Talk:1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4

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CDA4CDT and IHE comparison notes

The following sections are required by CDA4CDT for the H&P. This is a quick analysis of the sections and their IHE counterparts (where they exist)

Reason for Visit

  • Reason for Visit is from provider, Chief Complaint is from patient
  • While CDA4CDT specifies to use one of three LOINCs and IHE only has one - they both have Chief Complaint LOINC (10154-3) in common
  • so this section is ok

History of Present Illness

  • CDA4CDT references IHE HPI Section 1.3.6.1.4.1.19376.1.5.3.1.3.4 so they both use the same LOINC
  • this section is ok

Past Medical History

  • new IHE section to be created
  • general definition is created - is further specification needed? i.e. define Entries, etc.

Medications

  • both use same LOINC
  • this is ok

Allergies

  • both use same LOINC
  • this is ok

Social History

  • both reference CCD as parent
  • both use same LOINC
  • this is ok

Family History

  • both use same LOINC so this is ok

Vital Signs

  • both use the same LOINC
  • so this is ok

Review of Systems

  • CDA4CDT references 1.3.6.1.4.1.19376.1.5.3.1.3.18 so they both use same LOINC
  • this is ok

Physical Examination

  • both use the same LOINC so this is ok

Diagnostic Findings

  • CDA4CDT uses LOINC 30954-2 and specifies this as lab results and other findings
  • not sure if or where this exists in IHE

Assessment and Plan

  • CDA4CDT uses LOINCs: AAPLN-X/ASSMT-X/18776-5
  • IHE uses LOINC: X-AANDP
  • does this mean that both specifications have requested LOINC codes?
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