Clinical Summary (Consultation Referral Clinical Summary)
HITSP C154: Data Element Set Elements
ID Table(s) (DES) Name (Non-normative Sample)
Continuity of Care Data Categories (Source: ASTM CCR, HL7 CCD)
CORE
Demographics including…
Name, DOB, Next of Kin, Address,
DES1 Person: 2-4, 2-5 Person Information Phone Number, Gender, Marital Status,
Religion, Race, Ethnicity
Language Spoken: 2- Person Information -
DES41
6 continued
DES2 Support: 2-7, 2-8 Contact Information Contact Name, Contact Number
Insurance Provider: 2- Insurance Name, Phone #, Group #,
DES3 11, 2-12, 2-13, 2-14, Insurance Information Type, Member #, Subscriber Name,
2-15, 2-16, 2-17 Financial responsibility
Communication preferences (mail, usb,
email, etc.)
Active Problem List
Condition: 2-23 Current Diseases &
DES6 [Severity Code fr 2- Problem List Conditions monitored for the patient
22] and status
Active Medication List
Medication: 2-24, 2- List of Current Medication Names ;
DES14 Medications
25, 2-26 date, route, dose, frequency
Discontinued Medications
List of historical medication names,
Admission
DES15 See DES14 dose, route, frequency, date patient has
Medications History
taken prior
Allergies and Intolerances
Allergy/Drug Allergy Type; and Date
Allergies and Other
DES5 Sensitivity: 2-19, 2- Substance intolerance
Adverse Reactions
20, 2-21, 2-22 Associated Adverse Events
Care Plan
Care Plan Team Members
Healthcare Provider: 2- Provider Name, Address, Phone
DES4 Healthcare Provider
9, 2-10 Number, Type
Plan Version, Plan ID, Creator,
time/date stamp
Plan element editors, time/date stamp
Goals
Patient Instructions
Data Elements needed for indicating
future state (including a data element
to describe intent, promise and status
of the future state)
Proposed Events
Proposed interventions and procedures
DES27 Plan of Care: 2-40 Plan of Care
for patient
Intended events
Scheduled events
Care Summary
Subjective - History of Present Illness
History of Present Sequence of events proceeding
DES10 Condition: 2-23
Illness patient's disease/condition
Subjective- Review of Systems
Condition: 2-23 Functions of various body systems;
(where Problem Type Neuro, Derm, GI, GU, Cardiac,
DES23 = Problem reported by Review of Systems Pulmonary, MS, Repro, Nervous,
subject of history Endocrine
provider);
Subjective-Pertinent History (medical
history, surgical/procedure history,
social history, family history, behavioral
health history)
Diseases & Conditions Patient has
DES7 Condition: 2-23 History of Past Illness
suffered in the past
Procedure: 2-37 (w
DES11 List of Surgeries List of types of surgeries and dates
constraints?)
Hospital Admission
DES12 Condition: 2-23 List of Hospital Diagnosis and dates
Diagnosis
Dates with Disease Suffered, Age of
DES28 Familiy History: 2-38 Family History
Death, other genetic information
Patient's beliefs, home life, social/risky
DES29 Social History: 2-39 Social History
habits, family life, work history
DES30 Encounter: 2-36 Encounters Current and historical encounters; dates
Medical Equipment: Implanted and External Medical
DES31 Medical Equipment
None Devices; Dates
Objective - Medication History
Objective - Immunization History
Immunization: 2-32, Immunizations name, dose, route, date
DES20 Immunizations
2-33 administered to the patient
Objective - Relevant physical exam
findings
Multiple C154
modules are
appropriate to cover
this DES, e.g.
Condition: 2-23
(where Problem Type
= Clinical Finding),
Physical Findings of the Patient; VS,
DES21 VS, H&P, etc. Physical Examination
Biometrics, Review of Systems
Functional Status
section would be
included in the
exchange document
but the content would
be free test at this
time.
Objective - Relevant Vital Signs
Patient's Vital Signs ; Heart rate, Resp
DES22 Vital Sign: 2-34 Vital Signs
Rate, Pulse Ox, Temp, B/P, Pain
Objective - Procedres and Diagnostic
tests performed
Sequence of (name, diagnosis
None: Narrative text
DES24 Hospital Course associated with) events and dates from
in C83 only
admission to discharge of hospital stay
Results and dates of Diagnostic
DES25 Results: 2-35 Diagnostic Results
Procedures
Procedure: 2-37
(provided together Operative Note Date and Description of Procedure
DES37
with DES34 for textual Surgical Procedure Performed
description)
Objective - Operative summary(s)
Condition: 2-23
(Problem Type =
Diagnosis expanded to Preoperative Diagnosis ( Date) assigned to patient
DES32
include different types Diagnosis prior to surgery
of diagnoses in CDA
Consolidation)
Condition: 2-23
(Problem Type =
Diagnosis expanded to Postoperative Diagnosis ( Date) assigned to patient
DES33
include different types Diagnosis after surgery
of diagnoses in CDA
Consolidation)
None: Narrative text Particulars of Surgery (narrative)
DES34 Surgery Description
in C83 only (images)
Condition: 2-23
Surgical Operation Clinically significant observations found
DES35 (Problem Type =
Note Findings during surgery
Clinical Findings)
Objective - Admitting and discharge
diagnoses
Conditions/Diseases identified during
DES13 Condition: 2-23 Discharge Diagnosis
hospital stay and dates
Consultant(s) Assessment(s) and
Plan(s) - Recommendations
May involve multiple
C154 modules and its
content may vary by
situation. C83 has
specific sections for Assessment of patients conditions and
DES26 Assessment and Plan
Conditions, expectations/goals of care
Assessment & Plan,
Plan, etc) that may
be included in a
document.
