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C-CDA Meaningful Use Stage 2 - Templates
 
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[{"label":"CDA Document Level Template","value":"0","attributes":{"class":"","xxforms-open":"false"},"children":[{"label":"MU2 Clinical Summary (MU2)","value":"1","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 Consultation Note (MU2)","value":"2","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 Continuity of Care Document (CCD) (MU2)","value":"3","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 Discharge Summary (MU2)","value":"4","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 General Header Constraints (MU2)","value":"5","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 H&P Note (MU2)","value":"6","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 Transition Of Care (MU2)","value":"7","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 Transition Of Care Ambulatory Summary (MU2)","value":"8","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 Transition Of Care Inpatient Summary (MU2)","value":"9","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 VDT Ambulatory Summary (MU2)","value":"10","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 VDT Inpatient Summary (MU2)","value":"11","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 VDT Summary (MU2)","value":"12","attributes":{"class":"node-template-active","xxforms-open":"false"}}]},{"label":"CDA Section Level Template","value":"13","attributes":{"class":"","xxforms-open":"false"},"children":[{"label":"Admission Diagnosis Section (V3)","value":"14","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Admission Medications Section (entries optional) (V3)","value":"15","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Advance Directives Section (entries optional) (V3)","value":"16","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Allergies and Intolerances Section (entries optional) (V3)","value":"17","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Assessment and Plan Section (V2)","value":"18","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Assessment Section","value":"19","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Chief Complaint and Reason for Visit Section","value":"20","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Chief Complaint Section","value":"21","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Discharge Diagnosis Section (V3)","value":"22","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Discharge Diet Section (DEPRECATED)","value":"23","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Discharge Medications Section (entries optional) (V3)","value":"24","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Discharge Medications Section (entries required) (V3)","value":"25","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Encounters Section (entries optional) (V3)","value":"26","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Family History Section (V3)","value":"27","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Functional Status Section (V2)","value":"28","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"General Status Section","value":"29","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"History of Past Illness Section (V3)","value":"30","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"History of Present Illness Section","value":"31","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Hospital Consultations Section","value":"32","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Hospital Course Section","value":"33","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Hospital Discharge Instructions Section","value":"34","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Hospital Discharge Physical Section","value":"35","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Hospital Discharge Studies Summary Section","value":"36","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Immunizations Section (entries optional) (V3)","value":"37","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Instructions Section (V2)","value":"38","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Medical Equipment Section (V2)","value":"39","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Medications Administered Section (V2)","value":"40","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Medications Section (entries optional) (V2)","value":"41","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"MU2 Allergies Section (entries required) (MU2)","value":"42","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 Encounters Section (entries required) (MU2)","value":"43","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 Immunizations Section (entries required) (MU2)","value":"44","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 Medications Section (entries required) (MU2)","value":"45","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 Problem Section (entries required) (MU2)","value":"46","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 Social History Section (MU2)","value":"47","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"MU2 Vital Signs Section (entries required) (MU2)","value":"48","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"Payers Section (V3)","value":"49","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Physical Exam Section (V3)","value":"50","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Plan of Treatment Section (V2)","value":"51","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Problem Section (entries optional) (V3)","value":"52","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Procedures Section (entries optional) (V2)","value":"53","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Procedures Section (entries required) (V2)","value":"54","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Reason for Referral Section (V2)","value":"55","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Reason for Visit Section","value":"56","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Results Section (entries optional) (V3)","value":"57","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Results Section (entries required) (V3)","value":"58","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Review of Systems Section","value":"59","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Vital Signs Section (entries optional) (V3)","value":"60","attributes":{"class":"node-template-","xxforms-open":"false"}}]},{"label":"CDA Entry Level Template","value":"61","attributes":{"class":"","xxforms-open":"true"},"children":[{"label":"Allergy Concern Act (V3)","value":"62","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Encounter Activity (V3)","value":"63","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Immunization Activity (V3)","value":"64","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Medication Activity (V2)","value":"65","attributes":{"class":"node-template-","xxforms-open":"true"},"selected":true},{"label":"MU2 Smoking Status Observation (MU2)","value":"66","attributes":{"class":"node-template-active","xxforms-open":"false"}},{"label":"Problem Concern Act (V3)","value":"67","attributes":{"class":"node-template-","xxforms-open":"false"}},{"label":"Vital Signs Organizer (V3)","value":"68","attributes":{"class":"node-template-","xxforms-open":"false"}}]},{"label":"Template type not specified","value":"69","attributes":{"class":"","xxforms-open":"false"},"children":[{"label":"Assigned Entity (MU2)","value":"70","attributes":{"class":"node-template-active","xxforms-open":"false"}}]}]
Medication Activity –
Issues (3)
Change Request Status = Closed (ccda-issue-21): Erratum-423 Update to allow an effectiveTime with just a TS to support single dose [CONF:7508]
TypeChange RequestStatusChange Request Status = Closed PriorityNormal
Events
Tracking / Status = Closed 2017-09-13 02:40:43: Tracking by Lisa Nelson
Description
This one was complex. We needed to add a choice and add the first choice element.  Then move the element that was outside of the choice, into the choice (temple tool)  Finally we applied the notes into the descriptions and added references to record the needed conformance labels.
Assignment2017-08-28 23:25:09: Assigned To dr Kai U. Heitmann by Lisa Nelson
Tracking / Status = Feedback needed 2017-08-28 23:25:00: Tracking by Lisa Nelson
Description
Totally confused by CONF numbers. Lots of complex conditional logic in the expression of the conformance statement.
Tracking / Status = Feedback needed 2017-08-25 14:55:53: Tracking by Lisa Nelson
Description
We need to understand how CONF numbers are working.  Should the statements we add be matching to the CONF #.Where are the conformance numbers reported in the errata list for C-CDA R1.1 coming from????
Assignment2017-08-25 14:54:19: Assigned To Didi Davis by Lisa Nelson
Tracking / Status = In Progress 2017-08-25 14:53:58: Tracking by Lisa Nelson
Tracking / Status = Open 2017-08-25 14:53:33: Tracking by Lisa Nelson
Description
Finding:

-Update to allow an effectiveTime with just a TS to support a single dose. The pharmacy work group considers our current modeling to be incorrect.

