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Difference between revisions of "CDA Example Task Force"

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<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
  
−
  2/19/2015:
 
−
    1. Result Reference Range - request for location string text.
 
−
    2. Identifying organizer result type (drop or pickup?)
 
−
    3. [https://docs.google.com/spreadsheets/d/1smfM0Vf66nFp10UF7VZxlG68F-LQX6CwkZeKLpMGUvg/edit#gid=1605284656 Prioritize Results Samples]
 
  
−
Out for block vote on
 
−
SDWG 2/19:
 
  
−
    1. [https://github.com/benjaminflessner/HL7-C-CDA-Task-Force-Examples/blob/master/Family_History_Siblings.xml Family History; two individuals with the same relationship to the patient]
+
     
−
    2. [https://github.com/benjaminflessner/HL7-C-CDA-Task-Force-Examples/blob/master/Family_History_Generic.xml Family History; generic history (not scoped to individuals)]
+
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])
−
    3. [https://docs.google.com/spreadsheets/d/1d0RJoyzVQISK4ai3zbjKT6PCuOEQzgWBCqarDHyD-JE/edit#gid=798164205 Medication statusCode (reviewed with TDJ from Pharmacy)]
 
  
−
Please contact the SDWG co-chairs (primary Brett Marquard) if you any questions.
+
[[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.
  
−
The management of approved and planned samples is now managed in a google spreadsheet:
+
[[CDA_Example_Task_Force_Quality_Criteria|CDA Example Task Force Quality Criteria]]
  
−
[https://docs.google.com/spreadsheets/d/1smfM0Vf66nFp10UF7VZxlG68F-LQX6CwkZeKLpMGUvg/edit?usp=sharing CDA Example Task Force Examples - '''Approved and On Deck''']
+
Discuss updating samples for C-CDA R2.0/R2.1 to support gold standard
  
−
Historical reference only: [[CDA Example Task Force - Previous Review Cycles]]
+
Please contact the SDWG co-chairs (primary Brett Marquard) if you any questions.
  
−
== Formatting of CDA Template Samples ==
+
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]
  
−
===PROTOTYPIC TEMPLATE===
+
== Examples - Organized by Section ==
−
'''Meaningful template example name'''
 
−
* Approved by: (list all approving bodies, including approval date)
 
−
* [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: TemplateId Name(s) (OID Number(s), e.g. 2.16.840.1.113883.10.20.22.1.2)
 
−
** [http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force#PROTOTYPIC_TEMPLATE Link to C-CDA 1.1 Example in hosted repository, e.g. GitHub]
 
−
* C-CDA 2.0 (link to CDA Implementation Guide, when available) Implementation Guide Example
 
−
**TemplateId(s) illustrated: TemplateId Name(s) (OID Number(s), e.g. 2.16.840.1.113883.10.20.22.1.2.2)
 
−
** [http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force#PROTOTYPIC_TEMPLATE Link to C-CDA 1.1 Example in hosted repository, e.g. GitHub]
 
−
* Known bad example?: Explain if this is a deliberately created bad example.
 
−
* Reference to full CDA sample: [http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force#PROTOTYPIC_TEMPLATE Full example of validated document (hyperlinked)]
 
−
* Custodian: Name, email address and repository username of the steward for the referenced sample
 
−
* Validation location: list of all validators tested against
 
−
* Comments: free text comments about the example
 
  
 +
===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac56 ALLERGIES, ADVERSE REACTIONS OR ALERTS]===
  
−
===APPROVED EXAMPLES OVERVIEW TABLE===
+
'''Allergies are now in the new HL7 search tool!'''
−
(Click on Table Headers to sort)
 
  
−
{| class="wikitable sortable" style="font-size:90%; width:99%;"
+
Samples included:
−
|-
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*[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)
  
−
! style="font-size:110%; width:140px; background: #B0C4DE" | Section
+
===CDA HEADER===
−
! style="font-size:110%; width:140px; background: #B0C4DE" | Meaningful template example name
 
−
! style="font-size:110%; background: #B0C4DE" | Approved Good C-CDA Example for [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA R1.1] and [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=379 C-CDA R2.0]
 
−
! style="font-size:110%; background: #B0C4DE" | Custodian
 
−
! style="font-size:110%; background: #B0C4DE" | Comments
 
  
−
|-
+
===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac79 CDA Header]===
  
−
! ALLERGIES, ADVERSE REACTIONS OR ALERTS
+
'''CDA Header Examples are now in the new HL7 search tool!'''
−
| [[#No Known Allergies with Author Timestamp|No Known Allergies with Author Timestamp]]
+
*Patient demographic information
−
|
+
*Previous Patient Name
−
* C-CDA R1.1:
+
*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).
 
−
** [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 R2.0: None yet posted.
 
−
| Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
 
−
| This is an example of how an author can record a patient has no known allergies.
 
  
−
|-
+
===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac62 ENCOUNTERS]===
 +
'''Encounters are now in the new HL7 search tool!'''
  
−
! ALLERGIES, ADVERSE REACTIONS OR ALERTS
+
Samples included:
−
| [[#No Known Medication Allergies with Author Timestamp|No Known Medication Allergies with Author Timestamp]]
+
*Hospital Discharge Encounter with Billable Diagnoses
−
|
+
*Outpatient Encounter with Diagnoses
−
* C-CDA R1.1:
+
*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).
+
*Inpatient Encounter Discharged to Rehab Location
−
** [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 R2.0: None yet posted.
 
