|
|
| (168 intermediate revisions by 3 users not shown) |
| Line 1: |
Line 1: |
| | + | <span style="font-size:200%;">Approved samples have been migrated to the following resource:</span> <br /><br /> |
| | + | <span style="font-size:300%;"> [http://cdasearch.hl7.org Official HL7 CDA Example Search]</span><br /><br /> |
| | + | |
| | SDWG formed the CDA template example task force to collect and share member submitted samples. The task force developed a process with SDWG to receive approval for samples. | | SDWG formed the CDA template example task force to collect and share member submitted samples. The task force developed a process with SDWG to receive approval for samples. |
| | + | |
| | + | '''Please join us! Our calls a generally held on Thursdays at 12 PM ET, following the SDWG call. Phone number and webinar registration (free) information can be found at [[SDWG_Teleconferences]]. ''' |
| | | | |
| | The approved samples are posted below. | | The approved samples are posted below. |
| Line 5: |
Line 10: |
| | == Current Task Force Work == | | == Current Task Force Work == |
| | | | |
| − | '''Our calls planned for Thursdays 12 PM ET will focus on ... examples. Please join us!''' | + | '''Current week''' |
| | + | [https://trello.com/b/kJaKXp0Z/example-task-force See Trello!] |
| | + | |
| | + | If time allows: |
| | + | ?. Procedures and Care Team Sample development with John |
| | + | ?. Administered Medications section |
| | + | a) Including medication order information (that would have the start and end dates + frequency for the med) along with entries for the actual administrations. |
| | + | b) Last date medication was documented, ordered, prescribed, refilled, dispensed, or edited |
| | | | |
| − | '''Upcoming Weeks'''
| + | |
| − | 1/28 –
| + | |
| − | 1. [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Goals_No_Entries_Example.xml Narrative-only Goals Section] | + | |
| − | 2. [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Health_Concern_No_Entries_Example.xml Narrative-only Health Concerns Section]
| + | Draft IP Sample - ([https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/FUNCTIONAL_Impairment_Test.xml Functional and Cognitive Impairment], [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_SC_Basal_Insulin.xml Subcutaneous medication administered with event time]) |
| − |
| |
| − | Future: Draft IP Sample - ([https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_BMP_with_Tropinin.xml Normal BMP Results (with Troponin)], [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/FUNCTIONAL_Impairment_Test.xml Functional and Cognitive Impairment], [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_SC_Basal_Insulin.xml Subcutaneous medication administered with event time])
| |
| | | | |
| | [[170.314(b)(2)_Transitions_of_care|'''170.314(b)(2) Transitions of care – create and transmit summary care record''']] sample creation is the current focus of the example task force. | | [[170.314(b)(2)_Transitions_of_care|'''170.314(b)(2) Transitions of care – create and transmit summary care record''']] sample creation is the current focus of the example task force. |
| Line 23: |
Line 33: |
| | | | |
| | Historical reference only: [[CDA Example Task Force - Previous Review Cycles]], [https://docs.google.com/spreadsheets/d/1smfM0Vf66nFp10UF7VZxlG68F-LQX6CwkZeKLpMGUvg/edit?usp=sharing CDA Example Task Force Examples - Approved and On Deck] | | Historical reference only: [[CDA Example Task Force - Previous Review Cycles]], [https://docs.google.com/spreadsheets/d/1smfM0Vf66nFp10UF7VZxlG68F-LQX6CwkZeKLpMGUvg/edit?usp=sharing CDA Example Task Force Examples - Approved and On Deck] |
| − |
| |
| − | ===APPROVED EXAMPLES OVERVIEW TABLE===
| |
| − | (Click on Table Headers to sort)
| |
| − |
| |
| − | {| class="wikitable sortable" style="font-size:90%; width:99%;"
| |
| − | |-
| |
| − |
| |
| − | ! style="font-size:110%; width:140px; background: #B0C4DE" | Section
| |
| − | ! style="font-size:110%; width:140px; background: #B0C4DE" | Example name
| |
| − | ! style="font-size:110%; background: #B0C4DE" | Approved C-CDA Examples (github)
| |
| − | ! style="font-size:110%; background: #B0C4DE" | Comments
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! ALLERGIES, ADVERSE REACTIONS OR ALERTS
| |
| − | | [[#No Known Allergies with Author Timestamp|No Known Allergies with Author Timestamp]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Known_Allergies_Status_with_Author_Timestamp.xml No Known Allergies with Author Timestamp(Github)].
| |
| − | | This is an example of how an author can record a patient has no known allergies.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! ALLERGIES, ADVERSE REACTIONS OR ALERTS
| |
| − | | [[#No Known Medication Allergies with Author Timestamp|No Known Medication Allergies with Author Timestamp]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Known_Medication_Allergies_Status_with_Author_Timestamp.xml No Known Medication Allergies with Author Timestamp(Github)].
| |
| − | | This is an example of how an author can record a patient has no known medication allergies.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! ALLERGIES, ADVERSE REACTIONS OR ALERTS
| |
| − | | [[#Allergy to Specific Drug|Allergy to Specific Drug]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Drug_with_RxNorm.xml Allergy to specific drug (penicillin) C-CDA 1.1]
| |
| − | | This is an example of an allergy to a specific drug (penicillin) using RxNorm as terminology with information on both allergic reaction and reaction severity. For drug allergies, this example illustrates a good practice of encoding the allergen at the ingredient level (penicillin) not administration level (10 mg tablet). See DSTU 219 for update regarding act/code.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! ALLERGIES, ADVERSE REACTIONS OR ALERTS
| |
| − | | [[#Allergy to Drug Class|Allergy to Drug Class]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Drug_Class_with_NDF-RT.xml Allergy to drug class (penicillins)]
| |
| − | * C-CDA R2.0: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/C-CDAR2.0/ALLERGY_Drug_Class_with_NDF-RT.xml Allergy to drug class (penicillins)]
| |
| − | | This is an example of an allergy to a drug class (penicillins) using NDF-RT as terminology with information on both allergic reaction and reaction severity. See DSTU 219 for update regarding act/code.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! ALLERGIES, ADVERSE REACTIONS OR ALERTS
| |
| − | | [[#Propensity to adverse reaction to substance (Latex)|Propensity to adverse reaction to substance (Latex)]]
| |
| − | |
| |
| − | * C-CDA R1.1:[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Propensity_to_adverse_reactions_to_substance.xml Propensity to adverse reaction to substance (Latex)]
| |
| − | | This is an example of a propensity to substance allergy with information on both allergic reaction and reaction severity. It was based upon discussion with Russ Leftwich and Lisa Nelson in coordination with Patient Care Committee. See DSTU 219 for update regarding act/code.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! ALLERGIES, ADVERSE REACTIONS OR ALERTS
| |
| − | | [[#Food allergy (Egg)|Food allergy (Egg)]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Food_allergy.xml Food allergy (Egg)]
| |
| − | | This is an example of a food allergy with information on both allergic reaction and reaction severity. It was based upon discussion with Russ Leftwich and Lisa Nelson in coordination with Patient Care Committee. See DSTU 219 for update regarding act/code
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! ALLERGIES, ADVERSE REACTIONS OR ALERTS
| |
| − | | [[#Drug intolerance with multiple reactions (epinephrine)|Drug intolerance with multiple reactions (epinephrine)]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Drug_Intolerance_with_RxNorm.xml Drug intolerance with multiple reactions (epinephrine)]
| |
| − | | This is an example of a propensity to drug adverse event with information on multiple allergic reactions each with reaction severity. It was based upon discussion with Russ Leftwich and Lisa Nelson in coordination with Patient Care Committee. See DSTU 219 for update regarding act/code.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! ALLERGIES, ADVERSE REACTIONS OR ALERTS
| |
| − | | [[#Drug intolerance with multiple reactions (codeine)|Drug intolerance with multiple reactions (codeine)]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Allergy_Intolerance_Observation_Codeine-snippet.xml Drug intolerance with multiple reactions (codeine)]
| |
| − | | This is an example of a propensity to drug adverse event with information on multiple allergic reactions each with reaction severity. It was based upon discussion with Rob Hausam and John D'Amore and Russ Leftwich in coordination with Patient Care Committee. This sample replaces the Epinephrine sample which had less clinical accuracy/relevance. See DSTU 219 for update regarding act/code
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! ENCOUNTERS
| |
| − | | [[#Hospital Discharge Encounter with Billable Diagnoses|Hospital Discharge Encounter with Billable Diagnoses]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ENC_Encounter_hospitalization_with_diagnoses.xml Encounter of hospitalization with discharge diagnoses].
| |
| − | * C-CDA R2.0: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/C-CDAR2.0/ALLERGY_Drug_with_RxNorm.xml Allergy to specific drug (penicillin) C-CDA 1.1]
| |
| − | | This is an example of an allergy to a specific drug (penicillin) using RxNorm as terminology with information on both allergic reaction and reaction severity. For drug allergies, this example illustrates a good practice of encoding the allergen at the ingredient level (penicillin) not administration level (10 mg tablet). See DSTU 219 for update regarding act/code
| |
| − |
| |
| − | |-
| |
| − | ! Family History
| |
| − | | [[#Normal Family History; Father deceased with conditions; Mother alive with no conditions|Normal Family History; Father deceased with conditions; Mother alive with no conditions]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/benjaminflessner/HL7-C-CDA-Task-Force-Examples/blob/master/Family_History_Normal.xml Family History Section] .
| |
| − | | Example shows multiple observations for one family member, identifying the cause of death, and a family member with no known problems.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! GENERAL PATTERNS
| |
| − | | [[#No Information Problems Section|No Information Problems Section]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Information_Problems_Section.xml No Information Problems Section R1.1 (via GitHub)].
| |
| − | * C-CDA R2.0: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Information_Problems_Section_R2.xml No Information Problems Section R2 (via GitHub)]
| |
| − | | This is an example of how an author can record a section contains No Information. This is an exceptional case and does not cover 'No Known' scenarios. See [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Known_Allergies_Status_with_Author_Timestamp.xml No Known Allergies with Author Timestamp (GitHub)] for an example of 'No Known'. See [http://www.hl7.org/dstucomments/showdetail_comment.cfm?commentid=384 DSTU Comment 384]
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! GENERAL PATTERNS
| |
| − | | [[#No Information Specific Entry within a Section that requires entries|No Information Specific Entry within a Section that requires entries]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PLAN_No_Information.xml No Entry Information Procedures Section R1.1 (via GitHub)]
| |
| − | | This is an example of how an author can record no information about an entry in a section that requires an entry. This pattern is a temporary solution until generic codes are available to identify each entry.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! IMMUNIZATIONS
| |
| − | | [[#Unknown Patient Immunization Status|Unknown Patient Immunization Status]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Unknown_Immunization_Status.xml Unknown Patient Immunization Status C-CDA R1.1 (via GitHub)]
| |
| − | * C-CDA R2.0: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Unknown_Immunization_Status_R2.xml Unknown Patient Immunization Status C-CDA R2 (via GitHub)]
| |
| − | | This is an example of how an author can record they do now know whether the patient has received any vaccinations.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! MEDICATIONS
| |
| − | | [[#Patient prescribed oral medication QID PRN without precondition specified|Patient prescribed oral medication QID PRN without precondition specified]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Oral_Med_QID_with_PRN.xml Patient prescribed oral medication QID PRN without precondition specified]
| |
| − | | This is an example of a medication which is QID and PRN (as needed) but with no precondition specified. It was generated based on SDWG list-serv discussion in December 2013. It also demonstrated a pre-coordinated generic medication coded at the SDC level (generic 600mg Oral Tablet) in RxNorm hierarchy.
| |
| − | *Additional content - the following file illustrates 3 different medication entries. These examples are meant to illustrate the coding of a medication precondition or indication.
| |
| − | **[https://github.com/gecole/HL7-Task-Force-Examples/blob/master/MED_Oral_Med_Comparisions_for_PRN_Instructions_Indications.xml Patient prescribed oral medication for pain]
| |
| − | ***Summary of examples:
| |
| − | ****PRN with a coded precondition - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours PRN for joint pain
| |
| − | ****Instructions; similar to above but NOT a PRN - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours as Directed
| |
| − | ****Indication; again, NOT a PRN - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours for joint pain.
| |
| − | |-
| |
| − |
| |
| − | ! MEDICATIONS
| |
| − | | [[#Patient Prescribed Medication Every 4-6 Hours|Patient Prescribed Medication Every 4-6 Hours]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Med_Every_4-6_hrs.xml Patient prescribed medication every 4 to 6 hours]
| |
| − | * C-CDA R2.0: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Med_Every_4-6_hrs.xml Patient prescribed medication every 4 to 6 hours]
| |
| − | | This is an example of a medication (Sudafed) which to be administered every 4-6 hours, a common dosing pattern. Representing the range of potential of hours is done through a low and high child element of the period within effectiveTime of PIVL_TS.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! MEDICATIONS
| |
| − | | [[#Debate continues - see document and comments below - Patient Prescribed Oral Antibiotic with Dosing Regimen that Varies Over Prescription Course (Loading or Tapered)|Debate continues - see document and comments below - Patient Prescribed Oral Antibiotic with Dosing Regimen that Varies Over Prescription Course (Loading or Tapered)]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Med_Dose_Change.xml Patient prescribed oral antibiotic with a dosing regimen that varies over course of prescription (loading or tapered dosing)]
| |
| − | * C-CDA R2.0: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/C-CDAR2.0/MED_Med_Every_4-6_hrs.xml Patient prescribed medication every 4 to 6 hours]
| |
| − | | This is an example of a common pattern for antibiotic administration which is complex (double dose on day 1, commonly known as Z-PAK). SDWG reviewed this example with the Pharmacy working group in February 2014. This dosing regimen may be characterized as a loading dose, but a similar approach could be used for a tapered dose as well. At the May 2014 Working Group the committee discussed whether this example would be better with just a free text sig. The committee could not agree on the most appropriate location for the free text so this issue remains open. Use this example with caution until a free text sig is available and included.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! MEDICATIONS
| |
| − | | [[#Single Administration of Medication (at Single Point in Time)|Single Administration of Medication (at Single Point in Time)]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Med_Single_Administration.xml Single administration of medication (at single point in time)]
| |
| − | * C-CDA R2.0: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/C-CDAR2.0/MED_Med_Single_Administration.xml Single administration of medication (at single point in time)]
| |
| − | | This is an example of two baby aspirin being administered at a single point in time. At the January 2014 San Antonio meeting of HL7, this approach was decided as appropriate for medication timing of a point in time. Subsequent to that meeting, the TTT validator was adjusted to accept this format for medication times.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! MEDICATIONS
| |
| − | | [[#No Medications|No Medications]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/noKnownMedication_R1.1.xml No Medications R1.1]
| |
| − | * C-CDA R2.0: [https://github.com/donaldson-ed/taskforceExample/blob/master/noKnownMedications_r2.xml No Medications R2]
| |
| − | | Alternate Opinion: 1 Task Force member voted against approving this samples. In her opinion, the narrative text did not convey the same semantic meaning as the information represented in the structured data. For additional information on this point of view, see the sample titled, "XXXXX" in the "Unapproved Samples" area below.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! MEDICATIONS
| |
| − | | [[#Patient Reported Medication without Reported Brand/Dose|Patient Reported Medication without Reported Brand/Dose]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Oral_Patient_Reported.xml Patient reported oral medication no brand/dose]
| |
| − | | Patients often report medications that they are taking, either self-prescribed or by another provider, and know the drug name but do not know any specific brand or dose. This is an example of how to record an herbal supplement (echinicea) that a patient has reported taking using the informant to denote that this is patient reported.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! MEDICATIONS
| |
| − | | [[#Antibiotic Administered with Normal Saline (i.e. in hospital)|Antibiotic Administered with Normal Saline (i.e. in hospital)]]
| |
| − | |
| |
| − | * C-CDA R1.1:[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_IV_Antibiotics.xml Penicillin administered via IV infusion]
| |
| − | | Many medications administered in hospital are done through IV infusion with another agent. In this example, a loading dose of penicillin is administered via IV infusion with normal saline.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! PLAN Of TREATMENT
| |
| − | | [[#Care Plan Goals Instructions Section|Care Plan Goals Instructions Section]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/20150629%20Care%20Plan%20Goals-Instructions-Section.xml Plan Goals Instructions Section (via GitHub)]
| |
| − | | 170.314(b)(2) Transitions of care: K) Care Plan (Goals and Instructions)
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! PROBLEMS
| |
| − | | [[#Patient with No Known Problems|Patient with No Known Problems]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Known_Problems_Section_20140226.xml Patient with No Known Problems R1.1 - Problem Section 2.16.840.1.113883.10.20.22.2.5.1 (via GitHub)]
| |
| − | * C-CDA R2.0: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Known_Problems_Section_R2.xml Patient with No Known Problems R2 - Problem Section 2.16.840.1.113883.10.20.22.2.5.2 (via GitHub)]
| |
| − | |
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! PROBLEMS
| |
| − | | [[#Problem which has been resolved/completed|Problem which has been resolved/completed]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PROBLEM_Resolved_Problem.xml Problem which has been resolved/completed]
| |
| − | | This example illustrates how to structure a resolved problem, both by having a biological resolution date and a completed status of the concern.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! PROBLEMS
| |
| − | | [[#Active Problem|Active Problem]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Problem_List_Active_Problem.xml Active Problem]
| |
| − | | This example illustrates how to structure an active problem.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − |
| |
| − | |-
| |
| − | ! PROCEDURES
| |
| − | | [[#Procedure Activity Procedure Example in Procedures Section|Procedure Activity Procedure Example in Procedures Section]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PROCEDURE_Procedure_Example.xml Procedure Activity Procedure Example in Procedures Section]
| |
| − | | This example illustrates how a procedure which "alters the physical state" of the patient and should be classified as a procedure.
| |
| − |
| |
| − | |-
| |
| − |
| |
| − | ! PROCEDURES
| |
| − | | [[#Procedures Activity Observation Example in Procedures Section|Procedures Activity Observation Example in Procedures Section]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PROCEDURE_Observation_Example.xml Procedures Activity Observation Example in Procedures Section]
| |
| − | | This example illustrates how an observation within a procedure section.
| |
| − |
| |
| − | |-
| |
| − | ! PROCEDURES
| |
| − | | [[#Procedure Activity Act Example in Procedures Section|Procedure Activity Act Example in Procedures Section]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PROCEDURE_Act_Example.xml Procedure Activity Act Example in Procedures Section]
| |
| − | | This example illustrates an act within a procedure section.
| |
| − | |-
| |
| − |
| |
| − | ! RESULTS
| |
| − | | [[#Result with less than a specified value|Result with less than a specified value]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Value_Less_Than_Physical_Quantity.xml Result with less than a specified value (via GitHub)]
| |
| − | | This is an example of how to encode "less than" a specific range when returned from lab equipment. The example is for BNP, an immunoassay where the lower threshold for detection is often 5 pg/mL. The lower bound of the interval is zero in this example, even though this is none may be specified, since zero is the lower bound for measures of physical quantity. This example also includes a structured reference range.
| |
| − | |-
| |
| − |
| |
| − | ! RESULTS
| |
| − | | [[#Result with greater than a specified value|Result with greater than a specified value]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Value_Greater_Than_Physical_Quantity.xml Result with greater than a specified value (via GitHub)]
| |
| − | | This is an example of how to encode "greater than" a specific range when returned from lab equipment. The example is for a point-of-care glucometer, which measures blood sugar for diabetics. Often these devices may have an upper bound, 500 mg/dL is shown in this example. The upper bound of the interval is positive infinity in this example. This example also includes two structured reference ranges for normal and high.
| |
| − | |-
| |
| − |
| |
| − | ! RESULTS
| |
| − | | [[#Result panel with the display of two ordinal values of negative/positive|Result panel with the display of two ordinal values of negative/positive]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Panel_with_Two_Ordinal_Values.xml Result panel with the display of two ordinal values of negative/positive]
| |
| − | | This is an example of how to encode positive and negative, which are common data types returned form lab equipment. While some technologies may represent this as a type of ST (string), it is logical and easily possible to encode this information using SNOMED-CT. This would allow structured examination of this information downstream as well as comparison to a structured reference range, as shown in the example.
| |
| − | |-
| |
| − |
| |
| − | ! RESULTS
| |
| − | | [[#Result with an unstructured string as the value (e.g. urine color)|Result with an unstructured string as the value (e.g. urine color)]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Use_of_String_Value.xml Result with an unstructured string as the value (e.g. urine color)]
| |
| − | | This is an example of a value from a lab result that may not be structured.
| |
| − | |-
| |
| − |
| |
| − | ! RESULTS
| |
| − | | [[#Result Which Requires Translation for its Unit Represented in UCUM|Result Which Requires Translation for its Unit Represented in UCUM]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Value_UCUM_Translation.xml Result which requires translation for its unit represented in UCUM]
| |
| − | * C-CDA R2.0: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/C-CDAR2.0/RESULT_Value_UCUM_Translation.xml Result which requires translation for its unit represented in UCUM]
| |
| − | | This is an example of a value from a lab result that may not be structured.
| |
| − | |-
| |
| − |
| |
| − | ! RESULTS
| |
| − | | [[#Result with a pending component|Result with a pending component]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/donaldson-ed/taskforceExample/blob/master/Result_panel_with_pending_component.xml Result with a pending component]
| |
| − | | Result with a pending component.
| |
| − | |-
| |
| − | <!--
| |
| − | ! PAYER
| |
| − | | [[#Coverage Activity referencing the holder's employer|Coverage Activity referencing the holder's employer]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/20140403%20EmployerExample-Payer%20Section.xml Coverage Activity referencing the holder's employer(via GitHub)]
| |
| − | | This is an example of how to encode the policy holder's employer through which the insurance is provided - Finding major issues with the Coverage Activity and Policy Activity Templates. See C-CDA R1.1 DSTU Comment #994.
| |
| − | |-
| |
| − | -->
| |
| − |
| |
| − | ! SOCIAL HISTORY - SMOKING
| |
| − | | [[#Unknown Smoking Status|Unknown Smoking Status]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/SMOKING_Unknown_Smoker.xml Unknown Smoking Status]
| |
| − | | This is an example of unknown smoking status. There is a major variation in how no information is managed for smoking status. C-CDA 1.1 explicitly guides to not utilize a nullFlavor for this information. Instead a SNOMED code should be used as demonstrated in the example. A best practice to avoid confusion is for each social history section to only include a single smoking status.
| |
| − | |-
| |
| − |
| |
| − | ! SOCIAL HISTORY - SMOKING
| |
| − | | [[#Former Smoker in Smoking Status|Former Smoker in Smoking Status]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/SMOKING_Former_Smoker.xml Former Smoking Status]
| |
| − | | This is an example of a former smoker in smoking status. There is a variation in how effectiveTime/high is used since this represents when the patient stopped smoking, not when they stopped being a former smoker. C-CDA 1.1 explicitly guides to this usage of effectiveTime. A best practice to avoid confusion is for each social history section to only include a single smoking status.
| |
| − | |-
| |
| − |
| |
| − | ! SOCIAL HISTORY - SMOKING
| |
| − | | [[#Never Smoker in Smoking Status|Never Smoker in Smoking Status]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/SMOKING_Never_Smoker.xml Never Smoker Status]
| |
| − | | This is an example of a never smoker in smoking status. A best practice to avoid confusion is for each social history section to only include a single smoking status.
| |
| − | |-
| |
| − |
| |
| − | ! SOCIAL HISTORY - SMOKING
| |
| − | | [[#Current Smoker in Smoking Status|Current Smoker in Smoking Status]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/SMOKING_Current_Smoker.xml Current Smoking Status]
| |
| − | | This is an example of current smoking status. This example also includes a coordinating social history observation to convey the amount of smoking using a SNOMED code. This SNOMED code in the accompanying observation is not acceptable since smoking status, which is constrained by HL7 and Meaningful Use value set requirements. A best practice to avoid confusion is for each social history section to only include a single smoking status.
