U.S. Health and Human Services
Office of the National Coordinator for Health IT
Standards & Interoperability Framework
Transitions of Care Initiative
Discharge Summary Implementation Guidance
Version 2.0
November 15, 2011
Office of the National Coordinator for
Health Information Technology
Revision History
Date
Document
Version
Document Revision Description
8/13/2011
1.0
Initial draft of Discharge Summary Implementation Guidance, intended to serve
as an implementation primer for potential pilot participants
2.0
Version 2 of the Discharge Summary Implementation Guidance is now available
for public review, and focuses on specific improvements in assisting
implementers with care transition information exchanges:
 Alignment of CDA to CIM
 Full designation of applicable value sets
 High level constraints applied to each CDA Section
 Additional split out of Care Transition Information Exchanges into
individual guidance documents
 Expanded tooling support now available within MDHT
11/15/2011
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Table of Contents
1. Introduction ..................................................................................................................................................... 6
Purpose ...........................................................................................................................................................6
Scope ...............................................................................................................................................................6
1.2.1 Use Case Scenarios .............................................................................................................................7
1.2.2 Description of Discharge Summary .....................................................................................................7
Audience..........................................................................................................................................................7
Organization of This Guide ..............................................................................................................................8
Templates ........................................................................................................................................................8
Conformance ...................................................................................................................................................8
Conventions.....................................................................................................................................................8
Section Preamble ............................................................................................................................................8
1.8.1 CDA Implementation Table .................................................................................................................9
1.8.2 Implementer Notes .............................................................................................................................9
2. Discharge Summary Implementation Guidance .............................................................................................. 10
CDA Header Information ...............................................................................................................................10
2.1.1 Contact Information .........................................................................................................................11
2.1.2 Person Information ...........................................................................................................................12
2.1.3 Provider Information ........................................................................................................................13
Discharge Summary .......................................................................................................................................14
2.2.1 Allergies, Adverse Reactions, and Alerts Section ..............................................................................16
2.2.2 Chief Complaint Section....................................................................................................................18
2.2.3 Chief Complaint/ Reason for Visit Section ........................................................................................19
2.2.4 Discharge Diet Section ......................................................................................................................19
2.2.5 Family History Section ......................................................................................................................20
2.2.6 Functional Status Section..................................................................................................................22
2.2.7 History of Present Illness Section .....................................................................................................23
2.2.8 Hospital Course Section ....................................................................................................................24
2.2.9 Hospital Discharge Diagnosis Section ...............................................................................................24
2.2.10 Hospital Discharge Medications Section ...........................................................................................25
2.2.11 Hospital Discharge Physical Section ..................................................................................................25
2.2.12 Hospital Discharge Studies Summary Section...................................................................................26
2.2.13 Immunizations Section .....................................................................................................................26
2.2.14 List of Surgeries Section ....................................................................................................................28
2.2.15 Plan of Care Section ..........................................................................................................................29
2.2.16 Problem List Section .........................................................................................................................29
2.2.17 Procedures Section ...........................................................................................................................31
2.2.18 Reason for Visit Section ....................................................................................................................32
2.2.19 Review of Systems Section ...............................................................................................................32
2.2.20 Social History Section ........................................................................................................................33
2.2.21 Vital Signs Section .............................................................................................................................34
3. TOC Clinical Information Model (CIM) ............................................................................................................ 36
ToC CIM Objects ............................................................................................................................................36
4. Additional Guidance for Implementers and Vendors ...................................................................................... 40
Tools ..............................................................................................................................................................40
4.1.1 OHT/MDHT .......................................................................................................................................40
4.1.2 Trifolia ...............................................................................................................................................40
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4.1.3 NIST Validation/MU testing sites ......................................................................................................41
4.1.4 TOC Quickstart Site ...........................................................................................................................41
4.1.5 myCDA ..............................................................................................................................................41
Educational Resources ..................................................................................................................................41
4.2.1 Clinical Document Architecture (CDA) ..............................................................................................41
4.2.1.1 HL7 Structured Documents Technical Committee Wiki ...................................................41
5. Appendix A – Reference Documents ............................................................................................................... 42
6. Appendix B – Acronym List ............................................................................................................................. 43
7. Appendix C – Recommended Value Sets ......................................................................................................... 44
Advance Directive Type Recommended Value Set........................................................................................44
Allergy/Adverse Event Food and Other Allergens Value Set .........................................................................45
Allergy/Adverse Event Reaction Value Set ....................................................................................................45
Allergy/Adverse Event Type Value Set ..........................................................................................................45
Care Transition – Body Site Value Set ...........................................................................................................45
Care Transition – Contact Type Value Set .....................................................................................................46
Care Transition – Country Value Set .............................................................................................................46
Care Transition – Medication Brand Name Value Set ...................................................................................46
Care Transition - Medication Clinical Drug Name Value Set .........................................................................46
Care Transition - Medication Drug Class Value Set .......................................................................................47
Care Transition – Patient Class Value Set ......................................................................................................47
Care Transition – Postal Code Value Set .......................................................................................................47
Care Transition - Problem Value Set .............................................................................................................48
Care Transition – Provider Role Value Set .....................................................................................................54
Care Transition – Provider Type Value Set ....................................................................................................55
Care Transition – Relationship Value Set ......................................................................................................56
Care Transition - Severity Value Set ..............................................................................................................57
Care Transition – State Value Set ..................................................................................................................57
Encounter Type Value Set .............................................................................................................................57
Health Insurance Subscriber Relationship Value Set.....................................................................................58
Health Insurance Type Value Set ...................................................................................................................58
Ingredient Name Value Set ...........................................................................................................................59
Immunizations Administered Vaccines Value Set Recommendation ............................................................59
Immunization Reason Value Set ....................................................................................................................62
Medication Fill Status Value Set ....................................................................................................................62
Medication Method of Delivery Value Set ....................................................................................................63
Medication Product Form Value Set .............................................................................................................63
Medication Route Value Set ..........................................................................................................................63
Medication Type Value Set ............................................................................................................................63
Problem Status Value Set ..............................................................................................................................63
Problem Type Value Set ................................................................................................................................64
Procedure Value Set ......................................................................................................................................64
Result Type Value Set ....................................................................................................................................66
Results Value Set ...........................................................................................................................................66
Social History Type Value Set ........................................................................................................................68
Vital Signs Result Type Value Set ...................................................................................................................68
8. Appendix D – XML Examples for Discharge Summary ..................................................................................... 69
Sample CDA Header XML Schema .................................................................................................................69
Sample RecordTarget XML Schema ...............................................................................................................69
Sample Author XML Schema .........................................................................................................................70
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Sample Informant XML Schema ....................................................................................................................70
Sample Custodian XML Schema ....................................................................................................................71
Sample Participant XML Schema ...................................................................................................................71
Sample DocumentationOf XML Schema .......................................................................................................72
Sample Advance Directives XML Schema ......................................................................................................73
Sample Allergy XML Schema .........................................................................................................................74
Sample Problems XML Schema .....................................................................................................................75
Sample Medication XML Schema ..................................................................................................................78
Sample Immunization XML Schema ..............................................................................................................96
Sample Vital Signs XML Schema ....................................................................................................................97
Sample Emergency Encounter XML Schema .................................................................................................99
Sample Inpatient Encounter XML Schema ..................................................................................................100
Sample Results XML Schema .......................................................................................................................103
Sample Procedures XML Schema ................................................................................................................106
Sample Social History XML Schema .............................................................................................................110
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1. Introduction
In support of the national objectives for healthcare reform, the Office of the National Coordinator for Health
Information Technology (ONC) Standards and Interoperability (S&I) Framework has sponsored the development of
harmonized interoperability specifications. These specifications are designed to support national health initiatives
and healthcare priorities, including Meaningful Use, the Nationwide Health Information Network, and the ongoing
mission to improve population health.
The S&I Framework is comprised of several initiatives, each focusing on a single challenge with a set of valuecreating goals and outcomes to enhance the efficiency and effectiveness of healthcare delivery. Among the first
initiatives launched by the S&I Framework is the Transitions of Care (ToC) Initiative, which focuses on improving
the exchange of core clinical information among providers, patients, and other authorized entities in support of
Meaningful Use for the improvement of patient care.
The S&I Framework Transitions of Care Initiative identified core information to be exchanged in the following
scenarios:
1.
2.
When a patient transfers between healthcare providers
When electronic clinical information is shared from providers to patients.
The Transition of Care information exchanges are accomplished using the recommended Clinical Document
Architecture (CDA) interchange standard developed by Health Level Seven (HL7). This implementation guidance
is provided to assist the implementation community in their efforts to quickly access the numerous resources
available as well as provide practical guidance that is outside the scope of the HL7 balloted standards.
Purpose
This implementation guide enables the exchange of key clinical information among providers in the instance of a
transition of patient care. Adopting and implementing transition of care standards provides the following benefits:
1.
Establishes a common standard for the exchange of clinical information. By adherence to a common
semantic model, the standard provides semantically consistent information across instances of exchange.
2.
Implementation of the clinical constructs defined by the Transitions of Care Initiative ensures compliance
with the following Meaningful Use criteria: Electronic Copy of Health Information, Electronic Copy of
Discharge Instructions, and Clinical Summary for each Office Visit.
3.
Facilitates the ease of adoption of Meaningful Use 1 and anticipated Stage 2 for which eligible providers
receive a monetary incentive.
Scope
The scope of the transition of patient care is defined in the use case as two scenarios, both supported by key
outputs or constructs that contain specific patient information to facilitate the exchange of information in the
event of a care transition.
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1.2.1
Use Case Scenarios
Scenario 1: The Transfer of Patient Information from One Provider to Another Actor: The transfer of patient
information from one provider to another actor occurs in two ways:
1.
2.
The exchange of Discharge Instructions and Discharge Summary between a provider and patient to
support the transfer of a patient between care settings, or
The exchange of clinical summaries between providers and patients to support the closed-loop transfer of
a patient from one care setting to another consultation referral.
Scenario 2: The Transfer of Patient Information between Providers: The transfer of patient information between
providers occurs in three ways:
1.
2.
3.
1.2.2

The exchange of information to support the transfer of patient information from one provider to another,
A closed loop referral, or
A complex series of care transitions.
Description of Discharge Summary
Discharge Summary: The Discharge Summary is the clinical document used in the event that a patient is
discharged from a healthcare provider. This document contains a standard set of information to be
communicated from one provider to another provider in accordance with local policy, regulations and law.
The Discharge Summary content includes demographic information, active reconciled medication list (with
doses and sig), allergy list, problem list, and reason for admission.


Sender: Hospital EHR System
Receiver: PCP EHR System
The Discharge Summary is supported by the Transition of Care Clinical Information Model (CIM). The CIM model
provides a concise and defined vocabulary for the sharing of care transition information used to generate the
constructs. The ToC CIM can be represented in XML but provides specialized XML tag names and other structure
for data that is constrained to meet the specific information exchange requirements of the care transition. The ToC
CIM also provides the reference vocabulary for consistent and reusable care transition information exchanges. The
structure and meaning of ToC CIM object data is defined by the model and associated data dictionary and are
represented as an XML schema, thereby providing a common framework for the exchange of information during a
care transition. For more information on the ToC CIM, see Section 3.
Audience
The audience of this implementation guide includes, but is not limited to, software developers, vendors, the ToC
Reference Implementation and Pilots Workgroup, and other HIT implementer parties. This implementation guide is
also intended to be of specific use to ONC Initiative Partners (OIP) who are interested in transitioning from current
CDA-based solutions to a new Consolidated CDA approach. Several assumptions are made regarding the audience:



There is a solid understanding and knowledge of HL7 CDA R2 prior to implementing this guidance
The reader has a foundational understanding of healthcare standards.
The reader has technical knowledge of data models and implementation experience.
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Organization of This Guide
This implementation guide contains both CDA sections and entries to show how specific care transition CDA-based
documents can be assembled in support of health information exchange. Each exchange or set of exchanges would
contain a general CDA header and one or more of four critical care transition constructs. The CDA Header is
applied across all the construct document-level templates uniquely defined in this guide. Each care transition
construct references reusable section-level and entry-level templates from the Consolidated CDA Release 2
Implementation Guide, which serves as a library documents, sections and entries.
Templates
Template identifiers (template IDs) are assigned at the document, section, and entry level. When valued in an
instance, the template identifier signals the imposition of a set of template-defined constraints. The value of this
attribute provides a unique identifier for the template in question. Please refer to the Consolidated CDA IG
(Section 1.6) for additional information on template identifiers and how they are used.
Conformance
CDA implementers characterize conformance requirements in terms of three general levels that correspond to
three different, incremental types of conformance statements:
 Level 1 requirements impose constraints upon the CDA Header. The body of a Level 1 document may be XML
or an alternate allowed format. If XML, it must be CDA-conformant markup.

Level 2 requirements specify constraints at the section level of a CDA XML document: most critically, the
section code and the cardinality of the sections themselves, whether optional or required.

Level 3 requirements specify constraints at the entry level within a section. A specification is considered "Level
3" if it requires any entry-level templates.
Refer to the Consolidated CDA IG (Section 1.7) for additional information regarding levels of constraint,
conformance statements, conformance verbs, cardinality, vocabulary conformance, and null flavor.
Conventions
The conventions used in this document are intended to outline a set of tables for implementers to use as guidance.
Refer to the Consolidated CDA IG (Section 1.8) for information regarding XPath notation, XML examples, and
sample documents.
Section Preamble
A description of the CDA section is provided, within the context of a care transition. This preamble includes the list
of conformance statements required for the CDA section template, as well as underlying entry-level templates that
may apply. These conformance statements MAY be an addition to the conformance statements contained within
the Consolidated CDA guide. Some of these conformance statements also specify the use of specific value sets for
a care transition, which are drawn from existing implementation guidance such as HITSP C80 and HITSP C83. A full
listing of all conformance statements can be drawn from the conformance statements links in the Implementer
Notes (Section 1.7.2).
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1.8.1
CDA Implementation Table
The CDA Implementation table immediately follows the section preamble and contains key implementation details
about the section.
Reference Document
The source for the
section template.





1.8.2
CDA Template ID
(Proposed)
The CDA Template ID
for the section. The
implementer SHALL
include the template
ID in each section to
declare conformance
to the CDA
Consolidation Guide.
Required/
Optional
Indicates whether
the CDA Section is
required or optional
for the care
transition.
Consolidated CDA IG
Reference
Provides the specific
reference to the CDA
Consolidation
Implementation
Guide to determine
conformance
requirements and
optionality.
Code Set
Provides the
recommended
terminology to be
used for that section.
Reference Document: For some sections, implementation guidance is provided both for Consolidated
CDA and HITSP C83. This is provided to ensure smooth transition planning for those implementers who
may already be using a C32 or CCD for a care transition information exchange.
CDA Template ID (Proposed): A conformance statement that should be followed for each CDA Section. In
order to be conformant with the Consolidated CDA Guide, a CDA Document SHALL declare conformance
for the specific section by including a <templateID> element with the root attribute set to the value.
Required/Optional: This indicates whether the CDA Section and/or Entry is required for the particular
information exchange or is optional.
Consolidated CDA IG Reference: This will indicate the specific location of the CDA Section and/or Entry
within the Consolidated CDA Guide. This reference allows an implementer to quickly access the relevant
conformance statements for the CDA Section and/or Entry.
Code Set: The recommended code set to be used for that CDA Section and/or Entry.
Implementer Notes
The implementer notes include the following:


Links to conformance statements
Links to XML samples of the CDA Section and/or Entry, where appropriate
These links are provided as an implementer resource and are derived from CDAtools.org made available by Open
Health Tools (OHT) for use in support of this implementation guidance. In many cases, the current samples and
conformance statements provided are linked to HITSP C32 and/or the CCD. As the Consolidated CDA Guide is
completed within the HL7 ballot process, all links will be updated to point to the most recent Consolidated CDA
examples and conformance statements. The HITSP C32 and/or CCD examples and conformance statements are
FULLY USABLE in conjunction with Consolidated CDA.
Data Element
CDA XPath
Reference
R/O
CIM Reference
Null Values
Notes
Does the data
element allow for
Additional
implementation
CDA FULL XPATH REFERENCE HERE
HITSP C83 data
element listed for
A link to the CDA
XPath specific to
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Required or
Optional
A reference to
the applicable
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implementer
reference (to
include business
names in future
releases)






this data
element, so
implementers
know where a
specific data
element will go
CIM Object and
CIM Data
Element
a null value or
not?
notes, such as
required value
sets, required
XML entries, etc.
Data Element: The data element listed in this table is drawn from HITSP C154 and is provided to give
implementers a specific business name to reference when populating the relevant CDA Section and/or
Entry.
CDA XPath Reference: This XML expression outlines where the data element would be captured within a
CDA document.
R/O: Indicates whether the data element is required or optional within the specific CDA Section and/or
Entry.
Null Values: Outlines whether null values are allowed or not for this data element.
CIM Reference: References the specific ToC CIM data element.
Notes: Additional implementation notes, such as which value set to be used to encode an element or
where this data might also be represented within a CDA document.
2. Discharge Summary Implementation Guidance
The following construct sections describe the purpose and rules for constructing a conforming CDA document.
Construct templates include constraints on the CDA header and refer to section-level templates. The Document
Types and Required/Optional Sections table lists the sections used by each document type. Each document-level
template contains the following information:





Scope and intended use of the document type
Description and explanatory narrative.
Template metadata (e.g., templateID, etc.)
Header constraints: this includes a reference to the US Realm Clinical Document Header template and
additional constraints specific to each document type
Required and optional section-level templates
CDA Header Information
The CDA header would contain most of the demographic information needed in support of the CIM Objects listed
below. The table below maps the header to the ToC CIM, for requirements traceability.
CDA Section
Name
US Realm
Header
CDA Template ID (Proposed)
2.16.840.1.113883.10.20.21.1.1
[US Realm Document Header]
2.16.840.1.113883.10.20.21.1.1
[US Realm Document Header]
2.16.840.1.113883.10.20.21.1.1
[US Realm Document Header]
2.16.840.1.113883.10.20.21.1.1
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Required/
Optional
CIM Object
Required
Patient Information
Required
Culturally Sensitive Patient Care
Required
Patient Contact Information
Required
Support Contacts
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[US Realm Document Header]
2.16.840.1.113883.10.20.21.1.1
[US Realm Document Header]
2.1.1





Required
Primary Care Providers and
Designated Providers
Contact Information
For a support contact, the classCode attribute, representing the Contact Type, shall be coded as specified
in the Care Transition – Contact Type Value Set
For a support contact, the contact relationship SHALL have be coded as specified in the Care Transition –
Relationship Value Set
For a support contact, the state part of an address SHALL be recorded using the Care Transition – State
Value Set
For a support contact, the postal code part of an address in the United States SHALL be recorded using the
Care Transition – Postal Code Value Set
For a support contact, the country part of an address SHALL be recorded using the Care Transition –
Country Value Set
Data Element
CDA XPath Reference
R/O
CIM Reference
Null Values
Notes
/cda:ClinicalDocument/cda:participant
Date
cda:time
R
cda:associatedEntity or cda:patientRole/cda:patient/cda:guardian
Contact Type
@classCode
R
Contact
Relationship
cda:code
R
Contact
Address
cda:addr
R2
cda:telecom
R
Contact
Phone/Email/
URL
cda:associatedPerson/cda
:name OR
Contact Name
R
cda:guardianPerson/cda:
name
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Contact Type
Primary and/or
Secondary
Emergency
Contact
Relationship
Primary and/or
Secondary
Emergency
Contact Address
Primary and/or
Secondary
Emergency
Contact Phone
Use – Care
Transition – Contact
Type Value Set
Use – Care
Transition –
Relationship Value
Set
Primary and/or
Secondary
Emergency
Contact Name
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2.1.2






























Person Information
For a patient address, each address part SHALL be identified using the <streetAddressLine>, <city>,
<state>, <postalCode> and <country> tags
For a patient address, more than one <streetAddressLine> MAY be present
For a patient address, NO MORE than four <streetAddressLine> elements SHALL be present
For a patient address, the <country> element SHALL be present for addresses outside of the United States
For a patient address, at most one address for a person SHALL have a use attribute with a value containing
"HP"
For a patient address, at least one address for a patient SHOULD have a use attribute with a value
containing "HP"
For a patient address, one or more vacation addresses MAY be present for a person
For a patient address, a vacation address SHALL be recorded with a use attribute containing the value
"HV"
For a patient address, one or more work addresses MAY be present
For a patient address, a work address SHALL be recorded with a use attribute containing the value "WP"
For a patient address, the <country> SHALL be recorded using Care Transition – Country Value Set
For a patient name, each name part SHALL be identified using one of the tags <given>, <family>, <prefix>
or <suffix>
For a patient name the "first" name of the patient SHALL appear in the first <given> tag.
For a patient name, the "middle" name of the patient, if it exists, SHALL appear in the second <given> tag.
For a patient name, the name parts within a <name> tag SHALL be ordered in proper display order
For a patient name, at most one <name> tag SHALL have a use attribute containing the value "L",
indicating that it is the legal name of the patient
For a patient name, more than one <name> tag MAY be present to retain birth name, maiden name and
aliases
For a patient name, an alias or former name MAY be identified by the inclusion of a use attribute
containing the value "P"
For a patient name, name parts MAY be identified as being a name given at birth or adoption by the
inclusion of a qualifier attribute containing the value "BR" for birth or "AD" for adoption
For a patient name, a name part SHALL be identified as the patient's preferred name by the inclusion of a
qualifier attribute containing the value "CL" on the name part
For a patient name, a prefix or suffix that is an academic title or credential SHALL be identified by the
inclusion of a qualifier attribute containing the value "AC" on the name part
For a patient, the ethnicity SHALL be coded as specified in Care Transition – Ethnicity Value Set
For a patient, the marital status SHALL be coded as specified in Care Transition – Marital Status Value Set
For a patient, the gender SHALL be coded as specified in Care Transition – Gender Value Set
For a patient, the race SHALL be coded as specified in Care Transition – Race Value Set
The primary religious affiliation MAY appear in the <religiousAffilliationCode> element
For a patient, the religious affiliation SHALL be coded as specified in Care Transition – Religion Value Set
For a patient, a home phone number SHALL be represented with a use attribute containing the value "HP"
For a patient, a vacation home phone number SHALL be represented with a use attribute containing the
value "HV"
For a patient, a work phone number SHALL be represented with a use attribute containing the value "WP"
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

For a patient, a mobile phone number SHALL be represented with a use attribute containing the value
"MC"
For a patient, an e-mail address SHALL appear in a <telecom> element using the 'mailto:' URL scheme (see
IETF/RFC-2368), and SHALL encode only a single mailing address, without any headers
Data Element
CDA XPath Reference
R/O
CIM Reference
Null Values
Notes
/cda:ClinicalDocument/cda:effectiveTime
Document
Timestamp
n/a
R
Not Applicable
Not Allowed
One entry only
/cda:ClinicalDocument/cda:recordTarget/cda:patientRole
Person ID
Person Address
Person Phone
/Email /URL
cda:id
R
Patient Identifiers
Not Allowed
cda:addr
R
Patient Address
Allowed
cda:telecom
R
Patient Phone
Allowed
cda:patient
Person Name
cda:name
R
Patient Name
Allowed
cda:administrativeGen
derCode
R
Patient Gender
Allowed
Person Date of
Birth
cda:birthTime
R
Marital Status
cda:maritalStatusCode
R2
Religious
Affiliation
cda:religiousAffiliation
Code
O
Race
cda:raceCode OR
sdtc:raceCode
R
Ethnicity
cda:ethnicityCode
R
Gender
Patient Date of
Birth
Patient Marital
Status
Culturally
Sensitive Patient
Care: Religion
Culturally
Sensitive Patient
Care: Race
Culturally
Sensitive Patient
Care: Ethnicity
Allowed
cda:recordTarget/cda:patientRole/cda:patient/cda:languageCommunication
Language
2.1.3



n/a
R
Patient Language
Provider Information
For a provider, the provider role SHALL be coded as specified in Care Transition - Provider Role Value Set
in Appendix C
For a provider, the provider type SHALL be coded as specified in Care Transition – Provider Type Value Set
in Appendix C
For a provider, the state part of an address SHALL be recorded using Care Transition – State Value Set in
Appendix C
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

For a provider, the postal code part of an address in the United States SHALL be recorded using Care
Transition – Postal Code Value Set in Appendix C
For a provider, the country part of an address SHALL be recorded using Care Transition – Country Value
Set in Appendix C
Data Element
CDA XPath Reference
R/O
CIM Reference
Null Values
Notes
/cda:ClinicalDocument/cda:documentationOf/cda:serviceEvent/cda:performer
Date Range
cda:time
R
None Applicable
Provider Role
Coded
cda:functionCode
R2
Designated
Provider Domain
of Management
Provider Role
Free Text
cda:originalText
R2
None Applicable
cda:assignedEntity
Provider Type
Provider
Address
Provider
Phone/Email/
URL
Provider Name
Provider's
Organization
Name
Provider's
Patient ID
National
Provider ID
cda:code
R
cda:addr
R
cda:telecom
R
cda:assignedPerson/
cda:name
cda:
representedOrganization/
cda:name
R
R
Designated
Provider
Specialties
Designated
Provider Address
Designated
Provider Phone
Designated
Provider Name
Designated
Provider
Organization
Allowed
Allowed
Allowed
sdtc:patient/sdtc:id
R2
None Applicable
Allowed
n/a
R2
Designated
Provider NPI
Allowed
Discharge Summary
Each section of the Discharge Summary listed below contains both document-level and section-level templates:


Document-level templates contain the CDA section name, CDA template ID, whether the section is
required or optional, the CIM object mapping and the recommended terminology/vocabulary to be used.
Section-level templates contain a section description, the CDA template ID, required vs. optional, the
respective Consolidated CDA IG reference pointer, and the recommended terminology/vocabulary to be
used.
The Discharge Summary contains a standard set of data surrounding a discharge, and discharge context-relevant
data, which is determined by the discharging provider organization in accordance with local policy, regulations and
law. The receiving provider through its EHR system may determine how to incorporate and present the Discharge
Summary document. The Discharge Summary should always include a basic set of information on the discharge
that might also include content for the Discharge Instruction as well as the Discharge Summary. Discharge
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summary content examples include demographic information, active reconciled medication list (with doses and
sig), allergy list, problem list, and reason for admission.
The following table summarizes the specific CDA templates that align to these requirements. Both Consolidated
CDA and HITSP C83 Content Modules are provided for implementers:
CDA Section Name
Allergies, Adverse
Reactions, Alerts
Chief Complaint
Chief
Complaint/Reason for
Visit
Discharge Diet
Family History
Functional Status
History of Present
Illness
Hospital Course
Hospital Discharge
Diagnosis
Hospital Discharge
Medications
Hospital Discharge
Physical
Hospital Discharge
Studies Summary
Document
Reference
Consolidated
CDA IG
CDA Template ID (Proposed)
Required/
Optional
2.16.840.1.113883.10.20.21.2.6.1
2.16.840.1.113883.10.20.21.2.6.
Required
HITSP/C83
2.16.840.1.113883.3.88.11.83.102
Required
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
Optional
2.16.840.1.113883.3.88.11.83.105
Optional
2.16.840.1.113883.10.20.22.2.13
Optional
2.16.840.1.113883.3.88.11.83.105
Optional
1.3.6.1.4.1.19376.1.5.3.1.3.33
Optional
1.3.6.1.4.1.19376.1.5.3.1.3.33
Optional
2.16.840.1.113883.10.20.22.2.15
Optional
2.16.840.1.113883.3.88.11.83.125
Optional
2.16.840.1.113883.10.20.22.2.14
Optional
2.16.840.1.113883.3.88.11.83.109
Optional
1.3.6.1.4.1.19376.1.5.3.1.3.4
Optional
2.16.840.1.113883.3.88.11.83.107
Optional
1.3.6.1.4.1.19376.1.5.3.1.3.5
Required
2.16.840.1.113883.3.88.11.83.121
Required
2.16.840.1.113883.10.20.22.2.24
Required
HITSP/C83*
2.16.840.1.113883.3.88.11.83.111
Required
Consolidated
CDA IG
2.16.840.1.113883.10.20.22.2.11.1
2.16.840.1.113883.10.20.22.2.11
Required
HITSP/C83*
2.16.840.1.113883.3.88.11.83.114
Required
Consolidated
CDA IG
1.3.6.1.4.1.19376.1.5.3.1.3.26
Optional
IHE
1.3.6.1.4.1.19376.1.5.3.1.3.26
Optional
Consolidated
CDA IG
2.16.840.1.113883.10.20.22.2.16
Optional
HL7 CDT
2.16.840.1.113883.10.20.16.2.3
Optional
Consolidated
CDA IG
HITSP/C83*
Consolidated
CDA IG
HITSP/C83*
Consolidated
CDA IG
IHE
Consolidated
CDA IG
HITSP/C83
Consolidated
CDA IG
HITSP/C83
Consolidated
CDA IG
HITSP/C83
Consolidated
CDA IG
HITSP/C83*
Consolidated
CDA IG
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Code Set
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Immunizations
List of Surgeries
(History of Procedures)
Plan of Care
Problem List
Consolidated
CDA IG
2.16.840.1.113883.10.20.22.2.2.1
2.16.840.1.113883.10.20.22.2.2
Optional
HITSP/C83
2.16.840.1.113883.3.88.11.83.117
Optional
Consolidated
CDA IG
2.16.840.1.113883.10.20.22.2.7
Optional
HITSP/C83
2.16.840.1.113883.3.88.11.83.108
Optional
2.16.840.1.113883.10.20.22.2.10
Required
2.16.840.1.113883.3.88.11.83.124
2.16.840.1.113883.10.20.22.2.5.1
2.16.840.1.113883.10.20.22.2.5
Required
2.16.840.1.113883.3.88.11.83.103
Required
2.16.840.1.113883.10.20.22.2.7.1
Optional
2.16.840.1.113883.3.88.11.83.108
Optional
2.16.840.1.113883.10.20.22.2.12
Optional
2.16.840.1.113883.3.88.11.83.105
Optional
1.3.6.1.4.1.19376.1.5.3.1.3.18
Optional
2.16.840.1.113883.3.88.11.83.120
Optional
2.16.840.1.113883.10.20.22.2.17
Optional
2.16.840.1.113883.3.88.11.83.126
2.16.840.1.113883.10.20.22.2.4.1
2.16.840.1.113883.10.20.22.2.4
Optional
2.16.840.1.113883.3.88.11.83.119
Optional
Consolidated
CDA IG
HITSP/C83*
Consolidated
CDA IG
HITSP/C83*
Procedures
Reason for Visit
Review of Systems
Consolidated
CDA IG
HITSP/C83
Consolidated
CDA IG
HITSP/C83*
Consolidated
CDA IG
HITSP/C83
Social History
Vital Signs
Consolidated
CDA IG
HITSP/C83
Consolidated
CDA IG
HITSP/C83
Required
Optional
Due to the current transition from source CDA implementation guides, such as HITSP/C83 and IHE PCC, to the
Consolidated CDA IG, both document references have been included. This mapping is included for the transition of
discharge summaries to Consolidated CDA and is NOT included for other care transition information exchanges.
2.2.1
Allergies, Adverse Reactions, and Alerts Section
The Allergies, Adverse Reactions, and Alerts Section lists and describes any medication allergies, adverse reactions,
idiosyncratic reactions, anaphylaxis/anaphylactoid reactions to food items, and metabolic variations or adverse
reactions/allergies to other substances (such as latex, iodine, tape adhesives) used to assure the safety of health
care delivery. At a minimum, it should list currently active and any relevant historical allergies and adverse
reactions. In general this section should not include environmental allergies, even if severe and directly related to
the presenting problem, since they constitute a medical problem; environmental allergies should be listed in the
problem list and past medical history. In addition to conformance statements defined in the Consolidated CDA
guide, the following additional conformance statements are applicable:


The Allergies Section SHOULD contain at least one Allergy Problem Act entry
The Allergies Section SHALL include all data elements listed
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





The Adverse Event Type in the Allergies Section SHALL be coded as specified in Allergy/Adverse Event
Type Value Set in Appendix C
Food and substance allergies (captured in Product Coded data element) in the Allergies Section SHALL be
coded as specified in the Allergy/Adverse Event Food and Other Allergens Value Set in Appendix C
Allergies to a class of medication (captured in Product Coded data element) in the Allergies Section SHALL
be coded as specified in the Allergy/Adverse Event Medication Drug Class Value Set in Appendix C
Allergies to a specific medication (captured in Product Coded data element) in the Allergies Section SHALL
be coded as specified in the Allergy/Adverse Event Medication Clinical Drug Name Value Set in Appendix C
The Reaction Coded in the Allergies Section SHALL be coded as specified in the Allergy/Adverse Event
Reaction Value Set in Appendix C
The Severity Coded in the Allergies Section SHALL be coded as specified in the Allergy/Adverse Event
Reaction Value Set in Appendix C
Reference
Document
CDA Template ID (Proposed)
Consolidated
CDA IG
2.16.840.1.113883.10.20.21.2.6.1
2.16.840.1.113883.10.20.21.2.6.
HITSP/C83*
2.16.840.1.113883.3.88.11.83.102
Required/
Optional
Consolidated CDA IG
Reference
Required
Refer to the CDAR2_IG,
Section 48765-2 for
Required/Optional Entries
Required
Refer to Section 2.2.1.2
Allergies and Other
Reactions Section in
HITSP/C83 for
Required/Optional Entries
Code Set
LOINC
2.16.840.1.1
13883.6.1
LOINC
2.16.840.1.1
13883.6.1
Implementer Notes



The value sets recommended for the Allergies, Adverse Reactions, and Alerts Section are available in
Appendix C of this guide.
Allergies Reactions Section conformance statements and XML examples can be found in the Allergies
Reaction Section of HITSP C32/C83
Alert Section conformance statements and XML examples can be found in the Alerts Section of the CCD
Data Element
CDA XPath Reference
R/O
CIM Reference
Null Values
Notes
cda:act[cda:templateId/@root=’2.16.840.1.113883.10.20.22.4.30’]/cda:entryRelationship[@typeCode='SUBJ']/cda:o
bservation[cda:templateId/@root='2.16.840.1.113883.10.20.22.4.7’]
Adverse Event
cda:effectiveTime
R
Reaction Date
Allowed
Date
Recommended code
list is SNOMED-CT
Adverse Event
Allowed with
cda:code
R
Reaction Type
Type
specific constraints Use Allergy/Adverse
Event Type Value
Set
cda:participant[@typeCode='CSM']/
cda:participantRole[@classCode='MANU']/
cda:playingEntity[@classCode='MMAT']/
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Product FreeText
cda:name
R
All Environmental
Allergens
AND/OR
All Food Allergens
AND/OR
Medication
Intolerance
Allowed
Use Allergy/Adverse
Event Medication
Drug Class Value Set
Product Coded
cda:code
R
A/I Attributes
Allowed
OR
Use Allergy/Adverse
Event Medication
Clinical Drug Name
Value Set
cda:entryRelationship[@typeCode='MFST']/
cda:observation[templateId/@root=’2.16.840.1.113883.10.20.22.4.9’]
Reaction FreeText
cda:text
R2
List of Reactions
Allowed
Reaction Coded
cda:value
R2
Reaction
Attributes
Allowed
Severity FreeText
Severity Coded
2.2.2
Use Allergy/Adverse
Event Reaction
Value Set
cda:entryRelationship[@typeCode='SUBJ']/
cda:observation[templateId/@root=’2.16.840.1.113883.10.20.22.4.8’]
Severity of
cda:text
R2
Intolerance or
Allowed
Allergy
cda:value
R2
Severity
Attributes
If not known, a
codified Null value
is required
If not known, a
codified Null value
is required
If not known, a
codified Null value
is required
If not known, a
codified Null value
is required
Allowed
Use Allergy/Adverse
Event Reaction
Value Set
Chief Complaint Section
This section records the patient's chief complaint (the patient’s own description).



The Chief Complaint Section SHALL conform to the HL7 History and Physical Note requirements from the
Consolidated CDA Implementation Guide for this section
The Chief Compliant section SHALL include at least one Problem Entry.
The Chief Compliant section SHALL provide the chief complaint in coded form.
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Reference
Document
CDA Template ID (Proposed)
Required/
Optional
Consolidated
CDA IG
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
Optional
HITSP/C83*
2.16.840.1.113883.3.88.11.83.105
Optional
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 10154-3 for
Required/Optional Entries
Refer to Section 2.2.1.5
Chief Complaint Section in
HITSP/C83 for
Required/Optional Entries
Code Set
LOINC
2.16.840.1.1
13883.6.1
LOINC
2.16.840.1.1
13883.6.1
Implementer Notes

2.2.3
Chief Complaint Section conformance statements and XML examples can be found in the Chief Complaint
Section of the HITSP C32/C83
Chief Complaint/ Reason for Visit Section
This section records the patient's chief complaint (the patient’s own description) and/or the reason for the
patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information
is divided into two sections or recorded in one section serving both purposes.

In the Chief Complaint/Reason for Visit Section, under the <paragraph> element of the <text>element, at
least one reason for visit SHALL be documented IF no chief complaint has been documented.
Reference
Document
CDA Template ID (Proposed)
Required/
Optional
Consolidated
CDA IG
2.16.840.1.113883.10.20.22.2.13
Optional
HITSP/C83*
2.16.840.1.113883.3.88.11.83.105
Optional
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 46239-0 for
Required/Optional Entries
Refer to Section 2.2.1.5
Chief Complaint Section in
HITSP/C83 for
Required/Optional Entries
Code Set
LOINC
2.16.840.1.1
13883.6.1
LOINC
2.16.840.1.1
13883.6.1
Implementer Notes

2.2.4
Chief Complaint/Reason for Visit Section conformance statements and XML examples can be found in the
Chief Complaint Section of the HITSP C32/C83
Discharge Diet Section
This section records a narrative description of the expectations for diet, including proposals, goals, and order
requests for monitoring, tracking, or improving the dietary control of the patient, used in a discharge from a facility
such as an emergency department, hospital, or nursing home.

In the Discharge Diet Section, under the <text>element, the Discharge Diet instructions SHALL be
provided in narrative form.
Reference
Document
CDA Template ID (Proposed)
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Created on 8/31/2011
Required/
Optional
Consolidated CDA IG
Reference
Code Set
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Consolidated
CDA IG
1.3.6.1.4.1.19376.1.5.3.1.3.33
Optional
IHE PCC*
1.3.6.1.4.1.19376.1.5.3.1.3.33
Optional
Refer to the CDAR2_IG,
Section 10154-3 for
Required/Optional Entries
Refer to Section 6.3.3.6.4 in
IHE PCC for
Required/Optional Entries
Implementer Notes

2.2.5
For an example of a Discharge Diet CDA Section, please reference Appendix D – CDA Section Examples.
Family History Section
This section contains data defining the patient’s genetic relatives in terms of possible or relevant health risk factors
that have a potential impact on the patient’s healthcare risk profile.





When providing structured family history information the Family History section SHALL include all data
elements listed
The Family History Relationship in the Family History Section SHALL be coded as specified in the Family
History Relationship Type Value Set in Appendix C
The Family Member Race in the Family History Section SHALL be coded as specified in the Care Transition
- Race Value Set in Appendix C
The Family Member Ethnicity in the Family History Section SHALL be coded as specified in the Care
Transition - Ethnicity Value Set in Appendix C
The Family Member Condition in the Family History Section SHALL be coded as specified in the Problem
Type Value Set in Appendix C

Reference
Document
CDA Template ID (Proposed)
Required/
Optional
Consolidated
CDA IG
2.16.840.1.113883.10.20.22.2.15
Optional
HITSP/C83*
2.16.840.1.113883.3.88.11.83.125
Optional
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 10157-6 for
Required/Optional Entries
Refer to Section 2.2.1.25 in
HITSP/C83 for
Required/Optional Entries
Code Set
LOINC
2.16.840.1.1
13883.6.1
LOINC
2.16.840.1.1
13883.6.1
Implementer Notes

Family History Section conformance statements and XML examples can be found in the Family History
Section of the CCD
Data Element
CDA XPath Reference
R/O
CIM Reference
Null Values
Notes
cda:section[cda:templateId/@root = '2.16.840.1.113883.10.20.1.23']
Pedigree
cda:entry/
cda:observationMedia
O
None Identified
cda:entry/cda:organizer[cda:templateId/@root = ‘2.16.840.1.113883.3.88.11.83.18']
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Family Member
Information
Family Member
Demographics
Family Member
Relationship
Family Member
Relationship
Free Text
R
cda:subject/
cda:relatedSubject
R
cda:code/@code
R
cda:code/cda:original
Text
O
cda:subject
Family Member
Identifier
Family Member
Name
Family Member
Date of Birth
Family Member
Administrative
Gender
Family Member
Race
Family Member
Ethnicity
Family Member
Relationship
Family Member
Medical History
sdtc:id
R
cda:name
R2
cda:birthTime
R2
cda:administrativeGen
derCode
O
sdtc:raceCode
R2
sdtc:ethnicGroupCode
R2
Genetic Relative
Name
Genetic Relative
Date of Birth
Genetic Relative
Gender
Genetic Relative
Race
Genetic Relative
Ethnicity
Use Care Transition
– Race Value Set
Use Care Transition
– Ethnicity Value Set
R2
cda:component
R2
cda:observation[cda:templateId/@root = ' 1.3.6.1.4.1.19376.1.5.3.1.4.13.3']
Family Member
Condition
Use Problem Type
Value Set
R2
cda:entryRelationship/cda:observation[cda:templateId/@root ='2.16.840.1.113883.10.20.1.38']
Family Member
Age (at Onset)
R2
Genetic Relative
Age at Birth
cda:entryRelationship[@typeCode='CAUS'] cda:observation
Family Member
Cause of Death
R2
Genetic Relative
Cause of Death
cda:entryRelationship/cda:observation[cda:templateId/@root ='2.16.840.1.113883.10.20.1.38']
Family Member
Age (at Death)
R2
Genetic Relative
Age at Death
cda:observation[cda:templateId/@root = ' 1.3.6.1.4.1.19376.1.5.3.1.4.13.3']
Family Member
Biological Sex
O
Genetic Relative
Sex
cda:observation[cda:templateId/@root = ' 1.3.6.1.4.1.19376.1.5.3.1.4.13.3']
Family Member
Multiple Birth
Status
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cda:observation [cda:templateId/@root = '2.16.840.1.113883.10.20.1.38']
Family Member
Age
R2
cda:observation[cda:templateId/@root = ' 1.3.6.1.4.1.19376.1.5.3.1.4.13.3']
Family Member
Genetic Test
Information
Family Member
Genetic Test
Code
Family Member
Genetic Test
Name
Family Member
Genetic Test
Result
Family Member
Genetic Test
Date
2.2.6
R2
cda:code/@code
R2
cda:code/cda:original
Text
R
cda:value
R2
cda:effectiveTime
R2
Functional Status Section
The Functional Status Section describes the patient’s status of normal functioning at the time the Care Record was
created. Functional statuses include information regarding the patient relative to:

