Specification - Extended

HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes DSTU Release 2.1 - US Realm

Document Description

extended per extended per TSC tracker 12437, again with 14128 and jira.hl7.org/browse/TSC-38

Existing Wording

Health Status Evaluations and Outcomes Section [section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.61 (open)] The purpose statement for the Health Status Evaluation and Outcomes Section needs to be clarified to provide clearer guidance to implementers about the types of information intended to be included in this section. Existing Wording says: This template represents observations regarding the outcome of care from the interventions used to treat the patient. These observations represent status, at points in time, related to established care plan goals and/or interventions.

Proposed Wording

Proposed description: This template represents observations regarding the evaluation or assessment of the patient, and the outcome of care from the interventions used to treat the patient. These observations represent status information, at points in time, related to established, as well as the establishment of, care plan goals and/or interventions. Justification: The current definition is limited to the “outcomes” part of Health Status Evaluations and Outcomes, and does not address the “evaluations” part which are critical for documents such as Care Plans. Care Plans typically include assessment (evaluation) information, which may or may not be tied to the interventions themselves and may include the evidence to support the assessed outcome of progress toward goals. In Long Term Services and Supports (LTSS) service plans, CMS requires that information be captured regarding whether the person chose where they reside and whether they participated in the development of the plan. A person may also indicate preferences, for example that they prefer a female caregiver. Information such as this also may be included as “health status evaluations”.