| |
| − | |-
| |
| − |
| |
| − | ! VITAL SIGNS
| |
| − | | [[#Panel of Vital Signs in Metric Units|Panel of Vital Signs in Metric Units]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/VITALS_Complete_Panel_Metric.xml Vital sign panel in metric units]
| |
| − | | This is panel of the nine common vital signs collected on an adult in metric units. Note that body surface area (BSA), head circumference and height (lying) are not included.
| |
| − | |-
| |
| − |
| |
| − | ! VITAL SIGNS
| |
| − | | [[#Panel of Vital Signs in Mixed Metric/Imperial Units|Panel of Vital Signs in Mixed Metric/Imperial Units]]
| |
| − | |
| |
| − | * C-CDA R1.1: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/VITALS_Complete_Panel_Mixed_Units.xml Vital Sign panel with mixed units]
| |
| − | | This is panel of the nine common vital signs collected on an adult in mixed metric/imperial units. Note that body surface area (BSA), head circumference and height (lying) are not included.
| |
| − | |-
| |
| − |
| |
| − | |-
| |
| − | ! FAMILY HISTORY
| |
| − | | [[#Normal Family History; Father deceased with conditions; Mother alive with no conditions|Normal Family History; Father deceased with conditions; Mother alive with no conditions]]
| |
| − | |
| |
| − | * C-CDA R2.0: [https://github.com/benjaminflessner/HL7-C-CDA-Task-Force-Examples/blob/master/Family_History_Normal.xml Family History Section]
| |
| − | | Example shows multiple observations for one family member, identifying the cause of death, and a family member with no known problems.
| |
| − | |-
| |
| − |
| |
| − | ! FAMILY HISTORY
| |
| − | | [[#Family History; two individuals with the same relationship to the patient|Family History; two individuals with the same relationship to the patient]]
| |
| − | |
| |
| − | * C-CDA R2.0: [https://github.com/benjaminflessner/HL7-C-CDA-Task-Force-Examples/blob/master/Family_History_Siblings.xml Family History Section (Two Brothers)]
| |
| − | | Example shows two brothers with multiple conditions. Though they have the same relationship to the patient, they can be identified by their separation into two family history organizers as well as by their subject ID's.
| |
| − | |-
| |
| − |
| |
| − |
| |
| − | ! FAMILY HISTORY
| |
| − | | [[#Family History; generic history (not scoped to individuals)|Family History; generic history (not scoped to individuals)]]
| |
| − | |
| |
| − | * C-CDA R2.0: [https://github.com/benjaminflessner/HL7-C-CDA-Task-Force-Examples/blob/master/Family_History_Generic.xml Family History Section (Generic History)]
| |
| − | | Example shows generic "family history of x" and "no family history of x" with commentary suggesting better options.
| |
| − | |-
| |
| − |
| |
| − |
| |
| − | ! style="font-size:110%; width:140px; background: #B0C4DE" | Section
| |
| − | ! style="font-size:110%; width:140px; background: #B0C4DE" | Example name
| |
| − | ! style="font-size:110%; background: #B0C4DE" | Approved C-CDA Examples (github)
| |
| − | ! style="font-size:110%; background: #B0C4DE" | Comments
| |
| − | |}
| |
| | | | |
| | == Examples - Organized by Section == | | == Examples - Organized by Section == |
| | | | |
| − | ===ALLERGIES, ADVERSE REACTIONS OR ALERTS=== | + | ===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac56 ALLERGIES, ADVERSE REACTIONS OR ALERTS]=== |
| | | | |
| − | ======'''No Known Allergies with Author Timestamp'''======
| + | '''Allergies are now in the new HL7 search tool!''' |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force on 1/9/2014. Approved by SDWG 1/16/2014.
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: Allergy Concern Act (2.16.840.1.113883.10.20.22.4.30) and Allergy Intolerance Observation (2.16.840.1.113883.10.20.22.4.7)
| |
| − | ** [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Known_Allergies_Status_with_Author_Timestamp.xml No Known Allergies with Author Timestamp(Github)]
| |
| − | * C-CDA 2.0 Example: none yet posted
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/CCD_Transition_of_Care_Ambulatory_Complete_NoKnown_Allergies.xml No Known Allergies in compliant MU2 Sample (via GitHub)]
| |
| − | * Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
| |
| − | * Validation location: [http://sitenv.org/web/sit/ccda-validator SITE Validator TOC Ambulatory]
| |
| − | * Comments: This is an example of how an author can record a patient has no known allergies.
| |
| | | | |
| | + | Samples included: |
| | + | *[http://hl7-c-cda-examples.herokuapp.com/examples/1 Allergy to specific substance (cat hair)] |
| | + | *Allergy to Specific Drug |
| | + | *Allergy to Drug Class |
| | + | *Propensity to adverse reaction to substance (Latex) |
| | + | *Food allergy (Egg) |
| | + | *No Known Allergies with Author Timestamp |
| | + | *No Known Medication Allergies with Author Timestamp |
| | + | *Drug intolerance with multiple reactions (epinephrine) |
| | + | *Drug intolerance with multiple reactions (codeine) |
| | | | |
| − | ======'''No Known Medication Allergies with Author Timestamp'''====== | + | ===CDA HEADER=== |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force on 10/23/2014. Approved by SDWG 11/06/2014.
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: Allergy Concern Act (2.16.840.1.113883.10.20.22.4.30) and Allergy Intolerance Observation (2.16.840.1.113883.10.20.22.4.7)
| |
| − | ** [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Known_Medication_Allergies_Status_with_Author_Timestamp.xml No Known Medication Allergies with Author Timestamp(Github)]
| |
| − | * C-CDA 2.0 Example: none yet posted
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/CCD_Transition_of_Care_Ambulatory_Complete_NoKnown_Medication_Allergies.xml No Known Medication Allergies in compliant MU2 Sample (via GitHub)]
| |
| − | * Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
| |
| − | * Validation location: [http://sitenv.org/web/sit/ccda-validator SITE Validator TOC Ambulatory]
| |
| − | * Comments: This is an example of how an author can record a patient has no known medication allergies.
| |
| | | | |
| | + | ===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac79 CDA Header]=== |
| | | | |
| − | ======'''Allergy to specific substance (cat hair)'''======
| + | '''CDA Header Examples are now in the new HL7 search tool!''' |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| + | *Patient demographic information |
| − | * Approved by: Task force approved 4/10/2014. Withdrawn from consideration since not clinically relevant. | + | *Previous Patient Name |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example | + | *Care Team In Transition of Care Documents |
| − | ** TemplateId(s) illustrated: Allergy Concern Act (2.16.840.1.113883.10.20.22.4.30) and Allergy Intolerance Observation (2.16.840.1.113883.10.20.22.4.7) Reaction Observation (2.16.840.1.113883.10.20.22.4.9) Severity Observation (2.16.840.1.113883.10.20.22.4.8) | |
| − | ** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Substance_with_UNII.xml Allergy to specific substance (cat hair)]
| |
| − | * C-CDA 2.0 Example: none yet posted
| |
| − | * Known bad example?: Valid example with one error for act/code (based on DSTU 219 and C-CDA IG 2.0 clarification) and warning since severity only nested within reaction
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Examples_in_empty_CCD.xml Allergies in empty CCD]
| |
| − | * Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ TTT Validator]
| |
| − | * Comments: This is an example of an allergy to a specific substance (cat hair) using UNII as terminology with information on both allergic reaction and reaction severity. See DSTU 219 for update regarding act/code
| |
| | | | |
| | + | ===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac62 ENCOUNTERS]=== |
| | + | '''Encounters are now in the new HL7 search tool!''' |
| | | | |
| − | ======'''Allergy to Specific Drug'''======
| + | Samples included: |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| + | *Hospital Discharge Encounter with Billable Diagnoses |
| − | * Approved by: Task force approved 4/10/2014. Approved by SDWG on 4/24/2014
| + | *Outpatient Encounter with Diagnoses |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] | + | *Outpatient Encounter Patient Disenrolled |
| − | ** TemplateId(s) illustrated: Allergy Concern Act (2.16.840.1.113883.10.20.22.4.30) and Allergy Intolerance Observation (2.16.840.1.113883.10.20.22.4.7) Reaction Observation (2.16.840.1.113883.10.20.22.4.9) Severity Observation (2.16.840.1.113883.10.20.22.4.8)
| + | *Inpatient Encounter Discharged to Rehab Location |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Drug_with_RxNorm.xml Allergy to specific drug (penicillin) C-CDA 1.1]
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0] | |
| − | ** TemplateId(s) illustrated: Allergy Concern Act (2.16.840.1.113883.10.20.22.4.30.2) and Allergy Intolerance Observation (2.16.840.1.113883.10.20.22.4.7.2) Reaction Observation (2.16.840.1.113883.10.20.22.4.9.2) Severity Observation (2.16.840.1.113883.10.20.22.4.8.2)
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/C-CDAR2.0/ALLERGY_Drug_with_RxNorm.xml Allergy to specific drug (penicillin) C-CDA 1.1]
| |
| − | * Known bad example?: Valid example with one error for act/code (based on DSTU 219 and C-CDA IG 2.0 clarification) and warning since severity only nested within reaction
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Examples_in_empty_CCD.xml Allergies in empty CCD] | |
| − | * Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore) | |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ TTT Validator]
| |
| − | * Comments: This is an example of an allergy to a specific drug (penicillin) using RxNorm as terminology with information on both allergic reaction and reaction severity. For drug allergies, this example illustrates a good practice of encoding the allergen at the ingredient level (penicillin) not administration level (10 mg tablet). See DSTU 219 for update regarding act/code
| |
| | | | |
| | + | ===FUNCTIONAL AND COGNITIVE STATUS (deprecated, not moved)=== |
| | | | |
| − | ======'''Allergy to Drug Class'''====== | + | ======'''No Impairment (on trello)'''====== |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force approved 4/10/2014. Approved by SDWG on 4/24/2014.
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: Allergy Concern Act (2.16.840.1.113883.10.20.22.4.30) and Allergy Intolerance Observation (2.16.840.1.113883.10.20.22.4.7) Reaction Observation (2.16.840.1.113883.10.20.22.4.9) Severity Observation (2.16.840.1.113883.10.20.22.4.8)
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Drug_Class_with_NDF-RT.xml Allergy to drug class (penicillins)]
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0]
| |
| − | ** TemplateId(s) illustrated: Allergy Concern Act (2.16.840.1.113883.10.20.22.4.30.2) and Allergy Intolerance Observation (2.16.840.1.113883.10.20.22.4.7.2) Reaction Observation (2.16.840.1.113883.10.20.22.4.9.2) Severity Observation (2.16.840.1.113883.10.20.22.4.8.2)
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/C-CDAR2.0/ALLERGY_Drug_Class_with_NDF-RT.xml Allergy to drug class (penicillins)]
| |
| − | * Known bad example?: Valid example with one error for act/code (based on DSTU 219 and C-CDA IG 2.0 clarification) and warning since severity only nested within reaction
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Examples_in_empty_CCD.xml Allergies in empty CCD]
| |
| − | * Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ TTT Validator]
| |
| − | * Comments: This is an example of an allergy to a drug class (penicillins) using NDF-RT as terminology with information on both allergic reaction and reaction severity. See DSTU 219 for update regarding act/code
| |
| − | | |
| − | | |
| − | ======'''Propensity to adverse reaction to substance (Latex)'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task Force approved 4/17/2014, reviewed again on 3/12/2015 TF call. SDWG Approved 3/19/2015.