Suggestion:

-Conformance Statements Prior to Change

8. SHALL contain exactly one [1..1] effectiveTime (CONF:7508) such that it

a. SHALL contain exactly one [1..1] low (CONF:7511).

b. SHALL contain exactly one [1..1] high (CONF:7512).

- Conformance Statements After Change

8. SHALL contain exactly one [1..1] effectiveTime (CONF:7508) such that it

Note: This effectiveTime represents either the medication duration (i.e., the time the medication was started and stopped) or the single-administration timestamp.

a. SHOULD contain zero or one [0..1] @value (CONF:26525).

Note: indicates a single-administration timestamp

b. SHOULD contain zero or one [0..1] low (CONF:26526).

Note: indicates when medication started

c. MAY contain zero or one [0..1] high (CONF:26527).

Note: indicates when medication stopped

d. This effectiveTime SHALL contain either a low or a @value but not both (CONF:26528).

Further explanation:

-CONF:7508

Change Request Status = Closed (ccda-issue-22): Erratum-572 Add template for free text Sig. [CONF:????]
TypeChange RequestStatusChange Request Status = Closed PriorityNormal
Events
Tracking / Status = Closed 2017-09-10 03:59:57: Tracking by Lisa Nelson
Assignment2017-08-29 00:02:13: Assigned To dr Kai U. Heitmann by Lisa Nelson
Tracking / Status = Feedback needed 2017-08-29 00:02:03: Tracking by Lisa Nelson
Description
Reviewed on 8/28.  

This is more complicated and the Erratum does not provide enough guidance. We need to study how this was implemented in C-CDA R2.1 and then add a new template in C-CDA R1.1 and then modify existing templates to contain this new templates.  This will be a more challenging type of change than the others.

We think that the text element needs to be added back in CONF:7501  (for C-CDA R2.1).  This is still needed for proper text linking. The comment about it being used for the Free Text Sig info was the part that was wrong. Only that guidance should have been removed.
Tracking / Status = Feedback needed 2017-08-25 18:14:10: Tracking by Lisa Nelson
Assignment2017-08-25 18:13:16: Assigned To Didi Davis by Lisa Nelson
Tracking / Status = In Progress 2017-08-25 18:12:56: Tracking by Lisa Nelson
Description
Need to learn how to make a new template.
Tracking / Status = In Progress 2017-08-25 18:12:35: Tracking by Lisa Nelson
Description
Here is how Medication Free Text Sig template was added in C-CDA R2.1:

27. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32907) such that it
a. SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32908).
b. SHALL contain exactly one [1..1] Medication Free Text Sig (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.147) (CONF:1098-32909).

Not sure how we will address the use of these Conformance ID's???
Assignment2017-08-25 18:09:10: Assigned To Lisa Nelson by Lisa Nelson
Tracking / Status = Open 2017-08-25 18:09:09: Tracking by Lisa Nelson
Description
Finding:

-Add guidance for free text Sig.

Suggestion:

-Conformance Statements Prior to Update:
C-CDA R1.1 states the freeTextSig is sent in the substanceAdministration/text. Per pharmacy WG, this is incorrect.

- Conformance Statements After Update:
1. new template created for Medication Free Text Sig 2.16.840.1.113883.10.20.22.4.147
2. Medication Activity templates includes optional containment of the new Medication Free Text Sig template.

Further explanation:

-[CONF:32770]  Not sure this conformance number makes sense.

Change Request Status = Closed (ccda-issue-36): Erratum 705 Update value set binding on the substanceAdministration/administrationUnitCode [CONF:7519]
TypeChange RequestStatusChange Request Status = Closed PriorityNormal
Events
Tracking / Status = Closed 2017-09-05 22:27:26: Tracking by Lisa Nelson
Assignment2017-09-01 21:12:40: Assigned To dr Kai U. Heitmann by Lisa Nelson
Tracking / Status = Feedback needed 2017-09-01 21:12:32: Tracking by Lisa Nelson
Description
See tab 705.  
Same issue as in the Immunization Template.
Assignment2017-08-30 13:05:46: Assigned To Didi Davis by Lisa Nelson
Tracking / Status = Feedback needed 2017-08-30 13:05:36: Tracking by Lisa Nelson
Description
Seems straight forward. Just want to walk through the steps of changing the valueset together.
Assignment2017-08-30 13:04:43: Assigned To Lisa Nelson by Lisa Nelson
Tracking / Status = Open 2017-08-30 13:04:42: Tracking by Lisa Nelson
Description
Finding:
-Update value set binding on the substanceAdministration/administrationUnitCode

Suggestion:
-Conformance Statements prior to change:

Medication Activity (urn:oid:2.16.840.1.113883.10.20.22.4.16)
14. MAY contain zero or one [0..1] administrationUnitCode, which SHALL be selected from ValueSet Medication Product Form 2.16.840.1.113883.3.88.12.3221.8.11 DYNAMIC (CONF:8846).

- Conformance Statements After Change:

Update the concepts to new Value Set AdministrationUnitDoseForm

(2.16.840.1.113762.1.4.1021.30).


Further explanation: 
CONF:7519
 
 
Structure Definitions (External repositories)