Difference between revisions of "CDA Release 2.0 Content Modules"

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The sections defined below provide historical information about the patient's conditions.
 
The sections defined below provide historical information about the patient's conditions.
 
|Body=
 
|Body=
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.4|History of Present Illness|APR|XDS-MS|EDES|EDR}}{{
+
{{TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.4|PCC TF 2:6.3.3.2.1 History of Present Illness|APR|XDS-MS|EDES|EDR}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.5|Hospital Course|XDS-MS}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.5|PCC TF 2:6.3.3.2.2 Hospital Course|XDS-MS}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.6|Active Problems|IC|XDS-MS|XPHR|EDR|APS|APR|EDES}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.6|PCC TF 2:6.3.3.2.3 Active Problems|IC|XDS-MS|XPHR|EDR|APS|APR|EDES}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.7|Discharge Diagnosis|XDS-MS}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.7|PCC TF 2:6.3.3.2.4 Discharge Diagnosis|XDS-MS}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.8|History of Past Illness|IC|APR|XDS-MS|XPHR|EDR|EDES}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.8|PCC TF 2:6.3.3.2.5 History of Past Illness|IC|APR|XDS-MS|XPHR|EDR|EDES}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3|Encounter Histories|XPHR}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3|PCC TF 2:6.3.3.2.6 Encounter Histories|XPHR}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.9|History of Outpatient Visits|XDS-MS}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.9|PCC TF 2:6.3.3.2.7 History of Outpatient Visits|XDS-MS}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.10|History of Inpatient Visits|XDS-MS}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.10|PCC TF 2:6.3.3.2.8 History of Inpatient Visits|XDS-MS}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.11|List of Surgeries|XDS-MS|XPHR|EDR|EDES}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.11|PCC TF 2:6.3.3.2.9 List of Surgeries|XDS-MS|XPHR|EDR|EDES}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.12|Coded List of Surgeries|XDS-MS|XPHR|EDES}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.12|PCC TF 2:6.3.3.2.10 Coded List of Surgeries|XDS-MS|XPHR|EDES}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.13|Allergies and Other Adverse Reactions|XDS-MS|XPHR|APS|APR|EDR|EDES|IC}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.13|PCC TF 2:6.3.3.2.11 Allergies and Other Adverse Reactions|XDS-MS|XPHR|APS|APR|EDR|EDES|IC}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.14|Family Medical History|XDS-MS|XPHR|APS|APR|EDR|EDES}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.14|PCC TF 2:6.3.3.2.12 Family Medical History|XDS-MS|XPHR|APS|APR|EDR|EDES}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.15|Coded Family Medical History|XDS-MS|XPHR|APS|APR|EDR|EDES}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.15|PCC TF 2:6.3.3.2.13 Coded Family Medical History|XDS-MS|XPHR|APS|APR|EDR|EDES}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.5|Pre-procedure Family Medical History|PPHP}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.5|Pre-procedure Family Medical History|PPHP}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.16|Social History|XDS-MS|XPHR|APS|APR|EDR|EDES}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.16|PCC TF 2:6.3.3.2.14 Social History|XDS-MS|XPHR|APS|APR|EDR|EDES}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.17|Functional Status|XDS-MS|XPHR|FSA|EDES}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.17|PCC TF 2:6.3.3.2.15 Functional Status|XDS-MS|XPHR|FSA|EDES}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1|Coded Functional Status|XDS-MS|XPHR|FSA|EDES}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1|Coded Functional Status|XDS-MS|XPHR|FSA|EDES}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2|Pain Scale Assessment|XDS-MS|XPHR|FSA|EDES}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2|Pain Scale Assessment|XDS-MS|XPHR|FSA|EDES}}{{
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TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4|Geriatric Depression Scale|XDS-MS|XPHR|FSA|EDES}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4|Geriatric Depression Scale|XDS-MS|XPHR|FSA|EDES}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5|Physical Function|XDS-MS|XPHR|FSA|EDES}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5|Physical Function|XDS-MS|XPHR|FSA|EDES}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.18|Review of Systems|APR|XDS-MS|EDR|EDES}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.3.18|PCC TF 2:6.3.3.2.16 Review of Systems|APR|XDS-MS|EDR|EDES}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.13|Preprocedure Review of Systems|PPHP}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.13|Preprocedure Review of Systems|PPHP}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1|Hazardous Working Conditions|XPHR}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.1|PCC TF 2:6.3.3.2.17 Hazardous Working Conditions|XPHR}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4|Pregnancy History|IC|XPHR|EDES|APR|APS}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4|PCC TF 2:6.3.3.2.18 Pregnancy History|IC|XPHR|EDES|APR|APS}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1|Estimated Delivery Dates Section|APS|APR}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1|Estimated Delivery Dates Section|APS|APR}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5|Medical Devices|XPHR}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5|PCC TF 2:6.3.3.2.19 Medical Devices|XPHR}}{{
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6|Foreign Travel|XPHR}}{{
+
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.6|PCC TF 2:6.3.3.2.20 Foreign Travel|XPHR}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.8|History of Tobacco Use|PPHP}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.8|History of Tobacco Use|PPHP}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.10|Current Alcohol/Substance Abuse|PPHP}}{{
 
TOCLink|1.3.6.1.4.1.19376.1.5.3.1.1.9.10|Current Alcohol/Substance Abuse|PPHP}}{{

Revision as of 11:32, 23 July 2009

HL7 Version 3.0 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.

{{HeadingIfBody|Heading=

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

Relevant Studies

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

CDA and HL7 Version 3 Entry Content Modules