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: Allergy Concern Act (2.16.840.1.113883.10.20.22.4.30) and Allergy Intolerance Observation (2.16.840.1.113883.10.20.22.4.7) Reaction Observation (2.16.840.1.113883.10.20.22.4.9) Severity Observation (2.16.840.1.113883.10.20.22.4.8)
| |
| − | ** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Propensity_to_adverse_reactions_to_substance.xml Propensity to adverse reaction to substance (Latex)]
| |
| − | * C-CDA 2.0 Example: none yet posted
| |
| − | * Known bad example?: Valid example with one error for act/code (based on DSTU 219 and C-CDA IG 2.0 clarification) and warning since severity only nested within reaction
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Examples_in_empty_CCD.xml Allergies in empty CCD]
| |
| − | * Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ TTT Validator]
| |
| − | * Comments: This is an example of a propensity to substance allergy with information on both allergic reaction and reaction severity. It was based upon discussion with Russ Leftwich and Lisa Nelson in coordination with Patient Care Committee. See DSTU 219 for update regarding act/code
| |
| − | | |
| − | ======'''Food allergy (Egg)'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task Force approved 4/17/2014, reviewed again on 3/12/2015 TF call. SDWG Approved 3/19/2015.
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: Allergy Concern Act (2.16.840.1.113883.10.20.22.4.30) and Allergy Intolerance Observation (2.16.840.1.113883.10.20.22.4.7) Reaction Observation (2.16.840.1.113883.10.20.22.4.9) Severity Observation (2.16.840.1.113883.10.20.22.4.8)
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Food_allergy.xml Food allergy (Egg)]
| |
| − | * C-CDA 2.0 Example: none yet posted
| |
| − | * Known bad example?: Valid example with one error for act/code (based on DSTU 219 and C-CDA IG 2.0 clarification) and warning since severity only nested within reaction
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Examples_in_empty_CCD.xml Allergies in empty CCD]
| |
| − | * Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ TTT Validator]
| |
| − | * Comments: This is an example of a food allergy with information on both allergic reaction and reaction severity. It was based upon discussion with Russ Leftwich and Lisa Nelson in coordination with Patient Care Committee. See DSTU 219 for update regarding act/code
| |
| − | | |
| − | ======'''Drug intolerance with multiple reactions (epinephrine)'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task Force approved 4/17/2014; Pulled on block with SDWG since any patient given enough epinephrine will have an intolerance.
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: Allergy Concern Act (2.16.840.1.113883.10.20.22.4.30) and Allergy Intolerance Observation (2.16.840.1.113883.10.20.22.4.7) Reaction Observation (2.16.840.1.113883.10.20.22.4.9) Severity Observation (2.16.840.1.113883.10.20.22.4.8)
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Drug_Intolerance_with_RxNorm.xml Drug intolerance with multiple reactions (epinephrine)]
| |
| − | * C-CDA 2.0 Example: none yet posted
| |
| − | * Known bad example?: Valid example with one error for act/code (based on DSTU 219 and C-CDA IG 2.0 clarification) and warning since severity only nested within reaction
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Examples_in_empty_CCD.xml Allergies in empty CCD]
| |
| − | * Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ TTT Validator]
| |
| − | * Comments: This is an example of a propensity to drug adverse event with information on multiple allergic reactions each with reaction severity. It was based upon discussion with Russ Leftwich and Lisa Nelson in coordination with Patient Care Committee. See DSTU 219 for update regarding act/code
| |
| − | | |
| − | ======'''Drug intolerance with multiple reactions (codeine)'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task Force approved 4/17/2014; SDWG Approved 4/16/2015
| |
| − | ** [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: Allergy Concern Act (2.16.840.1.113883.10.20.22.4.30) and Allergy Intolerance Observation (2.16.840.1.113883.10.20.22.4.7) Reaction Observation (2.16.840.1.113883.10.20.22.4.9) Severity Observation (2.16.840.1.113883.10.20.22.4.8)
| |
| − | **[https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Allergy_Intolerance_Observation_Codeine-snippet.xml Drug intolerance with multiple reactions (codeine)]
| |
| − | * C-CDA 2.0 Example: none yet posted
| |
| − | * Known bad example?: Valid example with one error for act/code (based on DSTU 219 and C-CDA IG 2.0 clarification) and warning since severity only nested within reaction
| |
| − | * Reference to full CDA sample: https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Allergy_Intolerance_Observation_Codeine.xml Allergies in empty CCD]
| |
| − | * Custodian: Lisa R. Nelson LisaRNelson@cox.net (GitHub: lisarnelson)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ TTT Validator]
| |
| − | * Comments: This is an example of a propensity to drug adverse event with information on multiple allergic reactions each with reaction severity. It was based upon discussion with Rob Hausam and John D'Amore and Russ Leftwich in coordination with Patient Care Committee. This sample replaces the Epinephrine sample which had less clinical accuracy/relevance. See DSTU 219 for update regarding act/code
| |
| − | | |
| − | ===CDA HEADER===
| |
| − | ====='''Patient demographic information'''=====
| |
| − | * Approved by: Task force approved 9/24/2015. SDWG approved 10/15/2015.
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.1.1, 2.16.840.1.113883.10.20.22.1.2 (recordTarget)
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/DEMO_Record_Target_Example.xml Patient demographics in recordTarget]
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
| |
| − | ** Not yet created
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference in full CDA Sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/DEMO_Example_in_empty_CCD.xml recordTarget Packaged in C-CDA Skeleton]
| |
| − | * Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Message Validator for VDT Ambulatory] validated April 23, 2015
| |
| − | * Keywords: Demographics, Name, Address, Telecom, Phone, Email, Race, Ethnicity, Religious Affiliation, Marital Status, Language
| |
| − | * Comments: This example illustrates how to structure Patient Demographics for the 170.314(b)(2) Transitions of care – A) Patient Demographics.
| |
| − | | |
| − | ====='''Care Team'''=====
| |
| − | * Approved by: Task force approved 6/11/2015. SDWG approved 7/9/2015.
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.1.1 (serviceEvent and Performer)
| |
| − | **[https://github.com/gecole/HL7-Task-Force-Examples/blob/master/CareTeamToC170.314b2Ambulatory.xml Care Team]
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
| |
| − | ** Not yet created
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference in full CDA Sample:
| |
| − | * Custodian: George Cole
| |
| − | * Validation location:
| |
| − | * Comments: This example illustrates how to structure Care Team for the 170.314(b)(2) Transitions of care – B) Care Team.
| |
| − | | |
| − | ===ENCOUNTERS===
| |
| − | ====='''Hospital Discharge Encounter with Billable Diagnoses'''=====
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force approved 12/18/2014; SDWG approved 2/12/2015
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.2.22, 2.16.840.1.113883.10.20.22.4.49, 2.16.840.1.113883.10.20.22.4.32, 2.16.840.1.113883.10.20.22.4.33, 2.16.840.1.113883.10.20.22.4.4
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ENC_Encounter_hospitalization_with_diagnoses.xml Encounter of hospitalization with discharge diagnoses]
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
| |
| − | ** Not yet created
| |
| − | * Known bad example?: Valid example (NIST Validator shows error on dischargeDiposition, but look right to me)
| |
| − | * Reference in full CDA Sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ENC_Examples_in_Empty_CCD.xml Results Packaged in C-CDA Skeleton]
| |
| − | * Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Message Validator for VDT Ambulatory] validated October 22, 2014
| |
| − | * Keywords: Hospital Encounter, Discharge Diagnoses, participant, performer
| |
| − | * Comments: This is an example of a hospitalization with discharge diagnoses. Meaningful Use requires a place to document encounter diagnoses, and this example attempts to satisfy. This example aligns with QRDA suggestion for encounter diagnosis.
| |
| − | | |
| − | ====='''Outpatient Encounter with Diagnoses'''=====
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force approved 5/7/2015; SDWG approved
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.2.22.1, 2.16.840.1.113883.10.20.22.4.49, 2.16.840.1.113883.10.20.22.4.32, 2.16.840.1.113883.10.20.22.4.80, 2.16.840.1.113883.10.20.22.4.4, 2.16.840.1.113883.10.20.22.4.6
| |
| − | **[https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Encounter%20Diagnosis%20snippet.xml Encounter of outpatient visit with encounter diagnoses that is active]
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
| |
| − | ** Not yet created
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference in full CDA Sample: [https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/20150423_Encounter_Diagnosis_Ambulatory_ToC.xml Results Packaged in C-CDA Skeleton with header to match ToC scenario]
| |
| − | * Custodian: Lisa R Nelson, LisaRNelson@cox.net (GitHub: LisaRNelson)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Message Validator for VDT Ambulatory] validated May 13, 2015
| |
| − | * Keywords: Outpatient Visit, Encounter Diagnoses, performer, visit location
| |
| − | * Comments: This example illustrates how to structure Encounter Diagnosis for the 170.314(b)(2) Transitions of care - L) Encounter Diagnosis
| |
| − | | |
| − | ===FUNCTIONAL AND COGNITIVE STATUS===
| |
| − | | |
| − | ======'''No Impairment'''======
| |
| | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]] | | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]] |
| | * Status: Approved by task force on 6/18/2015. SDWG approved 7/9/2015 | | * Status: Approved by task force on 6/18/2015. SDWG approved 7/9/2015 |
| Line 596: |
Line 85: |
| | * Comments: This is an example of no functional or cognitive impairment. It only illustrates two of multiple potential templated within the functional status section and was prepared for the 170.314(b)(2) Transitions of care - M) Functional and Cognitive Status. Note that there are significant changes to functional and cognitive status in C-CDA 2.0 and 2.1 (including section breakout and deprecation of certain tempaltes). We may re-visit this sample after reconciliation of such changes. | | * Comments: This is an example of no functional or cognitive impairment. It only illustrates two of multiple potential templated within the functional status section and was prepared for the 170.314(b)(2) Transitions of care - M) Functional and Cognitive Status. Note that there are significant changes to functional and cognitive status in C-CDA 2.0 and 2.1 (including section breakout and deprecation of certain tempaltes). We may re-visit this sample after reconciliation of such changes. |
| | | | |
| − | ======'''Functional and Cognitive Status with Impairment'''====== | + | ======'''Functional and Cognitive Status with Impairment (on trello)'''====== |
| | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]] | | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]] |
| | * Status: Not yet approved | | * Status: Not yet approved |
| Line 610: |
Line 99: |
| | * Comments: This is an example of functional and cognitive impairment as outlined in MU2 inpatient test data. | | * Comments: This is an example of functional and cognitive impairment as outlined in MU2 inpatient test data. |
| | | | |
| − | ===GENERAL PATTERNS=== | + | ===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac6e GENERAL PATTERNS]=== |
| − | [https://drive.google.com/open?id=0B44mVoChqHDtem1YTHpsb0kwQXc&authuser=0 Allergy and Problem Status observation Review] - This is a summary of the work done by the example task force to review the extra 'status observations' in C-CDA R1.1 and whether the deprecation in C-CDA R2.0 adequately covers key clinical statuses. | |
| | | | |
| − | ======'''No Information Problems Section'''======
| + | '''General Patterns are now in the new HL7 search tool!''' |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Status: Approved on task force 1/30/2014; Approved by SDWG on 2/6/2014.
