There are two tables below. The first one maps data elements in the CDA Header. These are supported in all CDA Documents (not just those in the Consolidated Guide).
The second table maps data elements to CDA Sections, listing the CDA Consolidation Guide section, and the entries needed in that section to conform to Meaningful Use. On the right hand side it shows which of those sections appear in the different documents in the consolidation guide. In looking at this table, it seems impossible to meet the Meaningful Use requirements with the CDA Consolidation guide, but you should realize that you can add sections to any of the documents in the CDA Consolidation Guide that are appropriately specified, so if it were appropriate in a provider workflow to generate a Consultation Note, but it didn't have a section listed as being optional (O) or required (R) for Patient Instructions, you could still include the Instructions Section (perhaps as a subsection under the Care Plan).
It appears from this spreadsheet, that the Consultation Note, CCD 1.1, Discharge Summary and History and Physical Note, Procedure Note and Progress Note could all readily meet the Meaningful Use requirements with just a few added sections. The operative note doesn't really work without adding quite a few sections that fall outside of the normal workflows for documenting a surgical procedure, but could still be made to work.
I've updated the spreadsheet from yesterday from which these tables came, linking the first sheet to the appropriate rows from these two tables. Maybe we can convince Robin Raiford to make a pretty poster out of this one too.
Section Data Elements | Section Type | Section Template(s) | CDA Entries | Entry Template(s) | Notes | Consultation Note | Continuity of Care Document | Discharge Summary | History and Physical | Procedure Note | Operative Note | Progress Note |
Smoking | Social History | 2.16.840.1.113883.10.20.22.2.17 | Social History Observation | 2.16.840.1.113883.10.20.22.4.38 | observation/code = SNOMED CT:229819007 observation/value needs a vocabulary (possibly SNOMED) and value set for: Current every day smoker; current some day smoker; former smoker; never smoker; smoker, current status unknown; and unknown if ever smoked | O | O | O | O | O | ||
Vitals | Vital Signs | 2.16.840.1.113883.10.20.22.2.4.1 | Vital Signs Organizer | 2.16.840.1.113883.10.20.22.4.26 | O | O | O | R | O | |||
Vital Signs Observation | 2.16.840.1.113883.10.20.22.4.27 | |||||||||||
Problems | Problem | 2.16.840.1.113883.10.20.22.2.5 | Problem Concern Act | 2.16.840.1.113883.10.20.22.4.3 | O | R | O | O | O | |||
Problem Observation | 2.16.840.1.113883.10.20.22.4.4 | |||||||||||
History of Past Illness | 2.16.840.1.113883.10.20.22.2.20 | Problem Observation | 2.16.840.1.113883.10.20.22.4.4 | Relevant Past problems (not recent history) | O | O | R | O | ||||
Medications | Medications | 2.16.840.1.113883.10.20.22.2.1.1 | Medication Activity | 2.16.840.1.113883.10.20.22.4.16 | O | R | O | O | O | |||
Admission Medications | 2.16.840.1.113883.10.20.22.4.36 | Medication Activity | 2.16.840.1.113883.10.20.22.4.16 | Template does not require Medication Activity, but Rule does | O | |||||||
Hospital Discharge Medic | 2.16.840.1.113883.10.20.22.2.11.1 | Medication Activity | 2.16.840.1.113883.10.20.22.4.16 | R | ||||||||
Medications Administere | 2.16.840.1.113883.10.20.22.2.38 | Medication Activity | 2.16.840.1.113883.10.20.22.4.16 | O | ||||||||
Allergies | Allergy | 2.16.840.1.113883.10.20.22.2.6.1 | Allergy Problem Act | 2.16.840.1.113883.10.20.22.4.30 | O | R | O | O | O | O | ||
Allergy Observation | 2.16.840.1.113883.10.20.22.4.7 | |||||||||||
Procedures | Procedures | 2.16.840.1.113883.10.20.22.2.7.1 | Procedure Activity Act | 2.16.840.1.113883.10.20.22.4.12 | O | O | O | O | O | |||
Procedure Activity Observation | 2.16.840.1.113883.10.20.22.4.13 | |||||||||||
Procedure Activity Procedure | 2.16.840.1.113883.10.20.22.4.14 | |||||||||||
Labs | Lab Results | 2.16.840.1.113883.10.20.22.2.3.1 | Results Organizer | 2.16.840.1.113883.10.20.22.4.1 | O | R | R | O | ||||
Results Observation | 2.16.840.1.113883.10.20.22.4.2 | |||||||||||
