Co-Chair: Craig Gabron Blue Cross Blue Shield of South Carolina Co-Editor: Dan Kalwa CMS Co-Editor: Robert Dieterle Enablecare, LLC Co-Editor: Mark Pilley, MD StrategicHealthSolutions, LLC Co-Editor: Viet Nguyen, MD Systems Made Simple Co-Editor Bob Yencha RTY, LLC include in the ONC S&I Framework HL7 Attachments Work Group
fulfilment of the order. The process of and fulfillment of the order is represented by other entries. ntry-level template hich data is not available have the appropriate nullFlavor specified (see section 3.4 regarding the use of nullFlavors). SHALL contain exactly one [1..1] templateId (2901) such that it SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.35.2.3” (2902). SHALL contain exactly one [1..1] code (2903). This code SHALL contain exactly one [1..1] @code="TBD” Orders Placed (2904). This code contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (2905). contain exactly one [1..1] title (2906).
contain exactly one [1..1] templateId (CONF:7936) such that it SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20." (3401). SHALL contain exactly one [1..1] code (3402). This code SHALL contain exactly one [1..1] @code="29762-2" Social History (3403). This code contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC 2.16.840.1.113883.6.1) (3404). contain exactly one [1..1] title (3405). SHALL contain exactly one [1..1] text (3406). SHALL contain one or more [1..*] entry (3407) such that it SHALL contain exactly one [1..1] (3408). SHALL contain one or more [1..*] entry (3409) such that it SHALL contain exactly one [1..1] (3410). contain one or more [1..*] entry (3411) such that it SHALL contain exactly one [1..1] (V2) (3412). SHALL contain one or more [1..*] entry (3413) such that it SHALL contain exactly one [1..1] (3414). contain one or more [1..*] entry (3415) such that it SHALL contain exactly one [1..1] (3416). SHALL contain one or more [1..*] entry (3417) such that it SHALL contain exactly one [1..1] Cultural and Religious Observation (3418). contain one or more [1..*] entry (3419) such that it contain exactly one [1..1] Characteristics of Home Environment (3420).
Figure 26: Externally Defined CDE () Example <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.35.4.3"/> <id root="7c0704bb-9c40-41b5-9c7d-26b2d59e234f"/> <code code="TBD" <name> <CMS=”2.16.840.1.113883.10.20.35.5.111”> This is the question </ CMS=”2.16.840.1.113883.10.20.35.5.111”> </name> <answer> This is the value that was entered by the provider </answer> </value> </observation> Externally Defined CDE Organizer () [act: templateId 2.16.840.1.113883.10.20.35.4.4 (open)] Table 31: Externally Defined CDE () Contexts Contained By: Contains: Externally Defined Clinical Data Elements Section () Author Participation Externally Defined CDE () This template provides a mechanism for grouping externally defined CDEs on the external template used to collect the name-value pairs or model. It contains information applicable to all externally defined CDEs. The Externally Defined CDE Organizer categorizes the contained CDEs based on their template library (e.g., “CMS Table 32: Externally Defined CDE Organizer Constraints Overview XPath Card. Verb Data Type CONF# Fixed Value organizer[templateId/@root = '2.16.840.1.113883.10.20.35.4.4'] @classCode 1..1 SHALL 3801 2.16.840.1.113883.5.6 (HL7ActClass) @moodCode 1..1 SHALL 3802 2.16.840.1.113883.5.1001 (ActMood) = EVN templateId 1..1 SHALL 3803 @root 1..1 SHALL 3804 text 1..1 SHALL 3805 @mediaType 1..1 SHALL 3806 application/CDE
The other document types defined in the C-CDA R2 may be used for any of the original intended clinical or administrative purposes where the provider deems the information contained in the document type for the encounter necessary and sufficient for the intended purpose. D.4 Contents of New Document Templates Each new document-level template contains, all of the sections defined for the C-CDA R2 document level template(s) listed. Please note that all new document templates require the contents of each section or a null flavor to define why the information is not included (see Section 3.4 on use of null flavors). Each new document type includes additional section level templates that are defined or additionally constrained in this implementation guide. Encounter Document includes all: C-CDA R2 Progress Note Document sections C-CDA R2 Consult Document sections C-CDA R2 History and Physical Document sections Document includes all: C-CDA R2 Discharge Summary Document sections C-CDA R2 History and Physical Document sections Procedure Document includes all: C-CDA R2 Procedure Document sections Operative Note Document includes all: C-CDA R2 Operative Note Document sections Document has no equivalent templates. D.5 Comparison Tables The following tables provide a comparison of the new Document templates in this implementation guide versus the existing Document Level templates in the C-CDA R2. Definitions: