ࡱ>   FbjbjcTcT G>>x -- .i8=9Q9Q9Q989u=<Q9C oPP:PPQq, z$w\-IjQQO--PP).:-P-PI ҼPsQ9YRDڿWHuu(ҼҼu4R|0"_III||||||IIIIu||||||||| ,: CDAR2_PROCNOTE_R1D1_2010JAN  Implementation Guide for CDA Release 2.0 Procedure Note (Universal Realm) Release 1 Levels 1 and 2 2010 Health Level Seven, Inc. Ann Arbor, MI All rights reserved. Co-ChairRobert H. Dolin, MD Semantically Yours, LLC  HYPERLINK "mailto:bobdolin@gmail.com" bobdolin@gmail.comCo-Chair/Co-EditorLiora Alschuler Alschuler Associates, LLC  HYPERLINK "mailto:liora@alschulerassociates.com" liora@alschulerassociates.comCo-ChairCalvin Beebe Mayo Clinic  HYPERLINK "mailto:cbeebe@mayo.edu" cbeebe@mayo.eduCo-ChairKeith W. Boone GE Healthcare  HYPERLINK "mailto:keith.boone@ge.com" keith.boone@ge.comPrimary Editor:Judy Logan, MD (etc?)  HYPERLINK "mailto:loganju@ohsu.edu" loganju@ohsu.edu Primary Editor:Thomas Carr, MD (etc?)  HYPERLINK "mailto:carrt@ohsu.edu" carrt@ohsu.edu Co-Editor:Gay Giannone, MSN RN Alschuler Associates, LLC  HYPERLINK "mailto:gay@alschulerassociates.com" gay@alschulerassociates.comCo-Editor:Helmut Koenig, MD Siemens AG Helmut.koenig@siemens.comCo-Editor:Mark Diehl, DDS American Dental Association  HYPERLINK "mailto:markdata@aol.com" markdata@aol.com Co-Editor:Harry Soloman GE Healthcare  HYPERLINK "mailto:harry.soloman@med.ge.com" harry.soloman@med.ge.comCo-Editor:Laura Bryan ADHI HYPERLINK "mailto:Laura@MTWerks.com"Laura@MTWerks.com Current Working Group also includes: Juergen Fritsch, Kristen Willoughby, Bob Agamalian, Brian Fors, Donna DuLong, John Roberts, Kristin Hagen, Luigi Sison, Matt Green, Mike Lincoln, Monica Harry Acknowledgments The completion of this implementation guide was made possible by the efforts of the Health Story Project (formerly CDA for Common Document Types, or 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, Webmedx, MDinTouch, 3M, Imagetek, ALife, Misys Healthcare, and QuadraMed. Without their support and participation, this Implementation Guide would not have been possible. In addition, this project has benefited from the participation of the American Society for Gastrointestinal Endoscopy, Quality Committee. 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 and co-sponsorship of the Patient Care Committee and the Clinical Interoperability 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. Table of Contents  TOC \o "1-3" 1 Introduction  PAGEREF _Toc247517663 \h 9 1.1 Purpose  PAGEREF _Toc247517664 \h 9 1.2 Audience  PAGEREF _Toc247517665 \h 9 1.3 Approach  PAGEREF _Toc247517666 \h 9 1.4 Organization of This Guide  PAGEREF _Toc247517667 \h 10 1.5 Use of Templates  PAGEREF _Toc247517668 \h 10 1.5.1 Originator Responsibilities: General Case  PAGEREF _Toc247517669 \h 10 1.5.2 Recipient Responsibilities General Case  PAGEREF _Toc247517670 \h 11 1.6 Conventions Used in This Guide  PAGEREF _Toc247517671 \h 11 1.6.1 Explanatory Statements  PAGEREF _Toc247517672 \h 11 1.6.2 Conformance Requirements  PAGEREF _Toc247517673 \h 11 1.6.3 Vocabulary Conformance  PAGEREF _Toc247517674 \h 11 1.6.4 XPath Notation  PAGEREF _Toc247517675 \h 12 1.6.5 Keywords  PAGEREF _Toc247517676 \h 12 1.6.6 XML Examples  PAGEREF _Toc247517677 \h 12 1.6.7 Sample XML  PAGEREF _Toc247517678 \h 13 1.7 Scope  PAGEREF _Toc247517679 \h 13 1.7.1 Levels of Constraint  PAGEREF _Toc247517680 \h 13 1.7.2 Future Work  PAGEREF _Toc247517681 \h 14 2 CDA Header Constraints  PAGEREF _Toc247517682 \h 15 2.1 Header Attributes  PAGEREF _Toc247517683 \h 15 2.1.1 ClinicalDocument/typeID  PAGEREF _Toc247517684 \h 15 2.1.2 ClinicalDocument/templateId  PAGEREF _Toc247517685 \h 15 2.1.3 Name, Address, and Telephone Numbers  PAGEREF _Toc247517686 \h 15 2.1.4 ClinicalDocument/code  PAGEREF _Toc247517687 \h 16 2.1.5 ClinicalDocument/title  PAGEREF _Toc247517688 \h 17 2.1.6 ClinicalDocument/effectiveTime  PAGEREF _Toc247517689 \h 17 2.1.7 ClinicalDocument/languageCode  PAGEREF _Toc247517690 \h 17 2.2 Header Participants  PAGEREF _Toc247517691 \h 18 2.2.1 recordTarget  PAGEREF _Toc247517692 \h 18 2.2.2 Author  PAGEREF _Toc247517693 \h 20 2.2.3 DataEnterer  PAGEREF _Toc247517694 \h 20 2.2.4 Custodian  PAGEREF _Toc247517695 \h 21 2.2.5 Generic participant/encounterParticipant - referring provider  PAGEREF _Toc247517696 \h 21 2.2.6 Generic participant - primary care provider  PAGEREF _Toc247517697 \h 22 2.2.7 Participant scenarios  PAGEREF _Toc247517698 \h 22 2.3 Consent  PAGEREF _Toc247517699 \h 24 2.4 ServiceEvent  PAGEREF _Toc247517700 \h 25 2.5 Performer  PAGEREF _Toc247517701 \h 26 2.6 Rendering Header Information for Human Presentation  PAGEREF _Toc247517702 \h 27 3 Body  PAGEREF _Toc247517703 \h 29 3.1 Section Descriptions  PAGEREF _Toc247517704 \h 29 3.2 Required Sections  PAGEREF _Toc247517705 \h 31 3.2.1 Indications IND-X  PAGEREF _Toc247517706 \h 31 3.2.2 Procedure Description PROCDES-X  PAGEREF _Toc247517707 \h 32 3.2.3 Postprocedure Diagnosis POSTPR-X  PAGEREF _Toc247517708 \h 33 3.2.4 Complications 19818-4  PAGEREF _Toc247517709 \h 34 3.2.6 Assessment and Plan 51847-2/51848-0/18776-5  PAGEREF _Toc247517710 \h 35 3.3 Optional Sections  PAGEREF _Toc247517711 \h 36 3.3.1 Medical History 11329-0  PAGEREF _Toc247517712 \h 36 3.3.2 Physical Examination 29545-1  PAGEREF _Toc247517713 \h 37 3.3.3 Planned Procedure PLNPROC-X  PAGEREF _Toc247517714 \h 40 3.3.4 Anesthesia ANES-X  PAGEREF _Toc247517715 \h 40 3.3.5 Medications Administered 29549-3  PAGEREF _Toc247517716 \h 41 3.3.6 Medication History 10160-0  PAGEREF _Toc247517717 \h 42 3.3.7 Estimated Blood Loss EBL-X  PAGEREF _Toc247517718 \h 45 3.3.8 Specimens Removed SPECRE-X  PAGEREF _Toc247517719 \h 46 3.3.9 Implants IMPL-X  PAGEREF _Toc247517720 \h 47 3.3.10 Findings FIND-X  PAGEREF _Toc247517721 \h 48 3.3.11 Disposition DISPO-X  PAGEREF _Toc247517722 \h 48 4 References  PAGEREF _Toc247517723 \h 50 Acronyms and abbreviations  PAGEREF _Toc247517724 \h 51 Vocabulary  PAGEREF _Toc247517725 \h 52 Introduction  PAGEREF _Toc247517726 \h 52 Vocabulary  PAGEREF _Toc247517727 \h 52 Template IDs in this Guide  PAGEREF _Toc247517728 \h 53 Appendix X - List of Additional medical HIstory Subsections  PAGEREF _Toc247517729 \h 55 Appendix B - List of Additional Physical Examination Subsections  PAGEREF _Toc247517730 \h 55 appendix c - Externally Defined Constraints  PAGEREF _Toc247517731 \h 58  Table of Figures TOC \h \z \c "Figure"   HYPERLINK \l "_Toc247436974" Figure 1: ClinicalDocument example  PAGEREF _Toc247436974 \h 12  HYPERLINK \l "_Toc247436975" Figure 2: ClinicalDocument/templateId CategoryI example  PAGEREF _Toc247436975 \h 15  HYPERLINK \l "_Toc247436976" Figure 3: ClinicalDocument/code example  PAGEREF _Toc247436976 \h 17  HYPERLINK \l "_Toc247436977" Figure 4: ClinicalDocument/title example  PAGEREF _Toc247436977 \h 17  HYPERLINK \l "_Toc247436978" Figure 5: ClinicalDocument/languageCode example with language only  PAGEREF _Toc247436978 \h 17  HYPERLINK \l "_Toc247436979" Figure 6: ClinicalDocument/languageCode example with language and country  PAGEREF _Toc247436979 \h 17  HYPERLINK \l "_Toc247436980" Figure 7: recordTarget example  PAGEREF _Toc247436980 \h 19  HYPERLINK \l "_Toc247436981" Figure 8: assignedAuthor example  PAGEREF _Toc247436981 \h 20  HYPERLINK \l "_Toc247436982" Figure 9: DataEnterer example  PAGEREF _Toc247436982 \h 21  HYPERLINK \l "_Toc247436983" Figure 10: Custodian example  PAGEREF _Toc247436983 \h 21  HYPERLINK \l "_Toc247436984" Figure 11: Consent example  PAGEREF _Toc247436984 \h 25  HYPERLINK \l "_Toc247436985" Figure 12: serviceEvent example  PAGEREF _Toc247436985 \h 26  HYPERLINK \l "_Toc247436986" Figure 12: serviceEvent international example  PAGEREF _Toc247436986 \h 26  HYPERLINK \l "_Toc247436987" Figure 13: Performer example  PAGEREF _Toc247436987 \h 27  HYPERLINK \l "_Toc247436988" Figure 14: Indications section example  PAGEREF _Toc247436988 \h 31  HYPERLINK \l "_Toc247436989" Figure 15: Procedure Description section example  PAGEREF _Toc247436989 \h 33  HYPERLINK \l "_Toc247436990" Figure 16: Postprocedure Diagnosis section example  PAGEREF _Toc247436990 \h 34  HYPERLINK \l "_Toc247436991" Figure 17: Complications section example  PAGEREF _Toc247436991 \h 35  HYPERLINK \l "_Toc247436992" Figure 18: Assessment and plan example  PAGEREF _Toc247436992 \h 36  Table of Tables  TOC \c "Table" Table 1: Procedure Note LOINC Document Codes  PAGEREF _Toc247437000 \h 16 Table 2: HITSP Harmonized Sex structure AdministrativeGenderCode  PAGEREF _Toc247437001 \h 18 Table 3: Participant Scenarios  PAGEREF _Toc247437002 \h 23 Table 4: LOINC Codes for Procedure Note Sections  PAGEREF _Toc247437003 \h 30 Table 5: Procedure Note LOINC Document Codes  PAGEREF _Toc247437004 \h 52 Table 6: Template IDs in This Guide  PAGEREF _Toc247437005 \h 53  Introduction Purpose The purpose of this document is to describe constraints on the CDA Header and Body elements for Procedure Note documents. Procedure Note is a broad term for many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation and many other specialty fields. Procedures Notes are differentiated from Operative Notes in that the procedures they document do not involve incision or excision as the primary act. The Procedure Note or Report is created immediately following a non-operative procedure and records the indications for the procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, as well as the patient tolerance of the procedure.patient for the procedure. The report should be sufficiently detailed to justify the procedure, document the course of the procedure, and provide continuity of care. Audience The audience for this document includes software developers and consultants responsible for implementation of Electronic Health Record (EHR) 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 developed according to this specification. 