PCC TF-2 - IHE
Integrating the Healthcare Enterprise
5
10
IHE Patient Care Coordination (PCC)
Technical Framework
Volume 2
IHE PCC TF-2
Transactions and Content Modules
15
20
Revision 10.0 - Final Text
November 4, 2014
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Copyright В© 2014: IHE International, Inc.
IHE Patient Care Coordination Technical Framework, Volume 2 (PCC TF-2): Transactions and
Content Profiles
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CONTENTS
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1 Preface to Volume 2 ................................................................................................................. 11
1.1 Intended Audience ............................................................................................................ 11
1.2 Related Information for the Reader .................................................................................. 11
1.2.1 How this Document is Organized .............................................................................. 12
1.2.2 Conventions Used in this Volume ............................................................................. 12
1.2.2.1 The Generic IHE Transaction Model ................................................................. 12
1.3 Copyright Permissions ...................................................................................................... 13
1.4 How to Contact Us ............................................................................................................ 13
2 Introduction .............................................................................................................................. 14
2.1 Relationship to Standards ................................................................................................. 14
2.2 Relationship to Product Implementations ......................................................................... 15
2.3 Relation of this Volume to the Technical Framework ...................................................... 15
2.3.1 Content Modules ........................................................................................................ 16
2.3.1.1 Document Content Module Constraints ............................................................. 18
2.3.1.2 Section Content Module Constraints .................................................................. 19
2.3.1.3 Entry and Header Content Modules Constraints ................................................ 21
3 IHE Transactions ...................................................................................................................... 23
3.1 Cross Enterprise Document Content Transactions ........................................................... 23
3.1.1 View Option............................................................................................................... 23
3.1.2 Document Import Option ........................................................................................... 23
3.1.3 Section Import Option ............................................................................................... 24
3.1.4 Discrete Data Import Option ..................................................................................... 24
4 IHE Patient Care Coordination Bindings ................................................................................. 24
4.1 Medical Document Binding to XDS, XDM and XDR ..................................................... 26
4.1.1 XDSDocumentEntry Metadata .................................................................................. 26
4.1.1.1 XDSSubmissionSet Metadata ............................................................................ 30
4.1.1.2 Use of XDS Submission Set ............................................................................... 31
4.1.1.3 Use of XDS Folders............................................................................................ 31
4.1.1.4 Configuration ...................................................................................................... 31
4.1.2 Extensions from other Domains ................................................................................ 31
4.1.2.1 Scanned Documents (XDS-SD) ......................................................................... 31
4.1.2.2 Basic Patient Privacy Consents (BPPC) ............................................................. 32
4.1.2.3 Laboratory Reports (XD-LAB) .......................................................................... 32
5 Namespaces and Vocabularies ................................................................................................. 34
5.1.1 IHE Format Codes ..................................................................................................... 34
5.1.2 IHEActCode Vocabulary ........................................................................................... 36
5.1.3 IHERoleCode Vocabulary ......................................................................................... 37
6 PCC Content Modules ............................................................................................................. 37
6.1 Conventions ...................................................................................................................... 37
6.2 Folder Content Modules ................................................................................................... 38
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6.2.1 EDES Folder Specification ........................................................................................ 38
6.2.2 APR Folder Specification .......................................................................................... 38
6.2.3 LDR Folder Specification .......................................................................................... 38
6.3 HL7 Version 3.0 Content Modules ................................................................................... 38
6.3.1 CDA Document Content Modules............................................................................. 38
6.3.1.1 Medical Documents Specification 1.3.6.1.4.1.19376.1.5.3.1.1.1 ....................... 38
6.3.1.2 Medical Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.2 ......................... 41
6.3.1.3 Referral Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.3 ......................... 42
6.3.1.4 Discharge Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.4 ...................... 48
6.3.1.5 PHR Extract Specification 1.3.6.1.4.1.19376.1.5.3.1.1.5 ................................... 53
6.3.1.6 PHR Update Specification 1.3.6.1.4.1.19376.1.5.3.1.1.6 ................................... 60
6.3.1.7 Emergency Department Referral Specification 1.3.6.1.4.1.19376.1.5.3.1.1.10 . 62
6.3.1.8 History and Physical Specification ..................................................................... 67
6.3.1.9 Antepartum Summary Specification .................................................................. 67
6.3.1.10
Immunization Content Specification1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2 .. 67
6.3.2 CDA Header Content Modules .................................................................................. 70
6.3.2.1 Language Communication 1.3.6.1.4.1.19376.1.5.3.1.2.1................................... 70
6.3.2.2 Employer and School Contacts 1.3.6.1.4.1.19376.1.5.3.1.2.2 ........................... 71
6.3.2.3 Healthcare Providers and Pharmacies 1.3.6.1.4.1.19376.1.5.3.1.2.3 ................. 73
6.3.2.4 Patient Contacts 1.3.6.1.4.1.19376.1.5.3.1.2.4 ................................................... 75
6.3.2.5 Reserved for (Spouse) ........................................................................................ 76
6.3.2.6 Reserved for (Natural Father of Fetus) ............................................................... 76
6.3.2.7 Reserved for (Authorization) .............................................................................. 76
6.3.3 CDA Section Content Modules ................................................................................. 77
6.3.3.1 Reasons for Care................................................................................................. 77
6.3.3.1.1 Reason for Referral Section 1.3.6.1.4.1.19376.1.5.3.1.3.1 ....................... 77
6.3.3.1.2 Coded Reason for Referral Section 1.3.6.1.4.1.19376.1.5.3.1.3.2............ 77
6.3.3.1.3 Chief Complaint Section 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 .................... 78
6.3.3.1.4 Hospital Admission Diagnosis Section 1.3.6.1.4.1.19376.1.5.3.1.3.3...... 79
6.3.3.1.5 Reserved for (Proposed Procedure Section) ............................................. 79
6.3.3.1.6 Reserved for (EBS Estimated Blood Loss Section) .................................. 79
6.3.3.1.7 Reserved for (Proposed Anesthesia Section) ............................................ 79
6.3.3.1.8 Reserved for (Reason for Procedure Section) ........................................... 80
6.3.3.1.9 Reserved for (Reason for Visit Section) ................................................... 80
6.3.3.1.10 Reserved for (Injury Incident Description Section) .................................. 80
6.3.3.2 Other Condition Histories................................................................................... 80
6.3.3.2.1 History of Present Illness Section 1.3.6.1.4.1.19376.1.5.3.1.3.4 .............. 80
6.3.3.2.2 Hospital Course Section 1.3.6.1.4.1.19376.1.5.3.1.3.5 ............................. 80
6.3.3.2.3 Active Problems Section 1.3.6.1.4.1.19376.1.5.3.1.3.6 ............................ 81
6.3.3.2.4 Discharge Diagnosis Section 1.3.6.1.4.1.19376.1.5.3.1.3.7 ..................... 82
6.3.3.2.5 History of Past Illness Section 1.3.6.1.4.1.19376.1.5.3.1.3.8 ................... 82
6.3.3.2.6 Encounter Histories Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3................. 83
6.3.3.2.7 History of Outpatient Visits Section 1.3.6.1.4.1.19376.1.5.3.1.3.9 .......... 84
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6.3.3.2.8 History of Inpatient Visits Section 1.3.6.1.4.1.19376.1.5.3.1.3.10........... 84
6.3.3.2.9 List of Surgeries Section 1.3.6.1.4.1.19376.1.5.3.1.3.11 .......................... 85
6.3.3.2.10 Coded List of Surgeries Section 1.3.6.1.4.1.19376.1.5.3.1.3.12 .............. 85
6.3.3.2.11 Allergies and Other Adverse Reactions Section
1.3.6.1.4.1.19376.1.5.3.1.3.13................................................................... 86
6.3.3.2.12 Family Medical History Section 1.3.6.1.4.1.19376.1.5.3.1.3.14 .............. 87
6.3.3.2.13 Coded Family Medical History Section 1.3.6.1.4.1.19376.1.5.3.1.3.15 ... 88
6.3.3.2.14 Social History Section 1.3.6.1.4.1.19376.1.5.3.1.3.16.............................. 88
6.3.3.2.15 Functional Status Section 1.3.6.1.4.1.19376.1.5.3.1.3.17......................... 89
6.3.3.2.16 Review of Systems Section 1.3.6.1.4.1.19376.1.5.3.1.3.18...................... 89
6.3.3.2.17 Hazardous Working Conditions Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1
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6.3.3.2.18 Pregnancy History Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4................... 90
6.3.3.2.19 Medical Devices Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5...................... 91
6.3.3.2.20 Foreign Travel Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6 ......................... 92
6.3.3.2.21 Pre-procedure Family Medical History Section
1.3.6.1.4.1.19376.1.5.3.1.1.9.5 (Deprecated) ............................................ 92
6.3.3.2.22 Reserved for Coded Functional Status Assessment Section ..................... 92
6.3.3.2.23 Reserved for Pain Scale Assessment Section ........................................... 92
6.3.3.2.24 Reserved for Braden Score Section Reserved for ..................................... 92
6.3.3.2.25 Reserved for Geriatric Depression Scale Section ..................................... 92
6.3.3.2.26 Reserved for Physical Function Section ................................................... 92
6.3.3.2.27 Reserved for Preprocedure Review of Systems Section ........................... 92
6.3.3.2.28 Reserved for Estimated Delivery Date Section ........................................ 92
6.3.3.2.29 Reserved for History of Tobacco Use Section .......................................... 92
6.3.3.2.30 Reserved for Current Alcohol/Substance Abuse Section ......................... 92
6.3.3.2.31 Reserved for History of Blood Transfusion Section ................................. 92
6.3.3.2.32 Reserved for Anesthesia Risk Review of Systems Section ...................... 92
6.3.3.2.33 Reserved for Implanted Medical Device Review Section ........................ 93
6.3.3.2.34 Reserved for Pregnancy Status Review Section ....................................... 93
6.3.3.2.35 Reserved for History of Infection Section ................................................ 93
6.3.3.2.36 Reserved for Coded Social History Section.............................................. 93
6.3.3.2.37 Reserved for Coded History of Infection Section ..................................... 93
6.3.3.2.38 Reserved for Prenatal Events Section ....................................................... 93
6.3.3.2.39 Reserved for Labor and Delivery Events Section ..................................... 93
6.3.3.2.40 Reserved for Newborn Delivery Information Section .............................. 93
6.3.3.2.41 Reserved for Postpartum Hospitalization Treatment Section ................... 93
6.3.3.2.42 Reserved for Event Outcomes Section ..................................................... 93
6.3.3.2.43 Reserved for Newborn Status at Maternal Discharge ............................... 93
6.3.3.2.44 Reserved for History of Surgical Procedures Section............................... 93
6.3.3.2.45 Reserved for Operative Note Section ....................................................... 93
6.3.3.2.46 Reserved for Child Functional Status Assessment ................................... 93
6.3.3.2.47 Reserved for Psychomotor Development Section .................................... 93
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6.3.3.2.48 Reserved for Eating and Sleeping Assessment Section ............................ 93
6.3.3.2.49 Reserved for Coded Event Outcomes Reserved for ................................. 93
6.3.3.2.50 Occupational History ................................................................................ 93
6.3.3.2.51 Patient Status............................................................................................. 93
6.3.3.2.52 Cancer Control .......................................................................................... 94
6.3.3.2.53 Reserved for Notifications, Alerts, and Reminders Section ..................... 94
6.3.3.2.54 Reserved for Pain Assessment Panel Section ........................................... 94
6.3.3.2.55 Reserved for History of Cognitive Function Section................................ 94
6.3.3.2.56 Reserved for Isolation Status Section ....................................................... 94
6.3.3.2.57 Reserved for Restraints Section ................................................................ 94
6.3.3.2.58 Reserved for Risk Indicators for Hearing Loss......................................... 94
6.3.3.2.59 Reserved for Cancer Diagnosis Section .................................................... 94
6.3.3.3 Medications ........................................................................................................ 94
6.3.3.3.1 Medications Section 1.3.6.1.4.1.19376.1.5.3.1.3.19 ................................. 94
6.3.3.3.2 Admission Medication History Section 1.3.6.1.4.1.19376.1.5.3.1.3.20 ... 95
6.3.3.3.3 Medications Administered Section 1.3.6.1.4.1.19376.1.5.3.1.3.21 .......... 96
6.3.3.3.4 Hospital Discharge Medications Section 1.3.6.1.4.1.19376.1.5.3.1.3.22 . 96
6.3.3.3.5 Immunizations Section 1.3.6.1.4.1.19376.1.5.3.1.3.23............................. 97
6.3.3.4 Physical Exams ................................................................................................... 98
6.3.3.4.1 Physical Examination Section 1.3.6.1.4.1.19376.1.5.3.1.3.24.................. 98
6.3.3.4.2 Detailed Physical Examination Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.15 98
6.3.3.4.3 Hospital Discharge Physical Exam Section 1.3.6.1.4.1.19376.1.5.3.1.3.26
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6.3.3.4.4 Vital Signs Section 1.3.6.1.4.1.19376.1.5.3.1.3.25................................. 103
6.3.3.4.5 Coded Vital Signs Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 ................. 104
6.3.3.4.6 General Appearance Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.16 ............... 104
6.3.3.4.7 Visible Implanted Medical Devices Section
1.3.6.1.4.1.19376.1.5.3.1.1.9.48.............................................................. 105
6.3.3.4.8 Integumentary System Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.17 ........... 105
6.3.3.4.9 Head Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.18 ....................................... 106
6.3.3.4.10 Eyes Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.19 ........................................ 107
6.3.3.4.11 Ears, Nose, Mouth and Throat Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.20 107
6.3.3.4.12 Ears Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.21 ........................................ 108
6.3.3.4.13 Nose Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.22 ....................................... 108
6.3.3.4.14 Mouth, Throat and Teeth Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.23 ....... 109
6.3.3.4.15 Neck Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.24 ....................................... 110
6.3.3.4.16 Endocrine System Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.25 .................. 110
6.3.3.4.17 Thorax and Lungs Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.26 .................. 111
6.3.3.4.18 Chest Wall Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.27.............................. 111
6.3.3.4.19 Breast Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.28 ..................................... 112
6.3.3.4.20 Heart Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.29....................................... 113
6.3.3.4.21 Respiratory System Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.30 ................ 113
6.3.3.4.22 Abdomen Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.31 ................................ 114
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6.3.3.4.23 Lymphatic System Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.32 ................. 114
6.3.3.4.24 Vessels Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.33 ................................... 115
6.3.3.4.25 Musculoskeletal System Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.34......... 115
6.3.3.4.26 Neurologic System Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.35 ................. 116
6.3.3.4.27 Genitalia Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.36 ................................. 117
6.3.3.4.28 Rectum Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.37 ................................... 117
6.3.3.4.29 Extremities Section 1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1 .......................... 118
6.3.3.5 Relevant Studies ............................................................................................... 119
6.3.3.5.1 Results Section 1.3.6.1.4.1.19376.1.5.3.1.3.27 ....................................... 119
6.3.3.5.2 Coded Results Section 1.3.6.1.4.1.19376.1.5.3.1.3.28 ........................... 119
6.3.3.5.3 Hospital Studies Summary Section 1.3.6.1.4.1.19376.1.5.3.1.3.29........ 120
6.3.3.5.4 Reserved for (Coded Hospital Studies Summary) .................................. 121
6.3.3.5.5 Reserved for (Consultations) .................................................................. 121
6.3.3.5.6 Reserved for (Antenatal Testing and Surveillance Section) ................... 121
6.3.3.5.7 Reserved for (Coded Antenatal Testing and Surveillance Section)........ 121
6.3.3.5.8 Diagnosis................................................................................................. 121
6.3.3.5.9 TNM Stage .............................................................................................. 122
6.3.3.5.10 Cancer Supporting Documentation ......................................................... 122
6.3.3.5.11 Reserved for (Hearing Screening Coded Results) .................................. 122
6.3.3.6 Plans of Care..................................................................................................... 122
6.3.3.6.1 Care Plan Section 1.3.6.1.4.1.19376.1.5.3.1.3.31 ................................... 122
6.3.3.6.2 Assessment and Plan Section 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5 ........... 122
6.3.3.6.3 Discharge Disposition Section 1.3.6.1.4.1.19376.1.5.3.1.3.32 ............... 123
6.3.3.6.4 Discharge Diet Section 1.3.6.1.4.1.19376.1.5.3.1.3.33 .......................... 123
6.3.3.6.5 Advance Directives Section 1.3.6.1.4.1.19376.1.5.3.1.3.34 ................... 124
6.3.3.6.6 Coded Advance Directives Section 1.3.6.1.4.1.19376.1.5.3.1.3.35 ....... 124
6.3.3.6.7 Transport Mode Section .......................................................................... 125
6.3.3.6.8 Reserved for (Procedure Care Plan Status Report Section) .................... 125
6.3.3.6.9 Reserved for (Health Maintenance Care Plan Section) .......................... 125
6.3.3.6.10 Reserved for (Health Maintenance Care Plan Status Report Section) .... 125
6.3.3.6.11 Reserved for (Provider Orders Section) .................................................. 125
6.3.3.6.12 Reserved for (Birth Plan Section) ........................................................... 126
6.3.3.6.13 Immunization Recommendations 1.3.6.1.4.1.19376.1.5.3.1.1.18.3.1 .... 126
6.3.3.6.14 Reserved for Patient Education Section .................................................. 126
6.3.3.6.15 Reserved for Coded Care Plan Section ................................................... 126
6.3.3.6.16 Reserved for Diet and Nutrition Section................................................. 126
6.3.3.6.17 Reserved for Intake and Output Section ................................................. 126
6.3.3.6.18 Cancer Course of Treatment ................................................................... 126
6.3.3.6.19 Cancer Treatment Plan ............................................................................ 126
6.3.3.6.20 Reserved for (Procedure Care Plan Section) .......................................... 126
6.3.3.6.21 Reserved for (Protocols Used Section) ................................................... 126
6.3.3.6.22 Reserved for (Invasive Airway Section) ................................................. 126
6.3.3.6.23 Reserved for (Ventilator Usage Section) ................................................ 126
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6.3.3.7 Administrative and Other Information ............................................................. 127
6.3.3.7.1 Payers Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7 .................................... 127
6.3.3.7.2 Referral Source Section 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3 ................... 127
6.3.3.7.3 Transport Mode Section 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 ................... 128
6.3.3.7.4 ED Disposition Section 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10 .................. 128
6.3.3.7.5 Cancer Payers.......................................................................................... 129
6.3.3.7.6 Reserved for Sending Facility Section.................................................... 129
6.3.3.7.7 Reserved for Receiving Facility Section................................................. 129
6.3.3.7.8 Reserved for Mass Casualty Incident Section ........................................ 129
6.3.3.7.9 Reserved for Unit Response Level Section ............................................ 129
6.3.3.7.10 Reserved for Extra Attendants Information Section ............................... 129
6.3.3.7.11 Reserved for Provider Level Section ...................................................... 129
6.3.3.8 Interventions ..................................................................................................... 129
6.3.3.8.1 Intentionally left blank ............................................................................ 129
6.3.3.8.2 Intentionally left blank ............................................................................ 129
6.3.3.8.3 Reserved for Procedures and Interventions Section ............................... 129
6.3.3.8.4 Reserved for Intravenous Fluids Administered Section ......................... 130
6.3.3.9 Impressions ....................................................................................................... 130
6.3.3.9.1 Pre-procedure Impressions Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.42
(Deprecated) ............................................................................................ 130
6.3.3.9.2 Reserved for Pre-procedure Risk Assessment Section ........................... 130
6.3.3.9.3 Reserved for Antepartum Visit Summary Flowsheet Section ................ 130
6.3.3.9.4 Reserved for Progress Note Section ....................................................... 130
6.3.3.9.5 Reserved for ED Diagnosis Section ........................................................ 130
6.3.3.9.6 Reserved for Acuity Assessment Section ............................................... 130
6.3.3.9.7 Reserved for Assessments Section.......................................................... 130
6.3.3.10
Section Content Modules (non-categorized) .......................................... 130
6.3.3.10.1 Reserved for VRDR Death Report Section ............................................ 130
6.3.3.10.2 Reserved for Coded Hospital Course Section ......................................... 130
6.3.3.10.3 Reserved for Resources to Support Goals Section ................................. 130
6.3.3.10.4 Reserved for Healthy Weight Care Plan Section .................................... 130
6.3.3.10.5 Reserved for Occupational Data for Health Section ............................... 130
6.3.4 CDA Entry Content Modules .................................................................................. 130
6.3.4.1 Authors and Informants .................................................................................... 130
6.3.4.2 Linking Narrative and Coded Entries ............................................................... 131
6.3.4.3 Severity 1.3.6.1.4.1.19376.1.5.3.1.4.1 .............................................................. 133
6.3.4.4 Problem Status Observation 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 ........................... 135
6.3.4.5 Health Status 1.3.6.1.4.1.19376.1.5.3.1.4.1.2 ................................................... 137
6.3.4.6 Comments 1.3.6.1.4.1.19376.1.5.3.1.4.2 .......................................................... 139
6.3.4.7 Patient Medication Instructions 1.3.6.1.4.1.19376.1.5.3.1.4.3 ......................... 142
6.3.4.8 Medication Fulfillment Instructions 1.3.6.1.4.1.19376.1.5.3.1.4.3.1 ............... 144
6.3.4.9 External References 1.3.6.1.4.1.19376.1.5.3.1.4.4 ........................................... 145
6.3.4.10
Internal References 1.3.6.1.4.1.19376.1.5.3.1.4.4.1 ............................... 147
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6.3.4.11
Concern Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5.1 ....................................... 148
6.3.4.12
Problem Concern Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5.2......................... 151
6.3.4.13
Allergy and Intolerance Concern 1.3.6.1.4.1.19376.1.5.3.1.4.5.3 .......... 152
6.3.4.14
Problem Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5 .......................................... 153
6.3.4.15
Allergies and Intolerances 1.3.6.1.4.1.19376.1.5.3.1.4.6........................ 158
6.3.4.16
Medications 1.3.6.1.4.1.19376.1.5.3.1.4.7 .............................................. 161
6.3.4.17
Immunizations 1.3.6.1.4.1.19376.1.5.3.1.4.12........................................ 172
6.3.4.18
Supply Entry 1.3.6.1.4.1.19376.1.5.3.1.4.7.3 ......................................... 176
6.3.4.19
Product Entry 1.3.6.1.4.1.19376.1.5.3.1.4.7.2 ........................................ 179
6.3.4.20
Simple Observations 1.3.6.1.4.1.19376.1.5.3.1.4.13 .............................. 181
6.3.4.21
Vital Signs Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.13.1 .......................... 184
6.3.4.22
Vital Signs Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.2 ...................... 185
6.3.4.23
Family History Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.15 ...................... 187
6.3.4.24
Social History Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.4 ................. 190
6.3.4.25
Pregnancy Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.5 ....................... 192
6.3.4.26
Pregnancy History Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.13.5.1 ........... 194
6.3.4.27 Birth Event Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.13.5.2............................. 196
6.3.4.28 Reserved for (Antepartum Visit Summary Battery) ...................................... 199
6.3.4.29 Advance Directive Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.7 ................ 199
6.3.4.30 Reserved for Blood Type Observation .......................................................... 201
6.3.4.31 Reserved for Encounters................................................................................ 201
6.3.4.32 Reserved for Update Entry ............................................................................ 201
6.3.4.33 Reserved for Procedure Entry ....................................................................... 201
6.3.4.34 Transport 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1................................................. 201
6.3.4.35 Reserved for Encounter Disposition .............................................................. 202
6.3.4.36 Coverage Entry 1.3.6.1.4.1.19376.1.5.3.1.4.17 .............................................. 202
6.3.4.37 Payer Entry 1.3.6.1.4.1.19376.1.5.3.1.4.18 ................................................... 204
6.3.4.38 Reserved for Pain Score Observation ............................................................ 208
6.3.4.39 Reserved for Future Use ................................................................................ 208
6.3.4.40 Reserved for Future Use ................................................................................ 208
6.3.4.41 Reserved for Future Use ................................................................................ 208
6.3.4.42 Reserved for Future Use ................................................................................ 208
6.3.4.43 Reserved for Survey Panel ............................................................................ 208
6.3.4.44 Reserved for Survey Observation .................................................................. 208
6.3.4.45 Reserved for Acuity....................................................................................... 208
6.3.4.46 Reserved for Intravenous Fluids .................................................................... 208
6.3.4.47 Reserved for Nursing Assessments Battery .................................................. 208
6.3.4.48 Reserved for Antenatal Testing and Surveillance Battery ............................ 208
6.3.4.49 Immunization Recommendation 1.3.6.1.4.1.19376.1.5.3.1.4.12.2 ............... 208
6.3.4.50 Alert Entry 1.3.6.1.4.1.19376.1.5.3.1.4.12.3 ................................................. 211
6.3.4.51 Antigen Dose 1.3.6.1.4.1.19376.1.5.3.1.4.12.1 ............................................. 212
6.3.4.52 Reserved for Future Use ................................................................................ 213
6.3.4.53 Reserved for Future Use ................................................................................ 213
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6.3.4.54 Reserved for Observation Request ................................................................ 213
6.3.4.55 Reserved for Risk Indicators for Hearing Loss Entry ................................... 213
6.3.4.56 Reserved for Cancer Diagnosis Entry ........................................................... 213
6.3.4.57 Family History Observation 1.3.6.1.4.19376.1.5.3.1.4.13.3 ......................... 213
6.3.4.58 Reserved for Death Pronouncement Entry Content Module ......................... 215
6.3.4.59 Reserved for Death Location Type Entry Content Module........................... 215
6.3.4.60 Reserved for Occupational Data For Health Organizer ................................ 215
6.3.4.61 Reserved for Employment Status Organizer ................................................. 215
6.3.4.62 Reserved for Usual Occupation and Industry Organizer ............................... 215
6.3.4.63 Reserved for History of Occupation Organizer ............................................. 215
6.3.4.64 Reserved for Employment Status Observation.............................................. 215
6.3.4.65 Reserved for Usual Occupation and Industry Observation Entry ................. 215
6.3.4.66 Reserved for Occupation Observation Entry................................................. 215
6.3.4.67 Reserved for Work Shift Observation Entry ................................................. 215
6.3.4.68 Reserved for Weekly Work Hours Observation Entry .................................. 215
6.3.4.69 Reserved for Usual Occupation Duration Entry ............................................ 215
6.3.4.70 Reserved for Usual Industry Duration Entry ................................................. 215
6.3.4.71 Reserved for Future Use ................................................................................ 215
6.3.4.72 Reserved for Future Use ................................................................................ 215
6.3.4.73 Reserved for Future Use ................................................................................ 215
6.3.4.74 Reserved for Future Use ................................................................................ 215
6.3.4.75 Reserved for Future Use ................................................................................ 215
6.3.4.76 Reserved for Future Use ................................................................................ 215
6.3.4.77 Reserved for Future Use ................................................................................ 215
6.3.4.78 Reserved for Future Use ................................................................................ 215
6.3.4.79 Reserved for Future Use ................................................................................ 215
6.3.4.80 Reserved for Future Use ................................................................................ 215
6.3.4.81 Reserved for Future Use ................................................................................ 216
6.3.4.82 Reserved for Future Use ................................................................................ 216
6.3.4.83 Reserved for Future Use ................................................................................ 216
6.3.4.84 Reserved for Future Use ................................................................................ 216
6.3.4.85 Reserved for Future Use ................................................................................ 216
6.3.4.86 Reserved for Future Use ................................................................................ 216
6.3.4.87 Reserved for Future Use ................................................................................ 216
6.3.4.88 Reserved for Future Use ................................................................................ 216
6.3.4.89 Reserved for Future Use ................................................................................ 216
6.3.4.90 Reserved for Future Use ................................................................................ 216
6.3.4.91 Reserved for Future Use ............................................................................... 216
6.3.4.92 Reserved for Future Use ................................................................................ 216
6.3.4.93 Subject Participation 1.3.6.1.4.1.19376.1.5.3.1.4.15.2 .................................. 216
6.4 HL7 Version 2.0 Content Modules For care management ............................................ 218
6.5 PCC Value Sets ............................................................................................................... 218
6.5.1 APR H&P History of Past Illness Value Set ........................................................... 218
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6.5.2 APR H&P Social History Value Set ........................................................................ 218
Examples Using PCC Content Profiles....................................................................................... 218
Validating CDA Documents using the Framework .................................................................... 218
A.1 Validating Documents .................................................................................................... 219
A.2 Validating Sections ......................................................................................................... 220
A.3 Phases of Validation and Types of Errors....................................................................... 220
Extensions to CDA Release 2.0 .................................................................................................. 221
A.4 IHE PCC Extensions ....................................................................................................... 222
A.4.1 replacementOf.......................................................................................................... 222
A.5 Extensions Defined Elsewhere used by IHE PCC .......................................................... 223
A.5.1 Entity Identifiers ...................................................................................................... 223
A.5.2 Patient Identifier ...................................................................................................... 223
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1 Preface to Volume 2
385
1.1 Intended Audience
The intended audience of this document is:
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Technical staff of vendors planning to participate in the IHE initiative
•
IT departments of healthcare institutions
•
Experts involved in standards development
•
Anyone interested in the technical aspects of integrating healthcare information systems
1.2 Related Information for the Reader
The reader of volume 2 should read or be familiar with the following documents:
•
Volume 1 of the Cross-Enterprise Document Sharing (XDS) Integration Profile
documented in the ITI Infrastructure Technical Framework
(See http://www.ihe.net/Technical_Frameworks).
•
Volume 1 of the Notification of Document Availability (NAV) Integration Profile
documented in the ITI Infrastructure Technical Framework
(See http://www.ihe.net/Technical_Frameworks).
•
Volume 1 of the Audit Trail and Node Authentication (ATNA) Integration Profile
documented in the ITI Infrastructure Technical Framework (See
http://www.ihe.net/Technical_Frameworks).
•
HL7 Clinical Document Architecture Release 2: Section 1, CDA Overview.
•
Care Record Summary – Implementation Guide for CDA Release 2 (US Realm): Section
1
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1.2.1 How this Document is Organized
Section 1 is the preface, describing the intended audience, related resources, and organizations
and conventions used within this document.
410
Section 2 provides an overview of the concepts of IHE actors and transactions used in IHE to
define the functional components of a distributed healthcare environment.
Section 3 defines transactions in detail, specifying the roles for each actor, the standards
employed, the information exchanged, and in some cases, implementation options for the
transaction.
Section 4 defines a set of payload bindings with transactions.
415
Section 5 defines the content modules that may be used in transactions.
1.2.2 Conventions Used in this Volume
This document has adopted the following conventions for representing the framework concepts
and specifying how the standards upon which the IHE Technical Framework is based should be
applied.
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1.2.2.1 The Generic IHE Transaction Model
Transaction descriptions are provided in section 4. In each transaction description, the actors, the
roles they play, and the transactions between them are presented as use cases.
The generic IHE transaction description includes the following components:
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•
Scope: a brief description of the transaction.
•
Use case roles: textual definitions of the actors and their roles, with a simple diagram
relating them, e.g.,:
Figure 1.2.2.1-1: Use Case Role Diagram
•
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Referenced Standards: the standards (stating the specific parts, chapters or sections
thereof) to be used for the transaction.
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•
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Interaction Diagram: a graphical depiction of the actors and transactions, with related
processing within an actor shown as a rectangle and time progressing downward, similar
to:
Figure 1.2.2.1-2: Interaction Diagram
The interaction diagrams used in the IHE Technical Framework are modeled after those
described in Grady Booch, James Rumbaugh, and Ivar Jacobson, The Unified Modeling
Language User Guide, ISBN 0-201-57168-4. Simple acknowledgment messages are omitted
from the diagrams for brevity.
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•
Message definitions: descriptions of each message involved in the transaction, the events
that trigger the message, its semantics, and the actions that the message triggers in the
receiver.
1.3 Copyright Permissions
445
Health Level Seven, Inc., has granted permission to the IHE to reproduce tables from the HL7
standard. The HL7 tables in this document are copyrighted by Health Level Seven, Inc. All rights
reserved. Material drawn from these documents is credited where used.
1.4 How to Contact Us
450
IHE International welcomes comments on this document and the IHE initiative. They can be
submitted using the Web-based comment form at http://www.ihe.net/PCC_Public_Comments or
by sending an email to the co-chairs and secretary of the Patient Care Coordination domain
committees at [email protected]
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2 Introduction
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This document, the IHE Patient Care Coordination Technical Framework (IHE PCC TF-2),
defines specific implementations of established standards. These are intended to achieve
integration goals that promote appropriate exchange of medical information to coordinate the
optimal patient care among care providers in different care settings. It is expanded annually, after
a period of public review, and maintained regularly through the identification and correction of
errata. The latest version of the document is always available via the Internet at
http://www.ihe.net/Resources/Technical_Frameworks, where the technical framework volumes
specific to the various healthcare domains addressed by IHE may be found.
The IHE Patient Care Coordination Technical Framework identifies a subset of the functional
components of the healthcare enterprises and health information networks, called IHE actors, and
specifies their interactions in terms of a set of coordinated, standards-based transactions.
The other domains within the IHE initiative also produce Technical Frameworks within their
respective areas that together form the IHE Technical Framework. Currently, the following IHE
Technical Framework(s) are available:
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IHE IT Infrastructure Technical Framework
•
IHE Cardiology Technical Framework
•
IHE Laboratory Technical framework
•
IHE Radiology Technical Framework
•
IHE Patient Care Coordination Technical Framework
Where applicable, references are made to other technical frameworks. For the conventions on
referencing other frameworks, see the preface of this volume.
2.1 Relationship to Standards
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485
The IHE Technical Framework identifies functional components of a distributed healthcare
environment (referred to as IHE actors), solely from the point of view of their interactions in the
healthcare enterprise. At its current level of development, it defines a coordinated set of
transactions based on standards (such as HL7, IETF, ASTM, DICOM, ISO, OASIS, etc.) in
order to accomplish a particular use case. As the scope of the IHE initiative expands, transactions
based on other standards may be included as required.
Each transaction may have as its payload one or more forms of content, as well as specific
metadata describing that content within the transaction. The specification of the payload and
metadata about it are the components of a Content Integration Profile. The payload is specified in
a Content Module, and the impacts of any particular payload on a transaction are described
within a content binding. The payloads of each transaction are also based on standards (such as
HL7, IETF, ASTM, DICOM, ISO, OASIS, etc.), again, in order to meet the needs of a specific
use case.
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In some cases, IHE recommends selection of specific options supported by these standards.
However, IHE does not introduce technical choices that contradict conformance to these
standards. If errors in or extensions to existing standards are identified, IHE's policy is to report
them to the appropriate standards bodies for resolution within their conformance and standards
evolution strategy.
495
IHE is therefore an implementation framework, not a standard. Conformance claims for products
must still be made in direct reference to specific standards. In addition, vendors who have
implemented IHE integration capabilities in their products may publish IHE Integration
Statements to communicate their products' capabilities. Vendors publishing IHE Integration
Statements accept full responsibility for their content. By comparing the IHE Integration
Statements from different products, a user familiar with the IHE concepts of actors and
integration profiles can determine the level of integration between them. See IHE PCC TF-1:
Appendix C for the format of IHE Integration Statements.
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2.2 Relationship to Product Implementations
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510
515
520
The IHE actors and transactions described in the IHE Technical Framework are abstractions of
the real-world healthcare information system environment. While some of the transactions are
traditionally performed by specific product categories (e.g., HIS, Clinical Data Repository,
Electronic Health record systems, Radiology Information Systems, Clinical Information Systems
or Cardiology Information Systems), the IHE Technical Framework intentionally avoids
associating functions or actors with such product categories. For each actor, the IHE Technical
Framework defines only those functions associated with integrating information systems. The
IHE definition of an actor should therefore not be taken as the complete definition of any product
that might implement it, nor should the framework itself be taken to comprehensively describe
the architecture of a healthcare information system.
The reason for defining actors and transactions is to provide a basis for defining the interactions
among functional components of the healthcare information system environment. In situations
where a single physical product implements multiple functions, only the interfaces between the
product and external functions in the environment are considered to be significant by the IHE
initiative. Therefore, the IHE initiative takes no position as to the relative merits of an integrated
environment based on a single, all-encompassing information system versus one based on
multiple systems that together achieve the same end.
2.3 Relation of this Volume to the Technical Framework
The IHE Technical Framework is based on actors that interact through transactions using some
form of content.
525
Actors are information systems or components of information systems that produce, manage, or
act on information associated with operational activities in the enterprise.
Transactions are interactions between actors that transfer the required information through
standards-based messages.
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The implementation of the transactions described in this IHE PCC TF-2 support the specification
of Integration Profiles defined in IHE PCC TF-1. The role and implementation of these
transactions require the understanding of the integration profile they support.
There is often a very clear distinction between the transactions in a messaging framework used to
package and transmit information, and the information content actually transmitted in those
messages. This is especially true when the messaging framework begins to move towards
mainstream computing infrastructures being adopted by the healthcare industry.
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540
In these cases, the same transactions may be used to support a wide variety of use cases in
healthcare, and so more and more the content and use of the message also needs to be profiled,
sometimes separately from the transaction itself. Towards this end IHE has developed the
concept of a Content Integration Profile.
Content Integration Profiles specify how the payload of a transaction fits into a specific use of
that transaction. A content integration profile has three main parts. The first part describes the
use case. The second part is binding to a specific IHE transaction, which describes how the
content affects the transaction. The third part is a Content Module, which describes the payload
of the transaction. A content module is specified so as to be independent of the transaction in
which it appears.
545
2.3.1 Content Modules
550
The Patient Care Coordination Technical Framework organizes content modules categorically by
the base standard. At present, the PCC Technical Framework uses only one base standard, CDA
Release 2.0, but this is expected to change over time. Underneath each standard, the content
modules are organized using a very coarse hierarchy inherent to the standard. So for CDA
Release 2.0 the modules are organized by document, section, entry, and header elements.
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Each content module can be viewed as the definition of a "class" in software design terms, and
has associated with it a name. Like "class" definitions in software design, a content module is a
"contract", and the PCC Technical Framework defines that contract in terms of constraints that
must be obeyed by instances of that content module. Each content module has a name, also
known as its template identifier. The template identifiers are used to identify the contract agreed
to by the content module. The PCC Technical Committee is responsible for assigning the
template identifiers to each content module.
Like classes, content modules may inherit features of other content modules of the same type
(Document, Section or Entry) by defining the parent content module that they inherit from. They
may not inherit features from a different type. Although information in the CDA Header is in a
different location that information in a CDA Entry, these two content modules are considered to
be of the same type, and so may inherit from each other when necessary.
The PCC Technical Framework uses the convention that a content module cannot have more
than one parent (although it may have several ancestors). This is similar to the constraint in the
Javaв„ў programming language, where classes can derive from only one parent. This convention
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is not due to any specific technical limitation of the technical framework, but does make it easier
for software developers to implement content modules.
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575
Each content module has a list of data elements that are required (R), required if known (R2),
and optional (O). The presentation of this information varies with the type of content module,
and is described in more detail below. Additional data elements may be provided by the sender
that are not defined by a specific content module, but the receiver is not required to interpret
them.
Required data elements must always be sent. Data elements that are required may under
exceptional circumstances have an unknown value (e.g., the name of an unconscious patient). In
these cases the sending application is required to indicate the reason that the data is not available.
Data elements that are marked required if known (R2) must be sent when the sending application
has that data available. The sending application must be able to demonstrate that it can send all
required if known elements, unless it does not in fact gather that data. When the information is
not available, the sending application may indicate the reason that the data is not available.
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600
605
Data elements that are marked optional (O) may be sent at the choice of the sending application.
Since a content module may include data elements not specified by the profile, some might ask
why these are specified in a content module. The reason for specifying the optional data elements
is to ensure that both sender and receiver use the appropriate semantic interpretation of these
elements. Thus, an optional element need not be sent, but when it is sent, the content module
defines the meaning of that data element, and a receiver can always be assured of what that data
element represents when it is present. Senders should not send an optional data element with an
unknown value. If the value is not known, simply do not send the data element.
Other data elements may be included in an instance of a content module over what is defined by
the PCC Technical Framework. Receivers are not required to process these elements, and if they
do not understand them, must ignore them. Thus, it is not an error to include more than is asked
for, but it is an error to reject a content module because it contains more than is defined by the
framework. This allows value to be added to the content modules delivered in this framework,
through extensions to it that are not defined or profiled by IHE. It further allows content modules
to be defined later by IHE that are refinements or improvements over previous content modules.
For example, there is a Referral Summary content module defined in this framework. In later
years an ED Referral content module can be created that inherits the constraints of the Referral
Summary content module, with a few more use case specific constraints added. Systems that do
not understand the ED Referral content module but do understand the Referral Summary content
module will be able to interoperate with systems that send instances of documents that conform
to the ED Referral content module. This interoperability, albeit at a reduced level of
functionality, is by virtue of the fact that ED Referrals are simply a refinement of the Referral
Summary.
In order to retain this capability, there are a few rules about how the PCC Technical Committee
creates constraints. Constraints that apply to any content module will always apply to any
content modules that inherit from it. Thus, the "contracts" are always valid down the inheritance
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610
hierarchy. Secondly, data elements of a content module will rarely be deprecated. This will
usually occur only in the cases where they have been deprecated by the base standard. While any
specific content module has a limited scope and set of use cases, deprecating the data element
prevents any future content module from taking advantage of what has already been defined
when a particular data element has been deprecated simply because it was not necessary in the
original use case.
2.3.1.1 Document Content Module Constraints
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635
Each document content module will define the appropriate codes used to classify the document,
and will also describe the specific data elements that are included. The code used to classify it is
specified using an external vocabulary, typically LOINC in the case of CDA Release 2.0
documents. The set of data elements that make up the document are defined, including the
whether these data elements must, should or may be included in the document. Each data
element is typically a section within the document, but may also describe information that is
contained elsewhere within of the document (e.g., in the header). Each data element is mapped
into a content module via a template identifier, and the document content module will further
indicate whether these are data elements are required, required if known or optional. Thus, a
document content module shall contain as constraints:
•
The template identifier of the parent content module when there is one.
•
The LOINC code or codes that shall be used to classify the document.
•
A possibly empty set of required, required if known, and optional section content
modules, and their template identifiers.
•
A possibly empty set of required, required if known, and optional header content
modules, and their template identifiers.
•
Other constraints as necessary.
The template identifier for the document will be provided in the narrative, as will the legal
LOINC document type codes and if present, any parent template identifier.
The remaining constraints are presented in two tables. The first table identifies the relevant data
elements as determined during the technical analysis, and maps these data elements to one or
more standards. The second table actually provides the constraints, wherein each data element
identified in the first table is repeated, along with whether it is required, required if known, or
optional. Following this column is a reference to the specification for the content module that
encodes that data element, and the template identifier assigned to it. The simple example below
completes the content specification described above. A simplified example is shown below.
Sample Document Specification SampleDocumentOID
Sample Document has one required section, and one entry that is required if known
6.3.1.A.4 Specification
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Content Profiles
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Table 6.3.1.A.4.1-1:
Data Element Name
Opt
Template ID
Sample Section
Comment on section
R
SampleSectionOID
Sample Entry
Comment on entry
R2
SampleEntryOID
6.3.1.B.5 Conformance
CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their
conformance by the inclusion of the appropriate <templateId> elements in the header of the document.
This is shown in the sample document below.
<ClinicalDocument xmlns='urn:hl7-org:v3'>
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<templateId root='SampleDocumentOID'/>
<id root=' ' extension=' '/>
<code code=' ' displayName=' '
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<title>Sample Document</title>
<effectiveTime value='20080601012005'/>
<confidentialityCode code='N' displayName='Normal'
codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
<languageCode code='en-US'/>
:
<component><structuredBody>
<component>
<section>
<templateId root='SampleSectionOID'/>
<!-- Required Sample Section Section content -->
</section>
</component>
</structuredBody></component>
</ClinicalDocument>
640
2.3.1.2 Section Content Module Constraints
Section content modules will define the content of a section of a clinical document. Sections will
usually contain narrative text, and so this definition will often describe the information present in
the narrative, although sections may be wholly comprised of subsections.
645
650
Sections may contain various subsections, and these may be required, required if known or
optional. Sections may also contain various entries, and again, these may be required, required if
known, or optional. A section may not contain just entries; it must have at least some narrative
text or subsections to be considered to be valid content.
Again, sections can inherit features from other section content modules. Once again, sections are
classified using an external vocabulary (again typically this would be LOINC), and so the list of
possible section codes is also specified. Sections that inherit from other sections will not specify
a LOINC code unless it is to restrict the type of section to smaller set of LOINC codes specified
by one of its ancestors.
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Thus, a section content module will contain as constraints:
655
660
•
The template identifier of the parent content module when there is one.
•
The LOINC code or codes that shall be used to classify the section.
•
A possibly empty set of required, required if known, and optional section content
modules, and their template identifiers for the subsections of this section.
•
A possibly empty set of required, required if known, and optional entry content modules,
and their template identifiers.
• Other constraints as necessary.
These constraints are presented in this document using a table for each section content module,
as shown below.
Sample Section
SampleSectionOID
foo (SampleParentOID)
Description of this section
Opt
XXXXX-X
R
Entries
OID
SECTION NAME
Opt
R
Subsections
OID
Description
Description
Sample Entry
Opt
R
Description
Sample Subsection
Table 0-1
Table 0-2
Table 0-3
Table 0-4 LOINC Codes
Table 0-5 General Description
Table 0-6 Parent Template
2.3.1.2.1 Parent Template
The parent of this template is foo.