Pending Tests and Procedures
Reason for consult request
Encounter: 2-36
DES9 Reason for Transfer Reason Patient is being referred
(16.13)
Pertinant part of care plan
Pertinent Results
Plan and instructions specific to the
care provided by the specialist
Informed Consent
These items below did not clearly
match to any of the data elements
from the Roadmap document.
Should they all be
dropped/removed?
Description of Patient's Complaint
DES8 Condition: None Chief Complaint
(narrative)
Medications names, doses, frequency,
Hospital Discharge
DES16 See DES14 route ordered for the patient for after
Medications
discharge
Medications administered to patient
Medications
DES17 See DES14 during the course of an encounter;
Administered
name, dose, route, frequency
Advance Directive: 2- A summary of patient's expectations for
DES18 Advanced Directives
31 care
DES19 Pregnancy: 2-27 Pregnancy Pregnant, Yes/NO
None: Narrative text
DES36 Complications Section Known risks or unidentified problems
in C83
Additional DES (for LRI and future use cases)
• Data elements and common identifier
Clinical Research: 2- Clinical Research
DES38 variables that pertain to research-
41 Information
specific workflow
DES39 Order: 2-42 Orders • Data describing orders for a patient
• Data describing the specimen
DES40 Specimen: 2-43 Specimen information associated with an order
and the results
Consolidated CDA Templates (Ballot April 2011)
CDA Consolidation Guide: US Realm Header
[ClinicalDocument: templateId
2.16.840.1.113883.10.20.21.1.1]
(See 2.1.1 RecordTarget)
CDA Consolidation Guide: US Realm Header
[ClinicalDocument: templateId
2.16.840.1.113883.10.20.21.1.1]
(See 2.1.1 RecordTarget)
CDA Consolidation Guide: US Realm Header
[ClinicalDocument: templateId
2.16.840.1.113883.10.20.21.1.1]
(See 2.1.1 RecordTarget)
CDA Consolidation Guide: US Realm Header
[ClinicalDocument: templateId
2.16.840.1.113883.10.20.21.1.1]
(See 3.2.1.3 Participant)
OR
Payers Section
[section: templateId
2.16.840.1.113883.10.20.22.2.18
(See 4.33 Payers Section in Consolidated guide) Note:
This sections entry conformance statements have not
yet been harmonized in the project and are not in the
guide. See base CCD spec templateId
2.16.840.1.113883.10.20.1.20)
CDA Consolidation Guide:
See: 4.40 Problem List Section 11450-4
Optional Entries
[section: templateId
2.16.840.1.113883.10.20.22.2.5]
Required Entries
[section: templateId
2.16.840.1.113883.10.20.22.2.5.1
See: 5.6 Condition Entry
[Observation: templateId
2.16.840.1.113883.10.20.22.4.4]
CDA Consolidation Guide:
See: 4.28 Medications Section
Optional Entries
[section: templateId 2.16.840.1.113883.10.20.21.2.1
Required Entries
[section: templateId
2.16.840.1.113883.10.20.21.2.1.1
See: 5.14 Medication Activity
[substanceAdministration: templateId
2.16.840.1.113883.10.20.21.4.16]
This medication activity template contains or may
contain the following termplates: (not repeated in
T.CC.15, T.CC.16, T.CC.17, T.CC.18 - but would be
true everywhere the med activity template is sited.)
See:5.16 Medication Information
[manufacturedProduct: templateId
2.16.840.1.113883.10.20.21.4.23
See 5.9 Drug Vehicle
[participantRole: templateId
2.16.840.1.113883.10.20.21.4.24
See: 5.12 Indication
[observation: templateId
2.16.840.1.113883.10.20.21.4.19
See: 5.13 Instructions
[act: templateId 2.16.840.1.113883.10.20.21.4.20
See: 5.17 Medication Supply Order
[supply: templateId
2.16.840.1.113883.10.20.21.4.17
See:5.15 Medication Dispense
[supply: templateId
2.16.840.1.113883.10.20.21.4.18
CDA Consolidation Guide:
See: 5.14 Medication Activity
[substanceAdministration: templateId
2.16.840.1.113883.10.20.21.4.16]
Note it was determined during consolidation analysis
that and additional section for "Admission
Medications" was un-needed. The admission
medications should be modeled as an admission
medication stand- alone act entry regardless of the
section it is contained in .There is guidance on
modeling a discharge medication in the Consolidated
guide (see cell below T.CC.16). Similar Guidance is
needed for admission medication.
CDA Consolidation Guide:
See:4.2 Allergies, Adverse Reactions, Alerts Section
Section Templates:
Optional Entries
[section: templateId 2.16.840.1.113883.10.20.22.2.6
Required Entries
[section: templateId
2.16.840.1.113883.10.20.21.2.6.1
Entry Template:
See 5.3: Allergy Problem Act
[act: templateId 2.16.840.1.113883.10.20.21.4.30]
which contains 5.4 Allergy/Alert Observation
[observation: templateId
2.16.840.1.113883.10.20.21.4.7]
CDA Consolidation Guide: US Realm Header
[ClinicalDocument: templateId
2.16.840.1.113883.10.20.21.1.1]
(See 2.1.1 RecordTarget/providerOrganization)
Note- depending on the use case there are other US
Realm Header participants that provide ways to
provide additrional info about various providers such
as: 2.1.2 Author, 2.1.4 Informant, 2.1.6
informationRecipient, 2.1.7 legalAuthenticator
CDA Consolidation Guide:
4.35 Plan Section 18776-5
[section: templateId
2.16.840.1.113883.10.20.21.2.10]
CDA Consolidation Guide:
See: 4.18 History of Present Illness Section 11348-0
[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.3.4]
CDA Consolidation Guide:
See 4.51 Review of Systems Section 10187-3
[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.3.18
CDA Consolidation Guide:
See:4.17 History of Past Illness Section 11348-0
[section: templateId 2.16.840.1.113883.10.20.2.9]
CDA Consolidation Guide:
See: 4.48 Procedures Section
Optional Entries
[section: templateId 2.16.840.1.113883.10.20.22.2.7
Required Entries
[section: templateId
2.16.840.1.113883.10.20.22.2.7.1
Procedure Activity Procedure
(templateId:2.16.840.1.113883.10.20.22.4.14)
(CONF:6277).
