CDA Section Content Modules: Difference between revisions
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==== Reasons for Care ==== | ==== Reasons for Care ==== | ||
Technical Framework Volume 2: 6.3.3.1 '''Reasons for Care''' | |||
The sections described below describe various reasons why healthcare is being provided to the patient. | The sections described below describe various reasons why healthcare is being provided to the patient. | ||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.1|PCC 2:6.3.3.1.1 Reason for Referral}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.2|PCC 2:6.3.3.1.2 Coded Reason for Referral}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.3|PCC 2:6.3.3.1.4 Hospital Admission Diagnosis}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.1|Proposed Procedure}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.2|Expected Blood Loss}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.3|Proposed Anesthesia}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.4|Reason for Procedure}} | |||
====Other Condition Histories==== | ====Other Condition Histories==== | ||
The sections defined below provide historical information about the patient's conditions. | The sections defined below provide historical information about the patient's conditions. | ||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.4|History of Present Illness }} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.5|Hospital Course}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.6|Active Problems}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.7|Discharge Diagnosis}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.8|Resolved Problems}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3|Encounter Histories}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.9|History of Outpatient Visits}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.10|History of Inpatient Visits}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.11|List of Surgeries}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.12|Coded List of Surgeries }} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.13|Allergies and Other Adverse Reactions}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.14|Family Medical History}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.15|Coded Family Medical History }} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.5|Pre-procedure Family Medical History}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.16|Social History}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.17|Functional Status}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.18|Review of Systems}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.13|Preprocedure Review of Systems}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1|Hazardous Working Conditions}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4|Pregnancy History}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5|Medical Devices }} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6|Foreign Travel}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.8|History of Tobacco Use}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.10|Current Alcohol/Substance Abuse }} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.12|Transfusion History}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.14|Anesthesia Risk Review of Systems}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.46|Implanted Medical Device Review}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.47|Pregnancy Status Review}} | |||
====Medications==== | ====Medications==== | ||
This section contains section content modules that describe activities surrounding the use of medication. | This section contains section content modules that describe activities surrounding the use of medication. | ||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.19|Medications}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.20|Admission Medication History}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.21|Medications Administered}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.22|Hospital Discharge Medications}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.23|Immunizations}} | |||
====Physical Exams==== | ====Physical Exams==== | ||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.24|Physical Exam}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Physical Exam (with subsections)}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.26|Hospital Discharge Physical Exam}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.25|Vital Signs}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2|Coded Vital Signs}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.16|General Appearance}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.48|Visible Implanted Medical Devices}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.17|Integumentary System}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.18|Head}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.19|Eyes}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.20|Ears, Nose, Mouth and Throat}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.21|Ears}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.22|Nose}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.23|Mouth, Throat, and Teeth}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.24|Neck}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.25|Endocrine System}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.26|Thorax and Lungs}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.27|Chest Wall}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.28|Breasts}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.29|Heart}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.30|Respiratory System}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.31|Abdomen}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.32|Lymphatic System}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.33|Vessels}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.34|Musculoskeletal System}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.35|Neurologic System}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.36|Genitalia}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.37|Rectum}} | |||
====Relevant Studies==== | ====Relevant Studies==== | ||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.27|Results }} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.28}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.29}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.30}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2}} | |||
====Plans of Care==== | ====Plans of Care==== | ||
This section provides content modules for sections that describe the plan of care intended for the patient. | This section provides content modules for sections that describe the plan of care intended for the patient. | ||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.31}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1|ED Care Plan}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.32}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.33}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.34}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.35}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.40}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.45}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.50}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.41}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2|Transport Mode}} | |||
==== Procedures Performed ==== | ==== Procedures Performed ==== | ||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.38}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.38}} | |||
==== Impressions==== | ==== Impressions==== | ||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.42}} | |||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.44}} | |||
====Administrative and Other Information==== | ====Administrative and Other Information==== | ||
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7}} | |||
Latest revision as of 22:12, 22 July 2009
Section Content Modules
This list defines the sections that may appear in a medical document. It is intended to be a comprehensive list of all document sections that are used by any content profile defined in the Patient Care Coordination Technical Framework. All sections shall have a narrative component that may be freely formatted into normal text, lists, tables, or other appropriate human-readable presentations. Additional subsections or entry content modules may be required.
Reasons for Care
Technical Framework Volume 2: 6.3.3.1 Reasons for Care
The sections described below describe various reasons why healthcare is being provided to the patient.