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<component>
<section>
<templateId root='SampleParentOID'/>
<templateId root='SampleSectionOID'/>
<id root=' ' extension=' '/>
<code code=' ' displayName=' '
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
Required and optional entries as described above
</entry>
<component>
Required and optional subsections as described above
</component>
</section>
Table 2.3.1.2.1-1: Template ID
665
670
675
2.3.1.3 Entry and Header Content Modules Constraints
Entry and Header content modules are the lowest level of content for which content modules are
defined. These content modules are associated with classes from the HL7 Reference Information
Model (RIM). These "RIM" content modules will constrain a single RIM class. Entry content
modules typically constrain an "Act" class or one of its subtypes, while header content modules
will normally constrain "Participation", "Role" or "Entity" classes, but may also constrain an
"Act" class.
Entry and Header content modules will describe the required, required if known, and optional
XML elements and attributes that are present in the CDA Release 2.0 instance. Header and Entry
content modules may also be built up using other Header and Entry content modules. An entry or
header content module may also specify constraints on the vocabularies used for codes found in
the entry, or data types for the values found in the entry. Thus, an entry or header content module
will contain as constraints:
•
The template identifier of the parent content module when there is one.
•
A description of the XML elements and attributes used in the entry, along with
explanations of their meaning.
•
An indication of those XML elements or attributes that are required, required if known,
or optional.
•
Vocabulary domains to use when coding the entry.
•
Data types used to specify the value of the entry.
•
Other constraints as necessary.
680
685
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An example is shown below, providing guidance on how an entry is typically structured in the
technical framework. The section numbering used below is for example purposes only and will
reflect the actual section numbers used for any given entry.
690
a.b.x Sample Entry
Some text describing the entry.
695
<observation classCode='OBS' moodCode='EVN'>
<templateId root='foo'/>
</observation>
a.b.x.x <observation classCode='OBS' moodCode='EVN'>
Some details about the observation element
a.b.x.y <templateId root='foo'/>
700
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3 IHE Transactions
This section defines each IHE transaction in detail, specifying the standards used, and the
information transferred.
3.1 Cross Enterprise Document Content Transactions
705
At present, all transactions used by the PCC Content Profiles appear in IHE ITI TF-2. General
Options defined in content profiles for a Content Consumer are described below.
3.1.1 View Option
A Content Consumer that supports the View Option shall be able to:
710
715
720
1. Use the appropriate XD* transactions to obtain the document along with associated necessary
metadata.
2. Render the document for viewing. This rendering shall meet the requirements defined for
CDA Release 2 content presentation semantics (See Section 1.2.4 of the CDA Specification:
Human readability and rendering CDA Documents). CDA Header information providing
context critical information shall also be rendered in a human readable manner. This includes
at a minimum the ability to render the document with the stylesheet specifications provided
by the document source, if the document source provides a stylesheet. Content Consumers
may optionally view the document with their own stylesheet, but must provide a mechanism
to view using the source stylesheet.
3. Support traversal of any links contained within the <linkHTML> elements in the narrative as
described in PCC TF2-6.3.4.9.9.
4. Print the document to paper.
3.1.2 Document Import Option
725
730
735
This Option requires that the View Option be supported. In addition, the Content Consumer that
supports the Document Import Option shall be able to support the storage of the entire document
(as provided by the sharing framework, along with sufficient metadata to ensure its later
viewing) both for discharge summary or referral documents. This Option requires the proper
tracking of the document origin. Once a document has been imported, the Content Consumer
shall offer a means to view the document without the need to retrieve it again from the sharing
framework. When viewed after it was imported, a Content Consumer may choose to access the
sharing framework to find out if the related Document viewed has been deprecated, replaced or
addended.
Note: For example, when using XDS, a Content Consumer may choose to query the Document Registry about a
document previously imported in order to find out if this previously imported document may have been replaced or has
received an addendum. This capability is offered to Content Consumers by this Integration Profile, but not required, as the
events that may justify such a query are extremely implementation specific.
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3.1.3 Section Import Option
740
745
This Option requires that the View Option be supported. In addition, the Content Consumer that
supports the Section Import Option shall be able to support the import of one or more sections of
the document (along with sufficient metadata to link the data to its source). This Option requires
the proper tracking of the document section origin. Once sections have been selected, a Content
Consumer shall offer a means to copy the imported section(s) into local data structures as free
text. This is to support the display of section level information for comparison or editing in
workflows such as medication reconciliation while discrete data import is not possible. When
viewed again after it is imported, a Content Consumer may choose to access the sharing
framework to find out if the related information has been updated.
Note: For example, when using XDS, a Content Consumer may choose to query the Document Registry about a
document whose sections were previously imported in order to find out if this previously imported document may have
been replaced or has received an addendum. This capability is offered to Content Consumers by this Integration Profile, but
not required, as the events that may justify such a query are extremely implementation specific.
750
This Option does not require, but does not exclude the Content Consumer from offering a means
to select and import specific subsets of the narrative text of a section.
3.1.4 Discrete Data Import Option
755
760
This Option does not require that the View, Import Document or Section Import Options be
supported. The Content Consumer that supports the Discrete Data Import Option shall be able to
support the storage of the structured content of one or more sections of the document. This
Option requires that the user be offered the possibility to select among the specific sections that
include structured content a set of clinically relevant record entries (e.g., a problem or an allergy
in a list) for import as part of the local patient record with the proper tracking of its origin.
Note: The Discrete Data Import Option does not require the support of the View, Import Document or Import Sections
Options so that it could be used alone to support implementations of Content Consumers such as Public Health Data or
Clinical Research systems that might aggregate and anonymize specific population healthcare information data as
Document Consumer Actors, but one where no care provider actually views the medical summaries.
When discrete data is accessed after it was imported, a Content Consumer may choose to check
if the document related to the discrete data viewed has been deprecated, replaced or addended.
765
A Content Consumer Actor grouped with the XDS Document Source Actor may query the
Document Registry about a document from which discrete data was previously imported in order
to find out if this previously imported document may have been replaced or has received an
addendum. This capability is offered to Content Consumers by this Integration Profile, but not
required, as the events that may justify such a query are extremely implementation specific.
770
4 IHE Patient Care Coordination Bindings
This section describes how the payload used in a transaction of an IHE profile is related to and/or
constrains the data elements sent or received in those transactions. This section is where any
specific dependencies between the content and transaction are defined.
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775
A content integration profile can define multiple bindings. Each binding should identify the
transactions and content to which it applies.
The source for all required and optional attributes have been defined in the bindings below.
Three tables describe the three main XDS object types: XDSDocumentEntry,
XDSSubmissionSet, and XDSFolder. XDSSubmissionSet and XDSDocumentEntry are required.
Use of XDSFolder is optional. These concepts are universal to XDS, XDR and XDM.
780
The columns of the following tables are:
•
<XXX> attribute – name of an XDS attribute, followed by any discussion of the binding
detail.
•
Optional? - Indicates the required status of the XDS attribute, and is one of R, R2, or O
(optional). This column is filled with the values specified in the XDS Profile as a
convenience.
•
Source Type – Will contain one of the following values:
785
Source Type
Description
SA
Source document Attribute – value is copied directly from source document. The Source/Value column
identifies where in the source document this attribute comes from. Specify the location in XPath when
possible.
SAT
Source document Attribute with Transformation – value is copied from source document and
transformed. The Source/Value column identifies where in the source document this attribute comes
from. Specify the location in XPath when possible. Extended Discussion column must not be empty
and the transform must be defined in the extended discussion
FM
Fixed (constant) by Mapping - for all source documents. Source/Value column contains the value to be
used in all documents.
FAD
Fixed by Affinity Domain – value configured into Affinity Domain, all documents will use this value.
CAD
Coded in Affinity Domain – a list of acceptable codes are to be configured into Affinity Domain. The
value for this attribute shall be taken from this list.
CADT
Coded in Affinity Domain with Transform - a list of acceptable codes are to be configured into
Affinity Domain. The value for this attribute shall be taken from this list.
n/a
Not Applicable – may be used with an optionality R2 or O attribute to indicate it is not to be used.
DS
Document Source – value comes from the Document Source Actor. Use Source/Value column or
Extended Discussion to give details.
O
Other – Extended Discussion must be 'yes' and details given in an Extended Discussion.
•
Source/Value – This column indicates the source or the value used.
790
The following tables are intended to be summaries of the mapping and transforms. The
accompanying sections labeled 'Extended Discussion' are to contain the details as necessary.
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4.1 Medical Document Binding to XDS, XDM and XDR
795
800
This binding defines a transformation that generates metadata for the XDSDocumentEntry and
XDSSubmissionSet elements of appropriate transactions from the XDS, XDM and XDR profiles
given a medical document and information from other sources. The medical document refers to
the document being stored in a repository that will be referenced in the registry. The other
sources of information include the configuration of the Document Source Actor, the XDS
Affinity Domain, the site or facility, local agreements, other documents in the registry/repository,
and this Content Profile.
In many cases, the CDA document is created for the purposes of sharing within an XDS Affinity
Domain. In these cases the context of the CDA and the context of the XDS Affinity Domain are
the same, in which case the following mappings shall apply.
805
In other cases, the CDA document may have been created for internal use, and are subsequently
being shared. In these cases the context of the CDA document would not necessarily coincide
with that of the XDS Affinity Domain, and the mappings below would not necessarily apply.
Please note the specifics given in the table below.
4.1.1 XDSDocumentEntry Metadata
XDSDocumentEntry
Attribute
Optional?
Source
Type
availabilityStatus
R
DS
authorInstitution
R2
SAT
Source/ Value
$inst <= /ClinicalDocument/author
/assignedAuthor
/representedOrganization
The authorInstitution can be formatted
using the following XPath expression, where
$inst in the expression below represents the
representedOrganization.
concat($inst/name)
authorPerson
R2
SAT
$person <= /ClinicalDocument/author
The author can be formatted using the following
XPath expression, where $person in the
expression below represents the author.
concat(
$person/id/@extension,"^",
$person/assignedPerson/name/family,"^",
$person/assignedPerson/name/given[1],"^",
$person/assignedPerson/name/given[2],"^",
$person/assignedPerson/name/suffix,"^",
$person/assignedPerson/name/prefix,"^",
"^^^&", $person/id/@root,"&ISO")
authorRole
R2
SAT
This metadata element should be based on a
mapping of the participation function defined in
the CDA document to the set of author roles
configured for the affinity domain. If the context
of the CDA coincides with that of the affinity
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XDSDocumentEntry
Attribute
Optional?
Source
Type
Source/ Value
domain, then the following x-path may be
appropriate:
/ClincicalDocument/author/
participationFunction
authorSpecialty
R2
SAT
This metadata element should be based on a
mapping of the code associated with the
assignedAuthor to detailed defined classification
system for healthcare providers such configured
in the affinity domain. Possible classifications
include those found in SNOMED-CT, or the
HIPAA Healthcare Provider Taxonomy. If the
context of the CDA coincides with that of the
affinity domain, then the following x-path may
be appropriate:
/ClinicalDocument/author/
assignedAuthor/code
classCode
R
CADT
Derived from a mapping of
/ClinicalDocument/code/@code to an Affinity
Domain specified coded value to use and coding
system. Affinity Domains are encouraged to use
the appropriate value for Type of Service, based
on the LOINC Type of Service (see Page 53 of
the LOINC User's Manual). Must be consistent
with /ClinicalDocument/code/@code
classCodeDisplayName
R
CADT
DisplayName of the classCode derived. Derived
from a mapping of
/ClinicalDocument/code/@code to the
appropriate Display Name based on the Type of
Service. Must be consistent with
/ClinicalDocument/code/@code
confidentialityCode
R
CADT
Derived from a mapping of
/ClinicalDocument/confidentialityCode/@code
to an Affinity Domain specified coded value and
coding system.
/ClinicalDocument/
confidentialityCode/@code
comments
O
DS
creationTime
R
SAT
/ClinicalDocument/effectiveTime
Times specified in clinical documents may be
specified with a precision in fractional sections,
and may contain a time zone offset. In the XDS
Metadata, it can be precise to the second, and is
always given in UTC, so the timezone offset if
present must be added to the current time to
obtain the UTC time.
entryUUID
R
DS
eventCodeList
O
CADT
These values express a collection of keywords
that may be relevant to the consumer of the
documents in the registry. They may come from
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XDSDocumentEntry
Attribute
Optional?
Source
Type
Source/ Value
anywhere in the CDA document, according to its
purpose.
eventCodeDisplayNameList
R
(if event
Code is
valued)
CADT
These are the display names for the collection of
keywords described above.
formatCode
R
FM
The format code for each PCC Document
content profile is provided within the document
specifications.
healthcareFacilityTypeCode
R
CAD
A fixed value assigned to the Document Source
and configured form a set of XDS Affinity
Domain defined values. Must be consistent with
/clinicalDocument/code
healthcareFacility
TypeCodeDisplay
Name
R
CAD
Must be consistent with /clinicalDocument/code
languageCode
R
SA
/ClinicalDocument/languageCode
legalAuthenticator
O
SAT
$person <= /ClinicalDocument/
legalAuthenticator
The legalAuthenticator can be formatted using
the following XPath expression, where $person
in the expression below represents the
legalAuthenticator.
concat(
$person/id/@extension,"^",
$person/assignedPerson/name/family,"^",
$person/assignedPerson/name/given[1],"^",
$person/assignedPerson/name/given[2],"^",
$person/assignedPerson/name/suffix,"^",
$person/assignedPerson/name/prefix,"^",
"^^^&", $person/id/@root,"&ISO")
mimeType
R
FM
text/xml
parentDocumentRelationship
R
(when
applicable)
DS
Local document versions need not always be
published, and so no exact mapping can be
determined from the content of the CDA
document.
The parentDocumentRelationship may be
determined in some configurations from the
relatedDocument element present in the CDA
document. If the context of the CDA coincides
with that of the affinity domain, then the
following x-path may be appropriate:
/ClinicalDocument/relatedDocument/@typeCode
parentDocumentId
R
(when
parent
Document
DS
Local document versions need not always be
published, and so no exact mapping can be
determined from the content of the CDA
document.
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XDSDocumentEntry
Attribute
Optional?
Source
Type
Relationship
is present)
Source/ Value
The parentDocumentId may be determined in
some configurations from the relatedDocument
element present in the CDA document. If the
context of the CDA coincides with that of the
affinity domain, then the following x-path may
be appropriate:
$docID <= /ClinicalDocument/
relatedDocument/parentDocument/id
The parentDocumentId can be formatted using
the following XPath expression, where $docID
in the expression below represents the identifier.
concat($docID/@root,"^", $docID/@extension)
patientId
R
DS
The XDS Affinity Domain patient ID can be
mapped from the patientRole/id element using
transactions from the ITI PIX or PDQ profiles.
See sourcePatientId below. If the context of the
CDA coincides with that of the affinity domain,
then the following x-path may be appropriate:
$patID <= /ClinicalDocument/recordTarget/
patientRole/id
practiceSettingCode
R
CAD
This element should be based on a coarse
classification system for the class of specialty
practice. Recommend the use of the
classification system for Practice Setting, such as
that described by the Subject Matter Domain in
LOINC.
practiceSettingCodeDisplayName
R
CAD
This element shall contain the display names
associated with the codes described above.
serviceStartTime
R2
SAT
/ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/low/
@value
Times specified in clinical documents may be
specified with a precision in fractional sections,
and may contain a time zone offset. In the XDS
Metadata, it can be precise to the second, and is
always given in UTC, so the timezone offset if
present must be added to the current time to
obtain the UTC time.
serviceStopTime
R2
SAT
/ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/high/
@value
Times specified in clinical documents may be
specified with a precision in fractional sections,
and may contain a time zone offset. In the XDS
Metadata, it can be precise to the second, and is
always given in UTC, so the timezone offset if
present must be added to the current time to
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XDSDocumentEntry
Attribute
Optional?
Source
Type
Source/ Value
obtain the UTC time.
sourcePatientId
R
SAT
$patID <= /ClinicalDocument/recordTarget/
patientRole/id
The patientId can be formatted using the
following XPath expression, where $patID in
the expression below represents the appropriate
identifier.
concat($patID/@extension,"^^^&",
$patID/@root, "&ISO")
sourcePatientInfo
R
SAT
/ClinicalDocument/recordTarget/
patientRole
The sourcePatientInfo metadata element can be
assembled from various components of the
patientRole element in the clinical document.
title
O
SA
/ClinicalDocument/title
typeCode
R
CADT
/ClinicalDocument/code/@code
The typeCode should be mapped from the
ClinicalDocument/code element to a set of
document type codes configured in the affinity
domain. One suggested coding system to use for
typeCode is LOINC, in which case the mapping
step can be omitted.
typeCodeDisplay
Name
R
CADT
/ClinicalDocument/code/@displayName
uniqueId
R
SAT
$docID <= /ClinicalDocument/id
The uniqueId can be formatted using the
following XPath expression, where $docID in
the expression below represents the identifier.
concat($docID/@root,"^", $docID/@extension)
810
4.1.1.1 XDSSubmissionSet Metadata
The submission set metadata is as defined for XDS, and is not necessarily affected by the content
of the clinical document. Metadata values in an XDSSubmissionSet with names identical to
those in the XDSDocumentEntry may be inherited from XDSDocumentEntry metadata, but this
is left to XDS Affinity Domain policy and/or application configuration.
815
For XDR and XDM the XDS Submission Set intendedRecipient attribute may be populated as
specified in the table below.
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XDSSubmissionSet
Attribute
Optional?
Source
Type
intendedRecipient
O
SAT
Source/ Value
$person <= /ClinicalDocument/intendedRecipient
and/or
$inst <=
/ClinicalDocument/intendedRecipient/receivedOrganization
The intendedRecipient can be formatted
using the following XPath expression, where $inst in the
expression below represents the receivedOrganization and
where $person in the expression below represents the
intendedRecipient.
concat(
$person/id/@extension,"^",
$person/informationRecipient/name/family,"^",
$person/informationRecipient/name/given[1],"^",
$person/informationRecipient/name/given[2],"^",
$person/informationRecipient/name/suffix,"^",
$person/informationRecipient/name/prefix,"^",
"^^^&", $person/id/@root,"&ISO",
"|"
$inst/name)
"^^^^^&",
$inst/id/@root, "&ISO", "^^^^", $inst/id/@extension)
-->
820
4.1.1.2 Use of XDS Submission Set
825
This content format uses the XDS Submission Set to create a package of information to send
from one provider to another. All documents referenced by the Medical Summary in this
Package must be in the submission set.
4.1.1.3 Use of XDS Folders
No specific requirements identified.
830
4.1.1.4 Configuration
IHE Content Profiles using this binding require that Content Creators and Content Consumers be
configurable with institution and other specific attributes or parameters. Implementers should be
aware of these requirements to make such attributes easily configurable. There shall be a
mechanism for the publishing and distribution of style sheets used to view clinical documents.
4.1.2 Extensions from other Domains
4.1.2.1 Scanned Documents (XDS-SD)
835
XDS-SD is a CDA R2 document and thus conforms to the XDS Metadata requirements in the
IHE PCC-TF-2:5 unless otherwise specified below.
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4.1.2.1.1 XDSDocumentEntry
XDS-SD leverages the XDS DocumentEntry Metadata requirements in the IHE PCC-TF2:5.1.1.1.1 and in PCC_TF-2/Bindings unless otherwise specified below.
840
4.1.2.1.1.1 XDSDocumentEntry.formatCode
The XDSDocumentEntry.formatCode shall be urn:ihe:iti:xds-sd:pdf:2008 when the document is
scanned pdf and urn:ihe:iti:xds-sd:text:2008 when the document is scanned text. The formatCode
codeSystem shall be 1.3.6.1.4.1.19376.1.2.3.
4.1.2.1.1.2 XDSDocumentEntry.uniqueId
845
This value shall be the ClinicalDocument/id in the HL7 CDA R2 header. The root attribute is
required, and the extension attribute is optional. In accordance with the XDS.a Profile, total
length is limited to 128 characters; for XDS.b the limit is 256 characters. Additionally see IHE
PCC TF-2:5.1.1.1.1 or PCC_TF-2/Bindings for further content specification.
4.1.2.1.1.3 Relating instances of XDS-SD documents
850
855
In general, most instances of XDS-SD will not have parent documents. It is possible, however, in
some specific use cases that instances of XDS-SD documents are related. For example, for a
particular document it may be the case that both the PDF scanned content and somewhat
equivalent plaintext need to be wrapped and submitted. Each document would correspond to
separate XDSDocumentEntries linked via an XFRM Association that indicates one document is
a transform of the other. These can be submitted in a single submission set, or in separate ones.
Other specific examples may exist and this profile does not preclude the notion of a parent
document for these cases.
4.1.2.1.2 XDSSubmissionSet
860
No additional constraints. Particular to this profile, a legitimate use of submission sets would be
to maintain a logical grouping of multiple XDS-SD documents. We encourage such usage. For
more information, see IHE PCC-TF-2:5.1.1.1.2 or PCC_TF-2/Bindings.
4.1.2.1.3 XDSFolder
No additional requirements. For more information, see IHE PCC-TF-2:5.1.1.1.3 or PCC_TF2/Bindings.
865
4.1.2.2 Basic Patient Privacy Consents (BPPC)
4.1.2.3 Laboratory Reports (XD-LAB)
XD-Lab is a CDA R2 document and thus conforms to the XDS Metadata requirements in the
IHE PCC-TF-2:5 unless otherwise specified below.
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4.1.2.3.1 XDSDocumentEntry
870
XD-Lab leverages the XDS DocumentEntry Metadata requirements in the IHE PCC-TF2:5.1.1.1.1 and in PCC_TF-2/Bindings unless otherwise specified below
4.1.2.3.1.1 XDSDocumentEntry.eventCodeList
XD-Lab documents further constrain the XDSDocumentEntry.eventCodeList to the following.
XDSDocumentEntry
Attribute
eventCodeList
Optional?
Source
Type
R2
SAT
Source/ Value
ClinicalDocument / component / structuredBody / component / section / entry /
act / entryRelationship / organizer (templateId="1.3.6.1.4.1.19376.1.3.1.1")/
component / observation(templateId="1.3.6.1.4.1.19376.1.3.1.1.1")/code
AND
ClinicalDocument / component / structuredBody / component / section / entry /
act / subject / code
If the document has Reportable Condition, then this code shall be among those
listed in the eventCodeList. Additionally, if the document contains information
about a Non-Human Subject, then the code that indicates what this subject is
shall be among those listed in the eventCodeList. Thus, this attribute has been
enhanced from the XDS Profile from O to R2.
875
4.1.2.3.1.2 XDSDocumentEntry.formatCode
The XDSDocumentEntry.formatCode shall be urn:ihe:lab:xd-lab:2008. The formatCode
codeSystem shall be 1.3.6.1.4.1.19376.1.2.3.
4.1.2.3.2 XDSSubmissionSet
880
No additional constraints. For more information, see IHE PCC TF-2:5.1.1.1.2 or PCC_TF2/Bindings.
4.1.2.3.3 XDSFolder
No additional requirements. For more information, see IHE PCC TF-2:5.1.1.1.3 or PCC_TF2/Bindings.
885
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5 Namespaces and Vocabularies
This section lists the namespaces and identifiers defined or referenced by the IHE PCC Technical
Framework, and the vocabularies defined or referenced herein.
890
The following vocabularies are referenced in this document. An extensive list of registered
vocabularies can be found at http://hl7.amg-hq.net/oid/frames.cfm.
codeSystem
codeSystemName
Description
1.3.6.1.4.1.19376.1.5.3.1
IHE PCC Template
Identifiers
This is the root OID for all IHE PCC Templates. A list of
PCC templates can be found below in CDA Release 2.0
Content Modules.
1.3.6.1.4.1.19376.1.5.3.2
IHEActCode
See IHEActCode Vocabulary below
1.3.6.1.4.1.19376.1.5.3.3
IHE PCC RoleCode
See IHERoleCode Vocabulary below
1.3.6.1.4.1.19376.1.5.3.4
Namespace OID used for IHE Extensions to CDA Release
2.0
2.16.840.1.113883.10.20.
1
CCD Root OID
Root OID used for by ASTM/HL7 Continuity of Care
Document
2.16.840.1.113883.5.112
RouteOfAdministration
See the HL7 RouteOfAdministration Vocabulary
2.16.840.1.113883.5.1063
SeverityObservation
See the HL7 SeverityObservation Vocabulary
2.16.840.1.113883.6.1
LOINC
Logical Observation Identifier Names and Codes
2.16.840.1.113883.6.96
SNOMED-CT
SNOMED Controlled Terminology
2.16.840.1.113883.6.103
ICD-9CM (diagnosis codes)
International Classification of Diseases, Clinical Modifiers,
Version 9
2.16.840.1.113883.6.104
ICD-9CM (procedure codes)
International Classification of Diseases, Clinical Modifiers,
Version 9
2.16.840.1.113883.6.26
MEDCIN
A classification system from MEDICOMP Systems.
2.16.840.1.113883.6.88
RxNorm
RxNorm
2.16.840.1.113883.6.63
FDDC
First DataBank Drug Codes
2.16.840.1.113883.6.12
C4
Current Procedure Terminology 4 (CPT-4) codes.
2.16.840.1.113883.6.257
Minimum Data Set for Long
Term Care
The root OID for Minimum Data Set Answer Lists
5.1.1 IHE Format Codes
895
The table below lists the format codes, template identifiers and media types used by the IHE
Profiles specified in the PCC Technical Framework, and also lists, for reference purposes the
same values for other selected IHE Profiles from other committees.
Note that the code system for these codes is 1.3.6.1.4.1.19376.1.2.3 as assigned by the ITI
Domain for codes used for the purposes of cross-enterprise document sharing (XDS). For more
information see XDS Coding System (1.3.6.1.4.1.19376.1.2.3).
900
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Profile
Format Code
Media
Type
Template ID
2006 Profiles
Medical Summaries (XDSMS)
urn:ihe:pcc:xds-ms:2007
text/xml
1.3.6.1.4.1.19376.1.5.3.1.1.3 (Referral)
1.3.6.1.4.1.19376.1.5.3.1.1.4 (Discharge
Summary)
2007 Profiles
Exchange of Personal Health
Records (XPHR)
urn:ihe:pcc:xphr:2007
text/xml
1.3.6.1.4.1.19376.1.5.3.1.1.5 (Extract)
1.3.6.1.4.1.19376.1.5.3.1.1.6 (Update)
Emergency Department
Referral (EDR)
urn:ihe:pcc:edr:2007
text/xml
1.3.6.1.4.1.19376.1.5.3.1.1.10
Antepartum Summary (APS)
urn:ihe:pcc:aps:2007
text/xml
1.3.6.1.4.1.19376.1.5.3.1.1.11.2
Emergency Department
Encounter Summary (EDES)
urn:ihe:pcc:edes:2007
text/xml
1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 (Triage
Note)
1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2 (Nursing
Note)
1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
(Composite Triage and Nursing Note)
1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
(Physician Note)
Antepartum Record (APR) History and Physical
urn:ihe:pcc:apr:handp:2008
text/xml
1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1
(Antepartum History and Physical)
Antepartum Record (APR) Laboratory
urn:ihe:pcc:apr:lab:2008
text/xml
1.3.6.1.4.1.19376.1.5.3.1.1.16.1.2
(Antepartum Laboratory)
Antepartum Record (APR) Education
urn:ihe:pcc:apr:edu:2008
text/xml
1.3.6.1.4.1.19376.1.5.3.1.1.16.1.3
(Antepartum Education)
Immunization Content (IC)
urn:ihe:pcc:ic:2008
text/xml
1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2
(Immunization Detail)
Cancer Registry Content
(CRC)
urn:ihe:pcc:crc:2008
text/xml
Care Management (CM)
urn:ihe:pcc:cm:2008
text/xml
2008 Profiles
2009 Profiles
ITI Profiles
Scanned Documents (PDF)
urn:ihe:iti:xds-sd:pdf:2008
text/xml
1.3.6.1.4.1.19376.1.2.20 (Scanned
Document)
Scanned Documents (text)
urn:ihe:iti:xds-sd:text:2008
text/xml
1.3.6.1.4.1.19376.1.2.20 (Scanned
Document)
Basic Patient Privacy
Consents
urn:ihe:iti:bppc:2007
text/xml
1.3.6.1.4.1.19376.1.5.3.1.1.7 (BPPC with
no scanned part)
Basic Patient Privacy
Consents with Scanned
Document
urn:ihe:iti:bppc-sd:2007
text/xml
1.3.6.1.4.1.19376.1.5.3.1.1.7.1 (BPPC with
scanned part)
LAB Profiles
CDA Laboratory Report
urn:ihe:lab:xd-lab:2008
text/xml
1.3.6.1.4.1.19376.1.3.3 (Laboratory Report)
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HL7 Implementation Guides
HL7 Implementation Guides
for CDA Release 2: IHE
Health Story Consolidation,
DSTU Release 1.1 - US
Realm (C-CDA)
urn:hl7-org:sdwg:ccdastructuredBody:1.1
text/xml
urn:hl7-org:sdwg:ccdanonXMLBody:1.1
text/xml
See the HL7 Guide at
http://www.hl7.org/dstucomments
/showdetail.cfm?dstuid=82 for template
identifiers 1.
5.1.2 IHEActCode Vocabulary
905
CCD
ASTM/HL7 Continuity of Care Document
CCR
ASTM CCR Implementation Guide
The IHEActCode vocabulary is a small vocabulary of clinical acts that are not presently
supported by the HL7 ActCode vocabulary. The root namespace (OID) for this vocabulary is
1.3.6.1.4.1.19376.1.5.3.2. These vocabulary terms are based on the vocabulary and concepts used
in the CCR and CCD standards listed above.
Code
1
Description
COMMENT
This is the act of commenting on another act.
PINSTRUCT
This is the act of providing instructions to a patient regarding the use of medication.
FINSTRUCT
This is the act of providing instructions to the supplier regarding the fulfillment of the medication order.
IMMUNIZ
The act of immunization of a patient using a particular substance or class of substances identified using a
specified vocabulary. Use of this vocabulary term requires the use of either the SUBSTANCE or
SUBSTCLASS qualifier described below, along with an identified substance or class of substances.
DRUG
The act of treating a patient with a particular substance or class of substances identified using a specified
vocabulary. Use of this vocabulary term requires the use of either the SUBSTANCE or SUBSTCLASS
qualifier described below, along with an identified substance or class of substances.
INTOL
An observation that a patient is somehow intolerant of (e.g., allergic to) a particular substance or class of
substances using a specified vocabulary. Use of this vocabulary term requires the use of either the
SUBSTANCE or SUBSTCLASS qualifier described below, along with an identified substance or class of
substances.
SPRECEIVE
The action taken by a clinical laboratory staff to receive incoming specimens and check the usability of
those specimens in the context of a laboratory test order.
SUBSTANCE
A qualifier that identifies the substance used to treat a patient in an immunization or drug treatment act.
The substance is expected to be identified using a vocabulary such as RxNORM, SNOMED CT or other
See http://wiki.hl7.org/index.php?title=CDA_Format_Codes_for_IHE_XDS for more details.
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similar vocabulary and should be specific enough to identify the ingredients of the substance used.
SUBSTCLASS
910
A qualifier that identifies the class of substance used to treat a patient in an immunization or drug treatment
act. The class of substances is expected to be identified using a vocabulary such as NDF-RT, SNOMED
CT or other similar vocabulary, and should be broad enough to classify substances by mechanism of action
(e.g., Beta Blocker), intended effect (Diuretic, antibiotic) or ...
5.1.3 IHERoleCode Vocabulary
The IHERoleCode vocabulary is a small vocabulary of role codes that are not presently
supported by the HL7 Role Code vocabulary. The root namespace (OID) for this vocabulary is
1.3.6.1.4.1.19376.1.5.3.3.
Code
915
Description
EMPLOYER
The employer of a person.
SCHOOL
The school in which a person is enrolled.
AFFILIATED
An organization with which a person is affiliated (e.g., a volunteer organization).
PHARMACY
The pharmacy a person uses.
6 PCC Content Modules
6.1 Conventions
Various tables used in this section will further constrain the content. Within this volume, the
follow conventions are used.
R
920
A "Required" data element is one that shall always be provided. If there is information
available, the data element must be present. If there is no information available, or it cannot
be transmitted, the data element must contain a value indicating the reason for omission of
the data. (See IHE PCC TF-2:5.3.4.2 for a list of appropriate statements).
R2
925
A "Required if data present" data element is one that shall be provided when a value exists. If
the information cannot be transmitted, the data element shall contain a value indicating the
reason for omission of the data. If no such information is available to the creator or if such
information is not available in a well identified manner (e.g., buried in a free form narrative
that contains additional information relevant to other sections) or if the creator requires that
information be absent, the R2 section shall be entirely absent. (See section IHE PCC TF2:5.3.4.2 for a list of appropriate statements).
930
O
935
An optional data element is one that may be provided, irrespective of whether the
information is available or not. If the implementation elects to support this optional section,
then its support shall meet the requirement set forth for the "Required if data present" or R2.
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C
A conditional data element is one that is required, required if known or optional depending
upon other conditions. These will have further notes explaining when the data element is
required, et cetera.
940
Note: The definitions of R, R2, and O differ slightly from other IHE profiles. This is due in part
to the fact that local regulations and policies may in fact prohibit the transmission of
certain information, and that a human decision to transmit the information may be
required in many cases.
6.2 Folder Content Modules
945
This section contains modules that describe the content requirements of Folders used with XDS,
XDM or XDR. When workflows are completed normally, the folders will contain documents
with the optionality specified in the tables shown below. Under certain circumstances, the folders
will not meet the optionality requirements described below, for example, when the patient leaves
before treatment is completed.
950
6.2.1 EDES Folder Specification
This section intentionally left blank.
6.2.2 APR Folder Specification
This section intentionally left blank.
6.2.3 LDR Folder Specification
955
This section intentionally left blank.
6.3 HL7 Version 3.0 Content Modules
This section contains content modules based upon the HL7 CDA Release 2.0 Standard, and
related standards and/or implementation guides.
6.3.1 CDA Document Content Modules
960
6.3.1.1 Medical Documents Specification 1.3.6.1.4.1.19376.1.5.3.1.1.1
This section defines the base set of constraints used by almost all medical document profiles
described the PCC Technical Framework.
6.3.1.1.1 Standards
CDAR2
HL7 CDA Release 2.0
CDTHP
CDA for Common Document Types History and Physical Notes (DSTU)
XMLXSL Associating Style Sheets with XML documents
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6.3.1.1.2 Conformance
965
970
975
980
CDA Release 2.0 documents that conform to the requirements of this content module shall
indicate their conformance by the inclusion of the appropriate <templateId> elements in the
header of the document. This is shown in the sample document below.
<ClinicalDocument xmlns='urn:hl7-org:v3'>
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
<id root=' ' extension=' '/>
<code code=' ' displayName=' '
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<title>Medical Documents</title>
<effectiveTime value='20081004012005'/>
<confidentialityCode code='N' displayName='Normal'
codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
<languageCode code='en-US'/>
:
<component><structuredBody>
</structuredBody></component>
</ClinicalDocument>
Figure 6.3.1.1.2-1: Sample Medical Documents Document
985
990
<!-- Verify the document type code -->
<assert test='cda:code[@code = "{{{LOINC}}}"]'>
Error: The document type code of a Medical Documents must be {{{LOINC}}}
</assert>
<assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
Error: The document type code must come from the LOINC code
system (2.16.840.1.113883.6.1).
</assert>
6.3.1.1.3 Specification
995
The constraints for encoding of the CDA Header (Level 1) can be found in the CDA for
Common Document Types History and Physical Implementation Guide, in the section 2. CDA
Header -- General Constraints.
1000
•
IHE Medical Documents SHALL follow all constraints found in that section with the
exception of the constraint on realmcode found in CONF-HP-15:.
•
IHE Medical Documents which are implemented for the US Realm SHALL follow ALL
constraints found in that section, and SHALL use both the IHE Medical Document
templateId (1.3.6.1.4.1.19376.1.5.3.1.1.1) and the HL7 General Header Constraints
templateId (2.16.840.1.113883.10.20.3).}}
Realm
Constraints
Template IDs Required
Universal
CONF-HP-1 through CONF-HP-14
CONF-HP-16 through CONF-HP-40
1.3.6.1.4.1.19376.1.5.3.1.1.1
US
CONF-HP-1 through CONF-HP-40
1.3.6.1.4.1.19376.1.5.3.1.1.1
2.16.840.1.113883.10.20.3
1005
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6.3.1.1.4 Style Sheets
1010
1015
Document sources SHOULD provide an XML style sheet to render the content of the Medical
Summary document. The output of this style sheet SHALL be an XHTML Basic (see
http://www.w3.org/TR/xhtml-basic/) document that renders the clinical content of a Medical
Summary Document as closely as possible as the sending provider viewed the completed
document. When a style sheet is provided, at least one processing instruction SHALL be included
in the document that including a link to the URL for the XML style sheet. To ensure that the
style sheet is available to all receivers, more than one stylesheet link MAY be included.
When a stylesheet is used within an XDS Affinity domain, the link to it SHALL be provided using
an HTTPS or HTTP URL.
<?xml-stylesheet href='https://foobar:8080/mystylesheet.xsl' type='text/xsl'?>
1020
When using XDM or XDR to exchange documents, the stylesheet SHALL also be exchanged on
the media. The link to the stylesheet SHALL be recorded as a relative URL.
<?xml-stylesheet href='../../stylesheets/mystylesheet.xsl' type='text/xsl'?>
1025
Style sheets SHOULD NOT rely on graphic or other media resources. If graphics other media
resources are used, these SHALL be accessible in the same way as the stylesheet. The Content
Creator NEED NOT be the provider of the resources (stylesheet or graphics).
When a Content Creator provides a style sheet, Content Consumers MUST provide a mechanism
to render the document with that style sheet. Content Consumers MAY view the document with
their own style sheet.
1030
1035
To record the stylesheet within a CDA Document that might be used in both an XDS and XDM
environment, more than one stylesheet processing instruction is required. In this case, all style
sheet processing instructions included MUST include the alternate='yes' attribute.
<?xml-stylesheet href='https://foobar:8080/mystylesheet.xsl' type='text/xsl' alternate='yes'?>
<?xml-stylesheet href='../../stylesheets/mystylesheet.xsl' type='text/xsl' alternate='yes'?>
A Content Consumer that is attempting to render a document using the document supplied
stylesheet MAY use the first style sheet processing instruction for which it is able to obtain the
style sheet content, and SHALL NOT report any errors if it is able to find at least one stylesheet to
render with.
1040
6.3.1.1.5 Distinctions of None
Information that is sent MUST clearly identify distinctions between
None
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1045
It is known with complete confidence that there are none. Used in the context of problem
and medication lists, this indicates that the sender knows that there is no relevant
information that can be sent.
None Known
1050
None are known at this time, but it is not known with complete confidence than none
exist. Used in the context of allergy lists, where essentially, it is impossible to prove the
negative that no allergies exist, it is only possible to assert that none have been found to
date.
None Known Did Ask
1055
None are known at this time, and it is not known with complete confidence than none
exist, but the information was requested. Also used in the context of allergy lists, where
essentially, it is impossible to prove the negative that no allergies exist, it is only possible
to assert that none have been found to date.
Unknown
The information is not known, or is otherwise unavailable.
In the context of CDA, sections that are required to be present but have no information should
use one of the above phrases where appropriate.
1060
An appropriate machine readable entry shall be present for problems, medications and allergies
to indicate the reason for no information. Codes for recording unknown or no information are
provided in the section on the Problem, Allergy and Medications Entry.
6.3.1.2 Medical Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.2
1065
A medical summary contains a snapshot of the patient's medical information, including at the
very least, a list of the patients problems, medications and allergies. A Medical Summary is an
abstract template that is expected to be further refined by additional document templates.
6.3.1.2.1 Parent Template
This document is an instance of the Medical Document template.
6.3.1.2.2 Standards
CDAR2 HL7 CDA Release 2.0
1070
6.3.1.2.3 Specification
Table 6.3.1.2.3-1: Medical Summary Data Elements
Data Element Name
Opt
Template ID
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Problem Concern Entry
R
1.3.6.1.4.1.19376.1.5.3.1.4.5.2
Allergy Concern Entry
R
1.3.6.1.4.1.19376.1.5.3.1.4.5.3
Medications
R
1.3.6.1.4.1.19376.1.5.3.1.4.7
Payers
O
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7
6.3.1.2.4 Conformance
1075
1080
1085
1090
1095
CDA Release 2.0 documents that conform to the requirements of this content module shall
indicate their conformance by the inclusion of the appropriate <templateId> elements in the
header of the document. This is shown in the sample document below. A CDA Document may
conform to more than one template. This content module inherits from the Medical Document
content module, and so must conform to the requirements of that template as well, thus all
<templateId> elements shown in the example below shall be included.
<ClinicalDocument xmlns='urn:hl7-org:v3'>
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
<id root=' ' extension=' '/>
<code code=' ' displayName=' '
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<title>Medical Summary</title>
<effectiveTime value='20081004012005'/>
<confidentialityCode code='N' displayName='Normal'
codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
<languageCode code='en-US'/>
:
<component><structuredBody>
</structuredBody></component>
</ClinicalDocument>
Figure 6.3.1.2.4-1: Sample Medical Summary Document
1100
6.3.1.2.5 Document Specification
A medical summary is a type of medical document, and incorporates the constraints defined for
Medical Documents, and requires the recording of Problems, Allergies and Medications. It also
allows for the recording of the payers via the Payers Section.
6.3.1.3 Referral Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.3
1105
1110
The use case is described fully in IHE PCC TF-1:3.2.1 for the Ambulatory Specialist Referral.
Briefly, it involves a "collaborative" transfer of care for the referral of a patient from a primary
care provider (PCP) to a specialist. The important document data elements identified by
physicians and nurses for this use case are listed in the table below under the column "Data
Elements". These were then mapped to the categories given HL7 Care Record Summary
Implementation Guide, and HL7 CDA Release 2.0. These mappings are provided in the next two
columns.
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A referral summary is a type of Medical Summary, and incorporates the constraints defined for a
Medical Summary above. This section defines additional constraints for Medical Summary
Content used in a Referral summary. These tables present the Categories, as defined in Section 3
of CRS. In no case are these IHE requirements less strict than those defined by CRS.
6.3.1.3.1 Format Code
The XDSDocumentEntry format code for this content is urn:ihe:pcc:xds-ms:2007
6.3.1.3.2 Parent Template
This document is an instance of the Medical Summary template.
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6.3.1.3.3 Standards
CDAR2 HL7 CDA Release 2.0
CRS
HL7 Care Record Summary
CCD
ASTM/HL7 Continuity of Care Document
6.3.1.3.4 Data Element Index
Data Elements
HL7 Care Record
Summary
CDA Release 2.0
Reason for Referral
Reason for Referral
REASON FOR REFERRAL
History Present Illness
History of Present
Illness
HISTORY OF PRESENT ILLNESS
Active Problems
Conditions
PROBLEM LIST
Current Meds
Medications
HISTORY OF MEDICATION USE
Allergies
Allergies and Adverse
Reactions
HISTORY OF ALLERGIES
History of Past Illness
Conditions
HISTORY OF PAST ILLNESS
List of Surgeries
Past Surgical History
HISTORY OF PRIOR SURGERIES
Immunizations
Immunizations
HISTORY OF IMMUNIZATIONS
Family History
Family History
HISTORY OF FAMILY ILLNESS
Social History
Social History
SOCIAL HISTORY
Pertinent Review of Systems
Review of Systems
REVIEW OF SYSTEMS
Vital Signs
Physical Exam
VITAL SIGNS
Physical Exam
Physical Exam
GENERAL STATUS, PHYSICAL FINDINGS
Relevant Diagnostic Surgical Procedures /
Clinical Reports (including links)
Studies and Reports
RELEVANT DIAGNOSTIC TESTS AND/OR
LABORATORY DATA
Relevant Diagnostic Test and Reports (Lab,
Imaging, EKG's, etc.) including links.
Studies and Reports
RELEVANT DIAGNOSTIC TESTS AND/OR
LABORATORY DATA
Plan of Care (new meds labs, or x-rays
ordered)
Care Plan
TREATMENT PLAN
Advance Directives
Advance Directives
ADVANCE DIRECTIVES
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Patient Administrative Identifiers
Header
patientRole/id
Pertinent Insurance Information
Participant
participant[@classCode='HLD']
Data needed for state and local referral
forms, if different than above
Optional Sections
section
6.3.1.3.5 Specification
1125
Table 6.3.1.3.5-1: Referral Summary Data Elements
Data Element Name
Opt
Template ID
Reason for Referral
R
1.3.6.1.4.1.19376.1.5.3.1.3.1
History Present Illness
R
1.3.6.1.4.1.19376.1.5.3.1.3.4
Active Problems
R
1.3.6.1.4.1.19376.1.5.3.1.3.6
Current Meds
R
1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies
R
1.3.6.1.4.1.19376.1.5.3.1.3.13
History of Past Illness
R2
1.3.6.1.4.1.19376.1.5.3.1.3.8
List of Surgeries
R2
1.3.6.1.4.1.19376.1.5.3.1.3.11
Immunizations
R2
1.3.6.1.4.1.19376.1.5.3.1.3.23
Family History
R2
1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History
R2
1.3.6.1.4.1.19376.1.5.3.1.3.16
Pertinent Review of Systems
O
1.3.6.1.4.1.19376.1.5.3.1.3.18
Vital Signs
R2
1.3.6.1.4.1.19376.1.5.3.1.3.25
Physical Examination
R2
1.3.6.1.4.1.19376.1.5.3.1.3.24
Relevant Diagnostic Surgical Procedures / Clinical
Reports and Relevant Diagnostic Test and Reports
(Lab, Imaging, EKG's, etc.) including links.
R2
1.3.6.1.4.1.19376.1.5.3.1.3.27
Plan of Care (new meds, labs, or x-rays ordered)
R2
1.3.6.1.4.1.19376.1.5.3.1.3.31
Advance Directives
R2
1.3.6.1.4.1.19376.1.5.3.1.3.34
Patient Administrative Identifiers
Handled by the Medical Documents Content Profile by
reference to constraints in HL7 CRS.
R
Pertinent Insurance Information
Refer to Appropriate Payers Section -- TBD
R2
Data needed for state and local referral forms, if
different than above
These are handed by including additional sections within
the summary.
R2
6.3.1.3.6 Conformance
CDA Release 2.0 documents that conform to the requirements of this content module shall
indicate their conformance by the inclusion of the appropriate <templateId> elements in the
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header of the document. This is shown in the sample document below. A CDA Document may
conform to more than one template. This content module inherits from the Medical Summary
content module, and so must conform to the requirements of that template as well, thus all
<templateId> elements shown in the example below shall be included.
<ClinicalDocument xmlns='urn:hl7-org:v3'>
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.3'/>
<id root=' ' extension=' '/>
<code code=' ' displayName=' '
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<title>Referral Summary</title>
<effectiveTime value='20081004012005'/>
<confidentialityCode code='N' displayName='Normal'
codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
<languageCode code='en-US'/>
:
<component><structuredBody>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
<!-- Required Reason for Referral Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
<!-- Required History Present Illness Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
<!-- Required Active Problems Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
<!-- Required Current Meds Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
<!-- Required Allergies Section content -->
</section>
</component>
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<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
<!-- Required if known History of Past Illness Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
<!-- Required if known List of Surgeries Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
<!-- Required if known Immunizations Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/>
<!-- Required if known Family History Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/>
<!-- Required if known Social History Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
<!-- Optional Pertinent Review of Systems Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
<!-- Required if known Vital Signs Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
<!-- Required if known Physical Examination Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.27'/>
<!-- Required if known Relevant Diagnostic Surgical Procedures / Clinical Reports and
Relevant Diagnostic Test and Reports Section content -->
</section>
</component>
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<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
<!-- Required if known Plan of Care (new meds, labs, or x-rays ordered) Section content -
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->
</section>
</component>
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<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
<!-- Required if known Advance Directives Section content -->
</section>
</component>
</structuredBody></component>
</ClinicalDocument>
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Figure 6.3.1.3.6-1: Sample Referral Summary Document
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6.3.1.4 Discharge Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.4
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This use case is described fully in the XDS-MS Profile found in IHE PCC TF-1:3.2.2. Briefly, it
involves an episodic transfer of care in the form of a patient discharge from a hospital to home.
The important data elements identified by physicians and nurses for this use case are listed in the
table below under the column "Data Elements". These are mapped to the categories given HL7
Care Record Summary Implementation Guide, and HL7 CDA Release 2.0 in the next two
columns.
A discharge summary is a type of medical summary, and incorporates the constraints defined for
Medical Summaries.
This section defines additional constraints for Medical Summary Content used in a Discharge
Summary. These tables present the data elements described above, along with their optionality,
and references to the section and template where these sections or header data elements are
further defined.
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In no case are these IHE requirements less strict than those defined by the HL7 Care Record
Summary.
6.3.1.4.1 Format Code
The XDSDocumentEntry format code for this content is urn:ihe:pcc:xds-ms:2007
6.3.1.4.2 Parent Template
1285
This document is an instance of the Medical Summary template.
6.3.1.4.3 Standards
CDAR2 HL7 CDA Release 2.0
CRS
HL7 Care Record Summary
CCD
ASTM/HL7 Continuity of Care Document
6.3.1.4.4 Data Element Index
Data Elements
Date of Admission
HL7 Care Record
Summary
Header
CDA Release 2.0
encompassingEncounter/effectiveTime
Date of Discharge
Header
encompassingEncounter/effectiveTime
Participating Providers and Roles
Header
documentationOf/serviceEvent/performer
Discharge Disposition (who, how, where)
Care Plan
DISCHARGE DISPOSITION
Admitting Diagnosis
Conditions
HOSPITAL ADMISSION DX
History of Present Illness
History of Present Illness
HISTORY OF PRESENT ILLNESS
Hospital Course
Hospital Course
HOSPITAL COURSE
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Data Elements
HL7 Care Record
Summary
CDA Release 2.0
Discharge Diagnosis (including active and
resolved problems)
Conditions
HOSPITAL DISCHARGE DX
Selected Medicine Administered during
Hospitalization
Medications
HISTORY OF MEDICATION USE
Discharge Medications
Medications
HOSPITAL DISCHARGE
MEDICATIONS
Allergies and adverse reactions
Allergies and Adverse
Reactions
HISTORY OF ALLERGIES
Discharge Diet
Optionally found in Care
Plan
DISCHARGE DIET
Review of Systems
Review of Systems
REVIEW OF SYSTEMS
Vital Signs (most recent, high/low/average)
Physical Exam
VITAL SIGNS
Functional Status
Functional Status
HISTORY OF FUNCTIONAL STATUS
Relevant Procedures and Reports (including
links)
Studies and Reports
HOSPITAL DISCHARGE STUDIES
Relevant Diagnostic Tests and Reports
(including links)
Studies and Reports
HOSPITAL DISCHARGE STUDIES
Plan of Care
Care Plan
TREATMENT PLAN
Administrative Identifiers
Header
patient/id
Pertinent Insurance Information
Header
participant[@classCode='HLD']
6.3.1.4.5 Specification
1290
Table 6.3.1.4.5-1: Discharge Summary Specification
Data Element Name
Opt
Template ID
Active Problems
R
1.3.6.1.4.1.19376.1.5.3.1.3.6
Resolved Problems
R
1.3.6.1.4.1.19376.1.5.3.1.3.8
Discharge Diagnosis
R
1.3.6.1.4.1.19376.1.5.3.1.3.7
Admitting Diagnosis
R
1.3.6.1.4.1.19376.1.5.3.1.3.3
Selected Meds Administered
R2
1.3.6.1.4.1.19376.1.5.3.1.3.2
1
Discharge Meds
R
1.3.6.1.4.1.19376.1.5.3.1.3.2
2
Admission Medications
R2
1.3.6.1.4.1.19376.1.5.3.1.3.2
0
Allergies
R
1.3.6.1.4.1.19376.1.5.3.1.3.1
3
Hospital Course
R
1.3.6.1.4.1.19376.1.5.3.1.3.5
Advance Directives
O
1.3.6.1.4.1.19376.1.5.3.1.3.3
4
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Data Element Name
Opt
Template ID
History of Present Illness
R2
1.3.6.1.4.1.19376.1.5.3.1.3.4
Functional Status
O
1.3.6.1.4.1.19376.1.5.3.1.3.1
7
Review of Systems
O
1.3.6.1.4.1.19376.1.5.3.1.3.1
8
Physical Examination
O
1.3.6.1.4.1.19376.1.5.3.1.3.2
4
Vital Signs
O
1.3.6.1.4.1.19376.1.5.3.1.3.2
5
Discharge Procedures Tests, Reports
O
1.3.6.1.4.1.19376.1.5.3.1.3.2
9
Plan of Care
R
1.3.6.1.4.1.19376.1.5.3.1.3.3
1
Discharge Diet
O
1.3.6.1.4.1.19376.1.5.3.1.3.3
3
6.3.1.4.6 Conformance
1295
CDA Release 2.0 documents that conform to the requirements of this content module shall
indicate their conformance by the inclusion of the appropriate <templateId> elements in the
header of the document. This is shown in the sample document below. A CDA Document may
conform to more than one template. This content module inherits from the Medical Summary
content module, and so must conform to the requirements of that template as well, thus all
<templateId> elements shown in the example below shall be included.
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<ClinicalDocument xmlns='urn:hl7-org:v3'>
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.4'/>
<id root=' ' extension=' '/>
<code code=' ' displayName=' '
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<title>Discharge Summary</title>
<effectiveTime value='20081004012005'/>
<confidentialityCode code='N' displayName='Normal'
codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
<languageCode code='en-US'/>
:
<component><structuredBody>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
<!-- Required Active Problems Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
<!-- Required Resolved Problems Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.7'/>
<!-- Required Discharge Diagnosis Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.3'/>
<!-- Required Admitting Diagnosis Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/>
<!-- Required if known Selected Meds Administered Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.22'/>
<!-- Required Discharge Meds Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.20'/>
<!-- Required if known Admission Medications Section content -->
</section>
</component>
<component>
<section>
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<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
<!-- Required Allergies Section content -->
</section>
</component>
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<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.5'/>
<!-- Required Hospital Course Section content -->
</section>
</component>
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1420
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<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
<!-- Optional Advance Directives Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
<!-- Required if known History of Present Illness Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/>
<!-- Optional Functional Status Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
<!-- Optional Review of Systems Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
<!-- Optional Physical Examination Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
<!-- Optional Vital Signs Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.29'/>
<!-- Optional Discharge Procedures Tests, Reports Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
<!-- Required Plan of Care Section content -->
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</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.33'/>
<!-- Optional Discharge Diet Section content -->
</section>
</component>
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</structuredBody></component>
</ClinicalDocument>
Figure 6.3.1.4.6-1: Sample Discharge Summary Document
6.3.1.5 PHR Extract Specification 1.3.6.1.4.1.19376.1.5.3.1.1.5
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The PHR Extract module describes the document content that summarizes information contained
within a Personal Health Record. While a PHR can contain a great deal more information
(including clinical documents, lab reported, images, trend data, monitoring data) et cetera, this
content module only deals with the format of the summary information from the PHR.
A PHR Extract Module is a type of medical summary, and incorporates the constraints defined
for Medical Summaries. While mappings have been provided to various standards, this content
module conforms to the ASTM/HL7 Continuity of Care Document as well as this guide.
The following table describes the data elements that may be present in a PHR Extract. The first
column of this table is drawn from the Common Data Elements in the PHR found in Appendix B
of the AHIMA Report: The Role of the Personal Health Record in the EHR. Indented items in
this column of the table provide more detail for the item they appear underneath.
These data elements were then mapped to the ASTM CCR, HL7 CDA, CRS and CCD and the
implicit data elements referenced by the HL7 PHR Conformance Criteria.
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A further requirement of transfers of information between PHR and EHR systems is that
authorship of the information stored within the PHR shall be traceable through the various
import/export cycles. PHR Manager Actors must be secure nodes or secure applications, which
requires logging of any updates to or accesses of PHR information. The DSG Profile should be
used to ensure that information coming into, or exiting these systems is verifiably authored.
6.3.1.5.1 Format Code
The XDSDocumentEntry format code for this content is urn:ihe:pcc:xphr:2007
1465
6.3.1.5.2 Parent Template
This document is an instance of the Medical Summary template.
6.3.1.5.3 LOINC Code
The LOINC code for this document is 34133-9 Summary of Episode Note
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6.3.1.5.4 Standards
AHIMA-PHR
AHIMA PHR Common Data Elements
CDAR2
HL7 CDA Release 2.0
CRS
HL7 Care Record Summary
CCD
ASTM/HL7 Continuity of Care Document
HL7-PHR
HL7 PHR Functional Model (Draft)
LOINC
Logical Observation Identifier Names and Codes
1470
6.3.1.5.5 Data Element Index
AHIMA
Common Data
Elements
ASTM
Continuity of
Care Record
HL7 Clinical Document Architecture,
Care Record Summary or Continuity
of Care Document
HL7 PHR
Conformance
Criteria
Personal Information
Patient
patientRole
Demographic
Information
Name
Patient
patient/name
Demographic
Information
Address
Patient
patientRole/addr
Contact Information
Contact Information
Patient
patientRole/telecom
Contact Information
Personal
Identification
Information
Patient
patientRole/id
Demographic
Information
Gender
Patient
patient/administrativeGenderCode
Demographic
Information
Date of Birth
Patient
patient/birthTime
Demographic
Information
Marital Status
Patient
patient/maritalStatusCode
Race
Patient
patient/raceCode
Ethnicity
Patient
patient/ethnicGroupCode
Demographic
Information
(Religious
Affiliation[1])
Patient
patient/religiousAffiliationCode
Spiritual Affiliation /
Considerations
Languages Spoken
Patient
patient/languageCommunication
Employer and School
Contacts
Social History
Hazardous Working
Conditions
Social History
Emergency Contacts
Support
Healthcare Providers
Practitioners
serviceEvent/performer
Insurance Providers
Insurance
Health Insurance or Pharmacy Insurance
HISTORY OF OCCUPATIONAL EXPOSURE
Healthcare Providers
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AHIMA
Common Data
Elements
ASTM
Continuity of
Care Record
Pharmacy
HL7 Clinical Document Architecture,
Care Record Summary or Continuity
of Care Document
HL7 PHR
Conformance
Criteria
performer
Advance Directives
Advance
Directives
ADVANCE DIRECTIVES
General Medical
Information
Height, Weight
Vital Signs
VITAL SIGNS
Blood Type
Results
RELEVANT DIAGNOSTIC TESTS AND/OR
LABORATORY DATA
Last Physical or
Checkup
Encounters
HISTORY OF OUTPATIENT VISITS
Clinical Encounters
and Procedures List
Allergies and Drug
Sensitivities
Alerts
HISTORY OF ALLERGIES
Allergy and Reaction
List
Conditions
Problems
HISTORY OF PAST ILLNESS
- or PROBLEM LIST
Problem List
Surgeries
Procedures
HISTORY OF SURGICAL PROCEDURES
Clinical Encounters
and Procedures List
Medications –
Prescription and
Non-Prescription
Medications
HISTORY OF MEDICATION USE
Medication List
Immunizations
Immunizations
HISTORY OF IMMUNIZATIONS
Immunizations List
Doctor Visits
Encounters
HISTORY OF OUTPATIENT VISITS
Clinical Encounters
and Procedures List
Hospitalizations
Encounters
HISTORY OF HOSPITALIZATIONS
Clinical Encounters
and Procedures List
Other Healthcare
Visits
Encounters
HISTORY OF OUTPATIENT VISITS
Clinical Encounters
and Procedures List
Clinical Tests
Results
RELEVANT DIAGNOSTIC TESTS AND/OR
LABORATORY DATA
Laboratory and Test
Results
Pregnancies
Advance Directive
HISTORY OF PREGNANCIES
Medical Devices
Medical Devices
HISTORY OF MEDICAL DEVICE USE
Family Member
History
Family History
HISTORY OF FAMILY MEMBER DISEASES
Foreign Travel
Family History
HISTORY OF TRAVEL
Therapy
Plan of Care
TREATMENT PLAN
Care Plans, Goals and
Disease Management
Vital Signs
Vital signs
VITAL SIGNS
(Functional
Status[2])
Functional Status
FUNCTIONAL STATUS
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6.3.1.5.6 Specification
Table 6.3.1.5.6-1: PHR Extract Specification
Data Element Name
Opt
Personal Information
Template ID
R
1.3.6.1.4.1.19376.1.5.3.1.1.1
R2
1.3.6.1.4.1.19376.1.5.3.1.1.1
O
1.3.6.1.4.1.19376.1.5.3.1.1.1
Languages Spoken
R2
1.3.6.1.4.1.19376.1.5.3.1.2.1
Employer and School Contacts
O
1.3.6.1.4.1.19376.1.5.3.1.2.2
Hazardous Working Conditions
O
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.
1
Patient Contacts
R2
1.3.6.1.4.1.19376.1.5.3.1.2.4
Healthcare Providers
R
1.3.6.1.4.1.19376.1.5.3.1.2.3
Insurance Providers
R2
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.
7
Pharmacy
R2
1.3.6.1.4.1.19376.1.5.3.1.2.3
Advance Directives
R2
1.3.6.1.4.1.19376.1.5.3.1.3.34
Allergies and Drug Sensitivities
R
1.3.6.1.4.1.19376.1.5.3.1.3.13
Conditions
R
1.3.6.1.4.1.19376.1.5.3.1.3.8
Conditions (cont.)
R
1.3.6.1.4.1.19376.1.5.3.1.3.6
Surgeries
R2
1.3.6.1.4.1.19376.1.5.3.1.3.12
Medications – Prescription and Non-Prescription
R
1.3.6.1.4.1.19376.1.5.3.1.3.19
Immunizations
R2
1.3.6.1.4.1.19376.1.5.3.1.3.23
Doctor Visits / Last Physical or Checkup
O
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.
3
Hospitalizations
O
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.
3
Name
Address
Contact Information
Personal Identification
Gender
Date of Birth
These components are required of all Medical
Documents
Personal Information
Marital Status
This component is optional in Medical Documents, but
required if known in this specification.
Personal Information
Race
Ethnicity
Religious Affiliation [2]
These components are optional in Medical Documents
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Data Element Name
Opt
Template ID
Other Healthcare Visits
O
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.
3
Clinical Tests / Blood Type
O
1.3.6.1.4.1.19376.1.5.3.1.3.28
Pregnancies
O
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.
4
Medical Devices
R2
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.
5
Coded Family Medical History
O
1.3.6.1.4.1.19376.1.5.3.1.3.15
Foreign Travel
O
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.
6
Plan of Care
O
1.3.6.1.4.1.19376.1.5.3.1.3.31
Coded Vital signs
O
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.
2
Functional Status
O
1.3.6.1.4.1.19376.1.5.3.1.3.17
1475
6.3.1.5.7 Conformance
1480
CDA Release 2.0 documents that conform to the requirements of this content module shall
indicate their conformance by the inclusion of the appropriate <templateId> elements in the
header of the document. This is shown in the sample document below. A CDA Document may
conform to more than one template. This content module inherits from the Medical Summary
content module, and so must conform to the requirements of that template as well, thus all
<templateId> elements shown in the example below shall be included.
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1495
1500
1505
1510
1515
1520
1525
1530
1535
1540
1545
<ClinicalDocument xmlns='urn:hl7-org:v3'>
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5'/>
<id root=' ' extension=' '/>
<code code='34133-9' displayName='Summary of Episode Note'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<title>PHR Extract</title>
<effectiveTime value='20081004012005'/>
<confidentialityCode code='N' displayName='Normal'
codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
<languageCode code='en-US'/>
:
<component><structuredBody>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1'/>
<!-- Optional Hazardous Working Conditions Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
<!-- Required if known Advance Directives Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
<!-- Required Allergies and Drug Sensitivities Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
<!-- Required Conditions Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
<!-- Required Conditions (cont.) Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.12'/>
<!-- Required if known Surgeries Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
<!-- Required Medications – Prescription and Non-Prescription Section content -->
</section>
</component>
<component>
<section>
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1570
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1580
1585
1590
1595
1600
1605
1610
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
<!-- Required if known Immunizations Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'/>
<!-- Optional Doctor Visits / Last Physical or Checkup Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'/>
<!-- Optional Hospitalizations Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'/>
<!-- Optional Other Healthcare Visits Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.28'/>
<!-- Optional Clinical Tests / Blood Type Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/>
<!-- Optional Pregnancies Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5'/>
<!-- Required if known Medical Devices Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.15'/>
<!-- Optional Coded Family Medical History Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6'/>
<!-- Optional Foreign Travel Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
<!-- Optional Plan of Care Section content -->
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1620
1625
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
<!-- Optional Coded Vital signs Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/>
<!-- Optional Functional Status Section content -->
</section>
</component>
1630
</structuredBody></component>
</ClinicalDocument>
Figure 6.3.1.5.7-1: Sample PHR Extract Document
6.3.1.5.8 Additional Constraints
1635
The assignedAuthoring device shall be populated with information about the EHR and/or PHR
which assisted in creation of the document.
All sections and entries within the document shall contain an <id> element.
6.3.1.6 PHR Update Specification 1.3.6.1.4.1.19376.1.5.3.1.1.6
1640
1645
The PHR Update Content Module is similar to the PHR Extract content module, except that it
has a number of different constraints. First of all, it is not required to contain all of the
information that the PHR Extract content module does. The reason for this is because the
purpose of this module is to reflect the changes that should be made to a PHR based on a
previously existing PHR Extract content module. So, while it makes use of the same data
element index, almost all of the data elements are optional. The purpose of this module is to
make it easier for an EHR to create content that can be used to update a PHR.
6.3.1.6.1 Format Code
The XDSDocumentEntry format code for this content is urn:ihe:pcc:xphr:2007
6.3.1.6.2 Conformance
1650
CDA Release 2.0 documents that conform to the requirements of this content module shall
indicate their conformance by the inclusion of the appropriate <templateId> elements in the
header of the document. This is shown in the sample document below.
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1660
1665
<ClinicalDocument xmlns='urn:hl7-org:v3'>
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.6'/>
<id root=' ' extension=' '/>
<code code=' ' displayName=' '
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<title>PHR Update</title>
<effectiveTime value='20081004012005'/>
<confidentialityCode code='N' displayName='Normal'
codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
<languageCode code='en-US'/>
:
<component><structuredBody>
</structuredBody></component>
</ClinicalDocument>
Figure 6.3.1.6.2-1: Sample PHR Update Document
1670
1675
<!-- Verify the document type code -->
<assert test='cda:code[@code = "{{{LOINC}}}"]'>
Error: The document type code of a PHR Update must be {{{LOINC}}}
</assert>
<assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
Error: The document type code must come from the LOINC code
system (2.16.840.1.113883.6.1).
</assert>
6.3.1.6.3 Requirements
1680
The requirements of this module are that it support recording updates to the original PHR
Extract. The PHR Extract is made up of a header, and several sections, each of which may
contain one or more entries. Suggestions to add, remove or update a section or entry are
described in more detail below.
6.3.1.6.4 Adding a New Section or Appending to an Existing Section
1685
A PHR Reviewer Actor may suggest additional material for an existing or new section by simply
adding that section to the PHR Update document.
6.3.1.6.5 Replacing a Section
1690
A PHR Reviewer Actor may suggest a revision to a section in the PHR Extract by replacing that
section. To replace a section, the PHR Reviewer Actor creates a section in the PHR Update
document that is of the same type as the section to be replaced in the PHR Extract document, and
adds a <ppc:replacementOf> element to that section to indicate the section that it replaces.
The replacementOf element is an extension to the CDA Release 2.0 standard, and is further
described below in Appendix C Extensions to CDA Release 2.0.
6.3.1.6.6 Adding an Entry
1695
A PHR Reviewer Actor may suggest a new entry be added to a section by simply including that
entry in a like section in the PHR Update document.
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6.3.1.6.7 Replacing or Removing an Entry
1700
The PHR Review Actor can replace an existing entry by adding an entry of the same type with
new or modified information, and including in that entry a <reference> element that has an
<externalAct> element. The <id> element of the <externalAct> shall be that of the act that is
being replaced
6.3.1.6.8 Removing an Entry
The PHR Reviewer Actor can suggest that an entry be removed by replacing it with an act whose
<statusCode> element has been set to nullified.
6.3.1.6.9 Constraints
1705
The LOINC document type code is the same as for the PHR Extract content module. The PHR
Update Content module must record the PHR Extract which it is updating
6.3.1.7 Emergency Department Referral Specification
1.3.6.1.4.1.19376.1.5.3.1.1.10
1710
An ED Referral is a type of Referral Summary, and incorporates the constraints defined for
Referral Summaries.
1715
This use case is described fully in the EDR Profile in IHE PCC TF-1. Briefly, it involves a
collaborative transfer of care for the referral of a patient from a care provider to an emergency
department. Using this use case the contents of documents used in collaborative transfers of care
were discussed with physicians and nurses in detail to identify major sections. The sections
identified by physicians during the use case exercise as important are listed in the table below.
Using this information from the use case, the following mappings were made to existing
standards.
6.3.1.7.1 Format Code
The XDSDocumentEntry format code for this content is urn:ihe:pcc:edr:2007
1720
6.3.1.7.2 Parent Template
This document is an instance of the Medical Summary template.
6.3.1.7.3 Data Element Index
Data Elements
HL7 Care Record
Summary
CDA Release 2.0
Reason for Referral
Reason for Referral
REASON FOR REFERRAL
History Present Illness
History of Present
Illness
HISTORY OF PRESENT ILLNESS
Active Problems
Conditions
PROBLEM LIST
Current Meds
Medications
HISTORY OF MEDICATION USE
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Data Elements
HL7 Care Record
Summary
CDA Release 2.0
Allergies
Allergies and Adverse
Reactions
HISTORY OF ALLERGIES
Resolved Problems
Conditions
HISTORY OF PAST ILLNESS
List of Surgeries
Past Surgical History
HISTORY OF PRIOR SURGERIES
Immunizations
Immunizations
HISTORY OF IMMUNIZATIONS
Family History
Family History
HISTORY OF FAMILY ILLNESS
Social History
Social History
SOCIAL HISTORY
Pertinent Review of Systems
Review of Systems
REVIEW OF SYSTEMS
Vital Signs
Physical Exam
VITAL SIGNS
Physical Exam
Physical Exam
GENERAL STATUS, PHYSICAL FINDINGS
Relevant Surgical Procedures / Clinical
Reports (including links)
Studies and Reports
RELEVANT DIAGNOSTIC TESTS AND/OR
LABORATORY DATA
Relevant Diagnostic Test and Reports (Lab,
Imaging, EKG’s, etc.) including links.
Studies and Reports
RELEVANT DIAGNOSTIC TESTS AND/OR
LABORATORY DATA
Care Plan (new meds labs, or x-rays
ordered)
Care Plan
TREATMENT PLAN
Proposed ED Disposition
ED DISPOSITION
Mode of Transport to the Emergency
Department
Care Plan
MODE OF TRANSPORT
Estimated Time of Arrival to the ED
Care Plan
MODE OF TRANSPORT
Advance Directives
Advance Directives
ADVANCE DIRECTIVES
Patient Administrative Identifiers
Header
patientRole/id
Pertinent Insurance Information
Participant
participant[@roleCode='HLD']
Data needed for state and local referral
forms, if different than above
Optional Sections
section
6.3.1.7.4 Specification
Data Element Name
Opt
Template ID
Reason for Referral
R
1.3.6.1.4.1.19376.1.5.3.1.3.1
History Present Illness
R
1.3.6.1.4.1.19376.1.5.3.1.3.4
Active Problems
R
1.3.6.1.4.1.19376.1.5.3.1.3.6
Current Meds
R
1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies
R
1.3.6.1.4.1.19376.1.5.3.1.3.13
Resolved Problems
R2
1.3.6.1.4.1.19376.1.5.3.1.3.8
List of Surgeries
R2
1.3.6.1.4.1.19376.1.5.3.1.3.11
Immunizations
R2
1.3.6.1.4.1.19376.1.5.3.1.3.23
Family History
R2
1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History
R2
1.3.6.1.4.1.19376.1.5.3.1.3.16
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Data Element Name
1725
Opt
Template ID
Pertinent Review of Systems
O
1.3.6.1.4.1.19376.1.5.3.1.3.18
Vital Signs
R2
1.3.6.1.4.1.19376.1.5.3.1.3.25
Physical Examination
R2
1.3.6.1.4.1.19376.1.5.3.1.3.24
Relevant Diagnostic Results and/or Clinical Reports
Includes Diagnostic Surgical Procedures, Clinical Reports and
Diagnostic Tests and Results (Lab, Imaging, EKG’s, etc.)
including links to relevant documents.
R2
1.3.6.1.4.1.19376.1.5.3.1.3.27
Care Plan
(new meds, labs, or x-rays ordered)
R2
1.3.6.1.4.1.19376.1.5.3.1.3.31
Mode of Transport to the Emergency Department
(includes ETA)
R
1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
Proposed ED Disposition
R2
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10
Advance Directives
The availability of information about Advance Directives must
be provided. A common concern among ED providers is over
situations where patients presented to the ED require extensive
resuscitative efforts, only later to discover that the patient had
a DNR order.
R
1.3.6.1.4.1.19376.1.5.3.1.3.34
Patient Administrative Identifiers
These are handed by the Medical Documents Content Profile
by reference to constraints in HL7 CRS.
R
Pertinent Insurance Information
R2
Data needed for state and local referral forms, if different
than above
These are handed by including additional sections within the
summary.
R2
Note: Highlighted items in the table above are different from what appears in the XDS-MS Profile. All other data
elements have identical definitions.
6.3.1.7.5 Conformance
1730
CDA Release 2.0 documents that conform to the requirements of this content module shall
indicate their conformance by the inclusion of the appropriate <templateId> elements in the
header of the document. This is shown in the sample document below. A CDA Document may
conform to more than one template. This content module inherits from the Medical Summary
content module, and so must conform to the requirements of that template as well, thus all
<templateId> elements shown in the example below shall be included.
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1785
1790
1795
<ClinicalDocument xmlns='urn:hl7-org:v3'>
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.3'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10'/>
<id root=' ' extension=' '/>
<code code=' ' displayName=' '
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<title>Emergency Department Referral</title>
<effectiveTime value='20081004012005'/>
<confidentialityCode code='N' displayName='Normal'
codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
<languageCode code='en-US'/>
:
<component><structuredBody>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
<!-- Required Reason for Referral Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
<!-- Required History Present Illness Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
<!-- Required Active Problems Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
<!-- Required Current Meds Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
<!-- Required Allergies Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
<!-- Required if known Resolved Problems Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
<!-- Required if known List of Surgeries Section content -->
</section>
</component>
<component>
<section>
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<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
<!-- Required if known Immunizations Section content -->
</section>
</component>
1805
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/>
<!-- Required if known Family History Section content -->
</section>
</component>
1810
1815
1820
1825
1830
1835
1840
1845
1850
1855
1860
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/>
<!-- Required if known Social History Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
<!-- Optional Pertinent Review of Systems Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
<!-- Required if known Vital Signs Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
<!-- Required if known Physical Examination Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.27'/>
<!-- Required if known Relevant Diagnostic Results and/or Clinical Reports Section
content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
<!-- Required if known Care Plan Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/>
<!-- Required Mode of Transport to the Emergency Department
(includes ETA) Section content -->
</section>
</component>
<component>
<section>
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<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'/>
<!-- Required if known Proposed ED Disposition Section content -->
</section>
</component>
1870
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
<!-- Required Advance Directives Section content -->
</section>
</component>
1875
</structuredBody></component>
</ClinicalDocument>
1880
Figure 6.3.1.7.5-1: Sample Emergency Department Referral Document
6.3.1.8 History and Physical Specification
6.3.1.9 Antepartum Summary Specification
6.3.1.10 Immunization Content Specification1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2
1885
1890
The immunization content module specifies the information that can appear within a clinical
document or message to convey information about immunizations. When used within a clinical
document, this specification has the usual requirements. When used within a message, the
encoded clinical data must be present, but the sections need not be. Systems accessing this
content through a message must be able to process these messages regardless of whether the
sections are present.
Appendix F Transforming CDA Documents to Care Record Messages found in the Request for
Clinical Guide Profile Supplement 2 describes the model by which the document created using
this content module can be transformed to the Care Record message used in the Request for
Clinical Guidance transaction.
6.3.1.10.1 LOINC Code
1895
The LOINC code for this document is 11369-6 HISTORY OF IMMUNIZATIONS
2
See http://ihe.net/Technical_Frameworks/#pcc for the material contained within the Request for Clinical Guidance
Supplement to the PCC Technical Framework.
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6.3.1.10.2 Standards
CDAR2
CCD
HL7 CDA Release 2.0
ASTM/HL7 Continuity of Care Document
6.3.1.10.4 Specification
Data Element Name
Opt
Template ID
Vol 2
Immunizations
R
1.3.6.1.4.1.19376.1.5.3.1.3.23
PCC TF-2:6.3.3.3.5
Authors and Informants
R
NONE
PCC TF-2:6.3.4.1
Active Problems
R2
1.3.6.1.4.1.19376.1.5.3.1.3.6
PCC TF-2:6.3.3.2.3
History of Past Illness
R2
1.3.6.1.4.1.19376.1.5.3.1.3.8
PCC TF-2:6.3.3.2.5
Allergies and Other Adverse Reactions
R2
1.3.6.1.4.1.19376.1.5.3.1.3.13
PCC TF-2:6.3.3.2.11
Medications
R2
1.3.6.1.4.1.19376.1.5.3.1.3.19
PCC TF-2:6.3.3.3.1
Coded Results
This section should contain information pertaining
to tests that have been completed on the patient (in
vivo).
R2
1.3.6.1.4.1.19376.1.5.3.1.3.28
PCC TF-2:6.3.3.5.2
Coded Vital Signs
R2
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
PCC TF-2:6.3.3.4.5
Pregnancy History
When present, the pregnancy history section shall
contain a Pregnancy Observation using the 114496 PREGNANCY STATUS code from LOINC to
indicate whether the patient is pregnant.
R2
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
PCC TF-2:6.3.3.2.18
Coded Advance Directives
R2
1.3.6.1.4.1.19376.1.5.3.1.3.35
PCC TF-2:6.3.3.6.6
Lab Results
This section should contain information pertaining
to tests that have been completed on the samples
(in vitro).
O
1.3.6.1.4.1.19376.1.3.3.2.1
LAB TF-3:2.3.4.1
Comments
R2
1.3.6.1.4.1.19376.1.5.3.1.4.2
PCC TF-2:6.3.4.6
Simple Observation
The gestational age at birth of the patient may be
recorded using the IHE Simple Observation
template with a code identifying this observation
as the gestational age of the patient at birth. One
such code supporting that interpretation from
R2
1.3.6.1.4.1.19376.1.5.3.1.4.13
PCC TF-2:6.3.4.20
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Data Element Name
Opt
Template ID
Vol 2
SNOMED CT is 268477000 fetal gestation at
delivery 3. This observation may appear in any
relevant section 4.
Immunization Recommendations
The section may be present to document the
schedule of vaccinations that are intended or
proposed for the patient. When present the section
shall include Immunization entries in intent or
proposal mood describing the immunization plan.
The section may include a reference to one or
more specific guidelines in definition mood to
indicate the guidelines being used.
C
(see
note 1
1.3.6.1.4.1.19376.1.5.3.1.1.18.3.1
PCC CDA Supplement
2:6.3.3.6.13
Note 1: This section is conditionally required based upon the use of the content. When the content module appears within
a clinical document is required if known. When used in a clinical decision support message it is required.
1900
6.3.1.10.5 Conformance
CDA Release 2.0 documents that conform to the requirements of this content module shall
indicate their conformance by the inclusion of the appropriate <templateId> elements in the
header of the document. Please note that when instantiated as a document this content module
must also conform to the IHE Medical Document specification found in PCC TF-2:6.1.1.1.
1905
1910
1915
1920
This is shown in the sample document below.
<ClinicalDocument xmlns='urn:hl7-org:v3'>
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2'/>
<id root=' ' extension=' '/>
<code code='11369-6' displayName='HISTORY OF IMMUNIZATIONS'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<title>Immunization Detail</title>
<effectiveTime value='20080724012005'/>
<confidentialityCode code='N' displayName='Normal'
codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
<languageCode code='en-US'/>
<author>
<!-- Required Authors and Informants Section content -->
</author>
:
3
This code used the preferred term “fetal gestation at delivery” and is a “neonate observable” which makes it more
appropriate for a newborn than the “length of gestation at birth” which is a “measure of fetus”.
4
For infants born prematurely that this may appear within the problem list section, but after a certain age, it might
be considered history and so appear elsewhere (e.g., history of past illness).
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1925
1930
1935
1940
1945
1950
1955
1960
1965
1970
<component><structuredBody>
<component><section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
<!-- Required History of Immunizations Section content -->
</section></component>
<component><section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2’/>
<!-- Required if known Comments Section content -->
</section></component>
<component><section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
<!-- Required if known Problem List Section content -->
</section></component>
<component><section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
<!-- Required if known History of Past Illness Section content -->
</section></component>
<component><section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
<!-- Required if known Allergies and Intolerances Section content -->
</section></component>
<component><section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
<!-- Required if known Medications Section content -->
</section></component>
<component><section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<!-- Required if known Lab Results Section content -->
</section></component>
<component><section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
<!-- Required if known Coded Vital Signs Section content -->
</section></component>
<component><section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/>
<!-- Required if known Pregnancy History Section content -->
</section></component>
<component><section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.35'/>
<!-- Required if known Coded Advance Directives Section content -->
</section></component>
<component><section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.18.3.1'/>
<!-- Conditional Immunization Recommendations Section content -->
</section></component>
</structuredBody>
</component>
</ClinicalDocument>
Figure 6.3.1.10.5-1: Sample Immunization Content Document
6.3.2 CDA Header Content Modules
6.3.2.1 Language Communication 1.3.6.1.4.1.19376.1.5.3.1.2.1
1975
Languages spoken shall be recorded using the languageCommunication infrastructure class
associated with the patient. The <languageCommunication> element describes the primary and
secondary languages of communication for a person. When used, these shall be described using
the languageCommunication element as follows.
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6.3.2.1.1 Specification
1980
1985
<languageCommunication>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.1'/>
<languageCode code='en-US'/>
<modeCode code='' codeSystem='2.16.840.1.113883.5.60'
codeSystemName='LanguageAbilityMode'/>
<preferenceInd value='true|false'/>
</languageCommunication>
6.3.2.1.2 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.1'/>
The <templateId> element identifies this <languageCommunication> element for validation of
the content. The templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.2.1'.
6.3.2.1.3 <languageCode code=' '/>
1990
This element describes the language code. It uses the same vocabulary described for the
ClinicalDocument/languageCode element described in more detail in HL7 CRS: 2.1.1. This
element is required.
6.3.2.1.4 <modeCode code=' ' codeSystem='2.16.840.1.113883.5.60'
codeSystemName='LanguageAbilityMode'/>
1995
This element describes the mode of use, and is only necessary when there are differences
between expressive and receptive abilities. This element is optional. When not present, the
assumption is that any further detail provided within the languageCommunication element refers
to all common modes of communication. The coding system used shall be the HL7
LanguageAbilityMode vocabulary when this element is communicated.
2000
6.3.2.1.5 <proficiencyLevelCode code=' ' codeSystem='2.16.840.1.113883.5.61'
codeSystemName='LanguageProficiencyCode' />
This element describes the proficiency of the patient (with respect to the mode if specified). This
element is optional. The coding system used shall be the HL7 LanguageProficiencyCode
vocabulary when this element is communicated.
2005
6.3.2.1.6 <preferenceInd value=' '/>
This element shall be present on all languageCommunication elements when more than one is
provided. It shall be valued "true" if this language is the patient’s preferred language for
communication, or "false" if this is not the patient’s preferred language. More than one language
may be preferred, and at least one must be preferred.
2010
6.3.2.2 Employer and School Contacts 1.3.6.1.4.1.19376.1.5.3.1.2.2
Employer and school informational contacts shall be recorded as participants in the CDA Header
as demonstrated in the figure below. These contacts shall conform to the General Constraints
found in HL7 CRS: 2.1.1 with respect to the requirements for name, address, telephone numbers
and other contact information.
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2015
The figure below shows how the information for this element is coded, and further constraints
are provided in the following sections.
6.3.2.2.1 Specification
2020
2025
2030
2035
<participant typeCode='IND'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.2'/>
<time>
<low value=''/>
<high value=''/>
</time>
<associatedEntity classCode='CON'>
<id root='' extension=''/>
<code code='EMPLOYER|SCHOOL|AFFILIATED' codeSystem='1.3.6.1.4.1.19376.1.5.3.3'
codeSystemName='IHERoleCode'/>
<associatedPerson><name>…</name></associatedPerson>
<scopingOrganization>
<name>…</name>
<telecom value='' use=''/>
<addr>…</addr>
</scopingOrganization>
</associatedEntity>
</participant>
6.3.2.2.2 <participant typeCode='IND'>
The typeCode of the participant shall be IND.
6.3.2.2.3 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.2'/>
2040
The <templateId> element identifies this <participant> as a school or employer contact for
validation of the content. The templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.2.2'.
6.3.2.2.4 <time><low value=' '/><high value=' '/></time>
The time element indicates the start and stop time range for this contact. These dates shall
correspond to the start and stop dates for employment, enrollment, or other affiliation with the
organization described.
2045
6.3.2.2.5 <associatedEntity classCode='CON'>
The <associatedEntity> element provides the contact information (classCode='CON') for the
school, employer or affiliated organization.
2050
6.3.2.2.6 <code code='EMPLOYER|SCHOOL|AFFILIATED'
codeSystem='1.3.6.1.4.1.19376.1.5.3.3'
codeSystemName='IHERoleCode'/>
The code value shall indicate whether the participant is the employer, school or other affiliated
(e.g., volunteer) organization. See also the IHE Role Code Vocabulary
(1.3.6.1.4.1.19376.1.5.3.3)
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6.3.2.2.7 <associatedPerson><name>…</name></associatedPerson>
2055
This element should be present. When present is shall provide the name of a contact person
within the organization.
6.3.2.2.8 <scopingOrganization><name>…</name><telecom value=
use=/><addr>…</addr></scopingOrganization>
2060
This element shall be present, and shall provide the name, address and telephone number of the
organization.
6.3.2.3 Healthcare Providers and Pharmacies 1.3.6.1.4.1.19376.1.5.3.1.2.3
2065
Healthcare providers (including pharmacies) shall be recorded as described in CCD: 3.17. The
identifier that the patient is known by to these providers may be included using the Patient
Identifier extension described in Extensions to HL7 CDA Release 2.0. See the example shown in
for use of this extension element.
6.3.2.3.1 Specification
2070
2075
2080
2085
2090
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime><low value=""/><high value=""/></effectiveTime>
<performer typeCode="PRF">
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.3'/>
<functionCode code='' displayName='' codeSystem='' codeSystemName=''/>
<time>
<low value=''/>
<high value=''/>
</time>
<assignedEntity>
<id root='' extension=''/>
<code code='' displayName='' codeSystem='' codeSystemName=''/>
<addr></addr>
<telecom value='' use=''/>
<assignedPerson><name></name></assignedPerson>
<representedOrganization><name></name></representedOrganization>
<sdtc:patient>
<sdtc:id root='' extension=''/>
</sdtc:patient>
</assignedEntity>
</performer>
</serviceEvent>
<documentationOf>
6.3.2.3.2 <documentationOf>
The <documentationOf> element records the service events that were performed. This element
shall be present.
2095
6.3.2.3.3 <serviceEvent classCode="PCPR">
The <serviceEvent> element describes the activity being documented. This element shall be
present, and shall have a classCode attribute of 'PCPR'.
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6.3.2.3.4 <effectiveTime><low value=""/><high value=""/></effectiveTime>
2100
The <effectiveTime> element records the time over which care provision activities are recorded
in the document. There shall be a <low> element which records the starting date of care
provision, and a <high> element which records the ending date of care provision. The ending
date may extend into the future in the document describes care that is intended to be provided,
but that has not actually occurred.
6.3.2.3.5 <performer typeCode="PRF">
2105
2110
The <performer> elements in the <serviceEvent> identify the providers of care. At least one
<performer> element should be present. When a provider gives care over two distinct time
intervals (e.g., as in the case of a specialist who treats the patient for short periods of time in
different years), the provider may be recorded multiple times as a performer.
6.3.2.3.6 <functionCode code=' ' displayName=' ' codeSystem=' '
codeSystemName=' '/>
The function of the provider in the care of the patient should be present, and will be described in
the <functionCode> element. This may be used for example, to identify the primary care
provider.
6.3.2.3.7 <time><low value=' '/><high value=' '/></time>
2115
The <time> element is used to show the time period over which the provider gave care to the
patient. The <low> and <high> elements must be present, and indicate the time over which care
was (or is to be) provided.
6.3.2.3.8 <assignedEntity classCode='ASSIGNED'>
2120
The <assignedEntity> element contains elements that identify the individual provider, and shall
be present.
6.3.2.3.9 <id root=' ' extension=' '/>
The <id> element may be present and identifies the provider.
6.3.2.3.10 <code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>
2125
The <code> element describes the type of provider and can be used to distinguish pharmacies
from other providers.
6.3.2.3.11 <addr></addr>
The <addr> element gives the address of the provider.
6.3.2.3.12 <telecom value=' ' use=' '/>
The <telecom> element gives the telephone number of the provider.
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6.3.2.3.13 <assignedPerson><name></name></assignedPerson>
The providers name should be present. If not present, then the <scopingOrganization> shall be
present (see below).
6.3.2.3.14 <representedOrganization><name></name></representedOrganization>
This element should be present, and shall provide the name of the organization.
2135
6.3.2.3.15 <sdtc:patient><sdtc:id root=' ' extension=' '/></sdtc:patient>
2140
The <sdtc:patient> element may be present to represent the patient's medical record number with
the given provider. The root attribute of <sdtc:id> element shall be present and identifies the
namespace used for the identifier. The extension attribute shall be present and is the patient's
medical record or account number with the provider. This element is an HL7 extension to CDA
Release 2.0.
6.3.2.4 Patient Contacts 1.3.6.1.4.1.19376.1.5.3.1.2.4
Patient contacts are recorded as described in HL7 CCD: 3.3
6.3.2.4.1 Specification
2145
2150
<guardian classCode='GUARD'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.4'/>
<code code='' displayName='' codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
<addr></addr>
<telecom />
<guardianPerson>
<name></name>
</guardianPerson>
</guardian>
Figure 6.3.2.4.1-1: Guardians
2155
2160
<participant typeCode='IND'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.4'/>
<time value='20070213'/>
<associatedEntity classCode='AGNT|CAREGIVER|ECON|NOK|PRS'>
<code code='' displayName='' codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
<addr></addr>
<telecom value='' use=''/>
<assignedPerson><name></name></assignedPerson>
</associatedEntity>
</participant>
2165
Figure 6.3.2.4.1-2: Other Contacts
6.3.2.4.2 <guardian classCode='GUARD'>
The guardians of a patient shall be recorded in the <guardian> element beneath the <patient>
element.
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6.3.2.4.3 <participant typeCode='IND'>
2170
Other contacts are recorded as <participant> elements appearing in the document header. The
classCode attribute shall be set to 'IND'.
6.3.2.4.4 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.2.4'/>
The <templateId> element identifies this person as a patient contact and must be recorded
exactly as shown above.
2175
6.3.2.4.5 <time value=' '>
The <time> element may be present and indicates the time of the participation.
6.3.2.4.6 <associatedEntity classCode='AGNT|CAREGIVER|ECON|NOK|PRS'>
2180
The <associatedEntity> element identifies the type of contact. The classCode attribute shall be
present, and contains a value from the set AGNT, CAREGIVER, ECON, NOK, or PRS to
identify contacts that are agents of the patient, care givers, emergency contacts, next of kin, or
other relations respectively.
6.3.2.4.7 <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.5.111'
codeSystemName='RoleCode'/>
2185
The relationship between the patient and the guardian or other contact should be recorded in the
<code> element. The code attribute is required and comes from the HL7
PersonalRelationshipRoleType vocabulary. The codeSystem attribute is required and shall be
represented exactly as shown above.
6.3.2.4.8 <addr>
2190
The address of the guardian or other contact should be present, and shall be represented as any
other address would be in CDA.
6.3.2.4.9 <telecom>
The phone number of the guardian or other contact should be present, and shall be represented as
any other phone number would be in CDA.
6.3.2.4.10 <guardianPerson><name/> or <assignedPerson><name/>
2195
The name of the guardian or other contact shall be present, and shall be represented as any other
name would be in CDA.
6.3.2.5 Reserved for (Spouse)
6.3.2.6 Reserved for (Natural Father of Fetus)
6.3.2.7 Reserved for (Authorization)
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6.3.3 CDA Section Content Modules
This list defines the sections that may appear in a medical document. It is intended to be a
comprehensive list of all document sections that are used by any content profile defined in the
Patient Care Coordination Technical Framework. All sections SHALL have a narrative
component that may be freely formatted into normal text, lists, tables, or other appropriate
human-readable presentations. Additionally, the title element SHALL be present in each section
and SHOULD be valued with an appropriate text string representing the clinical data in that
section. All sections SHALL have an instance id to uniquely identify that section content
module. Sections MAY require explicit subject identification when the section contains
information that is not about the recordTarget of the document. Additional subsections or entry
content modules MAY be required.
Please note: As of 2013, section content modules are no longer being categorized into one of the
nine existing categories (6.3.3.1 through 6.3.3.9). Instead, going forward, all section content
modules will be placed under the 6.3.3.10 heading.
6.3.3.1 Reasons for Care
2215
The sections described below describe various reasons why healthcare is being provided to the
patient.
6.3.3.1.1 Reason for Referral Section 1.3.6.1.4.1.19376.1.5.3.1.3.1
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.1
The reason for referral section shall contain a narrative description of the reason that the
patient is being referred.
LOINC Code
42349-1
2220
2225
2230
Opt
R
Description
REASON FOR REFERRAL
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
<id root=' ' extension=' '/>
<code code='42349-1' displayName='REASON FOR REFERRAL'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.1.1-1: Sample Reason for Referral Section
6.3.3.1.2 Coded Reason for Referral Section 1.3.6.1.4.1.19376.1.5.3.1.3.2
Template ID
Parent Template
1.3.6.1.4.1.19376.1.5.3.1.3.2
Reason for Referral (1.3.6.1.4.1.19376.1.5.3.1.3.1)
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General Description
This section shall include at least one entry describing the reason for referral as
described in the Entry Content Module.
LOINC Code
42349-1
Opt
R
Entries
Description
REASON FOR REFERRAL
Opt
Description
1.3.6.1.4.1.19376.1.5.3.1.4.13
R
Simple Observations
1.3.6.1.4.1.19376.1.5.3.1.4.5
R
Conditions Entry
6.3.3.1.2.1 Parent Template
The parent of this template is Reason for Referral.
2235
2240
2245
2250
2255
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.2'/>
<id root=' ' extension=' '/>
<code code='42349-1' displayName='REASON FOR REFERRAL'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Simple Observations element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
:
</entry>
<entry>
:
<!-- Required Conditions Entry element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
2260
Figure 6.3.3.1.2.1-1: Sample Coded Reason for Referral Section
6.3.3.1.3 Chief Complaint Section 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
This contains a narrative description of the patient's chief complaint.
LOINC Code
10154-3
Opt
R
Description
CHIEF COMPLAINT
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<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/>
<id root=' ' extension=' '/>
<code code='10154-3' displayName='CHIEF COMPLAINT'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
2275
Figure 6.3.3.1.3-1: Sample Chief Complaint Section
6.3.3.1.4 Hospital Admission Diagnosis Section 1.3.6.1.4.1.19376.1.5.3.1.3.3
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.3
The hospital admitting diagnosis section shall contain a narrative description of the
primary reason for admission to a hospital facility. It shall include entries for
observations as described in the Entry Content Modules.
LOINC Code
46241-6
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.5.2
2280
2285
2290
2295
Description
HOSPITAL ADMISSION DX
Opt
R
Description
Problem Concern Entry
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.3'/>
<id root=' ' extension=' '/>
<code code='46241-6' displayName='HOSPITAL ADMISSION DX'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Problem Concern Entry element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/>
:
</entry>
</section>
</component>
Figure 6.3.3.1.4-1: Sample Hospital Admission Diagnosis Section
6.3.3.1.5 Reserved for (Proposed Procedure Section)
6.3.3.1.6 Reserved for (EBS Estimated Blood Loss Section)
6.3.3.1.7 Reserved for (Proposed Anesthesia Section)
2300
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6.3.3.1.8 Reserved for (Reason for Procedure Section)
6.3.3.1.9 Reserved for (Reason for Visit Section)
6.3.3.1.10 Reserved for (Injury Incident Description Section)
6.3.3.2 Other Condition Histories
2305
The sections defined below provide historical information about the patient's conditions.
6.3.3.2.1 History of Present Illness Section 1.3.6.1.4.1.19376.1.5.3.1.3.4
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.4
The history of present illness section shall contain a narrative description of the
sequence of events preceding the patient’s current complaints.
LOINC Code
10164-2
2310
2315
Opt
R
Description
HISTORY OF PRESENT ILLNESS
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
<id root=' ' extension=' '/>
<code code='10164-2' displayName='HISTORY OF PRESENT ILLNESS'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
2320
Figure 6.3.3.2.1-1: Sample History of Present Illness Section
6.3.3.2.2 Hospital Course Section 1.3.6.1.4.1.19376.1.5.3.1.3.5
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.5
The hospital course section shall contain a narrative description of the sequence of
events from admission to discharge in a hospital facility.
LOINC Code
8648-8
Opt
R
Description
HOSPITAL COURSE
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<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.5'/>
<id root=' ' extension=' '/>
<code code='8648-8' displayName='HOSPITAL COURSE'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
2335
Figure 6.3.3.2.2-1: Sample Hospital Course Section
6.3.3.2.3 Active Problems Section 1.3.6.1.4.1.19376.1.5.3.1.3.6
Template ID
Parent Template
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.6
CCD 3.5 (2.16.840.1.113883.10.20.1.11)
The active problem section shall contain a narrative description of the conditions
currently being monitored for the patient. It shall include entries for patient conditions as
described in the Entry Content Module.
LOINC Code
11450-4
Opt
R
Entries
Description
PROBLEM LIST
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5.2
R
Description
Problem Concern Entry
6.3.3.2.3.1 Parent Template
The parent of this template is CCD 3.5.
2340
2345
2350
2355
<component>
<section>
<templateId root='2.16.840.1.113883.10.20.1.11'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
<id root=' ' extension=' '/>
<code code='11450-4' displayName='PROBLEM LIST'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Problem Concern Entry element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/>
:
</entry>
</section>
</component>
Figure 6.3.3.2.3.1-1: Sample Active Problems Section
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6.3.3.2.4 Discharge Diagnosis Section 1.3.6.1.4.1.19376.1.5.3.1.3.7
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.7
The discharge diagnosis section shall contain a narrative description of the conditions
that need to be monitored after discharge from the hospital and those that were resolved
during the hospital course. It shall include entries for patient conditions as described in
the Entry Content Module.
LOINC Code
11535-2
Opt
R
Entries
2370
2375
HOSPITAL DISCHARGE DX
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5.2
2365
Description
R
Description
Problem Concern Entry
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.7'/>
<id root=' ' extension=' '/>
<code code='11535-2' displayName='HOSPITAL DISCHARGE DX'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Problem Concern Entry element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/>
:
</entry>
</section>
</component>
2380
Figure 6.3.3.2.4-1: Sample Discharge Diagnosis Section
6.3.3.2.5 History of Past Illness Section 1.3.6.1.4.1.19376.1.5.3.1.3.8
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.8
The History of Past Illness section shall contain a narrative description of the conditions
the patient suffered in the past. It shall include entries for problems as described in the
Entry Content Modules.
LOINC Code
11348-0
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.5.2
Description
HISTORY OF PAST ILLNESS
Opt
R
Description
Problem Concern Entry
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2395
2400
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
<id root=' ' extension=' '/>
<code code='11348-0' displayName='HISTORY OF PAST ILLNESS'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Problem Concern Entry element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/>
:
</entry>
</section>
</component>
Figure 6.3.3.2.5-1: Sample History of Past Illness Section
6.3.3.2.6 Encounter Histories Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
Template ID
Parent Template
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
2.16.840.1.113883.10.20.1.3 (2.16.840.1.113883.10.20.1.3)
The encounter history section contains coded entries describing the patient history of
encounters.
LOINC Code
46240-8
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.14
Description
HISTORY OF ENCOUNTERS
Opt
R
Description
Encounters
6.3.3.2.6.1 Parent Template
2405
The parent of this template is 2.16.840.1.113883.10.20.1.3.
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2410
2415
2420
<component>
<section>
<templateId root='2.16.840.1.113883.10.20.1.3'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3'/>
<id root=' ' extension=' '/>
<code code='46240-8' displayName='HISTORY OF ENCOUNTERS'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Encounters element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.14'/>
:
</entry>
</section>
</component>
2425
Figure 6.3.3.2.6.1-1: Sample Encounter Histories Section
6.3.3.2.7 History of Outpatient Visits Section 1.3.6.1.4.1.19376.1.5.3.1.3.9
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.9
The outpatients visit section shall contain a narrative description of the completed visits
to ambulatory facilities.
LOINC Code
11346-4
2430
2435
Opt
R
Description
HISTORY OF OUTPATIENT VISITS
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.9'/>
<id root=' ' extension=' '/>
<code code='11346-4' displayName='HISTORY OF OUTPATIENT VISITS'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
2440
Figure 6.3.3.2.7-1: Sample History of Outpatient Visits Section
6.3.3.2.8 History of Inpatient Visits Section 1.3.6.1.4.1.19376.1.5.3.1.3.10
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.10
The inpatient admissions section shall contain a narrative description of the admissions
and discharges to inpatient facilities.
LOINC Code
11336-5
Opt
R
Description
HISTORY OF HOSPITALIZATIONS
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2450
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.10'/>
<id root=' ' extension=' '/>
<code code='11336-5' displayName='HISTORY OF HOSPITALIZATIONS'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
2455
Figure 6.3.3.2.8-1: Sample History of Inpatient Visits Section
6.3.3.2.9 List of Surgeries Section 1.3.6.1.4.1.19376.1.5.3.1.3.11
Template ID
Parent Template
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.11
CCD 3.14 (2.16.840.1.113883.10.20.1.12)
The list of surgeries section shall contain a narrative description of the diagnostic and
therapeutic operative procedures and associated anesthetic techniques the patient
received in the past.
LOINC Code
47519-4
Opt
R
Description
HISTORY OF PROCEDURES
6.3.3.2.9.1 Parent Template
The parent of this template is CCD 3.14.
2460
2465
2470
<component>
<section>
<templateId root='2.16.840.1.113883.10.20.1.12'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
<id root=' ' extension=' '/>
<code code='47519-4' displayName='HISTORY OF PROCEDURES'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.2.9.1-1: Sample List of Surgeries Section
6.3.3.2.10 Coded List of Surgeries Section 1.3.6.1.4.1.19376.1.5.3.1.3.12
Template ID
Parent Template
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.12
List of Surgeries (1.3.6.1.4.1.19376.1.5.3.1.3.11)
The list of surgeries section shall include entries for procedures and references to
procedure reports when known as described in the Entry Content Modules.
LOINC Code
47519-4
Opt
R
Description
HISTORY OF PROCEDURES
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Entries
Opt
Description
1.3.6.1.4.1.19376.1.5.3.1.4.19
R
Procedure Entry
1.3.6.1.4.1.19376.1.5.3.1.4.4
R2
References Entry
2475
6.3.3.2.10.1 Parent Template
The parent of this template is List of Surgeries.
2480
2485
2490
2495
2500
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.12'/>
<id root=' ' extension=' '/>
<code code='47519-4' displayName='HISTORY OF PROCEDURES'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Procedure Entry element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
:
</entry>
<entry>
:
<!-- Required if known References Entry element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
:
</entry>
</section>
</component>
Figure 6.3.3.2.10.1-1: Sample Coded List of Surgeries Section
2505
6.3.3.2.11 Allergies and Other Adverse Reactions Section
1.3.6.1.4.1.19376.1.5.3.1.3.13
Template ID
Parent Template
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.13
CCD 3.8 (2.16.840.1.113883.10.20.1.2)
The adverse and other adverse reactions section shall contain a narrative description of
the substance intolerances and the associated adverse reactions suffered by the patient. It
shall include entries for intolerances and adverse reactions as described in the Entry
Content Modules.
LOINC Code
48765-2
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.5.3
Description
Allergies, adverse reactions, alerts
Opt
R
Description
Allergies and Intolerances Concern
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Content Profiles
______________________________________________________________________________
6.3.3.2.11.1 Parent Template
The parent of this template is CCD 3.8. This template is compatible with the ASTM/HL7
Continuity of Care Document template: 2.16.840.1.113883.10.20.1.2
2510
2515
2520
2525
<component>
<section>
<templateId root='2.16.840.1.113883.10.20.1.2'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
<id root=' ' extension=' '/>
<code code='48765-2' displayName='Allergies, adverse reactions, alerts'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Allergies and Intolerances Concern element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.3'/>
:
</entry>
</section>
</component>
Figure 6.3.3.2.11.1-1: Sample Allergies and Other Adverse Reactions Section
2530
6.3.3.2.12 Family Medical History Section 1.3.6.1.4.1.19376.1.5.3.1.3.14
Template ID
Parent Template
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.14
CCD 3.6 (2.16.840.1.113883.10.20.1.4)
The family history section shall contain a narrative description of the genetic family
members, to the extent that they are known, the diseases they suffered from, their ages at
death, and other relevant genetic information.
LOINC Code
10157-6
Opt
R
Description
HISTORY OF FAMILY MEMBER DISEASES
6.3.3.2.12.1 Parent Template
The parent of this template is CCD 3.6.
2535
2540
2545
<component>
<section>
<templateId root='2.16.840.1.113883.10.20.1.4'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/>
<id root=' ' extension=' '/>
<code code='10157-6' displayName='HISTORY OF FAMILY MEMBER DISEASES'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.2.12.1-1: Sample Family Medical History Section
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Content Profiles
______________________________________________________________________________
6.3.3.2.13 Coded Family Medical History Section 1.3.6.1.4.1.19376.1.5.3.1.3.15
Template ID
Parent Template
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.15
Family Medical History (1.3.6.1.4.1.19376.1.5.3.1.3.14)
The family history section shall include entries for family history as described in the
Entry Content Modules.
LOINC Code
10157-6
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.15
2550
Description
HISTORY OF FAMILY MEMBER DISEASES
Opt
R
Description
Family History Organizer
6.3.3.2.13.1 Parent Template
The parent of this template is Family Medical History.
2555
2560
2565
2570
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.15'/>
<id root=' ' extension=' '/>
<code code='10157-6' displayName='HISTORY OF FAMILY MEMBER DISEASES'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Family History Organizer element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.15'/>
:
</entry>
</section>
</component>
Figure 6.3.3.2.13.1-1: Sample Coded Family Medical History Section
6.3.3.2.14 Social History Section 1.3.6.1.4.1.19376.1.5.3.1.3.16
Template ID
Parent Template
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.16
CCD 3.7 (2.16.840.1.113883.10.20.1.15)
The social history section shall contain a narrative description of the person’s beliefs,
home life, community life, work life, hobbies, and risky habits.
LOINC Code
29762-2
Opt
R
Description
SOCIAL HISTORY
6.3.3.2.14.1 Parent Template
2575
The parent of this template is CCD 3.7.
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Content Profiles
______________________________________________________________________________
2580
2585
<component>
<section>
<templateId root='2.16.840.1.113883.10.20.1.15'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/>
<id root=' ' extension=' '/>
<code code='29762-2' displayName='SOCIAL HISTORY'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.2.14.1-1: Sample Social History Section
2590
6.3.3.2.15 Functional Status Section 1.3.6.1.4.1.19376.1.5.3.1.3.17
Template ID
Parent Template
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.17
CCD 3.4 (2.16.840.1.113883.10.20.1.5)
The functional status section shall contain a narrative description of capability of the
patient to perform acts of daily living.
LOINC Code
47420-5
Opt
R
Description
FUNCTIONAL STATUS ASSESSMENT
6.3.3.2.15.1 Parent Template
The parent of this template is CCD 3.4.
2595
2600
2605
<component>
<section>
<templateId root='2.16.840.1.113883.10.20.1.5'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/>
<id root=' ' extension=' '/>
<code code='47420-5' displayName='FUNCTIONAL STATUS ASSESSMENT'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.2.15.1-1: Sample Functional Status Section
6.3.3.2.16 Review of Systems Section 1.3.6.1.4.1.19376.1.5.3.1.3.18
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.18
The review of systems section shall contain a narrative description of the responses the
patient gave to a set of routine questions on the functions of each anatomic body system.
LOINC Code
10187-3
Opt
R
Description
REVIEW OF SYSTEMS
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2610
2615
2620
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
<id root=' ' extension=' '/>
<code code='10187-3' displayName='REVIEW OF SYSTEMS'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.2.16-1: Sample Review of Systems Section
6.3.3.2.17 Hazardous Working Conditions Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1
Hazardous working conditions contains a narrative description of the patient's hazardous
risks.
LOINC Code
10161-8
2625
2630
2635
Opt
R
Description
HISTORY OF OCCUPATIONAL EXPOSURE
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1'/>
<id root=' ' extension=' '/>
<code code='10161-8' displayName='HISTORY OF OCCUPATIONAL EXPOSURE'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.2.17-1: Sample Hazardous Working Conditions Section
6.3.3.2.18 Pregnancy History Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
The pregnancy history section contains coded entries describing the patient history of
pregnancies.
LOINC Code
10162-6
Opt
R
Entries
2640
Description
HISTORY OF PREGNANCIES
Opt
1
Description
1.3.6.1.4.1.19376.1.5.3.1.4.13.5
R
Pregnancy Observation
1.3.6.1.4.1.19376.1.5.3.1.4.13.5.1
O1
Pregnancy History Organizer
1
At least one pregnancy observation or pregnancy history organizer must be present in this section. The pregnancy history
organizer contains one or more pregnancy observations so the inclusion of a pregnancy history organizer ensures that a
pregnancy observation is present.
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2645
2650
2655
2660
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/>
<id root=' ' extension=' '/>
<code code='10162-6' displayName='HISTORY OF PREGNANCIES'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Pregnancy Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5'/>
:
<!-- Optional Pregnancy History Organizer element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5.1'/>
:
</entry>
</section>
</component>
Figure 6.3.3.2.18-1: Sample Pregnancy History Section
2665
6.3.3.2.19 Medical Devices Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5
Template ID
Parent Template
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5
2.16.840.1.11383.10.20.1.7 (2.16.840.1.11383.10.20.1.7)
The medical devices section contains narrative text describing the patient history of
medical device use.
LOINC Code
46264-8
Opt
R
Description
HISTORY OF MEDICAL DEVICE USE
6.3.3.2.19.1 Parent Template
The parent of this template is 2.16.840.1.11383.10.20.1.7.
2670
2675
2680
<component>
<section>
<templateId root='2.16.840.1.11383.10.20.1.7'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5'/>
<id root=' ' extension=' '/>
<code code='46264-8' displayName='HISTORY OF MEDICAL DEVICE USE'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.2.19.1-1: Sample Medical Devices Section
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Content Profiles
______________________________________________________________________________
6.3.3.2.20 Foreign Travel Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6
Template ID
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6
General Description
The foreign travel section contains only narrative text describing the patient's travel
history.
LOINC Code
Opt
10182-4
2685
2690
2695
R
Description
HISTORY OF TRAVEL
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6'/>
<id root=' ' extension=' '/>
<code code='10182-4' displayName='HISTORY OF TRAVEL'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.2.20-1: Sample Foreign Travel Section
2700
6.3.3.2.21 Pre-procedure Family Medical History Section
1.3.6.1.4.1.19376.1.5.3.1.1.9.5 (Deprecated)
6.3.3.2.22 Reserved for Coded Functional Status Assessment Section
6.3.3.2.23 Reserved for Pain Scale Assessment Section
6.3.3.2.24 Reserved for Braden Score Section Reserved for
6.3.3.2.25 Reserved for Geriatric Depression Scale Section
2705
6.3.3.2.26 Reserved for Physical Function Section
6.3.3.2.27 Reserved for Preprocedure Review of Systems Section
6.3.3.2.28 Reserved for Estimated Delivery Date Section
6.3.3.2.29 Reserved for History of Tobacco Use Section
6.3.3.2.30 Reserved for Current Alcohol/Substance Abuse Section
2710
6.3.3.2.31 Reserved for History of Blood Transfusion Section
6.3.3.2.32 Reserved for Anesthesia Risk Review of Systems Section
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Content Profiles
______________________________________________________________________________
6.3.3.2.33 Reserved for Implanted Medical Device Review Section
6.3.3.2.34 Reserved for Pregnancy Status Review Section
6.3.3.2.35 Reserved for History of Infection Section
2715
6.3.3.2.36 Reserved for Coded Social History Section
6.3.3.2.37 Reserved for Coded History of Infection Section
6.3.3.2.38 Reserved for Prenatal Events Section
6.3.3.2.39 Reserved for Labor and Delivery Events Section
6.3.3.2.40 Reserved for Newborn Delivery Information Section
2720
6.3.3.2.41 Reserved for Postpartum Hospitalization Treatment Section
6.3.3.2.42 Reserved for Event Outcomes Section
6.3.3.2.43 Reserved for Newborn Status at Maternal Discharge
6.3.3.2.44 Reserved for History of Surgical Procedures Section
6.3.3.2.45 Reserved for Operative Note Section
2725
6.3.3.2.46 Reserved for Child Functional Status Assessment
6.3.3.2.47 Reserved for Psychomotor Development Section
6.3.3.2.48 Reserved for Eating and Sleeping Assessment Section
6.3.3.2.49 Reserved for Coded Event Outcomes Reserved for
6.3.3.2.50 Occupational History
2730
Removed from the CDA Content Modules supplement removed 2011-09 at the request of
QRPH.
6.3.3.2.51 Patient Status
Removed from the CDA Content Modules supplement removed 2011-09 at the request of
QRPH.
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2735
6.3.3.2.52 Cancer Control
Removed from the CDA Content Modules supplement removed 2011-09 at the request of
QRPH.
6.3.3.2.53 Reserved for Notifications, Alerts, and Reminders Section
6.3.3.2.54 Reserved for Pain Assessment Panel Section
2740
6.3.3.2.55 Reserved for History of Cognitive Function Section
6.3.3.2.56 Reserved for Isolation Status Section
6.3.3.2.57 Reserved for Restraints Section
6.3.3.2.58 Reserved for Risk Indicators for Hearing Loss
6.3.3.2.59 Reserved for Cancer Diagnosis Section
2745
6.3.3.3 Medications
This section contains section content modules that describe activities surrounding the use of
medication.
6.3.3.3.1 Medications Section 1.3.6.1.4.1.19376.1.5.3.1.3.19
Template ID
Parent Template
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.19
CCD 3.9 (2.16.840.1.113883.10.20.1.8)
The medications section shall contain a description of the relevant medications for the
patient, e.g., an ambulatory prescription list. It shall include entries for medications as
described in the Entry Content Module.
LOINC Code
10160-0
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.7
2750
Description
HISTORY OF MEDICATION USE
Opt
R
Description
Medications
6.3.3.3.1.1 Parent Template
The parent of this template is CCD 3.9.
___________________________________________________________________________
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Content Profiles
______________________________________________________________________________
2755
2760
2765
2770
<component>
<section>
<templateId root='2.16.840.1.113883.10.20.1.8'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
<id root=' ' extension=' '/>
<code code='10160-0' displayName='HISTORY OF MEDICATION USE'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Medications element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/>
:
</entry>
</section>
</component>
Figure 6.3.3.3.1.1-1: Sample Medications Section
Note:
This LOINC code is typically used to record the current medication list found in an EHR.
6.3.3.3.2 Admission Medication History Section 1.3.6.1.4.1.19376.1.5.3.1.3.20
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.20
The admission medication history section shall contain a narrative description of the
relevant medications administered to a patient prior to admission to a facility. It shall
include entries for medication administration as described in the Entry Content Module.
LOINC Code
42346-7
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.7
Description
MEDICATIONS ON ADMISSION
Opt
R
Description
Medications
2775
2780
2785
2790
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.20'/>
<id root=' ' extension=' '/>
<code code='42346-7' displayName='MEDICATIONS ON ADMISSION'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Medications element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/>
:
</entry>
</section>
</component>
Figure 6.3.3.3.2-1: Sample Admission Medication History Section
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2795
6.3.3.3.3 Medications Administered Section 1.3.6.1.4.1.19376.1.5.3.1.3.21
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.21
The medications administered section shall contain a narrative description of the
relevant medications administered to a patient during the course of an encounter. It shall
include entries for medication administration as described in the Entry Content Module.
LOINC Code
18610-6
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.7
2800
2805
2810
Description
MEDICATION ADMINISTERED
Opt
R
Description
Medications
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/>
<id root=' ' extension=' '/>
<code code='18610-6' displayName='MEDICATION ADMINISTERED'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Medications element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/>
:
</entry>
</section>
</component>
2815
Figure 6.3.3.3.3-1: Sample Medications Administered Section
6.3.3.3.4 Hospital Discharge Medications Section 1.3.6.1.4.1.19376.1.5.3.1.3.22
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.22
The hospital discharge medications section shall contain a narrative description of the
medications requested (ordered) to be administered to the patient after discharge from
the hospital. It shall include entries for medication requests as described in the Entry
Content Module.
LOINC Code
10183-2
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.7
Description
HOSPITAL DISCHARGE MEDICATIONS
Opt
R
Description
Medications
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2820
2825
2830
2835
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.22'/>
<id root=' ' extension=' '/>
<code code='10183-2' displayName='HOSPITAL DISCHARGE MEDICATIONS'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Medications element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/>
:
</entry>
</section>
</component>
Figure 6.3.3.3.4-1: Sample Hospital Discharge Medications Section
Note:
All medications in this section must have substanceAdministration/@moodCode = "INT"
6.3.3.3.5 Immunizations Section 1.3.6.1.4.1.19376.1.5.3.1.3.23
Template ID
Parent Template
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.23
CCD 3.11 (2.16.840.1.113883.10.20.1.6)
The immunizations section shall contain a narrative description of the immunizations
administered to the patient in the past. It shall include entries for medication
administration as described in the Entry Content Modules.
LOINC Code
11369-6
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.12
2840
Description
HISTORY OF IMMUNIZATIONS
Opt
R
Description
Immunization
6.3.3.3.5.1 Parent Template
The parent of this template is CCD 3.11.
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2845
2850
2855
2860
<component>
<section>
<templateId root='2.16.840.1.113883.10.20.1.6'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
<id root=' ' extension=' '/>
<code code='11369-6' displayName='HISTORY OF IMMUNIZATIONS'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Immunization element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12'/>
:
</entry>
</section>
</component>
Figure 6.3.3.5.1-1: Sample Immunizations Section
6.3.3.4 Physical Exams
6.3.3.4.1 Physical Examination Section 1.3.6.1.4.1.19376.1.5.3.1.3.24
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.24
The physical examination section shall contain a narrative description of the patient’s
physical findings.
LOINC Code
29545-1
2865
2870
2875
Opt
R
Description
PHYSICAL EXAMINATION
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
<id root=' ' extension=' '/>
<code code='29545-1' displayName='PHYSICAL EXAMINATION'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.4.1-1: Sample Physical Examination Section
6.3.3.4.2 Detailed Physical Examination Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.15
Template ID
Parent Template
General Description
LOINC Code
1.3.6.1.4.1.19376.1.5.3.1.1.9.15
1.3.6.1.4.1.19376.1.5.3.1.3.24 (1.3.6.1.4.1.19376.1.5.3.1.3.24)
The Detailed Physical Examination section shall contain only the required and optional
subsections performed.
Opt
Description
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29545-1
2880
R
PHYSICAL EXAMINATION
Entries
Opt
Description
Subsections
Opt
Description
1.3.6.1.4.1.19376.1.5.3.1.3.25
O
Vital Signs
Vital signs may be a subsection of the physical exam or they may stand
alone
1.3.6.1.4.1.19376.1.5.3.1.1.9.16
O
General Appearance
1.3.6.1.4.1.19376.1.5.3.1.1.9.48
O
Visible Implanted Medical Devices
1.3.6.1.4.1.19376.1.5.3.1.1.9.17
O
Integumentary System
1.3.6.1.4.1.19376.1.5.3.1.1.9.18
O
Head
1.3.6.1.4.1.19376.1.5.3.1.1.9.19
O
Eyes
1.3.6.1.4.1.19376.1.5.3.1.1.9.20
O
Ears, Nose, Mouth and Throat
1.3.6.1.4.1.19376.1.5.3.1.1.9.21
O
Ears
1.3.6.1.4.1.19376.1.5.3.1.1.9.22
O
Nose
1.3.6.1.4.1.19376.1.5.3.1.1.9.23
O
Mouth, Throat, and Teeth
1.3.6.1.4.1.19376.1.5.3.1.1.9.24
O
Neck
1.3.6.1.4.1.19376.1.5.3.1.1.9.25
O
Endocrine System
1.3.6.1.4.1.19376.1.5.3.1.1.9.26
O
Thorax and Lungs
1.3.6.1.4.1.19376.1.5.3.1.1.9.27
O
Chest Wall
1.3.6.1.4.1.19376.1.5.3.1.1.9.28
O
Breasts
1.3.6.1.4.1.19376.1.5.3.1.1.9.29
O
Heart
1.3.6.1.4.1.19376.1.5.3.1.1.9.30
O
Respiratory System
1.3.6.1.4.1.19376.1.5.3.1.1.9.31
O
Abdomen
1.3.6.1.4.1.19376.1.5.3.1.1.9.32
O
Lymphatic System
1.3.6.1.4.1.19376.1.5.3.1.1.9.33
O
Vessels
1.3.6.1.4.1.19376.1.5.3.1.1.9.34
O
Musculoskeletal System
1.3.6.1.4.1.19376.1.5.3.1.1.9.35
O
Neurologic System
1.3.6.1.4.1.19376.1.5.3.1.1.9.36
O
Genitalia
1.3.6.1.4.1.19376.1.5.3.1.1.9.37
O
Rectum
1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1
O
Extremities
6.3.3.4.2.1 Parent Template
The parent of this template is 1.3.6.1.4.1.19376.1.5.3.1.3.24.
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2885
2890
2895
2900
2905
2910
2915
2920
2925
2930
2935
2940
2945
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/>
<id root=' ' extension=' '/>
<code code='29545-1' displayName='PHYSICAL EXAMINATION'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
<!-- Optional Vital Signs Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.16'/>
<!-- Optional General Appearance Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.48'/>
<!-- Optional Visible Implanted Medical Devices Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.17'/>
<!-- Optional Integumentary System Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.18'/>
<!-- Optional Head Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.19'/>
<!-- Optional Eyes Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.20'/>
<!-- Optional Ears, Nose, Mouth and Throat Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.21'/>
<!-- Optional Ears Section content -->
</section>
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</component>
2950
2955
2960
2965
2970
2975
2980
2985
2990
2995
3000
3005
3010
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.22'/>
<!-- Optional Nose Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.23'/>
<!-- Optional Mouth, Throat, and Teeth Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.24'/>
<!-- Optional Neck Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.25'/>
<!-- Optional Endocrine System Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.26'/>
<!-- Optional Thorax and Lungs Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.27'/>
<!-- Optional Chest Wall Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.28'/>
<!-- Optional Breasts Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.29'/>
<!-- Optional Heart Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.30'/>
<!-- Optional Respiratory System Section content -->
</section>
</component>
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3015
3020
3025
3030
3035
3040
3045
3050
3055
3060
3065
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.31'/>
<!-- Optional Abdomen Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.32'/>
<!-- Optional Lymphatic System Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.33'/>
<!-- Optional Vessels Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.34'/>
<!-- Optional Musculoskeletal System Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.35'/>
<!-- Optional Neurologic System Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.36'/>
<!-- Optional Genitalia Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.37'/>
<!-- Optional Rectum Section content -->
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1'/>
<!-- Optional Extremities Section content -->
</section>
</component>
</section>
</component>
3070
Figure 6.3.3.4.2.1-1: Sample Detailed Physical Examination Section
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______________________________________________________________________________
6.3.3.4.3 Hospital Discharge Physical Exam Section 1.3.6.1.4.1.19376.1.5.3.1.3.26
Template ID
1.3.6.1.4.1.19376.1.5.3.1.3.26
General Description
The hospital discharge physical exam section shall contain a narrative description of the
patient’s physical findings at discharge from a hospital facility.
LOINC Code
Opt
10184-0
3075
3080
R
Description
HOSPITAL DISCHARGE PHYSICAL
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.26'/>
<id root=' ' extension=' '/>
<code code='10184-0' displayName='HOSPITAL DISCHARGE PHYSICAL'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
3085
Figure 6.3.3.4.3-1: Sample Hospital Discharge Physical Exam Section
6.3.3.4.4 Vital Signs Section 1.3.6.1.4.1.19376.1.5.3.1.3.25
Template ID
1.3.6.1.4.1.19376.1.5.3.1.3.25
Parent Template
CCD 3.12 (2.16.840.1.113883.10.20.1.16)
General Description
The vital signs section shall contain a narrative description of the measurement results
of a patient’s vital signs.
LOINC Code
Opt
8716-3
R
Description
VITAL SIGNS
6.3.3.4.4.1 Parent Template
The parent of this template is CCD 3.12.
3090
3095
3100
<component>
<section>
<templateId root='2.16.840.1.113883.10.20.1.16'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
<id root=' ' extension=' '/>
<code code='8716-3' displayName='VITAL SIGNS'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.4.4.1-1: Sample Vital Signs Section
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6.3.3.4.5 Coded Vital Signs Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Template ID
Parent Template
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Vital Signs (1.3.6.1.4.1.19376.1.5.3.1.3.25)
The vital signs section contains coded measurement results of a patient’s vital signs.
LOINC Code
8716-3
Opt
R
Entries
Description
VITAL SIGNS
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.13.1
R
Description
Vital Signs Organizer
3105
6.3.3.4.5.1 Parent Template
The parent of this template is Vital Signs.
3110
3115
3120
3125
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
<id root=' ' extension=' '/>
<code code='8716-3' displayName='VITAL SIGNS'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.5.1-1: Sample Coded Vital Signs Section
6.3.3.4.6 General Appearance Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.16
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.9.16
The general appearance section shall contain a description of the overall, visiblyapparent condition of the patient.
LOINC Code
10210-3
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.5
Description
GENERAL STATUS
Opt
O
Description
Problem Observation
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3130
3135
3140
3145
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.16'/>
<id root=' ' extension=' '/>
<code code='10210-3' displayName='GENERAL STATUS'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.6-1: Sample General Appearance Section
6.3.3.4.7 Visible Implanted Medical Devices Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.48
Template ID
1.3.6.1.4.1.19376.1.5.3.1.1.9.48
The visible implanted medical devices section shall contain a description of the medical
devices apparent on physical exam that have been inserted into the patient, whether
internal or partially external.
General Description
LOINC Code
Opt
XX-VisibleImplantedDevices
R
Entries
3155
3160
3165
Visible implanted medical devices
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3150
Description
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.48'/>
<id root=' ' extension=' '/>
<code code='TBD' displayName='TBD'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.7-1: Sample Visible Implanted Medical Devices Section
6.3.3.4.8 Integumentary System Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.17
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.9.17
The integumentary system section shall contain a description of any type of integumentary
system exam.
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LOINC Code
29302-7
Opt
R
Entries
3175
3180
3185
INTEGUMENTARY SYSTEM
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3170
Description
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.17'/>
<id root=' ' extension=' '/>
<code code='29302-7' displayName='INTEGUMENTARY SYSTEM'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.8-1: Sample Integumentary System Section
6.3.3.4.9 Head Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.18
Template ID
1.3.6.1.4.1.19376.1.5.3.1.1.9.18
General Description
The head section shall contain a description of any type of head exam.
LOINC Code
Opt
10199-8
R
Entries
3195
3200
3205
HEAD
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3190
Description
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.18'/>
<id root=' ' extension=' '/>
<code code='10199-8' displayName='HEAD'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.9-1: Sample Head Section
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6.3.3.4.10 Eyes Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.19
Template ID
1.3.6.1.4.1.19376.1.5.3.1.1.9.19
General Description
The eyes section shall contain a description of any type of eye exam.
LOINC Code
Opt
10197-2
R
Entries
3215
3220
3225
EYE
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3210
Description
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.19'/>
<id root=' ' extension=' '/>
<code code='10197-2' displayName='EYE'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.10-1: Sample Eyes Section
6.3.3.4.11 Ears, Nose, Mouth and Throat Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.20
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.9.20
The ears, nose, mouth, and throat section shall contain a description of any type of ears,
nose, mouth, or throat exam.
LOINC Code
11393-6
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.5
Description
EARS and NOSE and MOUTH and THROAT
Opt
O
Description
Problem Observation
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<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.20'/>
<id root=' ' extension=' '/>
<code code='11393-6' displayName='EARS and NOSE and MOUTH and THROAT'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.11-1: Sample Ears, Nose, Mouth and Throat Section
6.3.3.4.12 Ears Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.21
Template ID
1.3.6.1.4.1.19376.1.5.3.1.1.9.21
General Description
The ears section shall contain a description of any type of ear exam.
LOINC Code
Opt
10195-6
R
Entries
3255
3260
3265
EAR
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3250
Description
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.21'/>
<id root=' ' extension=' '/>
<code code='10195-6' displayName='EAR'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.12-1: Sample Ears Section
6.3.3.4.13 Nose Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.22
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.9.22
The nose section shall contain a description of any type of nose exam.
LOINC Code
10203-8
Opt
R
Description
NOSE
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Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3270
3275
3280
3285
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.22'/>
<id root=' ' extension=' '/>
<code code='10203-8' displayName='NOSE'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.13-1: Sample Nose Section
6.3.3.4.14 Mouth, Throat and Teeth Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.23
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.9.23
The mouth, throat, and teeth section shall contain a description of any type of mouth,
throat, or teeth exam.
LOINC Code
10201-2
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.5
3290
3295
3300
3305
Description
MOUTH and THROAT and TEETH
Opt
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.23'/>
<id root=' ' extension=' '/>
<code code='10201-2' displayName='MOUTH and THROAT and TEETH'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.14-1: Sample Mouth, Throat and Teeth Section
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6.3.3.4.15 Neck Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.24
Template ID
1.3.6.1.4.1.19376.1.5.3.1.1.9.24
General Description
The neck section shall contain a description of any type of neck exam.
LOINC Code
Opt
11411-6
R
Entries
3315
3320
3325
NECK
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3310
Description
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.24'/>
<id root=' ' extension=' '/>
<code code='11411-6' displayName='NECK'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.15-1: Sample Neck Section
6.3.3.4.16 Endocrine System Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.25
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.9.25
The endocrine system section shall contain a description of any type of endocrine
system exam.
LOINC Code
29307-6
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.5
Description
ENDOCRINE SYSTEM
Opt
O
Description
Problem Observation
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<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.25'/>
<id root=' ' extension=' '/>
<code code='29307-6' displayName='ENDOCRINE SYSTEM'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.16-1: Sample Endocrine System Section
6.3.3.4.17 Thorax and Lungs Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.26
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.9.26
The thorax and lungs section shall contain a description of any type of thoracic or lung
exams.
LOINC Code
10207-9
Opt
R
Entries
3355
3360
3365
THORAX+LUNGS
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3350
Description
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.26'/>
<id root=' ' extension=' '/>
<code code='10207-9' displayName='THORAX+LUNGS'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.17-1: Sample Thorax and Lungs Section
6.3.3.4.18 Chest Wall Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.27
Template ID
General Description
LOINC Code
1.3.6.1.4.1.19376.1.5.3.1.1.9.27
The chest wall section shall contain a description of any type of chest wall exam.
Opt
Description
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11392-8
R
Entries
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3370
3375
3380
3385
CHEST WALL
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.27'/>
<id root=' ' extension=' '/>
<code code='11392-8' displayName='CHEST WALL'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.18-1: Sample Chest Wall Section
6.3.3.4.19 Breast Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.28
Template ID
1.3.6.1.4.1.19376.1.5.3.1.1.9.28
General Description
The breast section shall contain a description of any type of breast exam.
LOINC Code
Opt
10193-1
R
Entries
3395
3400
3405
BREASTS
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3390
Description
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.28'/>
<id root=' ' extension=' '/>
<code code='10193-1' displayName='BREASTS'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.19-1: Sample Breast Section
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6.3.3.4.20 Heart Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.29
Template ID
1.3.6.1.4.1.19376.1.5.3.1.1.9.29
General Description
The heart section shall contain a description of any type of heart exam.
LOINC Code
Opt
10200-4
R
Entries
3415
3420
3425
HEART
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3410
Description
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.29'/>
<id root=' ' extension=' '/>
<code code='10200-4' displayName='HEART'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.20-1: Sample Heart Section
6.3.3.4.21 Respiratory System Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.30
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.9.30
The respiratory system section shall contain a description of any type of respiratory
exam.
LOINC Code
11412-4
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.5
Description
RESPIRATORY SYSTEM
Opt
O
Description
Problem Observation
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<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.30'/>
<id root=' ' extension=' '/>
<code code='11412-4' displayName='RESPIRATORY SYSTEM'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.21-1: Sample Respiratory System Section
6.3.3.4.22 Abdomen Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.31
Template ID
1.3.6.1.4.1.19376.1.5.3.1.1.9.31
General Description
The abdomen system section shall contain a description of any type of abdominal exam.
LOINC Code
Opt
10191-5
R
Entries
3455
3460
3465
ABDOMEN
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3450
Description
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.31'/>
<id root=' ' extension=' '/>
<code code='10191-5' displayName='ABDOMEN'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.22-1: Sample Abdomen Section
6.3.3.4.23 Lymphatic System Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.32
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.9.32
The lymphatic system section shall contain a description of any type of lymphatic exam.
LOINC Code
11447-0
Opt
R
Description
HEMATOLOGIC+LYMPHATIC+IMMUNOLOGIC SYSTEM
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Entries
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3470
3475
3480
3485
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.32'/>
<id root=' ' extension=' '/>
<code code='11447-0' displayName='HEMATOLOGIC+LYMPHATIC+IMMUNOLOGIC SYSTEM'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.23-1: Sample Lymphatic System Section
6.3.3.4.24 Vessels Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.33
Template ID
1.3.6.1.4.1.19376.1.5.3.1.1.9.33
General Description
The vessels section shall contain a description of any type of vessels exam.
LOINC Code
Opt
10208-7
R
Entries
3495
3500
3505
VESSELS
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3490
Description
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.33'/>
<id root=' ' extension=' '/>
<code code='10208-7' displayName='VESSELS'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.24-1: Sample Vessels Section
6.3.3.4.25 Musculoskeletal System Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.34
Template ID
1.3.6.1.4.1.19376.1.5.3.1.1.9.34
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General Description
The musculoskeletal system section shall contain a description of any type of
musculoskeletal exam.
LOINC Code
11410-8
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.5
3510
3515
3520
3525
Description
MUSCULOSKELETAL SYSTEM
Opt
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.34'/>
<id root=' ' extension=' '/>
<code code='11410-8' displayName='MUSCULOSKELETAL SYSTEM'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.25-1: Sample Musculoskeletal System Section
6.3.3.4.26 Neurologic System Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.35
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.9.35
The neurologic system section shall contain a description of any type of neurologic
exam.