−
| Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
 
−
| This is an example of how an author can record a patient has no known medication allergies.
 
  
−
|-
+
===FUNCTIONAL AND COGNITIVE STATUS (deprecated, not moved)===
  
−
! ALLERGIES, ADVERSE REACTIONS OR ALERTS
+
======'''No Impairment (on trello)'''======
−
| [[#Allergy to specific substance (cat hair)|Allergy to specific substance (cat hair)]]
+
[[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
−
|
+
* Status: Approved by task force on 6/18/2015. SDWG approved 7/9/2015
−
* C-CDA R1.1:
+
* 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).
+
** TemplateId(s) illustrated: Functional Status Section (2.16.840.1.113883.10.20.22.2.14), Functional Status Problem Observation (2.16.840.1.113883.10.20.22.4.68), Cognitive Status Problem Observation (2.16.840.1.113883.10.20.22.4.73)
−
** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/ALLERGY_Substance_with_UNII.xml Allergy to specific substance (cat hair)].
+
** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/FUNCTIONAL_No_Impairment.xml No Impairment Functional Status Section R1.1 (via GitHub)]
−
* C-CDA R2.0: None yet posted.
+
* CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
−
| John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
+
** Not yet completed
−
| 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
 
−
 
 
−
|-
 
−
 
 
−
! ALLERGIES, ADVERSE REACTIONS OR ALERTS
 
−
| [[#Allergy to Specific Drug|Allergy to Specific Drug]]
 
−
|
 
−
* C-CDA R1.1:
 
−
** 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_with_RxNorm.xml Allergy to specific drug (penicillin) C-CDA 1.1]
 
−
* C-CDA R2.0: None yet posted.
 
−
| John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
 
−
| 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:
 
−
** 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)]
 
−
* C-CDA R2.0:
 
−
** 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)]
 
−
| John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
 
−
| 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:
 
−
** 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_with_UNII.xml Propensity to adverse reaction to substance (Latex)]
 
−
* C-CDA R2.0: Not yet posted.
 
−
| John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
 
−
| 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:
 
−
** 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_with_UNII.xml Food allergy (Egg)]
 
−
* C-CDA R2.0: Not yet posted.
 
−
| John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
 
−
| 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:
 
−
** 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 R2.0: Not yet posted.
 
−
| John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
 
−
| 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:
 
−
** 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 R2.0: Not yet posted.
 
−
| John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
 
−
| 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:
 
−
** 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].
 
−
* C-CDA R2.0:
 
−
** 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]
 
−
| John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
 
−
| 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:
 
−
** 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] .
 
−
* C-CDA R2.0: Not yet posted
 
−
| Benjamin Flessner, benjamin@epic.com (GitHub: benjaminflessner)
 
−
| 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:
 
−
** 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)].
 
−
* C-CDA R2.0:
 
−
** 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)]
 
−
| Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
 
−
| 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:
 
−
** 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)]
 
−
* C-CDA R2.0:
 
−
** TemplateId(s) illustrated: Not done yet
 
−
** TBD
 
−
| Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
 
−
| 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:
 
−
** 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)]
 
−
* C-CDA R2.0:
 
−
** 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)]
 
−
| Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
 
−
| 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:
 
−
** 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 R2.0: None yet posted.
 
−
| John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
 
−
| 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_5_Themes_PRN.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:
 
−
** 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]
 
−
* C-CDA R2.0:
 
−
** 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]
 
−
| John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
 
−
| 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:
 
−
** 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)]
 
−
* C-CDA R2.0:
 
−
** 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]
 
−
| John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
 
−
| 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
 
−
| [[#Patient prescribed basal insulin administered at bedtime|Patient prescribed basal insulin administered at bedtime]]
 
−
|
 
−
* C-CDA R1.1:
 
−
** TemplateId(s) illustrated: [https://trifolia.lantanagroup.com/TemplateManagement/View?templateId=610 Medication Activity], [https://trifolia.lantanagroup.com/TemplateManagement/View?templateId=631 Medication Information]
 
−
** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_SC_Basal_Insulin.xml Patient prescribed basal insulin administered at bedtime]
 
−
* C-CDA R2.0: None yet posted
 
−
| John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
 
−
| 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.
 
−
 
 
−
|-
 
−
 
 
−
! MEDICATIONS
 
−
| [[#Single Administration of Medication (at Single Point in Time)|Single Administration of Medication (at Single Point in Time)]]
 
−
|
 
−
* C-CDA R1.1:
 
−
** 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)]
 
−
* C-CDA R2.0:
 
−
** 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)]
 
−
| John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
 
−
| 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:
 
−
** 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]
 
−
* C-CDA R2.0:
 
−
** 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]
 
−
| Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
 
−
| 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:
 
−
** TemplateId(s) illustrated: Medication Activity (2.16.840.1.113883.10.20.22.4.16)
 
−
** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/MED_Oral_Patient_Reported.xml Patient reported oral medication no brand/dose]
 
−
* C-CDA R2.0: None yet created.
 
−
| John D'Amore jdamore@diameterhealth.com GitHub: jddamore)
 
−
| 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:
 
−
** 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 R2.0: None yet created.
 
−
| John D'Amore jdamore@diameterhealth.com GitHub: jddamore)
 
−
| 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.
 
−
 
 
−
|-
 
−
 
 
−
! PROBLEMS
 
−
| [[#Patient with No Known Problems|Patient with No Known Problems]]
 
−
|
 
−
* C-CDA R1.1:
 
−
** 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
 
−
* C-CDA R2.0:
 
−
** 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)]
 
−
| Brett Marquard
 
−
|
 
−
 
 
−
|-
 
−
 
 
−
! PROBLEMS
 
−
| [[#Problem which has been resolved/completed|Problem which has been resolved/completed]]
 
−
|
 
−
* C-CDA R1.1:
 
−
** 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]
 
−
CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
 
−
* C-CDA R2.0: none yet posted
 
−
| John D'Amore jdamore@diameterhealth.com
 
−
| 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:
 
−
** 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]
 
−
CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
 
−
* C-CDA R2.0: none yet posted
 
−
| Brett Marquard
 
−
| This example illustrates how to structure an active problem.
 
−
 
 
−
|-
 
−
 
 
−
! PROBLEMS
 
−
| [[#Complaint of no foot pain - Problem Section|Complaint of no foot pain - Problem Section]]
 
−
|
 
−
* C-CDA R1.1:
 
−
** TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
 
−
** [https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Snippet-Complaint%20of%20No%20Foot%20Pain%2020140227.xml Complaint of No foot pain - 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
 
−
* C-CDA R2.0: none yet posted
 
−
| Lisa R. Nelson LisaRNelson@cox.net
 
−
| This one shows use of Observation.ValueNegationInd
 
−
 
 
−
|-
 
−
 
 
−
! PROBLEMS
 
−
| [[#No Complaint of foot pain - Problem Section|No Complaint of foot pain - Problem Section]]
 
−
|
 
−
* C-CDA R1.1:
 
−
** TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
 
−
** [https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Snippet-No%20Complaint%20of%20Foot%20Pain%2020140228.xml No Complaint of foot pain - 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
 
−
* C-CDA R2.0: none yet posted
 
−
| Lisa R. Nelson LisaRNelson@cox.net
 
−
| This one shows use of Act.NegationInd
 
−
 
 
−
|-
 
−
! PROCEDURES
 
−
| [[#Procedure Activity Procedure Example in Procedures Section|Procedure Activity Procedure Example in Procedures Section]]
 
−
|
 
−
* C-CDA R1.1:
 
−
** 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]
 
−
CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
 
−
* C-CDA R2.0: none yet posted
 
−
| John D'Amore jdamore@diameterhealth.com
 
−
| 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:
 
−
** TemplateId(s) illustrated: Procedure Section, Procedure Activity Procedure
 
−
** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PROCEDURE_Observation_Example.xml Procedures Activity Observation Example in Procedures Section]
 
−
CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
 
−
* C-CDA R2.0: none yet posted
 
−
| John D'Amore jdamore@diameterhealth.com
 
−
| 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:
 
−
** 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]
 
−
CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
 
−
* C-CDA R2.0: none yet posted
 
−
| John D'Amore jdamore@diameterhealth.com
 
−
| This example illustrates an act within a procedure section.
 
−
|-
 
−
 
 
−
 
 
−
! RESULTS - TO BE COMPLETED
 
−
|-
 
−
! PAYER
 
−
| [[#Coverage Activity referencing the holder's employer|Coverage Activity referencing the holder's employer]]
 
−
|
 
−
* C-CDA R1.1:
 
−
** TemplateId(s) illustrated: [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=614 2.16.840.1.113883.10.20.22.4.61 (Trifolia Log-in Required)], [http://trifolia.lantanagroup.com/TemplateManagement/View?templateId=615 2.16.840.1.113883.10.20.22.4.61 (Trifolia Log-in Required)]
 
−
** [https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/20140403%20EmployerExample-Payer%20Section.xml Coverage Activity referencing the holder's employer(via GitHub)]
 
−
CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
 
−
* C-CDA R2.0: none yet posted
 
−
| Lisa R. Nelson, lisarnelson@cox.net (GitHub: lisarnelson)
 
−
| 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)  - TO BE COMPLETED
 
−
| [[#Unknown Smoking Status|Unknown Smoking Status]]
 
−
|
 
−
* C-CDA R1.1:
 
−
** 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 R2.0: none yet created
 
−
| John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
 
−
| 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)  - TO BE COMPLETED
 
−
| [[#Former Smoker in Smoking Status|Former Smoker in Smoking Status]]
 
−
|
 
−
* C-CDA R1.1:
 
−
** 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 R2.0: none yet created
 
−
| John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
 
−
| 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)  - TO BE COMPLETED
 
−
| [[#Never Smoker in Smoking Status|Never Smoker in Smoking Status]]
 
−
|
 
−
* C-CDA R1.1:
 
−
** 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 R2.0: none yet created
 
−
| John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
 
−
| 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.
 
−
|-
 
−
 
 
−
! VITAL SIGNS - TO BE COMPLETED
 
−
|-
 
−
! FAMILY HISTORY - TO BE COMPLETED
 
−
|-
 
−
! style="width:140px; background: #B0C4DE" | Section
 
−
! style="width:140px; background: #B0C4DE" | Meaningful template example name
 
−
! style="background: #B0C4DE" | Approved Good C-CDA Example for [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA R1.1] and [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=379 C-CDA R2.0]
 
