None / unknown encounters and procedures

[Andrew McCaffrey]

Hello PCC folks,

I have two related questions. The first concerns the Encounter entry
(1.3.6.1.4.1.19376.1.5.3.1.4.14). Is there a good/recommended way of
indicating that no encounter occurred or is scheduled (or that it is
unknown whether encounters occurred or are scheduled)? The reason I ask
is because I'm working with an IG that has a Care Plan Section that
introduces a SHALL conditional that an IHE PCC Encounter
(1.3.6.1.4.1.19376.1.5.3.1.4.14) exist. It's possible to simply
nullFlavor every required element:

<!--Care Plan Section-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.10"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.31"/>
<id root="xxx" extension="xxx"/>
<code code="18776-5" displayName="Plan of Treatment"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Care Plan Section</title>
<text>Not applicable</text>
<entry>
<encounter classCode="ENC" moodCode="APT">
<templateId root="2.16.840.1.113883.10.20.1.25"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.14"/>
<id root="xxx" extension="xxx"/>
<code nullFlavor="NA"/>
<text>
<reference nullFlavor="NA"/>
</text>
</encounter>
</entry>
</section>
</component>

�but I'm wondering if there's a "more correct" way. Are there any
appropriate codes that could be used here?

The second question is along the same lines. A coded results section
(1.3.6.1.4.1.19376.1.5.3.1.3.28) requires a Procedure Entry
(1.3.6.1.4.1.19376.1.5.3.1.4.19). Is there a recommended way to say
that no procedures occurred (or are planned) or that it is unknown
whether procedures occurred (or are planned)? Again, it would be
possible to null out every element, but is there a better way to do this?

Thanks.

--
Andrew McCaffrey
andrew.m...@nist.gov
----
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[Boone, Keith W (GE Healthcare)]

Right now in CDA, you cannot use the negation indicator with an encounter, but, you can still use negation indicator on Act, and indicate in code that the act is some type of an encounter. That's one way to indicate that the event (a patient encounter) didn't occur. An encounter is still an act.

Keith

_________________________________
Keith W. Boone
Standards Architect
GE Healthcare

M +1 617 640 7007
keith...@ge.com
www.gehealthcare.com

116 Huntington Ave
Boston, MA 02116
USA
GE imagination at work

.but I'm wondering if there's a "more correct" way. Are there any appropriate codes that could be used here?

The second question is along the same lines. A coded results section
(1.3.6.1.4.1.19376.1.5.3.1.3.28) requires a Procedure Entry (1.3.6.1.4.1.19376.1.5.3.1.4.19). Is there a recommended way to say that no procedures occurred (or are planned) or that it is unknown whether procedures occurred (or are planned)? Again, it would be possible to null out every element, but is there a better way to do this?

Thanks.

--
Andrew McCaffrey
andrew.m...@nist.gov
----
The words above do not necessarily reflect the opinions of my employers or any organization I may be associated with. In fact, by the time you read them, they may not even reflect my own opinions anymore.
----
Any mention of commercial products within NIST web pages or email is for information only; it does not imply recommendation or endorsement by NIST.

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[Andrew McCaffrey]

Ah, interesting, I hadn't thought of using an act in that way...
Unfortunately, the IG is using the 1.3.6.1.4.1.19376.1.5.3.1.4.14
(Encounters Entry) template, which appears to require the use of the
encounter element. "The classCode SHALL be 'ENC'", which I can't do in
an act...

[Boone, Keith W (GE Healthcare)]

Hmm, sounds like a CP may be needed.

Keith