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Encounter Summary C-CDA Specificationathenahealth, Inc.Version 16.9 Published: September 2016

athenahealth, Inc.

Encounter Summary C-CDA Specification

1 Table of Contents1 TABLE OF CONTENTS..........................................................................................................22 OVERVIEW.........................................................................................................................53 DOCUMENT LEVEL SPECIFICATION.......................................................................................63.1 ENCOUNTER SUMMARY..................................................................................................................................6

3.1.1 Purpose........................................................................................................................................... 63.1.2 Trigger(s)........................................................................................................................................ 63.1.3 Sections Supported.........................................................................................................................6

4 SECTIONS..........................................................................................................................74.1 SECTION CREATION...................................................................................................................................... 75 HEADER SECTION...............................................................................................................8

5.1.1 XML Data Elements.........................................................................................................................85.1.1.1 ClinicalDocument..........................................................................................................................................85.1.1.2 Patient..........................................................................................................................................................85.1.1.3 Author (athenaHealth)..................................................................................................................................95.1.1.1 Custodian..................................................................................................................................................... 95.1.1.1 DocumentationOf.........................................................................................................................................95.1.1.2 ComponentOf, EncompassingEncounter....................................................................................................10

6 REASON FOR VISIT SECTION..............................................................................................126.1.1 XML Data Elements.......................................................................................................................126.1.2 Reason for Visit – XML Example....................................................................................................12

7 INSTRUCTIONS SECTION...................................................................................................137.1.1 XML Data Elements.......................................................................................................................137.1.2 Instructions Section – XML Example..............................................................................................14

8 PLAN OF CARE SECTION....................................................................................................158.1.1 XML Data Elements.......................................................................................................................15

8.1.1.1 Future Encounter........................................................................................................................................158.1.1.2 Future Test.................................................................................................................................................168.1.1.3 Goal............................................................................................................................................................168.1.1.4 Instructions.................................................................................................................................................17

8.1.2 Plan of Care – XML Example..........................................................................................................19

9 MEDICATIONS SECTION.....................................................................................................219.1.1 XML Data Elements.......................................................................................................................21

9.1.1.1 Medication Activity.....................................................................................................................................219.1.1.2 Medication Information...............................................................................................................................229.1.1.3 Instructions.................................................................................................................................................22

9.1.2 Medications – XML Example..........................................................................................................23

10 MEDICATIONS ADMINISTERED SECTION...........................................................................2410.1.1 XML Data Elements.....................................................................................................................24

10.1.1.1 Medications Activity.................................................................................................................................2410.1.1.2 Medication Information.............................................................................................................................2510.1.1.3 Instructions...............................................................................................................................................25

www.athenahealth.com athenahealth, Inc. Confidential and Proprietary 2

http://www.athenahealth.com/


10.1.2 Medications Administered – XML Example..................................................................................26

11 VITAL SIGNS SECTION.....................................................................................................2711.1.1 XML Data Elements.....................................................................................................................27

11.1.1.1 Vitals Organizer........................................................................................................................................2711.1.1.2 Vitals Observation....................................................................................................................................28

11.1.2 Vital Signs – XML Example..........................................................................................................29

12 LAB RESULTS SECTION....................................................................................................3012.1.1 XML Data Elements.....................................................................................................................30

12.1.1.1 Result Organizer.......................................................................................................................................3012.1.1.2 Result Observation...................................................................................................................................31

12.1.2 Lab Results – XML Sample...........................................................................................................32

13 ALLERGIES SECTION.......................................................................................................3313.1.1 XML Data Elements.....................................................................................................................33

13.1.1.1 Allergies, Adverse Reactions, Alerts.........................................................................................................3313.1.1.2 Assertion...................................................................................................................................................3413.1.1.3 Participant................................................................................................................................................3413.1.1.4 Reaction Observation...............................................................................................................................3513.1.1.5 Severity Observation................................................................................................................................35

13.1.2 Supported List of Reactions and Severities.................................................................................3613.1.3 NKDA Behavior............................................................................................................................3613.1.4 No Known Allergies Entry............................................................................................................3613.1.5 NKDA Behavior - XML Example....................................................................................................36

14 PROBLEMS SECTION.......................................................................................................3914.1.1 XML Data Elements.....................................................................................................................39

14.1.1.1 Problem Concern Act (Condition).............................................................................................................3914.1.1.2 Problem Observation................................................................................................................................39

14.1.2 Problems – XML Example............................................................................................................41

15 PROCEDURES SECTION....................................................................................................4215.1.1 XML Data Elements.....................................................................................................................42

15.1.1.1 Procedure Activity Procedure...................................................................................................................4215.1.1.2 Procedure Activity Observation................................................................................................................4315.1.1.3 Procedure Activity Act..............................................................................................................................44

15.1.2 Procedures – XML Example.........................................................................................................44

16 IMMUNIZATIONS SECTION...............................................................................................4616.1.1 XML Data Elements.....................................................................................................................4616.1.2 Immunization – XML Example......................................................................................................47

17 SOCIAL HISTORY SECTION...............................................................................................4817.1.1 XML Data Elements.....................................................................................................................48

17.1.1.1 Smoking Status Observation....................................................................................................................48Smoking Status Mapping Table..............................................................................................................4917.1.2 Smoking Status – XML Example..................................................................................................49

18 PAST ENCOUNTERS SECTION...........................................................................................5018.1.1 XML Data Elements.....................................................................................................................50

18.1.1.1 Encounter Activities..................................................................................................................................5018.1.1.2 Performer, Location..................................................................................................................................50




18.1.1.3 Patient......................................................................................................................................................5118.1.1.4 Encounter Diagnosis.................................................................................................................................52

18.1.2 Past Encounter – XML Example...................................................................................................53

19 HISTORY OF PRESENT ILLNESS SECTION..........................................................................5419.1.1 XML Data Elements.....................................................................................................................5419.1.2 History of Present Illness – XML Example....................................................................................54

20 REVIEW OF SYSTEMS SECTION........................................................................................5520.1.1 XML Data Elements.....................................................................................................................5520.1.2 Review of Systems – XML Example.............................................................................................55

21 PHYSICAL EXAM SECTION................................................................................................5621.1.1 XML Data Elements.....................................................................................................................5621.1.1 Physical Exam – XML Example....................................................................................................56




2 OverviewThis C-CDA Specification (CCDA Spec) is an implementation guide that provides an understanding of the Encounter Summary document created using Health Level 7’s (HL7) Consolidated CDA Standard. This standard governs the format of the document in accordance with measures defined by Meaningful Use Stage 2. The content within the document is defined both by HL7 and Meaningful Use. This athenahealth specification will contain additional, unique details and is to be used in conjunction with the HL7 Implementation Guide.The most basic specification for all of these documents is HL7’s Clinical Document Architecture, a document markup (XML) standard defined by HL7. As of July 2012, HL7 released an implementation guide for the “Consolidated Clinical Document Architecture” (CCDA). Building off of the CDA standard, the CCDA defines requirements for both a “header” which remains consistent across all documents and also sections which are used to construct different document types. Each section is comprised of entries, a defined structure for storing specific clinical data. The Encounter Summary is constructed using the document type “Continuity of Care Document” (CCD). By adding different sections, the CCD v1.1 can be used to satisfy different Meaningful Use requirements.

For more information on Meaningful Use visit: http://www.healthit.gov/policy-researchers-implementers/meaningful-use-resources

For more information about the mark up standard visit: http://www.hl7.org/


Additional Info. Header

Results Header

MU2 Measure

Encounter Summary

170.317(e)(2): Provide clinical summaries for

patients for each office visitProcedures

Problems

MedicationsAllergies

Header

athenaNet

CCD 1.1: Continuity of Care Document

CCDA


http://www.hl7.org/

http://www.healthit.gov/policy-researchers-implementers/meaningful-use-resources


3 Document Level Specification3.1 Encounter Summary 3.1.1 PurposeThe Encounter Summary is an episodic document that satisfies the Meaningful Use 2 measure 170.317(e)(2): Provide clinical summaries for patients for each office visit.

3.1.2 Trigger(s)The Encounter Summary is generated to give to a patient after an encounter is completed in order to provide a summary of the most recent encounter.

3.1.3 Sections SupportedSection DescriptionHeader Document, Patient, and Provider InformationReason for Visit Symptoms as reported by the patientInstructions Instructions for the patient: clinical instructions, patient decision aidsPlan of Care Goals and instructions for the patientMedications List of active and completed medicationsMedications Administered Medications given to the patient during the office visitVital Signs List of historical vital signs: height, weight, blood pressure, BMILab Results List of historical lab resultsAllergies List of active and deactivated allergiesProblems List of active and unknown problemsProcedures List of historical proceduresImmunizations List of vaccines and immunizationsSocial History Current smoking statusPast Encounters List of encounter dates, encounter providers, and encounter diagnosesHistory of Present Illness Description of current illnessReview of Systems Description of the physician’s review of the patient’s systemsPhysical Exam Description of the physician’s physical exam of the patient




4 Sections4.1 Section CreationThe consolidated CDA standard (CCDA) is comprised of over 60 sections. Each section is constructed using entries which define and hold clinical data within the XML schema. Located at the top of each section is an entry dedicated to free text. This entry is used to surface all the relevant clinical data from its corresponding section. These values are pulled from the XML structure and wrapped in basic HTML tags. A complete CCDA is used in conjunction with an XSLT style-sheet to read these values and their HTML tags.


XML

HTML

Entry Static Data

o Template IDo Statuso Mood Code

Dynamic Datao Effective Time = “A”o Value = “B”o Code = “C”o CodeSet = “D”

EntryEffecti

ve Time

Value Code CodeSet

A B C D



5 Header SectionThe header is consistent across all athenahealth CCDA documents. Its purpose is to provide basic information pertaining to the patient, provider, and encounter.

