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'''Our calls planned for Thursdays 12 PM ET will focus on ... examples. Please join us!''' | '''Our calls planned for Thursdays 12 PM ET will focus on ... examples. Please join us!''' | ||
| − | ''' | + | '''7/9/2015''' |
1. Welcome | 1. Welcome | ||
| − | 2 | + | 2. Conveying result units discretely when value is non-numeric (Benjamin) |
| − | + | 3. Care Plan Goal Example (Lisa) | |
| − | + | ||
Revision as of 17:14, 25 June 2015
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.
The approved samples are posted below.
Contents
- 1 Current Task Force Work
- 2 Formatting of CDA Template Samples
- 3 Examples - Organized by Section
- 3.1 ALLERGIES, ADVERSE REACTIONS OR ALERTS
- 3.1.1 No Known Allergies with Author Timestamp
- 3.1.2 No Known Medication Allergies with Author Timestamp
- 3.1.3 Allergy to specific substance (cat hair)
- 3.1.4 Allergy to Specific Drug
- 3.1.5 Allergy to Drug Class
- 3.1.6 Propensity to adverse reaction to substance (Latex)
- 3.1.7 Food allergy (Egg)
- 3.1.8 Drug intolerance with multiple reactions (epinephrine)
- 3.1.9 Drug intolerance with multiple reactions (codeine)
- 3.2 DEMOGRAPHICS
- 3.3 ENCOUNTERS
- 3.4 FUNCTIONAL AND COGNITIVE STATUS
- 3.5 GENERAL PATTERNS
- 3.6 IMMUNIZATIONS
- 3.7 MEDICATIONS
- 3.7.1 Patient prescribed oral medication QID PRN without precondition specified
- 3.7.2 Patient Prescribed Medication Every 4-6 Hours
- 3.7.3 Debate continues - see document and comments below - Patient Prescribed Oral Antibiotic with Dosing Regimen that Varies Over Prescription Course (Loading or Tapered)
- 3.7.4 Patient prescribed basal insulin administered at bedtime
- 3.7.5 Single Administration of Medication (at Single Point in Time)
- 3.7.6 No Medications
- 3.7.7 Patient Reported Medication without Reported Brand/Dose
- 3.7.8 Antibiotic Administered with Normal Saline (i.e. in hospital)
- 3.8 PROBLEMS
- 3.9 PROCEDURES
- 3.10 RESULTS
- 3.10.1 Result with less than a specified value
- 3.10.2 Result with greater than a specified value
- 3.10.3 Result panel with the display of two ordinal values of negative/positive
- 3.10.4 Result with an unstructured string as the value (e.g. urine color)
- 3.10.5 Result Which Requires Translation for its Unit Represented in UCUM
- 3.10.6 Result with a pending component
- 3.10.7 Result of CO2 Test (MU2 Example)
- 3.11 PAYER
- 3.12 SOCIAL HISTORY (SMOKING)
- 3.13 VITAL SIGNS
- 3.14 FAMILY HISTORY
- 3.1 ALLERGIES, ADVERSE REACTIONS OR ALERTS
- 4 Resources and Draft materials
Current Task Force Work
Our calls planned for Thursdays 12 PM ET will focus on ... examples. Please join us!
7/9/2015 1. Welcome 2. Conveying result units discretely when value is non-numeric (Benjamin) 3. Care Plan Goal Example (Lisa)
Discuss updating samples for C-CDA R2.0 to support gold standard
Please contact the SDWG co-chairs (primary Brett Marquard) if you any questions.
The management of approved and planned samples is now managed in a google spreadsheet:
CDA Example Task Force Examples - Approved and On Deck
Historical reference only: CDA Example Task Force - Previous Review Cycles
Formatting of CDA Template Samples
PROTOTYPIC TEMPLATE
Meaningful template example name
- Approved by: (list all approving bodies, including approval date)
- 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)
- 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)
- 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: 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
APPROVED EXAMPLES OVERVIEW TABLE
(Click on Table Headers to sort)
| Section | Meaningful template example name | Approved Good C-CDA Example for C-CDA R1.1 and C-CDA R2.0 | Custodian | Comments |
|---|---|---|---|---|
| ALLERGIES, ADVERSE REACTIONS OR ALERTS | No Known Allergies with Author Timestamp |
|
Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard) | This is an example of how an author can record a patient has no known allergies. |
| ALLERGIES, ADVERSE REACTIONS OR ALERTS | No Known Medication Allergies with Author Timestamp |
|
Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard) | This is an example of how an author can record a patient has no known medication allergies. |
| ALLERGIES, ADVERSE REACTIONS OR ALERTS | Allergy to Specific Drug |
|
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 |
|
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) |
|
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) |
|
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) |
|
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) |
|
Lisa R. Nelson LisaRNelson@cox.net (GitHub: lisarnelson) | 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 |
|
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 |
|
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 |
|
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 No Known Allergies with Author Timestamp (GitHub) for an example of 'No Known'. See DSTU Comment 384 |
| GENERAL PATTERNS | No Information Specific Entry within a Section that requires entries |
|
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 |
|
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 |
|
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.
|
| MEDICATIONS | Patient Prescribed Medication Every 4-6 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) |
|
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 | 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 |
|
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 |
|
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) |
|
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 |
CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
|
Brett Marquard | |
| PROBLEMS | Problem which has been resolved/completed |
CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
|
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 |
CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
|
Brett Marquard | This example illustrates how to structure an active problem. |
| PROCEDURES | Procedure Activity Procedure Example in Procedures Section |
CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
|
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 |
CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
|
John D'Amore jdamore@diameterhealth.com | This example illustrates how an observation within a procedure section. |
| PROCEDURES | Procedure Activity Act Example in Procedures Section |
CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
|
John D'Amore jdamore@diameterhealth.com | This example illustrates an act within a procedure section. |
| RESULTS | Result with less than a specified value |
CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
|
John D'Amore jdamore@diameterhealth.com | This is an example of how to encode "less than" a specific range when returned from lab equipment. The example is for BNP, an immunoassay where the lower threshold for detection is often 5 pg/mL. The lower bound of the interval is zero in this example, even though this is none may be specified, since zero is the lower bound for measures of physical quantity. This example also includes a structured reference range. |
| RESULTS | Result with greater than a specified value |
|
John D'Amore jdamore@diameterhealth.com | This is an example of how to encode "greater than" a specific range when returned from lab equipment. The example is for a point-of-care glucometer, which measures blood sugar for diabetics. Often these devices may have an upper bound, 500 mg/dL is shown in this example. The upper bound of the interval is positive infinity in this example. This example also includes two structured reference ranges for normal and high. |
| RESULTS | Result panel with the display of two ordinal values of negative/positive |
|
John D'Amore jdamore@diameterhealth.com | This is an example of how to encode positive and negative, which are common data types returned form lab equipment. While some technologies may represent this as a type of ST (string), it is logical and easily possible to encode this information using SNOMED-CT. This would allow structured examination of this information downstream as well as comparison to a structured reference range, as shown in the example. |
| RESULTS | Result with an unstructured string as the value (e.g. urine color) |
|
John D'Amore jdamore@diameterhealth.com | This is an example of a value from a lab result that may not be structured. |
