170.314(b)(2) Transitions of care

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This page is a one stop location to find all the examples to support the 170.314(b)(2) Transitions of care testing scenarios.

note on the data in the example files

Two types of examples exist:

• Created specifically for this test data: an example was created using all of the given test data. These show, by example, how to use the test data, but the examples may also contain additional content not specified by the test data.
• 'Representative' example: a previously created example covers the concept presented in the test data. These show different data content than the specifics of the test data.

Ambulatory Setting

This section contains test data to be used as an illustration of 170.314(b)(2) in the ambulatory setting. The data contained within this document are intended to provide a patient record to be formatted according to the Consolidated CDA IG (HL7 Implementation Guide for CDA Release 2: IHE Health Story Consolidation, DSTU Release 1.1 Draft Standard for Trial Use July 2012) and subsequently transmitted.

170.314(b)(2) – 1: Ambulatory - Complete 170.314(b)(2) Transitions of care Sample

Mr. Adam Everyman is a 50-year-old White male with a history of asthma controlled by albuterol for breakthrough. He presented at Get Well Clinic on August 15, 2012 with a one day history of increased difficulty breathing. Nancy Nightingale, RN, took Mr. Everyman’s vital signs after which Dr. Samir Khan saw him. Dr. Khan diagnosed Mr. Everyman with costal chondritis. He was instructed to take over-thecounter analgesic medication as needed and was referred to Dr. Penny Puffer, a pulmonologist, for pulmonary function tests.

A) Patient Demographics

• Patient name: Adam Everyman
• Sex: M
• Date of birth: 10/22/1962
• Race: White
• Ethnicity: Not Hispanic or Latino
• Preferred language: English

B) Care Team

• Dr. Samir Khan, Tel, 555-555-1004, Get Well Clinic, 1004 Healthcare Dr. Portland, OR 97005
• Nancy Nightingale, RN, 555-555-1014, Get Well Clinic, 1004 Healthcare Dr. Portland, OR 97005

C) Social History - Representative Never Smoker Example

• Smoking Status: Never smoker, [SNOMED-CT: 266919005]

D) Medication Allergies - Representative Allergy to Drug Example and Representative Allergy to Drug Class Example

• Allergen: Penicillin G benzathine, [RxNorm: 7982]
  • Reaction: Hives
  • Status: Vendor supplied (for example, Active)
• Allergen: Codeine, [RxNorm: 2670]
  • Reaction: Nausea
  • Status: Vendor supplied (for example, Active)

E) Medications - Representative Medication Example

• Albuterol 0.09 MG/ACTUAT [Proventil], [RxNorm: 573621], 2 puffs every 6 hours PRN wheezing, select any date prior to 8/15/2012, Active

F) Problems - Representative Active Problem Example

• Costal Chondritis, [SNOMED CT: 64109004], Start: 8/15/2012, Active
• Asthma, [SNOMED-CT: 195967001], 9/25/2011, Active

G) Procedures - Representative Example with No Problems Section

• None

H) Vital Signs - Representative Vital Signs Example

• Height: 70 in.
• Weight: 195 lbs
• Blood Pressure: Select systolic (140-160)/Select diastolic (90-100) mmHg
• BMI: 28

I) Laboratory Tests and Values/Results

• CO2, [LOINC: 2028-9], Select (23-29) mmol/L, 8/15/2012

J) Immunizations

• Influenza virus vaccine, [CVX: 88], 8/15/2010, Completed

K) Care Plan (Goals and Instructions)

• Goal: weight loss, [SNOMED CT: 289169006],
• Instructions: diet and exercise counseling provided during visit
• Goal: asthma management, [SNOMED CT: 406162001]
• Instructions: resources and instructions provided during visit

L) Encounter Diagnosis

• Costal Chondritis, [SNOMED-CT: 64109004], Start: 8/15/2012, Active

M) Functional and Cognitive Status

• No impairment, [SNOMED-CT: 66557003], 8/15/2012, Active

N) Referral

• Pulmonary function tests, Dr. Penny Puffer, Tel: 555-555-1049, 1047 Healthcare Drive, Portland, OR 97005, Scheduled date: Test date + 2 days

Inpatient Setting

This section contains test data to be used as an illustration of 170.314(b)(2) in the inpatient setting. The data contained within this section are intended to provide a patient record formatted according to the Consolidated CDA IG (HL7 Implementation Guide for CDA Release 2: IHE Health Story Consolidation, DSTU Release 1.1 Draft Standard for Trial Use July 2012).