MU2 Data Requirements Certification Criterion 170.314(b)(1)- Receive, Display, and Incorporate Transition of Care/Referral Summaries 170.314(b)(2)- Create and Transmit Transition of Care/Referral Summaries 170.314(b)(7)- Data Portability 170.314(e)(1)- View, Download, and Transmit to a 3rd Party 170.314(e)(2)- Clinical Summary Summary Type Transition of Care/Referral Summary Transition of Care/Referral Summary Export Summary Ambulatory Summary Inpatient Summary Clinical Summary Common MU Data Set Common MU Data Set Patient Name Sex Date of Birth Race Ethnicity Preferred language Smoking Status Problems Medication List Medication Allergies Laboratory test(s) Laboratory value(s)/result(s) Vital signs – height, weight, blood pressure, BMI Care plan field(s), including goals and instructions Procedures Care team member(s) Consolidated CDA Template General Header General Header General Header General Header General Header General Header Social History Section Smoking Status Observation Entry Problem Section Medications (entries required) Section Hospital Discharge Medications Section Allergies (entries required) Section Plan of Care Section Plan of Care Activity Observation Entry Results (entries required) Section Vital Signs Section Plan of Care Section Procedures (entries required) Section General Header Transitions of Care/Referral Summary and Export Summary Data Requirements Cognitive Status Discharge Instructions- Inpatient Only Encounter Diagnoses Consolidated CDA Template Functional Status Section Hospital Discharge Instructions Section Problems (entries required) Section Hospital Discharge Diagnosis Section Functional Status Immunizations Provider Name & Office Contact Information- Ambulatory Only Reason for Referral- Ambulatory Only Functional Status Section Immunizations (entries required) Section General Header Reason for Referral Section Ambulatory or Inpatient Summary Data Requirements Dates and Location of Admission and Discharge- Inpatient Only Discharge Instructions- Inpatient Only Provider Name and Office Contact Information- Ambulatory Only Reason for Hospitalization- Inpatient Only Consolidated CDA Template General Header Hospital Discharge Instructions Section General Header Reason for Visit and/or Chief Complaint Section(s) Clinical Summary Data Requirements Clinical Instructions Date and Location of Visit Diagnostic Tests Pending Future Appointments Future Scheduled Tests Immunizations administered during the Visit Medications administered during the Visit Provider Name and Office Contact Information Reason for Visit Recommended Patient Decision Aids Referrals to other Providers Consolidated CDA Template Instructions Section General Header Plan of Care Section Plan of Care Section Plan of Care Section Immunizations (entries required) Section Medications (entries required) Section Medications Administered Section General Header Reason for Visit and/or Chief Complaint Section(s) Instructions Section Plan of Care Section Complete List of MU2 Data Requirements MU Data Requirement Care plan field(s), including goals and instructions Care team member(s) Clinical Instructions Cognitive Status Date and Location of Visit Consolidated CDA Template Plan of Care Section General Header Instructions Section Functional Status Section General Header Date of Birth Dates and Location of Admission and Discharge- Inpatient Only Diagnostic Tests Pending Discharge Instructions- Inpatient Only Ethnicity Functional Status Future Appointments Future Scheduled Tests Immunizations Immunizations Administered during the Visit Laboratory test(s) Laboratory value(s)/result(s) Medication Allergies Medication List Medications Administered during the Visit Patient Name Preferred language Problems Procedures Provider Name and Office Contact Information Race Reason for Hospitalization- Inpatient Only Reason for Referral- Ambulatory Only Reason for Visit Recommended Patient Decision Aids Referrals to other Providers Sex Smoking Status Vital signs – height, weight, blood pressure, BMI General Header General Header Plan of Care Section Plan of Care Activity Observation Entry Hospital Discharge Instructions Section General Header Functional Status Section Plan of Care Section Plan of Care Section Immunizations (entries required) Section Immunizations (entries required) Section Plan of Care Section Plan of Care Activity Observation Entry Results (entries required) Section Allergies (entries required) Section Medications (entries required) Section Hospital Discharge Medications Section Medications (entries required) Section Hospital Discharge Medications Section Medications Administered Section General Header General Header Problem Section Procedures (entries required) Section General Header General Header Reason for Visit and/or Chief Complaint Section(s) Reason for Referral Section Reason for Visit and/or Chief Complaint Section(s) Instructions Section Plan of Care Section General Header Social History Section Smoking Status Observation Entry Vital Signs Section