LOINC Code
10202-0
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.5
Description
NEUROLOGIC SYSTEM
Opt
O
Description
Problem Observation
___________________________________________________________________________
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3535
3540
3545
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.35'/>
<id root=' ' extension=' '/>
<code code='10202-0' displayName='NEUROLOGIC SYSTEM'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.26-1: Sample Neurologic System Section
6.3.3.4.27 Genitalia Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.36
Template ID
1.3.6.1.4.1.19376.1.5.3.1.1.9.36
General Description
The genitalia section shall contain a description of any type of genital exam.
LOINC Code
Opt
11400-9
R
Entries
3555
3560
3565
GENITALIA
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3550
Description
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.36'/>
<id root=' ' extension=' '/>
<code code='11400-9' displayName='GENITALIA'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.27-1: Sample Genitalia Section
6.3.3.4.28 Rectum Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.37
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.9.37
The rectum section shall contain a description of any type of rectal exam.
LOINC Code
10205-3
Opt
R
Description
RECTUM
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Entries
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3570
3575
3580
3585
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.37'/>
<id root=' ' extension=' '/>
<code code='10205-3' displayName='RECTUM'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.28-1: Sample Rectum Section
6.3.3.4.29 Extremities Section 1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1
Template ID
1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1
General Description
The Extremities section SHALL contain a description of any type of exam on the
patient's extremities.
LOINC Code
Opt
10196-4
R
Entries
3595
3600
3605
EXTREMITIES
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.5
3590
Description
O
Description
Problem Observation
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1'/>
<id root=' ' extension=' '/>
<code code='10196-4' displayName='EXTREMITIES'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Optional Problem Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
:
</entry>
</section>
</component>
Figure 6.3.3.4.29-1: Sample Extremities Section
___________________________________________________________________________
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Content Profiles
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6.3.3.5 Relevant Studies
6.3.3.5.1 Results Section 1.3.6.1.4.1.19376.1.5.3.1.3.27
Template ID
1.3.6.1.4.1.19376.1.5.3.1.3.27
General Description
The results section shall contain a narrative description of the patient’s relevant studies.
LOINC Code
Opt
30954-2
3610
3615
3620
R
Description
Relevant diagnostic tests/laboratory data
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.27'/>
<id root=' ' extension=' '/>
<code code='30954-2' displayName='Relevant diagnostic tests/laboratory data'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.5.1-1: Sample Results Section
6.3.3.5.2 Coded Results Section 1.3.6.1.4.1.19376.1.5.3.1.3.28
Template ID
1.3.6.1.4.1.19376.1.5.3.1.3.28
Parent Template ID
1.3.6.1.4.1.19376.1.5.3.1.3.27
General Description
The results section shall contain a narrative description of the relevant diagnostic
procedures the patient received in the past. It shall include entries for procedures and
references to procedure reports when known as described in the Entry Content Modules.
LOINC Code
30954-2
Opt
R
Entries
Description
Relevant diagnostic tests/laboratory data
Opt
Description
1.3.6.1.4.1.19376.1.5.3.1.4.19
R
Procedure Entry
1.3.6.1.4.1.19376.1.5.3.1.4.4
R2
References Entry
1.3.6.1.4.1.19376.1.5.3.1.4.13
R
Simple Observation
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Content Profiles
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3625
3630
3635
3640
3645
3650
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.28'/>
<id root=' ' extension=' '/>
<code code='30954-2' displayName='Relevant diagnostic tests/laboratory data'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Procedure Entry element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
:
</entry>
<entry>
:
<!-- Required if known References Entry element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
:
</entry>
<entry>
:
<!-- Optional Simple Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
:
</entry>
</section>
</component>
3655
Figure 6.3.3.5.2-1: Sample Coded Results Section
6.3.3.5.3 Hospital Studies Summary Section 1.3.6.1.4.1.19376.1.5.3.1.3.29
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.29
The hospital studies summary section shall contain a narrative description of the
relevant diagnostic procedures the patient received during the hospital admission.
LOINC Code
11493-4
3660
3665
Opt
R
Description
HOSPITAL DISCHARGE STUDIES SUMMARY
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.29'/>
<id root=' ' extension=' '/>
<code code='11493-4' displayName='HOSPITAL DISCHARGE STUDIES SUMMARY'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
3670
Figure 6.3.3.5.3-1: Sample Hospital Studies Summary Section
6.3.3.5.3.1 Coded Hospital Studies Summary Section 1.3.6.1.4.1.19376.1.5.3.1.3.30
Template ID
1.3.6.1.4.1.19376.1.5.3.1.3.30
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Content Profiles
______________________________________________________________________________
Parent Template
General Description
Hospital Studies Summary (1.3.6.1.4.1.19376.1.5.3.1.3.29)
The hospital studies summary section shall include entries for diagnostic procedures and
references to procedure reports when known as described in the Entry Content Modules.
LOINC Code
11493-4
Opt
R
Entries
Description
HOSPITAL DISCHARGE STUDIES SUMMARY
Opt
Description
1.3.6.1.4.1.19376.1.5.3.1.4.16
R
Procedure Entry
1.3.6.1.4.1.19376.1.5.3.1.4.4
R2
References Entry
6.3.3.5.3.1.1 Parent Template
The parent of this template is Hospital Studies Summary.
3675
3680
3685
3690
3695
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.29'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.30'/>
<id root=' ' extension=' '/>
<code code='11493-4' displayName='HOSPITAL DISCHARGE STUDIES SUMMARY'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Procedure Entry element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.16'/>
:
</entry>
<entry>
:
<!-- Required if known References Entry element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
:
</entry>
</section>
</component>
3700
Figure 6.3.3.5.3.1.1-1: Sample Coded Hospital Studies Summary Section
6.3.3.5.4 Reserved for (Coded Hospital Studies Summary)
6.3.3.5.5 Reserved for (Consultations)
6.3.3.5.6 Reserved for (Antenatal Testing and Surveillance Section)
6.3.3.5.7 Reserved for (Coded Antenatal Testing and Surveillance Section)
3705
6.3.3.5.8 Diagnosis
Removed from CDA Content Module supplement 2011-09 at the request of QRPH
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______________________________________________________________________________
6.3.3.5.9 TNM Stage
Removed from CDA Content Module supplement 2011-09 at the request of QRPH
6.3.3.5.10 Cancer Supporting Documentation
3710
Removed from CDA Content Module supplement 2011-09 at the request of QRPH
6.3.3.5.11 Reserved for (Hearing Screening Coded Results)
6.3.3.6 Plans of Care
This section provides content modules for sections that describe the plan of care intended for the
patient.
3715
6.3.3.6.1 Care Plan Section 1.3.6.1.4.1.19376.1.5.3.1.3.31
Template ID
1.3.6.1.4.1.19376.1.5.3.1.3.31
Parent Template
CCD 3.16 (2.16.840.1.113883.10.20.1.10)
General Description
The care plan section shall contain a narrative description of the expectations for care
including proposals, goals, and order requests for monitoring, tracking, or improving the
condition of the patient.
LOINC Code
Opt
61145-9
R
Description
PATIENT PLAN OF CARE
6.3.3.6.1.1 Parent Template
The parent of this template is CCD 3.16.
3720
3725
3730
<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=' ' extension=' '/>
<code code='61145-9' displayName='PATIENT PLAN OF CARE'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.6.1.1-1: Sample Care Plan Section
6.3.3.6.2 Assessment and Plan Section 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5
Template ID
General Description
LOINC Code
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5
The assessment and plan section shall contain a narrative description of the assessment
of the patient condition and expectations for care including proposals, goals, and order
requests for monitoring, tracking, or improving the condition of the patient.
Opt
Description
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______________________________________________________________________________
51847-2
3735
3740
3745
R
ASSESSMENT AND PLAN
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5'/>
<id root=' ' extension=' '/>
<code code='51847-2' displayName='ASSESSMENT AND PLAN'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.6.2-1: Sample Assessment and Plan Section
6.3.3.6.3 Discharge Disposition Section 1.3.6.1.4.1.19376.1.5.3.1.3.32
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.32
The Discharge Disposition section shall contain a narrative description of the state or
disposition of the patient at the time of discharge from the hospital.
LOINC Code
8650-4
3750
3755
3760
Opt
R
Description
Hospital discharge disposition
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.32'/>
<id root=' ' extension=' '/>
<code code='8650-4' displayName='Hospital discharge disposition'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.6.3-1: Sample Discharge Disposition Section
6.3.3.6.4 Discharge Diet Section 1.3.6.1.4.1.19376.1.5.3.1.3.33
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.33
The discharge diet section shall contain a narrative description of the expectations for
diet including proposals, goals, and order requests for monitoring, tracking, or
improving the dietary control of the patient, specifically used in a discharge from a
facility such as an emergency department, hospital, or nursing home.
LOINC Code
42344-2
Opt
R
Description
DISCHARGE DIET
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3765
3770
3775
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.33'/>
<id root=' ' extension=' '/>
<code code='42344-2' displayName='DISCHARGE DIET'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.6.4-1: Sample Discharge Diet Section
6.3.3.6.5 Advance Directives Section 1.3.6.1.4.1.19376.1.5.3.1.3.34
Template ID
Parent Template
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.34
CCD 3.2 (2.16.840.1.113883.10.20.1.1)
The advance directive section shall contain a narrative description of the list of
documents (e.g., Durable Power of Attorney, Code Status) that define the patient’s
expectations and requests for care along with the locations of the documents.
LOINC Code
42348-3
Opt
R
Description
ADVANCE DIRECTIVES
6.3.3.6.5.1 Parent Template
3780
3785
3790
The parent of this template is CCD 3.2. This template is compatible with the ASTM/HL7
Continuity of Care Document template: 2.16.840.1.113883.10.20.1.1
<component>
<section>
<templateId root='2.16.840.1.113883.10.20.1.1'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
<id root=' ' extension=' '/>
<code code='42348-3' displayName='ADVANCE DIRECTIVES'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
3795
Figure 6.3.3.6.5.1-1: Sample Advance Directives Section
6.3.3.6.6 Coded Advance Directives Section 1.3.6.1.4.1.19376.1.5.3.1.3.35
Template ID
Parent Template
General Description
1.3.6.1.4.1.19376.1.5.3.1.3.35
Advance Directives (1.3.6.1.4.1.19376.1.5.3.1.3.34)
The advance directive section shall include entries for references to consent and advance
directive documents (e.g., Durable Power of Attorney, Code Status) when known as
described in the Entry Content Modules.
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Content Profiles
______________________________________________________________________________
LOINC Code
42348-3
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.13.7
Description
ADVANCE DIRECTIVES
Opt
R2
Description
Advance Directive Observation
6.3.3.6.6.1 Parent Template
The parent of this template is Advance Directives.
3800
3805
3810
3815
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.35'/>
<id root=' ' extension=' '/>
<code code='42348-3' displayName='ADVANCE DIRECTIVES'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required if known Advance Directive Observation element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.7'/>
:
</entry>
</section>
</component>
Figure 6.3.3.6.6.1-1: Sample Coded Advance Directives Section
3820
6.3.3.6.7 Transport Mode Section
This section intentionally left blank. Transport Section 6.3.3.6.7 removed as a duplicate of
6.3.3.7.3.
6.3.3.6.8 Reserved for (Procedure Care Plan Status Report Section)
Defined in the CDA Content Modules supplement,
3825
6.3.3.6.9 Reserved for (Health Maintenance Care Plan Section)
Defined in the CDA Content Modules supplement.
6.3.3.6.10 Reserved for (Health Maintenance Care Plan Status Report Section)
Defined in the CDA Content Modules supplement.
6.3.3.6.11 Reserved for (Provider Orders Section)
3830
Defined in the CDA Content Modules supplement.
___________________________________________________________________________
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6.3.3.6.12 Reserved for (Birth Plan Section)
Defined in the CDA Content Modules supplement.
6.3.3.6.13 Immunization Recommendations 1.3.6.1.4.1.19376.1.5.3.1.1.18.3.1
Template Id
General Description
LOINC Code
18776-5
1.3.6.1.4.1.19376.1.5.3.1.1.18.3.1
The Immunization Recommendation section shall be present to document the
recommended vaccinations for the patient. It shall include Immunization entries in
proposal mood describing the immunization plan to be developed. It may include a
reference to a specific guideline in definition mood to indicate the guideline that
should be conformed to, and may also include references to patient education
information.
Opt
R
Entries
1.3.6.1.4.1.19376.1.5.3.1.4.12.2
Description
TREATMENT PLAN
Opt
R
Description
Immunization Recommendation Entry
At least one Immunization Plan Entry shall be present in Proposal
mood to indicate what the proposed care is for the patient. Other
Immunization Plan entries may appear in intent mood to indicate the
current plan.
6.3.3.6.14 Reserved for Patient Education Section
3835
6.3.3.6.15 Reserved for Coded Care Plan Section
6.3.3.6.16 Reserved for Diet and Nutrition Section
6.3.3.6.17 Reserved for Intake and Output Section
6.3.3.6.18 Cancer Course of Treatment
Removed from the CDA Content Modules Supplement 2011-09 at the request of QRPH.
3840
6.3.3.6.19 Cancer Treatment Plan
Removed from the CDA Content Modules Supplement 2011-09 at the request of QRPH.
6.3.3.6.20 Reserved for (Procedure Care Plan Section)
6.3.3.6.21 Reserved for (Protocols Used Section)
6.3.3.6.22 Reserved for (Invasive Airway Section)
3845
6.3.3.6.23 Reserved for (Ventilator Usage Section)
___________________________________________________________________________
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______________________________________________________________________________
6.3.3.7 Administrative and Other Information
6.3.3.7.1 Payers Section 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7
Template ID
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7
Parent Template
CCD 3.1 (2.16.840.1.113883.10.20.1.9)
The Payers section contains data on the patient’s payers, whether a �third party’
insurance, self-pay, other payer or guarantor, or some combination.
General Description
LOINC Code
Opt
48768-6
R
Entries
Description
PAYMENT SOURCES
Opt
1.3.6.1.4.1.19376.1.5.3.1.4.17
R2
Description
Coverage Entry
3850
6.3.3.7.1.1 Parent Template
The parent of this template is CCD 3.1.
3855
3860
3865
3870
<component>
<section>
<templateId root='2.16.840.1.113883.10.20.1.9'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7'/>
<id root=' ' extension=' '/>
<code code='48768-6' displayName='PAYMENT SOURCES'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required if known Coverage Entry element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.17'/>
:
</entry>
</section>
</component>
Figure 6.3.3.7.1.1-1: Sample Payers Section
6.3.3.7.2 Referral Source Section 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3
The Referral Source section shall contain a narrative description of the referral source of
the patient. Patients who are not referred by a particular agency or health care provider
should be designated as "self referred".
LOINC Code
11293-8
Opt
R
Description
ED REFERRAL SOURCE
___________________________________________________________________________
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3875
3880
3885
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3'/>
<id root=' ' extension=' '/>
<code code='11293-8' displayName='ED REFERRAL SOURCE'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
</section>
</component>
Figure 6.3.3.7.2-1: Sample Referral Source Section
6.3.3.7.3 Transport Mode Section 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
Template ID
1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
General Description
The transport mode section contains a description of the mode of transport and the time
of departure or arrival of the patient to a facility.
LOINC Code
Opt
11459-5
R
Entries
3895
3900
3905
TRANSPORT MODE
Opt
1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1
3890
Description
R
Description
Transport
This entry provides coded values giving the mode and time of departure or
arrival of the patient to a facility.
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/>
<id root=' ' extension=' '/>
<code code='11459-5' displayName='TRANSPORT MODE'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Transport element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'/>
:
</entry>
</section>
</component>
Figure 6.3.3.7.3-1: Sample Transport Mode Section
6.3.3.7.4 ED Disposition Section 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10
Template ID
General Description
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10
The ED Disposition section contains descriptions of the various components of ED
Disposition, including disposition from the ED, time of disposition, intended
transportation mode, time of transport, and the non-ED practitioner the patient's care
will be transferred to.
___________________________________________________________________________
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______________________________________________________________________________
LOINC Code
Opt
11302-7
R
Entries
Description
ED DISPOSITION
Opt
1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2
R
Description
Encounter Disposition
This required entry describes the expected or actual disposition of the
patient after the emergency department encounter has been completed.
3910
3915
3920
3925
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'/>
<id root=' ' extension=' '/>
<code code='11302-7' displayName='ED DISPOSITION'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text>
Text as described above
</text>
<entry>
:
<!-- Required Encounter Disposition element -->
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2'/>
:
</entry>
</section>
</component>
Figure 6.3.3.7.4-1: Sample ED Disposition Section
3930
6.3.3.7.5 Cancer Payers
Removed from the CDA Content Modules Supplement 2011-09 at the request of QRPH.
6.3.3.7.6 Reserved for Sending Facility Section
6.3.3.7.7 Reserved for Receiving Facility Section
6.3.3.7.8 Reserved for Mass Casualty Incident Section
3935
6.3.3.7.9 Reserved for Unit Response Level Section
6.3.3.7.10 Reserved for Extra Attendants Information Section
6.3.3.7.11 Reserved for Provider Level Section
6.3.3.8 Interventions
6.3.3.8.1 Intentionally left blank
3940
6.3.3.8.2 Intentionally left blank
6.3.3.8.3 Reserved for Procedures and Interventions Section
___________________________________________________________________________
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6.3.3.8.4 Reserved for Intravenous Fluids Administered Section
6.3.3.9 Impressions
3945
6.3.3.9.1 Pre-procedure Impressions Section 1.3.6.1.4.1.19376.1.5.3.1.1.9.42
(Deprecated)
6.3.3.9.2 Reserved for Pre-procedure Risk Assessment Section
6.3.3.9.3 Reserved for Antepartum Visit Summary Flowsheet Section
6.3.3.9.4 Reserved for Progress Note Section
6.3.3.9.5 Reserved for ED Diagnosis Section
3950
6.3.3.9.6 Reserved for Acuity Assessment Section
6.3.3.9.7 Reserved for Assessments Section
6.3.3.10 Section Content Modules (non-categorized)
3955
Please note: As of 2013, section content modules are no longer being categorized into one of the
nine existing categories (6.3.3.1 through 6.3.3.9). Instead, going forward, all section content
modules will be placed under the 6.3.3.10 heading.
6.3.3.10.1 Reserved for VRDR Death Report Section
6.3.3.10.2 Reserved for Coded Hospital Course Section
6.3.3.10.3 Reserved for Resources to Support Goals Section
6.3.3.10.4 Reserved for Healthy Weight Care Plan Section
3960
6.3.3.10.5 Reserved for Occupational Data for Health Section
6.3.4 CDA Entry Content Modules
6.3.4.1 Authors and Informants
3965
Each clinical statement that can be made in a CDA Document or HL7 Version 3 message shall
be attributable to one or more authors. These are found in <author> elements, either directly
within the clinical statement, or in one of its ancestors in the XML document or message.
Each clinical statement may also contain information from zero or more informants. These are
found in <informant> elements, again, either directly within the clinical statement, or in one of
its ancestors in the XML document or message.
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6.3.4.1.1 <author>
3970
Authors shall be described in an <author> element that is either directly on the clinical statement,
or which can be reached by one of its ancestors.
6.3.4.1.2 <time value=' '/>
The time of authorship shall be recorded in the <time> element.
3975
3980
6.3.4.1.3 <assignedAuthor> -OR- <assignedEntity1>
<id root=' ' extension=' '>
<addr></addr>
<telecom value=' ' use=' '>
In a CDA document details about the author are provided in the <assignedAuthor> element. In
Version 3 messages, they are provided in the <assignedEntity1> element. The semantics are
identical even though the element names differ. The identifier of the author, and their address
and telephone number shall be present inside the <id>, <addr> and <telecom> elements.
6.3.4.1.4 <assignedPerson><name></name></assignedPerson>
<representedOrganization><name></name></representedOrganization>
3985
The author's and/or the organization's name shall be present when the <author> element is
present.
6.3.4.2 Linking Narrative and Coded Entries
This section defines a linking mechanism that allows entries or portions thereof to be connected
to the text of the clinical document.
6.3.4.2.1 Standards
RIM
HL7 Version 3 Reference Information Model
CDAR2 HL7 Clinical Document Architecture Release 2.0
3990
6.3.4.2.2 Constraints for CDA
Elements within the narrative <text> will use the ID attribute to provide a destination for links.
Elements within an <entry> will be linked to the text via a URI reference using this attribute as
the fragment identifier. This links the coded entry to the specific narrative text it is related to
within the CDA instance, and can be traversed in either direction. This serves three purposes:
3995
1. It supports diagnostics during software development and testing.
2. It provides a mechanism to enrich the markup that can be supported in the viewing
application.
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4000
4005
3. It eliminates the need to duplicate content in two places, which prevents a common
source of error, and eliminates steps needed to validate that content that should be
identical in fact is.
Each narrative content element within CDA may have an ID attribute. This attribute is of type
xs:ID. This means that each ID in the document must be unique within that document. Within an
XML document, an attribute of type xs:ID must start with a letter, and may be followed one or
more letters, digits, hyphens or underscores . Three different examples showing the use of the ID
attribute, and references to it appear below:
Table 6.3.4.2.2-1: Example Uses of ID
Use of ID
4010
References to ID
<tr ID='foo'>
<td ID='bar'>Table Cell 1</td>
<td>Table Cell 2</td>
</tr>
<code>
<originalText><reference value='#foo'></originalText>
</code>
<code>
<originalText><reference value='#bar'></originalText>
</code>
<list>
<item ID='baz'>List item 1</item>
</list>
<code>
<originalText><reference value='#baz'></originalText>
</code>
<paragraph ID='p-1'>A paragraph
<content ID='c-1'>with
content</content>
</paragraph>
<code>
<originalText><reference value='#p-1'></originalText>
</code>
<code>
<originalText><reference value='#c-1'></originalText>
</code>
This allows the text to be located with a special type of URI reference, which simply contains a
fragment identifier. This URI is local to the document and so just begins with a hash mark (#),
and is followed by the value of the ID being referenced. Given one of these URIs stored in a
variable named theURI, the necessary text value can be found via the following XPath
expression:
string(//*[@ID=substring-after('#',$theURI)])
4015
The table below shows the result of this expression using the examples above:
$theURI
Returned Value
"#bar"
"Table Cell 1"
"#foo"
"Table Cell 1Table Cell 2" (note the spacing issue between 1
and T)
"#p-1"
"A paragraph with content"
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$theURI
"#c-1"
Returned Value
"with content"
If your XSLT processor is schema aware, even more efficient mechanisms exist to locate the
element than the above expression.
4020
4025
Having identified the critical text in the narrative, any elements using the HL7 CD datatype (e.g.,
<code>) can then contain a <reference> to the <originalText> found in the narrative. That is
why, although CDA allows <value> to be of any type in <entry> elements, this profile restricts
them to always be of xsi:type='CD'.
Now, given an item with an ID stored in a variable named theID all <reference> elements
referring to it can be found via the following XPath expression:
//cda:reference[@URI=concat('#',$theID)]
6.3.4.2.3 Constraints for HL7 Version 3 Messages
4030
Unlike CDA entries, structured statements in HL7 Version 3 Messages do not have a related
narrative text section. Therefore full text representations should be included in the <text>
element care statement acts.
6.3.4.3 Severity 1.3.6.1.4.1.19376.1.5.3.1.4.1
Any condition or allergy may be the subject of a severity observation. This structure is included
in the target act using the <entryRelationship> element defined in the CDA Schema.
4035
The example below shows the recording the condition or allergy severity, and is used as the
context for the following sections.
6.3.4.3.1 Standards
PatCareStruct HL7 Care Provision Domain (DSTU)
CCD
ASTM/HL7 Continuity of Care Document
6.3.4.3.2 Specification
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4045
4050
4055
<observation classCode='COND' moodCode='EVN'>
<entryRelationship typeCode='SUBJ' inversionInd='true'>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.55'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1'/>
<code code='SEV' displayName='Severity'
codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode' />
<text><reference value='#severity-2'/></text>
<statusCode code='completed'/>
<value xsi:type='CD' code='H|M|L'
codeSystem='2.16.840.1.113883.5.1063'
codeSystemName='ObservationValue' />
</observation>
</entryRelationship>
</observation>
4060
4065
This specification models a severity observation as a separate observation from the condition.
While this model is different from work presently underway by various organizations (i.e.,
SNOMED, HL7, TermInfo), it is not wholly incompatible with that work. In that work, qualifiers
may be used to identify severity in the coded condition observation, and a separate severity
observation is no longer necessary. The use of qualifiers is not precluded by this specification.
However, to support semantic interoperability between EMR systems using different
vocabularies, this specification does require that severity information also be provided in a
separate observation. This ensures that all EMR systems have equal access to the information,
regardless of the vocabularies they support.
6.3.4.3.2.1 <entryRelationship typeCode='SUBJ' inversionInd='true'>
4070
4075
The related statement is made about the severity of the condition (or allergy). For CDA, this
observation is recorded inside an <entryRelationship> element occurring in the condition, allergy
or medication entry. The containing <entry> is the subject (typeCode='SUBJ') of this new
observation, which is the inverse of the normal containment structure, thus inversionInd='true'.
For HL7 Version 3 Messages this relationship is represented with a <sourceOf> element,
however the semantics, typeCode, and inversionInd is unchanged.
6.3.4.3.2.2 <observation moodCode='EVN' classCode='OBS'>
The related statement is another event (moodCode='EVN') observing (<observation
classCode='OBS'>) the severity of the (surrounding) related entry (e.g., a condition or allergy).
4080
6.3.4.3.2.3 <templateId root='2.16.840.1.113883.10.20.1.55'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1'/>
The <templateId> elements identifies this <observation> as a severity observation, allowing for
validation of the content. As a side effect, readers of the CDA can quickly locate and identify
severity observations. The templateId elements shown above must be present.
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6.3.4.3.2.4 <code code='SEV' codeSystem='2.16.840.1.113883.5.4'
displayName='Severity' codeSystemName='ActCode' />
This observation is of severity, as indicated by the <code> element listed above. This element is
required. The code and codeSystem attributes shall be recorded exactly as shown above.
6.3.4.3.2.5 <text><reference value='#severity-2'/></text>
4090
The <observation> element shall contain a <text> element. For CDA, the <text> elements shall
contain a <reference> element pointing to the narrative where the severity is recorded, rather
than duplicate text to avoid ambiguity. For HL7 Version 3 Messages, the <text> element should
contain the full narrative text.
6.3.4.3.2.6 <statusCode code='completed'/>
4095
The code attribute of <statusCode> for all severity observations shall be completed. While the
<statusCode> element is required in all acts to record the status of the act, the only sensible value
of this element in this context is completed.
6.3.4.3.2.7 <value xsi:type='CD' code='H|M|L'
codeSystem='2.16.840.1.113883.5.1063'
codeSystemName='SeverityObservation'>
4100
4105
The <value> element contains the level of severity. It is always represented using the CD
datatype (xsi:type='CD'), even though the value may be a coded or uncoded string. If coded, it
should use the HL7 SeverityObservation vocabulary (codeSystem='2.16.840.1.113883.5.1063')
containing three values (H, M, and L), representing high, moderate and low severity depending
upon whether the severity is life threatening, presents noticeable adverse consequences, or is
unlikely substantially affect the situation of the subject.
6.3.4.4 Problem Status Observation 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
4110
Any problem or allergy observation may reference a problem status observation. This structure is
included in the target observation using the <entryRelationship> element defined in the CDA
Schema. The clinical status observation records information about the current status of the
problem or allergy, for example, whether it is active, in remission, resolved, et cetera. The
example below shows the recording of clinical status of a condition or allergy, and is used as the
context for the following sections.
6.3.4.4.1 Standards
CCD ASTM/HL7 Continuity of Care Document
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6.3.4.4.2 Specification
4115
4120
4125
4130
<entry>
<observation classCode='OBS' moodCode='EVN'>
<entryRelationship typeCode='REFR' inversionInd='false'>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.57'/>
<templateId root='2.16.840.1.113883.10.20.1.50'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1.1'/>
<code code='33999-4' displayName='Status'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />
<text><reference value='#cstatus-2'/></text>
<statusCode code='completed'/>
<value xsi:type='CE' code=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED
CT'/>
</observation>
</entryRelationship>
</observation>
</entry>
4135
4140
This CCD models a problem status observation as a separate observation from the problem,
allergy or medication observation. While this model is different from work presently underway
by various organizations (i.e., SNOMED, HL7, TermInfo), it is not wholly incompatible with
that work. In that work, qualifiers may be used to identify problem status in the coded condition
observation, and a separate clinical status observation is no longer necessary. The use of
qualifiers in the problem observation is not precluded by this specification or by CCD. However,
to support semantic interoperability between EMR systems using different vocabularies, this
specification does require that problem status information also be provided in a separate
observation. This ensures that all EMR systems have equal access to the information, regardless
of the vocabularies they support.
6.3.4.4.3 <entryRelationship typeCode='REFR' inversionInd='false'>
4145
The related statement is made about the clinical status of the problem or allergy. For CDA, this
observation is recorded inside an <entryRelationship> element occurring in the problem or
allergy. For HL7 Version 3 Messages, the <entryRelationship> tag name is <sourceOf>, though
the typeCode and inversionInd attributes and other semantics remain the same. The containing
observation refers to (typeCode='REFR') this new observation.
4150
6.3.4.4.4 <observation moodCode='EVN' classCode='OBS'>
The related statement is another event (moodCode='EVN') observing (<observation
classCode='OBS'>) the clinical status of the (surrounding) related observation (e.g., a problem or
allergy).
4155
6.3.4.4.5 <templateId root='2.16.840.1.113883.10.20.1.57'/>
<templateId root='2.16.840.1.113883.10.20.1.50'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1.1'/>
These <templateId> elements identify this <observation> as a problem status observation,
allowing for validation of the content.
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6.3.4.4.6 <code code='33999-4' codeSystem='2.16.840.1.113883.6.1'
displayName='Status' codeSystemName='LOINC' />
This observation is of clinical status, as indicated by the <code> element. This element must be
present. The code and codeSystem shall be recorded exactly as shown above.
6.3.4.4.7 <text><reference value='#cstatus-2'/></text>
4165
The <observation> element shall contain a <text> element that points to the narrative text
describing the clinical status. For CDA, the <text> elements shall contain a <reference> element
pointing to the narrative section (see Linking Narrative and Coded Entries), rather than duplicate
text to avoid ambiguity. For HL7 Version 3 Messages, the <text> element SHALL contain the
full narrative text.
6.3.4.4.8 <statusCode code='completed'/>
4170
The code attribute of <statusCode> for all clinical status observations shall be completed. While
the <statusCode> element is required in all acts to record the status of the act, the only sensible
value of this element in this context is completed.
6.3.4.4.9 <value xsi:type='CE' code=' ' displayName=' '
codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'>
4175
The <value> element contains the clinical status. It is always represented using the CE datatype
(xsi:type='CE'). It shall contain a code from the following set of values from SNOMED CT.
Code
Description
55561003
Active
73425007
Inactive
90734009
Chronic
7087005
Intermittent
255227004
Recurrent
415684004
Rule out
410516002
Ruled out
413322009
Resolved
6.3.4.5 Health Status 1.3.6.1.4.1.19376.1.5.3.1.4.1.2
4180
A problem observation may reference a health status observation. This structure is included in
the target observation using the <entryRelationship> element defined in the CDA Schema. The
health status observation records information about the current health status of the patient. The
example below shows the recording the health status, and is used as the context for the following
sections.
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4185
6.3.4.5.1 Specification
<entry>
<observation classCode='OBS' moodCode='EVN'>
4190
4195
4200
<entryRelationship typeCode='REFR' inversionInd='false'>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.51'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1.2'/>
<code code='11323-3' displayName='Health Status'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />
<text><reference value='#hstatus-2'/></text>
<statusCode code='completed'/>
</value>
<value xsi:type='CE' code=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED
CT'/>
</observation>
</entryRelationship>
</observation>
</entry>
4205
This specification models a health status observation as a separate observation about the patient.
6.3.4.5.2 <entryRelationship typeCode='REFR'>
4210
The related statement is made about the health status of the patient. For CDA, this observation is
recorded inside an <entryRelationship> element occurring in the observation. The contained
observation is referenced (typeCode='REFR') by the observation entry. For HL7 Version 3
Messages, the entryRelationship tagName is sourceOf, though the typeCode and inversionInd
attributes and other semantics remain the same.
6.3.4.5.3 <observation moodCode='EVN' classCode='OBS'>
The related statement is another event (moodCode='EVN') observing (<observation
classCode='OBS'>) the health status of the patient.
4215
6.3.4.5.4 <templateId root='2.16.840.1.113883.10.20.1.51'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.1.2'/>
The <templateId> element identifies this <observation> as a health status observation, allowing
for validation of the content.
4220
6.3.4.5.5 <code code='11323-3'
displayName='Health Status'
codeSystem='2.16.840.1.113883.6.1'
codeSystemName='LOINC' />
This observation is of health status, as indicated by the <code> element. This element must be
present. The code and codeSystem attributes shall be recorded exactly as shown above.
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4225
6.3.4.5.6 <text><reference value='#hstatus-2'/></text>
4230
The <observation> element shall contain a <text> element that contains the narrative text
describing the clinical status. For CDA, the <text> elements shall contain a <reference> element
pointing to the narrative section (see Linking Narrative and Coded Entries, rather than duplicate
text to avoid ambiguity. For HL7 Version 3 Messages, the <text> element shall contain the full
narrative text.
6.3.4.5.7 <statusCode code='completed'/>
The code attribute of <statusCode> for all health status observations shall be completed. While
the <statusCode> element is required in all acts to record the status of the act, the only sensible
value of this element in this context is completed.
4235
6.3.4.5.8 <value xsi:type='CE' code=' ' displayName=' '
codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'>
The <value> element contains the clinical status. It is always represented using the CE datatype
(xsi:type='CE').
Code
Description
81323004
Alive and well
313386006
In remission
162467007
Symptom free
161901003
Chronically ill
271593001
Severely ill
21134002
Disabled
161045001
Severely
disabled
419099009
Deceased
4240
6.3.4.6 Comments 1.3.6.1.4.1.19376.1.5.3.1.4.2
4245
This entry allows for a comment to be supplied with each entry. For CDA this structure is
usually included in the target act using the <entryRelationship> element defined in the CDA
Schema, but can also be used in the <component> element when the comment appears within an
<organizer>. The example below shows recording a comment for an <entry>, and is used as
context for the following sections. For HL7 Version 3 Messages, this relationship is represented
with the element <sourceOf>, although the remainder of the typecodes and semantics are
unchanged.
Any condition or allergy may be the subject of a comment.
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6.3.4.6.1 Standards
CareStruct HL7 Care Provision Care Structures (DSTU)
CCD
ASTM/HL7 Continuity of Care Document
6.3.4.6.2 Specification
4255
4260
4265
4270
4275
4280
4285
4290
4295
<entry>
<observation classCode='OBS' moodCode='EVN'>
∶
<entryRelationship typeCode='SUBJ' inversionInd='true'>
<act classCode='ACT' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.40'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>
<code code='48767-8' displayName='Annotation Comment'
codeSystem='2.16.840.1.113883.6.1'
codeSystemName='LOINC' />
<text><reference value='#comment-2'/></text>
<statusCode code='completed' />
<author>
<time value=''/>
<assignedAuthor>
<id root='' extension=''>
<addr></addr>
<telecom value='' use=''>
<assignedPerson><name></name></assignedPerson>
<representedOrganization><name></name></representedOrganization>
</assignedAuthor>
</author>
</act>
</entryRelationship>
∶
</observation>
</entry>
<entry>
<organizer>
<component typeCode='COMP'>
<act classCode='ACT' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.40'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>
<code code='48767-8' displayName='Annotation Comment'
codeSystem='2.16.840.1.113883.6.1'
codeSystemName='LOINC' />
:
</act>
</component>
</organizer>
</entry>
6.3.4.6.3 <entryRelationship typeCode='SUBJ' inversionInd='true'> or
<component typeCode='COMP'/>
A related statement is made about an act, or a cluster or battery of results. In CDA the former
shall be recorded inside an <entryRelationship> element occurring at the end of the entry. The
containing act is the subject (typeCode='SUBJ') of this new observation, which is the inverse of
the normal containment structure, thus inversionInd='true'.
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For HL7 Version 3 Messages, the relationship element is <sourceOf>, however the typeCode
and inversionInd remain the same.
In the latter case, the comment shall be recorded inside a <component> element contained within
the <organizer> element.
6.3.4.6.4 <act classCode='ACT' moodCode='EVN'>
4305
The related statement is an event (moodCode='EVN') describing the act (classCode='ACT') of
making an arbitrary comment or providing instruction on the related entry.
6.3.4.6.5 <templateId root='2.16.840.1.113883.10.20.1.40'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>
4310
These <templateId> elements identify this <act> as a comment, allowing for validation of the
content.
6.3.4.6.6 <code code='48767-8' displayName='Annotation Comment'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />
The <code> element indicates that this is a comment and shall be recorded as shown above. The
codeSystem and code attributes shall use the values specified above.
4315
6.3.4.6.7 <text><reference value='#comment-2'/></text>
4320
The <text> element provides a way to represent the <reference> to the text of the comment in the
narrative portion of the document. For CDA, this SHALL be represented as a <reference>
element that points to the narrative text section of the CDA. The comment itself is not the act
being coded, so it appears in the <text> of the <observation>, not as part of the <code>. For HL7
Version 3 Messages, the <text> element SHALL contain the full narrative text.
6.3.4.6.8 <statusCode code='completed' />
The code attribute of <statusCode> for all comments must be completed.
6.3.4.6.9 <author>
The comment may have an author.
4325
6.3.4.6.10 <time value=' '/>
The time of the comment creation shall be recorded in the <time> element when the <author>
element is present.
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6.3.4.6.11 <assignedAuthor>
<id root=' ' extension=' '>
<addr></addr>
<telecom value=' ' use=' '>
The identifier of the author, and their address and telephone number must be present inside the
<id>, <addr> and <telecom> elements when the <author> element is present.
4335
6.3.4.6.12 <assignedPerson><name></name></assignedPerson>
<representedOrganization><name></name></representedOrganization>
The author's and/or the organization's name must be present when the <author> element is
present.
6.3.4.7 Patient Medication Instructions 1.3.6.1.4.1.19376.1.5.3.1.4.3
4340
Any medication may be the subject of further instructions to the patient, for example to indicate
that it should be taken with food, et cetera.
This structure is included in the target substance administration or supply act using the
<entryRelationship> element defined in the CDA Schema. The example below shows the
recording of patient medication instruction for an <entry>, and is used as context for the
following section.
4345
6.3.4.7.1 Standards
Pharmacy HL7 Pharmacy Domain (Normative)
6.3.4.7.2 Specification
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4355
4360
<entry>
<substanceAdministration classCode='SBADM' moodCode='EVN'>
∶
<entryRelationship typeCode='SUBJ' inversionInd='true'>
<act classCode='ACT' moodCode='INT'>
<templateId root='2.16.840.1.113883.10.20.1.49'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.3'/>
<code code='PINSTRUCT' codeSystem='1.3.6.1.4.1.19376.1.5.3.2'
codeSystemName='IHEActCode' />
<text><reference value='#comment-2'/></text>
<statusCode code='completed' />
</act>
</entryRelationship>
∶
</substanceAdministration>
</entry>
4365
6.3.4.7.3 <entryRelationship typeCode='SUBJ' inversionInd='true'>
4370
Again, a related statement is made about the medication or immunization. This observation is
recorded inside an <entryRelationship> element occurring at the end of the substance
administration or supply entry. The containing <entry> is the subject (typeCode='SUBJ') of this
new observation, which is the inverse of the normal containment structure, thus
inversionInd='true'.
6.3.4.7.4 <act classCode='ACT' moodCode='INT'>
The related statement is the intent (moodCode='INT') on how the related entry is to be
performed. .
4375
6.3.4.7.5 <templateId root='2.16.840.1.113883.10.20.1.49'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.3'/>
These <templateId> elements identify this <act> as a medication instruction, allowing for
validation of the content. As a side effect, readers of the CDA can quickly locate and identify
medication instructions.
4380
6.3.4.7.6 <code code='PINSTRUCT' codeSystem='1.3.6.1.4.1.19376.1.5.3.2'
codeSystemName='IHEActCode' />
The <code> element indicates that this is a patient medication instruction. This element shall be
recorded exactly as specified above.
Note:
These values will be sent to HL7 for harmonization with the HL7 Act Vocabulary.
6.3.4.7.7 <text><reference value='#comment-2'/></text>
4385
The <text> element indicates the text of the comment. For CDA, this SHALL be represented as a
<reference> element that points at the narrative portion of the document. The comment itself is
not the act being coded, so it appears in the <text> of the <observation>, not as part of the
<code>. For HL7 Version 3 Messages, the full text SHALL be represented here.
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6.3.4.7.8 <statusCode code='completed' />
4390
The code attribute of <statusCode> for all comments must be completed.
6.3.4.8 Medication Fulfillment Instructions 1.3.6.1.4.1.19376.1.5.3.1.4.3.1
Any medication may be the subject of further instructions to the pharmacist, for example to
indicate that it should be labeled in Spanish, et cetera.
4395
This structure is included in the target substance administration or supply act using the
<entryRelationship> element defined in the CDA Schema. The figure below is an example of
recording an instruction for an <entry>, and is used as context for the following sections.
6.3.4.8.1 Standards
Pharmacy HL7 Pharmacy Domain (Normative)
6.3.4.8.2 Specification
4400
4405
4410
4415
<entry>
<supply classCode='SPLY' moodCode='EVN'>
∶
<entryRelationship typeCode='SUBJ' inversionInd='true'>
<act classCode='ACT' moodCode='INT'>
<templateId root='2.16.840.1.113883.10.20.1.43'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.3.1'/>
<code code='FINSTRUCT' codeSystem='1.3.6.1.4.1.19376.1.5.3.2'
codeSystemName='IHEActCode' />
<text><reference value='#comment-2'/></text>
<statusCode code='completed' />
</act>
</entryRelationship>
∶
</supply>
</entry>
6.3.4.8.3 <entryRelationship typeCode='SUBJ' inversionInd='true'>
4420
4425
Again, a related statement is made about the medication or immunization. In CDA, this
observation is recorded inside an <entryRelationship> element occurring at the end of the
substance administration or supply entry. The containing <act> is the subject (typeCode='SUBJ')
of this new observation, which is the inverse of the normal containment structure, thus
inversionInd='true'. For HL7 Version 3 Messages, this relationship is represented with the
<sourceOf> element however the semantics, typeCode, and inversionInd remain the same.
6.3.4.8.4 <act classCode='ACT' moodCode='INT'>
The related statement is the intent (moodCode='INT') on how the related entry is to be
performed.
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6.3.4.8.5 <templateId root='2.16.840.1.113883.10.20.1.43'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.3.1'/>
4430
These <templateId> elements identify this <act> as a medication fulfillment instruction, allowing
for validation of the content.
6.3.4.8.6 <code code='FINSTRUCT' codeSystem='1.3.6.1.4.1.19376.1.5.3.2'
codeSystemName='IHEActCode' />
4435
The <code> element indicates that this is a medication fulfillment instruction. This element shall
be recorded exactly as specified above.
Note:
These values will be sent to HL7 for harmonization with the HL7 Act Vocabulary.
6.3.4.8.7 <text><reference value='#comment-2'/></text>
4440
The <text> element contains a free text representation of the instruction. For CDA this SHALL
contain a provides a <reference>element to the link text of the comment in the narrative portion
of the document. The comment itself is not the act being coded, so it appears in the <text> of the
<observation>, not as part of the <code>. For HL7 Version 3 Messages, the full text SHALL be
represented here.
6.3.4.8.8 <statusCode code='completed' />
The code attribute of <statusCode> for all comments must be completed.
4445
4450
6.3.4.9 External References 1.3.6.1.4.1.19376.1.5.3.1.4.4
CDA Documents may reference information contained in other documents. While CDA Release
2.0 supports references in content via the <linkHtml> element, this is insufficient for many EMR
systems as the link is assumed to be accessible via a URL, which is often not the case. In order to
link an external reference, one needs the document identifier, and access to the clinical system
wherein the document resides. For a variety of reasons, it is desirable to refer to the document by
its identity, rather than by linking through a URL.
4. The identity of a document does not change, but the URLs used to access it may vary
depending upon location, implementation, or other factors.
4455
4460
5. Referencing clinical documents by identity does not impose any implementation specific
constraints on the mechanism used to resolve these references, allowing the content to be
implementation neutral. For example, in the context of an XDS Affinity domain the
clinical system used to access documents would be an XDS Registry and one or more
XDS Repositories where documents are stored. In other contexts, access might be
through a Clinical Data Repository (CDR), or Document Content Management System
(DCMS). Each of these may have different mechanisms to resolve a document identifier
to the document resource.
6. The identity of a document is known before the document is published (e.g., in an XDS
Repository, Clinical Data Repository, or Document Content Management System), but its
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4465
URL is often not known. Using the document identity allows references to existing
documents to be created before those documents have been published to a URL. This is
important to document creators, as it does not impose workflow restrictions on how links
are created during the authoring process.
Fortunately, CDA Release 2.0 also provides a mechanism to refer to external documents in an
entry, as shown below.