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: HYPERLINK "http://www.regenstrief.org/loinc"Clinical LOINC document and section codes HYPERLINK "http://www.hl7.org/documentcenter/ballots/2007MAY/downloads/ASIG_INFOSPECS_CDAR2_I2_2007MAY.zip"HL7 ASIG CDA R2 Attachment for Clinical Notes  HYPERLINK "http://www.hl7.org/v3ballot/html/infrastructure/cda/cda.htm" HL7 Clinical Document Architecture, Release 2 Normative Web Edition, 2005 HL7 Implementation Guide for CDA Release 2: History and Physical (H&P) Notes HL7 Implementation Guide for CDA Release 2: Operative Note HL7 Implementation Guide for CDA Release 2: Imaging Integration CDA Release 2  HYPERLINK "http://www.hl7.org/documentcenter/ballots/2007JAN/downloads/CDAR2_IMPL_CCD_I2_2007JAN.zip" CCD: Continuity of Care Document (CCD)  HYPERLINK "http://www.jointcommission.org/AccreditationPrograms/Office-BasedSurgery/Standards/FAQs/Management+of+Info/Patient+Specific+Info/Operative_Reports.htm" Joint Commission Operative Note Requirements: Standard IM.6.30, Elements of Performance for IM.6.30  HYPERLINK "http://www.cms.hhs.gov/manuals/Downloads/som107ap_a_hospitals.pdf" Centers for Medicare & Medicaid Services (CMS) Operative Note Requirements: Survey Protocol, Regulations and Interpretive Guidelines for Hospitals: A-0396 482.51(b)(6). Non-CDA sample documents supplied by participating providers and vendors In addition, M*Modal provided statistical analysis of approximately 14,000 sample procedure reports and the American Society for Gastrointestinal Endoscopy (ASGE), 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 designed to increase the degree of consistency with minimal disruption to current practice and workflow. Organization of This Guide The requirements laid out in the body of this DSTU document are on track to become normative after a trial period of use and will be subject to change under the policies for DSTU per the HL7 Governance and Operations Manual. The document is organized into the following major sections: Header Constraints Required Sections Optional Sections Each major section or subsection of the document is organized to provide: A narrative that provides an overview and scope for that section CDA R2 constraints Use of Templates When valued in an instance, the template identifier signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question. Originator Responsibilities: General Case An originator can apply a templateId if there is a desire to assert conformance with a particular template. In the most general forms of CDA exchange, an originator need not apply a templateId for every template that an object in an instance document conforms to. The Implementation Guide (IG) shall assert whenever templateIds are required for conformance. Recipient Responsibilities General Case A recipient may reject an instance that does not contain a particular templateId (e.g., a recipient looking to receive only CCD documents can reject an instance without the appropriate templateId). A recipient may process objects in an instance document that do not contain a templateId (e.g., a recipient can process entries that contain Observation acts within a Problems section, even if the entries do not have templateIds). Conventions Used in This Guide This Implementation Guide is a conformance profile, as described in the HYPERLINK "http://www.hl7.org/v3ballot/html/infrastructure/conformance/conformance.htm"Refinement and Localization section of the HL7 Version 3 standards. The base standard for this Implementation Guide is the HYPERLINK "http://www.hl7.org/v3ballot/html/infrastructure/cda/cda.htm"HL7 Clinical Document Architecture, Release 2.0. As defined in that document, this Implementation Guide is both an annotation profile and a localization profile. CDA R2 is not fully described in this Guide, so implementers must be familiar with the requirements of the base specification. Explanatory Statements As an annotation profile, portions of this Implementation Guide summarize or explain the base standard; therefore, not all requirements stated here are original to the DSTU. Some originate in the base specification. Those requirements that do not add further constraints to the base standard and that can be validated through CDA.xsd do not have corresponding conformance statements. Where no constraints are stated in this Guide, Procedure Note instances are subject to and are to be created in accordance with the base CDA R2 specification. Where, for instance, the CDA R2 specification declares an attribute to be optional and the Procedure Note specification contains no additional constraints, that attribute remains optional for use in an Procedure Note instance. Conformance Requirements The conformance statements within this Implementation Guide are labeled as CONF-PN-nn, where PN represents Procedure Note, are numbered sequentially (nn), and appear in the format shown below: CONF-PN-1: This is an example conformance requirement original to this Procedure Note DSTU. Vocabulary Conformance Formalisms for value set constraints are based on the latest recommendations from the HL7 Vocabulary Committee. Value set constraints can be static, meaning that they are bound to a specified version of a value set, or dynamic, meaning that they are bound to the most current version of a value set. A simplified constraint is used when binding is to a single code. Syntax for vocabulary binding to dynamic or static value sets is as follows: The value for (pathName of coded element) (shall | should | may) be selected from ValueSet valueSetOID localValueSet Name dynamic | static (valueSetEffectiveDate). CONF-ex1: The value for ClinicalDocument/code shall be selected from ValueSet 2.16.840.1.113883.1.11.10870 DocumentType dynamic. CONF-ex2: The value for ClinicalDocument/code shall be selected from ValueSet 2.16.840.1.113883.1.11.10870 DocumentType static 20061017. Syntax for vocabulary binding to a single code is as follows: The value for (pathName of coded element) (shall | should | may) be (code [displayName] codeSystemOID [codeSystemName] static. CONF-ex3: The value for ClinicalDocument/code shall be 34133-9 Summarization of episode note 2.16.840.1.113883.6.1 LOINC static. XPath Notation Instead of the traditional dotted notation used by HL7 to represent RIM classes, this document uses XPath notation in conformance statements and elsewhere to identify the XML elements and attributes within the CDA document instance to which various constraints are applied. The implicit context of these expressions is the root of the document. The purpose of using this notation is to provide a mechanism that will be familiar to developers for identifying parts of an XML document. Keywords The keywords shall, shall not, should, should not, may, and need not in this document are to be interpreted as described in the HYPERLINK "http://www.hl7.org/v3ballot/html/help/pfg/pfg.htm"HL7 Version 3 Publishing Facilitator's Guide. XML Examples XML examples appear in various figures in this document in this small monospace font. Portions of the XML content may be omitted from the content for brevity, marked by an ellipsis () as shown in the example below. Figure  SEQ Figure \* ARABIC 1: ClinicalDocument example ... Within the narrative, XML element and attribute names will appear in this larger monospace font. Literal attribute values will appear in this italic font. XPath expressions are used in the narrative and conformance requirements to identify elements because they are familiar to many XML implementers Sample XML A sample document is provided that conforms to theLevel1 and Level 2 constraints of this DSTU (see Section 1.7.1 Levels of Constraint). this sample document is an actual sample of a patient's Procedure Note with identifying information changed for privacy. It was provided by a project participant and used as a test of the DSTU design. Because it is drawn from actual practice rather than composed to illustrate the DSTU, it covers all requirements and some of the options described here. Scope This specification defines constraints on CDA Header and Body elements used in a Procedure Note document in the universal realm. This DSTU Implementation Guide is one of a series of DSTUs being developed through the efforts of Health Story (formerly CDA4CDT), where the CDA architecture is defined down to CDA Level2 granularity with reuse of previously created level 3 entry-level templates where appropriate. The intention with the Health Story DSTUs is to compile them all into a single Implementation Guide for normative balloting after the DSTU trial periods have completed. Levels of Constraint Within this DSTU, the required and optional clinical content within the Body is identified. This DSTU specifies three levels of conformance requirements: Level1 requirements specify constraints upon the CDA Header and the content of the document. Level2 requirements specify constraints at the section level of the structuredBody of the ClinicalDocument element of the CDA document. Level3 requirements specify constraints at the entry level within a section. The only Level3 entries defined in this Implementation Guide are those that have been previously created in CCD or other HL7 CDA implementation guides if deemed appropriate for a procedure report. Note that these levels are rough indications of what a recipient can expect in terms of machine-processable coding and content reuse. They do not reflect the level or type of clinical content and many additional distinctions in reusability could be defined. Conformance to the DSTU carries with it an implicit adherence to Level1. Level1 asserts header element constraints. Therefore, conformance to the DSTU with no level specified or with Level1 specified asserts header element constraints and allows for the use of a non-XML body or an XML body that may or may not conform to additional templates defined herein. Likewise, conformance to the DSTU at Level2 does not require conformance to entry-level templates, but does assert conformance to Header- and section-level templates. In all cases, required clinical content must be present. For example, a CDA Procedure Note carrying the templateId that asserts conformance with Level1 may use a PDF or HTML format for the body of the document that contains the required clinical content. Future Work Future work includes the definition of increasingly refined (granular) machine-verifiable processing structures. This work will be performed in conjunction with other HL7 technical committees and in cooperation with professional societies and other Standards Development Organizations (SDOs).There are many parallel efforts to create CDA IGs and standards based on CDA. Future work will address libraries of templates, including those defined and reused here, and refinement of