Ambulatory ability

Mental status or competency

Activities of Daily Living (ADLs), including bathing, dressing, feeding, grooming

Home / living situation having an effect on the health status of the patient

Ability to care for self

Social activity, including issues with social cognition, participation with friends and acquaintances other
than family members

Occupation activity, including activities partly or directly related to working, housework or volunteering,
family and home responsibilities or activities related to home and family

Communication ability, including issues with speech, writing or cognition required for communication

Perception, including sight, hearing, taste, skin sensation, kinesthetic sense, proprioception, or balance
Any deviation from normal function that the patient displays and is recorded in the record should be included. Of
particular interest are those limitations that would in any way interfere with self care or the medical therapeutic
process. In addition, an improvement, any change in or noting that the patient has normal functioning status is
also valid for inclusion.


A Functional Status Section SHALL be expressed in one of 3 different forms (a Problem, a Result or as
text.)
A Functional Status Section SHALL contain one or more Problem Act and/or Result Organizer
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








In the Functional Status Section, a problem observation or result observation SHALL contain exactly one
observation / code
If the Functional Status Section was assembled using a standardized assessment instrument, then the
instrument itself SHOULD be represented in the Organizer / code of a result organizer
If the Functional Status Section was assembled using a standardized assessment instrument, then the
question within that instrument SHOULD be represented in the Observation / code of a result observation
If the Functional Status Section was assembled using a standardized assessment instrument containing
questions with enumerated values as answers, then the answer SHOULD be represented in the
Observation / value of a result observation
If Observation / value in a result observation in the Functional Status Section is of data type CE or CD, then
it SHOULD use the same code system used to code the question in Observation / code.
Observation / value in a result observation in the Functional Status Section MAY be of datatype CE or CD
and MAY contain one or more Observation / value / translation, to represent equivalent values from
other code systems.
A Problem Observation or Result Observation in the Functional Status Section MAY use codes from the
International Classification of Functioning, Disability, and Health (ICF)
A Problem Observation in the Functional Status Section SHALL contain exactly one status of functional
status observation
A Result Observation in the Functional Status Section SHALL contain exactly one status of functional status
observation.
Reference
Document
CDA Template ID (Proposed)
Required/
Optional
Consolidated
CDA IG
2.16.840.1.113883.10.20.22.2.14
Optional
HITSP/C83*
2.16.840.1.113883.3.88.11.83.109
Optional
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 47420-5 for
Required/Optional Entries
Refer to Section 2.2.1.9 in
HITSP/C83 for
Required/Optional Entries
Code Set
LOINC
2.16.840.1.1
13883.6.1
LOINC
2.16.840.1.1
13883.6.1
Implementer Notes

2.2.7
Functional Status Section conformance statements and XML examples can be found in the Functional
Status Section of the CCD
History of Present Illness Section
The History of Present Illness Section describes the history related to the reason for the procedure. It contains the
historical details leading up to and pertaining to the patient’s current complaint or reason for seeking medical care.
Because history of present illness can include past surgical history and other procedures, the Procedure History
Section may be included under the History of Present Illness Section or it may stand alone as its own section.

In the History of Present Illness Section, under the <text>element, the History of Present Illness SHALL be
provided in narrative form.
Reference
Document
CDA Template ID (Proposed)
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Required/
Optional
Consolidated CDA IG
Reference
Code Set
Page 23 of 111
Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
Consolidated
CDA IG
1.3.6.1.4.1.19376.1.5.3.1.3.4
Optional
HITSP/C83*
2.16.840.1.113883.3.88.11.83.107
Optional
Refer to the CDAR2_IG,
Section 11348-0 for
Required/Optional Entries
Refer to Section 2.2.1.7 in
HITSP/C83 for
Required/Optional Entries
LOINC
2.16.840.1.1
13883.6.1
LOINC
2.16.840.1.1
13883.6.1
Implementer Notes

2.2.8
History of Present Illness Section conformance statements and XML examples can be found in the History
of Present Illness Section of the CCD
Hospital Course Section
The Hospital Course Section describes the sequence of events from admission to discharge in a hospital facility. In
addition to conformance statements defined in the Consolidated CDA guide, the following additional conformance
statements are applicable:
Reference
Document
CDA Template ID (Proposed)
Required/
Optional
Consolidated
CDA IG
1.3.6.1.4.1.19376.1.5.3.1.3.5
Required
HITSP/C83*
2.16.840.1.113883.3.88.11.83.121
Required
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 8648-8 for
Required/Optional Entries
Refer to Section 2.2.1.21
Hospital Course Section in
HITSP/C83 for
Required/Optional Entries
Code Set
LOINC
2.16.840.1.1
13883.6.1
LOINC
2.16.840.1.1
13883.6.1
Implementer Notes

2.2.9
Hospital Course Section conformance statements and XML examples can be found in the Hospital Course
Section of the HITSP C32/C83.
Hospital Discharge Diagnosis Section
The Hospital Discharge Diagnosis Section describes the relevant problems or diagnoses that occurred during the
hospitalization or that need to be followed after hospitalization. This section includes an optional entry to record
patient conditions.


The Hospital Discharge Diagnosis Section SHALL contain exactly one Problem Observation entry level
template
The Hospital Discharge Diagnosis Section SHALL provide the discharge diagnosis in coded form.
Reference
Document
CDA Template ID (Proposed)
Required/
Optional
Consolidated
CDA IG
2.16.840.1.113883.10.20.22.2.24
Required
HITSP/C83*
2.16.840.1.113883.3.88.11.83.111
Required
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 48765-2 for
Required/Optional Entries
Refer to Section 2.2.1.211
Discharge Diagnosis
Section in HITSP/C83 for
Code Set
LOINC
2.16.840.1.1
13883.6.1
LOINC
2.16.840.1.1
13883.6.1
Page 24 of 111
Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
Required/Optional Entries
Implementer Notes

2.2.10
Hospital Discharge Diagnosis Section conformance statements and XML examples can be found in the
Discharge Diagnosis Section of the HITSP C32/C83
Hospital Discharge Medications Section
The Hospital Discharge Medications Section defines the medications that the patient is intended to take (or stop)
after discharge. At a minimum, the currently active medications should be listed with an entire medication history
as an option. The section may also include a patient’s prescription history and indicate the source of the
medication list, for example, from a pharmacy system versus from the patient. In addition to conformance
statements defined in the Consolidated CDA guide, the following additional conformance statements are
applicable:


The Hospital Discharge Medications Section SHALL include zero or more Discharge Medication entry-level
templates
The Hospital Discharge Medications Section SHALL provide the relevant medications ordered for the
patient for use after discharge in coded form.
Reference
Document
CDA Template ID (Proposed)
Required/
Optional
Consolidated
CDA IG
2.16.840.1.113883.10.20.22.2.11.1
2.16.840.1.113883.10.20.22.2.11
Required
HITSP/C83*
2.16.840.1.113883.3.88.11.83.114
Required
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 10183-2 for
Required/Optional Entries
Refer to Section 2.2.1.14
Hospital Discharge
Medications Section in
HITSP/C83 for
Required/Optional Entries
Code Set
LOINC
2.16.840.1.1
13883.6.1
LOINC
2.16.840.1.1
13883.6.1
Implementer Notes

2.2.11
Hospital Discharge Medications Section conformance statements and XML examples can be found in the
Hospital Discharge Medications Section of the HITSP C32/C83
Hospital Discharge Physical Section
The Hospital Discharge Physical Section records a narrative description of the patient’s physical findings.

In the Hospital Discharge Physical Section, under the <text>element, the Hospital Discharge Physical
SHALL be provided in narrative form.
Reference
Document
Consolidated
CDA IG
CDA Template ID (Proposed)
1.3.6.1.4.1.19376.1.5.3.1.3.26
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Required/
Optional
Optional
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 10184-0 for
Required/Optional Entries
Code Set
Page 25 of 111
Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
IHE PCC*
1.3.6.1.4.1.19376.1.5.3.1.3.26
Optional
Refer to Section 6.3.3.4.3 in
IHE PCC for
Required/Optional Entries
Implementer Notes

2.2.12
Hospital Discharge Physical Section conformance statements and XML examples can be found in the
Hospital Discharge Physical IHE PCC Template.
Hospital Discharge Studies Summary Section
This section records the results of observations generated by laboratories, imaging procedures, and other
procedures. The scope includes hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray,
ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations.
This section often includes notable results such as abnormal values or relevant trends, and could record all results
for the period of time being documented.
Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry,
hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations
are based on analysis of specimens obtained from the patient and submitted to the laboratory.
Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where
a cardiologist reports the left ventricular ejection fraction based on the review of an echocardiogram.
Procedure results are typically generated by a clinician wanting to provide more granular information about
component observations made during the performance of a procedure, such as when a gastroenterologist reports
the size of a polyp observed during a colonoscopy.

In the Hospital Discharge Studies Summary Section, under the <text>element, the Hospital Discharge
Studies Summary SHALL be provided in a table format.
Reference
Document
CDA Template ID (Proposed)
Required/
Optional
Consolidated
CDA IG
2.16.840.1.113883.10.20.22.2.16
Optional
HL7 CDT*
2.16.840.1.113883.10.20.16.2.3
Optional
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 11493-4 for
Required/Optional Entries
Refer to HL7 CDT for
Required/Optional Entries
Code Set
Implementer Notes

Note that there are discrepancies between CCD and the lab domain model, such as the effectiveTime in
specimen collection.

Hospital Discharge Studies Summary Section conformance statements and XML examples can be found in
the Hospital Discharge Studies Summary – Common Document Types.
2.2.13
Immunizations Section
The Immunizations Section defines a patient’s immunization status in the context of a care transition.