5.1.1 XML Data Elements

5.1.1.1 ClinicalDocument

Subject XPath Code Set & Mapping DescriptionRealm /ClinicalDocument/realmCode “US”Type /ClinicalDocument/typeID root="2.16.840.1.113883.1.3"

extension="POCD_HD000040"HL7 Registered Model

CCDA Template

/ClinicalDocument/templateId

root="2.16.840.1.113883.10.20.22.1.1” root="2.16.840.1.113883.10.20.22.1.2”

Denotes document is a CCDA

Global Doc ID /ClinicalDocument/id GUID Unique document ID

Document Code

/ClinicalDocument/code

LOINCcode=”34133-9”codeSystem=”2.16.840.1.113883.6.1”

Document Template: ‘Summarization of Episode Note’

Document Title /ClinicalDocument/title ‘Encounter Summary’

Doc Creation Time /ClinicalDocument/effectiveTime US Realm Date/Time Date the document

was createdConfidentiality /ClinicalDocument/confidentialityCode HL7 Confidentiality Found in HL7

Implementation GuideLanguage /ClinicalDocument/languageCode Language ValueSet Found in HL7

Implementation Guide

5.1.1.2 Patient

Subject XPath Code Set & Mapping DescriptionPatient IDs /ClinicalDocument/recordTarget/patientRole/id athenaNet PatientID

Patient SSN‘root’: athenaNet OID.PracticeID‘extension’: athenaNet PatientID

Patient Address /ClinicalDocument/recordTarget/patientRole/

addrUS Realm Address “HP”

Patient Phone /ClinicalDocument/recordTarget/patientRole/

telecomTelecom Use(US Realm Header)

Patient Name /ClinicalDocument/recordTarget/patientRole/patient/name

US Realm Patient Name

Patient Gender /ClinicalDocument/recordTarget/patientRole/

patient/administrativeGenderCodeHL7 V3 Admin. Gender

Patient DOB /ClinicalDocument/recordTarget/patientRole/patient/birthTime

Stored as ‘YYYYMMDD”e.g. “19800212"

Patient Marital /ClinicalDocument/recordTarget/patientRole/

patient/maritalStatusCodeHL7 Marital Status

Patient Race /ClinicalDocument/recordTarget/patientRole/patient/raceCode

CDC Race/Ethnicity Multiple and specific races supported using “extension”




Patient Ethnicity /ClinicalDocument/recordTarget/patientRole/

patient/ethnicGroupCodeCDC Race/Ethnicity Stored as either

Hispanic/Latino or Not Hispanic/Latino

Patient Language /ClinicalDocument/recordTarget/patientRole/

patient/languageCommunication/languageCodeLanguage ValueSet Patient’s Preferred

Language

5.1.1.3 Author (athenaHealth)

The author captures the creator of the document. This is set to athenahealth for CCDAs.

Subject XPath Code Set & Mapping DescriptionTimestamp

/ClinicalDocument/author/timeUS Realm Date/Time Found in HL7

Implementation GuideAuthor ID /ClinicalDocument/author/assignedAuthor/id athenahealth OID Found in HL7

Implementation GuideAuthor Address /ClinicalDocument/author/assignedAuthor/addr

US Realm Address “WP” “311 Arsenal St”, “Watertown”, “MA” “02472”, “US”

Author Phone /ClinicalDocument/author/assignedAuthor/telecom Telecom Use “(617) 402-1000”

Author Device - Manufacturer

/ClinicalDocument/author/assignedAuthor/assignedAuthoringDevice/manufaacturerModelName

‘athenahealth’

Author Device - Software

/ClinicalDocument/author/assignedAuthor/assignedAuthoringDevice/softwareName

‘athenahealth’

5.1.1.1 Custodian

The custodian is the party responsible for the life-cycle of the document. This is coded to athenahealth for CCDAs.

Subject XPath Code Set & Mapping

Description

Custodian ID

/ClinicalDocument/custodian/assignedCustodian/representedCustodianOrganization/id

athenahealth OID Found in HL7 Implementation Guide

Custodian Name /ClinicalDocument/custodian/assignedCustodian/

representedCustodianOrganization/nameSet to athenaHealth

Custodian Phone /ClinicalDocument/custodian/assignedCustodian/

representedCustodianOrganization/telecomTelecom Use “(617) 402-1000”

Custodian Address

/ClinicalDocument/custodian/assignedCustodian/representedCustodianOrganization/addr

US Realm Address “WP”

“311 Arsenal St”, “Watertown”, “MA” “02472”, “US”

5.1.1.1 DocumentationOf

The Care Team entries will be empty if there are no care team members on the chart. This section only includes care team members with ‘relevant’ roles (excludes “Test,” “Oncologist,” “Cardiologist,” and “Patient” roles).


Description

Class Code /ClinicalDocument/documentationOf/serviceEvent classCode = “PCPR” classCode PCPR = Care Provision

Created Date

/ClinicalDocument/documentationOf/serviceEvent/effectiveTime

Performer Type Code

/ClinicalDocument/documentationOf/performer typeCode = “PRF” Clinicians who actually and principally carry out serviceEvent

Performer Template ID

/ClinicalDocument/documentationOf/serviceEvent/performer/templateID

Root = "2.16.840.1.113883.10.20.6.2.1”




Performer Function /ClinicalDocument/documentationOf/

serviceEvent/performer/functionCodeCare Team ID /ClinicalDocument/documentationOf/

serviceEvent/performer/assignedEntity/id

NPIOnly if Care Team member is a Clinical Provider

Found in HL7 Implementation Guide

Care Team Code /ClinicalDocument/documentationOf/

serviceEvent/performer/assignedEntity/codeNUCC HC Provider Taxonomy

Found in HL7 Implementation Guide

Care Team Address /ClinicalDocument/documentationOf/

serviceEvent/performer/assignedEntity/addr


CareTeam section in Health History. Applicable to AS, DP, and SpecRegClinical Provider Address

Care Team Phone /ClinicalDocument/documentationOf/

serviceEvent/performer/assignedEntity/telecomTelecom Use

Care Team Provider

/ClinicalDocument/documentationOf/serviceEvent/performer/assignedEntity/assignedPerson

Care Team Represented Organization ID

/ClinicalDocument/documentationOf/serviceEvent/performer/assignedEntity/representedOrganization/id

GUID Organization of treating clinicians

Care Team Represented Organization Name

/ClinicalDocument/documentationOf/serviceEvent/performer/assignedEntity/representedOrganization/name

Care Team Represented Organization Phone Number

/ClinicalDocument/documentationOf/serviceEvent/performer/assignedEntity/representedOrganization/telecom

Care Team Represented Organization Address

/ClinicalDocument/documentationOf/serviceEvent/performer/assignedEntity/representedOrganization/addr

5.1.1.2 ComponentOf, EncompassingEncounter

Referring Provider is not included.


Description

ComponentOf Encounter ID

/ClinicalDocument/componentOf/encompassingEncounter/id

GUID Encounter that spawned the document.

CompOf Date /ClinicalDocument/componentOf/encompassingEncounter/effectiveTime

Date of encounter

Encounter Participant typeCode

/ClinicalDocument/componentOf/encompassingEncounter/encounterParticipant

typeCode = “ATND”

Provider ID /ClinicalDocument/componentOf/encompassingEncounter/id

NPI Root = athenaNet OIDExtension = provider’s NPI




Provider Code /ClinicalDocument/componentOf/

encompassingEncounter/codeNUCC HC Provider Taxonomy

Provider Address /ClinicalDocument/componentOf/

encompassingEncounter/addr


CareTeam section in Health History. Applicable to PCS and SCRClinical Provider Address for the Most Recent Encounter

Provider Phone /ClinicalDocument/componentOf/

encompassingEncounter/telecomTelecom Use

Provider Name /ClinicalDocument/componentOf/

encompassingEncounter/assignedPerson/name




6 Reason for Visit SectionThe Reason for Visit Section describes symptoms from the patient’s point of view. It pulls all checked boxes and free text from the “Reason for Visit/Chief Complaint” section of the encounter. This section only contains a single text element.

6.1.1 XML Data ElementsSubject XPath Code Set & Mapping DescriptionTemplate ID /ClinicalDocument/component/structuredBody/

component/section/templateID

Root = "2.16.840.1.113883.10.20.22.2.12"

HL7 Registered Model

Global Doc ID /ClinicalDocument/component/structuredBody/

component/section/idGUID

Section Code

/ClinicalDocument/component/structuredBody/component/section/code

Code = “29299-5”Code System = “2.16.840.1.113883.6.1”

LOINC codes used for Reason for Visit section

Section Title /ClinicalDocument/component/structuredBody/

component/section/title“Reason for Visit”

Reason for Visit /ClinicalDocument/component/structuredBody/

component/section/text/All checked boxes and free text entered in the “Reason for Visit” section

6.1.2 Reason for Visit – XML Example


<component><section>

<templateId root="2.16.840.1.113883.10.20.22.2.12"/><id root="1e7775c9-2013-9ede-07d1-001A64958C30"/><code code="29299-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/><title>Reason for visit</title><text>Mild Fever, 2 Days; Chills, 2 Days; Cough productive greenish sputum, 2 days</text>

</section></component>



7 Instructions SectionThe Instructions Section contains a single instructions entry capturing “clinical instructions” added through the discussion note in athenaNet. It also contains any “Patient info” orders given to the patient entered into the assessment note. These are orders for informational pamphlets usually related to a condition, medication, or other clinical situation. Diagnoses notes will be shown only if the provider has the “Include notes for diagnoses in the encounter summary” user preference enabled.

7.1.1 XML Data ElementsSubject XPath Code Set &

MappingDescription

Template ID /ClinicalDocument/component/structuredBody/

component/section/templateId

Root = "2.16.840.1.113883.10.20.22.2.45"




Section Code


LOINCCode = “69730-0”Code System = “2.16.840.1.113883.6.1”

LOINC codes used for Instructions section


component/section/title“Instructions”

Entry Act Code

/ClinicalDocument/component/structuredBody/component/section/entry/act

moodCode = “INT”classCode = “ACT”

Act Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/act/templateId

Root = "2.16.840.1.113883.10.20.22.4.20"


Act GUID /ClinicalDocument/component/structuredBody/component/section/entry/act/id

GUID

Act Code /ClinicalDocument/component/structuredBody/component/section/entry/act/code

Code = "311401005" codeSystem = "2.16.840.1.113883.6.96"

SNOMEDPatient Education

Text /ClinicalDocument/component/structuredBody/component/section/entry/act/text

Physician instruction notes for each instruction item

Status /ClinicalDocument/component/structuredBody/component/section/entry/act/statusCode

Set to ‘Completed’




7.1.2 Instructions Section – XML Example


<component><section>

<entry><act moodCode="INT" classCode="ACT">

<templateId root="2.16.840.1.113883.10.20.22.4.20"/><code code="311401005" codeSystem="2.16.840.1.113883.6.96"

displayName="Patient Education" codeSystemName="SNOMED CT"/><text>Clinical Instructions: excercise</text><statusCode code="completed"/>

</act></entry><entry>

<act moodCode="INT" classCode="ACT"><templateId root="2.16.840.1.113883.10.20.22.4.20"/><code code="311401005" codeSystem="2.16.840.1.113883.6.96"

displayName="Patient Education" codeSystemName="SNOMED CT"/><text>ASTHMA ACTION PLAN: AFTER YOUR VISIT</text><statusCode code="completed"/>

</act></entry>

</section></component>



8 Plan of Care SectionThe Plan of Care section contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only, which are indicated by the @moodCode of the entries within this section. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current care of the patient should be listed unless constrained due to privacy issues. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders. Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and health-care quality improvements, including widely accepted performance measures. The plan may also indicate that patient education will be provided.