−
! style="background: #B0C4DE" | Custodian
 
−
! style="background: #B0C4DE" | Comments
 
−
|}
 
−
 
 
−
== Examples - Organized by Section ==
 
−
 
 
−
===ALLERGIES, ADVERSE REACTIONS OR ALERTS===
 
−
 
 
−
======'''No Known Allergies with Author Timestamp'''======
 
−
[[#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
 
* 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)]
+
* Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/FUNCTIONAL_Example_in_empty_CCD.xml No Impairment Functional Status section in empty C-CDA]
−
* Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)  
+
* Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)  
−
* Validation location: [http://sitenv.org/web/sit/ccda-validator SITE Validator TOC Ambulatory]
+
* Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Validator Ambulatory]
−
* Comments: This is an example of how an author can record a patient has no known allergies.
+
* 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 (on trello)'''======
−
======'''No Known Medication Allergies with Author Timestamp'''======  
+
[[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
+
* Status: Not yet approved
−
* Approved by: Task force on 10/23/2014. Approved by SDWG 11/06/2014.
+
* 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]
−
* [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
+
** TemplateId(s) illustrated: Functional Status Section (2.16.840.1.113883.10.20.22.2.14), Functional Status Problem Observation (2.16.840.1.113883.10.20.22.4.68), Cognitive Status Problem Observation (2.16.840.1.113883.10.20.22.4.73)
−
** 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/jddamore/HL7-Task-Force-Examples/blob/master/FUNCTIONAL_Impairment_Test.xml Functional and Cognitive Status with Impairment]
−
** [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)]
+
* CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
−
* C-CDA 2.0 Example: none yet posted
+
** Not yet completed
 
* Known bad example?: Valid example
 
* 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)]
+
* Reference to full CDA sample: [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/FUNCTIONAL_Impariment_in_empty_CCD.xml Functional and Cognitive Status in full C-CDA Sample]
−
* Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)  
+
* Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)  
−
* Validation location: [http://sitenv.org/web/sit/ccda-validator SITE Validator TOC Ambulatory]
+
* Validation location: [http://transport-testing.nist.gov/ttt/ NIST TTT Validator Ambulatory]
−
* Comments: This is an example of how an author can record a patient has no known medication allergies.
+
* Comments: This is an example of functional and cognitive impairment as outlined in MU2 inpatient test data.
  
 +
===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac6e GENERAL PATTERNS]===
  
−
======'''Allergy to specific substance (cat hair)'''======
+
'''General Patterns are now in the new HL7 search tool!'''
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 
−
* Approved by: Task force approved 4/10/2014. Withdrawn from consideration since not clinically relevant.
 
−
* [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_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
 
  
 +
Samples included:
 +
*No Information Problems Section
  
−
======'''Allergy to Specific Drug'''======
+
'''To Be Discussed'''
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 
−
* Approved by: Task force approved 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: 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_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
 
  
 +
[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.
  
−
======'''Allergy to Drug Class'''======
+
===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac77 Goals]===
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 
−
* Approved by: Task force approved 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: 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
 
  
 +
'''Goals are now in the new HL7 search tool!'''
 +
*Goals Section Narrative-only
  
−
======'''Propensity to adverse reaction to substance (Latex)'''======
+
===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac7d Health Concerns]===
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 
−
* Approved by: Task Force approved 4/17/2014
 
−
* [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) 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_with_UNII.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
 
  
 +
'''Health Concerns are now in the new HL7 search tool!'''
 +
*Health Concerns Section Narrative-only
 +
*Health Concern Linking Example
 +
*No Known Health Concerns
  
−
======'''Food allergy (Egg)'''======
+
===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac82 IMMUNIZATIONS]===
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 
−
* Approved by: Task Force approved 4/17/2014
 
−
* [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) 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_with_UNII.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
 
  
 +
'''Immunizations are now in the new HL7 search tool!'''
  
−
======'''Drug intolerance with multiple reactions (epinephrine)'''======
+
Samples included:
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
+
*Immunization Not Given - Patient Refused
−
* Approved by: Task Force approved 4/17/2014
+
*Influenza Vaccination
−
* [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
+
*Unknown Patient Immunization Status
−
** 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
 
  
 +
===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac86 Medical Equipment]===
  
−
======'''Drug intolerance with multiple reactions (codeine)'''======
+
'''Medical Equipment now in the new HL7 search tool!'''
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 
−
* Approved by: To be reviewed
 
−
** [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
 
  
−
===ENCOUNTERS===
+
Samples included:
−
====='''Hospital Discharge Encounter with Billable Diagnoses'''=====
+
*Implanted Device - Procedure Unknown
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
+
*No Implanted Devices
−
* 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.
 
  
−
===GENERAL PATTERNS===
 
−
======'''No Information Problems Section'''======
 
−
[[#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'''======
 
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 
−
* Status: Under review
 
−
* 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.
 
  
−
===IMMUNIZATIONS===
+
======'''Multiple Implants Same Procedure (on trello)'''======
 +
[[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 +
* Approved by: 7/14/2016
  
−
======'''Unknown Patient Immunization Status'''======
+
* 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]
−
[[#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 on 11/21/2013. Approved by SDWG 12/5/2013.
+
** [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: 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
 
* 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]
+
* Reference to full CDA sample: Not available
−
* Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)  
+
* Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)  
 
* Validation location: [http://sitenv.org/web/sit/ccda-validator SITE Validator TOC Ambulatory]
 
* 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.
+
* 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.
  
−
===MEDICATIONS===
+
===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac8a MEDICATIONS]===
−
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)).
 
