| Data Item | Xpath | Section | CDA Template | Comments |
| Patient First Given Name | /ClinicalDocument/recordTarget/patientRole/patient/name/given | (Header) | National Health Care Surveys (V2) | |
| Patient Second Given Name (midde name) | /ClinicalDocument/recordTarget/patientRole/patient/name/given[2] | (Header) | National Health Care Surveys (V2) | |
| Patient Surname (last name) | /ClinicalDocument/recordTarget/patientRole/patient/name/family | (Header) | National Health Care Surveys (V2) | |
| Patient Generational Suffix (eg Jr, Sr) | /ClinicalDocument/recordTarget/patientRole/patient/name/suffix | (Header) | National Health Care Surveys (V2) | |
| Patient Address 1 | /ClinicalDocument/recordTarget/patientRole/addr/streetAddressLine | (Header) | National Health Care Surveys (V2) | |
| Patient Address 2 | /ClinicalDocument/recordTarget/patientRole/addr/streetAddressLine | (Header) | National Health Care Surveys (V2) | |
| Patient City | /ClinicalDocument/recordTarget/patientRole/addr/city | (Header) | National Health Care Surveys (V2) | |
| Patient State | /ClinicalDocument/recordTarget/patientRole/addr/state | (Header) | National Health Care Surveys (V2) | |
| Patient Zip | /ClinicalDocument/recordTarget/patientRole/addr/postalCode | (Header) | National Health Care Surveys (V2) | |
| Patient SSN | /ClinicalDocument/recordTarget/patientRole/id[@root="2.16.840.1.113883.4.1"] | (Header) | National Health Care Surveys (V2) | |
| Patient Medicare number | /ClinicalDocument/recordTarget/patientRole/id[@root="2.16.840.1.113883.4.572"] | (Header) | National Health Care Surveys (V2) | |
| Patient's medical record number | /ClinicalDocument/recordTarget/patientRole/id | (Header) | National Health Care Surveys (V2) | |
| Patient Date of Birth | /ClinicalDocument/recordTarget/patientRole/patient/birthTime | (Header) | National Health Care Surveys (V2) | |
| Patient Sex | /ClinicalDocument/recordTarget/patientRole/patient/administrativeGenderCode | (Header) | National Health Care Surveys (V2) | |
| Patient Race | /ClinicalDocument/recordTarget/patientRole/patient/raceCode | (Header) | National Health Care Surveys (V2) | |
| Patient Ethnicity | /ClinicalDocument/recordTarget/patientRole/patient/ethnicGroupCode | (Header) | National Health Care Surveys (V2) | |
| Patient Marital Status | /ClinicalDocument/recordTarget/patientRole/patient/maritalStatusCode | (Header) | National Health Care Surveys (V2) | |
| Patient Residence Type | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.25"]/value | Patient Information Section (V3) | Patient Residence Observation | |
| Type of clinic/location where visit occurred (family practice, cardiology, etc.) | /ClinicalDocument/componentOf/encompassingEncounter/location/healthCareFacility/code | (Header) | Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) | |
| Has patient been seen in clinic/location before | //act[templateId/@root="2.16.840.1.113883.10.20.34.3.9"]/code[@code="108220007"][@codeSystem="2.16.840.1.113883.6.96"] | Outpatient Encounters Section (V3) | Current Outpatient Visit (V3)/New Patient Act | |
| If yes, how many visits in previous 12 months (excluding this visit) | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.26"]/value | Outpatient Encounters Section (V3) | Current Outpatient Visit (V3)/Number of Visits in the Last 12 Months | Value contains the number of visits |
| NPI of physicians | /ClinicalDocument/documentationOf/serviceEvent/performer/assignedEntity/id/@extension | (Header) | National Health Care Surveys (V2) | |
| Types of care providers seen (including attending, resident, intern, N.P., P. A., consulting, specialist(s), Nurse, mental health providers, social workers) | /ClinicalDocument/documentationOf/serviceEvent/performer/assignedEntity/code | (Header) | National Health Care Surveys (V2) | |
| Anesthesia Provider Type | /ClinicalDocument/documentationOf/serviceEvent/performer/assignedEntity/code | (Header) | National Health Care Surveys (V2) | Will be a code representing an anesthesia provider |
| Seen by PCP | /ClinicalDocument/documentationOf/serviceEvent/performer/functionCode[@code="PP"][@codeSystem="2.16.840.1.113883.12.443"] | (Header) | Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V2) | |
| Source of referral | //reference/externalDocument/code[@code="57113-1"] | Outpatient Encounters Section (V3) | Current Outpatient Visit (V3)/Clinical Note and External Document Reference | |
| Encounter Number | /ClinicalDocument/componentOf/encompassingEncounter/id | (Header) | National Health Care Surveys (V2) | |
| Date/Time of admission/visit/arrival | /ClinicalDocument/componentOf/encompassingEncounter/effectiveTime/low | (Header) | National Health Care Surveys (V2) | |
| Date/Time of departure/discharge | /ClinicalDocument/componentOf/encompassingEncounter/effectiveTime/high | (Header) | National Health Care Surveys (V2) | |
| Expected source(s) of payment | //act[templateId/@root="2.16.840.1.113883.10.20.22.4.129"]/entryRelationship/act/code | Payment Sources Section | Planned Coverage | |
| Is this visit for a new problem, chronic problem (routine or flare-up), preventive care, pre-/post-surgery, surgery/procedure | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.7"]/value | Outpatient Encounters Section (V3) | Current Outpatient Visit (V3)/Major Reason for Visit | |
| Initial or follow-up visit? | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.32"][templateId/@extension="2015-04-01"]/value | Outpatient Encounters Section (V3) | Current Outpatient Visit (V3)/Episode of Care Observation (V2) | |
| Discharge disposition | /ClinicalDocument/componentOf/encompassingEncounter/dischargeDispositionCode |
(Header) | National Health Care Surveys (V2) | |
| Did someone attempt to follow-up with this patient within 24-hours after this surgery | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.42"][templateId/@extension="2015-04-01"]/value | Outpatient Encounters Section (V3) | Current Outpatient Visit (V3)/Procedure Follow-Up Attempt Observation | |
| If follow-up attempt was made, what was learned? | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.43"][templateId/@extension="2015-04-01"]/value | Outpatient Encounters Section (V3) | Current Outpatient Visit (V3)/Procedure Follow-Up Attempt Observation/ Follow-up Attempt Outcome Observation |
|
| Reason for Visit (Patient) | //section[templateId/@root="2.16.840.1.113883.10.20.34.2.14"][templateId/@extension="2016-07-01"]/text | Reasons for Visit Section (V2) | Free text | |
| Reason for Visit (Patient) | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.41"][templateId/@extension="2015-04-01"]/code | Reasons for Visit Section (V2) | Patient's Reason for Visit Observation | Coded |
| Diagnosis | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.1"][templateId/@extension="2015-04-01"]/value | Problems Section (V3) | Problem/Diagnosis/Symptom/Condition Observation (V2) | |
| Primary Diagnosis | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.6"][templateId/@extension="2015-04-01"]/value | Problems Section (V3) | Primary Diagnosis Observation (V2) | |
| Active Problems | Any of the Admission Diagnosis, Diagnosis or Primary Diagnosis where there is no effectiveTime/high | Problems Section (V3) | Admission Diagnosis Observation Problem/Diagnosis/Symptom/Condition Observation (V2) Primary Diagnosis Observation (V2) |
|
| Problems the patient has (all others besides asthma) (Co-morbid conditions) | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.1"][templateId/@extension="2015-04-01"]/value | Problems Section (V3) | Problem/Diagnosis/Symptom/Condition Observation (V2) | |
| Adverse effect of medical treatment | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.14"]/value | Problems Section (V3) | Adverse Effect of Medical Treatment | |
| Lab Tests - Test Name | //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.2"][templateId/@extension="2014-06-09"]/code/@displayName | Results Section (Entries Optional) | Result Observation (V2) | |
| Lab Tests - Test Code | //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.2"][templateId/@extension="2014-06-09"]/code/@code | Results Section (Entries Optional) | Result Observation (V2) | |
| Lab Tests - Test Datetime | //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.2"][templateId/@extension="2014-06-09"]/effectiveTime | Results Section (Entries Optional) | Result Observation (V2) | |
| Lab Test - Quantitative Result | //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.2"][templateId/@extension="2014-06-09"]/value | Results Section (Entries Optional) | Result Observation (V2) | |
| Lab Test - Qualitative Result | //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.2"][templateId/@extension="2014-06-09"]/interpretationCode | Results Section (Entries Optional) | Result Observation (V2) | |
| Provided: Examinations | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.3"]/code | Services and Procedures Section | Provided Service Observation | |
| Provided: Blood Tests | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.3"]/code | Services and Procedures Section | Provided Service Observation | |
| Provided: Imaging Services | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.3"]/code | Services and Procedures Section | Provided Service Observation | |
| Provided: Other tests and Procedures (except Excision of tissue, biopsy) | //act[templateId/@root="2.16.840.1.113883.10.20.34.3.20"]/code | Services and Procedures Section | Provided Service Act | |
| Provided: Excision of tissue, biopsy | //procedure[templateId/@root="2.16.840.1.113883.10.20.34.3.12"]/code | Services and Procedures Section | Provided Service Procedure | |
| Provided: Non-medication Tx | //act[templateId/@root="2.16.840.1.113883.10.20.34.3.20"]/code | Services and Procedures Section | Provided Service Act | |
| Provided: Health Education/Counselling | //act[templateId/@root="2.16.840.1.113883.10.20.34.3.20"]/code | Services and Procedures Section | Provided Service Act | |
| Ordered: Examinations | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.2"]/code | Services and Procedures Section | Ordered Service Observation | |
| Ordered: Blood Tests | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.2"]/code | Services and Procedures Section | Ordered Service Observation | |
| Ordered: Imaging Services | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.2"]/code | Services and Procedures Section | Ordered Service Observation | |
| Ordered: Other tests and Procedures (except Excision of tissue, biopsy) | //act[templateId/@root="2.16.840.1.113883.10.20.34.3.19"]/code | Services and Procedures Section | Ordered Service Act | |
| Ordered: Excision of tissue, biopsy | //procedure[templateId/@root="2.16.840.1.113883.10.20.34.3.11"]/code | Services and Procedures Section | Ordered Service Procedure | |
| Ordered: Non-medication Tx | //act[templateId/@root="2.16.840.1.113883.10.20.34.3.19"]/code | Services and Procedures Section | Ordered Service Act | |
| Ordered: Health Education/Counselling | //act[templateId/@root="2.16.840.1.113883.10.20.34.3.19"]/code | Services and Procedures Section | Ordered Service Act | |
| Procedures using CPT and HCPCS CODES | //act[templateId/@root="2.16.840.1.113883.10.20.34.3.20"]/code OR //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.3"]/code OR //procedure[templateId/@root="2.16.840.1.113883.10.20.34.3.12"]/code |
Services and Procedures Section | Provided Service Act OR Provided Service Observation OR Provided Service Procedure |
Choose one of the CDA Templates depending on the type of procedure (i.e. Act, Observation, or Procedure). See template descriptions in IG for details. |
| Supplied/Administered Medication | //substanceAdministration[templateId/@root="2.16.840.1.113883.10.20.22.4.16"][templateId/@extension="2014-06-09"]/consumable/manufacturedProduct/manufacturedMaterial/code | Medications Section | Medication Activity (V2) | Continued medication: substanceAdministration/effectiveTime/low < encounter date New medication: substanceAdministration/effectiveTime/low >= encounter date |
| Ordered Medication | //substanceAdministration[templateId/@root="2.16.840.1.113883.10.20.22.4.42"][templateId/@extension="2014-06-09"]/consumable/manufacturedProduct/manufacturedMaterial/code | Medications Section | Planned Medication Activity (V2) | Continued medication: substanceAdministration/effectiveTime/low < encounter date New medication: substanceAdministration/effectiveTime/low >= encounter date |
| Type(s) of Anesthesia administered | //substanceAdministration[templateId/@root="2.16.840.1.113883.10.20.22.4.16"][templateId/@extension="2014-06-09"]/consumable/manufacturedProduct/manufacturedMaterial/code | Medications Section | Medication Activity (V2) | Code would be a type of anesthesia |
| Supplied/Administered Immunization | //substanceAdministration[templateId/@root="2.16.840.1.113883.10.20.22.4.52"][templateId/@extension="2014-06-09"]/consumable/manufacturedProduct/manufacturedMaterial/code | Immunizations Section | Immunization Activity (V2) | Continued immunization: substanceAdministration/effectiveTime/low < encounter date New immunization: substanceAdministration/effectiveTime/low >= encounter date |
| Ordered Immunization | //substanceAdministration[templateId/@root="2.16.840.1.113883.10.20.22.4.120"][templateId/@extension="2014-06-09"]/consumable/manufacturedProduct/manufacturedMaterial/code | Immunizations Section | Planned Immunization Activity (V2) | Continued medication: substanceAdministration/effectiveTime/low < encounter date New medication: substanceAdministration/effectiveTime/low >= encounter date |
| Tobacco Use | //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.85"][templateId/@extension="2014-06-09"]/value | Patient Information Section (V3) | Tobacco Use (V2) | |
| Smoking Status | //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.78"][templateId/@extension="2014-06-09"]/value | Patient Information Section (V3) | Smoking Status - Meaningful Use (V2) | |
| Is Female Pregnant | //observation[templateId/@root="2.16.840.1.113883.10.20.15.3.8"]/value | Patient Information Section (V3) | Pregnancy Observation | |
| Estimated Date of Delivery | //observation[templateId/@root="2.16.840.1.113883.10.20.15.3.1"]/value | Patient Information Section (V3) | Estimated Date of Delivery | |
| Patient Asthmatic | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.1"][templateId/@extension="2015-04-01"]/value | Problems Section (V3) | Problem/Diagnosis/Symptom/Condition Observation (V2) | |
| Vital sign - Height | //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.27"][templateId/@extension="2014-06-09"][code/@code="8302-2"]/value | Vital Signs Section (entries required) (V2) | Vital Sign Observation (V2) | value/@value=<numeric value> value/@unit=<unit of measurement> |
| Vital sign - Weight | //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.27"][templateId/@extension="2014-06-09"][code/@code="3141-9"]/value | Vital Signs Section (entries required) (V2) | Vital Sign Observation (V2) | value/@value=<numeric value> value/@unit=<unit of measurement> |
| Vital sign - Temperature | //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.27"][templateId/@extension="2014-06-09"][code/@code="8310-5"]/value | Vital Signs Section (entries required) (V2) | Vital Sign Observation (V2) | value/@value=<numeric value> value/@unit=<unit of measurement> |
| Vital sign - Blood Pressure - Systolic | //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.27"][templateId/@extension="2014-06-09"][code/@code="8480-6"]/value | Vital Signs Section (entries required) (V2) | Vital Sign Observation (V2) | value/@value=<numeric value> value/@unit=<unit of measurement> |
| Vital sign - Blood Pressure - Diastolic | //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.27"][templateId/@extension="2014-06-09"][code/@code="8462-4"]/value | Vital Signs Section (entries required) (V2) | Vital Sign Observation (V2) | value/@value=<numeric value> value/@unit=<unit of measurement> |
| Vital sign - others | //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.27"][templateId/@extension="2014-06-09"]/code //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.27"][templateId/@extension="2014-06-09"]/value |
Vital Signs Section (entries required) (V2) | Vital Sign Observation (V2) | code contains the vital sign being measured value contains the measurement value/@value=<numeric value> value/@unit=<unit of measurement> |
| Temperature on arrival and last taken | //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.27"][templateId/@extension="2014-06-09"][code/@code="8310-5"]/value | Vital Signs Section (entries required) (V2) | Vital Sign Observation (V2) | Use date to get the two values |
| Historical Labs | //observation[templateId/@root="2.16.840.1.113883.10.20.22.4.2"][templateId/@extension="2014-06-09"]/code/@displayName | Results Section (Entries Optional) | Result Observation (V2) | Use date to get historical labs |
| If injury, intentionality | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.17"][templateId/@extension="2015-04-01"]/value | Problems Section (V3) | Injury or Poisoning Observation (V2) | |
| If injury, cause | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.17"][templateId/@extension="2015-04-01"]/entryRelationship/observation[templateId/@root="2.16.840.1.113883.10.20.34.3.27"]/value | Problems Section (V3) | Injury or Poisoning Observation (V2)/Cause of Injury, Poisoning or Adverse Effect | |
| Symptoms(s) present during or after surgery/procedure | //observation[templateId/@root="2.16.840.1.113883.10.20.34.3.1"][templateId/@extension="2015-04-01"]/value | Problems Section (V3) | Problem/Diagnosis/Symptom/Condition Observation (V2) | Use date to find inclusion in this set |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |