IHE PCC - Routine Interfacility Patient Transport (RIPT)
2.0.0-draft - ci-build
IHE PCC - Routine Interfacility Patient Transport (RIPT), published by IHE Patient Care Coordination. This is not an authorized publication; it is the continuous build for version 2.0.0-draft). This version is based on the current content of https://github.com/IHE/PCC.RIPT/ and changes regularly. See the Directory of published versions
Consuming systems to be responsible for translating Standard specific codes to NEMSIS codes
The XDSDocumentEntry format code for this content is urn:ihe:pcc:ript:2017
International Patient Summary (2.16.840.1.113883.10.22.1.1) IPS CDA Templates
All standards which are referenced in this document are listed below with their common abbreviation, full title, and link to the standard.
This section identifies the mapping of data between referenced standards into the CDA implementation guide. TODO
This section specifies the header, section, and entry content modules which comprise the Routine Interfacility Patient Transport (RIPT) Document Content Module, using the Template ID as the key identifier. Sections that are used according to the definitions in other specifications are identified with the relevant specification document. Additional constraints on vocabulary value sets, not specifically constrained within the section template, are also identified.
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CDA Release 2.0 documents that conform to the requirements of this document content module shall indicate their conformance by the inclusion of the
Within the Problems section the Content Creator SHALL be able to create a Problem concern entry (TemplateID 1.3.6.1.4.1.19376.1.5.3.1.4.5.2 [PCC TF-2]) to identify Medical/surgical History conditions and findings for the patient being transported. Including behaviors that may affect transport personnel (e.g., combativeness).
The …/code SHALL be “finding” and …/ value SHALL contain the coded value for the condition using the ICD-10-CM vocabulary.
Within the Payor section the Content Creator SHOULD be able to create a Coverage Entry (Template ID 1.3.6.1.4.1.19376.1.5.3.1.4.17 [PCC TF-2]) to identify the payment information for the patient being transported. The coverage information SHOULD include:
Optionality | Cardinality | Name | Vocabulary |
---|---|---|---|
RE | [0..*] | Insurance Company Name | |
RE | [0..1] | Insurance Company Billing Priority | |
RE | [0..1] | Insurance Company Address | |
RE | [0..1] | Insurance Company City | |
RE | [0..1] | Insurance Company State | |
RE | [0..1] | Insurance Company Zip code | |
RE | [0..1] | Insurance Company Country | |
RE | [0..1] | Insurance Group ID | |
RE | [0..1] | Insurance Policy ID Number | |
RE | [0..1] | Last Name of the Insured | |
RE | [0..1] | First Name of the Insured | |
RE | [0..1] | Middle initial/name of the Insured | |
RE | [0..1] | Relationship to the Insured | |
RE | [0..1] | Insurance Group Name |
Within the Social History section the content creator SHALL Support the Ocupational data for health option.The Content Creator SHALL be able to include the following data elements:
Optionality | Cardinality | Name | Vocabulary |
---|---|---|---|
RE | [0..1] | Patient’s Employer | |
RE | [0..1] | Patient’s Employer’s Address | |
RE | [0..1] | Patient’s Employer’s City | |
RE | [0..1] | Patient’s Employer’s State | |
RE | [0..1] | Patient’s Employer’s Zip code | |
RE | [0..1] | Patient’s Employer’s Country | |
RE | [0..1] | Patient’s Employer’s Primary Phone Number |
Within the Allergies and Other Adverse Reactions section the Content Creator SHALL be able to create an Allergies and Intolerances Concern entry (Template ID 1.3.6.1.4.1.19376.1.5.3.1.4.5.3 [PCC TF-2]) to identify the patient’s medication and environmental/food allergies. Environmental/food allergies using SNOMED-CT SHOULD be used to identify the allergen.
Medication allergies using RxNorm SHOULD be used to identify an allergy as a specific drug. To indicate an allergy to a class of drug ICD-10 SHOULD be used to indicate an allergy to a class of drug.
Within the Procedures and Other Interventions section the Content Creator SHALL be able to create a procedure entry (TemplateID 1.3.6.1.4.1.19376.1.5.3.1.4.19 [PCC TF-2]) to identify any procedures the patient has undergone using ICD-10-PCS
Within the Medications section the Content Creator SHALL be able to create a medications entry (TemplateID 1.3.6.1.4.1.19376.1.5.3.1.4.7 [PCC TF-2]) to identify the current medications that have been given to the patient using RxNorm. In a narrative form there SHALL be an indication of the date, and time of the last medication administered to the patient.
