Consolidated CDA (Sequoia)

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Consolidated CDA (Sequoia) - Templates

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Templates


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Templates [{"label":"CDA Document Level Template","value":"0","attributes":{"class":"","xxforms-open":"false"},"children":[{"label":"Care Plan (V2) (2.1)","value":"1","attributes":{"class":"node-reptemplate-draft","xxforms-open":"false"}},{"label":"Consultation Note (V3) (2.1)","value":"2","attributes":{"class":"node-reptemplate-draft","xxforms-open":"false"}},{"label":"Continuity of Care Document (CCD) (V3) (2.1)","value":"3","attributes":{"class":"node-reptemplate-draft","xxforms-open":"false"}},{"label":"Diagnostic Imaging Report (V3) (2.1)","value":"4","attributes":{"class":"node-reptemplate-draft","xxforms-open":"false"}},{"label":"Discharge Summary (V3) (2.1)","value":"5","attributes":{"class":"node-reptemplate-draft","xxforms-open":"false"}},{"label":"History and Physical (V3) (2.1)","value":"6","attributes":{"class":"node-reptemplate-draft","xxforms-open":"false"}},{"label":"Operative Note (V3) (2.1)","value":"7","attributes":{"class":"node-reptemplate-draft","xxforms-open":"false"}},{"label":"Procedure Note (V3) (2.1)","value":"8","attributes":{"class":"node-reptemplate-draft","xxforms-open":"false"}},{"label":"Progress Note (V3) (2.1)","value":"9","attributes":{"class":"node-reptemplate-draft","xxforms-open":"false"}},{"label":"Referral Note (V2) (2.1)","value":"10","attributes":{"class":"node-reptemplate-draft","xxforms-open":"false"}},{"label":"Transfer Summary (V2) (2.1)","value":"11","attributes":{"class":"node-reptemplate-draft","xxforms-open":"false"}},{"label":"Unstructured Document (V3) (2.1)","value":"12","attributes":{"class":"node-reptemplate-draft","xxforms-open":"false"}},{"label":"US Realm Header (V3) (2.1)","value":"13","attributes":{"class":"node-reptemplate-draft","xxforms-open":"false"}},{"label":"US Realm Header for Patient Generated Document (V2) (2.1)","value":"14","attributes":{"class":"node-reptemplate-draft","xxforms-open":"false"}}]},{"label":"CDA Header Level Template","value":"15","attributes":{"class":"","xxforms-open":"false"},"children":[{"label":"Provenance - Assembler Participation (C-CDA R2.1)","value":"16","attributes":{"class":"node-template-pending","xxforms-open":"false"}}]},{"label":"CDA Section Level Template","value":"17","attributes":{"class":"","xxforms-open":"false"},"children":[{"label":"Admission Diagnosis Section (V3) (2.1)","value":"18","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Admission Medications Section (entries optional) (V3) (2.1)","value":"19","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Advance Directives Section (entries optional) (V3) (2.1)","value":"20","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Advance Directives Section (entries required) (V3) (2.1)","value":"21","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Allergies and Intolerances Section (entries optional) (V3) (2.1)","value":"22","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Allergies and Intolerances Section (entries required) (V3) (2.1)","value":"23","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Anesthesia Section (V2) (2.1)","value":"24","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Assessment and Plan Section (V2) (2.1)","value":"25","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Assessment Section (2.1)","value":"26","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Care Teams Section (C-CDA R2.1)","value":"27","attributes":{"class":"node-template-pending","xxforms-open":"false"}},{"label":"Chief Complaint and Reason for Visit Section (2.1)","value":"28","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Chief Complaint Section 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(2.1)","value":"36","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Discharge Medications Section (entries required) (V3) (2.1)","value":"37","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Encounters Section (entries optional) (V3) (2.1)","value":"38","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Encounters Section (entries required) (V3) (2.1)","value":"39","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Family History Section (V3) (2.1)","value":"40","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Fetus Subject Context (2.1)","value":"41","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Findings Section (DIR) (2.1)","value":"42","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Functional Status Section (V2) (2.1)","value":"43","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"General Status Section (2.1)","value":"44","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Goals Section (2.1)","value":"45","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Health Concerns Section (V2) (2.1)","value":"46","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Health Status Evaluations and Outcomes Section (2.1)","value":"47","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"History of Present Illness Section (2.1)","value":"48","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Hospital Consultations Section (2.1)","value":"49","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Hospital Course Section (2.1)","value":"50","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Hospital Discharge Instructions Section (2.1)","value":"51","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Hospital