C-CDA Scorecard Rubric Update

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Project Summary

The following process has been established and approved by SDWG: the C-CDA R2.1 Rubric Process, it is used to identify and evaluate potential best practice tests (rubrics) that could be added to the C-CDA scoring tools. The current rubric is being utilized by the ONC C-CDA Scorecard. Please review the process and use this page to propose new rubrics.

Meeting Time / Info

Wednesday's from 11 am - 12 pm EST

Next meeting is 6/6/18

https://meetingserver.hhs.gov/orion/join?siteurl=meetingserver Meeting Number: 998 544 663 Audio Connection: Meeting Server Main Number:2027742300 Access Code:998 544 663

Rubrics to be pushed to SDWG

1. Check whether there is an encounter in the Encounter section (not a null flavor)

2. Check whether the encompassing encounter is present in all encounter based documents ie Discharge Summary, Referral Note, etc. (do not ding if using CCD/Care Plan)

3. Check if the Encounter date/time and ID in the header is present in one of the EncounterActivity entries in the Encounter section of the body.

4. Patient Birth Sex must always be present in every C-CDA document

  a. This should be recorded as part of the SocialHistory/BirthSexObservation template

5. If a note activity is present, it must include a link to an Encounter in the encounters section or encompassing encounter

6. Allergy Observation entry must have a reaction. Require a nullFlavor if not known.

7. If there’s a goal you must be able to tell what health concern(s) the goal is related to (Care Plan Document Template specific rubric for now, but will throw a warning for CCD, Referral Note and Discharge Summary - may ding for all document templates in the future)

8. If there’s an intervention you must be able to tell what goal(s) the intervention is related to (Care Plan Document Template specific rubric for now, but will throw a warning for CCD, Referral Note and Discharge Summary - may ding for all document templates in the future)

9. Author entry must include at least a timestamp with information of the last modified date and be present within the Problems entry, which could be at the concern or observation level.

10. Author entry must include at least a timestamp with information of the last modified date and be present within the Medication Activity entry.

11. Author entry must include at least a timestamp with information of the last modified date and be present within the Allergies entry, which could be at the concern or observation level.

12. The narrative name of the Allergy medication should represent the concept meaning of the code in the entry

13. The narrative name of the Immunization should represent the concept meaning of the code in the entry

14. The narrative name of the drug should represent the concept meaning of the code in the entry

15. The machine readable doseQuantity should agree with the narrative sig

16. The Substance administration/effectiveTime @xsi:type = pivl should agree with the narrative sig

17. The Substance administration/effectiveTime @institution specified should agree with the narrative sig

18. The substance administration/route code should agree with the narrative sig

19. The substance administration/route code should reconcile with the medication consumable

20. The substance administration status code should not conflict with the medication status observation

21. When Medication status is active the high time should be in the future relative to the document generation date

22. The narrative name of the Problem should represent the meaning of the code in the Problem Observation value

23. BMI should match height and weight

24. There should be a document level identifier that specifies the document type

25. Allergies should be structured in UNII, NDF-RT, SNOMED or RxNorm

26. The problem observation value should not be set to the problem observation code (problem type value set)

27. If the observation range in the reference range with a value of PQ should not use string

28. Vital signs and results should use a LOINC Code

29. Vital sign and results units should be UCUM conformant

30. Procedures should be structured in CPT, ICD-9, ICD-10, SNOMED, HCPCS or LOINC (will update current rubric to include all of these)