source: qrda/schematron/QRDA_CategoryI.xml@ 1438

Last change on this file since 1438 was 906, checked in by George Lilly, 14 years ago

initial QRDA schematron checking
File size: 10.0 KB
RevLine 
[906]1<?xml version="1.0" encoding="utf-8"?>
2<?xml-stylesheet type="text/xsl" href="cda.xsl"?>
3<!-- Created with Liquid XML Studio 1.0.8.0 (http://www.liquid-technologies.com) -->
4<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
5 <!--
6********************************************************
7CDA Header
8********************************************************
9-->
10 <realmCode code="US" />
11 <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040" />
12 <!-- QRDA Category I generic template ID. -->
13 <templateId root="2.16.840.1.113883.10.20.12" />
14 <id root="88414c01-715a-45bb-83bb-db7ac860fe9d" />
15 <!-- QRDA document type code (yet to be created). -->
16 <code code="55182-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Quality Measure Report" />
17 <title>QRDA Incidence Report</title>
18 <effectiveTime value="20080513" />
19 <confidentialityCode codeSystem="2.16.840.1.113883.5.25" code="N" />
20 <languageCode code="en-US" />
21 <!-- This is the patient for which the report is describing. -->
22 <recordTarget>
23 <patientRole>
24 <id extension="123456789" root="2.16.840.1.113883.19.5" />
25 <patient>
26 <name>
27 <given>Henry</given>
28 <family>Levin</family>
29 <suffix>the 7th</suffix>
30 </name>
31 <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" />
32 <birthTime value="19320924" />
33 </patient>
34 </patientRole>
35 </recordTarget>
36 <!-- This example assumes a workflow whereby a quality manager nurse is creating the report. -->
37 <author>
38 <time value="2000040714" />
39 <assignedAuthor>
40 <id root="bc01a5d1-3a34-4286-82cc-43eb04c972a7" />
41 <assignedPerson>
42 <name>
43 <given>Nancy</given>
44 <family>Nightingale</family>
45 <suffix>N</suffix>
46 </name>
47 </assignedPerson>
48 <representedOrganization>
49 <id root="2.16.840.1.113883.19.5" />
50 <name>Good Health Clinic</name>
51 </representedOrganization>
52 </assignedAuthor>
53 </author>
54<!-- The reporting healthcare facility is represented using the CCD "Source of Information" construct, via the Informant participant. -->
55 <informant>
56 <assignedEntity>
57 <id nullFlavor="NA"/>
58 <representedOrganization>
59 <id root="2.16.840.1.113883.19.5"/>
60 <name>Good Health Clinic</name>
61 </representedOrganization>
62 </assignedEntity>
63 </informant>
64 <!-- This example assumes that the institution responsible for the data is serving as custodian. -->
65 <custodian>
66 <assignedCustodian>
67 <representedCustodianOrganization>
68 <id root="2.16.840.1.113883.19.5" />
69 <name>Good Health Clinic</name>
70 </representedCustodianOrganization>
71 </assignedCustodian>
72 </custodian>
73 <!-- In this example, the author is also serving as legal authenticator. -->
74 <legalAuthenticator>
75 <time value="20000408" />
76 <signatureCode code="S" />
77 <assignedEntity>
78 <id root="bc01a5d1-3a34-4286-82cc-43eb04c972a7" />
79 <assignedPerson>
80 <name>
81 <given>Nancy</given>
82 <family>Nightingale</family>
83 <suffix>N</suffix>
84 </name>
85 </assignedPerson>
86 <representedOrganization>
87 <id root="2.16.840.1.113883.19.5" />
88 <name>Good Health Clinic</name>
89 </representedOrganization>
90 </assignedEntity>
91 </legalAuthenticator>
92 <!--
93********************************************************
94CDA Body
95********************************************************
96-->
97 <component>
98 <structuredBody>
99 <!--
100********************************************************
101MeasureSet: NQF Pneumonia, V2.5
102********************************************************
103-->
104 <component>
105 <section>
106 <templateId root="2.16.840.1.113883.19.1"/> <!-- templateId uniquely identifies the measure set (Fake ID for illustration) -->
107 <code code="55185-3" codeSystem="2.16.840.1.113883.6.1" />
108 <title>Measure Set: NQF Pneumonia Measure Set, V2.5</title>
109 <text>... (optional) description of measure set ...</text>
110 <!--
111 ********************************************************
112 Measure Section
113 ********************************************************
114 -->
115 <component>
116 <section>
117 <!-- QRDA Category I measure-specific template ID for each measure in this section (Fake IDs for illustration). -->
118 <templateId root="2.16.840.1.113883.19.2" />
119 <templateId root="2.16.840.1.113883.19.3" />
120 <templateId root="2.16.840.1.113883.19.4" />
121 <code code="55186-1" codeSystem="2.16.840.1.113883.6.1" />
122 <title>Measure Section</title>
123 <text>
124 <list>
125 <item>NQF PN-1: Oxygenation Assessment, V2.5</item>
126 <item>NQF PN-4: Adult Smoking Cessation Advice/Counseling, V2.5</item>
127 <item>NQF PN-6a: Initial Antibiotic Selection for CAP in Immunocompetent - ICU Patient, V2.5</item>
