Section heading template constraints
Note - in CDA implementations a number of structured headings are represented using the coded CDA header information and not as section templates. These AoMRC headings are:
- Patient demographics (mandatory)
- GP practice (mandatory)
- Distribution list (mandatory)
When the CDA document is rendered, the HTML should show this information as headings.
The table below specifies the constraints applicable to this profile. Sections not referenced are prohibited by default.
Section name |
Version |
Mandatory |
Optional |
Allergies and Adverse Reactions Section |
01 |
|
X |
Crisis Care Plan Section |
01 |
|
X |
Diagnosis Section |
01 |
|
X |
End OF Life Section |
01 |
|
X |
Individual Requirements Section |
02 |
|
X |
Legal Information Section |
01 |
|
X |
Medications And Medical Devices Section |
01 |
|
X |
Person And Carer Concerns, Expectations And Wishes Section |
01 |
|
X |
Person Completing Record Section |
01 |
|
X |
Problems And Issues Section |
02 |
|
X |
Relevant Past Medical Surgical And Mental Health History Section |
01 |
|
X |
Safety Alerts Section |
01 |
|
X |
Social Context Section |
01 |
|
X |
Coded entry template constraints
For a coded entry to be used in an implementation of this profile the corresponding section (i.e. the section to which the coded entry is attached) must be included in the profile. This section only details constraints on the coded entry when the section is included in the profile and the constraint imposed by this profile is in addition to any specified in the “Structured Headings Generic Model”.
The table below lists the coded entries applicable and the associated section templates.
Coded entry name
|
Version
|
Mandatory
|
Optional
|
Associated section name
|
Accommodation
|
01
|
|
X
|
Social Context Section
|
Advance Decision To Refuse Treatment
|
02
|
|
X
|
Legal Information Section
|
Advance Statement
|
01
|
|
X
|
Person And Carer Concerns, Expectations And Wishes Section
|
Allergic Or Adverse Reaction Event
|
02
|
|
X
|
Allergies and Adverse Reactions Section
|
Allergy Propensity
|
01
|
|
X
|
Allergies and Adverse Reactions Section
|
Anticipatory Medicine Box Issue Procedure
|
01
|
|
X
|
Crisis Care Plan Section
|
Authority to Lasting Power of Attorney
|
02
|
|
X
|
Legal Information Section
|
Clinical Risk
|
01
|
|
X
|
Problems And Issues Section
|
Crisis Care Observation
|
01
|
|
X
|
Crisis Care Plan Section
|
Crisis Care Plan
|
01
|
|
X
|
Crisis Care Plan Section
|
DNA CPR Decision
|
03
|
|
X
|
Crisis Care Plan Section
|
Diagnosis
|
02
|
|
X
|
Diagnosis Section
|
Discontinued Medication
|
01
|
|
X
|
Medications And Medical Devices Section
|
EoL Care Plan
|
02
|
|
X
|
End Of Life Section
|
Housing
|
01
|
|
X
|
Social Context Section
|
Legal Status
|
01
|
|
X
|
Legal Information Section
|
Medical Devices
|
01
|
|
X
|
Medications And Medical Devices Section
|
Medications Administered
|
01
|
|
X
|
Medications And Medical Devices Section
|
Medications and Medical Devices Supplied
|
01
|
|
X
|
None - part of Anticipatory Medicine Box Issue Procedure template.
|
Mobility
|
01
|
|
X
|
Individual Requirements Section
|
Patient Death Information
|
01
|
|
X
|
End Of Life Section
|
Prognosis
|
01
|
|
X
|
Crisis Care Plan Section
|
Personal Care Preference
|
02
|
|
X
|
Person And Carer Concerns, Expectations And Wishes Section
|
Risk To Patient
|
01
|
|
X
|
Safety Alerts Section
|
Risk To Person
|
01
|
|
X
|
Safety Alerts Section
|
Safeguarding
|
01
|
|
X
|
Legal Information Section
|
Service
|
01
|
|
X
|
Social Context Section
|
Significant Past Medical History
|
01
|
|
X
|
Relevant Past Medical Surgical And Mental Health History Section
|
Social Or Personal Circumstance
|
01
|
|
X
|
Social Context Section
|
Tissue And Organ Donation
|
01
|
|
X
|
Legal Information Section
|
Specific coded entry template constraints: Crisis Care Observation version 01
This section details constraints, which must be applied to individual coded entry templates.
Use of CrisisCareObservation.code
- The XML attribute code must contain fixed value of "CCO".
- The XML attribute codeSystem must contain the value "2.16.840.1.113883.2.1.3.2.4.17.532".
- The XML attribute displayName must contain the value “Crisis Care Observation”
Qualification of code “CCO”
The XML element qualifier must be used to further describe the crisis care observation as follows:
- The XML attribute code must contain one of the values from the table below.
- The XML attribute displayName must carry the description for the code in the table below.
- The XML attribute codeSystem must contain the value "2.16.840.1.113883.2.1.3.2.4.17.533".
Code |
Description |
ICOSD |
In Case of Sudden Deterioration |
ICOGD |
In Case of Gradual Deterioration |
ICOB |
In Case of Breathlessness |
ICOPC |
In Case of Pain Crises |
ICOS |
In Case of Seizures |
ICOMH |
In Case of Major Haemorrhage |
ICOI |
In Case of Infections |
ICONV |
In Case of Nausea/Vomiting |
AMHEPSMP |
Anticipated Mental Health Emergencies Management Plan |
ICOR |
In Case of Restlessness |
ICORS |
In Case of Respiratory Secretions |
ICOO |
In Case of Others |
AA |
Anticipated Actions |
POC |
Priorities of Care |
Use of CrisisCareObservation.value
The XML element value is used to carry text associated with the crisis care observation. It must be populated as follows:
- The XML attribute xsi:type must contain the value "CD".
- The XML attribute code must not be present.
- The XML attribute codeSystem must not be present.
- The XML attribute displayName must not be present.
- The XML element qualifier must not be present.
- The XML element originalText must contain the associated text
Last edited: 5 April 2019 1:27 pm