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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":"true"},"selected":true},{"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":"false"}},{"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"}}]}]
Encounter Activity (V3) –
Issues (4)
Change Request Status = Closed (ccda-issue-64): Erratum-797 Incorrect cardinality CONF-32177
TypeChange RequestStatusChange Request Status = Closed PriorityNormal
Events
Tracking / Status = Closed 2017-10-09 17:33:12: Tracking by Lisa Nelson
Assignment2017-10-03 06:47:18: Assigned To dr Kai U. Heitmann by Lisa Nelson
Description
I changed the description but could not see how to modify the cardinality expectation in the template.
Assignment2017-09-18 06:11:08: Assigned To Lisa Nelson by Lisa Nelson
Tracking / Status = Open 2017-09-18 05:57:25: Tracking by Lisa Nelson
Description
Finding:

- Incorrect Cardinality

Suggestion:

-Prior Conformance
This sdtc:dischargeDispositionCode SHOULD contain exactly [1..1] @code, which SHOULD be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) DYNAMIC or, if access to NUBC is unavailable, from CodeSystem 2.16.840.1.113883.12.112 HL7 Discharge Disposition (CONF:1198-32177).

-Conformance After Update

a.This sdtc:dischargeDispositionCode SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) DYNAMIC or, if access to NUBC is unavailable, from CodeSystem 2.16.840.1.113883.12.112 HL7 Discharge Disposition (CONF:1198-32177).


Further explanation:

-CONF:32177

Change Request Status = Closed (ccda-issue-65): Erratum-798 Incorrect Cardinality CONF-32377
TypeChange RequestStatusChange Request Status = Closed PriorityNormal
Events
Tracking / Status = Closed 2017-10-09 17:32:21: Tracking by Lisa Nelson
Assignment2017-10-03 06:51:11: Assigned To dr Kai U. Heitmann by Lisa Nelson
Description
This is not making sense to me. Why do we have a constraint that has cardinality parameter when the element can't have its cardinality set?
Assignment2017-09-18 06:10:50: Assigned To Lisa Nelson by Lisa Nelson
Tracking / Status = Open 2017-09-18 06:00:29: Tracking by Lisa Nelson
Description
Finding:

-Incorrect Cardinality

Suggestion:

-Prior Conformance:
b.This sdtc:dischargeDispositionCode SHOULD contain exactly [1..1] @codeSystem, which SHOULD be either CodeSystem: NUBC 2.16.840.1.113883.6.301.5 OR CodeSystem: HL7 Discharge Disposition 2.16.840.1.113883.12.112 (CONF:1198-32377).

-Conformance After Update

b.This sdtc:dischargeDispositionCode SHOULD contain zero or one [0..1] @codeSystem, which SHOULD be either CodeSystem: NUBC 2.16.840.1.113883.6.301.5 OR CodeSystem: HL7 Discharge Disposition 2.16.840.1.113883.12.112 (CONF:1198-32377).


Further explanation:

-CONF:32377

Change Request Status = In Progress (ccda-issue-73): Erratum-825 Invalid codes in Encounter Type Code Value Set
TypeChange RequestStatusChange Request Status = In Progress PriorityNormal
Events
Tracking / Status = In Progress 2017-10-23 23:08:33: Tracking by Lisa Nelson
Description
Added STU Comment 1477

The EncounterType Value Set 2.16.840.1.113883.3.88.12.80.32 has a newer version 2017-09-15 that has a status of Published in the authoring area of the VSAC. However, this version of the value set is not available from the Value Set Search side of the VSAC. The only versions we see as available for downloading are versions: 2017-06-09 and 2017-06-23.

We think there is a problem that the latest published version of the value set is not available from the Value Set Search or from the C-CDA R2.1 filter.
Assignment2017-09-28 02:48:00: Assigned To Didi Davis by Lisa Nelson
Description
Need training on Value Set updates.
Assignment2017-09-18 15:40:58: Assigned To Lisa Nelson by Lisa Nelson
Tracking / Status = Open 2017-09-18 15:40:57: Tracking by Lisa Nelson
Description
Finding:

-Invalid codes in Encounter Type Code Value Set

Suggestion:

-Prior Conformance-

Value Set: EncounterTypeCode urn:oid:2.16.840.1.113883.3.88.12.80.32


This value set includes only the codes of the Current Procedure and Terminology designated for Evaluation and Management (99200 – 99607) (subscription to AMA Required 


Value Set Source: http://www.amacodingonline.com/


------------

Snowmed Codes included. 

-Conformance After Update-

Value Set: EncounterTypeCode urn:oid:2.16.840.1.113883.3.88.12.80.32


This value set includes only the codes of the Current Procedure and Terminology designated for Evaluation and Management (99200 – 99607) (subscription to AMA Required)


Value Set Source: https://vsac.nlm.nih.gov/


---------

Snowmed Codes were removed. 


Further explanation:

-

Change Request Status = Closed (ccda-issue-108): Erratum-1239 Incorrect binding on the typeCode for participants used to encode a Service Delivery Location.
TypeChange RequestStatusChange Request Status = Closed PriorityNormal
Events
Tracking / Status = Closed 2017-09-30 19:53:17: Tracking by Lisa Nelson
Description
Has the font problem I just noticed and will be speaking with Kai about.
Assignment2017-09-22 03:13:15: Assigned To Lisa Nelson by Lisa Nelson
Tracking / Status = Open 2017-09-22 03:13:14: Tracking by Lisa Nelson
Description
Finding:
-Incorrect binding on the typeCode for participants used to encode a Service Delivery Location. Change HL7ActRelationshipType to HL7ParticipationType.

Suggestion:
-Prior Conformance:
a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem:     HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1198-8740).
b. SHALL contain exactly one [1..1] Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:1198-14903).
-Conformance After Update:
a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1098-7766).
b. SHALL contain exactly one [1..1] Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:1098-15912).


Further explanation:
Encounter Activity (V3) 1198-8740 became 1198-7766


 
 
Structure Definitions (External repositories)