NHS Digital CDA profile specification for Crisis Care Extract domain
This guidance specifies the design constraints that must be applied to the “Structured Heading Generic Model” for the NHS Digital CDA domain profile for the Crisis Care Extract domain.
Introduction
Profile configuration
Domain
| Domain name | Crisis Care Extract |
| Version | 1.0 |
| Status | RC2 |
Message
| Message name | Crisis Care Extract |
| Message identifier | POCD_MT000037GB01 |
| Message Profile Identifier | urn:nhs-en:profile:CrisisCareExtract-v2-1 |
Baseline structured heading generic model
| Version | 1.0 |
| Status | RC4 |
Clinical document class constraints
This section specifies any constraints that must be applied to the ClinicalDocument class HL7 attributes. Where there are no additional constraints over and above those specified in the “Structured Headings Generic Model” then there will be no reference to the HL7 attribute.
| ClinicalDocument.code | The code must equal “810301000000103:810311000000101=325661000000106,8103 21000000107=CCC”. The codeSystem must equal: “2.16.840.1.113883.2.1.3.2.4.15.1”. The displayName must equal: “810301000000103|Clinical document descriptor|:810311000000101|Type of clinical document|=325661000000106|Care plan|,810321000000107|Care setting of clinical document|=CCC|DDD|” Where CCC is a code from the SNOMED CT UK Correspondence Care setting type subset with subset original id 43971000000130. Where DDD is the preferred term for the code chosen from the SNOMED CT UK Correspondence Care setting type subset with subset original id 43971000000130. |
| ClinicalDocument.mess ageType | Must equal “POCD_MT000037GB01” |
Document header participant constraints
This section specifies any constraints that must be applied to the document header participants. Where there are no additional constraints over and above those specified in the “Structured Headings Generic Model” then there will be no reference to the participation templates.
Informant constraints
| Informant participation | Prohibited in profile |
Generic participant constraints
This section details the constraints applied to the generic document participant located on the bottom left hand side of the CDA header on the “Structured Headings Generic Model”. The type of participant is described by the value carried in the participant typeCode. Some participant types are unsuitable.
For this profile, there are no additional constraints over and above those stated in the “Populating HSCIC CDA Document Participant Templates” guidance documentation. This guidance is contained within the relevant Baseline Structured Heading Generic Model, as stated in the Profile Configuration section of this document.
Header templates
This section details the constraints on the other coded header relationships and templates:
- authorization relationship for Consent
- componentOf relationship for Encompassing encounter
- documentationOf relationship for ServiceEvent
- inFulfillmentOf relationship for Order
Where there are no additional constraints on these relationships or templates, there will be no reference to the relationships in this section.
Encompassing encounter constraints
| The componentOf relationship for encompassing encounter | Prohibited in profile |
Order constraints
| The inFulfillmentOf relationship for Order | Prohibited in profile |
Service event constraints
| The documentationOf relationship for ServiceEvent | Prohibited in profile |
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 | |
| Clinical Summary Section | 01 | X | |
| Crisis Care Plan Section | 01 | X | |
| Diagnosis Section | 01 | X | |
| History Section | 01 | X | |
| Legal Information Section | 01 | X | |
| Medications And Medical Devices Section | 01 | X | |
| Patient And Carer Concerns Section | 01 | X | |
| Person Completing Record Section | 01 | X | |
| Plan And Requested Actions Section | 01 | X | |
| Safety Alerts Section | 01 | X | |
| Social Context Section | 01 | X | |
| Special Requirements 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 this profile and the constraint imposed is additional 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 template name |
|---|---|---|---|---|
| Allergic Or Adverse Reaction Event | 02 | X | Allergies and Adverse Reactions Section | |
| Crisis Care Observation | 01 | X | Crisis Care Plan Section | |
| Diagnosis | 02 | X | Diagnoses Section | |
| Discontinued Medication | 01 | X | Medications And Medical Devices Section | |
| Medical Devices | 01 | X | Medications And Medical Devices Section | |
| Medications Administered | 01 | X | Medications And Medical Devices Section |
Specific coded entry template constraints: Crisis Care Observation version 01
This section details constraints, which must be applied.
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 10:56 am