The Immunizations Section SHOULD include current immunization status
The Immunizations Section MAY contain the entire immunization history.
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Page 26 of 111
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Office of the National Coordinator for
Health Information Technology









The Immunizations Section SHALL contain at least one [1..*] Entry, such that each Entry contains exactly
one [1..1] Immunization Clinical Statement template
The Immunizations Clinical Statement Template SHALL conform to the Medication Clinical Statement
template
The Immunization Clinical Statement template SHALL contain zero or more [0..*] approachSiteCode
The Immunization Clinical Statement template SHALL contain zero or one [0..1] doseQuantity
The Immunization Clinical Statement template SHALL contain zero or one [0..1] rateQuantity
CPT-4 codes MAY be used for immunization procedures
The Immunizations Section SHALL support all data elements listed.
The Coded Product Name in the Immunizations Section SHALL be coded as specified in the Immunizations
Administered Vaccines Value Set in Appendix C
The Refusal Reason in the Immunizations Section SHALL be coded as specified in the Immunizations
Reason Value Set in Appendix C
Reference
Document
CDA Template ID (Proposed)
Required/
Optional
Consolidated
CDA IG
2.16.840.1.113883.10.20.22.2.2.1
2.16.840.1.113883.10.20.22.2.2
Optional
HITSP/C83*
2.16.840.1.113883.3.88.11.83.117
Optional
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 11369-6 for
Required/Optional Entries
Refer to Section 2.2.1.17
HITSP/C83 for
Required/Optional Entries
Code Set
LOINC
2.16.840.1.1
13883.6.1
LOINC
2.16.840.1.1
13883.6.1
Implementer Notes



The value sets recommended for the Immunizations Section are available in Appendix C of this guide.
Immunization Section conformance statements and XML examples can be found in the Immunizations
Section of the CDA R2 Consolidation Guide.
This section also needs to conform to the Immunizations Narrative Section conformance statements.
Data Element
CDA XPath Reference
R/O
CIM Reference
Null Values
Notes
cda:substanceAdministration[cda:templateId/@root = '2.16.840.1.113883.10.20.1.24']
Refusal
Administered
Date
@negationInd
R
Contraindication
Allowed
cda:effectiveTime
R
Immunization
Date
Allowed
cda:entryRelationship[@typeCode='SUBJ']/cda:observation/cda:value
Medication
Series
Number
Reaction
Performer
R
Immunization
Series
Allowed
cda:entryRelationship[@typeCode='CAUS']/cda:observation[cda:templateId/@root=
2.16.840.1.113883.10.20.1.54]
Observed
O
Reaction
cda:performer/
O
Immunization ID
cda:assignedEntity
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Page 27 of 111
Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
cda:consumable/cda:manufacturedProduct
Coded
Product
Name
Free Text
Product
Name
Drug
Manufacturer
Lot Number
cda:
manufacturedMaterial/
cda:code
cda:originalText
cda:
manufacturerOrganization
cda:manufacturedMaterial
/cda:lotNumberText
R
R
R
R
Active Medication
List
Active Medication
List
Active Medication
List
Active Medication
List
Allowed
Allowed
If the name of the
product is unknown,
the type, purpose or
other description
may be supplied.
Allowed
Allowed
cda:entryRelationship[@typeCode=RSON]/cda:act[cda:templateId/@root=2.16.840.1.113883.10.20.1.27]
Refusal
Reason
2.2.14
R2
Contraindication
Reason
List of Surgeries Section
This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to
the patient historically at the time the document is generated. The section may contain all procedures for the
period of time being summarized, but should include notable procedures. The common notion of "procedure" is
broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore this section
contains procedure templates represented with three RIM classes Act: Observation and Procedure. Procedure act
is for procedures the alter that physical condition of a patient (Splenectomy). Observation act is for procedures
that result in new information about a patient but do not cause physical alteration (EEG). Act is for all other types
of procedures (dressing change).





The List of Surgeries Section SHALL conform to the Surgeries Narrative Section conformance statements.
The List of Surgeries Section SHALL include entries from the Procedure section
The List of Surgeries Section SHOULD contain zero or one [0..1] entry, such that contains exactly one [1..1]
External Reference
The List of Surgeries Section SHOULD contain at least one [1..*] entry, such that contains exactly one [1..1]
Procedure Activity Procedure
The List of Surgeries Section SHOULD satisfy one or more of the following Clinical Statement Templates:
o ProcedureActivityAct
o ProcedureActivityObservation
o ProcedureActivityProcedure
Reference
Document
CDA Template ID (Proposed)
Required/
Optional
Consolidated
CDA IG
2.16.840.1.113883.10.20.22.2.7
Optional
HITSP/C83*
2.16.840.1.113883.3.88.11.83.108
Optional
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 47519-4 for
Required/Optional Entries
Refer to Section 2.2.1.8
HITSP/C83 for
Required/Optional Entries
Code Set
LOINC
2.16.840.1.1
13883.6.1
LOINC
2.16.840.1.1
13883.6.1
Page 28 of 111
Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
Implementer Notes


2.2.15
List of Surgeries Section conformance statements and XML examples can be found in the Surgeries
Section of the CDA R2 Consolidation Guide.
This section also needs to conform to the Surgeries Narrative Section conformance statements.
Plan of Care Section
The Plan of Care Section contains data that defines pending orders, interventions, encounters, services, and
procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only. All
active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of
clinical significance to the current care of the patient should be listed unless constrained due to privacy issues. The
plan may also contain information about ongoing care of the patient and information regarding goals and clinical
reminders. Clinical reminders are placed here to provide prompts for disease prevention and management, patient
safety, and health-care quality improvements, including widely accepted performance measures. The plan may
also indicate that patient education was given or will be provided. In addition to conformance statements defined
in the Consolidated CDA guide, the following additional conformance statements are applicable:


This section SHALL conform to the HL7 History and Physical Note and HL7 Consultation Note requirements
for this section
This section MAY include entries conforming to the Hospital Discharge Medications and Immunizations
Sections to provide information about the intended care plan.
Reference
Document
CDA Template ID (Proposed)
Required/
Optional
Consolidated
CDA IG
2.16.840.1.113883.10.20.22.2.10
Required
HITSP/C83*
2.16.840.1.113883.3.88.11.83.124
Required
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 18776-5 for
Required/Optional Entries
Refer to Section 2.2.1.24
Plan of Care Section in
HITSP/C83 for
Required/Optional Entries
Code Set
LOINC
2.16.840.1.1
13883.6.1
LOINC
2.16.840.1.1
13883.6.1
Implementer Notes

Plan of Care Section conformance statements and XML examples can be found in the Plan of Care Section
of the CCD
NOTE: The data elements required for the Plan of Care Section are being developed as part of the S&I Framework
Longitudinal Coordination of Care WG.
2.2.16
Problem List Section
This section lists and describes all relevant clinical problems at the time the document is generated. At a minimum,
all pertinent current and historical problems should be listed. In addition to conformance statements defined in
the Consolidated CDA guide, the following additional conformance statements are applicable:

The Problem List Section SHOULD contain all reconciled problems, including all discharge diagnoses.
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Page 29 of 111
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Office of the National Coordinator for
Health Information Technology






In the Problem List Section, the Problem Name SHALL be recorded in the Problem Entry by recording a
<reference> where the value attribute points to the narrative text containing the name of the problem.
In the Problem List Section, the Age (at Onset) SHALL be recorded in the <low> element of the
<effectiveTime> element
In the Problem List Section, the Treating Provider or Providers SHALL be recorded in a <performer>
element under the <act> that describes the problem
In the Problem List Section, the Treating Provider ID SHALL be present in the <id> element beneath the
<assignedEntity>
In the Problem List Section, the Problem Type SHALL be coded as specified in the Problem Type Value Set
in Appendix C.
In the Problem List Section, the Problem SHALL be coded as specified in the Care Transition - Problem
Value Set Recommendation in Appendix C
Reference
Document
CDA Template ID (Proposed)
Required/
Optional
Consolidated
CDA IG
2.16.840.1.113883.10.20.22.2.5.1
2.16.840.1.113883.10.20.22.2.5
Required
HITSP/C83*
2.16.840.1.113883.3.88.11.83.103
Required
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 11450-4 for
Required/Optional Entries
Refer to Section 2.2.1.3
Problem List Section in
HITSP/C83 for
Required/Optional Entries
Code Set
SNOMED-CT
2.16.840.1.1
13883.6.96
LOINC
2.16.840.1.1
13883.6.1
Implementer Notes



The value sets recommended for the Problems Section are available in Appendix C of this guide.
Problem List Section conformance statements and XML examples can be found in the Problem List Section
of the CDA R2 Consolidation Guide.
This section also needs to conform to the Problem List Narrative Section conformance statements.
Data Element
CDA XPath Reference
R/O
CIM Reference
Null Values
Notes
cda:act[cda:templateId/@root='2.16.840.1.113883.10.20.1.27']/
cda:entryRelationship[@typeCode='SUBJ']/cda:observation[cda:templateId/@root='2.16.840.1.113883.10.20.1.28']
Start Date of
Problem Date
cda:effectiveTime
R
Allowed
Problem Entry
Problem
Active Problem
Problem Type
cda:code
R
Not Allowed
Problem Entry
Type
Active Problem
Problem Name cda:text
R
Allowed
Problem Entry
Name
Active Problem
Problem Code
cda:value
R
Allowed
Problem Entry
Attributes
cda:act[cda:templateId/@root='2.16.840.1.113883.10.20.1.27']/cda:performer
Treating
Provider
O
Problem Assignee
cda:entryRelationship/cda:observation[cda:templateId/@root ='2.16.840.1.113883.10.20.1.38']
Age (at Onset)
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
O
Page 30 of 111
Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
cda:entryRelationship[@typeCode='CAUS']/cda:observation
Cause of Death
R
Allowed
cda:entryRelationship/cda:observation[cda:templateId/@root ='2.16.840.1.113883.10.20.1.38']
Age (at Death)
O
Time of Death
R
Treating
Provider ID
R2
Problem Status
2.2.17
cda:entryRelationship
/cda:observation
/value/@code
R
Allowed
Problem Assignee
ID
See Notes
Allowed
Allowed
The CIM assumes
for an active
problem list that the
Problem Status is
Active
Procedures Section
This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to
the patient historically at the time the document is generated. The section may contain all procedures for the
period of time being summarized, but should include notable procedures.