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: Problem Section with Coded Entries(2.16.840.1.113883.10.20.22.2.5.1)
| |
| − | ** [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Information_Problems_Section.xml No Information Problems Section R1.1 (via GitHub)]
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
| |
| − | ** TemplateId(s) illustrated: Problem Section with Coded Entries(2.16.840.1.113883.10.20.22.2.5.1.2)
| |
| − | ** [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Information_Problems_Section_R2.xml No Information Problems Section R2 (via GitHub)]
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/CCD_Transition_of_Care_Ambulatory_Complete_NoInformation_Problems.xml No Information Problem section]
| |
| − | * Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
| |
| − | * Validation location: [http://sitenv.org/web/sit/ccda-validator SITE Validator TOC Ambulatory]
| |
| − | * Comments: This is an example of how an author can record a section contains No Information. This is an exceptional case and does not cover 'No Known' scenarios. See [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Known_Allergies_Status_with_Author_Timestamp.xml No Known Allergies with Author Timestamp (GitHub)] for an example of 'No Known'. See DSTU Comment 384: http://www.hl7.org/dstucomments/showdetail_comment.cfm?commentid=384
| |
| | | | |
| − | ======'''No Information Specific Entry within a Section that requires entries'''======
| + | Samples included: |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| + | *No Information Problems Section |
| − | * Status: Task force on 11/20/2014; SDWG Approved on 4/16/2015
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: Procedures Section (entries required)(2.16.840.1.113883.10.20.22.2.7.11)
| |
| − | ** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PLAN_No_Information.xml No Entry Information Procedures Section R1.1 (via GitHub)] | |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
| |
| − | ** TemplateId(s) illustrated: Not done yet
| |
| − | ** TBD
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample: TBD
| |
| − | * Custodian: John D'Amore and Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
| |
| − | * Validation location: [http://sitenv.org/web/sit/ccda-validator SITE Validator TOC Ambulatory]
| |
| − | * Comments: This is an example of how an author can record no information about an entry in a section that requires an entry. This pattern is a temporary solution until generic codes are available to identify each entry.
| |
| | | | |
| − | ===Health Concerns===
| + | '''To Be Discussed''' |
| | | | |
| − | ======'''Health Concern Linking Example'''======
| + | [https://drive.google.com/open?id=0B44mVoChqHDtem1YTHpsb0kwQXc&authuser=0 Allergy and Problem Status observation Review] - This is a summary of the work done by the example task force to review[ the extra 'status observations' in C-CDA R1.1 and whether the deprecation in C-CDA R2.0 adequately covers key clinical statuses. |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]] | |
| − | * Approved by: Task Force Approved 12/15/15
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=408 C-CDA 2.1]
| |
| − | ** TemplateId(s) illustrated: Health Concern Section (2.16.840.1.113883.10.20.22.2.58:2015-08-01) Health Concern Act (2.16.840.1.113883.10.20.22.4.132:2015-08-01)
| |
| − | ** [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Health_Concern_Linking_Example.xml Health Concern Link to Problems Section (via GitHub)]
| |
| − | ** [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Health_Concern_Linking_Example_w_linkHtml.xml Health Concern Link to Problems Section with linkHTML (via GitHub)]
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample:
| |
| − | * Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
| |
| − | * Validation location: [http://sitenv.org/web/sit/ccda-validator SITE Validator TOC Ambulatory]
| |
| − | * Comments: This is an example of how to link a concern to a problem in the problem list section.
| |
| | | | |
| − | ======'''No Known Health Concerns'''====== | + | ===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac77 Goals]=== |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force on 11/5/2015. Approved by SDWG 11/12/2015.
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=408 C-CDA 2.1]
| |
| − | ** TemplateId(s) illustrated: Health Concern Section (2.16.840.1.113883.10.20.22.2.58:2015-08-01) Health Concern Act (2.16.840.1.113883.10.20.22.4.132:2015-08-01)
| |
| − | ** [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Known_Health_Concerns.xml No Known Health Concerns (via GitHub)]
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample:
| |
| − | * Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
| |
| − | * Validation location: [http://sitenv.org/web/sit/ccda-validator SITE Validator TOC Ambulatory]
| |
| − | * Comments: This is an example of how an author can record they have no health concerns for a patient.
| |
| | | | |
| − | ===IMMUNIZATIONS===
| + | '''Goals are now in the new HL7 search tool!''' |
| | + | *Goals Section Narrative-only |
| | | | |
| − | ======'''Unknown Patient Immunization Status'''====== | + | ===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac7d Health Concerns]=== |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force on 11/21/2013. Approved by SDWG 12/5/2013.
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: Immunization Activity (2.16.840.1.113883.10.20.22.4.52)
| |
| − | ** [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Unknown_Immunization_Status.xml Unknown Patient Immunization Status C-CDA R1.1 (via GitHub)]
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
| |
| − | ** TemplateId(s) illustrated: Immunization Activity (2.16.840.1.113883.10.20.22.4.52.2)
| |
| − | ** [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Unknown_Immunization_Status_R2.xml Unknown Patient Immunization Status C-CDA R2 (via GitHub)]
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/CCD_Transition_of_Care_Ambulatory_Complete_Unknown_Immunizations.xml Immunization section in compliant MU2 C-CDA sample]
| |
| − | * Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
| |
| − | * Validation location: [http://sitenv.org/web/sit/ccda-validator SITE Validator TOC Ambulatory]
| |
| − | * Comments: This is an example of how an author can record they do now know whether the patient has received any vaccinations.
| |
| | | | |
| − | ======'''Influenza Vaccination'''======
| + | '''Health Concerns are now in the new HL7 search tool!''' |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| + | *Health Concerns Section Narrative-only |
| − | * Approved by: Task force on 4/16/2015. SDWG Approved 4/23/2015
| + | *Health Concern Linking Example |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| + | *No Known Health Concerns |
| − | ** TemplateId(s) illustrated: Immunization Activity (2.16.840.1.113883.10.20.22.4.52)
| |
| − | ** [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Influenza_Immunization_Complete.xml Influenza Vaccination Completed] | |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0 | |
| − | ** TemplateId(s) illustrated: Immunization Activity (2.16.840.1.113883.10.20.22.4.52.2)
| |
| − | ** Not Completed
| |
| − | * Known bad example?: Valid example | |
| − | * Reference to full CDA sample: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/CCD_Transition_of_Care_Ambulatory_Influenza_Immunization_Complete.xml Immunization section in compliant MU2 C-CDA sample]
| |
| − | * Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
| |
| − | * Validation location: [http://sitenv.org/web/sit/ccda-validator SITE Validator TOC Ambulatory]
| |
| − | * Comments: This example illustrates how to structure Immunizations for the 170.314(b)(2) Transitions of care - J) Immunizations.
| |
| | | | |
| − | ======'''Immunization Not Given - Patient Refused'''====== | + | ===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac82 IMMUNIZATIONS]=== |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force on 10/29/2015. Approved by SDWG 11/12/2015.
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: Immunization Activity (2.16.840.1.113883.10.20.22.4.52)
| |
| − | ** [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Immunization_Not_Given_Patient_Refusal.xml Immunization Not Given - Patient Refused (via GitHub)]
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
| |
| − | ** TemplateId(s) illustrated: Immunization Activity (2.16.840.1.113883.10.20.22.4.52.2)
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample:
| |
| − | * Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
| |
| − | * Validation location: [http://sitenv.org/web/sit/ccda-validator SITE Validator TOC Ambulatory]
| |
| − | * Comments: This is an example of how an author can record a patient refused an immunization.
| |
| | | | |
| − | ===MEDICAL EQUIPMENT===
| + | '''Immunizations are now in the new HL7 search tool!''' |
| − | ======'''No Implanted Devices'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task Force Approved 12/15/15.
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=408 C-CDA 2.1]
| |
| − | ** TemplateId(s) illustrated: Medical Equipment Section (V2) (2.16.840.1.113883.10.20.22.2.23:2014-06-09) and Procedure Activity Procedure (V2) (2.16.840.1.113883.10.20.22.4.14:2014-06-09 )
| |
| − | ** [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Implanted_Devices.xml No Implanted Devices - No UDI (via GitHub)]
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample:
| |
| − | * Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
| |
| − | * Validation location: [http://sitenv.org/web/sit/ccda-validator SITE Validator TOC Ambulatory]
| |
| − | * Comments: This is an example of how an author can record a patient has no implanted devices
| |
| | | | |
| − | ===MEDICATIONS===
| + | Samples included: |
| − | For all Medication examples the example task force agreed (8/28/2014) to only include institutionSpecified on the effectiveTime when the value is true. InstitutionSpecified indicates whether the exact timing is up to the party executing the schedule (e.g., to distinguish "every 8 hours" (false) from "3 times a day" (true)).
| + | *Immunization Not Given - Patient Refused |
| | + | *Influenza Vaccination |
| | + | *Unknown Patient Immunization Status |
| | | | |
| − | [https://docs.google.com/document/d/1Y0Z458o_MrR2aPnpx6EygO6hpI88Bl95esjRWZ0agtY/edit?usp=sharing Medication Frequencies] Approved 9/17/2014 at Chicago WG | + | ===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac86 Medical Equipment]=== |
| | | | |
| − | (keywords: bid, two times daily; q12h, every 12 hours; tid, three times daily; q8h, every 8 hours; qid, four times daily; q6h, every 6 hours; qd, daily; q24h, every 24 hours; qod, every other day; qm, Once a month; Every other week; 1 hour after meal;
| + | '''Medical Equipment now in the new HL7 search tool!''' |
| − | before dinner; before lunch (from lat. ante cibus diurnus))
| |
| | | | |
| − | [https://docs.google.com/spreadsheets/d/1d0RJoyzVQISK4ai3zbjKT6PCuOEQzgWBCqarDHyD-JE/edit#gid=798164205 Medication statusCodes] Approved on 2/19/2015 SDWG call.
| + | Samples included: |
| | + | *Implanted Device - Procedure Unknown |
| | + | *No Implanted Devices |
| | | | |
| | | | |
| − | ======'''Patient prescribed oral medication QID PRN without precondition specified'''====== | + | ======'''Multiple Implants Same Procedure (on trello)'''====== |
| | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]] | | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]] |
| − | * Approved by: Task force on 1/9/2014. Task force approved 1/16/2014 | + | * Approved by: 7/14/2016 |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: [https://trifolia.lantanagroup.com/TemplateManagement/View?templateId=610 Medication Activity] [https://trifolia.lantanagroup.com/TemplateManagement/View?templateId=631 Medication Information] [https://trifolia.lantanagroup.com/TemplateManagement/View?templateId=627 Precondition for Substance Administration] (Trifolia Log-in Required)
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Oral_Med_QID_with_PRN.xml Patient prescribed oral medication QID PRN without precondition specified]
| |
| − | * C-CDA 2.0 Example: none yet posted
| |
| − | * Known bad example?: Valid example when PRN but no precondition specified
| |
| − | * Reference in full CDA Sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Examples_in_empty_CCD.xml Results Packaged in C-CDA Skeleton]
| |
| − | * Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Message Validator for VDT Ambulatory] validated December 18, 2013
| |
| − | * Keywords: Precondition, Pre-coordinated medication code, dose frequency
| |
| − | * Comments: This is an example of a medication which is QID and PRN (as needed) but with no precondition specified. It was generated based on SDWG list-serv discussion in December 2013. It also demonstrated a pre-coordinated generic medication coded at the SDC level (generic 600mg Oral Tablet) in RxNorm hierarchy.
| |
| − | ** Additional content - the following file illustrates 5 different medication entries. These examples are meant to illustrate the coding of a medication precondition or indication.
| |
| − | ***[https://github.com/gecole/HL7-Task-Force-Examples/blob/master/MED_Oral_Med_Comparisions_for_PRN_Instructions_Indications.xml Patient prescribed oral medication for pain]
| |
| − | ****Summary of examples:
| |
| − | ****PRN with a coded precondition - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours PRN for joint pain
| |
| − | ****Instructions; similar to above but NOT a PRN - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours as Directed
| |
| − | ****Indication; again, NOT a PRN - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours for joint pain
| |
| | | | |
| − | ======'''Patient Prescribed Medication Every 4-6 Hours'''======
| + | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=408 C-CDA 2.1] |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| + | ** TemplateId(s) illustrated: Medical Equipment Section (V2) (2.16.840.1.113883.10.20.22.2.23:2014-06-09) and Procedure Activity Procedure (V2) (2.16.840.1.113883.10.20.22.4.14:2014-06-09 ) |
| − | * Approved by: Task force 1/30/2014. Approved by SDWG on 2/6/2014.
| + | ** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/EQUIPMENT_Multiple_Implants.xml Multiple Implants same Procedure (via GitHub)] |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] | |
| − | ** TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.2.1.1, 2.16.840.1.113883.10.20.22.4.16, 2.16.840.1.113883.10.20.22.4.23 | |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Med_Every_4-6_hrs.xml Patient prescribed medication every 4 to 6 hours]
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
| |
| − | ** TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.2.1.1.2, 2.16.840.1.113883.10.20.22.4.16.2, 2.16.840.1.113883.10.20.22.4.23.2
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Med_Every_4-6_hrs.xml Patient prescribed medication every 4 to 6 hours] | |
| | * Known bad example?: Valid example | | * Known bad example?: Valid example |
| − | * Reference in full CDA Sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Examples_in_empty_CCD.xml Results Packaged in C-CDA Skeleton] | + | * Reference to full CDA sample: Not available |
| | * Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore) | | * Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore) |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Message Validator for VDT Ambulatory] validated February 12, 2014 | + | * Validation location: [http://sitenv.org/web/sit/ccda-validator SITE Validator TOC Ambulatory] |
| − | * Keywords: Dose frequency, pre-coordinated medication
| + | * Comments: This is an example of how a single procedure (angioplasty) can have multiple implants (2 drug eluting stents). There are still two entries since this is being included in medical equipment rather than procedure section. |
| − | * Comments: This is an example of a medication (Sudafed) which to be administered every 4-6 hours, a common dosing pattern. Representing the range of potential of hours is done through a low and high child element of the period within effectiveTime of PIVL_TS. | |
| | | | |
| | + | ===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac8a MEDICATIONS]=== |
| | | | |
| − | ======''' Debate continues - see [http://wiki.hl7.org/images/e/ee/2014-05-22_Critique_of_HL7_CDA_structured_tapering_dose_Azithromycin_example_w_Figures.docx document] and comments below - Patient Prescribed Oral Antibiotic with Dosing Regimen that Varies Over Prescription Course (Loading or Tapered)'''======
| + | '''Medications are now in new HL7 search tool!''' |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| + | |
| − | *Previously, approved by: Task force on 3/6. Approved by SDWG on 4/10/2014.
| + | Samples included: |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.2.1.1, 2.16.840.1.113883.10.20.22.4.16, 2.16.840.1.113883.10.20.22.4.23
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Med_Dose_Change.xml Patient prescribed oral antibiotic with a dosing regimen that varies over course of prescription (loading or tapered dosing)]
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
| |
| − | ** TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.2.1.1.2, 2.16.840.1.113883.10.20.22.4.16.2, 2.16.840.1.113883.10.20.22.4.23.2
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/C-CDAR2.0/MED_Med_Every_4-6_hrs.xml Patient prescribed medication every 4 to 6 hours]
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference in full CDA Sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Examples_in_empty_CCD.xml Results Packaged in C-CDA Skeleton]
| |
| − | * Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Message Validator for VDT Ambulatory] validated February 12, 2014
| |
| − | * Keywords: Pre-coordinated medication code, dose frequency, tapered dose, loading dose
| |
| − | * Comments: This is an example of a common pattern for antibiotic administration which is complex (double dose on day 1, commonly known as Z-PAK). SDWG reviewed this example with the Pharmacy working group in February 2014. This dosing regimen may be characterized as a loading dose, but a similar approach could be used for a tapered dose as well. At the May 2014 Working Group the committee discussed whether this example would be better with just a free text sig. The committee could not agree on the most appropriate location for the free text so this issue remains open. Use this example with caution until a free text sig is available and included.
| |
| | | | |
| | + | *[https://docs.google.com/document/d/1Y0Z458o_MrR2aPnpx6EygO6hpI88Bl95esjRWZ0agtY/edit?usp=sharing Medication Frequencies] |
| | + | *[https://docs.google.com/spreadsheets/d/1d0RJoyzVQISK4ai3zbjKT6PCuOEQzgWBCqarDHyD-JE/edit#gid=798164205 Medication statusCodes] |
| | + | *Patient prescribed oral medication QID PRN without precondition specified |
| | + | *Patient Prescribed Medication Every 4-6 Hours |
| | + | *Single Administration of Medication (at Single Point in Time) |
| | + | *No Medications |
| | + | *Patient Reported Medication without Reported Brand/Dose |
| | + | *Patient Prescribed Oral Antibiotic with Dosing Regimen that Varies Over Prescription Course (Loading or Tapered) |
| | | | |
| − | ======'''Patient prescribed basal insulin administered at bedtime'''====== | + | ======''' Patient prescribed basal insulin administered at bedtime (on trello)'''====== |
| | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]] | | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]] |
| | * Approved by: Not yet approved | | * Approved by: Not yet approved |
| Line 806: |
Line 180: |
| | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Message Validator for VDT Ambulatory] validated February 27, 2014 | | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Message Validator for VDT Ambulatory] validated February 27, 2014 |
| | * Keywords: Pre-coordinated medication code, dose frequency | | * Keywords: Pre-coordinated medication code, dose frequency |
| − | * Comments: This is an example of a subcutaneous dose of a common basal insulin. Please note that this insulin dosage does not vary. This dose is administered at bedtime so the dosing frequency utilizes EIVL_TS type to denote this. | + | * Comments: This is an example of a subcutaneous dose of a common basal insulin. Please note that this insulin dosage does not vary. This dose is administered at bedtime so the dosing frequency utilizes EIVL_TS type to denote this. |
| | | | |
| | + | ===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac98 Plan of Treatment]=== |
| | | | |
| − | ======''' Single Administration of Medication (at Single Point in Time)''' ======
| + | '''Plan of Treatment Examples are now in new HL7 search tool!''' |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | ** Approved by: Task force on 3/13. Approved by SDWG on 4/10/2014.
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.2.1.1, 2.16.840.1.113883.10.20.22.4.16, 2.16.840.1.113883.10.20.22.4.23
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Med_Single_Administration.xml Single administration of medication (at single point in time)]
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
| |
| − | ** TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.2.1.1.2, 2.16.840.1.113883.10.20.22.4.16.2, 2.16.840.1.113883.10.20.22.4.23.2, 2.16.840.1.113883.10.20.22.4.119
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/C-CDAR2.0/MED_Med_Single_Administration.xml Single administration of medication (at single point in time)]
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference in full CDA Sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Examples_in_empty_CCD.xml Results Packaged in C-CDA Skeleton]
| |
| − | * Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Message Validator for VDT Ambulatory] validated October 16, 2014
| |
| − | * Keywords: Pre-coordinated medication code, single administration, point in time
| |
| − | * Comments: This is an example of two baby aspirin being administered at a single point in time. At the January 2014 San Antonio meeting of HL7, this approach was decided as appropriate for medication timing of a point in time. Subsequent to that meeting, the TTT validator was adjusted to accept this format for medication times.
| |
| | | | |
| | + | Samples included: |
| | + | *Care Plan Goals and Instructions |
| | + | *No Planned Tests |
| | + | *Planned EKG |
| | + | *Planned Encounter - Referral |
| | | | |
| − | ======'''No Medications'''====== | + | ===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac9d PROBLEMS]=== |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force on 3/13. Approved by SDWG on 4/10/2014.
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: Medication Activity (2.16.840.1.113883.10.20.22.4.16)
| |
| − | ** [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/noKnownMedication_R1.1.xml No Medications R1.1]
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
| |
| − | ** TemplateId(s) illustrated: Medication Activity (2.16.840.1.113883.10.20.22.4.16.2)
| |
| − | ** [https://github.com/donaldson-ed/taskforceExample/blob/master/noKnownMedications_r2.xml No Medications R2]
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/CCD_Transition_of_Care_Ambulatory_Complete_No_Known_Medications.xml No Medications in compliant MU2 C-CDA R1.1 sample]
| |
| − | * Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
| |
| − | * Validation location: [http://sitenv.org/web/sit/ccda-validator SITE Validator TOC Ambulatory]
| |
| − | * Comments: .
| |
| − | * Alternate Opinion: 1 Task Force member voted against approving this samples. In her opinion, the narrative text did not convey the same semantic meaning as the information represented in the structured data. For additional information on this point of view, see the sample titled, "XXXXX" in the "Unapproved Samples" area below.
| |
| | | | |
| | + | '''Problems are now in new HL7 search tool!''' |
| | | | |
| − | ======'''Patient Reported Medication without Reported Brand/Dose'''======
| + | Samples included: |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| + | *Patient with No Known Problems |
| − | * Approved by: Not yet approved
| + | *Active Problem' |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| + | *Problem which has been resolved/completed |
| − | ** TemplateId(s) illustrated: Medication Activity (2.16.840.1.113883.10.20.22.4.16)
| + | *Patient with No Known Diabetes |
| − | ** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Oral_Patient_Reported.xml Patient reported oral medication no brand/dose]
| |
| − | * C-CDA 2.0 Example: none yet created
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Examples_in_empty_CCD.xml Medications in skeleton CCD]
| |
| − | * Custodian: John D'Amore jdamore@diameterhealth.com GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT VDT Ambulatory] validated June 4, 2014
| |
| − | * Comments: Patients often report medications that they are taking, either self-prescribed or by another provider, and know the drug name but do not know any specific brand or dose. This is an example of how to record an herbal supplement (echinicea) that a patient has reported taking using the informant to denote that this is patient reported.
| |
| − | | |
| − | | |
| − | ======'''Antibiotic Administered with Normal Saline (i.e. in hospital)'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Not yet approved
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: Medication Activity (2.16.840.1.113883.10.20.22.4.16) Drug Vehicle (2.16.840.1.113883.10.20.22.4.24)
| |
| − | ** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_IV_Antibiotics.xml Penicillin administered via IV infusion]
| |
| − | * C-CDA 2.0 Example: none yet created
| |
| − | * Known bad example?: Valid example. Returns one warning since no PIVL_TS or EIVL_TS included
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Examples_in_empty_CCD.xml Medications in skeleton CCD]
| |
| − | * Custodian: John D'Amore jdamore@diameterhealth.com GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT VDT Ambulatory] validated June 4, 2014
| |
| − | * Comments: Many medications administered in hospital are done through IV infusion with another agent. In this example, a loading dose of penicillin is administered via IV infusion with normal saline.
| |
| − | | |
| − | ===PLAN OF TREATMENT===
| |
| − | This section was previously named Plan of Care.
| |
| − | ======'''Care Plan Goals Instructions Section'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force approved August 20, 2015. SDWG Approved 9/10/2015.
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: Plan of Care Activity Observation
| |
| − | **[https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/20150629%20Care%20Plan%20Goals-Instructions-Section.xml Plan Goals Instructions Section]
| |
| − | * C-CDA 2.0 Example: None yet posted | |
| − | * Reference to full CDA sample:
| |
| − | * Custodian: Lisa Nelson
| |
| − | * Validation location:
| |
| − | * Comments: This example illustrates how to structure a Goals and Instructions for the 170.314(b)(2) Transitions of care - K) Care Plan (Goals and Instructions).
| |
| − | | |
| − | ======'''Planned EKG'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task Force Approved 11/25/15
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: Plan of Care Activity Observation
| |
| − | **[https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Plan_of_Treatment_EKG.xml Planned EKG]
| |
| − | * C-CDA 2.0 Example: None yet posted
| |
| − | * Reference to full CDA sample:
| |
| − | * Custodian: Brett Marquard
| |
| − | * Validation location:
| |
| − | * Comments: This example illustrates how to structure a planned observation.
| |
| − | | |
| − | ======'''Planned Encounter (Referral)'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force 9/24/2015, SDWG 10/15/2015
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: Plan of Care Activity Encounter
| |
| − | **[https://github.com/gecole/HL7-Task-Force-Examples/blob/master/ReferralToC170.314b2Ambulatory.xml Referral]
| |
| − | * C-CDA 2.0 Example: None yet posted
| |
| − | * Reference to full CDA sample:
| |
| − | * Custodian: George Cole
| |
| − | * Validation location:
| |
| − | * Comments: This example illustrates how to structure a Referral for the 170.314(b)(2) Transitions of care - N) Referral
| |
| − | | |
| − | ===PROBLEMS===
| |
| − | | |
| − | ======'''Patient with No Known Problems'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force on 2/27, SDWG on 3/6. | |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation | |
| − | ** [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Known_Problems_Section_20140226.xml Patient with No Known Problems R1.1 - Problem Section 2.16.840.1.113883.10.20.22.2.5.1 (via GitHub)]
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0 | |
| − | ** TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
| |
| − | ** [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Known_Problems_Section_R2.xml Patient with No Known Problems R2 - Problem Section 2.16.840.1.113883.10.20.22.2.5.2 (via GitHub)]
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Doc-No%20Known%20Problems%2020140226.xml Full Sample No Known Problems]
| |
| − | * Custodian: Brett Marquard
| |
| − | * Validation location: TTT VDT Ambulatory
| |
| − | * Comments:
| |
| | | | |
| − | ======'''Patient with No Known Diabetes'''====== | + | ===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70daca3 PROCEDURES]=== |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force on 11/5/2015. Approved by SDWG 11/12/2015.