4470
4475
4480
4485
4490
6.3.4.9.1 Specification
<entry>
<act classCode='ACT' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
<id root='' extension=''/>
<code nullFlavor='NA' />
<text><reference value='#study-1'/></text>
<!-- For CDA -->
<reference typeCode='REFR|SPRT'>
<externalDocument classCode='DOC' moodCode='EVN'>
<id extension='' root=''/>
<text><reference value='http://foo..'/></text>
</externalDocument>
</reference>
<!-- For HL7 Version 3 Messages
<sourceOf typeCode='REFR|SPRT'>
<act classCode='DOC' moodCode='EVN'>
<id extension='' root=''/>
<text><reference value='http://foo…'</text>
</act>
</sourceOf>
-->
</act>
</entry>
6.3.4.9.2 <act classCode='ACT' moodCode='EVN'>
4495
The external reference is an act that refers to documentation of an <act> (classCode='ACT'), that
previously occurred (moodCode='EVN').
6.3.4.9.3 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
4500
The <templateId> element identifies this <act> as a reference act, allowing for validation of the
content. As a side effect, readers of the CDA can quickly locate and identify reference acts. The
templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.4.1.4.4'.
6.3.4.9.4 <id root=' ' extension=' '/>
The reference is an act of itself, and must be uniquely identified. If there is no explicit identifier
for this act in the source EMR system, a GUID may be used for the root attribute, and the
extension may be omitted.
4505
6.3.4.9.5 <code nullFlavor='NA'/>
The reference act has no code associated with it.
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6.3.4.9.6 <text><reference value='#study-1'/></text>
4510
In order to connect this external reference to the narrative text which it refers, the value of the
<reference> element in the <text> element is a URI to an element in the CDA narrative of this
document.
6.3.4.9.7 <reference typeCode='SPRT|REFR'>
<externalDocument classCode='DOC' moodCode='EVN'>
4515
4520
External references are listed as either supporting documentation (typeCode='SPRT') or simply
reference material (typeCode='REFR') for the reader. If this distinction is not supported by the
source EMR system, the value of typeCode should be REFR. For CDA, the reference is indicated
by a <reference> element containing an <externalDocument> element which documents
(classCode='DOC') the event (moodCode='EVN'). For HL7 Version 3 Messages, the reference is
represented with the element <sourceOf> and the external document is represented with a <act>
element, however semantics, and attributes remain otherwise without change.
6.3.4.9.8 <id extension=' ' root=' '/>
The identifier of the document is supplied in the <id> element.
6.3.4.9.9 <text><reference value=' '/></text>
4525
A link to the original document may be provided here. This shall be a URL where the referenced
document can be located. For CDA, the link should also be present in the narrative inside the
CDA Narrative in a <linkHTML> element.
6.3.4.10 Internal References 1.3.6.1.4.1.19376.1.5.3.1.4.4.1
CDA and HL7 Version 3 Entries may reference (point to) information contained in other entries
within the same document or message as shown below.
6.3.4.10.1 Specification
4530
4535
<entryRelationship typeCode='' inversionInd='true|false'>
<act classCode='' moodCode=''>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
<id root='' extension=''/>
<code code='' displayName='' codeSystem='' codeSystemName=''/>
</act>
</entryRelationship>
6.3.4.10.2 <entryRelationship typeCode=' ' inversionInd='true|false'>
4540
For CDA the act being referenced appears inside a related entryRelationship. The type
(typeCode) and direction (inversionInd) attributes will be specified in the entry content module
that contains the reference. For HL7 Version 3 Messages, the relationship is indicated with a
<sourceOf> element, however typeCodes and semantics remain unchanged.
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6.3.4.10.3 <act classCode=' ' moodCode=' '>
4545
The act being referred to can be any CDA Clinical Statement element type (act, procedure,
observation, substanceAdministration, supply, et cetera). For compatibility with the Clinical
Statement model the internal reference shall always use the <act> class, regardless of the XML
element type of the act it refers to.
6.3.4.10.4 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
The <templateId> element identifies this as an internal reference that conforms to all rules
specified in this section.
4550
6.3.4.10.5 <id root=' ' extension=' '/>
This element shall be present. The root and extension attributes shall identify an element defined
elsewhere in the same document.
6.3.4.10.6 <code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>
4555
This element shall be present. It shall be valued when the internal reference is to element that has
a <code> element, and shall have the same attributes as the <code> element in the act it
references. If the element it references does not have a <code> element, then the nullFlavor
attribute should be set to "NA".
6.3.4.11 Concern Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5.1
4560
4565
This event (moodCode='EVN') represents an act (<act classCode='ACT') of being concerned
about a problem, allergy or other issue. The <effectiveTime> element describes the period of
concern. The subject of concern is one or more observations about related problems (see
1.3.6.1.4.1.19376.1.5.3.1.4.5.2) or allergies and intolerances (see
1.3.6.1.4.1.19376.1.5.3.1.4.5.3). Additional references can be provided having additional
information related to the concern. The concern entry allows related acts to be grouped. This
allows representing the history of a problem as a series of observation over time, for example.
6.3.4.11.1 Standards
CCD
ASTM/HL7 Continuity of Care Document
CareStruct HL7 Care Provision Care Structures (DSTU)
ClinStat
ClinStat HL7 Clinical Statement (DRAFT)
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6.3.4.11.2 Specification
4570
4575
4580
4585
4590
4595
<act classCode='ACT' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.27'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
<id root='' extension=''/>
<code nullFlavor='NA'/>
<statusCode code='active|suspended|aborted|completed'/>
<effectiveTime>
<low value=''/>
<high value=''/>
</effectiveTime>
<!-- one or more entry relationships identifying problems of concern -->
<entryRelationship typeCode='SUBJ' inversionInd='false'>
:
</entryRelationship>
<!-- For HL7 Version 3 Messages
<sourceOf typeCode='SUBJ' inversionInd='false'>
:
</sourceOf>
-->
<!-- optional entry relationship providing more information about the concern -->
<entryRelationship typeCode='REFR'>
:
</entryRelationship>
<!-- For HL7 Version 3 Messages
<sourceOf typeCode='REFR' inversionInd='false'>
:
</sourceOf>
-->
</act>
6.3.4.11.3 <act classCode='ACT' moodCode='EVN'>
4600
All concerns reflect the act of recording (<act classCode='ACT'>) the event (moodCode='EVN')
of being concerned about a problem, allergy or other issue about the patient condition.
6.3.4.11.4 <templateId root='2.16.840.1.113883.10.20.1.27'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
4605
These template identifiers indicates this entry conforms to the concern content module. This
content module inherits constraints from the HL7 CCD Template for problem acts, and so also
includes that template identifier.
6.3.4.11.5 <id root=' ' extension=' '/>
This required element identifies the concern.
6.3.4.11.6 <code nullFlavor='NA'/>
The code is not applicable to a concern act, and so shall be recorded as shown above.
4610
6.3.4.11.7 <statusCode code='active|suspended|aborted|completed'/>
The statusCode associated with any concern must be one of the following values:
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Value
4615
Description
active
A concern that is still being tracked.
suspended
A concern that is active, but which may be set aside. For example, this value might be used to suspend concern
about a patient problem after some period of remission, but before assumption that the concern has been
resolved.
aborted
A concern that is no longer actively being tracked, but for reasons other than because the problem was resolved.
This value might be used to mark a concern as being aborted after a patient leaves care against medical advice.
completed
The problem, allergy or medical state has been resolved and the concern no longer needs to be tracked except for
historical purposes.
Note: A concern in the "active" state represents one for which some ongoing clinical activity is expected, and that no
activity is expected in other states. Specific uses of the suspended and aborted states are left to the implementation.
6.3.4.11.8 <effectiveTime><low value=' '/><high value=' '/></effectiveTime>
The <effectiveTime> element records the starting and ending times during which the concern
was active. The <low> element shall be present. The <high> element shall be present for
concerns in the completed or aborted state, and shall not be present otherwise.
4620
4625
6.3.4.11.9 <!-- 1..* entry relationships identifying problems of concern -->
<entryRelationship type='SUBJ' inversionInd='false'>
Each concern is about one or more related problems or allergies. This entry shall contain one or
more problem or allergy entries that conform to the specification in section Problem Entry or
Allergies and Intolerances. This is how a series of related observations can be grouped as a
single concern.
For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3
Messages, this SHALL be represented as a <sourceOf> element. The typeCode SHALL be
�SUBJ’ for both HL7 Version 3 and CDA. HL7 Version 3 additionally requires that inversionInd
SHALL be �false’.
4630
Note:
The Allergy and Intolerances entry is a refinement of the Problem entry.
6.3.4.11.10 <!-- 0..n optional entry relationship providing more information about
the concern -->
<entryRelationship type='REFR' inversionInd='false'>
4635
Each concern may have 0 or more related references. These may be used to represent related
statements such related visits. This may be any valid CDA clinical statement, and SHOULD be
an IHE entry template. For CDA this SHALL be represented with the <entryRelationship>
element. For HL7 Version 3 Messages, this SHALL be represented as a <subjectOf> element.
The typeCode SHALL be �SUBJ’ and inversionInd SHALL be �false’
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4640
6.3.4.12 Problem Concern Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5.2
This entry is a specialization of the Concern Entry, wherein the subject of the concern is focused
on a problem. Elements shown in the example below in gray are explained in the Concern Entry.
6.3.4.12.1 Standards
CCD
ASTM/HL7 Continuity of Care Document
CareStruct HL7 Care Provision Care Structures (DSTU)
ClinStat
HL7 Clinical Statement Pattern (Draft)
6.3.4.12.2 Parent Template
4645
The parent of this template is Concern Entry. This template is compatible with the ASTM/HL7
Continuity of Care Document template: 2.16.840.1.113883.10.20.1.27
6.3.4.12.3 Specification
4650
4655
4660
4665
4670
<act classCode='ACT' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.27'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/>
<id root=' ' extension=' '/>
<code nullFlavor='NA'/>
<statusCode code='active|suspended|aborted|completed'/>
<effectiveTime>
<low value=' '/>
<high value=' '/>
</effectiveTime>
<!-- 1..* entry relationships identifying problems of concern -->
<entryRelationship type='SUBJ'>
<observation classCode='OBS' moodCode='EVN'/>
<templateID root='1.3.6.1.4.1.19376.1.5.3.1.4.5'>
:
</observation>
</entryRelationship>
<!-- optional entry relationship providing more information about the concern -->
<entryRelationship type='REFR'>
</entryRelationship>
</act>
6.3.4.12.4 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.2'/>
4675
This entry has a template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5.2, and is a subtype of the
Concern Entry, and so must also conform to that specification, with the template identifier of
1.3.6.1.4.1.19376.1.5.3.1.4.5.1. These elements are required and shall be recorded exactly as
shown above.
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6.3.4.12.5 <!-- 1..* entry relationships identifying problems of concern -->
<entryRelationship type='SUBJ' inversionInd=’false’>
<observation classCode='OBS' moodCode='EVN'>
<templateID root=' 1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
…
</observation>
</entryRelationship>
4680
4685
This entry shall contain one or more problem entries that conform to the Problem Entry template
1.3.6.1.4.1.19376.1.5.3.1.4.5. For CDA this SHALL be represented with the <entryRelationship>
element. For HL7 Version 3 Messages, this SHALL be represented as a <subjectOf> element.
The typeCode SHALL be �SUBJ’ and inversionInd SHALL be �false’
6.3.4.13 Allergy and Intolerance Concern 1.3.6.1.4.1.19376.1.5.3.1.4.5.3
4690
This entry is a specialization of the Concern Entry, wherein the subject of the concern is focused
on an allergy or intolerance. Elements shown in the example below in gray are explained in that
entry.
6.3.4.13.1 Standards
CCD
ASTM/HL7 Continuity of Care Document
CareStruct HL7 Care Provision Care Structures (DSTU)
ClinStat
HL7 Clinical Statement Pattern (Draft)
6.3.4.13.2 Parent Template
4695
The parent of this template is Concern Entry. This template is compatible with the ASTM/HL7
Continuity of Care Document template: 2.16.840.1.113883.10.20.1.27
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6.3.4.13.3 Specification
4700
4705
4710
4715
<act classCode='ACT' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.27'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.3'/>
<id root=' ' extension=' '/>
<code nullFlavor='NA'/>
<statusCode code='active|suspended|aborted|completed'/>
<effectiveTime>
<low value=' '/>
<high value=' '/>
</effectiveTime>
<!-- 1..* entry relationships identifying allergies of concern -->
<entryRelationship typeCode='SUBJ'>
<observation classCode='OBS' moodCode='EVN'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6'/>
:
</observation>
</entryRelationship>
<!-- optional entry relationship providing more information about the concern -->
<entryRelationship type='REFR'>
</entryRelationship>
</act>
4720
6.3.4.13.4 <templateId root='2.16.840.1.113883.10.20.1.27'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.3'/>
4725
4730
4735
This entry has a template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5.3, and is a subtype of the
Concern entry, and so must also conform to the rules of the Concern Entry. These elements are
required and shall be recorded exactly as shown above.
6.3.4.13.5 <!-- 1..* entry relationships identifying allergies of concern -->
<observation classCode='OBS' moodCode='EVN'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6'/>
:
</observation>
<entryRelationship typeCode='SUBJ'>
This entry shall contain one or more allergy or intolerance entries that conform to the Allergy
and Intolerance Entry. For CDA this SHALL be represented with the <entryRelationship>
element. For HL7 Version 3 Messages, this SHALL be represented as a <sourceOf> element.
The typeCode SHALL be �SUBJ’ and inversionInd SHALL be �false’
6.3.4.14 Problem Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5
4740
This section makes use of the linking, severity, clinical status and comment content
specifications defined elsewhere in the technical framework. In HL7 RIM parlance, observations
about a problem, complaint, symptom, finding, diagnosis, or functional limitation of a patient is
the event (moodCode='EVN') of observing (<observation classCode='OBS'>) that problem. The
<value> of the observation comes from a controlled vocabulary representing such things. The
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<code> contained within the <observation> describes the method of determination from yet
another controlled vocabulary. An example appears below in the figure below.
4745
6.3.4.14.1 Standards
CCD
ASTM/HL7 Continuity of Care Document
CareStruct HL7 Care Provision Care Structures (DSTU)
ClinStat
HL7 Clinical Statement Pattern (Draft)
6.3.4.14.2 Parent Template
This template is compatible with the ASTM/HL7 Continuity of Care Document template:
2.16.840.1.113883.10.20.1.28
6.3.4.14.3 Specification
4750
4755
4760
4765
4770
<observation classCode='OBS' moodCode='EVN' negationInd=' false|true '>
<templateId root='2.16.840.1.113883.10.20.1.28'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
<id root=' ' extension=' '/>
<code code=' ' displayName=' '
codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
<text><reference value=' '/></text>
<statusCode code='completed'/>
<effectiveTime><low value=' '/><high value=' '/></effectiveTime>
<value xsi:type='CD' code=' '
codeSystem=' ' displayName=' ' codeSystemName=' '>
<originalText><reference value=' '/></originalText>
</value>
<
<!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements
identifying the health status of concern -->
<!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements
containing clinical status -->
<!-- zero to many <entryRelationship typeCode='REFR' inversionInd='true'> elements
containing comments -->
</observation>
6.3.4.14.4 <observation classCode='OBS' moodCode='EVN'
negationInd='false|true'>
4775
4780
The basic pattern for reporting a problem uses the CDA <observation> element, setting the
classCode='OBS' to represent that this is an observation of a problem, and the moodCode='EVN',
to represent that this is an observation that has in fact taken place. The negationInd attribute, if
true, specifies that the problem indicated was observed to not have occurred (which is subtly but
importantly different from having not been observed). The value of negationInd should not
normally be set to true. Instead, to record that there is "no prior history of chicken pox", one
would use a coded value indicated exactly that. However, it is not always possible to record
problems in this manner, especially if using a controlled vocabulary that does not supply precoordinated negations , or which do not allow the negation to be recorded with post-coordinated
coded terminology.
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6.3.4.14.5 <templateId root='2.16.840.1.113883.10.20.1.28'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
These <templateId> elements identify this <observation> as a problem, under both IHE and
CCD specifications. This SHALL be included as shown above.
6.3.4.14.6 <id root=' ' extension=' '/>
4790
The specific observation being recorded must have an identifier (<id>) that shall be provided for
tracking purposes. If the source EMR does not or cannot supply an intrinsic identifier, then a
GUID shall be provided as the root, with no extension (e.g., <id root='CE1215CD-69EC-4C7B805F-569233C5E159'/>). At least one identifier must be present, more than one may appear.
6.3.4.14.7 <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.96'
codeSystemName='SNOMED CT'>
4795
4800
The <code> describes the process of establishing a problem. The code element should be used,
as the process of determining the value is important to clinicians (e.g., a diagnosis is a more
advanced statement than a symptom). When a physical exam observation is being recorded the
code used should be “Finding.” When a review of systems observation is being recorded the
code used should be “Symptom.” The recommended vocabulary for describing problems is
shown in the table below. Subclasses of this content module may specify other vocabularies.
When the list below is used, the codeSystem is '2.16.840.1.113883.6.96' and codeSystemName is
SNOMED CT.
Code
4805
Description
64572001
Condition
418799008
Symptom
404684003
Finding
409586006
Complaint
248536006
Functional limitation
55607006
Problem
282291009
Diagnosis
6.3.4.14.8 <text><reference value=' '/></text>
The <text> element is required and points to the text describing the problem being recorded;
including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This
URI points to the free text description of the problem in the document that is being described.
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6.3.4.14.9 <statusCode code='completed'/>
4810
A clinical document normally records only those condition observation events that have been
completed, not observations that are in any other state. Therefore, the <statusCode> shall always
have code='completed'.
6.3.4.14.10 <effectiveTime><low value=' '/><high value=' '/></effectiveTime>
4815
4820
4825
4830
The <effectiveTime> of this <observation> is the time interval over which the <observation> is
known to be true. The <low> and <high> values should be no more precise than known, but as
precise as possible. While CDA allows for multiple mechanisms to record this time interval (e.g.,
by low and high values, low and width, high and width, or center point and width), we are
constraining Medical summaries to use only the low/high form. The <low> value is the earliest
point for which the condition is known to have existed. The <high> value, when present,
indicates the time at which the observation was no longer known to be true. Thus, the implication
is made that if the <high> value is specified, that the observation was no longer seen after this
time, and it thus represents the date of resolution of the problem. Similarly, the <low> value may
seem to represent onset of the problem. Neither of these statements is necessarily precise, as the
<low> and <high> values may represent only an approximation of the true onset and resolution
(respectively) times. For example, it may be the case that onset occurred prior to the <low>
value, but no observation may have been possible before that time to discern whether the
condition existed prior to that time. The <low> value should normally be present. There are
exceptions, such as for the case where the patient may be able to report that they had chicken
pox, but are unsure when. In this case, the <effectiveTime> element shall have a <low> element
with a nullFlavor attribute set to 'UNK'. The <high> value need not be present when the
observation is about a state of the patient that is unlikely to change (e.g., the diagnosis of an
incurable disease).
6.3.4.14.11 <value xsi:type='CD' code=' ' codeSystem=' ' codeSystemName=' '
displayName=' '>
4835
4840
The <value> is the condition that was found. This element is required. While the value may be a
coded or an un-coded string, the type is always a coded value (xsi:type='CD'). If coded, the code
and codeSystem attributes shall be present. The codeSystem should reference a controlled
vocabulary describing problems, complaints, symptoms, findings, diagnoses, or functional
limitations, e.g., ICD-9, SNOMED-CT or MEDCIN, or others. The table below is an incomplete
listing of acceptable values for the codeSystem attribute, along with the codeSystemName.
CodeSystem
codeSystemName
Description
2.16.840.1.113883.6.96
SNOMED-CT
SNOMED Controlled Terminology
2.16.840.1.113883.6.10
3
ICD-9CM (diagnoses)
International Classification of Diseases, Clinical Modifiers,
Version 9
2.16.840.1.113883.6.26
MEDCIN
A classification system from MEDICOMP Systems.
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4845
It is recommended that the codeSystemName associated with the codeSystem, and the
displayName for the code also be provided for diagnostic and human readability purposes, but
this is not required by this profile.
If uncoded, all attributes other than xsi:type='CD' must be absent.
In cases where information about a problem or allergy is unknown or where there are no
problems or allergies, an entry shall use codes from the table below to record this fact:
Entry Type
Code
Display Name
Description
Problem
396782006
Past Medical History
Unknown
To indicate unknown medical history
Problem
407559004
Family History Unknown
To indicate that the patient's family history is not
known.
Problem
160243008
No Significant Medical
History
To indicate no relevant medical history
Problem
160245001
No current problems or
disability
To indicate that the patient has no current problems (as
distinct from no history).
Allergy
409137002
No Known Drug
Allergies
To indicate that there are no known Drug allergies for
this patient.
Allergy
160244002
No Known Allergies
To indicate that there are no known allergies for this
patient.
Allergy
64970000
Substance Type
Unknown
To indicate the state where there is a known allergy or
intolerance to an unknown substance
4850
6.3.4.14.12 <originalText><reference value=' '/></originalText>
4855
The <value> contains a <reference> to the <originalText> in order to link the coded value to the
problem narrative text (minus any dates, comments, et cetera). The <reference> contains a URI
in value attribute. This URI points to the free text description of the problem in the document
that is being described.
6.3.4.14.13 <!-- zero or one <entryRelationship typeCode='SUBJ'
inversionInd='true'> elements containing severity -->
4860
An optional <entryRelationship> element may be present indicating the severity of the problem.
When present, this <entryRelationship> element shall contain a severity observation conforming
to the Severity entry template (1.3.6.1.4.1.19376.1.5.3.1.4.1).
For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3
Messages, this SHALL be represented as a <subjectOf> element. The typeCode SHALL be
�SUBJ’ and inversionInd SHALL be �true’.
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6.3.4.14.14 <!-- zero or one <entryRelationship typeCode='REFR'
inversionInd='false'> elements containing clinical status -->
An optional <entryRelationship> may be present indicating the clinical status of the problem,
e.g., resolved, in remission, active. When present, this <entryRelationship> element shall contain
a clinical status observation conforming to the Problem Status Observation template
(1.3.6.1.4.1.19376.1.5.3.1.4.1.1).
4870
For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3
Messages, this SHALL be represented as a <sourceOf> element. The typeCode SHALL be
�REFR’ and inversionInd SHALL be �false’.
4875
6.3.4.14.15 <!-- zero or one <entryRelationship typeCode='REFR'
inversionInd='false'> elements identifying the health status of concern ->
4880
An optional <entryRelationship> may be present referencing the health status of the patient, e.g.,
resolved, in remission, active. When present, this <entryRelationship> element shall contain a
clinical status observation conforming to the Health Status Observation template
(1.3.6.1.4.1.19376.1.5.3.1.4.1.1). The typeCode SHALL be �REFR’ and inversionInd SHALL be
�false’.
For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3
Messages, this SHALL be represented as a <sourceOf> element.
6.3.4.14.16 <!-- zero to many <entryRelationship typeCode='SUBJ'
inversionInd='true'> element containing comments -->
4885
One or more optional <entryRelationship> elements may be present providing additional
comments (annotations) for the condition. When present, this <entryRelationship> element shall
contain a comment observation conforming to the Comment entry template
(1.3.6.1.4.1.19376.1.5.3.1.4.2). The typeCode SHALL be �SUBJ’ and inversionInd SHALL be
�true’.
4890
For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3
Messages, this SHALL be represented as a <sourceOf> element.
6.3.4.15 Allergies and Intolerances 1.3.6.1.4.1.19376.1.5.3.1.4.6
4895
Allergies and intolerances are special kinds of problems, and so are also recorded in the CDA
<observation> element, with classCode='OBS'. They follow the same pattern as the problem
entry, with exceptions noted below.
6.3.4.15.1 Standards
CCD
ASTM/HL7 Continuity of Care Document
CareStruct HL7 Care Provision Care Structures (DSTU)
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ClinStat
HL7 Clinical Statement Pattern (Draft)
6.3.4.15.2 Specification
4900
4905
4910
4915
4920
4925
4930
<observation classCode='OBS' moodCode='EVN' negationInd='false'>
<templateId root='2.16.840.1.113883.10.20.1.18'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
<id root=' ' extension=' '/>
<code
code='ALG|OINT|DALG|EALG|FALG|DINT|EINT|FINT|DNAINT|ENAINT|FNAINT'
codeSystem='2.16.840.1.113883.5.4'
codeSystemName='ObservationIntoleranceType'/>
<text><reference value=' '/></text>
<statusCode code='completed'/>
<effectiveTime>
<low value=' '/>
<high value=' '/>
</effectiveTime>
<value xsi:type='CD' code=' ' codeSystem=' ' displayName=' ' codeSystemName=' '/>
<participant typeCode='CSM'>
<participantRole classCode='MANU'>
<playingEntity classCode='MMAT'>
<code code=' ' codeSystem=' '>
<originalText><reference value='#substance'/></orginalText>
</code>
<name></name>
</playingEntity>
</participantRole>
</participant>
<!-- zero to many <entryRelationship> elements containing reactions -->
<!-- zero or one <entryRelationship> elements containing severity -->
<!-- zero or one <entryRelationship> elements containing clinical status -->
<!-- zero to many <entryRelationship> elements containing comments -->
</observation>
6.3.4.15.3 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6'/>
4935
4940
This entry has a template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.6, and is a subtype of the
Problem Entry, and so must also conform to the rules of the problem entry, which has the
template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5.5. These elements are required and shall be
recorded exactly as shown above.
6.3.4.15.4 <code
code='ALG|OINT|DINT|EINT|FINT|DALG|EALG|FALG|DNAINT|ENAINT|FN
AINT' displayName=' ' codeSystem='2.16.840.1.113883.5.4'
codeSystemName='ObservationIntoleranceType'/>
The <code> element represents the kind of allergy observation made, to a drug, food or
environmental agent, and whether it is an allergy, non-allergy intolerance, or unknown class of
intolerance (not known to be allergy or intolerance). The <code> element of an allergy entry
shall be provided, and a code and codeSystem attribute shall be present. The example above uses
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the HL7 ObservationIntoleranceType vocabulary domain, which does provide suitable
observation codes. Other vocabularies may be used, such as SNOMED-CT or MEDCIN. The
displayName and codeSystemName attributes should be present.
6.3.4.15.5 <value xsi:type='CD' code=' ' codeSystem=' ' codeSystemName=' '
displayName=' '>
4950
4955
The <value> is a description of the allergy or adverse reaction. While the value may be a coded
or an uncoded string, the type is always a coded value (xsi:type='CD'). If coded, the code and
codeSystem attributes must be present. The codingSystem should reference a controlled
vocabulary describing allergies and adverse reactions, see Table 5.4 12 above. If uncoded, all
attributes other than xsi:type='CD' must be absent. The allergy or intolerance may not be known,
in which case that fact shall be recorded appropriately. This might occur in the case where a
patient experiences an allergic reaction to an unknown substance.
6.3.4.15.6 <participant typeCode='CSM'>
<participantRole classCode='MANU'>
<playingEntity classCode='MMAT'>
4960
The substance that causes the allergy or intolerance may be specified in the <participant>
element.
6.3.4.15.7 <code code=' ' codeSystem=' '>
<originalText><reference value=' '/></originalText>
</code>
4965
The <code> element shall be present. It may contain a code and codeSystem attribute to indicate
the code for the substance causing the allergy or intolerance. It shall contain a <reference> to the
<originalText> in the narrative where the substance is named.
6.3.4.15.8 <!-- zero to many <entryRelationship> elements containing reactions -->
4970
An allergy entry can record the reactions that are manifestations of the allergy or intolerance as
shown below.
4975
<entryRelationship typeCode='MFST'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.6.1'/>
<!-- a problem entry -->
<observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.54'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
∶
</observation>
</entryRelationship>
4980
6.3.4.15.9 <entryRelationship typeCode='MFST'>
This is a related entry (<entryRelationship>) that indicates the manifestations
(typeCode='MFST') the reported allergy or intolerance. These are events that may occur, or have
occurred in the past as a reaction to the allergy or intolerance.
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4990
6.3.4.15.10 <observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.54'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
∶
</observation>
The entry contained with this entry relationship is some sort of problem that is a manifestation of
the allergy. It is recorded using the Problem Entry structure, with the additional template
identifier (2.16.840.1.113883.10.20.1.54) indicating that this problem is a reaction.
6.3.4.15.11 <!-- zero or one <entryRelationship typeCode='SUBJ'
inversionInd='true'> elements containing severity -->
4995
5000
5005
An optional <entryRelationship> element may be present indicating the severity of the problem.
When present, this <entryRelationship> element shall contain a severity observation conforming
to the Severity entry template (1.3.6.1.4.1.19376.1.5.3.1.4.1). For CDA this SHALL be
represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be
represented as a <sourceOf> element. The typeCode SHALL be �SUBJ’ and inversionInd
SHALL be �true’.
6.3.4.15.12 <!-- zero or one <entryRelationship typeCode='REFR'
inversionInd='false'> elements containing clinical status -->
An optional <entryRelationship> may be present indicating the clinical status of the allergy, e.g.,
resolved, in remission, active. When present, this <entryRelationship> element shall contain a
clinical status observation conforming to the Problem Status Observation template
(1.3.6.1.4.1.19376.1.5.3.1.4.1.1). The typeCode SHALL be �REFR’ and inversionInd SHALL be
�false’. For CDA this SHALL be represented with the <entryRelationship> element. For HL7
Version 3 Messages, this SHALL be represented as a <sourceOf> element.
6.3.4.15.13 <!-- zero to many <entryRelationship typeCode='SUBJ'
inversionInd='true'> element containing comments -->
5010
5015
One or more optional <entryRelationship> elements may be present providing additional
comments (annotations) for the allergy. When present, this <entryRelationship> element shall
contain an entry conforming to the Comment entry template (1.3.6.1.4.1.19376.1.5.3.1.4.2). The
typeCode SHALL be �SUBJ’ and inversionInd SHALL be �true’.
For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3
Messages, this SHALL be represented as a <sourceOf> element.
6.3.4.16 Medications 1.3.6.1.4.1.19376.1.5.3.1.4.7
This content module describes the general structure for a medication. All medication
administration acts will be derived from this content module.
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6.3.4.16.1 Standards
Pharmacy HL7 Pharmacy Domain (Normative)
CCD
5020
5025
5030
5035
5040
5045
5050
5055
5060
5065
ASTM/HL7 Continuity of Care Document
6.3.4.16.2 Specification
<substanceAdministration classCode='SBADM' moodCode='INT|EVN'>
<templateId root='2.16.840.1.113883.10.20.1.24'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/>
<templateId root=''/>
<id root='' extension=''/>
<code code='' codeSystem='' displayName='' codeSystemName=''/>
<text><reference value='#med-1'/></text>
<statusCode code='completed'/>
<effectiveTime xsi:type='IVL_TS'>
<low value=''/>
<high value=''/>
</effectiveTime>
<effectiveTime operator='A' xsi:type='TS|PIVL_TS|EIVL_TS|PIVL_PPD_TS|SXPR_TS'>
:
</effectiveTime>
<routeCode code='' codeSystem='' displayName='' codeSystemName=''/>
<doseQuantity value='' unit=''/>
<approachSiteCode code='' codeSystem='' displayName='' codeSystemName=''/>
<rateQuantity value='' unit=''/>
<consumable>
:
.
</consumable>
<!-- 0..* entries describing the components -->
<entryRelationship typeCode='COMP' >
<sequenceNumber value=''/>
</entryRelationship>
<!-- An optional entry relationship that indicates the reason for use -->
<entryRelationship typeCode='RSON'>
<act classCode='ACT' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
<id root='' extension=''/>
</act>
</entryRelationship>
<!-- An optional entry relationship that provides prescription activity -->
<entryRelationship typeCode='REFR'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>
:
.
</entryRelationship>
<precondition>
<criterion>
<text><reference value=''></text>
</criterion>
</precondition>
</substanceAdministation>
This section makes use of the linking, severity and instruction entries.
5070
Medications are perhaps the most difficult data elements to model due to variations in the ways
that medications are prescribed.
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This profile identifies the following relevant fields of a medication as being important to be able
to generate in a medical summary. The table below identifies and describes these fields, and
indicates the constraints on whether or not they are required to be sent. The fields are listed in the
order that they appear in the CDA XML content.
5075
6.3.4.16.2.1 Medication Fields
Table 6.3.4.16.2.1-1:
Field
Opt
CDA Tag
Description
Start and Stop
Date
R2
<effectiveTime>
The date (and time if available) when the medication regimen
began and is expected to finish. The first component of the
<effectiveTime> encodes the lower and upper bounds over which
the <substanceAdministration> occurs, and the start time is
determined from the lower bound. If the medication has been
known to be stopped, the high value must be present, but
expressed as a flavor of null (e.g., Unknown).
Frequency
R2
<effectiveTime>
The frequency indicates how often the medication is to be
administered. It is often expressed as the number of times per day,
but which may also include information such as 1 hour
before/after meals, or in the morning, or evening. The second
<effectiveTime> element encodes the frequency. In cases where
split or tapered doses are used, these may be found in subordinate
<substanceAdministration> elements.
Route
R2
<routeCode>
The route is a coded value, and indicates how the medication is
received by the patient (by mouth, intravenously, topically, et
cetera).
Dose
R2
<doseQuantity>
The amount of the medication given. This should be in some
known and measurable unit, such as grams, milligrams, et cetera.
It may be measured in "administration" units (such as tablets or
each), for medications where the strength is relevant. In this case,
only the unit count is specified , no units are specified. It may be a
range.
Site
O
<approachSiteCo
de>
The site where the medication is administered, usually used with
IV or topical drugs.
Rate
R2
<rateQuantity>
The rate is a measurement of how fast the dose is given to the
patient over time (e.g., .5 liter / 1 hr), and is often used with IV
drugs.
Product
R1
<consumable>
<name>
</consumable>
The name of the substance or product. This should be sufficient
for a provider to identify the kind of medication. It may be a trade
name or a generic name. This information is required in all
medication entries. If the name of the medication is unknown, the
type, purpose or other description may be supplied. The name
should not include packaging, strength or dosing information.
Note: Due to restrictions of the CDA schema, there is no way to
explicitly link the name to the narrative text.
Strength
R2
<consumable>
<code>
<originalText/>
</code>
</consumable>
The name and strength of the medication. This information is only
relevant for some medications, as the dose of the medication is
often sufficient to indicate how much medication the patient
receives. For example, the medication Percocet comes in a variety
of strengths, which indicate specific amounts of two different
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Field
Opt
CDA Tag
Description
medications being received in single tablet. Another example is
eye-drops, where the medication is in a solution of a particular
strength, and the dose quantity is some number of drops. The
originalText referenced by the <code> element in the consumable
should refer to the name and strength of the medication in the
narrative text. Note: Due to restrictions of the CDA schema, there
is no way to separately record the strength.
Code
R2
<consumable>
<code/>
</consumable>
A code describing the product from a controlled vocabulary, such
as RxNorm, First DataBank, et cetera.
Instructions
R2
<entryRelationsh
ip>
A place to put free text comments to support additional relevant
information, or to deal with specialized dosing instructions. For
example, "take with food", or tapered dosing.
Indication
O
<entryRelationsh
ip>
A link to supporting clinical information about the reason for
providing the medication (e.g., a link to the relevant diagnosis).
6.3.4.16.3 <substanceAdministration classCode='SBADM' moodCode='INT|EVN'>
5080
5085
5090
The general model is to record each prescribed medication in a <substanceAdministration>
intent (moodCode='INT'). Medications that have been reported by the patient or administered
(instead of prescribed ), are recorded in the same element, except that this is now an event
(moodCode='EVN'). The <substanceAdministration> element may contain subordinate
<substanceAdministration> elements in a related component entry to deal with special cases (see
the section below on Special Cases). These cases include split, tapered, or conditional dosing, or
combination medications. The use of subordinate <substanceAdministration> elements to deal
with these cases is optional. The comment field should always be used in these cases to provide
the same information as free text in the top level <substanceAdministration> element. There are
a variety of special cases for dosing that need to be accounted for. These are described below.
Most of these special cases involve changing the dosage or frequency over time, or based on
some measurement. When the dosage changes, then additional entries are required for each
differing dosage. The last case deals with combination medications.
6.3.4.16.3.1 Normal Dosing 1.3.6.1.4.1.19376.1.5.3.1.4.7.1
5095
This template identifier is used to identify medication administration events that do not require
any special processing. The parent template is 1.3.6.1.4.1.19376.1.5.3.1.4.7. Medications that use
this template identifier shall not use subordinate <substanceAdministation> acts.
6.3.4.16.3.2 Tapered Doses 1.3.6.1.4.1.19376.1.5.3.1.4.8
5100
This template identifier is used to identify medication administration events that require special
processing to handle tapered dosing. The parent template is 1.3.6.1.4.1.19376.1.5.3.1.4.7. A
tapered dose is often used for certain medications where abrupt termination of the medication
can have negative consequences. Tapered dosages may be done by adjusting the dose frequency,
the dose amount, or both.
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5105
When merely the dose frequency is adjusted, (e.g., Prednisone 5mg b.i.d. for three days, then
5mg. daily for three days, and then 5mg every other day), then only one medication entry is
needed, multiple frequency specifications recorded in <effectiveTime> elements. When the dose
varies (e.g., Prednisone 15mg daily for three days, then 10 mg daily for three days, the 5 mg
daily for three days), subordinate medication entries should be created for each distinct dosage.
6.3.4.16.3.3 Split Dosing 1.3.6.1.4.1.19376.1.5.3.1.4.9
5110
5115
This template identifier is used to identify medication administration events that require special
processing to handle split dosing. The parent template is 1.3.6.1.4.1.19376.1.5.3.1.4.7. A split
dose is often used when different dosages are given at different times (e.g., at different times of
day, or on different days). This may be to account for different metabolism rates at different
times of day, or to simply address drug packaging deficiencies (e.g., and order for Coumadin
2mg on even days, 2.5mg on odd days is used because Coumadin does not come in a 2.25mg
dose form).
In this case a subordinate <substanceAdministration> entry is required for each separate dosage.
6.3.4.16.3.4 Conditional Dosing 1.3.6.1.4.1.19376.1.5.3.1.4.10
5120
This template identifier is used to identify medication administration events that require special
processing to handle conditional dosing. The parent template is 1.3.6.1.4.1.19376.1.5.3.1.4.7. A
conditional dose is often used when the dose amount differs based on some measurement (e.g.,
an insulin sliding scale dose based on blood sugar level). In this case a subordinate
<substanceAdministration> entry is required for each different dose, and the condition should be
recorded.
6.3.4.16.3.5 Combination Medications 1.3.6.1.4.1.19376.1.5.3.1.4.11
5125
5130
This template identifier is used to identify medication administration events that require special
processing to handle combination medications. The parent template is
1.3.6.1.4.1.19376.1.5.3.1.4.7. A combination medication is made up of two or more other
medications. These may be prepackaged, such as Percocet, which is a combination of
Acetaminophen and oxycodone in predefined ratios, or prepared by a pharmacist, such as a GI
cocktail.
In the case of the prepackaged combination, it is sufficient to supply the name of the
combination drug product, and its strength designation in a single <substanceAdministation>
entry. The dosing information should then be recorded as simply a count of administration units.
5135
In the latter case of a prepared mixture, the description of the mixture should be provided as the
product name (e.g., "GI Cocktail") , in the <substanceAdministration> entry. That entry may, but
is not required, to have subordinate <substanceAdministration> entries included beneath it to
record the components of the mixture.
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6.3.4.16.4 <templateId root='2.16.840.1.113883.10.20.1.24'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7' />
5140
All medications entries use the <templateId> elements specified above to indicate that they are
medication acts. This element is required. In addition, a medication entry shall further identify
itself using one of the template identifiers detailed in the next section.
6.3.4.16.5 <templateId root=' ' />
5145
The <templateId> element identifies this <entry> as a particular type of medication event,
allowing for validation of the content. As a side effect, readers of the CDA can quickly locate
and identify medication events. The templateId must use one of the values in the table below for
the root attribute.
Table 6.3.4.16.5-1:
Root
Description
1.3.6.1.4.1.19376.1.5.3.1.4.7.1
A "normal" <substanceAdministration> act that may not contain any subordinate
<substanceAdministration> acts.
1.3.6.1.4.1.19376.1.5.3.1.4.8
A <substanceAdministration> act that records tapered dose information in subordinate
<substanceAdministration> act.
1.3.6.1.4.1.19376.1.5.3.1.4.9
A <substanceAdministration> act that records split dose information in subordinate
<substanceAdministration> acts.
1.3.6.1.4.1.19376.1.5.3.1.4.10
A <substanceAdministration> act that records conditional dose information in
subordinate <substanceAdministration> acts.
1.3.6.1.4.1.19376.1.5.3.1.4.11
A <substanceAdministration> act that records combination medication component
information in subordinate <substanceAdministration> acts.
5150
6.3.4.16.6 <id root=' ' extension=' '/>
5155
A top level <substanceAdministration> element must be uniquely identified. If there is no
explicit identifier for this observation in the source EMR system, a GUID may be used for the
root attribute, and the extension may be omitted. At least one identifier must be present, more
than one may appear. Subordinate <substanceAdministration> elements may, but need not be
uniquely identified.
6.3.4.16.7 <code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '>
5160
The <code> element is used to supply a code that describes the <substanceAdministration> act,
not the medication being administered or prescribed. This may be a procedure code, such as
those found in CPT-4 (and often used for billing), or may describe the method of medication
administration, such as by intravenous injection. The type of medication is coded in the
consumable, do not supply the code for the medication in this element. This element is optional.
One of the following values from SNOMED CT shall be used in the <code> element to record
that a patient is either not on medications, or that medications are not known.
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5165
Table 6.3.4.16.7-1:
Entry Type
Code
Display Name
Description
Medication
182904002
Drug Treatment Unknown
To indicate lack of knowledge about
drug therapy
Medication
182849000
No Drug Therapy Prescribed
To indicate the absence of any
prescribed medications
Medication
408350003
Patient Not On Self-Medications
To indicate no treatment
6.3.4.16.8 <text><reference value=' '/></text>
5170
The URI given in the value attribute of the <reference> element points to an element in the
narrative content that contains the complete text describing the medication. In a CDA document,
the URI given in the value attribute of the <reference> element points to an element in the
narrative content that contains the complete text describing the medication. In an HL7 message,
the content of the text element shall contain the complete text describing the medication.
6.3.4.16.9 <statusCode code='completed'/>
5175
The status of all <substanceAdministration> elements must be "completed". The act has either
occurred, or the request or order has been placed.
6.3.4.16.10 <effectiveTime xsi:type='IVL_TS'>
5180
The first <effectiveTime> element encodes the start and stop time of the medication regimen.
This is an interval of time (xsi:type='IVL_TS'), and must be specified as shown. This is an
additional constraint placed upon CDA Release 2.0 by this profile, and simplifies the exchange
of start/stop and frequency information between EMR systems.
6.3.4.16.11 <low value=' '/><high value=' '/> or <width value=’ �/> unit=’ �/>
When using templateId subtypes described in section 6.3.4.16.3 other than the template for
Delayed Start Dosing:
5185
5190
The <low> and <high> values of the first <effectiveTime> element represent the start and
stop times for the medication. The <low> value represents the start time, and the <high>
value represents the stop time. If either the <low> or the <high> value is unknown, this shall
be recorded by setting the nullFlavor attribute to UNK. The <high> value records the end of
the medication regime according to the information provided in the prescription or order. For
example, if the prescription is for enough medication to last 30 days, then the high value
should contain a date that is 30 days later then the <low> value. The rationale is that a
provider, seeing an un-refilled prescription would normally assume that the medication is no
longer being taken, even if the intent of the treatment plan is to continue the medication
indefinitely.
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5195
When using the Delayed Start Dosing templateId subtype (1.3.6.1.4.1.19376.1.5.3.1.4.21)
described in section 6.3.4.16.3.6:
In the special case that just the duration of the medication is known whereas at the same time
the start time is unknown a <width> element shall be given instead of <low> and <high>
elements. The <width> element represents the duration of the medication regime. Legal
values for the unit attribute of <width> are s, min, h, d, wk and mo representing seconds,
minutes, hours, days, weeks, and months respectively.
5200
6.3.4.16.12 <effectiveTime operator='A'
xsi:type='TS|PIVL_TS|EIVL_TS|PIVL_PPD_TS|SXPR_TS' />
5205
The second <effectiveTime> element records the frequency of administration. This
<effectiveTime> element must be intersected with the previous time specification (operator='A'),
producing the bounded set containing only those time specifications that fall within the start and
stop time of the medication regimen. Several common frequency expressions appear in the table
below, along with their XML representations.
6.3.4.16.12.1 Specifying Medication Frequency
5210
Table 6.3.4.16.12.1-1:
Freq
XML Representation
Twice a day
<effectiveTime xsi:type='PIVL_TS' institutionSpecified='true' operator='A'>
<period value='12' unit='h' /></effectiveTime>
q12h
Every 12 hours
<effectiveTime xsi:type='PIVL_TS' institutionSpecified='false'
operator='A'> <period value='12' unit='h' /></effectiveTime>
Once
Once, on 2005-09-01 at 1:18am.
<effectiveTime xsi:type='TS' value='200509010118'/>
t.i.d.
Three times a day, at times
determined by the person
administering the medication .
