Details
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Change Request
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Resolution: Not Persuasive
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Medium
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C-CDA Templates Clinical Notes (CDA)
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2.1.0.6 [deprecated]
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Structured Documents
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Templates [deprecated]
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3.82
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Jean Duteau / Brett Marquard : 15-0-0
Description
The specification is ambiguous as to how to model provider acts for patient chart review which don't directly alter the patient's physical state. In particular I am interested in CPT Category II code 1111F (Discharge medications reconciled with the current medication list in outpatient medical record). This code is used in the NCQA HEDIS quality measure Transitions of Care (TRC). I think the best fit would be the Procedure Activity Observation (V2) template. However the only examples it lists are: "diagnostic imaging procedures, EEGs, and EKGs".
I recommend that we update the examples to explicitly include chart review procedures. And note that the value element @nullFlavor attribute should generally be set in that case as chart reviews generally don't result in a distinct "value" as such.
Note that this would be consistent with the Da Vinci Project DEQM use case where the FHIR Observation resource is used for code 1111F.