profile Dependencies 4.2 Actors/ Transactions It is expected that exchanges of Pre-procedure History & Physicals will occur in an environment where the physician offices and hospitals have a coordinated infrastructure that serves the information sharing needs of this community of care. Several mechanisms are supported by IHE profiles: A registry/repository-based infrastructure is defined by the IHE Cross-Enterprise Document Sharing (XDS) and other IHE Integration Profiles such as patient identification (PIX & PDQ), and notification of availability of documents (NAV). A media-based infrastructure is defined by the IHE Cross-Enterprise Document Media Interchange (XDM) profile. A reliable messaging-based infrastructure is defined by the IHE Cross-Enterprise Document Reliable Interchange (XDR) profile. 7

8 150 All of these infrastructures support Security and privacy through the use of the Consistent Time (CT) and Audit Trail and Node Authentication (ATNA) profiles. For more details on these profiles, see the IHE IT Infrastructure Technical Framework, found here: 8

9 PPHP Integration Profile Patient Care Coordination relating to same day procedures or ambulatory procedures that require anesthesia generates an extensive collection of data that must be available prior to the procedure to evaluate and / or ameliorate risk. This same data is required on the day of the procedure to adequately prepare the peri-operative and postprocedure teams for any special needs a patient may require. Medical Diagnoses, proposed procedure, authorizations, laboratory and imaging studies, and the preprocedure History & Physical, and other data gathering must all be performed in the ambulatory environment prior to scheduling a procedure in order to pre-operatively evaluate the risk of both the anesthesia and the procedure itself. A procedure risk assessment must be present and evaluated by the operative and after-care teams before the patient is allowed to have the procedure. Missing information is frequently a reason for canceling the procedure for the day, which leads to expensive underutilization of resources and dissatisfied patients. Further, incomplete information about the patient s clinical or home status may create a situation where a procedure is performed that ultimately results in an injury, inadequate aftercare or other undesirable outcome. 7.1 PPHP Process Flow Use Case 1: Pre-procedure H&P to Surgical Center This use case involves a sequence of events leading up to the patient s admission to the operating room in a surgical center. Included in these events is the creation and communication of the pre-procedure history and physical document required by quality review organizations prior to most surgeries. Precondition: The patient s primary care physician sees the patient for a problem that may require or benefit from an interventional modality (procedure). That patient is given a diagnosis related to a possible beneficial procedure and referred to a specialist for consultation. A surgical specialist sees a patient, determines the patient requires surgery, obtains pre-authorization from the payer, orders lab and imaging, schedules the surgery with the surgical coordinator, and refers the patient back to the primary care physician for pre-surgical H&P to be done in the primary care physician s office. The surgical consultation results, including the proposed procedure to be performed to address medical diagnosis, duration of procedure, estimated blood loss, and any special positioning required for the procedure, are available electronically to the primary care physician at the time of the H&P. Events: The patient is seen in the primary care physician s office where a complete medical and relevant social history are taken by the nurse and recorded in the office EHR, incorporating data from the surgeon s consultation report as appropriate. Laboratory and imaging reports ordered by the surgeon as well as the surgeon s consultation report are displayed electronically to the primary care physician. The 9

10 physician reviews the consultation report from the surgeon s office and pre-operative studies ordered by the surgeon along with data recorded by the nurse. Physical exam reveals some abnormalities. The physician orders additional laboratory, and the patient leaves the office. When the laboratory results return, the physician completes the pre-surgical H&P, Allergies, Medications, includes the data prepared or ordered by the surgeon, and makes it available to the surgeon and surgical center. This data includes an assessment of the patient s health status compared to the risk of the type of anesthesia planned and the procedure itself. The surgical coordinator documents that the complete collection of documents needed for surgery is available and administratively certifies that the patient is ready for surgery. The Surgical Center discharge planning is notified and assures that there is a suitable environment with appropriate support for post-procedure after-care. Postcondition: The Pre-surgical H&P with appropriate relationships to the Surgical Consultation and all the pre-operative laboratory and imaging are available to the surgeon and the surgical center personnel for incorporation into their respective EHRs. The H&P is also available to the patient for viewing and incorporation into the patient s PHR. Potential Stakeholders: Patient, primary care physician, pre-procedure physician (if different), surgeons, anesthesiologist, schedulers, insurance authorization, bed control, supply procurement, pre-op/or/post-op care teams, discharge planning and billing personnel. 7.2 PPHP Binding The PPHP integration profile reuses the Medical Document to XDS and Medical Document to XDP bindings defined in PCC TF-1: PPHP Document Content Module A Pre-procedure History and Physical content document is a type of medical document, and incorporates the constraints defined for medical documents found in section PCC TF- 2: Medical Document above. In addition, the PPHP content profile includes additional information to support the reasons for the procedure as well as the assessments of procedure risk and anesthesia risk. 10

11 225 Volume 2 Add the following section to the IHE Content Profiles Section of Volume II of the Patient Care Coordination Technical Framework. 5 Content Profile Namespaces and Vocabularies Namespaces for Vocabularies used in this Document Add the following row to the list of Namespaces codesystem codesystemname urn:oid: IHE PCC Template Identifiers URN to use in namespace declarations for IHE Extensions to CDA Release Add the following row to the list of IHE PCC Template Identifiers root The template identifier used to indicate that a CDA document conforms to the Pre-procedure History and Physical Module Specification. Add the following section to PCC TF-2: 5.4 the IHE Content Profiles Section of Volume II of the Patient Care Coordination Technical Framework. 5.4 CDA Release 2.0 Content Modules PPHP Module A Pre-procedure History and Physical is a type of medical document, and incorporates the constraints defined for medical documents found in section 5.4 Medical Documents above Standards 245 IHE Medical Document Content Integration Profiles HL7 Reference Information Model ANSI Standard 11

12 250 HL7 CDA R2 ANSI Standard HL7 Care Provision Domain DSTU (in process) Related Implementation Guides o HL7 Care Record Summary CDA R2 Implementation Guide (in process) o HL7/ASTM Continuity of Care Document Implementation Guide (in process) Data Element Index This use case is described fully in PCC TF-1: Briefly, this use case involves a sequence of events leading up to the patient s admission to the operating room in a surgical center. Included in these events is the creation and communication of the preprocedure history and physical document required by quality review organizations prior to most surgeries. Using this use case, the contents of documents used in collaborative transfers of care were discussed with physicians and nurses in detail to identify major sections. The sections identified by physicians during the use case exercise as important are listed in the table below under the column Use Case Documentation Section. Using this information from the use case, the following mappings were made to existing standards and implementation guides. As illustrated, there is quite a bit of overlap between sections in this integration profile and in sections specified in the HL7 Care Record Summary CDA implementation guide. Data Element Requirements Proposed Procedure: (coded procedure) Expected Blood Loss Sections in HL7 CDA-R2/ HL7 Care Record Summary PROCEDURE LOINC s OPERATIVE NOTE ESTIMATED BLOOD LOSS OPERATIVE NOTE ANESTHESIA OPERATIVE NOTE INDICATIONS Proposed Anesthesia Reason for Procedure: (coded diagnosis) HPI (free text leading up History of Present Illness HISTORY OF PRESENT ILLNESS to procedure) Current Problem List Conditions PROBLEM LIST Past Medical History Conditions HISTORY OF PAST ILLNESS Past Surgical-Anesthesia Past Surgical History HISTORY OF SURGICAL PROCEDURES History Medication List Medications HISTORY OF MEDICATION USE Allergy List Allergies and Adverse Reactions HISTORY OF ALLERGIES 12

13 Immunizations Immunizations HISTORY OF IMMUNIZATIONS History of Tobacco Use HISTORY OF TOBACCO USE Current Alcohol/Substance Abuse Transfusion History Family History (specifically includes): Family History HISTORY OF PRESENT ALCOHOL AND/OR SUBSTANCE ABUSE TBD HISTORY OF FAMILY MEMBER DISEASES -Family History Family History HISTORY OF FAMILY MEMBER DISEASES -Family History of Anesthesia Complications Social History Family History HISTORY OF FAMILY MEMBER DISEASES SOCIAL HISTORY Advance Directives Advance Directives ADVANCE DIRECTIVES Functional Capacity Functional Status HISTORY OF FUNCTIONAL STATUS Review of Systems Review of Systems REVIEW OF SYSTEMS (specifically includes): -General Review Review of Systems REVIEW OF SYSTEMS -Implanted Medical Review of Systems TBD needs narrative LOINC code Devices -Pregnancy Status (if female) Review of Systems PREGNANCY STATUS (needs narrative code) -Anesthesia Review of Review of Systems REVIEW OF SYSTEMS Systems Physical Exam Physical Examination PHYSICAL EXAM.TOTAL (specifically includes): -Vitals Vital Signs VITAL SIGNS -General Appearance GENERAL STATUS -Visible Medical Devices Needs narrative LOINC Code -Integumentary System INTEGUMENTARY SYSTEM -Head HEAD -Eyes EYE -Ears, Nose, Mouth and EARS & NOSE & MOUTH & THROAT Throat (may include): --Ears EAR --Nose NOSE --Mouth, Throat, and MOUTH & THROAT & TEETH Teeth -Neck NECK -Endocrine System ENDOCRINE SYSTEM -Thorax and Lungs (may THORAX+LUNGS include): --Chest Wall CHEST WALL --Breasts BREASTS --Heart HEART 13

14 --Respiratory System RESPIRATORY SYSTEM -Abdomen ABDOMEN -Lymphatic System HEMATOLOGIC+LYMPHATIC+IMMUNO LOGIC SYSTEM -Vessels VESSELS -Musculoskeletal System MUSCULOSKELETAL SYSTEM -Neurologic System NEUROLOGIC SYSTEM -Genitalia GENITALIA -Rectum RECTUM Studies and Reports Studies and Reports STUDIES SUMMARY Health Maintenance Status TREATMENT PLAN Pre-procedure Care Plan TREATMENT PLAN Status Report Pre-procedure Impressions DIAGNOSIS (specifically includes): -Updated Problem List Conditions PROBLEM LIST -Pre-Procedure Risk OPERATIVE NOTE COMPLICATIONS Assessment Pre-procedure Care Plan Plan of Care TREATMENT PLAN Patient Education/Consents EDUCATION NOTE Document Specification This section defines additional constraints for Medical Document Content used in a PPHD PPHD Document Section Opt Found Below in: Template ID Comments Proposed Procedure: (coded procedure) includes: -Reason for Procedure: (coded diagnosis) R Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. R Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. -Proposed Anesthesia R Content same as corresponding Op Note section except that this section describes what is planned to happen instead of 14

15 PPHD Document Section Opt Found Below in: Template ID Comments what happened. -Expected Blood Loss R Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. Needs narrative LOINC code -Procedure Care Plan R Care Plan generated by the surgeon or surgical coordinator prior to the H&P HPI (free text leading R up to procedure) Current Problem List R Problem List (if known) is represented as current at beginning of H&P encounter. Past Medical History R Past Surgical- R Anesthesia History Medication List R Allergy List R Immunizations R History of Tobacco Use R Current R Alcohol/Substance Abuse Transfusion History R Family History R (specifically includes): -Family History R Family History of R Anesthesia Complications Social History R Advance Directives R Functional Capacity R Review of Systems R (specifically includes): -General Review R Implanted Medical R Devices -Pregnancy Status (if R female) -Anesthesia Review of Systems R

16 PPHD Document Section Physical Exam (specifically includes): Opt Found Template ID Below in: R Comments -Vitals R General Appearance O Visible Implanted O Medical Devices -Integumentary O System -Head O Eyes O Ears, Nose, Mouth O and Throat (may include): --Ears O Nose O Mouth, Throat, and O Teeth -Neck O Endocrine System O Thorax and Lungs O (may include): --Chest Wall O Breasts O Heart O Respiratory System O Abdomen O Lymphatic System O Vessels O Musculoskeletal O System -Neurologic System O Genitalia O Rectum O Studies and Reports R Health Maintenance R Actions completed to date Care Plan Status Report Procedure Care Plan R Actions completed to date Status Report Pre-procedure R Impressions (specifically includes): - Problems R Updated at completion of encounter 16

17 PPHD Document Section -Pre-Procedure Risk Assessment Opt Found Below in: Template ID Comments R Content same as corresponding Op Note section except that this section describes what is at risk of happening instead of what happened. Procedure Care Plan R Updated with additional or modified actions to be executed in future Patient Education/Consents R Performed during H&P encounter 275 Table PPHP Document Content Module Constraints Header Content Modules This profile does not define any header content modules Section Content Modules Reasons for Care TemplateID Parent Template NONE Section Title Proposed Procedure General The proposed procedure section shall contain a description of the procedures for which a risk assessment is required including procedure names and codes, patient position, dates, and names of surgeons. It shall include entries for procedures as described in the Entry Content Modules and the required and optional subsections. Valid LOINC CODES Opt R PROCEDURE Procedure R IHE Procedure Structure R Reason for Procedure R Proposed Anesthesia R2 Expected Blood Loss R2 Procedure Care Plan TemplateID Parent Template NONE 17

18 Section Title Expected Blood Loss General The expected blood loss section shall contain a description of the blood loss for the procedure for which a risk assessment is required. Valid LOINC CODES Opt TBD (needs narrative code in R OPERATIVE NOTE EXPECTED BLOOD LOSS addition to quantitative code) Observation R IHE Simple Observation Structure TemplateID Parent Template NONE Section Title Proposed Anesthesia General The proposed anesthesia section shall contain a description of the anesthetic techniques for which a risk assessment is required. It shall include entries for anesthetic procedures as described in the Entry Content Modules. Valid LOINC CODES Opt R OPERATIVE NOTE ANESTHESIA Procedure R IHE Procedure Structure TemplateID Parent Template NONE Section Title Reason for Procedure General The reason for procedure section shall contain a description of the reason that the patient is receiving the procedure. It shall include entries for conditions as described in the Entry Content Module. Valid LOINC CODES Opt R OPERATIVE NOTE INDICATIONS R2 Error! Reference source not found. Conditions Entry

19 Other Condition Histories TemplateID Parent Template Section Title Pre-procedure Family Medical History General The pre-procedure family history section shall contain only the required and optional subsections describing the known genetic family members and their problems, especially those relating to anesthesia. Valid LOINC CODES Opt R HISTORY OF FAMILY MEMBER DISEASES No R Family Medical History R Family Medical History of Anesthesia Complications TemplateID Parent Template NONE Section Title Family Medical History General The family history section shall contain a description of the genetic family members, to the extent that they are known, the diseases they suffered from, their ages at death, and other relevant genetic information. Valid LOINC CODES Opt R HISTORY OF FAMILY MEMBER DISEASES 290 TemplateID Parent Template Section Title Family Medical History of Anesthesia Complications General The family history of Anesthesia Complications section shall contain a description of the genetic family members who have suffered complications during anesthesia such as malignant hyperthermia, bleeding, etc. It shall include entries for family history as described in the Entry Content Modules. Valid LOINC CODES Opt R HISTORY OF FAMILY MEMBER DISEASES 19

20 GeneticFamily R IHE GeneticFamily Structure R2 Error! Reference source not found. Conditions Entry TemplateID Section Title History of Tobacco Use General The history of tobacco use section shall contain a description of the responses the patient gave to a set of routine questions on the history of tobacco use. Valid LOINC CODES Opt R HISTORY OF TOBACCO USE TemplateID Parent Template Section Title History of Tobacco Use General The history of tobacco use section shall contain a description of the responses the patient gave to a set of routine questions on the history of tobacco use. It shall include entries for substance administration as described in the Entry Content Modules. Valid LOINC CODES Opt R HISTORY OF TOBACCO USE SubstanceAdministration R IHE Substance Administration Structure TemplateID Section Title Current Alcohol/Substance Abuse General The history of alcohol/substance abuse section shall contain a description of the responses the patient gave to a set of routine questions on the current abuse of alcohol or other substances. Valid LOINC CODES Opt R HISTORY OF PRESENT ALCOHOL AND/OR SUBSTANCE ABUSE 20

21 295 TemplateID Parent Template Section Title Current Alcohol/Substance Abuse General The history of alcohol/substance abuse section shall contain a description of the responses the patient gave to a set of routine questions on the current abuse of alcohol or other substances. It shall include entries for substance administration as described in the Entry Content Modules. Valid LOINC CODES Opt R HISTORY OF PRESENT ALCOHOL AND/OR SUBSTANCE ABUSE SubstanceAdministration R IHE Substance Administration Structure TemplateID Section Title Transfusion History General The transfusion history section shall contain a description of the blood products the patient has received in the past, including any reactions to blood products. It shall include entries for substance administration as described in the Entry Content Modules. Valid LOINC CODES Opt TBD R BLOOD PRODUCTS ADMINISTRATION TemplateID Parent Template Section Title Transfusion History General The transfusion history section shall contain a description of the blood products the patient has received in the past, including any reactions to blood products. It shall include only entries for blood 21

22 products administration and blood products administration allergies Valid LOINC CODES Opt TBD R BLOOD PRODUCTS ADMINISTRATION SubstanceAdministration R IHE Substance Administration Structure R Error! Reference source not found. Allergies and Intolerances Entry 300 TemplateID Parent Template Section Title Pre-procedure Review of Systems General The pre-procedure review of systems section shall contain only required and optional subsections dealing with the responses the patient gave to a set of routine questions on body systems in general and specific risks of anesthesia not covered in general review of systems. Valid LOINC CODES Opt R REVIEW OF SYSTEMS No R General Review of Systems R History of Implanted Medical Devices R2 Pregnancy Status History R Anesthesia Risk Review of Systems TemplateID Parent Template Section Title Anesthesia Risk Review of Systems General The anethesia review of systems section shall contain a description of the responses the patient gave to a set of routine questions on specific risks of anesthesia not covered in general review of systems such as broken teeth, airway limitations, positioning limitations, recent infections, and history of personal anethesia problems. Valid LOINC CODES Opt R REVIEW OF SYSTEMS 22

23 TemplateID Section Title Implanted Medical Device Review General The implanted medical device review section shall contain a description of the medical devices that are inserted into the patient, whether internal or partially external. Valid LOINC CODES Opt R REVIEW OF SYSTEMS TemplateID Section Title Pregnancy Status Review General The pregnancy status review section shall contain a description of the responses the patient gave to a set of routine questions regarding potential pregnancy in females of child-bearing-age. Valid LOINC CODES Opt R REVIEW OF SYSTEMS Medications Physical Exams TemplateID Parent Template Section Title Pre-procedure Physical Exam General The physical exam section shall contain only the required and optional subsections performed to determine procedure risk factors. 23

24 Valid LOINC CODES Opt R PHYSICAL EXAM.TOTAL No R Vital Signs O General Appearance O Visible Implanted Medical Devices O Integumentary System O Head O Eyes O Ears, Nose, Mouth and Throat O Ears O Nose O Mouth, Throat, and Teeth O Neck O Endocrine System O Thorax and Lungs O Chest Wall O Breasts O Heart O Respiratory System O Abdomen O Lymphatic System O Vessels O Musculoskeletal System O Neurologic System O Genitalia O Rectum 310 TemplateID Parent Template Section Title Vital Signs General The vital signs section shall contain a description of the measurement results of a patient s vital signs. It shall include required (height, weight, blood pressure, respiratory rate, heart rate) and optional (oxygen saturation) elements as described in the Entry Content Modules. Valid LOINC CODES Opt 24

