CHANGES: HL7 CDA® R2 Implementation Guide: C-CDA Templates for Clinical Notes STU Companion Guid...

1. 6. USCDI Guidance : ADDED SECTION

1.1. 6.1 General USCDI Guidance

1.1.1. 6.1.1 Best Practices for Implementing Templates revised to support USCDI v2 and v3

1.1.2. 6.1.2 Social Determinant of Health Vocabulary Design Notes

1.2. 6.2 USCDI Data Class and Data Element Guidance

1.2.1. 6.2.1 Assessment and Plan of Treatment (USCDIv2)

1.2.1.1. 6.2.1.1 SDOH Assessment

1.2.2. 6.2.2 Care Team Member(s) (USCDIv2)

1.2.2.1. Care Team Member Name

1.2.2.2. Care Team Member Identifier

1.2.2.3. Care Team Member Role

1.2.2.4. Care Team Member Location

1.2.2.5. Care Team Member Telecom

1.2.3. 6.2.3 Clinical Tests (USCDIv2)

1.2.3.1. Clinical Test

1.2.3.2. Clinical Test Report/Result

1.2.4. 6.2.4 Diagnostic Imaging (USCDIv2)

1.2.4.1. Diagnostic Imaging Test

1.2.4.2. Diagnostic Imaging Report

1.2.5. 6.2.5 Encounter Information (USCDIv2)

1.2.5.1. Encounter Diagnosis

1.2.5.2. Encounter Disposition

1.2.5.3. Encounter Location

1.2.5.4. Encounter Time

1.2.5.5. Encounter Type

1.2.6. 6.2.6 Goals (USCDIv2)

1.2.6.1. SDOH Goals

1.2.7. 6.2.7 Health Insurance Information (USCDIv3)

1.2.7.1. Coverage Status

1.2.7.2. Coverage Type

1.2.7.3. Relationship to Subscriber

1.2.7.4. Member identifier

1.2.7.5. Subscriber Identifier

1.2.7.6. Group Identifier

1.2.7.7. Payer Identifier

1.2.8. 6.2.8 Health Status/Assessments (USCDIv3)

1.2.8.1. Functional Status

1.2.8.2. Disability Status

1.2.8.3. Mental/Cognitive Status

1.2.8.4. Pregnancy Status

1.2.9. 6.2.9 Laboratory (USCDIv3)

1.2.9.1. Specimen Type

1.2.9.2. Result Status

1.2.10. 6.2.10 Medication (USCDIv3)

1.2.10.1. Dose

1.2.10.2. Dose Unit of Measure

1.2.10.3. Indication

1.2.10.4. Fill Status

1.2.11. 6.2.11 Patient Demographics (USCDIv2, USCDIv3)

1.2.11.1. USCDIv2

1.2.11.1.1. Sexual Orientation (USCDIv2)

1.2.11.1.2. Gender Identity (USCDIv2)

1.2.11.2. USCDIv3

1.2.11.2.1. Date of Death

1.2.11.2.2. Tribal Affiliation

1.2.11.2.3. Relalted Person's Name

1.2.11.2.4. Relalted Person's Relationship

1.2.11.2.5. Occupation

1.2.11.2.6. Occupation Industry

1.2.11.2.7. Sex

1.2.12. 6.2.12 Problems (USCDIv2)

1.2.12.1. SDOH Problems/Health =Concerns

1.2.12.2. Date of Diagnosis

1.2.12.3. Date of Resolution

1.2.13. 6.2.13 Procedures (USCDIv2, USCDIv3)

1.2.13.1. SDOH Interventions (USCDIv2)

1.2.13.2. Reason for Referral (USCDIv3)

2. 7 Resources: ADDED SECTION

2.1. 7.1 Sample C-CDA Files

2.2. 7.2 Published HL7 CDA and C-CDA Specifications

2.3. 7.3 Published C-CDA Implementer Community Guidance

2.3.1. 7.3.1 The Joint Document Content Work Group

2.3.2. 7.3.2 Integrating the Healthcare Enterprise (IHE)

2.3.3. 7.3.3 The Payer Community

2.3.4. 7.3.4 Quality Community

2.4. 7.4 Tools

2.4.1. 7.4.1 CDA Schema, C-CDA Schematrons, Sample Stylesheet

2.4.2. 7.4.2 ONC Validation Testing and C-CDA Scorecard Resources

2.4.3. Model Drive Health Tools (MDHT)

2.5. 7.5 Educational and Support Resources

2.5.1. HL7 Training

2.5.2. The CDA Book (Amazon)

2.5.3. HL7 CDA Management Group Confluence Space

2.5.4. HL7 Listserv Registration

2.5.5. HL7 Sample Search

3. APPENDIX A:Templates defined in C-CDA R2.1 Companion Guide 4.1

4. APPENDIX B: UDI Organizer template from C-CDA Supplemental Templates for Unique Device Identifier (UDI) R4.1

5. 3 Document Level: Templates

5.1. DELETED: 3.2.9.1Payer-focused Constraints on C-CDA Documents

6. 4 Section Level: Templates

6.1. ADDED: 4.1.5.1 Best Practices for Implementing Templates revised to support USCDI v2 and v3

7. 5 Entry Level: Template

7.1. ADDED: Guidance on how Provenance in CCDA maps to FHIR

7.2. CHANGED: 5.2.6.2 Problem Observation

7.3. CHANGED: 5.2.6.3 Health Concern, Risk Concern

7.4. CHANGED: 5.2.9.1 Goal Observation

7.5. CHANGED: 5.2.10 Social History Observation

7.6. CHANGED: 5.2.15 Procedure

7.7. CHANGED: 5.2.16.1 Assessment Scale Observation