the document type hierarchy. Future related work may create specific Procedure Note examples or Implementation Guides with Level3 constraints according to type of procedure, specialty, or clinical setting. CDA Header Constraints This section describes constraints that apply to the CDA Procedure Note header. These constraints describe constraints on the CDAR2 base standard to meet the needs of a procedure note. Not every available CDA component is reiterated in this IG nor is it precluded. Header Attributes This section describes the CDA attributes in a Procedure Note header. ClinicalDocument/typeID The value of typeID/@root shall be 2.16.840.1.113883.1.3 and value of typeID/@extension shall be POCD_HD000040. ClinicalDocument/templateId This ClinicalDocument/templateId element identifies the template that defines constraints on the content of a CDA Procedure Note document. A CDA Procedure Note shall contain at least one Clinical Document/templateId element. The value of one ClinicalDocument/templateId/@root shall be 2.16.840.1.113883.10.20.18.1 representing conformance to CDA Procedure Note. Figure  SEQ Figure \* ARABIC 2: ClinicalDocument/templateId CategoryI example Name, Address, and Telephone Numbers To support communication between the receiver of the document and the patient or any other person or organization mentioned within it, the elements representing them will be named. All patient, guardianPerson, assignedPerson, maintainingPerson, relatedPerson, intendedRecipient/informationRecipient, associatedPerson, and relatedSubject/subject elements shall have a name. All patientRole, assignedAuthor, assignedEntity[not(parent::dataEnterer)] and associatedEntity elements shall have an addr and telecom element. ClinicalDocument/code CDA R2 states that LOINC is the preferred vocabulary for document type specification. As of publication of this Implementation Guide, the current LOINC codes that meet the criteria in Procedure Note Conformance Statement 3 can be found in  REF _Ref247423293 \h  \* MERGEFORMAT Table 1: Procedure Note LOINC Document Codes. These codes may be added to or deleted in LOINC. The CDA Procedure Note is a universal realm document, therefore LOINC use will not be mandated but is still the preferred document code vocabulary. Some of the LOINC codes recommended in this IG also indicate the practice setting or the training or professional level of the author. These are pre-coordinated document type codes. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. A Procedure Note shall contain exactly one ClinicalDocument/code. The value of ClinicalDocument/code shall be selected from Value Set 2.16.840.1.113883.11.20.6.1 LOINC ProcedureNoteDocumentTypeCode dynamic. Table  SEQ Table \* ARABIC 1: Procedure Note LOINC Document Codes Value Set: ProcedureNoteDocumentTypeCodes: 2.16.840.1.113883.11.20.6.1 Code System: LOINC 2.16.840.1.113883.6.1LOINC CodeType of Service ComponentSetting SystemSpecialty/Training/Professional Level Method_Type11505-5Procedure note{Setting}Physician18836-7ProcedureCardiac stress study*28570-0Procedure note{Setting}{Provider}28577-5Procedure note{Setting}Dentistry28625-2Procedure note{Setting}Podiatry34121-4Interventional procedure note{Setting}34122-2Pathology procedure note{Setting}Pathology34107-3Education procedure noteHome health{Provider}34896-1Interventional procedure note{Setting}Cardiology34899-5Interventional procedure note{Setting}Gastroenterology47519-4History of Procedures{Setting}{Provider}55111-9Current imaging procedure descriptions^Patient55114-3Prior imaging procedure descriptions^Patient Figure  SEQ Figure \* ARABIC 3: ClinicalDocument/code example ClinicalDocument/title A CDA Procedure Note shall contain exactly one ClinicalDocument/title element valued with a case-insensitive, text string that specifies the local name used for the document. The clinicalDocument/Title shall not conflict with the clinicalDocument/code. ClinicalDocument/effectiveTime ClinicalDocument/effectiveTime element shall be present and specifies the creation time of the document. All Procedure Note documents should record an effectiveTime that is precise to the minute. Figure  SEQ Figure \* ARABIC 4: ClinicalDocument/title example Endoscopy Procedure Note ClinicalDocument/languageCode The ClinicalDocument/languageCode specifies the language of the History and Physical. History and Physicals must be readable by medical practitioners, caregivers, and patients. ClinicalDocument / languageCode shall be present. ClinicalDocument / languageCode shall be in the form nn, or nn-CC. The nn portion of ClinicalDocument / languageCode shall be a legal ISO-639-1 language code in lowercase. The CC portion ClinicalDocument / languageCode, if present, shall be an ISO-3166 country code in uppercase. Figure  SEQ Figure \* ARABIC 5: ClinicalDocument/languageCode example with language only Figure  SEQ Figure \* ARABIC 6: ClinicalDocument/languageCode example with language and country Header Participants This section describes the participants in a Procedure Note header. recordTarget The recordTarget element must be present. The record target element records the patient whose health information is described by the clinical document. A Procedure Note shall contain exactly one ClinicalDocument/recordTarget/PatientRole. A patient/birthTime element shall be present. The patient/birthTime element shall be precise at least to the year, and should be precise at least to the day. If unknown, it shall be represented using a flavor of null. A patient/administrativeGenderCode element shall be present. If unknown, it shall be represented using a flavor of null. Values for administrativeGenderCode should be drawn from the HL7 vocabulary  REF _Ref245020574 \h  \* MERGEFORMAT Table 2: HITSP Harmonized Sex structure AdministrativeGenderCode. Table  SEQ Table \* ARABIC 2: HITSP Harmonized Sex structure AdministrativeGenderCode Value Set: HITSP Harmonized Sex Structure(administrative) Value Set 2.16.840.1.114443.1.1 Code System: SNOMED 2.16.840.1.113883.6.96CodeMeaning1086007Female10052007Male37791004Indeterminate The guardian element shall be present when the patient is a minor child. The providerOrganization element should be present reflecting the organization where the procedure was performed. Figure  SEQ Figure \* ARABIC 7: recordTarget example 17 Daws Rd. Ann Arbor MI 02368 USA Kari Kidd 555 Residential Lane Blue Bell MA 99999 USA Martha Mumm Good Health Clinic 21 North Ave Burlington MA 01803 USA Author The author element represents the creator of the clinical document. The author may be a device, a person or an organization. A Procedure Note shall contain one or more ClinicalDocument/author/assignedAuthor/assignedPerson and/or ClinicalDocument/author/assignedAuthor/assignedAuthoringDevice The assignedAuthor/id element shall be present. Figure  SEQ Figure \* ARABIC 8: assignedAuthor example DataEnterer The dataEnterer element represents the person who transferred the information from other sources into the clinical document, where the other sources wrote the content of the note. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation. The dataEnterer adds that information to the electronic system. If the role of the actor is to transfer information from one source to another (e.g., transcription or transfer from paper form to electronic system), that actor is considered a dataEnterer. When dataEnterer is present, an assignedEntity/assignedPerson element shall be present. Figure  SEQ Figure \* ARABIC 9: DataEnterer example Custodian A custodian is required in CDA The custodian of the Procedure Note is the organization where the procedure was provided. A Procedure Note shall contain exactly one custodian/assignedCustodian/representedCustodianOrganization/ id element. The custodian shall be the organization where the procedure was performed. Figure  SEQ Figure \* ARABIC 10: Custodian example Good Health Clinic Generic participant/encounterParticipant - referring provider The referring provider may be designated in one of two manners, as an componentOf/EncompassingEncounter/encounterParticipant or as a generic Participant A Procedure Note may contain a componentOf/encompassingEncounter/encounterParticipant element who is the referring provider When an encompassingEncounter/encounterParticipant representing the referring provider is present, the encounterParticipant/@typeCode shall be REFERRER and an assignedEntity shall be present. A Procedure Note may contain a Participant who is the referring provider When a Participant representing the referring provider is present, the Participant/@typeCode shall be REF The Participant shall have an associatedEntity The Participant associatedEntity/@classCode shall be PROV The associatedEntity shall have an associatedPerson Generic participant - primary care provider The primary care provider for a patient undergoing a procedure may be different from the referring provider and may not be a participant in an encompassingEncounter. A Procedure Note may contain a Participant who is the primary care provider When a Participant representing the primary care provider is present, the Participant/@typeCode shall be IND The Participant shall have an associatedEntity and the associatedEntity/@classCode shall be PROV The associatedEntity shall have an associatedPerson Participant scenarios The following  REF _Ref245618310 \h  \* MERGEFORMAT Table 3: Participant Scenarios shows a number of scenarios and the values for various participants. Note that not all participants in the scenario table below are stated above in  REF _Ref245620068 \w \h  \* MERGEFORMAT 2.2  REF _Ref245620078 \h  \* MERGEFORMAT Header Participants if there are no additional constraints on the base standard regarding those participants. Table  SEQ Table \* ARABIC 3: Participant Scenarios Scenario AuthorCusto-dianData EntererEncom-passing Encounter/ Encounter ParticipantLegal Authen-ticator Parti-cipantService Event/ PerformerColonoscopy Participant Scenario: A surgeon refers a patient to an endoscopist. . A colonoscopy is performed at an outpatient surgery center. The Endoscopist inputs information into an EHR. The outpatient surgery center EHR generates a Procedure Note to send to the Hospital EHR.Endo-scopic CDA Procedure