Minutes and Results. ASTM Committee E31 and the Massachusetts Medical Society Workshop
on XML Document Type Definitions In Health Care. October 4-5, 1999.]
---Samples (Draft only)---
See source: http://www.astm.org/COMMIT/E31Oct99rprt.zip
==========================================================
Diagnostic Imaging
<!--Including, radiology, including: CT, MRI, ULTRASOUND, etc.
The group forming this set of tags felt we needed more knowledge from imaging experts. Consider preliminary.-->
<!ELEMENT DIAGNOSTICIMAGING (PROCEDURE.DATE,PRIOREXAM.DATE?,PROCEDURETYPE,BODYPART,
VIEW?,TECHNIQUE?,CONTRASTAGENTS?,MEDICATIONS?,INDICATIONS?,REASON?,
FINDINGS,IMPRESSION,SERVICEPROVIDER*,RECOMMENDATIONS?,FILELINK*,
SIGNATURE+) >
<!--Date of procedure-->
<!ELEMENT PROCEDURE.DATE (#PCDATA) >
<!--Date of prior exam, may be used for comparison or progress, e.g., mammography.-->
<!ELEMENT PRIOREXAM.DATE (#PCDATA) >
<!--e.g., MRI, CT, etc.-->
<!ELEMENT PROCEDURETYPE (#PCDATA) >
<!ELEMENT BODYPART (#PCDATA) >
<!--e.g., anterior, posterior, etc.-->
<!ELEMENT VIEW (#PCDATA) >
<!--This could be a more general description of procedure, including physical position of patient, technical instruments, data, equipment, etc.-->
<!ELEMENT TECHNIQUE (#PCDATA) >
<!--include name and dose-->
<!ELEMENT CONTRASTAGENTS (#PCDATA) >
<!ELEMENT MEDICATIONS (#PCDATA) >
<!--This element represents diagnostic purpose of procedure, e.g.,
rule-out, may include dx code. May be used synonymously with Reason. Definitions of Indications and reason are thought to be controversial.-->
<!ELEMENT INDICATIONS (#PCDATA) >
<!--This element may be used to describe reason for study, e.g., patient experiencing pain, symptoms-->
<!ELEMENT REASON (#PCDATA) >
<!--Interpretations, comments, narrative-->
<!ELEMENT FINDINGS (#PCDATA) >
<!--summary of findings, conclusion, comments-->
<!ELEMENT IMPRESSION (#PCDATA) >
<!--This may be a repeating element of several providers of type: 'ordering', 'primary care', 'interpreting','technologist'-->
<!ELEMENT SERVICEPROVIDER (#PCDATA) >
<!--e.g., follow up recommendations-->
<!ELEMENT RECOMMENDATIONS (#PCDATA) >
<!--There could be several discrete elements for supporting files, including: image, wave, etc.-->
<!ELEMENT FILELINK (#PCDATA) >
==========================================================
Draft DTD for a Prescription
<!--Will depend on sanction or input from NCPDP-->
<!ELEMENT PRESCRIPTION (PATIENT,PRESCRIBED.DATE,DRUG,INTERCHANGE?,REFILLS,STATUS?,
REASON?,ALLERGIES?,PHYSICIAN,FACILITY?,GENERATEDBY?,
PREFERREDPHARMACIES?,SIGNATURE) >
<!ELEMENT PATIENT (NAME,ID+,GENDER,DOB,ADDRESS+,PHONE*) >
<!ELEMENT PRESCRIBED.DATE (#PCDATA) >
<!--This normally includes form, e.g., amoxicillin liquid. Will include generic or brand name. Broken down here as anticipate NCPDP would suggest more structure.-->
<!ELEMENT DRUG (NAME,FORM?,STRENGTH,QUANTITY,SIG) >
<!--Substitutions, allowed or not.-->
<!ELEMENT INTERCHANGE (#PCDATA) >
<!--Quantity of refill-->
<!ELEMENT REFILLS (#PCDATA) >
<!--e.g., new or changed-->
<!ELEMENT STATUS (#PCDATA) >
<!--Not sure of the proper element name for this: used to indicate workman's comp related or accident related.-->
<!ELEMENT REASON (#PCDATA) >
<!ELEMENT ALLERGIES (#PCDATA) >
<!--perhaps should be PRESCRIBING.PHYSICIAN-->
<!ELEMENT PHYSICIAN (NAME,ADDRESS+,PHONE+,ID+) >
<!--Not sure of this one: generated by... system, institution...???-->
<!ELEMENT GENERATEDBY (#PCDATA) >
<!--List of preferred, recommended or favorite pharmacies?-->
<!ELEMENT PREFERREDPHARMACIES (#PCDATA) >
<!--may include form, e.g., liquid vs. tablet and-->
<!ELEMENT NAME (#PCDATA) >
<!--one or two id's usually necessary: SSN, policy, etc., for patient; DEA#, provider ID for physician-->
<!ELEMENT ID (#PCDATA) >
<!ELEMENT GENDER (#PCDATA) >
<!ELEMENT DOB (#PCDATA) >
<!--made this optional as may be part of name-->
<!ELEMENT FORM (#PCDATA) >
<!--#, units-->
<!ELEMENT STRENGTH (#PCDATA) >
<!--also called dispense amount-->
<!ELEMENT QUANTITY (#PCDATA) >
<!--Instructions for usage-->
<!ELEMENT SIG (#PCDATA) >
===============
Draft DTD for an Operative Report
<!ELEMENT Operative.Report (Operation.Date , Preoperative.Diagnosis?,
Post.Operative.Diagnosis? , Operation+ ,
Procedure.Details* , Anesthesia+,
Estimated.Blood.Loss?,
Complications*, Surgeon+ ,
Anesthetiologist+, Indications*,
Findings* >
<!ELEMENT Operation.Date (#PCDATA) >
<!ELEMENT Preoperative.Diagnosis (#PCDATA)>
<!ELEMENT Post.Operative.Diagnosis (#PCDATA)>
<!ELEMENT Operation (Operation.Start?, Operation.End?)>
<!ELEMENT Complications (#PCDATA)>
<!ELEMENT Surgeon (#PCDATA)>
<!ELEMENT Anesthetiologist (#PCDATA)>
<!ELEMENT Anesthesia (#PCDATA)>
<!ELEMENT Indications (#PCDATA)>
<!ELEMENT Findings (#PCDATA)>
<!ELEMENT Procedure.Details (#PCDATA | Blood.Given | Medications.Given | Prep |
Details | Closure |Drains | Tissue.Removed |
Patient.Condition |
Sponge.Count | Needle.Count |Instrument.Count )* >
<!ELEMENT Estimated.Blood.Loss (#PCDATA)>
<!ELEMENT Operation.Ended (#PCDATA)>
<!ELEMENT Operation.Start (#PCDATA)>
<!ELEMENT Blood.Given (#PCDATA)>
<!ELEMENT Medications.Given (#PCDATA)>
<!ELEMENT Prep (#PCDATA)>
<!ELEMENT Details (#PCDATA)>
<!ELEMENT Closure (#PCDATA)>
<!ELEMENT Drains (#PCDATA)>
<!ELEMENT Tissue.Removed (#PCDATA)>
<!ELEMENT Patient.Condition (#PCDATA)>
<!ELEMENT Sponge.Count (#PCDATA)>
<!ELEMENT Needle.Count (#PCDATA)>
<!ELEMENT Instrument.Count(#PCDATA)>
=====
Draft DTD for the HCFA 1500
<!ENTITY % hcfa.name "family.name, given.name, MI">
<!ENTITY % hcfa.sex " (female | male )">
<!ENTITY % hcfa.address "street.address?, city?, state.or.province?,
zip.or.postal.code?, phone.number">
<!ENTITY % hcfa.yesno "yes|no">
<!ENTITY % hcfa.date " (month, day, year )">
<!ELEMENT HCFA.1500 (insurance.type , insured.ID , patient.name ,
patient.date.of.birth , patient.sex , insured.name ,
patient.address , patient.relationship.to.insured ,
insured.address , patient.status , other.insured.name ,
patient.condition.related.to , insured.policyGroup.FECANumber ,
patient.signature , insured.signature , date.current ,
date.SameSimliar.Illness , date.unable.to.work , practitioner.id ,
related.hospitalization , local.markup , outside.lab , diagnosis ,
medicaid.resubmission.number , prior.authorization.number , claim.list ,
federal.tax.id.number , patient.account.number , accept.assignment ,
total.charge , amount.paid , balance.due , practitioner.signature ,
facility , practitioner.billing.info )>
<!ELEMENT insurance.type EMPTY>
<!ATTLIST insurance.type number.type (medicare | medicaid |
champus | champva |
group | feca |
other ) #REQUIRED >
<!ELEMENT insured.ID (#PCDATA )>
<!ELEMENT patient.name (%hcfa.name; )>
<!ATTLIST patient.name condition.relation CDATA #IMPLIED >
<!ELEMENT patient.date.of.birth (month , day , year )>
<!ELEMENT patient.sex (%hcfa.sex; )>
<!ELEMENT insured.name (%hcfa.name; )>
<!ELEMENT patient.address (%hcfa.address; )>
<!ELEMENT patient.relationship.to.insured EMPTY>
<!ATTLIST patient.relationship.to.insured relationship.type (self |
spouse |
child |
other ) #REQUIRED >
<!ELEMENT insured.address (%hcfa.address; )>
<!ELEMENT patient.status (#PCDATA )>
<!ATTLIST patient.status patient.maritalStatus.type (single | married | other ) #REQUIRED
patient.employmentStatus.type (employed |
FullTimeStudent |
partTimeStudent ) #REQUIRED >
<!ELEMENT other.insured.name (#PCDATA | %hcfa.name; )*>
<!ELEMENT patient.condition.related.to (related.to.employment , related.to.autoAccident , related.to.otherAccident )>
<!ELEMENT insured.policyGroup.FECANumber (#PCDATA )>
<!ELEMENT patient.signature (#PCDATA )>
<!ELEMENT insured.signature (#PCDATA )>
<!ELEMENT date.current (illness , injury , pregnancy )>
<!ELEMENT date.SameSimliar.Illness (%hcfa.date; )*>
<!ELEMENT date.unable.to.work (from , to )>
<!ELEMENT practitioner.id (#PCDATA )>
<!ELEMENT related.hospitalization (from , to )>
<!ELEMENT local.markup (#PCDATA )>
<!ELEMENT outside.lab (charges )>
<!ELEMENT diagnosis (#PCDATA )>
<!ELEMENT medicaid.resubmission.number (medicaid.code , original.ref.number )>
<!ELEMENT prior.authorization.number (#PCDATA )>
<!ELEMENT claim.list (service.dates , service.place , service.type , procedures ,
diagnosis.code , charges , days.or.units , epsdt , emg ,
cob , local.markup )>
<!ELEMENT federal.tax.id.number (#PCDATA )>
<!ATTLIST federal.tax.id.number tax.id.type (ssn | ein ) #REQUIRED >
<!ELEMENT patient.account.number (#PCDATA )>
<!ELEMENT accept.assignment (#PCDATA )>
<!ELEMENT total.charge (#PCDATA )>
<!ELEMENT amount.paid (#PCDATA )>
<!ELEMENT balance.due (#PCDATA )>
<!ELEMENT practitioner.signature (#PCDATA )>
<!ELEMENT facility (organization.name , %hcfa.address; )>
<!ELEMENT practitioner.billing.info (%hcfa.address; )*>
<!ELEMENT family.name (#PCDATA )>
<!ELEMENT given.name (#PCDATA )>
<!ELEMENT MI (#PCDATA )>
<!ELEMENT street.address (#PCDATA )>
<!ELEMENT city (#PCDATA )>
<!ELEMENT state.or.province (#PCDATA )>
<!ELEMENT zip.or.postal.code (#PCDATA )>
<!ELEMENT phone.number (#PCDATA )>
<!ELEMENT month (#PCDATA )>
<!ELEMENT day (#PCDATA )>
<!ELEMENT year (#PCDATA )>
<!ELEMENT female EMPTY>
<!ELEMENT male EMPTY>
<!ELEMENT related.to.employment EMPTY>
<!ELEMENT related.to.autoAccident (place )>
<!ELEMENT related.to.otherAccident EMPTY>
<!ELEMENT organization.name (#PCDATA )>
<!ELEMENT service.dates (from , to )>
<!ELEMENT service.place (#PCDATA )>
<!ELEMENT service.type (#PCDATA )>
<!ELEMENT procedures (cpt.hcpcs , modifier )>
<!ELEMENT diagnosis.code (#PCDATA )>
<!ELEMENT charges (#PCDATA )>
<!ELEMENT days.or.units (#PCDATA )>
<!ELEMENT epsdt (#PCDATA )>
<!ELEMENT cob (#PCDATA )>
<!ELEMENT from (%hcfa.date; )>
<!ELEMENT to (%hcfa.date; )*>
<!ELEMENT emg (#PCDATA )>
<!ELEMENT cpt.hcpcs (#PCDATA )>
<!ELEMENT modifier (#PCDATA )>
<!ELEMENT medicaid.code (#PCDATA )>
<!ELEMENT original.ref.number (#PCDATA )>
<!ELEMENT illness (%hcfa.date; )>
<!ELEMENT injury (%hcfa.date; )>
<!ELEMENT pregnancy (%hcfa.date; )>
<!ELEMENT place (#PCDATA )>
===========