−
 
 
−
The SDWG discussed medication frequencies in great detail and developed the following summary - [https://docs.google.com/document/d/1Y0Z458o_MrR2aPnpx6EygO6hpI88Bl95esjRWZ0agtY/edit?usp=sharing Reviewed and approved 9/17 at Chicago WG - Medication Frequencies]
 
−
 
 
−
======'''Patient prescribed oral medication QID PRN without precondition specified'''======
 
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 
−
* Approved by: Task force on 1/9/2014. Task force approved 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: [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_5_Themes_PRN.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'''======
 
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 
−
* Approved by: 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: 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
 
−
* 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: Dose frequency, pre-coordinated medication
 
−
* 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. 
 
  
 +
'''Medications are now in new HL7 search tool!'''
  
−
======''' 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)'''======
+
Samples included:
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 
−
*Previously, approved by: Task force on 3/6. 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_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)'''======
−
[[#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
 
* [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Example  
 
* [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Example  
Line 775: 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!'''
−
[[#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]===
−
[[#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:
−
[[#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.
 
  
 +
===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70daca3 PROCEDURES]===
  
−
======'''Antibiotic Administered with Normal Saline (i.e. in hospital)'''======
+
'''Procedures are now in new HL7 search tool!'''
−
[[#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.
 
  
−
===PROBLEMS===
+
Samples included:
 +
*Procedure Activity Procedure Example in Procedures Section
 +
*Procedures Activity Observation Example in Procedures Section
 +
*Procedure Activity Act Example in Procedures Section
  
−
======'''Patient with No Known Problems'''======
+
===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70daca7 RESULTS]===
−
[[#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:
 
−
 
 
−
 
 
−
======'''Problem which has been resolved/completed'''======
 
−
[[#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.
 
  
 +
'''Results are now in new HL7 search tool!'''
  
−
======'''Active Problem'''======
+
Samples included:
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
+
*Result panel with the display of two ordinal values of negative/positive
−
* Approved by: Task force approved October 2, 2014. Approved by SDWG 11/06/2014.
+
*Result with an unstructured string as the value (e.g. urine color)
−
* [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example
+
*Result with greater than a specified value
−
** TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
+
*Result with lab location
−
**[https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Problem_List_Active_Problem.xml Active Problem]
+
*Result with discrete units and non-numeric value
−
* C-CDA 2.0 Example: None yet posted
+
*Results Unit Non-UCUM  
−
* 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
+
*Result with a pending component
−
* Custodian: Brett Marquard
+
*Results with less than specific value
−
* Validation location: SITE, October 1, 2014
+
*Results with translation unit
−
* Comments: This example illustrates how to structure an active problem.
+
*Result of CO2 Test
−
 
+
*Results Radiology with Image Narrative
−
 
+
*Results of Basic Metabolic Panel and Troponin
−
'''''Under Development -'''''
 
−
======'''Complaint of no foot pain - Problem Section'''======
 
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 
−
** Status: Not Yet Reviewed
 
−
* [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/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Snippet-Complaint%20of%20No%20Foot%20Pain%2020140227.xml Complaint of No foot pain - Problem Section 2.16.840.1.113883.10.20.22.2.5.1 (via GitHub)]
 
−
* C-CDA 2.0 Example: None yet posted
 
−
* Reference to full CDA sample: https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Doc-No%20Known%20Problems%2020140203.xml
 
−
* Custodian: Lisa R. Nelson LisaRNelson@cox.net
 
−
* Validation location: TTT
 
−
* Comments: This one shows use of Observation.ValueNegationInd
 
−
 
 
−
 
 
−
'''''Under Development -'''''
 
−
======'''No Complaint of foot pain - Problem Section'''======
 
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 
−
** Status: Not Yet Reviewed
 
−
* [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/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Snippet-No%20Complaint%20of%20Foot%20Pain%2020140228.xml No Complaint of foot pain - Problem Section 2.16.840.1.113883.10.20.22.2.5.1 (via GitHub)]
 
−
* C-CDA 2.0 Example: None yet posted
 
−
* Reference to full CDA sample: https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Doc-No%20Known%20Problems%2020140203.xml
 
−
* Custodian: Lisa R. Nelson LisaRNelson@cox.net
 
−
* Validation location: TTT
 
−
* Comments: This one shows use of Act.NegationInd
 
−
 
 
−
===PROCEDURES===
 
−
 
 
−
======'''Procedure Activity Procedure Example in Procedures Section'''======
 
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 
−
* Approved by: Approved by task for 5/22
 
−
* [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
 
−
 
 
−
 
 
−
======'''Procedures Activity Observation Example in Procedures Section'''======
 
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 
−
* Approved by: Approved by task for 5/22
 
−
* [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 Procedure
 
−
**[https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PROCEDURE_Observation_Example.xml Procedures Activity Observation 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 an observation within a procedure section. 
 
−
 
 
−
 
 
−
======'''Procedure Activity Act Example in Procedures Section'''======
 
−
[[#EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 
−
* Approved by: Approved by task for 5/22
 
−
* [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 a specified value'''
 
−
* Approved by: Reviewed with SDWG on 12/5/2013. Patrick will review with OO and report back.
 
−
* [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" 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 by: Not yet reviewed. Based on SDWG request from Kumara February 2014. 
 
−
* [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" 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. 
 
−
 
 
−
 
 
−
'''Result panel with the display of two ordinal values of negative/positive'''
 
−
* Approved by: Task force on 11/21/2013. Ready for SDWG review.
 
−
* [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 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: [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 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 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.
 
−
 
 
  
 
===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 by: Sample not yet reviewed
 
* Approved by: Sample not yet reviewed
 
* [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example  
 
* [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example  
Line 1,051: 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'''
+
Samples included:
−
* Approved by: Task Force Approved 6/19
+
*Unknown Smoking Status
−
* 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]
+
*Former Smoker in Smoking Status
−
** 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)
+
*Never Smoker in Smoking Status
−
** [https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/SMOKING_Unknown_Smoker.xml Unknown Smoking Status]
+
*Current Smoker in 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.
 
  
 +
===[http://cdasearch.hl7.org/sections/595166e9e6ca6a48c70dacba VITAL SIGNS]===
  
−
'''Former Smoker in Smoking Status'''
+
'''Vital Signs are now in new HL7 search tool!'''
−
* Approved by: Task Force Approved 6/19
 
−
* 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.
 
  
 +
Samples included:
 +
*Panel of Vital Signs in Metric Units
 +
*Panel of Vital Signs in Mixed Metric/Imperial Units
  
−
'''Never Smoker in Smoking Status'''
+
===[http://cdasearch.hl7.org/sections/595166e8e6ca6a48c70dac67 Family History]===
−
* 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: 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.
 
  
 +
'''Family History examples are now in new HL7 search tool!'''
  
−
'''Current Smoker in Smoking Status'''
+
Samples included:
−
* Approved by: Not yet approved
+
*Family History; generic history (not scoped to individuals)
−
* 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]
+
*Normal Family History; Father deceased with conditions; Mother alive with no conditions
−
** 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)
+
*Family History; two individuals with the same relationship to the patient
−
** [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. 
 
  
 +
== Formatting of CDA Template Samples ==
  
−
===VITAL SIGNS===
+
===PROTOTYPIC TEMPLATE===
−
 
+
'''Meaningful template example name'''
−
'''Panel of Vital Signs in Metric Units'''  
+
* Approved by: (list all approving bodies, including approval date)
−
* 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 (link to CDA Implementation Guide)] Implementation Guide Example
−
* [http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 C-CDA 1.1] Implementation Guide Example  
+
** TemplateId(s) illustrated: TemplateId Name(s) (OID Number(s), e.g. 2.16.840.1.113883.10.20.22.1.2)
−
** 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
+
** [http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force#PROTOTYPIC_TEMPLATE Link to C-CDA 1.1 Example in hosted repository, e.g. GitHub]  
−
** [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.
 
−
 
 
−
 
 
−
'''Panel of Vital Signs in Mixed Metric/Imperial Units'''
 
−
* 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_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===
 
−
 
 
−
======'''Normal Family History; Father deceased with conditions; Mother alive with no conditions'''======
 
−
* Approved by: Task force approved 1/15/2015; SDWG approved 2/12/2015
 
 
* C-CDA 2.0 (link to CDA Implementation Guide, when available) Implementation Guide Example
 
* 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)
+
**TemplateId(s) illustrated: TemplateId Name(s) (OID Number(s), e.g. 2.16.840.1.113883.10.20.22.1.2.2)
−
** [https://github.com/benjaminflessner/HL7-C-CDA-Task-Force-Examples/blob/master/Family_History_Normal.xml Family History Section]  
+
** [http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force#PROTOTYPIC_TEMPLATE Link to C-CDA 1.1 Example in hosted repository, e.g. GitHub]  
−
* Known bad example?: No
+
* Known bad example?: Explain if this is a deliberately created bad example.
−
* Reference to full CDA sample:  
+
* Reference to full CDA sample: [http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force#PROTOTYPIC_TEMPLATE Full example of validated document (hyperlinked)]
−
* Custodian: Benjamin Flessner, benjamin@epic.com (GitHub: benjaminflessner)
+
* Custodian: Name, email address and repository username of the steward for the referenced sample
−
* Validation location: C-CDAR2 schema and schematron
+
* Validation location: list of all validators tested against
−
* Comments: Example shows multiple observations for one family member, identifying the cause of death, and a family member with no known problems.
+
* Comments: free text comments about the example
  
−
'''Family History; two individuals with the same relationship to the patient'''
+
== Resources and Draft materials==
−
* Approved by: Task force approved 2/12/2015
+
======'''Link to C-CDA 1.1 testing script'''======
−
* C-CDA 2.0 (link to CDA Implementation Guide, when available) Implementation Guide Example
+
* [http://www.healthit.gov/sites/default/files/170_314b2toc_create_transmit_2014_td_approved_v1.5.pdf Test Data (as referred in multiple samples above)]
−
**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 by: Task force approved 2/12/2015
 
−
* 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.
 
−
 
−
== Resources and Draft materials==
 
  
 
'''C-CDA Empty shell that will validate without errors using NIST TTT.'''
 
'''C-CDA Empty shell that will validate without errors using NIST TTT.'''
Line 1,180: Line 305:
  
 
* Result with less than a specified value (via GitHub)- Awaiting review from Patrick Lloyd with OO
 
* Result with less than a specified value (via GitHub)- Awaiting review from Patrick Lloyd with OO
−
 
  
 
----
 
----
Line 1,250: Line 374:
 
