DECOR Information for Project: Trifolia conversion (ccda-)

Scenarios

  2012‑06‑15

Name Id
1.2.3
doublearrow Transaction group id: 1.2.99.99.4.0
Name Consolidated CDA documents
Content
rotate Transaction id: 1.2.99.99.4.1
Name Consultation Note
Actor - Sender (person)
Name CDA creator
Representing template
Template id 2.16.840.1.113883.10.20.22.1.4For 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, registered dietitians, 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 American Medical Association (AMA) guidelines.
rotate Transaction id: 1.2.99.99.4.2
Name ContinuityofCareDocumentCCD
Actor - Sender (person)
Name CDA creator
Representing template
Template id 2.16.840.1.113883.10.20.22.1.2This section—Continuity of Care Document (CCD) Release 1.1—describes CDA constraints in accordance with Stage 1 Meaningful Use. The CCD requirements in this guide supersede CCD Release 1; in the near future, this guide could supersede HITSP C32. The CCD is a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care. The primary use case for the CCD is to provide a snapshot in time containing the pertinent clinical, demographic, and administrative data for a specific patient . More specific use cases, such as a Discharge Summary or Progress Note, are available as alternative documents in this guide.
rotate Transaction id: 1.2.99.99.4.3
Name ProgressNote
Actor - Sender (person)
Name CDA creator
Representing template
Template id 2.16.840.1.113883.10.20.22.1.9A Progress Note documents a patient’s clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter. Taber’s medical dictionary defines a Progress Note as “An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note.” Mosby’s medical dictionary defines a Progress Note as “Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned.” A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833(e) defines the requirements of a Medicare Progress Report.
rotate Transaction id: 1.2.99.99.4.4
Name ProcedureNote
Actor - Sender (person)
Name CDA creator
Representing template
Template id 2.16.840.1.113883.10.20.22.1.6Procedure Note is a broad term that encompasses many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are documents that are differentiated from Operative Notes in that the procedures documented do not involve incision or excision as the primary act. The Procedure Note 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, and the patient’s tolerance of the procedure. The document should be sufficiently detailed to justify the procedure, describe the course of the procedure, and provide continuity of care.
rotate Transaction id: 1.2.99.99.4.5
Name OperativeNote
Actor - Sender (person)
Name CDA creator
Representing template
Template id 2.16.840.1.113883.10.20.22.1.7The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies. The Operative Note or Report is created immediately following a surgical or other high-risk procedure and records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.
rotate Transaction id: 1.2.99.99.4.6
Name HistoryandPhysical
Actor - Sender (person)
Name CDA creator
Representing template
Template id 2.16.840.1.113883.10.20.22.1.3A History and Physical (H&P) Note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status. The first portion of the report is a current collection of organized information unique to an individual, typically supplied by the patient or their caregiver, about the current medical problem or the reason for the patient encounter. This information is followed by a description of any past or ongoing medical issues, including current medications and allergies. Information is also obtained about the patient's lifestyle, habits, and diseases among family members. The next portion of the report contains information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures. The report ends with the clinician's assessment of the patient's situation and the intended plan to address those issues. A History and Physical Examination is required upon hospital admission as well as before operative procedures. An initial evaluation in an ambulatory setting is often documented in the form of an H&P Note.
rotate Transaction id: 1.2.99.99.4.7
Name DischargeSummary
Actor - Sender (person)
Name CDA creator
Representing template
Template id 2.16.840.1.113883.10.20.22.1.8The Discharge Summary is a document that is a synopsis of a patient's admission to a hospital; it provides pertinent information for the continuation of care following discharge. The Joint Commission requires the following information to be included in the Discharge Summary: • The reason for hospitalization • The procedures performed • The care, treatment, and services provided • The patient’s condition and disposition at discharge • Information provided to the patient and family • Provisions for follow-up care
rotate Transaction id: 1.2.99.99.4.8
Name DiagnosticImagingReport
Actor - Sender (person)
Name CDA creator
Representing template
Template id 2.16.840.1.113883.10.20.22.1.5A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialist’s interpretation of image data. It conveys the interpretation to the referring (ordering) physician and becomes part of the patient’s medical record. It is for use in Radiology, Endoscopy, Cardiology, and other imaging specialties.

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