Attachment H_EHR Implementation guide templates

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Attachment H_EHR Implementation guide templates

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Attachment H- EHR Implementation Guide Templates
CDAR2_IG_NHCS_R1_DSTU1.2_2016AUG_Vol2

HL7 CDA® R2 Implementation Guide:
National Health Care Surveys Release 1,
DSTU Release 1.2 –
US Realm
August 2016
Draft Standard for Trial Use (DSTU)
Volume 2 — Templates and Supporting
Sponsored by:
Public Health and Emergency Response Work Group
Structured Documents Work Group
Publication of this draft standard for trial use and comment has been approved by Health Level Seven
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in any form is strictly forbidden without the written permission of the publisher. HL7 and Health Level Seven are
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Use of this material is governed by HL7's IP Compliance Policy

Attachment G- EHR Implementation Guide Templates

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Attachment G- EHR Implementation Guide Templates

Table of Contents
1

DOCUMENT-LEVEL TEMPLATES................................................................................... 22
1.1

2

US Realm Header (V2) .............................................................................................. 22

1.1.1

Properties ......................................................................................................... 31

1.1.2

National Health Care Surveys (V2) ..................................................................... 66

1.1.3

Properties ......................................................................................................... 69

1.1.4

Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) ..................... 73

1.1.5

Properties ......................................................................................................... 76

1.1.6

Inpatient Encounter (NHCS-IP) (V3) ................................................................... 81

1.1.7

Properties ......................................................................................................... 84

1.1.8

Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) ....................... 89

1.1.9

Properties ......................................................................................................... 92

SECTION-LEVEL TEMPLATES ....................................................................................... 98
2.1

Chief Complaint and Reason for Visit Section ........................................................... 99

2.1.1
2.2

Encounters Section (entries optional) (V2) ............................................................... 102

2.2.1

Emergency Department Encounters Section (V2) ............................................. 104

2.2.2

Inpatient Encounters Section (V2) ................................................................... 106

2.2.3

Outpatient Encounters Section (V3) ................................................................ 108

2.3

Medications Section (entries optional) (V2) .............................................................. 109

2.3.1

Immunizations Section .................................................................................... 111

2.3.2

Medications Section ........................................................................................ 113

2.4

Payers Section (V2) ................................................................................................ 114

2.4.1

Payment Sources Section ................................................................................ 116

2.5

Problems Section (V3) ............................................................................................ 118

2.6

Results Section (entries optional) (V2) ..................................................................... 122

2.7

Services and Procedures Section ............................................................................ 124

2.8

Social History Section (V2) ..................................................................................... 128

2.8.1
2.9

Patient Information Section (V3) ...................................................................... 133

Triage Section ........................................................................................................ 137

2.10

Vital Signs Section (entries optional) (V2) ........................................................ 140

2.10.1
3

Reasons for Visit Section (V2) .......................................................................... 100

Vital Signs Section (entries required) (V2) ........................................................ 141

ENTRY-LEVEL TEMPLATES ......................................................................................... 144
3.1

Admission Priority Observation .............................................................................. 144

Attachment G- EHR Implementation Guide Templates

3.2

Age Observation ..................................................................................................... 147

3.3

Assessment Scale Observation ............................................................................... 149

3.3.1

Pain Assessment Scale Observation ................................................................. 152

3.3.2

Triage Level Assigned Observation ................................................................... 154

3.4

Assessment Scale Supporting Observation .............................................................. 156

3.5

Asthma Diagnosis Observation (RETIRED) .............................................................. 158

3.6

Caregiver Characteristics ....................................................................................... 160

3.7

Cause of Injury, Poisoning, or Adverse Effect .......................................................... 163

3.8

Characteristics of Home Environment ..................................................................... 166

3.9

Clinical Note and External Document Reference ..................................................... 168

3.10

Co-morbid Condition Observation (RETIRED) ................................................. 170

3.11

Condition Control Observation ....................................................................... 172

3.12

Coverage Activity (V2) ..................................................................................... 174

3.13

Cultural and Religious Observation ................................................................ 177

3.14

Discharge Status Observation ........................................................................ 178

3.15

Drug Monitoring Act ....................................................................................... 181

3.16

Drug Vehicle .................................................................................................. 185

3.17

Encounter Activity (V2)................................................................................... 187

3.17.1

Current Emergency Department Visit (V2) ....................................................... 193

3.17.2

Current Inpatient Visit .................................................................................... 198

3.17.3

Current Outpatient Visit (V3) .......................................................................... 202

3.17.4

Hospital Admission Encounter ........................................................................ 207

3.17.5

Observation Unit Stay Encounter .................................................................... 213

3.17.6

Specialty Unit Stay Encounter ......................................................................... 215

3.18

Encounter Diagnosis (V2) ............................................................................... 218

3.19

Episode of Care Observation (V2) .................................................................... 220

3.20

Estimated Date of Delivery ............................................................................. 222

3.21

Follow-up Attempt Outcome Observation ........................................................ 224

3.22

Hospital Discharge Diagnosis (V2) .................................................................. 227

3.23

Immunization Activity (V2) ............................................................................. 230

3.24

Immunization Medication Information (V2) ..................................................... 242

3.25

Immunization Refusal Reason ........................................................................ 246

3.26

Indication (V2) ............................................................................................... 249

3.26.1

Major Reason for Visit ..................................................................................... 253

3.27

Instruction (V2) .............................................................................................. 256

3.28

Listed for Admission to Hospital Act ............................................................... 258

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3.29

Medication Activity (V2) .................................................................................. 260

3.30

Medication Dispense (V2) ............................................................................... 270

3.31

Medication Free Text Sig ................................................................................ 274

3.32

Medication Information (V2) ........................................................................... 277

3.33

Medication Supply Order (V2) ......................................................................... 280

3.34

New Patient Act .............................................................................................. 283

3.35

Number of Visits in the Last 12 Months .......................................................... 285

3.36

On Oxygen on Arrival Observation .................................................................. 287

3.37

Patient Residence Observation ........................................................................ 289

3.38

Patient Seen in this ED in last 72 Hours and Discharged ................................ 291

3.39

Planned Act (V2) ............................................................................................ 293

3.39.1

Ordered Service Act ........................................................................................ 297

3.40

Planned Coverage ........................................................................................... 299

3.41

Planned Immunization Activity ....................................................................... 303

3.42

Planned Medication Activity (V2) ..................................................................... 309

3.43

Planned Observation (V2) ............................................................................... 314

3.43.1
3.44
3.44.1

Ordered Service Observation ........................................................................... 320
Planned Procedure (V2) .................................................................................. 322
Ordered Service Procedure .............................................................................. 328

3.45

Point of Origin Observation ............................................................................ 329

3.46

Policy Activity (V2) .......................................................................................... 332

3.47

Precondition for Substance Administration (V2) .............................................. 342

3.48

Pregnancy Observation ................................................................................... 343

3.49

Present on Admission Observation.................................................................. 346

3.50

Priority Preference .......................................................................................... 348

3.51

Problem Observation (V2) ............................................................................... 351

3.51.1

Admission Diagnosis Observation .................................................................... 361

3.51.2

Adverse Effect of Medical Treatment ................................................................ 362

3.51.3

Injury or Poisoning Observation (V2) ............................................................... 365

3.51.4

Patient's Reason for Visit Observation ............................................................. 369

3.51.5

Primary Diagnosis Observation (V2)................................................................. 371

3.51.6

Problem/Diagnosis/Symptom/Condition Observation (V2) .............................. 374

3.52

Problem Status (DEPRECATED) ..................................................................... 376

3.53

Procedure Activity Act (V2) ............................................................................. 377

3.53.1
3.54

Provided Service Act ........................................................................................ 386
Procedure Activity Observation (V2) ................................................................ 388

Attachment G- EHR Implementation Guide Templates

3.54.1
3.55

Procedure Activity Procedure (V2) ................................................................... 398

3.55.1

4

Provided Service Observation .......................................................................... 396
Provided Service Procedure ............................................................................. 406

3.56

Procedure Follow-Up Attempt Observation ...................................................... 408

3.57

Product Instance ............................................................................................ 411

3.58

Prognosis Observation .................................................................................... 413

3.59

Reaction Observation (V2) .............................................................................. 416

3.60

Result Observation (V2) .................................................................................. 420

3.61

Result Organizer (V2) ..................................................................................... 427

3.62

Service Delivery Location ................................................................................ 430

3.63

Severity Observation (V2) ............................................................................... 433

3.64

Smoking Status - Meaningful Use (V2) ............................................................ 436

3.65

Social History Observation (V2) ...................................................................... 440

3.66

Substance Administered Act ........................................................................... 443

3.67

Tobacco Use (V2) ............................................................................................ 445

3.68

Transport Mode to Hospital Observation ......................................................... 449

3.69

Vital Sign Observation (V2) ............................................................................. 452

3.70

Vital Signs Organizer (V2) ............................................................................... 456

PARTICIPATION AND OTHER TEMPLATES ................................................................... 460
4.1

Author Participation ............................................................................................... 460

4.2

US Realm Address (AD.US.FIELDED) ..................................................................... 463

4.3

US Realm Date and Time (DTM.US.FIELDED) ......................................................... 467

4.4

US Realm Patient Name (PTN.US.FIELDED) ............................................................ 468

4.5

US Realm Person Name (PN.US.FIELDED) .............................................................. 471

5

TEMPLATE IDS IN THIS GUIDE ................................................................................... 473

6

VALUE SETS IN THIS GUIDE ....................................................................................... 503

7

CODE SYSTEMS IN THIS GUIDE ................................................................................. 508

8

CHANGES FROM PREVIOUS VERSION ........................................................................ 510
8.1

Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) .......................... 510

8.2

Inpatient Encounter (NHCS-IP) (V3) ........................................................................ 512

8.3

Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) ............................ 513

8.4

Asthma Diagnosis Observation (RETIRED) .............................................................. 515

8.5

Co-morbid Condition Observation (RETIRED) ......................................................... 517

8.6

Current Emergency Department Visit (V2) .............................................................. 519

Attachment G- EHR Implementation Guide Templates

8.7

Current Outpatient Visit (V3) ................................................................................. 520

8.8

Emergency Department Encounters Section (V2) .................................................... 521

8.9

Inpatient Encounters Section (V2) .......................................................................... 521

8.10

Outpatient Encounters Section (V3) ................................................................ 522

8.11

Patient Information Section (V3) ..................................................................... 522

8.12

Problems Section (V3)..................................................................................... 523

8.13

Reasons for Visit Section (V2) ......................................................................... 524

Table of Figures
Figure 1: US Realm Header (V2) Example ......................................................................................... 31
Figure 2: recordTarget Example ....................................................................................................... 36
Figure 3: author Example ................................................................................................................ 39
Figure 4: dateEnterer Example ........................................................................................................ 40
Figure 5: Assigned Health Care Provider informant Example ............................................................ 41
Figure 6: Personal Relation informant Example ................................................................................ 42
Figure 7: custodian Example ........................................................................................................... 43
Figure 8: informationRecipient Example ........................................................................................... 44
Figure 9: Digital signature Example ................................................................................................. 45
Figure 10: legalAuthenticator Example ............................................................................................. 46
Figure 11: authenticator Example .................................................................................................... 48
Figure 12: Supporting Person participant Example ........................................................................... 49
Figure 13: inFulfillmentOf Example ................................................................................................. 50
Figure 14: performer Example.......................................................................................................... 52
Figure 15: documentationOf Example .............................................................................................. 53
Figure 16: authorization Example .................................................................................................... 54
Figure 17: National Health Care Surveys (V2) Example ..................................................................... 69
Figure 18: recordTarget Example ..................................................................................................... 71
Figure 19: performer Example.......................................................................................................... 72
Figure 20: encompassingEncounter Example ................................................................................... 73
Figure 21: Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) Example ..................... 76
Figure 22: performer Example.......................................................................................................... 77
Figure 23: componentOf/encompassingEncounter Example ............................................................. 78
Figure 24: In-Patient Encounter (NHCS-IP) (V3) Example .................................................................. 85

Attachment G- EHR Implementation Guide Templates

Figure 25: componentOf/encompassingEncounter Example ............................................................. 86
Figure 26: Out-Patient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) Example ..................... 92
Figure 27: performer Example.......................................................................................................... 93
Figure 28: componentOf/encompassingEncounter Example ............................................................. 94
Figure 29: Chief Complaint and Reason for Visit Example .............................................................. 100
Figure 30: Reasons for Visit Section (V2) Example .......................................................................... 102
Figure 31: Emergency Department Encounters Section (V2) Example ............................................. 105
Figure 32: Inpatient Encounters Section (V2) Example ................................................................... 107
Figure 33: Outpatient Encounters Section (V3) ............................................................................... 109
Figure 34: Immunizations Section Example .................................................................................... 112
Figure 35: Medications Section Example ........................................................................................ 114
Figure 36: Payers Section (V2) Example ......................................................................................... 116
Figure 37: Payment Sources Section Example ................................................................................ 118
Figure 38: Problems Section (V3) Example ..................................................................................... 121
Figure 39: Services and Procedures Section Example ..................................................................... 127
Figure 40: Social History Section (V2) Example .............................................................................. 132
Figure 41: Patient Information Section (V2) Example ...................................................................... 136
Figure 42: Triage Section Example ................................................................................................. 139
Figure 43: Vital Signs Section (entries required) (V2) Example ........................................................ 143
Figure 44: Admission Priority Observation Example ....................................................................... 146
Figure 45: Age Observation Example .............................................................................................. 149
Figure 46: Assessment Scale Observation Example ........................................................................ 152
Figure 47: Pain Assessment Scale Observation Example ................................................................. 154
Figure 48: Triage Level Assigned Observation Example ................................................................... 156
Figure 49: Assessment Scale Supporting Observation Example....................................................... 158
Figure 50: Asthma Diagnosis Observation (V2) Example ................................................................. 159
Figure 51: Caregiver Characteristics Example ................................................................................ 162
Figure 52: Cause of Injury, Poisoning, or Adverse Effect (Free Text) Example .................................. 165
Figure 53: Cause of Injury, Poisoning, or Adverse Effect (Coded) Example ....................................... 165
Figure 54: Characteristics of Home Environment Example.............................................................. 168
Figure 55: Clinical Note and External Document Reference - Non-CDA Example ............................. 170
Figure 56: Clinical Note and External Document Reference - CDA Document (Referral) Example ..... 170
Figure 57: Co-morbid Condition Observation (V2) Example............................................................. 171

Attachment G- EHR Implementation Guide Templates

Figure 58: Condition Control Observation Example ........................................................................ 173
Figure 59: Coverage Activity (V2) Example ...................................................................................... 176
Figure 60: Cultural and Religious Observation Example ................................................................. 178
Figure 61: Discharge Status Observation Example ......................................................................... 180
Figure 62: Drug Monitoring Act Example........................................................................................ 185
Figure 63: Drug Vehicle Example ................................................................................................... 187
Figure 64: Encounter Activity (V2) Example ................................................................................... 192
Figure 65: Current Emergency Department Visit (V2) Example ....................................................... 197
Figure 66: Current Inpatient Visit Example .................................................................................... 201
Figure 67: Current Outpatient Visit (V3) Example .......................................................................... 206
Figure 68: Hospital Admission Encounter Example ........................................................................ 212
Figure 69: Observation Unit Stay Encounter Example .................................................................... 215
Figure 70: Special Unit Stay Encounter Example............................................................................ 218
Figure 71: Encounter Diagnosis (V2) Example ................................................................................ 220
Figure 72: Episode of Care Observation (V2) Example ..................................................................... 222
Figure 73: Estimated Date of Delivery Example .............................................................................. 224
Figure 74: Follow-up Attempt Outcome Observation ....................................................................... 227
Figure 75: Hospital Discharge Diagnosis (V2) Example ................................................................... 229
Figure 76: Immunization Activity (V2) Example .............................................................................. 241
Figure 77: Immunization Medication Information (V2) Example ...................................................... 246
Figure 78: Immunization Refusal Reason Example ......................................................................... 248
Figure 79: Indication (V2) Example ................................................................................................ 253
Figure 80: Major Reason for Visit Example ..................................................................................... 255
Figure 81: Instruction (V2) Example ............................................................................................... 258
Figure 82: Listed for Admission to Hospital Act Example ................................................................ 260
Figure 83: Medication Activity (V2) Example ................................................................................... 269
Figure 84: No Known Medications Example .................................................................................... 270
Figure 85: Medication Dispense (V2) Example ................................................................................ 273
Figure 86: Medication Free Text Sig Example ................................................................................. 276
Figure 87: Medication Information (V2) Example ............................................................................ 280
Figure 88: Medication Supply Order (V2) Example .......................................................................... 283
Figure 89: New Patient Act Example ............................................................................................... 285
Figure 90: Number of Visits in the Last 12 Months Example ........................................................... 287

Attachment G- EHR Implementation Guide Templates

Figure 91: On Oxygen on Arrival Observation Example ................................................................... 289
Figure 92: Patient Residence Example ............................................................................................ 291
Figure 93: Patient Seen in this ED in last 72 Hours and Discharged Example ................................. 293
Figure 94: Planned Act (V2) Example ............................................................................................. 297
Figure 95: Ordered Service Act Example ......................................................................................... 299
Figure 96: Planned Coverage Example............................................................................................ 302
Figure 97: Planned Immunization Activity ...................................................................................... 308
Figure 98: Planned Medication Activity (V2) Example...................................................................... 314
Figure 99: Planned Observation (V2) Example ................................................................................ 320
Figure 100: Ordered Service Observation Example ......................................................................... 322
Figure 101: Planned Procedure (V2) Example ................................................................................. 327
Figure 102: Ordered Service Procedure Example ............................................................................ 329
Figure 103: Point of Origin Observation Example ........................................................................... 332
Figure 104: Policy Activity (V2) Example ......................................................................................... 340
Figure 105: Precondition for Substance Administration (V2) Example ............................................. 343
Figure 106: Pregnancy Observation Example .................................................................................. 345
Figure 107: Present on Admission Observation Example ................................................................ 348
Figure 108: Priority Preference Example ......................................................................................... 350
Figure 109: Problem Observation (V2) Example .............................................................................. 356
Figure 110: No Known Problems Example ...................................................................................... 357
Figure 111: Resolved Problem and Resolved Concern Example ....................................................... 358
Figure 112: Problem with Qualifiers Example ................................................................................. 360
Figure 113: Admission Diagnosis Observation Example .................................................................. 362
Figure 114: Adverse Effect of Medical Treatment Example .............................................................. 364
Figure 115: Injury or Poisoning Observation (V2) Example .............................................................. 369
Figure 116: Patient's Reason for Visit Observation Example............................................................ 371
Figure 117: Primary Diagnosis Observation (V2) Example ............................................................... 373
Figure 118: Problem/Diagnosis/Symptom/Condition Observation (V2) Example ............................. 375
Figure 119: Procedure Activity Act Example ................................................................................... 385
Figure 120: Provided Service Act Example 1 ................................................................................... 387
Figure 121: Provided Service Act Example 2 ................................................................................... 388
Figure 122: Procedure Activity Observation (V2) Example ............................................................... 395
Figure 123: Provided Service Observation Example ......................................................................... 398

Attachment G- EHR Implementation Guide Templates

Figure 124: Procedure Activity Procedure (V2) Example .................................................................. 406
Figure 125: Provided Service Procedure Example ............................................................................ 408
Figure 126: Procedure Follow-Up Attempt Observation ................................................................... 411
Figure 127: Product Instance Example ........................................................................................... 413
Figure 128: Prognosis, Free Text Example ...................................................................................... 415
Figure 129: Prognosis, Coded Example .......................................................................................... 415
Figure 130: Reaction Observation (V2) Example ............................................................................. 420
Figure 131: Result Observation (V2) Example ................................................................................. 425
Figure 132: Pending Result Observation (V2) Example .................................................................... 426
Figure 133: Original Lab Units in  Example................................................................ 426
Figure 134: Result Organizer (V2) Example .................................................................................... 430
Figure 135: Service Delivery Location Example ............................................................................... 433
Figure 136: Severity Observation (V2) Example .............................................................................. 435
Figure 137: Smoking Status - Meaningful Use (V2) Example ........................................................... 439
Figure 138: Social History Observation (V2) Example ..................................................................... 442
Figure 139: Substance Administered Act Example .......................................................................... 444
Figure 140: Tobacco Use (V2) Example ........................................................................................... 449
Figure 141: Transport Mode to Hospital Observation Example ........................................................ 451
Figure 142: Vital Sign Observation (V2) Example ............................................................................ 455
Figure 143: Vital Signs Organizer (V2) Example .............................................................................. 459
Figure 144: New Author Participant Example ................................................................................. 462
Figure 145: Existing Author Reference Example ............................................................................. 463
Figure 146: US Realm Address Example ........................................................................................ 466
Figure 147: US Realm Date and Time Example .............................................................................. 467
Figure 148: US Realm Patient Name Example ................................................................................ 471

Table of Tables
Table 1: US Realm Header (V2) Contexts .......................................................................................... 22
Table 2: US Realm Header (V2) Constraints Overview ....................................................................... 23
Table 3: HL7 BasicConfidentialityKind ............................................................................................. 55
Table 4: Language ........................................................................................................................... 56
Table 5: Telecom Use (US Realm Header).......................................................................................... 56
Table 6: Administrative Gender (HL7 V3) .......................................................................................... 57

Attachment G- EHR Implementation Guide Templates

Table 7: Marital Status .................................................................................................................... 57
Table 8: Religious Affiliation ............................................................................................................. 58
Table 9: Race Category Excluding Nulls ........................................................................................... 58
Table 10: Ethnicity .......................................................................................................................... 59
Table 11: Personal And Legal Relationship Role Type ........................................................................ 59
Table 12: Country ............................................................................................................................ 60
Table 13: PostalCode ....................................................................................................................... 60
Table 14: PatientLanguage ............................................................................................................... 61
Table 15: LanguageAbilityMode ........................................................................................................ 62
Table 16: LanguageAbilityProficiency ............................................................................................... 62
Table 17: Race ................................................................................................................................. 63
Table 18: Healthcare Provider Taxonomy (HIPAA) ............................................................................. 64
Table 19: INDRoleclassCodes ........................................................................................................... 65
Table 20: x_ServiceEventPerformer .................................................................................................. 65
Table 21: ParticipationFunction ....................................................................................................... 65
Table 22: Detailed Ethnicity ............................................................................................................. 66
Table 23: National Health Care Surveys (V2) Constraints Overview ................................................... 68
Table 24: Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) Contexts ...................... 73
Table 25: Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) Constraints Overview ... 74
Table 26: Provider ED (NCHS) .......................................................................................................... 80
Table 27: Disposition ED (NCHS) ..................................................................................................... 81
Table 28: Inpatient Encounter (NHCS-IP) (V3) Contexts .................................................................... 81
Table 29: Inpatient Encounter (NHCS-IP) (V3) Constraints Overview ................................................. 83
Table 30: Discharge Disposition IP (NCHS) ....................................................................................... 88
Table 31: Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) Contexts ........................ 89
Table 32: Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) Constraints Overview ..... 90
Table 33: Disposition OPD (NCHS) ................................................................................................... 96
Table 34: Type of clinic/location (NCHS) .......................................................................................... 97
Table 35: Chief Complaint and Reason for Visit Section Constraints Overview................................... 99
Table 36: Reasons for Visit Section (V2) Contexts ........................................................................... 100
Table 37: Reasons for Visit Section (V2) Constraints Overview ........................................................ 101
Table 38: Encounters Section (entries optional) (V2) Contexts ......................................................... 102
Table 39: Encounters Section (entries optional) (V2) Constraints Overview ...................................... 103

Attachment G- EHR Implementation Guide Templates

Table 40: Emergency Department Encounters Section (V2) Contexts .............................................. 104
Table 41: Emergency Department Encounters Section (V2) Constraints Overview ........................... 104
Table 42: Inpatient Encounters Section (V2) Contexts .................................................................... 106
Table 43: Inpatient Encounters Section (V2) Constraints Overview ................................................. 106
Table 44: Outpatient Encounters Section (V3) Contexts .................................................................. 108
Table 45: Outpatient Encounters Section (V3) Constraints Overview ............................................... 108
Table 46: Medications Section (entries optional) (V2) Contexts ........................................................ 109
Table 47: Medications Section (entries optional) (V2) Constraints Overview ..................................... 110
Table 48: Immunizations Section Contexts ..................................................................................... 111
Table 49: Immunizations Section Constraints Overview .................................................................. 111
Table 50: Medications Section Contexts ......................................................................................... 113
Table 51: Medications Section Constraints Overview ...................................................................... 113
Table 52: Payers Section (V2) Contexts ........................................................................................... 114
Table 53: Payers Section (V2) Constraints Overview ........................................................................ 115
Table 54: Payment Sources Section Contexts ................................................................................. 116
Table 55: Payment Sources Section Constraints Overview .............................................................. 117
Table 56: Problems Section (V3) Contexts ....................................................................................... 118
Table 57: Problems Section (V3) Constraints Overview .................................................................... 119
Table 58: Results Section (entries optional) (V2) Contexts ............................................................... 122
Table 59: Results Section (entries optional) (V2) Constraints Overview ............................................ 123
Table 60: Services and Procedures Section Contexts ....................................................................... 124
Table 61: Services and Procedures Section Constraints Overview .................................................... 125
Table 62: Social History Section (V2) Contexts ................................................................................ 128
Table 63: Social History Section (V2) Constraints Overview ............................................................. 129
Table 64: Patient Information Section (V3) Contexts ....................................................................... 133
Table 65: Patient Information Section (V3) Constraints Overview .................................................... 134
Table 66: Triage Section Contexts .................................................................................................. 137
Table 67: Triage Section Constraints Overview ............................................................................... 138
Table 68: Vital Signs Section (entries optional) (V2) Contexts .......................................................... 140
Table 69: Vital Signs Section (entries optional) (V2) Constraints Overview ....................................... 140
Table 70: Vital Signs Section (entries required) (V2) Contexts .......................................................... 141
Table 71: Vital Signs Section (entries required) (V2) Constraints Overview ....................................... 142
Table 72: Admission Priority Observation Contexts ......................................................................... 144

Attachment G- EHR Implementation Guide Templates

Table 73: Admission Priority Observation Constraints Overview ...................................................... 145
Table 74: Priority (Type) of Admission or Visit (NCHS) ..................................................................... 146
Table 75: Age Observation Contexts ............................................................................................... 147
Table 76: Age Observation Constraints Overview ............................................................................ 147
Table 77: AgePQ_UCUM ................................................................................................................. 148
Table 78: Assessment Scale Observation Contexts .......................................................................... 149
Table 79: Assessment Scale Observation Constraints Overview ....................................................... 150
Table 80: Pain Assessment Scale Observation Contexts .................................................................. 152
Table 81: Pain Assessment Scale Observation Constraints Overview ............................................... 153
Table 82: Triage Level Assigned Observation Contexts .................................................................... 154
Table 83: Triage Level Assigned Observation Constraints Overview ................................................. 155
Table 84: Triage System (NCHS) ..................................................................................................... 156
Table 85: Assessment Scale Supporting Observation Contexts ........................................................ 156
Table 86: Assessment Scale Supporting Observation Constraints Overview ..................................... 157
Table 87: Asthma Diagnosis Observation (RETIRED) Constraints Overview ..................................... 158
Table 88: Caregiver Characteristics Contexts .................................................................................. 160
Table 89: Caregiver Characteristics Constraints Overview ............................................................... 161
Table 90: Cause of Injury, Poisoning, or Adverse Effect Contexts .................................................... 163
Table 91: Cause of Injury, Poisoning, or Adverse Effect Constraints Overview ................................. 164
Table 92: Characteristics of Home Environment Contexts ............................................................... 166
Table 93: Characteristics of Home Environment Constraints Overview ............................................ 166
Table 94: Residence and Accommodation Type ............................................................................... 167
Table 95: Clinical Note and External Document Reference Contexts ................................................ 168
Table 96: Clinical Note and External Document Reference Constraints Overview ............................. 169
Table 97: Co-morbid Condition Observation (RETIRED) Constraints Overview ................................. 171
Table 98: Condition Control Observation Constraints Overview ...................................................... 172
Table 99: Condition Control (NCHS) ............................................................................................... 173
Table 100: Coverage Activity (V2) Contexts ..................................................................................... 174
Table 101: Coverage Activity (V2) Constraints Overview .................................................................. 175
Table 102: Cultural and Religious Observation Contexts ................................................................ 177
Table 103: Cultural and Religious Observation Constraints Overview ............................................. 177
Table 104: Discharge Status Observation Contexts ......................................................................... 178
Table 105: Discharge Status Observation Constraints Overview ...................................................... 179

Attachment G- EHR Implementation Guide Templates

Table 106: Hospital Discharge Status (NCHS) ................................................................................. 180
Table 107: Drug Monitoring Act Contexts ....................................................................................... 181
Table 108: Drug Monitoring Act Constraints Overview .................................................................... 182
Table 109: ActStatus ..................................................................................................................... 184
Table 110: Drug Vehicle Contexts .................................................................................................. 185
Table 111: Drug Vehicle Constraints Overview ............................................................................... 186
Table 112: Encounter Activity (V2) Contexts ................................................................................... 187
Table 113: Encounter Activity (V2) Constraints Overview ................................................................ 188
Table 114: EncounterTypeCode...................................................................................................... 191
Table 115: Current Emergency Department Visit (V2) Contexts ...................................................... 193
Table 116: Current Emergency Department Visit (V2) Constraints Overview ................................... 194
Table 117: Current Inpatient Visit Contexts ................................................................................... 198
Table 118: Current Inpatient Visit Constraints Overview ................................................................ 199
Table 119: Current Outpatient Visit (V3) Contexts .......................................................................... 202
Table 120: Current Outpatient Visit (V3) Constraints Overview ....................................................... 203
Table 121: Hospital Admission Encounter Contexts ........................................................................ 207
Table 122: Hospital Admission Encounter Constraints Overview ..................................................... 208
Table 123: Disposition (NCHS) ....................................................................................................... 211
Table 124: Observation Unit Stay Encounter Contexts ................................................................... 213
Table 125: Observation Unit Stay Encounter Constraints Overview................................................. 214
Table 126: Specialty Unit Stay Encounter Contexts ........................................................................ 215
Table 127: Specialty Unit Stay Encounter Constraints Overview ..................................................... 216
Table 128: Specialty Unit Type (NCHS) ........................................................................................... 217
Table 129: Encounter Diagnosis (V2) Contexts ............................................................................... 218
Table 130: Encounter Diagnosis (V2) Constraints Overview ............................................................ 219
Table 131: Episode of Care Observation (V2) Contexts .................................................................... 220
Table 132: Episode of Care Observation (V2) Constraints Overview ................................................. 221
Table 133: Episode of Care (NCHS) ................................................................................................ 222
Table 134: Estimated Date of Delivery Contexts ............................................................................. 222
Table 135: Estimated Date of Delivery Constraints Overview........................................................... 223
Table 136: Follow-up Attempt Outcome Observation Contexts ........................................................ 224
Table 137: Follow-up Attempt Outcome Observation Constraints Overview ..................................... 225
Table 138: Follow-up Attempt Outcome (NCHS) .............................................................................. 226

Attachment G- EHR Implementation Guide Templates

Table 139: NullValues_UNK_OTH ................................................................................................... 226
Table 140: Hospital Discharge Diagnosis (V2) Contexts .................................................................. 227
Table 141: Hospital Discharge Diagnosis (V2) Constraints Overview................................................ 228
Table 142: Immunization Activity (V2) Contexts .............................................................................. 230
Table 143: Immunization Activity (V2) Constraints Overview ........................................................... 231
Table 144: MoodCodeEvnInt .......................................................................................................... 236
Table 145: Medication Route FDA .................................................................................................. 237
Table 146: Body Site ...................................................................................................................... 238
Table 147: UnitsOfMeasureCaseSensitive ....................................................................................... 239
Table 148: AdministrationUnitDoseForm ....................................................................................... 240
Table 149: Immunization Medication Information (V2) Contexts ..................................................... 242
Table 150: Immunization Medication Information (V2) Constraints Overview ................................... 243
Table 151: CVX Vaccines Administered - Vaccine Set ..................................................................... 244
Table 152: Vaccine Clinical Drug ................................................................................................... 245
Table 153: Specific Vaccine Clinical Drug ....................................................................................... 245
Table 154: Immunization Refusal Reason Contexts ........................................................................ 246
Table 155: Immunization Refusal Reason Constraints Overview...................................................... 247
Table 156: No Immunization Reason Value Set ............................................................................... 248
Table 157: Indication (V2) Contexts ................................................................................................ 249
Table 158: Indication (V2) Constraints Overview ............................................................................. 250
Table 159: Problem ........................................................................................................................ 251
Table 160: Problem Type ................................................................................................................ 252
Table 161: Major Reason for Visit Contexts .................................................................................... 253
Table 162: Major Reason for Visit Constraints Overview ................................................................. 254
Table 163: Major Reason for Visit (NCHS) ....................................................................................... 255
Table 164: Instruction (V2) Contexts .............................................................................................. 256
Table 165: Instruction (V2) Constraints Overview ........................................................................... 257
Table 166: Patient Education ......................................................................................................... 258
Table 167: Listed for Admission to Hospital Act Contexts................................................................ 258
Table 168: Listed for Admission to Hospital Act Constraints Overview ............................................. 259
Table 169: Medication Activity (V2) Contexts .................................................................................. 260
Table 170: Medication Activity (V2) Constraints Overview ............................................................... 262
Table 171: Medication Dispense (V2) Contexts ............................................................................... 270

Attachment G- EHR Implementation Guide Templates

Table 172: Medication Dispense (V2) Constraints Overview............................................................. 271
Table 173: Medication Fill Status ................................................................................................... 273
Table 174: Medication Free Text Sig Contexts ................................................................................. 274
Table 175: Medication Free Text Sig Constraints Overview .............................................................. 275
Table 176: Medication Information (V2) Contexts............................................................................ 277
Table 177: Medication Information (V2) Constraints Overview ......................................................... 277
Table 178: Medication Clinical Drug .............................................................................................. 278
Table 179: Clinical Substance ........................................................................................................ 279
Table 180: Medication Supply Order (V2) Contexts ......................................................................... 280
Table 181: Medication Supply Order (V2) Constraints Overview ...................................................... 281
Table 182: New Patient Act Contexts .............................................................................................. 283
Table 183: New Patient Act Constraints Overview ........................................................................... 284
Table 184: Number of Visits in the Last 12 Months Contexts .......................................................... 285
Table 185: Number of Visits in the Last 12 Months Constraints Overview ....................................... 286
Table 186: On Oxygen on Arrival Observation Contexts .................................................................. 287
Table 187: On Oxygen on Arrival Observation Constraints Overview ............................................... 288
Table 188: Patient Residence Observation Contexts ........................................................................ 289
Table 189: Patient Residence Observation Constraints Overview ..................................................... 290
Table 190: Patient Residence (NCHS) ............................................................................................. 291
Table 191: Patient Seen in this ED in last 72 Hours and Discharged Contexts ................................ 291
Table 192: Patient Seen in this ED in last 72 Hours and Discharged Constraints Overview ............. 292
Table 193: Planned Act (V2) Contexts ............................................................................................. 293
Table 194: Planned Act (V2) Constraints Overview .......................................................................... 294
Table 195: Planned moodCode (Act/Encounter/Procedure) ............................................................. 296
Table 196: Ordered Service Act Contexts ........................................................................................ 297
Table 197: Ordered Service Act Constraints Overview ..................................................................... 298
Table 198: Planned Coverage Contexts ........................................................................................... 299
Table 199: Planned Coverage Constraints Overview ........................................................................ 300
Table 200: Payer ............................................................................................................................ 302
Table 201: Planned Immunization Activity Contexts ....................................................................... 303
Table 202: Planned Immunization Activity Constraints Overview .................................................... 304
Table 203: Planned moodCode (SubstanceAdministration/Supply) ................................................. 307
Table 204: Planned Medication Activity (V2) Contexts ..................................................................... 309

Attachment G- EHR Implementation Guide Templates

Table 205: Planned Medication Activity (V2) Constraints Overview .................................................. 310
Table 206: Planned Observation (V2) Contexts ............................................................................... 314
Table 207: Planned Observation (V2) Constraints Overview ............................................................ 316
Table 208: Planned moodCode (Observation) .................................................................................. 319
Table 209: Ordered Service Observation Contexts........................................................................... 320
Table 210: Ordered Service Observation Constraints Overview ........................................................ 321
Table 211: Planned Procedure (V2) Contexts .................................................................................. 322
Table 212: Planned Procedure (V2) Constraints Overview ............................................................... 323
Table 213: Ordered Service Procedure Contexts .............................................................................. 328
Table 214: Ordered Service Procedure Constraints Overview ........................................................... 328
Table 215: Point of Origin Observation Contexts ............................................................................. 329
Table 216: Point of Origin Observation Constraints Overview .......................................................... 330
Table 217: Point of Origin (NCHS) .................................................................................................. 331
Table 218: Policy Activity (V2) Contexts .......................................................................................... 332
Table 219: Policy Activity (V2) Constraints Overview ....................................................................... 333
Table 220: HL7FinanciallyResponsiblePartyType ............................................................................ 339
Table 221: Coverage Role Type ....................................................................................................... 339
Table 222: Precondition for Substance Administration (V2) Contexts .............................................. 342
Table 223: Precondition for Substance Administration (V2) Constraints Overview ........................... 342
Table 224: Pregnancy Observation Contexts ................................................................................... 343
Table 225: Pregnancy Observation Constraints Overview ................................................................ 344
Table 226: Present on Admission Observation Contexts .................................................................. 346
Table 227: Present on Admission Observation Constraints Overview ............................................... 347
Table 228: Priority Preference Contexts .......................................................................................... 348
Table 229: Priority Preference Constraints Overview ....................................................................... 349
Table 230: Priority Level ................................................................................................................ 350
Table 231: Problem Observation (V2) Contexts ............................................................................... 351
Table 232: Problem Observation (V2) Constraints Overview ............................................................ 352
Table 233: Admission Diagnosis Observation Contexts ................................................................... 361
Table 234: Admission Diagnosis Observation Constraints Overview ................................................ 361
Table 235: Adverse Effect of Medical Treatment Contexts ............................................................... 362
Table 236: Adverse Effect of Medical Treatment Constraints Overview............................................. 363
Table 237: Injury or Poisoning Observation (V2) Contexts ............................................................... 365

Attachment G- EHR Implementation Guide Templates

Table 238: Injury or Poisoning Observation (V2) Constraints Overview ............................................ 366
Table 239: Injury or Poisoning (NCHS) ........................................................................................... 368
Table 240: Patient's Reason for Visit Observation Contexts ............................................................. 369
Table 241: Patient's Reason for Visit Observation Constraints Overview .......................................... 370
Table 242: Primary Diagnosis Observation (V2) Contexts ................................................................ 371
Table 243: Primary Diagnosis Observation (V2) Constraints Overview ............................................. 372
Table 244: Problem/Diagnosis/Symptom/Condition Observation (V2) Contexts .............................. 374
Table 245: Problem/Diagnosis/Symptom/Condition Observation (V2) Constraints Overview ........... 374
Table 246: Problem Status (DEPRECATED) Contexts ...................................................................... 376
Table 247: Problem Status (DEPRECATED) Constraints Overview ................................................... 376
Table 248: Problem Status ............................................................................................................. 377
Table 249: Procedure Activity Act (V2) Contexts .............................................................................. 377
Table 250: Procedure Activity Act (V2) Constraints Overview ........................................................... 379
Table 251: Act Priority ................................................................................................................... 384
Table 252: ProcedureAct statusCode .............................................................................................. 384
Table 253: Provided Service Act Contexts ....................................................................................... 386
Table 254: Provided Service Act Constraints Overview .................................................................... 386
Table 255: Procedure Activity Observation (V2) Contexts ................................................................ 388
Table 256: Procedure Activity Observation (V2) Constraints Overview ............................................. 389
Table 257: Provided Service Observation Contexts .......................................................................... 396
Table 258: Provided Service Observation Constraints Overview ....................................................... 397
Table 259: Procedure Activity Procedure (V2) Contexts ................................................................... 398
Table 260: Procedure Activity Procedure (V2) Constraints Overview ................................................ 400
Table 261: Provided Service Procedure Contexts ............................................................................. 406
Table 262: Provided Service Procedure Constraints Overview .......................................................... 407
Table 263: Procedure Follow-Up Attempt Observation Contexts ...................................................... 408
Table 264: Procedure Follow-Up Attempt Observation Constraints Overview ................................... 409
Table 265: Product Instance Contexts ............................................................................................ 411
Table 266: Product Instance Constraints Overview ......................................................................... 412
Table 267: Prognosis Observation Contexts .................................................................................... 413
Table 268: Prognosis Observation Constraints Overview ................................................................. 414
Table 269: Reaction Observation (V2) Contexts .............................................................................. 416
Table 270: Reaction Observation (V2) Constraints Overview............................................................ 417

Attachment G- EHR Implementation Guide Templates

Table 271: Result Observation (V2) Contexts .................................................................................. 420
Table 272: Result Observation (V2) Constraints Overview ............................................................... 421
Table 273: Result Status................................................................................................................ 423
Table 274: Observation Interpretation (HL7) ................................................................................... 424
Table 275: Result Organizer (V2) Contexts ..................................................................................... 427
Table 276: Result Organizer (V2) Constraints Overview................................................................... 428
Table 277: Service Delivery Location Contexts ................................................................................ 430
Table 278: Service Delivery Location Constraints Overview ............................................................. 431
Table 279: HealthcareServiceLocation ............................................................................................ 432
Table 280: Severity Observation (V2) Contexts ................................................................................ 433
Table 281: Severity Observation (V2) Constraints Overview ............................................................. 434
Table 282: Problem Severity ........................................................................................................... 435
Table 283: Smoking Status - Meaningful Use (V2) Contexts ............................................................ 436
Table 284: Smoking Status - Meaningful Use (V2) Constraints Overview ......................................... 437
Table 285: Current Smoking Status ............................................................................................... 439
Table 286: Social History Observation (V2) Contexts ....................................................................... 440
Table 287: Social History Observation (V2) Constraints Overview .................................................... 441
Table 288: Substance Administered Act Contexts ........................................................................... 443
Table 289: Substance Administered Act Constraints Overview ........................................................ 443
Table 290: Tobacco Use (V2) Contexts ............................................................................................ 445
Table 291: Tobacco Use (V2) Constraints Overview ......................................................................... 446
Table 292: Tobacco Use ................................................................................................................. 448
Table 293: Transport Mode to Hospital Observation Contexts ......................................................... 449
Table 294: Transport Mode to Hospital Observation Constraints Overview ...................................... 450
Table 295: Transport Mode to Hospital (NCHS) ............................................................................... 451
Table 296: Vital Sign Observation (V2) Contexts ............................................................................. 452
Table 297: Vital Sign Observation (V2) Constraints Overview .......................................................... 453
Table 298: Vital Sign Result ........................................................................................................... 455
Table 299: Vital Signs Organizer (V2) Contexts ............................................................................... 456
Table 300: Vital Signs Organizer (V2) Constraints Overview ............................................................ 457
Table 301: Author Participation Contexts ....................................................................................... 460
Table 302: Author Participation Constraints Overview .................................................................... 461
Table 303: US Realm Address (AD.US.FIELDED) Contexts .............................................................. 463

Attachment G- EHR Implementation Guide Templates

Table 304: US Realm Address (AD.US.FIELDED) Constraints Overview ........................................... 463
Table 305: PostalAddressUse ......................................................................................................... 465
Table 306: StateValueSet ............................................................................................................... 466
Table 307: US Realm Date and Time (DTM.US.FIELDED) Contexts ................................................. 467
Table 308: US Realm Date and Time (DTM.US.FIELDED) Constraints Overview .............................. 467
Table 309: US Realm Patient Name (PTN.US.FIELDED) Contexts .................................................... 468
Table 310: US Realm Patient Name (PTN.US.FIELDED) Constraints Overview ................................. 468
Table 311: EntityNameUse ............................................................................................................. 470
Table 312: EntityPersonNamePartQualifier ..................................................................................... 471
Table 313: US Realm Person Name (PN.US.FIELDED) Contexts ...................................................... 471
Table 314: US Realm Person Name (PN.US.FIELDED) Constraints Overview ................................... 472
Table 315: Template List ................................................................................................................ 473
Table 316: Template Containments ................................................................................................ 479
Table 317: Value Sets .................................................................................................................... 503
Table 318: Code Systems ............................................................................................................... 508

Attachment G- EHR Implementation Guide Templates

1

DOCUMENT-LEVEL TEMPLATES
Document-level templates describe the purpose and rules for constructing a conforming CDA
document. Document templates include constraints on the CDA header and indicate contained
section-level templates.
Each document-level template contains the following information:
• Scope and intended use of the document type
• Description and explanatory narrative
• Template metadata (e.g., templateId, etc.)
• Header constraints (e.g., document type, template id, participants)
• Required and optional section-level templates

1.1

US Realm Header (V2)
[ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.1.1:201406-09 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R2
Table 1: US Realm Header (V2) Contexts

Contained By:

Contains:
US Realm Address (AD.US.FIELDED)
US Realm Date and Time (DTM.US.FIELDED)
US Realm Person Name (PN.US.FIELDED)

This template defines constraints that represent common administrative and demographic
concepts for US Realm CDA documents. Further specification, such as
ClinicalDocument/code, are provided in document templates that conform to this template.

Attachment G- EHR Implementation Guide Templates

Table 2: US Realm Header (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

ClinicalDocument (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.1.1:2014-06-09)
realmCode

1..1

SHALL

109816791

typeId

1..1

SHALL

10985361

@root

1..1

SHALL

10985250

2.16.840.1.113883.1.3

@extension

1..1

SHALL

10985251

POCD_HD000040

1..1

SHALL

10985252

@root

1..1

SHALL

109810036

2.16.840.1.113883.10.20.22.1.1

@extension

1..1

SHALL

109832503

2014-06-09

id

1..1

SHALL

10985363

code

1..1

SHALL

10985253

title

1..1

SHALL

10985254

effectiveTime

1..1

SHALL

10985256

US Realm Date and Time
(DTM.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.4

confidentialityCode

1..1

SHALL

10985259

urn:oid:2.16.840.1.113883.1.11.1
6926 (HL7
BasicConfidentialityKind)

languageCode

1..1

SHALL

10985372

urn:oid:2.16.840.1.113883.1.11.1
1526 (Language)

setId

0..1

MAY

10985261

versionNumber

0..1

MAY

10985264

recordTarget

1..*

SHALL

10985266

patientRole

1..1

SHALL

10985267

id

1..*

SHALL

10985268

addr

1..*

SHALL

10985271

templateId

US

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

Attachment G- EHR Implementation Guide Templates

telecom

1..*

SHALL

10985280

@use

0..1

SHOUL
D

10985375

patient

1..1

SHALL

10985283

name

1..*

SHALL

10985284

US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1.1

administrativeGenderCode

1..1

SHALL

10986394

urn:oid:2.16.840.1.113883.1.11.1
(Administrative Gender (HL7 V3))

birthTime

1..1

SHALL

10985298

maritalStatusCode

0..1

SHOUL
D

10985303

urn:oid:2.16.840.1.113883.1.11.1
2212 (Marital Status)

religiousAffiliationCode

0..1

MAY

10985317

urn:oid:2.16.840.1.113883.1.11.1
9185 (Religious Affiliation)

raceCode

1..1

SHALL

10985322

urn:oid:2.16.840.1.113883.3.207
4.1.1.3 (Race Category Excluding
Nulls)

sdtc:raceCode

0..*

MAY

10987263

urn:oid:2.16.840.1.113883.1.11.1
4914 (Race)

ethnicGroupCode

1..1

SHALL

10985323

urn:oid:2.16.840.1.114222.4.11.8
37 (Ethnicity)

sdtc:ethnicGroupCode

0..*

MAY

109832901

urn:oid:2.16.840.1.114222.4.11.8
77 (Detailed Ethnicity)

guardian

0..*

MAY

10985325

code

0..1

SHOUL
D

10985326

urn:oid:2.16.840.1.113883.11.20.
12.1 (Personal And Legal
Relationship Role Type)

addr

0..*

SHOUL
D

10985359

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

telecom

0..*

SHOUL
D

10985382

@use

0..1

SHOUL
D

10987993

1..1

SHALL

10985385

1..*

SHALL

10985386

0..1

MAY

1098-

guardianPerson
name

birthplace

urn:oid:2.16.840.1.113883.11.20.
9.20 (Telecom Use (US Realm
Header))

urn:oid:2.16.840.1.113883.11.20.
9.20 (Telecom Use (US Realm
Header))

US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1.1

Attachment G- EHR Implementation Guide Templates

5395
place

1..1

SHALL

10985396

1..1

SHALL

10985397

country

0..1

SHOUL
D

10985404

urn:oid:2.16.840.1.113883.3.88.1
2.80.63 (Country)

postalCode

0..1

MAY

10985403

urn:oid:2.16.840.1.113883.3.88.1
2.80.2 (PostalCode)

1..*

SHALL

10985406

languageCode

1..1

SHALL

10985407

urn:oid:2.16.840.1.113883.11.20.
9.64 (PatientLanguage)

modeCode

0..1

MAY

10985409

urn:oid:2.16.840.1.113883.1.11.1
2249 (LanguageAbilityMode)

proficiencyLevelCode

0..1

SHOUL
D

10989965

urn:oid:2.16.840.1.113883.1.11.1
2199 (LanguageAbilityProficiency)

preferenceInd

0..1

SHOUL
D

10985414

providerOrganization

0..1

MAY

10985416

1..*

SHALL

10985417

0..1

SHOUL
D

109816820

name

1..*

SHALL

10985419

telecom

1..*

SHALL

10985420

@use

0..1

SHOUL
D

10987994

urn:oid:2.16.840.1.113883.11.20.
9.20 (Telecom Use (US Realm
Header))

1..*

SHALL

10985422

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

author

1..*

SHALL

10985444

time

1..1

SHALL

10985445

assignedAuthor

1..1

SHALL

10985448

id

1..*

SHALL

10985449

id

0..1

SHOUL
D

109832882

addr

languageCommunication

id
@root

addr

2.16.840.1.113883.4.6

US Realm Date and Time
(DTM.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.4

Attachment G- EHR Implementation Guide Templates

@nullFlavor

0..1

MAY

109832883

urn:oid:2.16.840.1.113883.5.100
8 (HL7NullFlavor) = UNK

@root

1..1

SHALL

109832884

2.16.840.1.113883.4.6

@extension

0..1

SHOUL
D

109832885

0..1

SHOUL
D

109816787

1..1

SHALL

109816788

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

addr

1..*

SHALL

10985452

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

telecom

1..*

SHALL

10985428

@use

0..1

SHOUL
D

10987995

0..1

SHOUL
D

10985430

1..*

SHALL

109816789

0..1

SHOUL
D

109816783

manufacturerModelName

1..1

SHALL

109816784

softwareName

1..1

SHALL

109816785

0..1

MAY

10985441

1..1

SHALL

10985442

1..*

SHALL

10985443

0..1

SHOUL
D

109816821

2.16.840.1.113883.4.6

code

0..1

MAY

109832173

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

addr

1..*

SHALL

10985460

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

telecom

1..*

SHALL

10985466

code
@code

assignedPerson
name

assignedAuthoringDevice

dataEnterer
assignedEntity
id
@root

urn:oid:2.16.840.1.113883.11.20.
9.20 (Telecom Use (US Realm
Header))

US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1.1

Attachment G- EHR Implementation Guide Templates

@use

0..1

SHOUL
D

10987996

1..1

SHALL

10985469

name

1..*

SHALL

10985470

informant

0..*

MAY

10988001

1..1

SHALL

10988002

id

1..*

SHALL

10989945

code

0..1

MAY

109832174

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

addr

1..*

SHALL

10988220

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

assignedPerson

1..1

SHALL

10988221

name

1..*

SHALL

10988222

informant

0..*

MAY

109831355

1..1

SHALL

109831356

1..1

SHALL

10985519

1..1

SHALL

10985520

1..1

SHALL

10985521

1..*

SHALL

10985522

0..1

SHOUL
D

109816822

name

1..1

SHALL

10985524

telecom

1..1

SHALL

10985525

@use

0..1

SHOUL
D

10987998

assignedPerson

assignedEntity

relatedEntity
custodian
assignedCustodian

representedCustodianOrganization
id
@root

urn:oid:2.16.840.1.113883.11.20.
9.20 (Telecom Use (US Realm
Header))

US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1.1

US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1.1

2.16.840.1.113883.4.6

urn:oid:2.16.840.1.113883.11.20.
9.20 (Telecom Use (US Realm
Header))

Attachment G- EHR Implementation Guide Templates

addr

1..1

SHALL

10985559

informationRecipient

0..*

MAY

10985565

intendedRecipient

1..1

SHALL

10985566

id

0..*

MAY

109832399

informationRecipient

0..1

MAY

10985567

1..*

SHALL

10985568

0..1

MAY

10985577

1..1

SHALL

10985578

0..1

SHOUL
D

10985579

time

1..1

SHALL

10985580

signatureCode

1..1

SHALL

10985583

1..1

SHALL

10985584

sdtc:signatureText

0..1

MAY

109830810

assignedEntity

1..1

SHALL

10985585

1..*

SHALL

10985586

0..1

MAY

109816823

2.16.840.1.113883.4.6

code

0..1

MAY

109817000

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

addr

1..*

SHALL

10985589

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

telecom

1..*

SHALL

10985595

@use

0..1

SHOUL
D

10987999

name

receivedOrganization
name
legalAuthenticator

@code

id
@root

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1.1

US Realm Date and Time
(DTM.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.4

urn:oid:2.16.840.1.113883.5.89
(Participationsignature) = S

urn:oid:2.16.840.1.113883.11.20.
9.20 (Telecom Use (US Realm

Attachment G- EHR Implementation Guide Templates

Header))
assignedPerson

1..1

SHALL

10985597

1..*

SHALL

10985598

0..*

MAY

10985607

time

1..1

SHALL

10985608

signatureCode

1..1

SHALL

10985610

1..1

SHALL

10985611

sdtc:signatureText

0..1

MAY

109830811

assignedEntity

1..1

SHALL

10985612

1..*

SHALL

10985613

0..1

SHOUL
D

109816824

0..1

MAY

109816825

0..1

MAY

109816826

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

addr

1..*

SHALL

10985616

US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.2

telecom

1..*

SHALL

10985622

@use

0..1

SHOUL
D

10988000

1..1

SHALL

10985624

name

1..*

SHALL

10985625

participant

0..*

MAY

109810003

0..1

MAY

109810004

name

authenticator

@code

id
@root
code
@code

assignedPerson

time

US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1.1

US Realm Date and Time
(DTM.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.4

urn:oid:2.16.840.1.113883.5.89
(Participationsignature) = S

2.16.840.1.113883.4.6

urn:oid:2.16.840.1.113883.11.20.
9.20 (Telecom Use (US Realm
Header))

US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.
22.5.1.1

Attachment G- EHR Implementation Guide Templates

inFulfillmentOf

0..*

MAY

10989952

order

1..1

SHALL

10989953

id

1..*

SHALL

10989954

0..*

MAY

109814835

1..1

SHALL

109814836

1..1

SHALL

109814837

1..1

SHALL

109814838

0..*

SHOUL
D

109814839

@typeCode

1..1

SHALL

109814840

functionCode

0..1

MAY

109816818

0..1

SHOUL
D

109832889

1..1

SHALL

109814841

1..*

SHALL

109814846

0..1

SHOUL
D

109814847

2.16.840.1.113883.4.6

0..1

SHOUL
D

109814842

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

0..*

MAY

109816792

1..1

SHALL

109816793

id

0..*

MAY

109816794

code

0..1

MAY

109816795

statusCode

1..1

SHALL

109816797

1..1

SHALL

109816798

0..1

MAY

10989955

1..1

SHALL

10989956

documentationOf
serviceEvent
effectiveTime
low
performer

@code
assignedEntity
id
@root
code

authorization
consent

@code
componentOf
encompassingEncounter

urn:oid:2.16.840.1.113883.1.11.1
9601 (x_ServiceEventPerformer)

urn:oid:2.16.840.1.113883.1.11.1
0267 (ParticipationFunction)

urn:oid:2.16.840.1.113883.5.6
(HL7ActClass) = completed

Attachment G- EHR Implementation Guide Templates

id

1..*

SHALL

10989959

effectiveTime

1..1

SHALL

10989958

1.1.1 Properties
1.1.1.1 realmCode
1. SHALL contain exactly one [1..1] realmCode="US" (CONF:1098-16791).
Figure 1: US Realm Header (V2) Example









Patient Chart Summary






. . .


2. SHALL contain exactly one [1..1] typeId (CONF:1098-5361).
a. This typeId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.1.3"
(CONF:1098-5250).
b. This typeId SHALL contain exactly one [1..1] @extension="POCD_HD000040"
(CONF:1098-5251).
3. SHALL contain exactly one [1..1] templateId (CONF:1098-5252) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.1"
(CONF:1098-10036).
b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32503).
4. SHALL contain exactly one [1..1] id (CONF:1098-5363).
a. This id SHALL be a globally unique identifier for the document (CONF:1098-9991).
5. SHALL contain exactly one [1..1] code (CONF:1098-5253).
a. This code SHALL specify the particular kind of document (e.g., History and
Physical, Discharge Summary, Progress Note) (CONF:1098-9992).

Attachment G- EHR Implementation Guide Templates

6. SHALL contain exactly one [1..1] title (CONF:1098-5254).
Note: The title can either be a locally defined name or the displayName corresponding to
clinicalDocument/code
7. SHALL contain exactly one [1..1] US Realm Date and Time (DTM.US.FIELDED)
(identifier: urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:1098-5256).
8. SHALL contain exactly one [1..1] confidentialityCode, which SHOULD be selected from
ValueSet HL7 BasicConfidentialityKind urn:oid:2.16.840.1.113883.1.11.16926
STATIC 2010-04-21 (CONF:1098-5259).
9. SHALL contain exactly one [1..1] languageCode, which SHALL be selected from ValueSet
Language urn:oid:2.16.840.1.113883.1.11.11526 DYNAMIC (CONF:1098-5372).
10. MAY contain zero or one [0..1] setId (CONF:1098-5261).
a. If setId is present versionNumber SHALL be present (CONF:1098-6380).
11. MAY contain zero or one [0..1] versionNumber (CONF:1098-5264).
a. If versionNumber is present setId SHALL be present (CONF:1098-6387).

1.1.1.2 recordTarget
The recordTarget records the administrative and demographic data of the patient whose health
information is described by the clinical document; each recordTarget must contain at least one
patientRole element
12. SHALL contain at least one [1..*] recordTarget (CONF:1098-5266).
a. Such recordTargets SHALL contain exactly one [1..1] patientRole (CONF:10985267).
i.

This patientRole SHALL contain at least one [1..*] id (CONF:1098-5268).

ii. This patientRole SHALL contain at least one [1..*] US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1098-5271).
iii. This patientRole SHALL contain at least one [1..*] telecom (CONF:10985280).
1. Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL
be selected from ValueSet Telecom Use (US Realm Header)
urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:10985375).
iv. This patientRole SHALL contain exactly one [1..1] patient (CONF:10985283).
1. This patient SHALL contain at least one [1..*] US Realm Person Name
(PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:10985284).
2. This patient SHALL contain exactly one [1..1]
administrativeGenderCode, which SHALL be selected from
ValueSet Administrative Gender (HL7 V3)
urn:oid:2.16.840.1.113883.1.11.1 DYNAMIC (CONF:1098-6394).
3. This patient SHALL contain exactly one [1..1] birthTime
(CONF:1098-5298).

Attachment G- EHR Implementation Guide Templates

a. SHALL be precise to year (CONF:1098-5299).
b. SHOULD be precise to day (CONF:1098-5300).
For cases where information about newborn's time of birth needs to be captured.
c. MAY be precise to the minute (CONF:1098-32418).
4. This patient SHOULD contain zero or one [0..1] maritalStatusCode,
which SHALL be selected from ValueSet Marital Status
urn:oid:2.16.840.1.113883.1.11.12212 DYNAMIC (CONF:10985303).
5. This patient MAY contain zero or one [0..1]
religiousAffiliationCode, which SHALL be selected from
ValueSet Religious Affiliation
urn:oid:2.16.840.1.113883.1.11.19185 DYNAMIC (CONF:10985317).
6. This patient SHALL contain exactly one [1..1] raceCode, which SHALL
be selected from ValueSet Race Category Excluding Nulls
urn:oid:2.16.840.1.113883.3.2074.1.1.3 DYNAMIC (CONF:10985322).
7. This patient MAY contain zero or more [0..*] sdtc:raceCode, which
SHALL be selected from ValueSet Race
urn:oid:2.16.840.1.113883.1.11.14914 DYNAMIC (CONF:10987263).
Note: The sdtc:raceCode is only used to record additional values
when the patient has indicated multiple races or additional race
detail beyond the five categories required for Meaningful Use Stage 2.
The prefix sdtc: SHALL be bound to the namespace “urn:hl7org:sdtc”. The use of the namespace provides a necessary extension
to CDA R2 for the use of the additional raceCode elements.
a. If sdtc:raceCode is present, then the patient SHALL contain
[1..1] raceCode (CONF:1098-31347).
8. This patient SHALL contain exactly one [1..1] ethnicGroupCode,
which SHALL be selected from ValueSet Ethnicity
urn:oid:2.16.840.1.114222.4.11.837 DYNAMIC (CONF:10985323).
9. This patient MAY contain zero or more [0..*] sdtc:ethnicGroupCode,
which SHALL be selected from ValueSet Detailed Ethnicity
urn:oid:2.16.840.1.114222.4.11.877 DYNAMIC (CONF:109832901).
10. This patient MAY contain zero or more [0..*] guardian (CONF:10985325).
a. The guardian, if present, SHOULD contain zero or one [0..1]
code, which SHALL be selected from ValueSet Personal And
Legal Relationship Role Type
urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC
(CONF:1098-5326).

Attachment G- EHR Implementation Guide Templates

b. The guardian, if present, SHOULD contain zero or more [0..*] US
Realm Address (AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:10985359).
c. The guardian, if present, SHOULD contain zero or more [0..*]
telecom (CONF:1098-5382).
i.

The telecom, if present, SHOULD contain zero or one
[0..1] @use, which SHALL be selected from ValueSet
Telecom Use (US Realm Header)
urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC
(CONF:1098-7993).

d. The guardian, if present, SHALL contain exactly one [1..1]
guardianPerson (CONF:1098-5385).
i.

This guardianPerson SHALL contain at least one [1..*]
US Realm Person Name (PN.US.FIELDED)
(identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1.1)
(CONF:1098-5386).

11. This patient MAY contain zero or one [0..1] birthplace (CONF:10985395).
a. The birthplace, if present, SHALL contain exactly one [1..1]
place (CONF:1098-5396).
i.

This place SHALL contain exactly one [1..1] addr
(CONF:1098-5397).

1. This addr SHOULD contain zero or one [0..1] country,
which SHALL be selected from ValueSet Country
urn:oid:2.16.840.1.113883.3.88.12.80.63
DYNAMIC (CONF:1098-5404).
2. This addr MAY contain zero or one [0..1] postalCode,
which SHALL be selected from ValueSet PostalCode
urn:oid:2.16.840.1.113883.3.88.12.80.2
DYNAMIC (CONF:1098-5403).
3. If country is US, this addr SHOULD contain zero to
one [0..1] state, which SHALL be selected from
ValueSet StateValueSet
2.16.840.1.113883.3.88.12.80.1 DYNAMIC
(CONF:1098-5402).
12. This patient SHALL contain at least one [1..*]
languageCommunication (CONF:1098-5406).
a. Such languageCommunications SHALL contain exactly one
[1..1] languageCode, which SHALL be selected from ValueSet
PatientLanguage
urn:oid:2.16.840.1.113883.11.20.9.64 DYNAMIC
(CONF:1098-5407).
b. Such languageCommunications MAY contain zero or one [0..1]
modeCode, which SHALL be selected from ValueSet

Attachment G- EHR Implementation Guide Templates

LanguageAbilityMode
urn:oid:2.16.840.1.113883.1.11.12249 DYNAMIC
(CONF:1098-5409).
c. Such languageCommunications SHOULD contain zero or one
[0..1] proficiencyLevelCode, which SHALL be selected from
ValueSet LanguageAbilityProficiency
urn:oid:2.16.840.1.113883.1.11.12199 DYNAMIC
(CONF:1098-9965).
d. Such languageCommunications SHOULD contain zero or one
[0..1] preferenceInd (CONF:1098-5414).
v. This patientRole MAY contain zero or one [0..1] providerOrganization
(CONF:1098-5416).
1. The providerOrganization, if present, SHALL contain at least one [1..*]
id (CONF:1098-5417).
a. Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider
Identifier (CONF:1098-16820).
2. The providerOrganization, if present, SHALL contain at least one [1..*]
name (CONF:1098-5419).
3. The providerOrganization, if present, SHALL contain at least one [1..*]
telecom (CONF:1098-5420).
a. Such telecoms SHOULD contain zero or one [0..1] @use, which
SHALL be selected from ValueSet Telecom Use (US Realm
Header) urn:oid:2.16.840.1.113883.11.20.9.20
DYNAMIC (CONF:1098-7994).
4. The providerOrganization, if present, SHALL contain at least one [1..*]
US Realm Address (AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1098-5422).

Attachment G- EHR Implementation Guide Templates

Figure 2: recordTarget Example






2222 Home Street
Beaverton
OR
97867
US







Eve

Betterhalf



Eve

Everywoman














2222 Home Street
Beaverton

Attachment G- EHR Implementation Guide Templates

OR
97867
US




Boris
Bo
Betterhalf






4444 Home Street
Beaverton
OR
97867
US














The DoctorsTogether Physician Group


1007 Health Drive
Portland
OR
99123
US





1.1.1.3 author
The author element represents the creator of the clinical document. The author may be a
device or a person.

Attachment G- EHR Implementation Guide Templates

13. SHALL contain at least one [1..*] author (CONF:1098-5444).
a. Such authors SHALL contain exactly one [1..1] US Realm Date and Time
(DTM.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:1098-5445).
b. Such authors SHALL contain exactly one [1..1] assignedAuthor (CONF:1098-5448).
i.

This assignedAuthor SHALL contain at least one [1..*] id (CONF:1098-5449).

If this assignedAuthor is an assignedPerson
ii. This assignedAuthor SHOULD contain zero or one [0..1] id (CONF:109832882) such that it
If id with @root="2.16.840.1.113883.4.6" National Provider Identifier is unknown then
1. MAY contain zero or one [0..1] @nullFlavor="UNK" Unknown
(CodeSystem: HL7NullFlavor
urn:oid:2.16.840.1.113883.5.1008) (CONF:1098-32883).
2. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.6"
National Provider Identifier (CONF:1098-32884).
3. SHOULD contain zero or one [0..1] @extension (CONF:1098-32885).
Only if this assignedAuthor is an assignedPerson should the assignedAuthor contain a code.
iii. This assignedAuthor SHOULD contain zero or one [0..1] code (CONF:109816787).
1. The code, if present, SHALL contain exactly one [1..1] @code, which
SHOULD be selected from ValueSet Healthcare Provider Taxonomy
(HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC
(CONF:1098-16788).
iv. This assignedAuthor SHALL contain at least one [1..*] US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1098-5452).
v. This assignedAuthor SHALL contain at least one [1..*] telecom (CONF:10985428).
1. Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL
be selected from ValueSet Telecom Use (US Realm Header)
urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:10987995).
vi. This assignedAuthor SHOULD contain zero or one [0..1] assignedPerson
(CONF:1098-5430).
1. The assignedPerson, if present, SHALL contain at least one [1..*] US
Realm Person Name (PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:109816789).
vii. This assignedAuthor SHOULD contain zero or one [0..1]
assignedAuthoringDevice (CONF:1098-16783).
1. The assignedAuthoringDevice, if present, SHALL contain exactly one
[1..1] manufacturerModelName (CONF:1098-16784).

Attachment G- EHR Implementation Guide Templates

2. The assignedAuthoringDevice, if present, SHALL contain exactly one
[1..1] softwareName (CONF:1098-16785).
viii. There SHALL be exactly one assignedAuthor/assignedPerson or exactly one
assignedAuthor/assignedAuthoringDevice (CONF:1098-16790).
Figure 3: author Example



1.1.1.4 dataEnterer
The dataEnterer element represents the person who transferred the content, written or
dictated, into the clinical document. To clarify, an author provides the content found within the
header or body of a document, subject to their own interpretation; a dataEnterer adds an
author's information to the electronic system.
14. MAY contain zero or one [0..1] dataEnterer (CONF:1098-5441).
a. The dataEnterer, if present, SHALL contain exactly one [1..1] assignedEntity
(CONF:1098-5442).
i.

This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-5443).
1. Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider Identifier
(CONF:1098-16821).

ii. This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be
selected from ValueSet Healthcare Provider Taxonomy (HIPAA)
urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1098-32173).

Attachment G- EHR Implementation Guide Templates

iii. This assignedEntity SHALL contain at least one [1..*] US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1098-5460).
iv. This assignedEntity SHALL contain at least one [1..*] telecom (CONF:10985466).
1. Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL
be selected from ValueSet Telecom Use (US Realm Header)
urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:10987996).
v. This assignedEntity SHALL contain exactly one [1..1] assignedPerson
(CONF:1098-5469).
1. This assignedPerson SHALL contain at least one [1..*] US Realm
Person Name (PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:10985470).
Figure 4: dateEnterer Example




1007 Healthcare Drive
Portland
OR
99123
US




Ellen
Enter





1.1.1.5 informant
The informant element describes an information source for any content within the clinical
document. This informant is constrained for use when the source of information is an assigned
health care provider for the patient.
15. MAY contain zero or more [0..*] informant (CONF:1098-8001) such that it
a. SHALL contain exactly one [1..1] assignedEntity (CONF:1098-8002).
i.

This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-9945).
1. If assignedEntity/id is a provider then this id, SHOULD include zero
or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National
Provider Identifier (CONF:1098-9946).

Attachment G- EHR Implementation Guide Templates

ii. This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be
selected from ValueSet Healthcare Provider Taxonomy (HIPAA)
urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1098-32174).
iii. This assignedEntity SHALL contain at least one [1..*] US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1098-8220).
iv. This assignedEntity SHALL contain exactly one [1..1] assignedPerson
(CONF:1098-8221).
1. This assignedPerson SHALL contain at least one [1..*] US Realm
Person Name (PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:10988222).
Figure 5: Assigned Health Care Provider informant Example




1007 Healthcare Drive
Portland
OR
99123
US




Harold
Hippocrates
M.D.



The DoctorsApart Physician Group




1.1.1.6 informant
The informant element describes an information source (who is not a provider) for any content
within the clinical document. This informant would be used when the source of information
has a personal relationship with the patient or is the patient.
16. MAY contain zero or more [0..*] informant (CONF:1098-31355) such that it
a. SHALL contain exactly one [1..1] relatedEntity (CONF:1098-31356).

Attachment G- EHR Implementation Guide Templates

Figure 6: Personal Relation informant Example






Boris
Bo
Betterhalf





1.1.1.7 custodian
The custodian element represents the organization that is in charge of maintaining and is
entrusted with the care of the document.
There is only one custodian per CDA document. Allowing that a CDA document may not
represent the original form of the authenticated document, the custodian represents the
steward of the original source document. The custodian may be the document originator, a
health information exchange, or other responsible party.
17. SHALL contain exactly one [1..1] custodian (CONF:1098-5519).
a. This custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:10985520).
i.

This assignedCustodian SHALL contain exactly one [1..1]
representedCustodianOrganization (CONF:1098-5521).
1. This representedCustodianOrganization SHALL contain at least one
[1..*] id (CONF:1098-5522).
a. Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider
Identifier (CONF:1098-16822).
2. This representedCustodianOrganization SHALL contain exactly one
[1..1] name (CONF:1098-5524).
3. This representedCustodianOrganization SHALL contain exactly one
[1..1] telecom (CONF:1098-5525).
a. This telecom SHOULD contain zero or one [0..1] @use, which
SHALL be selected from ValueSet Telecom Use (US Realm
Header) urn:oid:2.16.840.1.113883.11.20.9.20
DYNAMIC (CONF:1098-7998).
4. This representedCustodianOrganization SHALL contain exactly one
[1..1] US Realm Address (AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1098-5559).

Attachment G- EHR Implementation Guide Templates

Figure 7: custodian Example




Good Health HIE


1009 Healthcare Drive 
Portland
OR
99123
US





1.1.1.8 informationRecipient
The informationRecipient element records the intended recipient of the information at the time
the document was created. In cases where the intended recipient of the document is the
patient's health chart, set the receivedOrganization to the scoping organization for that chart.
18. MAY contain zero or more [0..*] informationRecipient (CONF:1098-5565).
a. The informationRecipient, if present, SHALL contain exactly one [1..1]
intendedRecipient (CONF:1098-5566).
i.

This intendedRecipient MAY contain zero or more [0..*] id (CONF:109832399).

ii. This intendedRecipient MAY contain zero or one [0..1]
informationRecipient (CONF:1098-5567).
1. The informationRecipient, if present, SHALL contain at least one [1..*]
US Realm Person Name (PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:10985568).
iii. This intendedRecipient MAY contain zero or one [0..1]
receivedOrganization (CONF:1098-5577).
1. The receivedOrganization, if present, SHALL contain exactly one [1..1]
name (CONF:1098-5578).

Attachment G- EHR Implementation Guide Templates

Figure 8: informationRecipient Example




Sara
Specialize
M.D.



The DoctorsApart Physician Group




1.1.1.9 legalAuthenticator
The legalAuthenticator identifies the single person legally responsible for the document and
must be present if the document has been legally authenticated. A clinical document that does
not contain this element has not been legally authenticated.
The act of legal authentication requires a certain privilege be granted to the legal authenticator
depending upon local policy. Based on local practice, clinical documents may be released
before legal authentication.
All clinical documents have the potential for legal authentication, given the appropriate
credentials.
Local policies MAY choose to delegate the function of legal authentication to a device or system
that generates the clinical document. In these cases, the legal authenticator is a person
accepting responsibility for the document, not the generating device or system.
Note that the legal authenticator, if present, must be a person.
19. SHOULD contain zero or one [0..1] legalAuthenticator (CONF:1098-5579).
a. The legalAuthenticator, if present, SHALL contain exactly one [1..1] US Realm Date
and Time (DTM.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:1098-5580).
b. The legalAuthenticator, if present, SHALL contain exactly one [1..1] signatureCode
(CONF:1098-5583).
i.

This signatureCode SHALL contain exactly one [1..1] @code="S"
(CodeSystem: Participationsignature
urn:oid:2.16.840.1.113883.5.89 STATIC) (CONF:1098-5584).

1.1.1.10 sdtc:signatureText
The sdtc:signatureText extension provides a location in CDA for a textual or multimedia
depiction of the signature by which the participant endorses and accepts responsibility for his
or her participation in the Act as specified in the Participation.typeCode. Details of what goes in
the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013.

Attachment G- EHR Implementation Guide Templates

c. The legalAuthenticator, if present, MAY contain zero or one [0..1]
sdtc:signatureText (CONF:1098-30810).
Note: The signature can be represented either inline or by reference according to the
ED data type. Typical cases for CDA are:
1) Electronic signature: this attribute can represent virtually any electronic
signature scheme.
2) Digital signature: this attribute can represent digital signatures by reference to a
signature data block that is constructed in accordance to a digital signature
standard, such as XML-DSIG, PKCS#7, PGP, etc.

Figure 9: Digital signature Example
omSJUEdmde9j44zmMiromSJUEdmde9j44zmMirdMDSsWdIJdksIJR3373jeu83
6edjzMMIjdMDSsWdIJdksIJR3373jeu83MNYD83jmMdomSJUEdmde9j44zmMir
... MNYD83jmMdomSJUEdmde9j44zmMir6edjzMMIjdMDSsWdIJdksIJR3373jeu83
4zmMir6edjzMMIjdMDSsWdIJdksIJR3373jeu83==

d. The legalAuthenticator, if present, SHALL contain exactly one [1..1] assignedEntity
(CONF:1098-5585).
i.

This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-5586).
1. Such ids MAY contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider Identifier
(CONF:1098-16823).

ii. This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be
selected from ValueSet Healthcare Provider Taxonomy (HIPAA)
urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1098-17000).
iii. This assignedEntity SHALL contain at least one [1..*] US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1098-5589).
iv. This assignedEntity SHALL contain at least one [1..*] telecom (CONF:10985595).
1. Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL
be selected from ValueSet Telecom Use (US Realm Header)
urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:10987999).
v. This assignedEntity SHALL contain exactly one [1..1] assignedPerson
(CONF:1098-5597).
1. This assignedPerson SHALL contain at least one [1..*] US Realm
Person Name (PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:10985598).

Attachment G- EHR Implementation Guide Templates

Figure 10: legalAuthenticator Example



1.1.1.11 authenticator
The authenticator identifies a participant or participants who attest to the accuracy of the
information in the document.
20. MAY contain zero or more [0..*] authenticator (CONF:1098-5607) such that it
a. SHALL contain exactly one [1..1] US Realm Date and Time (DTM.US.FIELDED)
(identifier: urn:oid:2.16.840.1.113883.10.20.22.5.4) (CONF:1098-5608).
b. SHALL contain exactly one [1..1] signatureCode (CONF:1098-5610).
i.

This signatureCode SHALL contain exactly one [1..1] @code="S"
(CodeSystem: Participationsignature
urn:oid:2.16.840.1.113883.5.89 STATIC) (CONF:1098-5611).

The sdtc:signatureText extension provides a location in CDA for a textual or multimedia
depiction of the signature by which the participant endorses and accepts responsibility for his
or her participation in the Act as specified in the Participation.typeCode. Details of what goes in
the field are described in the HL7 CDA Digital Signature Standard balloted in Fall of 2013.
c. MAY contain zero or one [0..1] sdtc:signatureText (CONF:1098-30811).
Note: The signature can be represented either inline or by reference according to the
ED data type. Typical cases for CDA are:
1) Electronic signature: this attribute can represent virtually any electronic
signature scheme.
2) Digital signature: this attribute can represent digital signatures by reference to a

Attachment G- EHR Implementation Guide Templates

signature data block that is constructed in accordance to a digital signature
standard, such as XML-DSIG, PKCS#7, PGP, etc.
d. SHALL contain exactly one [1..1] assignedEntity (CONF:1098-5612).
i.

This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-5613).
1. Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider Identifier
(CONF:1098-16824).

ii. This assignedEntity MAY contain zero or one [0..1] code (CONF:1098-16825).
1. The code, if present, MAY contain zero or one [0..1] @code, which
SHOULD be selected from ValueSet Healthcare Provider Taxonomy
(HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 STATIC
(CONF:1098-16826).
iii. This assignedEntity SHALL contain at least one [1..*] US Realm Address
(AD.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1098-5616).
iv. This assignedEntity SHALL contain at least one [1..*] telecom (CONF:10985622).
1. Such telecoms SHOULD contain zero or one [0..1] @use, which SHALL
be selected from ValueSet Telecom Use (US Realm Header)
urn:oid:2.16.840.1.113883.11.20.9.20 DYNAMIC (CONF:10988000).
v. This assignedEntity SHALL contain exactly one [1..1] assignedPerson
(CONF:1098-5624).
1. This assignedPerson SHALL contain at least one [1..*] US Realm
Person Name (PN.US.FIELDED) (identifier:
urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:10985625).

Attachment G- EHR Implementation Guide Templates

Figure 11: authenticator Example



1.1.1.12 participant
The participant element identifies supporting entities, including parents, relatives, caregivers,
insurance policyholders, guarantors, and others related in some way to the patient.
A supporting person or organization is an individual or an organization with a relationship to
the patient. A supporting person who is playing multiple roles would be recorded in multiple
participants (e.g., emergency contact and next-of-kin).
21. MAY contain zero or more [0..*] participant (CONF:1098-10003) such that it
a. MAY contain zero or one [0..1] time (CONF:1098-10004).
b. SHALL contain associatedEntity/associatedPerson AND/OR
associatedEntity/scopingOrganization (CONF:1098-10006).
c. When participant/@typeCode is IND, associatedEntity/@classCode SHOULD be
selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC
2011-09-30 (CONF:1098-10007).

Attachment G- EHR Implementation Guide Templates

Figure 12: Supporting Person participant Example





2222 Home Street
Beaverton
OR
97867
US




Boris
Bo
Betterhalf









2222 Home Street
Beaverton
OR
97867
US




Boris
Bo
Betterhalf





1.1.1.13 inFulfillmentOf
The inFulfillmentOf element represents orders that are fulfilled by this document such as a
radiologists’ report of an x-ray.
22. MAY contain zero or more [0..*] inFulfillmentOf (CONF:1098-9952).
a. The inFulfillmentOf, if present, SHALL contain exactly one [1..1] order (CONF:10989953).
i.

This order SHALL contain at least one [1..*] id (CONF:1098-9954).

Attachment G- EHR Implementation Guide Templates

Figure 13: inFulfillmentOf Example







1.1.1.14 documentationOf
23. MAY contain zero or more [0..*] documentationOf (CONF:1098-14835).
A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac
stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other
longitudinal providers, are recorded within the serviceEvent. If the document is about a single
encounter, the providers associated can be recorded in the
componentOf/encompassingEncounter template.
a. The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent
(CONF:1098-14836).
i.

This serviceEvent SHALL contain exactly one [1..1] effectiveTime
(CONF:1098-14837).
1. This effectiveTime SHALL contain exactly one [1..1] low (CONF:109814838).

1.1.1.15 performer
The performer participant represents clinicians who actually and principally carry out the
serviceEvent. In a transfer of care this represents the healthcare providers involved in the
current or pertinent historical care of the patient. Preferably, the patient’s key healthcare care
team members would be listed, particularly their primary physician and any active consulting
physicians, therapists, and counselors.
ii. This serviceEvent SHOULD contain zero or more [0..*] performer
(CONF:1098-14839).
1. The performer, if present, SHALL contain exactly one [1..1]
@typeCode, which SHALL be selected from ValueSet
x_ServiceEventPerformer
urn:oid:2.16.840.1.113883.1.11.19601 STATIC 2014-09-01
(CONF:1098-14840).
2. The performer, if present, MAY contain zero or one [0..1]
functionCode (CONF:1098-16818).
a. The functionCode, if present, SHOULD contain zero or one [0..1]
@code, which SHOULD be selected from ValueSet
ParticipationFunction
urn:oid:2.16.840.1.113883.1.11.10267 STATIC 2014-0901 (CONF:1098-32889).

Attachment G- EHR Implementation Guide Templates

3. The performer, if present, SHALL contain exactly one [1..1]
assignedEntity (CONF:1098-14841).
a. This assignedEntity SHALL contain at least one [1..*] id
(CONF:1098-14846).
i.

Such ids SHOULD contain zero or one [0..1]
@root="2.16.840.1.113883.4.6" National Provider
Identifier (CONF:1098-14847).

b. This assignedEntity SHOULD contain zero or one [0..1] code,
which SHOULD be selected from ValueSet Healthcare
Provider Taxonomy (HIPAA)
urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC
(CONF:1098-14842).

Attachment G- EHR Implementation Guide Templates

Figure 14: performer Example


Primary Care Provider





1004 Healthcare Drive 
Portland
OR
99123
US




Patricia
Patty
Primary
M.D.




The DoctorsTogether Physician Group


1004 Health Drive
Portland
OR
99123
US





Attachment G- EHR Implementation Guide Templates

Figure 15: documentationOf Example











Primary Care Provider





1004 Healthcare Drive 
Portland
OR
99123
US




Patricia
Patty
Primary
M.D.




The DoctorsTogether Physician Group


1004 Health Drive
Portland
OR
99123
US







Attachment G- EHR Implementation Guide Templates

1.1.1.16 authorization
The authorization element represents information about the patient’s consent.
The type of consent is conveyed in consent/code. Consents in the header have been finalized
(consent/statusCode must equal Completed) and should be on file. This specification does not
address how 'Privacy Consent' is represented, but does not preclude the inclusion of ‘Privacy
Consent’.
The authorization consent is used for referring to consents that are documented elsewhere in
the EHR or medical record for a health condition and/or treatment that is described in the
CDA document.
24. MAY contain zero or more [0..*] authorization (CONF:1098-16792) such that it
a. SHALL contain exactly one [1..1] consent (CONF:1098-16793).
i.

This consent MAY contain zero or more [0..*] id (CONF:1098-16794).

ii. This consent MAY contain zero or one [0..1] code (CONF:1098-16795).
Note: The type of consent (e.g., a consent to perform the related serviceEvent)
is conveyed in consent/code.
iii. This consent SHALL contain exactly one [1..1] statusCode (CONF:109816797).
1. This statusCode SHALL contain exactly one [1..1]
@code="completed" Completed (CodeSystem: HL7ActClass
urn:oid:2.16.840.1.113883.5.6) (CONF:1098-16798).
Figure 16: authorization Example








1.1.1.17 componentOf
The encompassing encounter represents the setting of the clinical encounter during which the
document act(s) or ServiceEvent(s) occurred.
In order to represent providers associated with a specific encounter, they are recorded within
the encompassingEncounter as participants.
In a CCD, the encompassingEncounter may be used when documenting a specific encounter
and its participants. All relevant encounters in a CCD may be listed in the encounters section.
25. MAY contain zero or one [0..1] componentOf (CONF:1098-9955).

Attachment G- EHR Implementation Guide Templates

a. The componentOf, if present, SHALL contain exactly one [1..1]
encompassingEncounter (CONF:1098-9956).
i.

This encompassingEncounter SHALL contain at least one [1..*] id
(CONF:1098-9959).

ii. This encompassingEncounter SHALL contain exactly one [1..1]
effectiveTime (CONF:1098-9958).
Table 3: HL7 BasicConfidentialityKind
Value Set: HL7 BasicConfidentialityKind urn:oid:2.16.840.1.113883.1.11.16926
A value set of HL7 Code indication the level of confidentiality an act.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

N

ConfidentialityCode

urn:oid:2.16.840.1.11388
3.5.25

normal

R

ConfidentialityCode

urn:oid:2.16.840.1.11388
3.5.25

restricted

V

ConfidentialityCode

urn:oid:2.16.840.1.11388
3.5.25

very restricted

Attachment G- EHR Implementation Guide Templates

Table 4: Language
Value Set: Language urn:oid:2.16.840.1.113883.1.11.11526
A value set of codes defined by Internet RFC 4646 (replacing RFC 3066). Please see ISO 639 language code set
maintained by Library of Congress for enumeration of language codes.
Value Set Source: http://www.loc.gov/standards/iso639-2/php/code_list.php
Code

Code System

Code System OID

Print Name

aa

Language

urn:oid:2.16.840.1.11388
3.6.121

Afar

ab

Language

urn:oid:2.16.840.1.11388
3.6.121

Abkhazian

ace

Language

urn:oid:2.16.840.1.11388
3.6.121

Achinese

ach

Language

urn:oid:2.16.840.1.11388
3.6.121

Acoli

ada

Language

urn:oid:2.16.840.1.11388
3.6.121

Adangme

ady

Language

urn:oid:2.16.840.1.11388
3.6.121

Adyghe; Adygei

ae

Language

urn:oid:2.16.840.1.11388
3.6.121

Avestan

af

Language

urn:oid:2.16.840.1.11388
3.6.121

Afrikaans

afa

Language

urn:oid:2.16.840.1.11388
3.6.121

Afro-Asiatic (Other)

afh

Language

urn:oid:2.16.840.1.11388
3.6.121

Afrihili

...

Table 5: Telecom Use (US Realm Header)
Value Set: Telecom Use (US Realm Header) urn:oid:2.16.840.1.113883.11.20.9.20
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

HP

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

Primary home

HV

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

Vacation home

WP

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

Work place

MC

AddressUse

urn:oid:2.16.840.1.11388
3.5.1119

Mobile contact

Attachment G- EHR Implementation Guide Templates

Table 6: Administrative Gender (HL7 V3)
Value Set: Administrative Gender (HL7 V3) urn:oid:2.16.840.1.113883.1.11.1
Administrative Gender based upon HL7 V3 vocabulary. This value set contains only male, female and
undifferentiated concepts.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

F

AdministrativeGender

urn:oid:2.16.840.1.11388
3.5.1

Female

M

AdministrativeGender

urn:oid:2.16.840.1.11388
3.5.1

Male

UN

AdministrativeGender

urn:oid:2.16.840.1.11388
3.5.1

Undifferentiated

Table 7: Marital Status
Value Set: Marital Status urn:oid:2.16.840.1.113883.1.11.12212
Marital Status is the domestic partnership status of a person.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

A

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Annulled

D

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Divorced

T

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Domestic partner

I

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Interlocutory

L

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Legally Separated

M

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Married

S

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Never Married

P

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Polygamous

W

MaritalStatus

urn:oid:2.16.840.1.11388
3.5.2

Widowed

Attachment G- EHR Implementation Guide Templates

Table 8: Religious Affiliation
Value Set: Religious Affiliation urn:oid:2.16.840.1.113883.1.11.19185
A value set of codes that reflect spiritual faith affiliation.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

1001

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Adventist

1002

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

African Religions

1003

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Afro-Caribbean Religions

1004

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Agnosticism

1005

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Anglican

1006

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Animism

1007

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Atheism

1008

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Babi & Baha'I faiths

1009

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Baptist

1010

ReligiousAffiliation

urn:oid:2.16.840.1.11388
3.5.1076

Bon

...

Table 9: Race Category Excluding Nulls
Value Set: Race Category Excluding Nulls urn:oid:2.16.840.1.113883.3.2074.1.1.3
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

1002-5

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

American Indian or
Alaska Native

2028-9

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Asian

2054-5

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Black or African
American

2076-8

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Native Hawaiian or Other
Pacific Islander

2106-3

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

White

Attachment G- EHR Implementation Guide Templates

Table 10: Ethnicity
Value Set: Ethnicity urn:oid:2.16.840.1.114222.4.11.837
Code System: Race & Ethnicity - CDC 2.16.840.1.113883.6.238
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

2135-2

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Hispanic or Latino

2186-5

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Not Hispanic or Latino

Table 11: Personal And Legal Relationship Role Type
Value Set: Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1
A personal or legal relationship records the role of a person in relation to another person, or a person to himself
or herself. This value set is to be used when recording relationships based on personal or family ties or through
legal assignment of responsibility.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.113883.11.20.12.1
Code

Code System

Code System OID

Print Name

SELF

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

self

MTH

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

mother

FTH

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

father

DAU

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

natural daughter

SON

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

natural son

DAUINLAW

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

daughter in-law

SONINLAW

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

son in-law

GUARD

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

guardian

HPOWATT

RoleCode

urn:oid:2.16.840.1.11388
3.5.111

healthcare power of
attorney

...

Attachment G- EHR Implementation Guide Templates

Table 12: Country
Value Set: Country urn:oid:2.16.840.1.113883.3.88.12.80.63
This identifies the codes for the representation of names of countries, territories and areas of geographical
interest.
Value Set Source: http://www.iso.org/iso/country_codes/iso_3166_code_lists.htm
Code

Code System

Code System OID

Print Name

AW

Country

urn:oid:2.16.840.1.11388
3.3.88.12.80.63

Aruba

IL

Country

urn:oid:2.16.840.1.11388
3.3.88.12.80.63

Israel

...

Table 13: PostalCode
Value Set: PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2
A value set of postal (ZIP) Code of an address in the United States
Value Set Source: http://ushik.ahrq.gov/ViewItemDetails?system=mdr&itemKey=86671000
Code

Code System

Code System OID

Print Name

19009

USPostalCodes

urn:oid:2.16.840.1.11388
3.6.231

Bryn Athyn

92869-1736

USPostalCodes

urn:oid:2.16.840.1.11388
3.6.231

Orange, CA

32830-8413

USPostalCodes

urn:oid:2.16.840.1.11388
3.6.231

Lake Buena Vista, FL

...

Attachment G- EHR Implementation Guide Templates

Table 14: PatientLanguage
Value Set: PatientLanguage urn:oid:2.16.840.1.113883.11.20.9.64
This value set contains codes for the representation of language names as defined by the Library of Congress,
the ISO 639-2 registration authority. This value set contains a subset of the ISO 639-2 alpha-3 code set, limited
to those that have a corresponding ISO 639-1 alpha-2 code as required for representing a patient's language
under Meaningful Use Stage 2.
Value Set Source: http://www.loc.gov/standards/iso639-2/php/code_list.php
Code

Code System

Code System OID

Print Name

aar

Language

urn:oid:2.16.840.1.11388
3.6.121

Afar

abk

Language

urn:oid:2.16.840.1.11388
3.6.121

Abkhazian

afr

Language

urn:oid:2.16.840.1.11388
3.6.121

Afrikaans

aka

Language

urn:oid:2.16.840.1.11388
3.6.121

Akan

sqi

Language

urn:oid:2.16.840.1.11388
3.6.121

Albanian

amh

Language

urn:oid:2.16.840.1.11388
3.6.121

Amharic

ara

Language

urn:oid:2.16.840.1.11388
3.6.121

Arabic

arg

Language

urn:oid:2.16.840.1.11388
3.6.121

Aragonese

hye

Language

urn:oid:2.16.840.1.11388
3.6.121

Armenian

asm

Language

urn:oid:2.16.840.1.11388
3.6.121

Assamese

...

Attachment G- EHR Implementation Guide Templates

Table 15: LanguageAbilityMode
Value Set: LanguageAbilityMode urn:oid:2.16.840.1.113883.1.11.12249
This identifies the language ability of the individual. A value representing the method of expression of the
language.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

ESGN

LanguageAbilityMode

urn:oid:2.16.840.1.11388
3.5.60

Expressed signed

ESP

LanguageAbilityMode

urn:oid:2.16.840.1.11388
3.5.60

Expressed spoken

EWR

LanguageAbilityMode

urn:oid:2.16.840.1.11388
3.5.60

Expressed written

RSGN

LanguageAbilityMode

urn:oid:2.16.840.1.11388
3.5.60

Received signed

RSP

LanguageAbilityMode

urn:oid:2.16.840.1.11388
3.5.60

Received spoken

RWR

LanguageAbilityMode

urn:oid:2.16.840.1.11388
3.5.60

Received written

Table 16: LanguageAbilityProficiency
Value Set: LanguageAbilityProficiency urn:oid:2.16.840.1.113883.1.11.12199
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

E

LanguageAbilityProficienc
y

urn:oid:2.16.840.1.11388
3.5.61

Excellent

F

LanguageAbilityProficienc
y

urn:oid:2.16.840.1.11388
3.5.61

Fair

G

LanguageAbilityProficienc
y

urn:oid:2.16.840.1.11388
3.5.61

Good

P

LanguageAbilityProficienc
y

urn:oid:2.16.840.1.11388
3.5.61

Poor

Attachment G- EHR Implementation Guide Templates

Table 17: Race
Value Set: Race urn:oid:2.16.840.1.113883.1.11.14914
Concepts in the race value set include the 5 minimum categories for race specified by OMB along with a more
detailed set of race categories used by the Bureau of Census.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

1002-5

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

American Indian or
Alaska Native

2028-9

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Asian

2054-5

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Black or African
American

2076-8

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Native Hawaiian or Other
Pacific Islander

2106-3

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

White

1006-6

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Abenaki

1579-2

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Absentee Shawnee

1490-2

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Acoma

2126-1

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Afghanistani

1740-0

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Ahtna

...

Attachment G- EHR Implementation Guide Templates

Table 18: Healthcare Provider Taxonomy (HIPAA)
Value Set: Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066
The Health Care Provider Taxonomy value set is a collection of unique alphanumeric codes, ten characters in
length. The code set is structured into three distinct Levels including Provider Type, Classification, and Area of
Specialization. The Health Care Provider Taxonomy code set allows a single provider (individual, group, or
institution) to identify their specialty category. Providers may have one or more than one value associated to
them. When determining what value or values to associate with a provider, the user needs to review the
requirements of the trading partner with which the value(s) are being used.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.1066
Code

Code System

Code System OID

Print Name

171100000X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Acupuncturist

363LA2100X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Nurse Practitioner - Acute
Care

364SA2100X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Clinical Nurse Specialist Acute Care

101YA0400X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Counselor - Addiction
(Substance Use Disorder)

103TA0400X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Psychologist - Addiction
(Substance Use Disorder)

163WA0400X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Registered Nurse Addiction (Substance Use
Disorder)

207LA0401X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Anesthesiology Addiction Medicine

207QA0401X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Family Medicine Addiction Medicine

207RA0401X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Internal Medicine Addiction Medicine

2084A0401X

Healthcare Provider
Taxonomy (HIPAA)

urn:oid:2.16.840.1.11388
3.6.101

Psychiatry & Neurology Addiction Medicine

...

Attachment G- EHR Implementation Guide Templates

Table 19: INDRoleclassCodes
Value Set: INDRoleclassCodes urn:oid:2.16.840.1.113883.11.20.9.33
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

PRS

RoleClass

urn:oid:2.16.840.1.11388
3.5.110

personal relationship

NOK

RoleClass

urn:oid:2.16.840.1.11388
3.5.110

next of kin

CAREGIVER

RoleClass

urn:oid:2.16.840.1.11388
3.5.110

caregiver

AGNT

RoleClass

urn:oid:2.16.840.1.11388
3.5.110

agent

GUAR

RoleClass

urn:oid:2.16.840.1.11388
3.5.110

guarantor

ECON

RoleClass

urn:oid:2.16.840.1.11388
3.5.110

emergency contact

Table 20: x_ServiceEventPerformer
Value Set: x_ServiceEventPerformer urn:oid:2.16.840.1.113883.1.11.19601
Value Set Source:

http://www.hl7.org/documentcenter/public/standards/vocabulary/vocabulary_tables/in
frastructure/vocabulary/vocabulary.html
Code

Code System

Code System OID

Print Name

PRF

HL7ParticipationType

urn:oid:2.16.840.1.11388
3.5.90

performer

SPRF

HL7ParticipationType

urn:oid:2.16.840.1.11388
3.5.90

secondary performer

PPRF

HL7ParticipationType

urn:oid:2.16.840.1.11388
3.5.90

primary performer

Table 21: ParticipationFunction
Value Set: ParticipationFunction urn:oid:2.16.840.1.113883.1.11.10267
This HL7-defined value set can be used to specify the exact function an actor had in a service in all necessary
detail.
Value Set Source: https://vsac.nlm.nih.gov/
Code

Code System

Code System OID

Print Name

SNRS

participationFunction

urn:oid:2.16.840.1.11388
3.5.88

Scrub nurse

participationFunction

urn:oid:2.16.840.1.11388
3.5.88

Second assistant surgeon

SASST
...

Attachment G- EHR Implementation Guide Templates

Table 22: Detailed Ethnicity
Value Set: Detailed Ethnicity urn:oid:2.16.840.1.114222.4.11.877
List of detailed ethnicity codes reported on a limited basis
Value Set Source: http://phinvads.cdc.gov/vads/ViewValueSet.action?id=34D34BBC-617F-

DD11-B38D-00188B398520#
Code

Code System

Code System OID

Print Name

2138-6

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Andalusian

2166-7

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Argentinean

2139-4

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Asturian

2142-8

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Belearic Islander

2167-5

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Bolivian

2163-4

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Canal Zone

2145-1

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Canarian

2140-2

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Castillian

2141-0

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Catalonian

2155-0

Race & Ethnicity - CDC

urn:oid:2.16.840.1.11388
3.6.238

Central American

...

1.1.2 National Health Care Surveys (V2)
[ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.1.1:201504-01 (open)]
Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US
Realm
This document-level template describes constraints that apply to three National Health Care
Surveys conducted by the Center for Disease Control and Prevention (CDC) National Center for
Health Statistics (NCHS): the National Ambulatory Medical Care Survey (NAMCS), the National
Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Hospital Care Survey
(NHCS) These surveys collect data from physicians, ambulatory care centers, and hospitals
about visits to inpatient (IP), outpatient (OP), and emergency department (ED) settings. The
data collected is analyzed to produce nationally representative statistics to answer key
questions about health care utilization, quality, and disparities that are of interest to public
health professionals, researchers, and health care policy makers. Data captured include
information on patient demographics, symptoms, diagnoses, medications, therapeutic and
diagnostic procedures, patient management, and planned future treatments. Given the

Attachment G- EHR Implementation Guide Templates

similarities of data collected across the surveys, the structured documents specified in this
guide are organized by setting of visit rather than by survey. This template is applicable for all
three surveys (NAMCS, NHAMCS, and NHCS) and all care settings (ED, IP, and OP).

Attachment G- EHR Implementation Guide Templates

Table 23: National Health Care Surveys (V2) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

ClinicalDocument (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.1.1:2015-04-01)
templateId

1..1

SHALL

1184-1

@root

1..1

SHALL

1184-2

2.16.840.1.113883.10.20.34.1.1

@extension

1..1

SHALL

1184877

2015-04-01

1..1

SHALL

1184-3

@code

1..1

SHALL

1184-4

75619-7

@codeSystem

1..1

SHALL

1184-5

2.16.840.1.113883.6.1

recordTarget

1..*

SHALL

1184-6

patientRole

1..1

SHALL

1184-7

id

0..1

SHOUL
D

11841164

id

0..1

SHOUL
D

11841162

@root

1..1

SHALL

11841165

@extension

1..1

SHOUL
D

11841166

0..1

SHOUL
D

11841163

@root

1..1

SHALL

11841167

@extension

1..1

SHOUL
D

11841168

1..1

SHALL

118411

1..1

SHALL

118412

@nullFlavor

0..1

MAY

1184643

@code

0..1

SHOUL
D

1184644

birthTime

1..1

SHALL

118413

0..*

MAY

118420

serviceEvent

1..1

SHALL

118421

performer

0..*

SHOUL
D

118422

1..1

SHALL

118453

code

id

patient
administrativeGenderCode

documentationOf

assignedEntity

2.16.840.1.113883.4.572

2.16.840.1.113883.4.1

OTH

Attachment G- EHR Implementation Guide Templates

code

1..1

SHALL

118456

0..1

MAY

118417

1..1

SHALL

118418

id

0..1

SHOUL
D

1184361

effectiveTime

1..1

SHALL

118423

low

1..1

SHALL

1184198

high

1..1

SHALL

11841169

1..1

SHALL

118424

1..1

SHALL

118425

componentOf
encompassingEncounter

component
structuredBody

urn:oid:2.16.840.1.114222.4.11.1
066 (Healthcare Provider
Taxonomy (HIPAA))

1.1.3 Properties
1. Conforms to US Realm Header (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.1.1:2014-06-09).

1.1.3.1 templateId
2. SHALL contain exactly one [1..1] templateId (CONF:1184-1) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.1.1"
(CONF:1184-2).
b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-877).
Figure 17: National Health Care Surveys (V2) Example







...


3. SHALL contain exactly one [1..1] code (CONF:1184-3).
a. This code SHALL contain exactly one [1..1] @code="75619-7" National healthcare
survey panel NAMCS (CONF:1184-4).

Attachment G- EHR Implementation Guide Templates

b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CONF:1184-5).

1.1.3.2 recordTarget
4. SHALL contain at least one [1..*] recordTarget (CONF:1184-6).
a. Such recordTargets SHALL contain exactly one [1..1] patientRole (CONF:1184-7).
i.

This patientRole SHOULD contain zero or one [0..1] id (CONF:1184-1164).
Note: Patient's Medical Record Number

ii. This patientRole SHOULD contain zero or one [0..1] id (CONF:1184-1162)
such that it
1. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.4.572" Medicare HIC number
(CONF:1184-1165).
2. SHOULD contain exactly one [1..1] @extension (CONF:1184-1166).
Note: Patient's Medicare Number
iii. This patientRole SHOULD contain zero or one [0..1] id (CONF:1184-1163)
such that it
1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.1"
SSN (CONF:1184-1167).
2. SHOULD contain exactly one [1..1] @extension (CONF:1184-1168).
Note: Patient's SSN
iv. This patientRole SHALL contain exactly one [1..1] patient (CONF:1184-11).
Use only M (male) or F (female) for administrativeGenderCode. UN (Undifferentiated) is not
allowed, in this case use @nullFlavor="OTH".
1. This patient SHALL contain exactly one [1..1]
administrativeGenderCode (CONF:1184-12).
Note: Form Element: Sex
a. This administrativeGenderCode MAY contain zero or one [0..1]
@nullFlavor="OTH" (CONF:1184-643).
b. This administrativeGenderCode SHOULD contain zero or one
[0..1] @code (CONF:1184-644).
i.

Where code is used it SHALL be either M (male) or F
(female) (CONF:1184-645).

See US Realm Header recordTarget/patientRole/patient/birthTime for further birthTime
constraints
2. This patient SHALL contain exactly one [1..1] birthTime
(CONF:1184-13).
Note: Form Element: Date of Birth
a. SHOULD be precise to month if day is not available
(CONF:1184-773).

Attachment G- EHR Implementation Guide Templates

Figure 18: recordTarget Example











124 Any Street
Anyville
CA

97812
US




Samantha
Smith

















5. MAY contain zero or more [0..*] documentationOf (CONF:1184-20).

1.1.3.3 serviceEvent
a. The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent
(CONF:1184-21).

Attachment G- EHR Implementation Guide Templates

1.1.3.4 performer
i.

This serviceEvent SHOULD contain zero or more [0..*] performer
(CONF:1184-22) such that it
Note: Type of Care Providers Seen
1. SHALL contain exactly one [1..1] assignedEntity (CONF:1184-53).
a. This assignedEntity SHALL contain exactly one [1..1] code,
which SHOULD be selected from ValueSet Healthcare
Provider Taxonomy (HIPAA)
urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC
(CONF:1184-56).
Figure 19: performer Example

















6. MAY contain zero or one [0..1] componentOf (CONF:1184-17).

1.1.3.5 encompassingEncounter
a. The componentOf, if present, SHALL contain exactly one [1..1]
encompassingEncounter (CONF:1184-18).
i.

This encompassingEncounter SHOULD contain zero or one [0..1] id
(CONF:1184-361).
Note: Encounter Number

ii. This encompassingEncounter SHALL contain exactly one [1..1]
effectiveTime (CONF:1184-23).
1. This effectiveTime SHALL contain exactly one [1..1] low (CONF:1184198).
Note: Date/Time of admission/visit/arrival

Attachment G- EHR Implementation Guide Templates

2. This effectiveTime SHALL contain exactly one [1..1] high (CONF:11841169).
Note: Date/Time of departure/discharge
Figure 20: encompassingEncounter Example



...






...


7. SHALL contain exactly one [1..1] component (CONF:1184-24).

1.1.3.6 structuredBody
a. This component SHALL contain exactly one [1..1] structuredBody (CONF:1184-25).

1.1.4 Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3)
[ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.1.4:201607-01 (open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
Table 24: Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) Contexts
Contained By:

Contains:
Emergency Department Encounters Section (V2)
Immunizations Section
Medications Section
Patient Information Section (V3)
Payment Sources Section
Problems Section (V3)
Reasons for Visit Section (V2)
Results Section (entries optional) (V2)
Services and Procedures Section
Triage Section
Vital Signs Section (entries required) (V2)

This template describes constraints that are specific to the emergency department encounter
surveys (NHCS-ED, NHAMCS-ED).

Attachment G- EHR Implementation Guide Templates

Table 25: Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

ClinicalDocument (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.1.4:2016-07-01)
templateId

1..1

SHALL

3256570

@root

1..1

SHALL

3256583

2.16.840.1.113883.10.20.34.1.4

@extension

1..1

SHALL

3256866

2016-07-01

0..*

MAY

3256667

serviceEvent

1..1

SHALL

3256668

performer

0..*

SHOUL
D

3256669

1..1

SHALL

3256670

1..1

SHALL

32561170

1..1

SHALL

3256857

1..1

SHALL

3256858

urn:oid:2.16.840.1.114222.4.11.7
419 (Provider ED (NCHS))

0..1

MAY

3256865

OTH

1..1

SHALL

3256671

1..1

SHALL

3256672

1..1

SHALL

32561057

@code

1..1

SHALL

32561058

EMER

@codeSystem

1..1

SHALL

32561059

urn:oid:2.16.840.1.113883.5.4
(ActCode) =
2.16.840.1.113883.5.4

1..1

SHALL

3256863

urn:oid:2.16.840.1.114222.4.11.7
437 (Disposition ED (NCHS))

0..1

MAY

3256864

urn:oid:2.16.840.1.113883.5.100
8 (HL7NullFlavor) = OTH

1..1

SHALL

3256571

structuredBody

1..1

SHALL

3256572

component

1..1

SHALL

3256573

documentationOf

time
low
assignedEntity
code
@nullFlavor
componentOf
encompassingEncounter
code

dischargeDispositionCode
@nullFlavor
component

Attachment G- EHR Implementation Guide Templates

section

1..1

SHALL

3256582

component

1..1

SHALL

3256574

section

1..1

SHALL

3256584

component

1..1

SHALL

3256575

section

1..1

SHALL

3256585

component

1..1

SHALL

3256576

section

1..1

SHALL

3256586

component

1..1

SHALL

3256577

section

1..1

SHALL

3256587

component

1..1

SHALL

3256578

section

1..1

SHALL

3256588

component

1..1

SHALL

3256579

section

1..1

SHALL

3256589

component

1..1

SHALL

3256581

section

1..1

SHALL

3256591

component

1..1

SHALL

3256759

section

1..1

SHALL

3256760

component

1..1

SHALL

3256-

Payment Sources Section
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.4

Vital Signs Section (entries
required) (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.2.4.1:2014-06-09

Reasons for Visit Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.14:2016-07-01

Problems Section (V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.2:2016-07-01

Services and Procedures Section
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.3

Medications Section (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.1

Immunizations Section (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.7

Triage Section (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.10

Emergency Department
Encounters Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.13:2016-07-01

Attachment G- EHR Implementation Guide Templates

809
section

1..1

SHALL

3256810

component

1..1

SHALL

32561104

section

1..1

SHALL

32561105

Patient Information Section (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.5:2016-07-01

Results Section (entries optional)
(V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.2.3:2014-06-09

1.1.5 Properties
1. Conforms to National Health Care Surveys (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.1.1:2015-04-01).

1.1.5.1 templateId
2. SHALL contain exactly one [1..1] templateId (CONF:3256-570) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.1.4"
(CONF:3256-583).
b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-866).
Figure 21: Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) Example










...


1.1.5.2 documentationOf
3. MAY contain zero or more [0..*] documentationOf (CONF:3256-667).
a. The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent
(CONF:3256-668).

1.1.5.3 performer
See National Health Care Surveys template for other performer elements.

Attachment G- EHR Implementation Guide Templates

i.

This serviceEvent SHOULD contain zero or more [0..*] performer
(CONF:3256-669) such that it
Note: Type of care provider seen
1. SHALL contain exactly one [1..1] time (CONF:3256-670).
a. This time SHALL contain exactly one [1..1] low (CONF:32561170).
Note: Date/Time of provider contact
2. SHALL contain exactly one [1..1] assignedEntity (CONF:3256-857).
a. This assignedEntity SHALL contain exactly one [1..1] code,
which SHOULD be selected from ValueSet Provider ED
(NCHS) urn:oid:2.16.840.1.114222.4.11.7419 DYNAMIC
(CONF:3256-858).
i.

This code MAY contain zero or one [0..1]
@nullFlavor="OTH" (CONF:3256-865).

Figure 22: performer Example





















1.1.5.4 componentOf
4. SHALL contain exactly one [1..1] componentOf (CONF:3256-671).

Attachment G- EHR Implementation Guide Templates

See National Health Care Surveys template for other encompassingEncounter elements.
a. This componentOf SHALL contain exactly one [1..1] encompassingEncounter
(CONF:3256-672).
i.

This encompassingEncounter SHALL contain exactly one [1..1] code
(CONF:3256-1057).
1. This code SHALL contain exactly one [1..1] @code="EMER" Emergency
(CONF:3256-1058).
2. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode
urn:oid:2.16.840.1.113883.5.4) (CONF:3256-1059).

ii. This encompassingEncounter SHALL contain exactly one [1..1]
dischargeDispositionCode, which SHOULD be selected from ValueSet
Disposition ED (NCHS) urn:oid:2.16.840.1.114222.4.11.7437
DYNAMIC (CONF:3256-863).
1. This dischargeDispositionCode MAY contain zero or one [0..1]
@nullFlavor="OTH" Other (CodeSystem: HL7NullFlavor
urn:oid:2.16.840.1.113883.5.1008) (CONF:3256-864).
Figure 23: componentOf/encompassingEncounter Example
















1.1.5.5 component
5. SHALL contain exactly one [1..1] component (CONF:3256-571).
a. This component SHALL contain exactly one [1..1] structuredBody (CONF:3256572).
i.

This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-573) such that it

Attachment G- EHR Implementation Guide Templates

1. SHALL contain exactly one [1..1] Payment Sources Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.4)
(CONF:3256-582).
ii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-574) such that it
1. SHALL contain exactly one [1..1] Vital Signs Section (entries
required) (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.4.1:2014-06-09)
(CONF:3256-584).
iii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-575) such that it
1. SHALL contain exactly one [1..1] Reasons for Visit Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.14:2016-07-01)
(CONF:3256-585).
iv. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-576) such that it
1. SHALL contain exactly one [1..1] Problems Section (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.2:2016-07-01)
(CONF:3256-586).
v. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-577) such that it
1. SHALL contain exactly one [1..1] Services and Procedures
Section (identifier:
urn:oid:2.16.840.1.113883.10.20.34.2.3) (CONF:3256-587).
vi. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-578) such that it
1. SHALL contain exactly one [1..1] Medications Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.1)
(CONF:3256-588).
vii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-579) such that it
1. SHALL contain exactly one [1..1] Immunizations Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.7)
(CONF:3256-589).
viii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-581) such that it
1. SHALL contain exactly one [1..1] Triage Section (identifier:
urn:oid:2.16.840.1.113883.10.20.34.2.10) (CONF:3256-591).
ix. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-759) such that it
1. SHALL contain exactly one [1..1] Emergency Department
Encounters Section (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.13:2016-07-01)
(CONF:3256-760).

Attachment G- EHR Implementation Guide Templates

x. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-809) such that it
1. SHALL contain exactly one [1..1] Patient Information Section
(V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.5:2016-07-01)
(CONF:3256-810).
xi. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-1104) such that it
1. SHALL contain exactly one [1..1] Results Section (entries
optional) (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.3:2014-06-09)
(CONF:3256-1105).
Table 26: Provider ED (NCHS)
Value Set: Provider ED (NCHS) urn:oid:2.16.840.1.114222.4.11.7419
Provider types
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7419
Code

Code System

Code System OID

Print Name

405279007

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Attending physician

405277009

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Resident physician

309343006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Physician

442251000124100

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Licensed Practical Nurse

224535009

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Registered nurse

224571005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Nurse practitioner

449161006

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Physician assistant

397897005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Paramedic

310191001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Clinical psychologist

310190000

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Mental health counselor

...

Attachment G- EHR Implementation Guide Templates

Table 27: Disposition ED (NCHS)
Value Set: Disposition ED (NCHS) urn:oid:2.16.840.1.114222.4.11.7437
The final arrangement or transfer of care made when a patient completes and emergency department
encounter.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7437
Code

Code System

Code System OID

Print Name

442291000124106

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Discharge from
observation unit

63238001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Dead on arrival

445060000

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Left against medical
advice

3780001

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

No follow-up planned

442271000124105

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Patient transfer to
psychiatric hospital

25675004

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Patient transfer to skilled
nursing facility (SNF)

223446004

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Return to ED

306227000

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Return/refer to
physician/clinic for
outpatient mental health
treatment

396150002

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Return/refer to
physician/clinic for
substance abuse
treatment

183664005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Return/refer to
physician/clinic for
follow-up

...

1.1.6 Inpatient Encounter (NHCS-IP) (V3)
[ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.1.2:201607-01 (open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
Table 28: Inpatient Encounter (NHCS-IP) (V3) Contexts
Contained By:

Contains:
Immunizations Section
Inpatient Encounters Section (V2)
Medications Section

Attachment G- EHR Implementation Guide Templates

Contained By:

Contains:
Patient Information Section (V3)
Payment Sources Section
Problems Section (V3)
Results Section (entries optional) (V2)
Services and Procedures Section
Vital Signs Section (entries required) (V2)

This template describes constraints that are specific to the Inpatient Encounter Surveys.

Attachment G- EHR Implementation Guide Templates

Table 29: Inpatient Encounter (NHCS-IP) (V3) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

ClinicalDocument (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.1.2:2016-07-01)
templateId

1..1

SHALL

3256304

@root

1..1

SHALL

3256305

2.16.840.1.113883.10.20.34.1.2

@extension

1..1

SHALL

3256767

2016-07-01

0..*

MAY

3256422

1..1

SHALL

3256423

1..1

SHALL

3256250

1..1

SHALL

3256251

1..1

SHALL

32561040

@code

1..1

SHALL

32561041

IMP

@codeSystem

1..1

SHALL

32561042

urn:oid:2.16.840.1.113883.5.4
(ActCode) =
2.16.840.1.113883.5.4

1..1

SHALL

32561173

urn:oid:2.16.840.1.114222.4.11.7
360 (Discharge Disposition IP
(NCHS))

0..1

MAY

32561174

urn:oid:2.16.840.1.113883.5.100
8 (HL7NullFlavor) = OTH

1..1

SHALL

3256244

structuredBody

1..1

SHALL

3256245

component

1..1

SHALL

3256246

section

1..1

SHALL

3256247

component

1..1

SHALL

3256248

section

1..1

SHALL

3256249

component

1..1

SHALL

3256254

documentationOf
serviceEvent
componentOf
encompassingEncounter
code

dischargeDispositionCode

@nullFlavor
component

Patient Information Section (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.5:2016-07-01

Payment Sources Section
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.4

Attachment G- EHR Implementation Guide Templates

section

1..1

SHALL

3256255

component

1..1

SHALL

3256258

section

1..1

SHALL

3256259

component

1..1

SHALL

3256260

section

1..1

SHALL

3256261

component

1..1

SHALL

3256262

section

1..1

SHALL

3256263

component

1..1

SHALL

3256264

section

1..1

SHALL

3256265

component

1..1

SHALL

3256505

section

1..1

SHALL

3256506

component

1..1

SHALL

section

1..1

SHALL

Compo
nent3

Vital Signs Section (entries
required) (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.2.4.1:2014-06-09

Inpatient Encounters Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.12:2016-07-01

Problems Section (V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.2:2016-07-01

Services and Procedures Section
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.3

Medications Section (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.1

Immunizations Section (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.7

3256765
3256766

Results Section (entries optional)
(V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.2.3:2014-06-09

1.1.7 Properties
1. Conforms to National Health Care Surveys (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.1.1:2015-04-01).

1.1.7.1 templateId
2. SHALL contain exactly one [1..1] templateId (CONF:3256-304) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.1.2"
(CONF:3256-305).
b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-767).

Attachment G- EHR Implementation Guide Templates

Figure 24: In-Patient Encounter (NHCS-IP) (V3) Example









...


1.1.7.2 documentationOf
3. MAY contain zero or more [0..*] documentationOf (CONF:3256-422).
See National Health Care Surveys template for other serviceEvent elements.
a. The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent
(CONF:3256-423).

1.1.7.3 componentOf
4. SHALL contain exactly one [1..1] componentOf (CONF:3256-250).
See National Health Care Surveys template for other encompassingEncounter elements.
a. This componentOf SHALL contain exactly one [1..1] encompassingEncounter
(CONF:3256-251).
i.

This encompassingEncounter SHALL contain exactly one [1..1] code
(CONF:3256-1040).
1. This code SHALL contain exactly one [1..1] @code="IMP" Inpatient
(CONF:3256-1041).
2. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode
urn:oid:2.16.840.1.113883.5.4) (CONF:3256-1042).

ii. This encompassingEncounter SHALL contain exactly one [1..1]
dischargeDispositionCode, which SHOULD be selected from ValueSet
Discharge Disposition IP (NCHS)
urn:oid:2.16.840.1.114222.4.11.7360 DYNAMIC (CONF:3256-1173).
1. This dischargeDispositionCode MAY contain zero or one [0..1]
@nullFlavor="OTH" Other (CodeSystem: HL7NullFlavor
urn:oid:2.16.840.1.113883.5.1008) (CONF:3256-1174).

Attachment G- EHR Implementation Guide Templates

Figure 25: componentOf/encompassingEncounter Example
















5. SHALL contain exactly one [1..1] component (CONF:3256-244).

1.1.7.4 structuredBody
a. This component SHALL contain exactly one [1..1] structuredBody (CONF:3256245).
i.

This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-246) such that it
1. SHALL contain exactly one [1..1] Patient Information Section
(V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.5:2016-07-01)
(CONF:3256-247).

ii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-248) such that it
1. SHALL contain exactly one [1..1] Payment Sources Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.4)
(CONF:3256-249).
iii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-254) such that it
1. SHALL contain exactly one [1..1] Vital Signs Section (entries
required) (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.4.1:2014-06-09)
(CONF:3256-255).
iv. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-258) such that it

Attachment G- EHR Implementation Guide Templates

1. SHALL contain exactly one [1..1] Inpatient Encounters Section
(V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.12:2016-07-01)
(CONF:3256-259).
v. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-260) such that it
1. SHALL contain exactly one [1..1] Problems Section (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.2:2016-07-01)
(CONF:3256-261).
vi. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-262) such that it
1. SHALL contain exactly one [1..1] Services and Procedures
Section (identifier:
urn:oid:2.16.840.1.113883.10.20.34.2.3) (CONF:3256-263).
vii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-264) such that it
1. SHALL contain exactly one [1..1] Medications Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.1)
(CONF:3256-265).
viii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-505) such that it
1. SHALL contain exactly one [1..1] Immunizations Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.7)
(CONF:3256-506).
ix. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-765) such that it
1. SHALL contain exactly one [1..1] Results Section (entries
optional) (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.3:2014-06-09)
(CONF:3256-766).

Attachment G- EHR Implementation Guide Templates

Table 30: Discharge Disposition IP (NCHS)
Value Set: Discharge Disposition IP (NCHS) urn:oid:2.16.840.1.114222.4.11.7360
The final arrangement or transfer of care made when a patient is released from an inpatient admission.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7360
Code

Code System

Code System OID

Print Name

01

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Discharged to home or
self care

02

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Discharged/transferred to
a short-term General
Hospital for Inpatient
Care

03

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Discharged /transferred
to Skilled Nursing Facility
with Medicare
Certification
in anticipation of skilled
care

04

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Discharged/transferred to
a Facility that provides
custodial or supportive
care

05

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Discharged to a
Designated Cancer Center
or Children's Hospital

06

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Discharged/transferred to
home under care of an
organized Home Health
Service Organization in
anticipation of covered
skilled care

07

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Left against Medical
advice or discontinued
care

20

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Expired

21

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Discharged/transferred to
Court/Law Enforcement

43

HL7 Discharge
disposition

urn:oid:2.16.840.1.11388
3.12.112

Discharged/Transferred
to a Federal Healthcare
Facility

...

Attachment G- EHR Implementation Guide Templates

1.1.8 Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3)
[ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.1.3:201607-01 (open)]
Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm
Table 31: Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) Contexts
Contained By:

Contains:
Immunizations Section
Medications Section
Outpatient Encounters Section (V3)
Patient Information Section (V3)
Payment Sources Section
Problems Section (V3)
Reasons for Visit Section (V2)
Results Section (entries optional) (V2)
Services and Procedures Section
Vital Signs Section (entries required) (V2)

This template describes constraints that are specific to the outpatient encounter surveys
(NHCS-OPD, NAMCS, NHAMCS-OPD).

Attachment G- EHR Implementation Guide Templates

Table 32: Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) Constraints Overview
XPath

Card.

Verb

Data
Type

CONF#

Value

ClinicalDocument (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.1.3:2016-07-01)
templateId

1..1

SHALL

3256306

@root

1..1

SHALL

3256307

2.16.840.1.113883.10.20.34.1.3

@extension

1..1

SHALL

3256768

2016-07-01

0..*

MAY

3256455

serviceEvent

1..1

SHALL

3256456

performer

0..1

SHOUL
D

3256457

1..1

SHALL

3256458

@code

1..1

SHALL

3256459

PP

@codeSystem

1..1

SHALL

3256460

2.16.840.1.113883.3.88.12.3221.
4

0..1

MAY

3256917

1..1

SHALL

3256918

1..1

SHALL

32561060

@code

1..1

SHALL

32561061

AMB

@codeSystem

1..1

SHALL

32561062

urn:oid:2.16.840.1.113883.5.4
(ActCode) =
2.16.840.1.113883.5.4

1..1

SHALL

32561171

urn:oid:2.16.840.1.114222.4.11.7
361 (Disposition OPD (NCHS))

0..1

MAY

32561172

urn:oid:2.16.840.1.113883.5.100
8 (HL7NullFlavor) = OTH

0..1

MAY

3256919

1..1

SHALL

3256920

code

1..1

SHALL

3256921

component

1..1

SHALL

3256284

1..1

SHALL

3256-

documentationOf

functionCode

componentOf
encompassingEncounter
code

dischargeDispositionCode
@nullFlavor
location
healthCareFacility

structuredBody

urn:oid:2.16.840.1.114222.4.11.7
364 (Type of clinic/location
(NCHS))

Attachment G- EHR Implementation Guide Templates

285
component

1..1

SHALL

3256286

section

1..1

SHALL

3256287

component

1..1

SHALL

3256288

section

1..1

SHALL

3256289

component

1..1

SHALL

3256290

section

1..1

SHALL

3256291

component

1..1

SHALL

3256292

section

1..1

SHALL

3256293

component

1..1

SHALL

3256294

section

1..1

SHALL

3256295

component

1..1

SHALL

3256296

section

1..1

SHALL

3256297

component

1..1

SHALL

3256298

section

1..1

SHALL

3256299

component

1..1

SHALL

3256300

section

1..1

SHALL

3256301

component

1..1

SHALL

3256507

Patient Information Section (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.5:2016-07-01

Payment Sources Section
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.4

Vital Signs Section (entries
required) (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.2.4.1:2014-06-09

Reasons for Visit Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.14:2016-07-01

Outpatient Encounters Section
(V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.8:2016-07-01

Problems Section (V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.34.2.2:2016-07-01

Services and Procedures Section
(identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.3

Medications Section (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.1

Attachment G- EHR Implementation Guide Templates

section

1..1

SHALL

3256508

component

1..1

SHALL

3256763

section

1..1

SHALL

3256764

Immunizations Section (identifier:
urn:oid:2.16.840.1.113883.10.20.
34.2.7

Results Section (entries optional)
(V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.2
0.22.2.3:2014-06-09

1.1.9 Properties
1. Conforms to National Health Care Surveys (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.1.1:2015-04-01).

1.1.9.1 templateId
2. SHALL contain exactly one [1..1] templateId (CONF:3256-306) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.1.3"
(CONF:3256-307).
b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-768).
Figure 26: Out-Patient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) Example







/>
/>
(V3) -->
/>

1.1.9.2 documentationOf
3. MAY contain zero or more [0..*] documentationOf (CONF:3256-455).
See National Health Care Surveys template for other serviceEvent elements.
a. The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent
(CONF:3256-456).

1.1.9.3 performer
i.

This serviceEvent SHOULD contain zero or one [0..1] performer (CONF:3256457) such that it
Note: Patient's Primary Care Provider

Attachment G- EHR Implementation Guide Templates

1. SHALL contain exactly one [1..1] functionCode (CONF:3256-458).
Note: Form Element: Patient's Primary Care Provider
a. This functionCode SHALL contain exactly one [1..1]
@code="PP" Primary Care Provider (CONF:3256-459).
b. This functionCode SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.3.88.12.3221.4"
(CONF:3256-460).
Figure 27: performer Example









1.1.9.4 componentOf
4. MAY contain zero or one [0..1] componentOf (CONF:3256-917).
a. The componentOf, if present, SHALL contain exactly one [1..1]
encompassingEncounter (CONF:3256-918).
i.

This encompassingEncounter SHALL contain exactly one [1..1] code
(CONF:3256-1060).
1. This code SHALL contain exactly one [1..1] @code="AMB" Ambulatory
(outpatient) (CONF:3256-1061).
2. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode
urn:oid:2.16.840.1.113883.5.4) (CONF:3256-1062).

ii. This encompassingEncounter SHALL contain exactly one [1..1]
dischargeDispositionCode, which SHOULD be selected from ValueSet
Disposition OPD (NCHS) urn:oid:2.16.840.1.114222.4.11.7361
DYNAMIC (CONF:3256-1171).
1. This dischargeDispositionCode MAY contain zero or one [0..1]
@nullFlavor="OTH" Other (CodeSystem: HL7NullFlavor
urn:oid:2.16.840.1.113883.5.1008) (CONF:3256-1172).
iii. This encompassingEncounter MAY contain zero or one [0..1] location
(CONF:3256-919).
Note: Type of clinic/location where visit occurred
1. The location, if present, SHALL contain exactly one [1..1]
healthCareFacility (CONF:3256-920).
a. This healthCareFacility SHALL contain exactly one [1..1] code,
which SHOULD be selected from ValueSet Type of

Attachment G- EHR Implementation Guide Templates

clinic/location (NCHS)
urn:oid:2.16.840.1.114222.4.11.7364 DYNAMIC
(CONF:3256-921).
Figure 28: componentOf/encompassingEncounter Example






















1.1.9.5 component
5. SHALL contain exactly one [1..1] component (CONF:3256-284).
a. This component SHALL contain exactly one [1..1] structuredBody (CONF:3256285).
i.

This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-286) such that it
1. SHALL contain exactly one [1..1] Patient Information Section
(V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.5:2016-07-01)
(CONF:3256-287).

ii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-288) such that it

Attachment G- EHR Implementation Guide Templates

1. SHALL contain exactly one [1..1] Payment Sources Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.4)
(CONF:3256-289).
iii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-290) such that it
1. SHALL contain exactly one [1..1] Vital Signs Section (entries
required) (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.2.4.1:2014-06-09)
(CONF:3256-291).
iv. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-292) such that it
1. SHALL contain exactly one [1..1] Reasons for Visit Section (V2)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.14:2016-07-01)
(CONF:3256-293).
v. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-294) such that it
1. SHALL contain exactly one [1..1] Outpatient Encounters Section
(V3) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.8:2016-07-01)
(CONF:3256-295).
vi. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-296) such that it
1. SHALL contain exactly one [1..1] Problems Section (V3)
(identifier:
urn:hl7ii:2.16.840.1.113883.10.20.34.2.2:2016-07-01)
(CONF:3256-297).
vii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-298) such that it
1. SHALL contain exactly one [1..1] Services and Procedures
Section (identifier:
urn:oid:2.16.840.1.113883.10.20.34.2.3) (CONF:3256-299).
viii. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-300) such that it
1. SHALL contain exactly one [1..1] Medications Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.1)
(CONF:3256-301).
ix. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-507) such that it
1. SHALL contain exactly one [1..1] Immunizations Section
(identifier: urn:oid:2.16.840.1.113883.10.20.34.2.7)
(CONF:3256-508).
x. This structuredBody SHALL contain exactly one [1..1] component
(CONF:3256-763) such that it
1. SHALL contain exactly one [1..1] Results Section (entries
optional) (V2) (identifier:

Attachment G- EHR Implementation Guide Templates

urn:hl7ii:2.16.840.1.113883.10.20.22.2.3:2014-06-09)
(CONF:3256-764).
Table 33: Disposition OPD (NCHS)
Value Set: Disposition OPD (NCHS) urn:oid:2.16.840.1.114222.4.11.7361
The final arrangement or transfer of care made when a patient completes an outpatient visit.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7361
Code

Code System

Code System OID

Print Name

PHC1395

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Return to referring
physician/provider

449221000124102

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Refer to other
physician/provider

PHC1396

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Return in less than 1
week

PHC1397

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Return in 1 week to less
than 2 months

PHC1398

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Return in 2 months or
greater

PHC1406

PHIN VADS code system

urn:oid:2.16.840.1.11422
2.4.5.274

Return at unspecified
time

91310009

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Return as needed (p.r.n.)

183452005

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Refer to E.R./Admit to
hospital

65537008

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Routine discharge to
customary residence

PHC1399

SNOMED CT

urn:oid:2.16.840.1.11388
3.6.96

Discharge to observation
status

...

Attachment G- EHR Implementation Guide Templates

Table 34: Type of clinic/location (NCHS)
Value Set: Type of clinic/location (NCHS) urn:oid:2.16.840.1.114222.4.11.7364
The kind of place or hospital department where a procedure, treatment, or service may be performed or
provided.
Value Set Source:

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7364
Code

Code System

Code System OID

Print Name

1162-7

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

24-Hour Observation
Area

1210-4

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Adult Mixed Acuity Unit

1099-1

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Adult Step Down Unit
(post-critical care)

1110-6

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Allergy Clinic

1166-8

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Ambulatory Surgery
Center

1212-0

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Any Age Mixed Acuity
Unit

1106-4

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Assisted Living Area

1145-2

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Behavioral Health Clinic

1022-3

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Bone Marrow Transplant
SCA

1026-4

HL7
HealthcareServiceLocatio
n

urn:oid:2.16.840.1.11388
3.6.259

Burn Critical Care

...

Attachment G- EHR Implementation Guide Templates

2

SECTION-LEVEL TEMPLATES
This chapter contains the section-level templates referenced by one or more of the document
types of this guide. These templates describe the purpose of each section and the section-level
constraints.
Section-level templates are always included in a document. One and only one of each section
type is allowed in a given document instance. Please see the document context tables to
determine the sections that are contained in a given document type. Please see the
conformance verb in the conformance statements to determine if it is required (SHALL),
strongly recommended (SHOULD) or optional (MAY).
Each section-level template contains the following:
• Template metadata (e.g., templateId, etc.)
• Description and explanatory narrative
• LOINC section code
• Section title
• Requirements for a text element
• Entry-level template names and Ids for referenced templates (required and optional)
Narrative Text
The text element within the section stores the narrative to be rendered, as described in the
CDA R2 specification, and is referred to as the CDA narrative block.
The content model of the CDA narrative block schema is hand crafted to meet requirements of
human readability and rendering. The schema is registered as a MIME type (text/x-hl7text+xml), which is the fixed media type for the text element.
As noted in the CDA R2 specification, the document originator is responsible for ensuring that
the narrative block contains the complete, human readable, attested content of the section.
Structured entries support computer processing and computation and are not a replacement
for the attestable, human-readable content of the CDA narrative block. The special case of
structured entries with an entry relationship of "DRIV" (is derived from) indicates to the
receiving application that the source of the narrative block is the structured entries, and that
the contents of the two are clinically equivalent.
As for all CDA documents—even when a report consisting entirely of structured entries is
transformed into CDA—the encoding application must ensure that the authenticated content
(narrative plus multimedia) is a faithful and complete rendering of the clinical content of the
structured source data. As a general guideline, a generated narrative block should include the
same human readable content that would be available to users viewing that content in the
originating system. Although content formatting in the narrative block need not be identical to
that in the originating system, the narrative block should use elements from the CDA narrative
block schema to provide sufficient formatting to support human readability when rendered
according to the rules defined in Section Narrative Block (§ 4.3.5 ) of the CDA R2 specification.

Attachment G- EHR Implementation Guide Templates

By definition, a receiving application cannot assume that all clinical content in a section (i.e.,
in the narrative block and multimedia) is contained in the structured entries unless the entries
in the section have an entry relationship of "DRIV".
Additional specification information for the CDA narrative block can be found in the CDA R2
specification in sections 1.2.1, 1.2.3, 1.3, 1.3.1, 1.3.2, 4.3.4.2, and 6.

2.1

Chief Complaint and Reason for Visit Section
[section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.13 (open)]
Published as part of Consolidated CDA Templates for Clinical Notes (US Realm)
DSTU R1.1
This section records the patient's chief complaint (the patient’s own description) and/or the
reason for the patient's visit (the provider’s description of the reason for visit). Local policy
determines whether the information is divided into two sections or recorded in one section
serving both purposes.
Table 35: Chief Complaint and Reason for Visit Section Constraints Overview

XPath

Card.

Verb

Data
Type

CONF#

Value

section (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.13)
templateId

1..1

SHALL

817840

1..1

SHALL

8110383

1..1

SHALL

8115449

@code

1..1

SHALL

8115450

46239-0

@codeSystem

1..1

SHALL

8126473

urn:oid:2.16.840.1.113883.6.1
(LOINC) = 2.16.840.1.113883.6.1

title

1..1

SHALL

817842

text

1..1

SHALL

817843

@root
code

2.16.840.1.113883.10.20.22.2.13

1. SHALL contain exactly one [1..1] templateId (CONF:81-7840) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.13"
(CONF:81-10383).
2. SHALL contain exactly one [1..1] code (CONF:81-15449).
a. This code SHALL contain exactly one [1..1] @code="46239-0" Chief Complaint and
Reason for Visit (CONF:81-15450).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC
urn:oid:2.16.840.1.113883.6.1) (CONF:81-26473).
3. SHALL contain exactly one [1..1] title (CONF:81-7842).

Attachment G- EHR Implementation Guide Templates

4. SHALL contain exactly one [1..1] text (CONF:81-7843).
Figure 29: Chief Complaint and Reason for Visit Example
CHIEF COMPLAINT Back Pain
2.1.1 Reasons for Visit Section (V2) [section: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.2.14:2016-07-01 (open)] Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm Table 36: Reasons for Visit Section (V2) Contexts Contained By: Contains: Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) (required) Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) (required) Patient's Reason for Visit Observation This section records the patient's chief complaint (the NHCS calls this the "patient's reason for visit") in the patient's own words and/or the reason for the patient's visit in the provider's words. It can also contain a coded reason for visit in the contained Patient's Reason for Visit Observation. Attachment G- EHR Implementation Guide Templates Table 37: Reasons for Visit Section (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.2.14:2016-07-01) templateId 1..1 SHALL 32561066 @root 1..1 SHALL 32561068 2.16.840.1.113883.10.20.34.2.14 @extension 0..1 MAY 32561161 2016-07-01 0..* MAY 32561085 1..1 SHALL 32561086 entry observation Patient's Reason for Visit Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.41:2015-04-01 1. Conforms to Chief Complaint and Reason for Visit Section template (identifier: urn:oid:2.16.840.1.113883.10.20.22.2.13). 2. SHALL contain exactly one [1..1] templateId (CONF:3256-1066) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.14" (CONF:3256-1068). b. MAY contain zero or one [0..1] @extension="2016-07-01" (CONF:3256-1161). 3. MAY contain zero or more [0..*] entry (CONF:3256-1085). a. The entry, if present, SHALL contain exactly one [1..1] Patient's Reason for Visit Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.41:2015-04-01) (CONF:32561086). Attachment G- EHR Implementation Guide Templates Figure 30: Reasons for Visit Section (V2) Example
Reasons for Visit
Patient's Reason for Visit (Chief Complaint) Providers Reason for Visit
Having trouble breathing Dyspnea
...
2.2 Encounters Section (entries optional) (V2) [section: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.2.22:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 38: Encounters Section (entries optional) (V2) Contexts Contained By: Contains: Encounter Activity (V2) This section lists and describes any healthcare encounters pertinent to the patient’s current health status or historical health history. An encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patient’s condition. It may include visits, appointments, or non-face-to-face interactions. It is also a contact between a patient and a practitioner who Attachment G- EHR Implementation Guide Templates has primary responsibility (exercising independent judgment) for assessing and treating the patient at a given contact. This section may contain all encounters for the time period being summarized, but should include notable encounters. Table 39: Encounters Section (entries optional) (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.22:2014-06-09) templateId 1..1 SHALL 10987940 @root 1..1 SHALL 109810386 2.16.840.1.113883.10.20.22.2.22 @extension 1..1 SHALL 109832547 2014-06-09 1..1 SHALL 109815461 @code 1..1 SHALL 109815462 46240-8 @codeSystem 1..1 SHALL 109831136 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 title 1..1 SHALL 10987942 text 1..1 SHALL 10987943 entry 0..* SHOUL D 10987951 1..1 SHALL 109815465 code encounter Encounter Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.49:2014-06-09 1. SHALL contain exactly one [1..1] templateId (CONF:1098-7940) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.22" (CONF:1098-10386). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32547). 2. SHALL contain exactly one [1..1] code (CONF:1098-15461). a. This code SHALL contain exactly one [1..1] @code="46240-8" Encounters (CONF:1098-15462). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-31136). 3. SHALL contain exactly one [1..1] title (CONF:1098-7942). 4. SHALL contain exactly one [1..1] text (CONF:1098-7943). 5. SHOULD contain zero or more [0..*] entry (CONF:1098-7951) such that it a. SHALL contain exactly one [1..1] Encounter Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09) (CONF:109815465). Attachment G- EHR Implementation Guide Templates 2.2.1 Emergency Department Encounters Section (V2) [section: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.2.13:2016-07-01 (open)] Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm Table 40: Emergency Department Encounters Section (V2) Contexts Contained By: Contains: Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) (required) Current Emergency Department Visit (V2) Hospital Admission Encounter Observation Unit Stay Encounter This section contains emergency department encounter information such as the current encounter, and any hospital admission or observation unit stays that might occur. Table 41: Emergency Department Encounters Section (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.2.13:2016-07-01) templateId 1..1 SHALL 32561050 @root 1..1 SHALL 32561052 2.16.840.1.113883.10.20.34.2.13 @extension 1..1 SHALL 32561053 2016-07-01 1..1 SHALL 32561049 1..1 SHALL 32561051 0..* MAY 32561111 1..1 SHALL 32561113 0..* MAY 32561112 1..1 SHALL 32561114 entry encounter entry encounter entry encounter Current Emergency Department Visit (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.40:2016-07-01 Hospital Admission Encounter (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.18 Observation Unit Stay Encounter (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.33 1. Conforms to Encounters Section (entries optional) (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.22:2014-06-09). Attachment G- EHR Implementation Guide Templates 2. SHALL contain exactly one [1..1] templateId (CONF:3256-1050) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.13" (CONF:3256-1052). b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-1053). 3. SHALL contain exactly one [1..1] entry (CONF:3256-1049) such that it a. SHALL contain exactly one [1..1] Current Emergency Department Visit (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.40:2016-07-01) (CONF:3256-1051). 4. MAY contain zero or more [0..*] entry (CONF:3256-1111) such that it a. SHALL contain exactly one [1..1] Hospital Admission Encounter (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.18) (CONF:3256-1113). 5. MAY contain zero or more [0..*] entry (CONF:3256-1112) such that it a. SHALL contain exactly one [1..1] Observation Unit Stay Encounter (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.33) (CONF:32561114). Figure 31: Emergency Department Encounters Section (V2) Example
Emergency Department Encounters ... ...
Attachment G- EHR Implementation Guide Templates 2.2.2 Inpatient Encounters Section (V2) [section: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.2.12:2016-07-01 (open)] Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm Table 42: Inpatient Encounters Section (V2) Contexts Contained By: Contains: Inpatient Encounter (NHCS-IP) (V3) (required) Current Inpatient Visit Specialty Unit Stay Encounter This section contains information about the inpatient encounter such as current visit and any specialty unit stay encounters. Table 43: Inpatient Encounters Section (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.2.12:2016-07-01) templateId 1..1 SHALL 32561044 @root 1..1 SHALL 32561046 2.16.840.1.113883.10.20.34.2.12 @extension 1..1 SHALL 32561047 2016-07-01 0..1 SHOUL D 32561043 1..1 SHALL 32561045 0..* MAY 32561064 1..1 SHALL 32561065 entry encounter entry encounter Current Inpatient Visit (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.39:2015-04-01 Specialty Unit Stay Encounter (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.38:2015-04-01 1. Conforms to Encounters Section (entries optional) (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.22:2014-06-09). 2. SHALL contain exactly one [1..1] templateId (CONF:3256-1044) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.12" (CONF:3256-1046). b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-1047). 3. SHOULD contain zero or one [0..1] entry (CONF:3256-1043) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] Current Inpatient Visit (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.39:2015-04-01) (CONF:32561045). 4. MAY contain zero or more [0..*] entry (CONF:3256-1064) such that it a. SHALL contain exactly one [1..1] Specialty Unit Stay Encounter (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.38:2015-04-01) (CONF:32561065). Figure 32: Inpatient Encounters Section (V2) Example
Inpatient Encounters Section ... ...
/> /> /> /> /> /> Attachment G- EHR Implementation Guide Templates 2.2.3 Outpatient Encounters Section (V3) [section: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.2.8:2016-07-01 (open)] Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm Table 44: Outpatient Encounters Section (V3) Contexts Contained By: Contains: Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) (required) Current Outpatient Visit (V3) This section contains information about the current outpatient encounter. Table 45: Outpatient Encounters Section (V3) Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.2.8:2016-07-01) templateId 1..1 SHALL 3256431 @root 1..1 SHALL 3256432 2.16.840.1.113883.10.20.34.2.8 @extension 1..1 SHALL 32561048 2016-07-01 1..1 SHALL 3256439 1..1 SHALL 3256440 entry encounter Current Outpatient Visit (V3) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.10:2016-07-01 1. Conforms to Encounters Section (entries optional) (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.22:2014-06-09). 2. SHALL contain exactly one [1..1] templateId (CONF:3256-431) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.8" (CONF:3256-432). b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-1048). 3. SHALL contain exactly one [1..1] entry (CONF:3256-439) such that it a. SHALL contain exactly one [1..1] Current Outpatient Visit (V3) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.10:2016-07-01) (CONF:3256-440). Attachment G- EHR Implementation Guide Templates Figure 33: Outpatient Encounters Section (V3)
Outpatient Encounters ... ...
2.3 Medications Section (entries optional) (V2) [section: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.2.1:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 46: Medications Section (entries optional) (V2) Contexts Contained By: Contains: Medication Activity (V2) The Medications Section contains a patient's current medications and pertinent medication history. At a minimum, the currently active medications are listed. An entire medication history is an option. The section can describe a patient's prescription and dispense history and information about intended drug monitoring. Attachment G- EHR Implementation Guide Templates Table 47: Medications Section (entries optional) (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.1:2014-06-09) templateId 1..1 SHALL 10987791 @root 1..1 SHALL 109810432 2.16.840.1.113883.10.20.22.2.1 @extension 1..1 SHALL 109832500 2014-06-09 1..1 SHALL 109815385 @code 1..1 SHALL 109815386 10160-0 @codeSystem 1..1 SHALL 109830824 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 title 1..1 SHALL 10987793 text 1..1 SHALL 10987794 entry 0..* SHOUL D 10987795 1..1 SHALL 109810076 code substanceAdministration Medication Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.16:2014-06-09 1. SHALL contain exactly one [1..1] templateId (CONF:1098-7791) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.1" (CONF:1098-10432). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32500). 2. SHALL contain exactly one [1..1] code (CONF:1098-15385). a. This code SHALL contain exactly one [1..1] @code="10160-0" History of medication use (CONF:1098-15386). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-30824). 3. SHALL contain exactly one [1..1] title (CONF:1098-7793). 4. SHALL contain exactly one [1..1] text (CONF:1098-7794). 5. SHOULD contain zero or more [0..*] entry (CONF:1098-7795) such that it a. SHALL contain exactly one [1..1] Medication Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09) (CONF:109810076). Attachment G- EHR Implementation Guide Templates 2.3.1 Immunizations Section [section: identifier urn:oid:2.16.840.1.113883.10.20.34.2.7 (open)] Draft as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 48: Immunizations Section Contexts Contained By: Contains: Inpatient Encounter (NHCS-IP) (V3) (required) Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) (required) Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) (required) Immunization Activity (V2) Planned Immunization Activity This section contains immunizations that were ordered, supplied, administered, or continued during this visit. A continued immunization has an effectiveTime/low that is less than the encompassingEncounter/effectiveTime/low (date/time of admission/visit/arrival) and a new immunization has an effectiveTime/low that is equal to or greater than the encompassingEncounter/effectiveTime/low. When recording Immunization Medication Information contained in the Planned Immunization Activity template, if the lot number is not known, use lotNumberText/@nullFlavor="NA". Table 49: Immunizations Section Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:oid:2.16.840.1.113883.10.20.34.2.7) templateId @root entry substanceAdministration entry substanceAdministration 1..1 SHALL 1106501 1..1 SHALL 1106504 0..* SHOUL D 1106499 1..1 SHALL 1106502 0..* SHOUL D 1106500 1..1 SHALL 1106503 2.16.840.1.113883.10.20.34.2.7 Immunization Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.52:2014-06-09 Planned Immunization Activity (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.120 1. Conforms to Medications Section (entries optional) (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.1:2014-06-09). 2. SHALL contain exactly one [1..1] templateId (CONF:1106-501) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.7" (CONF:1106-504). 3. SHOULD contain zero or more [0..*] entry (CONF:1106-499) such that it a. SHALL contain exactly one [1..1] Immunization Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.52:2014-06-09) (CONF:1106-502). 4. SHOULD contain zero or more [0..*] entry (CONF:1106-500) such that it a. SHALL contain exactly one [1..1] Planned Immunization Activity (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.120) (CONF:1106-503). Figure 34: Immunizations Section Example
Immunizations ... ... ...
Attachment G- EHR Implementation Guide Templates 2.3.2 Medications Section [section: identifier urn:oid:2.16.840.1.113883.10.20.34.2.1 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 50: Medications Section Contexts Contained By: Contains: Inpatient Encounter (NHCS-IP) (V3) (required) Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) (required) Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) (required) Medication Activity (V2) Planned Medication Activity (V2) This section contains medications (other than immunizations) that were ordered, supplied, administered, or continued during this visit. It includes Rx and OTC drugs, allergy shots, oxygen, anesthetics, chemotherapy, and dietary supplements. A continued medication has an effectiveTime/low that is less than the encompassingEncounter/effectiveTime/low (date/time of admission/visit/arrival) and a new medication has an effectiveTime/low that is equal to or greater than the encompassingEncounter/effectiveTime/low. Table 51: Medications Section Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:oid:2.16.840.1.113883.10.20.34.2.1) templateId @root entry substanceAdministration entry substanceAdministration 1..1 SHALL 1106356 1..1 SHALL 1106357 0..* SHOUL D 1106348 1..1 SHALL 1106349 0..* SHOUL D 1106350 1..1 SHALL 1106351 2.16.840.1.113883.10.20.34.2.1 Medication Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.16:2014-06-09 Planned Medication Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.42:2014-06-09 1. Conforms to Medications Section (entries optional) (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.1:2014-06-09). 2. SHALL contain exactly one [1..1] templateId (CONF:1106-356) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.1" (CONF:1106-357). 3. SHOULD contain zero or more [0..*] entry (CONF:1106-348) such that it a. SHALL contain exactly one [1..1] Medication Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09) (CONF:1106-349). 4. SHOULD contain zero or more [0..*] entry (CONF:1106-350) such that it a. SHALL contain exactly one [1..1] Planned Medication Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.42:2014-06-09) (CONF:1106-351). Figure 35: Medications Section Example
Medications ... ... ...
2.4 Payers Section (V2) [section: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.2.18:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 52: Payers Section (V2) Contexts Contained By: Contains: Coverage Activity (V2) Attachment G- EHR Implementation Guide Templates The Payers Section contains data on the patient’s payers, whether "third party" insurance, selfpay, other payer or guarantor, or some combination of payers, and is used to define which entity is the responsible fiduciary for the financial aspects of a patient’s care. Each unique instance of a payer and all the pertinent data needed to contact, bill to, and collect from that payer should be included. Authorization information that can be used to define pertinent referral, authorization tracking number, procedure, therapy, intervention, device, or similar authorizations for the patient or provider, or both should be included. At a minimum, the patient’s pertinent current payment sources should be listed. The sources of payment are represented as a Coverage Activity, which identifies all of the insurance policies or government or other programs that cover some or all of the patient's healthcare expenses. The policies or programs are sequenced by preference. The Coverage Activity has a sequence number that represents the preference order. Each policy or program identifies the covered party with respect to the payer, so that the identifiers can be recorded. Table 53: Payers Section (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.18:2014-06-09) templateId 1..1 SHALL 10987924 @root 1..1 SHALL 109810434 2.16.840.1.113883.10.20.22.2.18 @extension 1..1 SHALL 109832597 2014-06-09 1..1 SHALL 109815395 @code 1..1 SHALL 109815396 48768-6 @codeSystem 1..1 SHALL 109832149 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 title 1..1 SHALL 10987926 text 1..1 SHALL 10987927 entry 0..* SHOUL D 10987959 act 1..1 SHALL 109815501 code Coverage Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.60:2014-06-09 1. SHALL contain exactly one [1..1] templateId (CONF:1098-7924) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.18" (CONF:1098-10434). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32597). 2. SHALL contain exactly one [1..1] code (CONF:1098-15395). Attachment G- EHR Implementation Guide Templates a. This code SHALL contain exactly one [1..1] @code="48768-6" Payers (CONF:109815396). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-32149). 3. SHALL contain exactly one [1..1] title (CONF:1098-7926). 4. SHALL contain exactly one [1..1] text (CONF:1098-7927). 5. SHOULD contain zero or more [0..*] entry (CONF:1098-7959) such that it a. SHALL contain exactly one [1..1] Coverage Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.60:2014-06-09) (CONF:109815501). Figure 36: Payers Section (V2) Example
Insurance Providers . . . ...
2.4.1 Payment Sources Section [section: identifier urn:oid:2.16.840.1.113883.10.20.34.2.4 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 54: Payment Sources Section Contexts Contained By: Contains: Inpatient Encounter (NHCS-IP) (V3) (required) Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) (required) Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) (required) Planned Coverage This section contains the expected sources of payment for this visit. Attachment G- EHR Implementation Guide Templates Table 55: Payment Sources Section Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:oid:2.16.840.1.113883.10.20.34.2.4) templateId 1..1 SHALL 1106199 1..1 SHALL 1106200 entry 0..* SHOUL D 1106201 act 1..1 SHALL 1106202 @root 2.16.840.1.113883.10.20.34.2.4 Planned Coverage (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.129 1. Conforms to Payers Section (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.18:2014-06-09). 2. SHALL contain exactly one [1..1] templateId (CONF:1106-199) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.4" (CONF:1106-200). 3. SHOULD contain zero or more [0..*] entry (CONF:1106-201) such that it a. SHALL contain exactly one [1..1] Planned Coverage (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.129) (CONF:1106-202). Attachment G- EHR Implementation Guide Templates Figure 37: Payment Sources Section Example
Payment Sources Section ... ... ...
2.5 Problems Section (V3) [section: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.2.2:2016-07-01 (open)] Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm Table 56: Problems Section (V3) Contexts Contained By: Contains: Inpatient Encounter (NHCS-IP) (V3) (required) Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) (required) Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) (required) Admission Diagnosis Observation Adverse Effect of Medical Treatment Injury or Poisoning Observation (V2) Primary Diagnosis Observation (V2) Problem/Diagnosis/Symptom/Condition Observation (V2) This section contains problems, including current diagnoses, chronic conditions and symptoms. Attachment G- EHR Implementation Guide Templates Table 57: Problems Section (V3) Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.2.2:2016-07-01) templateId 1..1 SHALL 325667 @root 1..1 SHALL 325668 2.16.840.1.113883.10.20.34.2.2 @extension 0..1 MAY 32561175 2016-07-01 1..1 SHALL 3256509 @code 1..1 SHALL 3256510 11450-4 @codeSystem 1..1 SHALL 3256511 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 title 1..1 SHALL 3256512 text 1..1 SHALL 3256513 entry 1..1 SHALL 325674 1..1 SHALL 325675 0..1 MAY 3256875 1..1 SHALL 3256876 0..* SHOUL D 3256332 1..1 SHALL 3256333 0..* MAY 3256415 1..1 SHALL 3256416 0..1 MAY 3256497 1..1 SHALL 3256- code observation entry observation entry observation entry observation entry observation Primary Diagnosis Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.6:2015-04-01 Admission Diagnosis Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.34:2015-04-01 Problem/Diagnosis/Symptom/Co ndition Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.1:2015-04-01 Injury or Poisoning Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.17:2015-04-01 Adverse Effect of Medical Attachment G- EHR Implementation Guide Templates 498 Treatment (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.14 1. SHALL contain exactly one [1..1] templateId (CONF:3256-67) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.2" (CONF:3256-68). b. MAY contain zero or one [0..1] @extension="2016-07-01" (CONF:3256-1175). 2. SHALL contain exactly one [1..1] code (CONF:3256-509). a. This code SHALL contain exactly one [1..1] @code="11450-4" Problem List (CONF:3256-510). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:3256-511). 3. SHALL contain exactly one [1..1] title (CONF:3256-512). 4. SHALL contain exactly one [1..1] text (CONF:3256-513). If no other means of determination is possible, use first listed diagnosis as the primary diagnosis. 5. SHALL contain exactly one [1..1] entry (CONF:3256-74) such that it a. SHALL contain exactly one [1..1] Primary Diagnosis Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.6:2015-04-01) (CONF:3256-75). 6. MAY contain zero or one [0..1] entry (CONF:3256-875) such that it a. SHALL contain exactly one [1..1] Admission Diagnosis Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.34:2015-04-01) (CONF:3256-876). b. If the document is an Inpatient Encounter then this entry SHALL be present (CONF:3256-887). 7. SHOULD contain zero or more [0..*] entry (CONF:3256-332) such that it a. SHALL contain exactly one [1..1] Problem/Diagnosis/Symptom/Condition Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.1:2015-04-01) (CONF:3256-333). 8. MAY contain zero or more [0..*] entry (CONF:3256-415) such that it a. SHALL contain exactly one [1..1] Injury or Poisoning Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.17:2015-04-01) (CONF:3256-416). i. If this is an Outpatient Observation then this entry MAY be present (CONF:3256-1110). 9. MAY contain zero or one [0..1] entry (CONF:3256-497) such that it a. SHALL contain exactly one [1..1] Adverse Effect of Medical Treatment (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.14) (CONF:3256-498). Attachment G- EHR Implementation Guide Templates Figure 38: Problems Section (V3) Example
Problems ... ... ... ... ... Attachment G- EHR Implementation Guide Templates ...
2.6 Results Section (entries optional) (V2) [section: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.2.3:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 58: Results Section (entries optional) (V2) Contexts Contained By: Contains: Inpatient Encounter (NHCS-IP) (V3) (required) Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) (required) Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) (required) Result Organizer (V2) This section contains the results of observations generated by laboratories, imaging and other procedures. The scope includes observations of hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. This section often includes notable results such as abnormal values or relevant trends. It can contain all results for the period of time being documented. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory. Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram. Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy. Attachment G- EHR Implementation Guide Templates Table 59: Results Section (entries optional) (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.3:2014-06-09) templateId 1..1 SHALL 10987116 @root 1..1 SHALL 10989136 2.16.840.1.113883.10.20.22.2.3 @extension 1..1 SHALL 109832591 2014-06-09 1..1 SHALL 109815431 @code 1..1 SHALL 109815432 30954-2 @codeSystem 1..1 SHALL 109831041 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 title 1..1 SHALL 10988891 text 1..1 SHALL 10987118 entry 0..* SHOUL D 10987119 1..1 SHALL 109815515 code organizer Result Organizer (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.1:2014-06-09 1. SHALL contain exactly one [1..1] templateId (CONF:1098-7116) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.3" (CONF:1098-9136). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32591). 2. SHALL contain exactly one [1..1] code (CONF:1098-15431). a. This code SHALL contain exactly one [1..1] @code="30954-2" Relevant diagnostic tests and/or laboratory data (CONF:1098-15432). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-31041). 3. SHALL contain exactly one [1..1] title (CONF:1098-8891). 4. SHALL contain exactly one [1..1] text (CONF:1098-7118). 5. SHOULD contain zero or more [0..*] entry (CONF:1098-7119) such that it a. SHALL contain exactly one [1..1] Result Organizer (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.1:2014-06-09) (CONF:109815515). Attachment G- EHR Implementation Guide Templates 2.7 Services and Procedures Section [section: identifier urn:oid:2.16.840.1.113883.10.20.34.2.3 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 60: Services and Procedures Section Contexts Contained By: Contains: Inpatient Encounter (NHCS-IP) (V3) (required) Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) (required) Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) (required) Ordered Service Act Ordered Service Observation Ordered Service Procedure Provided Service Act Provided Service Observation Provided Service Procedure This section contains services and procedures such as examinations, blood tests, imaging, other tests, non-medication treatment, and health education ordered for or provided to the patient. Attachment G- EHR Implementation Guide Templates Table 61: Services and Procedures Section Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:oid:2.16.840.1.113883.10.20.34.2.3) templateId 1..1 SHALL 110676 1..1 SHALL 110686 entry 0..* MAY 110682 act 1..1 SHALL 1106275 entry 0..* MAY 110684 act 1..1 SHALL 110685 entry 0..* MAY 1106276 1..1 SHALL 1106277 0..* MAY 1106278 1..1 SHALL 1106279 0..* MAY 1106280 1..1 SHALL 1106281 0..* MAY 1106282 1..1 SHALL 1106283 @root observation entry observation entry procedure entry procedure 2.16.840.1.113883.10.20.34.2.3 Provided Service Act (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.20 Ordered Service Act (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.19 Provided Service Observation (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.3 Ordered Service Observation (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.2 Provided Service Procedure (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.12 Ordered Service Procedure (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.11 1. SHALL contain exactly one [1..1] templateId (CONF:1106-76) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.3" (CONF:1106-86). 2. MAY contain zero or more [0..*] entry (CONF:1106-82) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] Provided Service Act (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.20) (CONF:1106-275). Note: Form Element Categories (Services): Provided Other Tests and Procedures (except Excision of Tissue), Provided Non-medication treatment, Provided Health Education/Counseling 3. MAY contain zero or more [0..*] entry (CONF:1106-84) such that it a. SHALL contain exactly one [1..1] Ordered Service Act (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.19) (CONF:1106-85). Note: Form Element Categories (Services): Ordered Other Tests and Procedures (except Excision of Tissue), Ordered Non-medication treatment, Ordered Health Education/Counseling 4. MAY contain zero or more [0..*] entry (CONF:1106-276) such that it a. SHALL contain exactly one [1..1] Provided Service Observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.3) (CONF:1106-277). Note: Form Element Categories (Services): Provided Examinations, Provided Blood Tests, Provided Imaging 5. MAY contain zero or more [0..*] entry (CONF:1106-278) such that it a. SHALL contain exactly one [1..1] Ordered Service Observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.2) (CONF:1106-279). Note: Form Element Categories (Services): Ordered Examinations, Ordered Blood Tests, Ordered Imaging 6. MAY contain zero or more [0..*] entry (CONF:1106-280) such that it a. SHALL contain exactly one [1..1] Provided Service Procedure (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.12) (CONF:1106-281). Note: Form Element (Services): Provided Excision of Tissue 7. MAY contain zero or more [0..*] entry (CONF:1106-282) such that it a. SHALL contain exactly one [1..1] Ordered Service Procedure (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.11) (CONF:1106-283). Note: Form Element (Services): Ordered Excision of Tissue Attachment G- EHR Implementation Guide Templates Figure 39: Services and Procedures Section Example
Services and Procedures Section ... ... ... ... ... /> /> /> /> Attachment G- EHR Implementation Guide Templates ... ... ...
2.8 Social History Section (V2) [section: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.2.17:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 62: Social History Section (V2) Contexts Contained By: Contains: Caregiver Characteristics Characteristics of Home Environment Cultural and Religious Observation Pregnancy Observation Smoking Status - Meaningful Use (V2) Social History Observation (V2) Tobacco Use (V2) This section contains social history data that influence a patient’s physical, psychological or emotional health (e.g., smoking status, pregnancy). Demographic data, such as marital status, race, ethnicity, and religious affiliation, is captured in the header. Attachment G- EHR Implementation Guide Templates Table 63: Social History Section (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.17:2014-06-09) templateId 1..1 SHALL 10987936 @root 1..1 SHALL 109810449 2.16.840.1.113883.10.20.22.2.17 @extension 1..1 SHALL 109832494 2014-06-09 1..1 SHALL 109814819 @code 1..1 SHALL 109814820 29762-2 @codeSystem 1..1 SHALL 109830814 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 title 1..1 SHALL 10987938 text 1..1 SHALL 10987939 entry 0..* MAY 10987953 1..1 SHALL 109814821 0..* MAY 10989132 1..1 SHALL 109814822 0..* SHOUL D 109814823 1..1 SHALL 109814824 0..* MAY 109816816 1..1 SHALL 109816817 0..* MAY 109828361 1..1 SHALL 109828362 code observation entry observation entry observation entry observation entry observation Social History Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.38:2014-06-09 Pregnancy Observation (identifier: urn:oid:2.16.840.1.113883.10.20. 15.3.8 Smoking Status - Meaningful Use (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.78:2014-06-09 Tobacco Use (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.85:2014-06-09 Caregiver Characteristics (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.72 Attachment G- EHR Implementation Guide Templates entry observation entry observation 0..* MAY 109828366 1..1 SHALL 109828367 0..* MAY 109828825 1..1 SHALL 109828826 Cultural and Religious Observation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.111 Characteristics of Home Environment (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.109 1. SHALL contain exactly one [1..1] templateId (CONF:1098-7936) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.17" (CONF:1098-10449). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32494). 2. SHALL contain exactly one [1..1] code (CONF:1098-14819). a. This code SHALL contain exactly one [1..1] @code="29762-2" Social History (CONF:1098-14820). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-30814). 3. SHALL contain exactly one [1..1] title (CONF:1098-7938). 4. SHALL contain exactly one [1..1] text (CONF:1098-7939). 5. MAY contain zero or more [0..*] entry (CONF:1098-7953) such that it a. SHALL contain exactly one [1..1] Social History Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.38:2014-06-09) (CONF:1098-14821). 6. MAY contain zero or more [0..*] entry (CONF:1098-9132) such that it a. SHALL contain exactly one [1..1] Pregnancy Observation (identifier: urn:oid:2.16.840.1.113883.10.20.15.3.8) (CONF:1098-14822). 7. SHOULD contain zero or more [0..*] entry (CONF:1098-14823) such that it a. SHALL contain exactly one [1..1] Smoking Status - Meaningful Use (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.78:2014-06-09) (CONF:1098-14824). 8. MAY contain zero or more [0..*] entry (CONF:1098-16816) such that it a. SHALL contain exactly one [1..1] Tobacco Use (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.85:2014-06-09) (CONF:109816817). 9. MAY contain zero or more [0..*] entry (CONF:1098-28361) such that it a. SHALL contain exactly one [1..1] Caregiver Characteristics (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.72) (CONF:1098-28362). 10. MAY contain zero or more [0..*] entry (CONF:1098-28366) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] Cultural and Religious Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.111) (CONF:109828367). 11. MAY contain zero or more [0..*] entry (CONF:1098-28825) such that it a. SHALL contain exactly one [1..1] Characteristics of Home Environment (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.109) (CONF:109828826). Attachment G- EHR Implementation Guide Templates Figure 40: Social History Section (V2) Example
SOCIAL HISTORY . . . ... ... ... ... ...
Attachment G- EHR Implementation Guide Templates 2.8.1 Patient Information Section (V3) [section: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.2.5:2016-07-01 (open)] Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm Table 64: Patient Information Section (V3) Contexts Contained By: Contains: Inpatient Encounter (NHCS-IP) (V3) (required) Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) (required) Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) (required) Patient Residence Observation Pregnancy Observation Smoking Status - Meaningful Use (V2) Tobacco Use (V2) This section contains patient information such as tobacco use, pregnancy status, and type of patient residence. Attachment G- EHR Implementation Guide Templates Table 65: Patient Information Section (V3) Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.2.5:2016-07-01) templateId 1..1 SHALL 3256203 @root 1..1 SHALL 3256204 2.16.840.1.113883.10.20.34.2.5 @extension 1..1 SHALL 32561108 2016-07-01 0..* MAY 3256205 1..1 SHALL 3256206 0..1 MAY 32561106 1..1 SHALL 32561107 0..1 MAY 3256207 1..1 SHALL 3256208 0..1 MAY 3256676 1..1 SHALL 3256677 entry observation entry observation entry observation entry observation Tobacco Use (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.85:2014-06-09 Smoking Status - Meaningful Use (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.78:2014-06-09 Pregnancy Observation (identifier: urn:oid:2.16.840.1.113883.10.20. 15.3.8 Patient Residence Observation (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.25 1. Conforms to Social History Section (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.17:2014-06-09). 2. SHALL contain exactly one [1..1] templateId (CONF:3256-203) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.5" (CONF:3256-204). b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-1108). 3. MAY contain zero or more [0..*] entry (CONF:3256-205) such that it a. SHALL contain exactly one [1..1] Tobacco Use (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.85:2014-06-09) (CONF:3256-206). b. If the document is an Outpatient Encounter then at least one of this entry SHALL be present (CONF:3256-663). 4. MAY contain zero or one [0..1] entry (CONF:3256-1106) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] Smoking Status - Meaningful Use (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.78:2014-06-09) (CONF:3256-1107). i. If the document is an Outpatient Encounter then this entry SHALL be present (CONF:3256-1109). 5. MAY contain zero or one [0..1] entry (CONF:3256-207) such that it a. SHALL contain exactly one [1..1] Pregnancy Observation (identifier: urn:oid:2.16.840.1.113883.10.20.15.3.8) (CONF:3256-208). b. If the patient is male, then this section SHALL NOT contain this entry. If the document is an Inpatient Encounter or an Outpatient Encounter then this entry MAY be present (CONF:3256-514). 6. MAY contain zero or one [0..1] entry (CONF:3256-676) such that it a. SHALL contain exactly one [1..1] Patient Residence Observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.25) (CONF:3256-677). Attachment G- EHR Implementation Guide Templates Figure 41: Patient Information Section (V2) Example
Patient Information .. ... ... ... ... ... ...
Attachment G- EHR Implementation Guide Templates 2.9 Triage Section [section: identifier urn:oid:2.16.840.1.113883.10.20.34.2.10 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 66: Triage Section Contexts Contained By: Contains: Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) (required) On Oxygen on Arrival Observation Pain Assessment Scale Observation Triage Level Assigned Observation This section contains triage information such as triage index, pain scale and whether the patient was on oxygen on arrival. Attachment G- EHR Implementation Guide Templates Table 67: Triage Section Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:oid:2.16.840.1.113883.10.20.34.2.10) templateId 1..1 SHALL 1106646 1..1 SHALL 1106647 1..1 SHALL 1106648 @code 0..1 MAY 1106649 54094-8 @codeSystem 0..1 MAY 1106650 2.16.840.1.113883.6.1 title 1..1 SHALL 1106651 text 1..1 SHALL 1106652 entry 1..1 SHALL 1106622 1..1 SHALL 1106624 1..1 SHALL 1106623 1..1 SHALL 1106625 1..1 SHALL 1106716 1..1 SHALL 1106717 @root code observation entry observation entry observation 2.16.840.1.113883.10.20.34.2.10 Triage Level Assigned Observation (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.23 Pain Assessment Scale Observation (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.22 On Oxygen on Arrival Observation (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.29 1. SHALL contain exactly one [1..1] templateId (CONF:1106-646) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.2.10" (CONF:1106-647). 2. SHALL contain exactly one [1..1] code (CONF:1106-648). a. This code MAY contain zero or one [0..1] @code="54094-8" Triage Note (CONF:1106649). b. This code MAY contain zero or one [0..1] @codeSystem="2.16.840.1.113883.6.1" (CONF:1106-650). 3. SHALL contain exactly one [1..1] title (CONF:1106-651). Attachment G- EHR Implementation Guide Templates 4. SHALL contain exactly one [1..1] text (CONF:1106-652). 5. SHALL contain exactly one [1..1] entry (CONF:1106-622) such that it a. SHALL contain exactly one [1..1] Triage Level Assigned Observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.23) (CONF:1106-624). 6. SHALL contain exactly one [1..1] entry (CONF:1106-623) such that it a. SHALL contain exactly one [1..1] Pain Assessment Scale Observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.22) (CONF:1106-625). 7. SHALL contain exactly one [1..1] entry (CONF:1106-716) such that it a. SHALL contain exactly one [1..1] On Oxygen on Arrival Observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.29) (CONF:1106-717). Figure 42: Triage Section Example
Triage Section ... ... ... ...
Attachment G- EHR Implementation Guide Templates 2.10 Vital Signs Section (entries optional) (V2) [section: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.2.4:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 68: Vital Signs Section (entries optional) (V2) Contexts Contained By: Contains: Vital Signs Organizer (V2) The Vital Signs Section contains relevant vital signs for the context and use case of the document type, such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area. The section should include notable vital signs such as the most recent, maximum and/or minimum, baseline, or relevant trends. Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions. Table 69: Vital Signs Section (entries optional) (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.4:2014-06-09) templateId 1..1 SHALL 10987268 @root 1..1 SHALL 109810451 2.16.840.1.113883.10.20.22.2.4 @extension 1..1 SHALL 109832584 2014-06-09 1..1 SHALL 109815242 @code 1..1 SHALL 109815243 8716-3 @codeSystem 1..1 SHALL 109830902 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 title 1..1 SHALL 10989966 text 1..1 SHALL 10987270 entry 0..* SHOUL D 10987271 1..1 SHALL 109815517 code organizer Vital Signs Organizer (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.26:2014-06-09 Attachment G- EHR Implementation Guide Templates 1. SHALL contain exactly one [1..1] templateId (CONF:1098-7268) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.4" (CONF:1098-10451). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32584). 2. SHALL contain exactly one [1..1] code (CONF:1098-15242). a. This code SHALL contain exactly one [1..1] @code="8716-3" Vital Signs (CONF:109815243). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-30902). 3. SHALL contain exactly one [1..1] title (CONF:1098-9966). 4. SHALL contain exactly one [1..1] text (CONF:1098-7270). 5. SHOULD contain zero or more [0..*] entry (CONF:1098-7271) such that it a. SHALL contain exactly one [1..1] Vital Signs Organizer (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.26:2014-06-09) (CONF:109815517). 2.10.1 Vital Signs Section (entries required) (V2) [section: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.2.4.1:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 70: Vital Signs Section (entries required) (V2) Contexts Contained By: Contains: Inpatient Encounter (NHCS-IP) (V3) (required) Outpatient Encounter (NHCS-OPD, NAMCS, NHAMCS-OPD) (V3) (required) Emergency Department Encounter (NHCS-ED, NHAMCS-ED) (V3) (required) Vital Signs Organizer (V2) The Vital Signs Section contains relevant vital signs for the context and use case of the document type, such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area. The section should include notable vital signs such as the most recent, maximum and/or minimum, baseline, or relevant trends. Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions. Attachment G- EHR Implementation Guide Templates Table 71: Vital Signs Section (entries required) (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value section (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.4.1:2014-06-09) @nullFlavor 0..1 MAY 109832874 templateId 1..1 SHALL 10987273 @root 1..1 SHALL 109810452 2.16.840.1.113883.10.20.22.2.4. 1 @extension 1..1 SHALL 109832585 2014-06-09 1..1 SHALL 109815962 @code 1..1 SHALL 109815963 8716-3 @codeSystem 1..1 SHALL 109830903 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 title 1..1 SHALL 10989967 text 1..1 SHALL 10987275 entry 1..* SHALL 10987276 1..1 SHALL 109815964 code organizer urn:oid:2.16.840.1.113883.5.100 8 (HL7NullFlavor) = NI Vital Signs Organizer (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.26:2014-06-09 1. Conforms to Vital Signs Section (entries optional) (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.2.4:2014-06-09). 2. MAY contain zero or one [0..1] @nullFlavor="NI" No information (CodeSystem: HL7NullFlavor urn:oid:2.16.840.1.113883.5.1008) (CONF:1098-32874). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-7273) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.4.1" (CONF:1098-10452). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32585). 4. SHALL contain exactly one [1..1] code (CONF:1098-15962). a. This code SHALL contain exactly one [1..1] @code="8716-3" Vital Signs (CONF:109815963). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-30903). 5. SHALL contain exactly one [1..1] title (CONF:1098-9967). 6. SHALL contain exactly one [1..1] text (CONF:1098-7275). Attachment G- EHR Implementation Guide Templates If section/@nullFlavor is not present: 7. SHALL contain at least one [1..*] entry (CONF:1098-7276) such that it a. SHALL contain exactly one [1..1] Vital Signs Organizer (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.26:2014-06-09) (CONF:109815964). Figure 43: Vital Signs Section (entries required) (V2) Example
VITAL SIGNS . . . . . .
Attachment G- EHR Implementation Guide Templates 3 ENTRY-LEVEL TEMPLATES This chapter describes the clinical statement entry templates used within the sections of the document. Entry templates contain constraints that are required for conformance. Entry-level templates are always in sections. Each entry-level template description contains the following information: • Key template metadata (e.g., templateId, etc.) • Description and explanatory narrative. • Required CDA acts, participants and vocabularies. • Optional CDA acts, participants and vocabularies. Several entry-level templates require an effectiveTime: The effectiveTime of an observation is the time interval over which the observation is known to be true. The low and high values should be as precise as possible, but no more precise than known. While CDA has multiple mechanisms to record this time interval (e.g., by low and high values, low and width, high and width, or center point and width), we constrain most to use only the low/high form. The low value is the earliest point for which the condition is known to have existed. The high value, when present, indicates the time at which the observation was no longer known to be true. The full description of effectiveTime and time intervals is contained in the CDA R2 normative edition. ID in entry templates: Entry-level templates may also describe an id element, which is an identifier for that entry. This id may be referenced within the document, or by the system receiving the document. The id assigned must be globally unique. 3.1 Admission Priority Observation [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.35:2015-04-01 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US Realm Table 72: Admission Priority Observation Contexts Contained By: Contains: Current Inpatient Visit (optional) This template represents the priority of this admission or visit. Attachment G- EHR Implementation Guide Templates Table 73: Admission Priority Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.35:2015-04-01) @classCode 1..1 SHALL 1184884 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1184885 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1184878 @root 1..1 SHALL 1184880 2.16.840.1.113883.10.20.34.3.35 @extension 1..1 SHALL 1184881 2015-04-01 1..1 SHALL 1184879 @code 1..1 SHALL 1184882 78020-5 @codeSystem 1..1 SHALL 1184883 2.16.840.1.113883.6.1 1..1 SHALL 1184886 urn:oid:2.16.840.1.114222.4.11.7 365 (Priority (Type) of Admission or Visit (NCHS)) code value CD 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1184-884). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-885). 3. SHALL contain exactly one [1..1] templateId (CONF:1184-878) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.35" (CONF:1184-880). b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-881). 4. SHALL contain exactly one [1..1] code (CONF:1184-879). a. This code SHALL contain exactly one [1..1] @code="78020-5" Admission priority (CONF:1184-882). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CONF:1184-883). 5. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Priority (Type) of Admission or Visit (NCHS) urn:oid:2.16.840.1.114222.4.11.7365 DYNAMIC (CONF:1184-886). Attachment G- EHR Implementation Guide Templates Table 74: Priority (Type) of Admission or Visit (NCHS) Value Set: Priority (Type) of Admission or Visit (NCHS) urn:oid:2.16.840.1.114222.4.11.7365 The kind or importance of the process which resulted in the patient’s being admitted as an inpatient. Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7365 Code Code System Code System OID Print Name 183452005 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Emergency 448381000124100 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Urgent hospital admission 8715000 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Elective 447941000124106 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Hospital admission of newborn 183497001 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Non-urgent Trauma Admission 183463008 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Admit Trauma Emergency ... Figure 44: Admission Priority Observation Example Attachment G- EHR Implementation Guide Templates 3.2 Age Observation [observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.31 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R1.1 Table 75: Age Observation Contexts Contained By: Contains: Problem Observation (V2) (optional) This Age Observation represents the subject's age at onset of an event or observation. The age of a relative in a Family History Observation at the time of that observation could also be inferred by comparing RelatedSubject/subject/birthTime with Observation/effectiveTime. However, a common scenario is that a patient will know the age of a relative when the relative had a certain condition or when the relative died, but will not know the actual year (e.g., "grandpa died of a heart attack at the age of 50"). Often times, neither precise dates nor ages are known (e.g., "cousin died of congenital heart disease as an infant"). Table 76: Age Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.31) @classCode 1..1 SHALL 817613 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 817614 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 817899 1..1 SHALL 8110487 1..1 SHALL 817615 @code 1..1 SHALL 8116776 445518008 @codeSystem 1..1 SHALL 8126499 urn:oid:2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96 1..1 SHALL 8115965 1..1 SHALL 8115966 1..1 SHALL PQ 817617 1..1 SHALL CS 817618 @root code statusCode @code value @unit 2.16.840.1.113883.10.20.22.4.31 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed urn:oid:2.16.840.1.113883.11.20. 9.21 (AgePQ_UCUM) Attachment G- EHR Implementation Guide Templates 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-7613). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-7614). 3. SHALL contain exactly one [1..1] templateId (CONF:81-7899) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.31" (CONF:81-10487). 4. SHALL contain exactly one [1..1] code (CONF:81-7615). a. This code SHALL contain exactly one [1..1] @code="445518008" Age At Onset (CONF:81-16776). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT urn:oid:2.16.840.1.113883.6.96) (CONF:81-26499). 5. SHALL contain exactly one [1..1] statusCode (CONF:81-15965). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:8115966). 6. SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:81-7617). a. This value SHALL contain exactly one [1..1] @unit, which SHALL be selected from ValueSet AgePQ_UCUM urn:oid:2.16.840.1.113883.11.20.9.21 DYNAMIC (CONF:81-7618). Table 77: AgePQ_UCUM Value Set: AgePQ_UCUM urn:oid:2.16.840.1.113883.11.20.9.21 A value set of UCUM codes for representing age value units. Value Set Source: http://unitsofmeasure.org/ucum.html Code Code System Code System OID Print Name min UCUM urn:oid:2.16.840.1.11388 3.6.8 Minute h UCUM urn:oid:2.16.840.1.11388 3.6.8 Hour d UCUM urn:oid:2.16.840.1.11388 3.6.8 Day wk UCUM urn:oid:2.16.840.1.11388 3.6.8 Week mo UCUM urn:oid:2.16.840.1.11388 3.6.8 Month a UCUM urn:oid:2.16.840.1.11388 3.6.8 Year Attachment G- EHR Implementation Guide Templates Figure 45: Age Observation Example 3.3 Assessment Scale Observation [observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.69 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R1.1 Table 78: Assessment Scale Observation Contexts Contained By: Contains: Assessment Scale Supporting Observation An assessment scale is a collection of observations that together yield a summary evaluation of a particular condition. Examples include the Braden Scale (assesses pressure ulcer risk), APACHE Score (estimates mortality in critically ill patients), Mini-Mental Status Exam (assesses cognitive function), APGAR Score (assesses the health of a newborn), and Glasgow Coma Scale (assesses coma and impaired consciousness). Attachment G- EHR Implementation Guide Templates Table 79: Assessment Scale Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.69) @classCode 1..1 SHALL 8114434 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 8114435 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 8114436 1..1 SHALL 8114437 id 1..* SHALL 8114438 code 1..1 SHALL 8114439 derivationExpr 0..1 MAY 8114637 statusCode 1..1 SHALL 8114444 1..1 SHALL 8119088 effectiveTime 1..1 SHALL 8114445 value 1..1 SHALL 8114450 interpretationCode 0..* MAY 8114459 0..* MAY 8114888 author 0..* MAY 8114460 entryRelationship 0..* SHOUL D 8114451 @typeCode 1..1 SHALL 8116741 COMP observation 1..1 SHALL 8116742 Assessment Scale Supporting Observation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.86 referenceRange 0..* MAY 8116799 1..1 SHALL 8116800 0..1 SHOUL D 8116801 0..1 SHOUL 81- @root @code translation observationRange text reference 2.16.840.1.113883.10.20.22.4.69 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed Attachment G- EHR Implementation Guide Templates @value 0..1 D 16802 MAY 8116803 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-14434). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-14435). 3. SHALL contain exactly one [1..1] templateId (CONF:81-14436) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.69" (CONF:81-14437). 4. SHALL contain at least one [1..*] id (CONF:81-14438). 5. SHALL contain exactly one [1..1] code (CONF:81-14439). a. SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) identifying the assessment scale (CONF:8114440). Such derivation expression can contain a text calculation of how the components total up to the summed score 6. MAY contain zero or one [0..1] derivationExpr (CONF:81-14637). 7. SHALL contain exactly one [1..1] statusCode (CONF:81-14444). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:8119088). Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) 8. SHALL contain exactly one [1..1] effectiveTime (CONF:81-14445). 9. SHALL contain exactly one [1..1] value (CONF:81-14450). 10. MAY contain zero or more [0..*] interpretationCode (CONF:81-14459). a. The interpretationCode, if present, MAY contain zero or more [0..*] translation (CONF:81-14888). 11. MAY contain zero or more [0..*] author (CONF:81-14460). 12. SHOULD contain zero or more [0..*] entryRelationship (CONF:81-14451) such that it a. SHALL contain exactly one [1..1] @typeCode="COMP" has component (CONF:8116741). b. SHALL contain exactly one [1..1] Assessment Scale Supporting Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.86) (CONF:81-16742). The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) 13. MAY contain zero or more [0..*] referenceRange (CONF:81-16799). a. The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:81-16800). Attachment G- EHR Implementation Guide Templates The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) i. This observationRange SHOULD contain zero or one [0..1] text (CONF:8116801). 1. The text, if present, SHOULD contain zero or one [0..1] reference (CONF:81-16802). a. The reference, if present, MAY contain zero or one [0..1] @value (CONF:81-16803). i. This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-16804). Figure 46: Assessment Scale Observation Example Text description of the calculation . . . 3.3.1 Pain Assessment Scale Observation [observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.22 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 80: Pain Assessment Scale Observation Contexts Contained By: Contains: Triage Section (required) This template represents pain severity on a scale of 0 to 10 where 0 is no pain and 10 is the worst pain imaginable. To record "unknown" use nullFlavor="UNK". Attachment G- EHR Implementation Guide Templates Table 81: Pain Assessment Scale Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.22) @classCode 1..1 SHALL 1106598 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1106599 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106592 1..1 SHALL 1106595 1..1 SHALL 1106593 @code 1..1 SHALL 1106596 72514-3 @codeSystem 1..1 SHALL 1106597 2.16.840.1.113883.6.1 1..1 SHALL @nullFlavor 0..1 MAY 1106653 @value 0..1 SHOUL D 1106600 @root code value INT 2.16.840.1.113883.10.20.34.3.22 1106594 UNK 1. Conforms to Assessment Scale Observation template (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.69). 2. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1106-598). 3. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1106-599). 4. SHALL contain exactly one [1..1] templateId (CONF:1106-592) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.22" (CONF:1106-595). 5. SHALL contain exactly one [1..1] code (CONF:1106-593). a. This code SHALL contain exactly one [1..1] @code="72514-3" Pain severity - 0-10 verbal numeric rating [#] - Reported (CONF:1106-596). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CONF:1106-597). 6. SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:1106-594). Note: Form element: Pain scale (0-10) a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" Unknown (CONF:1106-653). b. This value SHOULD contain zero or one [0..1] @value (CONF:1106-600). i. SHALL be >= 0 and SHALL be <=10 (CONF:1106-654). Attachment G- EHR Implementation Guide Templates Figure 47: Pain Assessment Scale Observation Example 3.3.2 Triage Level Assigned Observation [observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.23 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 82: Triage Level Assigned Observation Contexts Contained By: Contains: Triage Section (required) This template represents the triage level assigned by a triage nurse upon arrival at the emergency department (ED). The triage system used is recorded in the code element and the level is recorded in the value element. If the triage system used is not covered by the list of codes, use code/nullFlavor="OTH". If the triage system is known but the triage level is unknown, use value/nullFlavor="UNK". If the triage system is unknown, use code/nullFlavor="UNK" and value/nullFlavor="UNK". Attachment G- EHR Implementation Guide Templates Table 83: Triage Level Assigned Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.23) @classCode 1..1 SHALL 1106620 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1106621 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106617 1..1 SHALL 1106618 2.16.840.1.113883.10.20.34.3.23 1..1 SHALL 1106655 urn:oid:2.16.840.1.114222.4.11.7 401 (Triage System (NCHS)) 0..1 MAY 1106854 1..1 SHALL @nullFlavor 0..1 MAY 1106657 @value 1..1 SHOUL D 1106659 @root code @nullFlavor value INT 1106619 1. Conforms to Assessment Scale Observation template (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.69). 2. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1106-620). 3. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1106-621). 4. SHALL contain exactly one [1..1] templateId (CONF:1106-617) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.23" (CONF:1106-618). 5. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Triage System (NCHS) urn:oid:2.16.840.1.114222.4.11.7401 DYNAMIC (CONF:1106-655). a. This code MAY contain zero or one [0..1] @nullFlavor (CONF:1106-854). i. NullFlavor SHALL be "UNK" Unknown or "OTH" Other (CONF:1106-855). 6. SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:1106-619). a. This value MAY contain zero or one [0..1] @nullFlavor (CONF:1106-657). i. NullFlavor SHALL be "UNK" Unknown, "OTH" Other, or "NA" Not Applicable (CONF:1106-658). b. This value SHOULD contain exactly one [1..1] @value (CONF:1106-659). Attachment G- EHR Implementation Guide Templates Table 84: Triage System (NCHS) Value Set: Triage System (NCHS) urn:oid:2.16.840.1.114222.4.11.7401 These values describe different types of triage systems. Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7401 Code Code System Code System OID Print Name 75614-8 LOINC urn:oid:2.16.840.1.11388 3.6.1 Three level triage system 75615-5 LOINC urn:oid:2.16.840.1.11388 3.6.1 Four level triage system 75616-3 LOINC urn:oid:2.16.840.1.11388 3.6.1 Five level triage system 75910-0 LOINC urn:oid:2.16.840.1.11388 3.6.1 Canadian triage and acuity scale CTAS 75636-1 LOINC urn:oid:2.16.840.1.11388 3.6.1 Emergency severity index ... Figure 48: Triage Level Assigned Observation Example 3.4 Assessment Scale Supporting Observation [observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.86 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R1.1 Table 85: Assessment Scale Supporting Observation Contexts Contained By: Assessment Scale Observation (optional) Contains: Attachment G- EHR Implementation Guide Templates An Assessment Scale Supporting Observation represents the components of a scale used in an Assessment Scale Observation. The individual parts that make up the component may be a group of cognitive or functional status observations. Table 86: Assessment Scale Supporting Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.86) @classCode 1..1 SHALL 8116715 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 8116716 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 8116722 1..1 SHALL 8116723 id 1..* SHALL 8116724 code 1..1 SHALL 8119178 1..1 SHALL 8119179 1..1 SHALL 8116720 1..1 SHALL 8119089 1..* SHALL 8116754 @root @code statusCode @code value 2.16.840.1.113883.10.20.22.4.86 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-16715). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-16716). 3. SHALL contain exactly one [1..1] templateId (CONF:81-16722) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.86" (CONF:81-16723). 4. SHALL contain at least one [1..*] id (CONF:81-16724). 5. SHALL contain exactly one [1..1] code (CONF:81-19178). a. This code SHALL contain exactly one [1..1] @code (CONF:81-19179). i. Such that the @code SHALL be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) and represents components of the scale (CONF:8119180). 6. SHALL contain exactly one [1..1] statusCode (CONF:81-16720). Attachment G- EHR Implementation Guide Templates a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:8119089). 7. SHALL contain at least one [1..*] value (CONF:81-16754). a. If xsi:type="CD", MAY have a translation code to further specify the source if the instrument has an applicable code system and value set for the integer (CONF:14639) (CONF:81-16755). Figure 49: Assessment Scale Supporting Observation Example 3.5 Asthma Diagnosis Observation (RETIRED) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.5:2016-07-01 (open)] Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm This template represents a diagnosis of Asthma. Retired as per STU Comment: http://www.hl7.org/dstucomments/showdetail_comment.cfm?commentid=925 Asthma Diagnoses are now represented using the Problem/Diagnosis/Symptom/Condition Observation. Table 87: Asthma Diagnosis Observation (RETIRED) Constraints Overview X Card. P a t h Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.5:2016-07-01) Attachment G- EHR Implementation Guide Templates Figure 50: Asthma Diagnosis Observation (V2) Example ... ... ... Attachment G- EHR Implementation Guide Templates 3.6 Caregiver Characteristics [observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.72 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R1.1 Table 88: Caregiver Characteristics Contexts Contained By: Contains: Social History Section (V2) (optional) This clinical statement represents a caregiver’s willingness to provide care and the abilities of that caregiver to provide assistance to a patient in relation to a specific need. Attachment G- EHR Implementation Guide Templates Table 89: Caregiver Characteristics Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.72) @classCode 1..1 SHALL 8114219 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 8114220 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 8114221 1..1 SHALL 8114222 id 1..* SHALL 8114223 code 1..1 SHALL 8114230 statusCode 1..1 SHALL 8114233 1..1 SHALL 8119090 value 1..1 SHALL participant 1..* SHALL 8114227 @typeCode 1..1 SHALL 8126451 time 0..1 MAY 8114830 low 1..1 SHALL 8114831 high 0..1 MAY 8114832 participantRole 1..1 SHALL 8114228 @classCode 1..1 SHALL 8114229 @root @code CD 2.16.840.1.113883.10.20.22.4.72 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 8114599 IND CAREGIVER 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-14219). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-14220). 3. SHALL contain exactly one [1..1] templateId (CONF:81-14221) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.72" (CONF:81-14222). 4. SHALL contain at least one [1..*] id (CONF:81-14223). 5. SHALL contain exactly one [1..1] code (CONF:81-14230). Attachment G- EHR Implementation Guide Templates a. This code MAY be drawn from LOINC (CodeSystem: LOINC 2.16.840.1.113883.6.1) or MAY be bound to ASSERTION (CodeSystem: ActCode 2.16.840.1.113883.5.4 STATIC) (CONF:81-26513). 6. SHALL contain exactly one [1..1] statusCode (CONF:81-14233). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:8119090). 7. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:81-14599). a. The code SHALL be selected from LOINC (codeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:81-14600). 8. SHALL contain at least one [1..*] participant (CONF:81-14227). a. Such participants SHALL contain exactly one [1..1] @typeCode="IND" (CONF:8126451). b. Such participants MAY contain zero or one [0..1] time (CONF:81-14830). i. The time, if present, SHALL contain exactly one [1..1] low (CONF:81-14831). ii. The time, if present, MAY contain zero or one [0..1] high (CONF:81-14832). c. Such participants SHALL contain exactly one [1..1] participantRole (CONF:8114228). i. This participantRole SHALL contain exactly one [1..1] @classCode="CAREGIVER" (CONF:81-14229). Figure 51: Caregiver Characteristics Example Attachment G- EHR Implementation Guide Templates 3.7 Cause of Injury, Poisoning, or Adverse Effect [observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.27 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 90: Cause of Injury, Poisoning, or Adverse Effect Contexts Contained By: Contains: Adverse Effect of Medical Treatment (optional) Injury or Poisoning Observation (V2) (optional) This template represents the cause of injury, poisoning, or adverse effect. The place and events that preceded the injury, poisoning, or adverse effect (e.g., allergy to penicillin, bee sting, pedestrian hit by car driven by drunk driver, spouse beaten with fists by spouse, heroin overdose, infected shunt, etc.) should be described and recorded. Proper names of people or places should not be recorded. For a motor vehicle crash, indicate if it occurred on the street or highway versus a driveway or parking lot. Attachment G- EHR Implementation Guide Templates Table 91: Cause of Injury, Poisoning, or Adverse Effect Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.27) @classCode 1..1 SHALL 1106626 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1106627 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106628 1..1 SHALL 1106629 id 1..* SHALL 1106630 code 1..1 SHALL 1106631 @code 1..1 SHALL 1106632 69543-7 @codeSystem 1..1 SHALL 1106633 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 1106634 1..1 SHALL 1106635 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1..1 SHALL 1106636 urn:oid:2.16.840.1.113883.6.3 (ICD10) @nullFlavor 0..1 MAY 1106859 OTH originalText 0..1 MAY 1106861 @root statusCode @code value CD 2.16.840.1.113883.10.20.34.3.27 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-626). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-627). 3. SHALL contain exactly one [1..1] templateId (CONF:1106-628). a. This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.27" (CONF:1106-629). 4. SHALL contain at least one [1..*] id (CONF:1106-630). 5. SHALL contain exactly one [1..1] code (CONF:1106-631). a. This code SHALL contain exactly one [1..1] @code="69543-7" Cause of Injury (NCHS) (CONF:1106-632). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1106-633). Attachment G- EHR Implementation Guide Templates 6. SHALL contain exactly one [1..1] statusCode (CONF:1106-634). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-635). If no code is available use nullFlavor="OTH" and enter the value as free text in code/originalText. 7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from CodeSystem ICD10 (urn:oid:2.16.840.1.113883.6.3) (CONF:1106-636). a. This value MAY contain zero or one [0..1] @nullFlavor="OTH" (CONF:1106-859). b. This value MAY contain zero or one [0..1] originalText (CONF:1106-861). c. Value MAY be selected from ICD-9/10/CM (based on the current version in US realm) (CONF:1106-860). Figure 52: Cause of Injury, Poisoning, or Adverse Effect (Free Text) Example Husband put arsenic in patient's tea Figure 53: Cause of Injury, Poisoning, or Adverse Effect (Coded) Example Attachment G- EHR Implementation Guide Templates 3.8 Characteristics of Home Environment [observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.109 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 92: Characteristics of Home Environment Contexts Contained By: Contains: Social History Section (V2) (optional) This template represents the patient's home environment including, but not limited to, type of residence (trailer, single family home, assisted living), living arrangement (e.g., alone, with parents), and housing status (e.g., evicted, homeless, home owner). Table 93: Characteristics of Home Environment Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.109) @classCode 1..1 SHALL 109827890 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 109827891 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 109827892 1..1 SHALL 109827893 id 1..* SHALL 109827894 code 1..1 SHALL 109831352 @code 1..1 SHALL 109831353 75274-1 @codeSystem 1..1 SHALL 109831354 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 109827901 1..1 SHALL 109827902 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1..1 SHALL 109828823 urn:oid:2.16.840.1.113883.11.20. 9.49 (Residence and Accommodation Type) @root statusCode @code value CD 2.16.840.1.113883.10.20.22.4.10 9 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-27890). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-27891). Attachment G- EHR Implementation Guide Templates 3. SHALL contain exactly one [1..1] templateId (CONF:1098-27892) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.109" (CONF:1098-27893). 4. SHALL contain at least one [1..*] id (CONF:1098-27894). 5. SHALL contain exactly one [1..1] code (CONF:1098-31352). a. This code SHALL contain exactly one [1..1] @code="75274-1" Characteristics of residence (CONF:1098-31353). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-31354). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-27901). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109827902). 7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Residence and Accommodation Type urn:oid:2.16.840.1.113883.11.20.9.49 DYNAMIC (CONF:1098-28823). Table 94: Residence and Accommodation Type Value Set: Residence and Accommodation Type urn:oid:2.16.840.1.113883.11.20.9.49 A value set of SNOMED-CT codes descending from "365508006" "Residence and accommodation circumstances - finding" reflecting type of residence, status of accommodations, living situation and environment. Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.113883.11.20.9.49 Code Code System Code System OID Print Name 424661000 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 cluttered living space (finding) 160708008 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 stairs in house (finding) 160751007 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 eviction from dwelling (finding) 423859003 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 crowded living space (finding) 160720000 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 harassment by landlord (finding) 105529008 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 lives alone (finding) 60585007 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 slum area living (finding) 365508006 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 unsatisfactory living conditions (finding) 422491004 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 housing contains exposed wiring (finding) ... Attachment G- EHR Implementation Guide Templates Figure 54: Characteristics of Home Environment Example 3.9 Clinical Note and External Document Reference [externalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.44:201607-01 (open)] Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm Table 95: Clinical Note and External Document Reference Contexts Contained By: Contains: Current Outpatient Visit (V3) (optional) Current Emergency Department Visit (V2) (optional) This template represents relevant clinical (e.g., physicians', nurses', P.A.s', N.P.s' and C.N.M.s') notes for this visit, such as Triage, Intake, History of Present Illness, Clinical Impression and Discharge. If the current visit is the result of a referral, the referral document can be referenced using this template. These notes or documents can be CDA documents or they can be other types of documents such as PDF. The following (non-exhaustive) table lists some LOINC code examples for relevant document types: Document type LOINC code History of Present Illness Narrative 10164-2 Evaluation and Plan Note 51847-2 Evaluation Note 51848-0 Hospital Discharge Dx Narrative 11535-2 Reason for Visit Narrative 29299-5 Referral Note 57113-1 Attachment G- EHR Implementation Guide Templates Table 96: Clinical Note and External Document Reference Constraints Overview XPath Card. Verb Data Type CONF# Value externalDocument (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.44:2016-07-01) @classCode 1..1 SHALL 32561189 @moodCode 1..1 SHALL 32561178 templateId 1..1 SHALL 32561176 @root 1..1 SHALL 32561180 2.16.840.1.113883.10.20.34.3.44 @extension 1..1 SHALL 32561181 2016-07-01 id 1..* SHALL 32561182 code 0..1 MAY 32561179 text 0..1 MAY 32561185 @mediaType 1..1 SHALL 32561187 reference 0..1 MAY 32561186 @value 1..1 SHALL 32561188 setId 0..1 MAY 32561183 versionNumber 0..1 MAY 32561184 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN If referencing a CDA document use DOCCLIN, otherwise use DOC. 1. SHALL contain exactly one [1..1] @classCode (CONF:3256-1189). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:3256-1178). 3. SHALL contain exactly one [1..1] templateId (CONF:3256-1176) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.44" (CONF:3256-1180). b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-1181). 4. SHALL contain at least one [1..*] id (CONF:3256-1182). The code represents the type of document. Either a code and/or text description should be used to describe the external document. 5. MAY contain zero or one [0..1] code (CONF:3256-1179). 6. MAY contain zero or one [0..1] text (CONF:3256-1185). Attachment G- EHR Implementation Guide Templates a. The text, if present, SHALL contain exactly one [1..1] @mediaType (CONF:3256-1187). b. The text, if present, MAY contain zero or one [0..1] reference (CONF:3256-1186). i. The reference, if present, SHALL contain exactly one [1..1] @value (CONF:3256-1188). 7. MAY contain zero or one [0..1] setId (CONF:3256-1183). 8. MAY contain zero or one [0..1] versionNumber (CONF:3256-1184). Figure 55: Clinical Note and External Document Reference - Non-CDA Example Figure 56: Clinical Note and External Document Reference - CDA Document (Referral) Example 3.10 Co-morbid Condition Observation (RETIRED) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.4:2016-07-01 (open)] Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm This template represents a co-morbid condition. Retired as per STU Comment: http://www.hl7.org/dstucomments/showdetail_comment.cfm?commentid=921 Attachment G- EHR Implementation Guide Templates Co-morbid conditions are now represented using the Problem/Diagnosis/Symptom/Condition Observation. Table 97: Co-morbid Condition Observation (RETIRED) Constraints Overview X Card. P a t h Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.4:2016-07-01) Figure 57: Co-morbid Condition Observation (V2) Example ... Attachment G- EHR Implementation Guide Templates 3.11 Condition Control Observation [observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.21 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm This template represents the degree to which the manifestations of the condition are minimized by therapeutic interventions. Care should be taken to ensure that the identified level of control does not conflict with the SNOMED/ICD diagnosis code. Table 98: Condition Control Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.21) @classCode 1..1 SHALL 1106234 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1106235 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106236 1..1 SHALL 1106237 id 1..* SHALL 1106238 code 1..1 SHALL 1106239 1..1 SHALL 1106240 1..1 SHALL 1106241 1..1 SHALL 1106242 1..1 SHALL 1..1 SHALL @root @code statusCode @code value @code CD 2.16.840.1.113883.10.20.34.3.21 urn:oid:2.16.840.1.113883.5.4 (ActCode) = ASSERTION urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1106243 1106389 urn:oid:2.16.840.1.114222.4.11.7 433 (Condition Control (NCHS)) 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-234). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-235). 3. SHALL contain exactly one [1..1] templateId (CONF:1106-236) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.21" (CONF:1106-237). 4. SHALL contain at least one [1..*] id (CONF:1106-238). 5. SHALL contain exactly one [1..1] code (CONF:1106-239). Attachment G- EHR Implementation Guide Templates a. This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion (CodeSystem: ActCode urn:oid:2.16.840.1.113883.5.4) (CONF:1106-240). 6. SHALL contain exactly one [1..1] statusCode (CONF:1106-241). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-242). 7. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:1106-243). a. This value SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Condition Control (NCHS) urn:oid:2.16.840.1.114222.4.11.7433 DYNAMIC (CONF:1106-389). Table 99: Condition Control (NCHS) Value Set: Condition Control (NCHS) urn:oid:2.16.840.1.114222.4.11.7433 Descendants of Disease Condition Finding (371314008) in SNOMED CT Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7433 Code Code System Code System OID Print Name 67106002 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Condition determination, moderately controlled 12650007 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Condition determination, fairly well controlled 39431006 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Condition determination, slightly controlled 28876000 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Condition determination, uncontrolled 1194003 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Condition determination, well controlled 2761002 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Condition determination, arrested 51231003 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Condition determination, cured Figure 58: Condition Control Observation Example Attachment G- EHR Implementation Guide Templates 3.12 Coverage Activity (V2) [act: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.60:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 100: Coverage Activity (V2) Contexts Contained By: Contains: Payers Section (V2) (optional) Policy Activity (V2) A Coverage Activity groups the policy and authorization acts within a Payers Section to order the payment sources. A Coverage Activity contains one or more Policy Activities, each of which contains zero or more Authorization Activities. The Coverage Activity id is the ID from the patient's insurance card. The sequenceNumber/@value shows the policy order of preference. Attachment G- EHR Implementation Guide Templates Table 101: Coverage Activity (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value act (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.60:2014-06-09) @classCode 1..1 SHALL 10988872 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode 1..1 SHALL 10988873 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 10988897 @root 1..1 SHALL 109810492 2.16.840.1.113883.10.20.22.4.60 @extension 1..1 SHALL 109832596 2014-06-09 id 1..* SHALL 10988874 code 1..1 SHALL 10988876 @code 1..1 SHALL 109819160 48768-6 @codeSystem 1..1 SHALL 109832156 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 10988875 1..1 SHALL 109819094 1..* SHALL 10988878 @typeCode 1..1 SHALL 10988879 sequenceNumber 0..1 MAY 109817174 1..1 SHALL 109817175 1..1 SHALL 109815528 statusCode @code entryRelationship @value act urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = COMP Policy Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.61:2014-06-09 1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8872). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-8873). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-8897) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.60" (CONF:1098-10492). Attachment G- EHR Implementation Guide Templates b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32596). 4. SHALL contain at least one [1..*] id (CONF:1098-8874). 5. SHALL contain exactly one [1..1] code (CONF:1098-8876). a. This code SHALL contain exactly one [1..1] @code="48768-6" Payment sources (CONF:1098-19160). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-32156). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-8875). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819094). 7. SHALL contain at least one [1..*] entryRelationship (CONF:1098-8878) 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 STATIC) (CONF:1098-8879). b. MAY contain zero or one [0..1] sequenceNumber (CONF:1098-17174). i. The sequenceNumber, if present, SHALL contain exactly one [1..1] @value (CONF:1098-17175). c. SHALL contain exactly one [1..1] Policy Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.61:2014-06-09) (CONF:109815528). Figure 59: Coverage Activity (V2) Example . . . Attachment G- EHR Implementation Guide Templates 3.13 Cultural and Religious Observation [observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.111 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 102: Cultural and Religious Observation Contexts Contained By: Contains: Social History Section (V2) (optional) This template represents a patient’s spiritual, religious, and cultural belief practices, such as a kosher diet or fasting ritual. religiousAffiliationCode in the document header captures only the patient’s religious affiliation. Table 103: Cultural and Religious Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.111) @classCode 1..1 SHALL 109827924 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 109827925 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 109827926 1..1 SHALL 109827927 id 1..* SHALL 109827928 code 1..1 SHALL 109827929 @code 1..1 SHALL 109827930 75281-6 @codeSystem 1..1 SHALL 109827931 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 109827936 1..1 SHALL 109827937 1..1 SHALL 109828442 @root statusCode @code value 2.16.840.1.113883.10.20.22.4.11 1 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-27924). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-27925). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-27926) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.111" (CONF:1098-27927). 4. SHALL contain at least one [1..*] id (CONF:1098-27928). 5. SHALL contain exactly one [1..1] code (CONF:1098-27929). a. This code SHALL contain exactly one [1..1] @code="75281-6" Personal belief (CONF:1098-27930). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-27931). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-27936). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109827937). 7. SHALL contain exactly one [1..1] value (CONF:1098-28442). a. If xsi:type is CD, SHALL contain exactly one 1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMEDCT urn:oid:2.16.840.1.113883.6.96 STATIC) (CONF:1098-32487). Figure 60: Cultural and Religious Observation Example Does not accept blood transfusions, or donates, or stores blood for transfusion. 3.14 Discharge Status Observation [observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.28 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 104: Discharge Status Observation Contexts Contained By: Hospital Admission Encounter (required) Contains: Attachment G- EHR Implementation Guide Templates This template represents the patient's status at time of discharge. If the status is unknown use nullFlavor="UNK". Table 105: Discharge Status Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.28) @classCode 1..1 SHALL 1106685 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1106686 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106687 1..1 SHALL 1106688 id 1..* SHALL 1106689 code 1..1 SHALL 1106690 @code 1..1 SHALL 1106691 75527-2 @codeSystem 1..1 SHALL 1106692 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 1106693 1..1 SHALL 1106694 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1..1 SHALL 1106695 urn:oid:2.16.840.1.114222.4.11.7 440 (Hospital Discharge Status (NCHS)) 0..1 MAY 1106696 UNK @root statusCode @code value @nullFlavor CD 2.16.840.1.113883.10.20.34.3.28 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-685). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-686). 3. SHALL contain exactly one [1..1] templateId (CONF:1106-687) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.28" (CONF:1106-688). 4. SHALL contain at least one [1..*] id (CONF:1106-689). 5. SHALL contain exactly one [1..1] code (CONF:1106-690). a. This code SHALL contain exactly one [1..1] @code="75527-2" Vital status at discharge (CONF:1106-691). Attachment G- EHR Implementation Guide Templates b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1106-692). 6. SHALL contain exactly one [1..1] statusCode (CONF:1106-693). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-694). 7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Hospital Discharge Status (NCHS) urn:oid:2.16.840.1.114222.4.11.7440 DYNAMIC (CONF:1106-695). a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" Unknown (CONF:1106-696). Table 106: Hospital Discharge Status (NCHS) Value Set: Hospital Discharge Status (NCHS) urn:oid:2.16.840.1.114222.4.11.7440 This value set represents the patient's status at discharge. Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7440 Code Code System Code System OID Print Name 371827001 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Patient discharged alive 371828006 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Patient deceased during stay (discharge status = dead) ... Figure 61: Discharge Status Observation Example Attachment G- EHR Implementation Guide Templates 3.15 Drug Monitoring Act [act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.123 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 107: Drug Monitoring Act Contexts Contained By: Contains: Medication Activity (V2) (optional) US Realm Patient Name (PTN.US.FIELDED) This template represents the act of monitoring the patient's medication and includes a participation to record the person responsible for monitoring the medication. The prescriber of the medication is not necessarily the same person or persons monitoring the drug. The effectiveTime indicates the time when the activity is intended to take place. For example, a cardiologist may prescribe a patient Warfarin. The patient's primary care provider may monitor the patient's INR and adjust the dosing of the Warfarin based on these lab results. Here the person designated to monitor the drug is the primary care provider. Attachment G- EHR Implementation Guide Templates Table 108: Drug Monitoring Act Constraints Overview XPath Card. Verb Data Type CONF# Value act (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.123) @classCode 1..1 SHALL 109830823 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode 1..1 SHALL 109828656 INT templateId 1..1 SHALL 109828657 1..1 SHALL 109828658 id 1..* SHALL 109831920 code 1..1 SHALL 109828660 @code 1..1 SHALL 109830818 395170001 @codeSystem 1..1 SHALL 109830819 urn:oid:2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96 1..1 SHALL 109831921 1..1 SHALL 109832358 effectiveTime 1..1 SHALL 109831922 participant 1..* SHALL 109828661 @typeCode 1..1 SHALL 109828663 participantRole 1..1 SHALL 109828662 @classCode 1..1 SHALL 109828664 id 1..* SHALL 109828665 playingEntity 1..1 SHALL 109828667 @classCode 1..1 SHALL 109828668 PSN name 1..1 SHALL 109828669 US Realm Patient Name (PTN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20. 22.5.1 @root statusCode @code 2.16.840.1.113883.10.20.22.4.12 3 urn:oid:2.16.840.1.113883.1.11.1 59331 (ActStatus) RESP ASSIGNED Attachment G- EHR Implementation Guide Templates 1. SHALL contain exactly one [1..1] @classCode="ACT" act (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1098-30823). 2. SHALL contain exactly one [1..1] @moodCode="INT" (CONF:1098-28656). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-28657) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.123" (CONF:1098-28658). 4. SHALL contain at least one [1..*] id (CONF:1098-31920). 5. SHALL contain exactly one [1..1] code (CONF:1098-28660). a. This code SHALL contain exactly one [1..1] @code="395170001" medication monitoring (regime/therapy) (CONF:1098-30818). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT urn:oid:2.16.840.1.113883.6.96) (CONF:1098-30819). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-31921). a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ActStatus urn:oid:2.16.840.1.113883.1.11.159331 DYNAMIC (CONF:1098-32358). 7. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-31922). 8. SHALL contain at least one [1..*] participant (CONF:1098-28661) such that it a. SHALL contain exactly one [1..1] @typeCode="RESP" (CONF:1098-28663). b. SHALL contain exactly one [1..1] participantRole (CONF:1098-28662). i. This participantRole SHALL contain exactly one [1..1] @classCode="ASSIGNED" (CONF:1098-28664). ii. This participantRole SHALL contain at least one [1..*] id (CONF:1098-28665). iii. This participantRole SHALL contain exactly one [1..1] playingEntity (CONF:1098-28667). 1. This playingEntity SHALL contain exactly one [1..1] @classCode="PSN" (CONF:1098-28668). 2. This playingEntity SHALL contain exactly one [1..1] US Realm Patient Name (PTN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1) (CONF:1098-28669). Attachment G- EHR Implementation Guide Templates Table 109: ActStatus Value Set: ActStatus urn:oid:2.16.840.1.113883.1.11.159331 Contains the names (codes) for each of the states in the state-machine of the RIM Act class. Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid= 2.16.840.1.113883.1.11.15933 Code Code System Code System OID Print Name normal ActStatus urn:oid:2.16.840.1.11388 3.5.14 normal aborted ActStatus urn:oid:2.16.840.1.11388 3.5.14 aborted active ActStatus urn:oid:2.16.840.1.11388 3.5.14 active cancelled ActStatus urn:oid:2.16.840.1.11388 3.5.14 cancelled completed ActStatus urn:oid:2.16.840.1.11388 3.5.14 completed held ActStatus urn:oid:2.16.840.1.11388 3.5.14 held new ActStatus urn:oid:2.16.840.1.11388 3.5.14 new suspended ActStatus urn:oid:2.16.840.1.11388 3.5.14 suspended nullified ActStatus urn:oid:2.16.840.1.11388 3.5.14 nullified obsolete ActStatus urn:oid:2.16.840.1.11388 3.5.14 obsolete Attachment G- EHR Implementation Guide Templates Figure 62: Drug Monitoring Act Example Listener Larry DR 3.16 Drug Vehicle [participantRole: identifier urn:oid:2.16.840.1.113883.10.20.22.4.24 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R1.1 Table 110: Drug Vehicle Contexts Contained By: Contains: Medication Activity (V2) (optional) Immunization Activity (V2) (optional) This template represents the vehicle (e.g., saline, dextrose) for administering a medication. Attachment G- EHR Implementation Guide Templates Table 111: Drug Vehicle Constraints Overview XPath Card. Verb Data Type CONF# Value participantRole (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.24) @classCode 1..1 SHALL 817490 templateId 1..1 SHALL 817495 1..1 SHALL 8110493 1..1 SHALL 8119137 @code 1..1 SHALL 8119138 412307009 @codeSystem 1..1 SHALL 8126502 urn:oid:2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96 1..1 SHALL 817492 code 1..1 SHALL 817493 name 0..1 MAY 817494 @root code playingEntity urn:oid:2.16.840.1.113883.5.110 (RoleClass) = MANU 2.16.840.1.113883.10.20.22.4.24 1. SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110 STATIC) (CONF:81-7490). 2. SHALL contain exactly one [1..1] templateId (CONF:81-7495) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.24" (CONF:81-10493). 3. SHALL contain exactly one [1..1] code (CONF:81-19137). a. This code SHALL contain exactly one [1..1] @code="412307009" Drug Vehicle (CONF:81-19138). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT urn:oid:2.16.840.1.113883.6.96) (CONF:81-26502). 4. SHALL contain exactly one [1..1] playingEntity (CONF:81-7492). This playingEntity/code is used to supply a coded term for the drug vehicle. a. This playingEntity SHALL contain exactly one [1..1] code (CONF:81-7493). b. This playingEntity MAY contain zero or one [0..1] name (CONF:81-7494). i. This playingEntity/name MAY be used for the vehicle name in text, such as Normal Saline (CONF:81-10087). Attachment G- EHR Implementation Guide Templates Figure 63: Drug Vehicle Example Aerosol 3.17 Encounter Activity (V2) [encounter: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 112: Encounter Activity (V2) Contexts Contained By: Contains: Encounters Section (entries optional) (V2) (optional) Encounter Diagnosis (V2) Indication (V2) Service Delivery Location This clinical statement describes an interaction between a patient and clinician. Interactions may include in-person encounters, telephone conversations, and email exchanges. Attachment G- EHR Implementation Guide Templates Table 113: Encounter Activity (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value encounter (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09) @classCode 1..1 SHALL 10988710 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ENC @moodCode 1..1 SHALL 10988711 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 10988712 @root 1..1 SHALL 109826353 2.16.840.1.113883.10.20.22.4.49 @extension 1..1 SHALL 109832546 2014-06-09 id 1..* SHALL 10988713 code 1..1 SHALL 10988714 originalText 0..1 SHOUL D 10988719 reference 0..1 SHOUL D 109815970 @value 0..1 SHOUL D 109815971 translation 0..1 MAY 109832323 effectiveTime 1..1 SHALL 10988715 sdtc:dischargeDispositionCode 0..1 MAY 109832176 performer 0..* MAY 10988725 1..1 SHALL 10988726 code 0..1 MAY 10988727 participant 0..* SHOUL D 10988738 @typeCode 1..1 SHALL 10988740 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = LOC participantRole 1..1 SHALL 109814903 Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.32 entryRelationship 0..* MAY 1098- assignedEntity urn:oid:2.16.840.1.113883.3.88.1 2.80.32 (EncounterTypeCode) urn:oid:2.16.840.1.114222.4.11.1 066 (Healthcare Provider Taxonomy (HIPAA)) Attachment G- EHR Implementation Guide Templates 8722 @typeCode 1..1 SHALL 10988723 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = RSON observation 1..1 SHALL 109814899 Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.19:2014-06-09 0..* MAY 109815492 1..1 SHALL 109815973 entryRelationship act Encounter Diagnosis (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.80:2014-06-09 1. SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8710). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-8711). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-8712) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.49" (CONF:1098-26353). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32546). 4. SHALL contain at least one [1..*] id (CONF:1098-8713). 5. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet EncounterTypeCode urn:oid:2.16.840.1.113883.3.88.12.80.32 DYNAMIC (CONF:1098-8714). a. This code SHOULD contain zero or one [0..1] originalText (CONF:1098-8719). i. The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:1098-15970). 1. The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:1098-15971). a. This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:109815972). The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) valueset to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) valueset. b. This code MAY contain zero or one [0..1] translation (CONF:1098-32323). 6. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-8715). 7. MAY contain zero or one [0..1] sdtc:dischargeDispositionCode (CONF:1098-32176). Note: The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the dischargeDispositionCode element Attachment G- EHR Implementation Guide Templates a. 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:1098-32177). 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:109832377). 8. MAY contain zero or more [0..*] performer (CONF:1098-8725). a. The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1098-8726). i. This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1098-8727). 9. SHOULD contain zero or more [0..*] participant (CONF:1098-8738) such that it a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8740). b. SHALL contain exactly one [1..1] Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:1098-14903). 10. MAY contain zero or more [0..*] entryRelationship (CONF:1098-8722) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8723). b. SHALL contain exactly one [1..1] Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109814899). 11. MAY contain zero or more [0..*] entryRelationship (CONF:1098-15492) such that it a. SHALL contain exactly one [1..1] Encounter Diagnosis (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.80:2014-06-09) (CONF:109815973). Attachment G- EHR Implementation Guide Templates Table 114: EncounterTypeCode 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/ Code Code System Code System OID Print Name 99201 CPT4 urn:oid:2.16.840.1.11388 3.6.12 Office or other outpatient visit (problem focused) 99202 CPT4 urn:oid:2.16.840.1.11388 3.6.12 Office or other outpatient visit (expanded problem (expanded) 99203 CPT4 urn:oid:2.16.840.1.11388 3.6.12 Office or other outpatient visit (detailed) 99204 CPT4 urn:oid:2.16.840.1.11388 3.6.12 Office or other outpatient visit (comprehensive, (comprehensive moderate) 99205 CPT4 urn:oid:2.16.840.1.11388 3.6.12 Office or other outpatient visit (comprehensive, comprehensive-high) 19681004 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Nursing evaluation of patient and report (procedure) 207195004 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 History and physical examination with evaluation and management of nursing facility patient (procedure) 209099002 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 History and physical examination with management of domiciliary or rest home patient (procedure) 210098006 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Domiciliary or rest home patient evaluation and management (procedure) 225929007 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Joint home visit (procedure) ... Attachment G- EHR Implementation Guide Templates Figure 64: Encounter Activity (V2) Example . . . . . . . . . Attachment G- EHR Implementation Guide Templates 3.17.1 Current Emergency Department Visit (V2) [encounter: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.40:2016-07-01 (open)] Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm Table 115: Current Emergency Department Visit (V2) Contexts Contained By: Contains: Emergency Department Encounters Section (V2) (required) Clinical Note and External Document Reference Episode of Care Observation (V2) Major Reason for Visit Patient Seen in this ED in last 72 Hours and Discharged Point of Origin Observation Transport Mode to Hospital Observation This template represents the patient's current emergency department visit. The major reason for this visit is represented by the Major Reason for this Visit template. To indicate whether this is an initial or follow-up visit use the Episode of Care template. The method of transport to the hospital is recorded in the Transport Mode to Hospital Observation. The point of origin of the patient is entered in the Point of Origin Observation template. The Clinical Note and External Document Reference template is used to record clinician notes (e.g., physicians', nurses', P.A.s', N.P.s' and C.N.M.s' notes) such as Triage, Intake, History of Present Illness, Clinical Impression and Discharge. Attachment G- EHR Implementation Guide Templates Table 116: Current Emergency Department Visit (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value encounter (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.40:2016-07-01) @classCode 1..1 SHALL 32561036 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ENC @moodCode 1..1 SHALL 32561037 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 3256997 @root 1..1 SHALL 32561010 2.16.840.1.113883.10.20.34.3.40 @extension 1..1 SHALL 32561011 2016-07-01 1..1 SHALL 32561006 @code 1..1 SHALL 32561038 EMER @codeSystem 1..1 SHALL 32561039 urn:oid:2.16.840.1.113883.5.4 (ActCode) = 2.16.840.1.113883.5.4 entryRelationship 0..1 MAY 3256999 @typeCode 1..1 SHALL 32561016 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = RSON observation 1..1 SHALL 32561015 Major Reason for Visit (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.7 0..1 MAY 32561001 @typeCode 1..1 SHALL 32561021 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 32561115 Episode of Care Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.32:2015-04-01 0..1 MAY 32561002 @typeCode 1..1 SHALL 32561024 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 32561025 Transport Mode to Hospital Observation (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.24 0..1 MAY 3256- code entryRelationship entryRelationship entryRelationship Attachment G- EHR Implementation Guide Templates 1003 @typeCode 1..1 SHALL 32561027 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 32561028 Patient Seen in this ED in last 72 Hours and Discharged (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.31 0..1 MAY 32561005 @typeCode 1..1 SHALL 32561033 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 32561034 Point of Origin Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.36:2015-04-01 0..* MAY 32561155 @typeCode 1..1 SHALL 32561156 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR externalDocument 1..1 SHALL 32561157 Clinical Note and External Document Reference (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.44:2016-07-01 entryRelationship reference 1. Conforms to Encounter Activity (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:3256-1036). 3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:3256-1037). 4. SHALL contain exactly one [1..1] templateId (CONF:3256-997) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.40" (CONF:3256-1010). b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-1011). 5. SHALL contain exactly one [1..1] code (CONF:3256-1006). a. This code SHALL contain exactly one [1..1] @code="EMER" Emergency (CONF:32561038). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode urn:oid:2.16.840.1.113883.5.4) (CONF:3256-1039). 6. MAY contain zero or one [0..1] entryRelationship (CONF:3256-999) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:32561016). Attachment G- EHR Implementation Guide Templates b. SHALL contain exactly one [1..1] Major Reason for Visit (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.7) (CONF:3256-1015). Note: Major Reason for This Visit 7. MAY contain zero or one [0..1] entryRelationship (CONF:3256-1001) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:32561021). b. SHALL contain exactly one [1..1] Episode of Care Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.32:2015-04-01) (CONF:3256-1115). 8. MAY contain zero or one [0..1] entryRelationship (CONF:3256-1002) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:32561024). b. SHALL contain exactly one [1..1] Transport Mode to Hospital Observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.24) (CONF:32561025). Note: Mode of arrival 9. MAY contain zero or one [0..1] entryRelationship (CONF:3256-1003) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:32561027). b. SHALL contain exactly one [1..1] Patient Seen in this ED in last 72 Hours and Discharged (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.31) (CONF:3256-1028). Note: Was this patient seen in this ED and discharged in the prior 72 hours? 10. MAY contain zero or one [0..1] entryRelationship (CONF:3256-1005) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:32561033). b. SHALL contain exactly one [1..1] Point of Origin Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.36:2015-04-01) (CONF:32561034). Note: Point of Origin 11. MAY contain zero or more [0..*] reference (CONF:3256-1155). a. The reference, if present, SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:3256-1156). b. The reference, if present, SHALL contain exactly one [1..1] Clinical Note and External Document Reference (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.44:2016-07-01) (CONF:32561157). Attachment G- EHR Implementation Guide Templates Figure 65: Current Emergency Department Visit (V2) Example ... ... ... ... Attachment G- EHR Implementation Guide Templates ... ... 3.17.2 Current Inpatient Visit [encounter: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.39:2015-04-01 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US Realm Table 117: Current Inpatient Visit Contexts Contained By: Contains: Inpatient Encounters Section (V2) (optional) Admission Priority Observation Point of Origin Observation This template represents the patient's current inpatient visit to the facility. The priority level of the admission is indicated using the Admission Priority Observation template and the point of origin of the patient is entered in the Point of Origin Observation template. Attachment G- EHR Implementation Guide Templates Table 118: Current Inpatient Visit Constraints Overview XPath Card. Verb Data Type CONF# Value encounter (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.39:2015-04-01) @classCode 1..1 SHALL 1184983 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ENC @moodCode 1..1 SHALL 1184984 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1184949 @root 1..1 SHALL 1184961 2.16.840.1.113883.10.20.34.3.39 @extension 1..1 SHALL 1184989 2015-04-01 1..1 SHALL 1184988 @code 1..1 SHALL 1184990 IMP @codeSystem 1..1 SHALL 1184991 urn:oid:2.16.840.1.113883.5.4 (ActCode) = 2.16.840.1.113883.5.4 entryRelationship 0..1 MAY 1184956 @typeCode 1..1 SHALL 1184980 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 1184981 Admission Priority Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.35:2015-04-01 0..1 MAY 1184957 @typeCode 1..1 SHALL 1184985 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 1184986 Point of Origin Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.36:2015-04-01 code entryRelationship 1. Conforms to Encounter Activity (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1184-983). 3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-984). 4. SHALL contain exactly one [1..1] templateId (CONF:1184-949) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.39" (CONF:1184-961). b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-989). 5. SHALL contain exactly one [1..1] code (CONF:1184-988). a. This code SHALL contain exactly one [1..1] @code="IMP" Inpatient (CONF:1184-990). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode urn:oid:2.16.840.1.113883.5.4) (CONF:1184-991). 6. MAY contain zero or one [0..1] entryRelationship (CONF:1184-956) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1184980). b. SHALL contain exactly one [1..1] Admission Priority Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.35:2015-04-01) (CONF:1184-981). Note: Admission priority 7. MAY contain zero or one [0..1] entryRelationship (CONF:1184-957) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1184985). b. SHALL contain exactly one [1..1] Point of Origin Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.36:2015-04-01) (CONF:1184-986). Note: Point of Origin Attachment G- EHR Implementation Guide Templates Figure 66: Current Inpatient Visit Example ... ... Attachment G- EHR Implementation Guide Templates 3.17.3 Current Outpatient Visit (V3) [encounter: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.10:2016-07-01 (open)] Draft as part of National Health Care Surveys Release 1, DSTU Release 1.2 US Realm Table 119: Current Outpatient Visit (V3) Contexts Contained By: Contains: Outpatient Encounters Section (V3) (required) Clinical Note and External Document Reference Episode of Care Observation (V2) Major Reason for Visit New Patient Act Number of Visits in the Last 12 Months Procedure Follow-Up Attempt Observation This template represents the patient's current outpatient visit to the facility. If the current visit is the result of a referral, the referral document is referenced through the Clinical Note and External Document Reference template. If the patient is an established patient, then a count of all visits in the last 12 months (excluding this visit) is entered in the Number of Visits in the Last 12 Months template. If the patient is a new patient, this is indicated using the New Patient Act template. The major reason for this visit is represented by the Major Reason for this Visit template. To indicate whether this is an initial or follow-up visit use the Episode of Care template. Information about follow-up after surgery is contained in the Procedure Follow-up Attempt Observation template. Attachment G- EHR Implementation Guide Templates Table 120: Current Outpatient Visit (V3) Constraints Overview XPath Card. Verb Data Type CONF# Value encounter (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.10:2016-07-01) @classCode 1..1 SHALL 3256463 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ENC @moodCode 1..1 SHALL 3256464 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 3256465 @root 1..1 SHALL 3256466 2.16.840.1.113883.10.20.34.3.10 @extension 1..1 SHALL 3256993 2016-07-01 1..1 SHALL 3256992 @code 1..1 SHALL 3256994 AMB @codeSystem 1..1 SHALL 3256995 urn:oid:2.16.840.1.113883.5.4 (ActCode) = 2.16.840.1.113883.5.4 entryRelationship 0..1 MAY 3256469 @typeCode 1..1 SHALL 3256474 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 3256470 Number of Visits in the Last 12 Months (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.26 0..1 MAY 3256471 @typeCode 1..1 SHALL 3256475 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = RSON observation 1..1 SHALL 3256472 Major Reason for Visit (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.7 0..1 MAY 3256484 @typeCode 1..1 SHALL 3256485 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR act 1..1 SHALL 3256486 New Patient Act (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.9 0..1 MAY 3256747 code entryRelationship entryRelationship entryRelationship Attachment G- EHR Implementation Guide Templates @typeCode 1..1 SHALL 3256748 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 32561063 Episode of Care Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.32:2015-04-01 0..1 MAY 32561152 @typeCode 1..1 SHALL 32561153 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 32561154 Procedure Follow-Up Attempt Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.42:2015-04-01 0..* MAY 32561158 @typeCode 1..1 SHALL 32561159 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR externalDocument 1..1 SHALL 32561160 Clinical Note and External Document Reference (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.44:2016-07-01 entryRelationship reference 1. Conforms to Encounter Activity (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:3256-463). 3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:3256-464). 4. SHALL contain exactly one [1..1] templateId (CONF:3256-465) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.10" (CONF:3256-466). b. SHALL contain exactly one [1..1] @extension="2016-07-01" (CONF:3256-993). 5. SHALL contain exactly one [1..1] code (CONF:3256-992). a. This code SHALL contain exactly one [1..1] @code="AMB" Ambulatory (outpatient) (CONF:3256-994). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode urn:oid:2.16.840.1.113883.5.4) (CONF:3256-995). 6. MAY contain zero or one [0..1] entryRelationship (CONF:3256-469) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:3256474). Attachment G- EHR Implementation Guide Templates b. SHALL contain exactly one [1..1] Number of Visits in the Last 12 Months (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.26) (CONF:3256-470). Note: Number of Past Visits in the Last 12 Months 7. MAY contain zero or one [0..1] entryRelationship (CONF:3256-471) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:3256475). b. SHALL contain exactly one [1..1] Major Reason for Visit (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.7) (CONF:3256-472). Note: Major Reason for This Visit 8. MAY contain zero or one [0..1] entryRelationship (CONF:3256-484) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:3256485). b. SHALL contain exactly one [1..1] New Patient Act (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.9) (CONF:3256-486). Note: Has patient been seen in clinic/location before 9. MAY contain zero or one [0..1] entryRelationship (CONF:3256-747) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:3256748). b. SHALL contain exactly one [1..1] Episode of Care Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.32:2015-04-01) (CONF:3256-1063). Note: Initial or follow-up visit 10. MAY contain zero or one [0..1] entryRelationship (CONF:3256-1152) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:32561153). b. SHALL contain exactly one [1..1] Procedure Follow-Up Attempt Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.42:2015-04-01) (CONF:3256-1154). 11. MAY contain zero or more [0..*] reference (CONF:3256-1158). a. The reference, if present, SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:3256-1159). b. The reference, if present, SHALL contain exactly one [1..1] Clinical Note and External Document Reference (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.44:2016-07-01) (CONF:32561160). Attachment G- EHR Implementation Guide Templates Figure 67: Current Outpatient Visit (V3) Example ... ... ... ... ... Attachment G- EHR Implementation Guide Templates ... 3.17.4 Hospital Admission Encounter [encounter: identifier urn:oid:2.16.840.1.113883.10.20.34.3.18 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 121: Hospital Admission Encounter Contexts Contained By: Contains: Emergency Department Encounters Section (V2) (optional) Discharge Status Observation Hospital Discharge Diagnosis (V2) Listed for Admission to Hospital Act Service Delivery Location This template represents the encounter when the patient was admitted to hospital this ED visit. If efforts have been exhausted to collect the data, set the appropriate nullFlavor to "UNK". Attachment G- EHR Implementation Guide Templates Table 122: Hospital Admission Encounter Constraints Overview XPath Card. Verb Data Type CONF# Value encounter (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.18) @classCode 1..1 SHALL 1106540 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ENC @moodCode 1..1 SHALL 1106541 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106532 1..1 SHALL 1106542 1..1 SHALL 1106533 @code 1..1 SHALL 1106543 32485007 @codeSystem 1..1 SHALL 1106544 urn:oid:2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96 1..1 SHALL 1106534 low 1..1 SHALL 1106545 high 1..1 SHALL 1106546 sdtc:dischargeDispositionCode 0..1 SHOUL D 1106548 participant 1..1 SHALL 1106531 @typeCode 1..1 SHALL 1106547 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = LOC participantRole 1..1 SHALL 1106539 Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.32 1..1 SHALL 1106536 @typeCode 1..1 SHALL 1106551 participantRole 1..1 SHALL 1106537 @classCode 0..1 MAY 1106552 urn:oid:2.16.840.1.113883.5.110 (RoleClass) = ASSIGNED code 1..1 SHALL 1106553 urn:oid:2.16.840.1.114222.4.11.1 066 (Healthcare Provider Taxonomy (HIPAA)) @root code effectiveTime participant 2.16.840.1.113883.10.20.34.3.18 urn:oid:2.16.840.1.114222.4.11.7 436 (Disposition (NCHS)) urn:oid:2.16.840.1.113883.5.90 (HL7ParticipationType) = ADM Attachment G- EHR Implementation Guide Templates entryRelationship 1..1 SHALL 1106535 @typeCode 1..1 SHALL 1106550 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = COMP act 1..1 SHALL 1106549 Hospital Discharge Diagnosis (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.33:2014-06-09 1..1 SHALL @typeCode 1..1 SHALL 1106698 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = COMP observation 1..1 SHALL 1106699 Discharge Status Observation (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.28 1..1 SHALL 1106538 @typeCode 1..1 SHALL 1106554 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SAS act 1..1 SHALL 1106555 Listed for Admission to Hospital Act (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.15 entryRelationship entryRelationship EntryR elation ship 1106697 1. Conforms to Encounter Activity (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-540). 3. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-541). 4. SHALL contain exactly one [1..1] templateId (CONF:1106-532) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.18" (CONF:1106-542). 5. SHALL contain exactly one [1..1] code (CONF:1106-533). a. This code SHALL contain exactly one [1..1] @code="32485007" Hospital admission (CONF:1106-543). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT urn:oid:2.16.840.1.113883.6.96) (CONF:1106-544). 6. SHALL contain exactly one [1..1] effectiveTime (CONF:1106-534). a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:1106-545). Note: Form Element: Date and time patient actually left the ED or observation unit Attachment G- EHR Implementation Guide Templates b. This effectiveTime SHALL contain exactly one [1..1] high (CONF:1106-546). Note: Form Element: Hospital Discharge Date 7. SHOULD contain zero or one [0..1] sdtc:dischargeDispositionCode, which SHALL be selected from ValueSet Disposition (NCHS) urn:oid:2.16.840.1.114222.4.11.7436 DYNAMIC (CONF:1106-548). Note: Form Element: Hospital discharge disposition 8. SHALL contain exactly one [1..1] participant (CONF:1106-531) such that it a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1106547). b. SHALL contain exactly one [1..1] Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:1106-539). Note: Form Element: Admitted To 9. SHALL contain exactly one [1..1] participant (CONF:1106-536) such that it a. SHALL contain exactly one [1..1] @typeCode="ADM" Admitter (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1106-551). b. SHALL contain exactly one [1..1] participantRole (CONF:1106-537). Note: Form Element: Admitting Physician i. This participantRole MAY contain zero or one [0..1] @classCode="ASSIGNED" (CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110) (CONF:1106-552). ii. This participantRole SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1106-553). 10. SHALL contain exactly one [1..1] entryRelationship (CONF:1106-535) such that it a. SHALL contain exactly one [1..1] @typeCode="COMP" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1106550). b. SHALL contain exactly one [1..1] Hospital Discharge Diagnosis (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.33:2014-06-09) (CONF:1106-549). Note: Form Element: Principal Hospital Discharge Diagnosis 11. SHALL contain exactly one [1..1] entryRelationship (CONF:1106-697) such that it a. SHALL contain exactly one [1..1] @typeCode="COMP" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1106698). b. SHALL contain exactly one [1..1] Discharge Status Observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.28) (CONF:1106-699). Note: Form Element: Discharge Status 12. SHALL contain exactly one [1..1] entryRelationship (CONF:1106-538) such that it a. SHALL contain exactly one [1..1] @typeCode="SAS" Starts after start (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1106554). Attachment G- EHR Implementation Guide Templates b. SHALL contain exactly one [1..1] Listed for Admission to Hospital Act (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.15) (CONF:1106-555). Note: Form Element: Date and time bed requested for hospital admission Table 123: Disposition (NCHS) Value Set: Disposition (NCHS) urn:oid:2.16.840.1.114222.4.11.7436 This value set describes visit disposition concepts. Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7436 Code Code System Code System OID Print Name PHC1270 PHIN VADS code system urn:oid:2.16.840.1.11422 2.4.5.274 Refer to other physician PHC1271 PHIN VADS code system urn:oid:2.16.840.1.11422 2.4.5.274 Return at specified time PHC1272 PHIN VADS code system urn:oid:2.16.840.1.11422 2.4.5.274 Refer to ER/Admit to hospital PHC1273 PHIN VADS code system urn:oid:2.16.840.1.11422 2.4.5.274 Other ... Attachment G- EHR Implementation Guide Templates Figure 68: Hospital Admission Encounter Example ... Attachment G- EHR Implementation Guide Templates ... ... 3.17.5 Observation Unit Stay Encounter [encounter: identifier urn:oid:2.16.840.1.113883.10.20.34.3.33 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 124: Observation Unit Stay Encounter Contexts Contained By: Contains: Emergency Department Encounters Section (V2) (optional) This template represents the encounter when the patient stayed in the observation unit. If this information is not available at time of abstraction, then complete the Hospital Admission Log. Attachment G- EHR Implementation Guide Templates Table 125: Observation Unit Stay Encounter Constraints Overview XPath Card. Verb Data Type CONF# Value encounter (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.33) @classCode 1..1 SHALL 1106797 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ENC @moodCode 1..1 SHALL 1106798 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106775 1..1 SHALL 1106785 1..1 SHALL 1106776 @code 1..1 SHALL 1106868 75912-6 @codeSystem 1..1 SHALL 1106869 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 1106777 1..1 SHALL 1106788 @nullFlavor 0..1 MAY 1106799 @value 0..1 SHOUL D 1106800 1..1 SHALL 1106789 @nullFlavor 0..1 MAY 1106801 @value 0..1 SHOUL D 1106802 @root code effectiveTime low high 2.16.840.1.113883.10.20.34.3.33 UNK UNK 1. Conforms to Encounter Activity (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-797). 3. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-798). 4. SHALL contain exactly one [1..1] templateId (CONF:1106-775) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.33" (CONF:1106-785). 5. SHALL contain exactly one [1..1] code (CONF:1106-776). a. This code SHALL contain exactly one [1..1] @code="75912-6" Observation unit stay discharge (CONF:1106-868). Attachment G- EHR Implementation Guide Templates b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1106-869). If either the admission or discharge date and time is unknown, use @nullFlavor="UNK" 6. SHALL contain exactly one [1..1] effectiveTime (CONF:1106-777). a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:1106-788). Note: Form Element: Date and time of observation unit admission i. This low MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1106799). ii. This low SHOULD contain zero or one [0..1] @value (CONF:1106-800). b. This effectiveTime SHALL contain exactly one [1..1] high (CONF:1106-789). Note: Form Element: Date and time of observation unit discharge i. This high MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1106801). ii. This high SHOULD contain zero or one [0..1] @value (CONF:1106-802). Figure 69: Observation Unit Stay Encounter Example 3.17.6 Specialty Unit Stay Encounter [encounter: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.38:2015-04-01 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US Realm Table 126: Specialty Unit Stay Encounter Contexts Contained By: Contains: Inpatient Encounters Section (V2) (optional) This template represents a specialty unit (such as ICU, NICU or CCU) stay. Attachment G- EHR Implementation Guide Templates Table 127: Specialty Unit Stay Encounter Constraints Overview XPath Card. Verb Data Type CONF# Value encounter (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.38:2015-04-01) @classCode 1..1 SHALL 1184945 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ENC @moodCode 1..1 SHALL 1184946 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1184923 @root 1..1 SHALL 1184933 2.16.840.1.113883.10.20.34.3.38 @extension 1..1 SHALL 1184947 2015-04-01 code 1..1 SHALL 1184924 urn:oid:2.16.840.1.114222.4.11.7 363 (Specialty Unit Type (NCHS)) effectiveTime 1..1 SHALL 1184925 low 1..1 SHALL 1184936 high 1..1 SHALL 1184937 1. Conforms to Encounter Activity (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1184-945). 3. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-946). 4. SHALL contain exactly one [1..1] templateId (CONF:1184-923) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.38" (CONF:1184-933). b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-947). 5. SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet Specialty Unit Type (NCHS) urn:oid:2.16.840.1.114222.4.11.7363 DYNAMIC (CONF:1184-924). 6. SHALL contain exactly one [1..1] effectiveTime (CONF:1184-925). a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:1184-936). Note: Date patient entered the unit. b. This effectiveTime SHALL contain exactly one [1..1] high (CONF:1184-937). Note: Date patient left the unit. Attachment G- EHR Implementation Guide Templates Table 128: Specialty Unit Type (NCHS) Value Set: Specialty Unit Type (NCHS) urn:oid:2.16.840.1.114222.4.11.7363 The kind of hospital unit having any necessary specialized equipment and/or personnel for handling critically ill or injured patients. Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7363 Code Code System Code System OID Print Name 1026-4 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Burn critical care unit 1028-0 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Medical cardiac critical care unit 1027-2 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Medical critical care unit 1029-8 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Medical/Surgical critical care unit 1039-7 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Neonatal critical care unit [Level II/III] 1040-5 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Neonatal critical care unit [Level III] 1035-5 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Neurology critical care and stroke unit 1031-4 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Neurosurgical critical care unit 1042-1 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Pediatric burn critical care unit 1044-7 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Pediatric medical critical care unit ... Attachment G- EHR Implementation Guide Templates Figure 70: Special Unit Stay Encounter Example 3.18 Encounter Diagnosis (V2) [act: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.80:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 129: Encounter Diagnosis (V2) Contexts Contained By: Contains: Encounter Activity (V2) (optional) Problem Observation (V2) This template wraps relevant problems or diagnoses at the close of a visit or that need to be followed after the visit. If the encounter is associated with a Hospital Discharge, the Hospital Discharge Diagnosis must be used. This entry requires at least one Problem Observation entry. Attachment G- EHR Implementation Guide Templates Table 130: Encounter Diagnosis (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value act (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.80:2014-06-09) @classCode 1..1 SHALL 109814889 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode 1..1 SHALL 109814890 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 109814895 @root 1..1 SHALL 109814896 2.16.840.1.113883.10.20.22.4.80 @extension 1..1 SHALL 109832542 2014-06-09 1..1 SHALL 109819182 @code 1..1 SHALL 109819183 29308-4 @codeSystem 1..1 SHALL 109832160 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 entryRelationship 1..* SHALL 109814892 @typeCode 1..1 SHALL 109814893 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ observation 1..1 SHALL 109814898 Problem Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.4:2014-06-09 code 1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-14889). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-14890). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-14895) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.80" (CONF:1098-14896). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32542). 4. SHALL contain exactly one [1..1] code (CONF:1098-19182). a. This code SHALL contain exactly one [1..1] @code="29308-4" Diagnosis (CONF:1098-19183). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-32160). 5. SHALL contain at least one [1..*] entryRelationship (CONF:1098-14892) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-14893). b. SHALL contain exactly one [1..1] Problem Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09) (CONF:109814898). Figure 71: Encounter Diagnosis (V2) Example ... 3.19 Episode of Care Observation (V2) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.32:2015-04-01 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US Realm Table 131: Episode of Care Observation (V2) Contexts Contained By: Contains: Current Outpatient Visit (V3) (optional) Current Emergency Department Visit (V2) (optional) This template represents whether this is a follow-up visit to this facility for this problem or if it is the initial visit to this facility for this problem. If it is unknown whether or not this is a follow-up visit use nullFlavor="UNK". Attachment G- EHR Implementation Guide Templates Table 132: Episode of Care Observation (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.32:2015-04-01) @classCode 1..1 SHALL 1184846 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1184847 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1184842 1..1 SHALL 1184844 id 1..* SHALL 1184848 code 1..1 SHALL 1184849 @code 1..1 SHALL 1184851 78030-4 @codeSystem 1..1 SHALL 1184852 2.16.840.1.113883.6.1 1..1 SHALL 1184843 1..1 SHALL 1184845 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1..1 SHALL 1184850 urn:oid:2.16.840.1.114222.4.11.7 439 (Episode of Care (NCHS)) 0..1 MAY 1184853 UNK @root statusCode @code value @nullFlavor CD 2.16.840.1.113883.10.20.34.3.32 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1184-846). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-847). 3. SHALL contain exactly one [1..1] templateId (CONF:1184-842) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.32" (CONF:1184-844). 4. SHALL contain at least one [1..*] id (CONF:1184-848). 5. SHALL contain exactly one [1..1] code (CONF:1184-849). a. This code SHALL contain exactly one [1..1] @code="78030-4" Episode of Care (CONF:1184-851). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CONF:1184-852). 6. SHALL contain exactly one [1..1] statusCode (CONF:1184-843). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1184-845). Attachment G- EHR Implementation Guide Templates 7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Episode of Care (NCHS) urn:oid:2.16.840.1.114222.4.11.7439 DYNAMIC (CONF:1184-850). a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1184-853). Table 133: Episode of Care (NCHS) Value Set: Episode of Care (NCHS) urn:oid:2.16.840.1.114222.4.11.7439 These values specify the type of visit. Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7439 Code Code System Code System OID Print Name 315639002 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Initial patient assessment 185389009 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Follow-up visit ... Figure 72: Episode of Care Observation (V2) Example 3.20 Estimated Date of Delivery [observation: identifier urn:oid:2.16.840.1.113883.10.20.15.3.1 (closed)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R1.1 Table 134: Estimated Date of Delivery Contexts Contained By: Contains: Pregnancy Observation (optional) This clinical statement represents the anticipated date when a woman will give birth. Attachment G- EHR Implementation Guide Templates Table 135: Estimated Date of Delivery Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.15.3.1) @classCode 1..1 SHALL 81-444 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 81-445 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 8116762 1..1 SHALL 8116763 1..1 SHALL 8119139 @code 1..1 SHALL 8119140 11778-8 @codeSystem 1..1 SHALL 8126503 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 81-448 1..1 SHALL 8119096 1..1 SHALL @root code statusCode @code value TS 2.16.840.1.113883.10.20.15.3.1 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 81-450 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-444). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-445). 3. SHALL contain exactly one [1..1] templateId (CONF:81-16762) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.15.3.1" (CONF:81-16763). 4. SHALL contain exactly one [1..1] code (CONF:81-19139). a. This code SHALL contain exactly one [1..1] @code="11778-8" Estimated date of delivery (CONF:81-19140). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:81-26503). 5. SHALL contain exactly one [1..1] statusCode (CONF:81-448). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:8119096). 6. SHALL contain exactly one [1..1] value with @xsi:type="TS" (CONF:81-450). Attachment G- EHR Implementation Guide Templates Figure 73: Estimated Date of Delivery Example 3.21 Follow-up Attempt Outcome Observation [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.43:2015-04-01 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US Realm Table 136: Follow-up Attempt Outcome Observation Contexts Contained By: Contains: Procedure Follow-Up Attempt Observation (optional) This template represents the outcome of a follow-up attempt made within 24 hours of surgery. Attachment G- EHR Implementation Guide Templates Table 137: Follow-up Attempt Outcome Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.43:2015-04-01) @classCode 1..1 SHALL 11841145 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 11841146 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 11841135 @root 1..1 SHALL 11841139 2.16.840.1.113883.10.20.34.3.43 @extension 1..1 SHALL 11841140 2015-04-01 id 1..* SHALL 11841147 code 1..1 SHALL 11841136 @code 1..1 SHALL 11841141 78028-8 @codeSystem 1..1 SHALL 11841142 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 11841138 1..1 SHALL 11841144 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1..1 SHALL 11841137 urn:oid:2.16.840.1.114222.4.11.7 362 (Follow-up Attempt Outcome (NCHS)) 0..1 MAY 11841143 urn:oid:2.16.840.1.113883.10.20. 5.9.1 (NullValues_UNK_OTH) statusCode @code value @nullFlavor CD 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1184-1145). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1184-1146). 3. SHALL contain exactly one [1..1] templateId (CONF:1184-1135) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.43" (CONF:1184-1139). b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-1140). 4. SHALL contain at least one [1..*] id (CONF:1184-1147). 5. SHALL contain exactly one [1..1] code (CONF:1184-1136). a. This code SHALL contain exactly one [1..1] @code="78028-8" Follow-up attempt outcome (CONF:1184-1141). Attachment G- EHR Implementation Guide Templates b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1184-1142). 6. SHALL contain exactly one [1..1] statusCode (CONF:1184-1138). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1184-1144). 7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Follow-up Attempt Outcome (NCHS) urn:oid:2.16.840.1.114222.4.11.7362 DYNAMIC (CONF:1184-1137). a. This value MAY contain zero or one [0..1] @nullFlavor, which SHALL be selected from ValueSet NullValues_UNK_OTH urn:oid:2.16.840.1.113883.10.20.5.9.1 (CONF:1184-1143). Table 138: Follow-up Attempt Outcome (NCHS) Value Set: Follow-up Attempt Outcome (NCHS) urn:oid:2.16.840.1.114222.4.11.7362 The finding(s) or result(s) of contact made by healthcare staff with a patient after an outpatient surgical procedure. Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7362 Code Code System Code System OID Print Name 398090008 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Unable to reach Patient 160245001 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Patient reported no problems PHC1392 PHIN VADS code system urn:oid:2.16.840.1.11422 2.4.5.274 Patient reported problems and sought medical care PHC1393 PHIN VADS code system urn:oid:2.16.840.1.11422 2.4.5.274 Patient reported problems and was advised by ambulatory surgical staff to seek medical care PHC1394 PHIN VADS code system urn:oid:2.16.840.1.11422 2.4.5.274 Patient reported problems, but no followup medical care was needed ... Table 139: NullValues_UNK_OTH Value Set: NullValues_UNK_OTH urn:oid:2.16.840.1.113883.10.20.5.9.1 Null values of unknown and other. Code Code System Code System OID Print Name UNK HL7NullFlavor urn:oid:2.16.840.1.11388 3.5.1008 Unknown OTH HL7NullFlavor urn:oid:2.16.840.1.11388 3.5.1008 Other Attachment G- EHR Implementation Guide Templates Figure 74: Follow-up Attempt Outcome Observation 3.22 Hospital Discharge Diagnosis (V2) [act: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.33:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 140: Hospital Discharge Diagnosis (V2) Contexts Contained By: Contains: Hospital Admission Encounter (required) Problem Observation (V2) This template represents problems or diagnoses present at the time of discharge which occurred during the hospitalization or need to be monitored after hospitalization. It requires at least one Problem Observation entry. Attachment G- EHR Implementation Guide Templates Table 141: Hospital Discharge Diagnosis (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value act (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.33:2014-06-09) @classCode 1..1 SHALL 10987663 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode 1..1 SHALL 10987664 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 109816764 @root 1..1 SHALL 109816765 2.16.840.1.113883.10.20.22.4.33 @extension 1..1 SHALL 109832534 2014-06-09 1..1 SHALL 109819147 @code 1..1 SHALL 109819148 11535-2 @codeSystem 1..1 SHALL 109832163 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 entryRelationship 1..* SHALL 10987666 @typeCode 1..1 SHALL 10987667 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ observation 1..1 SHALL 109815536 Problem Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.4:2014-06-09 code 1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7663). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7664). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-16764) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.33" (CONF:1098-16765). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32534). 4. SHALL contain exactly one [1..1] code (CONF:1098-19147). a. This code SHALL contain exactly one [1..1] @code="11535-2" Hospital discharge diagnosis (CONF:1098-19148). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-32163). 5. SHALL contain at least one [1..*] entryRelationship (CONF:1098-7666) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7667). b. SHALL contain exactly one [1..1] Problem Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09) (CONF:109815536). Figure 75: Hospital Discharge Diagnosis (V2) Example ... Attachment G- EHR Implementation Guide Templates 3.23 Immunization Activity (V2) [substanceAdministration: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.52:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 142: Immunization Activity (V2) Contexts Contained By: Contains: Immunizations Section (optional) Author Participation Drug Vehicle Immunization Medication Information (V2) Immunization Refusal Reason Indication (V2) Instruction (V2) Medication Dispense (V2) Medication Supply Order (V2) Precondition for Substance Administration (V2) Reaction Observation (V2) Substance Administered Act An Immunization Activity describes immunization substance administrations that have actually occurred or are intended to occur. Immunization Activities in "INT" mood are reflections of immunizations a clinician intends a patient to receive. Immunization Activities in "EVN" mood reflect immunizations actually received. An Immunization Activity is very similar to a Medication Activity with some key differentiators. The drug code system is constrained to CVX codes. Administration timing is less complex. Patient refusal reasons should be captured. All vaccines administered should be fully documented in the patient's permanent medical record. Healthcare providers who administer vaccines covered by the National Childhood Vaccine Injury Act are required to ensure that the permanent medical record of the recipient indicates: 1) Date of administration 2) Vaccine manufacturer 3) Vaccine lot number 4) Name and title of the person who administered the vaccine and the address of the clinic or facility where the permanent record will reside 5) Vaccine information statement (VIS) a. Date printed on the VIS b. Date VIS given to patient or parent/guardian. This information should be included in an Immunization Activity when available. (Reference: http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/D/vacc_admin.p df) Attachment G- EHR Implementation Guide Templates Table 143: Immunization Activity (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value substanceAdministration (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.52:2014-06-09) @classCode 1..1 SHALL 10988826 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = SBADM @moodCode 1..1 SHALL 10988827 urn:oid:2.16.840.1.113883.11.20. 9.18 (MoodCodeEvnInt) @negationInd 0..1 MAY 10988985 templateId 1..1 SHALL 10988828 @root 1..1 SHALL 109810498 2.16.840.1.113883.10.20.22.4.52 @extension 1..1 SHALL 109832528 2014-06-09 id 1..* SHALL 10988829 code 0..1 MAY 10988830 statusCode 1..1 SHALL 10988833 1..1 SHALL 109832359 effectiveTime 1..1 SHALL 10988834 repeatNumber 0..1 MAY 10988838 routeCode 0..1 MAY 10988839 urn:oid:2.16.840.1.113883.3.88.1 2.3221.8.7 (Medication Route FDA) approachSiteCode 0..1 MAY 10988840 urn:oid:2.16.840.1.113883.3.88.1 2.3221.8.9 (Body Site) doseQuantity 0..1 SHOUL D 10988841 0..1 SHOUL D 10988842 urn:oid:2.16.840.1.113883.1.11.1 2839 (UnitsOfMeasureCaseSensitive) administrationUnitCode 0..1 MAY 10988846 urn:oid:2.16.840.1.113762.1.4.10 21.30 (AdministrationUnitDoseForm) consumable 1..1 SHALL 10988847 1..1 SHALL 109815546 @code @unit manufacturedProduct SET urn:oid:2.16.840.1.113883.1.11.1 59331 (ActStatus) Immunization Medication Information (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.54:2014-06-09 Attachment G- EHR Implementation Guide Templates performer 0..1 SHOUL D 10988849 author 0..* SHOUL D 109831151 participant 0..* MAY 10988850 @typeCode 1..1 SHALL 10988851 urn:oid:2.16.840.1.113883.5.90 (HL7ParticipationType) = CSM participantRole 1..1 SHALL 109815547 Drug Vehicle (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.24 entryRelationship 0..* MAY 10988853 @typeCode 1..1 SHALL 10988854 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = RSON observation 1..1 SHALL 109815537 Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.19:2014-06-09 0..1 MAY 10988856 @typeCode 1..1 SHALL 10988857 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ @inversionInd 1..1 SHALL 10988858 true act 1..1 SHALL 109831392 Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.20:2014-06-09 0..1 MAY 10988860 @typeCode 1..1 SHALL 10988861 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR supply 1..1 SHALL 109815539 Medication Supply Order (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.17:2014-06-09 0..1 MAY 10988863 @typeCode 1..1 SHALL 10988864 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR supply 1..1 SHALL 109815540 Medication Dispense (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.18:2014-06-09 0..1 MAY 1098- entryRelationship entryRelationship entryRelationship entryRelationship Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 Attachment G- EHR Implementation Guide Templates 8866 @typeCode 1..1 SHALL 10988867 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = CAUS observation 1..1 SHALL 109815541 Reaction Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.9:2014-06-09 0..1 MAY 10988988 @typeCode 1..1 SHALL 10988989 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = RSON observation 1..1 SHALL 109815542 Immunization Refusal Reason (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.53 0..* SHOUL D 109831510 @typeCode 1..1 SHALL 109831511 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = COMP @inversionInd 1..1 SHALL 109831512 true sequenceNumber 0..1 MAY 109831513 act 1..1 SHALL 109831514 precondition 0..* MAY 10988869 @typeCode 1..1 SHALL 10988870 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = PRCN criterion 1..1 SHALL 109815548 Precondition for Substance Administration (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.25:2014-06-09 entryRelationship entryRelationship Substance Administered Act (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.118 1. SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8826). 2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt urn:oid:2.16.840.1.113883.11.20.9.18 STATIC 2014-09-01 (CONF:1098-8827). 3. MAY contain zero or one [0..1] @negationInd (CONF:1098-8985). Note: Use negationInd="true" to indicate that the immunization was not given. 4. SHALL contain exactly one [1..1] templateId (CONF:1098-8828) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.52" (CONF:1098-10498). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32528). 5. SHALL contain at least one [1..*] id (CONF:1098-8829). 6. MAY contain zero or one [0..1] code (CONF:1098-8830). Note: SubstanceAdministration.code is an optional field. Per HL7 Pharmacy Committee, "this is intended to further specify the nature of the substance administration act. To date the committee has made no use of this attribute". Because the type of substance administration is generally implicit in the routeCode, in the consumable participant, etc., the field is generally not used and there is no defined value set. 7. SHALL contain exactly one [1..1] statusCode (CONF:1098-8833). a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ActStatus urn:oid:2.16.840.1.113883.1.11.159331 DYNAMIC (CONF:1098-32359). 8. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-8834). In "INT" (intent) mood, the repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a substance administration event means that the current administration is the 3rd in a series. 9. MAY contain zero or one [0..1] repeatNumber (CONF:1098-8838). 10. MAY contain zero or one [0..1] routeCode, which SHALL be selected from ValueSet Medication Route FDA urn:oid:2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC (CONF:1098-8839). 11. MAY contain zero or one [0..1] approachSiteCode, where the code SHALL be selected from ValueSet Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:1098-8840). 12. SHOULD contain zero or one [0..1] doseQuantity (CONF:1098-8841). a. The doseQuantity, if present, SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-8842). 13. MAY contain zero or one [0..1] administrationUnitCode, which SHALL be selected from ValueSet AdministrationUnitDoseForm urn:oid:2.16.840.1.113762.1.4.1021.30 DYNAMIC (CONF:1098-8846). 14. SHALL contain exactly one [1..1] consumable (CONF:1098-8847). a. This consumable SHALL contain exactly one [1..1] Immunization Medication Information (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.54:2014-06-09) (CONF:109815546). 15. SHOULD contain zero or one [0..1] performer (CONF:1098-8849). 16. SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31151). 17. MAY contain zero or more [0..*] participant (CONF:1098-8850) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] @typeCode="CSM" (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:10988851). b. SHALL contain exactly one [1..1] Drug Vehicle (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.24) (CONF:1098-15547). 18. MAY contain zero or more [0..*] entryRelationship (CONF:1098-8853) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8854). b. SHALL contain exactly one [1..1] Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109815537). 19. MAY contain zero or one [0..1] entryRelationship (CONF:1098-8856) such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8857). b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-8858). c. SHALL contain exactly one [1..1] Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109831392). 20. MAY contain zero or one [0..1] entryRelationship (CONF:1098-8860) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8861). b. SHALL contain exactly one [1..1] Medication Supply Order (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.17:2014-06-09) (CONF:109815539). 21. MAY contain zero or one [0..1] entryRelationship (CONF:1098-8863) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8864). b. SHALL contain exactly one [1..1] Medication Dispense (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.18:2014-06-09) (CONF:109815540). 22. MAY contain zero or one [0..1] entryRelationship (CONF:1098-8866) such that it a. SHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8867). b. SHALL contain exactly one [1..1] Reaction Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.9:2014-06-09) (CONF:109815541). 23. MAY contain zero or one [0..1] entryRelationship (CONF:1098-8988) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8989). Attachment G- EHR Implementation Guide Templates b. SHALL contain exactly one [1..1] Immunization Refusal Reason (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.53) (CONF:1098-15542). The following entryRelationship is used to indicate a given immunization's order in a series. The nested Substance Administered Act identifies an administration in the series. The entryRelationship/sequenceNumber shows the order of this particular administration in that series. 24. SHOULD contain zero or more [0..*] entryRelationship (CONF:1098-31510) such that it a. SHALL contain exactly one [1..1] @typeCode="COMP" Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831511). b. SHALL contain exactly one [1..1] @inversionInd="true" (CONF:1098-31512). c. MAY contain zero or one [0..1] sequenceNumber (CONF:1098-31513). d. SHALL contain exactly one [1..1] Substance Administered Act (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.118) (CONF:1098-31514). 25. MAY contain zero or more [0..*] precondition (CONF:1098-8869) such that it a. SHALL contain exactly one [1..1] @typeCode="PRCN" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8870). b. SHALL contain exactly one [1..1] Precondition for Substance Administration (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.25:2014-0609) (CONF:1098-15548). Table 144: MoodCodeEvnInt Value Set: MoodCodeEvnInt urn:oid:2.16.840.1.113883.11.20.9.18 Contains moodCode EVN and INT Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name EVN ActMood urn:oid:2.16.840.1.11388 3.5.1001 Event INT ActMood urn:oid:2.16.840.1.11388 3.5.1001 Intent Attachment G- EHR Implementation Guide Templates Table 145: Medication Route FDA Value Set: Medication Route FDA urn:oid:2.16.840.1.113883.3.88.12.3221.8.7 Route of Administration value set is based upon FDA Drug Registration and Listing Database (FDA Orange Book) which are used in FDA Structured Product Labeling (SPL). Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.113883.3.88.12.32 21.8.7 Code Code System Code System OID Print Name C38192 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 AURICULAR (OTIC) C38193 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 BUCCAL C38194 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 CONJUNCTIVAL C38675 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 CUTANEOUS C38197 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 DENTAL C38633 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 ELECTRO-OSMOSIS C38205 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 ENDOCERVICAL C38206 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 ENDOSINUSIAL C38208 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 ENDOTRACHEAL C38209 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 ENTERAL ... Attachment G- EHR Implementation Guide Templates Table 146: Body Site Value Set: Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 Contains values descending from the SNOMED CT® Anatomical Structure (91723000) hierarchy or Acquired body structure (body structure) (280115004) or Anatomical site notations for tumor staging (body structure) (258331007) or Body structure, altered from its original anatomical structure (morphologic abnormality) (118956008) or Physical anatomical entity (body structure) (91722005) This indicates the anatomical site. Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name 362783006 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 entire medial surface of lower extremity (body structure) 302539009 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 entire hand (body structure) 287679003 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 left hip region structure (body structure) 3341006 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 right lung structure (body structure) 87878005 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 left ventricular structure (body structure) 49848007 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 structure of myocardium of left ventricle (body structure) 38033009 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 amputation stump (body structure) 305005006 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 6/7 interchondral joint (body structure) 28726007 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 corneal structure (body structure) 75324005 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 70 to 79 percent of body surface (body structure) ... Attachment G- EHR Implementation Guide Templates Table 147: UnitsOfMeasureCaseSensitive Value Set: UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 The UCUM code system provides a set of structural units from which working codes are built. There is an unlimited number of possible valid UCUM codes. Value Set Source: http://unitsofmeasure.org/ucum.html Code Code System Code System OID Print Name min UCUM urn:oid:2.16.840.1.11388 3.6.8 minute hour UCUM urn:oid:2.16.840.1.11388 3.6.8 hr % UCUM urn:oid:2.16.840.1.11388 3.6.8 percent cm UCUM urn:oid:2.16.840.1.11388 3.6.8 centimeter g UCUM urn:oid:2.16.840.1.11388 3.6.8 gram g/(12.h) UCUM urn:oid:2.16.840.1.11388 3.6.8 gram per 12 hour g/L UCUM urn:oid:2.16.840.1.11388 3.6.8 gram per liter mol UCUM urn:oid:2.16.840.1.11388 3.6.8 mole [IU] UCUM urn:oid:2.16.840.1.11388 3.6.8 international unit Hz UCUM urn:oid:2.16.840.1.11388 3.6.8 Hertz ... Attachment G- EHR Implementation Guide Templates Table 148: AdministrationUnitDoseForm Value Set: AdministrationUnitDoseForm urn:oid:2.16.840.1.113762.1.4.1021.30 Codes that are similar to a drug "form" but limited to those used as units when describing drug administration when the drug item is a physical form that is continuous and therefore not administered as an "each" of the physical form, or is not using standard measurement units (inch, ounce, gram, etc.) This set does not include unit concepts that mimic "physical form" concepts that can be counted using "each", such as tablet, bar, lozenge, packet, etc. Code Code System Code System OID Print Name C122629 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 Actuation Dosing Unit C25397 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 Application Unit C102405 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 Capful Dosing Unit C122631 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 Dropperful Dosing Unit C48501 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 Inhalation Dosing Unit C48491 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 Metric Drop C71204 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 Nebule Dosing Unit NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 Puff Dosing Unit C48536 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 Scoopful Dosing Unit C48537 NCI Thesaurus (NCIt) urn:oid:2.16.840.1.11388 3.3.26.1.1 Spray Dosing Unit C65060 ... Attachment G- EHR Implementation Guide Templates Figure 76: Immunization Activity (V2) Example 1 Health LS - Immuno Inc. 1007 Health Drive Portland OR 99123 US Harold Hippocrates Good Health Clinic 1007 Health Drive Portland OR 99123 US Attachment G- EHR Implementation Guide Templates 3.24 Immunization Medication Information (V2) [manufacturedProduct: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.54:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 149: Immunization Medication Information (V2) Contexts Contained By: Contains: Immunization Activity (V2) (required) Medication Supply Order (V2) (optional) Medication Dispense (V2) (optional) Planned Immunization Activity (required) The Immunization Medication Information represents product information about the immunization substance. The vaccine manufacturer and vaccine lot number are typically recorded in the medical record and should be included if known. Attachment G- EHR Implementation Guide Templates Table 150: Immunization Medication Information (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value manufacturedProduct (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.54:2014-06-09) @classCode 1..1 SHALL 10989002 templateId 1..1 SHALL 10989004 @root 1..1 SHALL 109810499 2.16.840.1.113883.10.20.22.4.54 @extension 1..1 SHALL 109832602 2014-06-09 id 0..* MAY 10989005 manufacturedMaterial 1..1 SHALL 10989006 1..1 SHALL 10989007 urn:oid:2.16.840.1.113762.1.4.10 10.6 (CVX Vaccines Administered - Vaccine Set ) translation 0..* MAY 109831543 urn:oid:2.16.840.1.113762.1.4.10 10.8 (Vaccine Clinical Drug) translation 0..* MAY 109831881 urn:oid:2.16.840.1.113762.1.4.10 10.10 (Specific Vaccine Clinical Drug) lotNumberText 1..1 SHALL 10989014 0..1 SHOUL D 10989012 code manufacturerOrganization urn:oid:2.16.840.1.113883.5.110 (RoleClass) = MANU 1. SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110 STATIC) (CONF:1098-9002). 2. SHALL contain exactly one [1..1] templateId (CONF:1098-9004) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.54" (CONF:1098-10499). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32602). 3. MAY contain zero or more [0..*] id (CONF:1098-9005). 4. SHALL contain exactly one [1..1] manufacturedMaterial (CONF:1098-9006). a. This manufacturedMaterial SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet CVX Vaccines Administered - Vaccine Set urn:oid:2.16.840.1.113762.1.4.1010.6 DYNAMIC (CONF:1098-9007). i. This code MAY contain zero or more [0..*] translation, which MAY be selected from ValueSet Vaccine Clinical Drug urn:oid:2.16.840.1.113762.1.4.1010.8 DYNAMIC (CONF:1098-31543). ii. This code MAY contain zero or more [0..*] translation, which MAY be selected from ValueSet Specific Vaccine Clinical Drug urn:oid:2.16.840.1.113762.1.4.1010.10 DYNAMIC (CONF:1098-31881). Attachment G- EHR Implementation Guide Templates b. This manufacturedMaterial SHALL contain exactly one [1..1] lotNumberText (CONF:1098-9014). 5. SHOULD contain zero or one [0..1] manufacturerOrganization (CONF:1098-9012). Table 151: CVX Vaccines Administered - Vaccine Set Value Set: CVX Vaccines Administered - Vaccine Set urn:oid:2.16.840.1.113762.1.4.1010.6 CVX vaccine concepts that represent actual vaccines types. This does not include the identifiers for CVX codes that do not represent vaccines. Value set intensionally defined from CVX (OID: 2.16.840.1.113883.12.292) FilterOnProperty(nonvaccine,FALSE). Value Set Source: http://www2a.cdc.gov/vaccines/iis/iisstandards/vaccines.asp?rpt=cvx Code Code System Code System OID Print Name 19 CDC Vaccine Code (CVX) urn:oid:2.16.840.1.11388 3.12.292 BCG 26 CDC Vaccine Code (CVX) urn:oid:2.16.840.1.11388 3.12.292 Cholera 24 CDC Vaccine Code (CVX) urn:oid:2.16.840.1.11388 3.12.292 Anthrax 27 CDC Vaccine Code (CVX) urn:oid:2.16.840.1.11388 3.12.292 Botulinum antitoxin ... Attachment G- EHR Implementation Guide Templates Table 152: Vaccine Clinical Drug Value Set: Vaccine Clinical Drug urn:oid:2.16.840.1.113762.1.4.1010.8 Administrable vaccine medication formulations represented using either a "generic" or "brand-specific" concept. Value set intensionally defined from RXNORM (OID: 2.16.840.1.113883.6.88), comprised of those codes whose ingredients map to NDC codes that the CDC associates with CVX codes. Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name 898572 RxNorm urn:oid:2.16.840.1.11388 3.6.88 0.17 ML Rho(D) Immune Globulin 0.3 MG/ML Prefilled Syringe [HyperRHO] 807276 RxNorm urn:oid:2.16.840.1.11388 3.6.88 0.5 ML diphtheria toxoid vaccine, inactivated 4 UNT/ML / tetanus toxoid vaccine, inactivated 10 UNT/ML Prefilled Syringe [Decavac] 798482 RxNorm urn:oid:2.16.840.1.11388 3.6.88 0.5 ML Hepatitis A Vaccine (Inactivated) Strain HM175 1440 UNT/ML Prefilled Syringe [Havrix] 836636 RxNorm urn:oid:2.16.840.1.11388 3.6.88 0.5 ML Hepatitis A Vaccine, Inactivated 50 UNT/ML Prefilled Syringe [Vaqta] ... Table 153: Specific Vaccine Clinical Drug Value Set: Specific Vaccine Clinical Drug urn:oid:2.16.840.1.113762.1.4.1010.10 This value set contains extensionally identified RxNorm vaccine codes. It should be used to supplement the Vaccine Clinical Drug Value Set (Value Set OID 2.16.840.1.113762.1.4.1010.8). Intensional rules for the latter value set are being refined, but at this time lack complete sensitivity, and as a result can miss including relevant codes. This Specific Vaccine Clinical Drug Value Set is used to manually provide for these other RxNorm codes. (At the time of Consolidated CDA R2 publication, the value set has no members) Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name NA RxNorm urn:oid:2.16.840.1.11388 3.6.88 At the time of Consolidated CDA R2 publication, the value set has no members ... Attachment G- EHR Implementation Guide Templates Figure 77: Immunization Medication Information (V2) Example 1 Health LS - Immuno Inc. 3.25 Immunization Refusal Reason [observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.53 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R1.1 Table 154: Immunization Refusal Reason Contexts Contained By: Contains: Immunization Activity (V2) (optional) The Immunization Refusal Reason documents the rationale for the patient declining an immunization. Attachment G- EHR Implementation Guide Templates Table 155: Immunization Refusal Reason Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.53) @classCode 1..1 SHALL 818991 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 818992 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 818993 1..1 SHALL 8110500 id 1..* SHALL 818994 code 1..1 SHALL 818995 statusCode 1..1 SHALL 818996 1..1 SHALL 8119104 @root @code 2.16.840.1.113883.10.20.22.4.53 urn:oid:2.16.840.1.113883.1.11.1 9717 (No Immunization Reason Value Set) urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-8991). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-8992). 3. SHALL contain exactly one [1..1] templateId (CONF:81-8993) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.53" (CONF:81-10500). 4. SHALL contain at least one [1..*] id (CONF:81-8994). 5. SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet No Immunization Reason Value Set urn:oid:2.16.840.1.113883.1.11.19717 DYNAMIC (CONF:81-8995). 6. SHALL contain exactly one [1..1] statusCode (CONF:81-8996). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:8119104). Attachment G- EHR Implementation Guide Templates Table 156: No Immunization Reason Value Set Value Set: No Immunization Reason Value Set urn:oid:2.16.840.1.113883.1.11.19717 Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name IMMUNE ActReason urn:oid:2.16.840.1.11388 3.5.8 Immunity MEDPREC ActReason urn:oid:2.16.840.1.11388 3.5.8 Medical precaution OSTOCK ActReason urn:oid:2.16.840.1.11388 3.5.8 Out of stock PATOBJ ActReason urn:oid:2.16.840.1.11388 3.5.8 Patient objection PHILISOP ActReason urn:oid:2.16.840.1.11388 3.5.8 Philosophical objection RELIG ActReason urn:oid:2.16.840.1.11388 3.5.8 Religious objection VACEFF ActReason urn:oid:2.16.840.1.11388 3.5.8 Vaccine efficacy concerns VACSAF ActReason urn:oid:2.16.840.1.11388 3.5.8 Vaccine safety concerns Figure 78: Immunization Refusal Reason Example Attachment G- EHR Implementation Guide Templates 3.26 Indication (V2) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 157: Indication (V2) Contexts Contained By: Contains: Medication Activity (V2) (optional) Procedure Activity Act (V2) (optional) Procedure Activity Procedure (V2) (optional) Procedure Activity Observation (V2) (optional) Immunization Activity (V2) (optional) Encounter Activity (V2) (optional) Planned Act (V2) (optional) Planned Procedure (V2) (optional) Planned Observation (V2) (optional) Planned Medication Activity (V2) (optional) Planned Immunization Activity (optional) This template represents the rationale for an action such as an encounter, a medication administration, or a procedure. The id element can be used to reference a problem recorded elsewhere in the document, or can be used with a code and value to record the problem. Indications for treatment are not laboratory results; rather the problem associated with the laboratory result should be sited (e.g., hypokalemia instead of a laboratory result of Potassium 2.0 mEq/L). Use the Drug Monitoring Act [templateId 2.16.840.1.113883.10.20.22.4.123] to indicate if a particular drug needs special monitoring (e.g., anticoagulant therapy). Use Precondition for Substance Administration (V2) [templateId 2.16.840.1.113883.10.20.22.4.25.2] to represent that a medication is to be administered only when the associated criteria are met. Attachment G- EHR Implementation Guide Templates Table 158: Indication (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) @classCode 1..1 SHALL 10987480 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 10987481 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 10987482 @root 1..1 SHALL 109810502 2.16.840.1.113883.10.20.22.4.19 @extension 1..1 SHALL 109832570 2014-06-09 id 1..* SHALL 10987483 code 1..1 SHALL 109831229 statusCode 1..1 SHALL 10987487 1..1 SHALL 109819105 effectiveTime 0..1 SHOUL D 10987488 value 0..1 MAY @code CD 10987489 urn:oid:2.16.840.1.113883.3.88.1 2.3221.7.2 (Problem Type) urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed urn:oid:2.16.840.1.113883.3.88.1 2.3221.7.4 (Problem) 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7480). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7481). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-7482) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.19" (CONF:1098-10502). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32570). 4. SHALL contain at least one [1..*] id (CONF:1098-7483). Note: If the id element is used to reference a problem recorded else where in the document then this id must equal another entry/id in the same document instance. Application Software must be responsible for resolving the identifier back to its original object and then rendering the information in the correct place in the containing section's narrative text. Its purpose is to obviate the need to repeat the complete XML representation of the referred to entry when relating one entry to another. 5. SHALL contain exactly one [1..1] code, which MAY be selected from ValueSet Problem Type urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2014-09-02 (CONF:109831229). Attachment G- EHR Implementation Guide Templates 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-7487). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819105). 7. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7488). 8. MAY contain zero or one [0..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Problem urn:oid:2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:1098-7489). Table 159: Problem Value Set: Problem urn:oid:2.16.840.1.113883.3.88.12.3221.7.4 A value set of SNOMED-CT codes limited to terms descending from the Clinical Findings (404684003) or Situation with Explicit Context (243796009) hierarchies. Specific URL Pending Value Set Source: http://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.113883.3.88.12.322 1.7.4 Code Code System Code System OID Print Name 46635009 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 diabetes mellitus type 1 234422006 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 acute intermittent porphyria 31712002 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 primary biliary cirrhosis 302002000 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 difficulty moving 15188001 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 hearing loss 129851009 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 alteration in bowel elimination 247472004 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 hives 39579001 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 anaphylaxis 274945004 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 AA amyloidosis (disorder) 129851009 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 alteration in comfort: pain ... Attachment G- EHR Implementation Guide Templates Table 160: Problem Type Value Set: Problem Type urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 This value set indicates the level of medical judgment used to determine the existence of a problem. Value Set Source: http://www.loinc.org Code Code System Code System OID Print Name 75326-9 LOINC urn:oid:2.16.840.1.11388 3.6.1 Problem HL7.CCDAR2 75325-1 LOINC urn:oid:2.16.840.1.11388 3.6.1 Symptom HL7.CCDAR2 75324-4 LOINC urn:oid:2.16.840.1.11388 3.6.1 Diagnosis 75321-0 LOINC urn:oid:2.16.840.1.11388 3.6.1 Clinical finding HL7.CCDAR2 75323-6 LOINC urn:oid:2.16.840.1.11388 3.6.1 Condition HL7.CCDAR2 29308-4 LOINC urn:oid:2.16.840.1.11388 3.6.1 Complaint HL7.CCDAR2 75322-8 LOINC urn:oid:2.16.840.1.11388 3.6.1 Functional performance HL7.CCDAR2 75275-8 LOINC urn:oid:2.16.840.1.11388 3.6.1 Cognitive Function HL7.CCDAR2 75318-6 LOINC urn:oid:2.16.840.1.11388 3.6.1 Problem family member HL7.CCDAR2 75319-4 LOINC urn:oid:2.16.840.1.11388 3.6.1 Symptom family member HL7.CCDAR2 ... Attachment G- EHR Implementation Guide Templates Figure 79: Indication (V2) Example 0.09 MG/ACTUAT inhalant solution, 2 puffs QID PRN wheezing ... ... 3.26.1 Major Reason for Visit [observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.7 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 161: Major Reason for Visit Contexts Contained By: Contains: Current Outpatient Visit (V3) (optional) Current Emergency Department Visit (V2) (optional) This template represents the major reason for this visit. Attachment G- EHR Implementation Guide Templates Table 162: Major Reason for Visit Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.7) @classCode 1..1 SHALL 1106405 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1106406 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106407 1..1 SHALL 1106408 1..1 SHALL 1106409 @code 1..1 SHALL 1106410 ASSERTION @codeSystem 1..1 SHALL 1106411 urn:oid:2.16.840.1.113883.5.4 (ActCode) = 2.16.840.1.113883.5.4 1..1 SHALL 1106412 urn:oid:2.16.840.1.114222.4.11.7 404 (Major Reason for Visit (NCHS)) @root code value CD 2.16.840.1.113883.10.20.34.3.7 1. Conforms to Indication (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-405). 3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-406). 4. SHALL contain exactly one [1..1] templateId (CONF:1106-407) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.7" (CONF:1106-408). 5. SHALL contain exactly one [1..1] code (CONF:1106-409). a. This code SHALL contain exactly one [1..1] @code="ASSERTION" (CONF:1106-410). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode urn:oid:2.16.840.1.113883.5.4) (CONF:1106-411). 6. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Major Reason for Visit (NCHS) urn:oid:2.16.840.1.114222.4.11.7404 DYNAMIC (CONF:1106-412). Attachment G- EHR Implementation Guide Templates Table 163: Major Reason for Visit (NCHS) Value Set: Major Reason for Visit (NCHS) urn:oid:2.16.840.1.114222.4.11.7404 These codes describe the major reason for the visit. Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7404 Code Code System Code System OID Print Name PHC1268 PHIN VADS code system urn:oid:2.16.840.1.11422 2.4.5.274 Chronic problem, flare-up PHC1267 PHIN VADS code system urn:oid:2.16.840.1.11422 2.4.5.274 Chronic problem, routine PHC1265 PHIN VADS code system urn:oid:2.16.840.1.11422 2.4.5.274 New problem (<3 mos. onset) PHC1269 PHIN VADS code system urn:oid:2.16.840.1.11422 2.4.5.274 Pre/Post surgery PHC1266 PHIN VADS code system urn:oid:2.16.840.1.11422 2.4.5.274 Preventive care (e.g., routine prenatal, wellbaby, screening, insurance, general exams) ... Figure 80: Major Reason for Visit Example Attachment G- EHR Implementation Guide Templates 3.27 Instruction (V2) [act: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 164: Instruction (V2) Contexts Contained By: Contains: Medication Activity (V2) (optional) Procedure Activity Act (V2) (optional) Procedure Activity Procedure (V2) (optional) Procedure Activity Observation (V2) (optional) Immunization Activity (V2) (optional) Planned Act (V2) (optional) Planned Procedure (V2) (optional) Planned Observation (V2) (optional) Planned Medication Activity (V2) (optional) Medication Supply Order (V2) (optional) Planned Immunization Activity (optional) The Instruction template can be used in several ways, such as to record patient instructions within a Medication Activity or to record fill instructions within a supply order. The template's moodCode can only be INT. If an instruction was already be given, the Procedure Activity Act template (instead of this template) should be used to represent the already occurred instruction. The act/code defines the type of instruction. Though not defined in this template, a Vaccine Information Statement (VIS) document could be referenced through act/reference/externalDocument, and patient awareness of the instructions can be represented with the generic participant and the participant/awarenessCode. Attachment G- EHR Implementation Guide Templates Table 165: Instruction (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value act (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) @classCode 1..1 SHALL 10987391 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode 1..1 SHALL 10987392 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = INT templateId 1..1 SHALL 10987393 @root 1..1 SHALL 109810503 2.16.840.1.113883.10.20.22.4.20 @extension 1..1 SHALL 109832598 2014-06-09 code 1..1 SHALL 109816884 urn:oid:2.16.840.1.113883.11.20. 9.34 (Patient Education) statusCode 1..1 SHALL 10987396 1..1 SHALL 109819106 @code urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7391). 2. SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7392). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-7393) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.20" (CONF:1098-10503). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32598). 4. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Patient Education urn:oid:2.16.840.1.113883.11.20.9.34 DYNAMIC (CONF:1098-16884). 5. SHALL contain exactly one [1..1] statusCode (CONF:1098-7396). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819106). Attachment G- EHR Implementation Guide Templates Table 166: Patient Education Value Set: Patient Education urn:oid:2.16.840.1.113883.11.20.9.34 Limited to terms descending from the Education (409073007) hierarchy. Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name 311401005 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Patient Education 171044003 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Immunization Education 243072006 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Cancer Education ... Figure 81: Instruction (V2) Example Possible flu-like symptoms for three days. 3.28 Listed for Admission to Hospital Act [act: identifier urn:oid:2.16.840.1.113883.10.20.34.3.15 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 167: Listed for Admission to Hospital Act Contexts Contained By: Contains: Hospital Admission Encounter (required) This template represents the time that a bed was requested for the patient for hospital admission. Attachment G- EHR Implementation Guide Templates Table 168: Listed for Admission to Hospital Act Constraints Overview XPath Card. Verb Data Type CONF# Value act (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.15) @classCode 1..1 SHALL 1106700 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode 1..1 SHALL 1106701 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106560 1..1 SHALL 1106564 id 1..* SHALL 1106565 code 1..1 SHALL 1106561 @code 1..1 SHALL 1106566 183767005 @codeSystem 1..1 SHALL 1106567 2.16.840.1.113883.6.96 1..1 SHALL 1106563 1..1 SHALL 1106569 1..1 SHALL 1106562 1..1 SHALL 1106568 @root statusCode @code effectiveTime low 2.16.840.1.113883.10.20.34.3.15 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-700). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-701). 3. SHALL contain exactly one [1..1] templateId (CONF:1106-560) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.15" (CONF:1106-564). 4. SHALL contain at least one [1..*] id (CONF:1106-565). 5. SHALL contain exactly one [1..1] code (CONF:1106-561). a. This code SHALL contain exactly one [1..1] @code="183767005" Listed for admission to hospital (CONF:1106-566). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" SNOMED (CONF:1106-567). 6. SHALL contain exactly one [1..1] statusCode (CONF:1106-563). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-569). Attachment G- EHR Implementation Guide Templates 7. SHALL contain exactly one [1..1] effectiveTime (CONF:1106-562). a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:1106-568). Note: Form Element: Date and time bed was requested for hospital admission Figure 82: Listed for Admission to Hospital Act Example 3.29 Medication Activity (V2) [substanceAdministration: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 169: Medication Activity (V2) Contexts Contained By: Contains: Medications Section (entries optional) (V2) (optional) Reaction Observation (V2) (optional) Procedure Activity Act (V2) (optional) Procedure Activity Procedure (V2) (optional) Procedure Activity Observation (V2) (optional) Medications Section (optional) Author Participation Drug Monitoring Act Drug Vehicle Indication (V2) Instruction (V2) Medication Dispense (V2) Medication Free Text Sig Medication Information (V2) Medication Supply Order (V2) Precondition for Substance Administration (V2) Reaction Observation (V2) Substance Administered Act A Medication Activity describes substance administrations that have actually occurred (e.g., pills ingested or injections given) or are intended to occur (e.g., "take 2 tablets twice a day for the next 10 days"). Medication activities in "INT" mood are reflections of what a clinician intends a patient to be taking. For example, a clinician may intend that a patient to be administered Lisinopril 20 mg PO for blood pressure control. If what was actually administered was Lisinopril 10 mg., then the Medication activities in the "EVN" mood would reflect actual use. Attachment G- EHR Implementation Guide Templates A moodCode of INT is allowed, but it is recommended that the Planned Medication Activity (V2) template be used for moodCodes other than EVN if the document type contains a section that includes Planned Medication Activity (V2) (for example a Care Plan document with Plan of Treatment, Intervention, or Goal sections). At a minimum, a Medication Activity shall include an effectiveTime indicating the duration of the administration (or single-administration timestamp). Ambulatory medication lists generally provide a summary of use for a given medication over time - a medication activity in event mood with the duration reflecting when the medication started and stopped. Ongoing medications will not have a stop date (or will have a stop date with a suitable NULL value). Ambulatory medication lists will generally also have a frequency (e.g., a medication is being taken twice a day). Inpatient medications generally record each administration as a separate act. The dose (doseQuantity) represents how many of the consumables are to be administered at each administration event. As a result, the dose is always relative to the consumable and the interval of administration. Thus, a patient consuming a single "metoprolol 25mg tablet" per administration will have a doseQuantity of "1", whereas a patient consuming "metoprolol" will have a dose of "25 mg". Attachment G- EHR Implementation Guide Templates Table 170: Medication Activity (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value substanceAdministration (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09) @classCode 1..1 SHALL 10987496 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = SBADM @moodCode 1..1 SHALL 10987497 urn:oid:2.16.840.1.113883.11.20. 9.18 (MoodCodeEvnInt) templateId 1..1 SHALL 10987499 @root 1..1 SHALL 109810504 2.16.840.1.113883.10.20.22.4.16 @extension 1..1 SHALL 109832498 2014-06-09 id 1..* SHALL 10987500 code 0..1 MAY 10987506 statusCode 1..1 SHALL 10987507 1..1 SHALL 109832360 1..1 SHALL @value 0..1 SHOUL D 109832775 low 0..1 SHOUL D 109832776 high 0..1 MAY 109832777 effectiveTime 0..1 SHOUL D 10987513 @operator 1..1 SHALL 10989106 repeatNumber 0..1 MAY 10987555 routeCode 0..1 SHOUL D 10987514 urn:oid:2.16.840.1.113883.3.88.1 2.3221.8.7 (Medication Route FDA) approachSiteCode 0..1 MAY 10987515 urn:oid:2.16.840.1.113883.3.88.1 2.3221.8.9 (Body Site) doseQuantity 1..1 SHALL 10987516 0..1 SHOUL D 10987526 0..1 MAY 1098- @code effectiveTime @unit rateQuantity IVL_TS SET urn:oid:2.16.840.1.113883.1.11.1 59331 (ActStatus) 10987508 A urn:oid:2.16.840.1.113883.1.11.1 2839 (UnitsOfMeasureCaseSensitive) Attachment G- EHR Implementation Guide Templates 7517 @unit 1..1 SHALL maxDoseQuantity 0..1 MAY administrationUnitCode 0..1 MAY 10987519 consumable 1..1 SHALL 10987520 1..1 SHALL 109816085 performer 0..1 MAY 10987522 author 0..* SHOUL D 109831150 participant 0..* MAY 10987523 @typeCode 1..1 SHALL 10987524 urn:oid:2.16.840.1.113883.5.90 (HL7ParticipationType) = CSM participantRole 1..1 SHALL 109816086 Drug Vehicle (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.24 entryRelationship 0..* MAY 10987536 @typeCode 1..1 SHALL 10987537 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = RSON observation 1..1 SHALL 109816087 Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.19:2014-06-09 0..1 MAY 10987539 @typeCode 1..1 SHALL 10987540 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ @inversionInd 1..1 SHALL 10987542 true act 1..1 SHALL 109831387 Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.20:2014-06-09 0..1 MAY 10987543 1..1 SHALL 10987547 manufacturedProduct entryRelationship entryRelationship @typeCode 10987525 RTO

urn:oid:2.16.840.1.113883.1.11.1 2839 (UnitsOfMeasureCaseSensitive) 10987518 urn:oid:2.16.840.1.113762.1.4.10 21.30 (AdministrationUnitDoseForm) Medication Information (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.23:2014-06-09 Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = Attachment G- EHR Implementation Guide Templates REFR supply 1..1 SHALL 109816089 0..* MAY 10987549 @typeCode 1..1 SHALL 10987553 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR supply 1..1 SHALL 109816090 Medication Dispense (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.18:2014-06-09 0..* MAY 10987552 @typeCode 1..1 SHALL 10987544 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = CAUS observation 1..1 SHALL 109816091 Reaction Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.9:2014-06-09 0..1 MAY 109830820 @typeCode 1..1 SHALL 109830821 COMP act 1..1 SHALL 109830822 Drug Monitoring Act (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.123 0..* MAY 109831515 @typeCode 1..1 SHALL 109831516 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = COMP @inversionInd 1..1 SHALL 109831517 true sequenceNumber 0..1 MAY 109831518 act 1..1 SHALL 109831519 0..* MAY 109832907 @typeCode 1..1 SHALL 109832908 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = COMP substanceAdministration 1..1 SHALL 1098- Medication Free Text Sig (identifier: entryRelationship entryRelationship entryRelationship entryRelationship entryRelationship Medication Supply Order (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.17:2014-06-09 Substance Administered Act (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.118 Attachment G- EHR Implementation Guide Templates 32909 urn:oid:2.16.840.1.113883.10.20. 22.4.147 precondition 0..* MAY 109831520 @typeCode 1..1 SHALL 109831882 PRCN criterion 1..1 SHALL 109831883 Precondition for Substance Administration (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.25:2014-06-09 1. SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7496). 2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt urn:oid:2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 (CONF:1098-7497). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-7499) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.16" (CONF:1098-10504). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32498). 4. SHALL contain at least one [1..*] id (CONF:1098-7500). 5. MAY contain zero or one [0..1] code (CONF:1098-7506). Note: SubstanceAdministration.code is an optional field. Per HL7 Pharmacy Committee, "this is intended to further specify the nature of the substance administration act. To date the committee has made no use of this attribute". Because the type of substance administration is generally implicit in the routeCode, in the consumable participant, etc., the field is generally not used, and there is no defined value set. 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-7507). a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ActStatus urn:oid:2.16.840.1.113883.1.11.159331 DYNAMIC (CONF:1098-32360). The substance administration effectiveTime field can repeat, in order to represent varying levels of complex dosing. effectiveTime can be used to represent the duration of administration (e.g., "10 days"), the frequency of administration (e.g., "every 8 hours"), and more. Here, we require that there SHALL be an effectiveTime documentation of the duration (or single-administration timestamp), and that there SHOULD be an effectiveTime documentation of the frequency. Other timing nuances, supported by the base CDA R2 standard, may also be included. 7. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-7508) 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:1098-32775). Note: indicates a single-administration timestamp b. SHOULD contain zero or one [0..1] low (CONF:1098-32776). Note: indicates when medication started Attachment G- EHR Implementation Guide Templates c. MAY contain zero or one [0..1] high (CONF:1098-32777). Note: indicates when medication stopped d. This effectiveTime SHALL contain either a low or a @value but not both (CONF:1098-32890). 8. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it Note: This effectiveTime represents the medication frequency (e.g., administration times per day). a. SHALL contain exactly one [1..1] @operator="A" (CONF:1098-9106). b. SHALL contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:109828499). In "INT" (intent) mood, the repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a substance administration event means that the current administration is the 3rd in a series. 9. MAY contain zero or one [0..1] repeatNumber (CONF:1098-7555). 10. SHOULD contain zero or one [0..1] routeCode, which SHALL be selected from ValueSet Medication Route FDA urn:oid:2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC (CONF:1098-7514). 11. MAY contain zero or one [0..1] approachSiteCode, where the code SHALL be selected from ValueSet Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:1098-7515). 12. SHALL contain exactly one [1..1] doseQuantity (CONF:1098-7516). a. This doseQuantity SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-7526). b. Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet" per administration) (CONF:1098-16878). c. Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is simply "metoprolol"), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879). 13. MAY contain zero or one [0..1] rateQuantity (CONF:1098-7517). a. The rateQuantity, if present, SHALL contain exactly one [1..1] @unit, which SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-7525). 14. MAY contain zero or one [0..1] maxDoseQuantity (CONF:1098-7518). administrationUnitCode@code describes the units of medication administration for an item using a code that is pre-coordinated to include a physical unit form (ointment, powder, solution, etc.) which differs from the units used in administering the consumable (capful, spray, drop, etc.). For example when recording medication administrations, “metric drop Attachment G- EHR Implementation Guide Templates (C48491)” would be appropriate to accompany the RxNorm code of 198283 (Timolol 0.25% Ophthalmic Solution) where the number of drops would be specified in doseQuantity@value. 15. MAY contain zero or one [0..1] administrationUnitCode, which SHALL be selected from ValueSet AdministrationUnitDoseForm urn:oid:2.16.840.1.113762.1.4.1021.30 DYNAMIC (CONF:1098-7519). 16. SHALL contain exactly one [1..1] consumable (CONF:1098-7520). a. This consumable SHALL contain exactly one [1..1] Medication Information (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.23:2014-06-09) (CONF:1098-16085). 17. MAY contain zero or one [0..1] performer (CONF:1098-7522). 18. SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31150). 19. MAY contain zero or more [0..*] participant (CONF:1098-7523) such that it a. SHALL contain exactly one [1..1] @typeCode="CSM" (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:10987524). b. SHALL contain exactly one [1..1] Drug Vehicle (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.24) (CONF:1098-16086). 20. MAY contain zero or more [0..*] entryRelationship (CONF:1098-7536) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7537). b. SHALL contain exactly one [1..1] Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109816087). 21. MAY contain zero or one [0..1] entryRelationship (CONF:1098-7539) such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7540). b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-7542). c. SHALL contain exactly one [1..1] Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109831387). 22. MAY contain zero or one [0..1] entryRelationship (CONF:1098-7543) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7547). b. SHALL contain exactly one [1..1] Medication Supply Order (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.17:2014-06-09) (CONF:109816089). 23. MAY contain zero or more [0..*] entryRelationship (CONF:1098-7549) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7553). Attachment G- EHR Implementation Guide Templates b. SHALL contain exactly one [1..1] Medication Dispense (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.18:2014-06-09) (CONF:109816090). 24. MAY contain zero or more [0..*] entryRelationship (CONF:1098-7552) such that it a. SHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7544). b. SHALL contain exactly one [1..1] Reaction Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.9:2014-06-09) (CONF:109816091). 25. MAY contain zero or one [0..1] entryRelationship (CONF:1098-30820) such that it a. SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CONF:109830821). b. SHALL contain exactly one [1..1] Drug Monitoring Act (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.123) (CONF:1098-30822). The following entryRelationship is used to indicate a given medication's order in a series. The nested Substance Administered Act identifies an administration in the series. The entryRelationship/sequenceNumber shows the order of this particular administration in that series. 26. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31515) such that it a. SHALL contain exactly one [1..1] @typeCode="COMP" Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831516). b. SHALL contain exactly one [1..1] @inversionInd="true" (CONF:1098-31517). c. MAY contain zero or one [0..1] sequenceNumber (CONF:1098-31518). d. SHALL contain exactly one [1..1] Substance Administered Act (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.118) (CONF:1098-31519). 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:109832908). 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). 28. MAY contain zero or more [0..*] precondition (CONF:1098-31520). a. The precondition, if present, SHALL contain exactly one [1..1] @typeCode="PRCN" (CONF:1098-31882). b. The precondition, if present, SHALL contain exactly one [1..1] Precondition for Substance Administration (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.25:2014-06-09) (CONF:109831883). 29. Medication Activity SHOULD include doseQuantity OR rateQuantity (CONF:1098-30800). Attachment G- EHR Implementation Guide Templates Figure 83: Medication Activity (V2) Example Attachment G- EHR Implementation Guide Templates Figure 84: No Known Medications Example 3.30 Medication Dispense (V2) [supply: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.18:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 171: Medication Dispense (V2) Contexts Contained By: Contains: Medication Activity (V2) (optional) Immunization Activity (V2) (optional) Immunization Medication Information (V2) Medication Information (V2) Medication Supply Order (V2) US Realm Address (AD.US.FIELDED) This template records the act of supplying medications (i.e., dispensing). Attachment G- EHR Implementation Guide Templates Table 172: Medication Dispense (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value supply (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.18:2014-06-09) @classCode 1..1 SHALL 10987451 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = SPLY @moodCode 1..1 SHALL 10987452 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 10987453 @root 1..1 SHALL 109810505 2.16.840.1.113883.10.20.22.4.18 @extension 1..1 SHALL 109832580 2014-06-09 id 1..* SHALL 10987454 statusCode 1..1 SHALL 10987455 1..1 SHALL 109832361 effectiveTime 0..1 SHOUL D 10987456 repeatNumber 0..1 SHOUL D 10987457 quantity 0..1 SHOUL D 10987458 product 0..1 MAY 10987459 1..1 SHALL 109815607 0..1 MAY 10989331 1..1 SHALL 109831696 0..1 MAY 10987461 1..1 SHALL 10987467 0..1 SHOUL D 10987468 0..1 MAY 10987473 @code manufacturedProduct product manufacturedProduct performer assignedEntity addr entryRelationship urn:oid:2.16.840.1.113883.3.88.1 2.80.64 (Medication Fill Status) Medication Information (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.23:2014-06-09 Immunization Medication Information (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.54:2014-06-09 US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20. 22.5.2 Attachment G- EHR Implementation Guide Templates @typeCode 1..1 SHALL 10987474 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR supply 1..1 SHALL 109815606 Medication Supply Order (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.17:2014-06-09 1. SHALL contain exactly one [1..1] @classCode="SPLY" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7451). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7452). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-7453) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.18" (CONF:1098-10505). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32580). 4. SHALL contain at least one [1..*] id (CONF:1098-7454). 5. SHALL contain exactly one [1..1] statusCode (CONF:1098-7455). a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Medication Fill Status urn:oid:2.16.840.1.113883.3.88.12.80.64 STATIC 2014-04-23 (CONF:109832361). 6. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7456). In "INT" (intent) mood, the repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a substance administration event means that the current administration is the 3rd in a series. 7. SHOULD contain zero or one [0..1] repeatNumber (CONF:1098-7457). 8. SHOULD contain zero or one [0..1] quantity (CONF:1098-7458). 9. MAY contain zero or one [0..1] product (CONF:1098-7459) such that it a. SHALL contain exactly one [1..1] Medication Information (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.23:2014-06-09) (CONF:109815607). 10. MAY contain zero or one [0..1] product (CONF:1098-9331) such that it a. SHALL contain exactly one [1..1] Immunization Medication Information (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.54:2014-06-09) (CONF:1098-31696). 11. MAY contain zero or one [0..1] performer (CONF:1098-7461). a. The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1098-7467). i. This assignedEntity SHOULD contain zero or one [0..1] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1098-7468). Attachment G- EHR Implementation Guide Templates 1. The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:109810565). 12. MAY contain zero or one [0..1] entryRelationship (CONF:1098-7473) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7474). b. SHALL contain exactly one [1..1] Medication Supply Order (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.17:2014-06-09) (CONF:109815606). 13. A supply act SHALL contain one product/Medication Information OR one product/Immunization Medication Information template (CONF:1098-9333). Table 173: Medication Fill Status Value Set: Medication Fill Status urn:oid:2.16.840.1.113883.3.88.12.80.64 Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name aborted ActStatus urn:oid:2.16.840.1.11388 3.5.14 Aborted completed ActStatus urn:oid:2.16.840.1.11388 3.5.14 Completed Figure 85: Medication Dispense (V2) Example . . . . . . Attachment G- EHR Implementation Guide Templates 3.31 Medication Free Text Sig [substanceAdministration: identifier urn:oid:2.16.840.1.113883.10.20.22.4.147 (closed)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2.1 Table 174: Medication Free Text Sig Contexts Contained By: Contains: Medication Activity (V2) (optional) The template is available to explicitly identify the free text Sig within each medication. An example free text sig: Thyroxin 150 ug, take one tab by mouth every morning. Attachment G- EHR Implementation Guide Templates Table 175: Medication Free Text Sig Constraints Overview XPath Card. Verb Data Type CONF# Value substanceAdministration (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.147) @classCode 1..1 SHALL 119832770 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = SBADM @moodCode 1..1 SHALL 119832771 urn:oid:2.16.840.1.113883.11.20. 9.18 (MoodCodeEvnInt) templateId 1..1 SHALL 119832753 1..1 SHALL 119832772 2.16.840.1.113883.10.20.22.4.14 7 1..1 SHALL 119832775 urn:oid:2.16.840.1.113883.6.1 (LOINC) @code 1..1 SHALL 119832780 76662-6 @codeSystem 1..1 SHALL 119832781 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 119832754 reference 1..1 SHALL 119832755 @value 0..1 SHOUL D 119832756 1..1 SHALL 119832776 1..1 SHALL 119832777 1..1 SHALL 119832778 1..1 SHALL 119832779 @root code text consumable manufacturedProduct manufacturedLabeledDrug @nullFlavor NA 1. SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-32770). 2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt urn:oid:2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 (CONF:1198-32771). Note: moodCode must match the parent substanceAdministration EVN or INT 3. SHALL contain exactly one [1..1] templateId (CONF:1198-32753) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.147" (CONF:1198-32772). 4. SHALL contain exactly one [1..1] code (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1198-32775). a. This code SHALL contain exactly one [1..1] @code="76662-6" Instructions Medication (CONF:1198-32780). Attachment G- EHR Implementation Guide Templates b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1 STATIC) (CONF:1198-32781). 5. SHALL contain exactly one [1..1] text (CONF:1198-32754). Reference into the section/text to a tag that only contains free text sig. a. This text SHALL contain exactly one [1..1] reference (CONF:1198-32755). i. This reference SHOULD contain zero or one [0..1] @value (CONF:1198-32756). 1. This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-32774). 6. SHALL contain exactly one [1..1] consumable (CONF:1198-32776). a. This consumable SHALL contain exactly one [1..1] manufacturedProduct (CONF:1198-32777). i. This manufacturedProduct SHALL contain exactly one [1..1] manufacturedLabeledDrug (CONF:1198-32778). 1. This manufacturedLabeledDrug SHALL contain exactly one [1..1] @nullFlavor="NA" Not Applicable (CONF:1198-32779). Figure 86: Medication Free Text Sig Example Attachment G- EHR Implementation Guide Templates 3.32 Medication Information (V2) [manufacturedProduct: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.23:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 176: Medication Information (V2) Contexts Contained By: Contains: Medication Activity (V2) (required) Planned Medication Activity (V2) (required) Medication Supply Order (V2) (optional) Medication Dispense (V2) (optional) A medication should be recorded as a pre-coordinated ingredient + strength + dose form (e.g., “metoprolol 25mg tablet”, “amoxicillin 400mg/5mL suspension”) where possible. This includes RxNorm codes whose Term Type is SCD (semantic clinical drug), SBD (semantic brand drug), GPCK (generic pack), BPCK (brand pack). The dose (doseQuantity) represents how many of the consumables are to be administered at each administration event. As a result, the dose is always relative to the consumable. Thus, a patient consuming a single "metoprolol 25mg tablet" per administration will have a doseQuantity of "1", whereas a patient consuming "metoprolol" will have a dose of "25 mg". Table 177: Medication Information (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value manufacturedProduct (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.23:2014-06-09) @classCode 1..1 SHALL 10987408 templateId 1..1 SHALL 10987409 @root 1..1 SHALL 109810506 2.16.840.1.113883.10.20.22.4.23 @extension 1..1 SHALL 109832579 2014-06-09 id 0..* MAY 10987410 manufacturedMaterial 1..1 SHALL 10987411 1..1 SHALL 10987412 urn:oid:2.16.840.1.113762.1.4.10 10.4 (Medication Clinical Drug) 0..* MAY 109831884 urn:oid:2.16.840.1.113762.1.4.10 10.2 (Clinical Substance) 0..1 MAY 10987416 code translation manufacturerOrganization urn:oid:2.16.840.1.113883.5.110 (RoleClass) = MANU Attachment G- EHR Implementation Guide Templates 1. SHALL contain exactly one [1..1] @classCode="MANU" (CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110 STATIC) (CONF:1098-7408). 2. SHALL contain exactly one [1..1] templateId (CONF:1098-7409) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.23" (CONF:1098-10506). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32579). 3. MAY contain zero or more [0..*] id (CONF:1098-7410). 4. SHALL contain exactly one [1..1] manufacturedMaterial (CONF:1098-7411). Note: A medication should be recorded as a pre-coordinated ingredient + strength + dose form (e.g., “metoprolol 25mg tablet”, “amoxicillin 400mg/5mL suspension”) where possible. This includes RxNorm codes whose Term Type is SCD (semantic clinical drug), SBD (semantic brand drug), GPCK (generic pack), BPCK (brand pack). a. This manufacturedMaterial SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet Medication Clinical Drug urn:oid:2.16.840.1.113762.1.4.1010.4 DYNAMIC (CONF:1098-7412). i. This code MAY contain zero or more [0..*] translation, which MAY be selected from ValueSet Clinical Substance urn:oid:2.16.840.1.113762.1.4.1010.2 DYNAMIC (CONF:1098-31884). 5. MAY contain zero or one [0..1] manufacturerOrganization (CONF:1098-7416). Table 178: Medication Clinical Drug Value Set: Medication Clinical Drug urn:oid:2.16.840.1.113762.1.4.1010.4 All prescribable medication formulations represented using either a "generic" or "brand-specific" concept. This includes RxNorm codes whose Term Type is SCD (semantic clinical drug), SBD (semantic brand drug), GPCK (generic pack), BPCK (brand pack), SCDG (semantic clinical drug group), SBDG (semantic brand drug group), SCDF (semantic clinical drug form), or SBDF (semantic brand drug form). Value set intensionally defined as a GROUPING made up of: Value Set: Medication Clinical General Drug (2.16.840.1.113883.3.88.12.80.17) (RxNorm Generic Drugs); Value Set: Medication Clinical Brand-specific Drug (2.16.840.1.113762.1.4.1010.5) (RxNorm Branded Drugs). Value Set Source: http://phinvads.cdc.gov/vads/ViewValueSet.action?id=239BEF3E-971C- DF11-B334-0015173D1785 Code Code System Code System OID Print Name 978727 RxNorm urn:oid:2.16.840.1.11388 3.6.88 0.2 ML Dalteparin Sodium 12500 UNT/ML Prefilled Syringe [Fragmin] 827318 RxNorm urn:oid:2.16.840.1.11388 3.6.88 Acetaminophen 250 MG / Aspirin 250 MG / Caffeine 65 MG Oral Capsule 199274 RxNorm urn:oid:2.16.840.1.11388 3.6.88 Aspirin 300 MG Oral Capsule 362867 RxNorm urn:oid:2.16.840.1.11388 3.6.88 Cefotetan Injectable Solution [Cefotan] ... Attachment G- EHR Implementation Guide Templates Table 179: Clinical Substance Value Set: Clinical Substance urn:oid:2.16.840.1.113762.1.4.1010.2 All substances that may need to be represented in the context of health care related activities. This value set is quite broad in coverage and includes concepts that may never be needed in a health care activity event, particularly the included SNOMED CT concepts. The code system-specific value sets in this grouping value set are intended to provide broad coverage of all kinds of agents, but the expectation for use is that the chosen concept identifier for a substance should be appropriately specific and drawn from the appropriate code system as noted: prescribable medications should use RXNORM concepts, more specific drugs and chemicals should be represented using UNII concepts, and any substances not found in either of those two code systems, should use the appropriate SNOMED CT concept. This overarching grouping value set is intended to support identification of prescribable medications, foods, general substances and environmental entities. Value set intensionally defined as a GROUPING made up of: Value Set: Medication Clinical Drug (2.16.840.1.113762.1.4.1010.4) (RxNorm generic and brand codes); Value Set: Unique Ingredient Identifier Complete Set (2.16.840.1.113883.3.88.12.80.20) (UNII codes); Value Set: Substance Other Than Clinical Drug (2.16.840.1.113762.1.4.1010.9) (SNOMED CT codes). Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name 369436 RxNorm urn:oid:2.16.840.1.11388 3.6.88 6-Aminocaproic Acid Oral Tablet [Amicar] 1116447 RxNorm urn:oid:2.16.840.1.11388 3.6.88 Acepromazine Oral Tablet 9042592173 Unique Ingredient Identifier (UNII) urn:oid:2.16.840.1.11388 3.4.9 ATROMEPINE 7673326042 Unique Ingredient Identifier (UNII) urn:oid:2.16.840.1.11388 3.4.9 IRINOTECAN 413480003 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Almond product (substance) 256915001 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Aluminum hydroxide absorbed plasma (substance) 10020007 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Biperiden hydrochloride (substance) 10133003 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Cyclizine lactate (substance) 10174003 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Procarbazine hydrochloride (substance) 102259006 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Citrus fruit (substance) ... Attachment G- EHR Implementation Guide Templates Figure 87: Medication Information (V2) Example Medication Factory Inc. 3.33 Medication Supply Order (V2) [supply: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.17:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 180: Medication Supply Order (V2) Contexts Contained By: Contains: Medication Activity (V2) (optional) Immunization Activity (V2) (optional) Medication Dispense (V2) (optional) Immunization Medication Information (V2) Instruction (V2) Medication Information (V2) This template records the intent to supply a patient with medications. Attachment G- EHR Implementation Guide Templates Table 181: Medication Supply Order (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value supply (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.17:2014-06-09) @classCode 1..1 SHALL 10987427 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = SPLY @moodCode 1..1 SHALL 10987428 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = INT templateId 1..1 SHALL 10987429 @root 1..1 SHALL 109810507 2.16.840.1.113883.10.20.22.4.17 @extension 1..1 SHALL 109832578 2014-06-09 id 1..* SHALL 10987430 statusCode 1..1 SHALL 10987432 1..1 SHALL 109832362 0..1 SHOUL D 1..1 SHALL 109815144 repeatNumber 0..1 SHOUL D 10987434 quantity 0..1 SHOUL D 10987436 product 0..1 MAY 10987439 1..1 SHALL 109816093 0..1 MAY 10989334 1..1 SHALL 109831695 author 0..1 MAY 10987438 entryRelationship 0..1 MAY 10987442 1..1 SHALL 10987444 @code effectiveTime high manufacturedProduct product manufacturedProduct @typeCode IVL_TS urn:oid:2.16.840.1.113883.1.11.1 59331 (ActStatus) 109815143 Medication Information (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.23:2014-06-09 Immunization Medication Information (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.54:2014-06-09 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ Attachment G- EHR Implementation Guide Templates @inversionInd 1..1 SHALL 10987445 true act 1..1 SHALL 109831391 Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.20:2014-06-09 1. SHALL contain exactly one [1..1] @classCode="SPLY" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7427). 2. SHALL contain exactly one [1..1] @moodCode="INT" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7428). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-7429) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.17" (CONF:1098-10507). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32578). 4. SHALL contain at least one [1..*] id (CONF:1098-7430). 5. SHALL contain exactly one [1..1] statusCode (CONF:1098-7432). a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ActStatus urn:oid:2.16.840.1.113883.1.11.159331 DYNAMIC (CONF:1098-32362). 6. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-15143) such that it a. SHALL contain exactly one [1..1] high (CONF:1098-15144). In "INT" (intent) mood, the repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a substance administration event means that the current administration is the 3rd in a series. 7. SHOULD contain zero or one [0..1] repeatNumber (CONF:1098-7434). 8. SHOULD contain zero or one [0..1] quantity (CONF:1098-7436). 9. MAY contain zero or one [0..1] product (CONF:1098-7439) such that it a. SHALL contain exactly one [1..1] Medication Information (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.23:2014-06-09) (CONF:109816093). 10. MAY contain zero or one [0..1] product (CONF:1098-9334) such that it a. SHALL contain exactly one [1..1] Immunization Medication Information (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.54:2014-06-09) (CONF:1098-31695). i. A supply act SHALL contain one product/Medication Information OR one product/Immunization Medication Information template (CONF:109816870). 11. MAY contain zero or one [0..1] author (CONF:1098-7438). 12. MAY contain zero or one [0..1] entryRelationship (CONF:1098-7442). a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7444). Attachment G- EHR Implementation Guide Templates b. The entryRelationship, if present, SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-7445). c. The entryRelationship, if present, SHALL contain exactly one [1..1] Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-0609) (CONF:1098-31391). Figure 88: Medication Supply Order (V2) Example . . . . . . . . . 3.34 New Patient Act [act: identifier urn:oid:2.16.840.1.113883.10.20.34.3.9 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 182: New Patient Act Contexts Contained By: Contains: Current Outpatient Visit (V3) (optional) This template represents the fact that this patient is a new patient at this practice. Attachment G- EHR Implementation Guide Templates Table 183: New Patient Act Constraints Overview XPath Card. Verb Data Type CONF# Value act (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.9) @classCode 1..1 SHALL 1106476 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode 1..1 SHALL 1106477 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106478 1..1 SHALL 1106479 id 1..* SHALL 1106480 code 1..1 SHALL 1106481 @code 1..1 SHALL 1106482 108220007 @codeSystem 1..1 SHALL 1106483 urn:oid:2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96 1..1 SHALL 1106741 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed @root statusCode 2.16.840.1.113883.10.20.34.3.9 1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-476). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-477). 3. SHALL contain exactly one [1..1] templateId (CONF:1106-478) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.9" (CONF:1106-479). 4. SHALL contain at least one [1..*] id (CONF:1106-480). 5. SHALL contain exactly one [1..1] code (CONF:1106-481). a. This code SHALL contain exactly one [1..1] @code="108220007" Evaluation and/or management - new patient (CONF:1106-482). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT urn:oid:2.16.840.1.113883.6.96) (CONF:1106-483). 6. SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-741). Attachment G- EHR Implementation Guide Templates Figure 89: New Patient Act Example 3.35 Number of Visits in the Last 12 Months [observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.26 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 184: Number of Visits in the Last 12 Months Contexts Contained By: Contains: Current Outpatient Visit (V3) (optional) This template represents the number of visits in the last 12 months, excluding the current visit. Attachment G- EHR Implementation Guide Templates Table 185: Number of Visits in the Last 12 Months Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.26) @classCode 1..1 SHALL 1106521 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1106522 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106523 1..1 SHALL 1106524 id 1..* SHALL 1106525 code 1..1 SHALL 1106526 @code 0..1 MAY 1106527 75612-2 @codeSystem 0..1 MAY 1106528 2.16.840.1.113883.6.1 statusCode 1..1 SHALL 1106529 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed value 1..1 SHALL @root INT 2.16.840.1.113883.10.20.34.3.26 1106530 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-521). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-522). 3. SHALL contain exactly one [1..1] templateId (CONF:1106-523) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.26" (CONF:1106-524). 4. SHALL contain at least one [1..*] id (CONF:1106-525). 5. SHALL contain exactly one [1..1] code (CONF:1106-526). a. This code MAY contain zero or one [0..1] @code="75612-2" Number of visits to this healthcare entity in the last 12MO (CONF:1106-527). b. This code MAY contain zero or one [0..1] @codeSystem="2.16.840.1.113883.6.1" (CONF:1106-528). 6. SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-529). 7. SHALL contain exactly one [1..1] value with @xsi:type="INT" (CONF:1106-530). Note: Form Element: Number of Visits in the Last 12 Months Attachment G- EHR Implementation Guide Templates Figure 90: Number of Visits in the Last 12 Months Example 3.36 On Oxygen on Arrival Observation [observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.29 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 186: On Oxygen on Arrival Observation Contexts Contained By: Contains: Triage Section (required) This template represents whether or not the patient was on oxygen on arrival. If it is unknown whether the patient was on oxygen on arrival use nullFlavor="UNK". Attachment G- EHR Implementation Guide Templates Table 187: On Oxygen on Arrival Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.29) @classCode 1..1 SHALL 1106704 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1106705 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106706 1..1 SHALL 1106707 id 1..* SHALL 1106708 code 1..1 SHALL 1106709 @code 1..1 SHALL 1106713 75610-6 @codeSystem 0..1 MAY 1106714 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 1106710 1..1 SHALL 1106711 1..1 SHALL @nullFlavor 0..1 MAY 1106715 @value 0..1 SHOUL D 1106856 @root statusCode @code value BL 2.16.840.1.113883.10.20.34.3.29 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1106712 UNK 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-704). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-705). 3. SHALL contain exactly one [1..1] templateId (CONF:1106-706) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.29" (CONF:1106-707). 4. SHALL contain at least one [1..*] id (CONF:1106-708). 5. SHALL contain exactly one [1..1] code (CONF:1106-709). a. This code SHALL contain exactly one [1..1] @code="75610-6" Oxygen therapy at arrival (CONF:1106-713). b. This code MAY contain zero or one [0..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1106-714). 6. SHALL contain exactly one [1..1] statusCode (CONF:1106-710). Attachment G- EHR Implementation Guide Templates a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-711). 7. SHALL contain exactly one [1..1] value with @xsi:type="BL" (CONF:1106-712). a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1106-715). b. This value SHOULD contain zero or one [0..1] @value (CONF:1106-856). Figure 91: On Oxygen on Arrival Observation Example 3.37 Patient Residence Observation [observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.25 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 188: Patient Residence Observation Contexts Contained By: Contains: Patient Information Section (V3) (optional) This template represents the patient residence type. If the type of residence is other use nullFlavor="OTH". If the type of residence is unknown use nullFlavor="UNK". Attachment G- EHR Implementation Guide Templates Table 189: Patient Residence Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.25) @classCode 1..1 SHALL 1106606 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1106607 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106601 1..1 SHALL 1106603 id 1..* SHALL 1106679 code 1..1 SHALL 1106602 @code 1..1 SHALL 1106604 75617-1 @codeSystem 1..1 SHALL 1106605 2.16.840.1.113883.6.1 1..1 SHALL 1106680 0..1 MAY 1106681 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1..1 SHALL 1106608 urn:oid:2.16.840.1.114222.4.11.7 402 (Patient Residence (NCHS)) 0..1 MAY 1106675 urn:oid:2.16.840.1.113883.10.20. 5.9.1 (NullValues_UNK_OTH) @root statusCode @code value @nullFlavor CD 2.16.840.1.113883.10.20.34.3.25 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1106-606). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1106-607). 3. SHALL contain exactly one [1..1] templateId (CONF:1106-601) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.25" (CONF:1106-603). 4. SHALL contain at least one [1..*] id (CONF:1106-679). 5. SHALL contain exactly one [1..1] code (CONF:1106-602). a. This code SHALL contain exactly one [1..1] @code="75617-1" Residence (CONF:1106-604). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CONF:1106-605). 6. SHALL contain exactly one [1..1] statusCode (CONF:1106-680). a. This statusCode MAY contain zero or one [0..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-681). Attachment G- EHR Implementation Guide Templates 7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Patient Residence (NCHS) urn:oid:2.16.840.1.114222.4.11.7402 DYNAMIC (CONF:1106-608). a. This value MAY contain zero or one [0..1] @nullFlavor, which SHALL be selected from ValueSet NullValues_UNK_OTH urn:oid:2.16.840.1.113883.10.20.5.9.1 STATIC 2014-01-01 (CONF:1106-675). Table 190: Patient Residence (NCHS) Value Set: Patient Residence (NCHS) urn:oid:2.16.840.1.114222.4.11.7402 These codes describe the patient's residence type. Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7402 Code Code System Code System OID Print Name 394778007 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Client's or patient's home 42665001 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Nursing home 32911000 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Homeless ... Figure 92: Patient Residence Example 3.38 Patient Seen in this ED in last 72 Hours and Discharged [observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.31 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 191: Patient Seen in this ED in last 72 Hours and Discharged Contexts Contained By: Current Emergency Department Visit (V2) (optional) Contains: Attachment G- EHR Implementation Guide Templates This template represents whether or not the patient has been seen in this ED within the last 72 hours and discharged. If this fact is unknown use nullFlavor="UNK". Table 192: Patient Seen in this ED in last 72 Hours and Discharged Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.31) @classCode 1..1 SHALL 1106722 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1106723 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106718 1..1 SHALL 1106720 id 1..* SHALL 1106724 code 1..1 SHALL 1106725 @code 0..1 MAY 1106727 75611-4 @codeSystem 0..1 MAY 1106728 2.16.840.1.113883.6.1 1..1 SHALL 1106719 1..1 SHALL 1106721 1..1 SHALL @nullFlavor 0..1 MAY 1106729 @value 0..1 SHOUL D 1106862 @root statusCode @code value BL 2.16.840.1.113883.10.20.34.3.31 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1106726 UNK 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-722). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-723). 3. SHALL contain exactly one [1..1] templateId (CONF:1106-718) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.31" (CONF:1106-720). 4. SHALL contain at least one [1..*] id (CONF:1106-724). 5. SHALL contain exactly one [1..1] code (CONF:1106-725). a. This code MAY contain zero or one [0..1] @code="75611-4" Patient seen in this ED in last 72H and discharged (CONF:1106-727). Attachment G- EHR Implementation Guide Templates b. This code MAY contain zero or one [0..1] @codeSystem="2.16.840.1.113883.6.1" (CONF:1106-728). 6. SHALL contain exactly one [1..1] statusCode (CONF:1106-719). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-721). Use @value="true" for "yes", @value="false" for "no" and @nullFlavor="UNK" for "unknown". 7. SHALL contain exactly one [1..1] value with @xsi:type="BL" (CONF:1106-726). a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1106-729). b. This value SHOULD contain zero or one [0..1] @value (CONF:1106-862). Figure 93: Patient Seen in this ED in last 72 Hours and Discharged Example 3.39 Planned Act (V2) [act: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.39:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 193: Planned Act (V2) Contexts Contained By: Contains: Author Participation Indication (V2) Instruction (V2) Priority Preference This template represents planned acts that are not classified as an observation or a procedure according to the HL7 RIM. Examples of these acts are a dressing change, the teaching or feeding of a patient or the providing of comfort measures. The priority of the activity to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the activity is intended to take place. Attachment G- EHR Implementation Guide Templates Table 194: Planned Act (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value act (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.39:2014-06-09) @classCode 1..1 SHALL 10988538 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode 1..1 SHALL 10988539 urn:oid:2.16.840.1.113883.11.20. 9.23 (Planned moodCode (Act/Encounter/Procedure)) templateId 1..1 SHALL 109830430 @root 1..1 SHALL 109830431 2.16.840.1.113883.10.20.22.4.39 @extension 1..1 SHALL 109832552 2014-06-09 id 1..* SHALL 10988546 code 1..1 SHALL 109831687 statusCode 1..1 SHALL 109830432 1..1 SHALL 109832019 effectiveTime 0..1 SHOUL D 109830433 performer 0..* MAY 109830435 author 0..1 SHOUL D 109832020 entryRelationship 0..* MAY 109831067 @typeCode 1..1 SHALL 109831068 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 109831069 Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.143 0..* MAY 109832021 @typeCode 1..1 SHALL 109832022 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = RSON observation 1..1 SHALL 109832023 Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.19:2014-06-09 0..* MAY 109832024 @code entryRelationship entryRelationship urn:oid:2.16.840.1.113883.5.14 (ActStatus) = active Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 Attachment G- EHR Implementation Guide Templates @typeCode 1..1 SHALL 109832025 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ act 1..1 SHALL 109832026 Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.20:2014-06-09 1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8538). 2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Planned moodCode (Act/Encounter/Procedure) urn:oid:2.16.840.1.113883.11.20.9.23 STATIC 2011-09-30 (CONF:1098-8539). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-30430) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.39" (CONF:1098-30431). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32552). 4. SHALL contain at least one [1..*] id (CONF:1098-8546). 5. SHALL contain exactly one [1..1] code (CONF:1098-31687). a. This code in a Planned Act SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) OR SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1098-32030). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-30432). a. This statusCode SHALL contain exactly one [1..1] @code="active" Active (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:109832019). The effectiveTime in a planned act represents the time that the act should occur. 7. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-30433). The clinician who is expected to carry out the act could be identified using act/performer. 8. MAY contain zero or more [0..*] performer (CONF:1098-30435). The author in a planned act represents the clinician who is requesting or planning the act. 9. SHOULD contain zero or one [0..1] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32020). The following entryRelationship represents the priority that a patient or a provider places on the activity. 10. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31067) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831068). b. SHALL contain exactly one [1..1] Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:1098-31069). The following entryRelationship represents the indication for the act. Attachment G- EHR Implementation Guide Templates 11. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32021) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832022). b. SHALL contain exactly one [1..1] Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109832023). The following entryRelationship captures any instructions associated with the planned act. 12. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32024) such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832025). b. SHALL contain exactly one [1..1] Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109832026). Table 195: Planned moodCode (Act/Encounter/Procedure) Value Set: Planned moodCode (Act/Encounter/Procedure) urn:oid:2.16.840.1.113883.11.20.9.23 This value set is used to restrict the moodCode on an act, an encounter or a procedure to future moods Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name INT ActMood urn:oid:2.16.840.1.11388 3.5.1001 Intent ARQ ActMood urn:oid:2.16.840.1.11388 3.5.1001 Appointment Request PRMS ActMood urn:oid:2.16.840.1.11388 3.5.1001 Promise PRP ActMood urn:oid:2.16.840.1.11388 3.5.1001 Proposal RQO ActMood urn:oid:2.16.840.1.11388 3.5.1001 Request APT ActMood urn:oid:2.16.840.1.11388 3.5.1001 Appointment Attachment G- EHR Implementation Guide Templates Figure 94: Planned Act (V2) Example ... ... ... ... ... 3.39.1 Ordered Service Act [act: identifier urn:oid:2.16.840.1.113883.10.20.34.3.19 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 196: Ordered Service Act Contexts Contained By: Contains: Services and Procedures Section (optional) This template represents service activities ordered, but not yet provided. Examples of service acts include non-medication treatments, such as physical therapy or home health care, other Attachment G- EHR Implementation Guide Templates tests and procedures (except excision of tissue), as well as health education or counseling. To represent the ordered service act, the moodCode value is constrained to "RQO". Table 197: Ordered Service Act Constraints Overview XPath Card. Verb Data Type CONF# Value act (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.19) @classCode 1..1 SHALL 1106221 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode 1..1 SHALL 1106222 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = RQO templateId 1..1 SHALL 1106223 1..1 SHALL 1106224 1..1 SHALL 1106225 @code 0..1 SHOUL D 1106362 translation 0..* MAY 1106363 1..1 SHALL 1106378 @root code @code 2.16.840.1.113883.10.20.34.3.19 urn:oid:2.16.840.1.113883.6.12 (CPT4) 1. Conforms to Planned Act (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.39:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-221). 3. SHALL contain exactly one [1..1] @moodCode="RQO" Request (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-222). 4. SHALL contain exactly one [1..1] templateId (CONF:1106-223) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.19" (CONF:1106-224). 5. SHALL contain exactly one [1..1] code (CONF:1106-225). a. This code SHOULD contain zero or one [0..1] @code (CONF:1106-362). Note: Inclusion of both SNOMED CT/LOINC and a local code is permitted. When both codes are available, include the local code within the translation element. When only a local code is available, include the local code within the translation element and use @nullFlavor="OTH" in the code element. i. This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1106-767). b. This code MAY contain zero or more [0..*] translation (CONF:1106-363). i. The translation, if present, SHALL contain exactly one [1..1] @code (CodeSystem: CPT4 urn:oid:2.16.840.1.113883.6.12) (CONF:1106-378). Attachment G- EHR Implementation Guide Templates Figure 95: Ordered Service Act Example 3.40 Planned Coverage [act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.129 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 198: Planned Coverage Contexts Contained By: Contains: Planned Procedure (V2) (optional) Planned Observation (V2) (optional) Payment Sources Section (optional) Author Participation This template represents the insurance coverage intended to cover an act or procedure. Attachment G- EHR Implementation Guide Templates Table 199: Planned Coverage Constraints Overview XPath Card. Verb Data Type CONF# Value act (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.129) @classCode 1..1 SHALL 109831945 urn:oid:2.16.840.1.113883.5.4 (ActCode) = ACT @moodCode 1..1 SHALL 109831946 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = INT templateId 1..1 SHALL 109831947 1..1 SHALL 109831948 id 1..* SHALL 109831950 code 1..1 SHALL 109831951 @code 1..1 SHALL 109831952 48768-6 @codeSystem 1..1 SHALL 109831953 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 109831954 1..1 SHALL 109831955 urn:oid:2.16.840.1.113883.5.4 (ActCode) = active author 0..* MAY 109832178 Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 entryRelationship 1..1 SHALL 109831967 @typeCode 1..1 SHALL 109831968 act 1..1 SHALL 109831969 @classCode 1..1 SHALL 109831970 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode 1..1 SHALL 109831971 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = INT id 1..* SHALL 109831972 code 1..1 SHALL 109831973 statusCode 1..1 SHALL 109831974 1..1 SHALL 109831975 @root statusCode @code @code 2.16.840.1.113883.10.20.22.4.12 9 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = COMP urn:oid:2.16.840.1.114222.4.11.3 591 (Payer) urn:oid:2.16.840.1.113883.5.14 (ActStatus) = active Attachment G- EHR Implementation Guide Templates 1. SHALL contain exactly one [1..1] @classCode="ACT" act (CodeSystem: ActCode urn:oid:2.16.840.1.113883.5.4) (CONF:1098-31945). 2. SHALL contain exactly one [1..1] @moodCode="INT" Intent (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1098-31946). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-31947) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.129" (CONF:1098-31948). 4. SHALL contain at least one [1..*] id (CONF:1098-31950). 5. SHALL contain exactly one [1..1] code (CONF:1098-31951). a. This code SHALL contain exactly one [1..1] @code="48768-6" Payment Sources (CONF:1098-31952). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-31953). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-31954). a. This statusCode SHALL contain exactly one [1..1] @code="active" Active (CodeSystem: ActCode urn:oid:2.16.840.1.113883.5.4) (CONF:1098-31955). 7. MAY contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32178). 8. SHALL contain exactly one [1..1] entryRelationship (CONF:1098-31967) 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:109831968). b. SHALL contain exactly one [1..1] act (CONF:1098-31969). i. This act SHALL contain exactly one [1..1] @classCode="ACT" ACT (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1098-31970). ii. This act SHALL contain exactly one [1..1] @moodCode="INT" intent (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1098-31971). These act/identifiers are unique identifiers for the policy or program providing the coverage. iii. This act SHALL contain at least one [1..*] id (CONF:1098-31972). iv. This act SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet Payer urn:oid:2.16.840.1.114222.4.11.3591 DYNAMIC (CONF:1098-31973). v. This act SHALL contain exactly one [1..1] statusCode (CONF:1098-31974). 1. This statusCode SHALL contain exactly one [1..1] @code="active" Active (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1098-31975). Attachment G- EHR Implementation Guide Templates Table 200: Payer Value Set: Payer urn:oid:2.16.840.1.114222.4.11.3591 A value set of Public Health Data Standards Consortium Source of Payment Typology Version 3.0 Codes Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name 1 Source of Payment Typology (PHDSC) urn:oid:2.16.840.1.11388 3.3.221.5 Medicare 2 Source of Payment Typology (PHDSC) urn:oid:2.16.840.1.11388 3.3.221.5 Medicaid 311 Source of Payment Typology (PHDSC) urn:oid:2.16.840.1.11388 3.3.221.5 Tricare (CHAMPUS) 33 Source of Payment Typology (PHDSC) urn:oid:2.16.840.1.11388 3.3.221.5 Indian Health Service or Tribe 62 Source of Payment Typology (PHDSC) urn:oid:2.16.840.1.11388 3.3.221.5 BC Indemnity 61 Source of Payment Typology (PHDSC) urn:oid:2.16.840.1.11388 3.3.221.5 BC Managed Care 611 Source of Payment Typology (PHDSC) urn:oid:2.16.840.1.11388 3.3.221.5 BC Managed Care - HMO 619 Source of Payment Typology (PHDSC) urn:oid:2.16.840.1.11388 3.3.221.5 BC Managed Care - Other 613 Source of Payment Typology (PHDSC) urn:oid:2.16.840.1.11388 3.3.221.5 BC Managed Care - POS 612 Source of Payment Typology (PHDSC) urn:oid:2.16.840.1.11388 3.3.221.5 BC Managed Care - PPO ... Figure 96: Planned Coverage Example Attachment G- EHR Implementation Guide Templates 3.41 Planned Immunization Activity [substanceAdministration: identifier urn:oid:2.16.840.1.113883.10.20.22.4.120 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 201: Planned Immunization Activity Contexts Contained By: Contains: Immunizations Section (optional) Author Participation Immunization Medication Information (V2) Indication (V2) Instruction (V2) Precondition for Substance Administration (V2) Priority Preference This template represents planned immunizations. Planned Immunization Activity is very similar to Planned Medication Activity with some key differences, for example, the drug code system is constrained to CVX codes. The priority of the immunization activity to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the immunization activity is intended to take place and authorTime indicates when the documentation of the plan occurred. Attachment G- EHR Implementation Guide Templates Table 202: Planned Immunization Activity Constraints Overview XPath Card. Verb Data Type CONF# Value substanceAdministration (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.120) @classCode 1..1 SHALL 109832091 SBADM @moodCode 1..1 SHALL 109832097 urn:oid:2.16.840.1.113883.11.20. 9.24 (Planned moodCode (SubstanceAdministration/Suppl y)) templateId 1..1 SHALL 109832098 1..1 SHALL 109832099 id 1..* SHALL 109832100 statusCode 1..1 SHALL 109832101 1..1 SHALL 109832102 effectiveTime 1..1 SHALL 109832103 repeatNumber 0..1 MAY 109832126 routeCode 0..1 MAY 109832127 urn:oid:2.16.840.1.113883.3.88.1 2.3221.8.7 (Medication Route FDA) approachSiteCode 0..* MAY 109832128 urn:oid:2.16.840.1.113883.3.88.1 2.3221.8.9 (Body Site) doseQuantity 0..1 MAY 109832129 0..1 SHOUL D 109832130 1..1 SHALL 109832131 1..1 SHALL 109832132 performer 0..* MAY 109832104 author 0..* MAY 109832105 entryRelationship 0..* MAY 109832108 1..1 SHALL 1098- @root @code @unit consumable manufacturedProduct @typeCode 2.16.840.1.113883.10.20.22.4.12 0 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = active urn:oid:2.16.840.1.113883.1.11.1 2839 (UnitsOfMeasureCaseSensitive) Immunization Medication Information (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.54:2014-06-09 Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 urn:oid:2.16.840.1.113883.5.100 Attachment G- EHR Implementation Guide Templates observation 32109 2 (HL7ActRelationshipType) = REFR Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.143 1..1 SHALL 109832110 0..* MAY 109832114 @typeCode 1..1 SHALL 109832115 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = RSON observation 1..1 SHALL 109832116 Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.19:2014-06-09 0..* MAY 109832117 @typeCode 1..1 SHALL 109832118 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ act 1..1 SHALL 109832119 Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.20:2014-06-09 precondition 0..* MAY 109832123 @typeCode 1..1 SHALL 109832124 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = PRCN criterion 1..1 SHALL 109832125 Precondition for Substance Administration (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.25:2014-06-09 entryRelationship entryRelationship 1. SHALL contain exactly one [1..1] @classCode="SBADM" (CONF:1098-32091). 2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Planned moodCode (SubstanceAdministration/Supply) urn:oid:2.16.840.1.113883.11.20.9.24 STATIC 2014-09-01 (CONF:1098-32097). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-32098) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.120" (CONF:1098-32099). 4. SHALL contain at least one [1..*] id (CONF:1098-32100). 5. SHALL contain exactly one [1..1] statusCode (CONF:1098-32101). a. This statusCode SHALL contain exactly one [1..1] @code="active" Active (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:109832102). The effectiveTime in a planned immunization activity represents the time that the immunization activity should occur. 6. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-32103). Attachment G- EHR Implementation Guide Templates In a Planned Immunization Activity, repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. 7. MAY contain zero or one [0..1] repeatNumber (CONF:1098-32126). 8. MAY contain zero or one [0..1] routeCode, which SHALL be selected from ValueSet Medication Route FDA urn:oid:2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC (CONF:1098-32127). 9. MAY contain zero or more [0..*] approachSiteCode, which SHALL be selected from ValueSet Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:109832128). 10. MAY contain zero or one [0..1] doseQuantity (CONF:1098-32129). a. The doseQuantity, if present, SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-32130). 11. SHALL contain exactly one [1..1] consumable (CONF:1098-32131). a. This consumable SHALL contain exactly one [1..1] Immunization Medication Information (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.54:2014-06-09) (CONF:109832132). The clinician who is expected to perform the planned immunization activity could be identified using substanceAdministration/performer. 12. MAY contain zero or more [0..*] performer (CONF:1098-32104). The author in a planned immunization activity represents the clinician who is requesting or planning the immunization activity. 13. MAY contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32105). The following entryRelationship represents the priority that a patient or a provider places on the immunization activity. 14. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32108) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832109). b. SHALL contain exactly one [1..1] Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:1098-32110). The following entryRelationship represents the indication for the immunization activity. 15. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32114) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832115). b. SHALL contain exactly one [1..1] Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109832116). Attachment G- EHR Implementation Guide Templates The following entryRelationship captures any instructions associated with the planned immunization activity. 16. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32117) such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832118). b. SHALL contain exactly one [1..1] Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109832119). 17. MAY contain zero or more [0..*] precondition (CONF:1098-32123) such that it a. SHALL contain exactly one [1..1] @typeCode="PRCN" Precondition (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832124). b. SHALL contain exactly one [1..1] Precondition for Substance Administration (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.25:2014-0609) (CONF:1098-32125). Table 203: Planned moodCode (SubstanceAdministration/Supply) Value Set: Planned moodCode (SubstanceAdministration/Supply) urn:oid:2.16.840.1.113883.11.20.9.24 This value set is used to restrict the moodCode on a substance administration or a supply to future moods. Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name INT ActMood urn:oid:2.16.840.1.11388 3.5.1001 Intent PRMS ActMood urn:oid:2.16.840.1.11388 3.5.1001 Promise PRP ActMood urn:oid:2.16.840.1.11388 3.5.1001 Proposal RQO ActMood urn:oid:2.16.840.1.11388 3.5.1001 Request Attachment G- EHR Implementation Guide Templates Figure 97: Planned Immunization Activity ... ... ... ... ... ... Attachment G- EHR Implementation Guide Templates 3.42 Planned Medication Activity (V2) [substanceAdministration: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.42:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 204: Planned Medication Activity (V2) Contexts Contained By: Contains: Medications Section (optional) Author Participation Indication (V2) Instruction (V2) Medication Information (V2) Precondition for Substance Administration (V2) Priority Preference This template represents planned medication activities. The priority of the medication activity to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the medication activity is intended to take place. The authorTime indicates when the documentation of the plan occurred. Attachment G- EHR Implementation Guide Templates Table 205: Planned Medication Activity (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value substanceAdministration (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.42:2014-06-09) @classCode 1..1 SHALL 10988572 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = SBADM @moodCode 1..1 SHALL 10988573 urn:oid:2.16.840.1.113883.11.20. 9.24 (Planned moodCode (SubstanceAdministration/Suppl y)) templateId 1..1 SHALL 109830465 @root 1..1 SHALL 109830466 2.16.840.1.113883.10.20.22.4.42 @extension 1..1 SHALL 109832557 2014-06-09 id 1..* SHALL 10988575 statusCode 1..1 SHALL 109832087 1..1 SHALL 109832088 effectiveTime 1..1 SHALL 109830468 repeatNumber 0..1 MAY 109832066 routeCode 0..1 MAY 109832067 urn:oid:2.16.840.1.113883.3.88.1 2.3221.8.7 (Medication Route FDA) approachSiteCode 0..* MAY 109832078 urn:oid:2.16.840.1.113883.3.88.1 2.3221.8.9 (Body Site) doseQuantity 0..1 MAY 109832068 0..1 SHOUL D 109832133 0..1 MAY 109832079 0..1 SHOUL D 109832134 maxDoseQuantity 0..1 MAY 109832080 administrationUnitCode 0..1 MAY 109832081 consumable 1..1 SHALL 109832082 @code @unit rateQuantity @unit urn:oid:2.16.840.1.113883.5.14 (ActStatus) = active urn:oid:2.16.840.1.113883.1.11.1 2839 (UnitsOfMeasureCaseSensitive) urn:oid:2.16.840.1.113883.1.11.1 2839 (UnitsOfMeasureCaseSensitive) urn:oid:2.16.840.1.113762.1.4.10 21.30 (AdministrationUnitDoseForm) Attachment G- EHR Implementation Guide Templates manufacturedProduct 1..1 SHALL 109832083 performer 0..* MAY 109830470 author 0..1 SHOUL D 109832046 entryRelationship 0..* MAY 109831104 @typeCode 1..1 SHALL 109831105 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 109831106 Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.143 0..* MAY 109832069 @typeCode 1..1 SHALL 109832070 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = RSON observation 1..1 SHALL 109832071 Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.19:2014-06-09 0..* MAY 109832072 @typeCode 1..1 SHALL 109832073 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ act 1..1 SHALL 109832074 Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.20:2014-06-09 precondition 0..* MAY 109832084 @typeCode 1..1 SHALL 109832085 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = PRCN criterion 1..1 SHALL 109832086 Precondition for Substance Administration (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.25:2014-06-09 entryRelationship entryRelationship Medication Information (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.23:2014-06-09 Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 1. SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8572). 2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Planned moodCode (SubstanceAdministration/Supply) urn:oid:2.16.840.1.113883.11.20.9.24 STATIC 2011-09-30 (CONF:1098-8573). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-30465) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.42" (CONF:1098-30466). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32557). 4. SHALL contain at least one [1..*] id (CONF:1098-8575). 5. SHALL contain exactly one [1..1] statusCode (CONF:1098-32087). a. This statusCode SHALL contain exactly one [1..1] @code="active" Active (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:109832088). The effectiveTime in a planned medication activity represents the time that the medication activity should occur. 6. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-30468). In a Planned Medication Activity, repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. 7. MAY contain zero or one [0..1] repeatNumber (CONF:1098-32066). 8. MAY contain zero or one [0..1] routeCode, which SHALL be selected from ValueSet Medication Route FDA urn:oid:2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC (CONF:1098-32067). 9. MAY contain zero or more [0..*] approachSiteCode, which SHALL be selected from ValueSet Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:109832078). 10. MAY contain zero or one [0..1] doseQuantity (CONF:1098-32068). a. The doseQuantity, if present, SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-32133). 11. MAY contain zero or one [0..1] rateQuantity (CONF:1098-32079). a. The rateQuantity, if present, SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-32134). 12. MAY contain zero or one [0..1] maxDoseQuantity (CONF:1098-32080). 13. MAY contain zero or one [0..1] administrationUnitCode, which SHALL be selected from ValueSet AdministrationUnitDoseForm urn:oid:2.16.840.1.113762.1.4.1021.30 DYNAMIC (CONF:1098-32081). 14. SHALL contain exactly one [1..1] consumable (CONF:1098-32082). a. This consumable SHALL contain exactly one [1..1] Medication Information (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.23:2014-06-09) (CONF:1098-32083). The clinician who is expected to perform the medication activity could be identified using substanceAdministration/performer. 15. MAY contain zero or more [0..*] performer (CONF:1098-30470). The author in a planned medication activity represents the clinician who is requesting or planning the medication activity. Attachment G- EHR Implementation Guide Templates 16. SHOULD contain zero or one [0..1] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32046). The following entryRelationship represents the priority that a patient or a provider places on the planned medication activity. 17. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31104) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831105). b. SHALL contain exactly one [1..1] Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:1098-31106). The following entryRelationship represents the indication for the planned medication activity. 18. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32069) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832070). b. SHALL contain exactly one [1..1] Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109832071). The following entryRelationship captures any instructions associated with the planned medication activity. 19. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32072) such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832073). b. SHALL contain exactly one [1..1] Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109832074). 20. MAY contain zero or more [0..*] precondition (CONF:1098-32084). a. The precondition, if present, SHALL contain exactly one [1..1] @typeCode="PRCN" Precondition (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32085). b. The precondition, if present, SHALL contain exactly one [1..1] Precondition for Substance Administration (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.25:2014-06-09) (CONF:109832086). Attachment G- EHR Implementation Guide Templates Figure 98: Planned Medication Activity (V2) Example Heparin 0.25 ml Prefilled Syringe ... ... ... ... ... 3.43 Planned Observation (V2) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.44:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 206: Planned Observation (V2) Contexts Contained By: Contains: Author Participation Indication (V2) Instruction (V2) Planned Coverage Attachment G- EHR Implementation Guide Templates Contained By: Contains: Priority Preference This template represents planned observations that result in new information about the patient which cannot be classified as a procedure according to the HL7 RIM, i.e., procedures alter the patient's body. Examples of these observations are laboratory tests, diagnostic imaging tests, EEGs, and EKGs. The importance of the planned observation to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the observation is intended to take place and authorTime indicates when the documentation of the plan occurred. The Planned Observation template may also indicate the potential insurance coverage for the observation. Attachment G- EHR Implementation Guide Templates Table 207: Planned Observation (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.44:2014-06-09) @classCode 1..1 SHALL 10988581 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 10988582 urn:oid:2.16.840.1.113883.11.20. 9.25 (Planned moodCode (Observation)) templateId 1..1 SHALL 109830451 @root 1..1 SHALL 109830452 2.16.840.1.113883.10.20.22.4.44 @extension 1..1 SHALL 109832555 2014-06-09 id 1..* SHALL 10988584 code 1..1 SHALL 109831030 statusCode 1..1 SHALL 109830453 1..1 SHALL 109832032 effectiveTime 0..1 SHOUL D 109830454 value 0..1 MAY 109831031 methodCode 0..1 MAY 109832043 targetSiteCode 0..* SHOUL D 109832044 performer 0..* MAY 109830456 author 0..* SHOUL D 109832033 entryRelationship 0..* MAY 109831073 @typeCode 1..1 SHALL 109831074 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 109831075 Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.143 0..* MAY 109832034 1..1 SHALL 1098- @code entryRelationship @typeCode urn:oid:2.16.840.1.113883.6.1 (LOINC) urn:oid:2.16.840.1.113883.5.14 (ActStatus) = active urn:oid:2.16.840.1.113883.3.88.1 2.3221.8.9 (Body Site) Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 urn:oid:2.16.840.1.113883.5.100 Attachment G- EHR Implementation Guide Templates observation 32035 2 (HL7ActRelationshipType) = RSON Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.19:2014-06-09 1..1 SHALL 109832036 0..* MAY 109832037 @typeCode 1..1 SHALL 109832038 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ act 1..1 SHALL 109832039 Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.20:2014-06-09 0..* MAY 109832040 @typeCode 1..1 SHALL 109832041 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = COMP act 1..1 SHALL 109832042 Planned Coverage (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.129 entryRelationship entryRelationship 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8581). 2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Planned moodCode (Observation) urn:oid:2.16.840.1.113883.11.20.9.25 STATIC 2011-09-30 (CONF:1098-8582). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-30451) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.44" (CONF:1098-30452). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32555). 4. SHALL contain at least one [1..*] id (CONF:1098-8584). 5. SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1098-31030). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-30453). a. This statusCode SHALL contain exactly one [1..1] @code="active" Active (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:109832032). The effectiveTime in a planned observation represents the time that the observation should occur. 7. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-30454). 8. MAY contain zero or one [0..1] value (CONF:1098-31031). In a planned observation the provider may suggest that an observation should be performed using a particular method. 9. MAY contain zero or one [0..1] methodCode (CONF:1098-32043). Attachment G- EHR Implementation Guide Templates The targetSiteCode is used to identify the part of the body of concern for the planned observation. 10. SHOULD contain zero or more [0..*] targetSiteCode, which SHALL be selected from ValueSet Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:109832044). The clinician who is expected to perform the observation could be identified using procedure/performer. 11. MAY contain zero or more [0..*] performer (CONF:1098-30456). The author in a planned observation represents the clinician who is requesting or planning the observation. 12. SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32033). The following entryRelationship represents the priority that a patient or a provider places on the observation. 13. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31073) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831074). b. SHALL contain exactly one [1..1] Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:1098-31075). The following entryRelationship represents the indication for the observation. 14. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32034) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832035). b. SHALL contain exactly one [1..1] Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109832036). The following entryRelationship captures any instructions associated with the planned observation. 15. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32037) such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832038). b. SHALL contain exactly one [1..1] Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109832039). The following entryRelationship represents the insurance coverage the patient may have for the observation. 16. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32040) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109832041). b. SHALL contain exactly one [1..1] Planned Coverage (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.129) (CONF:1098-32042). Table 208: Planned moodCode (Observation) Value Set: Planned moodCode (Observation) urn:oid:2.16.840.1.113883.11.20.9.25 This value set is used to restrict the moodCode on an Observation to future moods. Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name INT ActMood urn:oid:2.16.840.1.11388 3.5.1001 Intent PRMS ActMood urn:oid:2.16.840.1.11388 3.5.1001 Promise PRP ActMood urn:oid:2.16.840.1.11388 3.5.1001 Proposal RQO ActMood urn:oid:2.16.840.1.11388 3.5.1001 Request Attachment G- EHR Implementation Guide Templates Figure 99: Planned Observation (V2) Example ... ... ... ... 3.43.1 Ordered Service Observation [observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.2 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 209: Ordered Service Observation Contexts Contained By: Contains: Services and Procedures Section (optional) This template represents service observations ordered, but not yet provided. Examples of service observations include examinations, blood tests, and imaging. To represent the ordered service observation, the moodCode value is constrained to "RQO". Attachment G- EHR Implementation Guide Templates Table 210: Ordered Service Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.2) @classCode 1..1 SHALL 1106381 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1106382 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = RQO templateId 1..1 SHALL 1106383 1..1 SHALL 1106384 1..1 SHALL 1106385 @code 0..1 SHOUL D 1106386 translation 0..* MAY 1106387 1..1 SHALL 1106388 @root code @code 2.16.840.1.113883.10.20.34.3.2 1. Conforms to Planned Observation (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.44:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-381). 3. SHALL contain exactly one [1..1] @moodCode="RQO" Request (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-382). 4. SHALL contain exactly one [1..1] templateId (CONF:1106-383) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.2" (CONF:1106-384). 5. SHALL contain exactly one [1..1] code (CONF:1106-385). a. This code SHOULD contain zero or one [0..1] @code (CONF:1106-386). Note: Inclusion of both SNOMED CT/LOINC and a local code is permitted. When both codes are available, include the local code within the translation element. When only a local code is available, include the local code within the translation element and use @nullFlavor="OTH" in the code element. i. This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1106-769). b. This code MAY contain zero or more [0..*] translation (CONF:1106-387). i. The translation, if present, SHALL contain exactly one [1..1] @code (CONF:1106-388). Attachment G- EHR Implementation Guide Templates Figure 100: Ordered Service Observation Example 3.44 Planned Procedure (V2) [procedure: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.41:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 211: Planned Procedure (V2) Contexts Contained By: Contains: Author Participation Indication (V2) Instruction (V2) Planned Coverage Priority Preference This template represents planned alterations of the patient's physical condition. Examples of such procedures are tracheostomy, knee replacement, and craniectomy. The priority of the procedure to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the procedure is intended to take place and authorTime indicates when the documentation of the plan occurred. The Planned Procedure Template may also indicate the potential insurance coverage for the procedure. Attachment G- EHR Implementation Guide Templates Table 212: Planned Procedure (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value procedure (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.41:2014-06-09) @classCode 1..1 SHALL 10988568 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = PROC @moodCode 1..1 SHALL 10988569 urn:oid:2.16.840.1.113883.11.20. 9.23 (Planned moodCode (Act/Encounter/Procedure)) templateId 1..1 SHALL 109830444 @root 1..1 SHALL 109830445 2.16.840.1.113883.10.20.22.4.41 @extension 1..1 SHALL 109832554 2014-06-09 id 1..* SHALL 10988571 code 1..1 SHALL 109831976 statusCode 1..1 SHALL 109830446 1..1 SHALL 109831978 effectiveTime 0..1 SHOUL D 109830447 methodCode 0..* MAY 109831980 targetSiteCode 0..* MAY 109831981 performer 0..* MAY 109830449 author 0..1 SHOUL D 109831979 entryRelationship 0..* MAY 109831079 @typeCode 1..1 SHALL 109831080 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 109831081 Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.143 0..* MAY 109831982 1..1 SHALL 109831983 @code entryRelationship @typeCode urn:oid:2.16.840.1.113883.5.14 (ActStatus) = active urn:oid:2.16.840.1.113883.3.88.1 2.3221.8.9 (Body Site) Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = RSON Attachment G- EHR Implementation Guide Templates observation 1..1 SHALL 109831984 0..* MAY 109831985 @typeCode 1..1 SHALL 109831986 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ @inversionInd 1..1 SHALL 109831987 true act 1..1 SHALL 109831989 Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.20:2014-06-09 0..* MAY 109831990 @typeCode 1..1 SHALL 109831991 COMP act 1..1 SHALL 109831992 Planned Coverage (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.129 entryRelationship entryRelationship Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.19:2014-06-09 1. SHALL contain exactly one [1..1] @classCode="PROC" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8568). 2. SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Planned moodCode (Act/Encounter/Procedure) urn:oid:2.16.840.1.113883.11.20.9.23 STATIC 2011-09-30 (CONF:1098-8569). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-30444) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.41" (CONF:1098-30445). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32554). 4. SHALL contain at least one [1..*] id (CONF:1098-8571). 5. SHALL contain exactly one [1..1] code (CONF:1098-31976). a. The procedure/code in a planned procedure SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) OR SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) OR ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:1098-31977). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-30446). a. This statusCode SHALL contain exactly one [1..1] @code="active" Active (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:109831978). The effectiveTime in a planned procedure represents the time that the procedure should occur. 7. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-30447). In a planned procedure the provider may suggest that a procedure should be performed using a particular method. Attachment G- EHR Implementation Guide Templates MethodCode SHALL NOT conflict with the method inherent in Procedure / code. 8. MAY contain zero or more [0..*] methodCode (CONF:1098-31980). The targetSiteCode is used to identify the part of the body of concern for the planned procedure. 9. MAY contain zero or more [0..*] targetSiteCode, which SHALL be selected from ValueSet Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:109831981). The clinician who is expected to perform the procedure could be identified using procedure/performer. 10. MAY contain zero or more [0..*] performer (CONF:1098-30449). The author in a planned procedure represents the clinician who is requesting or planning the procedure. 11. SHOULD contain zero or one [0..1] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31979). The following entryRelationship represents the priority that a patient or a provider places on the procedure. 12. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31079) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831080). b. SHALL contain exactly one [1..1] Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:1098-31081). The following entryRelationship represents the indication for the procedure. 13. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31982) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831983). b. SHALL contain exactly one [1..1] Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109831984). The following entryRelationship captures any instructions associated with the planned procedure. 14. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31985) such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831986). b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-31987). c. SHALL contain exactly one [1..1] Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109831989). Attachment G- EHR Implementation Guide Templates The following entryRelationship represents the insurance coverage the patient may have for the procedure. 15. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31990) such that it a. SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CONF:109831991). b. SHALL contain exactly one [1..1] Planned Coverage (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.129) (CONF:1098-31992). Attachment G- EHR Implementation Guide Templates Figure 101: Planned Procedure (V2) Example ... ... ... ... ... ... Attachment G- EHR Implementation Guide Templates 3.44.1 Ordered Service Procedure [procedure: identifier urn:oid:2.16.840.1.113883.10.20.34.3.11 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 213: Ordered Service Procedure Contexts Contained By: Contains: Services and Procedures Section (optional) This template represents procedure services ordered, but not yet provided. Examples of procedure services include excisions of tissue. To represent the ordered procedure service, the moodCode value is constrained to "RQO". Table 214: Ordered Service Procedure Constraints Overview XPath Card. Verb Data Type CONF# Value procedure (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.11) @classCode 1..1 SHALL 1106138 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = PROC @moodCode 1..1 SHALL 1106139 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = RQO templateId 1..1 SHALL 1106140 1..1 SHALL 1106141 1..1 SHALL 1106142 @code 0..1 SHOUL D translation 0..* MAY 1106379 1..1 SHALL 1106380 @root code @code CS 2.16.840.1.113883.10.20.34.3.11 1106143 1. Conforms to Planned Procedure (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.41:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="PROC" Procedure (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-138). 3. SHALL contain exactly one [1..1] @moodCode="RQO" Request (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-139). 4. SHALL contain exactly one [1..1] templateId (CONF:1106-140) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.11" (CONF:1106-141). 5. SHALL contain exactly one [1..1] code (CONF:1106-142). Attachment G- EHR Implementation Guide Templates a. This code SHOULD contain zero or one [0..1] @code (CONF:1106-143). Note: Inclusion of both SNOMED CT/LOINC and a local code is permitted. When both codes are available, include the local code within the translation element. When only a local code is available, include the local code within the translation element and use @nullFlavor="OTH" in the code element. i. This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1106-768). b. This code MAY contain zero or more [0..*] translation (CONF:1106-379). i. The translation, if present, SHALL contain exactly one [1..1] @code (CONF:1106-380). Figure 102: Ordered Service Procedure Example 3.45 Point of Origin Observation [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.36:2015-04-01 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US Realm Table 215: Point of Origin Observation Contexts Contained By: Contains: Current Inpatient Visit (optional) Current Emergency Department Visit (V2) (optional) This template represents the patient's point of origin before arrival for this visit. Attachment G- EHR Implementation Guide Templates Table 216: Point of Origin Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.36:2015-04-01) @classCode 1..1 SHALL 1184614 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1184615 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1184609 @root 1..1 SHALL 1184611 2.16.840.1.113883.10.20.34.3.36 @extension 1..1 SHALL 1184894 2015-04-01 id 1..* SHALL 1184682 code 1..1 SHALL 1184610 @code 1..1 SHALL 1184612 78029-6 @codeSystem 1..1 SHALL 1184613 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 1184683 1..1 SHALL 1184684 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1..1 SHALL 1184616 urn:oid:2.16.840.1.114222.4.11.7 359 (Point of Origin (NCHS)) 0..1 MAY 1184892 urn:oid:2.16.840.1.113883.10.20. 5.9.1 (NullValues_UNK_OTH) statusCode @code value @nullFlavor CD 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1184-614). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1184-615). 3. SHALL contain exactly one [1..1] templateId (CONF:1184-609) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.36" (CONF:1184-611). b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-894). 4. SHALL contain at least one [1..*] id (CONF:1184-682). 5. SHALL contain exactly one [1..1] code (CONF:1184-610). a. This code SHALL contain exactly one [1..1] @code="78029-6" Point of Origin (CONF:1184-612). Attachment G- EHR Implementation Guide Templates b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1184-613). 6. SHALL contain exactly one [1..1] statusCode (CONF:1184-683). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1184-684). 7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Point of Origin (NCHS) urn:oid:2.16.840.1.114222.4.11.7359 DYNAMIC (CONF:1184-616). a. This value MAY contain zero or one [0..1] @nullFlavor, which SHALL be selected from ValueSet NullValues_UNK_OTH urn:oid:2.16.840.1.113883.10.20.5.9.1 STATIC 2015-04-01 (CONF:1184-892). Table 217: Point of Origin (NCHS) Value Set: Point of Origin (NCHS) urn:oid:2.16.840.1.114222.4.11.7359 Where the patient came from immediately before arriving at the healthcare facility. Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7359 Code Code System Code System OID Print Name 4563007 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Transfer from a different hospital 448441000124103 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Transfer from Intermediate Care Facility 448421000124105 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Transfer from physician's office, NOS 1971000124109 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Transfer from a Hospice Facility 107724000 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Patient transfer from one unit to another 448431000124108 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Transfer from Assisted Living Facility 25986004 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Transfer from jail or court 285202004 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Non-Healthcare facility point of origin NOS 442311008 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Newborn born inside this hospital 445585003 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Newborn born outside this hospital ... Attachment G- EHR Implementation Guide Templates Figure 103: Point of Origin Observation Example 3.46 Policy Activity (V2) [act: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.61:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 218: Policy Activity (V2) Contexts Contained By: Contains: Coverage Activity (V2) (required) US Realm Address (AD.US.FIELDED) A policy activity represents the policy or program providing the coverage. The person for whom payment is being provided (i.e., the patient) is the covered party. The subscriber of the policy or program is represented as a participant that is the holder of the coverage. The payer is represented as the performer of the policy activity. Attachment G- EHR Implementation Guide Templates Table 219: Policy Activity (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value act (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.61:2014-06-09) @classCode 1..1 SHALL 10988898 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode 1..1 SHALL 10988899 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 10988900 @root 1..1 SHALL 109810516 2.16.840.1.113883.10.20.22.4.61 @extension 1..1 SHALL 109832595 2014-06-09 id 1..* SHALL 10988901 code 1..1 SHALL 10988903 statusCode 1..1 SHALL 10988902 @code 1..1 SHALL 109819109 performer 1..1 SHALL 10988906 @typeCode 1..1 SHALL 10988907 templateId 1..1 SHALL 109816808 1..1 SHALL 109816809 1..1 SHALL 10988908 id 1..* SHALL 10988909 code 0..1 SHOUL D 10988914 1..1 SHALL 109815992 urn:oid:2.16.840.1.113883.1.11.1 0416 (HL7FinanciallyResponsibleParty Type) addr 0..1 MAY 10988910 US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20. 22.5.2 telecom 0..* MAY 10988911 representedOrganization 0..1 SHOUL 1098- @root assignedEntity @code urn:oid:2.16.840.1.114222.4.11.3 591 (Payer) urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed urn:oid:2.16.840.1.113883.5.90 (HL7ParticipationType) = PRF 2.16.840.1.113883.10.20.22.4.87 Attachment G- EHR Implementation Guide Templates D 8912 0..1 SHOUL D 10988913 0..1 SHOUL D 10988961 1..1 SHALL 109816810 1..1 SHALL 109816811 time 0..1 SHOUL D 10988963 assignedEntity 1..1 SHALL 10988962 1..1 SHALL 10988968 @code 1..1 SHALL 109816096 GUAR @codeSystem 1..1 SHALL 109832165 2.16.840.1.113883.5.110 addr 0..1 SHOUL D 10988964 US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20. 22.5.2 telecom 0..* SHOUL D 10988965 participant 1..1 SHALL 10988916 @typeCode 1..1 SHALL 10988917 templateId 1..1 SHALL 109816812 1..1 SHALL 109816814 0..1 SHOUL D 10988918 low 0..1 SHOUL D 10988919 high 0..1 SHOUL D 10988920 1..1 SHALL 10988921 id 1..* SHALL 10988922 code 1..1 SHALL 10988923 0..1 SHOUL D 109816078 name performer templateId @root code @root time participantRole @code urn:oid:2.16.840.1.113883.5.90 (HL7ParticipationType) = PRF 2.16.840.1.113883.10.20.22.4.88 urn:oid:2.16.840.1.113883.5.90 (HL7ParticipationType) = COV 2.16.840.1.113883.10.20.22.4.89 urn:oid:2.16.840.1.113883.1.11.1 8877 (Coverage Role Type) Attachment G- EHR Implementation Guide Templates addr 0..1 SHOUL D 10988956 playingEntity 0..1 SHOUL D 10988932 name 1..* SHALL 10988930 sdtc:birthTime 1..1 SHALL 109831344 0..1 SHOUL D 10988934 @typeCode 1..1 SHALL 10988935 templateId 1..1 SHALL 109816813 1..1 SHALL 109816815 time 0..1 MAY 10988938 participantRole 1..1 SHALL 10988936 id 1..* SHALL 10988937 addr 0..1 SHOUL D 10988925 1..* SHALL 10988939 1..1 SHALL 10988940 participant @root entryRelationship @typeCode urn:oid:2.16.840.1.113883.5.90 (HL7ParticipationType) = HLD 2.16.840.1.113883.10.20.22.4.90 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR 1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8898). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-8899). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-8900) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.61" (CONF:1098-10516). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32595). This id is a unique identifier for the policy or program providing the coverage 4. SHALL contain at least one [1..*] id (CONF:1098-8901). 5. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Payer urn:oid:2.16.840.1.114222.4.11.3591 DYNAMIC (CONF:1098-8903). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-8902). Attachment G- EHR Implementation Guide Templates a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819109). This performer represents the Payer. 7. SHALL contain exactly one [1..1] performer (CONF:1098-8906) such that it a. SHALL contain exactly one [1..1] @typeCode="PRF" Performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:10988907). b. SHALL contain exactly one [1..1] templateId (CONF:1098-16808). i. This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.87" Payer Performer (CONF:1098-16809). c. SHALL contain exactly one [1..1] assignedEntity (CONF:1098-8908). i. This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-8909). ii. This assignedEntity SHOULD contain zero or one [0..1] code (CONF:10988914). 1. The code, if present, SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet HL7FinanciallyResponsiblePartyType urn:oid:2.16.840.1.113883.1.11.10416 DYNAMIC (CONF:109815992). iii. This assignedEntity MAY contain zero or one [0..1] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1098-8910). iv. This assignedEntity MAY contain zero or more [0..*] telecom (CONF:10988911). v. This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:1098-8912). 1. The representedOrganization, if present, SHOULD contain zero or one [0..1] name (CONF:1098-8913). This performer represents the Guarantor. 8. SHOULD contain zero or one [0..1] performer="PRF" Performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1098-8961) such that it a. SHALL contain exactly one [1..1] templateId (CONF:1098-16810). i. This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.88" Guarantor Performer (CONF:1098-16811). b. SHOULD contain zero or one [0..1] time (CONF:1098-8963). c. SHALL contain exactly one [1..1] assignedEntity (CONF:1098-8962). i. This assignedEntity SHALL contain exactly one [1..1] code (CONF:10988968). 1. This code SHALL contain exactly one [1..1] @code="GUAR" Guarantor (CONF:1098-16096). Attachment G- EHR Implementation Guide Templates 2. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.110" (CONF:1098-32165). ii. This assignedEntity SHOULD contain zero or one [0..1] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:1098-8964). iii. This assignedEntity SHOULD contain zero or more [0..*] telecom (CONF:1098-8965). iv. SHOULD include assignedEntity/assignedPerson/name AND/OR assignedEntity/representedOrganization/name (CONF:1098-8967). 9. SHALL contain exactly one [1..1] participant (CONF:1098-8916) such that it a. SHALL contain exactly one [1..1] @typeCode="COV" Coverage target (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:10988917). b. SHALL contain exactly one [1..1] templateId (CONF:1098-16812). i. This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.89" Covered Party Participant (CONF:1098-16814). c. SHOULD contain zero or one [0..1] time (CONF:1098-8918). i. The time, if present, SHOULD contain zero or one [0..1] low (CONF:10988919). ii. The time, if present, SHOULD contain zero or one [0..1] high (CONF:10988920). d. SHALL contain exactly one [1..1] participantRole (CONF:1098-8921). i. This participantRole SHALL contain at least one [1..*] id (CONF:1098-8922). 1. This id is a unique identifier for the covered party member. Implementers SHOULD use the same GUID for each instance of a member identifier from the same health plan (CONF:1098-8984). ii. This participantRole SHALL contain exactly one [1..1] code (CONF:10988923). 1. This code SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Coverage Role Type urn:oid:2.16.840.1.113883.1.11.18877 DYNAMIC (CONF:109816078). iii. This participantRole SHOULD contain zero or one [0..1] addr (CONF:10988956). 1. The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:109810484). iv. This participantRole SHOULD contain zero or one [0..1] playingEntity (CONF:1098-8932). If the covered party’s name is recorded differently in the health plan and in the registration/pharmacy benefit summary (due to marriage or for other reasons), use the name as it is recorded in the health plan. Attachment G- EHR Implementation Guide Templates 1. The playingEntity, if present, SHALL contain at least one [1..*] name (CONF:1098-8930). If the covered party’s date of birth is recorded differently in the health plan and in the registration/pharmacy benefit summary, use the date of birth as it is recorded in the health plan. 2. The playingEntity, if present, SHALL contain exactly one [1..1] sdtc:birthTime (CONF:1098-31344). a. The prefix sdtc: SHALL be bound to the namespace “urn:hl7org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the birthTime element (CONF:1098-31345). When the Subscriber is the patient, the participant element describing the subscriber SHALL NOT be present. This information will be recorded instead in the data elements used to record member information. 10. SHOULD contain zero or one [0..1] participant (CONF:1098-8934) such that it a. SHALL contain exactly one [1..1] @typeCode="HLD" Holder (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:10988935). b. SHALL contain exactly one [1..1] templateId (CONF:1098-16813). i. This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.90" Policy Holder Participant (CONF:1098-16815). c. MAY contain zero or one [0..1] time (CONF:1098-8938). d. SHALL contain exactly one [1..1] participantRole (CONF:1098-8936). i. This participantRole SHALL contain at least one [1..*] id (CONF:1098-8937). 1. This id is a unique identifier for the subscriber of the coverage (CONF:1098-10120). ii. This participantRole SHOULD contain zero or one [0..1] addr (CONF:10988925). 1. The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:109810483). e. When the Subscriber is the patient, the participant element describing the subscriber SHALL NOT be present. This information will be recorded instead in the data elements used to record member information (CONF:1098-17139). 11. SHALL contain at least one [1..*] entryRelationship (CONF:1098-8939) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8940). b. The target of a policy activity with act/entryRelationship/@typeCode="REFR" SHALL be an authorization activity (templateId 2.16.840.1.113883.10.20.1.19) OR an act, with act@classCode="ACT"] and act[@moodCode="DEF"], representing a description of the coverage plan (CONF:1098-8942). Attachment G- EHR Implementation Guide Templates c. A description of the coverage plan SHALL contain one or more act/id, to represent the plan identifier, and an act/text with the name of the plan (CONF:1098-8943). Table 220: HL7FinanciallyResponsiblePartyType Value Set: HL7FinanciallyResponsiblePartyType urn:oid:2.16.840.1.113883.1.11.10416 RoleClass 2.16.840.1.113883.5.110 http://www.hl7.org/memonly/downloads/v3edition.cfm#V32008 Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name GUAR RoleClass urn:oid:2.16.840.1.11388 3.5.110 Guarantor EMP RoleClass urn:oid:2.16.840.1.11388 3.5.110 Employee INVSBJ RoleClass urn:oid:2.16.840.1.11388 3.5.110 Investigation Subject Table 221: Coverage Role Type Value Set: Coverage Role Type urn:oid:2.16.840.1.113883.1.11.18877 A value set of HL7 role Codes for role recognized through the issuance of insurance coverage to an identified covered party who has this relationship with the policy holder such as the policy holder themselves (self), spouse, child, etc. Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name FAMDEP RoleCode urn:oid:2.16.840.1.11388 3.5.111 Family dependent FSTUD RoleCode urn:oid:2.16.840.1.11388 3.5.111 Full-time student SELF RoleCode urn:oid:2.16.840.1.11388 3.5.111 Self ... Attachment G- EHR Implementation Guide Templates Figure 104: Policy Activity (V2) Example 123 Insurance Road Blue Bell MA 02368 US Good Health Insurance 123 Insurance Road Blue Bell MA 02368 US 17 Daws Rd. Blue Bell MA Attachment G- EHR Implementation Guide Templates 02368 US Mr. Adam Frankie Everyman 17 Daws Rd. Blue Bell MA 02368 US Mr. Frank A. Everyman 17 Daws Rd. Blue Bell MA 02368 US Attachment G- EHR Implementation Guide Templates . . . 3.47 Precondition for Substance Administration (V2) [criterion: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.25:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 222: Precondition for Substance Administration (V2) Contexts Contained By: Contains: Medication Activity (V2) (optional) Immunization Activity (V2) (optional) Planned Medication Activity (V2) (optional) Planned Immunization Activity (optional) A criterion for administration can be used to record that the medication is to be administered only when the associated criteria are met. Table 223: Precondition for Substance Administration (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value criterion (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.25:2014-06-09) templateId 1..1 SHALL 10987372 @root 1..1 SHALL 109810517 2.16.840.1.113883.10.20.22.4.25 @extension 1..1 SHALL 109832603 2014-06-09 1..1 SHALL @code 1..1 SHALL 109832397 ASSERTION @codeSystem 1..1 SHALL 109832398 urn:oid:2.16.840.1.113883.5.4 (ActCode) = 2.16.840.1.113883.5.4 1..1 SHALL 10987369 urn:oid:2.16.840.1.113883.3.88.1 2.3221.7.4 (Problem) code value CD CD 109832396 Attachment G- EHR Implementation Guide Templates 1. SHALL contain exactly one [1..1] templateId (CONF:1098-7372) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.25" (CONF:1098-10517). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32603). 2. SHALL contain exactly one [1..1] code with @xsi:type="CD" (CONF:1098-32396). a. This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion (CONF:1098-32397). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode urn:oid:2.16.840.1.113883.5.4) (CONF:1098-32398). 3. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Problem urn:oid:2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:1098-7369). Figure 105: Precondition for Substance Administration (V2) Example 3.48 Pregnancy Observation [observation: identifier urn:oid:2.16.840.1.113883.10.20.15.3.8 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R1.1 Table 224: Pregnancy Observation Contexts Contained By: Contains: Social History Section (V2) (optional) Patient Information Section (V3) (optional) Estimated Date of Delivery This clinical statement represents current and/or prior pregnancy dates enabling investigators to determine if the subject of the case report was pregnant during the course of a condition. Attachment G- EHR Implementation Guide Templates Table 225: Pregnancy Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.15.3.8) @classCode 1..1 SHALL 81-451 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 81-452 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 8116768 1..1 SHALL 8116868 1..1 SHALL 8119153 @code 1..1 SHALL 8119154 ASSERTION @codeSystem 1..1 SHALL 8126505 urn:oid:2.16.840.1.113883.5.4 (ActCode) = 2.16.840.1.113883.5.4 1..1 SHALL 81-455 1..1 SHALL 8119110 effectiveTime 0..1 SHOUL D 812018 value 1..1 SHALL 1..1 SHALL 8126460 0..1 MAY 81-458 @typeCode 1..1 SHALL 81-459 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 8115584 Estimated Date of Delivery (identifier: urn:oid:2.16.840.1.113883.10.20. 15.3.1 @root code statusCode @code @code entryRelationship CD 2.16.840.1.113883.10.20.15.3.8 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 81-457 urn:oid:2.16.840.1.113883.6.96 (SNOMED CT) = 77386006 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-451). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-452). 3. SHALL contain exactly one [1..1] templateId (CONF:81-16768) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.15.3.8" (CONF:81-16868). 4. SHALL contain exactly one [1..1] code (CONF:81-19153). a. This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion (CONF:8119154). Attachment G- EHR Implementation Guide Templates b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode urn:oid:2.16.840.1.113883.5.4) (CONF:81-26505). 5. SHALL contain exactly one [1..1] statusCode (CONF:81-455). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:8119110). 6. SHOULD contain zero or one [0..1] effectiveTime (CONF:81-2018). 7. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:81-457). a. This value SHALL contain exactly one [1..1] @code="77386006" Pregnant (CodeSystem: SNOMED CT urn:oid:2.16.840.1.113883.6.96) (CONF:81-26460). 8. MAY contain zero or one [0..1] entryRelationship (CONF:81-458) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:81-459). b. SHALL contain exactly one [1..1] Estimated Date of Delivery (identifier: urn:oid:2.16.840.1.113883.10.20.15.3.1) (CONF:81-15584). Figure 106: Pregnancy Observation Example . . . Attachment G- EHR Implementation Guide Templates 3.49 Present on Admission Observation [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.37:2015-04-01 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US Realm Table 226: Present on Admission Observation Contexts Contained By: Contains: Injury or Poisoning Observation (V2) (optional) Primary Diagnosis Observation (V2) (optional) Problem/Diagnosis/Symptom/Condition Observation (V2) (optional) This template represents whether or not the containing diagnosis was present on admission (POA). If this fact is unknown use nullFlavor="UNK". Attachment G- EHR Implementation Guide Templates Table 227: Present on Admission Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.37:2015-04-01) @classCode 1..1 SHALL 1184905 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1184906 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1184899 @root 1..1 SHALL 1184903 2.16.840.1.113883.10.20.34.3.37 @extension 1..1 SHALL 1184912 2015-04-01 id 1..* SHALL 1184907 code 1..1 SHALL 1184901 @code 0..1 MAY 1184908 78026-2 @codeSystem 0..1 MAY 1184909 2.16.840.1.113883.6.1 1..1 SHALL 1184900 1..1 SHALL 1184904 1..1 SHALL @nullFlavor 0..1 MAY 1184910 @value 0..1 SHOUL D 1184911 statusCode @code value BL urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1184902 UNK 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1184-905). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-906). 3. SHALL contain exactly one [1..1] templateId (CONF:1184-899) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.37" (CONF:1184-903). b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-912). 4. SHALL contain at least one [1..*] id (CONF:1184-907). 5. SHALL contain exactly one [1..1] code (CONF:1184-901). a. This code MAY contain zero or one [0..1] @code="78026-2" Present on admission (CONF:1184-908). Attachment G- EHR Implementation Guide Templates b. This code MAY contain zero or one [0..1] @codeSystem="2.16.840.1.113883.6.1" (CONF:1184-909). 6. SHALL contain exactly one [1..1] statusCode (CONF:1184-900). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1184-904). Use @value="true" for "yes", @value="false" for "no" and @nullFlavor="UNK" for "unknown". 7. SHALL contain exactly one [1..1] value with @xsi:type="BL" (CONF:1184-902). a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1184-910). b. This value SHOULD contain zero or one [0..1] @value (CONF:1184-911). Figure 107: Present on Admission Observation Example 3.50 Priority Preference [observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.143 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 228: Priority Preference Contexts Contained By: Contains: Problem Observation (V2) (optional) Planned Act (V2) (optional) Planned Procedure (V2) (optional) Planned Observation (V2) (optional) Planned Medication Activity (V2) (optional) Planned Immunization Activity (optional) Author Participation This template represents priority preferences chosen by a patient or a care provider. Priority preferences are choices made by care providers or patients or both relative to options for care or treatment (including scheduling, care experience, and meeting of personal health goals), the sharing and disclosure of health information, and the prioritization of concerns and problems. Attachment G- EHR Implementation Guide Templates Table 229: Priority Preference Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.143) @classCode 1..1 SHALL 109830949 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 109830950 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 109830951 1..1 SHALL 109830952 id 1..* SHALL 109830953 code 1..1 SHALL 109830954 @code 1..1 SHALL 109830955 225773000 @codeSystem 1..1 SHALL 109830956 urn:oid:2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96 effectiveTime 0..1 SHOUL D 109832327 value 1..1 SHALL author 0..* SHOUL D @root CD 2.16.840.1.113883.10.20.22.4.14 3 109830957 urn:oid:2.16.840.1.113883.11.20. 9.60 (Priority Level) 109830958 Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1098-30949). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1098-30950). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-30951) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.143" (CONF:1098-30952). 4. SHALL contain at least one [1..*] id (CONF:1098-30953). 5. SHALL contain exactly one [1..1] code (CONF:1098-30954). a. This code SHALL contain exactly one [1..1] @code="225773000" Preference (CONF:1098-30955). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT urn:oid:2.16.840.1.113883.6.96) (CONF:1098-30956). 6. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-32327). Attachment G- EHR Implementation Guide Templates 7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Priority Level urn:oid:2.16.840.1.113883.11.20.9.60 STATIC 2014-06-11 (CONF:1098-30957). 8. SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-30958). Table 230: Priority Level Value Set: Priority Level urn:oid:2.16.840.1.113883.11.20.9.60 A value set of SNOMED-CT that contains concepts representing priority. Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name 394849002 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 High priority 394848005 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Normal priority 441808003 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Delayed priority Figure 108: Priority Preference Example Attachment G- EHR Implementation Guide Templates 3.51 Problem Observation (V2) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 231: Problem Observation (V2) Contexts Contained By: Contains: Hospital Discharge Diagnosis (V2) (required) Encounter Diagnosis (V2) (required) Age Observation Author Participation Priority Preference Problem Status (DEPRECATED) Prognosis Observation This template reflects a discrete observation about a patient's problem. Because it is a discrete observation, it will have a statusCode of "completed". The effectiveTime, also referred to as the “biologically relevant time” is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of heart attack that occurred five years ago, the effectiveTime is five years ago. The effectiveTime of the Problem Observation is the definitive indication of whether or not the underlying condition is resolved. If the problem is known to be resolved, then an effectiveTime/high would be present. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK". Attachment G- EHR Implementation Guide Templates Table 232: Problem Observation (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09) @classCode 1..1 SHALL 10989041 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 10989042 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN @negationInd 0..1 MAY 109810139 templateId 1..1 SHALL 109814926 @root 1..1 SHALL 109814927 2.16.840.1.113883.10.20.22.4.4 @extension 1..1 SHALL 109832508 2014-06-09 id 1..* SHALL 10989043 code 1..1 SHALL 10989045 statusCode 1..1 SHALL 10989049 1..1 SHALL 109819112 1..1 SHALL 10989050 low 1..1 SHALL 109815603 high 0..1 MAY 109815604 1..1 SHALL qualifier 0..* MAY 109831870 translation 0..* MAY 109816749 0..1 MAY 109816750 0..1 MAY 109831871 author 0..* SHOUL D 109831147 entryRelationship 0..1 MAY 10989059 1..1 SHALL 10989060 @code effectiveTime value @code @code @typeCode CD 10989058 urn:oid:2.16.840.1.113883.3.88.1 2.3221.7.2 (Problem Type) urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed urn:oid:2.16.840.1.113883.3.88.1 2.3221.7.4 (Problem) urn:oid:2.16.840.1.113883.6.90 (ICD-10-CM) Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = Attachment G- EHR Implementation Guide Templates SUBJ @inversionInd 1..1 SHALL 10989069 true observation 1..1 SHALL 109815590 Age Observation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.31 0..1 MAY 109829951 @typeCode 1..1 SHALL 109831531 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 109829952 Prognosis Observation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.113 0..* MAY 109831063 @typeCode 1..1 SHALL 109831532 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 109831064 Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.143 0..1 MAY 10989063 @typeCode 1..1 SHALL 10989068 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 109815591 Problem Status (DEPRECATED) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.6:2014-06-09 entryRelationship entryRelationship entryRelationship 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-9041). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-9042). The negationInd is used to indicate the absence of the condition in observation/value. A negationInd of "true" coupled with an observation/value of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. 3. MAY contain zero or one [0..1] @negationInd (CONF:1098-10139). 4. SHALL contain exactly one [1..1] templateId (CONF:1098-14926) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.4" (CONF:1098-14927). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32508). 5. SHALL contain at least one [1..*] id (CONF:1098-9043). Attachment G- EHR Implementation Guide Templates 6. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Problem Type urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2014-09-02 (CONF:10989045). 7. SHALL contain exactly one [1..1] statusCode (CONF:1098-9049). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819112). If the problem is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. Therefore, the existence of an high element within a problem does indicate that the problem has been resolved. 8. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-9050). The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:1098-15603). The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved. b. This effectiveTime MAY contain zero or one [0..1] high (CONF:1098-15604). 9. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Problem urn:oid:2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:1098-9058). The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML. a. This value MAY contain zero or more [0..*] qualifier (CONF:1098-31870). b. This value MAY contain zero or more [0..*] translation (CONF:1098-16749) such that it i. contain zero or one [0..1] @code (CodeSystem: ICD-10-CM urn:oid:2.16.840.1.113883.6.90 STATIC) (CONF:1098-16750). MAY A negationInd of "true" coupled with an observation/value/@code of SNOMED code 64572001 "Disease (disorder)" indicates that the patient has no known conditions. c. This value MAY contain zero or one [0..1] @code (CONF:1098-31871). 10. SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31147). Attachment G- EHR Implementation Guide Templates 11. MAY contain zero or one [0..1] entryRelationship (CONF:1098-9059) such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-9060). b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-9069). c. SHALL contain exactly one [1..1] Age Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.31) (CONF:1098-15590). 12. MAY contain zero or one [0..1] entryRelationship (CONF:1098-29951) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831531). b. SHALL contain exactly one [1..1] Prognosis Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.113) (CONF:1098-29952). 13. MAY contain zero or more [0..*] entryRelationship (CONF:1098-31063) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:109831532). b. SHALL contain exactly one [1..1] Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:1098-31064). 14. MAY contain zero or one [0..1] entryRelationship (CONF:1098-9063) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:10989068). b. SHALL contain exactly one [1..1] Problem Status (DEPRECATED) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.6:2014-06-09) (CONF:109815591). Attachment G- EHR Implementation Guide Templates Figure 109: Problem Observation (V2) Example Attachment G- EHR Implementation Guide Templates Figure 110: No Known Problems Example Attachment G- EHR Implementation Guide Templates Figure 111: Resolved Problem and Resolved Concern Example Attachment G- EHR Implementation Guide Templates Attachment G- EHR Implementation Guide Templates Figure 112: Problem with Qualifiers Example Attachment G- EHR Implementation Guide Templates 3.51.1 Admission Diagnosis Observation [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.34:2015-04-01 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US Realm Table 233: Admission Diagnosis Observation Contexts Contained By: Contains: Problems Section (V3) (optional) This template represents the admission diagnosis. Table 234: Admission Diagnosis Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.34:2015-04-01) @classCode 1..1 SHALL 1184869 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1184870 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1184867 @root 1..1 SHALL 1184871 2.16.840.1.113883.10.20.34.3.34 @extension 1..1 SHALL 1184874 2015-04-01 1..1 SHALL 1184868 @code 1..1 SHALL 1184872 8646-2 @codeSystem 1..1 SHALL 1184873 2.16.840.1.113883.6.1 code 1. Conforms to Problem Observation (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1184-869). 3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-870). 4. SHALL contain exactly one [1..1] templateId (CONF:1184-867) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.34" (CONF:1184-871). b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-874). 5. SHALL contain exactly one [1..1] code (CONF:1184-868). Attachment G- EHR Implementation Guide Templates a. This code SHALL contain exactly one [1..1] @code="8646-2" Hospital Admission Diagnosis (CONF:1184-872). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CONF:1184-873). Figure 113: Admission Diagnosis Observation Example 3.51.2 Adverse Effect of Medical Treatment [observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.14 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 235: Adverse Effect of Medical Treatment Contexts Contained By: Contains: Problems Section (V3) (optional) Cause of Injury, Poisoning, or Adverse Effect This template represents that the visit is related to an adverse effect of medical treatment. If it is unknown whether this visit is related to adverse effect of medical treatment use nullFlavor="UNK". Attachment G- EHR Implementation Guide Templates Table 236: Adverse Effect of Medical Treatment Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.14) @classCode 1..1 SHALL 1106487 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1106488 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106489 1..1 SHALL 1106490 1..1 SHALL 1106491 @code 1..1 SHALL 1106492 ASSERTION @codeSystem 1..1 SHALL 1106493 urn:oid:2.16.840.1.113883.5.4 (ActCode) = 2.16.840.1.113883.5.4 1..1 SHALL @nullFlavor 0..1 MAY 1106703 UNK @code 0..1 SHOUL D 1106495 269691005 @codeSystem 0..1 SHOUL D 1106496 2.16.840.1.113883.6.96 entryRelationship 0..1 MAY 1106640 @typeCode 1..1 SHALL 1106641 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = CAUS observation 1..1 SHALL 1106642 Cause of Injury, Poisoning, or Adverse Effect (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.27 @root code value CD 2.16.840.1.113883.10.20.34.3.14 1106494 1. Conforms to Problem Observation (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-487). 3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-488). 4. SHALL contain exactly one [1..1] templateId (CONF:1106-489) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.14" (CONF:1106-490). Attachment G- EHR Implementation Guide Templates 5. SHALL contain exactly one [1..1] code (CONF:1106-491). a. This code SHALL contain exactly one [1..1] @code="ASSERTION" Assertion (CONF:1106-492). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode urn:oid:2.16.840.1.113883.5.4) (CONF:1106-493). 6. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:1106-494). a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1106-703). b. This value SHOULD contain zero or one [0..1] @code="269691005" Medical accidents to patients during surgical and medical care (CONF:1106-495). c. This value SHOULD contain zero or one [0..1] @codeSystem="2.16.840.1.113883.6.96" (CONF:1106-496). 7. MAY contain zero or one [0..1] entryRelationship (CONF:1106-640). a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1106-641). b. The entryRelationship, if present, SHALL contain exactly one [1..1] Cause of Injury, Poisoning, or Adverse Effect (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.27) (CONF:1106-642). Figure 114: Adverse Effect of Medical Treatment Example ... Attachment G- EHR Implementation Guide Templates 3.51.3 Injury or Poisoning Observation (V2) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.17:2015-04-01 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US Realm Table 237: Injury or Poisoning Observation (V2) Contexts Contained By: Contains: Problems Section (V3) (optional) Cause of Injury, Poisoning, or Adverse Effect Present on Admission Observation This template represents whether this visit is related to an injury or poisoning. The code is constrained to "Clinical Finding" and the value is constrained to the Injury or Poisoning value set. If it is unknown whether this visit is related to an injury or poisoning use nullFlavor="UNK". Attachment G- EHR Implementation Guide Templates Table 238: Injury or Poisoning Observation (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.17:2015-04-01) @classCode 1..1 SHALL 1184209 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1184210 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1184211 1..1 SHALL 1184212 1..1 SHALL 1184445 @code 1..1 SHALL 1184446 75321-0 @codeSystem 1..1 SHALL 1184447 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 1184218 urn:oid:2.16.840.1.114222.4.11.7 403 (Injury or Poisoning (NCHS)) 0..1 MAY 1184702 UNK 0..1 MAY 1184637 @typeCode 1..1 SHALL 1184638 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = CAUS observation 1..1 SHALL 1184639 Cause of Injury, Poisoning, or Adverse Effect (identifier: urn:oid:2.16.840.1.113883.10.20. 34.3.27 0..1 MAY 11841096 @typeCode 1..1 SHALL 11841097 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ @inversionInd 1..1 SHALL 11841098 true observation 1..1 SHALL 11841099 Present on Admission Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.37:2015-04-01 @root code value @nullFlavor entryRelationship entryRelationship CD 2.16.840.1.113883.10.20.34.3.17 1. Conforms to Problem Observation (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1184-209). Attachment G- EHR Implementation Guide Templates 3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-210). 4. SHALL contain exactly one [1..1] templateId (CONF:1184-211) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.17" (CONF:1184-212). 5. SHALL contain exactly one [1..1] code (CONF:1184-445). a. This code SHALL contain exactly one [1..1] @code="75321-0" Clinical finding (CONF:1184-446). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1184-447). 6. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Injury or Poisoning (NCHS) urn:oid:2.16.840.1.114222.4.11.7403 DYNAMIC (CONF:1184-218). a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1184-702). 7. MAY contain zero or one [0..1] entryRelationship (CONF:1184-637) such that it a. SHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1184638). b. SHALL contain exactly one [1..1] Cause of Injury, Poisoning, or Adverse Effect (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.27) (CONF:1184-639). 8. MAY contain zero or one [0..1] entryRelationship (CONF:1184-1096) such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:11841097). b. SHALL contain exactly one [1..1] @inversionInd="true" (CONF:1184-1098). c. SHALL contain exactly one [1..1] Present on Admission Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.37:2015-04-01) (CONF:1184-1099). Attachment G- EHR Implementation Guide Templates Table 239: Injury or Poisoning (NCHS) Value Set: Injury or Poisoning (NCHS) urn:oid:2.16.840.1.114222.4.11.7403 All SNOMED CT concepts that are children of the SNOMED CT concept 'traumatic AND/OR non-traumatic injury', including the SNOMED CT concept 'traumatic AND/OR non-traumatic injury' plus all SNOMED CT concepts that are children of the SNOMED CT concept 'poisoning', including the SNOMED CT concept 'poisoning'. Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7403 Code Code System Code System OID Print Name 72431002 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Accidental Poisoning 410061008 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Intentional Poisoning 269736006 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Poisoning of undetermined intent 242056005 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Accidental injury 420025004 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Non-accidental injury 269735005 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Injury undetermined whether accidental or purposely inflicted ... Attachment G- EHR Implementation Guide Templates Figure 115: Injury or Poisoning Observation (V2) Example ... 3.51.4 Patient's Reason for Visit Observation [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.41:2015-04-01 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US Realm Table 240: Patient's Reason for Visit Observation Contexts Contained By: Contains: Reasons for Visit Section (V2) (optional) This template represents the patient's reason for the visit. Attachment G- EHR Implementation Guide Templates Table 241: Patient's Reason for Visit Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.41:2015-04-01) @classCode 1..1 SHALL 11841083 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 11841084 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 11841073 @root 1..1 SHALL 11841078 2.16.840.1.113883.10.20.34.3.41 @extension 1..1 SHALL 11841079 2015-04-01 1..1 SHALL 11841074 @code 1..1 SHALL 11841080 75322-8 @codeSystem 1..1 SHALL 11841081 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 code 1. Conforms to Problem Observation (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1184-1083). 3. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1184-1084). 4. SHALL contain exactly one [1..1] templateId (CONF:1184-1073) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.41" (CONF:1184-1078). b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-1079). 5. SHALL contain exactly one [1..1] code (CONF:1184-1074). a. This code SHALL contain exactly one [1..1] @code="75322-8" Complaint (CONF:1184-1080). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1184-1081). Attachment G- EHR Implementation Guide Templates Figure 116: Patient's Reason for Visit Observation Example 3.51.5 Primary Diagnosis Observation (V2) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.6:2015-04-01 (open)] Draft as part of National Health Care Surveys, Release 1, DSTU 1.1 - US Realm Table 242: Primary Diagnosis Observation (V2) Contexts Contained By: Contains: Problems Section (V3) (required) Present on Admission Observation This template represents the primary diagnosis. If no other means of determination is possible, use first listed diagnosis as the primary diagnosis. Attachment G- EHR Implementation Guide Templates Table 243: Primary Diagnosis Observation (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.6:2015-04-01) @classCode 1..1 SHALL 1184339 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1184340 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1184341 1..1 SHALL 1184342 1..1 SHALL 1184518 @code 1..1 SHALL 1184519 52534-5 @codeSystem 1..1 SHALL 1184520 2.16.840.1.113883.6.1 entryRelationship 0..1 MAY 11841100 @typeCode 1..1 SHALL 11841101 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ @inversionInd 0..1 MAY 11841102 true observation 1..1 SHALL 11841103 Present on Admission Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.37:2015-04-01 @root code 2.16.840.1.113883.10.20.34.3.6 1. Conforms to Problem Observation (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1184-339). 3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-340). 4. SHALL contain exactly one [1..1] templateId (CONF:1184-341) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.6" (CONF:1184-342). 5. SHALL contain exactly one [1..1] code (CONF:1184-518). a. This code SHALL contain exactly one [1..1] @code="52534-5" Principal Diagnosis (CONF:1184-519). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CONF:1184-520). 6. MAY contain zero or one [0..1] entryRelationship (CONF:1184-1100). Attachment G- EHR Implementation Guide Templates a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1184-1101). b. The entryRelationship, if present, MAY contain zero or one [0..1] @inversionInd="true" (CONF:1184-1102). c. The entryRelationship, if present, SHALL contain exactly one [1..1] Present on Admission Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.37:2015-04-01) (CONF:11841103). Figure 117: Primary Diagnosis Observation (V2) Example ... Attachment G- EHR Implementation Guide Templates 3.51.6 Problem/Diagnosis/Symptom/Condition Observation (V2) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.1:2015-04-01 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US Realm Table 244: Problem/Diagnosis/Symptom/Condition Observation (V2) Contexts Contained By: Contains: Problems Section (V3) (optional) Present on Admission Observation This template represents a problem such as a diagnosis or a symptom or a condition. It is based on the Problem Observation (V2) template. Table 245: Problem/Diagnosis/Symptom/Condition Observation (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.1:2015-04-01) @classCode 1..1 SHALL 1184268 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1184269 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1184270 @root 1..1 SHALL 1184271 2.16.840.1.113883.10.20.34.3.1 @extension 1..1 SHALL 11841117 2015-04-01 0..1 MAY 11841116 @typeCode 1..1 SHALL 11841118 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ @inversionInd 1..1 SHALL 11841119 true observation 1..1 SHALL 11841120 Present on Admission Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.37:2015-04-01 entryRelationship 1. Conforms to Problem Observation (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.4:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1184-268). 3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-269). Attachment G- EHR Implementation Guide Templates 4. SHALL contain exactly one [1..1] templateId (CONF:1184-270) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.1" (CONF:1184-271). b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-1117). 5. MAY contain zero or one [0..1] entryRelationship (CONF:1184-1116). a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1184-1118). b. The entryRelationship, if present, SHALL contain exactly one [1..1] @inversionInd="true" (CONF:1184-1119). c. The entryRelationship, if present, SHALL contain exactly one [1..1] Present on Admission Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.37:2015-04-01) (CONF:11841120). Figure 118: Problem/Diagnosis/Symptom/Condition Observation (V2) Example Attachment G- EHR Implementation Guide Templates 3.52 Problem Status (DEPRECATED) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.6:2014-06-09 (open)] Deprecated as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 246: Problem Status (DEPRECATED) Contexts Contained By: Contains: Problem Observation (V2) (optional) The Problem Status records whether the indicated problem is active, inactive, or resolved. THIS TEMPLATE HAS BEEN DEPRECATED IN C-CDA R2 AND MAY BE DELETED FROM A FUTURE RELEASE OF THIS IMPLEMENTATION GUIDE. USE OF THIS TEMPLATE IS NOT RECOMMENDED. Reason for deprecation: Per the explanation in Volume 1, Section 3.2 "Determining a Clinical Statement's Status", the status of a problem is determined based on attributes of the Problem Observation. Table 247: Problem Status (DEPRECATED) Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.6:2014-06-09) @classCode 1..1 SHALL 10987357 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 10987358 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 10987359 1..1 SHALL 109810518 1..1 SHALL 109819162 1..1 SHALL 109819163 1..1 SHALL 10987364 1..1 SHALL 109819113 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1..1 SHALL 10987365 urn:oid:2.16.840.1.113883.3.88.1 2.80.68 (Problem Status) @root code @code statusCode @code value CD 2.16.840.1.113883.10.20.22.4.6 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 33999-4 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7357). Attachment G- EHR Implementation Guide Templates 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7358). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-7359) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.6" (CONF:1098-10518). 4. SHALL contain exactly one [1..1] code (CONF:1098-19162). a. This code SHALL contain exactly one [1..1] @code="33999-4" Status (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1 STATIC) (CONF:1098-19163). 5. SHALL contain exactly one [1..1] statusCode (CONF:1098-7364). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819113). 6. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Problem Status urn:oid:2.16.840.1.113883.3.88.12.80.68 DYNAMIC (CONF:1098-7365). Table 248: Problem Status Value Set: Problem Status urn:oid:2.16.840.1.113883.3.88.12.80.68 A value set of SNOMED-CT codes reflecting state of existence. Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name 55561003 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Active 73425007 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Inactive 413322009 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Resolved 3.53 Procedure Activity Act (V2) [act: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.12:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 249: Procedure Activity Act (V2) Contexts Contained By: Contains: Author Participation Indication (V2) Instruction (V2) Medication Activity (V2) Service Delivery Location Attachment G- EHR Implementation Guide Templates This template represents any act that cannot be classified as an observation or procedure according to the HL7 RIM. Examples of these acts are a dressing change, teaching or feeding a patient, or providing comfort measures. The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g., splenectomy). Attachment G- EHR Implementation Guide Templates Table 250: Procedure Activity Act (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value act (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.12:2014-06-09) @classCode 1..1 SHALL 10988289 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode 1..1 SHALL 10988290 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 10988291 @root 1..1 SHALL 109810519 2.16.840.1.113883.10.20.22.4.12 @extension 1..1 SHALL 109832505 2014-06-09 id 1..* SHALL 10988292 code 1..1 SHALL 10988293 originalText 0..1 SHOUL D 109819186 reference 0..1 MAY 109819187 @value 0..1 MAY 109819188 1..1 SHALL 10988298 1..1 SHALL 109832364 effectiveTime 1..1 SHALL 10988299 priorityCode 0..1 MAY 10988300 performer 0..* SHOUL D 10988301 1..1 SHALL 10988302 id 1..* SHALL 10988303 addr 1..* SHALL 10988304 telecom 1..* SHALL 10988305 representedOrganization 0..1 SHOUL D 10988306 0..* SHOUL D 10988307 statusCode @code assignedEntity id urn:oid:2.16.840.1.113883.11.20. 9.22 (ProcedureAct statusCode) urn:oid:2.16.840.1.113883.1.11.1 6866 (Act Priority) Attachment G- EHR Implementation Guide Templates name 0..* MAY 10988308 telecom 1..* SHALL 10988310 addr 1..* SHALL 10988309 author 1..* SHOUL D 109832477 participant 0..* MAY 10988311 @typeCode 1..1 SHALL 10988312 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = LOC participantRole 1..1 SHALL 109815599 Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.32 entryRelationship 0..* MAY 10988314 @typeCode 1..1 SHALL 10988315 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = COMP @inversionInd 1..1 SHALL 10988316 true encounter 1..1 SHALL 10988317 @classCode 1..1 SHALL 10988318 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ENC @moodCode 1..1 SHALL 10988319 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN id 1..1 SHALL 10988320 0..1 MAY 10988322 @typeCode 1..1 SHALL 10988323 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ @inversionInd 1..1 SHALL 10988324 true act 1..1 SHALL 109831396 Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.20:2014-06-09 0..* MAY 10988326 1..1 SHALL 10988327 entryRelationship entryRelationship @typeCode Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = RSON Attachment G- EHR Implementation Guide Templates observation 1..1 SHALL 109815601 0..* MAY 10988329 @typeCode 1..1 SHALL 10988330 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = COMP substanceAdministration 1..1 SHALL 109815602 Medication Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.16:2014-06-09 entryRelationship Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.19:2014-06-09 1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8289). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-8290). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-8291) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.12" (CONF:1098-10519). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32505). 4. SHALL contain at least one [1..*] id (CONF:1098-8292). 5. SHALL contain exactly one [1..1] code (CONF:1098-8293). a. This code SHOULD contain zero or one [0..1] originalText (CONF:1098-19186). i. The originalText, if present, MAY contain zero or one [0..1] reference (CONF:1098-19187). 1. The reference, if present, MAY contain zero or one [0..1] @value (CONF:1098-19188). a. This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:109819189). b. This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19190). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-8298). a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ProcedureAct statusCode urn:oid:2.16.840.1.113883.11.20.9.22 STATIC 2014-04-23 (CONF:109832364). 7. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-8299). 8. MAY contain zero or one [0..1] priorityCode, which SHALL be selected from ValueSet Act Priority urn:oid:2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:1098-8300). Attachment G- EHR Implementation Guide Templates 9. SHOULD contain zero or more [0..*] performer (CONF:1098-8301). a. The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1098-8302). i. This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-8303). ii. This assignedEntity SHALL contain at least one [1..*] addr (CONF:10988304). iii. This assignedEntity SHALL contain at least one [1..*] telecom (CONF:10988305). iv. This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:1098-8306). 1. The representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:1098-8307). 2. The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:1098-8308). 3. The representedOrganization, if present, SHALL contain at least one [1..*] telecom (CONF:1098-8310). 4. The representedOrganization, if present, SHALL contain at least one [1..*] addr (CONF:1098-8309). 10. SHOULD contain at least one [1..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32477). 11. MAY contain zero or more [0..*] participant (CONF:1098-8311) such that it a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8312). b. SHALL contain exactly one [1..1] Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:1098-15599). 12. MAY contain zero or more [0..*] entryRelationship (CONF:1098-8314) 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 STATIC) (CONF:1098-8315). b. SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8316). c. SHALL contain exactly one [1..1] encounter (CONF:1098-8317). i. This encounter SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8318). ii. This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-8319). iii. This encounter SHALL contain exactly one [1..1] id (CONF:1098-8320). 1. Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:1098-16849). 13. MAY contain zero or one [0..1] entryRelationship (CONF:1098-8322) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8323). b. SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8324). c. SHALL contain exactly one [1..1] Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109831396). 14. MAY contain zero or more [0..*] entryRelationship (CONF:1098-8326) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8327). b. SHALL contain exactly one [1..1] Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109815601). 15. MAY contain zero or more [0..*] entryRelationship (CONF:1098-8329) 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 STATIC) (CONF:1098-8330). b. SHALL contain exactly one [1..1] Medication Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09) (CONF:109815602). Attachment G- EHR Implementation Guide Templates Table 251: Act Priority Value Set: Act Priority urn:oid:2.16.840.1.113883.1.11.16866 Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name A ActPriority urn:oid:2.16.840.1.11388 3.5.7 ASAP CR ActPriority urn:oid:2.16.840.1.11388 3.5.7 Callback results CS ActPriority urn:oid:2.16.840.1.11388 3.5.7 Callback for scheduling CSP ActPriority urn:oid:2.16.840.1.11388 3.5.7 Callback placer for scheduling CSR ActPriority urn:oid:2.16.840.1.11388 3.5.7 Contact recipient for scheduling EL ActPriority urn:oid:2.16.840.1.11388 3.5.7 Elective EM ActPriority urn:oid:2.16.840.1.11388 3.5.7 Emergency P ActPriority urn:oid:2.16.840.1.11388 3.5.7 Preoperative PRN ActPriority urn:oid:2.16.840.1.11388 3.5.7 As needed R ActPriority urn:oid:2.16.840.1.11388 3.5.7 Routine ... Table 252: ProcedureAct statusCode Value Set: ProcedureAct statusCode urn:oid:2.16.840.1.113883.11.20.9.22 A ValueSet of HL7 actStatus codes for use with a procedure activity Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name completed ActStatus urn:oid:2.16.840.1.11388 3.5.14 Completed active ActStatus urn:oid:2.16.840.1.11388 3.5.14 Active aborted ActStatus urn:oid:2.16.840.1.11388 3.5.14 Aborted cancelled ActStatus urn:oid:2.16.840.1.11388 3.5.14 Cancelled Attachment G- EHR Implementation Guide Templates Figure 119: Procedure Activity Act Example 1001 Village Avenue Portland OR 99123 US Community Health and Hospitals 1001 Village Avenue Portland OR 99123 US . . . . . . . . . Attachment G- EHR Implementation Guide Templates 3.53.1 Provided Service Act [act: identifier urn:oid:2.16.840.1.113883.10.20.34.3.20 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 253: Provided Service Act Contexts Contained By: Contains: Services and Procedures Section (optional) This template represents a service activity that has been provided. Examples of service acts include non-medication treatments, such as physical therapy, home health care, feeding a patient, medical nutrition therapy, other tests and procedures (except excision of tissue), as well as health education or counseling (e.g., nutrition counseling). To represent the provided service act, the moodCode value is constrained to "EVN" and the statusCode value is constrained to "completed". Table 254: Provided Service Act Constraints Overview XPath Card. Verb Data Type CONF# Value act (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.20) @classCode 1..1 SHALL 1106227 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode 1..1 SHALL 1106228 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106229 1..1 SHALL 1106230 1..1 SHALL 1106231 @code 0..1 SHOUL D 1106358 translation 0..* MAY 1106359 1..1 SHALL 1106375 1..1 SHALL 1106233 1..1 SHALL 1106364 @root code @code statusCode @code 2.16.840.1.113883.10.20.34.3.20 urn:oid:2.16.840.1.113883.6.12 (CPT4) urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed Attachment G- EHR Implementation Guide Templates 1. Conforms to Procedure Activity Act (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.12:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-227). 3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-228). 4. SHALL contain exactly one [1..1] templateId (CONF:1106-229) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.20" (CONF:1106-230). 5. SHALL contain exactly one [1..1] code (CONF:1106-231). a. This code SHOULD contain zero or one [0..1] @code (CONF:1106-358). Note: Inclusion of both SNOMED CT/LOINC and CPT/HCPCS codes is recommended. When both codes are available, include the CPT code within the translation element. When only the CPT code is available, include the CPT code within the translation element and use @nullFlavor="OTH" in the code element. i. This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1106-772). b. This code MAY contain zero or more [0..*] translation (CONF:1106-359). i. The translation, if present, SHALL contain exactly one [1..1] @code, which SHOULD be selected from CodeSystem CPT4 (urn:oid:2.16.840.1.113883.6.12) (CONF:1106-375). 6. SHALL contain exactly one [1..1] statusCode (CONF:1106-233). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-364). Figure 120: Provided Service Act Example 1 Attachment G- EHR Implementation Guide Templates Figure 121: Provided Service Act Example 2 3.54 Procedure Activity Observation (V2) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.13:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 255: Procedure Activity Observation (V2) Contexts Contained By: Contains: Author Participation Indication (V2) Instruction (V2) Medication Activity (V2) Reaction Observation (V2) Service Delivery Location The common notion of procedure is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g., splenectomy). This template represents procedures that result in new information about the patient that cannot be classified as a procedure according to the HL7 RIM. Examples of these procedures are diagnostic imaging procedures, EEGs, and EKGs. Attachment G- EHR Implementation Guide Templates Table 256: Procedure Activity Observation (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.13:2014-06-09) @classCode 1..1 SHALL 10988282 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 10988237 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 10988238 @root 1..1 SHALL 109810520 2.16.840.1.113883.10.20.22.4.13 @extension 1..1 SHALL 109832507 2014-06-09 id 1..* SHALL 10988239 code 1..1 SHALL 109819197 originalText 0..1 SHOUL D 109819198 reference 0..1 SHOUL D 109819199 @value 0..1 SHOUL D 109819200 1..1 SHALL 10988245 1..1 SHALL 109832365 effectiveTime 0..1 SHOUL D 10988246 priorityCode 0..1 MAY 10988247 value 1..1 SHALL 109816846 0..1 MAY 109832778 methodCode 0..1 MAY 10988248 targetSiteCode 0..* SHOUL D 10988250 performer 0..* SHOUL D 10988251 1..1 SHALL 10988252 1..* SHALL 10988253 statusCode @code @nullFlavor assignedEntity id urn:oid:2.16.840.1.113883.11.20. 9.22 (ProcedureAct statusCode) urn:oid:2.16.840.1.113883.1.11.1 6866 (Act Priority) urn:oid:2.16.840.1.113883.3.88.1 2.3221.8.9 (Body Site) Attachment G- EHR Implementation Guide Templates addr 1..* SHALL 10988254 telecom 1..* SHALL 10988255 representedOrganization 0..1 SHOUL D 10988256 id 0..* SHOUL D 10988257 name 0..* MAY 10988258 telecom 1..1 SHALL 10988260 addr 1..1 SHALL 10988259 author 1..* SHOUL D 109832478 participant 0..* MAY 10988261 @typeCode 1..1 SHALL 10988262 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = LOC participantRole 1..1 SHALL 109815904 Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.32 entryRelationship 0..* MAY 10988264 @typeCode 1..1 SHALL 10988265 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = COMP @inversionInd 1..1 SHALL 10988266 true encounter 1..1 SHALL 10988267 @classCode 1..1 SHALL 10988268 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ENC @moodCode 1..1 SHALL 10988269 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN id 1..1 SHALL 10988270 0..1 MAY 10988272 @typeCode 1..1 SHALL 10988273 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ @inversionInd 1..1 SHALL 10988274 true entryRelationship Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 Attachment G- EHR Implementation Guide Templates act 1..1 SHALL 109831394 0..* MAY 10988276 @typeCode 1..1 SHALL 10988277 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = RSON observation 1..1 SHALL 109815906 Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.19:2014-06-09 0..* MAY 10988279 @typeCode 1..1 SHALL 10988280 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = COMP substanceAdministration 1..1 SHALL 109815907 Medication Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.16:2014-06-09 0..* MAY 109832470 @typeCode 1..1 SHALL 109832471 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = COMP observation 1..1 SHALL 109832472 Reaction Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.9:2014-06-09 entryRelationship entryRelationship entryRelationship Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.20:2014-06-09 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8282). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-8237). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-8238) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.13" (CONF:1098-10520). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32507). 4. SHALL contain at least one [1..*] id (CONF:1098-8239). 5. SHALL contain exactly one [1..1] code (CONF:1098-19197). a. This code SHOULD contain zero or one [0..1] originalText (CONF:1098-19198). i. The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:1098-19199). 1. The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:1098-19200). a. This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach Attachment G- EHR Implementation Guide Templates defined in CDA Release 2, section 4.3.5.1) (CONF:109819201). b. This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-8245). a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ProcedureAct statusCode urn:oid:2.16.840.1.113883.11.20.9.22 STATIC 2014-04-23 (CONF:109832365). 7. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-8246). 8. MAY contain zero or one [0..1] priorityCode, which SHALL be selected from ValueSet Act Priority urn:oid:2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:1098-8247). 9. SHALL contain exactly one [1..1] value (CONF:1098-16846). If nothing is appropriate for value, use an appropriate nullFlavor. a. This value MAY contain zero or one [0..1] @nullFlavor (CONF:1098-32778). 10. MAY contain zero or one [0..1] methodCode (CONF:1098-8248). a. MethodCode SHALL NOT conflict with the method inherent in Observation / code (CONF:1098-8249). 11. SHOULD contain zero or more [0..*] targetSiteCode, which SHALL be selected from ValueSet Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:10988250). 12. SHOULD contain zero or more [0..*] performer (CONF:1098-8251). a. The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1098-8252). i. This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-8253). ii. This assignedEntity SHALL contain at least one [1..*] addr (CONF:10988254). iii. This assignedEntity SHALL contain at least one [1..*] telecom (CONF:10988255). iv. This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:1098-8256). 1. The representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:1098-8257). 2. The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:1098-8258). 3. The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:1098-8260). 4. The representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:1098-8259). Attachment G- EHR Implementation Guide Templates 13. SHOULD contain at least one [1..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32478). 14. MAY contain zero or more [0..*] participant (CONF:1098-8261) such that it a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8262). b. SHALL contain exactly one [1..1] Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:1098-15904). 15. MAY contain zero or more [0..*] entryRelationship (CONF:1098-8264) such that it a. SHALL contain exactly one [1..1] @typeCode="COMP" Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8265). b. SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8266). c. SHALL contain exactly one [1..1] encounter (CONF:1098-8267). i. This encounter SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8268). ii. This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-8269). iii. This encounter SHALL contain exactly one [1..1] id (CONF:1098-8270). 1. Set encounter/id to the id of an encounter in another section to signify they are the same encounter (CONF:1098-16847). 16. MAY contain zero or one [0..1] entryRelationship (CONF:1098-8272) such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8273). b. SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8274). c. SHALL contain exactly one [1..1] Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109831394). 17. MAY contain zero or more [0..*] entryRelationship (CONF:1098-8276) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8277). b. SHALL contain exactly one [1..1] Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109815906). 18. MAY contain zero or more [0..*] entryRelationship (CONF:1098-8279) 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 STATIC) (CONF:1098-8280). b. SHALL contain exactly one [1..1] Medication Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09) (CONF:109815907). Attachment G- EHR Implementation Guide Templates 19. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32470) 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:109832471). b. SHALL contain exactly one [1..1] Reaction Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.9:2014-06-09) (CONF:109832472). Attachment G- EHR Implementation Guide Templates Figure 122: Procedure Activity Observation (V2) Example 1001 Village Avenue Portland OR 99123 US Community Health and Hospitals 1001 Village Avenue Portland OR 99123 US . . . . . . Attachment G- EHR Implementation Guide Templates . . . 3.54.1 Provided Service Observation [observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.3 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 257: Provided Service Observation Contexts Contained By: Contains: Services and Procedures Section (optional) This template represents a service observation that has been provided. Examples of service observations include examinations, blood tests, and imaging. To represent the provided service observation, the moodCode value is constrained to "EVN" and the statusCode value is constrained to "completed". Attachment G- EHR Implementation Guide Templates Table 258: Provided Service Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.3) @classCode 1..1 SHALL 1106365 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1106366 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106367 1..1 SHALL 1106368 1..1 SHALL 1106369 @code 1..1 SHALL 1106370 translation 0..* MAY 1106371 1..1 SHALL 1106372 1..1 SHALL 1106373 1..1 SHALL 1106374 @root code @code statusCode @code 2.16.840.1.113883.10.20.34.3.3 urn:oid:2.16.840.1.113883.6.12 (CPT4) urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1. Conforms to Procedure Activity Observation (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.13:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-365). 3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-366). 4. SHALL contain exactly one [1..1] templateId (CONF:1106-367) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.3" (CONF:1106-368). 5. SHALL contain exactly one [1..1] code (CONF:1106-369). a. This code SHALL contain exactly one [1..1] @code (CONF:1106-370). Note: Inclusion of both SNOMED CT/LOINC and CPT/HCPCS codes is recommended. When both codes are available, include the CPT code within the translation element. When only the CPT code is available, include the CPT code within the translation element and use @nullFlavor="OTH" in the code element. i. This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1106-771). b. This code MAY contain zero or more [0..*] translation (CONF:1106-371). Attachment G- EHR Implementation Guide Templates i. The translation, if present, SHALL contain exactly one [1..1] @code, which SHOULD be selected from CodeSystem CPT4 (urn:oid:2.16.840.1.113883.6.12) (CONF:1106-372). 6. SHALL contain exactly one [1..1] statusCode (CONF:1106-373). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-374). Figure 123: Provided Service Observation Example 3.55 Procedure Activity Procedure (V2) [procedure: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.14:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 259: Procedure Activity Procedure (V2) Contexts Contained By: Contains: Reaction Observation (V2) (optional) Author Participation Indication (V2) Instruction (V2) Medication Activity (V2) Product Instance Reaction Observation (V2) Service Delivery Location The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g., splenectomy). Attachment G- EHR Implementation Guide Templates This template represents procedures whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the patient. Examples of these procedures are an appendectomy, hip replacement, and a creation of a gastrostomy. This template can be used with a contained Product Instance template to represent a device in or on a patient. In this case, targetSiteCode is used to record the location of the device in or on the patient's body. Equipment supplied to the patient (e.g., pumps, inhalers, wheelchairs) is represented by the Non-Medicinal Supply Activity (V2) template. Attachment G- EHR Implementation Guide Templates Table 260: Procedure Activity Procedure (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value procedure (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.14:2014-06-09) @classCode 1..1 SHALL 10987652 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = PROC @moodCode 1..1 SHALL 10987653 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 10987654 @root 1..1 SHALL 109810521 2.16.840.1.113883.10.20.22.4.14 @extension 1..1 SHALL 109832506 2014-06-09 id 1..* SHALL 10987655 code 1..1 SHALL 10987656 originalText 0..1 SHOUL D 109819203 reference 0..1 SHOUL D 109819204 @value 0..1 SHOUL D 109819205 1..1 SHALL 10987661 1..1 SHALL 109832366 effectiveTime 0..1 SHOUL D 10987662 priorityCode 0..1 MAY 10987668 methodCode 0..1 MAY 10987670 targetSiteCode 0..* SHOUL D 10987683 @code 1..1 SHALL 109816082 specimen 0..* MAY 10987697 1..1 SHALL 10987704 0..* SHOUL D 10987716 0..* SHOUL D 10987718 statusCode @code specimenRole id performer urn:oid:2.16.840.1.113883.11.20. 9.22 (ProcedureAct statusCode) urn:oid:2.16.840.1.113883.1.11.1 6866 (Act Priority) urn:oid:2.16.840.1.113883.3.88.1 2.3221.8.9 (Body Site) Attachment G- EHR Implementation Guide Templates assignedEntity 1..1 SHALL 10987720 id 1..* SHALL 10987722 addr 1..* SHALL 10987731 telecom 1..* SHALL 10987732 representedOrganization 0..1 SHOUL D 10987733 id 0..* SHOUL D 10987734 name 0..* MAY 10987735 telecom 1..1 SHALL 10987737 addr 1..1 SHALL 10987736 author 1..* SHOUL D 109832479 participant 0..* MAY 10987751 @typeCode 1..1 SHALL 10987752 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = DEV participantRole 1..1 SHALL 109815911 Product Instance (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.37 0..* MAY 10987765 @typeCode 1..1 SHALL 10987766 urn:oid:2.16.840.1.113883.5.90 (HL7ParticipationType) = LOC participantRole 1..1 SHALL 109815912 Service Delivery Location (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.32 entryRelationship 0..* MAY 10987768 @typeCode 1..1 SHALL 10987769 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = COMP @inversionInd 1..1 SHALL 10988009 true encounter 1..1 SHALL 10987770 1..1 SHALL 10987771 participant @classCode Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ENC Attachment G- EHR Implementation Guide Templates @moodCode 1..1 SHALL 10987772 id 1..1 SHALL 10987773 0..1 MAY 10987775 @typeCode 1..1 SHALL 10987776 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ @inversionInd 1..1 SHALL 10987777 true act 1..1 SHALL 109831395 Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.20:2014-06-09 0..* MAY 10987779 @typeCode 1..1 SHALL 10987780 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = RSON observation 1..1 SHALL 109815914 Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.19:2014-06-09 0..* MAY 10987886 @typeCode 1..1 SHALL 10987887 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = COMP substanceAdministration 1..1 SHALL 109815915 Medication Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.16:2014-06-09 0..* MAY 109832473 @typeCode 1..1 SHALL 109832474 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = COMP observation 1..1 SHALL 109832475 Reaction Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.9:2014-06-09 entryRelationship entryRelationship entryRelationship entryRelationship urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN 1. SHALL contain exactly one [1..1] @classCode="PROC" Procedure (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7652). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7653). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-7654) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.14" (CONF:1098-10521). Attachment G- EHR Implementation Guide Templates b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32506). 4. SHALL contain at least one [1..*] id (CONF:1098-7655). 5. SHALL contain exactly one [1..1] code (CONF:1098-7656). a. This code SHOULD contain zero or one [0..1] originalText (CONF:1098-19203). i. The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:1098-19204). 1. The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:1098-19205). a. This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:109819206). b. This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19207). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-7661). a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet ProcedureAct statusCode urn:oid:2.16.840.1.113883.11.20.9.22 STATIC 2014-04-23 (CONF:109832366). 7. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7662). 8. MAY contain zero or one [0..1] priorityCode, which SHALL be selected from ValueSet Act Priority urn:oid:2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:1098-7668). 9. MAY contain zero or one [0..1] methodCode (CONF:1098-7670). a. MethodCode SHALL NOT conflict with the method inherent in Procedure / code (CONF:1098-7890). In the case of an implanted medical device, targetSiteCode is used to record the location of the device, in or on the patient's body. 10. SHOULD contain zero or more [0..*] targetSiteCode (CONF:1098-7683). a. The targetSiteCode, if present, SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:1098-16082). 11. MAY contain zero or more [0..*] specimen (CONF:1098-7697). a. The specimen, if present, SHALL contain exactly one [1..1] specimenRole (CONF:1098-7704). i. This specimenRole SHOULD contain zero or more [0..*] id (CONF:1098-7716). 1. If you want to indicate that the Procedure and the Results are referring to the same specimen, the Procedure/specimen/specimenRole/id SHOULD be set to equal an Organizer/specimen/ specimenRole/id (CONF:1098-29744). Attachment G- EHR Implementation Guide Templates b. This specimen is for representing specimens obtained from a procedure (CONF:1098-16842). 12. SHOULD contain zero or more [0..*] performer (CONF:1098-7718) such that it a. SHALL contain exactly one [1..1] assignedEntity (CONF:1098-7720). i. This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-7722). ii. This assignedEntity SHALL contain at least one [1..*] addr (CONF:10987731). iii. This assignedEntity SHALL contain at least one [1..*] telecom (CONF:10987732). iv. This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:1098-7733). 1. The representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:1098-7734). 2. The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:1098-7735). 3. The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:1098-7737). 4. The representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:1098-7736). 13. SHOULD contain at least one [1..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32479). 14. MAY contain zero or more [0..*] participant (CONF:1098-7751) such that it a. SHALL contain exactly one [1..1] @typeCode="DEV" Device (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7752). b. SHALL contain exactly one [1..1] Product Instance (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.37) (CONF:1098-15911). 15. MAY contain zero or more [0..*] participant (CONF:1098-7765) such that it a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:10987766). 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). 16. MAY contain zero or more [0..*] entryRelationship (CONF:1098-7768) 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 STATIC) (CONF:1098-7769). b. SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8009). c. SHALL contain exactly one [1..1] encounter (CONF:1098-7770). i. This encounter SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7771). Attachment G- EHR Implementation Guide Templates ii. This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7772). iii. This encounter SHALL contain exactly one [1..1] id (CONF:1098-7773). 1. Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:1098-16843). 17. MAY contain zero or one [0..1] entryRelationship (CONF:1098-7775) such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7776). b. SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-7777). c. SHALL contain exactly one [1..1] Instruction (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09) (CONF:109831395). 18. MAY contain zero or more [0..*] entryRelationship (CONF:1098-7779) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7780). b. SHALL contain exactly one [1..1] Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:109815914). 19. MAY contain zero or more [0..*] entryRelationship (CONF:1098-7886) 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 STATIC) (CONF:1098-7887). b. SHALL contain exactly one [1..1] Medication Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09) (CONF:109815915). 20. MAY contain zero or more [0..*] entryRelationship (CONF:1098-32473) 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:109832474). b. SHALL contain exactly one [1..1] Reaction Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.9:2014-06-09) (CONF:109832475). Attachment G- EHR Implementation Guide Templates Figure 124: Procedure Activity Procedure (V2) Example ... 3.55.1 Provided Service Procedure [procedure: identifier urn:oid:2.16.840.1.113883.10.20.34.3.12 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 261: Provided Service Procedure Contexts Contained By: Contains: Services and Procedures Section (optional) This template represents a procedure service that has been provided. Examples of procedure services include excisions of tissue and biopsies. To represent the provided procedure service, the moodCode value is constrained to "EVN" and the statusCode value is constrained to "completed". Attachment G- EHR Implementation Guide Templates Table 262: Provided Service Procedure Constraints Overview XPath Card. Verb Data Type CONF# Value procedure (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.12) @classCode 1..1 SHALL 1106145 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = PROC @moodCode 1..1 SHALL 1106146 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106147 1..1 SHALL 1106148 1..1 SHALL 1106149 @code 0..1 SHOUL D translation 0..* MAY 1106360 urn:oid:2.16.840.1.113883.6.12 (CPT4) 1..1 SHALL 1106376 urn:oid:2.16.840.1.113883.6.12 (CPT4) 1..1 SHALL 1106152 1..1 SHALL 1106377 @root code @code statusCode @code CS 2.16.840.1.113883.10.20.34.3.12 1106150 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1. Conforms to Procedure Activity Procedure (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.14:2014-06-09). 2. SHALL contain exactly one [1..1] @classCode="PROC" Procedure (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1106-145). 3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1106-146). 4. SHALL contain exactly one [1..1] templateId (CONF:1106-147) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.12" (CONF:1106-148). 5. SHALL contain exactly one [1..1] code (CONF:1106-149). a. This code SHOULD contain zero or one [0..1] @code (CONF:1106-150). Note: Inclusion of both SNOMED CT/LOINC and CPT/HCPCS codes is recommended. When both codes are available, include the CPT code within the translation element. When only the CPT code is available, include the CPT code within the translation element and use @nullFlavor="OTH" in the code element. i. This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1106-770). b. This code MAY contain zero or more [0..*] translation (CodeSystem: CPT4 urn:oid:2.16.840.1.113883.6.12) (CONF:1106-360). Attachment G- EHR Implementation Guide Templates i. The translation, if present, SHALL contain exactly one [1..1] @code, which SHOULD be selected from CodeSystem CPT4 (urn:oid:2.16.840.1.113883.6.12) (CONF:1106-376). 6. SHALL contain exactly one [1..1] statusCode (CONF:1106-152). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-377). Figure 125: Provided Service Procedure Example 3.56 Procedure Follow-Up Attempt Observation [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.34.3.42:2015-04-01 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1.1 - US Realm Table 263: Procedure Follow-Up Attempt Observation Contexts Contained By: Contains: Current Outpatient Visit (V3) (optional) Follow-up Attempt Outcome Observation This template represents whether or not a follow-up attempt was made within 24-hours after surgery and if so, the results of that follow-up. If this fact is unknown use nullFlavor="UNK". Attachment G- EHR Implementation Guide Templates Table 264: Procedure Follow-Up Attempt Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.42:2015-04-01) @classCode 1..1 SHALL 11841127 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 11841128 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 11841121 @root 1..1 SHALL 11841125 2.16.840.1.113883.10.20.34.3.42 @extension 1..1 SHALL 11841134 2015-04-01 id 1..* SHALL 11841129 code 1..1 SHALL 11841123 @code 1..1 SHALL 11841130 78027-0 @codeSystem 1..1 SHALL 11841131 2.16.840.1.113883.6.1 1..1 SHALL 11841122 1..1 SHALL 11841126 1..1 SHALL @nullFlavor 0..1 MAY 11841132 @value 0..1 SHOUL D 11841133 0..1 SHOUL D 11841148 @typeCode 1..1 SHALL 11841149 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 11841150 Follow-up Attempt Outcome Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.34.3.43:2015-04-01 statusCode @code value entryRelationship BL urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 11841124 UNK 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1184-1127). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1184-1128). Attachment G- EHR Implementation Guide Templates 3. SHALL contain exactly one [1..1] templateId (CONF:1184-1121) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.42" (CONF:1184-1125). b. SHALL contain exactly one [1..1] @extension="2015-04-01" (CONF:1184-1134). 4. SHALL contain at least one [1..*] id (CONF:1184-1129). 5. SHALL contain exactly one [1..1] code (CONF:1184-1123). a. This code SHALL contain exactly one [1..1] @code="78027-0" Follow-up attempt made within 24-hours after surgery (CONF:1184-1130). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CONF:1184-1131). 6. SHALL contain exactly one [1..1] statusCode (CONF:1184-1122). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1184-1126). Use @value="true" for "yes", @value="false" for "no" and @nullFlavor="UNK" for "unknown". 7. SHALL contain exactly one [1..1] value with @xsi:type="BL" (CONF:1184-1124). a. This value MAY contain zero or one [0..1] @nullFlavor="UNK" (CONF:1184-1132). b. This value SHOULD contain zero or one [0..1] @value (CONF:1184-1133). 8. SHOULD contain zero or one [0..1] entryRelationship (CONF:1184-1148). a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1184-1149). b. The entryRelationship, if present, SHALL contain exactly one [1..1] Follow-up Attempt Outcome Observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.34.3.43:2015-04-01) (CONF:11841150). c. If a follow-up attempt was made then this entry SHALL be present (CONF:11841151). Attachment G- EHR Implementation Guide Templates Figure 126: Procedure Follow-Up Attempt Observation ... 3.57 Product Instance [participantRole: identifier urn:oid:2.16.840.1.113883.10.20.22.4.37 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R1.1 Table 265: Product Instance Contexts Contained By: Contains: Procedure Activity Procedure (V2) (optional) This clinical statement represents a particular device that was placed in a patient or used as part of a procedure or other act. This provides a record of the identifier and other details about the given product that was used. For example, it is important to have a record that indicates not just that a hip prostheses was placed in a patient but that it was a particular hip prostheses number with a unique identifier. The FDA Amendments Act specifies the creation of a Unique Device Identification (UDI) System that requires the label of devices to bear a unique identifier that will standardize device identification and identify the device through distribution and use. The FDA permits an issuing agency to designate that their Device Identifier (DI) + Production Identifier (PI) format qualifies as a UDI through a process of accreditation. Currently, there are three FDA-accredited issuing agencies that are allowed to call their format a UDI. These organizations are GS1, HIBCC, and ICCBBA. For additional information on technical formats that qualify as UDI from each of the issuing agencies see the UDI Appendix. Attachment G- EHR Implementation Guide Templates When communicating only the issuing agency device identifier (i.e., subcomponent of the UDI), the use of the issuing agency OID is appropriate. However, when communicating the unique device identifier (DI + PI), the FDA OID (2.16.840.1.113883.3.3719) must be used. When sending a UDI, populate the participantRole/id/@root with the FDA OID (2.16.840.1.113883.3.3719) and participantRole/id/@extension with the UDI. When sending a DI, populate the participantRole/id/@root with the appropriate assigning agency OID and participantRole/id/@extension with the DI. The scopingEntity/id should correspond to FDA or the appropriate issuing agency. Table 266: Product Instance Constraints Overview XPath Card. Verb Data Type CONF# Value participantRole (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.37) @classCode 1..1 SHALL 817900 templateId 1..1 SHALL 817901 1..1 SHALL 8110522 id 1..* SHALL 817902 playingDevice 1..1 SHALL 817903 0..1 SHOUL D 8116837 1..1 SHALL 817905 1..* SHALL 817908 @root code scopingEntity id urn:oid:2.16.840.1.113883.5.110 (RoleClass) = MANU 2.16.840.1.113883.10.20.22.4.37 1. SHALL contain exactly one [1..1] @classCode="MANU" Manufactured Product (CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110 STATIC) (CONF:81-7900). 2. SHALL contain exactly one [1..1] templateId (CONF:81-7901) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.37" (CONF:81-10522). 3. SHALL contain at least one [1..*] id (CONF:81-7902). 4. SHALL contain exactly one [1..1] playingDevice (CONF:81-7903). a. This playingDevice SHOULD contain zero or one [0..1] code (CONF:81-16837). 5. SHALL contain exactly one [1..1] scopingEntity (CONF:81-7905). a. This scopingEntity SHALL contain at least one [1..*] id (CONF:81-7908). Attachment G- EHR Implementation Guide Templates Figure 127: Product Instance Example 3.58 Prognosis Observation [observation: identifier urn:oid:2.16.840.1.113883.10.20.22.4.113 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 267: Prognosis Observation Contexts Contained By: Contains: Problem Observation (V2) (optional) This template represents the patient’s prognosis, which must be associated with a problem observation. It may serve as an alert to scope intervention plans. The effectiveTime represents the clinically relevant time of the observation. The observation/value is not constrained and can represent the expected life duration in PQ, an anticipated course of the disease in text, or coded term. Attachment G- EHR Implementation Guide Templates Table 268: Prognosis Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.113) @classCode 1..1 SHALL 109829035 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 109829036 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 109829037 1..1 SHALL 109829038 1..1 SHALL 109829039 @code 1..1 SHALL 109829468 75328-5 @codeSystem 1..1 SHALL 109831349 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 109831350 1..1 SHALL 109831351 effectiveTime 1..1 SHALL 109831123 value 1..1 SHALL 109829469 @root code statusCode @code 2.16.840.1.113883.10.20.22.4.11 3 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-29035). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-29036). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-29037) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.113" (CONF:1098-29038). 4. SHALL contain exactly one [1..1] code (CONF:1098-29039). a. This code SHALL contain exactly one [1..1] @code="75328-5" Prognosis (CONF:1098-29468). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-31349). 5. SHALL contain exactly one [1..1] statusCode (CONF:1098-31350). a. This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1098-31351). 6. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-31123). 7. SHALL contain exactly one [1..1] value (CONF:1098-29469). Attachment G- EHR Implementation Guide Templates Figure 128: Prognosis, Free Text Example Presence of a life limiting condition(>50% possibility of death within 2 year) Presence of a life limiting condition(>50% possibility of death within 2 year Figure 129: Prognosis, Coded Example Attachment G- EHR Implementation Guide Templates 3.59 Reaction Observation (V2) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.9:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 269: Reaction Observation (V2) Contexts Contained By: Contains: Medication Activity (V2) (optional) Procedure Activity Procedure (V2) (optional) Procedure Activity Observation (V2) (optional) Immunization Activity (V2) (optional) Medication Activity (V2) Procedure Activity Procedure (V2) Severity Observation (V2) This clinical statement represents the response to an undesired symptom, finding, etc. due to administered or exposed substance. This reaction may be an undesired symptom, finding, etc. or it could be a desired response to a treatment. A reaction can be defined with respect to its severity, and can have been treated by one or more interventions. Attachment G- EHR Implementation Guide Templates Table 270: Reaction Observation (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.9:2014-06-09) @classCode 1..1 SHALL 10987325 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 10987326 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 10987323 @root 1..1 SHALL 109810523 2.16.840.1.113883.10.20.22.4.9 @extension 1..1 SHALL 109832504 2014-06-09 id 1..* SHALL 10987329 code 1..1 SHALL 109816851 @code 1..1 SHALL 109831124 ASSERTION @codeSystem 1..1 SHALL 109832169 urn:oid:2.16.840.1.113883.5.4 (ActCode) = 2.16.840.1.113883.5.4 1..1 SHALL 10987328 1..1 SHALL 109819114 0..1 SHOUL D 10987332 low 0..1 SHOUL D 10987333 high 0..1 SHOUL D 10987334 value 1..1 SHALL entryRelationship 0..* MAY 10987337 @typeCode 1..1 SHALL 10987338 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = RSON @inversionInd 1..1 SHALL 10987343 true procedure 1..1 SHALL 109815920 Procedure Activity Procedure (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.14:2014-06-09 0..* MAY 1098- statusCode @code effectiveTime entryRelationship CD 10987335 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed urn:oid:2.16.840.1.113883.3.88.1 2.3221.7.4 (Problem) Attachment G- EHR Implementation Guide Templates 7340 @typeCode 1..1 SHALL 10987341 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = RSON @inversionInd 1..1 SHALL 10987344 true substanceAdministration 1..1 SHALL 109815921 Medication Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.16:2014-06-09 0..1 MAY 10987580 @typeCode 1..1 SHALL 10987581 urn:oid:2.16.840.1.113883.5.100 2 (HL7ActRelationshipType) = SUBJ @inversionInd 1..1 SHALL 109810375 true observation 1..1 SHALL 109815922 Severity Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.8:2014-06-09 entryRelationship 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7325). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7326). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-7323) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.9" (CONF:1098-10523). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32504). 4. SHALL contain at least one [1..*] id (CONF:1098-7329). 5. SHALL contain exactly one [1..1] code (CONF:1098-16851). a. This code SHALL contain exactly one [1..1] @code="ASSERTION" (CONF:1098-31124). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode urn:oid:2.16.840.1.113883.5.4) (CONF:1098-32169). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-7328). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819114). 7. SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7332). a. The effectiveTime, if present, SHOULD contain zero or one [0..1] low (CONF:10987333). b. The effectiveTime, if present, SHOULD contain zero or one [0..1] high (CONF:10987334). Attachment G- EHR Implementation Guide Templates 8. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Problem urn:oid:2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:1098-7335). 9. MAY contain zero or more [0..*] entryRelationship (CONF:1098-7337) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7338). b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-7343). This procedure activity is intended to contain information about procedures that were performed in response to an allergy reaction. c. SHALL contain exactly one [1..1] Procedure Activity Procedure (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.14:2014-06-09) (CONF:1098-15920). 10. MAY contain zero or more [0..*] entryRelationship (CONF:1098-7340) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7341). b. SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-7344). This medication activity is intended to contain information about medications that were administered in response to an allergy reaction. c. SHALL contain exactly one [1..1] Medication Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09) (CONF:109815921). 11. MAY contain zero or one [0..1] entryRelationship (CONF:1098-7580) such that it a. SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7581). b. SHALL contain exactly one [1..1] @inversionInd="true" TRUE (CONF:1098-10375). c. SHALL contain exactly one [1..1] Severity Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.8:2014-06-09) (CONF:109815922). Attachment G- EHR Implementation Guide Templates Figure 130: Reaction Observation (V2) Example . . . 3.60 Result Observation (V2) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.2:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 271: Result Observation (V2) Contexts Contained By: Contains: Result Organizer (V2) (required) Author Participation This template represents the results of a laboratory, radiology, or other study performed on a patient. The result observation includes a statusCode to allow recording the status of an observation. “Pending” results (e.g., a test has been run but results have not been reported yet) should be represented as “active” ActStatus. Attachment G- EHR Implementation Guide Templates Table 272: Result Observation (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.2:2014-06-09) @classCode 1..1 SHALL 10987130 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 10987131 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 10987136 @root 1..1 SHALL 10989138 2.16.840.1.113883.10.20.22.4.2 @extension 1..1 SHALL 109832575 2014-06-09 id 1..* SHALL 10987137 code 1..1 SHALL 10987133 statusCode 1..1 SHALL 10987134 1..1 SHALL 109814849 effectiveTime 1..1 SHALL 10987140 value 0..1 SHOUL D 10987143 interpretationCode 0..* SHOUL D 10987147 1..1 SHALL 109832476 methodCode 0..1 MAY SET 10987148 targetSiteCode 0..1 MAY SET 10987153 author 0..* SHOUL D 10987149 referenceRange 0..* SHOUL D 10987150 1..1 SHALL 10987151 code 0..0 SHALL NOT 10987152 value 1..1 SHALL 109832175 @code @code observationRange urn:oid:2.16.840.1.113883.6.1 (LOINC) urn:oid:2.16.840.1.113883.11.20. 9.39 (Result Status) urn:oid:2.16.840.1.113883.6.96 (SNOMED CT) urn:oid:2.16.840.1.113883.1.11.7 8 (Observation Interpretation (HL7)) Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 Attachment G- EHR Implementation Guide Templates 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7130). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7131). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-7136) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.2" (CONF:1098-9138). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32575). 4. SHALL contain at least one [1..*] id (CONF:1098-7137). 5. SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1098-7133). a. This code SHOULD be a code from the LOINC that identifies the result observation. If an appropriate LOINC code does not exist, then the local code for this result SHALL be sent (CONF:1098-19212). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-7134). a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Result Status urn:oid:2.16.840.1.113883.11.20.9.39 STATIC 2013-08-09 (CONF:1098-14849). 7. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-7140). Note: Represents the biologically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test). 8. SHOULD contain zero or one [0..1] value, which SHOULD be selected from CodeSystem SNOMED CT (urn:oid:2.16.840.1.113883.6.96) (CONF:1098-7143). a. If Observation/value is a physical quantity (xsi:type="PQ"), the unit of measure SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-31484). b. A coded value MAY contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab (CONF:1098-31866). c. If Observation/value is a CD (xsi:type="CD") the value SHOULD be SNOMED-CT (CONF:1098-32610). 9. SHOULD contain zero or more [0..*] interpretationCode (CONF:1098-7147). a. The interpretationCode, if present, SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Observation Interpretation (HL7) urn:oid:2.16.840.1.113883.1.11.78 STATIC 2014-09-01 (CONF:1098-32476). 10. MAY contain zero or one [0..1] methodCode (CONF:1098-7148). 11. MAY contain zero or one [0..1] targetSiteCode (CONF:1098-7153). 12. SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-7149). 13. SHOULD contain zero or more [0..*] referenceRange (CONF:1098-7150). a. The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:1098-7151). i. This observationRange SHALL NOT contain [0..0] code (CONF:1098-7152). Attachment G- EHR Implementation Guide Templates ii. This observationRange SHALL contain exactly one [1..1] value (CONF:109832175). Table 273: Result Status Value Set: Result Status urn:oid:2.16.840.1.113883.11.20.9.39 Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name aborted ActStatus urn:oid:2.16.840.1.11388 3.5.14 aborted active ActStatus urn:oid:2.16.840.1.11388 3.5.14 active cancelled ActStatus urn:oid:2.16.840.1.11388 3.5.14 cancelled completed ActStatus urn:oid:2.16.840.1.11388 3.5.14 completed held ActStatus urn:oid:2.16.840.1.11388 3.5.14 held suspended ActStatus urn:oid:2.16.840.1.11388 3.5.14 suspended Attachment G- EHR Implementation Guide Templates Table 274: Observation Interpretation (HL7) Value Set: Observation Interpretation (HL7) urn:oid:2.16.840.1.113883.1.11.78 Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name A HITSP-CS-83 urn:oid:2.16.840.1.11388 3.5.83 abnormal B HITSP-CS-83 urn:oid:2.16.840.1.11388 3.5.83 better Carrier HITSP-CS-83 urn:oid:2.16.840.1.11388 3.5.83 carrier D HITSP-CS-83 urn:oid:2.16.840.1.11388 3.5.83 decreased HX HITSP-CS-83 urn:oid:2.16.840.1.11388 3.5.83 above high threshold I HITSP-CS-83 urn:oid:2.16.840.1.11388 3.5.83 intermediate IND HITSP-CS-83 urn:oid:2.16.840.1.11388 3.5.83 indeterminate LX HITSP-CS-83 urn:oid:2.16.840.1.11388 3.5.83 below low threshold MS HITSP-CS-83 urn:oid:2.16.840.1.11388 3.5.83 moderately susceptible N HITSP-CS-83 urn:oid:2.16.840.1.11388 3.5.83 normal ... Attachment G- EHR Implementation Guide Templates Figure 131: Result Observation (V2) Example Attachment G- EHR Implementation Guide Templates Figure 132: Pending Result Observation (V2) Example Figure 133: Original Lab Units in Example 6.7 billion per liter Attachment G- EHR Implementation Guide Templates 3.61 Result Organizer (V2) [organizer: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.1:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 275: Result Organizer (V2) Contexts Contained By: Contains: Results Section (entries optional) (V2) (optional) Author Participation Result Observation (V2) This template provides a mechanism for grouping result observations. It contains information applicable to all of the contained result observations. The Result Organizer code categorizes the contained results into one of several commonly accepted values (e.g., “Hematology”, “Chemistry”, “Nuclear Medicine”). If any Result Observation within the organizer has a statusCode of "active", the Result Organizer must also have a statusCode of "active". Attachment G- EHR Implementation Guide Templates Table 276: Result Organizer (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value organizer (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.1:2014-06-09) @classCode 1..1 SHALL 10987121 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) @moodCode 1..1 SHALL 10987122 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 10987126 @root 1..1 SHALL 10989134 2.16.840.1.113883.10.20.22.4.1 @extension 1..1 SHALL 109832588 2014-06-09 id 1..* SHALL 10987127 code 1..1 SHALL 10987128 statusCode 1..1 SHALL 10987123 1..1 SHALL 109814848 0..1 MAY 109831865 low 1..1 SHALL 109832488 high 1..1 SHALL 109832489 author 0..* SHOUL D 109831149 component 1..* SHALL 10987124 1..1 SHALL 109814850 @code effectiveTime observation urn:oid:2.16.840.1.113883.11.20. 9.39 (Result Status) Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 Result Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.2:2014-06-09 1. SHALL contain exactly one [1..1] @classCode (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7121). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7122). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-7126) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.1" (CONF:1098-9134). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32588). Attachment G- EHR Implementation Guide Templates 4. SHALL contain at least one [1..*] id (CONF:1098-7127). 5. SHALL contain exactly one [1..1] code (CONF:1098-7128). a. SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) OR SNOMED CT (codeSystem 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (codeSystem 2.16.840.1.113883.6.12) (CONF:1098-19218). b. Laboratory results SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or other constrained terminology named by the US Department of Health and Human Services Office of National Coordinator or other federal agency (CONF:109819219). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-7123). a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Result Status urn:oid:2.16.840.1.113883.11.20.9.39 STATIC 2013-08-09 (CONF:1098-14848). 7. MAY contain zero or one [0..1] effectiveTime (CONF:1098-31865). Note: The effectiveTime is an interval that spans the effectiveTimes of the contained result observations. Because all contained result observations have a required time stamp, it is not required that this effectiveTime be populated. a. The effectiveTime, if present, SHALL contain exactly one [1..1] low (CONF:109832488). b. The effectiveTime, if present, SHALL contain exactly one [1..1] high (CONF:109832489). 8. SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31149). 9. SHALL contain at least one [1..*] component (CONF:1098-7124) such that it a. SHALL contain exactly one [1..1] Result Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.2:2014-06-09) (CONF:109814850). Attachment G- EHR Implementation Guide Templates Figure 134: Result Organizer (V2) Example . . . . . . 3.62 Service Delivery Location [participantRole: identifier urn:oid:2.16.840.1.113883.10.20.22.4.32 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R1.1 Table 277: Service Delivery Location Contexts Contained By: Contains: Procedure Activity Act (V2) (optional) Procedure Activity Procedure (V2) (optional) Procedure Activity Observation (V2) (optional) Encounter Activity (V2) (optional) Hospital Admission Encounter (required) This clinical statement represents the location of a service event where an act, observation or procedure took place. Attachment G- EHR Implementation Guide Templates Table 278: Service Delivery Location Constraints Overview XPath Card. Verb Data Type CONF# Value participantRole (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.32) @classCode 1..1 SHALL 817758 templateId 1..1 SHALL 817635 1..1 SHALL 8110524 2.16.840.1.113883.10.20.22.4.32 code 1..1 SHALL 8116850 urn:oid:2.16.840.1.113883.1.11.2 0275 (HealthcareServiceLocation) addr 0..* SHOUL D 817760 telecom 0..* SHOUL D 817761 playingEntity 0..1 MAY 817762 @classCode 1..1 SHALL 817763 name 0..1 MAY 8116037 @root urn:oid:2.16.840.1.113883.5.111 (RoleCode) = SDLOC urn:oid:2.16.840.1.113883.5.41 (EntityClass) = PLC 1. SHALL contain exactly one [1..1] @classCode="SDLOC" (CodeSystem: RoleCode urn:oid:2.16.840.1.113883.5.111 STATIC) (CONF:81-7758). 2. SHALL contain exactly one [1..1] templateId (CONF:81-7635) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.32" (CONF:81-10524). 3. SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet HealthcareServiceLocation urn:oid:2.16.840.1.113883.1.11.20275 STATIC (CONF:81-16850). 4. SHOULD contain zero or more [0..*] addr (CONF:81-7760). 5. SHOULD contain zero or more [0..*] telecom (CONF:81-7761). 6. MAY contain zero or one [0..1] playingEntity (CONF:81-7762). a. The playingEntity, if present, SHALL contain exactly one [1..1] @classCode="PLC" (CodeSystem: EntityClass urn:oid:2.16.840.1.113883.5.41 STATIC) (CONF:817763). b. The playingEntity, if present, MAY contain zero or one [0..1] name (CONF:81-16037). Attachment G- EHR Implementation Guide Templates Table 279: HealthcareServiceLocation Value Set: HealthcareServiceLocation urn:oid:2.16.840.1.113883.1.11.20275 A comprehensive classification of locations and settings where healthcare services are provided. This value set is based on the National Healthcare Safety Network (NHSN) location code system that has been developed over a number of years through CDC's interaction with a variety of healthcare facilities and is intended to serve a variety of reporting needs where coding of healthcare service locations is required. Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name 1162-7 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 24-Hour observation area 1184-1 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Administrative area 1210-4 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Adult Mixed Acuity Unit 1099-1 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Adult step down unit [post-critical care] 1110-6 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Allergy clinic 1166-8 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Ambulatory surgical setting 1212-0 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Any Age Mixed Acuity Unit 1106-4 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Assisted living area 1145-2 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Behavioral health clinic 1185-8 HL7 HealthcareServiceLocatio n urn:oid:2.16.840.1.11388 3.6.259 Blood bank ... Attachment G- EHR Implementation Guide Templates Figure 135: Service Delivery Location Example 17 Daws Rd. Blue Bell MA 02368 US Community Health and Hospitals 3.63 Severity Observation (V2) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.8:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 280: Severity Observation (V2) Contexts Contained By: Contains: Reaction Observation (V2) (optional) This clinical statement represents the gravity of the problem, such as allergy or reaction, in terms of its actual or potential impact on the patient. The Severity Observation can be associated with an Allergy - Intolerance Observation, Substance or Device Allergy - Intolerance Observation, Reaction Observation or all. When the Severity Observation is associated directly with an allergy it characterizes the allergy. When the Severity Observation is associated with a Reaction Observation it characterizes a reaction. A person may manifest many symptoms in a reaction to a single substance, and each reaction to the substance can be represented. However, each reaction observation can have only one severity observation associated with it. For example, someone may have a rash reaction observation as well as an itching reaction observation, but each can have only one level of severity. Attachment G- EHR Implementation Guide Templates Table 281: Severity Observation (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.8:2014-06-09) @classCode 1..1 SHALL 10987345 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 10987346 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 10987347 @root 1..1 SHALL 109810525 2.16.840.1.113883.10.20.22.4.8 @extension 1..1 SHALL 109832577 2014-06-09 1..1 SHALL 109819168 @code 1..1 SHALL 109819169 SEV @codeSystem 1..1 SHALL 109832170 urn:oid:2.16.840.1.113883.5.4 (ActCode) = 2.16.840.1.113883.5.4 1..1 SHALL 10987352 1..1 SHALL 109819115 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1..1 SHALL 10987356 urn:oid:2.16.840.1.113883.3.88.1 2.3221.6.8 (Problem Severity) code statusCode @code value CD 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7345). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7346). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-7347) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.8" (CONF:1098-10525). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32577). 4. SHALL contain exactly one [1..1] code (CONF:1098-19168). a. This code SHALL contain exactly one [1..1] @code="SEV" Severity (CONF:109819169). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.5.4" (CodeSystem: ActCode urn:oid:2.16.840.1.113883.5.4) (CONF:1098-32170). 5. SHALL contain exactly one [1..1] statusCode (CONF:1098-7352). Attachment G- EHR Implementation Guide Templates a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819115). 6. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Problem Severity urn:oid:2.16.840.1.113883.3.88.12.3221.6.8 DYNAMIC (CONF:1098-7356). Table 282: Problem Severity Value Set: Problem Severity urn:oid:2.16.840.1.113883.3.88.12.3221.6.8 This is a description of the level of the severity of the problem. Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name 255604002 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Mild (qualifier value) 371923003 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Mild to moderate (qualifier value) 6736007 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Moderate (severity modifier) (qualifier value) 371924009 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Moderate to severe (qualifier value) 24484000 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Severe (severity modifier) (qualifier value) 399166001 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Fatal (qualifier value) Figure 136: Severity Observation (V2) Example Attachment G- EHR Implementation Guide Templates 3.64 Smoking Status - Meaningful Use (V2) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.78:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 283: Smoking Status - Meaningful Use (V2) Contexts Contained By: Contains: Social History Section (V2) (optional) Patient Information Section (V3) (optional) Author Participation This template represents the current smoking status of the patient as specified in Meaningful Use (MU) Stage 2 requirements. Historic smoking status observations as well as details about the smoking habit (e.g., how many per day) would be represented in the Tobacco Use template. This template represents a “snapshot in time” observation, simply reflecting what the patient’s current smoking status is at the time of the observation. As a result, the effectiveTime is constrained to a time stamp, and will approximately correspond with the author/time. Details regarding the time period when the patient is/was smoking would be recorded in the Tobacco Use template. If the patient's current smoking status is unknown, the value element must be populated with SNOMED CT code 266927001 to communicate "Unknown if ever smoked" from the Current Smoking Status Value Set. Attachment G- EHR Implementation Guide Templates Table 284: Smoking Status - Meaningful Use (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.78:2014-06-09) @classCode 1..1 SHALL 109814806 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 109814807 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 109814815 @root 1..1 SHALL 109814816 2.16.840.1.113883.10.20.22.4.78 @extension 1..1 SHALL 109832573 2014-06-09 id 1..* SHALL 109832401 code 1..1 SHALL 109819170 @code 1..1 SHALL 109831039 72166-2 @codeSystem 1..1 SHALL 109832157 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 109814809 1..1 SHALL 109819116 1..1 SHALL 109831928 low 0..0 SHALL NOT 109832894 width 0..0 SHALL NOT 109832895 high 0..0 SHALL NOT 109832896 center 0..0 SHALL NOT 109832897 1..1 SHALL 1..1 SHALL 109814817 urn:oid:2.16.840.1.113883.11.20. 9.38 (Current Smoking Status) 0..* SHOUL D 109831148 Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 statusCode @code effectiveTime value @code author CD urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 109814810 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-14806). Attachment G- EHR Implementation Guide Templates 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-14807). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-14815) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.78" (CONF:1098-14816). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32573). 4. SHALL contain at least one [1..*] id (CONF:1098-32401). 5. SHALL contain exactly one [1..1] code (CONF:1098-19170). a. This code SHALL contain exactly one [1..1] @code="72166-2" Tobacco smoking status NHIS (CONF:1098-31039). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-32157). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-14809). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819116). 7. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-31928). Note: This template represents a “snapshot in time” observation, simply reflecting what the patient’s current smoking status is at the time of the observation. As a result, the effectiveTime is constrained to just a time stamp, and will approximately correspond with the author/time. a. This effectiveTime SHALL NOT contain [0..0] low (CONF:1098-32894). b. This effectiveTime SHALL NOT contain [0..0] width (CONF:1098-32895). c. This effectiveTime SHALL NOT contain [0..0] high (CONF:1098-32896). d. This effectiveTime SHALL NOT contain [0..0] center (CONF:1098-32897). 8. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:1098-14810). a. This value SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Current Smoking Status urn:oid:2.16.840.1.113883.11.20.9.38 STATIC 2014-09-01 (CONF:1098-14817). b. If the patient's current smoking status is unknown, @code SHALL contain '266927001' (Unknown if ever smoked) from ValueSet Current Smoking Status (2.16.840.1.113883.11.20.9.38 STATIC 2014-09-01) (CONF:1098-31019). 9. SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31148). Attachment G- EHR Implementation Guide Templates Table 285: Current Smoking Status Value Set: Current Smoking Status urn:oid:2.16.840.1.113883.11.20.9.38 This value set indicates the current smoking status of a patient. Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name 449868002 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Current every day smoker 428041000124106 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Current some day smoker 8517006 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Former smoker 266919005 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Never smoker (Never Smoked) 77176002 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Smoker, current status unknown 266927001 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Unknown if ever smoked 428071000124103 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Heavy tobacco smoker 428061000124105 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Light tobacco smoker Figure 137: Smoking Status - Meaningful Use (V2) Example Attachment G- EHR Implementation Guide Templates 3.65 Social History Observation (V2) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.38:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 286: Social History Observation (V2) Contexts Contained By: Contains: Social History Section (V2) (optional) Author Participation This template represents a patient's occupations, lifestyle, and environmental health risk factors. Demographic data (e.g., marital status, race, ethnicity, religious affiliation) are captured in the header. Though tobacco use and exposure may be represented with a Social History Observation, it is recommended to use the Current Smoking Status template or the Tobacco Use template instead, to represent smoking or tobacco habits. Attachment G- EHR Implementation Guide Templates Table 287: Social History Observation (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.38:2014-06-09) @classCode 1..1 SHALL 10988548 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 10988549 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 10988550 @root 1..1 SHALL 109810526 2.16.840.1.113883.10.20.22.4.38 @extension 1..1 SHALL 109832495 2014-06-09 id 1..* SHALL 10988551 code 1..1 SHALL 10988558 originalText 0..1 SHOUL D 109819221 reference 0..1 SHOUL D 109819222 @value 0..1 SHOUL D 109819223 1..1 SHALL 10988553 1..1 SHALL 109819117 effectiveTime 1..1 SHALL 109831868 value 0..1 SHOUL D 10988559 author 0..* SHOUL D 109831869 statusCode @code urn:oid:2.16.840.1.113883.6.1 (LOINC) urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8548). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-8549). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-8550) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.38" (CONF:1098-10526). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32495). 4. SHALL contain at least one [1..*] id (CONF:1098-8551). Attachment G- EHR Implementation Guide Templates 5. SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) DYNAMIC (CONF:1098-8558). a. This code SHOULD contain zero or one [0..1] originalText (CONF:1098-19221). i. The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:1098-19222). 1. The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:1098-19223). a. This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:109819224). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-8553). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819117). 7. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-31868). 8. SHOULD contain zero or one [0..1] value (CONF:1098-8559). a. If Observation/value is a physical quantity (xsi:type="PQ"), the unit of measure SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive (2.16.840.1.113883.1.11.12839) DYNAMIC (CONF:1098-8555). 9. SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31869). Figure 138: Social History Observation (V2) Example ... Attachment G- EHR Implementation Guide Templates 3.66 Substance Administered Act [act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.118 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 288: Substance Administered Act Contexts Contained By: Contains: Medication Activity (V2) (optional) Immunization Activity (V2) (optional) This template represents the administration course in a series. The entryRelationship/sequenceNumber in the containing template shows the order of this particular administration in that medication series. Table 289: Substance Administered Act Constraints Overview XPath Card. Verb Data Type CONF# Value act (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.118) @classCode 1..1 SHALL 109831500 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = ACT @moodCode 1..1 SHALL 109831501 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 109831502 1..1 SHALL 109831503 id 1..* SHALL 109831504 code 1..1 SHALL 109831506 @code 1..1 SHALL 109831507 416118004 @codeSystem 1..1 SHALL 109831508 urn:oid:2.16.840.1.113883.6.96 (SNOMED CT) = 2.16.840.1.113883.6.96 statusCode 1..1 SHALL 109831505 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed effectiveTime 0..1 MAY 109831509 @root 2.16.840.1.113883.10.20.22.4.11 8 1. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1098-31500). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1098-31501). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-31502) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.118" (CONF:1098-31503). 4. SHALL contain at least one [1..*] id (CONF:1098-31504). 5. SHALL contain exactly one [1..1] code (CONF:1098-31506). a. This code SHALL contain exactly one [1..1] @code="416118004" Administration (CONF:1098-31507). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT urn:oid:2.16.840.1.113883.6.96) (CONF:1098-31508). 6. SHALL contain exactly one [1..1] statusCode="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1098-31505). 7. MAY contain zero or one [0..1] effectiveTime (CONF:1098-31509). Figure 139: Substance Administered Act Example ... ... ... Attachment G- EHR Implementation Guide Templates 3.67 Tobacco Use (V2) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.85:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 290: Tobacco Use (V2) Contexts Contained By: Contains: Social History Section (V2) (optional) Patient Information Section (V3) (optional) Author Participation This template represents a patient’s tobacco use. All the types of tobacco use are represented using the codes from the tobacco use and exposure-finding hierarchy in SNOMED CT, including codes required for recording smoking status in Meaningful Use Stage 2. The effectiveTime element is used to describe dates associated with the patient's tobacco use. Whereas the Smoking Status - Meaningful Use (V2) template (2.16.840.1.113883.10.20.22.4.78:2014-06-09) represents a “snapshot in time” observation, simply reflecting what the patient’s current smoking status is at the time of the observation, this Tobacco Use template uses effectiveTime to represent the biologically relevant time of the observation. Thus, to record a former smoker, an observation of “cigarette smoker” will have an effectiveTime/low defining the time the patient started to smoke cigarettes and an effectiveTime/high defining the time the patient ceased to smoke cigarettes. To record a current smoker, the effectiveTime/low will define the time the patient started smoking and will have no effectiveTime/high to indicated that the patient is still smoking. Attachment G- EHR Implementation Guide Templates Table 291: Tobacco Use (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.85:2014-06-09) @classCode 1..1 SHALL 109816558 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 109816559 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 109816566 @root 1..1 SHALL 109816567 2.16.840.1.113883.10.20.22.4.85 @extension 1..1 SHALL 109832589 2014-06-09 id 1..* SHALL 109832400 code 1..1 SHALL 109819174 @code 1..1 SHALL 109819175 11367-0 @codeSystem 1..1 SHALL 109832172 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 109816561 1..1 SHALL 109819118 1..1 SHALL 109816564 low 1..1 SHALL 109816565 high 0..1 MAY 109831431 1..1 SHALL 1..1 SHALL 109816563 urn:oid:2.16.840.1.113883.11.20. 9.41 (Tobacco Use) 0..* SHOUL D 109831152 Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 statusCode @code effectiveTime value @code author CD urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 109816562 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-16558). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-16559). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-16566) such that it Attachment G- EHR Implementation Guide Templates a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.85" (CONF:1098-16567). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32589). 4. SHALL contain at least one [1..*] id (CONF:1098-32400). 5. SHALL contain exactly one [1..1] code (CONF:1098-19174). a. This code SHALL contain exactly one [1..1] @code="11367-0" History of tobacco use (CONF:1098-19175). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-32172). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-16561). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819118). 7. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-16564). Note: The effectiveTime represents the biologically relevant time of the observation. A “former smoker” is recorded with the proper code “current smoker” with an effectiveTime/low and effectiveTime/high defining the time during which the patient was a smoker. a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:1098-16565). b. This effectiveTime MAY contain zero or one [0..1] high (CONF:1098-31431). 8. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:1098-16562). a. This value SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Tobacco Use urn:oid:2.16.840.1.113883.11.20.9.41 DYNAMIC (CONF:1098-16563). 9. SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31152). Attachment G- EHR Implementation Guide Templates Table 292: Tobacco Use Value Set: Tobacco Use urn:oid:2.16.840.1.113883.11.20.9.41 Contains values descending from the SNOMED CT® Finding of tobacco use and exposure (finding) (365980008) hierarchy excluding temporal findings such as 'Former Smoker' 'Never Chewed', etc. Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name 81703003 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Chews tobacco 228494002 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Snuff user 59978006 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Cigar smoker 43381005 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Passive smoker 228524006 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Exposed to tobacco smoke at home 427189007 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Maternal tobacco use 394871007 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Thinking about stopping smoking 65568007 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Cigarette smoker 160619003 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Rolls own cigarettes 266927001 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Pipe smoker ... Attachment G- EHR Implementation Guide Templates Figure 140: Tobacco Use (V2) Example 3.68 Transport Mode to Hospital Observation [observation: identifier urn:oid:2.16.840.1.113883.10.20.34.3.24 (open)] Published as part of National Health Care Surveys, Release 1, DSTU 1 - US Realm Table 293: Transport Mode to Hospital Observation Contexts Contained By: Contains: Current Emergency Department Visit (V2) (optional) This template represents the patient's mode of transport to the hospital. Attachment G- EHR Implementation Guide Templates Table 294: Transport Mode to Hospital Observation Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:oid:2.16.840.1.113883.10.20.34.3.24) @classCode 1..1 SHALL 1106614 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 1106615 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 1106609 1..1 SHALL 1106611 id 1..* SHALL 1106682 code 1..1 SHALL 1106610 @code 1..1 SHALL 1106612 74286-6 @codeSystem 1..1 SHALL 1106613 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 1106683 1..1 SHALL 1106684 urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 1..1 SHALL 1106616 urn:oid:2.16.840.1.114222.4.11.7 277 (Transport Mode to Hospital (NCHS)) 0..1 MAY @root statusCode @code value @nullFlavor CD 2.16.840.1.113883.10.20.34.3.24 1106866 1. SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1106-614). 2. SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1106-615). 3. SHALL contain exactly one [1..1] templateId (CONF:1106-609) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.34.3.24" (CONF:1106-611). 4. SHALL contain at least one [1..*] id (CONF:1106-682). 5. SHALL contain exactly one [1..1] code (CONF:1106-610). a. This code SHALL contain exactly one [1..1] @code="74286-6" Transport mode to hospital (CONF:1106-612). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1106-613). 6. SHALL contain exactly one [1..1] statusCode (CONF:1106-683). Attachment G- EHR Implementation Guide Templates a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1106-684). 7. SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet Transport Mode to Hospital (NCHS) urn:oid:2.16.840.1.114222.4.11.7277 DYNAMIC (CONF:1106-616). a. This value MAY contain zero or one [0..1] @nullFlavor (CONF:1106-866). i. NullFlavor SHALL be "UNK" Unknown, "OTH" Other, or "NA" Not Applicable (CONF:1106-867). Table 295: Transport Mode to Hospital (NCHS) Value Set: Transport Mode to Hospital (NCHS) urn:oid:2.16.840.1.114222.4.11.7277 The mode of transport (e.g., ground ambulance, walk-in, police) delivering the patient to a hospital. Value Set Source: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7277 Code Code System Code System OID Print Name 44613004 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Ground transport ambulance 32472009 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Medical helicopter 73957001 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Air transport ambulance 46160005 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Motor vehicle 257250006 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Pedestrian conveyance 442301000124107 SNOMED CT urn:oid:2.16.840.1.11388 3.6.96 Police vehicle Figure 141: Transport Mode to Hospital Observation Example Attachment G- EHR Implementation Guide Templates 3.69 Vital Sign Observation (V2) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.27:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 296: Vital Sign Observation (V2) Contexts Contained By: Contains: Vital Signs Organizer (V2) (required) Author Participation This template represents measurement of common vital signs. Vital signs are represented with additional vocabulary constraints for type of vital sign and unit of measure. The following is a list of recommended units for common types of vital sign measurements: Name Unit PulseOx % Height/Head Circumf cm Weight kg Temp Cel BP mm[Hg] Pulse/Resp Rate /min BMI kg/m2 BSA m2 Attachment G- EHR Implementation Guide Templates Table 297: Vital Sign Observation (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value observation (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.27:2014-06-09) @classCode 1..1 SHALL 10987297 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL 10987298 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 10987299 @root 1..1 SHALL 109810527 2.16.840.1.113883.10.20.22.4.27 @extension 1..1 SHALL 109832574 2014-06-09 id 1..* SHALL 10987300 code 1..1 SHALL 10987301 statusCode 1..1 SHALL 10987303 1..1 SHALL 109819119 effectiveTime 1..1 SHALL 10987304 value 1..1 SHALL 1..1 SHALL 109831579 0..1 MAY 10987307 1..1 SHALL 109832886 methodCode 0..1 MAY SET 10987308 targetSiteCode 0..1 MAY SET 10987309 author 0..* SHOUL D @code @unit interpretationCode @code PQ urn:oid:2.16.840.1.113883.3.88.1 2.80.62 (Vital Sign Result) urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed 10987305 10987310 urn:oid:2.16.840.1.113883.1.11.1 2839 (UnitsOfMeasureCaseSensitive) urn:oid:2.16.840.1.113883.1.11.7 8 (Observation Interpretation (HL7)) Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7297). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7298). Attachment G- EHR Implementation Guide Templates 3. SHALL contain exactly one [1..1] templateId (CONF:1098-7299) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.27" (CONF:1098-10527). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32574). 4. SHALL contain at least one [1..*] id (CONF:1098-7300). 5. SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Vital Sign Result urn:oid:2.16.840.1.113883.3.88.12.80.62 DYNAMIC (CONF:1098-7301). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-7303). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819119). 7. SHALL contain exactly one [1..1] effectiveTime (CONF:1098-7304). 8. SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:1098-7305). a. This value SHALL contain exactly one [1..1] @unit, which SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-31579). 9. MAY contain zero or one [0..1] interpretationCode (CONF:1098-7307). a. The interpretationCode, if present, SHALL contain exactly one [1..1] @code (ValueSet: Observation Interpretation (HL7) urn:oid:2.16.840.1.113883.1.11.78 STATIC 2014-09-01) (CONF:1098-32886). 10. MAY contain zero or one [0..1] methodCode (CONF:1098-7308). 11. MAY contain zero or one [0..1] targetSiteCode (CONF:1098-7309). 12. SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-7310). Attachment G- EHR Implementation Guide Templates Table 298: Vital Sign Result Value Set: Vital Sign Result urn:oid:2.16.840.1.113883.3.88.12.80.62 This identifies the vital sign result type. Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name 8310-5 LOINC urn:oid:2.16.840.1.11388 3.6.1 Body Temperature 8462-4 LOINC urn:oid:2.16.840.1.11388 3.6.1 BP Diastolic 8480-6 LOINC urn:oid:2.16.840.1.11388 3.6.1 BP Systolic 8287-5 LOINC urn:oid:2.16.840.1.11388 3.6.1 Head Circumference 8867-4 LOINC urn:oid:2.16.840.1.11388 3.6.1 Heart Rate 8302-2 LOINC urn:oid:2.16.840.1.11388 3.6.1 Height 39156-5 LOINC urn:oid:2.16.840.1.11388 3.6.1 BMI (Body Mass Index) 2710-2 LOINC urn:oid:2.16.840.1.11388 3.6.1 O2 % BldC Oximetry 9279-1 LOINC urn:oid:2.16.840.1.11388 3.6.1 Respiratory Rate 3141-9 LOINC urn:oid:2.16.840.1.11388 3.6.1 Weight Measured ... Figure 142: Vital Sign Observation (V2) Example .... Attachment G- EHR Implementation Guide Templates 3.70 Vital Signs Organizer (V2) [organizer: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.26:2014-06-09 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 299: Vital Signs Organizer (V2) Contexts Contained By: Contains: Vital Signs Section (entries optional) (V2) (optional) Vital Signs Section (entries required) (V2) (required) Author Participation Vital Sign Observation (V2) This template provides a mechanism for grouping vital signs (e.g., grouping systolic blood pressure and diastolic blood pressure). Attachment G- EHR Implementation Guide Templates Table 300: Vital Signs Organizer (V2) Constraints Overview XPath Card. Verb Data Type CONF# Value organizer (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.26:2014-06-09) @classCode 1..1 SHALL 10987279 urn:oid:2.16.840.1.113883.5.6 (HL7ActClass) = CLUSTER @moodCode 1..1 SHALL 10987280 urn:oid:2.16.840.1.113883.5.100 1 (ActMood) = EVN templateId 1..1 SHALL 10987281 @root 1..1 SHALL 109810528 2.16.840.1.113883.10.20.22.4.26 @extension 1..1 SHALL 109832582 2014-06-09 id 1..* SHALL 10987282 code 0..1 MAY 109832740 @code 1..1 SHALL 109832741 74728-7 @codeSystem 1..1 SHALL 109832742 urn:oid:2.16.840.1.113883.6.1 (LOINC) = 2.16.840.1.113883.6.1 1..1 SHALL 10987284 1..1 SHALL 109819120 effectiveTime 0..1 MAY 10987288 author 0..* SHOUL D 109831153 component 1..* SHALL 10987285 1..1 SHALL 109815946 statusCode @code observation urn:oid:2.16.840.1.113883.5.14 (ActStatus) = completed Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20. 22.4.119 Vital Sign Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.2 0.22.4.27:2014-06-09 1. SHALL contain exactly one [1..1] @classCode="CLUSTER" CLUSTER (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7279). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7280). 3. SHALL contain exactly one [1..1] templateId (CONF:1098-7281) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.26" (CONF:1098-10528). b. SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32582). Attachment G- EHR Implementation Guide Templates 4. SHALL contain at least one [1..*] id (CONF:1098-7282). 5. MAY contain zero or one [0..1] code (CONF:1098-32740). a. The code, if present, SHALL contain exactly one [1..1] @code="74728-7" Vital signs, weight, height, head circumference, oximetry, BMI, and BSA panel - HL7.CCDAr1.1 (CONF:1098-32741). b. The code, if present, SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1 " LOINC (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1098-32742). 6. SHALL contain exactly one [1..1] statusCode (CONF:1098-7284). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:109819120). 7. MAY contain zero or one [0..1] effectiveTime (CONF:1098-7288). Note: The effectiveTime is an interval that spans the effectiveTimes of the contained vital signs observations. Because all contained vital signs observations have a required time stamp, it is not required that this effectiveTime be populated. 8. SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31153). 9. SHALL contain at least one [1..*] component (CONF:1098-7285) such that it a. SHALL contain exactly one [1..1] Vital Sign Observation (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.27:2014-06-09) (CONF:109815946). Attachment G- EHR Implementation Guide Templates Figure 143: Vital Signs Organizer (V2) Example ... ... ... Attachment G- EHR Implementation Guide Templates 4 PARTICIPATION AND OTHER TEMPLATES 4.1 Author Participation [author: identifier urn:oid:2.16.840.1.113883.10.20.22.4.119 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R2 Table 301: Author Participation Contexts Contained By: Contains: Social History Observation (V2) (optional) Medication Activity (V2) (optional) Procedure Activity Act (V2) (optional) Procedure Activity Procedure (V2) (optional) Procedure Activity Observation (V2) (optional) Problem Observation (V2) (optional) Immunization Activity (V2) (optional) Planned Act (V2) (optional) Planned Procedure (V2) (optional) Planned Observation (V2) (optional) Planned Medication Activity (V2) (optional) Smoking Status - Meaningful Use (V2) (optional) Vital Sign Observation (V2) (optional) Result Observation (V2) (optional) Vital Signs Organizer (V2) (optional) Priority Preference (optional) Result Organizer (V2) (optional) Tobacco Use (V2) (optional) Planned Coverage (optional) Planned Immunization Activity (optional) This template represents the Author Participation (including the author timestamp). CDA R2 requires that Author and Author timestamp be asserted in the document header. From there, authorship propagates to contained sections and contained entries, unless explicitly overridden. The Author Participation template was added to those templates in scope for analysis in R2. Although it is not explicitly stated in all templates the Author Participation template can be used in any template. Attachment G- EHR Implementation Guide Templates Table 302: Author Participation Constraints Overview XPath Card. Verb Data Type CONF# Value author (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) templateId 1..1 SHALL 109832017 1..1 SHALL 109832018 time 1..1 SHALL 109831471 assignedAuthor 1..1 SHALL 109831472 id 1..* SHALL 109831473 code 0..1 SHOUL D 109831671 assignedPerson 0..1 MAY 109831474 0..* MAY 109831475 0..1 MAY 109831476 id 0..* MAY 109831478 name 0..* MAY 109831479 telecom 0..* MAY 109831480 addr 0..* MAY 109831481 @root name representedOrganization 2.16.840.1.113883.10.20.22.4.11 9 urn:oid:2.16.840.1.114222.4.11.1 066 (Healthcare Provider Taxonomy (HIPAA)) 1. SHALL contain exactly one [1..1] templateId (CONF:1098-32017) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.119" (CONF:1098-32018). 2. SHALL contain exactly one [1..1] time (CONF:1098-31471). 3. SHALL contain exactly one [1..1] assignedAuthor (CONF:1098-31472). a. This assignedAuthor SHALL contain at least one [1..*] id (CONF:1098-31473). Note: This id may be set equal to (a pointer to) an id on a participant elsewhere in the document (header or entries) or a new author participant can be described here. If the id is pointing to a participant already described elsewhere in the document, assignedAuthor/id is sufficient to identify this participant and none of the remaining details of assignedAuthor are required to be set. Application Software must be responsible for resolving the identifier back to its original object and then rendering the information in the correct place in the containing section's narrative text. This id must be a pointer to another author participant. Attachment G- EHR Implementation Guide Templates i. If the ID isn't referencing an author described elsewhere in the document, then the author components required in US Realm Header are required here as well (CONF:1098-32628). b. This assignedAuthor SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1098-31671). i. If the content is patient authored the code SHOULD be selected from Personal And Legal Relationship Role Type (2.16.840.1.113883.11.20.12.1) (CONF:1098-32315). c. This assignedAuthor MAY contain zero or one [0..1] assignedPerson (CONF:109831474). i. The assignedPerson, if present, MAY contain zero or more [0..*] name (CONF:1098-31475). d. This assignedAuthor MAY contain zero or one [0..1] representedOrganization (CONF:1098-31476). i. The representedOrganization, if present, MAY contain zero or more [0..*] id (CONF:1098-31478). ii. The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:1098-31479). iii. The representedOrganization, if present, MAY contain zero or more [0..*] telecom (CONF:1098-31480). iv. The representedOrganization, if present, MAY contain zero or more [0..*] addr (CONF:1098-31481). Figure 144: New Author Participant Example Attachment G- EHR Implementation Guide Templates Figure 145: Existing Author Reference Example 4.2 US Realm Address (AD.US.FIELDED) [addr: identifier urn:oid:2.16.840.1.113883.10.20.22.5.2 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R1.1 Table 303: US Realm Address (AD.US.FIELDED) Contexts Contained By: Contains: US Realm Header (V2) (required) Medication Dispense (V2) (optional) Policy Activity (V2) (optional) Reusable address template, for use in US Realm CDA Header. Table 304: US Realm Address (AD.US.FIELDED) Constraints Overview XPath Card. Verb Data Type CONF# Value addr (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) @use 0..1 SHOUL D 817290 urn:oid:2.16.840.1.113883.1.11.1 0637 (PostalAddressUse) country 0..1 SHOUL D 817295 urn:oid:2.16.840.1.113883.3.88.1 2.80.63 (Country) state 0..1 SHOUL D 817293 urn:oid:2.16.840.1.113883.3.88.1 2.80.1 (StateValueSet) city 1..1 SHALL 817292 postalCode 0..1 SHOUL D 817294 streetAddressLine 1..1 SHALL 817291 urn:oid:2.16.840.1.113883.3.88.1 2.80.2 (PostalCode) Attachment G- EHR Implementation Guide Templates 1. SHOULD contain zero or one [0..1] @use, which SHALL be selected from ValueSet PostalAddressUse urn:oid:2.16.840.1.113883.1.11.10637 STATIC 2005-05-01 (CONF:81-7290). 2. SHOULD contain zero or one [0..1] country, which SHALL be selected from ValueSet Country urn:oid:2.16.840.1.113883.3.88.12.80.63 DYNAMIC (CONF:81-7295). 3. SHOULD contain zero or one [0..1] state (ValueSet: StateValueSet urn:oid:2.16.840.1.113883.3.88.12.80.1 DYNAMIC) (CONF:81-7293). a. State is required if the country is US. If country is not specified, it's assumed to be US. If country is something other than US, the state MAY be present but MAY be bound to different vocabularies (CONF:81-10024). 4. SHALL contain exactly one [1..1] city (CONF:81-7292). 5. SHOULD contain zero or one [0..1] postalCode, which SHOULD be selected from ValueSet PostalCode urn:oid:2.16.840.1.113883.3.88.12.80.2 DYNAMIC (CONF:81-7294). a. PostalCode is required if the country is US. If country is not specified, it's assumed to be US. If country is something other than US, the postalCode MAY be present but MAY be bound to different vocabularies (CONF:81-10025). 6. SHALL contain exactly one [1..1] streetAddressLine (CONF:81-7291). 7. SHALL NOT have mixed content except for white space (CONF:81-7296). Attachment G- EHR Implementation Guide Templates Table 305: PostalAddressUse Value Set: PostalAddressUse urn:oid:2.16.840.1.113883.1.11.10637 A value set of HL7 Codes for address use. Value Set Source: https://vsac.nlm.nih.gov/ Code Code System Code System OID Print Name BAD AddressUse urn:oid:2.16.840.1.11388 3.5.1119 bad address CONF AddressUse urn:oid:2.16.840.1.11388 3.5.1119 confidential DIR AddressUse urn:oid:2.16.840.1.11388 3.5.1119 direct H AddressUse urn:oid:2.16.840.1.11388 3.5.1119 home address HP AddressUse urn:oid:2.16.840.1.11388 3.5.1119 primary home HV AddressUse urn:oid:2.16.840.1.11388 3.5.1119 vacation home PHYS AddressUse urn:oid:2.16.840.1.11388 3.5.1119 physical visit address PST AddressUse urn:oid:2.16.840.1.11388 3.5.1119 postal address PUB AddressUse urn:oid:2.16.840.1.11388 3.5.1119 public TMP AddressUse urn:oid:2.16.840.1.11388 3.5.1119 temporary ... Attachment G- EHR Implementation Guide Templates Table 306: StateValueSet Value Set: StateValueSet urn:oid:2.16.840.1.113883.3.88.12.80.1 Identifies addresses within the United States are recorded using the FIPS 5-2 two-letter alphabetic codes for the State, District of Columbia, or an outlying area of the United States or associated area Value Set Source: http://www.census.gov/geo/reference/ansi_statetables.html Code Code System Code System OID Print Name AL FIPS 5-2 (State) urn:oid:2.16.840.1.11388 3.6.92 Alabama AK FIPS 5-2 (State) urn:oid:2.16.840.1.11388 3.6.92 Alaska AZ FIPS 5-2 (State) urn:oid:2.16.840.1.11388 3.6.92 Arizona AR FIPS 5-2 (State) urn:oid:2.16.840.1.11388 3.6.92 Arkansas CA FIPS 5-2 (State) urn:oid:2.16.840.1.11388 3.6.92 California CO FIPS 5-2 (State) urn:oid:2.16.840.1.11388 3.6.92 Colorado CT FIPS 5-2 (State) urn:oid:2.16.840.1.11388 3.6.92 Connecticut DE FIPS 5-2 (State) urn:oid:2.16.840.1.11388 3.6.92 Delaware DC FIPS 5-2 (State) urn:oid:2.16.840.1.11388 3.6.92 District of Columbia FL FIPS 5-2 (State) urn:oid:2.16.840.1.11388 3.6.92 Florida ... Figure 146: US Realm Address Example 22 Sample Street Beaverton OR 97867 US Attachment G- EHR Implementation Guide Templates 4.3 US Realm Date and Time (DTM.US.FIELDED) [effectiveTime: identifier urn:oid:2.16.840.1.113883.10.20.22.5.4 (open)] Published as part of Consolidated CDA Templates for Clinical Notes (US Realm) DSTU R1.1 Table 307: US Realm Date and Time (DTM.US.FIELDED) Contexts Contained By: Contains: US Realm Header (V2) (required) The US Realm Clinical Document Date and Time datatype flavor records date and time information. If no time zone offset is provided, you can make no assumption about time, unless you have made a local exchange agreement. This data type uses the same rules as US Realm Date and Time (DT.US.FIELDED), but is used with elements having a datatype of TS. Table 308: US Realm Date and Time (DTM.US.FIELDED) Constraints Overview X Card. P a t h Verb Data Type CONF# Value effectiveTime (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.4) 1. SHALL be precise to the day (CONF:81-10127). 2. SHOULD be precise to the minute (CONF:81-10128). 3. MAY be precise to the second (CONF:81-10129). 4. If more precise than day, SHOULD include time-zone offset (CONF:81-10130). Figure 147: US Realm Date and Time Example

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