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cda4cdt_consults

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cda4cdt_consults

    CDAR2_CONSNOTE_R1_D2_2008MAR

    HL7 Implementation Guide for CDA Release 2:

    Consultation Notes

    (U.S. Realm)

    Draft Standard for Trial Use

    Release 1

    Levels 1, 2, and 3

    Published

    July 16, 2008

? 2008 Health Level Seven, Inc.

    Ann Arbor, MI

    All rights reserved.

Co-Chair/Co-Editor: Liora Alschuler

    Alschuler Associates, LLC

    liora@alschulerassociates.com Co-Chair/Co-Editor: Calvin Beebe

    Mayo Clinic

    cbeebe@mayo.edu Co-Chair/Co-Editor: Keith W. Boone

    GE Healthcare

    keith.boone@ge.com Co-Chair/Co-Editor: Robert H. Dolin, MD

    Semantically Yours, LLC

    bobdolin@gmail.com Co-Editor: Laura Bryan

    AHDI

    Laura@MTWerks.com Co-Editor: Juergen Fritsch

    M*Modal

    fritsch@mmodal.com Co-Editor: Rick Geimer

    Alschuler Associates, LLC

    rick@alschulerassociates.com Co-Editor: Kate Hamilton

    Alschuler Associates, LLC

    kate@alschulerassociates.com Co-Editor: Juggy Jugganathan

    MedQuist

    juggy@medquist.com Co-Editor: Crystal Kallem

    AHIMA

    crystal.kallem@ahima.org Co-Editor Detlef Koll

    M*Modal

    koll@mmodal.com Co-Editor Ryan Murphy

    Orca Web Design

    ryan.murphy@orcawebdesign.com Co-Editor: Harry Rhodes

    AHIMA

    Harry.Rhodes@AHIMA.org Current Working Paul Carpenter, Precyse Solutions; Sean Carroll,

    Group also includes: Webmedx; Todd Charest, Spheris; Duane Falk,

    UPMC; Gary Higbie, Interfix; Ken Lacy, Precyse

    Solutions; Kent Wreder, MDinTouch

    HL7 Implementation Guide for CDA R2 Consultation Notes (U.S. Realm) Page 2 Draft Standard for Trial Use Release 1 Levels 1, 2 & 3 Published July 2008 ? 2008 Health Level Seven, Inc. All rights reserved.

    Acknowledgments

    This Draft Standard for Trial Use (DSTU) was produced and developed through the efforts of a project called CDA for Common Document Types (CDA4CDT) founded by M*Modal, the American Health Information Management Association (AHIMA), and the Association for Healthcare Documentation Integrity (AHDI), formerly the American Association for Medical Transcription (AAMT), now affiliated with the Medical Transcription Industry Association (MTIA).

    These founders have been joined by industry benefactors Spheris, MedQuist, InterFix, Precyse Solutions, Wedmedx, MdinTouch, and 3M. Without their support and participation, this DSTU would not have been possible.

    In addition, this project has benefited from the participation of Acusis, Kaiser Permanente, Mayo Clinic, Military Health System, University of Pittsburgh Medical Center, and GE Healthcare. Project management was provided by Alschuler Associates, LLC.

    The co-editors would also like to express their appreciation for the support and sponsorship of the Structured Documents Technical Committee.

    Finally, we would like to acknowledge the foundational work on Health Level Seven (HL7) Version 3 and the Reference Information Model (RIM), the HL7 domain committees, especially Patient Care, and the work done on CDA itself. We would also like to acknowledge the development of the Care Record Summary, the first published Implementation Guide for CDA, the development of a series of implementation profiles based on CRS by Integrating the Healthcare Enterprise (IHE) and the collaborative effort of ASTM and HL7, which produced the Continuity of Care Document (CCD). All these efforts were critical ingredients to the development of this DSTU and the degree to which it reflects these efforts will foster interoperability across the spectrum of health care.

    HL7 Implementation Guide for CDA R2 Consultation Notes (U.S. Realm) Page 3 Draft Standard for Trial Use Release 1 Levels 1, 2 & 3 Published July 2008 ? 2008 Health Level Seven, Inc. All rights reserved.

