Details
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Change Request
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Resolution: Persuasive
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Highest
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C-CDA Templates Clinical Notes (CDA)
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2.1.0 [deprecated]
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Structured Documents
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Narrative Guidance [deprecated]
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Brett Marquard / Gay Dolin: 18-0-0
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Correction
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Non-substantive
Description
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 WordingCare Plan (V2) [ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.1.15:2015-08-01 (open)] The CDA Care Plan represents an instance of this dynamic Care Plan at a point in time. The CDA document itself is NOT dynamic. Key differentiators between a Care Plan CDA and CCD (another “snapshot in time” document): There are 2 required sections: o Health Concerns o Interventions There are 2 optional sections: o Goals o Outcomes • Provides the ability to identify patient and provider priorities with each act • Provides a header participant to indicate occurrences of Care Plan review A care plan document can include entry references from the information in these sections to the information (entries) in other sections. Please see Volume 1 of this guide to view a Care Plan Relationship diagram and story board.
Proposed WordingThere are 2 required sections: o Health Concerns o Goals There are 2 optional sections: o Interventions o Health Status Evaluations and Outcomes
Existing WordingCare Plan (V2) [ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.1.15:2015-08-01 (open)] The CDA Care Plan represents an instance of this dynamic Care Plan at a point in time. The CDA document itself is NOT dynamic. Key differentiators between a Care Plan CDA and CCD (another “snapshot in time” document): There are 2 required sections: o Health Concerns o Interventions There are 2 optional sections: o Goals o Outcomes • Provides the ability to identify patient and provider priorities with each act • Provides a header participant to indicate occurrences of Care Plan review A care plan document can include entry references from the information in these sections to the information (entries) in other sections. Please see Volume 1 of this guide to view a Care Plan Relationship diagram and story board.
Proposed WordingThere are 2 required sections: o Health Concerns o Goals There are 2 optional sections: o Interventions o Health Status Evaluations and Outcomes
Attachments
Issue Links
- relates to
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CDA-20949 Care Plan Interventions (Activities) section requirement
- Applied