C-CDA Scorecard Rubric Update

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Project Summary

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

Meeting Time / Info

Wednesday's from 11 am - 12 pm EST

Next meeting is on 1/10 Future Meetings: 1/17 and 1/24

New Rubrics to review on 1/10

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

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

2. Allergy Observation entry must have a Reaction (These are should in the IG)

3. Allergy Reaction entry must have a severity (These are should in the IG)

Others? Clinical notes?

Rubrics reviewed on 1/3 to be pushed to SDWG

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

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

3. Check whether there is an Encounter date/time in the header or body

Rubrics to be discussed on a future call please add below or send to Matt Rahn - matthew.rahn@hhs.gov

1. Author entry must be present within the Problems, Meds and Allergies section

  a. In most cases, the documents are used for reconciliation when received by another system, so having the author entry makes the 
     reconciliation process easier w.r.t timing data (last modified date etc).
  b. So suggest we create a rubric to check for the presence of author entries.

2. The need to include pregnancy status for anyone with birth sex of female.