8.1.1 XML Data ElementsSubject XPath Code Set & Mapping DescriptionTemplate ID

/ClinicalDocument/component/structuredBody/component/section/templateId

Root = "2.16.840.1.113883.10.20.22.2.10"


Global Doc ID /ClinicalDocument/component/

structuredBody/component/section/idGUID

Section Code /ClinicalDocument/component/

structuredBody/component/section/code

Code = “18776-5”Code System = “2.16.840.1.113883.6.1”

LOINC codes used for Plan of Care section

Section Title /ClinicalDocument/component/

structuredBody/component/section/title“Plan of Care”

8.1.1.1 Future Encounter

Subject XPath Code Set & Mapping DescriptionEncounter Section Code

/ClinicalDocument/component/structuredBody/component/section/entry/encounter

moodCode = “INT”classCode = “ENC”

Encounter Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/templateId

Root = "2.16.840.1.113883.10.20.22.4.40"


Encounter Code

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/code

Code = "311401005" CodeSystem = "2.16.840.1.113883.6.96"

SNOMED CTPatient Education

Encounter Date

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/effectiveTime

Date of future encounter

Performer Type Code

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/performer

typeCode = “PRF” Performer for future encounter

Performer GUID

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/performer/assignedEntity/id

GUID

Performer Address

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/performer/assignedEntity/addr





Performer Phone Number

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/performer/assignedEntity/atelecom

Telecom Use = “WP”

Performer Name

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/performer/assignedEntity/assignedPerson/name

8.1.1.2 Future Test

Subject XPath Code Set & Mapping DescriptionTest Section Code

/ClinicalDocument/component/structuredBody/component/section/entry/obesrvation

moodCode = “INT”classCode = “OBS”

Test Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/obesrvation/templateId

Root = "2.16.840.1.113883.10.20.22.4.44"


Test GUID/ClinicalDocument/component/structuredBody/component/section/entry/obesrvation/id

GUID

Test Code/ClinicalDocument/component/structuredBody/component/section/entry/obesrvation/code

Code = “311401005” CodeSystem = “2.16.840.1.113883.6.96”


Test Date/ClinicalDocument/component/structuredBody/component/section/entry/obesrvation/effectiveTime

Date of future test

8.1.1.3 Goal

Subject XPath Code Set & Mapping DescriptionGoal Section Code

/ClinicalDocument/component/structuredBody/component/section/entry/obesrvation

moodCode = “GOL”classCode = “OBS”

Goal Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/obesrvation/templateId

Root = "2.16.840.1.113883.10.20.22.4.44"


Goal GUID/ClinicalDocument/component/structuredBody/component/section/entry/obesrvation/id

GUID

Goal Code/ClinicalDocument/component/structuredBody/component/section/entry/obesrvation/code

Code = “311401005” CodeSystem = “2.16.840.1.113883.6.96”


Goal/ClinicalDocument/component/structuredBody/component/section/entry/obesrvation/text

Physician text notes for patient goals

Goal Status /ClinicalDocument/component/structuredBody/component/section/

Status ValueSet




entry/obesrvation/statusCode

Goal Date/ClinicalDocument/component/structuredBody/component/section/entry/obesrvation/effectiveTime

Date goal should be reached

8.1.1.4 Instructions

Subject XPath Code Set & Mapping Description

Entry Act Code



Act Template ID


Root = "2.16.840.1.113883.10.20.22.4.20"


Act Code/ClinicalDocument/component/structuredBody/component/section/entry/act/code

Code = "311401005" CodeSystem = "2.16.840.1.113883.6.96"


Instructions/ClinicalDocument/component/structuredBody/component/section/entry/act/text

Physician text notes of instructions to patients

Status/ClinicalDocument/component/structuredBody/component/section/entry/act/statusCode




--------Future Encounter--------<encounter moodCode="INT" classCode="ENC">

<templateId root="2.16.840.1.113883.10.20.22.4.40"/><id root="1e7775c9-2013-73cb-07d1-001A64958C30"/><code nullFlavor="UNK" codeSystem="2.16.840.1.113883.3.88.12.80.32" codeSystemName="CPT-4"/><effectiveTime value="20130630090000-0400"/><performer typeCode="PRF">

<assignedEntity><id root="1e7775c9-2013-be0a-07d1-001A64958C30"/><addr use="WP">

<streetAddressLine>1002 Healthcare Dr.</streetAddressLine><streetAddressLine nullFlavor="NA"/><city>Portland</city><state>OR</state><postalCode>97005-9999</postalCode>

</addr><telecom use="WP" value="555-555-1002"/><assignedPerson>

<name><given>HENRY</given><family>SEVEN</family>

</name></assignedPerson>

</assignedEntity></performer>

</encounter>

--------Future Procedure--------<procedure moodCode="INT" classCode="PROC">

<templateId root="2.16.840.1.113883.10.20.22.4.41"/><id root="1e7775c9-2013-e6da-07d1-001A64958C30"/><code code="71020" codeSystem="2.16.840.1.113883.6.12" displayName="(ORDER) CHEST X-RAY, PA

AND LATERAL VIEWS" codeSystemName="CPT"/><statusCode code="new"/><effectiveTime value="20120806000000-0400"/>

</procedure>

--------Future Test--------<observation moodCode="INT" classCode="OBS">

<templateId root="2.16.840.1.113883.10.20.22.4.44"/><id root="1e7775c9-2013-9aaf-07d1-001A64958C30"/><code code="30313-1" codeSystem="2.16.840.1.113883.6.1" displayName="Hemoglobin

[Mass/volume] in Arterial blood" codeSystemName="LOINC"/><effectiveTime value="20120813000000-0400"/>

</observation>

--------Goal--------<observation moodCode="GOL" classCode="OBS">

<templateId root="2.16.840.1.113883.10.20.22.4.44"/><id root="1e7775c9-2013-9c90-07d1-001A64958C30"/><code nullFlavor="UNK"/><text>smoking cessation</text><statusCode code="new"/><effectiveTime nullFlavor="NA"/>

</observation>


8.1.2 Plan of Care – XML Example





--------Instruction--------<act moodCode="INT" classCode="ACT">

<templateId root="2.16.840.1.113883.10.20.22.4.20"/><code code="311401005" codeSystem="2.16.840.1.113883.6.96" displayName="Patient Education"

codeSystemName="SNOMED"/><text>resources and instructions provided during visit</text><statusCode code="completed"/>

</act>



9 Medications SectionThe Medications Section captures a patient’s active medication list. It does not include hidden medications, deleted medications, or medications administered during the visit (see Medications Administered section). This section excludes unapproved medications.



Root = “2.16.840.1.113883.10.20.22.2.1”




Section Code /ClinicalDocument/component/structuredBody/

component/section/code


LOINC codes used for Medications section

Section Title /ClinicalDocument/component/structuredBody/component/section/title

“Medications”

9.1.1.1 Medication Activity

A medication activity describes substance administrations that have actually occurred (e.g. pills ingested or injections given) or are intended to occur (e.g. ""take 2 tablets twice a day for the next 10 days""). Medication activities in ""INT"" mood are reflections of what a clinician intends a patient to be taking. Medication activities in ""EVN"" mood reflect actual use.Medication timing is complex. This template requires that there be a substanceAdministration/effectiveTime valued with a time interval, representing the start and stop dates. Additional effectiveTime elements are optional, and can be used to represent frequency and other aspects of more detailed dosing regimens.Subject XPath Code Set & Mapping DescriptionAdministration /ClinicalDocument/component/structuredBody/

component/section/entry/substanceAdmnistrationmoodCode = “INT”classCode = “SBADM”

Template ID/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/templateId

Root = “2.16.840.1.113883.10.20.22.4.16”


Section ID /ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/id

GUID

Sig/Instructions /ClinicalDocument/component/structuredBody/

component/section/entry/substanceAdministration/text

Sig/Instructions for the medications

Status /ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/statusCode


Effective Time /ClinicalDocument/component/structuredBody/

component/section/entry/substanceAdministration/effectiveTime(xsi:type=”PIVL_TS”)/period

Xsi:type = “PIVL_TS”institutionSpecified = “false”

Medication administration frequency (timing)




Start/Stop Dates /ClinicalDocument/component/structuredBody/

component/section/entry/substanceAdministration/effectiveTime(xsi:type=”IVL_TS”)/

Xsi:type = “IVL_TS” Medication start/stop dates

Route /ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/routeCode

athenaNet codes mapped to NCI thesaurus

NCI Concepts

Dose /ClinicalDocument/component/structuredBody/component/section/entry/substanceAdminsitration/doseQuantity

Units of Measure Case Sensitive ValueSet

Value and units of medications

9.1.1.2 Medication Information

The medication can be recorded as a pre-coordinated product strength, product form, or product concentration (e.g., ""metoprolol 25mg tablet"", ""amoxicillin 400mg/5mL suspension""); or not pre-coordinated (e.g., ""metoprolol product"").

Subject XPath Code Set & Mapping DescriptionManufactured Product Code

/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/consumable/manufacturedProduct

classCode = “MANU”

Template ID /ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/consumable/manufacturedProduct/templateId

Root = “2.16.840.1.113883.10.20.22.4.23"


Manufactured Material Code

/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdminsitration/consumable/manufacturedProduct/manufacturedMaterial/code

Medication Clinical Drug Name ValueSet

RxCUI is RxNorm’s unique identifier for medications

Medication Translation Code

/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdminsitration/consumable/manufacturedProduct/manufacturedMaterial/code/translation

Translations can be used to represent generic product name, etc

Medication Name

/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdminsitration/consumable/manufacturedProduct/manufacturedMaterial/name


The Instructions template can be used in several ways, such as to record patient instructions within a Medication Activity or to record fill instructions within a supply order. The act/code defines the type of instruction.Subject XPath Code Set & Mapping DescriptionEntry Type Code /ClinicalDocument/component/structuredBody/

compnent/section/entry/substanceAdministration/entryRelationship

typeCode = “SUBJ”inversionInd = “true”

Act Code /ClinicalDocument/component/structuredBody/compnent/section/entry/substanceAdministration/entryRelationship/act


Act /ClinicalDocument/component/structuredBody/ Root = HL7 Registered Model



<entry><substanceAdministration moodCode="INT" classCode="SBADM">

<templateId root="2.16.840.1.113883.10.20.22.4.16"/><id root="1e7775c9-2013-3c5c-07d1-001A64958C30"/><text>

<reference value="#Med1"/>Take 1 tablet(s) twice a day by oral route for 7 days.</text>

<statusCode code="completed"/><effectiveTime xsi:type="IVL_TS">

<low value="20120806000000-0400"/><high nullFlavor="NA"/>

</effectiveTime><effectiveTime operator="A" xsi:type="PIVL_TS" institutionSpecified="true">

<period value="12" unit="h"/></effectiveTime><routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" displayName="ORAL"

codeSystemName="NCI Thesaurus"/><doseQuantity value="1" unit="tablet(s)"/><consumable>

<manufacturedProduct classCode="MANU"><templateId root="2.16.840.1.113883.10.20.22.4.23"/><manufacturedMaterial>

<code code="197517" displayName="Clarithromycin 500 MG Oral Tablet" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">

<originalText><reference value="#Med1"/>

</originalText><translation code="177323" codeSystemName="FDB MEDID"/>

</code><name>Clarithromycin 500 MG Oral Tablet</name>

</manufacturedMaterial></manufacturedProduct>

</consumable><entryRelationship typeCode="SUBJ" inversionInd="true">


displayName="Patient Education" codeSystemName="SNOMED CT"/><text/><statusCode code="completed"/>

</act></entryRelationship>

</substanceAdministration></entry>


Template ID compnent/section/entry/substanceAdministration/entryRelationship/act/templateId

"2.16.840.1.113883.10.20.22.4.20”

Act Code /ClinicalDocument/component/structuredBody/compnent/section/entry/substanceAdministration/entryRelationship/act/code

Code = "311401005"CodeSystem = "2.16.840.1.113883.6.96"

SNOMED CT CodesPatient Education

Timing Instructions /ClinicalDocument/component/structuredBody/

compnent/section/entry/substanceAdministration/entryRelationship/act/text

Instructions on when to take medications

Act Status /ClinicalDocument/component/structuredBody/compnent/section/entry/substanceAdministration/entryRelationship/act/statusCode


9.1.2 Medications – XML Example




10 Medications Administered SectionThe Medications Administered Section captures medications the patient received during the visit. The medication has to be marked as administered (not just ordered) in a specific encounter for this section to appear. This section excludes deleted, unapproved, and non-prescription orders.



Root = "2.16.840.1.113883.10.20.22.2.38"




Section Code



LOINC codes used for medications


“Medications Administered”

10.1.1.1 Medications Activity

A medication activity describes substance administrations that have actually occurred (e.g. pills ingested or injections given) or are intended to occur (e.g. ""take 2 tablets twice a day for the next 10 days""). Medication activities in ""INT"" mood are reflections of what a clinician intends a patient to be taking. Medication activities in ""EVN"" mood reflect actual use.Medication timing is complex. This template requires that there be a substanceAdministration/effectiveTime valued with a time interval, representing the start and stop dates. Additional effectiveTime elements are optional, and can be used to represent frequency and other aspects of more detailed dosing regimens.Subject XPath Code Set & Mapping DescriptionAdministration /ClinicalDocument/component/structuredBody/

component/section/entry/substanceAdmnistrationmoodCode = “EVN”classCode = “SBADM”

Entry Template ID /ClinicalDocument/component/structuredBody/

component/section/entry/substanceAdministration/templateId

Root = “2.16.840.1.113883.10.20.22.4.16”


Entry GUID /ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/id

GUID

Sig Information /ClinicalDocument/component/structuredBody/

component/section/entry/substanceAdministration/text

Sig/Instructions for the medications



Start Date /ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/effectiveTime/low

Start date of medication




Stop Date /ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/effectiveTime/high

Stop date of medication

Route /ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/routeCode

athenaNet codes mapped to NCI thesaurus

NCI Concepts

10.1.1.2 Medication Information

The medication can be recorded as a pre-coordinated product strength, product form, or product concentration (e.g., ""metoprolol 25mg tablet"", ""amoxicillin 400mg/5mL suspension""); or not pre-coordinated (e.g., ""metoprolol product"").

Subject XPath Code Set & Mapping DescriptionManufactured Product Code


classCode = “MANU”

Template ID /ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/consumable/manufacturedProduct/templateId

Root = “2.16.840.1.113883.10.20.22.4.23”


Manufactured material Name

/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdminsitration/consumable/manufacturedProduct/manufacturedMaterial/name

Medication List

Code /ClinicalDocument/component/structuredBody/component/section/entry/substanceAdminsitration/consumable/manufacturedProduct/manufacturedMaterial/code

Medication Clinical Drug Name Value ValueSet

RxCUI is RxNorm’s unique identifier for medications


The Instructions template can be used in several ways, such as to record patient instructions within a Medication Activity or to record fill instructions within a supply order. The act/code defines the type of instruction. Subject XPath Code Set & Mapping DescriptionEntry Type Code /ClinicalDocument/component/structuredBody/

component/section/entry/substanceAdministration/entryRelationship


Act Code /ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/entryRelationship/act


Act Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/entryRelationship/act/templateId

Root = "2.16.840.1.113883.10.20.22.4.20"


Act Code/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/entryRelationship/act/code

Code = "311401005" CodeSystem = "2.16.840.1.113883.6.96"

Patient Education ValueSet

Instructions /ClinicalDocument/component/structuredBody/component/section/entry/



<entry><substanceAdministration moodCode="EVN" classCode="SBADM">

<templateId root="2.16.840.1.113883.10.20.22.4.16"/><id root="1e7775c9-2013-0f72-07d1-001A64958C30"/><text>

<reference value="#MedAdmin1"/>2 Puffs Once</text><statusCode code="completed"/><effectiveTime xsi:type="IVL_TS">

<low nullFlavor="NI"/><high nullFlavor="NA"/>

</effectiveTime><effectiveTime operator="A" nullFlavor="NA"/><consumable>


<code code="745679" displayName="200 ACTUAT Albuterol 0.09 MG/ACTUAT Metered Dose Inhaler" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">

<originalText><reference value="#MedAdmin1"/>

</originalText><translation code="279394" codeSystemName="FDB

MEDID"/></code><name>200 ACTUAT Albuterol 0.09 MG/ACTUAT Metered Dose

Inhaler</name></manufacturedMaterial>

</manufacturedProduct></consumable><entryRelationship typeCode="SUBJ" inversionInd="true">


displayName="Patient Education" codeSystemName="SNOMED CT"/><text/><statusCode code="completed"/>

</act></entryRelationship>

</substanceAdministration></entry>


substanceAdministration/entryRelationship/act/text

Status/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/entryRelationship/act/statusCode


10.1.2 Medications Administered – XML Example




11 Vital Signs SectionThe Vital Signs Section captures a patient’s blood pressure, height, weight, and calculated body mass index (BMI). The most recent reading for reach vital is recorded.The Vital Signs Section is comprised of two entries: the Results Organizer and the Results Observation. The Results Organizer groups vitals by the encounter they were captured in.



Root = “2.16.840.1.113883.10.20.22.2.4.1”




Section Code


Code = “46680005”Code System = “2.16.840.1.113883.6.96”

SNOMED codes used for vital signs


“Vitals”

11.1.1.1 Vitals Organizer

The Vital Signs Organizer groups vital signs, which is similar to the Result Organizer, but with further constraints. An appropriate nullFlavor can be used when the organizer/code or organizer/id is unknown.Subject XPath Code Set & Mapping DescriptionVitals Organizer Type Code

/ClinicalDocument/component/structuredBody/component/section/entry

typeCode = “DRIV”

Vitals Organizer

/ClinicalDocument/component/structuredBody/component/section/entry/organizer

moodCode = “EVN”classCode = “CLUSTER”

Vitals Organizer Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/organizer/templateId

Root = "2.16.840.1.113883.10.20.22.4.26"


Vitals Organizer GUID

/ClinicalDocument/component/structuredBody/component/section/entry/organizer/id

GUID

Vitals Organizer Code

/ClinicalDocument/component/structuredBody/component/section/entry/organizer/code

Code = "46680005" codeSystem = "2.16.840.1.113883.6.96"

SNOMED CTVital Signs

Status/ClinicalDocument/component/structuredBody/component/section/entry/organizer/statusCode


Timestamp/ClinicalDocument/component/structuredBody/component/section/entry/organizer/effectiveTime

Clinically effective time of the measurement (when the measurement was performed)




11.1.1.2 Vitals Observation

Vital signs are represented as are other results, with additional vocabulary constraints.

Subject XPath Code Set & Mapping Description

Vital Observation

/ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation

moodCode = “EVN”classCode = “OBS”

Observation

Vital Observation Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation/templateid

Root = "2.16.840.1.113883.10.20.22.4.27”


Vital Observation GUID

/ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation/id

GUID

Vital Observation Code /ClinicalDocument/component/structuredBody/

component/section/entry/organizer/component/observation/code

Code = 3141-9"Code System = “2.16.840.1.113883.6.1”

LOINC code associated with the vital sign being recorded

Notes /ClinicalDocument/component/structuredBody/component/section/text/table/tbody/tr/td/content

Text Notes

Vital Name/ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation/code("displayName")

Vital Status /ClinicalDocument/component/structuredBody/component/section/entry/statusCode


Vital Timestamp /ClinicalDocument/component/structuredBody/

component/section/entry/effectiveTimeLast modified date on vital

Vital Value and Units /ClinicalDocument/component/structuredBody/

component/section/entry/organizer/component/observation/value

Xsi:type = “PQ” Includes units when applicable

11.1.2 Vital Signs – XML Example




12 Lab Results SectionResults can be recorded in athenaNet by either receiving an HL7 document or by creating a “Lab Results” document. Only documents in one of the following statuses can be pulled into the CCDA: Closed, Submitted, Followup, Only Analytes/Observations (in final status only). Results with no data in their value field will not be pulled into the CCDA document. Lab Results received via fax will not automatically be pulled into the CCDA document. Deleted, duplicated, and superseded lab results are excluded.



Root = “2.16.840.1.113883.10.20.22.2.3.1”






Code = “30954-2”Code System = “2.16.840.1.113883.6.1”

LOINC codes used


“Lab Results”

12.1.1.1 Result Organizer

This clinical statement identifies set of result observations. It contains information applicable to all of the contained result observations. Result type codes categorize a result into one of several commonly accepted values (e.g., “Hematology”, “Chemistry”, “Nuclear Medicine”). These values are often implicit in the Organizer/code (e.g., an Organizer/code of “complete blood count” implies a ResultTypeCode of “Hematology”). This template requires Organizer/code to include a ResultTypeCode either directly or as a translation of a code from some other code system.An appropriate nullFlavor can be used when the organizer/code or organizer/id is unknown.If any Result Observation within the organizer has a statusCode of ‘active’, the Result Organizer must also have as statusCode of ‘active.

Subject XPath Code Set & Mapping DescriptionResult Organizer

/ClinicalDocument/component/structuredBody/component/section/entry/organizer

moodCode = “EVN”classCode = “BATTERY”

Result Organizer Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/organizer/templateId

Root = "2.16.840.1.113883.10.20.22.4.1”


Result Organizer GUID

/ClinicalDocument/component/structuredBody/component/section/entry/organizer/id

GUID

Code/ClinicalDocument/component/structuredBody/component/section/entry/organizer/code

xsI;type = “CE”Code System = "2.16.840.1.113883.6.1"

LOINC Code for the Lab Order

Result Test Name /ClinicalDocument/component/structuredBody/

component/section/entry/organizer/code/translationName of test for which result was obtained

Status /ClinicalDocument/component/structuredBody/component/section/entry/organizer/statusCode


Date of Result /ClinicalDocument/component/structuredBody/




component/section/entry/organizer/effectiveTime

12.1.1.2 Result Observation

This clinical statement represents details of a lab, radiology, or other study performed on a patient.The result observation includes a statusCode to allow recording the status of an observation. If a Result Observation is not completed, the Result Organizer must include corresponding statusCode. “Pending” results (e.g., a test has been run but results have not been reported yet) should be represented as “active” ActStatus.Subject XPath Code Set & Mapping DescriptionResult Observation

/ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation


Result Observation Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation/templateID

Root = "2.16.840.1.113883.10.20.22.4.2"


Result Observation GUID

/ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation/id

GUID

Result Observation Name

/ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation/code(displayName)

LOINC Result observation metric name

Result Code /ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation/code

LOINC LOINC code for the lab result

Result Observation Status

/ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation/statusCode

Result Status ValueSet

Result Observation Time

/ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation/effectiveTime

Clinically effective time of the measurement

Result Value /ClinicalDocument/component/structuredBody/component/section/entry/organizer/component/observation/value

String or QTYXsi:type = “CD”

Description of the result

Interpretation Code /ClinicalDocument/component/structuredBody/

component/section/entry/organizer/component/observation/interpretationCode

Code System = “2.16.840.1.113883.5.83”

Observation Interpretation

Reference Range /ClinicalDocument/component/structuredBody/

component/section/entry/organizer/component/observation/referenceRange/observationRange/text

Average range of values for results



<entry><organizer moodCode="EVN" classCode="BATTERY">

<templateId root="2.16.840.1.113883.10.20.22.4.1"/><id root="248b2c03-2013-cd25-07d1-001A64958C30"/><code code="5671-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"

xsi:type="CE"/><statusCode code="completed"/><effectiveTime nullFlavor="NA"/><component>

<observation moodCode="EVN" classCode="OBS"><templateId root="2.16.840.1.113883.10.20.22.4.2"/><id root="248b2c03-2013-a8fd-07d1-001A64958C30"/><code code="20570-8" codeSystem="2.16.840.1.113883.6.1"

displayName="Hematocrit [Volume Fraction] of Blood" codeSystemName="LOINC"/><text>

<reference value="#result1"/></text><statusCode code="completed"/><effectiveTime value="20130613000000-0400"/><value xsi:type="PQ" value="41" unit="%"/><interpretationCode code="A" codeSystem="2.16.840.1.113883.5.83"/><referenceRange>

<observationRange><text>0-4</text>

</observationRange></referenceRange>

</observation></component>

</organizer></entry>


12.1.2 Lab Results – XML Sample




13 Allergies SectionThe Allergies Section captures all active allergies stored in the patient’s allergy list. It does not include soft-deleted allergies in the chart but does include NKDA pseudo-allergies (see NKDA note below).


MappingDescription

Template ID


Root = “2.16.840.1.113883.10.20.22.2.6”




Section Code



LOINC codes used for Allergies section


“Allergies”

13.1.1.1 Allergies, Adverse Reactions, Alerts

This section lists and describes any medication allergies, adverse reactions, idiosyncratic reactions, anaphylaxis/anaphylactoid reactions to food items, and metabolic variations or adverse reactions/allergies to other substances (such as latex, iodine, tape adhesives) used to assure the safety of health care delivery. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.Subject XPath Code Set &

MappingDescription

Act Class Code


classCode = “ACT”moodCode = “EVN”

Act Template ID


Root = “2.16.840.1.113883.10.20.22.4.30”


Act GUID/ClinicalDocument/component/structuredBody/component/section/entry/act/id

GUID

Section Code

/ClinicalDocument/component/structuredBody/component/section/entry/act/code


LOINC codes used for Allergies section“Allergies, adverse reactions, alerts”

Status/ClinicalDocument/component/structuredBody/component/section/entry/act/statusCode

ProblemAct statusCode ValueSet

If no deactivation date = “Active”If deactivation date is not blank = “Completed”

Act Effective Time

/ClinicalDocument/component/structuredBody/component/section/entry/act/effectiveTime/low

Date/time added to the chartIf active, effectiveTime contains ‘low’If completed, effectiveTime contains ‘high’




13.1.1.2 Assertion

This clinical statement represents that an allergy or adverse reaction exists or does not exist. The agent that is the cause of the allergy or adverse reaction is represented as a manufactured material participant playing entity in the allergy observation. While the agent is often implicit in the alert observation (e.g. ""allergy to penicillin""), it should also be asserted explicitly as an entity. The manufactured material participant is used to represent natural and non-natural occurring substances.

NOTE: The agent responsible for an allergy or adverse reaction is not always a manufactured material (for example, food allergies), nor is it necessarily consumed. The following constraints reflect limitations in the base CDA R2 specification, and should be used to represent any type of responsible agent. Subject XPath Code Set &

MappingDescription

Entry Type Code

/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/

typeCode = “SUBJ”

Observation Class Code

/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation

classCode = “OBS”moodCode = “EVN”

ObservationEvent

Observation Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/templateId

Root = “2.16.840.1.113883.10.20.22.4.7”


Observation GUID

/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/id

GUID

Sub-Section Header /ClinicalDocument/component/structuredBody/

component/section/entry/act/entryRelationship/observation/code

CodeSystem = “2.16.840.1.113883.5.4”

“ASSERTION”

Entry Status /ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/statusCode


Onset Date

/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/effectiveTime

If onset date is unknown, effectiveTime contains low/@nullFlavor = “UNK”If allergy is no longer a concern, effectiveTime may contain ‘high’

Entry Value /ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/value

Code = “CD”codeSystem="2.16.840.1.113883.6.96"

“Allergy to Substance”

13.1.1.3 Participant

Subject XPath Code Set & Mapping DescriptionType Code /ClinicalDocument/component/structuredBody/

component/section/entry/act/entryRelationship/observation/participant

typeCode = “CSM” Consumable

Participant Class Code

/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/participant/participantRole

classCode = “MANU” Manufactured Product

Playing Entity

/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/

classCode = “MMAT” Manufactured Material




observation/participant/participantRole/playingEntity

Playing Entity Code /ClinicalDocument/component/structuredBody/

component/section/entry/act/entryRelationship/observation/participant/participantRole/playingEntity/code

RxNormCode System = “2.16.840.1.113883.6.88”

RxNorm codes used for Allergies

Allergy Substance /ClinicalDocument/component/structuredBody/

component/section/entry/act/entryRelationship/observation/participant/participantRole/playingEntity/code(displayName)

ValueSet Allergy substance name

Translation /ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/participant/participantRole/playingEntity/code/translation

13.1.1.4 Reaction Observation

This clinical statement represents an undesired symptom, finding, etc., due to an administered or exposed substance. A reaction can be defined with respect to its severity, and can have been treated by one or more interventions.Subject XPath Code Set &

MappingDescription

Entry Type Code

/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/entryRelationship

typeCode = “MFST”inversionInd = “true”

Is Manifestation Of


/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/entryRelationship/observation


ObservationEvent


/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/entryRelationship/observation/templateId

Root ="2.16.840.1.113883.10.20.22.4.9"


Observation GUID

/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/entryRelationship/observation/id

GUID

Observation Code /ClinicalDocument/component/structuredBody/

component/section/entry/act/entryRelationship/observation/entryRelationship/observation/code

Status /ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/entryRelationship/observation/statusCode


Reaction /ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship(typeCode=”MFST”)/observation/entryRelationship/observation/value(displayName)

SNOMEDXsi:type = “CD”Problem ValueSet

See list below.

13.1.1.5 Severity Observation

This clinical statement represents the gravity of the problem, such as allergy or reaction, in terms of its actual or potential impact on the patient. The Severity Observation can be associated with an Allergy Observation, Reaction Observation, or both. When the Severity Observation is associated directly with an Allergy it characterizes the Allergy. When the Severity Observation is associated with a Reaction Observation it characterizes a Reaction. A person may manifest many symptoms in a reaction to a single substance, and each reaction to the substance can be represented. However, each reaction observation can have only one severity observation associated with it. For example, someone may have a rash reaction observation as well as an itching reaction observation, but each can have only one level of severity.

Subject XPath Code Set & Description




MappingEntry Type Code /ClinicalDocument/component/structuredBody/

comopnent/section/entry/act/entryRelationship/observation/entryRelationship


Has Subject


/ClinicalDocument/component/structuredBody/comopnent/section/entry/act/entryRelationship/observation/entryRelationship/observation


Observation


/ClinicalDocument/component/structuredBody/comopnent/section/entry/act/entryRelationship/observation/entryRelationship/observation/templateId

Root = "2.16.840.1.113883.10.20.22.4.8"


Code

/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/entryRelationship/observation/code

HL7 Act CodeCode = “SEV”Code System ="2.16.840.1.113883.5.4"

HL7 Act Code used for Severity

Status /ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/entryRelationship/observation/statusCode


Severity/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship(typeCode=”SUBJ”)/observation/entryRelationship/observation/value

Xsi:type = “CD”Observation Interpretation ValueSetSNOMED

A provider must choose to turn on an internal setting to display severity.

13.1.2 Supported List of Reactions and Severities

13.1.3 NKDA

BehaviorChecking the “NKDA” box in athenaNet creates an entry with values set to the null flavor “UNK.” If the user doesn’t check the NKDA box or indicate any allergies, we send the null flavor “NI.”

13.1.4 No Known Allergies EntryathenaNet allows for a “No Known Allergy” entry to be added to the allergy list. This indicated that there are no known allergies of any kind, and is separate from NKDA (which refers to drug allergies only). This is considered an ‘active’ absence of allergies, and is treated as any other active allergy.


ReactionAnaphylaxis Dizziness NauseaAngioedema Headache OtherArthralgia (joint pain)

Hives Photosensitivity

Chest pain Irregular Heart rate RashCough Itching Repiratory distressDiarrhea Myalgioas (muscle

pain)Vomiting

SeverityMildMild to moderateModerateModerate to SevereSevereFatal


<entry><act classCode="ACT" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.30"/><id root="3723fd63-2013-70c9-05d4-001A64958C30"/><code code="48765-2" codeSystem="2.16.840.1.113883.6.1" displayName="Allergies, adverse reactions, alerts"

codeSystemName="LOINC"/><statusCode code="active"/><effectiveTime>

<low value="20130925105240-0400"/></effectiveTime><entryRelationship typeCode="SUBJ">

<observation classCode="OBS" moodCode="EVN"><templateId root="2.16.840.1.113883.10.20.22.4.7"/><id root="3723fd63-2013-216b-05d4-001A64958C30"/><code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/><statusCode code="completed"/><effectiveTime>

<low value="20120806000000-0400"/></effectiveTime><value xsi:type="CD" code="419199007" codeSystem="2.16.840.1.113883.6.96"

displayName="Allergy to Substance"><originalText>

<reference value="#reaction1"/></originalText>

</value><participant typeCode="CSM">

<participantRole classCode="MANU"><playingEntity classCode="MMAT">

<code code="1191" codeSystem="2.16.840.1.113883.6.88" displayName="Aspirin" codeSystemName="RxNorm">

<originalText><reference value="#reaction1"/>

</originalText><translation code="13279" displayName="ASPIRIN"

codeSystemName="ATHENA_ALLERGYID"/></code>

</playingEntity></participantRole>

</participant><entryRelationship typeCode="MFST" inversionInd="true">

<observation classCode="OBS" moodCode="EVN"><templateId root="2.16.840.1.113883.10.20.22.4.9"/><id root="3723fd63-2013-af9f-05d4-001A64958C30"/><code nullFlavor="NI"/><text>

<reference value="#reaction1"/></text><statusCode code="completed"/><value code="126485001" codeSystem="2.16.840.1.113883.6.96"

displayName="Hives" xsi:type="CD"/></observation>

</entryRelationship><entryRelationship typeCode="SUBJ" inversionInd="true">

<observation moodCode="EVN" classCode="OBS"><templateId root="2.16.840.1.113883.10.20.22.4.8"/><code code="SEV" codeSystem="2.16.840.1.113883.5.4"

displayName="Severity Observation" codeSystemName="HL7ActCode"/>


13.1.5 NKDA Behavior - XML Example

13.1.6 Allergies – XML Example


<participant typeCode="CSM"><participantRole classCode="MANU">

<playingEntity classCode="MMAT"><code nullFlavor="UNK" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">


</originalText><translation nullFlavor="NI" displayName="NKDA"



</participant>


<entry><act classCode="ACT" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.30"/><id root="3723fd63-2013-70c9-05d4-001A64958C30"/><code code="48765-2" codeSystem="2.16.840.1.113883.6.1" displayName="Allergies, adverse reactions, alerts"

codeSystemName="LOINC"/><statusCode code="active"/><effectiveTime>

<low value="20130925105240-0400"/></effectiveTime><entryRelationship typeCode="SUBJ">

<observation classCode="OBS" moodCode="EVN"><templateId root="2.16.840.1.113883.10.20.22.4.7"/><id root="3723fd63-2013-216b-05d4-001A64958C30"/><code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/><statusCode code="completed"/><effectiveTime>

<low value="20120806000000-0400"/></effectiveTime><value xsi:type="CD" code="419199007" codeSystem="2.16.840.1.113883.6.96"

displayName="Allergy to Substance"><originalText>

<reference value="#reaction1"/></originalText>

</value><participant typeCode="CSM">

<participantRole classCode="MANU"><playingEntity classCode="MMAT">

<code code="1191" codeSystem="2.16.840.1.113883.6.88" displayName="Aspirin" codeSystemName="RxNorm">


</originalText><translation code="13279" displayName="ASPIRIN"



</participant><entryRelationship typeCode="MFST" inversionInd="true">

<observation classCode="OBS" moodCode="EVN"><templateId root="2.16.840.1.113883.10.20.22.4.9"/><id root="3723fd63-2013-af9f-05d4-001A64958C30"/><code nullFlavor="NI"/><text>

<reference value="#reaction1"/></text><statusCode code="completed"/><value code="126485001" codeSystem="2.16.840.1.113883.6.96"

displayName="Hives" xsi:type="CD"/></observation>

</entryRelationship><entryRelationship typeCode="SUBJ" inversionInd="true">

<observation moodCode="EVN" classCode="OBS"><templateId root="2.16.840.1.113883.10.20.22.4.8"/><code code="SEV" codeSystem="2.16.840.1.113883.5.4"

displayName="Severity Observation" codeSystemName="HL7ActCode"/>


14 Problems SectionThe Problems Section captures a patient’s active problem list. This section captures the problems on the chart even if the “No Known Problems Checked” flag is selected.


MappingDescription

Template ID


Root = “2.16.840.1.113883.10.20.22.4.3”




Section Code


Code = “11450-4”Code system: “2.16.840.1.113883.6.1"

LOINC


“Problems”

14.1.1.1 Problem Concern Act (Condition)

Observations of problems or other clinical statements captured at a point in time are wrapped in a ""Concern"" act, which represents the ongoing process tracked over time. This allows for binding related observations of problems. For example, the observation of ""Acute MI"" in 2004 can be related to the observation of ""History of MI"" in 2006 because they are the same concern. The conformance statements in this section define an outer ""problem act"" (representing the ""Concern"") that can contain a nested ""problem observation"" or other nested clinical statements.


Description

Act Code /ClinicalDocument/component/structuredBody/component/section/entry/act

moodCode = “EVN”classCode = “ACT”

Act Template ID


Root = "2.16.840.1.113883.10.20.22.4.3"


Act GUID /ClinicalDocument/component/structuredBody/component/section/entry/act/id

GUID

Problem Concern Status (Act)

/ClinicalDocument/component/structuredBody/component/section/entry/act/statusCode

Active or Completed if end date indicated

If the problem is marked hidden, the status is completed; otherwise, active

Problem Concern Code /ClinicalDocument/component/structuredBody/

component/section/entry/act/code

Code = “CONC”CodeSystem = "2.16.840.1.113883.5.6"

Concern

Act Date/ClinicalDocument/component/structuredBody/component/section/entry/act/effectiveTime/low

Start/stop dates the concern was active on the Problem List



<entry><act moodCode="EVN" classCode="ACT">

<templateId root="2.16.840.1.113883.10.20.22.4.3"/><id root="301b6649-2013-ec27-09db-001A64958C30"/><code code="CONC" codeSystem="2.16.840.1.113883.5.6"/><statusCode code="active"/><effectiveTime>

<low value="19990101000000-0500"/></effectiveTime><entryRelationship typeCode="SUBJ" inversionInd="false">

<observation moodCode="EVN" classCode="OBS">


14.1.1.2 Problem Observation

A problem is a clinical statement that a clinician has noted. In health care it is a condition that requires monitoring or diagnostic, therapeutic, or educational action. It also refers to any unmet or partially met basic human need.A Problem Observation is required to be wrapped in an act wrapper in locations such as the Problem Section, Allergies Section, and Hospital Discharge Diagnosis Section, where the type of problem needs to be identified or the condition tracked. A Problem Observation can be a valid ""standalone"" template instance in cases where a simple problem observation is to be sent.The negationInd attribute, if true, specifies that the problem indicated was observed to not have occurred (which is subtly but importantly different from having not been observed). NegationInd='true' is an acceptable way to make a clinical assertion that something did not occur, for example, 'no diabetes'.Subject XPath Code Set &

MappingDescription

Entry Type Code

/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship

typeCode = “SUBJ”inversionInd = “false”

Observation Code

/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation


negationInd = “true” if problem was not observed


/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/templateId

Root = "2.16.840.1.113883.10.20.22.4.4”


Observation GUID

/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/id

GUID

Observation Code

/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/code

Code = "55607006" CodeSystem = "2.16.840.1.113883.6.96"

Problem Type ValueSetSNOMED CT

Problem Status (Observation)

/ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/statusCode

Completed Set to “Completed” indicating the observation is complete

Onset Date /ClinicalDocument/component/structuredBody/component/section/entry/act/entryRelationship/observation/effectiveTime/low

Onset date in problem list

Completed Date /ClinicalDocument/component/structuredBody/

component/section/entry/act/entryRelationship/observation/effectiveTime/high

Resolution date in problem list

Problem Value /ClinicalDocument/component/structuredBody/

component/section/entry/act/entryRelationship/observation/value

Xsi:type = “CD”Problem ValueSet

Diagnosis or Problem List

14.1.2 Problems – XML Example



<entry><act moodCode="EVN" classCode="ACT">

<templateId root="2.16.840.1.113883.10.20.22.4.3"/><id root="301b6649-2013-ec27-09db-001A64958C30"/><code code="CONC" codeSystem="2.16.840.1.113883.5.6"/><statusCode code="active"/><effectiveTime>

<low value="19990101000000-0500"/></effectiveTime><entryRelationship typeCode="SUBJ" inversionInd="false">

<observation moodCode="EVN" classCode="OBS">


15 Procedures SectionThe Procedures Section displays all historical procedures ordered as either “Surgery/Px” or “Imaging” within athenaNet. When a CPT code is mapped, this code is captured and sent. This section does not include procedures from orders that are to be performed in the future.



Root = “2.16.840.1.113883.10.20.22.2.7.1”






Code = “47519-4”Code System = “2.16.840.1.113883.6.1”

LOINC Codes used for Procedure sectionHistory of Procedures


“Procedures”

15.1.1.1 Procedure Activity Procedure

The common notion of ""procedure"" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g. splenectomy). This clinical statement represents procedures whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the patient. Examples of these procedures are an appendectomy, hip replacement and a creation of a gastrostomy.

Subject XPath Code Set & Mapping DescriptionProcedure Activity Procedure

/ClinicalDocument/component/structuredBody/component/section/entry/procedure

moodCode = “INT”classCode = “PROC”

Procedure Template ID /ClinicalDocument/component/structuredBody/

component/section/entry/procedure/templateIdRoot = "2.16.840.1.113883.10.20.22.4.14"


Procedure GUID /ClinicalDocument/component/structuredBody/

component/section/entry/procedure/idGUID

Procedure Code

/ClinicalDocument/component/structuredBody/component/section/entry/procedure/code

CPT when available through charge integration, otherwise nullCode = “73140”Code System = "2.16.840.1.113883.6.12

If a surgery or procedure is ordered, it’s captured using a Procedure Activity Procedure. Imaging Procedures are represented by Procedure Activity Observation entries.

Procedure Name

/ClinicalDocument/component/structuredBody/component/section/entry/procedure/code(displayName)

Name of Procedure

Status /ClinicalDocument/component/structuredBody/component/section/entry/procedure/statusCode

ProcedureAct statusCode ValueSet

‘Active’ or ‘Completed’




Date of Procedure

/ClinicalDocument/component/structuredBody/component/section/entry/procedure/effectiveTime

Perform Date

15.1.1.2 Procedure Activity Observation

The common notion of ""procedure"" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g. splenectomy). This clinical statement represents procedures that result in new information about the patient that cannot be classified as a procedure according to the HL7 RIM. Examples of these procedures are diagnostic imaging procedures, EEGs and EKGs.Subject XPath Code Set & Mapping DescriptionProcedure Activity Observation

/ClinicalDocument/component/structuredBody/component/section/entry/observation

classCode = “OBS”moodCode = “INT”

Procedure Observation Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/observation/templateId

Root = "2.16.840.1.113883.10.20.22.4.13"


Procedure Observation GUID

/ClinicalDocument/component/structuredBody/component/section/entry/observation/id

GUID

Procedure Observation Code

/ClinicalDocument/component/structuredBody/component/section/entry/observation/code

LOINC or SNOMED

Procedure Observation Status

/ClinicalDocument/component/structuredBody/component/section/entry/observation/code(displayName)

ProcedureAct StatusCode ValueSet

Date of Procedure Observation

/ClinicalDocument/component/structuredBody/component/section/entry/observation/statusCode

Performer /ClinicalDocument/component/structuredBody/component/section/entry/procedure/effectiveTime

Provider or Organization that receives the order

Performer Address

/ClinicalDocument/component/structuredBody/component/section/entry/observation/performer/assignedEntity/addr

Address of the receiving provider


/ClinicalDocument/component/structuredBody/component/section/entry/observation/performer/assignedEntity/telecom

Phone number of the receiving provider

Represented Organization

/ClinicalDocument/component/structuredBody/component/section/entry/observation/performer/assignedEntity/representedOrganization

Organization of the receiving provider (if applicable)



<entry><observation classCode="OBS" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.13"/><id root="301b6649-2013-58b5-09db-001A64958C30"/><code code="73140" codeSystem="2.16.840.1.113883.6.12" displayName="X-RAY EXAM OF

FINGER(S)" codeSystemName="CPT" xsi:type="CE"/><statusCode code="completed"/><effectiveTime value="20070101000000-0500"/><value nullFlavor="NA" xsi:type="CE"/><performer>

<assignedEntity><id root="301b6649-2013-cf3b-09db-001A64958C30"/><addr use="WP">

<streetAddressLine>2573 STANTONSBURG RD</streetAddressLine><streetAddressLine>STE B</streetAddressLine><city>GREENVILLE</city><state>NC</state><postalCode>27834</postalCode><country nullFlavor="NI"/>

</addr><telecom use="WP" value="(252) 215-5200"/><representedOrganization>

<name>BOYETTE ORTHOPEDICS & SPORTS MEDICINE, PA</name><telecom use="WP" value="(252) 215-5200"/><addr use="WP">

<streetAddressLine>2573 STANTONSBURG RD</streetAddressLine>

<streetAddressLine>STE B</streetAddressLine>


15.1.1.3 Procedure Activity Act

The common notion of ""procedure"" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g., splenectomy). This clinical statement represents any procedure that cannot be classified as an observation or a procedure according to the HL7 RIM. Examples of these procedures are a dressing change, teaching or feeding a patient or providing comfort measures.Subject XPath Code Set & Mapping DescriptionProcedure Activity Act


classCode = “ACT”moodCode

Procedure Activity Act Template ID


Root = "2.16.840.1.113883.10.20.22.4.12"


Procedure Activity Act GUID

/ClinicalDocument/component/structuredBody/component/section/entry/act/id

GUID

Procedure Act Code

/ClinicalDocument/component/structuredBody/component/section/entry/act/code

LOINC or SNOMED

Procedure Act Status

/ClinicalDocument/component/structuredBody/component/section/entry/act/code(displayName)

ProcedureAct statusCode ValueSet

Date of Procedure Act

/ClinicalDocument/component/structuredBody/component/section/entry/act/statusCode

15.1.2 Procedures – XML Example



<entry><observation classCode="OBS" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.13"/><id root="301b6649-2013-58b5-09db-001A64958C30"/><code code="73140" codeSystem="2.16.840.1.113883.6.12" displayName="X-RAY EXAM OF

FINGER(S)" codeSystemName="CPT" xsi:type="CE"/><statusCode code="completed"/><effectiveTime value="20070101000000-0500"/><value nullFlavor="NA" xsi:type="CE"/><performer>

<assignedEntity><id root="301b6649-2013-cf3b-09db-001A64958C30"/><addr use="WP">

<streetAddressLine>2573 STANTONSBURG RD</streetAddressLine><streetAddressLine>STE B</streetAddressLine><city>GREENVILLE</city><state>NC</state><postalCode>27834</postalCode><country nullFlavor="NI"/>

</addr><telecom use="WP" value="(252) 215-5200"/><representedOrganization>

<name>BOYETTE ORTHOPEDICS & SPORTS MEDICINE, PA</name><telecom use="WP" value="(252) 215-5200"/><addr use="WP">

<streetAddressLine>2573 STANTONSBURG RD</streetAddressLine>

<streetAddressLine>STE B</streetAddressLine>


16 Immunizations SectionThe Immunizations Section includes both historical vaccinations and those administered during the visit. This section also includes vaccines which were prescribes but not administered. Deleted and refused vaccines are not included.


MappingDescription

Template ID


Root = “2.16.840.1.113883.10.20.22.2.2”




Section Code



LOINC codes used for immunizations


“Vaccine List”

Substance Administration Code

/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration

moodCode = “EVN”classCode = “SBADM”negationInd = “false”

negationInd = “true” indicates the immunization was not given

Entry Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/templateId

Root = "2.16.840.1.113883.10.20.22.4.52”


Entry GUID/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/id

GUID


‘Active’ or ‘Completed’

Effective Time

/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/effectiveTime

Administered Date

Dose /ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/doseQuantity

Units of Measure Case Sensitive ValueSet

Includes units, if applicable

Manufactured Product Code


classCode = “MANU” Manufactured Product

Manufactured Product Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/consumable/manufacturedProduct/templateId

Root = "2.16.840.1.113883.10.20.22.4.54”


Manufactured Material Code

/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/consumable/manufacturedProduct/manufacturedMaterial/code

CVXCodeSystem = "2.16.840.1.113883.12.292"

Vaccine Name

/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/

Name of vaccine provided



<entry><substanceAdministration moodCode="EVN" classCode="SBADM" negationInd="false">

<templateId root="2.16.840.1.113883.10.20.22.4.52"/><id root="1e7775c9-2013-8922-07d1-001A64958C30"/><text>

<reference value="#immun1"/></text><statusCode code="completed"/><effectiveTime value="20120806000000-0400"/><doseQuantity nullFlavor="UNK"/><consumable>


<code code="33" codeSystem="2.16.840.1.113883.12.292" displayName="pneumococcal polysaccharide PPV23" codeSystemName="CVX"/>

</manufacturedMaterial></manufacturedProduct>

</consumable></substanceAdministration>

</entry>


consumable/manufacturedProduct/manufacturedMaterial/code(displayName)

Lot Number /ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/consumable/manufacturedProduct/manufacturedMaterial/lotNumberText

Manufacturer Organization Code

/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/consumable/manufacturedProduct/manufacturedOrganization

classCode = “ORG”

Manufacturer Organization Name

/ClinicalDocument/component/structuredBody/component/section/entry/substanceAdministration/consumable/manufacturedProduct/manufacturedMaterial/manufacturedOrganization/name

16.1.2 Immunization – XML Example




17 Social History SectionThe Social History Section captures a patient’s more recently indicated smoking status.



Root = “2.16.840.1.113883.10.20.22.2.17”




Section Code


Code = “29762-2”Code System = “2.16.840.1.113883.6.1”

LOINC codes used for Smoking Status


“Social History”

17.1.1.1 Smoking Status Observation

This clinical statement represents a patient’s current smoking status. The vocabulary selected for this clinical statement is the best approximation of the statuses in Meaningful Use (MU) Stage 1. If the patient is a smoker (77176002), the effectiveTime/low element must be present. If the patient is an ex-smoker (8517006), both the effectiveTime/low and effectiveTime/high element must be present.The smoking status value set includes a special code to communicate if the smoking status is unknown which is different from how Consolidated CDA generally communicates unknown information.

Subject XPath Code Set & Mapping DescriptionSmoking Status Observation Code

/ClinicalDocument/component/structuredBody/component/section/entry/observation

moodCode = “EVN”classCode = “OBS"


/ClinicalDocument/component/structuredBody/component/section/entry/observation/templateId

Root = "2.16.840.1.113883.10.20.22.4.78”


Observation GUID

/ClinicalDocument/component/structuredBody/component/section/entry/observation/id

GUID

Observation Code


Code = “ASSERTION”Code System = "2.16.840.1.113883.5.4"

Assertion

Status /ClinicalDocument/component/structuredBody/component/section/entry/observation/statusCode


Observation Code


SNOMED Smoking Status

See Smoking Status mapping table below

Code System

/ClinicalDocument/component/structuredBody/component/section/entry/observation/code(codeSystem)

SNOMED

Start/End /ClinicalDocument/component/structuredBody/ Smoking Status observation



<observation moodCode="EVN" classCode="OBS"><templateId root="2.16.840.1.113883.10.20.22.4.78"/><id root="35d52545-2013-205a-01b0-001A64958C30"/><code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/><statusCode code="completed"/><effectiveTime>

<low nullFlavor="NI"/></effectiveTime><value code="266927001" codeSystem="2.16.840.1.113883.6.96" displayName="Unknown If

Ever Smoked" xsi:type="CD"/>


Date component/section/entry/observation/effectiveTime/low

date

Smoking Status

/ClinicalDocument/component/structuredBody/component/section/entry/observation/value(displayName)

Xsi:type = “CD” Smoking Status ValueSet

Author Timestamp

/ClinicalDocument/component/structuredBody/component/section/entry/observation/author/time

Assigned Author Code

/ClinicalDocument/component/structuredBody/component/section/entry/observation/author/assignedAuthor

classCode = “ASSIGNED”

Assigned Author ID

/ClinicalDocument/component/structuredBody/component/section/entry/observation/author/id

Assigned Author Address

/ClinicalDocument/component/structuredBody/component/section/entry/observation/author/addr

Assigned Author Name

/ClinicalDocument/component/structuredBody/component/section/entry/observation/author/name

Smoking Status Mapping TableathenaNet maps smoking status and the number of cigarettes smoked to one of 8 bolded SNOMED values in the table below.

athenaNet Smoking Status Value

athenaNet “How Much” Value

SNOMED Code SNOMED Description

Current Every day Smoker

(blank) 449868002 Current every day smoker

Current Some Day Smoker

(blank) 428041000124106 Current some day smoker

Former Smoker (blank) 8517006 Former smokerNever Smoker (blank) 266919005 Never smoker (Never

Smoked)Smoker, Current Status Unknown

(blank) 77176002 Smoker, current status unknown

Unknown if ever smoked

(blank) 266927001 Unknown if ever smoked


1 PPD, 1 ½ PPD, 2 PPD, 3+ PPD

428071000124103 Heavy Tobacco Smoker


¼ PPW, ½ PPW,1 PPW, 2 PPW

428061000124105 Light Tobacco Smoker

17.1.2 Smoking Status – XML Example



<observation moodCode="EVN" classCode="OBS"><templateId root="2.16.840.1.113883.10.20.22.4.78"/><id root="35d52545-2013-205a-01b0-001A64958C30"/><code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/><statusCode code="completed"/><effectiveTime>

<low nullFlavor="NI"/></effectiveTime><value code="266927001" codeSystem="2.16.840.1.113883.6.96" displayName="Unknown If

Ever Smoked" xsi:type="CD"/>


18 Past Encounters SectionThe Past Encounters Section lists and describes any healthcare encounters pertinent to the patient’s current health status or historical health history. This section also contains an “Encounter Diagnosis” entry, which defines the diagnosis associated with a specific encounter. The CCDA document captures encounter types of “visit.” Deleted encounters are excluded. Unscheduled encounters are included.Individual order groups are not considered encounters.



