Transcription
Healthix C-CDA R2.1 Care Plan Companion GuideDecember 12Healthix C-CDA R2.1 Care Plan Companion GuideDecember 12Page 1
Contents1DOCUMENT . 61.1Healthix Care Plan (V2) . 61.2US Realm Header (V3) . 191.2.123Properties . 29SECTION . 542.1Advance Directives Section (entries optional) (V3). 542.2Allergies and Intolerances Section (entries optional) (V3) . 562.3Allergies and Intolerances Section (entries required) (V3) . 582.4Encounters Section (entries optional) (V3) . 602.5Encounters Section (entries required) (V3) . 622.6Goals Section . 642.7Health Concerns Section (V2) . 662.8Health Status Evaluations and Outcomes Section . 692.9Interventions Section (V3) . 712.10Medications Section (entries optional) (V2) . 732.11Medications Section (entries required) (V2) . 752.12Payers Section (V3). 772.13Problem Section (entries optional) (V3) . 792.14Problem Section (entries required) (V3) . 812.15Procedures Section (entries optional) (V2) . 852.16Procedures Section (entries required) (V2) . 882.17Results Section (entries optional) (V3) . 912.18Results Section (entries required) (V3) . 932.19Vital Signs Section (entries optional) (V3) . 952.20Vital Signs Section (entries required) (V3) . 97ENTRY . 1003.1Advance Directive Observation (V3) . 1003.2Advance Directive Organizer (V2) . 1083.3Age Observation . 1123.4Allergy - Intolerance Observation (V2) . 1143.5Allergy Concern Act (V3) . 120Healthix C-CDA R2.1 Care Plan Companion GuideDecember 12Page 2
3.6Allergy Status Observation (DEPRECATED) . 1243.7Assessment Scale Observation . 1263.8Assessment Scale Supporting Observation . 1293.9Caregiver Characteristics . 1313.10Characteristics of Home Environment . 1343.11Coverage Activity (V3) . 1353.12Criticality Observation. 1383.13Cultural and Religious Observation . 1393.14Drug Monitoring Act . 1413.15Drug Vehicle . 1443.16Encounter Activity (V3). 1463.17Encounter Diagnosis (V3) . 1503.18Entry Reference . 1523.19Estimated Date of Delivery . 1573.20External Document Reference . 1583.21Family History Death Observation . 1603.22Family History Observation (V3) . 1623.23Family History Organizer (V3) . 1653.24Functional Status Observation (V2) . 1693.25Goal Observation . 1723.26Handoff Communication Participants . 1793.27Health Concern Act (V2) . 1833.28Health Status Observation (V2). 2003.29Highest Pressure Ulcer Stage . 2023.30Hospital Admission Diagnosis (V3) . 2043.31Immunization Activity (V3) . 2073.32Immunization Medication Information (V2) . 2153.33Immunization Refusal Reason . 2173.34Indication (V2) . 2193.35Instruction (V2) . 2223.36Intervention Act (V2) . 2243.37Longitudinal Care Wound Observation (V2). 2343.38Medication Activity (V2) . 2403.39Medication Dispense (V2) . 2503.40Medication Free Text Sig . 2533.41Medication Information (V2) . 256Healthix C-CDA R2.1 Care Plan Companion GuideDecember 12Page 3
3.42Medication Supply Order (V2) . 2583.43Mental Status Observation (V3) . 2613.44Non-Medicinal Supply Activity (V2) . 2663.45Number of Pressure Ulcers Observation (V3) . 2693.46Nutrition Assessment . 2733.47Nutrition Recommendation . 2763.48Nutritional Status Observation . 2793.49Outcome Observation . 2823.50Planned Act (V2) . 2873.51Planned Coverage . 2913.52Planned Encounter (V2) . 2953.53Planned Immunization Activity . 2993.54Planned Intervention Act (V2) . 3053.55Planned Medication Activity (V2) . 3153.56Planned Observation (V2) . 3213.57Planned Procedure (V2) . 3263.58Planned Supply (V2) . 3323.59Policy Activity (V3) . 3383.60Postprocedure Diagnosis (V3) . 3483.61Precondition for Substance Administration (V2) . 3503.62Pregnancy Observation . 3523.63Preoperative Diagnosis (V3) . 3543.64Priority Preference . 3563.65Problem Concern Act (V3) . 3593.66Problem Observation (V3) . 3653.67Problem Status (DEPRECATED) . 3703.68Procedure Activity Act (V2) . 3723.69Procedure Activity Observation (V2) . 3793.70Procedure Activity Procedure (V2) . 3873.71Product Instance . 3943.72Prognosis Observation . 3963.73Progress Toward Goal Observation . 3983.74Reaction Observation (V2) . 4003.75Result Observation (V3) . 4053.76Result Organizer (V3) . 4093.77Risk Concern Act (V2) . 413Healthix C-CDA R2.1 Care Plan Companion GuideDecember 12Page 4
43.78Self-Care Activities (ADL and IADL) . 4303.79Sensory Status . 4313.80Service Delivery Location . 4343.81Severity Observation (V2) . 4363.82Smoking Status - Meaningful Use (V2) . 4383.83Social History Observation (V3) . 4413.84Substance Administered Act . 4443.85Substance or Device Allergy - Intolerance Observation (V2) . 4463.86Tobacco Use (V2) . 4503.87Vital Sign Observation (V2) . 4543.88Vital Signs Organizer (V3) . 4583.89Wound Characteristic. 4623.90Wound Measurement Observation . 463UNSPECIFIED . 4664.1Author Participation . 4664.2US Realm Address (AD.US.FIELDED) . 4704.3US Realm Date and Time (DTM.US.FIELDED) . 4714.4US Realm Patient Name (PTN.US.FIELDED) . 4724.5US Realm Person Name (PN.US.FIELDED) . 4745TEMPLATE IDS IN THIS GUIDE . 4756VALUE SETS IN THIS GUIDE . 5937CODE SYSTEMS IN THIS GUIDE . 648Healthix C-CDA R2.1 Care Plan Companion GuideDecember 12Page 5
1DOCUMENT1.1Healthix Care Plan (V2)[ClinicalDocument: identifier 9 (open)]Draft as part of Healthix C-CDA R2.1 Care Plan Companion GuideTable 1: Healthix Care Plan (V2) ContextsContained By:Contains:Advance Directives Section (entries optional) (V3)Allergies and Intolerances Section (entries required)(V3)Encounters Section (entries required) (V3)Goals SectionHealth Concerns Section (V2)Health Status Evaluations and Outcomes SectionInterventions 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 DocumentTemplate. It contains the same conformance for the four cornerstone sections of a Care PlanDocument:1. Health Concerns2. Goals3. Interventions4. Health Status Evaluations and OutcomesHowever, in order to support the requirements of the Healthix Care Plan Pilot Project, it alsoincludes additional information needed to assess the person's health status and outcomes fromthe current plan. These additional sections include:5. Problems6. Allergies and Intolerances7. Medications8. Encounters9. Vital SignsHealthix C-CDA R2.1 Care Plan Companion GuideDecember 12Page 6
10. Procedures11. Tests (Results)12. Advance Directives13. PayersHealthix C-CDA R2.1 Care Plan Companion GuideDecember 12Page 7
Table 2: Healthix Care Plan (V2) Constraints cument (identifier: d:2.16.840.1.113883.6.1(LOINC) OrganizationauthenticatorHealthix C-CDA R2.1 Care Plan Companion GuideDecember 12US Realm Person Name(PN.US.FIELDED) .1urn:oid:2.16.840.1.114222.4.11.1066 (Healthcare ProviderTaxonomy (HIPAA))Page 8
1.1SHALL330531918urn:oid:2.16.840.1.113883.5.111 (HL7RoleCode) 31681urn:oid:2.16.840.1.113883.6.96(SNOMED CT) 1897participantHealthix C-CDA R2.1 Care Plan Companion GuideDecember ype) VRFurn:oid:2.16.840.1.113883.5.110 (HL7RoleClass) ASSIGNEDurn:oid:2.16.840.1.113883.11.20.12.1 (Personal And LegalRelationship Role onType) INDPage 9
ntereffectiveTimeHealthix C-CDA R2.1 Care Plan Companion GuideDecember 12urn:oid:2.16.840.1.113883.11.20.9.33 L7ActClass) PCPRUS Realm Person Name(PN.US.FIELDED) .1urn:oid:2.16.840.1.113883.11.20.9.62 (Related Document(append/replace))Page 10
532950component1.1SHALL330532951Healthix C-CDA R2.1 Care Plan Companion GuideDecember 12Health Concerns Section 22.2.58:2015-08-01Goals Section 0Interventions Section 21.2.3:2015-08-01Health Status Evaluations andOutcomes Section 1Problem Section (entriesrequired) (V3) .5.1:2015-08-01Allergies and IntolerancesSection (entries required) 22.2.6.1:2015-08-01Medications Section (entriesrequired) (V2) .1.1:2014-06-09Page 11
1.1SHALL330532962Encounters Section (entriesrequired) (V3) .22.1:2015-08-01Vital Signs Section (entriesrequired) (V3) .4.1:2015-08-01Procedures Section (entriesrequired) (V2) .7.1:2014-06-09Payers Section (V3) .18:2015-08-01Advance Directives Section(entries optional) (V3) .21:2015-08-01Results Section (entriesrequired) (V3) .3.1:2015-08-011. Conforms to US Realm Header (V3) template .1:2015-08-01).2. SHALL contain exactly one [1.1] templateId (CONF:3305-28741) such that ita. SHALL contain exactly one [1.1] @root .b. SHALL contain exactly one [1.1] @extension "2016-11-29" (CONF:3305-32877).c. When asserting this templateId, all C-CDA 2.1 section and entry templates that hada previous version in C-CDA R1.1 SHALL include both the C-CDA 2.1 templateIdand the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume1 - Design Considerations for additional detail (CONF:3305-32934).3. SHALL contain exactly one [1.1] code (CONF:3305-28745).a. This code SHALL contain exactly one [1.1] @code "52521-2" Overall Plan of Care/Advance Care Directives (CONF:3305-28746).Healthix C-CDA R2.1 Care Plan Companion GuideDecember 12Page 12
b. This code SHALL contain exactly one [1.1]@codeSystem "2.16.840.1.113883.6.1" (CodeSystem: LOINCurn:oid:2.16.840.1.113883.6.1) (CONF:3305-28747).4. SHOULD contain zero or one [0.1] setId (CONF:3305-32321).5. SHOULD contain zero or one [0.1] versionNumber (CONF:3305-32322).6. SHOULD contain zero or more [0.*] informationRecipient (CONF:3305-31993) such thatita. SHALL contain exactly one [1.1] intendedRecipient (CONF:3305-31994).i.This intendedRecipient SHALL contain at least one [1.*] id (CONF:330531996).ii. This intendedRecipient SHOULD contain zero or more [0.*] addr (CONF:330531997).iii. This intendedRecipient SHOULD contain zero or more [0.*] telecom(CONF:3305-31998).iv. This intendedRecipient SHOULD contain zero or one [0.1]informationRecipient (CONF:3305-31999).1. The informationRecipient, if present, SHALL contain exactly one [1.1]US Realm Person Name (PN.US.FIELDED) .1) (CONF:330532320).v. This intendedRecipient SHOULD contain zero or one [0.1]receivedOrganization (CONF:3305-32000).1. The receivedOrganization, if present, SHOULD contain zero or more[0.*] id (CONF:3305-32001).2. The receivedOrganization, if present, SHALL contain at least one [1.*]name (CONF:3305-32002).3. The receivedOrganization, if present, SHOULD contain zero or one[0.1] standardIndustryClassCode, which SHALL be selected fromValueSet Healthcare Provider Taxonomy (HIPAA)urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:330532003).7. SHOULD contain zero or one [0.1] authenticator (CONF:3305-31910) such that ita. SHALL contain exactly one [1.1] time (CONF:3305-31911).b. SHALL contain exactly one [1.1] signatureCode (CONF:3305-31912).c. MAY contain zero or one [0.1] sdtc:signatureText (CONF:3305-31913).d. SHALL contain exactly one [1.1] assignedEntity (CONF:3305-31914).i.This assignedEntity SHALL contain at least one [1.*] id (CONF:3305-31915).ii. This assignedEntity SHALL contain exactly one [1.1] code (CONF:330531916).1. This code SHALL contain exactly one [1.1] @code "ONESELF" Self(CONF:3305-31917).2. This code SHALL contain exactly one [1.1]@codeSystem "2.16.840.1.113883.5.111" (CodeSystem:HL7RoleCode urn:oid:2.16.840.1.113883.5.111) (CONF:330531918).Healthix C-CDA R2.1 Care Plan Companion GuideDecember 12Page 13
8. SHOULD contain zero or more [0.*] participant (CONF:3305-31677) such that ita. SHALL contain exactly one [1.1] @typeCode "VRF" Verifier (CodeSystem:HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:3305-31678).b. SHALL contain exactly one [1.1] functionCode (CONF:3305-31679).i.This functionCode SHALL contain exactly one [1.1] @code "425268008"Review of Care Plan (CONF:3305-31680).ii. This functionCode SHALL contain exactly one [1.1]@codeSystem "2.16.840.1.113883.6.96" (CodeSystem: SNOMED CTurn:oid:2.16.840.1.113883.6.96) (CONF:3305-31681).c. SHALL contain exactly one [1.1] time (CONF:3305-31682).d. SHALL contain exactly one [1.1] associatedEntity (CONF:3305-31683).i.This associatedEntity SHALL contain exactly one [1.1]@classCode "ASSIGNED" (CodeSystem: HL7RoleClassurn:oid:2.16.840.1.113883.5.110) (CONF:3305-31686).ii. This associatedEntity SHALL contain at least one [1.*] id (CONF:330531684).iii. This associatedEntity SHOULD contain zero or one [0.1] code (CONF:330531685).1. The code, if present, SHALL contain exactly one [1.1] @code(ValueSet: Personal And Legal Relationship Role Typeurn:oid:2.16.840.1.113883.11.20.12.1) (CONF:3305-32367).9. SHOULD contain zero or more [0.