CDA Section Content Modules: Difference between revisions

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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.  
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
==== Reasons for Care ====
==== 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.


{{:1.3.6.1.4.1.19376.1.5.3.1.3.1}}
[[1.3.6.1.4.1.19376.1.5.3.1.3.1|Reason for Referral]]


{{:1.3.6.1.4.1.19376.1.5.3.1.3.2}}
[[1.3.6.1.4.1.19376.1.5.3.1.3.2|Coded Reason for Referral]]


{{:1.3.6.1.4.1.19376.1.5.3.1.3.3}}
[[1.3.6.1.4.1.19376.1.5.3.1.3.3|Hospital Admission Diagnosis]]


{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.1}}
[[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}}
[[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}}
[[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}}
[[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.


{{:1.3.6.1.4.1.19376.1.5.3.1.3.4}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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.


{{:1.3.6.1.4.1.19376.1.5.3.1.3.19}}
[[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}}
[[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}}
[[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}}
[[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}}
[[1.3.6.1.4.1.19376.1.5.3.1.3.23|Immunizations]]


====Physical Exams====
====Physical Exams====
=====Physical Exam=====
=====Physical Exam=====
{{:1.3.6.1.4.1.19376.1.5.3.1.3.24}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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}}
[[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]]


{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.17}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.18}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.19}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.20}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.21}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.22}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.23}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.24}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.25}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.26}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.27}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.28}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.29}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.30}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.31}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.32}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.33}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.34}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.35}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.36}}
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.37}}


====Relevant Studies====
====Relevant Studies====
{{:1.3.6.1.4.1.19376.1.5.3.1.3.27}}
[[1.3.6.1.4.1.19376.1.5.3.1.3.27]]


{{:1.3.6.1.4.1.19376.1.5.3.1.3.28}}
[[1.3.6.1.4.1.19376.1.5.3.1.3.28]]


{{:1.3.6.1.4.1.19376.1.5.3.1.3.29}}
[[1.3.6.1.4.1.19376.1.5.3.1.3.29]]


{{:1.3.6.1.4.1.19376.1.5.3.1.3.30}}
[[1.3.6.1.4.1.19376.1.5.3.1.3.30]]


{{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2}}
[[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.


{{:1.3.6.1.4.1.19376.1.5.3.1.3.31}}
[[1.3.6.1.4.1.19376.1.5.3.1.3.31]]


{{:1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1}}
[[1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1|ED Care Plan]]


{{:1.3.6.1.4.1.19376.1.5.3.1.3.32}}
[[1.3.6.1.4.1.19376.1.5.3.1.3.32]]


{{:1.3.6.1.4.1.19376.1.5.3.1.3.33}}
[[1.3.6.1.4.1.19376.1.5.3.1.3.33]]


{{:1.3.6.1.4.1.19376.1.5.3.1.3.34}}
[[1.3.6.1.4.1.19376.1.5.3.1.3.34]]


{{:1.3.6.1.4.1.19376.1.5.3.1.3.35}}
[[1.3.6.1.4.1.19376.1.5.3.1.3.35]]


{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.40}}
[[1.3.6.1.4.1.19376.1.5.3.1.1.9.40]]


{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.45}}
[[1.3.6.1.4.1.19376.1.5.3.1.1.9.45]]


{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.50}}
[[1.3.6.1.4.1.19376.1.5.3.1.1.9.50]]


{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.41}}
[[1.3.6.1.4.1.19376.1.5.3.1.1.9.41]]


{{:1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2}}
[[1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2|Transport Mode]]


==== Procedures Performed ====
==== Procedures Performed ====
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.38}}
[[1.3.6.1.4.1.19376.1.5.3.1.1.9.38]]


{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.38}}
[[1.3.6.1.4.1.19376.1.5.3.1.1.9.38]]


====Impressions====
====Impressions====


[[1.3.6.1.4.1.19376.1.5.3.1.1.9.42]]


 
[[1.3.6.1.4.1.19376.1.5.3.1.1.9.44]]
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.42}}
 
{{:1.3.6.1.4.1.19376.1.5.3.1.1.9.44}}


====Administrative and Other Information====
====Administrative and Other Information====


{{:1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7}}
[[1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7]]

Revision as of 18:12, 24 May 2007

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.

  1. Reasons for Care

Reasons for Care

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

Reason for Referral

Coded Reason for Referral

Hospital Admission Diagnosis

Proposed Procedure

Expected Blood Loss

Proposed Anesthesia

Reason for Procedure

Other Condition Histories

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

History of Present Illness

Hospital Course

Active Problems

Discharge Diagnosis

Resolved Problems

Encounter Histories

History of Outpatient Visits

History of Inpatient Visits

List of Surgeries

Coded List of Surgeries

Allergies and Other Adverse Reactions

Family Medical History

Coded Family Medical History

Pre-procedure Family Medical History

Social History

Functional Status

Review of Systems

Preprocedure Review of Systems

Hazardous Working Conditions

Pregnancy History

Medical Devices

Foreign Travel

History of Tobacco Use

Current Alcohol/Substance Abuse

Transfusion History

Anesthesia Risk Review of Systems

Implanted Medical Device Review

Pregnancy Status Review

Medications

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

Medications

Admission Medication History

Medications Administered

Hospital Discharge Medications

Immunizations

Physical Exams

Physical Exam

Physical Exam

Physical Exam (with subsections)

Hospital Discharge Physical Exam

Vital Signs

Coded Vital Signs

General Appearance

Visible Implanted Medical Devices Integumentary System Head Eyes Ears, Nose, Mouth and Throat Ears Nose Mouth, Throat, and Teeth Neck Endocrine System Thorax and Lungs Chest Wall Breasts Heart Respiratory System Abdomen Lymphatic System Vessels Musculoskeletal System Neurologic System Genitalia Rectum


Relevant Studies

1.3.6.1.4.1.19376.1.5.3.1.3.27

1.3.6.1.4.1.19376.1.5.3.1.3.28

1.3.6.1.4.1.19376.1.5.3.1.3.29

1.3.6.1.4.1.19376.1.5.3.1.3.30

1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2

Plans of Care

This section provides content modules for sections that describe the plan of care intended for the patient.

1.3.6.1.4.1.19376.1.5.3.1.3.31

ED Care Plan

1.3.6.1.4.1.19376.1.5.3.1.3.32

1.3.6.1.4.1.19376.1.5.3.1.3.33

1.3.6.1.4.1.19376.1.5.3.1.3.34

1.3.6.1.4.1.19376.1.5.3.1.3.35

1.3.6.1.4.1.19376.1.5.3.1.1.9.40

1.3.6.1.4.1.19376.1.5.3.1.1.9.45

1.3.6.1.4.1.19376.1.5.3.1.1.9.50

1.3.6.1.4.1.19376.1.5.3.1.1.9.41

Transport Mode

Procedures Performed

1.3.6.1.4.1.19376.1.5.3.1.1.9.38

1.3.6.1.4.1.19376.1.5.3.1.1.9.38

Impressions

1.3.6.1.4.1.19376.1.5.3.1.1.9.42

1.3.6.1.4.1.19376.1.5.3.1.1.9.44

Administrative and Other Information

1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7

Retrieved from "http://wiki.ihe.net/index.php?title=CDA_Section_Content_Modules&oldid=6095"