Procedure Activity Observation
(templateId:2.16.840.1.113883.10.20.22.4.13)
(CONF:6279
Procedure Activity Act
(templateId:2.16.840.1.113883.10.20.22.4.12)
(CONF:8534).
CDA Consolidation Guide:
See: 4.40 Problem List Section 11450-4
Optional Entries
[section: templateId
2.16.840.1.113883.10.20.22.2.5]
Required Entries
[section: templateId
2.16.840.1.113883.10.20.22.2.5.1
See: 5.6 Condition Entry
[Observation: templateId
2.16.840.1.113883.10.20.22.4.4]
Note it was determined during consolidation analysis
that and additional section for "Admission Diagnosis"
was un-needed. The admission problem/diagnosis
should be modeled as an admission
problem/diagnosis stand- alone entry regardless of
the sectiion it is contained in. There is guidance on
modeling a discharge diagnosis in the Consolidated
guide (see cell below T.CC.13). Similar Guidance is
needed for admission diagnosis.
CDA Consolidation Guide:
See 4.12 Encounters Section 46240-8
[section: templateId
2.16.840.1.113883.10.20.22.2.22]
CDA Consolidation Guide:
See: 4.26 Medical Equipment Section 46264-8
[section: templateId
2.16.840.1.113883.10.20.22.2.23]
CDA Consolidation Guide:
4.24 Immunizations Section 11369-6
[section: templateId 2.16.840.1.113883.10.20.22.2.2
CDA Consolidation Guide:
4.34 Physical Exam Section 29545-1
[section: templateId 2.16.840.1.113883.10.20.2.10
CDA Consolidation Guide:
See 4.56 Vital Signs Section
Optional Entries
[section: templateId 2.16.840.1.113883.10.20.21.2.
Required Entries
[section: templateId
2.16.840.1.113883.10.20.21.2.4.1
See: 5.30 Vital Signs Organizer
[organizer: templateId
2.16.840.1.113883.10.20.21.4.26
See 5.31 Vital Sign Observation
[observation: templateId
2.16.840.1.113883.10.20.21.4.27
CDA Consolidation Guide:
See 4.19: Hospital Course Section 8648-8
[section: templateId 1.3.6.1.4.1.19376.1.5.3.1.3.5
CDA Consolidation Guide:
See: 4.50 Results Section 30954-2
Optional Entries
[section: templateId 2.16.840.1.113883.10.20.21.2.3
Required Entries
[component: templateId
2.16.840.1.113883.10.20.21.2.3.1
See: 5.26 Result Organizer
[organizer: templateId
2.16.840.1.113883.10.20.21.4.1
See: 5.27 Result Observation
[observation: templateId
2.16.840.1.113883.10.20.21.4.2
----- Frieda's LRI Data Sections Detail Work
5.26 Result Organizer
classCode (Battery or Cluster)
moodCode (EVN)
templateId/@root (2.16.840.1.113883.10.20.22.4.1)
id
code
statusCode/@code
component
Result_Observation
5.27 Result Observation
classCode (OBS)
moodCode (EVN)
templateID/@root (2.16.840.1.113883.10.20.22.4.2)
id
code
text
statusCode/@code (completed)
CDA Consolidation Guide:
3.7 Procedure Note
[ClinicalDocument: templateId
2.16.840.1.113883.10.20.22.1.6
NOTE: This is a document level mapping and
therefore includes all of the DES's that are in the US
Realm General Header template and all other sections
per the document model
CDA Consolidation Guide:
See: 4.39 Preoperative Diagnosis Section 10219-4
[section: templateId
2.16.840.1.113883.10.20.22.2.34]
CDA Consolidation Guide:
4.37 Postoperative Diagnosis Section 10218-6
[section: templateId
2.16.840.1.113883.10.20.22.2.35
CDA Consolidation Guide:
See: 4.41 Procedure Description Section 29554-3
[section: templateId
2.16.840.1.113883.10.20.22.2.27]
CDA Consolidation Guide:
See 3.6 Operative Note
[ClinicalDocument: templateId
2.16.840.1.113883.10.20.22.1.7
NOTE: This is a document level mapping and
therefore includes all of the DES's that are in the US
Realm General Header template and all other sections
per the document model
CDA Consolidation Guide:
See: 4.20 Hospital Discharge Diagnosis Section
[section: templateId
2.16.840.1.113883.10.20.22.2.24
See: 5.7 Discharge Diagnosis
[act: templateId 2.16.840.1.113883.10.20.22.4.33
CDA Consolidation Guide:
See: 4.4 Assessment Section 51848-0
[section: templateId
2.16.840.1.113883.10.20.21.2.8(open)]
See: 4.5 Assessment and Plan Section 51487-2
[section: templateId 2.16.840.1.113883.10.20.21.2.9
CDA Consolidation Guide:
See: 4.7 Chief Complaint and Reason for Visit Section
46239-0
[section: templateId
2.16.840.1.113883.10.20.22.2.13]
CDA Consolidation Guide:
Required: Narrative Entry only
Optional:
See: 4.6 Chief Complaint Section 10154-3
[section: templateId
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1]
CDA Consolidation Guide:
See: 4.21 Hospital Discharge Medications Section
(optional entries) 10183-2
[section: templateId
2.16.840.1.113883.10.20.22.2.11(open
See: 5.8 Discharge Medication
[act: templateId 2.16.840.1.113883.10.20.22.4.35
This template "wraps" the Medication Activity
[substanceAdministration: templateId
2.16.840.1.113883.10.20.21.4.16]
CDA Consolidation Guide:
See: 4.28 Medications Section
Optional Entries
[section: templateId 2.16.840.1.113883.10.20.21.2.1
Required Entries
[section: templateId
2.16.840.1.113883.10.20.21.2.1.1
See: 5.14 Medication Activity
[substanceAdministration: templateId
2.16.840.1.113883.10.20.21.4.16]
CDA Consolidation Guide:
See: 4.1 Advance Directives Section 42348-3
[section: templateId
2.16.840.1.113883.10.20.22.2.21]
From: HL7 Implementation Guide for CDA® Release
2: Public Health Case Reporting, Release 1 (US
Realm)
http://www.hl7.org/documentcenter/private/standard
s/cda/igs/cdar2_ig_ph_caserpt_r1_inform_2009.zip
Pregnancy observation entry: templateId
2.16.840.1.113883.10.20.15.3.8
CDA Consolidation Guide:
4.8 Complications Section 10830-8
[section: templateId
2.16.840.1.113883.10.20.22.2.32
4.9 Complications / Adverse Events Section 55109-3
[section: templateId
2.16.840.1.113883.10.20.22.2.37(open)]
ANA Recognized Terminologies [HITSP & S&I Interoperability Guidance: Any nursing vocabulary
ADA IDNT (Intern'l Dietetic and Nutrition
Clinical Care Classification (CCC)
Terminology)
Client History/Personal History/
Age CH-1.1.1
Gender CH-1.1.2
Race-Ethnicity CH 1.1.3
Managed by EMR
Language CH 1.1.4 (?)
Literacy Factors CH 1.1.5
Education CH 1.1.6
Nursing Diagnosis: Communication, M28.0;
Nursing Intervention: Communication Care, Language CH 1.1.4
M38.0
Managed by EMR (NA)
Managed by EMR (NA)
Nutrition Diagnosis
Intake NI 1.1 - NI 5.11.2
Nursing Diagnoses
Clinical NC 1.1 - NC3.4
Behavioral/Environmental NB 1.1 - NB 3.3
Medication and Herbal Supplement Use FH
Medication Care Component: H
3.1.1 - FH 3.1.3
Medication Care Component: H (NA)
Nursing Diagnoses: Endocrine Alteration,
I22.0; Immunologic Alteration, I23.0; Latex Patient/client OR family nutrition-oriented
Allergy Response, R46.5; Nursing medical/health history of immune function CH
Interventions: Allergic Reaction Care, I26.0; 2.1.8
Immunologic Care, I65.0
Managed by EMR (NA)
Nutrition Interventions
Food and/or nutrient delivery ND 1.1 - ND 6.2
Nursing Diagnoses, Nursing Interventions, and
Nutrition Education E 1.1 - E 2.3
Intervention Action Types
Nutrition Counseling C 1.1 - C 2.11
Coordination of Nutrition Care RC 1.1 - RC 2.2
Managed by EMR
Nutrution Focused Physical Findings (PD 1.1.1-
21 Care Components
PD 1.1.9)
Physical Regulation Care Component: K;
Patient/client OR family nutrition-oriented
Nursing Diagnoses; Nursing Intervention:
medical/health history CH 2.1.1 - CH 2.1.14
Health History, K31.1
Managed by EMR (NA)
Nursing Diagnoses; Dates Managed by EMR
Patient/client OR family nutrition-oriented
Role Relationship Care Component: M
medical/health history CH 2.1.1 - CH 2.1.14
Client History (CH) /Social History/ CH 3.1.1-
3.1.9
Client History / Personal History/ Tobacco use
CH 1.1.8
Role Relationship Care Component: M
Client History / Personal History/ Role in
Family CH 1.1.7
Managed by EMR (NA)
Nursing Interventions: Equipment Safety,
N42.2; Individual Safety, N42.3; Safety Adaptive equipment for feeding assistance ND
Precauations, N42.0; Enviromental Safety, 4.1
N42.1.
Nursing Interventions: Medication Care,
H24.0; Medication Treatment, H24.4; (NA)
Immunologic Care, I65.0.
Nursing Interventions: Physical Examination, Nutrution Focused Physical Findings (PD 1.1.1-
K31.3; Clinical Measurements, K31.4. PD 1.1.9)
Nursing Interventions: Vital Signs, K33.0;
Nutrtion Focused Physical Findings/ Vital
Blood Pressure, K33.1; Temperature, K33.2;
Signs/ PD 1.1.9
Pulse, K33.3; Respiration, K33.4.
Nursing Diagnoses and Interventions.
