Details
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Change Request
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Resolution: Persuasive
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Medium
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C-CDA Templates Clinical Notes (CDA)
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3.0.0-ballot
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Structured Documents
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Artifacts Summary
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Jean Duteau / Brett Marquard : 22-0-0
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Correction
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Non-substantive
Description
We have a handful of LOINC codes in C-CDA where the displayNames we list don't match VSAC. We should probably align the two...
| Code | C-CDA displayName | VSAC displayName |
|---|---|---|
| 42348-3 | Advance Directives | Advance directives |
| 51847-2 | Assessment and Plan | Evaluation + Plan note |
| 51848-0 | Assessments | Evaluation note |
| 55109-3 | Complications | Complications Document |
| 34133-9 | Summarization of Episode Note | Summary of episode note |
| 47420-5 | Functional Status | Functional status assessment note |
| 10210-3 | General Status | Physical findings of General status Narrative |
| 8653-8 | Hospital Discharge Instructions | Hospital Discharge instructions |
| 11329-0 | Medical (General History) | History general Narrative - Reported |
| 10190-7 | Mental Status | Mental status Narrative |
| 8716-3 | Vital Signs | Vital signs |
Likewise, the C-CDA IG has these LOINC codes which aren't in VSAC at all (because they're just one-off codes we prescribe rather than them being in any C-CDA value sets), but their displayNames don't match the ones returned by the LOINC API.
| Code | C-CDA displayName | LOINC displayName |
|---|---|---|
| 62387-6 | Interventions Provided | Interventions Narrative |
| 46241-6 | Hospital Admission diagnosis | Hospital admission diagnosis Narrative - Reported |
| 42346-7 | Medications on Admission | Medications on admission (narrative) |
| 45473-6 | Advance directive - living will | Advance directive/living will completed |
| 48765-2 | Allergies, adverse reactions, alerts | Allergies and adverse reactions Document |
| 33999-4 | Status | Diagnosis status |
| 59774-0 | Anesthesia | Procedure anesthesia Narrative |
| 86188-0 | History of Occupation Industry | History of Occupation industry |
| 76689-9 | Sex Assigned At Birth | Sex assigned at birth |
| 95541-9 | Care Experience Preference | Care experience preference |
| 46239-0 | Chief Complaint and Reason for Visit | Chief complaint+Reason for visit Narrative |
| 10154-3 | Chief Complaint | Chief complaint Narrative - Reported |
| 8648-8 | Hospital Course | Hospital course Narrative |
| 11535-2 | Hospital Discharge Diagnosis | Hospital discharge Dx Narrative |
| 10183-2 | Hospital Discharge Medications | Hospital discharge medications Narrative |
| 46240-8 | Encounters | History of Hospitalizations+Outpatient visits Narrative |
| 10157-6 | Family History | History of family member diseases Narrative |
| 61146-7 | Goals | Goals Narrative |
| 75310-3 | Health concerns document | Health concerns Document |
| 11383-7 | Patient Problem Outcome | Patient problem outcome Narrative |
| 10164-2 | History of Present Illness | History of Present illness Narrative |
| 18841-7 | Hospital Consultations Section | Hospital consultations Document |
| 10184-0 | Hospital Discharge Physical | Hospital discharge physical findings Narrative |
| 11493-4 | Hospital Discharge Studies Summary | Hospital discharge studies summary Narrative |
| 11369-6 | Immunizations | History of Immunization Narrative |
| 46264-8 | Medical Equipment | History of medical device use |
| 29549-3 | Medications Administered | Medication administered Narrative |
| 10160-0 | History of medication use | History of Medication use Narrative |
| 61144-2 | Diet and nutrition | Diet and nutrition Narrative |
| 61149-1 | Objective | Objective Narrative |
| 10216-0 | Operative Note Fluids | Surgical operation note fluids Narrative |
| 10223-6 | Operative Note Surgical Procedure | Surgical operation note surgical procedure Narrative |
| 11348-0 | History of Past Illness | History of Past illness Narrative |
| 48768-6 | Payers | Payment sources Document |
| 29545-1 | Physical Findings | Physical findings Narrative |
| 59772-4 | Planned Procedure | Planned procedure Narrative |
| 18776-5 | Plan of Treatment | Plan of care note |
| 10218-6 | Postoperative Diagnosis | Surgical operation note postoperative diagnosis Narrative |
| 59769-0 | Postprocedure Diagnosis | Postprocedure diagnosis Narrative |
| 10219-4 | Preoperative Diagnosis | Surgical operation note preoperative diagnosis Narrative |
| 11450-4 | Problem List | Problem list - Reported |
| 29554-3 | Procedure Description | Procedure Narrative |
| 59775-7 | Procedure Disposition | Procedure disposition Narrative |
| 59770-8 | Procedure Estimated Blood Loss | Procedure estimated blood loss Narrative |
| 59776-5 | Procedure Findings | Procedure findings Narrative |
| 59771-6 | Procedure Implants | Procedure implants Narrative |
| 59768-2 | Procedure Indications | Procedure indications [Interpretation] Narrative |
| 59773-2 | Procedure Specimens Taken | Procedure specimens taken Narrative |
| 47519-4 | History of Procedures | History of Procedures Document |
| 42349-1 | Reason for Referral | Reason for referral (narrative) |
| 29299-5 | Reason for Visit | Reason for visit Narrative |
| 30954-2 | Relevant diagnostic tests and/or laboratory data | Relevant diagnostic tests/laboratory data Narrative |
| 10187-3 | Review of Systems | Review of systems Narrative - Reported |
| 29762-2 | Social History | Social history Narrative |
| 93048-7 | Reason for specimen rejection | Reason for specimen rejection [Type] |
| 61150-9 | Subjective | Subjective Narrative |
| 11537-8 | Surgical Drains | Surgical drains Narrative |
| 75773-2 | Goals, preferences, and priorities for medical treatment | Goals, preferences, and priorities for medical treatment [Reported] |
Once again, we should probably make C-CDA align with what LOINC says here. And we have a few SNOMED ones as well:
| Code | C-CDA displayName | SNOMED displayName |
|---|---|---|
| 445518008 | Age At Onset | Age at onset of clinical finding |
| 420905001 | Highest Pressure Ulcer Stage | Highest pressure injury stage |