In the Procedures Section, for Body Site, implementers SHOULD use the Care Transition – Body Site Value
Set defined in Appendix C.
The Procedure Section SHALL contain all procedures.
The Procedures Section MAY be encoded using CPT-4 codes.
The Procedures Section SHOULD include one or more of the following entry-level CDA templates:
o ProcedureActivityAct
o ProcedureActivityObservation
o ProcedureActivityProcedure
Reference
Document
CDA Template ID (Proposed)
Required/
Optional
Consolidated
CDA IG
2.16.840.1.113883.10.20.22.2.7.1
Optional
HITSP/C83*
2.16.840.1.113883.3.88.11.83.108
Optional
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 47519-4 for
Required/Optional Entries
Refer to Section 2.2.1.8
HITSP/C83 for
Required/Optional Entries
Code Set
LOINC
2.16.840.1.1
13883.6.1
LOINC
2.16.840.1.1
13883.6.1
Implementer Notes



The CIM uses an object called Invasive and Non-Invasive procedures to capture procedure information.
That CIM Object is reflective of this CDA Section.
The value sets recommended for the Procedures Section are available in Appendix C of this guide.
Procedures Section conformance statements and XML examples can be found in the Procedures Section
of the CCD.
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Page 31 of 111
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Office of the National Coordinator for
Health Information Technology
Data Element
CDA XPath Reference
R/O
CIM Reference
Null Values
Notes
cda:procedure[cda:templateId/@root='2.16.840.1.113883.10.20.1.29']
Procedure ID
cda:id
R
cda:code
R
cda:originalText/
cda:reference/@value
R
Procedure Date
cda:effectiveTime
R
Procedure Date
Allowed
Procedure
Provider
cda:performer/
cda:assignedEntity
R
Entity Performing
Procedure
Allowed
Body Site
targetSiteCode
R2
Site of Procedure
Coded
Procedure Type
Procedure Type
Free Text
2.2.18
Procedure ID
Type of Procedure
Performed
Procedure
Narrative
Allowed
Use Procedure
Value Set
Allowed
Allowed
Use Care Transition
– Body Site Value
Set
Reason for Visit Section
This section records the patient's the reason for the patient's visit (the provider’s description of the reason for
visit). Local policy determines whether the information is divided into two sections or recorded in one section
serving both purposes.

The Reason for Visit Section MAY be entered as part of the Chief Complaint Section or entered as a
separate section.
Reference
Document
Consolidated
CDA IG
HITSP/C83*
CDA Template ID (Proposed)
2.16.840.1.113883.10.20.22.2.12
2.16.840.1.113883.3.88.11.83.105
Required/
Optional
Optional
Optional
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 29299-5 for
Required/Optional Entries
Refer to Section 2.2.1.5
HITSP/C83 for
Required/Optional Entries
Code Set
Implementer Notes

2.2.19
An implementation example of how to use the Reason for Visit Section with the Chief Complaint Section is
provided in Appendix D – XML Examples.
Review of Systems Section
The Review of Systems Section contains a relevant collection of symptoms and functions systematically gathered
by a clinician. It includes symptoms the patient is currently experiencing, some of which were not elicited during
the history of present illness, as well as a potentially large number of pertinent negatives, for example, symptoms
that the patient denied experiencing.

The Review of Systems Section SHALL conform to the HL7 Consultation Note
(2.16.840.1.113883.10.20.22.1.4)
Reference
Document
CDA Template ID (Proposed)
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Required/
Optional
Consolidated CDA IG
Reference
Code Set
Page 32 of 111
Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
Consolidated
CDA IG
1.3.6.1.4.1.19376.1.5.3.1.3.18
Optional
HITSP/C83*
2.16.840.1.113883.3.88.11.83.120
Optional
Refer to the CDAR2_IG,
Section 10187-3 for
Required/Optional Entries
Refer to Section 2.2.1.20
HITSP/C83 for
Required/Optional Entries
LOINC
2.16.840.1.1
13883.6.1
LOINC
2.16.840.1.1
13883.6.1
Implementer Notes

2.2.20
Review of Systems Section conformance statements and XML examples can be found in the Review of
Systems Section of HITSP C32/C83.
Social History Section
The Social History Section contains data defining the patient’s occupational, personal (e.g. lifestyle), social, and
environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity
and religious affiliation. Social history can have significant influence on a patient’s physical, psychological and
emotional health and wellbeing so should be considered in the development of a complete record.













The Social History Section SHALL support all the data elements listed
The Social History Section MAY contain zero or more [0..*] entry, such that contains exactly one [1..1]
Social History
In the Social History Section, the Social History Type SHALL be coded as specified in the Social History Type
Value Set in Appendix C
The Social History Section SHOULD contain zero or one [0..1] effectiveTime
The Social History Section SHALL contain exactly one [1..1] text
Marital status SHOULD be represented as maritalStatusCode. Additional information MAY be represented
as social history observations
Religious affiliation SHOULD be represented as religiousAffiliationCode. Additional information MAY be
represented as social history observations
A patient’s race SHOULD be represented as raceCode. Additional information MAY be represented as
social history observations
In the Social History Section, a patient’s race SHALL be coded as specified in the Care Transition - Race
Value Set in Appendix C
A patient’s ethnicity SHOULD be represented as ethnicGroupCode. Additional information MAY be
represented as social history observations.
In the Social History Section, a patient’s ethnicity SHALL be coded as specified in the Care Transition Ethnicity Value Set in Appendix C
The value for Observation code in a social history observation SHOULD be selected from a LOINC or
SNOMED-CT Value Set
In the Social History Section, where Observation / value is a physical quantity, the unit of measure SHALL
be expressed using a valid Unified Code for Units of Measure (UCUM) expression
Reference
Document
Consolidated
CDA IG
CDA Template ID (Proposed)
2.16.840.1.113883.10.20.22.2.17
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Required/
Optional
Optional
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 29762-2 for
Required/Optional Entries
Code Set
LOINC
2.16.840.1.1
13883.6.1
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HITSP/C83*
2.16.840.1.113883.3.88.11.83.126
Optional
Refer to Section 2.2.1.26
HITSP/C83 for
Required/Optional Entries
LOINC
2.16.840.1.1
13883.6.1
Implementer Notes


The value sets recommended for the Social History Section are available in Appendix C of this guide.
Social History Section conformance statements and XML examples can be found in the Social History
Section of the CCD.
Data Element
CDA XPath Reference
R/O
CIM Reference
Null Values
Notes
cda:observation[cda:templateId/@root= ' 2.16.840.1.113883.10.20.22.4.38’]
Social History
Dates
Social History
Type
Social History
Free Text
Social History
Observed Value
2.2.21
cda:effectiveTime
R
cda:code
R
cda:text
R
cda:value
O
Social History
Recorded Date
Social History
Type
Social History
Additional Details
Social History
Attributes
Allowed
Not Allowed
Use Social History
Type Value Set
Allowed
Allowed
Vital Signs Section
The Vital Signs Section contains current and historically relevant vital signs for the context and use case of the
document type, such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head
circumference, and pulse oximetry. The section should include notable vital signs such as the most recent,
maximum and/or minimum, baseline, or relevant trends.
Vital signs are represented in the same way as other results, but are aggregated into their own section to follow
clinical conventions.


The Vital Signs Section SHALL support all the data elements listed
The Vital Sign Result Type SHALL be coded as specified in the Vital Sign Result Type Value Set in Appendix
C
Reference
Document
CDA Template ID (Proposed)
Required/
Optional
Consolidated
CDA IG
2.16.840.1.113883.10.20.22.2.4.1
Optional
HITSP/C83*
2.16.840.1.113883.3.88.11.83.119
Optional
Consolidated CDA IG
Reference
Refer to the CDAR2_IG,
Section 8716-3 for
Required/Optional Entries
Refer to Section 2.2.1.19
HITSP/C83 for
Required/Optional Entries
CIM
Priority
SNOMED-CT
2.16.840.1.1
13883.6.96
LOINC
2.16.840.1.1
13883.6.1
Implementer Notes