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
| |
| − | ** [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Known_Diabetes_Problems_Section.xml Patient with No Known Diabetes(via GitHub)]
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
| |
| − | ** TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample: [https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Doc-No%20Known%20Problems%2020140226.xml Full Sample No Known Problems]
| |
| − | * Custodian: Brett Marquard
| |
| − | * Validation location: TTT VDT Ambulatory
| |
| − | * Comments:
| |
| | | | |
| − | ======'''Problem which has been resolved/completed'''======
| + | '''Procedures are now in new HL7 search tool!''' |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force approved May 30, 2014. SDWG approved June 5, 2014
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PROBLEM_Resolved_Problem.xml Problem which has been resolved/completed]
| |
| − | * C-CDA 2.0 Example: None yet posted
| |
| − | * Reference to full CDA sample: https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PROBLEM_Examples_in_empty_CCD.xml
| |
| − | * Custodian: John D'Amore jdamore@diameterhealth.com
| |
| − | * Validation location: TTT, April 17, 2014
| |
| − | * Comments: This example illustrates how to structure a resolved problem, both by having a biological resolution date and a completed status of the concern.
| |
| | | | |
| − | ======'''Active Problem'''======
| + | Samples included: |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| + | *Procedure Activity Procedure Example in Procedures Section |
| − | * Approved by: Task force approved October 2, 2014. Approved by SDWG 11/06/2014.
| + | *Procedures Activity Observation Example in Procedures Section |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example | + | *Procedure Activity Act Example in Procedures Section |
| − | ** TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation | |
| − | **[https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Problem_List_Active_Problem.xml Active Problem] | |
| − | * C-CDA 2.0 Example: None yet posted
| |
| − | * Reference to full CDA sample: https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/CCD_Transition_of_Care_Ambulatory_Active_Problem.xml
| |
| − | * Custodian: Brett Marquard
| |
| − | * Validation location: SITE, October 1, 2014
| |
| − | * Comments: This example illustrates how to structure an active problem.
| |
| | | | |
| − | ===PROCEDURES=== | + | ===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70daca7 RESULTS]=== |
| | | | |
| − | ======'''Procedure Activity Procedure Example in Procedures Section'''======
| + | '''Results are now in new HL7 search tool!''' |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Approved by task for 5/22/2014; SDWG Approved 5/29/2014.
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | **TemplateId(s) illustrated: Procedure Section, Procedure Activity Observation
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PROCEDURE_Procedure_Example.xml Procedure Activity Procedure Example in Procedures Section]
| |
| − | * C-CDA 2.0 Example: none yet posted
| |
| − | * Known bad example?: Valid example, although validator returns warning since performer not included in example
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA R1.1
| |
| − | * Reference to full CDA sample: https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PROCEDURE_Examples_in_empty_CCD.xml
| |
| − | * Custodian: John D'Amore jdamore@diameterhealth.com
| |
| − | * Validation location: TTT, April 30, 2014
| |
| − | * Comments: This example illustrates how a procedure which "alters the physical state" of the patient and should be classified as a procedure
| |
| | | | |
| − | | + | Samples included: |
| − | ======'''Procedures Activity Observation Example in Procedures Section'''======
| + | *Result panel with the display of two ordinal values of negative/positive |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| + | *Result with an unstructured string as the value (e.g. urine color) |
| − | * Approved by: Approved by task for 5/22/2014; SDWG Approved 5/29/2014.
| + | *Result with greater than a specified value |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| + | *Result with lab location |
| − | ** TemplateId(s) illustrated: Procedure Section, Procedure Activity Procedure
| + | *Result with discrete units and non-numeric value |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PROCEDURE_Observation_Example.xml Procedures Activity Observation Example in Procedures Section]
| + | *Results Unit Non-UCUM |
| − | * C-CDA 2.0 Example: none yet posted
| + | *Result with a pending component |
| − | * Known bad example?: Valid example, although validator returns warning since performer not included in example
| + | *Results with less than specific value |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA R1.1
| + | *Results with translation unit |
| − | * Reference to full CDA sample: https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PROCEDURE_Examples_in_empty_CCD.xml
| + | *Result of CO2 Test |
| − | * Custodian: John D'Amore jdamore@diameterhealth.com
| + | *Results Radiology with Image Narrative |
| − | * Validation location: TTT, April 30, 2014
| + | *Results of Basic Metabolic Panel and Troponin |
| − | * Comments: This example illustrates how an observation within a procedure section.
| |
| − | | |
| − | | |
| − | ======'''Procedure Activity Act Example in Procedures Section'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Approved by task for 5/22/2014; SDWG Approved 5/29/2014.
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: Procedure Section, Procedure Activity Act
| |
| − | ** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PROCEDURE_Act_Example.xml Procedure Activity Act Example in Procedures Section]
| |
| − | * C-CDA 2.0 Example: none yet posted
| |
| − | * Known bad example?: Valid example, although validator returns warning since performer not included in example
| |
| − | * Reference to full CDA sample: https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PROCEDURE_Examples_in_empty_CCD.xml
| |
| − | * Custodian: John D'Amore jdamore@diameterhealth.com
| |
| − | * Validation location: TTT, April 30, 2014
| |
| − | * Comments: This example illustrates an act within a procedure section.
| |
| − | | |
| − | ===RESULTS===
| |
| − | | |
| − | ======'''Result with less than or equal to a specified value'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Reviewed with SDWG on 12/5/2013. SDWG approved on 4/16/2015. Minor edits (inclusive attribute) and scheduled for re-vote 10/29/2015. Approved by SDWG 11/12/2015.
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=614 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required)] [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=615 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)]
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Value_Less_Than_Physical_Quantity.xml Result with less than a specified value (via GitHub)]
| |
| − | * C-CDA 2.0 Example: none yet posted
| |
| − | * Known bad example?: Valid example | |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Examples_in_empty_CCD.xml Result Packaged in C-CDA Skeleton]
| |
| − | * Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Message Validator for VDT Ambulatory] validated December 18, 2013
| |
| − | * Comments: This is an example of how to encode "less than or equal to" a specific range when returned from lab equipment. The example is for BNP, an immunoassay where the lower threshold for detection is often 5 pg/mL. The lower bound of the interval is zero in this example, even though this is none may be specified, since zero is the lower bound for measures of physical quantity. This example also includes a structured reference range.
| |
| − | | |
| − | ======'''Result with greater than a specified value'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Based on SDWG request from Kumara February 2014. Approved on SDWG 3/19/2015. Minor edits (inclusive attribute) and scheduled for re-vote 10/29/2015. Approved by SDWG 11/12/2015.
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=614 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required)] [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=615 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)]
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Value_Greater_Than_Physical_Quantity.xml Result with greater than a specified value (via GitHub)]
| |
| − | * C-CDA Example: none yet posted
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample: Not yet completed
| |
| − | * Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: Not yet validated
| |
| − | * Comments: This is an example of how to encode "greater than" (but not equal to) a specific range when returned from lab equipment. The example is for a point-of-care glucometer, which measures blood sugar for diabetics. Often these devices may have an upper bound, 500 mg/dL is shown in this example. An inclusive tag of false is shown to demonstrate a non-inclusive range. The upper bound of the interval is positive infinity in this example. This example also includes two structured reference ranges for normal and high.
| |
| − | | |
| − | ======'''Result panel with the display of two ordinal values of negative/positive'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force on 11/21/2013. Task force approved a second time on 3/05/2015. Approved by SDWG on 3/12/2015
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example | |
| − | ** TemplateId(s) illustrated: [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=614 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required)] [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=615 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)]
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Panel_with_Two_Ordinal_Values.xml Result panel with the display of two ordinal values of negative/positive]
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Examples_in_empty_CCD.xml Result Packaged in C-CDA Skeleton]
| |
| − | * Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Message Validator for VDT Ambulatory] validated December 18, 2013
| |
| − | * Comments: This is an example of how to encode positive and negative, which are common data types returned form lab equipment. While some technologies may represent this as a type of ST (string), it is logical and easily possible to encode this information using SNOMED-CT. This would allow structured examination of this information downstream as well as comparison to a structured reference range, as shown in the example.
| |
| − | | |
| − | | |
| − | ======'''Result with an unstructured string as the value (e.g. urine color)'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force approved 3/05/2015. Approved by SDWG on 3/12/2015
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=614 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required)] [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=615 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)]
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Use_of_String_Value.xml Result with an unstructured string as the value (e.g. urine color)] | |
| − | * C-CDA 2.0 Example: none yet posted | |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Examples_in_empty_CCD.xml Result Packaged in C-CDA Skeleton]
| |
| − | * Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Message Validator for VDT Ambulatory] validated December 18, 2013
| |
| − | * Comments: This is an example of a value from a lab result that may not be structured. | |
| − | | |
| − | | |
| − | ======''' Result Which Requires Translation for its Unit Represented in UCUM '''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force on 2/27, SDWG on 3/6.
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=614 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required)] [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=615 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)] | |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Value_UCUM_Translation.xml Result which requires translation for its unit represented in UCUM]
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
| |
| − | **TemplateId(s) illustrated: [2.16.840.1.113883.10.20.22.4.1.2, 2.16.840.1.113883.10.20.22.4.2.2]
| |
| − | **[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/C-CDAR2.0/RESULT_Value_UCUM_Translation.xml Result which requires translation for its unit represented in UCUM]
| |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Examples_in_empty_CCD.xml Result Packaged in C-CDA Skeleton]
| |
| − | * Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Message Validator for VDT Ambulatory] validated February 12, 2014 | |
| − | * Comments: This is an example of a value from a lab which requires a translation for its unit. All units for physical quantities should be represent in UCUM.
| |
| − | | |
| − | | |
| − | ======'''Result with a pending component'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Approved by Task Force 5/1/14; Approved by SDWG 5/22/14 | |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example | |
| − | ** TemplateId(s) illustrated: [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=614 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required)] [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=615 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)]
| |
| − | **[https://github.com/donaldson-ed/taskforceExample/blob/master/Result_panel_with_pending_component.xml Result with a pending component]
| |
| − | * C-CDA 2.0 Example: none yet posted | |
| − | * Known bad example?: Valid example
| |
| − | * Reference to full CDA sample: [https://github.com/donaldson-ed/taskforceExample/blob/master/Result_panel_with_pending_component.xml Result in C-CDA Section]
| |
| − | * Custodian: Ed Donaldson, ed.donaldson@greenwayhealth.com (GitHub: donaldson-ed)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT validator for Clinical Office Visit Summary - Clinical Summary] validated March 5, 2014
| |
| − | * Comments: Result with a pending component.
| |
| − | | |
| − | ======'''Result of CO2 Test'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force approved 5/7/2015. SDWG Approved 6/4/2015
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1 (link to CDA Implementation Guide)] Implementation Guide Example | |
| − | ** TemplateId(s) illustrated: [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=614 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required)] [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=615 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)]
| |
| − | ** [https://github.com/benjaminflessner/HL7-C-CDA-Task-Force-Examples/blob/master/Results%20CO2%20Example.xml Standard CO2 Result Example]
| |
| − | * C-CDA 2.0 Example: none yet posted | |
| − | * Known bad example?: Valid example
| |
| − | * Custodian: Benjamin Flessner, benjamin@epic.com (GitHub:benjaminflessner)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT validator for Clinical Office Visit Summary - Clinical Summary]
| |
| − | * Comments: This example illustrates how to structure Laboratory Tests and Values/Results for the 170.314(b)(2) Transitions of care - I) Laboratory Tests and Values/Results.