| RESULTS | Result Which Requires Translation for its Unit Represented in UCUM |
|
John D'Amore jdamore@diameterhealth.com | This is an example of a value from a lab result that may not be structured. |
| RESULTS | Result with a pending component |
|
Ed Donaldson, ed.donaldson@greenwayhealth.com (GitHub: donaldson-ed) | Result with a pending component. |
| SOCIAL HISTORY - SMOKING | Unknown Smoking Status |
|
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 | Former Smoker in Smoking Status |
|
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 | Never Smoker in Smoking Status |
|
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. |
| SOCIAL HISTORY - SMOKING | Current Smoker in Smoking Status |
|
John D'Amore jdamore@diameterhealth.com (GitHub: jddamore) | This is an example of current smoking status. This example also includes a coordinating social history observation to convey the amount of smoking using a SNOMED code. This SNOMED code in the accompanying observation is not acceptable since smoking status, which is constrained by HL7 and Meaningful Use value set requirements. A best practice to avoid confusion is for each social history section to only include a single smoking status. |
| VITAL SIGNS | Panel of Vital Signs in Metric Units |
|
John D'Amore jdamore@diameterhealth.com (GitHub: jddamore) | This is panel of the nine common vital signs collected on an adult in metric units. Note that body surface area (BSA), head circumference and height (lying) are not included. |
| VITAL SIGNS | Panel of Vital Signs in Mixed Metric/Imperial Units |
|
John D'Amore jdamore@diameterhealth.com (GitHub: jddamore) | 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 |
|
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. |
| FAMILY HISTORY | Family History; two individuals with the same relationship to the patient |
|
Benjamin Flessner, benjamin@epic.com (GitHub: benjaminflessner) | Example shows two brothers with multiple conditions. Though they have the same relationship to the patient, they can be identified by their separation into two family history organizers as well as by their subject ID's. |
| FAMILY HISTORY | Family History; generic history (not scoped to individuals) |
|
Benjamin Flessner, benjamin@epic.com (GitHub: benjaminflessner) | Example shows generic "family history of x" and "no family history of x" with commentary suggesting better options. |
| Section | Meaningful template example name | Approved Good C-CDA Example for C-CDA R1.1 and C-CDA R2.0 | Custodian | Comments |
Examples - Organized by Section
ALLERGIES, ADVERSE REACTIONS OR ALERTS
No Known Allergies with Author Timestamp
- Approved by: Task force on 1/9/2014. Approved by SDWG 1/16/2014.
- 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)
- No Known Allergies with Author Timestamp(Github)
- C-CDA 2.0 Example: none yet posted
- Known bad example?: Valid example
- Reference to full CDA sample: No Known Allergies in compliant MU2 Sample (via GitHub)
- Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
- Validation location: SITE Validator TOC Ambulatory
- Comments: This is an example of how an author can record a patient has no known allergies.
No Known Medication Allergies with Author Timestamp
- Approved by: Task force on 10/23/2014. Approved by SDWG 11/06/2014.
- 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)
- No Known Medication Allergies with Author Timestamp(Github)
- C-CDA 2.0 Example: none yet posted
- Known bad example?: Valid example
- Reference to full CDA sample: No Known Medication Allergies in compliant MU2 Sample (via GitHub)
- Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
- Validation location: SITE Validator TOC Ambulatory
- Comments: This is an example of how an author can record a patient has no known medication allergies.
Allergy to specific substance (cat hair)
- Approved by: Task force approved 4/10/2014. Withdrawn from consideration since not clinically relevant.
- 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)
- 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: Allergies in empty CCD
- Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: 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
Allergy to Specific Drug
- Approved by: Task force approved 4/10/2014. Approved by SDWG on 4/24/2014
- CDA Implementation Guide where template(s) is(are) defined: 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)
- 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)
- 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: Allergies in empty CCD
- Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: 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
Allergy to Drug Class
- Approved by: Task force approved 4/10/2014. Approved by SDWG on 4/24/2014.
- CDA Implementation Guide where template(s) is(are) defined: 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)
- 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)
- 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: Allergies in empty CCD
- Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: TTT Validator
- Comments: This is an example of an allergy to a drug class (penicillins) using NDF-RT as terminology with information on both allergic reaction and reaction severity. See DSTU 219 for update regarding act/code
Propensity to adverse reaction to substance (Latex)
- Approved by: Task Force approved 4/17/2014, reviewed again on 3/12/2015 TF call. SDWG Approved 3/19/2015.
- 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)
- 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: Allergies in empty CCD
- Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: TTT Validator
- Comments: This is an example of a propensity to substance allergy with information on both allergic reaction and reaction severity. It was based upon discussion with Russ Leftwich and Lisa Nelson in coordination with Patient Care Committee. See DSTU 219 for update regarding act/code
Food allergy (Egg)
- Approved by: Task Force approved 4/17/2014, reviewed again on 3/12/2015 TF call. SDWG Approved 3/19/2015.
- 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)
- 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: Allergies in empty CCD
- Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: TTT Validator
- Comments: This is an example of a food allergy with information on both allergic reaction and reaction severity. It was based upon discussion with Russ Leftwich and Lisa Nelson in coordination with Patient Care Committee. See DSTU 219 for update regarding act/code
Drug intolerance with multiple reactions (epinephrine)
- Approved by: Task Force approved 4/17/2014; Pulled on block with SDWG since any patient given enough epinephrine will have an intolerance.
- 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)
- 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: Allergies in empty CCD
- Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: TTT Validator
- Comments: This is an example of a propensity to drug adverse event with information on multiple allergic reactions each with reaction severity. It was based upon discussion with Russ Leftwich and Lisa Nelson in coordination with Patient Care Committee. See DSTU 219 for update regarding act/code
Drug intolerance with multiple reactions (codeine)
- Approved by: Task Force approved 4/17/2014; SDWG Approved 4/16/2015
- 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)
- 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: 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
DEMOGRAPHICS
Patient demographic information
- Approved by: Not yet approved
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.1.1, 2.16.840.1.113883.10.20.22.1.2 (recordTarget)
- Patient demographics in recordTarget
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
- Not yet created
- Known bad example?: Valid example
- Reference in full CDA Sample: recordTarget Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated April 23, 2015
- Keywords: Demographics, Name, Address, Telecom, Phone, Email, Race, Ethnicity, Religious Affiliation, Marital Status, Language
- Comments: Based on sample data from Meaningful Use Stage 2 certification testing.
ENCOUNTERS
Hospital Discharge Encounter with Billable Diagnoses
- Approved by: Task force approved 12/18/2014; SDWG approved 2/12/2015
- CDA Implementation Guide where template(s) is(are) defined: 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
- 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: Results Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated October 22, 2014
- Keywords: Hospital Encounter, Discharge Diagnoses, participant, performer
- Comments: This is an example of a hospitalization with discharge diagnoses. Meaningful Use requires a place to document encounter diagnoses, and this example attempts to satisfy. This example aligns with QRDA suggestion for encounter diagnosis.
Outpatient Encounter with Diagnoses
- Approved by: Task force approved 5/7/2015; SDWG approved
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.2.22.1, 2.16.840.1.113883.10.20.22.4.49, 2.16.840.1.113883.10.20.22.4.32, 2.16.840.1.113883.10.20.22.4.80, 2.16.840.1.113883.10.20.22.4.4, 2.16.840.1.113883.10.20.22.4.6
- Encounter of outpatient visit with encounter diagnoses that is active
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
- Not yet created
- Known bad example?: Valid example
- Reference in full CDA Sample: Results Packaged in C-CDA Skeleton with header to match ToC scenario
- Custodian: Lisa R Nelson, LisaRNelson@cox.net (GitHub: LisaRNelson)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated May 13, 2015
- Keywords: Outpatient Visit, Encounter Diagnoses, performer, visit location
- Comments: This is an example of an outpatient visit which aligns with the test criteria for the Transition of Care Test cases
FUNCTIONAL AND COGNITIVE STATUS
No Impairment
- Status: Approved by task force on 6/18/2015.
- 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 based on C-CDA testing data. 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.
GENERAL PATTERNS
Allergy and Problem Status observation Review - This is a summary of the work done by the example task force to review the extra 'status observations' in C-CDA R1.1 and whether the deprecation in C-CDA R2.0 adequately covers key clinical statuses.
No Information Problems Section
- Status: Approved on task force 1/30/2014; Approved by SDWG on 2/6/2014.
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- TemplateId(s) illustrated: Problem Section with Coded Entries(2.16.840.1.113883.10.20.22.2.5.1)
- 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)
- No Information Problems Section R2 (via GitHub)
- Known bad example?: Valid example
- Reference to full CDA sample: No Information Problem section
- Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
- Validation location: 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 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
- Status: Task force on 11/20/2014; SDWG Approved on 4/16/2015
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- TemplateId(s) illustrated: Procedures Section (entries required)(2.16.840.1.113883.10.20.22.2.7.11)
- 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: 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
Unknown Patient Immunization Status
- Approved by: Task force on 11/21/2013. Approved by SDWG 12/5/2013.
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- TemplateId(s) illustrated: Immunization Activity (2.16.840.1.113883.10.20.22.4.52)
- 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)
- Unknown Patient Immunization Status C-CDA R2 (via GitHub)
- Known bad example?: Valid example
- Reference to full CDA sample: Immunization section in compliant MU2 C-CDA sample
- Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
- Validation location: SITE Validator TOC Ambulatory
- Comments: This is an example of how an author can record they do now know whether the patient has received any vaccinations.
Influenza Vaccination
- Approved by: Task force on 4/16/2015
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- TemplateId(s) illustrated: Immunization Activity (2.16.840.1.113883.10.20.22.4.52)
- Influenza Vaccination Completed
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
- TemplateId(s) illustrated: Immunization Activity (2.16.840.1.113883.10.20.22.4.52.2)
- Not Completed
- Known bad example?: Valid example
- Reference to full CDA sample: Immunization section in compliant MU2 C-CDA sample
- Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
- Validation location: SITE Validator TOC Ambulatory
- Comments: This is an example of an influenza immunization record to support the minimum requirements of the transition of care 170.314(b)(2) test method.
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)).
Medication Frequencies Approved 9/17/2014 at Chicago WG
(keywords: bid, two times daily; q12h, every 12 hours; tid, three times daily; q8h, every 8 hours; qid, four times daily; q6h, every 6 hours; qd, daily; q24h, every 24 hours; qod, every other day; qm, Once a month; Every other week; 1 hour after meal; before dinner; before lunch (from lat. ante cibus diurnus))
Medication statusCodes Approved on 2/19/2015 SDWG call.
Patient prescribed oral medication QID PRN without precondition specified
- Approved by: Task force on 1/9/2014. Task force approved 1/16/2014
- C-CDA 1.1 Implementation Guide Example
- TemplateId(s) illustrated: Medication Activity Medication Information Precondition for Substance Administration (Trifolia Log-in Required)
- 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: Results Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: 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.
- 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 oral medication for pain
- Additional content - the following file illustrates 5 different medication entries. These examples are meant to illustrate the coding of a medication precondition or indication.
Patient Prescribed Medication Every 4-6 Hours
- Approved by: Task force 1/30/2014. Approved by SDWG on 2/6/2014.
- CDA Implementation Guide where template(s) is(are) defined: 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
- 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
- Patient prescribed medication every 4 to 6 hours
- Known bad example?: Valid example
- Reference in full CDA Sample: Results Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: 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.
Debate continues - see document and comments below - Patient Prescribed Oral Antibiotic with Dosing Regimen that Varies Over Prescription Course (Loading or Tapered)
- Previously, approved by: Task force on 3/6. Approved by SDWG on 4/10/2014.
- CDA Implementation Guide where template(s) is(are) defined: 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
- 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
- Patient prescribed medication every 4 to 6 hours
- Known bad example?: Valid example
- Reference in full CDA Sample: Results Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: 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.