Discharge Physical Section (2.1)","value":"52","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Hospital Discharge Studies Summary Section (2.1)","value":"53","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Immunizations Section (entries optional) (V3) (2.1)","value":"54","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Immunizations Section (entries required) (V3) (2.1)","value":"55","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Implants Section (DEPRECATED) (2.1)","value":"56","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Instructions Section (V2) 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(2.1)","value":"79","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Problem Section (entries required) (V3) (2.1)","value":"80","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Procedure Description Section (2.1)","value":"81","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Procedure Disposition Section (2.1)","value":"82","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Procedure Estimated Blood Loss Section (2.1)","value":"83","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Procedure Findings Section (V3) (2.1)","value":"84","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Procedure Implants Section (2.1)","value":"85","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Procedure Indications Section (V2) 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(2.1)","value":"93","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Review of Systems Section (2.1)","value":"94","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Social History Section (V3) (2.1)","value":"95","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Subjective Section (2.1)","value":"96","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Surgery Description Section (DEPRECATED) (2.1)","value":"97","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Surgical Drains Section (2.1)","value":"98","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Vital Signs Section (entries optional) (V3) (2.1)","value":"99","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Vital Signs Section (entries required) (V3) (2.1)","value":"100","attributes":{"class":"node-template-draft","xxforms-open":"false"}}]},{"label":"CDA Entry Level Template","value":"101","attributes":{"class":"","xxforms-open":"true"},"children":[{"label":"Admission Medication (V2) (2.1)","value":"102","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Advance Care Planning Intervention (V1) (C-CDA R2.1)","value":"103","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Advance Directive Observation (V4) (C-CDA R2.1)","value":"104","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Advance Directive Organizer (V3) (C-CDA R2.1)","value":"105","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Age Observation (2.1)","value":"106","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Allergy - Intolerance Observation (V2) (2.1)","value":"107","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Allergy Concern Act (V3) (2.1)","value":"108","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Allergy Status Observation (2.1 2019-06-20)","value":"109","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Assessment Scale Observation (2.1)","value":"110","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Assessment Scale Supporting Observation (2.1)","value":"111","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Authorization Activity (2.1)","value":"112","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Birth Sex Observation (C-CDA R2.1)","value":"113","attributes":{"class":"node-template-pending","xxforms-open":"false"}},{"label":"Boundary Observation 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(2.1)","value":"135","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Encounter Activity (V3) (2.1)","value":"136","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Encounter Diagnosis (V3) (2.1)","value":"137","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Entry Reference (2.1)","value":"138","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Estimated Date of Delivery (2.1)","value":"139","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Expiration Date Observation (C-CDA R2.1)","value":"140","attributes":{"class":"node-template-pending","xxforms-open":"false"}},{"label":"External Document Reference (2.1)","value":"141","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Family History Death Observation (2.1)","value":"142","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Family History Observation (V3) (2.1)","value":"143","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Family History Organizer (V3) (2.1)","value":"144","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Functional Status Observation (V2) (2.1)","value":"145","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Functional Status Organizer (V2) (2.1)","value":"146","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Functional Status Problem Observation (DEPRECATED) (2.1)","value":"147","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Goal Observation (2.1)","value":"148","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Handoff Communication Participants (2.1)","value":"149","attributes":{"class":"node-template-draft","xxforms-open":"false"}},{"label":"Health Concern Act (V2) 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Medication Dispense –

Issues (1)

Change Request Status = Closed (ccda-issue-184): CS-20180224 EntryRelationship constraint too tight.

Type

Change Request

Status

Change Request Status = Closed

Priority

High

Current Labels

(CS) Customer Support

Events

Tracking / Status = Closed	2018-06-06 15:37:55: Tracking by Didi Davis CS
Description	Feedback from IHE services on this issue on 2018-08-06 Cédric EOCHE-DUVAL Today 10:34 AM This issue has been solved by SEQUOIA-66. See validation result : https://gazellecontent.sequoiaproject.org/EVSClient/detailedResult.seam?type=CDA&oid=1.3.6.1.4.1.12559.11.28.13279 Moreover, There is no simple way to determine where there are other patterns like this, as it is a very specific case, strongly related between GOC, Art-Decor and specification document. The most efficient way is to wait for other feedback. Didi verified that issue ccda111962 no longer errors.

Assignment

2018-06-04 22:04:10: Assigned To Abderrazek Boufahja by Didi Davis

Tracking / Status = In Progress	2018-06-04 22:03:42: Tracking by Didi Davis CS
Description	Opened JIRA ticket #77 to advance this resolution. It was found during audit of all CS issues. Customer Service issue originally reported from Kent Stevenson (DoD) on 2/22/18 https://gazellecontent.sequoiaproject.org/EVSClient/detailedResult.seam?type=CDA&oid=1.3.6.1.4.1.12559.11.28.1772 Finding: -constraint that appears more restrictive than the specifications require. Suggestion: -The requirement CONF:7474 indicates that if a Medication Supply Order is included the entryRelationship/@typeCode SHALL be “REFR”. However, there is no prohibition of entryRelationships to something other than a Medication Supply Order. Lisa and I are unclear how to edit Art Decor to relax this constraint. We also would like you to allow a way to programatically determine where there are other patterns like this with a MAY and a SUCH THAT IT....? See email exchange with Kai when we reached out for guidance from him previously - you were copied - but I copied below: From: Kai U. Heitmann [mailto:info@kheitmann.de] Sent: Monday, February 26, 2018 4:47 AM To: Lisa R. Nelson <Lisarnelson@cox.net>; Abderrazek Boufahja <abderrazek.boufahja@gmail.com> Cc: 'Didi Davis' <ddavis@sequoiaproject.org> Subject: Re: Possible Validator issue using C-CDA R2.1 validation - Item #4 Resent due to know SPAM error in your email footers… Hi Lisa Maybe we need to discuss that on the phone more but I can tell that the ugly „such that is“ construct is about predication, and most of that is done automatically in ART-DECOR. In the example below the entryRelationship that is defined is with type code REFR into a supply. In the parent template itself, I assume, nothing else is allowed. [LRN] Kai, the statement I marked in yellow show the problem. There should be no assumption that nothing else is allowed. The validator is behaving as if nothing else were allowed and that is not the same as how this would be interpreted elsewhere. The MAY have an entryRelationship such that the typeCode is REFR DOES NOT MEAN YOU CAN’T HAVE entryRelationships where typeCode is not REFR. This is the validation behavior we need to change. You can’t assume nothing else is allowed. Our customer is pointing out that the AD validator is too restrictive. It should not complain about an entryRelationship with typeCode of COMP being present. The definition in AD automatically creates a predicate that the may be an entryRelationship to a supply with the corresponding template ID. The predicate that is used is generated based on the containment: 0..1 entryRelationship contains …10.20.22.4.18 Medication Supply Order that generates an entryRelationship where supply.templateId.root is …10.20.22.4.1 which exactly means 0..1 entryRelationship with a Medication Supply Order as said: automatically detected in most cases by AD In an open environment you may then have other entryRelationships. In a closed validation nothing else is allowed. That is by definition. The AD schematron engine generates the appropriate validation code. Obviously the IHE Gazelle validation is looking for an entryRelatonship REFR type code only which is equal to a closed validation. Thus, the entyrRelationship COMP is not allowed in the example instance below. If you want to allow other entyrRelationships declare them or do open validation (or in the AD schematrons you may choose for “closed warnings on open” which gives you warnings only instead of errors. I copied Abderrazek in this conversation because he knows best what is going on in Gazelle. Hope this help for now. Best regards --Kai PriorityMajor

Assignment

2018-04-30 22:25:26: Assigned To Didi Davis by Lisa Nelson

Tracking / Status = Open	2018-03-26 23:11:55: Tracking by Lisa Nelson CS
Description	Add label.

Tracking / Status = Open	2018-02-28 19:02:34: Tracking by Lisa Nelson
Description	Reviewed this with Didi, She will see if there is a way to programatically determine where there are other patterns like this with a MAY and a SUCH THAT IT....

Tracking / Status = Open	2018-02-24 14:47:28: Tracking by Lisa Nelson
Description	Sent a message to Kai to ask about this issue.

Assignment

2018-02-24 14:29:08: Assigned To Lisa Nelson by Lisa Nelson

Tracking / Status = Open	2018-02-24 14:29:07: Tracking by Lisa Nelson
Description	Finding: -constraint that appears more restrictive than the specifications require. Suggestion: -The requirement CONF:7474 indicates that if a Medication Supply Order is included the entryRelationship/@typeCode SHALL be “REFR”. However, there is no prohibition of entryRelationships to something other than a Medication Supply Order. Further explanation: - This is a "such that it" interpretation problem. I need to run this by Kai.

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Cédric EOCHE-DUVAL