NoteEndo-scopistOut-patient Surgery CenterNoneSurgeon [REF (referrer)] Endo-scopistNoneEndoscopistScenario AuthorCusto-dianData EntererEncom-passing Encounter/ Encounter ParticipantLegal Authen-ticator Parti-cipantService Event/ PerformerOffice Removal of Wart Participation Scenario: A wart is removed during an office visit. The PCP dictates the procedure into their local transcription system. The transcription system generates a CDA Procedure Note to the EHR.CDA Procedure NotePCPPCP officeTranscrip-tionistNonePCPNonePCPScenario AuthorCusto-dianData EntererEncom-passing Encounter/ Encounter ParticipantLegal Authen-ticator Parti-cipantService Event/ PerformerDental Procedure Participation Scenario: Dentist extracts a tooth after the patient has a cleaning by the hygenist. He enters the information into his Dental EHR.Procedure input to EHRDentistDentist OfficeVariesNoneDentistNoneDentist HygenistScenario AuthorCusto-dianData EntererEncom-passing Encounter/ Encounter ParticipantLegal Authen-ticator Parti-cipantService Event/ PerformerTransjugular Intrahepatic Portosystemic Shunt (TIPS) procedure (Interventional Radiology) Participant Scenario: At a university hospital, a TIPS procedure is performed. The procedure is performed by the interventional radiology fellow, with the help of an interventional radiology nurse, under the supervision of an attending interventional radiologist. The radiology technician enters the data into the EMR. The patient was referred to the University hospital by his oncologist. The patient is insured by Cigna.Procedure Note is input in EHRInterven-tional Radiology FellowGood Health HospitalInterven-tional Radiology Technician REF (referrer) OncologistAttending Interven-tional Radiolo-gistCigna Interven-tional Radiology Fellow Nurse Attending Interven-tional RadiologistScenario AuthorCusto-dianData EntererEncom-passing Encounter/ Encounter ParticipantLegal Authen-ticator Parti-cipantService Event/ PerformerLumbar Puncture (spinal tap) procedure Participant Scenario: At a university hospital, a lumbar puncture is performed. The procedure is performed by a medical student, with the help of an intern, under the supervisory authority of an attending neurologist. The student performs the procedure and dictates the note. The note is signed by the intern and attending. The patient has a family doctor that is not participating in the procedure, did not refer the patient and does not have privledges at the providing organization but is recorded in the note. Procedure Note is dictated by the medical studentMedical studentGood Health HospitalTranscrip-tionistNeurology Attending (Intern is Authen-ticator)Family DoctorMedical student Intern Consent The CDA Header provides a construct for handling consents associated with a procedure and information about the patients consent may also be recorded in the CDA Body. The type of consent (e.g., a consent to perform the related ServiceEvent or a consent for the information contained in the document to be released to a third party) is conveyed in Consent.code. Consents referenced in the CDA Header have been finalized (Consent.statusCode must equal "Completed") and should be on file. A consent, if present, shall be represented as ClinicalDocument/authorization/consent. Figure  SEQ Figure \* ARABIC 11: Consent example ... Figure  SEQ Figure \* ARABIC 13: serviceEvent international example ... Performer The performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists and Family Practice Physicians. Performers may also be Non Physician Providers (NPP) who have other significant roles in the procedure such as a radiology technician, dental assistant or a nurse. The primary performers (PPRF) shall be identified. For all performers: ServiceEvent/performer/assignedEntity/code shall be present. The value of ServiceEvent/performer/assigned entity/code should be selected from Healthcare Provider Taxonomy Code (NUCC) (codeSystem 2.16.840.1.113883.11.19465) and may be from a localized assignedEntity coding system for a given country. Any assistants shall be identified and shall be identified as secondary performers (SPRF). Figure  SEQ Figure \* ARABIC 14: Performer example 1013 Healthcare Drive Ann Arbor MI 99999 USA Dr. Charlie Chopper Rendering Header Information for Human Presentation Metadata carried in the header may already be available for rendering from EHRs or other sources external to the document; therefore, there is no strict requirement to render directly from the document. An example of this would be a doctor using an EHR that already contains the patients name, date of birth, and current address and phone number. When a CDA document is rendered within that EHR, those pieces of information may not need to be displayed since they are already known and displayed within the EHRs user interface. In an Procedure Note, the following information is typically displayed in the EHR and/or rendered directly in the document: The performers of the procedure, including any assistants The procedure performed (ServiceEvent) The date of the procedure Best practice would recommend that the following also be present whenever a document is viewed: Document title and document date Service and encounter types, and dates and date ranges as appropriate All persons named along with their roles, participations, participation date ranges, identifiers, and address and telecommunications information Selected organizations named along with their roles, participations, participation date ranges, identifiers, and address and telecommunications information Date of birth for recordTarget(s) Body An Procedure Note shall have either a structuredBody or nonXMLBody element. The contents of this element includes the human-readable text of the document. This information shall be organized into sections and may have subsections. A nonXMLBody element may contain the actual CDA content or may reference it by URL. Section Descriptions This Implementation Guide defines required and optional sections. All section elements in the Body of the document shall have a code and some nonblank text or one or more subsections, even if the purpose of the text is only to indicate that information is unknown. LOINC codes should be used with the sections in an Procedure Note. Procedure Note sections are shown in Table 4. Other sections not listed in Table 4 may be present as well. The exact text of the section names are not mandated. All sections may occur in any order and may be nested under other sections according to local policy. Sections and subsections shall have a title and the title shall not be empty. Note that section titles are shown in all caps per HYPERLINK "http://www.astm.org/cgi-bin/SoftCart.exe/DATABASE.CART/REDLINE_PAGES/E2184.htm?L+memberstore+psnw2999"ASTMs Standard Specifications for Healthcare Document Formats (E2184.02). Table  SEQ Table \* ARABIC 4: LOINC Codes for Procedure Note Sections Section NameRequired/OptionalCodeLOINC Component NameMedical History O11329-0MEDICAL HISTORYOptional SubsectionsSee Appendix A List of Additional Medical History SubsectionsAdditional optional subsections. Physical Examination O29545-1PHYSICAL FINDINGSOptional Subsections10210-3GENERAL STATUS, PHYSICAL FINDINGS (Optional, must be subsection)8716-3VITAL SIGNSSee Appendix B List of Additional Physical Examination SubsectionsAdditional optional subsections. IndicationsR IND-XINDICATIONSPlanned ProcedureOPLNPROC-XPLANNED PROCEDUREProcedure DescriptionRPROCDES-XPROCEDURE DESCRIPTIONAnesthesiaOANES-XANESTHESIAMedications Administered O29549-3 MEDICATIONS ADMINISTEREDMedication HistoryO10160-0HISTORY OF MEDICATION USEEstimated Blood LossOEBL-XESTIMATED BLOOD LOSSSpecimens RemovedOSPECRE-XSPECIMENSImplants OIMPL-XIMPLANTS FindingsOFIND-XPROCEDURE FINDINGSPostprocedure DiagnosisRPOSTPR-XPOSTPROCEDURE DIAGNOSISComplicationsR19818-4COMPLICATIONSAssessment and PlanR51847-2ASSESSMENT AND PLAN51848-0ASSESSMENT18776-5PLANDispositionODISPO-XDISPOSTIONSurgical drainsO11537-8SURGICAL DRAINS Required Sections Required sections in a Procedure Note are determined by data that is mandated by regulatory agencies where such regulations are available. Each section must contain text that addresses the section title. If no content is available, this must be denoted in the appropriate section. Local practice must ensure that their legal authenticator is aware that the no content delineation must be included in the legally authenticated document. A Procedure Note shall include the sections listed as Required (R) in  REF _Ref202590722 \h Table 4: LOINC Codes for Procedure Note Sections. 3.2.1 Indications IND-X The Indications section records details about the reason for the procedure. This section may include the preprocedure diagnosis or diagnoses as well as one or more symptoms which contribute to the reason that the procedure is being performed. The Procedure Note shall contain exactly one and shall not contain more than one Indications section. The Indications section shall contain Section/code. The value for Section/code shall be IND-X (INDICATIONS) 2.16.840.1.113883.6.1 LOINC static. The Indications section shall include a section/text element either directly or contained within a (sub)section text element The Indications section shall include a templateId element where @root is 2.16.840.1.113883.10.20.18.2.1 The Indications section may contain clinical statements referring to the procedure related problems. If present, these clinical statements shall conform to CCD problem observation template (CCD templateId 2.16.840.1.113883.10.20.1.28). The Indications section may contain clinical statements regarding the reason for the procedure. If present, there shall be an entry relationship: RSON: This entry relationship shall adhere to CCD CONF 439: A procedure activity may contain one or more entryRelationship/@typeCode=RSON, the target of which represents the indication or reason for the procedure. The Indications section may contain clinical statements referring imaging observations. If present, these clinical statements shall conform to PHCR Imaging observation template (PHCR templateId 2.16.840.1.113883.10.20.15.3.5). Figure  SEQ Figure \* ARABIC 15: Indications section example
INDICATIONS The procedure is performed for screening in a low risk individual.
3.2.2 Procedure Description PROCDES-X The Procedure Description section records the particulars of the procedure with an extensive narrative and may include procedure site preparation, pertinent details related to measurements and markings, procedure times, instrumentation, and vital signs and other monitoring data. Complications and Anesthesia may be recorded as subsections of this section (3.2.4 Complications 19818-4 and 3.3.4 Anesthesia ANES-X) . Local practice often identifies the level and type of detail required based on the procedure or specialty. The Procedure Note shall contain exactly one and shall not contain more than one Procedure Description section The Procedure Description Section shall contain Section/code. The value for Section/code shall be PROCDES-X PROCEDURE DESCRIPTION 2.16.840.1.113883.6.1 LOINC static. The Procedure Description section shall include a section/text element either directly or contained within a (sub)section text element The Procedure Description section shall include a templateId element where @root is 2.16.840.1.113883.10.20.18.2.2 If the Medications Administered section is NOT present, there may be a statement in the Procedure Description section providing details of medications or fluids administered during the procedure or explicitly stating that there were no medications or fluids administered (3.3.5 Medications Administered section 29549-3). If the Estimated Blood Loss section is NOT present, there may be a statement in the Procedure Description section providing details of the estimated blood lost during the procedure or explicitly stating there was no blood loss (3.3.7 Estimated Blood Loss section EBL-X). If the Specimens Removed section is NOT present, there may be a statement in the Procedure Description section providing details of the specimens removed during the procedure or explicitly stating that there were no specimens removed (3.3.8. Specimens Removed section SPECRE-X). If the Implants section is NOT present, there may be a statement in the Procedure Description section providing details of implants such as stents, clips or drains left during the procedure or explicitly stating that there were no implants left (3.3.9 Implants section IMPL-X). The Procedure section may contain clinical statements about the procedure activity. If present, these clinical statements shall conform to CCD procedure activity (CCD procedure activity 2.16.840.1.113883.10.20.1.29) CCD product template (CCD product 2.16.840.1.113883.10.20.1.53) and CCD product instance template (CCD product instance 2.16.840.1.113883.10.20.1.52). The Procedure section may also contain clinical statements referring to the procedure related problems. If present, these clinical statements shall conform to CCD problem observation template (CCD templateId 2.16.840.1.113883.10.20.1.28). The Procedures section may contain clinical statements referring imaging observations. If present, these clinical statements shall conform to PHCR Imaging observation template (PHCR templateId 2.16.840.1.113883.10.20.15.3.5). Figure  SEQ Figure \* ARABIC 16: Procedure Description section example
Procedure Description The patient was taken to the endoscopy suite where .
3.2.3 Postprocedure Diagnosis POSTPR-X The Postprocedure Diagnosis section records the diagnosis or diagnoses discovered or confirmed during the procedure. Often it is the same as the preprocedure diagnosis or indication. The Procedure Note shall contain exactly one and shall not contain more than one Postprocedure Diagnosis section. The Postprocedure Diagnosis section shall contain Section/code. The value for Section/code shall be POSTPR-X POSTPROCEDURE DIAGNOSIS 2.16.840.1.113883.6.1 LOINC static. The Postprocedure Diagnosis section shall include a section/text element either directly or contained within a (sub)section text element The Postprocedure Diagnosis section shall include a templateId element where @root is 2.16.840.1.113883.10.20.18.2.3 The Postprocedure Diagnosis section may contain clinical statements. If present, the clinical statements shall conform to CCD problem observation template (CCD templateId 2.16.840.1.113883.10.20.1.28). The Postprocedure section may contain clinical statements referring imaging observations. If present, these clinical statements shall conform to PHCR Imaging observation template (PHCR templateId 2.16.840.1.113883.10.20.15.3.5). Figure  SEQ Figure \* ARABIC 17: Postprocedure Diagnosis section example
Postprocedure Diagnosis Polyps, biopsied
3.2.4 Complications 19818-4 The Complications section records problems that occurred during the procedure. The complications may have been known risks or unanticipated problems. The Complications section may be a subsection of another section such as the Procedure Description section. The Procedure Note SHALL contain exactly one and shall not contain more than one Complications section. The Complications section shall contain Section/code. The value for Section/code shall be 19818-4 COMPLICATIONS 2.16.840.1.113883.6.1 LOINC static. The Complications section shall include a section/text element either directly or contained within a (sub)section text element. The Complications section shall include a templateId element where @root is 2.16.840.1.113883.10.20.18.2.4. There shall be a statement providing details of the complication(s) or it shall explicitly state there were no complications. The Complications section may contain clinical statements. If present, the clinical statements shall conform to CCD problem observations template (CCD problem observation templateId 2.16.840.1.113883.10.20.1.28). The Complications section may contain clinical statements referring imaging observations. If present, these clinical statements shall conform to PHCR Imaging observation template (PHCR templateId 2.16.840.1.113883.10.20.15.3.5). Figure  SEQ Figure \* ARABIC 18: Complications section example
Complications None
3.2.6 Assessment and Plan 51847-2/51848-0/18776-5 A Procedure Note contains either discrete sections for Assessment and for Plan or a single section combining the two (Assessment and Plan). The assessment (also dictated impression or diagnoses) represents the clinicians conclusions and working assumptions that will guide treatment of the patient. The assessment is used to formulate a specific plan or set of recommendations. The assessment may be a list of specific disease entities or a narrative block. The Plan section contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current care of the patient should be listed unless constrained due to issues of privacy. The Plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders. Clinical reminders are placed here for the purpose of providing prompts that may be used for disease prevention and management, patient safety, and health care quality improvements, including widely accepted performance measures. The Plan section may also indicate that patient education was given or will be provided. The assessment and plan may be interleaved or dictated as separate sections to meet local policy requirements When the Assessment and Plan are recorded separately, there shall be a section whose value for Section / code shall be 51848-0 Assessment 2.16.840.1.113883.6.1 LOINC STATIC The template identifier for the Assessment section shall be 2.1.6.840.1.113883.10.20.2.7; and there shall be a section whose value for Section / code shall be 18776-5 Plan 2.16.840.1.113883.6.1 LOINC STATIC; The template identifier for the Plan section shall be 2.16.840.1.113883.10.20.2.7 and there shall not be a section whose value for Section / code is 51847-2 ASSESSMENT AND PLAN. . When the Assessment and Plan and are recorded together, the value for Section / code shall be 51847-2 Assessment and Plan 2.16.840.1.113883.6.1 LOINC STATIC; and there shall not be a section whose value for Section / code is 51848-0 Assessment; and there shall not be a section whose value for Section / code is 18776-5 Plan. The template identifier for the assessment and plan section shall be 2.16.840.1.113883.10.20.2.7 The Assessment and Plan section(s) section may contain clinical statements. If present, the clinical statements shall conform to CCD Plan of care activity (CCD plan of care activity 2.16.840.1.113883.10.20.1.25). Figure  SEQ Figure \* ARABIC 19: Assessment and plan example
ASSESSMENT AND PLAN Sigmoid diverticulosis, moderate. High fiber diet Internal hemorrhoids. Treat conservatively with Canasa suppositories Colon polyp, 6mm, ascending colon, removed by snare. Patient to call for results
Optional Sections An Procedure Note may contain additional sections that provide more information. 3.3.1 Medical History 11329-0 The Medical History section describes all aspects of the medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. The history may be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections including Past Medical History, Social History and any of the subsections listed in Appendix A List of Additional Medical History Subsections. A Procedure Note MAY contain exactly one Medical History section (templateId 2.16.840.1.113883.10.20.18.2.5). The section code for the section describing medical history shall be 11329-0 (MEDICAL HISTORY). If the Medications section is NOT present, there may be a statement in the Medical History section providing details of historical medications taken by the patient at the time ofbefore the procedure including medications in preparation for the procedure such as pre-procedure antibiotics, body system preps and modifications to anticoagulant use for the procedure (3.3.6 Medications History 10160-0). The Medical History section may contain clinical statements. If present, the clinical statements shall conform to CCD problem observations template (CCD problem observation templateId 2.16.840.1.113883.10.20.1.28) and CCD problem status observation template (CCD problem status observation 2.16.840.1.113883.10.20.1.50. and problem healthstatus observation template (CCD problem healthstatus observation 2.16.840.1.113883.10.20.1.51). The Medical History section may contain clinical statements referring imaging observations. If present, these clinical statements shall conform to PHCR Imaging observation template (PHCR templateId 2.16.840.1.113883.10.20.15.3.5). Figure 19: Medical History section example
Medical History The patient is a 55 year old Caucasian male with a history of non-insulin dependent diabetes.
Figure 20: Medical History section example woth subsections
Medical History History of Present Illness The patient is a 55 year old Caucasian male with no history of major medical or surgical problems.
3.3.2 Physical Examination 29545-1 The Physical Examination section includes direct observations made by the clinician. The examination may include the use of simple instruments and may also describe simple maneuvers performed directly on the patients body. This section only includes observations made by the examining clinician using inspection, palpation, auscultation, and percussion; it does not include laboratory or imaging findings. The exam may be limited to pertinent body systems based on the patients chief complaint or it may include a comprehensive examination. The examination may be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections, including Vital Signs, General Status, and any of the subsections listed in Appendix B List of Additional Physical Examination Subsections. Note that Vital Signs can be a top-level section or subsection of Physical Exam. A Procedure Note MAY contain exactly one Physical Examination section (templateId 2.16.840.1.113883.10.20.2.10). The section code for the section describing physical examination shall be 29545-1 (PHYSICAL FINDINGS). The physical findings included in this section describe direct observations made by the clinician divided by organ or body system and may be included under appropriate subsections to Physical Exam. Systems are typically listed cephalic to caudal (i.e., starting with the head) and may include all body systems or only those pertinent to the chief complaint. The head, eyes, ears, nose, throat, mouth, and teeth may be described separately or combined into a single subsection labeled HEENT. Other subsections may include Skin, Neck, Lymph Nodes, Thorax (Chest) and Lungs, Cardiovascular, Breasts, Abdomen, Pelvic, Genitourinary, Musculoskeletal, Extremities including Peripheral Vascular, and Neurologic. A detailed Mental Status Examination may be included when pertinent.  SEQ Figure \* ARABIC 20: Physical examination section
PHYSICAL EXAMINATION
VITAL SIGNS Heart Rate: 78, Respiratory Rate: 12, Temp (degF): 96.7, Oxygen Sat (%): 100. Non-invasive Blood Pressure: Systolic: 107, Diastolic: 51, Mean: 64.
GENERAL STATUS Alert and in good spirits, no acute distress.
HEENT All normal to examination.
HEART RRR, no murmur.
...
3.3.3 Planned Procedure PLNPROC-X The Planned Procedure section records the procedure(s) that the clinican thought would need to be done based on the preprocedure assessment. The section will contain the procedure or procedures the patient specifically consented to. It may be important to record the procedure(s) that were originally planned for, consented to, and perhaps pre-approved by the payor, particularly if different from the actual procedure(s) and procedure details, to provide evidence to various stakeholders that the providers are aware of the discrepancy and the justification can be found in the procedure details. The Procedure Note may contain exactly one and shall not contain more than one Planned Procedure section. The Planned Procedure section shall contain Section/code. The value for Section/code shall be PLNPROC-X PLANNED PROCEDURE 2.16.840.1.113883.6.1 LOINC static The Planned Procedure section shall include a section/text element either directly or contained within a (sub)section/component/section element(s). The Planned Procedure section shall include a templateId element where @root is 2.16.840.1.113883.10.20.18.2.6. The Planned procedure section may contain clinical statements. If present, the clinical statements shall conform to CCD procedure activity (CCD procedure activity 2.16.840.1.113883.10.20.1.29) CCD product template (CCD product 2.16.840.1.113883.10.20.1.53) and CCD product instance template (CCD product instance 2.16.840.1.113883.10.20.1.52). The Indications section may contain clinical statements referring imaging observations. If present, these clinical statements shall conform to PHCR Imaging observation template (PHCR templateId 2.16.840.1.113883.10.20.15.3.5). Figure 21: Planned Procedure section example
Planned Procedure Colonoscopy
3.3.4 Anesthesia ANES-X The Anesthesia section briefly records the type of anesthesia (e.g., general, conscious or local) and may state the actual agent(s) used. This may or may not be a subsection of the Procedure Description section. The full details of anesthesia are sometimes found in a separate Anesthesia Note. The Procedure Note may contain exactly one and shall not contain more than one Anesthesia section. The Anesthesia section shall contain Section/code. The value for Section/code shall be ANES-X ANESTHESIA 2.16.840.1.113883.6.1 LOINC static. The Anesthesia section shall include a section/text element either directly or contained within a (sub)section text element. The Anesthesia section shall include a templateId element where @root is 2.16.840.1.113883.10.20.18.2.7 The Anesthesia section may contain clinical statements. If present, the clinical statements shall conform to CCD procedure activities template (CCD templateID 2.16.840.1.113883.10.20.1.29) or CCD medication activities template (CCD templateID 2.16.840.1.113883.10.20.1.24). (Note: If there is no ID the ID can be nulled or a UUID generated.) Figure 22: Anesthesia section example
Anesthesia Conscious sedation with propofol 200 mg IV
3.3.5 Medications Administered 29549-3 The Medications Administered section defines medications and fluids administered during the procedure excluding anethestic medications. Medications administered for anesthesia should be documented as described in 3.3.4 Anesthesia section ANES-X. The Procedure Note may contain exactly one and shall not contain more than one Medications Administered section. The Medications Administered section shall contain Section/code. The value for Section/code shall be 29549-3 MEDIATIONS ADMINISTERED 2.16.840.1.113883.6.1 LOINC static. The Medications Administered section shall include a section/text element either directly or contained within a (sub)section text element. The Medications Administered section shall include a templateId element where @root is 2.16.840.1.113883.10.20.18.2.8. The Medications Administered section may contain clinical statements. If present, the clinical statements shall conform to CCD medication activities template (CCD templateID 2.16.840.1.113883.10.20.1.24). Figure 23: Medications Administered section example
Medications Administered Secretin 100 IU administered IV
Figure 24: Medications Administered section example with coded entry
Medication administered 2 mg glucagon IV
3.3.6 Medication History 10160-0 The Medications section defines a patients current medications and pertinent medication history. At a minimum, the currently active medications should be listed with an entire medication history as an option. This section should also include any medications administered prior to but in preparation for the procedure such as preprocedure antibiotics, modifications to anticoagulant regimens, and body system preps. All constraints in this section are from the CCD Medications section. See Appendix C Externally Defined Constraints for CCD conformance requirements. This section shall include the CCD template identifier for the medications section (2.16.840.1.113883.10.20.1.8). Figure 24 Medications example with Level3 coding
CURRENT MEDICATIONS Lisinopril 5 mg 1 tablet once a day Atenolol 25 mg 1 tablet once a day Furosemide 40 mg 4 tablets daily in divided doses Gabapentin 300 mg 1 tablet twice a day Simvastatin (Zocor) 10 mg 1 tablet once a day at bedtime The patient has just completed a 4 week course of Vanco and Rifampin for a MRSA UTI. I note that this patient has been on Prednisone for ? adrenal insufficiency in the past.