<effectiveTime xsi:type='PIVL_TS' institutionSpecified='true' operator='A'>
<period value='8' unit='h' /></effectiveTime>
q8h
Every 8 hours
<effectiveTime xsi:type='PIVL_TS' institutionSpecified='false'
operator='A'> <period value='8' unit='h' /></effectiveTime>
qam
In the morning
<effectiveTime xsi:type='EIVL' operator='A'> <event
code='ACM'/></effectiveTime>
Every day at 8 in the morning for
10 minutes
<effectiveTime xsi:type='PIVL_TS' operator='A'> <phase> <low
value="198701010800" inclusive="true"/> <width value="10" unit="min"/>
</phase> <period value='1' unit='d'/></effectiveTime>
Every 4 to 6 hours.
<effectiveTime xsi:type='PIVL_PPD_TS' institutionSpecified='false'
operator='A'> <period value='5' unit='h' /> <standardDeviation value='1'
unit='h'></effectiveTime>
q4-6h
5215
Description
b.i.d.
The last frequency specification is about as bad as it gets, but can still be represented accurately
within the HL7 V3 datatypes. The mean (average) of the low and high values is specified for the
period. The mean of 4 and 6 is 5. The standard deviation is recorded as one half the difference
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between the high and low values, with an unspecified distribution. The type attribute of the
<effectiveTime> element describes the kind of frequency specification it contains. More detail is
given for each type in the table below.
6.3.4.16.12.2 Data types used in Frequency Specifications
5220
Table 6.3.4.16.12.2-1:
xsi:type
5225
Description
TS
An xsi:type of TS represents a single point in time, and is the simplest of all to represent. The value
attribute of the <effectiveTime> element specifies the point in time in HL7 date-time format
(CCYYMMDDHHMMSS)
PIVL_TS
An xsi:type of PIVL_TS is the most commonly used, representing a periodic interval of time. The <low>
element of <phase> may be present. If so it specifies the starting point, and only the lower order
components of this value are relevant with respect to the <period>. The <width> element represents the
duration of the dose administration (e.g., for IV administration). The <period> indicates how often the
dose is given. Legal values for the unit attribute of <period> are s, min, h, d, wk and mo representing
seconds, minutes, hours, days, weeks, and months respectively.
EIVL_TS
An xsi:type of EIVL_TS represents an event based time interval, where the event is not a precise time,
but is often used for timing purposes (e.g., with meals, between meals, before breakfast, before sleep).
Refer to the HL7 TimingEvent vocabulary for the codes to use for the <event> element. This interval may
specify an <offset> which provides information about the time offset from the specified event (e.g.,
<offset><low value='-1' unit='h'/><width value='10' unit='min'/></offset> means 1 hour before the event.
In that same example, the <width> element indicates the duration for the dose to be given.
PIVL_PPD_TS
An xsi:type of PIVL_PPD_TS represents a probabilistic time interval and is used to represent dosing
frequencies like q4-6h. This profile requires that the distributionType of this interval be left unspecified.
The <period> element specifies the average of the time interval, and the value of the <standardDeviation>
shall be computed as half the width of the interval. The unit attributes of the <period> and
<standardDeviation> elements shall be the same.
SXPR_TS
An xsi:type of SXPR_TS represents a parenthetical set of time expressions. This type is used when the
frequency varies over time (e.g., for some cases of tapered dosing, or to handle split dosing). The <comp>
elements of this <effectiveTime> element are themselves time expressions (using any of the types listed
above). Each <comp> element may specify an operator (e.g., to intersect or form the union of two sets).
6.3.4.16.13 <routeCode code=' ' displayName=' ' codeSystem=''
codeSystemName=''>
The <routeCode> element specifies the route of administration. A code must be specified if the
route is known, and the displayName attribute should be specified. The HL7
RouteOfAdministration vocabulary (2.16.840.1.113883.5.112) SHOULD be used. If the route is
unknown the reason it is unknown may be described using the nullFlavor attribute.
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5230
5235
6.3.4.16.14 <approachSiteCode code=' ' codeSystem=' '>
originalText><reference value=' '/></originalText>
</approachSiteCode>
The <approachSiteCode> element describes the site of medication administration. It may be
coded to a controlled vocabulary that lists such sites (e.g., SNOMED-CT). In CDA documents,
this element contains a URI in the value attribute of the <reference> that points to the text in the
narrative identifying the site. In a message, the <originalText> element shall contain the text
identifying the site.
6.3.4.16.15 <doseQuantity> <low value=' ' unit=' '/><high value=' ' unit=' '/>
</doseQuantity>
5240
The dose is specified if the <doseQuantity> element. If a dose range is given (e.g., 1-2 tablets, or
325-750mg), then the <low> and <high> bounds are specified in their respective elements,
otherwise both <low> and <high> have the same value. If the dose is in countable units (tablets,
caplets, "eaches"), then the unit attribute is not sent. Otherwise the units are sent. The unit
attribute should be derived from the HL7 UnitsOfMeasureCaseSensitive vocabulary .
5245
6.3.4.16.16 <low|high value=' '> <translation> <originalText><reference
value=' '/></originalText> </translation></low|high >
5250
Any <low> and <high> elements used for <doseQuantity> or <rateQuantity> should contain a
<translation> element that provides a <reference> to the <originalText> found in the narrative
body of the document. In a CDA document, any <low> and <high> elements used for
<doseQuantity> or <rateQuantity> should contain a <translation> element that provides a
<reference> to the <originalText> found in the narrative body of the document. In a message, the
<originalText> may contain the original text used to describe dose quantity.
6.3.4.16.17 <rateQuantity><low value=' ' unit=' '/><high value=' '
unit=' '/></rateQuantity>
5255
The rate is specified in the <rateQuantity> element. The rate is given in units that have measure
over time. In this case, the units should be specified as a string made up of a unit of measure (see
doseQuantity above), followed by a slash (/), followed by a time unit (s, min, h or d).
Again, if a range is given, then the <low> and <high> elements contain the lower and upper
bound of the range, otherwise, they contain the same value.
5260
6.3.4.16.18 <consumable>
The <consumable> element shall be present, and shall contain a <manufacturedProduct> entry
conforming to the Product Entry template
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6.3.4.16.19 <entryRelationship typeCode='REFR'>
&nsbp;<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>
5265
The top level <substanceAdministration> element may contain a reference (typeCode='REFR')
to related prescription activity as described in the Supply Entry.
6.3.4.16.20 <entryRelationship typeCode='COMP'>
<sequenceNumber value=' '>
5270
5275
A top level <substanceAdministration> element may contain one or more related components,
either to handle split, tapered or conditional dosing, or to support combination medications.
In the first three cases, the subordinate components shall specify only the changed <frequency>
and/or <doseAmount> elements. For conditional dosing, each subordinate component shall have
a <precondition> element that specifies the <observation> that must be obtained before
administration of the dose. The value of the <sequenceNumber> shall be an ordinal number,
starting at 1 for the first component, and increasing by 1 for each subsequent component.
Components shall be sent in <sequenceNumber> order.
6.3.4.16.21 <entryRelationship typeCode='SUBJ' inversionInd='true'/>
5280
5285
5290
At most one instruction may be provided for each <substanceAdministration> entry. If provided,
it shall conform to the requirements listed for Patient Medication Instructions. The instructions
shall contain any special case dosing instructions (e.g., split, tapered, or conditional dosing), and
may contain other information (take with food, et cetera).
6.3.4.16.22 <entryRelationship typeCode='RSON'>
<act classCode='ACT' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
<id root=' ' extension=' '/>
</act>
</entryRelationship>
A <substanceAdministration> event may indicate one or more reasons for the use of the
medication. These reasons identify the concern that was the reason for use via the Internal
Reference entry content module.
The extension and root of each observation present must match the identifier of a concern entry
contained elsewhere within the CDA document.
A consumer of the Medical Summary is encouraged, but not required to maintain these links on
import.
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5295
5300
5305
5310
6.3.4.16.23 <precondition><criterion>
<text><reference value=' '></text>
</criterion></precondition>
In a CDA document, the preconditions for use of the medication are recorded in the
<precondition> element. The value attribute of the <reference> element is a URL that points to
the CDA narrative describing those preconditions.
6.3.4.16.24 <condition typeCode='PRCN'>
<criterion>
<text></text>
<value nullFlavor='UNK'/>
<interpretationCode nullFlavor='UNK'/>
</criterion>
</condition>
In a message, the preconditions for use of the medication are recorded in the <condition>
element. The typeCode shall be PRCN. The <text> element of the criterion shall contain a text
description of the precondition. The <value> element is required, and may be recorded in a
structured data type if known, and if not, may be recorded using a nullFlavor as shown above.
The same is true for <interpretationCode>.
6.3.4.17 Immunizations 1.3.6.1.4.1.19376.1.5.3.1.4.12
An immunizations entry is used to record the patient's immunization history.
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6.3.4.17.1 Specification
<substanceAdministration typeCode='SBADM' moodCode='EVN' negationInd='true{{!}}false'>
<templateId root='2.16.840.1.113883.10.20.1.24'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12'/>
5320
5325
5330
5335
5340
5345
5350
5355
5360
5365
<id root='' extension=''/>
<code code='IMMUNIZ' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode'/>
<text><reference value='#xxx'/></text>
<statusCode code='completed'/>
<effectiveTime value=''/>
<!-- The reasonCode would normally provide a reason why the immunization was
not performed. It isn't supported by CDA R2, and so comments will have to suffice.
<reasonCode code='' codeSystem='' codeSystemName='ActNoImmunizationReasonIndicator'/>
-->
<routeCode code='' codeSystem='' codeSystemName='RouteOfAdministration'/>
<approachSiteCode code='' codeSystem='' codeSystemName='HumanSubstanceAdministrationSite'/>
<doseQuantity value='' units=''/>
<consumable typeCode='CSM'>
<manufacturedProduct classCode='MANU'>
<manufacturedLabeledDrug classCode='MMAT' determinerCode='KIND'>
<code code='' codeSystem='' codeSystemName=''>
<originalText><reference value='#yyy'/></originalText>
</code>
</manufacturedLabeledDrug>
</manufacturedProduct>
</consumable>
<!-- An optional entry relationship that provides prescription activity -->
<entryRelationship typeCode='REFR'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>
:
.
</entryRelationship>
<!-- An optional entry relationship that identifies the immunization series number -->
<entryRelationship typeCode='SUBJ'>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.46'/>
<code code='30973-2' displayName='Dose Number'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<statusCode code='completed'/>
<value xsi:type='INT' value=''/>
</observation>
</entryRelationship>
<entryRelationship inversionInd='false' typeCode='CAUS'>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.28'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
<templateId root='2.16.840.1.113883.10.20.1.54'/>
<id root='' extension=''/>
</observation>
</entryRelationship>
<!-- Optional <entryRelationship> element containing comments -->
</substanceAdministration>
Figure 6.3.4.17.1-1:
5370
6.3.4.17.2 <substanceAdministration typeCode='SBADM' moodCode='EVN'
negationInd='true|false'>
An immunization is a substance administration event. An immunization entry may be a record of
why a specific immunization was not performed. In this case, negationInd shall be set to "true",
otherwise, it shall be false.
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6.3.4.17.3 <templateId root='2.16.840.1.113883.10.20.1.24'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12'/>
The <templateId> elements identifies this <substanceAdministration> as an immunization. Both
elements shall be present as shown above.
6.3.4.17.4 <id root=' ' extension=' '/>
This shall be the identifier for the immunization event.
5380
5385
6.3.4.17.5 <code code='IMMUNIZ' codeSystem='2.16.840.1.113883.5.4'
codeSystemName='ActCode'/>
This required element records that the act was an immunization. The substance administration
act must have a <code> element with code and codeSystem attributes present. If no coding
system is used by the source, then simply record the code exactly as shown above. Another
coding system that may be used for codes for immunizations are the CPT-4 codes for
immunization procedures. This <code> element shall not be used to record the type of vaccine
used from a vocabulary of drug names.
Table 6.3.4.17.5-1:
codeSystem
codeSystemName
Description
2.16.840.1.113883.5.4
IMMUNIZ
The IMMUNIZ term from the HL7 ActCode vocabulary.
2.16.840.1.113883.6.12
C4
Current Procedure Terminology 4 (CPT-4) codes.
5390
6.3.4.17.6 <text><reference value='#xxx'/></text>
5395
In a CDA document, the URI given in the value attribute of the <reference> element points to an
element in the narrative content that contains the complete text describing the immunization
activity. In an HL7 message, the content of the text element shall contain the complete text
describing the immunization activity.
6.3.4.17.7 <statusCode code='completed'/>
The statusCode shall be set to "completed" for all immunizations.
6.3.4.17.8 <effectiveTime value=' '/>
5400
The effectiveTime element shall be present and should contain a time value that indicates the
date of the substance administration. If the date is unknown, this shall be recorded using the
nullFlavor attribute, with the reason that the information is unknown being specified. Otherwise,
the date shall be recorded, and should have precision of at least the day.
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6.3.4.17.9 <routeCode code=' ' codeSystem=' '
codeSystemName='RouteOfAdministration'/>
5405
See routeCode under Medications.
6.3.4.17.10 <approachSiteCode code=' ' codeSystem=' '
codeSystemName='HumanSubstanceAdministrationSite'/>
See approachSiteCode under Medications.
6.3.4.17.11 <doseQuantity value=' ' units=' '/>
5410
See doseQuantity under Medications.
6.3.4.17.12 <consumable typeCode='CSM'>
The <consumable> element shall be present, and shall contain a <manufacturedProduct> entry
conforming to the Product Entry template found in PCC TF-2:6.14.19.
5415
6.3.4.17.13 <entryRelationship typeCode='REFR'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>
The top level <substanceAdministration> element may contain a reference (typeCode='REFR')
to related Supply entry
5420
6.3.4.17.14 <entryRelationship typeCode='SUBJ'>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.46'/>
This optional entry relationship may be present to indicate that position of this immunization in a
series of immunizations.
6.3.4.17.15 <code code='30973-2' displayName='Dose Number'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
5425
The <code> element shall be present and must be recorded with the code and codeSystem
attributes shown above. This element indicates that the observation describes the dose number
for the immunization.
6.3.4.17.16 <statusCode code='completed'/>
5430
The <statusCode> element shall be present, and must be recorded exactly as shown above. This
element indicates that the observation has been completed.
6.3.4.17.17 <value xsi:type='INT' value=' '/>
The <value> element shall be present, and shall indicate the immunization series number in the
value attribute.
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6.3.4.17.18 <entryRelationship inversionInd='false' typeCode='CAUS'>
5435
This repeatable element should be used to identify adverse reactions caused by the
immunization.
6.3.4.17.19 <observation classCode='OBS' moodCode='EVN'>
This element is required, and provides a pointer to the adverse reaction caused by the
immunization.
5440
6.3.4.17.20 <templateId root='2.16.840.1.113883.10.20.1.28'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
<templateId root='2.16.840.1.113883.10.20.1.54'/>
It shall contain a conforming Problem Entry that also conform to the CCD Reaction template.
6.3.4.17.21 <id root=' ' extension=' '/>
5445
This element is required, and gives the identifier of the adverse reaction. The adverse reaction
pointed to by this element shall be described in more detail using the Allergies entry, elsewhere
in the document where this element was found.
6.3.4.17.22 <entryRelationship inversionInd='false' typeCode='COMP'>
5450
This repeatable element shall be used if needed to record the antigen doses applicable to an
immunization. It shall contain an Antigen Dose entry (templateId
1.3.6.1.4.1.19376.1.5.3.1.4.12.1).
6.3.4.18 Supply Entry 1.3.6.1.4.1.19376.1.5.3.1.4.7.3
The supply entry describes a prescription activity.
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6.3.4.18.1 Specification
5455
5460
5465
5470
5475
5480
5485
5490
<substanceAdministration classCode='SBADM' moodCode='INT|EVN'>
:
.
<entryRelationship typeCode='REFR' inversionInd='false'>
<sequenceNumber value=''/>
<supply classCode='SPLY' moodCode='INT|EVN'>
<templateId root='2.16.840.1.113883.10.20.1.34'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>
<id root='' extension=''/>
<repeatNumber value=''/>
<quantity value='' unit=''/>
<author>
<time value=''/>
<assignedAuthor>
<id root='' extension=''/>
<addr></addr>
<telecom use='' value=''/>
<assignedPerson><name></name></assignedPerson>
<representedOrganization><name></name></representedOrganization>
</assignedAuthor>
</author>
<performer typeCode='PRF'>
<time value=''/>
<assignedEntity>
<id root='' extension=''/>
<addr></addr>
<telecom use='' value=''/>
<assignedPerson><name></name></assignedPerson>
<representedOrganization><name></name></representedOrganization>
</assignedEntity>
</performer>
<!-- Optional Fulfillment instructions -->
<entryRelationship typeCode='SUBJ'>
</entryRelationship>
</supply>
</entryRelationship>
</substanceAdministration>
Figure 6.3.4.18.1-1:
6.3.4.18.2 <entryRelationship typeCode='REFR' inversionInd='false'>
5495
A <substanceAdministration> act may reference (typeCode='REFR') a prescription activity in an
<entryRelationship> element in a CDA document. In a message, the relationship is recorded
using a <sourceOf> element instead of the <entryRelationship> element. The typeCode and
inversionInd attributes, and the semantics remain identical.
6.3.4.18.3 <sequenceNumber value=' '/>
5500
The prescription activity may have a <sequenceNumber> element to indicate the fill number. A
value of 1, 2 or N indicates that it is the first, second, or Nth fill respectively of a specific
prescription. This element should be present when the embedded <supply> element has a
moodCode attribute of EVN.
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6.3.4.18.4 <supply classCode='SPLY' moodCode='INT|EVN'>
5505
The <supply> element shall be present. The moodCode attribute shall be INT to reflect that a
medication has been prescribed, or EVN to indicate that the prescription has been filled.
6.3.4.18.5 <templateId root='2.16.840.1.113883.10.20.1.34'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>
The <templateId> elements shown above shall be present, and identify this supply act as a
Supply Entry.
5510
6.3.4.18.6 <id root=' ' extension=' '/>
Each supply act shall have an identifier to uniquely identify the supply entry.
6.3.4.18.7 <repeatNumber value=' '/>
Each supply entry should have a <repeatNumber> element that indicates the number of times the
prescription can be filled.
5515
6.3.4.18.8 <quantity value=' ' unit=' '/>
5520
The supply entry should indicate the quantity supplied. The value attribute shall be present and
indicates the quantity of medication supplied. If the medication is supplied in dosing units
(tablets or capsules), then the unit attribute need not be present (and should be set to 1 if present).
Otherwise, the unit element shall be present to indicate the quantity (e.g., volume or mass) of
medication supplied.
6.3.4.18.9 <author>
A supply entry that describes an intent (<supply classCode='SPLY' moodCode='INT'>) may
include an <author> element to identify the prescribing provider.
6.3.4.18.10 <time value=' '/>
5525
The <time> element must be present to indicate when the author created the prescription. If this
information is unknown, it shall be recorded by setting the nullFlavor attribute to UNK.
6.3.4.18.11 <assignedAuthor>
The <assignedAuthor> element shall be present, and identifies the author.
6.3.4.18.12 <id root=' ' extension=' '/>
5530
One or more <id> elements should be present. These identifiers identify the author of the act.
When the author is the prescribing physician they may include local identifiers or regional
identifiers necessary for prescribing.
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6.3.4.18.13 <assignedPerson><name/></assignedPerson>
<representedOrganization><name/></ representedOrganization>
5535
An <assignedPerson> and/or <representedOrganization> element shall be present. This element
shall contain a <name> element to identify the prescriber or their organization.
6.3.4.18.14 <performer typeCode='PRF'>
The <performer> element may be present to indicate who is intended (moodCode='INT'), or
actually filled (moodCode='EVN') the prescription.
5540
6.3.4.18.15 <time value=' '/>
The <time> element shall be present to indicate when the prescription was filled
(moodCode='EVN'). If this information is unknown, it shall be recorded by setting the nullFlavor
attribute to UNK.
5545
The <time> element should be present to indicate when the prescription is intended to be filled
(moodCode='INT').
6.3.4.18.16 <assignedEntity>
The < assignedEntity> element shall be present, and identifies the filler of the prescription.
6.3.4.18.17 <id root=' ' extension=' '/>
One or more <id> elements should be present. These identify the performer.
5550
6.3.4.18.18 <assignedPerson><name/></assignedPerson>
<representedOrganization><name/></ representedOrganization>
An <assignedPerson> and/or <representedOrganization> element shall be present. This element
shall contain a <name> element to identify the filler or their organization.
5555
6.3.4.18.19 <!-- Optional Fulfillment instructions -->
<entryRelationship typeCode='SUBJ'>
</entryRelationship>
An entry relationship may be present to provide the fulfillment instructions. When present, this
entry relationship shall contain a Medication Fulfillment Instructions entry.
6.3.4.19 Product Entry 1.3.6.1.4.1.19376.1.5.3.1.4.7.2
5560
The product entry describes a medication or immunization used in a <substanceAdministration>
or <supply> act. It adopts the constraints of the ASTM/HL7 Continuity of Care Document.
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6.3.4.19.1 Specification
5565
5570
5575
5580
<!-- Within a CDA Document -->
<manufacturedProduct>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.2'/>
<templateId root='2.16.840.1.113883.10.20.1.53'/>
<manufacturedMaterial>
<code code='' displayName='' codeSystem='' codeSystemName=''>
<originalText><reference value=''/></originalText>
</code>
<name></name>
</manufacturedMaterial>
</manufacturedProduct>
<!-- Within a message -->
<administerableMaterial>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.2'/>
<templateId root='2.16.840.1.113883.10.20.1.53'/>
<administerableMaterial>
<code></code>
<desc></desc>
</administerableMaterial>
</administerableMaterial>
Figure 6.3.4.19.1-1:
5585
5590
6.3.4.19.2 <manufacturedProduct> -OR- <administerableMaterial>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.2'/>
<templateId root='2.16.840.1.113883.10.20.1.53'/>
<manufacturedMaterial> -OR- <administerableMaterial>
In a CDA document, the name and strength of the medication are specified in the elements under
the <manufacturedMaterial> element. In a message, they are contained within the
<administeredMaterial> element, inside another <administerableMaterial> element1. The
templateId elements are required and identify this as a product entry.
1
5595
5600
5605
This duplication of element names is an artifact of the standard.
6.3.4.19.3 <code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '>
<originalText><reference value=' '/></originalText>
</code>
The <code> element of the <manufacturedMaterial> describes the medication. This may be
coded using a controlled vocabulary, such as RxNorm, First Databank, or other vocabulary
system for medications, and should be the code that represents the generic medication name and
strength (e.g., acetaminophen and oxycodone -5/325), or just the generic medication name alone
if strength is not relevant (Acetaminophen).
In a CDA document, the <originalText> shall contain a <reference> who’s URI value points to
the generic name and strength of the medication, or just the generic name alone if strength is not
relevant. Inside a message, the <originalText> may contain the actual text that describes the
medication in similar fashion.
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5610
5615
Note: When the text is supplied from the narrative, the implication is that if you supply the components of a combination
medication in an entry, you must also display these in the narrative text, otherwise you would not be able to break the
combination medication down into its component parts. This is entirely consistent with the CDA Release 2.0 requirements
that the narrative supply the necessary and relevant human readable information content.
The <code> element is also used to support coding of the medication. If coded, it must provide a
code and codeSystem attribute using a controlled vocabulary for medications. The displayName
for the code and codeSystemName should be provided as well for diagnostic and human
readability purposes, but are not required. The table below provides the codeSystem and
codeSystemName for several controlled terminologies that may be used to encode medications
and/or immunizations.
Table 6.3.4.19.3-1:
codeSystem
5620
codeSystemName
Description
2.16.840.1.113883.6.88
RxNorm
RxNorm
2.16.840.1.113883.6.69
NDC
National Drug Codes
2.16.840.1.113883.6.63
FDDC
First DataBank Drug Codes
2.16.840.1.113883.6.96
SNOMED-CT
SNOMED Controlled
Terminology
2.16.840.1.113883.6.59
CVX
CDC Vaccine Codes
The code used for an immunization may use code systems other than what might be used for
other medications, such as the CDC maintained CVX codes. Code systems that describe
vaccination procedures (such as CPT-4) shall not be used to describe the vaccine entry.
6.3.4.19.4 <name> -OR- <desc>
5625
In a CDA document, the <name> element should contain the brand name of the medication (or
active ingredient in the case of subordinate <substanceAdministration> elements used to record
components of a medication). Within a message, this information shall be provided in the <desc>
element.
6.3.4.20 Simple Observations 1.3.6.1.4.1.19376.1.5.3.1.4.13
5630
The simple observation entry is meant to be an abstract representation of many of the
observations used in this specification. It can be made concrete by the specification of a few
additional constraints, namely the vocabulary used for codes, and the value representation. A
simple observation may also inherit constraints from other specifications (e.g., ASTM/HL7
Continuity of Care Document).
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6.3.4.20.1 Specification
5635
5640
5645
5650
5655
5660
<observation classCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<id root='' extension=''/>
<code code='' displayName='' codeSystem='' codeSystemName=''/>
<!-- for CDA -->
<text><reference value='#xxx'/></text>
<!-- For HL7 Version 3 Messages
<text>text</text>
-->
<statusCode code='completed'/>
<effectiveTime value=''/>
<repeatNumber value=''/>
<value xsi:type='' …/>
<interpretationCode code='' codeSystem='' codeSystemName=''/>
<methodCode code='' codeSystem='' codeSystemName=''/>
<targetSiteCode code='' codeSystem='' codeSystemName=''/>
<author typeCode='AUT'>
<assignedAuthor typeCode='ASSIGNED'><id ... /></assignedAuthor> <!-- for CDA -->
<!-- For HL7 Version 3 Messages
<assignedEntity typeCode='ASSIGNED'>
<Person classCode='PSN'>
<determinerCode root=''>
<name>…</name>
</Person>
<assignedEntity>
-->
</author>
</observation>
6.3.4.20.2 <observation classCode='OBS' moodCode='EVN'>
5665
These acts are simply observations that have occurred, and so are recorded using the
<observation> element as shown above.
6.3.4.20.3 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
The <templateId> element identifies this <observation> as a simple observation, allowing for
validation of the content. The templateId must appear as shown above.
5670
6.3.4.20.4 <id root=' ' extension=' '/>
Each observation shall have an identifier.
6.3.4.20.5 <code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>
5675
Observations shall have a code describing what was measured. The code system used is
determined by the vocabulary constraints on the types of measurements that might be recorded in
a section. Content modules that are derived from the Simple Observation content module may
restrict the code system and code values used for the observation.
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6.3.4.20.6 <text><reference value='#xxx'/></text> -OR- <text>text</text>
5680
Each observation measurement entry may contain a <text> element providing the free text that
provides the same information as the observation within the narrative portion of the document
with a <text> element. For CDA based uses of Simple Observations, this element SHALL be
present, and SHALL contain a <reference> element that points to the related string in the
narrative portion of the document. For HL7 Version 3 based uses, the <text> element MAY be
included.
6.3.4.20.7 <statusCode code='completed'/>
5685
The status code of all observations shall be completed.
6.3.4.20.8 <effectiveTime value=' '/>
5690
The <effectiveTime> element shall be present in standalone observations (those observations not
appearing in an organizer that contains an effective time of its own), and shall record the
clinically effective time of the observation. This element should be precise to the day. If the date
and time is unknown, this element should record that using the nullFlavor attribute. It shall be
recorded using the appropriate data type, which means that it may denote a single point in time
or an interval containing a <low> and <high> element.
6.3.4.20.9 <value xsi:type=' ' …/>
5695
The value of the observation shall be recording using a data type appropriate to the observation.
Content modules derived from the Simple Observation content module may restrict the allowable
data types used for the observation.
6.3.4.20.10 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
If there is an interpretation that can be performed using an observation result (e.g., high,
borderline, normal, low), these may be recorded within the interpretationCode element.
5700
6.3.4.20.11 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
The methodCode element may be used to record the specific method used to make an
observation when this information is not already pre-coordinated with the observation code .
6.3.4.20.12 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
5705
The targetSiteCode may be used to record the target site where an observation is made when this
information is not already pre-coordinated with the observation code.
6.3.4.20.13 <author><assignedAuthor
classCode='ASSIGNED'>...<assignedAuthor></author>
In CDA uses, SimpleObservations are assumed to be authored by the same author as the
document through context conduction. However specific authorship of observation may be
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5710
represented by listing the author in the header and referencing the author in a <author>
relationship. If authors are explicitly listed in documents, an <id> element SHOULD reference
the ID of the author in the header through an assignedAuthor Role. If the author of the
observation is not an author of the document the <person> object including a name and ID
SHALL be included.
5715
For HL7 Version 3 purposes, the <author> element SHOULD be present unless it can be
determined by conduction from organizers or higher level structures. When used for HL7
Version 3 the role element name is <assignedEntity> and the author is represented a
<assignedPerson> element.
6.3.4.21 Vital Signs Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.13.1
5720
A vital signs organizer collects vital signs observations.
6.3.4.21.1 Specification
5725
5730
5735
5740
5745
<organizer classCode='CLUSTER' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.32'/>
<templateId root='2.16.840.1.113883.10.20.1.35'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.1'/>
<id root='' extension=''/>
<code code='46680005' displayName='Vital signs'
codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
<statusCode code='completed'/>
<effectiveTime value=''/>
<!-- For HL7 Version 3 Messages
<author classCode='AUT'>
<assignedEntity1 typeCode='ASSIGNED'>
:
<assignedEntity1>
</author>
-->
<!-- one or more vital signs observations -->
<component typeCode='COMP'>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.2'/>
:
</observation>
</component>
</organizer>
6.3.4.21.2 <organizer classCode='CLUSTER' moodCode='EVN'>
The vital signs organizer is a cluster of vital signs observations.
5750
6.3.4.21.3 <templateId root='2.16.840.1.113883.10.20.1.32'/>
<templateId root='2.16.840.1.113883.10.20.1.35'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.1'/>
The vital signs organizer shall have the <templateId> elements shown above to indicate that it
inherits constraints from the ASTM/HL7 CCD Specification for Vital signs, and the constraints
of this specification.
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6.3.4.21.4 <id root=' ' extension=' '/>
5755
The organizer shall have an <id> element.
6.3.4.21.5 <code code='46680005' displayName='Vital signs'
codeSystem='2.16.840.1.113883.6.96'
codeSystemName='SNOMED CT'/>
5760
The <code> element shall be recorded as shown above to indicate that this organizer captures
information about patient vital signs.
6.3.4.21.6 <statusCode code='completed'/>
The observations have all been completed.
6.3.4.21.7 <effectiveTime value=' '/>
The effective time element shall be present to indicate when the measurement was taken.
5765
6.3.4.21.8 <author typeCode='AUT'><assignedEntity1
typeCode='ASSIGNED'>...</assignedEntity1></author>
For use with HL7 Version 3, Vital Sign organizers SHALL contain an <author> element to
represent the person or device.
5770
6.3.4.21.9 <!-- one or more vital signs observations -->
<component typeCode='COMP'>
The organizer shall have one or more <component> elements that are <observation> elements
using the Vital Signs Observation template.
6.3.4.22 Vital Signs Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.2
5775
A vital signs observation is a simple observation that uses a specific vocabulary, and inherits
constraints from CCD.
6.3.4.22.1 Specification
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5780
5785
5790
5795
5800
<observation classCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='2.16.840.1.113883.10.20.1.31'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.2'/>
<id root=' ' extension=' '/>
<code code=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text><reference value='#xxx'/></text>
<statusCode code='completed'/>
<effectiveTime value=' '/>
<repeatNumber value=' '/>
<value xsi:type='PQ' value=' ' unit=' '/>
<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>
6.3.4.22.2 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='2.16.840.1.113883.10.20.1.31'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.2'/>
A vital signs observation shall have the <templateId> elements shown above to indicate that it
inherits constraints from the ASTM/HL7 CCD Specification for Vital signs, and the constraints
of this specification.
6.3.4.22.3 <code code=' ' codeSystem='2.16.840.1.113883.6.1'
codeSystemName='LOINC'/>
A vital signs observation entry shall use one of the following LOINC codes, with the specified
data types and units.
5805
9279-1
5810
RESPIRATION RATE
/min
8867-4
HEART BEAT
2710-2
OXYGEN SATURATION
%
8480-6
INTRAVASCULAR SYSTOLIC
mm[Hg]
8462-4
INTRAVASCULAR DIASTOLIC
8310-5
BODY TEMPERATURE
Cel or [degF]
8302-2
BODY HEIGHT (MEASURED)
8306-3
BODY HEIGHT^LYING
m, cm,[in_us]
or [in_uk]
8287-5
CIRCUMFRENCE.OCCIPITAL-FRONTAL (TAPE
MEASURE)
3141-9
BODY WEIGHT (MEASURED)
PQ
kg, g, [lb_av]
or [oz_av]
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6.3.4.22.4 <value xsi:type='PQ' value=' ' unit=' '/>
The <value> element shall be present, and shall be of the appropriate data type specified for
measure in the table above.
5810
6.3.4.22.5 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
The interpretation code may be present to provide an interpretation of the vital signs measure
(e.g., High, Normal, Low, et cetera).
6.3.4.22.6 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
5815
The <methodCode> element may be present to indicate the method used to obtain the measure.
Note that method used is distinct from, but possibly related to the target site.
6.3.4.22.7 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
The target site of the measure may be identified in the <targetSiteCode> element (e.g., Left arm
[blood pressure], oral [temperature], et cetera).
6.3.4.23 Family History Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.15
5820
The family history organizer collects the problems of a patient's family member.
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6.3.4.23.1 Specification
5825
5830
5835
5840
5845
5850
5855
<entry>
<organizer classCode='CLUSTER' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.23'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.15'/>
<subject typeCode='SBJ'>
<relatedSubject classCode='PRS'>
<code code='' displayName=''
codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
<subject>
<sdtc:id root='' extension=''/>
<administrativeGenderCode code='' displayName=''
codeSystem='' codeSystemName=''/>
</subject>
</relatedSubject>
</subject>
<!-- zero or more participants linking to other relations -->
<participant typeCode='IND'>
<participantRole classCode='PRS'>
<code code='' displayName=''
codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
<playingEntity classCode='PSN'>
<sdtc:id root='' extension=''/>
</playingEntity>
</participantRole>
</participant>
<!-- one or more entry relationships for family history observations -->
<component typeCode='COMP'>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.22'/>
</observation>
</component>
</organizer>
</entry>
6.3.4.23.2 <organizer classCode='CLUSTER' moodCode='EVN'>
Each family history entry is organized (classCode='CLUSTER') into a group of observations
about a family member.
6.3.4.23.3 <templateId root='2.16.840.1.113883.10.20.1.23'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.15'/>
5860
The organizer is identified by the <templateId> elements, which shall be present as shown
above.
6.3.4.23.4 <subject typeCode='SUBJ'>
6.3.4.23.5
5865
<templateId root=’1'1.3.6.1.4.1.19376.1.5.3.1.4.15.2’2'/>
<relatedSubject classCode='PRS'>
The <subject> element shall be present and relates the subject of the observations to the patient.
It shall contain a <relatedSubject> element that is a personal relation of the patient
(classCode='PRS'). ). The subject should include the template id for the subject participant
template.
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5870
5875
Note: The subject participant was added to the technical framework subsequent to the final text publication that
originally defined this entry. The definition of that subject participant was derived from this entry. Following the principal
that changes must be backwards compatible, the Family History Organizer does not require the use of this template.
However, it is strongly recommended.
6.3.4.23.6 <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.5.111'
codeSystemName='RoleCode'/>
The <code> element shall be present, and give the relationship of the subject to the patient. The
code attribute shall be present, and shall contain a value from the HL7 FamilyMember
vocabulary. The codeSystem attribute shall be present and shall use the value shown above.
5880
6.3.4.23.7 <subject>
The <subject> element contains information about the relation.
6.3.4.23.8 <sdtc:id root=' ' extension=' '/>
The <sdtc:id> element should be present. It is used to identify the patient relation to create a
pedigree graph.
5885
6.3.4.23.9 <administrativeGenderCode code=' ' />
The <administrativeGenderCode> element should be present. It gives the gender of the relation.
6.3.4.23.10 <participant typeCode='IND'>
<participantRole classCode='PRS'>
5890
The <participant> element may be present to record the relationship of the subject to other
family members to create a pedigree graph. It shall contain a <participantRole> element showing
the relationship of the subject to other family members (classCode='PRS').
6.3.4.23.11 <code code=' ' displayName=' ' codeSystem=' '
codeSystemName=' '/>
5895
The <code> element shall be present, and gives the relationship of the participant to the subject.
The code attribute shall be present, and shall contain a value from the HL7 FamilyMember
vocabulary. The codeSystem attribute shall be present and shall use the value shown above.
6.3.4.23.12 <playingEntity classCode='PSN'>
The <playingEntity> element identifies the related person. It shall be recorded as shown above.
6.3.4.23.13 <sdtc:id root=' ' extension=' '/>
5900
The <sdtc:id> element shall be present. It must have the same root and extension attributes of the
<subject> of a separate family history organizer. See Appendix C of IHE PCC-TF for definition
of this extension to CDA.
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5905
6.3.4.23.14 <component typeCode='COMP'>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.3'/>
The family history organizer shall contain one or more components using the <component>
element shown above. These components must conform to the Family History Observation
template.
6.3.4.24 Social History Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.4
5910
A social history observation is a simple observation that uses a specific vocabulary, and inherits
constraints from CCD.
6.3.4.24.1 Standards
CCD ASTM/HL7 Continuity of Care Document
6.3.4.24.2 Parent Template
5915
The parent of this template is Simple Observation. This template is compatible with the
ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.33
6.3.4.24.3 Specification
5920
5925
5930
<observation typeCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='2.16.840.1.113883.10.20.1.33'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.4'/>
<id root=' ' extension=' '/>
<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>
<text><reference value='#xxx'/></text>
<statusCode code='completed'/>
<effectiveTime value=' '/>
<repeatNumber value=' '/>
<value xsi:type=' ' />
<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>
Figure 6.3.4.24.3-1: Social History Observation Example
5935
6.3.4.24.4 <templateId root='2.16.840.1.113883.10.20.1.33'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.4'/>
These <templateId> elements identify this as a Social History observation.
6.3.4.24.5 <code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>
The <code> element identifies the type social history observation.
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5940
229819007
Smoking
PQ
{pack}/d or
{pack}/wk or
{pack}/a
256235009
Exercise
{times}/wk
160573003
ETOH (Alcohol)
Use
{drink}/d or
{drink}/wk
364393001
Diet
364703007
Employment
425400000
Toxic Exposure
363908000
Drug Use
228272008
Other Social
History
CD
N/A
ANY
6.3.4.24.6 <repeatNumber value=' '/>
The <repeatNumber> element should not be used in a social history observation.
6.3.4.24.7 <value xsi:type=' ' ... />
The <value> element reports the value associated with the social history observation. The data
type to use for each observation should be drawn from the table above.
5945
5950
5955
Observations in the table above using the PQ data type have a unit in the form {xxx}/d,
{xxx}/wk or {xxx}/a represent the number of items per day, week or year respectively. The
value attribute indicates the number of times of the act performed, and the units represent the
frequency. The example below shows how to represent 1 drink per day.
:
<code code='160573003' displayName='ETOH Use'
codeSystem='2.16.840.1.113883.6.96'
codeSystemName='SNOMED CT'/>
:
<value xsi:type='PQ' value='1' unit='{drink}/d'/>
:
Observations in the table using the CD data type should include coded values from an
appropriate vocabulary to represent the social history item. The example below shows the
encoding to indicate drug use of cannabis.
5960
5965
:
<code code='363908000' displayName='Drug Use'
codeSystem='2.16.840.1.113883.6.96'
codeSystemName='SNOMED CT'/>
:
<value xsi:type='CD' code='398705004' displayName='cannabis'
codeSystem='2.16.840.1.113883.6.96'
codeSystemName='SNOMED CT'/>
:
Other social history observations may use any appropriate data type.
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5970
6.3.4.24.8 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
The <interpretationCode>, <methodCode>, and <targetSiteCode> elements should not be used in
a social history observation.
5975
6.3.4.25 Pregnancy Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.5
A pregnancy observation is a Simple Observation that uses a specific vocabulary to record
observations about a patient's current or historical pregnancies.
6.3.4.25.1 Parent Template
The parent of this template is Simple Observation.
5980
6.3.4.25.1.1 Uses
See Templates using Pregnancy Observation
6.3.4.25.2 Specification
Pregnancy Observation Example
5985
5990
5995
6000
6005
<observation classCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5'/>
<id root=' ' extension=' '/>
<code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<text><reference value='#xxx'/></text>
<statusCode code='completed'/>
<effectiveTime value=' '/>
<repeatNumber value=' '/>
<value xsi:type=' ' .../>
<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>
6.3.4.25.3 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5'/>
These <templateId> elements identify this <observation> as a pregnancy observation, allowing
for validation of the content. The <templateId> elements shall be recorded as shown above.
6.3.4.25.4 <code code=' ' displayName=' '
codeSystem='2.16.840.1.113883.6.1'
codeSystemName='LOINC'/>
A pregnancy observation shall have a code describing what facet of patient's pregnancy is being
recorded. These codes should come from the list of codes shown below. Additional codes may
be used to reflect additional information about the pregnancy history.
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6010
Table 6.3.4.25.4-1: Pregnancy Observation Codes
LOINC
CODE
Description
Type
Units or Vocabulary
Past Pregnancy History
11636-8
BIRTHS LIVE (REPORTED)
INT
N/A
11637-6
BIRTHS PRETERM (REPORTED)
INT
N/A
11638-4
BIRTHS STILL LIVING (REPORTED)
INT
N/A
11639-2
BIRTHS TERM (REPORTED)
INT
N/A
11640-0
BIRTHS TOTAL (REPORTED)
INT
N/A
11612-9
ABORTIONS (REPORTED)
INT
N/A
11613-7
ABORTIONS INDUCED (REPORTED)
INT
N/A
11614-5
ABORTIONS SPONTANEOUS (REPORTED)
INT
N/A
33065-4
ECTOPIC PREGNANCY (REPORTED)
SNOMED-CT 237364002
57062-2
Births.stillborn
SNOMED-CT 237364002
Detailed Pregnancy Data
5
11996-6
Pregnancies
INT
11639-2
Births.Term
INT
11637-6
Births.Preterm
INT
45371-2
Multiple pregnancy
BL
49051-6
Gestational age
PQ
wk
11887-7
FETUS, GESTATIONAL AGE (ESTIMATED FROM
SELECTED DELIVERY DATE)
PQ
d, wk or mo
32396-4
Labor duration
PQ
h
8339-4
Body weight at birth
PQ
kg, g, [lb_av] or [oz_av]
29300-1
Procedure 5
CE
8722-1
Surgical operation note anesthesia
CE
52829-9
Place of service
42839-1
Labor risk
CE
42840-9
Delivery risk
CE
11449-6
PREGNANCY STATUS
CE
SNOMED CT, ICD-9-CM
(V22)
8678-5
MENSTRUAL STATUS
CE
SNOMED CT
This is the procedure used for delivery and should be selected from an appropriate value set
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LOINC
CODE
Description
Type
Units or Vocabulary
8665-2
DATE LAST MENSTRUAL PERIOD
TS
N/A
11778-8
DELIVERY DATE (CLINICAL ESTIMATE)
TS
N/A
11779-6
DELIVERY DATE (ESTIMATED FROM LAST
MENSTRUAL PERIOD)
TS
N/A
11780-4
DELIVERY DATE (ESTIMATED FROM OVULATION
DATE)
TS
N/A
11884-4
FETUS, GESTATIONAL AGE (CLINICAL ESTIMATE)
PQ
d, wk or mo
11885-1
FETUS, GESTATIONAL AGE (ESTIMATED FROM
LAST MENSTRUAL PERIOD)
PQ
d, wk or mo
11886-9
FETUS, GESTATIONAL AGE (ESTIMATED FROM
OVULATION DATE)
PQ
d, wk or mo
6.3.4.25.5 <repeatNumber value=' '/>
The <repeatNumber> element should not be present in a pregnancy observation.
6015
6020
6.3.4.25.6 <value xsi:type=' ' .../>
The value of the observation shall be recording using a data type appropriate to the coded
observation according to the table above.
6.3.4.25.7 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
The <interpretationCode>, <methodCode>, and <targetSiteCode> should not be present in a
pregnancy observation.
6.3.4.26 Pregnancy History Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.13.5.1
6025
The pregnancy history organizer collects observations relevant to a single pregnancy within the
patient’s history. The organizer for a pregnancy event shall either contain subordinate birth event
organizers for each birth event associated with the pregnancy or shall conform to the birth event
organizer template, but not both.
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6.3.4.26.1
6030
6035
6040
6045
6050
6055
<organizer classCode='CLUSTER' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5.1'/>
<id root='' extension=''/>
<code code='118185001' displayName='Pregnancy Finding'
codeSystem='SNOMED CT'
codeSystemName='2.16.840.1.113883.6.96'/>
<statusCode code='completed'/>
<effectiveTime value=''/>
<!-- For HL7 Version 3 Messages
<author classCode='AUT'>
<assignedEntity1 typeCode='ASSIGNED'>
:
<assignedEntity1>
</author>
-->
<!-- One or more components -->
<component typeCode='COMP'>
<!-- Containing either a birth organizer -->
<sequenceNumber value='1'/>
<organizer classCode='CLUSTER' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5.2'/>
:
</organizer>
<!-- Or a pregnancy observation -->
<observation classCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5'/>
:
</observation>
</component>
</organizer>
6.3.4.26.2
6060
Specification
<organizer classCode='CLUSTER' moodCode='EVN'>
The pregnancy history organizer is a cluster of pregnancy observations.