Revision History

    Rev Date By Whom Changes Notes ballot 1.0 6 August 2007 AALLC, AHDI, Initial ballot draft

    AHIMA, M*Modal

    ballot 2.0 12 March 2008 G. Giannone, Preparation for publication:

    B. Marquard Conformance numbering QA, ?technical editing. New LOINC codes

    added.

    publication 16 July 2008 SDWG Changed references from ―ballot‖ to draft 1.0 ―publication‖; changed sample names

    to conform to Publishing Facilitator‘s

    Guide.

    HL7 Implementation Guide for CDA R2 Consultation Notes (U.S. Realm) Page 4 Draft Standard for Trial Use Release 1 Levels 1, 2 & 3 Published July 2008 ? 2008 Health Level Seven, Inc. All rights reserved.

Table of Contents

    1 INTRODUCTION................................................................................................................... 9 1.1 Purpose .......................................................................................................................... 9 1.2 Audience ........................................................................................................................ 9 1.3 Approach...................................................................................................................... 10 1.4 Use of Templates .......................................................................................................... 10 1.4.1 Originator Responsibilities .................................................................................... 11 1.4.2 Recipient Responsibilities ..................................................................................... 11 1.5 Conventions Used in This DSTU .................................................................................. 11 1.5.1 Explanatory Statements ....................................................................................... 11 1.5.2 Conformance Requirements .................................................................................. 11 1.5.3 Vocabulary Conformance ...................................................................................... 12 1.5.4 XPath Notation ..................................................................................................... 12 1.5.5 Keywords .............................................................................................................. 13 1.5.6 XML Samples ........................................................................................................ 13 1.5.7 Content of the Publication Package ...................................................................... 14 1.5.8 Sample XML ......................................................................................................... 14 1.6 Scope ........................................................................................................................... 14 1.6.1 Levels of Constraint .............................................................................................. 15 1.6.2 Future Work ......................................................................................................... 15 2 CDA HEADER GENERAL CONSTRAINTS ........................................................................ 17 3 CDA HEADER CONSULTATION NOTE-SPECIFIC CONSTRAINTS ................................... 19 3.1 ClinicalDocument/templateId ...................................................................................... 19 3.2 ClinicalDocument/code ............................................................................................... 19 3.2.1 Use of Local Document Type Codes ...................................................................... 19 3.2.2 Pre-coordinated Document Type Codes ................................................................ 20 3.3 Participants .................................................................................................................. 22 3.3.1 Participant ............................................................................................................ 22 3.3.2 Supporting Person or Organization ....................................................................... 22 3.3.3 inFulfillmentOf ..................................................................................................... 23 3.3.4 authorization ........................................................................................................ 23 3.3.5 componentOf ........................................................................................................ 24 HL7 Implementation Guide for CDA R2 Consultation Notes (U.S. Realm) Page 5 Draft Standard for Trial Use Release 1 Levels 1, 2 & 3 Published July 2008 ? 2008 Health Level Seven, Inc. All rights reserved.

    4 BODY .................................................................................................................. 25 4.1 Section Descriptions .................................................................................................... 25 4.2 Required Sections ........................................................................................................ 28

    4.2.1 Reason for Referral/Visit/42349-1/29299-5 ........................................................ 28

    4.2.2 History of Present Illness 10164-2 ........................................................................ 29

    4.2.3 Physical Examination 29545-1 ............................................................................. 29

    4.2.4 Assessment and Plan 51487-2/51848-0/18776-5 ............................................... 31 4.3 Optional Sections ......................................................................................................... 31

    4.3.1 Problems 11450-4................................................................................................. 32

    4.3.2 Procedure History 47519-4 ................................................................................... 32

    4.3.3 Past Medical History 11348-0 ............................................................................... 33

    4.3.4 Immunizations 11369-6 ....................................................................................... 34

    4.3.5 Medications 10160-0 ............................................................................................ 34

    4.3.6 Allergies 48765-2 .................................................................................................. 36

    4.3.7 Social History 29762-2 ......................................................................................... 36

    4.3.8 Family History 10157-6 ........................................................................................ 37

    4.3.9 Review of Systems 10187-3 .................................................................................. 38

    4.3.10 Vital Signs 8716-3 ................................................................................................ 38

    4.3.11 General Status 10210-3 ....................................................................................... 39

    4.3.12 Diagnostic Findings 30954-2 ................................................................................ 39 5 REFERENCES .................................................................................................................. 41 APPENDIX A VALIDATION.............................................................................................. 42 APPENDIX B EXTERNALLY DEFINED CONSTRAINTS ................................................... 50 APPENDIX C CDA4CDT-DEFINED TEMPLATE IDS ........................................................ 70 APPENDIX D LIST OF ADDITIONAL PHYSICAL EXAMINATION SUBSECTIONS ............. 71 APPENDIX E SECTION CARDINALITY ............................................................................ 73 HL7 Implementation Guide for CDA R2 Consultation Notes (U.S. Realm) Page 6 Draft Standard for Trial Use Release 1 Levels 1, 2 & 3 Published July 2008 ? 2008 Health Level Seven, Inc. All rights reserved.

Table of Figures

    Figure 1: Use of the templateId element to indicate use of this DSTU ...................................... 14 Figure 2: ClinicalDocument/templateId example ..................................................................... 19 Figure 3: ClinicalDocument/code example .............................................................................. 19 Figure 4: Use of a translation to include local equivalents for document type ......................... 20 Figure 5: Use of pre-coordinated document type codes in the CDA.......................................... 21 Figure 6: Use of a document type codes, not pre-coordinated .................................................. 22 Figure 7: participant example for a supporting person ............................................................ 23 Figure 8: inFulfillmentOf example ............................................................................................ 23 Figure 9: componentOf example .............................................................................................. 24 Figure 10: nonXMLBody example with content ........................................................................ 25 Figure 11: nonXMLBody example with a reference .................................................................. 25 Figure 12: Reason for referral visit/chief complaint example ................................................... 29 Figure 13: History of present illness example .......................................................................... 29 Figure 14: Physical examination example ................................................................................ 30 Figure 15: Assessment and plan example ................................................................................ 31 Figure 16: Problems ................................................................................................................. 32 Figure 17: Procedure rendering................................................................................................ 33 Figure 18: Procedure history section example .......................................................................... 33 Figure 19: Past medical history example .................................................................................. 34 Figure 20: History of immunizations example .......................................................................... 34 Figure 21: Medications example with Level 3 coding................................................................ 35 Figure 22: Allergies example .................................................................................................... 36 Figure 23: Social history example ............................................................................................ 36 Figure 24: Social history with Level 3 entries example ............................................................. 37 Figure 25: Family history example ........................................................................................... 38 Figure 26: Review of systems example ..................................................................................... 38 Figure 27: Vital signs example ................................................................................................. 39 Figure 28: Diagnostic findings example ................................................................................... 40 Figure 29: voc.xml structure .................................................................................................... 42 HL7 Implementation Guide for CDA R2 Consultation Notes (U.S. Realm) Page 7 Draft Standard for Trial Use Release 1 Levels 1, 2 & 3 Published July 2008 ? 2008 Health Level Seven, Inc. All rights reserved.

Table of Tables

    Table 1: Contents of the Publication Package .......................................................................... 14

    ?Table 2: LOINC Codes for Sections ......................................................................................... 27

    ?Table 3: Valid LOINC Document Type Codes .......................................................................... 44

    ?Table 4: Invalid LOINC Document Type Codes ....................................................................... 45 Table 5: Personal Relationship Role Type ................................................................................. 49

    HL7 Implementation Guide for CDA R2 Consultation Notes (U.S. Realm) Page 8 Draft Standard for Trial Use Release 1 Levels 1, 2 & 3 Published July 2008 ? 2008 Health Level Seven, Inc. All rights reserved.

1 INTRODUCTION

    1.1 Purpose

    This standard specifies constraints on the HL7 Clinical Document Architecture, Release

    2.0 (CDA R2) for Consultation Notes. It reuses section and entry-level templates created 1for CCD and for the History and Physical DSTU.

