Specification - Extended

HL7 CDA® R2 Implementation Guide: Quality Reporting Document Architecture I (QRDA I) Release 1, STU Release 5.2 - US Realm

Document Description

extended per TSC approval Jira TSC-68, errata by CTO

Existing Wording

The Encounter Performed (V5) template description on pg. 154 did not get updated to reflect that Diagnoses QDM attribute must now be represented using the Encounter Diagnosis QDM template because of QDM 5.5 updates.

Proposed Wording

Delete the outdated description "Diagnosis is a coded diagnosis/problem addressed during the encounter. Diagnosis attribute is intended to capture ALL diagnoses, including principal diagnosis. This is represented through entryRelationship to Encounter Diagnosis template as specified in the Encounter Activity (V3) parent template." New description: "Coded diagnoses/problems addressed during the encounter. The diagnoses attribute has three components: Diagnosis (code), PresentOnAdmissionIndicator (code), and Rank (positive integer). This is represented through entryRelationship to Encounter Diagnosis QDM template." Add conformance statement to constrain out using the Encounter Diagnosis from the parent Encounter Activity (V3) to make it clear.