6.3.4.26.3
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5.1'/>
The pregnancy organizer shall have the <templateId> element shown above to indicate that it
conforms to this specification.
6.3.4.26.4
6065
<id root=' ' extension=' '/>
The organizer shall have an <id> element.
6.3.4.26.5
<code code='118185001' displayName='Pregnancy Finding'
codeSystem='SNOMED CT'
codeSystemName='2.16.840.1.113883.6.96'/>
6070
The organizer shall contain a code describing the observations present. The recommended code
is shown above.
6.3.4.26.6
<statusCode code='completed'/>
The observations have all been completed.
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6.3.4.26.7
<effectiveTime value=' '/>
The effective time element shall be present to indicate the interval of the pregnancy.
6075
6.3.4.26.8
<author typeCode='AUT'><assignedEntity1
typeCode='ASSIGNED'>...</assignedEntity1></author>
For use with HL7 Version 3, Vital Sign organizers SHALL contain an <author> element to
represent the person or device.
6.3.4.26.9
<component typeCode='COMP'>
6080
The organizer shall have one or more <component> elements that are either instances of a birth
organizer, or pregnancy observations. A <component> element containing a birth organizer shall
contain a <sequenceNumber> element to indicate the birth order. If birth order is unknown, the
<sequenceNumber> shall be present but shall contain a value of null (e.g., <sequenceNumber
nullFlavor='UNK'/>)
6085
6.3.4.27 Birth Event Organizer 1.3.6.1.4.1.19376.1.5.3.1.4.13.5.2
The birth event organizer collects observations relevant to a single birth within the patient’s
history. This template can be combined with the pregnancy history organizer to organize
pregnancy and delivery findings under a single organizer (this is the preferred solution for a
single birth).
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6090
6095
6100
6105
6110
6115
6120
6125
6.3.4.27.1
Specification
<organizer classCode='CLUSTER' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5.2'/>
<id root='' extension=''/>
<code code='118215003' displayName='Delivery Finding'
codeSystem='SNOMED CT'
codeSystemName='2.16.840.1.113883.6.96'/>
<statusCode code='completed'/>
<effectiveTime value=''/>
<!-- For HL7 Version 3 Messages
<author classCode='AUT'>
<assignedEntity1 typeCode='ASSIGNED'>
:
<assignedEntity1>
</author>
-->
<subject typeCode='SBJ'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.15.2'/>
<relatedSubject classCode='PRS'>
<subject>
<sdtc:id root='' extension=''/>
<administrativeGenderCode code='' displayName=''
codeSystem='' codeSystemName=''/>
<birthTime value=''/>
<ihe:multipleBirthOrderNumber value=''/>
</subject>
</relatedSubject>
</subject>
<!-- One or more components -->
<component typeCode='COMP'>
<!-- Containing a pregnancy observation -->
<observation classCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5'/>
:
</observation>
</component>
</organizer>
6.3.4.27.2
<organizer classCode='CLUSTER' moodCode='EVN'>
The birth event organizer is a cluster of observations about a single birth event.
6.3.4.27.3
6130
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5.2'/>
The birth event organizer shall have the <templateId> element shown above to indicate that it
conforms to this specification.
6.3.4.27.4
<id root=' ' extension=' '/>
The organizer shall have an <id> element.
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6135
6.3.4.27.5
<code code='118215003' displayName='Delivery Finding'
codeSystem='SNOMED CT'
codeSystemName='2.16.840.1.113883.6.96'/>
The organizer shall contain a code describing the observations present. The recommended code
is shown above. When the birth event organizer is combined with the pregnancy history
organizer, the code should be that recommended for the pregnancy history organizer 6.
6140
6.3.4.27.6
<statusCode code='completed'/>
The observations have all been completed.
6.3.4.27.7
6145
<effectiveTime value=' '/>
The effective time element may be present to indicate the time period of the relevant findings.
Note that when combined with the pregnancy history organizer, this shall contain the interval
associated with the pregnancy.
6.3.4.27.8
<author typeCode='AUT'><assignedEntity1
typeCode='ASSIGNED'>...</assignedEntity1></author>
For use with HL7 Version 3, Birth Event organizers SHALL contain an <author> element to
represent the person or device.
6150
6.3.4.27.9
<subject typeCode='SBJ'>
<templateId root= '1.3.6.1.4.1.19376.1.5.3.1.4.15.2'> …
The birth event organizer shall contain a subject participant describing the child that was born
(e.g., name, age, gender).
6.3.4.27.10 <ihe:multipleBirthOrderNumber value=''/>
6155
The organizer may contain a multipleBirthOrderNumber representing the order in which the
child was born in a delivery where there are multiple births.
6.3.4.27.11 <component typeCode='COMP'>
The organizer shall have one or more <component> elements that are instances of a pregnancy
observation.
6
Delivery findings are pregnancy findings but not all pregnancy findings are delivery findings.
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6160
6.3.4.28 Reserved for (Antepartum Visit Summary Battery)
6.3.4.29 Advance Directive Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.7
An advance directive observation is a simple observation that uses a specific vocabulary, and
inherits constraints from CCD.
6.3.4.29.1 Standards
CCD
ASTM/HL7 Continuity of Care Document
6165
6.3.4.29.2 Specification
6170
6175
6180
6185
6190
<observation typeCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='2.16.840.1.113883.10.20.1.17'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.7'/>
<id root=' ' extension=' '/>
<code code=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
<text><reference value='#xxx'/></text>
<statusCode code='completed'/>
<effectiveTime value=' '/>
<value xsi:type='BL' value='true|false'/>
<reference typeCode='REFR'>
<templateId root='2.16.840.1.113883.10.20.1.36'/>
<externalDocument classCode='DOC' moodCode='EVN'>
<id root=' ' extension=' '/>
<text><reference value=' '/></text>
</externalDocument>
</reference>
</observation>
An advanced directive <observation> shall be represented as shown above. They shall not
contain any <repeatNumber>, <interpretationCode>, <methodCode> or <targetSiteCode>
elements.
6.3.4.29.3 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='2.16.840.1.113883.10.20.1.17'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.7'/>
The <templateId> elements shown above shall be present, and indicated that this is an Advance
Directive entry.
6.3.4.29.4 <code code=' ' codeSystem='2.16.840.1.113883.6.96'
codeSystemName='SNOMED CT'/>
6195
The <code> element records the type of advance directive. It should use one of the following
SNOMED codes in the table below.
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Code
Description
304251008
Resuscitation
52765003
Intubation
225204009
IV Fluid and Support
89666000
CPR
281789004
Antibiotics
78823007
Life Support
61420007
Tube Feedings
116859006
Transfusion of blood
product
71388002
Other Directive
Data Type
BL
<value> not permitted
6200
6.3.4.29.5 <value xsi:type='BL' value='true|false'/>
6205
The advance directive observation may include a <value> element using the Boolean
(xsi:type='BL') data type to indicate simply whether the procedure described is permitted.
Absence of the <value> element indicates that an advance directive of the specified type has
been recorded, and must be examined to determine what type of treatment should be performed.
The value element is not permitted when the <code> element describes an Other directive.
6210
6.3.4.29.6 <reference typeCode='REFR'>
<templateId root='2.16.840.1.113883.10.20.1.36'/>
<externalDocument classCode='DOC' moodCode='EVN'>
<id root=' ' extension=' '/>
<text><reference value=' '/></text>
6215
The advanced directive observation may contain a single reference to an external document. That
reference shall be recorded as shown above. The <id> element shall contain the appropriate root
and extension attributes to identify the document. The <text> element may be present to provide
a URL link to the document in the value attribute of the <reference> element. If the <reference>
element is present, the Advance Directive in the narrative shall contain a <linkHTML> element
to the same URL found in the value attribute.
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6.3.4.30 Reserved for Blood Type Observation
6.3.4.31 Reserved for Encounters
6.3.4.32 Reserved for Update Entry
6220
6.3.4.33 Reserved for Procedure Entry
6.3.4.34 Transport 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1
A transport entry indicates the intended or actual mode of transport and time of departure and/or
arrival of the patient.
6.3.4.34.1 Specification
6225
6230
6235
<entry>
<act classCode='ACT' moodCode='INT|EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'/>
<id root='' extension=''/>
<code code='' displayName=''
codeSystem='2.16.840.1.113883.6.102.4.2'
codeSystemName='DEEDS4.02'>
<originalText><reference value='#(ID of text coded)/></orginalText>
</code>
<text><reference value='#text/></text>
<high value=/>
</effectiveTime>
</act>
</entry>
6.3.4.34.1.1 <act classCode='ACT' moodCode='INT|EVN'>
6240
This element indicates that the entry is an act (of transporting the patient, as indicated by the
code below). This entry records the mode, and intended or actual ending time of transportation.
In intent mood (moodCode='INT') this is how the estimated time of departure or arrival is
indicated. In event mood (moodCode='EVN') this is how the actual departure or arrival of the
patient is recorded.
6245
6.3.4.34.1.2 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'/>
The <templateId> element identifies this <act> as about the transportation of the patient. The
templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'.
6.3.4.34.1.3 <id root='' extension=''/>
The entry must have an identifier.
6250
6.3.4.34.1.4 <code code='' displayName=''
codeSystem='2.16.840.1.113883.6.102.4.2' codeSystemName='DEEDS4.02'>
The code describes the intended mode of transport. For transport between facilities, IHE
recommends the use of a code system based on the DEEDS Mode of Transportation data element
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6255
value set. However, the vocabulary used within an affinity domain should be determined by a
policy agreement within the domain.
6.3.4.34.1.5 <originalText><reference value='#xxx'/><orginalText>
This is a reference to the narrative text within the section that describes the mode of
transportation.
6.3.4.34.1.6 <text><reference value='#text/></text>
6260
This is a reference to the narrative text corresponding to the transport act.
6.3.4.34.1.7 <effectiveTime>
The effectiveTime element shall be sent. It records the interval of time over which transport
occurs. Either low value or high value or both values SHALL be specified.
6.3.4.34.1.8 <low value=''/>
6265
This element records the time of departure. If unknown, it must be recorded using a flavor of
null. This element shall be sent using the TS data type, as shown above.
6.3.4.34.1.9 <high value=''/>
This element records the time of arrival. If unknown, it must be recorded using a flavor of null.
This element shall be sent using the TS data type as shown above.
6270
6.3.4.35 Reserved for Encounter Disposition
6.3.4.36 Coverage Entry 1.3.6.1.4.1.19376.1.5.3.1.4.17
Payers shall be recorded as described in CCD: 3.1.2.1.1.
6.3.4.36.1 Standards
CCD ASTM/HL7 Continuity of Care Document
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6275
6.3.4.36.2 Specification
Coverage Entry Example
6280
6285
6290
<act classCode='ACT' moodCode='DEF'>
<templateId root='2.16.840.1.113883.10.20.1.20'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.17'/>
<id root='' extension='' />
<code code='48768-6' displayName='Payment Sources'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<statusCode code='completed'/>
<entryRelationship typeCode='COMP'>
<sequenceNumber value=''/>
:
</entryRelationship>
</act>
6.3.4.36.3 <act classCode='ACT' moodCode='DEF'>
Coverage shall be recorded in an <act> that groups all patient coverage together, and defines
(moodCode='DEF') the payers.
6295
6.3.4.36.4 <templateId root='2.16.840.1.113883.10.20.1.20'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.17'/>
The <act> conforms to CCD: 3.1.2.1.1 as well as this specification. This shall be reflected by
including the <templateId> elements shown above.
6.3.4.36.5 <id root=' ' extension=' '/>
6300
The <id> element shall be present.
6.3.4.36.6 <code code='48768-6' displayName='PAYMENT SOURCES'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
The <code> element shall be recorded exactly as shown above.
6.3.4.36.7 <statusCode code='completed'/>
6305
The <statusCode> element shall be present exactly as shown above.
6.3.4.36.8 <entryRelationship typeCode='COMP'>
The coverage <act> shall have one or more <entryRelationship> elements. These elements
define the coverage. The entry relationships must contain Payer Entries.
6.3.4.36.9 <sequenceNumber value=' '/>
6310
The <sequenceNumber> element may be present. If present, it shall contain a value attribute that
indicates the priority of the payment source.
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6.3.4.37 Payer Entry 1.3.6.1.4.1.19376.1.5.3.1.4.18
The payer entry allows information about the patient's sources of payment to be recorded.
6.3.4.37.1 Standards
CCD ASTM/HL7 Continuity of Care Document
6315
6.3.4.37.2 Specification
Payer Entry Example
6320
6325
6330
6335
6340
6345
6350
6355
6360
<act classCode='ACT' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.26'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.18'/>
<id root='' extension=''/>
<code code='' displayName='' codeSystem='' codeSystemName=''/>
<statusCode code='completed'/>
<performer typeCode='PRF'><!-- payer -->
<assignedEntity classCode='ASSIGNED'>
<id root='' extension=''/>
<code code='PAYOR|GUAR|PAT' displayName=''
codeSystem='2.16.840.1.113883.5.110' codeSystemName='RoleClass'/>
<addr></addr>
<telecom value='' use=''/>
<representedOrganization typeCode='ORG'>
<name></name>
</representedOrganization>
</assignedEntity>
</performer>
<participant typeCode='COV'><!-- member -->
<participantRole classCode='PAT'>
<id root='' extension=''/>
<code code='' displayName=''
codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
<addr></addr>
<telecom value='' use=''/>
<playingEntity><name></name></playingEntity>
</participantRole>
</participant>
<participant typeCode='HLD'><!-- subscriber -->
<participantRole classCode='PAT'>
<id root='' extension=''/>
<playingEntity><name></name></playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode='REFR'>
<act classCode='ACT' moodCode='DEF'>
<id root='' extension=''/>
<code code='' displayName='' codeSystem='' codeSystemName=''/>
<text><reference value=''/></text>
</act>
</entryRelationship>
</act>
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6.3.4.37.3 <act classCode='ACT' moodCode='EVN'>
The Payer entry <act> describes the policy or program that has agreed to pay
(moodCode='EVN') for the patient's treatment.
6365
6.3.4.37.4 <templateId root='2.16.840.1.113883.10.20.1.26'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.18'/>
The <act> conforms to CCD: 3.1.2.1.2 and this guide. This shall be reflected by including the
<templateId> elements shown above.
6.3.4.37.5 <id root=' ' extension=' '/>
6370
The <act> shall contain at least one <id> element that represents the policy or group number of
the coverage. That identifier shall appear in the extension attribute.
6.3.4.37.6 <code code=' ' displayName=' '
codeSystem=' ' codeSystemName=' '/>
6375
The <code> element should be present, and represents the type of coverage provided by the
payer. Potential vocabularies to use include:
Table 6.3.4.37.6-1: Payer Type Vocabularies
Vocabulary
Description
OID
HL7
ActCoverageType
The HL7 ActCoverageType vocabulary describes payers
and programs. Note that HL7 does not have a specific
code to identify an individual payer, e.g., in the role of a
guarantor or patient.
2.16.840.1.113883.5.4
X12 Data Element
1336
The X12N 271 implementation guide includes various
types of payers. This code set does include a code to
identify individual payers.
2.16.840.1.113883.6.255.1336
6.3.4.37.7 <statusCode code='completed'/>
6380
The <statusCode> element shall be present, and should be recorded exactly as shown above.
6.3.4.37.8 <performer typeCode='PRF'>
<assignedEntity classCode='ASSIGNED'>
The <performer> element shall be present to represent the payer of the coverage.
6.3.4.37.9 <id root=' ' extension=' '/>
6385
The identity of the performer should be recorded in the <id> element.
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6.3.4.37.10 <code code='PAYOR|GUAR|PAT' displayName=' '
codeSystem='2.16.840.1.113883.5.110'
codeSystemName='RoleClass'/>
6390
The <code> element describes the role of the payer. It shall contain one of the values listed in the
table below.
Table 6.3.4.37.10-1: Payer Role Codes
Coding System
OID
ISBT 128
2.16.840.1.113883.6.18
SNOMED CT
2.16.840.1.113883.6.96
6.3.4.37.11 <addr></addr>
The <addr> element shall be used to record the address of the payer. This information will
usually come from the back of an insurance card.
6395
6.3.4.37.12 <telecom value=' ' use=' '/>
The <telecom> element shall be used to record the phone number of the payer. This information
will usually come from the back of an insurance card.
6.3.4.37.13 <representedOrganization typeCode='ORG'>
<name></name>
6400
The name of the payer organization shall be provided in the <name> element contained within
the <representedOrganization> element.
6.3.4.37.14 <participant typeCode='COV'>
<participantRole classCode='PAT'>
6405
Information about the patient with respect to the policy or program shall be recorded in the
<participantRole> element shown above. This element shall be present when the patient is a
member of a policy or program.
6.3.4.37.15 <id root=' ' extension=' '/>
The <id> element should contain the identifier of the patient with respect to the payer (the
subscriber or member id).
6410
6.3.4.37.16 <code code= displayName= codeSystem='2.16.840.1.113883.5.111'
codeSystemName='RoleCode'/>
The <code> element shall indicate the covered party’s relationship to the subscriber, and should
come from the HL7 CoverageRoleType value set.
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6.3.4.37.17 <addr></addr>
6415
The <addr> element should be used to record the address of the patient as known to the payer
when different from that recorded in the <patientRole> element.
6.3.4.37.18 <telecom value=' ' use=' '/>
The <telecom> element should be used to record the phone number of the patient when different
from that recorded in the <patientRole> element.
6420
6.3.4.37.19 <playingEntity><name></name></playingEntity>
The <name> element should be used to record the member name when it is different from that
recorded in the <patient> element.
6.3.4.37.20 <participant typeCode='HLD'>
<participantRole classCode='IND'>
6425
Information about subscriber to the policy or program shall be recorded in the <participantRole>
element shown above. This element shall be present when the subscriber is different from the
patient.
6.3.4.37.21 <id root=' ' extension=' '/>
6430
The <id> element shall contain the identifier of the subscriber when the subscriber is not the
patient.
6.3.4.37.22 <addr></addr>
The <addr> element shall be used to record the address of the subscriber when the subscriber is
not the patient.
6.3.4.37.23 <telecom value=' ' use=' '/>
6435
The <telecom> element shall be used to record the phone number of the subscriber when the
subscriber is not the patient.
6.3.4.37.24 <playingEntity><name></name></playingEntity>
The name of the subscriber shall be recorded in the <name> element of the <playingEntity>.
6440
6.3.4.37.25 <entryRelationship typeCode='REFR'>
classCode='ACT' moodCode='DEF'>
<act
The plan information may be provided in the elements described above.
6.3.4.37.26 <id root=' ' extension=' '/>
The health plan identifier is recorded in the <id> element.
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6.3.4.37.27 <text><reference value=' '/></text>
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This <reference> element shown above should be present and the value attribute should point to
the name of the plan contained in the narrative of the document.
6.3.4.38 Reserved for Pain Score Observation
6.3.4.39 Reserved for Future Use
6.3.4.40 Reserved for Future Use
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6.3.4.41 Reserved for Future Use
6.3.4.42 Reserved for Future Use
6.3.4.43 Reserved for Survey Panel
6.3.4.44 Reserved for Survey Observation
6.3.4.45 Reserved for Acuity
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6.3.4.46 Reserved for Intravenous Fluids
6.3.4.47 Reserved for Nursing Assessments Battery
6.3.4.48 Reserved for Antenatal Testing and Surveillance Battery
6.3.4.49 Immunization Recommendation 1.3.6.1.4.1.19376.1.5.3.1.4.12.2
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An immunization recommendation entry is used to record intended or proposed immunization
activities. Proposed activities are suggestions for care or treatment that are used in decision
making (these might appear as an input to, or output from clinical decision support). Intended
activities describe the currently accepted plan, and are part of the care activities expected to
occur for the patient.
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<substanceAdministrationIntent typeCode='SBADM' moodCode='INT|PRP' negationInd='true|false'>
<templateId root='2.16.840.1.113883.10.20.1.25'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12.2'/>
<id root='' extension=''/>
<code code='IMMUNIZ' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode'/>
<text><reference value='#xxx'/></text>
<statusCode code='completed'/>
<effectiveTime><low value=''/><high value=''/></effectiveTime>
<routeCode code='' codeSystem='' codeSystemName='RouteOfAdministration'/>
<approachSiteCode code='' codeSystem='' codeSystemName='HumanSubstanceAdministrationSite'/>
<doseQuantity value='' units=''/>
<consumable typeCode='CSM'>
:
.
</consumable>
<!-- An optional entry relationship that identifies the immunization series number -->
<entryRelationship typeCode='SUBJ'>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.46'/>
<code code='30973-2' displayName='Dose Number'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<statusCode code='completed'/>
<value xsi:type='INT' value=''/>
</observation>
</entryRelationship>
<!-- Optional <entryRelationship> element containing comments -->
</substanceAdministrationIntent>
Note:
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The CCD represents the observation of a series number in EVN mood, as we have shown above. However, when
the immunization is “intended” to be the second of a series, we do not believe this is the correct mood code. How
should this be addressed?
6.3.4.49.1 <substanceAdministrationIntent typeCode='SBADM'
moodCode='INT|PRP' negationInd='true|false'>
This entry represents the intent or proposal to administer (when negationInd = false), or not
administer (when negationInd = true) an immunization to a patient.
6.3.4.49.2 <templateId root='2.16.840.1.113883.10.20.1.25'/>
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This element represents a plan of care activity for the patient, and so shall conform to the CCD
Plan of Care activity template.
6.3.4.49.3 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12.2'/>
This element is an instance of an IHE PCC Immunization Recommendation entry, and shall
indicate that conformance by inclusion of the template identifier given above.
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6.3.4.49.4 <id root='' extension=''/>
Each plan of care activity shall contain an identifier.
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6.3.4.49.5 <code code='IMMUNIZ' codeSystem='2.16.840.1.113883.5.4'
codeSystemName='ActCode'/>
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An immunization care plan entry shall include a code identifying that this is in reference to an
immunization. If no coding system is required by the source, simply record as shown above. See
PCC TF-2:6.3.4.17 for additional coding systems that may appear in this element.
6.3.4.49.6 <text><reference value='#xxx'/></text>
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In a CDA document, the URI given in the value attribute of the <reference> element points to an
element in the narrative content that contains the complete text describing the immunization
activity. In an HL7 message, the content of the text element shall contain the complete text
describing the immunization activity.
6.3.4.49.7 <statusCode code='active'/>
The status code shall be active for all active proposals or intentions.
6.3.4.49.8
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<effectiveTime><low value=''/><high value=''/></effectiveTime>
The <effectiveTime> element should be present to indicate time interval over which the
suggested activity should take place. Intervals shall be represented using the IVL_TS data type.
6.3.4.49.9 <routeCode code='' codeSystem=''
codeSystemName='RouteOfAdministration'/>
<approachSiteCode code='' codeSystem=''
codeSystemName='HumanSubstanceAdministrationSite'/>
<doseQuantity value='' units=''/>
The <routeCode>, <approachSiteCode> and <doseQuantity> elements are used to
represent additional attributes of the proposed care. When present these elements must be
consistent with the rules for these elements specified in PCC TF-2:6.3.4.16 Medication Entry and
PCC TF-2:6.3.4.17 Immunization Entry.
6.3.4.49.10 <consumable typeCode='CSM'>
The <consumable> element shall be present, and shall contain a
<manufacturedProduct> entry conforming to the Product Entry template found in PCC
TF-2:6.14.19.
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6.3.4.49.11 <entryRelationship typeCode='SUBJ'>
<observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.46'/>
<code code='30973-2'
displayName='Dose Number'
codeSystem='2.16.840.1.113883.6.1'
codeSystemName='LOINC'/>
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<statusCode code='completed'/>
<value xsi:type='INT' value=''/>
</observation>
</entryRelationship>
The immunization plan of care entry may contain a single entry relationship identifying the
immunization series number. This entry shall use the CCD template
(2.16.840.1.113883.10.20.1.46) defined for that purpose.
6.3.4.49.12 <!-- Optional <entryRelationship> element referencing guidelines -->
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6.3.4.50 Alert Entry 1.3.6.1.4.1.19376.1.5.3.1.4.12.3
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The alert entry is an observation whose subject is any clinical statement. This entry provides
additional information about a clinical statement that may be of relevance to the care being
described. For example, some treatments may be contraindicated by other conditions or cooccurring treatment. For example, the use of aspirin and a blood thinning agent at the same time
may not be recommended. The alert entry is provided to record these annotations. An example
use of this entry is in a clinical decision support service that uses the alert entry to identify
vaccinations that are considered to be of reduced effectiveness when making immunization
recommendations for the patient. Another example of this use in a similar system would be to
identify treatments that are contraindicated subsequent to an immunization.
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<entryRelationship typeCode='SUBJ' inversionInd='true'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12.3'/>
<observation classCode='ALRT|OBS' moodCode='EVN'>
<id root='' id=''/>
<code code='' displayName='' codeSystem='' codeSystemName=''/>
<text><reference value='#ref-1'/></text>
</observation>
</entryRelationship>
6.3.4.50.1 <entryRelationship typeCode='SUBJ' inversionInd='true'>
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The alert has a preexisting entry as its subject (typeCode=SUBJ).
6.3.4.50.2 <templateId root='TBD'/>
This alert complies with the rules specified in the PCC technical framework for alerts, and so
must include the templateId specified above.
6.3.4.50.3 <observation classCode='OBS|ALRT' moodCode='EVN'>
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An alert is an observation that has occurred (moodCode=EVN). The HL7 classCode value of
ALRT shall be used where permitted (e.g., in an HL7 Care Record message). Where not
permitted, the classCode shall be OBS (e.g., in CDA Document).
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6.3.4.50.4 <id root='' extension=''/>
Each alert observation may have an identifier.
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6.3.4.50.5 <code code='' displayName='' codeSystem='2.16.840.1.113883.5.4'
codeSystemName='ActDetectedIssueCode'/>
Each alert observation shall have a code identifying the type of issue detected. The HL7
ActDetectedIssueCode value set (2.16.840.1.113883.1.11.16124) is one possible source of codes
for these issues.
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6.3.4.50.6 <text><reference value='#ref-1'/></text>
The text of the observation should provide some human readable explanation for the alert. In a
CDA document, this would appear within the narrative of the clinical document, and so would be
referenced by the alert. In an HL7 Version 3 message, this text would appear in the <text>
element of the alert entry.
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6.3.4.51 Antigen Dose 1.3.6.1.4.1.19376.1.5.3.1.4.12.1
An Antigen Dose entry is used to record additional details about the patient's immunization
history. These entries may be used to provide dose details about a specific antigen received
during an Immunization.
6.3.4.51.1 Specification
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<substanceAdministration typeCode='SBADM' moodCode='EVN' negationInd='false'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12.1'/>
<id root='' extension=''/>
<code code='IMMUNIZ' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode'/>
<text><reference value='#xxx'/><text>
<statusCode code='completed'/>
<effectiveTime value=' '/>
<routeCode code=' ' codeSystem=' ' codeSystemName='RouteOfAdministration'/>
<approachSiteCode code=' ' codeSystem=' '
codeSystemName='HumanSubstanceAdministrationSite'/>
<doseQuantity value='' units=''/>
<consumable typeCode='CSM'>
<manufacturedProduct classCode='MANU'>
<manufacturedLabeledDrug classCode='MMAT' determinerCode='KIND'>
<code code='' codeSystem='' codeSystemName=''>
<originalText><reference value='#yyy'/></originalText>
</code>
</manufacturedLabeledDrug>
</manufacturedProduct>
</consumable>
</substanceAdministration>
Figure 6.3.4.51.1-1: Immunizations Example
6.3.4.51.2 <substanceAdministration typeCode='SBADM' moodCode='EVN'
negationInd='false'>
An antigen dose entry is a substance administration event.
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6.3.4.51.3 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.12.1'/>
The <templateId> element identifies this <substanceAdministration> as an antigen dose,
allowing for validation of the content. The templateId must have
root='1.3.6.1.4.1.19376.1.5.3.1.4.12.1'.
6.3.4.51.4 <id root=' ' extension=' '/>
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This shall be the identifier for the antigen dose event.
6.3.4.51.5 <code/><text/><statusCode/><effectiveTime value=' '/>
<routeCode code=' ' codeSystem=' ' codeSystemName='RouteOfAdministration'/>
<approachSiteCode code=' ' codeSystem=' '
codeSystemName='HumanSubstanceAdministrationSite'/>
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Since the antigen dose entry is subordinate to an immunization entry, the code, text, status code,
effective time, route and approach site would all be repetitive and therefore should not be
present.
6.3.4.51.6 <doseQuantity value=' ' units=' '/>
This element gives the dose quantity of the specific antigen.
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6.3.4.51.7 <consumable typeCode='CSM'>
The <consumable> element shall be present, and shall contain a
<manufacturedProduct> entry conforming to the Product Entry template found in PCC
TF-2:6.3.4.19. This product entry describes the antigen to which the dose is applied.
6.3.4.52 Reserved for Future Use
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6.3.4.53 Reserved for Future Use
6.3.4.54 Reserved for Observation Request
6.3.4.55 Reserved for Risk Indicators for Hearing Loss Entry
6.3.4.56 Reserved for Cancer Diagnosis Entry
6.3.4.57 Family History Observation 1.3.6.1.4.19376.1.5.3.1.4.13.3
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A family history observation is a Simple Observation that uses a specific vocabulary, and
inherits constraints from CCD. Family history observations are found inside Family History
Organizers.
6.3.4.57.1 Standards
CCD ASTM/HL7 Continuity of Care Document
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6.3.4.57.2 Parent Template
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The parent of this template is Simple Observation. This template is compatible with the
ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.22
6.3.4.57.3 Specification
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<observation typeCode='OBS' moodCode='EVN'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='2.16.840.1.113883.10.20.1.22'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.3'/>
<id root=' ' extension=' '/>
<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>
<text><reference value='#xxx'/></text>
<statusCode code='completed'/>
<effectiveTime value=' '/>
<repeatNumber value=' '/>
<value xsi:type='CD' .../>
<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>
Figure 6.3.4.57.3-1: Family History Specification
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6.3.4.57.4 <templateId root='2.16.840.1.113883.10.20.1.22'/> <templateId
root='1.3.6.1.4.1.19376.1.5.3.1.4.13.3'/>
The <templateId> elements identify this observation as a family history observation, and shall be
present as shown above.
6.3.4.57.5 <code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>
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The <code> indicates the type of observation made (e.g., Diagnosis, et cetera). See the code
element in the Problem Entry entry for suggested values.
6.3.4.57.6 <value xsi:type='CD' code=' ' displayName=' ' codeSystem=' '
codeSystemName=' '/>
The <value> element indicates the information (e.g., diagnosis) of the family member. See the
value element in the Problem Entry for suggested values.
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6.3.4.58 Reserved for Death Pronouncement Entry Content Module
6.3.4.59 Reserved for Death Location Type Entry Content Module
6.3.4.60 Reserved for Occupational Data For Health Organizer
6.3.4.61 Reserved for Employment Status Organizer
6.3.4.62 Reserved for Usual Occupation and Industry Organizer
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6.3.4.63 Reserved for History of Occupation Organizer
6.3.4.64 Reserved for Employment Status Observation
6.3.4.65 Reserved for Usual Occupation and Industry Observation Entry
6.3.4.66 Reserved for Occupation Observation Entry
6.3.4.67 Reserved for Work Shift Observation Entry
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6.3.4.68 Reserved for Weekly Work Hours Observation Entry
6.3.4.69 Reserved for Usual Occupation Duration Entry
6.3.4.70 Reserved for Usual Industry Duration Entry
6.3.4.71 Reserved for Future Use
6.3.4.72 Reserved for Future Use
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6.3.4.73 Reserved for Future Use
6.3.4.74 Reserved for Future Use
6.3.4.75 Reserved for Future Use
6.3.4.76 Reserved for Future Use
6.3.4.77 Reserved for Future Use
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6.3.4.78 Reserved for Future Use
6.3.4.79 Reserved for Future Use
6.3.4.80 Reserved for Future Use
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6.3.4.81 Reserved for Future Use
6.3.4.82 Reserved for Future Use
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6.3.4.83 Reserved for Future Use
6.3.4.84 Reserved for Future Use
6.3.4.85 Reserved for Future Use
6.3.4.86 Reserved for Future Use
6.3.4.87 Reserved for Future Use
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6.3.4.88 Reserved for Future Use
6.3.4.89 Reserved for Future Use
6.3.4.90 Reserved for Future Use
6.3.4.91 Reserved for Future Use
6.3.4.92 Reserved for Future Use
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6.3.4.93 Subject Participation 1.3.6.1.4.1.19376.1.5.3.1.4.15.2
The subject participation identifies the subject of a section or entry within a CDA document.
This participation is used to identify family members (e.g., in a family history observation), or
newborns (e.g., in a labor and delivery record) for the purpose of identifying who the particular
content in the document applies to when it is other than the patient.
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6.3.4.93.1 Specification
<subject typeCode='SBJ'>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.15.2'>
<relatedSubject classCode='PRS'>
<code code='' displayName=''
codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
<subject>
<sdtc:id root='' extension=''/>
<administrativeGenderCode code='' displayName=''
codeSystem='' codeSystemName=''/>
<birthTime value=''/>
</subject>
</relatedSubject>
</subject>
6.3.4.93.2 <subject typeCode='SUBJ'>
<relatedSubject classCode='PRS'>
The <subject> element shall be present and relates the subject of the observations to the patient.
It shall contain a <relatedSubject> element that is a personal relation of the patient
(classCode='PRS').
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6.3.4.93.3 <code code=' ' displayName=' '
codeSystem='2.16.840.1.113883.5.111'
codeSystemName='RoleCode'/>
The <code> element shall be present, and give the relationship of the subject to the patient. The
code attribute shall be present, and shall contain a value from the HL7 FamilyMember
vocabulary. The codeSystem attribute shall be present and shall use the value shown above.
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6.3.4.93.4 <subject>
The <subject> element contains information about the relation.
6.3.4.93.5 <sdtc:id root=' ' extension=' '/>
The <sdtc:id> element should be present. It is used to identify the patient relation to create a
pedigree graph.
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6.3.4.93.6 <administrativeGenderCode code=' ' />
The <administrativeGenderCode> element should be present. It gives the gender of the relation.
6.3.4.93.7 <birthTime value=' ' />
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The <birthTime> element shall be present when known. It gives the birth date. This data element
should be precise at least to the year for most patients. It should be precise to the hour for
patients born in the last week (based on the document effective time).
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6.4 HL7 Version 2.0 Content Modules For care management
6.5 PCC Value Sets
6.5.1 APR H&P History of Past Illness Value Set
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6.5.2 APR H&P Social History Value Set
Examples Using PCC Content Profiles
Example documents conforming to each profile can be found on the IHE wiki at the following
URLs.
Profile and Content
URL
XDS-MS
Referral Summary
XDSMS Example1
Discharge Summary
XDSMS Example1
XPHR
XPHR Content
XPHR Example1
XPHR Update
XPHR Example2
(EDR) ED Referral
EDR Example
(APS) Antepartum Summary
APS Example
(EDES)
Triage Note
EDES Example1
ED Nursing Note
EDES Example2
Composite Triage and Nursing Note
EDES Example3
ED Physician Note
EDES Example4
(FSA) Functional Status Section
FSA Example
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Validating CDA Documents using the Framework
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Many of the constraints specified by the content modules defined in the PCC Technical
Framework can be validated automatically by software. Automated validation is a very desirable
capability, as it makes it easier for implementers to test the correctness of their implementations.
With regard to validation of the content module, the PCC Technical Framework narrative is the
authoritative specification, not any automated software tool. Having said that, it is still very easy
to create a validation framework for the IHE PCC Technical Framework using a XML validation
tool such as Schematron. Since each content module has a name (the template identifier), any
XML instance that reports itself to be of that "class" can be validated by creating assertions that
must be true for each constraint indicated for the content module. In the XML representation, the
<templateId> element is a child of the element that is claiming conformance to the template
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named. Thus the general pattern of a Schematron that validates a specific template is shown
below:
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<schema xmlns="http://www.ascc.net/xml/schematron" xmlns:cda="urn:hl7-org:v3">
<ns prefix="cda" uri="urn:hl7-org:v3" />
<pattern name='ReferralSummary'>
<rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.3]"'>
<!-- one or more assertions made by the content module -->
</rule>
</pattern>
</schema>
A.1 Validating Documents
For document content modules, the pattern can be extended to support common document
content module constraints as shown below:
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<schema xmlns="http://www.ascc.net/xml/schematron" xmlns:cda="urn:hl7-org:v3">
<ns prefix="cda" uri="urn:hl7-org:v3" />
<pattern name='ReferralSummary'>
<rule context='*[templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.3]"'>
<!-- Verify that the template id is used on the appropriate type of object -->
<assert test='../ClinicalDocument'>
Error: The referral content module can only be used on Clinical Documents.
</assert>
<!-- Verify that the parent templateId is also present. -->
<assert test='templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
Error: The parent template identifier for medical summary is not present.
</assert>
<!-- Verify the document type code -->
<assert test='code[@code = "34133-9"]'>
Error: The document type code of a referral summary must be
34133-9 SUMMARIZATION OF EPISODE NOTE.
</assert>
<assert test='code[@codeSystem = "2.16.840.1.113883.6.1"]'>
Error: The document type code must come from the LOINC code
system (2.16.840.1.113883.6.1).
</assert>
<!-- Verify that all required data elements are present -->
<assert test='.//templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.1"]'>
Error: A referral summary must contain a reason for referral.
</assert>
<!-- Alert on any missing required if known elements -->
<assert test='.//templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'>
Warning: A referral summary should contain a list of history of past illnesses.
</assert>
<!-- Note any missing optional elements -->
<assert test='.//templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'>
Note: This referral summary does not contain the pertinent review of systems.
</assert>
</rule>
</pattern>
</schema>
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A.2 Validating Sections
The same pattern can be also applied to sections with just a few minor alterations.
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<schema xmlns="http://www.ascc.net/xml/schematron" xmlns:cda="urn:hl7-org:v3">
<ns prefix="cda" uri="urn:hl7-org:v3" />
<pattern name='ReasonForReferralUncoded'>
<rule context='*[templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.1"]'>
<!-- Verify that the template id is used on the appropriate type of object -->
<assert test='section'>
Error: The coded reason for referral module can only be used on a section.
</assert>
<assert test='false'>
Manual: Manually verify that this section contains narrative providing the
reason for referral.
</assert>
<!-- Verify that the parent templateId is also present. -->
<assert test='templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.1"]'>
Error: The parent template identifier for the reason for referral
module is not present.
</assert>
<!-- Verify the section type code -->
<assert test='code[@code = "42349-1"]'>
Error: The section type code of the reason for referral section must be 42349-1
REASON FOR REFERRAL.
</assert>
<assert test='code[@codeSystem = "2.16.840.1.113883.6.1"]'>
Error: The section type code must come from the LOINC code
system (2.16.840.1.113883.6.1).
</assert>
</pattern>
<pattern name='ReasonForReferralCoded'>
<rule context='*[templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.2"]'>
<!-- The parent template will have already verified the type of object -->
<!-- Verify that the parent templateId is also present. -->
<assert test='templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.1"]'>
Error: The parent template identifier for the reason for referral
module is not present.
</assert>
<!-- Don't bother with the section type code, as the parent template caught it -->
<!-- Verify that all required data elements are present -->
<assert test='.//templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.13"]'>
Error: A coded reason for referral section must contain a simple observation.
</assert>
<!-- Alert on any missing required if known elements -->
<!-- Note any missing optional elements -->
</rule>
</pattern>
</schema>
A similar pattern can also be followed for Entry and Header content modules, and these are left
as an exercise for the reader.
A.3 Phases of Validation and Types of Errors
Note that each message in the Schematrons shown above start with a simple text string that
indicates whether the message indicates one of the following conditions:
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•
An error, e.g., the failure to transmit a required element,
•
A warning, e.g., the failure to transmit a required if known element,
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•
A note, e.g., the failure to transmit an optional element.
•
A manual test, e.g., a reminder to manually verify some piece of content.
Schematron supports the capability to group sets of rules into phases by the pattern name, and to
specify which phases of validation should be run during processing. To take advantage of this
capability, one simply breaks each <pattern> element above up into separate patterns depending
upon whether the assertion indicates an error, warning, note or manual test, and then associate
each pattern with a different phase. This is shown in the figure below.
<schema xmlns="http://www.ascc.net/xml/schematron" xmlns:cda="urn:hl7-org:v3">
<ns prefix="cda" uri="urn:hl7-org:v3" />
<phase id="errors">
<active pattern="ReasonForReferralUncoded_Errors"/>
<active pattern="ReasonForReferralCoded_Errors"/>
</phase>
<phase id="manual">
<active pattern="ReasonForReferralUncoded_Manual"/>
</phase>
<pattern name='ReasonForReferralUncoded_Errors'>
<rule context='*[templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.1"]'>
<assert test='section'>
Error: The coded reason for referral module can only be used on a section.
</assert>
<assert test='code[@code = "42349-1"]'>
Error: The section type code of the reason for referral section must be 42349-1
REASON FOR REFERRAL.
</assert>
<assert test='code[@codeSystem = "2.16.840.1.113883.6.1"]'>
Error: The section type code must come from the LOINC code
system (2.16.840.1.113883.6.1).
</assert>
</rule>
</pattern>
<pattern name='ReasonForReferralUncoded_Manual'>
<rule context='*[templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.1"]'>
<assert test='false'>
Manual: Manually verify that this section contains narrative providing the
reason for referral.
</assert>
</pattern>
<pattern name='ReasonForReferralCoded_Errors'>
<rule context='*[templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.2"]'>
<assert test='templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.1"]'>
Error: The parent template identifier for the reason for referral not present.
</assert>
<assert test='.//templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.13"]'>
Error: A coded reason for referral section must contain a simple observation.
</assert>
</rule>
</pattern>
</schema>
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Using these simple "templates" for template validation one can simply create a collection of
Schematron patterns that can be used to validate the content modules in the PCC Technical
Framework. Such Schematrons are expected to be made available as part of the MESA test tools
that are provided to IHE Connectathon participants, and which will also be made available to the
general public after connectathon.
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Extensions to CDA Release 2.0
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This section describes extensions to CDA Release 2.0 that are used by the IHE Patient Care
Coordination Technical Framework.
A.4 IHE PCC Extensions
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All Extensions to CDA Release 2.0 created by the IHE PCC Technical Committee are in the
namespace urn:ihe:pcc:hl7v3.
The approach used to create extension elements created for the PCC Technical Framework is the
same as was used for the HL7 Care Record Summary (see Appendix E) and the ASTM/HL7
Continuity of Care Document (see section 7.2).
A.4.1 replacementOf
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The <replacementOf> extension element is applied to a section appearing in a PHR Update
Document to indicate that that section's content should replace that of a previously existing
section. The identifier of the previously existing section is given so that the PHR Manager
receiving the Update content will know which section to replace. The model for this extension is
shown below.
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Figure A.4.1-1: Model for replacementOf
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Use of this extension is shown below. The <replacementOf> element appears after all other
elements within the <section> element. The <id> element appearing in the
<externalDocumentSection> element shall provide the identifier of the section being replaced in
the parent document.
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<section>
<id root=' ' extension=' '/>
<code code=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<title>Name of the Section</title>
<text>Text of the section</text>
<entry></entry>
<component></component>
<pcc:replacementOf xmlns:pcc='urn:ihe:pcc:hl7v3'>
<pcc:externalDocumentSection>
<pcc:id root='58FCBE50-D4F2-4bda-BC1C-2105B284BBE3'/>
<pcc:externalDocumentSection/>
</pcc:replacementOf>
</section>
A.5 Extensions Defined Elsewhere used by IHE PCC
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A.5.1 Entity Identifiers
There is often a need to record an identifier for an entity so that it can be subsequently
referenced. This extension provides a mechanism to store that identifier. The element appears
after any <realm>, <typeId> or <templateId> elements, but before all others in the entity where it
is used:
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<playingEntity classCode='ENT' determinerCode='INSTANCE'>
<sdtc:id root='1.3.6.4.1.4.1.2835.2' extension='EntityID'/>
:
.
</playingEntity>
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A.5.2 Patient Identifier
There is a need to record the identifier by which a patient is known to another healthcare
provider. This extension provides a role link between the assigned, related or associated entity,
and the patient role.
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Use of this extension to record the identifier under which the patient is known to a provider is
shown below.
<assignedEntity>
<id extension='1' root='1.3.6.4.1.4.1.2835.1'/>
<code code='59058001'
codeSystem='2.16.840.1.113883.6.96'
codeSystemName='SNOMED CT'
displayName='General Physician'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<assignedPerson>
<name>
<prefix>Dr.</prefix><given>Bernard</given><family>Wiseman</family><suffix>Sr.</suffix>
</name>
</assignedPerson>
<sdtc:patient xmlns:sdtc='urn:hl7-org:sdtc' >
<sdtc:id root='1.3.6.4.1.4.1.2835.2' extension='PatientMRN'/>
</sdtc:patient>
</assignedEntity>
The <patient> element records the link between the related, assigned or associated entity and the
patient. The <id> element provides the identifier for the patient. The root attribute of the <id>
should be the namespace used for patient identifiers by the entity. The extension attribute of the
<id> element shall be the patient's medical record number or other identifier used by the entity to
identify the patient.
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