Patient Instructions | Instructions | 2.16.840.1.113883.10.20.22.2.45 | Instructions | 2.16.840.1.113883.10.20.22.4.20 | May be included in Care Plan section | |||||||
Reason for Visit/Admission | Reason for Visit | 2.16.840.1.113883.10.20.22.2.12 | Problem Observation | 2.16.840.1.113883.10.20.22.4.4 | O | O | O | O | ||||
Chief Complaint and Reason for Visit | 2.16.840.1.113883.10.20.22.2.13 | Problem Observation | 2.16.840.1.113883.10.20.22.4.4 | O | O | O | O | |||||
Chief Complaint | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 | Problem Observation | 2.16.840.1.113883.10.20.22.4.4 | O | O | O | O | O | ||||
Reason for Referral | 1.3.6.1.4.1.19376.1.5.3.1.3.1 | Problem Observation | 2.16.840.1.113883.10.20.22.4.4 | O | ||||||||
Admission Diagnosis | 2.16.840.1.113883.10.20.22.2.43 | Problem Observation | 2.16.840.1.113883.10.20.22.4.4 | |||||||||
Preoperative Diagnosis | 2.16.840.1.113883.10.20.22.2.34 | Preoperative Diagnosis | 2.16.840.1.113883.10.20.22.4.65 | R | ||||||||
Care Plan | Care Plan | 2.16.840.1.113883.10.20.22.2.10 | O | O | R | O | O | O | O | |||
Assessment and Plan | 2.16.840.1.113883.10.20.22.2.9 | Plan of Care Activity Act | 2.16.840.1.113883.10.20.22.4.39 | O | O | O | O | |||||
Plan of Care Activity Encounter | 2.16.840.1.113883.10.20.22.4.40 | |||||||||||
Plan of Care Activity Observation | 2.16.840.1.113883.10.20.22.4.44 | |||||||||||
Plan of Care Activity Procedure | 2.16.840.1.113883.10.20.22.4.41 | |||||||||||
Plan of Care Activity Substance Administration | 2.16.840.1.113883.10.20.22.4.42 | |||||||||||
Plan of Care Activity Supply | 2.16.840.1.113883.10.20.22.4.43 | |||||||||||
Diagnosis | Assessment | 2.16.840.1.113883.10.20.22.2.8 | Problem Observation | 2.16.840.1.113883.10.20.22.4.4 | @codeSystem = 2.16.840.1.113883.6.90 (ICD-10-CM) | |||||||
Assessment and Plan | 2.16.840.1.113883.10.20.22.2.9 | Problem Observation | 2.16.840.1.113883.10.20.22.4.4 | |||||||||
Hospital Discharge Diagnosis | 2.16.840.1.113883.10.20.22.4.33 | Problem Observation | 2.16.840.1.113883.10.20.22.4.4 | |||||||||
Postoperative Diagnosis | 2.16.840.1.113883.10.20.22.2.35 | Problem Observation | 2.16.840.1.113883.10.20.22.4.4 | R | ||||||||
Postprocedure Diagnosis | 2.16.840.1.113883.10.20.22.2.36 | Postprocedure Diagnosis | 2.16.840.1.113883.10.20.22.4.51 | R | ||||||||
Immunizations Administere | Immunization | 2.16.840.1.113883.10.20.22.2.2.1 | Immunization Activity | 2.16.840.1.113883.10.20.22.4.52 | O | O | O | O | ||||
Patient Decision Aids | Instructions | 2.16.840.1.113883.10.20.22.2.45 | Instructions | 2.16.840.1.113883.10.20.22.4.20 | Details about Patient Decision Aids should appear in the Instructions section. | |||||||
Futured Scheduled Tests | Care Plan | 2.16.840.1.113883.10.20.22.2.10 | Plan of Care Activity Observation | 2.16.840.1.113883.10.20.22.4.44 | Details about future tests should appear in the care plan section | |||||||
Futured Scheduled Visits | Care Plan | 2.16.840.1.113883.10.20.22.2.10 | Plan of Care Activity Encounter | 2.16.840.1.113883.10.20.22.4.40 | Details about future visits should appear in the care plan section | |||||||
Referrals | Care Plan | 2.16.840.1.113883.10.20.22.2.10 | Plan of Care Activity Encounter | 2.16.840.1.113883.10.20.22.4.40 | Details about referrals should appear in the care plan section |
I just asked Robin-stand by!
ReplyDeleteHello,
ReplyDeleteI am looking for a sample CCDA for Clinical Office Visit Summary but i had no luck. I have created one by using the guide but it fails when I run through the validation tool. I would appreciate if you can help on that.
Thanks...
Anonymous: What you need is someone to help you on a discussion forum. I have successfully implemented the MU Stage 1 requirements in producing a Level 3 CDA document using the mdht api. The people there are very responsive. I can help you there if you post your questions.
ReplyDeleteI can't access "Care Plan" https://www.blogger.com/blogger.g?blogID=733074358901582680&pli=1
ReplyDeleteYour current account (######@#####.###) does not have access to view this page.
:'( <== Sad face there
Also I didn't find a way to send you a message mister Keith