25 R VITAL SIGNS VitalSigns R IHE Standard Vital Signs Structure TemplateID Section Title General Appearance General The general appearance section shall contain a description of the overall, visibly-apparent condition of the patient. Valid LOINC CODES Opt R GENERAL STATUS 315 TemplateID Section Title Visible Implanted Medical Devices General The visible implanted medical devices section shall contain a description of the medical devices apparent on physical exam that have been inserted into the patient, whether internal or partially external. Valid LOINC CODES Opt TBD R VISIBLE IMPLANTED MEDICAL DEVICES TemplateID Section Title Integumentary System General The integumentary system section shall contain a description of any type of integumentary system exam. Valid LOINC CODES Opt R INTEGUMENTARY SYSTEM 25

26 TemplateID Section Title Head General The head section shall contain a description of any type of head exam. Valid LOINC CODES Opt R HEAD TemplateID Section Title Eyes General The eyes section shall contain a description of any type of eye exam. Valid LOINC CODES Opt R EYE TemplateID Section Title Ears, Nose, Mouth and Throat General The ears, nose, mouth, and throat section shall contain a description of any type of ears, nose, mouth, or throat exam. Valid LOINC CODES Opt R EARS & NOSE & MOUTH & THROAT 26

27 320 TemplateID Parent Template Section Title Ears, Nose, Mouth and Throat General The ears, nose, mouth, and throat section shall contain a description of any type of ears, nose, mouth, or throat exam. It shall contain subsections on ears, nose, mouth, throat, and teeth. Valid LOINC CODES Opt R EARS & NOSE & MOUTH & THROAT No R Ears R Nose R Mouth, Throat, and Teeth TemplateID Section Title Ears General The ears section shall contain a description of any type of ear exam. Valid LOINC CODES Opt R EAR TemplateID Section Title Nose General The nose section shall contain a description of any type of nose exam. Valid LOINC CODES Opt R NOSE 27

28 325 TemplateID Section Title Mouth, Throat, and Teeth General The mouth, throat, and teeth section shall contain a description of any type of mouth, throat, or teeth exam. Valid LOINC CODES Opt R MOUTH & THROAT & TEETH TemplateID Section Title Neck General The neck section shall contain a description of any type of neck exam. Valid LOINC CODES Opt R NECK 330 TemplateID Section Title Endocrine System General The endocrine system section shall contain a description of any type of endocrine system exam. Valid LOINC CODES Opt R ENDOCRINE SYSTEM 28

29 TemplateID Section Title Thorax and Lungs General The thorax and lungs section shall contain a description of any type of thoracic or lung exams. Valid LOINC CODES Opt R THORAX+LUNGS TemplateID Parent Template Section Title Thorax and Lungs General The thorax and lungs section shall contain a description of any type of thoracic or lung exams. Valid LOINC CODES Opt R THORAX+LUNGS No O Chest Wall O Breasts O Heart O Respiratory System TemplateID Section Title Chest Wall General The chest wall section shall contain a description of any type of chest wall exam. Valid LOINC CODES Opt R CHEST WALL 29

30 TemplateID Section Title Breast General The breast section shall contain a description of any type of breast exam. Valid LOINC CODES Opt R BREASTS 335 TemplateID Section Title Heart General The heart section shall contain a description of any type of heart exam. Valid LOINC CODES Opt R HEART TemplateID Section Title Respiratory System General The respiratory system section shall contain a description of any type of respiratory exam. Valid LOINC CODES Opt R RESPIRATORY SYSTEM TemplateID

31 Section Title Abdomen General The abdomen system section shall contain a description of any type of abdominal exam. Valid LOINC CODES Opt R ABDOMEN TemplateID Section Title Lymphatic System General The lymphatic system section shall contain a description of any type of lymphatic exam. Valid LOINC CODES Opt R HEMATOLOGIC+LYMPHATIC+IMMUNOLOGIC SYSTEM TemplateID Section Title Vessels General The vessels section shall contain a description of any type of vessels exam. Valid LOINC CODES Opt R VESSELS 340 TemplateID Section Title Musculoskeletal System General The musculoskeletal system section shall contain a description of any type of musculoskeletal exam. 31

