Reason for Visit C-CDA Coded Social History Results (entries optional) O[0..1] C-CDA Ocular Physical Exam Review of Systems R[0..1] GEE, C-CDA Assessment and Plan Social History R[0..1] GEE, C-CDA, IRIS REGISTRY Signs (entries optional) O[0..1] C-CDA, IRIS REGISTRY Encounters (entries optional) O[0..1] IRIS REGISTRY Functional Status R[0..1] GEE Healthcare Providers and Pharmacies R[0..1] GEE, IRIS REGISTRY Instructions O[0..1] IRIS REGISTRY List of Surgeries R[0..1] GEE Coded List of Surgeries O[0..1] GEE Medications (entries required) R[0..1] GEE, IRIS REGISTRY Ocular History R[0..1] GEE, IRIS REGISTRY Ocular Physical Exam M[1..1] GEE, IRIS REGISTRY Ophthalmic Medications R[0..1] GEE, IRIS REGISTRY Problem (entries required) R[0..1] GEE, IRIS REGISTRY *Shall include an Assessment and Plan Section or an (Assessment Section and a Plan Section). Shall Not include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present. **Shall Not include a combined Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section. ***Shall include a Reason for Referral or Reason for Visit section. 3
6.3.2.16.1.2 <methodCode code=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT '/> The methodCode element SHALL be used to record the specific method used to make an observation. SNOMED CT Procedure hierarchy (71388002) SHOULD be used for method codes; however, other code sets MAY be used, if desired. The following SNOMED CT codes represent a very limited list of examples; it is not an exhaustive list for implementation. Code Value Code Description 398891008 Slit lamp biomicroscopy 76949005 Gonioscopy 414273009 Fluorescein staining of eye ----- ------ 6.3.2.16.1.3 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/> If there is an interpretation that can be performed using an observation result (e.g., high, borderline, normal, low), these MAY be recorded within the interpretationCode element. The SNOMED CT Clinical Findings hierarchy (404684003) SHOULD be used for interpretation however, other code sets MAY be used, if desired (e.g., ICD-10). The following SNOMED CT codes represent a very limited list of examples; it is not an exhaustive list for implementation. Code Value Code Description 301926003 Conjunctiva normal 301928002 Central corneal epithelial staining pattern 301929005 Peripheral corneal epithelial staining pattern 301936006 Anterior chamber of eye normal 314016000 Age-related lens opacity 370952005 Decreased tear film break-up ----- ------ 6.3.2.17 Posterior Segment 1.3.6.1.4.1.19376.1.12.1.2.18 Template ID 1.3.6.1.4.1.19376.1.12.1.2.18 Parent Template General Description The posterior segment section shall contain a description of any type of posterior segment exam.
163983009 On examination – retina normal ----- ------ 6.3.2.18 Lacrimal Template ID 1.3.6.1.4.1.19376.1.12.1.2.14 Parent Template General Description An examination of lacrimal structure and function. Section Code 70945-1, LOINC, “Lacrimal” Opt Data Element or Section Name Template ID Specification Document Constraint Entries R[1..*] Ocular Observation 1.3.6.1.4.1.19376.1.12.1.3.1 Example XML Code <component> <section> <templateId root='1.3.6.1.4.1.19376.1.12.1.2.14'/> <id root=' ' extension=' '/> <code code='70945-1' displayName='Lacrimal' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text> <entry> : <!-- Required Ocular Observation --> <templateId root='1.3.6.1.4.1.19376.1.12.1.3.1'/> : </entry> </section> </component> 6.3.2.18.1 Lacrimal Constraints This section specifies the constraint requirements for the Lacrimal content module section.
R [0..1] 246155009, SNOMED-CT, Type of lens CD 50121007, Single vision glasses 397283008, SNOMED-CT, Multifocal glasses 397285001, SNOMED-CT, Bifocal glasses 397284002, SNOMED-CT, Trifocal glasses 397286000, SNOMED-CT, Progressive addition glasses if applicable R[0..1] 50121007, SNOMED-CT, Eyeglasses ST Description of the eye glasses (physical object being measured) R [0..1] 397258008, SNOMED-CT, Interpupillary distance PQ mm 6.3.3.9.6 <text><reference value='#xxx'/></text> -OR- <text>text</text> Each lensometry observation measurement entry MAY contain a <text> element providing the free text that provides the same information as the observation within the narrative portion of the document with a <text> element. For CDA based uses of Lensometry Observations, this element SHALL be present, and SHALL contain a <reference> element that points to the related string in the narrative portion of the document. For HL7 Version 3 based uses, the <text> element MAY be included. 6.3.3.9.7 <statusCode code='completed'/> The status code of all observations SHALL be completed. 6.3.3.9.8 <effectiveTime value=' '/> The <effectiveTime> element SHALL be present in standalone observations and shall record the date and time when the measurement was taken. This element SHOULD be precise to the day. If the date and time is unknown, this element SHOULD record that using the nullFlavor attribute. Note: The organizer is required to capture the <effectiveTime> so if a nullFlavor is provided for the value of the underlying observation the <effectiveTime> can be inferred from the organizer.