The entry SHALL include the following elements:
Optionality | Cardinality | Name | Vocabulary |
---|---|---|---|
RE | [0..*] | Current Medications | |
RE | [0..1] | Current Medication Dose | |
RE | [0..1] | Current Medication Dosage Unit | |
RE | [0..1] | Current Medication Administration Route | |
RE | [0..1] | Current Medication Frequency |
Within the Results section the Content Creator SHALL include the narrative results of the Cardiac Rhythm / Electrocardiography (ECG) test, if known.
the Content Creator SHALL be able to create a Coded Result entry (TemplateID 1.3.6.1.4.1.19376.1.5.3.1.3.28 [PCC TF-2]) that will include the type and method of the Cardiac Rhythm / Electrocardiography (ECG) test interpretation, if known.
Within the Coded Vital Signs section the Content Creator SHALL be able to create a Vital signs observation entries (TemplateID 1.3.6.1.4.1.19376.1.5.3.1.4.13.2 [PCC TF-2]) for the followingvital signs:
Optionality | Cardinality | Name | LOINC | Constraint |
---|---|---|---|---|
RE | [0..1] | SBP (Systolic Blood Pressure) | 8480-6 | Indicating Method using valueset from BloodPressureMeasurementMethod 2.16.840.1.113883.17.3.11.107 |
RE | [0..1] | DBP (Diastolic Blood Pressure) | 8462-4 | Indicating Method using valueset from BloodPressureMeasurementMethod 2.16.840.1.113883.17.3.11.107 |
RE | [0..1] | Mean Arterial Pressure | 8478-0 | Indicating Method using valueset from BloodPressureMeasurementMethod 2.16.840.1.113883.17.3.11.107 |
RE | [0..1] | Heart Rate | 8867-4 | Indicating the method or heat rate measurement using 8886-4 |
RE | [0..1] | Pulse Oximetry | 2710-2 | |
RE | [0..1] | Pulse Rhythm | 44974-4 | |
RE | [0..1] | Respiratory Rate | 9279-1 | |
RE | [0..1] | Respiratory Effort | 80341-1 | |
RE | [0..1] | Carbon Dioxide (ETCO2) | 19889-5 | |
RE | [0..1] | Carbon Monoxide (CO) | 20563-3 | |
RE | [0..1] | Blood Glucose Level | 2339-0 | |
RE | [0..1] | Glasgow Coma Score-Eye | 9267-6 | |
RE | [0..1] | Glasgow Coma Score-Verbal | 9270-0 | |
RE | [0..1] | Glasgow Coma Score-Motor | 9268-4 | |
RE | [0..1] | Glasgow Coma Score-Qualifier | 55285-1 | |
RE | [0..1] | Total Glasgow Coma Score | 9269-2 | |
RE | [0..1] | Temperature | 8310-5 | |
RE | [0..1] | Temperature Method | 8327-9 | |
RE | [0..1] | Level of Responsiveness (AVPU) | 11454-6 | |
RE | [0..1] | Pain Scale Score | 38208-5 | |
RE | [0..1] | Pain Scale Type | 80316-3 | |
RE | [0..1] | Stroke Scale Score | 72089-6 | |
RE | [0..1] | Stroke Scale Type | 67521-5 | |
RE | [0..1] | Reperfusion Checklist | 67523-1 | |
RE | [0..1] | APGAR | ||
1 minute | 48334-7 | |||
5 minute | 48333-9 | |||
10 Minute | 48332-1 | |||
RE | [0..1] | Revised Trauma Score | Pending | |
RE | [0..1] | Estimated Body Weight in Kilograms | 3141-9 | |
RE | [0..1] | Length Based Tape Measure | 8302-2 |
Within the Functional Status section the Content Creator SHALL be able to create the following subsections:
Optionality | Cardinality | Name |
---|---|---|
RE | [0..1] | Physical Examination Section |
RE | [0..1] | Integumentary System Section |
RE | [0..1] | Head |
RE | [0..1] | Ears, Nose, Mouth, and Throat Section |
RE | [0..1] | Neck |
RE | [0..1] | Thorax and Lungs |
RE | [0..1] | Heart |
RE | [0..1] | Abdomen |
RE | [0..1] | Abdominal Assessment Finding Location |
RE | [0..1] | Abdomen Assessment |
RE | [0..1] | Genitalia |
RE | [0..1] | Back and Spine Assessment Finding Location |
RE | [0..1] | Back and Spine Assessment |
RE | [0..1] | Extremity Assessment Finding Location |
RE | [0..1] | Extremities Assessment |
RE | [0..1] | Eye Assessment Finding Location |
RE | [0..1] | Eye Assessment |
RE | [0..1] | Neurologic System |
Within the Transport Instructions section the Content Creator SHALL be able to create a Patient Transfer entry (Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.25.1.4.1 [PCC TF-2]) to identify the destination facility for the patient, expressing the address in: …/participant/participantRole/addr The address SHALL support the following elements:
Optionality | Cardinality | Name |
---|---|---|
R | [1..1] | Destination Street Address |
R | [1..1] | Destination City |
R | [1..1] | Destination State |
R | [1..1] | Destination County |
R | [1..1] | Destination ZIP Code |
R | [1..1] | Destination Country |
RE | [0..1] | Destination Facility Name |
No new Header Elements.
