Healthix C-CDA R2.1 Care Plan Companion Guide

[Pages:649]Healthix C-CDA R2.1 Care Plan Companion Guide

December 12

Healthix C-CDA R2.1 Care Plan Companion Guide December 12

Page 1

Contents

1 DOCUMENT ....................................................................................................................6 1.1 Healthix Care Plan (V2) ..............................................................................................6 1.2 US Realm Header (V3) .............................................................................................. 19 1.2.1 Properties ......................................................................................................... 29

2 SECTION....................................................................................................................... 54

2.1 Advance Directives Section (entries optional) (V3)...................................................... 54

2.2 Allergies and Intolerances Section (entries optional) (V3) ........................................... 56

2.3 Allergies and Intolerances Section (entries required) (V3)........................................... 58

2.4 Encounters Section (entries optional) (V3)................................................................. 60

2.5 Encounters Section (entries required) (V3) ................................................................ 62

2.6 Goals Section ........................................................................................................... 64

2.7 Health Concerns Section (V2) ................................................................................... 66

2.8 Health Status Evaluations and Outcomes Section..................................................... 69

2.9 Interventions Section (V3) ........................................................................................ 71

2.10

Medications Section (entries optional) (V2) ........................................................ 73

2.11

Medications Section (entries required) (V2)........................................................ 75

2.12

Payers Section (V3)........................................................................................... 77

2.13

Problem Section (entries optional) (V3) .............................................................. 79

2.14

Problem Section (entries required) (V3) ............................................................. 81

2.15

Procedures Section (entries optional) (V2) ......................................................... 85

2.16

Procedures Section (entries required) (V2) ......................................................... 88

2.17

Results Section (entries optional) (V3) ............................................................... 91

2.18

Results Section (entries required) (V3) .............................................................. 93

2.19

Vital Signs Section (entries optional) (V3) .......................................................... 95

2.20

Vital Signs Section (entries required) (V3) ......................................................... 97

3 ENTRY ........................................................................................................................ 100 3.1 Advance Directive Observation (V3) ........................................................................ 100 3.2 Advance Directive Organizer (V2) ............................................................................ 108 3.3 Age Observation ..................................................................................................... 112 3.4 Allergy - Intolerance Observation (V2) ..................................................................... 114 3.5 Allergy Concern Act (V3) ......................................................................................... 120

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3.6 Allergy Status Observation (DEPRECATED) ............................................................ 124

3.7 Assessment Scale Observation ............................................................................... 126

3.8 Assessment Scale Supporting Observation.............................................................. 129

3.9 Caregiver Characteristics ....................................................................................... 131

3.10

Characteristics of Home Environment............................................................. 134

3.11

Coverage Activity (V3) ..................................................................................... 135

3.12

Criticality Observation.................................................................................... 138

3.13

Cultural and Religious Observation ................................................................ 139

3.14

Drug Monitoring Act....................................................................................... 141

3.15

Drug Vehicle .................................................................................................. 144

3.16

Encounter Activity (V3)................................................................................... 146

3.17

Encounter Diagnosis (V3) ............................................................................... 150

3.18

Entry Reference ............................................................................................. 152

3.19

Estimated Date of Delivery ............................................................................. 157

3.20

External Document Reference ........................................................................ 158

3.21

Family History Death Observation .................................................................. 160

3.22

Family History Observation (V3) ..................................................................... 162

3.23

Family History Organizer (V3) ......................................................................... 165

3.24

Functional Status Observation (V2) ................................................................ 169

3.25

Goal Observation ........................................................................................... 172

3.26

Handoff Communication Participants ............................................................. 179

3.27

Health Concern Act (V2) ................................................................................. 183

3.28

Health Status Observation (V2)....................................................................... 200

3.29

Highest Pressure Ulcer Stage .......................................................................... 202

3.30

Hospital Admission Diagnosis (V3).................................................................. 204

3.31

Immunization Activity (V3) ............................................................................. 207

3.32

Immunization Medication Information (V2) ..................................................... 215

3.33

Immunization Refusal Reason ........................................................................ 217

3.34

Indication (V2) ............................................................................................... 219

3.35

Instruction (V2) .............................................................................................. 222

3.36

Intervention Act (V2) ...................................................................................... 224

3.37

Longitudinal Care Wound Observation (V2)..................................................... 234

3.38

Medication Activity (V2) .................................................................................. 240

3.39

Medication Dispense (V2) ............................................................................... 250

3.40

Medication Free Text Sig ................................................................................ 253

3.41

Medication Information (V2) ........................................................................... 256

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3.42 3.43 3.44 3.45 3.46 3.47 3.48 3.49 3.50 3.51 3.52 3.53 3.54 3.55 3.56 3.57 3.58 3.59 3.60 3.61 3.62 3.63 3.64 3.65 3.66 3.67 3.68 3.69 3.70 3.71 3.72 3.73 3.74 3.75 3.76 3.77

Medication Supply Order (V2) ......................................................................... 258 Mental Status Observation (V3) ...................................................................... 261 Non-Medicinal Supply Activity (V2) ................................................................. 266 Number of Pressure Ulcers Observation (V3) ................................................... 269 Nutrition Assessment ..................................................................................... 273 Nutrition Recommendation............................................................................. 276 Nutritional Status Observation ....................................................................... 279 Outcome Observation ..................................................................................... 282 Planned Act (V2) ............................................................................................ 287 Planned Coverage........................................................................................... 291 Planned Encounter (V2) ................................................................................. 295 Planned Immunization Activity ....................................................................... 299 Planned Intervention Act (V2) ......................................................................... 305 Planned Medication Activity (V2)..................................................................... 315 Planned Observation (V2) ............................................................................... 321 Planned Procedure (V2) .................................................................................. 326 Planned Supply (V2) ....................................................................................... 332 Policy Activity (V3).......................................................................................... 338 Postprocedure Diagnosis (V3) ......................................................................... 348 Precondition for Substance Administration (V2) .............................................. 350 Pregnancy Observation................................................................................... 352 Preoperative Diagnosis (V3) ............................................................................ 354 Priority Preference .......................................................................................... 356 Problem Concern Act (V3)............................................................................... 359 Problem Observation (V3) ............................................................................... 365 Problem Status (DEPRECATED) ..................................................................... 370 Procedure Activity Act (V2) ............................................................................. 372 Procedure Activity Observation (V2) ................................................................ 379 Procedure Activity Procedure (V2) ................................................................... 387 Product Instance ............................................................................................ 394 Prognosis Observation.................................................................................... 396 Progress Toward Goal Observation ................................................................. 398 Reaction Observation (V2) .............................................................................. 400 Result Observation (V3) .................................................................................. 405 Result Organizer (V3) ..................................................................................... 409 Risk Concern Act (V2) .................................................................................... 413

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3.78 3.79 3.80 3.81 3.82 3.83 3.84 3.85 3.86 3.87 3.88 3.89 3.90

Self-Care Activities (ADL and IADL)................................................................. 430 Sensory Status............................................................................................... 431 Service Delivery Location ................................................................................ 434 Severity Observation (V2) ............................................................................... 436 Smoking Status - Meaningful Use (V2) ............................................................ 438 Social History Observation (V3) ...................................................................... 441 Substance Administered Act ........................................................................... 444 Substance or Device Allergy - Intolerance Observation (V2) ............................. 446 Tobacco Use (V2)............................................................................................ 450 Vital Sign Observation (V2) ............................................................................. 454 Vital Signs Organizer (V3)............................................................................... 458 Wound Characteristic..................................................................................... 462 Wound Measurement Observation .................................................................. 463

4 UNSPECIFIED ............................................................................................................. 466 4.1 Author Participation............................................................................................... 466 4.2 US Realm Address (AD.US.FIELDED) ..................................................................... 470 4.3 US Realm Date and Time (DTM.US.FIELDED) ......................................................... 471 4.4 US Realm Patient Name (PTN.US.FIELDED) ............................................................ 472 4.5 US Realm Person Name (PN.US.FIELDED) .............................................................. 474

5 TEMPLATE IDS IN THIS GUIDE ................................................................................... 475

6 VALUE SETS IN THIS GUIDE....................................................................................... 593

7 CODE SYSTEMS IN THIS GUIDE ................................................................................. 648

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1 DOCUMENT

1.1 Healthix Care Plan (V2)

[ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.1.15:201611-29 (open)]

Draft as part of Healthix C-CDA R2.1 Care Plan Companion Guide

Contained By:

Table 1: Healthix Care Plan (V2) Contexts

Contains:

Advance Directives Section (entries optional) (V3) Allergies and Intolerances Section (entries required) (V3) Encounters Section (entries required) (V3) Goals Section Health Concerns Section (V2) Health Status Evaluations and Outcomes Section Interventions Section (V3) Medications Section (entries required) (V2) Payers Section (V3) Problem Section (entries required) (V3) Procedures Section (entries required) (V2) Results Section (entries required) (V3) US Realm Person Name (PN.US.FIELDED) Vital Signs Section (entries required) (V3)

This Care Plan Document Template is an extension of the C-CDA R2.1 Care Plan Document Template. It contains the same conformance for the four cornerstone sections of a Care Plan Document: 1. Health Concerns 2. Goals 3. Interventions 4. Health Status Evaluations and Outcomes However, in order to support the requirements of the Healthix Care Plan Pilot Project, it also includes additional information needed to assess the person's health status and outcomes from the current plan. These additional sections include: 5. Problems 6. Allergies and Intolerances 7. Medications 8. Encounters 9. Vital Signs

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10. Procedures 11. Tests (Results) 12. Advance Directives 13. Payers

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Table 2: Healthix Care Plan (V2) Constraints Overview

XPath

Card. Verb

Data Type

CONF Value #

ClinicalDocument (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.1.15:2016-11-29)

templateId

1..1 SHALL

330528741

@root

1..1 SHALL

3305- 2.16.840.1.113883.10.20.22.1.1 28742 5

@extension

1..1 SHALL

3305- 2016-11-29 32877

code

1..1 SHALL

330528745

@code

1..1 SHALL

3305- 52521-2 28746

@codeSystem

1..1 SHALL

330528747

urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1

setId

0..1 SHOULD

330532321

versionNumber

0..1 SHOULD

330532322

informationRecipient

0..* SHOULD

330531993

intendedRecipient

1..1 SHALL

330531994

id

1..* SHALL

3305-

31996

addr

0..* SHOULD

330531997

telecom

0..* SHOULD

330531998

informationRecipient

0..1 SHOULD

330531999

name

1..1 SHALL

330532320

US Realm Person Name (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.2 0.22.5.1.1

receivedOrganization

0..1 SHOULD

330532000

id

0..* SHOULD

3305-

32001

name

1..* SHALL

330532002

standardIndustryClassCode 0..1 SHOULD

330532003

urn:oid:2.16.840.1.114222.4.11. 1066 (Healthcare Provider Taxonomy (HIPAA))

authenticator

0..1 SHOULD

3305-

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