(NA)
Dates Managed by EMR
Biochemical Data , Medical Tests and
Managed by EMR
PROCEDURES (BD) BD 1.1.1 - BD 1.13.9
Managed by EMR (NA)
Nursing Diagnoses (NA)
Nursing Diagnoses (NA)
Managed by EMR (NA)
Managed by EMR (NA)
Nutrition Diagnosis
Intake NI 1.1 - NI 5.11.2
Nursing Diagnoses with Actual Outcomes
Clinical NC 1.1 - NC3.4
Behavioral/Environmental NB 1.1 - NB 3.3
Nutrition Assessment
Food/nutrition-related intake FH 1.1.1.1 - FH
8.1.1
Biochemical data, medical tests, and
procedures BD 1.1.1 - BD 1.13.9
Nutrition-focused physical findings PD 1.1.1 -
PD 1.1.9
Client History CH 1.1.1 - CH 3.1.9
Comparative Standards CS 1.1.1 - CS 5.1.3
Nursing Diagnoses and Nursing Interventions
Nutrition Diagnosis
Intake NI 1.1 - NI 5.11.2
Clinical NC 1.1 - NC3.4
Behavioral/Environmental NB 1.1 - NB 3.3
Nutrition Interventions
Food and/or nutrient delivery ND 1.1 - ND 6.2
Nutrition Education E 1.1 - E 2.3
Nutrition Counseling C 1.1 - C 2.11
Coordination of Nutrition Care RC 1.1 - RC 2.2
Managed by EMR (NA)
Nutrition Diagnosis
Intake NI 1.1 - NI 5.11.2
Nursing Diagnoses
Clinical NC 1.1 - NC3.4
Behavioral/Environmental NB 1.1 - NB 3.3
Medication Care Component: H; Nursing
Interventions and Definitions with Four Action Nutrition Prescription
Types
Medication Care Component: H; Nursing
(NA)
Intervention: Medication Treatment, H24.4.
Nursing Interventions: Terminal Care, E14.0;
(NA)
Dying/Death Measures, E14.2.
Nursing Diagnoses: Reproductive Risk, U59.0;
Pregnancy Risk, U60.1; Nursing Interventions:
Reproductive Care, U74.0; Fertility Care, (NA)
U74.1, Perinatal Care, U75.0; Pregnancy Care,
U75.1
Nursing Diagnoses and Interventions (NA)
Managed by EMR (NA)
Nursing Interventions (NA)
(NA)
ny nursing vocabulary that maintains mapping to SNOMED CT is applicable]
NANDA-Nursing Nursing Interventions
Diagnoses, Definitions, Classification System Omaha System
and Classification (NIC)
icable]
Nursing Management PeriOperative
Nursing Outcomes
Minimum Data Set Nursing Data Set
Classification (NOC)
(NMMDS) (PNDS)
International
Nursing Minimum Classification for
ABC Codes
Data Set (NMDS) Nursing Practice
(ICNP®)
LOINC Consolidated Entry Optional
Section DES ID
Code(s) TemplateId
Demographics Category
Person Information DES1
Language Information DES41
Support Information DES2
Provider Information DES4
Medications Category
Medications Section DES14, DES15 10160-0 2.16.840.1.113883.10.20.22.2.1
Hospital Discharge Medications Section DES16 10183-2 2.16.840.1.113883.10.20.22.2.11
Medications Administered Section[1] DES17 29549-3 Medications Administered
2.16.840.1.113883.10.20.22.2.38
18610-6 Medications
tbd
Immunizations Section DES20 11369-6 2.16.840.1.113883.10.20.22.2.2
Conditions/Concern Category
Allergies, Adverse Reactions, Alerts Section (2.2.1.2) DES5 48765-2 2.16.840.1.113883.10.20.22.2.6
Problem List Section [incl Pregnancy indication at entry DES6, DES12, 11450-4 2.16.840.1.113883.10.20.22.2.5
level] DES19
History of Past Illness Section (2.2.1.4) DES7 11348-0 2.16.840.1.113883.10.20.2.9
o DES13 11535-2 2.16.840.1.113883.10.20.22.2.24
Preoperative Diagnosis Section DES32 10219-4 2.16.840.1.113883.10.20.22.2.34
Postoperative Diagnosis Section DES33 10218-6 2.16.840.1.113883.10.20.22.2.35
Chief Complaint Section / Reason for Visit DES8 10154-3 Chief complaint
(1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1)
29299-5 Reason for Visit
(2.16.840.1.113883.10.20.22.2.12)
46239-0 Chief Complaint + Reason for Visit
(2.16.840.1.113883.10.20.22.2.13)
Reason for Referral Section DES9 42349-1 1.3.6.1.4.1.19376.1.5.3.1.3.1
History of Present Illness Section DES10 10164-2 N/A (use IHE 1.3.6.1.4.1.19376.1.5.3.1.3.4)
Medical (General) History Section 11329-0 2.16.840.1.113883.10.20.22.2.39
Procedure and Surgery Category
List of Surgeries (History of Procedures) Section DES11 47519-4 2.16.840.1.113883.10.20.22.2.7
Surgery Description Section DES34 29554-3 2.16.840.1.113883.10.20.22.2.26
Complications Section DES36 10830-8 2.16.840.1.113883.10.20.22.2.32
Operative Note Fluids Section 10216-0 2.16.840.1.113883.10.20.7.12
Operative Note Surgical Procedure Section DES35, DES37 10223-6 2.16.840.1.113883.10.20.7.14
Surgical Drains Section 11537-8 2.16.840.1.113883.10.20.7.13
Implants Section 55122-6 2.16.840.1.113883.10.20.22.2.33
Procedure Indications Section 59768-2 2.16.840.1.113883.10.20.22.2.29
Procedure Description Section 29554-3 2.16.840.1.113883.10.20.22.2.27
Postprocedure Diagnosis Section 59769-0 2.16.840.1.113883.10.20.22.2.36
Complications / Adverse Events Section 55109-3 2.16.840.1.113883.10.20.22.2.37
Anesthesia Section 59774-0 2.16.840.1.113883.10.20.22.2.25
Procedure Disposition Section 59775-7 2.16.840.1.113883.10.20.18.2.12
Procedure Estimated Blood Loss Section 59770-8 2.16.840.1.113883.10.20.18.2.9
Procedure Findings Section Relation to 59776-5 2.16.840.1.113883.10.20.22.2.28
DES35?
Procedure Implants Section 59771-6 2.16.840.1.113883.10.20.22.2.40
Planned Procedure Section 59772-4 2.16.840.1.113883.10.20.22.2.30
Procedure Specimens Taken Section 59773-2 2.16.840.1.113883.10.20.22.2.31
Care Planning/Assessment Category
Assessments Section 51848-0 2.16.840.1.113883.10.20.22.2.8
Assessment and Plan Section DES26 51487-2 2.16.840.1.113883.10.20.22.2.9
Plan of Care Section (may be used for Discharge DES27 18776-5 2.16.840.1.113883.10.20.22.2.10
Instructions)
Functional Status Section 47420-5 2.16.840.1.113883.10.20.22.2.14
Results Category
Results Section (Diagnostic Results in HITSP) DES25 30954-2 2.16.840.1.113883.10.20.22.2.3
Vital Signs Section DES22 8716-3 2.16.840.1.113883.10.20.22.2.4
DICOM Object Catalog Section 121181 N/A
Findings (Radiology Comparison Study - Observation) 18782-3 2.16.840.1.113883.10.20.6.1.2
Section
Other Templates
Payers Section DES3 48768-6 2.16.840.1.113883.10.20.22.2.18
Advance Directives Section DES18 42348-3 2.16.840.1.113883.10.20.22.2.21
Physical Exam Section DES21 29545-1 2.16.840.1.113883.10.20.2.10
Review of Systems Section DES23 10187-3 1.3.6.1.4.1.19376.1.5.3.1.3.18
Hospital Course Section (may be used as part of Discharge DES24 8648-8 1.3.6.1.4.1.19376.1.5.3.1.3.5
Summary)
Family History Section DES28 10157-6 2.16.840.1.113883.10.20.22.2.15
Social History Section(incl. smoking) DES29 29762-2 2.16.840.1.113883.10.20.22.2.17
Encounters Section DES30 46240-8 2.16.840.1.113883.10.20.22.2.22
Medical Equipment Section DES31 46264-8 2.16.840.1.113883.10.20.22.2.23
Hospital Discharge Physical Section 10184-0 N/A (1.3.6.1.4.1.19376.1.5.3.1.3.26)
General Status Section 10210-3 N/A (2.16.840.1.113883.10.20.2.5)
Objective Section 61149-1 N/A (2.16.840.1.113883.10.20.21.2.1)
Subjective Section 61150-9 N/A (2.16.840.1.113883.10.20.21.2.2)
Discharge Diet 42344-2 N/A (1.3.6.1.4.1.19376.1.5.3.1.3.33)
Hospital Discharge Studies Summary Section 11493-4 2.16.840.1.113883.10.20.22.2.16
Declared in CDA Header and may be overriden in one or
more of the specific data sections for that specific
encounter, procedure, etc
Declared in CDA Header and may be overriden in one or
more of the specific data sections for that specific
encounter, procedure, etc
[1] Requires further discussion and resolution.
Source: CDA Consolidated Ballot - Table 60
Consolidated Entry Required
Previous TemplateIds Source
TemplateId
phics Category
2.16.840.1.113883.10.20.21.1.1
[US Realm Document Header]
2.16.840.1.113883.10.20.21.1.1
[US Realm Document Header]
2.16.840.1.113883.10.20.21.1.1
[US Realm Document Header]
2.16.840.1.113883.10.20.21.1.1
[US Realm Document Header]
ons Category
2.16.840.1.113883.10.20.22.2.1.1 2.16.840.1.113883.10.20.1.8 (CCD) HL7
2.16.840.1.113883.3.88.11.83.112 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.19 IHE
2.16.840.1.113883.10.20.22.2.11.1 2.16.840.1.113883.10.20.16.2.2 (DS) HL7
2.16.840.1.113883.3.88.11.83.114 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.22 IHE
Future assignment 2.16.840.1.113883.10.20.18.2.8 (Proc Note) HL7
2.16.840.1.113883.3.88.11.83.115 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.21 IHE
Future assignment 2.16.840.1.113883.10.20.1.6 (CCD) HL7
2.16.840.1.113883.3.88.11.83.117 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.23 IHE
oncern Category
2.16.840.1.113883.10.20.22.2.6.1 2.16.840.1.113883.10.20.1.2 (CCD) HL7
2.16.840.1.113883.3.88.11.83.102 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.13 IHE
2.16.840.1.113883.10.20.22.2.5.1 2.16.840.1.113883.10.20.1.11 HL7
2.16.840.1.113883.3.88.11.83.103 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.6 IHE
2.16.840.1.113883.10.20.2.9 (H&P) HL7
2.16.840.1.113883.3.88.11.83.104 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.8 IHE
2.16.840.1.113883.10.20.16.2.1 (DS) HL7
2.16.840.1.113883.3.88.11.83.111 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.7 IHE
2.16.840.1.113883.10.20.7.1 (OpNote) HL7
2.16.840.1.113883.3.88.11.83.129 HITSP
2.16.840.1.113883.10.20.7.2 (OpNote) HL7
2.16.840.1.113883.3.88.11.83.130 HITSP
N/A (narrative-only) 2.16.840.1.113883.10.20.2.8 (H&P) HL7
2.16.840.1.113883.10.20.18.2.16 (Proc Note)
2.16.840.1.113883.3.88.11.83.105 HITSP
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 IHE
N/A (narrative-only) 2.16.840.1.113883.10.20.4.8 (Consult Note) HL7
2.16.840.1.113883.3.88.11.83.106 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.1 (narrative-only) IHE
1.3.6.1.4.1.19376.1.5.3.1.3.2 (coded)
N/A (narrative-only) 1.3.6.1.4.1.19376.1.5.3.1.3.4 HL7
2.16.840.1.113883.3.88.11.83.107 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.4 IHE
2.16.840.1.113883.10.20.18.2.5 (Proc Note) HL7
d Surgery Category