3.3.7 Estimated Blood Loss EBL-X Estimated blood loss should be recorded in a Procedure Note. The Estimated Blood Loss section may be a subsection of another section such as the Procedure Description section. The Estimated Blood Loss section records the approximate amount of blood that the patient lost during the procedure. It may be an accurate quantitative amount, e.g., 250 milliliters ,or may be descriptive, e.g., minimal or none.. The Procedure Note may contain exactly one and shall not contain more than one Estimated Blood Loss section. The Estimated Blood Loss section shall contain Section/code. The value for Section/code shall be EBL-X" ESTIMATED BLOOD LOSS 2.16.840.1.113883.6.1 LOINC static. The Estimated Blood Loss section shall include a section/text element either directly or contained within a (sub)section text element The Estimated Blood Loss section shall include a templateId element where @root is 2.16.840.1.113883.10.20.18.2.9 Figure 25: Estimated Blood Loss section example
Estimated Blood Loss Minimal
Estimated blood loss entry The estimated blood loss section may contain an entry representing the quantity of blood lost. This template is nearly identical to the Health Care Associated Infection (HAI) template which represents Estimated Maternal Blood Loss (templateId 2.16.840.1.113883.10.20.5.2.2.7.12)except using a more general SNOMED code. An Estimated Blood Loss Observation may be present. An Estimated Blood Loss Observation shall be represented with an observation element where the value of @classCode is OBS and the value of @moodCode is EVN. A templateId element shall be present where the value of @root is 2.16.840.1.113883.10.20.18.3.1. A code element shall be present where the value of @code is 409084000 Estimated blood loss 2.16.840.1.113883.6.96 SNOMED CT STATIC. A value element shall be present where the value of value/@xsi:type is PQ (Physical Quantity). The value of value/@value shall be a non-negative integer representing the estimated blood loss in terms of the units specified in @unit Figure  SEQ Figure \* ARABIC 21:Estimated blood loss observation example observation classCode="OBS" moodCode="EVN"> 3.3.8 Specimens Removed SPECRE-X The Specimens Removed section records the tissues, objects, or samples taken from the patient during the procedure including biopsies, aspiration fluid or other samples sent for pathological analysis. The narrative may include a description of the specimens. The Procedure Note may contain exactly one and shall not contain more than one Specimens Removed section. The Specimens Removed Section shall contain Section/code. The value for Section/code shall be SPECRE-X (SPECIMENS REMOVED) 2.16.840.1.113883.6.1 LOINC static. The Specimens Removed section shall include a section/text element either directly or contained within a (sub)section text element. The Specimens Removed section shall include a templateId element where @root is 2.16.840.1.113883.10.20.18.2.10. Specimens Removed section shall list all specimens removed or shall explicitly state that no specimens were removed. The Specimens removed section may contain clinical statements. If present, the clinical statements shall conform to CCD procedure activity (CCD procedure activity 2.16.840.1.113883.10.20.1.29) Specimens Removed section clinical statements may contain one or more specimen participant entries to reflect specimens that were obtained as part of the procedure. Each specimen should contain one specimen/specimenRole/id. Figure 26: Specimens Removed section with entry example
Specimens Removed Ascending colon polyp  
3.3.9 Implants IMPL-X The Implants section may be used to record any materials placed during the procedure including stents, tubes and drains. The Procedure Note may contain exactly one and shall not contain more than one Implants section. The Implants section shall contain Section/code. The value for Section/code shall be IMPL-X "IMPLANTS" 2.16.840.1.113883.6.1 LOINC static. The Implants section shall include a section/text element either directly or contained within a (sub)section text element. The Implants section shall include a templateId element where @root is 2.16.840.1.113883.10.20.18.2.11. The Implants section may contain clinical statements. If present, the clinical statements shall include one or more supply activities (CCD templateId 2.16.840.1.113883.10.20.1.34), may include product instance (CCD templateId 2.16.840.1.113883.10.20.1.52) and may include one or more medication activities (CCD templateId 2.16.840.1.113883.10.20.1.24). Figure 27: Implants section example
Implants No implants were placed.
3.3.10 Findings FIND-X The Findings section records clinically significant observations confirmed or discovered during the procedure. Often this section is a subsection of the Procedure Description section. This section is not for diagnostic findings that may be found in a History and Physical Note, as the results of observations generated by laboratories, imaging procedures, and other procedures would not yet be available. The Procedure Note may contain exactly one and shall not contain more than one Findings Section. The Procedure Note Findings Section shall contain Section/code. The value for Section/code shall be FIND-X "FINDINGS 2.16.840.1.113883.6.1 LOINC static. The Findings section shall include a section/text element either directly or contained within a (sub)section text element The Findings section shall include a templateId element where @root is 2.16.840.1.113883.10.20.18.2.X. The Findings section may contain clinical statements. If present, the clinical statements shall conform to CCD problem observation template (CCD templateId 2.16.840.1.113883.10.20.1.28). Figure 28: Findings section example
Procedure Note Findings A 9 mm sessile polyp was found in the ascending colon and removed by snare, no cautery. Bleeding was controlled.
3.3.11 Disposition DISPO-X  The Disposition section records the status and condition of the patient at the completion of the procedure. It often also states where the patent was transferred to for the next level of care. The Disposition section may be a subsection of another section such as Procedure Description. Following are some examples of typical disposition narratives: The patient was taken to the Post Anesthesia Care Unit (PACU) in stable condition and then discharged home. The patient was returned to the Intensive Care Unit (ICU) in stable condition. The patient was discharged home on completion of the procedure. The Procedure Note may contain exactly one and shall not contain more than one Disposition section. The Disposition section shall contain Section/code. The value for Section/code shall be DISPO-X DISPOSITION 2.16.840.1.113883.6.1 LOINC static. The Disposition section shall include a section/text element either directly or contained within a (sub)section text element. The Disposition section shall include a templateId element where @root is 2.16.840.1.113883.10.20.18.2.12. Figure 29: Disposition section example
Disposition The patient was taken to the Endoscopy Recovery Unit in stable condition.
References HYPERLINK "http://www.astm.org/cgi-bin/SoftCart.exe/DATABASE.CART/REDLINE_PAGES/E2184.htm?L+memberstore+psnw2999"ASTMs Standard Specifications for Healthcare Document Formats (E2184.02) (Headings and subheadings used in the health care industry and associated with specific report types)  HYPERLINK "http://www.regenstrief.org/loinc" LOINC: Logical Observation Identifiers Names and Codes, Regenstrief Institute  HYPERLINK "http://hl7.org/library/committees/ca/11-15-06%20CDAR1AIS0000R021_ImplementationGuide.doc" CDAR2AIS0000R021: HL7 Additional Information Specification Implementation Guide [HL7 Attachments Special Interest Group (ASIG)]  HYPERLINK "http://hl7.org/library/committees/ca/CDAR1AIS0004R021_ClinicalReports%2010-16-06.doc" CDAR2AIS0004R030: Additional Information Specification 0004, Clinical Reports Attachment HYPERLINK "http://www.hl7.org/documentcenter/ballots/2007MAY/downloads/ASIG_INFOSPECS_CDAR2_I2_2007MAY.zip"HL7 ASIG CDA R2 Attachment for Clinical Notes HYPERLINK "http://www.hl7.org/v3ballot/html/infrastructure/cda/cda.htm"CDA: Clinical Document Architecture Release 2: Clinical Document Architecture (CDA) Release 2, May 2005  HYPERLINK "http://www.ihe.net/Technical_Framework/upload/IHE_PCC_TF_Final_20060812.pdf" IHE XDS-MS: IHE Patient Care Coordination, Technical Framework, Volumes 1, 2, 3 and 10, Revision 3.0, 2007-2008 HL7 Implementation Guide for CDA Release 2: History and Physical (H&P) Notes, DSTU Release 1 CDAR2_HPRPT_R1_D2_2007SEP approved as DSTU - Published July 2008. DSTU period: begin Aug 20, 2008, end Aug 20, 2010. HL7 Implementation Guide for CDA Release 2: Consultation Notes  HYPERLINK "http://www.hl7.org/documentcenter/ballots/2007JAN/downloads/CDAR2_IMPL_CCD_I2_2007JAN.zip" CCD: Continuity of Care Document (CCD) ASTM/HL7  HYPERLINK "http://www.jointcommission.org/AccreditationPrograms/Office-BasedSurgery/Standards/FAQs/Management+of+Info/Patient+Specific+Info/Operative_Reports.htm" Joint Commission Operative Note Requirements: Standard IM.6.30, Elements of Performance for IM.6.30 Acronyms and abbreviations ADL Activity of Daily Living AHDI Association for Healthcare Documentation Integrity AHIMA American Health Information Management Association CCD Continuity of Care Document CDA Clinical Document Architecture CRS Care Record Summary DSTU Draft Standard for Trial Use EHR Electronic health record EMR Electronic medical record HL7 Health Level Seven IHE Integrating the Healthcare Enterprise MTIA Medical Transcription Industry Association PCC Patient Care Coordination PHR Personal Health Record RIM