Root = “2.16.840.1.113883.10.20.22.2.22”




Section Code



LOINC code used for Past Encounters


component/section/title“Past Encounters”

18.1.1.1 Encounter Activities

This clinical statement describes the interactions between the patient and clinicians. Interactions include in-person encounters, telephone conversations, and email exchanges.Subject XPath Code Set & Mapping DescriptionEntry Code /ClinicalDocument/component/structuredBody/

component/section/entry/encountermoodCode = “EVN” classCode = “ENC”

Code used for entry

Entry Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/templateId

Root = "2.16.840.1.113883.10.20.22.4.49"


Entry GUID/ClinicalDocument/component/structuredBody/component/section/entry/id

GUID

Entry Code/ClinicalDocument/component/structuredBody/component/section/entry/code

EncounterTypeCode Value Set

Effective Time /ClinicalDocument/component/structuredBody/

component/section/entry/encounter/effectiveTimeDate/time of the encounter

18.1.1.2 Performer, Location


Description

Performer Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/performer/assignedEntity/id

NPIRoot="2.16.840.1.113883.4.6"

HL7 Registered ModelExtension = NPI

Performer Code /ClinicalDocument/component/structuredBody/

component/section/entry/encounter/performer/Code = "207LP2900X" CodeSystem =




assignedEntity/code "2.16.840.1.113883.6.101"

Performer Department

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/performer/assignedEntity/code

NUCC HC Provider Taxonomy

Performer Address

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/performer/assignedEntity/addr



/ClinicalDocument/component/structuredBody/component/section/entry/encounter/performer/assignedEntity/telecom

Telecom use

Performer Name

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/performer/assignedEntity/assignedPerson/name

Provider for the encounter

18.1.1.3 Patient

This clinical statement represents the location of a service event where an act, observation or procedure took place.


Description

Participant Type Code

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/participant/

typeCode = “LOC” Location

Participant Class Code

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/participant/participantRole

classCode = “SDLOC”

Service Delivery Location

Participant Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/participant/participantRole/templateId

Root = "2.16.840.1.113883.10.20.22.4.32"


Participant Code

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/participant/participantRole/code

CodeSystem = "2.16.840.1.113883.6.259"

Healthcare Service Location

Participant Address

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/participant/participantRole/addr

Participant Phone Number

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/participant/participantRole/telecom

Location Address

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/participant/participantRole/playingEntity/addr


Address of the department the encounter occurred at

Location Phone Number

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/participant/participantRole/playingEntity/telecom

Telecom use Phone number of the department the encounter occurred at

Location Name

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/participant/participantRole/playingEntity/name

classCode = “PLC” Name of the department the encounter occurred at



<entry><encounter moodCode="EVN" classCode="ENC">

<templateId root="2.16.840.1.113883.10.20.22.4.49"/><id root="13156a2e-2014-bd26-07e1-001A64958C30"/><code nullFlavor="NI" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4">


18.1.1.4 Encounter Diagnosis

This template wraps relevant problems or diagnoses at the close of a visit or that need to be followed after the visit. If the encounter is associated with a Hospital Discharge, the Hospital Discharge Diagnosis must be used. This entry requires at least one Problem Observation entry.


Description

Entry Type Code

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/entryRelationship


Act Code/ClinicalDocument/component/structuredBody/component/section/entry/encounter/entryRelationship/act

moodCode = “EVN”classCode = “ACT”

Act Template ID

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/entryRelationship/act/templateId

Root = "2.16.840.1.113883.10.20.22.4.80"


Act Code/ClinicalDocument/component/structuredBody/component/section/entry/encounter/entryRelationship/act/code

Code = "29308-4" CodeSystem = "2.16.840.1.113883.6.1"

Encounter Diagnosis

Act Entry Type

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/entryRelationship/act/entryRelationship/


Observation Code

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/entryRelationship/act/entryRelationship/observation


ObservationEvent


/ClinicalDocument/component/structuredBody/component/section/entry/encounter/entryRelationship/act/entryRelationship/observation/templateId

Root = "2.16.840.1.113883.10.20.22.4.4"


Observation GUID

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/entryRelationship/act/entryRelationship/observation/id

GUID

Observation Code

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/entryRelationship/act/entryRelationship/observation/code

Code = "282291009" CodeSystem = "2.16.840.1.113883.6.96"

Diagnosis

Observation Status

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/entryRelationship/act/entryRelationship/observation/statusCode


Observation Onset Date

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/entryRelationship/act/entryRelationship/observation/effectiveTime

Low = Onset DateHigh = Resolution Date

Encounter Diagnosis

/ClinicalDocument/component/structuredBody/component/section/entry/encounter/entryRelationship/act/entryRelationship(typeCode=”SUBJ”)/observation/value

Xsi:type = “CD”SNOMED code

If the diagnosis or SNOMED code is unknown, @nullFlavor = “UNK”If code is not SNOMED, @nullFlavor = “OTH”

18.1.2 Past Encounter – XML Example



<entry><encounter moodCode="EVN" classCode="ENC">

<templateId root="2.16.840.1.113883.10.20.22.4.49"/><id root="13156a2e-2014-bd26-07e1-001A64958C30"/><code nullFlavor="NI" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4">


19 History of Present Illness SectionThe History of Present Illness Section describes symptoms and historical information pertinent to the patient’s current illness, if applicable. It pulls all free text from the “Reason for Visit” section of the encounter. This section only contains a single text element.


MappingDescription



Root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"




Section Code



LOINC codes used for History of Present Illness section


component/section/title“History of Present Illness”

History of Present Illness

/ClinicalDocument/component/structuredBody/component/section/text

Entered as free text

Physician Notes /ClinicalDocument/component/structuredBody/

component/section/text

Test notes for elements noted in history of present illness

19.1.2 History of Present Illness – XML Example


<component> <section> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.4"/> <id root="2b38acb8-2016-d00b-0dc5-001A64958C30"/> <code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>History of Present Illness</title> <text><br/><paragraph>52 yo cau male with low T.</paragraph>

<paragraph> <content styleCode="Bold">Review of Systems:</content> ROS as noted in the HPI

</paragraph>



20 Review of Systems SectionThe Review of Systems Section describes the physicians review of the patient’s body as documented during the encounter. This section only contains a single text element.


MappingDescription



Root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"




Section Code



LOINC codes used for Review of Systems section


component/section/title“Review of Systems”

Review of Systems



20.1.2 Review of Systems – XML Example


<component> <section> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.4"/> <id root="2b38acb8-2016-d00b-0dc5-001A64958C30"/> <code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>History of Present Illness</title> <text><br/><paragraph>52 yo cau male with low T.</paragraph>

<paragraph> <content styleCode="Bold">Review of Systems:</content> ROS as noted in the HPI

</paragraph>

<component> <section> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.18"/> <id root="2b38acb8-2016-100d-0dc5-001A64958C30"/> <code code="10187-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Review of Systems</title> <text> <table> <tbody> <tr><td> </td><td><content styleCode="Bold">General Adult ROS</content></td></tr> <tr><td><content styleCode="Bold">Reported By:</content></td><td>Patient</td></tr> <tr><td><content styleCode="Bold">Constitutional:</content></td><td>Constitutional: no fever, no night sweats, no significant weight gain, no significant weight loss, no exercise intolerance</td></tr> <tr><td><content styleCode="Bold">Eyes:</content></td><td>Eyes: no dry eyes, no irritation, no vision change</td></tr> <tr><td><content styleCode="Bold">ENMT:</content></td><td>Ears: no difficulty hearing, no ear pain. Nose: no frequent nosebleeds, no nose/sinus problems. Mouth/Throat: no sore throat, no bleeding gums, no snoring, no dry mouth, no mouth ulcers, no oral abnormalities, no teeth problems</td></tr> <tr><td><content styleCode="Bold">Allergic/Immunologic:</content></td><td>Allergy/Immunologic: no runny nose, no sinus pressure, no itching, no hives, no frequent sneezing</td></tr> </tbody> </table> </text> </section> </component>



21 Physical Exam SectionThe Physical Exam Section captures the physican’s notes from the physical exam of the patient during an encounter. This section only contains a single text element.


MappingDescription



Root = "2.16.840.1.113883.10.20.2.10"




Section Code


Code = “29545-1”Code System = “2.16.840.1.113883.6.1”

LOINC codes used for Physical Exam section


component/section/title“Physical Exam”

Physical Exam



Physician Notes


Physician notes for physical exam section

21.1.1 Physical Exam – XML Example


<component> <section> <templateId root="2.16.840.1.113883.10.20.2.10"/> <id root="2b38acb8-2016-e86a-0dc5-001A64958C30"/> <code code="29545-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Physical Exam</title> <text> <table> <tbody> <tr><td> </td><td><content styleCode="Bold">General Adult Exam</content></td></tr> <tr><td><content styleCode="Bold">Constitutional:</content></td><td>General Appearance: healthy-appearing, well-nourished, well-developed. Level of Distress: NAD. Ambulation: ambulating normally</td></tr> <tr><td><content styleCode="Bold">Eyes:</content></td><td>Lids and Conjunctivae: non-injected, no discharge, no pallor. Pupils: PERRLA. Corneas: grossly intact, fluorescein stain--normal. EOM: EOMI. Sclerae: non-icteric. Vision: peripheral vision grossly intact, acuity grossly intact</td></tr> <tr><td><content styleCode="Bold">Back:</content></td><td>Thoracolumbar Appearance: normal curvature</td></tr> </tbody> </table> </text> </section> </component>


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