*] participant (CONF:3305-31895) such that ita. SHALL contain exactly one [1.1] @typeCode "IND" Indirect (CodeSystem:HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:3305-31896).b. SHALL contain exactly one [1.1] associatedEntity (CONF:3305-31897).i.This associatedEntity SHALL contain exactly one [1.1] @classCode, whichSHALL be selected from ValueSet .33 STATIC (CONF:3305-31898).ii. This associatedEntity SHALL contain exactly one [1.1] associatedPerson(CONF:3305-31899).1. This associatedPerson SHALL contain at least one [1.*] name(CONF:3305-31900).The serviceEvent describes the provision of healthcare over a period of time. The duration overwhich care was provided is indicated in serviceEvent/effectiveTime. Additional data fromoutside this duration may also be included if it is relevant to care provided during that timerange (e.g., reviewed during the stated time range).10. SHALL contain exactly one [1.1] documentationOf (CONF:3305-31901) such that ita. SHALL contain exactly one [1.1] serviceEvent (CONF:3305-31902).i.This serviceEvent SHALL contain exactly one [1.1] @classCode "PCPR" CareProvision (CodeSystem: HL7ActClass . This serviceEvent SHALL contain exactly one [1.1] effectiveTime(CONF:3305-31904).Healthix C-CDA R2.1 Care Plan Companion GuideDecember 12Page 14
1. This effectiveTime SHALL contain exactly one [1.1] low (CONF:330532330).2. This effectiveTime MAY contain zero or one [0.1] high (CONF:330532331).iii. This serviceEvent SHALL contain at least one [1.*] performer (CONF:330531905) such that it1. SHALL contain exactly one [1.1] assignedEntity (CONF:330531907).a. This assignedEntity SHALL contain at least one [1.*] id(CONF:3305-31908).b. This assignedEntity MAY contain zero or one [0.1] code(CONF:3305-31909).c. This assignedEntity SHALL contain exactly one [1.1]assignedPerson (CONF:3305-32328).i.This assignedPerson SHALL contain exactly one [1.1]US Realm Person Name 83.10.20.22.5.1.1)(CONF:3305-32329).11. MAY contain zero or more [0.*] relatedDocument (CONF:3305-29893) such that ita. SHALL contain exactly one [1.1] @typeCode, which SHALL be selected from ValueSetRelated Document 62 STATIC (CONF:3305-31889).b. SHALL contain exactly one [1.1] parentDocument (CONF:3305-29894).i.This parentDocument SHALL contain exactly one [1.1] setId (CONF:330529895).ii. This parentDocument SHALL contain exactly one [1.1] versionNumber(CONF:3305-29896).12. SHOULD contain zero or one [0.1] componentOf (CONF:3305-32004) such that ita. SHALL contain exactly one [1.1] encompassingEncounter (CONF:3305-32005).i.This encompassingEncounter SHALL contain exactly one [1.1]effectiveTime (CONF:3305-32007).13. SHALL contain exactly one [1.1] component (CONF:3305-28753).a. This component SHALL contain exactly one [1.1] structuredBody (CONF:330532936).i.SHALLcontain exactly one [1.1] component (CONF:3305-32937) such that it1. SHALL contain exactly one [1.1] Health Concerns Section 22.2.58:2015-08-01)(CONF:3305-32938).ii. SHALL contain exactly one [1.1] component (CONF:3305-32939) such that it1. SHALL contain exactly one [1.1] Goals Section 0) (CONF:330532940).Healthix C-CDA R2.1 Care Plan Companion GuideDecember 12Page 15
iii. SHOULD contain zero or one [0.1] component (CONF:3305-32941) such thatit1. SHALL contain exactly one [1.1] Interventions Section 21.2.3:2015-08-01)(CONF:3305-32942).iv. SHOULD contain zero or one [0.1] component (CONF:3305-32943) such thatit1. SHALL contain exactly one [1.1] Health Status Evaluations andOutcomes Section 1) (CONF:330532944).v. SHALL contain exactly one [1.1] component (CONF:3305-32945) such that it1. SHALL contain exactly one [1.1] Problem Section (entriesrequired) (V3) .5.1:2015-08-01)(CONF:3305-32946).vi. SHALL contain exactly one [1.1] component (CONF:3305-32947) such that it1. SHALL contain exactly one [1.1] Allergies and Intoleran
Healthix C-CDA R2.1 Care Plan Companion Guide December 12 Page 6 1 DOCUMENT 1.1 Healthix Care Plan (V2) [ClinicalDocument: identifier 29 (open)] Draft as part of Healthix C-CDA R2.1 Care Plan Companion Guide Table 1: Healthix Care Plan (V2) Contexts Contained By: Contains:
