PCC - mobile Paramedicine Summary of Care (mPSC)
2.0.0-draft - ci-build
PCC - mobile Paramedicine Summary of Care (mPSC), published by IHE Patient Care Coordination. This guide is not an authorized publication; it is the continuous build for version 2.0.0-draft built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/PCC.PCS/ and changes regularly. See the Directory of published versions
Volume 3 contains content profiles.
This section corresponds to Content Module [domain-ZZ]
The Antepartum Summary represents a summary of the most critical information to an antepartum care provider regarding the status of a patient’s pregnancy. This document content module is a Medical Summary and inherits all header constraints from Medical Summary (1.3.6.1.4.1.19376.1.5.3.1.1.2).
The following new Format Codes are introduced with the mPSC Profile. A complete listing of IHE Format Codes can be found at http://wiki.ihe.net/index.php/IHE_Format_Codes.
The LOINC code for this document is 67796-3 EMS patient care report
This specification is fully deffined at this published URL (http://build.fhir.org/ig/IHE/PCC.APS/branches/master/artifacts.html)
Vital Signs The following Vital signs Should be references within the Vital Signs section of the composition:
Code | Code System | Description | ValueType | Value Units |
---|---|---|---|---|
8480-6 | LOINC | Systolic Blood Pressure | ||
8462-4 | LOINC | Diastolic Blood Pressure | ||
85354-9 | LOINC | Blood pressure systolic and diastolic | ||
8478-0 | LOINC | Mean Arterial Pressure | ||
8310-5 | LOINC | Body Temperature | ||
72089-6 | LOINC | Stroke Score | ||
8867-4 | LOINC | Heart Rate | ||
67670-0 | LOINC | Cardiac Rhythm | ||
19889-5 | LOINC | END TITLE CARBON DIOXIDE (ETCO2) | ||
2708-6 | LOINC | Pulse Oximetry(SPO2) | ||
19911-7 | LOINC | CARBON MONOXIDE (CO) | ||
2339-0 | LOINC | BLOOD GLUCOSE LEVEL | ||
35088-4 | LOINC | GLASGOW COMA Scale Panel | ||
9267-6 | LOINC | GLASGOW COMA SCORE-EYE | ||
9268-4 | LOINC | GLASGOW COMA SCORE-MOTOR | ||
9270-0 | LOINC | GLASGOW COMA SCORE-VERBAL | ||
9269-2 | LOINC | GLASGOW COMA SCORE-TOTAL SCORE | ||
55285-1 | LOINC | GLASGOW QUALIFIER | ||
72514-3 | LOINC | PAIN SCALE SCORE | ||
80316-3 | LOINC | PAIN SCALE TYPE | ||
72089-6 | LOINC | STROKE SCALE SCORE | ||
67520-7 | LOINC | Stroke Scale Score Interpretation | ||
67521-5 | LOINC | STROKE SCALE TYPE | ||
XXX | LOINC | APGAR Generic | ||
9272-6 | LOINC | APGAR 1 MINUTE | ||
9274-2 | LOINC | APGAR 5 MINUTE | ||
9271-8 | LOINC | APGAR 10 MINUTE | ||
80341-1 | LOINC | RESPIRATORY EFFORT | ||
67775-7 | LOINC | RESPONSIVENESS ASSESSMENT AT FIRST ENCOUNTER | ||
9279-1 | LOINC | Respiratory Rate | ||
8302-2 | LOINC | Body Height | ||
8306-3 | LOINC | Body Length | ||
29463-7 | LOINC | Body Weight | ||
85353-1 | LOINC | Vital Signs Panel | ||
273885003 | SNOMED-CT | Revised Trauma Score | ||
8884-9 | LOINC | Heart Rate Rhythm |
The Method of Measurement SHALL be included in the Vital Signs Observation for the following vital signs: • Systolic Blood Pressure • Diastolic Blood Pressure • Mean Arterial Pressure • Temperature • Stroke Score • and Heart Rate (if LOINC value 8886-4 is designated). Cardiac Rhythm
the following assessment sections/panles should be documented Skin Assessment Head Assessment Face Assessment Neck Assessment Heart Assessment Abdomen Assessment Pelvis/Genitourinary Assessment Back and Spine Assessment Extremities Assessment Eye Assessment 80310-6 Pupil assessment panel Lung Assessment Chest Assessment Mental Status Assessment Neurological Assessment Wound assessment panel Pain assessment panel acuitty assessment 11283-9 R ACUITY ASSESSMENT
Stroke/CVA Symptoms Resolved
functional Status scales pain scale Physical Function Section
airway assessment panel breathing assessment panel circulation assessment panel disability assessment panel
46012-1 Panel Modes of transfer
Intravenous Fluids Administered Cardiac Rhythm ECGType ECGInterpretationMethod SystolicBloodPressure DiastolicBloodPressure Mean Arterial Pressure HeartRate PulseOximetry HeartRateRhythm RespiratoryRate Respiratory Effort End Tidal Carbon Dioxide (ETCO2) Carbon Monoxide (CO) BloodGlucoseLevel GlasgowComaScore-Eye GlasgowComaScore-Verbal GlasgowComaScore-Motor GlasgowComaScore-Qualifier GlasgowComaScore-Total Temperature LevelOfResponsiveness PainSeverity Pain Scale Type StrokeScaleScore StrokeScaleType ContraindicationForThrombolyticUse APGAR 1 MINUTE APGAR 5 MINUTE APGAR 10 MINUTE RevisedTraumaScore
Exams The following Vital signs Should be references within the Physical Exams section of the composition: Body Weight Length Based Tape Measure Skin Assessment Head Assessment Face Assessment Neck Assessment Heart Assessment Abdomen Assessment Back and Spine Assessment Extremities Assessment Eye Assessment Lung Assessment Chest Assessment Mental Status Assessment Neurological Assessment Stroke/CVA Symptoms Resolved
N/A