CDA Release 2.0 Content Modules: Difference between revisions

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This section contains content modules based upon the HL7 CDA Release 2.0 Standard, and related standards and/or implementation guides.
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 Document Content Modules ===
## {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.1|Medical Documents Specification}}  
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.1|Medical Documents Specification}}  
## {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.2|Medical Summary Specification}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.2|Medical Summary Specification}}
## {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.3|Referral Summary Specification}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.3|Referral Summary Specification}}
## {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.4|Discharge Summary Specification}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.4|Discharge Summary Specification}}
## {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5|PHR Extract Specification}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5|PHR Extract Specification}}
## {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.6|PHR Update Specification}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.6|PHR Update Specification}}
## {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.7|Consent to Share Information Specification}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.7|Consent to Share Information Specification}}
## {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9|Preprocedure History and Physical Specification}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9|Preprocedure History and Physical Specification}}
## {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.10|Emergency Department Referral Specification}}  
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.10|Emergency Department Referral Specification}}  
# CDA Header Content Modules
 
## {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.2.1|Language Communication}}
=== CDA Header Content Modules ===
## {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.2.2|Employer and School Contacts}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.2.1|Language Communication}}
## {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.2.3|Healthcare Providers and Pharmacies}}  
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.2.2|Employer and School Contacts}}
## {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.2.4|Patient Contacts}}  
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.2.3|Healthcare Providers and Pharmacies}}  
## {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.2.5|Authorization}}  
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.2.4|Patient Contacts}}  
## {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.2.6|Consent Service Events}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.2.5|Authorization}}  
# [[CDA Section Content Modules]]
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.2.6|Consent Service Events}}
 
=== 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.
 
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.1|Reason for Referral}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.2|Coded Reason for Referral}}
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.3|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====
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====
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====
# {{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====
# {{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====
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 ====
# {{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====
 
# {{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====
 
# {{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7}}
 
# [[CDA Entry Content Modules]]
# [[CDA Entry Content Modules]]

Revision as of 09:56, 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. CDA Entry Content Modules
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