- (1.3.6.1.4.1.19376.1.5.3.1.3.1)PCC 2:6.3.3.1.1 Reason for Referral
- (1.3.6.1.4.1.19376.1.5.3.1.3.2)PCC 2:6.3.3.1.2 Coded Reason for Referral
- (1.3.6.1.4.1.19376.1.5.3.1.3.3)PCC 2:6.3.3.1.4 Hospital Admission Diagnosis
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.1)Proposed Procedure
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.2)Expected Blood Loss
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.3)Proposed Anesthesia
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.4)Reason for Procedure
Other Condition Histories
The sections defined below provide historical information about the patient's conditions.
- (1.3.6.1.4.1.19376.1.5.3.1.3.4)History of Present Illness
- (1.3.6.1.4.1.19376.1.5.3.1.3.5)Hospital Course
- (1.3.6.1.4.1.19376.1.5.3.1.3.6)Active Problems
- (1.3.6.1.4.1.19376.1.5.3.1.3.7)Discharge Diagnosis
- (1.3.6.1.4.1.19376.1.5.3.1.3.8)Resolved Problems
- (1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3)Encounter Histories
- (1.3.6.1.4.1.19376.1.5.3.1.3.9)History of Outpatient Visits
- (1.3.6.1.4.1.19376.1.5.3.1.3.10)History of Inpatient Visits
- (1.3.6.1.4.1.19376.1.5.3.1.3.11)List of Surgeries
- (1.3.6.1.4.1.19376.1.5.3.1.3.12)Coded List of Surgeries
- (1.3.6.1.4.1.19376.1.5.3.1.3.13)Allergies and Other Adverse Reactions
- (1.3.6.1.4.1.19376.1.5.3.1.3.14)Family Medical History
- (1.3.6.1.4.1.19376.1.5.3.1.3.15)Coded Family Medical History
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.5)Pre-procedure Family Medical History
- (1.3.6.1.4.1.19376.1.5.3.1.3.16)Social History
- (1.3.6.1.4.1.19376.1.5.3.1.3.17)Functional Status
- (1.3.6.1.4.1.19376.1.5.3.1.3.18)Review of Systems
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.13)Preprocedure Review of Systems
- (1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1)Hazardous Working Conditions
- (1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4)Pregnancy History
- (1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5)Medical Devices
- (1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6)Foreign Travel
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.8)History of Tobacco Use
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.10)Current Alcohol/Substance Abuse
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.12)Transfusion History
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.14)Anesthesia Risk Review of Systems
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.46)Implanted Medical Device Review
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.47)Pregnancy Status Review
Medications
This section contains section content modules that describe activities surrounding the use of medication.
- (1.3.6.1.4.1.19376.1.5.3.1.3.19)Medications
- (1.3.6.1.4.1.19376.1.5.3.1.3.20)Admission Medication History
- (1.3.6.1.4.1.19376.1.5.3.1.3.21)Medications Administered
- (1.3.6.1.4.1.19376.1.5.3.1.3.22)Hospital Discharge Medications
- (1.3.6.1.4.1.19376.1.5.3.1.3.23)Immunizations
Physical Exams
- (1.3.6.1.4.1.19376.1.5.3.1.3.24)Physical Exam
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.15)Physical Exam (with subsections)
- (1.3.6.1.4.1.19376.1.5.3.1.3.26)Hospital Discharge Physical Exam
- (1.3.6.1.4.1.19376.1.5.3.1.3.25)Vital Signs
- (1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2)Coded Vital Signs
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.16)General Appearance
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.48)Visible Implanted Medical Devices
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.17)Integumentary System
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.18)Head
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.19)Eyes
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.20)Ears, Nose, Mouth and Throat
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.21)Ears
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.22)Nose
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.23)Mouth, Throat, and Teeth
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.24)Neck
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.25)Endocrine System
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.26)Thorax and Lungs
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.27)Chest Wall
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.28)Breasts
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.29)Heart
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.30)Respiratory System
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.31)Abdomen
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.32)Lymphatic System
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.33)Vessels
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.34)Musculoskeletal System
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.35)Neurologic System
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.36)Genitalia
- (1.3.6.1.4.1.19376.1.5.3.1.1.9.37)Rectum
Relevant Studies
- (1.3.6.1.4.1.19376.1.5.3.1.3.27)Results
Plans of Care
This section provides content modules for sections that describe the plan of care intended for the patient.
- (1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1)ED Care Plan
- (1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2)Transport Mode