Consolidated CDA Templates Errata

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This page contains errata associated with the Consolidated CDA Templates DSTU. Items that are clearly technical corrections can be added to the technical corrections section. Items that are errata will be reviewed and approved by SDWG

Suggested Errata

2.4 US Realm Date and Time (DT.US.FIELDED) and 2.5 US Realm Date and Time (DTM.US.FIELDED)
CONF:10063 says the <effectiveTime> SHALL be conformant to the US Realm Date and Time (DT.US.FIELDED), which would require a @value within the <effectiveTime> element. However, for the <effectiveTime> elements, we typically use <low>, <high> and/or <width> elements. The DT.US.FIELDED should probably apply to those in individually (each <low> and <high> should use the DT.US.FIELDED requirements. We should consider rewording the DT.US.FIELDED and DTM.US.FIELDED text to state that the @value could be used in the elements , <effectiveTime>,<low>, or <high>.

Suggested Resolution: The IG should be changed to state that the DT.US.FIELDED and DTM.US.FIELDED apply to the children of the <effectiveTime> or . The changed conformance may need to be done throughout the IG where those data types are referenced or just in section 2.4 and 2.5 where those two data types are defined.

(I/Q)5.17 Family History Observation
Update CONF:8591 to DYNAMIC

From: SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code SHALL be selected from ValueSet Problem 2.16.840.1.113883.3.88.12.3221.7.4 STATIC (CONF:8591).

To: SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code SHALL be selected from ValueSet Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:8591).

5.39 Policy Activity - open for comment in May 2012 ballot
Add templates to CONF:8906, 8961
These have "SHALL contain exactly one performer such that .... ". It's easy to understand when you read it that there should only be one performer with those particular items in it. However, the schematron test is causing an error because this section has more than one performer with @typeCode="PRF"

Suggested Resolution: This is an example where these “specialized branches” need to actually be templates in their own right. A specialized branch must be uniquely identifiable with its context, and that is not true for either of these performers. We should consider a Payer Performer template, and a Guarantor Performer template.

5.56 (Result Observation) and 5.65 (Vital Sign Observation)

• Require interpretationCode/@system="2.16.840.1.113883.5.83"
• Update constraint on interpretationCode to require use of the ValueSet 2.16.840.1.113883.1.11.78
• Add a new table listing the codes in this ValueSet (http://phinvads.cdc.gov/vads/ViewValueSet.action?id=A8E75E17-176B-DE11-9B52-0015173D1785)

Table 201 (Medication Activity) incorrectly reports cardinality of CONF:7549
Cardinality should be 0..* but is incorrectly reported in the table as 0..1

Technical Corrections

(I/Q)1.2 Purpose
Update sentence "When released for publication, this guide will be the single..." to "This guide is the single..."

(I/Q)2.3 US Realm Address (AD.US.FIELDED)
Update value set PostalAddressUse 2.16.840.1.113883.1.11.10637 STATIC 2005-05-01 to codes in the CDA R2 release. The value 'CONF' Is not available.

(I/Q)3.3.2.1 DIR Section Constraints
Duplicate CONF number in IG. Update DIR CONF number to 9484.

From:SHALL contain exactly one [1..1] Findings Section (DIR) (templateId:2.16.840.1.113883.10.20.6.1.2) (CONF:8776).

To:SHALL contain exactly one [1..1] Findings Section (DIR) (templateId:2.16.840.1.113883.10.20.6.1.2) (CONF:9484).

Also, more structure is needed for this section. Update to narrative or add

1. SHALL contain exactly one [1..1] component (CONFXXX).

a. A Diagnostic Imaging Report can have either a structuredBody or a nonXMLBody. (CONF:XXXX).

i. A Diagnostic Imaging Report can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.5), coded entries are optional. (CONF:XXX).

b. If structuredBody, the component/structuredBody SHALL conform to the section constraints below. (CONF:XXX).

(I/Q)3.3.1.10 Physician Reading Study Performer
Update CONF:8428 to @codeSystem

From: SHALL contain a valid DICOM personal identification code sequence (@codeSystem is 1.2.840.10008.2.16.4) or an appropriate national health care provider coding system (e.g., NUCC in the U.S., where @code is 2.16.840.1.113883.6.101). (CONF:8428).

To: SHALL contain a valid DICOM personal identification code sequence (@codeSystem is 1.2.840.10008.2.16.4) or an appropriate national health care provider coding system (e.g., NUCC in the U.S., where @codeSystem is 2.16.840.1.113883.6.101). (CONF:8428).

(I/Q)3.4 Discharge Summary
Update broken link Joint Commission Requirements for Discharge Summary (JCAHO IM.6.10 EP7). See http://www.jointcommission.org/NR/rdonlyres/C9298DD0-6726-4105-A007-FE2C65F77075/0/CMS_New_Revised_HAP_FINAL_withScoring.pdf

(I/Q)3.6.1.3 documentationOf
Add assignedEntity under CONF:8495. Right now CONF:8490 includes a code element on the Performer which is incorrect.

(I/Q)3.7.1.6 serviceEvent
Update formatting so CONF:8520 and CONF:8524 properly nest underneath serviceEvent instead of documentationOf.

(I/Q)4.16 History of Past Illness Section 11348-0
Update text to: This History of Past Illness section describes the history of the patient‘s past  complaints, problems, or diagnoses.

It records these details having occurred up until, and possibly pertinent to,  the patient‘s current complaint or reason for seeking medical care.

(I/Q)5.11 Coverage Activity Update CONF 8872 to proper codeSystem

From: SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:8872).

To: SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:8872).

(I/Q)5.14 Encounter Activities
Update CONF 8711 to proper codeSystem

From: SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:8711).

To: SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:8711).

(I/Q)5.19 Health Status Observation
Update CONF:9075 with new value set

From: SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code SHALL be selected from ValueSet HITSPProblemStatus 2.16.840.1.113883.3.88.12.80.68 DYNAMIC (CONF:9075).

To: SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code SHALL be selected from ValueSet HealthStatus 2.16.840.1.113883.1.11.20.12 DYNAMIC (CONF:9075).

Add the ValueSet Table:

Table XXX:
HealthStatus Value Set
Value Set: HealthStatus 2.16.840.1.113883.1.11.20.12 DYNAMIC

Code System(s): SNOMED CT 2.16.840.1.113883.6.96
Description: Represents the general health status of the patient
Code Code System Print Name
81323004 SNOMED CT Alive and well
313386006 SNOMED CT In remission
162467007 SNOMED CT Symptom free
161901003 SNOMED CT Chronically ill
271593001 SNOMED CT Severely ill
21134002 SNOMED CT Disabled
161045001 SNOMED CT Severely disabled

(I/Q)5.39 Policy Activity

1. Update CONF 8898 to proper codeSystem
   

   From: SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: ActMood 2.16.840.1.113883.5.1001) (CONF:8898).
   

   To: SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6) (CONF:8898).

2. Update table 204 to codeSystem RoleClass 2.16.840.1.113883.5.110. Review figure.
3. Update cardinality for code attribute. CDA R2 schema has base Act code cardinality as [1..1] and cannot be restricted to [0..1]

   Modify the CONF:8903,CONF:8904 to indicate [1..1] for code. Also update the Table 'Policy Activity Constraints Overview'

   Modify the keyword for code from SHOULD to SHALL (due to the change in the cardinality)

4. The description for Guarantor Performer needs clarification on the severity keyword & cardinality for Performer & the typeCode attribute. Suggested change based on Payer..

   From: SHOULD contain zero or one [0..1] performer="PRF" Performer (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:8961) such that it

   To: [SHALL / SHOULD] contain exactly one [1..1] performer (CONF:XXXX) such that it

   SHALL contain exactly one [1..1] @typeCode="PRF" Performer (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:8961)

5.45 Problem Observation
(I/Q)Update Print Name entry for functional limitation in Table: Problem Type Value Set

From: 248536006 SNOMED CT Functional limitation

To: 248536006 SNOMED CT Finding of functional performance and activity

Add to table:373930000 SNOMED CT Cognitive function finding

Add Conformance Statement:

1. SHALL contain exactly one [1..1] templateId (CONF:XXXX) such that it

   SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.4(CONF:XXXX)

(I/Q)5.58 Series Act
Add CONF to require templateId. Update figure.

(I/Q)Table 44:Sections and Required/Optional Document Types with Structured Body
Update table cells that are blank with a '-'. Add to bottom of table that a '-' represents a section that is not required or optional. These sections can be included if appropriate for the document type.

(I/Q)FIGURES
Review all figures. Figures 155, 168 and 214 need to be updated and there are may be others. Sample files can be used to update the figures.