N/A (narrative-only) 2.16.840.1.113883.10.20.1.12 (CCD) HL7
HL7:2.16.840.1.113883.10.20.18.2.18 (Proc Note)
2.16.840.1.113883.3.88.11.83.108 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.12 IHE
2.16.840.1.113883.10.20.7.3 (OpNote) HL7
2.16.840.1.113883.10.20.7.10 (OpNote) HL7
2.16.840.1.113883.10.20.7.12 (OpNote) HL7
2.16.840.1.113883.10.20.7.14 (OpNote) HL7
2.16.840.1.113883.10.20.7.13 (OpNote) HL7
2.16.840.1.113883.10.20.7.15 (OpNote) HL7
2.16.840.1.113883.10.20.18.2.1 (Proc Note) HL7
2.16.840.1.113883.10.20.18.2.2 (Proc Note) HL7
2.16.840.1.113883.10.20.18.2.3 (Proc Note) HL7
2.16.840.1.113883.10.20.18.2.4 (Proc Note) HL7
2.16.840.1.113883.10.20.18.2.7 (Proc Note) HL7
2.16.840.1.113883.10.20.7.5 (OpNote)
2.16.840.1.113883.10.20.18.2.12 (Proc Note) HL7
2.16.840.1.113883.10.20.18.2.9 (Proc Note) HL7
2.16.840.1.113883.10.20.18.2.15 (Proc Note) HL7
2.16.840.1.113883.10.20.18.2.11 (Proc Note) HL7
2.16.840.1.113883.10.20.18.2.6 (Proc Note) HL7
2.16.840.1.113883.10.20.18.2.10 (Proc Note) HL7
ssessment Category
Need to assign 2.16.840.1.113883.10.20.2.7 (H&P) HL7
2.16.840.1.113883.10.20.18.2.13 (Proc Note)
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4 HITSP
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4 IHE
Need to assign 2.16.840.1.113883.10.20.2.7 (H&P) HL7
2.16.840.1.113883.10.20.18.2.14 (Proc Note)
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5 IHE
Need to assign 2.16.840.1.113883.10.20.2.7 (H&P) HL7
2.16.840.1.113883.10.20.1.10 (CCD)
2.16.840.1.113883.3.88.11.83.124 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.31 IHE
Need to assign 2.16.840.1.113883.10.20.1.5 (CCD) HL7
2.16.840.1.113883.3.88.11.83.109 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.17 IHE
s Category
2.16.840.1.113883.10.20.22.2.3.1 2.16.840.1.113883.10.20.1.14 (CCD) HL7
2.16.840.1.113883.3.88.11.83.122 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.28 IHE
2.16.840.1.113883.10.20.22.2.4.1 2.16.840.1.113883.10.20.1.16 (CCD) HL7
2.16.840.1.113883.10.20.2.4 (H&P)
2.16.840.1.113883.3.88.11.83.119 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.25 IHE
2.16.840.1.113883.10.20.6.1.1 2.16.840.1.113883.10.20.6.1.1 HL7
2.16.840.1.113883.10.20.6.1.2 HL7
Templates
Need to assign 2.16.840.1.113883.10.20.1.9 (CCD) HL7
2.16.840.1.113883.3.88.11.83.101.1 HITSP
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7 IHE
Need to assign 2.16.840.1.113883.10.20.1.1 (CCD) HL7
2.16.840.1.113883.3.88.11.83.116 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.34 (narrative-only) IHE
1.3.6.1.4.1.19376.1.5.3.1.3.35 (coded)
Need to assign 2.16.840.1.113883.10.20.2.10 (H&P) HL7
2.16.840.1.113883.3.88.11.83.118 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.24 (narrative-only) IHE
1.3.6.1.4.1.19376.1.5.3.1.1.9.15 (coded)
N/A (narrative-only) 2.16.840.1.113883.10.20.4.10 (Consult) HL7
2.16.840.1.113883.3.88.11.83.120 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.18 IHE
N/A (narrative-only) 1.3.6.1.4.1.19376.1.5.3.1.3.5 HL7
2.16.840.1.113883.3.88.11.83.121 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.5 IHE
Need to assign 2.16.840.1.113883.10.20.1.4 (CCD) HL7
2.16.840.1.113883.10.20.18.2.17 (Proc Note)
2.16.840.1.113883.3.88.11.83.125 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.14 (narrative-only) IHE
1.3.6.1.4.1.19376.1.5.3.1.3.15 (coded)
N/A (no stds require entry) 2.16.840.1.113883.10.20.1.15 (CCD) HL7
2.16.840.1.113883.3.88.11.83.126 HITSP
1.3.6.1.4.1.19376.1.5.3.1.3.16 IHE
Need to assign 2.16.840.1.113883.10.20.1.3 (CCD) HL7
2.16.840.1.113883.3.88.11.83.127 HITSP
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3 IHE
Need to assign 2.16.840.1.113883.10.20.1.7 (CCD) HL7
2.16.840.1.113883.3.88.11.83.128 HITSP
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5 IHE
N/A (narrative-only) N/A – Used IHE HL7
1.3.6.1.4.1.19376.1.5.3.1.3.26 IHE
N/A (narrative-only) 2.16.840.1.113883.10.20.2.5 (H&P) HL7
N/A (narrative-only) 2.16.840.1.113883.10.20.22.2.1 (Prog Note) HL7
N/A (narrative-only) 2.16.840.1.113883.10.20.22.2.2 (Prog Note) HL7
N/A (narrative-only) N/A – Used IHE HL7
1.3.6.1.4.1.19376.1.5.3.1.3.33 IHE
N/A (no stds require entry) 2.16.840.1.113883.10.20.16.2.3 (DS) HL7
Nursing Documentation
Any nursing vocabulary that maintains mapping to SNOMED CT is
applicable (e.g. CCC Mapping Notes)
Managed by EMR
Nursing Diagnosis: Communication, M28.0; Nursing Intervention: Communication
Care, M38.0
Role Relationship Care Component: M; Nursing Diagnoses: Role Performance,
M27.0; Parental Role, M27.1; Parenting, M27.2; Caregiver, M27.4, Family Process,
M29.0; Nursing Interventions: Home Situation, M39.1; Interpersonal Dynamics
Analysis, M39.2; Fmaily Process Analysis, M39.3; Social Network Analysis, M39.5.
