PCC - mobile Paramedicine Summary of Care (mPSC)
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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

1:XX. Content Module

Volume 3 contains content profiles.

This section corresponds to Content Module [domain-ZZ]

1:XX.6 : Paramedicine Summary Specification

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).

1:X.6.1 Format Code

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.

  • mobile Paramedicine Summary of Care – Clinical Subset (mPSC-CS)
  • mobile Paramedicine Summary of Care – Complete Report (mPSC-CR)

1:X.6.2 LOINC Code

The LOINC code for this document is 67796-3 EMS patient care report

1:X.6.3 Standards

1:X.6.4 Specification

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

1:X.6.5 Conformance

N/A