128 </list>
129 </text>
130 <entry typeCode="DRIV">
131 <!--
132 The measure is represented as an <act> in definition mood.
133 A narrative description of the measure is in act/text.
134 A formal computable representation of the measure is not included here, but potentially could be.
135 -->
136 <act classCode="ACT" moodCode="DEF">
137 <id root="4dd3b0b4-a5fc-4bd6-9a87-755da494f6eb" />
138 <!-- Fake code for illustration -->
139 <code code="11111-X" codeSystem="2.16.840.1.113883.6.1" displayName="Oxygenation Assessment,V2.5" />
140 <text>... (optional) description of measure ...</text>
141 <statusCode code="completed" />
142 </act>
143 </entry>
144 <entry typeCode="DRIV">
145 <act classCode="ACT" moodCode="DEF">
146 <id root="4dd3b0b4-a5fc-4bd6-9a87-755da494f6ee" />
147 <code code="11111-X" codeSystem="2.16.840.1.113883.6.1" displayName="Adult Smoking Cessation Advice/Counseling" />
148 <text>... (optional) description of measure ...</text>
149 <statusCode code="completed" />
150 </act>
151 </entry>
152 <entry typeCode="DRIV">
153 <act classCode="ACT" moodCode="DEF">
154 <id root="4dd3b0b4-a5fc-4bd6-9a87-755da494f6ea" />
155 <code code="11111-X" codeSystem="2.16.840.1.113883.6.1" displayName="Initial Antibiotic Selection for CAP in Immunocompetent - ICU Patient" />
156 <text>... (optional) description of measure ...</text>
157 <statusCode code="completed" />
158 </act>
159 </entry>
160 <!--
161 ********************************************************
162 Reporting Parameters
163 ********************************************************
164 -->
165 <component>
166 <section>
167 <code code="55187-9" codeSystem="2.16.840.1.113883.6.1" />
168 <title>Reporting Parameters</title>
169 <text>
170 <list>
171 <item>Reporting period: 01 Jan 2008 - 31 Mar 2008</item>
172 </list>
173 </text>
174 <entry>
175 <act classCode="ACT" moodCode="EVN">
176 <code code="252116004" codeSystem="2.16.840.1.113883.6.96" displayName="Observation Parameters" />
177 <effectiveTime>
178 <low value="20080101" /> <!-- The first day of the period reported. -->
179 <high value="20080331" /> <!-- The last day of the period reported. -->
180 </effectiveTime>
181 </act>
182 </entry>
183 </section>
184 </component>
185 <!--
186 ********************************************************
187 Patient Data
188 ********************************************************
189 -->
190 <component>
191 <section>
192 <code code="55188-7" codeSystem="2.16.840.1.113883.6.1" />
193 <title>Patient Data</title>
194 <text>
195 <list>
196 <item>Admission Date: 13 Feb 2008</item>
197 <item>Discharge Date: 20 Feb 2008</item>
198 <item>ICD Diagnosis Codes: 481 (Pneumococcal pneumonia)</item>
199 <item>Initial Oxygen Saturation: 85%</item>
200 <item>Initial Antibiotics: Levofloxacin 500mg IV q24 hours</item>
201 <item>Smoker: Yes</item>
202 <item>Smoking Cessation Counseling Provided: Yes</item>
203 </list>
204 </text>
205 <entry typeCode="DRIV">
206 <encounter classCode="ENC" moodCode="EVN">
207 <id root="3e547597-ac81-4232-b20f-317dfd1a3595" />
208 <code code="IMP" displayName="Inpatient" codeSystem="2.16.840.1.113883.5.83" codeSystemName="actEncounterCode" />
209 <effectiveTime>
210 <low value="20080213" />
211 <high value="20080220" />
212 </effectiveTime>
213 <entryRelationship typeCode="COMP">
214 <observation classCode="OBS" moodCode="EVN" negationInd="false">
215 <templateId root="2.16.840.1.113883.10.20.1.28" />
216 <!-- Problem observation template -->
217 <id root="f7a66e8a-f6e5-48fe-93e5-f0f1ed462c80" />
218 <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" />
219 <statusCode code="completed" />
220 <value xsi:type="CD" code="481" codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD9CM" displayName="Pneumococcal pneumonia" />
221 </observation>
222 </entryRelationship>
223 <entryRelationship typeCode="COMP">
224 <observation classCode="OBS" moodCode="EVN">
225 <templateId root="2.16.840.1.113883.10.20.1.31" />
226 <!-- Result observation template -->
227 <id root="5ac04863-aa06-4254-84a6-ac01fad60723" />
228 <code code="103228002" codeSystem="2.16.840.1.113883.6.96" displayName="Oxygen saturation" />
229 <statusCode code="completed" />
230 <effectiveTime>
231 <center value="200802131412" />
232 </effectiveTime>
233 <value xsi:type="PQ" value="85" unit="%" />
234 </observation>
235 </entryRelationship>
236 <!-- A real Category I would also include entries for:
237 <item>Initial Antibiotics: Levofloxacin 500mg IV q24 hours</item>
238 <item>Smoker: Yes</item>
239 <item>Smoking Cessation Counseling Provided: Yes</item>
240 -->
241 </encounter>
242 </entry>
243 </section>
244 </component>
245 </section>
246 </component>
247 </section>
248 </component>
249 </structuredBody>
250 </component>
251</ClinicalDocument>
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