Reference Information Model SDO Standards Development Organization SDWG Structured Documents Work Group XML Extensible Markup Language Vocabulary Introduction This appendix describes the vocabulary used for Procedure Note document codes. Vocabulary Table  SEQ Table \* ARABIC 5: Procedure Note LOINC Document Codes Value Set: ProcedureNote 2.16.840.1.113883.11.20.X.X Code System: LOINC 2.16.840.1.113883.6.1LOINC CodeType of Service ComponentSetting SystemSpecialty/Training/Professional Level Method_Type Template IDs in this Guide Table  SEQ Table \* ARABIC 6: Template IDs in This Guide Template ID defined in this guideDescription2.16.840.1.113883.10.20.18.1Procedure Note Clinical Document2.16.840.1.113883.10.20.18.2.1Indications Section2.16.840.1.113883.10.20.18.2.2Procedure (Description) Section2.16.840.1.113883.10.20.18.2.3Postprocedure Diagnosis Section2.16.840.1.113883.10.20.18.2.4Complications Section2.16.840.1.113883.10.20.18.2.5Medical History SectionPhysical Findings (Examination) SectionProcedure FindingsSection2.16.840.1.113883.10.20.18.2.6Planned Procedure SectionCCD Template IDDescription2.16.840.1.113883.10.20.1.28Problem Observation2.16.840.1.113883.10.20.1.29Procedure Activities2.16.840.1.113883.10.20.1.24Medication Activities 2.16.840.1.113883.10.20.1.34Supply Activities2.16.840.1.113883.10.20.1.52Product InstanceH&P Template IDDescription2.16.840.1.113883.10.20.2.7Assessment/Plan or Assessment and PlanIHE Template IDDescription1.3.6.1.4.1.19376.1.5.3.1.3.4History of Present Illness Section Appendix X - List of Additional medical HIstory Subsections Below is the list of additional optional subsections that may be used under the Medical History section. 29762-2SOCIAL HISTORY10157-6FAMILY HISTORY10187-3REVIEW OF SYSTEMS10154-3CHIEF COMPLAINT10164-2HISTORY OF PRESENT ILLNESS11348-0PAST MEDICAL HISTORY10167-5PAST SURGICAL HISTORY47519-4PROCEDURE HISTORY48765-2ALLERGIES Appendix B - List of Additional Physical Examination Subsections Below is the list of additional optional subsections that may be used under the Physical Examination section. Most of the codes for these subsections are included in the HL7 document entitled  HYPERLINK "http://hl7.org/library/committees/ca/CDAR1AIS0004R021_ClinicalReports%2010-16-06.doc" CDAR2AIS0004R030, Additional Information Specification 0004: Clinical Reports Attachment, which also lists  HYPERLINK \l "_General_Status_" General Status (10210-3) and  HYPERLINK \l "_Vital_Signs_8716-3" Vital Signs (8716-3), defined in the body of this Guide. 10190-7MENTAL STATUS 11451-2PSYCHIATRIC FINDINGS 10199-8HEAD, PHYSICAL FINDINGS 10197-2EYE, PHYSICAL FINDINGS 10195-6EAR, PHYSICAL FINDINGS 10203-8NOSE, PHYSICAL FINDINGS 11393-6EARS & NOSE & MOUTH & THROAT, PHYSICAL FINDINGS10201-2MOUTH & THROAT & TEETH, PHYSICAL FINDINGS51850-6HEAD & EARS & EYES & NOSE & THROAT, PHYSICAL FINDINGS11411-6NECK, PHYSICAL FINDINGS 10207-9THORAX & LUNGS, PHYSICAL FINDINGS 11391-0CHEST, PHYSICAL FINDINGS 11392-8CHEST WALL, PHYSICAL FINDINGS 10200-4HEART, PHYSICAL FINDINGS 10193-1BREASTS, PHYSICAL FINDINGS 10192-3BACK, PHYSICAL FINDINGS 10191-5ABDOMEN, PHYSICAL FINDINGS 10204-6PELVIS, PHYSICAL FINDINGS 11403-3GROIN, PHYSICAL FINDINGS 10198-0GENITOURINARY TRACT, PHYSICAL FINDINGS11400-9GENITALIA, PHYSICAL FINDINGS 11401-7GENITALIA FEMALE, PHYSICAL FINDINGS 11402-5GENITALIA MALE, PHYSICAL FINDINGS 11388-6BUTTOCKS, PHYSICAL FINDINGS 10205-3RECTUM, PHYSICAL FINDINGS 10196-4EXTREMITIES, PHYSICAL FINDINGS 11413-2SHOULDER, PHYSICAL FINDINGS 11387-8AXILLA, PHYSICAL FINDINGS 11386-0UPPER ARM, PHYSICAL FINDINGS 11394-4ELBOW, PHYSICAL FINDINGS 11398-5FOREARM, PHYSICAL FINDINGS 11415-7WRIST, PHYSICAL FINDINGS 11404-1HAND, PHYSICAL FINDINGS 11406-6HIP, PHYSICAL FINDINGS 11414-0THIGH, PHYSICAL FINDINGS 11407-4KNEE, PHYSICAL FINDINGS 11389-4CALF, PHYSICAL FINDINGS 11385-2ANKLE, PHYSICAL FINDINGS 11397-7FOOT, PHYSICAL FINDINGS 10209-5BALANCE+COORDINATION, PHYSICAL FINDINGS10212-9STRENGTH PHYSICAL FINDINGS 10211-1SENSATION, PHYSICAL FINDINGS 10206-1SKIN, PHYSICAL FINDINGS 10194-9DEEP TENDON REFLEXES, PHYSICAL FINDINGS10208-7VESSELS, PHYSICAL FINDINGS 11384-5PHYSICAL EXAMINATION BY ORGAN SYSTEMS11447-0HEMATOLOGIC+LYMPHATIC+IMMUNOLOGIC PHYSICAL FINDINGS11390-2CARDIOVASCULAR SYSTEM, PHYSICAL FINDINGS11399-3GASTROINTESTINAL SYSTEM, PHYSICAL FINDINGS10202-0NEUROLOGIC SYSTEM, PHYSICAL FINDINGS 11410-8MUSCULOSKELETAL SYSTEM, PHYSICAL FINDINGS appendix c - Externally Defined Constraints  HYPERLINK "http://www.jointcommission.org/AccreditationPrograms/Office-BasedSurgery/Standards/FAQs/Management+of+Info/Patient+Specific+Info/Operative_Reports.htm"http://www.jointcommission.org/AccreditationPrograms/Office-BasedSurgery/Standards/FAQs/Management+of+Info/Patient+Specific+Info/Operative_Reports.htm HYPERLINK "http://www.jointcommission.org/NR/rdonlyres/A032623D-02AF-4955-AF7C-08F3D5802E64/0/06_obs_im.pdf"http://www.jointcommission.org/NR/rdonlyres/A032623D-02AF-4955-AF7C-08F3D5802E64/0/06_obs_im.pdf.  GOM:  HYPERLINK "http://www.hl7.org/documentcenter/public/membership/HL7_Governance_and_Operations_Manual.pdf" http://www.hl7.org/documentcenter/public/membership/HL7_Governance_and_Operations_Manual.pdf     HL7 Implementation Guide for CDA R2 Procedure Note (International Realm) Page  PAGE 5 Release 1 Levels 1 & 2 Ballot January, 2010 2010 Health Level Seven, Inc. All rights reserved. Susan this whole page has a mind of its own can you fix this and above Brett I see this is in H&P but what does it mean??? Judy I added these as you had in your email we can remove if the group decides it is redundant over base CDA but I think it provides some nice direction I will ask Bob D too. Tom/Judy please verify the following typical elements I have highlighted in this table all sections that do not mention clinical statements. My thought is that the ones that could use clinical statements are EBL, Specimens and possibly Findings. Its my opinion that this code should be used for for this section and 29545-1 be used for (procedure) findings However I see this is the code that was used in consult note for general physical exam. (Note: this will be discussed on SDWG Thursday dec 3rd ) Why must this be a subsection? (see conf-PN-45) LEGIT request: 55104-4 Is specific to Op Note: Surgical operation note planned procedure No other appropriate code found May not be a LEGIT request: :A plain Description LOINC code should be requested Procedure Description with system ^patient (there is a current code with system endoscopy study LETS CONSIDER: LOINC does have a nar code (means appropriate for section code and will contain narrative text) 29554-3 Procedure we will just describe it contains the procedure desc LEGIT request: 10213-7 is too specific to OP Note Surgical operation note anesthesia No other appropriate code found JUDY/TOM: I note in the m*modal analysis the term anesthesia is used more commonly than the term sedation but what is in actual practice in your experience? LEGIT request 55103-6 is too specific to OP Note Surgical operation note estimated blood loss No other appropriate code found LEGIT request: 10221-0 is too specific to OP Note Surgical operation note specimens taken No other appropriate code found LEGIT request: 55122-6 is too specific to OP Note Surgical operation note implants No other appropriate code found The proc note work group contends a new LOINC code is needed here. Its my opinion that 29545-1 be used for (procedure) findings (Note: this will be discussed on SDWG Thursday dec 3rd ) LEGIT request: 10218-6 is too specific to OP Note Surgical operation note postoperative Dx No other appropriate code found LEGIT request: 55102-8 is too specific to OP Note Surgical operation note disposition - No other appropriate code found We might consider stating the specific aganecies (joint commission/CMS) I add this one I add this one Susan, figure 14 and 15 are bolded in the tables of figures I dont know why Susan can you put links in Susan., I dont know why these CONF numbers are italisized can you fix? I added this one I add this one I add this one I add this one I add this one I believe I recall that having the same template ID was intention al though not sure I agree with this shall we bring this up on SDWG? I added this one I added this one I add this one I added this one I add this one What is this? JL GGI removed I was asked to follow the pattern in the Discharge Summary, but that references IHE, so I have left as is. Not sure we need this long example There is a template from HAI we can ALMOST use its estimated maternal blood loss I think it will it be OK- we must run it by SDWG I know that we have made occasional exception to no new entries Not sure that we need to mention this I added this one Please align with sample file if you have the desired code/codesystem from ICD you may use If the old code is present in the sample file please change I dont believe there are any pre-existing templates for this section Do we need this? Brett/Susan Not sure if we need this- seems redundant May be reduntant Will need to get valueset root oid Susan I dont know why there is a large space before I cant get rid of it Leaving these out the tids for now till we figure out these two sections if we go with the code in the IG and the conf st that aligns with consult note and we will use that tid Leaving these out for now till we figure out these two sections Susan will pull in the references templates  !"$KL 1 2 3 E F G H j k xq h:hhqMh0J7j1hqMhUjhqMhU hqMh h(hM h hh h6hM h+hM hOmhM h'hM h" _hM jhKhM UmHnHu hyqhM h^hM hM h hM & "#[mnoyG ($Ifgd\gdM >gdM CgdM G H [ 4 XOkd$$Ifl0 " 44 lal ($Ifgd\Okd$$Ifl0 " 44 lal ! 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