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

2/21 meeting is cancelled; next meeting will be 2/28

https://meetingserver.hhs.gov/orion/join?siteurl=meetingserver

Meeting Number: 991 728 992

Audio Connection

2027742300 (Meeting Server Main Number)

Access Code: 991 728 992

New Rubrics to review on 2/28

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.

Rubrics to be pushed to SDWG

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

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

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

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

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

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

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

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

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

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

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

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