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Template Name: Certification of Medical Necessity
Template ID: 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.12
Parent Template: None
General Description:Indication of whether a physician certification statement (PCS) is available documenting the medical necessity for the EMS encounter. The Certification of Medical Necessity section includes the information necessary to document the justification for the medical transport, including the name and role of the person authorizing the medical transport. This information can be used to generate a Certificate of Medical Necessity (CMN) document for signature
Section Code: 52016-3, LOINC, “Ambulance transport, Physician certification for transport information Set”
Author: Patient’s doctor or physician
Informant: Patient’s doctor or physician
Subject: current recordTarge
Entries | |||||
---|---|---|---|---|---|
Opt and Card | Condition | Data Element or Section Name | Template ID | Specification Document | Vocabulary Constraint |
R [1..1] | Medical Necessity Entry | 1.3.6.1.4.1.19376.1.5.3.1.4.23 | PCC TF-3:6.3.4.E | ||
R [1..1] | Signature | TBD | TBD | ||
R [1..1] | Signer provider Type | TBD | TBD | ||
R [1..1] | Signer Name | TBD | TBD | ||
R [1..1] | Signature Date | TBD | TBD | ||
RE [1..1] | Justification (Narrative) | TBD | TBD | ||
RE [0..1] | Reason For Transport | TBD | TBD | ||
O [0..1] | Prior authorization code | TBD | TBD | ||
O [0..1] | Prior Authorization Code Payer | TBD | TBD |
ToDo As CDA Template Template Name: Transport Instructions Template ID: 1.3.6.1.4.1.19376.1.5.3.1.1.26.1.7 Parent Template: None General Description:This section contains narrative information provided by the patient’s care provider(s) to indicate any care that should be rendered during the transport and the Destination information. Section Code: 74213-0, LOINC, “Discharge instructions” Author: Patient’s care provider(s) Informant: Patient’s nurse or discharge planner Subject: current recordTarget
Entries | |||||
---|---|---|---|---|---|
Opt and Card | Condition | Data Element or Section Name | Template ID | Specification Document | Vocabulary Constraint |
R [1..1] | Transport Instructions Text | N/A | |||
R [1..1] | Destination Name | TBD | TBD | ||
R [1..1] | Destination Type | TBD | TBD | ||
R [1..1] | Destination Address | TBD | TBD |
The Medical Necessity observation is a Simple Observation that records the Reason for Physician Certification Statement.
ToDo As CDA Template
< observation classCode=’OBS’ moodCode=’EVN’>
<templateId root=’ 1.3.6.1.4.1.19376.1.5.3.1.4.13’
The Medical Necessity is recorded in an observation element, to describe the patient’s medical necessity taken during the encounter. In event mood (moodCode=’EVN’), this records the Medical Necessity.
The templateId indicates that this Medical Necessity entry conforms to the constraints of thiscontent module.
This required element shall contain an identifier.
This required element indicates the medical reason for ambulance transport. The code be 15515-0, LOINC, “Ambulance transport, Medical reason for transport”.
The
The
This
The
</assignedEntity></performer>
The element.
Observations of Medical Necessity should provide an indication of whether a physician certification statement (PCS) is available documenting the medical necessity for the EMS encounter.
An observation of whether a physician certification statement (PCS) is available SHALL be included if known.
codeSystemName=’LOINC’This observation is an indication of whether a physician certification statement (PCS) is available documenting the medical necessity or the EMS encounter as indicated by the element.
The observation of whether a physician certification statement (PCS) is available may include a
The observation of whether a physician certification statement (PCS) is available may contain a single reference to an external document. That reference shall be recorded as shown above. The
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Coding Scheme | SNOMED-CT |
---|---|
160685001 | Bed-ridden |
23852006 | Cardiac monitoring (regime/therapy) |
716777001 | Hemodynamic monitoring (regime/therapy) |
419284004 | Altered mental status (finding) |
67722007 | At risk for joint contractures (finding) |
65108000 | At risk for joint contractures (finding) |
225999004 | At risk for violence (finding) |
86340006 | At risk of deep vein thrombosis (finding) |
425423002 | Intravenous therapy (regime/therapy) |
238136002 | Pain provoked by movement (finding) |
134291007 | Morbid obesity (disorder) |
373062004 | Multiple fractures (disorder) |
225602000 | Device used (finding) |
35497000 | Restraint maintenance (procedure) |
26544005 | Unable to sit unsupported (finding) |
40174006 | Muscle weakness (finding) |
707808001 | Isolation procedure (procedure) |
410204009 | Oxygen therapy support (regime/therapy) |
62330004 | Oxygen therapy management (procedure) |
722179007 | Decreased muscle function (finding) |
225563000 | Dependent for sitting (finding) |
160685001 | Pressure ulcer of buttock (disorder) |
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To Do Documnent Contraints