Patient prescribed basal insulin administered at bedtime
- Approved by: Not yet approved
- C-CDA 1.1 Example
- TemplateId(s) illustrated: Medication Activity Medication Information
- Patient prescribed basal insulin administered at bedtime
- C-CDA 2.0 Example: none yet posted
- Known bad example?: Valid example
- Reference in full CDA Sample: Results Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated February 27, 2014
- 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.
Single Administration of Medication (at Single Point in Time)
- Approved by: Task force on 3/13. Approved by SDWG on 4/10/2014.
- CDA Implementation Guide where template(s) is(are) defined: 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
- 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
- Single administration of medication (at single point in time)
- Known bad example?: Valid example
- Reference in full CDA Sample: Results Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: 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.
No Medications
- Approved by: Task force on 3/13. Approved by SDWG on 4/10/2014.
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- TemplateId(s) illustrated: Medication Activity (2.16.840.1.113883.10.20.22.4.16)
- 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)
- No Medications R2
- Known bad example?: Valid example
- Reference to full CDA sample: No Medications in compliant MU2 C-CDA R1.1 sample
- Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
- Validation location: 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.
Patient Reported Medication without Reported Brand/Dose
- Approved by: Not yet approved
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- TemplateId(s) illustrated: Medication Activity (2.16.840.1.113883.10.20.22.4.16)
- 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: Medications in skeleton CCD
- Custodian: John D'Amore jdamore@diameterhealth.com GitHub: jddamore)
- Validation location: NIST TTT VDT Ambulatory validated June 4, 2014
- Comments: Patients often report medications that they are taking, either self-prescribed or by another provider, and know the drug name but do not know any specific brand or dose. This is an example of how to record an herbal supplement (echinicea) that a patient has reported taking using the informant to denote that this is patient reported.
Antibiotic Administered with Normal Saline (i.e. in hospital)
- Approved by: Not yet approved
- CDA Implementation Guide where template(s) is(are) defined: 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)
- 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: Medications in skeleton CCD
- Custodian: John D'Amore jdamore@diameterhealth.com GitHub: jddamore)
- Validation location: 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
Patient with No Known Problems
- Approved by: Task force on 2/27, SDWG on 3/6.
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
- 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
- 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: Full Sample No Known Problems
- Custodian: Brett Marquard
- Validation location: TTT VDT Ambulatory
- Comments:
Problem which has been resolved/completed
- Approved by: Task force approved May 30, 2014. SDWG approved June 5, 2014
- C-CDA 1.1 Implementation Guide Example
- TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
- Problem which has been resolved/completed
- C-CDA 2.0 Example: None yet posted
- Reference to full CDA sample: https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/PROBLEM_Examples_in_empty_CCD.xml
- Custodian: John D'Amore jdamore@diameterhealth.com
- Validation location: TTT, April 17, 2014
- Comments: This example illustrates how to structure a resolved problem, both by having a biological resolution date and a completed status of the concern.
Active Problem
- Approved by: Task force approved October 2, 2014. Approved by SDWG 11/06/2014.
- C-CDA 1.1 Implementation Guide Example
- TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
- Active Problem
- C-CDA 2.0 Example: None yet posted
- Reference to full CDA sample: https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/CCD_Transition_of_Care_Ambulatory_Active_Problem.xml
- Custodian: Brett Marquard
- Validation location: SITE, October 1, 2014
- Comments: This example illustrates how to structure an active problem.
Under Development -
Complaint of no foot pain - Problem Section
- Status: Not Yet Reviewed
- C-CDA 1.1 Implementation Guide Example
- TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
- (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
- Status: Not Yet Reviewed
- C-CDA 1.1 Implementation Guide Example
- TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
- 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
- Approved by: Approved by task for 5/22/2014; SDWG Approved 5/29/2014.
- C-CDA 1.1 Implementation Guide Example
- TemplateId(s) illustrated: Procedure Section, Procedure Activity Observation
- 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
- Approved by: Approved by task for 5/22/2014; SDWG Approved 5/29/2014.
