Specification - Extended

HL7 CDA® R2 Implementation Guide: Public Health Case Report, Release 2: the Electronic Initial Case Report (eICR), Release 1, STU Release 1.1 - US Realm

Document Description

extended per TSC Tracker 12574, extension TSC GF 15952, JIRA TSC-29, TSC-123

Existing Wording

The manual trigger template (2.16.840.1.113883.10.20.15.2.3.5) is defined (3.12.1) as being contained within an Encounter Activity (3.2) and conforming to the Problem Observation template (2.16.840.1.113883.10.20.22.4.4:2015-08-01). The Encounter Activity (3.2) is not listed as normally including Problem Observations. Instead, it includes Encounter Diagnoses (2.16.840.1.113883.10.20.22.4.80:2015-08-01) and those encounter diagnoses include Problem Observation templates. It would be appropriate to clarify which structure is desired in the document * Inclusion of the manual template within the encounter activity(section/entry/encounter/entryRelationship/observation) * Inclusion of the manual template within the encounter diagnosis (section/entry/encounter/entryRelationship/act/entryRelationship/observation)

Proposed Wording

Update the table for the Encounter Diagnosis (2.16.840.1.113883.10.20.22.4.80:2015-08-01) to indicate that it may include the Manual Trigger Template. Update the Manual Initiation Reason Observation Contexts table to indicate that it is included by the Encounter Diagnosis template, not by the Encounter Activity template.