| |
| − | | |
| − | ======'''Results of Basic Metabolic Panel and Troponin (MU2 Example)'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Not yet approved
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1 (link to CDA Implementation Guide)] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=614 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required)] [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=615 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)]
| |
| − | ** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_BMP_with_Tropinin.xml Basic Metabolic Panel with Troponin Example]
| |
| − | * C-CDA 2.0 Example: none yet posted
| |
| − | * Reference in Full C-CDA Sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Examples_in_empty_CCD2.xml BMP in full C-CDA sample]
| |
| − | * Known bad example?: Valid example
| |
| − | * Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub:jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT validator for Clinical Office Visit Summary - Clinical Summary]
| |
| − | * Comments: Sample from Meaningful Use test data (inpatient data)
| |
| | | | |
| | ===PAYER=== | | ===PAYER=== |
| | | | |
| − | ======'''Coverage Activity referencing the holder's employer'''====== | + | ======'''Coverage Activity referencing the holder's employer (on trello)'''====== |
| | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]] | | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]] |
| | * Approved by: Sample not yet reviewed | | * Approved by: Sample not yet reviewed |
| Line 1,132: |
Line 244: |
| | * Comments: This is an example of how to encode the policy holder's employer through which the insurance is provided - Finding major issues with the Coverage Activity and Policy Activity Templates. See C-CDA R1.1 DSTU Comment #994. | | * Comments: This is an example of how to encode the policy holder's employer through which the insurance is provided - Finding major issues with the Coverage Activity and Policy Activity Templates. See C-CDA R1.1 DSTU Comment #994. |
| | | | |
| | + | ===[http://cdasearch.hl7.org/sections/595166e9e6ca6a48c70dacb4 SOCIAL HISTORY (SMOKING)]=== |
| | | | |
| − | ===SOCIAL HISTORY (SMOKING)===
| + | '''Social History are now in new HL7 search tool!''' |
| − | | |
| − | ======'''Unknown Smoking Status'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task Force Approved 6/26; Approved by SDWG 7/03/14
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: Social History Section (2.16.840.1.113883.10.20.22.2.17) Smoking Status (2.16.840.1.113883.10.20.22.4.78)
| |
| − | ** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/SMOKING_Unknown_Smoker.xml Unknown Smoking Status]
| |
| − | * C-CDA 2.0 Example: none yet created
| |
| − | * Known bad example?: Valid example.
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/SMOKING_Examples_in_empty_CCD.xml Social History (Smoking Status)in skeleton CCD]
| |
| − | * Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT VDT Ambulatory] validated June 11, 2014
| |
| − | * Comments: This is an example of unknown smoking status. There is a major variation in how no information is managed for smoking status. C-CDA 1.1 explicitly guides to not utilize a nullFlavor for this information. Instead a SNOMED code should be used as demonstrated in the example. A best practice to avoid confusion is for each social history section to only include a single smoking status.
| |
| − | | |
| − | | |
| − | ======'''Former Smoker in Smoking Status'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task Force Approved 6/26; Approved by SDWG 7/03/14
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: Social History Section (2.16.840.1.113883.10.20.22.2.17) Smoking Status (2.16.840.1.113883.10.20.22.4.78)
| |
| − | ** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/SMOKING_Former_Smoker.xml Former Smoking Status]
| |
| − | * C-CDA 2.0 Example: none yet created
| |
| − | * Known bad example?: Valid example.
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/SMOKING_Examples_in_empty_CCD.xml Social History (Smoking Status)in skeleton CCD]
| |
| − | * Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT VDT Ambulatory] validated June 11, 2014
| |
| − | * Comments: This is an example of a former smoker in smoking status. There is a variation in how effectiveTime/high is used since this represents when the patient stopped smoking, not when they stopped being a former smoker. C-CDA 1.1 explicitly guides to this usage of effectiveTime. A best practice to avoid confusion is for each social history section to only include a single smoking status.
| |
| − | | |
| − | | |
| − | ======'''Never Smoker in Smoking Status'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task Force Approved 6/26; Approved by SDWG 7/03/14
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: Social History Section (2.16.840.1.113883.10.20.22.2.17) Smoking Status (2.16.840.1.113883.10.20.22.4.78)
| |
| − | ** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/SMOKING_Never_Smoker.xml Never Smoker Status]
| |
| − | * C-CDA 2.0 Example: none yet created
| |
| − | * Known bad example?: Valid example.
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/SMOKING_Examples_in_empty_CCD.xml Social History (Smoking Status)in skeleton CCD]
| |
| − | * Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT VDT Ambulatory] not yet validated
| |
| − | * Comments: This is an example of a never smoker in smoking status. A best practice to avoid confusion is for each social history section to only include a single smoking status.
| |
| − | | |
| − | | |
| − | ======'''Current Smoker in Smoking Status'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task Force Approved 6/26; Approved by SDWG 7/03/14
| |
| − | * CDA Implementation Guide where template(s) is(are) defined: [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1]
| |
| − | ** TemplateId(s) illustrated: Social History Section (2.16.840.1.113883.10.20.22.2.17) Smoking Status (2.16.840.1.113883.10.20.22.4.78)
| |
| − | ** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/SMOKING_Current_Smoker.xml Current Smoking Status]
| |
| − | * C-CDA 2.0 Example: none yet created
| |
| − | * Known bad example?: Valid example.
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/SMOKING_Examples_in_empty_CCD.xml Social History (Smoking Status)in skeleton CCD]
| |
| − | * Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT VDT Ambulatory] validated June 11, 2014
| |
| − | * Comments: This is an example of current smoking status. This example also includes a coordinating social history observation to convey the amount of smoking using a SNOMED code. This SNOMED code in the accompanying observation is not acceptable since smoking status, which is constrained by HL7 and Meaningful Use value set requirements. A best practice to avoid confusion is for each social history section to only include a single smoking status.
| |
| | | | |
| − | ===VITAL SIGNS===
| + | Samples included: |
| | + | *Unknown Smoking Status |
| | + | *Former Smoker in Smoking Status |
| | + | *Never Smoker in Smoking Status |
| | + | *Current Smoker in Smoking Status |
| | | | |
| − | ======'''Panel of Vital Signs in Metric Units'''====== | + | ===[http://cdasearch.hl7.org/sections/595166e9e6ca6a48c70dacba VITAL SIGNS]=== |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force approved May 30, 2014. SDWG approved June 5, 2014
| |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: Vital Sign Organizer 2.16.840.1.113883.10.20.22.4.26, Vital Sign Observation 2.16.840.1.113883.10.20.22.4.27
| |
| − | ** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/VITALS_Complete_Panel_Metric.xml Vital sign panel in metric units]
| |
| − | * C-CDA 2.0 Implementation Guide Example: none yet posted
| |
| − | * Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Message Validator for VDT Ambulatory] validated May 29, 2014
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/VITALS_Examples_in_empty_CCD.xml Vital Signs in C-CDA Skeleton]
| |
| − | * Comments: This is panel of the nine common vital signs collected on an adult in metric units. Note that body surface area (BSA), head circumference and height (lying) are not included.
| |
| | | | |
| | + | '''Vital Signs are now in new HL7 search tool!''' |
| | | | |
| − | ======'''Panel of Vital Signs in Mixed Metric/Imperial Units'''======
| + | Samples included: |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| + | *Panel of Vital Signs in Metric Units |
| − | * Approved by: Task force approved May 30, 2014. SDWG approved June 5, 2014 | + | *Panel of Vital Signs in Mixed Metric/Imperial Units |
| − | * [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
| |
| − | ** TemplateId(s) illustrated: Vital Sign Organizer 2.16.840.1.113883.10.20.22.4.26, Vital Sign Observation 2.16.840.1.113883.10.20.22.4.27
| |
| − | ** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/VITALS_Complete_Panel_Mixed_Units.xml Vital Sign panel with mixed units]
| |
| − | * C-CDA 2.0 Implementation Guide Example: none yet posted
| |
| − | * Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/VITALS_Examples_in_empty_CCD.xml Vital Signs in C-CDA Skeleton]
| |
| − | * Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
| |
| − | * Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Message Validator for VDT Ambulatory] validated May 29, 2014
| |
| − | * Comments: This is panel of the nine common vital signs collected on an adult in mixed metric/imperial units. Note that body surface area (BSA), head circumference and height (lying) are not included.
| |
| | | | |
| − | ===FAMILY HISTORY=== | + | ===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac67 Family History]=== |
| | | | |
| − | ======'''Normal Family History; Father deceased with conditions; Mother alive with no conditions'''======
| + | '''Family History examples are now in new HL7 search tool!''' |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force approved 1/15/2015; SDWG approved 2/19/2015
| |
| − | * C-CDA 2.0 (link to CDA Implementation Guide, when available) Implementation Guide Example
| |
| − | **TemplateId(s) illustrated: Family History Organizer (2.16.840.1.113883.10.20.22.4.45 2015-06-09), Family History Observation (2.16.840.1.113883.10.20.22.4.46 2015-06-09), Age Observation (2.16.840.1.113883.10.20.22.4.31), Family History Death Observation (2.16.840.1.113883.10.20.22.4.47)
| |
| − | ** [https://github.com/benjaminflessner/HL7-C-CDA-Task-Force-Examples/blob/master/Family_History_Normal.xml Family History Section]
| |
| − | * Known bad example?: No
| |
| − | * Reference to full CDA sample:
| |
| − | * Custodian: Benjamin Flessner, benjamin@epic.com (GitHub: benjaminflessner)
| |
| − | * Validation location: C-CDAR2 schema and schematron
| |
| − | * Comments: Example shows multiple observations for one family member, identifying the cause of death, and a family member with no known problems.
| |
| | | | |
| − | ======'''Family History; two individuals with the same relationship to the patient'''======
| + | Samples included: |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| + | *Family History; generic history (not scoped to individuals) |
| − | * Approved by: Task force approved 2/12/2015, SDWG approved 2/12/2015
| + | *Normal Family History; Father deceased with conditions; Mother alive with no conditions |
| − | * C-CDA 2.0 (link to CDA Implementation Guide, when available) Implementation Guide Example | + | *Family History; two individuals with the same relationship to the patient |
| − | **TemplateId(s) illustrated: Family History Organizer (2.16.840.1.113883.10.20.22.4.45 2015-06-09), Family History Observation (2.16.840.1.113883.10.20.22.4.46 2015-06-09)
| |
| − | ** [https://github.com/benjaminflessner/HL7-C-CDA-Task-Force-Examples/blob/master/Family_History_Siblings.xml Family History Section (Two Brothers)]
| |
| − | * Known bad example?: No
| |
| − | * Reference to full CDA sample:
| |
| − | * Custodian: Benjamin Flessner, benjamin@epic.com (GitHub: benjaminflessner)
| |
| − | * Validation location: C-CDAR2 schema and schematron
| |
| − | * Comments: Example shows two brothers with multiple conditions. Though they have the same relationship to the patient, they can be identified by their separation into two family history organizers as well as by their subject ID's.
| |
| − | | |
| − | ======'''Family History; generic history (not scoped to individuals)'''======
| |
| − | [[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
| |
| − | * Approved by: Task force approved 2/12/2015, SDWG approved 2/19/2015
| |
| − | * C-CDA 2.0 (link to CDA Implementation Guide, when available) Implementation Guide Example
| |
| − | **TemplateId(s) illustrated: Family History Organizer (2.16.840.1.113883.10.20.22.4.45 2015-06-09), Family History Observation (2.16.840.1.113883.10.20.22.4.46 2015-06-09) | |
| − | ** [https://github.com/benjaminflessner/HL7-C-CDA-Task-Force-Examples/blob/master/Family_History_Generic.xml Family History Section (Generic History)] | |
| − | * Known bad example?: Not "bad" but sub-optimal.
| |
| − | * Reference to full CDA sample:
| |
| − | * Custodian: Benjamin Flessner, benjamin@epic.com (GitHub: benjaminflessner)
| |
| − | * Validation location: C-CDAR2 schema and schematron
| |
| − | * Comments: Example shows generic "family history of x" and "no family history of x" with commentary suggesting better options.
| |
| | | | |
| | == Formatting of CDA Template Samples == | | == Formatting of CDA Template Samples == |
