CDA Section Content Modules

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

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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.

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ED Care Plan

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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

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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