    For the purpose of this Implementation Guide, a consultation visit is defined by the

    evaluation and management guidelines for a consultation established by the Centers for

    Medicare and Medicaid Services (CMS). According to those guidelines, a Consultation

    Note must be generated as a result of a physician or nonphysician practitioner‘s (NPP)

    request for an opinion or advice from another physician or NPP. Consultations must

    involve face-to-face time with the patient or fall under guidelines for telemedicine visits.

    A Consultation Note must be provided to the referring physician or NPP and must

    include the reason for the referral, history of present illness, physical examination, and

    decision-making component (Assessment and Plan).

    An NPP is defined as any licensed medical professional as recognized by the state in

    which the professional practices, including, but not limited to, physician assistants,

    nurse practitioners, clinical nurse specialists, social workers, physical therapists, and

    speech therapists.

    Reports on visits requested by a patient, family member, or other third party are not

    covered by this specification. Second opinions, sometimes called ―confirmatory

    consultations, also are not covered here. Any question on use of the Consultation Note

    defined here should be resolved by reference to CMS or AMA guidelines. 1.2 Audience

    The audience for this document includes software developers and consultants

    responsible for implementation of Electronic Health Record (EHR) systems, Electronic

    Medical Record (EMR) systems, Personal Health Record (PHR) systems,

    dictation/transcription systems, document management applications, and local,

    regional and national health information exchange networks who wish to create and/or

    process CDA documents created according to this specification.

     1 The HL7 Standard for History and Physical was balloted simultaneously with this document. Changes to that document may be reflected back into this document, per ballot reconciliation. HL7 Implementation Guide for CDA R2 Consultation Notes (U.S. Realm) Page 9 Draft Standard for Trial Use Release 1 Levels 1, 2 & 3 Published July 2008 ? 2008 Health Level Seven, Inc. All rights reserved.

    1.3 Approach

    The approach taken in the development of this specification was to review existing draft and final specifications or Implementation Guides for similar artifacts in the U.S., specifically:

    ? ASTM‘s Standard Specifications for Healthcare Document Formats (E2184.02)

    (Headings and subheadings used in the health care industry and associated 2with specific report types)

    ? ASTM/HL7 Continuity of Care Document (CCD)

    ?? Clinical LOINC document and section codes

    ? HL7 ASIG CDA R2 Attachment for Clinical Notes

    ? HL7 Care Record Summary (CRS)

    ? IHE profiles, including the content profiles within Patient Care Coordination

    ? MHS/DoD-VA-IM-IT Demo Project Discharge Summary and SOAP HL7 CDA R2

    Implementation Guides

    ? Sample CDA documents developed for local provider institutions (Mayo Clinic,

    University of Pittsburgh Medical Center, New York Presbyterian, and others)

    ? Non-CDA sample documents supplied by participating providers and vendors A sample Consultation Note was provided by Association for Healthcare Documentation Integrity (AHDI) and used as a test against the design of this DSTU. It is provided as an example instance in a separate XML file.

    In addition, M*Modal provided statistical analysis of 13,879 documents from almost 100 different facilities (with approximately 65 percent from acute-care hospitals). AHIMA, AHDI, and participating providers contributed extensive subject matter expertise. The design was matched against operational templates from transcription vendors and reviewed with the HL7 Structured Documents Technical Committee. While current divergent industry practices cannot be perfectly reflected in any consensus model, this design is optimized for widespread conformance and adoption with minimal disruption to current practice and workflow.

    1.4 Use of Templates

    Templates are collections of constraints that specify and validate agreed-to requirements for exchange. Collecting individual constraints and assigning a unique template identifier to the collection establishes a shorthand mechanism for the instance creator to assert conformance to those constraints. The template identifier itself carries no semantics. Validation errors against a template must not be construed as anything other than failure to meet the exact requirements of the template and absence of a template identifier need not be construed as failure to meet the constraints required by the template.

     2 This ASTM specification is in ballot. Changes reflected in that ballot that are available as of the close of

    this ballot will be reflected here.

    HL7 Implementation Guide for CDA R2 Consultation Notes (U.S. Realm) Page 10 Draft Standard for Trial Use Release 1 Levels 1, 2 & 3 Published July 2008 ? 2008 Health Level Seven, Inc. All rights reserved.

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