CDA Release 2.0 Content Modules: Difference between revisions

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# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7|Payers}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7|Payers}}


=== [[CDA Entry Content Modules]] ===
=== CDA Entry Content Modules ===
# {{TOCLink|Linking Narrative and Coded Entries }}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.1|Severity}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.1.1|Problem Status Observation}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.1.2|Health Status}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.2|Comments}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.3|Patient Medication Instructions}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.3.1|Medication Fulfillment Instructions}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.4|External References}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.4.1|Internal References}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.5.1|Concern Entry}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.5.2|Problem Concern Entry}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.5.3|Allergy and Intolerance Concern}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.5|Problem Entry}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.6|Allergies and Intolerances}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.7|Medications}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.12|Immunizations}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.7.3|Supply Entry}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.7.2|Product Entry}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.13|Simple Observations}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.13.1|Vital Signs Organizer}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.13.2|Vital Signs Observation}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.15|Family History Organizer}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.13.3|Family History Observation}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.13.4|Social History Observation}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.13.5|Pregnancy Observation}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.13.7|Advance Directive Observation}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.13.6|Blood Type Observation}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.14|Encounters}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.16|Update Entry}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.19|Procedure Entry}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1|Transport}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2|Intended Encounter Disposition}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.17|Coverage Entry}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.4.18|Payer Entry}}

Revision as of 10:19, 25 May 2007

CDA Release 2.0 Content Modules

This section contains content modules based upon the HL7 CDA Release 2.0 Standard, and related standards and/or implementation guides.

CDA Document Content Modules

CDA Header Content Modules

CDA 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

The sections described below describe various reasons why healthcare is being provided to the patient.

Other Condition Histories

The sections defined below provide historical information about the patient's conditions.

Medications

This section contains section content modules that describe activities surrounding the use of medication.

Physical Exams

  • (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
  • (1.3.6.1.4.1.19376.1.5.3.1.1.9.21)Ears
  • (1.3.6.1.4.1.19376.1.5.3.1.1.9.22)Nose
  • (1.3.6.1.4.1.19376.1.5.3.1.1.9.24)Neck
  • (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
  • (1.3.6.1.4.1.19376.1.5.3.1.1.9.31)Abdomen
  • (1.3.6.1.4.1.19376.1.5.3.1.1.9.33)Vessels
  • (1.3.6.1.4.1.19376.1.5.3.1.1.9.37)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.

Procedures Performed

Impressions

Administrative and Other Information

  • (1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7)Payers

CDA Entry Content Modules

  • (1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1)Transport
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