Managed by EMR
Medication Care Component: H
Medication Care Component: H
Medication Care Component: H; Nursing Intervention: Medication Treatment,
H24.4.
Nursing Interventions: Medication Care, H24.0; Medication Treatment, H24.4;
Immunologic Care, I65.0.
Nursing Diagnoses: Endocrine Alteration, I22.0; Immunologic Alteration, I23.0; Latex
Allergy Response, R46.5; Nursing Interventions: Allergic Reaction Care, I26.0;
Immunologic Care, I65.0
Nursing Diagnoses
Physical Regulation Care Component: K; Nursing Diagnoses; Nursing Intervention:
Health History, K31.1
Nursing Diagnoses
Nursing Diagnoses
21 Care Components; Nursing Diagnoses
Managed by EMR
Managed by EMR
Managed by EMR
Managed by EMR
Managed by EMR
Nursing Diagnoses and Interventions
Fluid Care Component: F; Nursing Interventions
Managed by EMR
Skin Integrity Care Component: R; Nursing Intervention: Drainage Tube Care, R55.1
Skin Integrity Care Component: R
Nursing Diagnoses
Managed by EMR
Nursing Diagnoses
Nursing Diagnoses and Interventions
Managed by EMR
Managed by EMR
Managed by EMR
Managed by EMR
Managed by EMR
Nursing Interventions
Physical Regulation Care Component: K; Nursing Interventions: Specimen Care,
K32.0; Blood Specimen Care, K32.1; Stool Specimen Care, K32.2; Urine Specimen
Care, K32.3; Sputum Specimen Care, K32.5
21 Care Components
Nursing Diagnoses and Interventions
Nursing Diagnoses, Interventions, and Intervention Action Types
Nursing Diagnoses and Interventions
Managed by EMR
Nursing Interventions: Vital Signs, K33.0; Blood Pressure, K33.1; Temperature, K33.2;
Pulse, K33.3; Respiration, K33.4.
Managed by EMR
Managed by EMR
Managed by EMR
Nursing Interventions: Terminal Care, E14.0; Dying/Death Measures, E14.2.
Nursing Interventions: Physical Examination, K31.3; Clinical Measurements, K31.4
21 Care Components
Nursing Diagnoses and Interventions
Role Relationship Care Component: M
Role Relationship Care Component: M
Managed by EMR
Nursing Interventions: Equipment Safety, N42.2; Individual Safety, N42.3; Safety
Precauations, N42.0; Enviromental Safety, N42.1.
Managed by EMR
Managed by EMR
Managed by EMR
Managed by EMR
Nutrition Care Component: J; Nursing Diagnosis: Nutrition, J24.0; Nursing
Intervention: Regular Diet, J29.3; Special Diet, J29.4; Enteral Feeding, J29.3
Managed by EMR
Link to CCC Wikipedia:
http://en.wikipedia.org/wiki/Clinical_Care_Classification_System
Code structure:
The CCC System uses a five-character structure to code the two
terminologies: (1) CCC of Nursing Diagnoses and Outcomes and (2) CCC of
Nursing Interventions and Actions. The CCC coding structure is paced on the
format of the International Statistical Classification of Diseases and Related
Health Problems: Tenth Revision: Volume 1, WHO, 1992 . The coding strategy
[19]
for each terminology consists of the following (Saba, 2007): The graphic
shows examples of the coding structure for a CCC diagnosis code and a CCC
intervention code.
First position: One alphabetic character code for Care Component
(A to U);
Second and Third positions: Two-digit code for a Core Concept
(major category) followed by a decimal point;
Fourth position: One-digit code for a subcategory, if available, followed by a
decimal point;
Fifth position: One-digit code for: one of three Expected or Actual Outcomes
and /or one of four Nursing Intervention Action Types.
Nutrition - IDNT
Food and Nutrition Related History FH 1.1.1.1-FH 7.3.11
Antropometric Measurements AD 1.1.1-AD 1.1.7
Height, weight, body mass index (BMI), growth
pattern indices/percentile ranks, and weight
history.