32 Valid LOINC CODES Opt R MUSCULOSKELETAL SYSTEM TemplateID Section Title Neurologic System General The neurologic system section shall contain a description of any type of neurologic exam. Valid LOINC CODES Opt R NEUROLOGIC SYSTEM TemplateID Section Title Genitalia General The genitalia section shall contain a description of any type of genital exam. Valid LOINC CODES Opt R GENITALIA TemplateID Section Title Rectum General The rectum section shall contain a description of any type of rectal exam. Valid LOINC CODES Opt R RECTUM 32

33 Relevant Studies Plans of Care TemplateID Parent Template Section Title Procedure Care Plan General The care plan section shall contain a description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient prior, during and after a procedure with goals of educating the patient, reducing the modifiable risks of the procedure and anethesia and otherwise optimizing the outcomes. The care plan will often be updated immediately following the addition of new impressions during the course of pre-procedure evaluation. Valid LOINC CODES Opt R TREATMENT PLAN TemplateID Parent Template Section Title Procedure Care Plan Status Report General The procedure care plan status report section shall contain a description of the progress towards completing expectations for care including actions completed in fulfilment of proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient prior to the procedure. Valid LOINC CODES Opt R TREATMENT PLAN 33

34 TemplateID Parent Template Section Title Health Maintenance Care Plan General The health maintenance care plan section shall contain a description of the expectations for wellness care including proposals, goals, and order requests for monitoring, tracking, or improving the lifetime condition of the patient with goals of educating the patient on how to reduce the modifiable risks of the patient s genetic, behavioral, and environmental pre-conditions and otherwise optimizing lifetime outcomes. Valid LOINC CODES Opt R TREATMENT PLAN 350 TemplateID Parent Template Section Title Health Maintenance Care Plan Status Report General The health maintenance status report section shall contain a description of the progress towards completing expectations for care including actions completed in fulfilment of proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. Valid LOINC CODES Opt R TREATMENT PLAN Procedures Performed TemplateID Section Title Patient Education and Consents General The patient education and consents section shall contain a description of the patient education the patient received, the results of the education, and the consents the patient signed. Valid LOINC CODES Opt R EDUCATION NOTE 34

35 355 TemplateID Parent Template Section Title Patient Education and Consents General The patient education and consents section shall contain a description of the patient education the patient received, the results of the education, and the consents the patient signed. It shall include entries for procedures and references to consent documents as described in the Entry Content Modules. Valid LOINC CODES Opt R EDUCATION NOTE Procedure R IHE Procedure Structure Observation R2 IHE Observation Structure ActRef R2 IHE External Reference Structure Impressions TemplateID Section Title Problems General The problems section shall contain a description of all types of concerns about the patient, active and inactive, cited by any author. It shall include entries for patient conditions as described in the Entry Content Module. The problems will often be updated immediately following the analysis of findings. Valid LOINC CODES Opt R PROBLEM LIST R Error! Reference source not found. Conditions Entry 35

36 TemplateID Parent Template Section Title Pre-procedure Impressions General The Impressions section shall contain only the required and optional subsections dealing with the updated problem list, the general risks the patient faces from the procedures, and the fixed and modifiable risks the patient faces because of specific patient findings. Valid LOINC CODES Opt R PROBLEM LIST No R Problems R Pre-procedure Risk Assessment 360 TemplateID Parent Template Section Title Pre-procedure Risk Assessment General The pre-procedure risk section shall contain a description of the risks the patient faces because of the planned procedure and associated anethesia, especially in the context of modifiable risks identified by patient findings. It shall include entries for patient risks as described in the Entry Content Module. Valid LOINC CODES Opt R PROBLEM LIST R Error! Reference source not found. Conditions Entry Entry Modules 36