** Validation location: validator.com
 
** Validation location: validator.com
 
** Comments: This is the best example EVER!
 
** Comments: This is the best example EVER!
 +
 +
 +
'''''Under Development -'''''
 +
======'''Complaint of no foot pain - Problem Section'''======
 +
[[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 +
** Status: Not Yet Reviewed
 +
* [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/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Snippet-Complaint%20of%20No%20Foot%20Pain%2020140227.xml Complaint of No foot pain - Problem Section 2.16.840.1.113883.10.20.22.2.5.1 (via GitHub)]
 +
* C-CDA 2.0 Example: None yet posted
 +
* Reference to full CDA sample: https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Doc-No%20Known%20Problems%2020140203.xml
 +
* Custodian: Lisa R. Nelson LisaRNelson@cox.net
 +
* Validation location: TTT
 +
* Comments: This one shows use of Observation.ValueNegationInd
 +
 +
 +
'''''Under Development -'''''
 +
======'''No Complaint of foot pain - Problem Section'''======
 +
[[#APPROVED EXAMPLES OVERVIEW TABLE|(back to overview table)]]
 +
** Status: Not Yet Reviewed
 +
* [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/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Snippet-No%20Complaint%20of%20Foot%20Pain%2020140228.xml No Complaint of foot pain - Problem Section 2.16.840.1.113883.10.20.22.2.5.1 (via GitHub)]
 +
* C-CDA 2.0 Example: None yet posted
 +
* Reference to full CDA sample: https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Doc-No%20Known%20Problems%2020140203.xml
 +
* Custodian: Lisa R. Nelson LisaRNelson@cox.net
 +
* Validation location: TTT
 +
* Comments: This one shows use of Act.NegationInd

Latest revision as of 12:15, 21 September 2017

Approved samples have been migrated to the following resource:

Official HL7 CDA Example Search

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.

Current Task Force Work

 Current week
        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



Draft IP Sample - (Functional and Cognitive Impairment, Subcutaneous medication administered with event time)

170.314(b)(2) Transitions of care – create and transmit summary care record sample creation is the current focus of the example task force.

CDA Example Task Force Quality Criteria

Discuss updating samples for C-CDA R2.0/R2.1 to support gold standard

Please contact the SDWG co-chairs (primary Brett Marquard) if you any questions.

Historical reference only: CDA Example Task Force - Previous Review Cycles, CDA Example Task Force Examples - Approved and On Deck

Examples - Organized by Section

ALLERGIES, ADVERSE REACTIONS OR ALERTS

Allergies are now in the new HL7 search tool!

Samples included:

  • 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)

CDA HEADER

CDA Header

CDA Header Examples are now in the new HL7 search tool!

  • Patient demographic information
  • Previous Patient Name
  • Care Team In Transition of Care Documents

ENCOUNTERS

Encounters are now in the new HL7 search tool!

Samples included:

  • Hospital Discharge Encounter with Billable Diagnoses
  • Outpatient Encounter with Diagnoses
  • Outpatient Encounter Patient Disenrolled
  • Inpatient Encounter Discharged to Rehab Location

FUNCTIONAL AND COGNITIVE STATUS (deprecated, not moved)

No Impairment (on trello)

(back to overview table)

  • Status: Approved by task force on 6/18/2015. SDWG approved 7/9/2015
  • CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
    • TemplateId(s) illustrated: Functional Status Section (2.16.840.1.113883.10.20.22.2.14), Functional Status Problem Observation (2.16.840.1.113883.10.20.22.4.68), Cognitive Status Problem Observation (2.16.840.1.113883.10.20.22.4.73)
    • No Impairment Functional Status Section R1.1 (via GitHub)
  • CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
    • Not yet completed
  • Known bad example?: Valid example
  • Reference to full CDA sample: No Impairment Functional Status section in empty C-CDA
  • Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
  • Validation location: NIST TTT Validator Ambulatory
  • 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 (on trello)

(back to overview table)

  • Status: Not yet approved
  • CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
    • TemplateId(s) illustrated: Functional Status Section (2.16.840.1.113883.10.20.22.2.14), Functional Status Problem Observation (2.16.840.1.113883.10.20.22.4.68), Cognitive Status Problem Observation (2.16.840.1.113883.10.20.22.4.73)
    • Functional and Cognitive Status with Impairment
  • CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
    • Not yet completed
  • Known bad example?: Valid example
  • Reference to full CDA sample: Functional and Cognitive Status in full C-CDA Sample
  • Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
  • Validation location: NIST TTT Validator Ambulatory
  • Comments: This is an example of functional and cognitive impairment as outlined in MU2 inpatient test data.

GENERAL PATTERNS

General Patterns are now in the new HL7 search tool!

Samples included:

  • No Information Problems Section

To Be Discussed

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.

Goals

Goals are now in the new HL7 search tool!

  • Goals Section Narrative-only

Health Concerns

Health Concerns are now in the new HL7 search tool!

  • Health Concerns Section Narrative-only
  • Health Concern Linking Example
  • No Known Health Concerns

IMMUNIZATIONS

Immunizations are now in the new HL7 search tool!

Samples included:

  • Immunization Not Given - Patient Refused
  • Influenza Vaccination
  • Unknown Patient Immunization Status

Medical Equipment

Medical Equipment now in the new HL7 search tool!

Samples included:

  • Implanted Device - Procedure Unknown
  • No Implanted Devices


Multiple Implants Same Procedure (on trello)

(back to overview table)

  • Approved by: 7/14/2016
  • CDA Implementation Guide where template(s) is(are) defined: 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 )
    • Multiple Implants same Procedure (via GitHub)
  • Known bad example?: Valid example
  • Reference to full CDA sample: Not available
  • Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
  • Validation location: SITE Validator TOC Ambulatory
  • 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.

MEDICATIONS

Medications are now in new HL7 search tool!

Samples included:

  • Medication Frequencies
  • 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 (on trello)

(back to overview table)

Plan of Treatment

Plan of Treatment Examples are now in new HL7 search tool!

Samples included:

  • Care Plan Goals and Instructions
  • No Planned Tests
  • Planned EKG
  • Planned Encounter - Referral

PROBLEMS

Problems are now in new HL7 search tool!

Samples included:

  • Patient with No Known Problems
  • Active Problem'
  • Problem which has been resolved/completed
  • Patient with No Known Diabetes

PROCEDURES

Procedures are now in new HL7 search tool!

Samples included:

  • Procedure Activity Procedure Example in Procedures Section
  • Procedures Activity Observation Example in Procedures Section
  • Procedure Activity Act Example in Procedures Section

RESULTS

Results are now in new HL7 search tool!

Samples included:

  • Result panel with the display of two ordinal values of negative/positive
  • Result with an unstructured string as the value (e.g. urine color)
  • Result with greater than a specified value
  • Result with lab location
  • Result with discrete units and non-numeric value
  • Results Unit Non-UCUM
  • Result with a pending component
  • Results with less than specific value
  • Results with translation unit
  • Result of CO2 Test
  • Results Radiology with Image Narrative
  • Results of Basic Metabolic Panel and Troponin

PAYER

Coverage Activity referencing the holder's employer (on trello)

(back to overview table)

SOCIAL HISTORY (SMOKING)

Social History are now in new HL7 search tool!

Samples included:

  • Unknown Smoking Status
  • Former Smoker in Smoking Status
  • Never Smoker in Smoking Status
  • Current Smoker in Smoking Status

VITAL SIGNS

Vital Signs are now in new HL7 search tool!

Samples included:

  • Panel of Vital Signs in Metric Units
  • Panel of Vital Signs in Mixed Metric/Imperial Units

Family History

Family History examples are now in new HL7 search tool!

Samples included:

  • Family History; generic history (not scoped to individuals)
  • Normal Family History; Father deceased with conditions; Mother alive with no conditions
  • Family History; two individuals with the same relationship to the patient

Formatting of CDA Template Samples

PROTOTYPIC TEMPLATE

Meaningful template example name

Resources and Draft materials

Link to C-CDA 1.1 testing script


C-CDA Empty shell that will validate without errors using NIST TTT.


KNOWN BAD EXAMPLES

  • Future bad examples will go here.

FEEDBACK AND AWAITING RESPONSE

  • Result with less than a specified value (via GitHub)- Awaiting review from Patrick Lloyd with OO

COMMUNITY REQUESTS FOR EXAMPLES (include name, email)

  • I would like an example of a preliminary lab result (John Doe, JohnDoe@email.com)
  • The SMART C-CDA Collaborative generated a list of approximately 50 requested samples here. See the section noted as "Annotated Examples." For more information on the SMART C-CDA Collaborative please visit here. (Ashley Swain, ashley.swain@lantanagroup.com, John D'Amore, jdamore@diameterhealth.com, Josh Mandel, jmandel@gmail.com)


DRAFT MATERIAL - PLEASE DON'T DELETE

How to Setup an XML example from GitHub

  • Sign up for GitHub account. It's free and quick
  • Once you've got an account, you will be able to fork repositories and comment on examples through the website
  • To post and manage examples, you will likely want to install a graphical user interface for GitHub. Here's where you can download: For Windows or For Mac
  • Once you've got the application installed, there are a few steps:
    • Click the "create" button to make a repository where you would like to upload/update to GitHub
    • Once you've created, the repository will exist online and on your local machine
    • On your local machine, place in new or revised files in the local folder (this will generally be under Documents/GitHub). It's good practice to include a text file named README.md, which appears online when people browse your repository. This is a good place to explain what you're working on.
    • Once you've made the edits (or new files) you want to post to GitHub, "commit" the sample entering a description and then hit the "sync" button to upload
    • At this point the changes and new files are posted online publicly
  • For an example GitHub repository with C-CDA samples, check out this one from Children's Hospital Boston


  • Add instructions for how to upload examples (to github, to other sites)
    • Add examples (to site of your choosing)
    • Add link and metadata too
  • enumerated lists
    • validators
    • approving bodies
      • SDWG
      • Infoway
      • NHS


HOW TO PREPARE A SAMPLE FOR APPROVAL BY SDWG

Observing these guidelines will streamline the process for all involved.

  • Include XML comments that will:
    • Make assumptions explicit
    • Annotate each lines
    • Highlight choices and key decisions that were made
  • Confirm statusCode/moodCode/effectiveTime are in agreement
  • Snippet should be in the context of a section
  • Confirm narrative to match entries - and content is linked
  • Does final sample name accurately reflect the final sample
  • Add disclaimer at the top of every sample: SAMPLE DEVELOPED BY HL7 SDWG SAMPLES TASK FORCE - PLEASE SEE http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force FOR ADDITIONAL DETAILS
  • Copy and paste the template below, and complete for your sample
  • Allergy to Substance X
    • Approved by: SDWG (Oct 31, 2013); NHS (Oct 31, 2013)
    • TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.4.30; 2.16.840.1.113883.10.20.22.4.7
    • CDA Implementation Guide where template(s) is(are) defined: C-CDA R2
    • Reference to full CDA sample: N/A
    • Custodian: John Doe (John.Doe@email.com)
    • Validation location: validator.com
    • Comments: This is the best example EVER!


Under Development -

Complaint of no foot pain - Problem Section

(back to overview table)


Under Development -

No Complaint of foot pain - Problem Section

(back to overview table)

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