- C-CDA 1.1 Implementation Guide Example
- TemplateId(s) illustrated: Procedure Section, Procedure Activity Procedure
- 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
- Approved by: Approved by task for 5/22/2014; SDWG Approved 5/29/2014.
- C-CDA 1.1 Implementation Guide Example
- TemplateId(s) illustrated: Procedure Section, Procedure Activity Act
- 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. SDWG approved on 4/16/2015
- C-CDA 1.1 Implementation Guide Example
- C-CDA 2.0 Example: none yet posted
- Known bad example?: Valid example
- Reference to full CDA sample: Result Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: 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: Based on SDWG request from Kumara February 2014. Approved on SDWG 3/19/2015.
- C-CDA 1.1 Implementation Guide Example
- 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. Task force approved a second time on 3/05/2015. Approved by SDWG on 3/12/2015
- C-CDA 1.1 Implementation Guide Example
- Known bad example?: Valid example
- Reference to full CDA sample: Result Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: 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: Task force approved 3/05/2015. Approved by SDWG on 3/12/2015
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- C-CDA 2.0 Example: none yet posted
- Known bad example?: Valid example
- Reference to full CDA sample: Result Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: 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: C-CDA 1.1
- 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]
- Result which requires translation for its unit represented in UCUM
- Known bad example?: Valid example
- Reference to full CDA sample: Result Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: 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
- C-CDA 1.1 Implementation Guide Example
- C-CDA 2.0 Example: none yet posted
- Known bad example?: Valid example
- Reference to full CDA sample: Result in C-CDA Section
- Custodian: Ed Donaldson, ed.donaldson@greenwayhealth.com (GitHub: donaldson-ed)
- Validation location: NIST TTT validator for Clinical Office Visit Summary - Clinical Summary validated March 5, 2014
- Comments: Result with a pending component.
Result of CO2 Test (MU2 Example)
- Approved by: Task force approved 5/7/2015
- C-CDA 1.1 (link to CDA Implementation Guide) Implementation Guide Example
- C-CDA 2.0 Example: none yet posted
- Known bad example?: Valid example
- Custodian: Benjamin Flessner, benjamin@epic.com (GitHub:benjaminflessner)
- Validation location: NIST TTT validator for Clinical Office Visit Summary - Clinical Summary
- Comments: Sample from Meaningful Use test data
PAYER
Coverage Activity referencing the holder's employer
- Approved by: Sample not yet reviewed
- C-CDA 1.1 Implementation Guide Example
- C-CDA 2.0 Example: none yet posted
- Known bad example?: Sample not yet reviewed
- Reference to full CDA sample:
- Custodian: Lisa R. Nelson, lisarnelson@cox.net (GitHub: lisarnelson)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated December 18, 2013
- 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.
SOCIAL HISTORY (SMOKING)
Unknown Smoking Status
- Approved by: Task Force Approved 6/26; Approved by SDWG 7/03/14
- CDA Implementation Guide where template(s) is(are) defined: 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)
- Unknown Smoking Status
- C-CDA 2.0 Example: none yet created
- Known bad example?: Valid example.
- Reference to full CDA sample: Social History (Smoking Status)in skeleton CCD
- Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT VDT Ambulatory validated June 11, 2014
- Comments: This is an example of unknown smoking status. There is a major variation in how no information is managed for smoking status. C-CDA 1.1 explicitly guides to not utilize a nullFlavor for this information. Instead a SNOMED code should be used as demonstrated in the example. A best practice to avoid confusion is for each social history section to only include a single smoking status.
Former Smoker in Smoking Status
- Approved by: Task Force Approved 6/26; Approved by SDWG 7/03/14
- CDA Implementation Guide where template(s) is(are) defined: 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)
- Former Smoking Status
- C-CDA 2.0 Example: none yet created
- Known bad example?: Valid example.
