Talk:1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4

CDA4CDT and IHE comparison notes

The following sections are required by CDA4CDT for the H&P. This is a quick analysis of the sections and their IHE counterparts (where they exist)

Reason for Visit

• Reason for Visit is from provider, Chief Complaint is from patient
• While CDA4CDT specifies to use one of three LOINCs and IHE only has one - they both have Chief Complaint LOINC (10154-3) in common
• this section is ok

History of Present Illness

• CDA4CDT references IHE HPI Section 1.3.6.1.4.1.19376.1.5.3.1.3.4 so they both use the same LOINC
• this section is ok

Past Medical History

• new IHE section to be created
• general definition is created - is further specification needed? i.e. define Entries, etc.
• (ts 4/28) will not create new section - use Resolved Problems (1.3.6.1.4.1.19376.1.5.3.1.3.8) instead
• this section is ok

Medications

• both use same LOINC
• this section is ok

Allergies

• both use same LOINC
• this section is ok

Social History

• both reference CCD as parent
• both use same LOINC
• this section is ok

Family History

• both use same LOINC
• this section is ok

Vital Signs

• both use the same LOINC
• this section is ok

Review of Systems

• CDA4CDT references 1.3.6.1.4.1.19376.1.5.3.1.3.18 so they both use same LOINC
• this section is ok

Physical Examination

• both use the same LOINC
• this section is ok

Diagnostic Findings

• CDA4CDT uses LOINC 30954-2 and specifies this as lab results and other findings
• not sure if or where this exists in IHE
• LOINC 30954-2 in IHE is Results Section (1.3.6.1.4.1.19376.1.5.3.1.3.28) - can use this
• this section is ok

Assessment and Plan

• CDA4CDT uses LOINCs: AAPLN-X/ASSMT-X/18776-5
• IHE uses LOINC: X-AANDP
• does this mean that both specifications have requested LOINC codes?