- Reference to full CDA sample: Social History (Smoking Status)in skeleton CCD
- Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT VDT Ambulatory validated June 11, 2014
- Comments: This is an example of a former smoker in smoking status. There is a variation in how effectiveTime/high is used since this represents when the patient stopped smoking, not when they stopped being a former smoker. C-CDA 1.1 explicitly guides to this usage of effectiveTime. A best practice to avoid confusion is for each social history section to only include a single smoking status.
Never Smoker in Smoking Status
- Approved by: Task Force Approved 6/26; Approved by SDWG 7/03/14
- CDA Implementation Guide where template(s) is(are) defined: 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)
- Never Smoker Status
- C-CDA 2.0 Example: none yet created
- Known bad example?: Valid example.
- Reference to full CDA sample: Social History (Smoking Status)in skeleton CCD
- Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT VDT Ambulatory not yet validated
- Comments: This is an example of a never smoker in smoking status. A best practice to avoid confusion is for each social history section to only include a single smoking status.
Current Smoker in Smoking Status
- Approved by: Task Force Approved 6/26; Approved by SDWG 7/03/14
- CDA Implementation Guide where template(s) is(are) defined: 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)
- Current Smoking Status
- C-CDA 2.0 Example: none yet created
- Known bad example?: Valid example.
- Reference to full CDA sample: Social History (Smoking Status)in skeleton CCD
- Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT VDT Ambulatory validated June 11, 2014
- Comments: This is an example of current smoking status. This example also includes a coordinating social history observation to convey the amount of smoking using a SNOMED code. This SNOMED code in the accompanying observation is not acceptable since smoking status, which is constrained by HL7 and Meaningful Use value set requirements. A best practice to avoid confusion is for each social history section to only include a single smoking status.
VITAL SIGNS
Panel of Vital Signs in Metric Units
- Approved by: Task force approved May 30, 2014. SDWG approved June 5, 2014
- 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
- 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: NIST TTT Message Validator for VDT Ambulatory validated May 29, 2014
- Reference to full CDA sample: 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
- 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
- Vital Sign panel with mixed units
- C-CDA 2.0 Implementation Guide Example: none yet posted
- Reference to full CDA sample: Vital Signs in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: 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 2/19/2015
- C-CDA 2.0 (link to CDA Implementation Guide, when available) Implementation Guide Example
- TemplateId(s) illustrated: Family History Organizer (2.16.840.1.113883.10.20.22.4.45 2015-06-09), Family History Observation (2.16.840.1.113883.10.20.22.4.46 2015-06-09), Age Observation (2.16.840.1.113883.10.20.22.4.31), Family History Death Observation (2.16.840.1.113883.10.20.22.4.47)
- Family History Section
- Known bad example?: No
- Reference to full CDA sample:
- Custodian: Benjamin Flessner, benjamin@epic.com (GitHub: benjaminflessner)
- Validation location: C-CDAR2 schema and schematron
- Comments: Example shows multiple observations for one family member, identifying the cause of death, and a family member with no known problems.
Family History; two individuals with the same relationship to the patient
- Approved by: Task force approved 2/12/2015, SDWG 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)
- 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, SDWG approved 2/19/2015
- C-CDA 2.0 (link to CDA Implementation Guide, when available) Implementation Guide Example
- TemplateId(s) illustrated: Family History Organizer (2.16.840.1.113883.10.20.22.4.45 2015-06-09), Family History Observation (2.16.840.1.113883.10.20.22.4.46 2015-06-09)
- 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
Link to C-CDA 1.1 testing script
C-CDA Empty shell that will validate without errors using NIST TTT.
- Note this example is used to help with testing examples and is not intended as a best practice, since information is suppressed in all sections
- Empty C-CDA CCD (No Information in required sections)
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
- validators
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
- Patient with allergies to different substances (via GitHub)
- Approved by: Not yet approved
- Patient taking pre-coordinated medication (via GitHub)
- Approved by: Not yet approved
- 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!