Vital Signs Section conformance statements and XML examples can be found in the Vital Signs Section of
the CDA R2 Consolidation Guide.
The value sets recommended for the Vital Signs Section are available in Appendix C of this guide.
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
This section also needs to conform to the Vital Signs Narrative Section conformance statements.
Data Element
CDA XPath Reference
R/O
CIM Reference
Null Values
Notes
cda:observation[cda:templateId/@root = ‘2.16.840.1.113883.10.20.22.4.27’]
Vital Sign Result
ID
Vital Sign Result
Date/Time
Vital Sign Result
Type
Vital Sign Result
Status
Vital Sign Result
Value
Vital Sign Result
Interpretation
Vital Sign Result
Reference
Range
cda:id
R
Vital Sign ID
Allowed
cda:effectiveTime
R
Observation Time
Allowed
cda:code
R
Vital Sign Type
Allowed
cda:statusCode
R
Status
Allowed
cda:value
R
Patient State
Allowed
cda:interpretationCode
O
Observation List
Allowed
cda:referenceRange
O
Observation
Range
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Created on 8/31/2011
Use Vital Sign Result
Type Value Set
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3. TOC Clinical Information Model (CIM)
The Transitions of Care (ToC) Clinical Information Model (CIM) has been developed in support of the S&I
Framework to promote healthcare stakeholders’ collective understanding of care transitions. It is a prototype that
is intended to serve as a logical overlay and unbiased representation of the data needed to support care
transitions. Moreover, while CIM provides insight to clinicians into the type of data needed to support care
transitions, it also gives implementers and vendors perspective on how to store and exchange that data. The ToC
CIM is intended to be a logical view of the common data model that underlies all care transition information. In
practice, it will manifest itself as physical data within an organization engaged in transitions of care but is not tied
to an underlying information model.
The focus of the CIM is on providing a clear view for a clinician on the data they are accustomed to looking at and
manipulating within their clinical workflow. In this way, it provides a functional perspective that allows for the
mapping of care transition requirements to an underlying technical standard. For the TOC CIM, this means
mapping to the underlying CDA on which entity, known as a CIM Object, would be based. A secondary purpose is
to enable the creation of an object-oriented model that maps the requirements for care transitions to ToC CIM
objects. This is a longer-term goal that will require further testing and analysis of the ToC CIM. For additional
information on the development of the CIM, reference the TOC Clinical Information Model on the wiki.
ToC CIM Objects
The following table lists the CDA implementation guidance for all ToC CIM Objects, as defined by the S&I
Framework Transitions of Care Initiative. Specific guidance is provided showing a mapping from each CIM Object to
the relevant CDA Section and Entry-Level templates that are used to provide the CIM Data Elements needed.
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All CDA Mappings
CIM Object Name
Active Medication List
Active Problem List
Admitting and Discharging Diagnoses
Allergies and Intolerances
Anticipatory Guidance
Behavioral Health History
Care Team Members
Consultant(s) Assessment(s) and
Plan(s) Recommendations
Culturally Sensitive Patient Care
Demographics
Diet
Discontinued Medications
Equipment
Existence of Advanced Directives
Family History
Follow-up Appointments
Goals
CDA Template ID
CDA Section ID
2.16.840.1.113883.10.20.22.2.1.1
2.16.840.1.113883.10.20.22.2.1
2.16.840.1.113883.10.20.22.2.38
4.28 Medications
2.16.840.1.113883.10.20.22.2.7
2.16.840.1.113883.10.20.22.2.24
2.16.840.1.113883.10.20.22.4.33
2.16.840.1.113883.10.20.21.2.6.1
2.16.840.1.113883.10.20.21.2.6.
TO BE DETERMINED
TO BE DETERMINED
TO BE DETERMINED
2.16.840.1.113883.10.20.22.1.9
2.16.840.1.113883.10.20.21.1.1
[US Realm Document Header]
2.16.840.1.113883.10.20.21.1.1
[US Realm Document Header]
1.3.6.1.4.1.19376.1.5.3.1.3.33
2.16.840.1.113883.10.20.22.2.1
2.16.840.1.113883.10.20.22.2.23
2.16.840.1.113883.10.20.22.2.21
2.16.840.1.113883.10.20.22.2.15
2.16.840.1.113883.10.20.21.2.10
2.16.840.1.113883.10.20.21.2.1
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
4.40 Problem List
4.20 Hospital Discharge Diagnosis
4.2 Allergies, Adverse Reactions,
Alerts
CDA Entry ID
5.14 Medication Activity
5.16 Medication Information
5.12 Indication
5.13 Instructions
5.17 Medication Supply Order
5.19 Precondition for Substance
Administration
5.9 Drug Vehicle
5.3 Allergy Problem Act
5.5 Condition
5.6 Condition Entry
5.7 Discharge Diagnosis
5.4 Allergy Alert Observation
5.3 Allergy Problem Act
4.35 Plan
4.4 Assessment
4.5 Assessment and Plan
4.11 Discharge Diet
4.28 Medications
5.14 Medication Activity
5.16 Medication Information
4.26 Medical Equipment
4.1 Advance Directives
4.13 Family History
4.35 Plan
4.30 Objective
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All CDA Mappings
CIM Object Name
CDA Template ID
Health Literacy
Health Maintenance
History Present Illness
TO BE DETERMINED
TO BE DETERMINED
1.3.6.1.4.1.19376.1.5.3.1.3.4
Immunization History
2.16.840.1.113883.10.20.22.2.2.1
2.16.840.1.113883.10.20.22.2.2
Invasive and Non-Invasive Procedures
2.16.840.1.113883.10.20.22.2.7
Medical History
2.16.840.1.113883.10.20.22.2.39
2.16.840.1.113883.10.20.22.2.1
Medication History
2.16.840.1.113883.10.20.22.1.7
Operative Summary
CDA Section ID
4.35 Plan
4.18 History of Present Illness
4.24 Immunizations
4.41 Procedure Description
4.42 Procedure Disposition
4.43 Procedure Estimated Blood Loss
4.44 Procedure Findings
4.45 Procedure Implants
4.46 Procedure Indications
4.47 Procedure Specimens Taken
4.48 Procedures Section
4.27 Medical History
4.28 Medications
5.21 Procedure Activity
5.22 Procedure Activity Act
5.23 Procedure Activity Observation
5.14 Medication Activity
5.16 Medication Information
5.2 Alert Status Observation
Patient Contact Information
2.16.840.1.113883.10.20.21.1.1
[US Realm Document Header]
2.16.840.1.113883.10.20.21.1.1
[US Realm Document Header]
Patient Information
2.16.840.1.113883.10.20.21.1.1
[US Realm Document Header]
Patient Instructions
Patient Self-Management
5.21 Immunization Activity
5.22 Immunization Medication
Information
5.23 Refusal Reason
4.31 Operative Note Fluid
4.32 Operative Note Surgical
Procedure
Outcome of Allergy/Intolerance
Patient Consent Directive
CDA Entry ID
2.16.840.1.113883.10.20.21.4.20
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5.13 Instructions
4.35 Plan
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All CDA Mappings
CIM Object Name
Payer Information
CDA Template ID
2.16.840.1.113883.10.20.22.2.18
Pending Tests and Procedures
Physical Activity
Physical Exam
Primary Care Physicians and
Designated Providers
Reason for Consult Request
Restorative Care
Review of Systems
Social Determinants of Health
Social History
Support Contacts
2.16.840.1.113883.10.20.21.2.2
2.16.840.1.113883.10.20.22.2.19
2.16.840.1.113883.10.20.21.1.1
[US Realm Document Header]
CDA Section ID
4.33 Payer
4.35 Plan
4.48 Procedure
4.53 Subjective
4.34 Physical Exam
CDA Entry ID
4.49 Reason for Visit
TO BE DETERMINED
1.3.6.1.4.1.19376.1.5.3.1.3.18
TO BE DETERMINED
2.16.840.1.113883.10.20.22.2.17
2.16.840.1.113883.10.20.21.1.1
[US Realm Document Header]
4.51 Review of Systems
4.5.2 Social History
5.59 Social History Observation
5.21 Procedure Activity
5.22 Procedure Activity Act
5.23 Procedure Activity Observation
5.30 Vital Signs Organizer
5.31 Vital Signs Observation
Surgical/Procedure History
2.16.840.1.113883.10.20.22.2.7
4.41 Procedure Description
4.48 Procedure
Vital Signs
2.16.840.1.113883.10.20.22.2.4.1
2.16.840.1.113883.10.20.22.2.4
4.34 Physical Exam
4.56 Vital Signs
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4. Additional Guidance for Implementers and Vendors
The following information is supplied as a starting point for information on the various tools and information one
may find useful (depending on their proficiency).
•
•
•
•
Comparison and conversion tools to migrate from the existing CDA standard to new Consolidated CDA
CCR-Consolidated CDA conversion tool for vendors who previously implemented CCR*
Openly available data modeling tools, reference implementation code, and test suite**, to aid to lower
implementation time and costs
Educational resources
Tools
The Transitions of Care Initiative has worked to enable the availability of multiple tools and educational resources
needed in support of using technology to improve care transitions. These tools are designed to provide the level of
automated tooling needed in support of Consolidated CDA.
4.1.1
OHT/MDHT
The implementation guidance used for Transitions of Care is designed to be generated directly from MDHT. The
MDHT-generated guidance includes the appropriate level of specification and detail needed to implement a care
transition information exchange, including API’s, code documentation, and models needed for implementation.
MDHT allows the creation of computable models of the templates in UML. These models can be used to produce:




Template Specifications (DITA, XHTML, PDF, Other)
Conformance/Validation Tools
Model Driven Code Generation
Schematron
The project has already built models from the following specifications:





HL7 Continuity of Care Document
HITSP C83 Sections and Entries
IHE Patient Care Coordination Technical Framework
HL7 Common Document Types
Consolidated CDA
MDHT is available for download at: https://www.projects.openhealthtools.org/sf/projects/mdht/
4.1.2
Trifolia
Tooling support is also provided by Lantana Group and their Trifolia Workbench, which supports standards
authors, developers and implementers in capturing, storing and managing HL7 Clinical Document Architecture
(CDA) templates.
Trifolia is available for download from http://www.lantanagroup.com/resources/tools/
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4.1.3
NIST Validation/MU testing sites
This site organizes key resources (e.g. HITSP, CCHIT, standards and testing tools) in a central place to provide a
resource for implementation and interoperability testing activities.
http://hit-testing.nist.gov/
http://xreg2.nist.gov/hit-testing/
4.1.4
TOC Quickstart Site
The Transitions of Care (TOC) Quickstart site is a central source to view and download Transitions of Care Initiative
guides, work products and models.
http://wiki.siframework.org/Transitions+of+Care+Quickstart+Page
4.1.5
myCDA
This wiki page serves as a central source for educational and training resources in support of Consolidated CDA.
With links to samples, FAQs, and guidance on implementing care transition information exchanges. Sample XML
and XSL code is also available to help implementers get started with the use of CDA.
The myCDA site is under development and will be available in the next release of this guidance.
Educational Resources
4.2.1
Clinical Document Architecture (CDA)
The full Clinical Document Architecture Normative Edition is available for purchase from www.HL7.org, this
package includes additional publications such as Datatypes, HL7 Value Sets, and other detailed information
required for proper implementation of CDA.
The following links are provided for those who wish to further their understanding of the HL7 CDA and the
ASTM/HL7 Continuity Of Care Document Implementation Guide. The former is the “base standard” selected by S&I
Transitions Of Care Initiative for all healthcare documents.


4.2.1.1



CDA Quick Start Guide (v1.5) This Quick Start Guide supports implementers working with simple CDA
documents. It covers required elements in the CDA header and body and explains fundamental concepts
including the CDA approach to identifiers, vocabulary and data types.
CCD Quick Start Guide (v1.0) This Quick Start Guide is for implementers working with the Continuity of
Care Document (CCD) which is the basis of the HITSP/C32. Readers should be familiar with the underlying
Clinical Document Architecture Release 2.0 (CDA R2) standard, (see the CDA Quick Start Guide).
HL7 Structured Documents Technical Committee Wiki
This Wiki site is a subset of the full HL7 Wiki site (wiki.hl7.org)
Login is not required for browsing pages: http://wiki.hl7.org/index.php?title=Structured_Documents
There are a number of sub-categories available from this page relative to the use of CDA, items of
particular interest may be: CDA Suggested Enhancements and the associated Formal Proposals, Continuity
of Care Document and CCD Errata
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5. Appendix A – Reference Documents
Document Description
Document Name
Consolidated CDA
Implementation Guide
Base standard implementation guide that is used. The
Consolidated CDA IG contains a library of CDA templates,
incorporating and harmonizing previous efforts from
Health Level Seven (HL7), Integrating the Healthcare
Enterprise (IHE), and Health Information Technology
Standards Panel (HITSP).
Consolidated CDA
Implementation Guide
can be accessed here
Click here to access
HITSP C80 in PDF Format
Click here to access HITSP
C83 in PDF Format
Click here to access HITSP
C154 in PDF Format
HITSP C80
HITSP C83
HITSP C154
S&I Framework
Transitions of Care
Clinical Information
Model (CIM)
CDA Quick Start Guide
v1.5
Reference Location
The TOC CIM can be
accessed here
This Quick Start Guide supports implementers working
with simple CDA documents. It covers required elements
in the CDA header and body and explains fundamental
concepts including the CDA approach to identifiers,
vocabulary and data types.
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Created on 8/31/2011
CDA Quick Start Guide
v1.5 can be accessed
here
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6. Appendix B – Acronym List
Acronym
CIM
CCR
CDA
FIPS
HITSP
HL7
Definition of Acronym
A Clinical Information Model is a conceptual definition of the
discrete structured clinical information that is used in a
clinical context. The model defines the data elements,
attributes, possible values and types of attributes that are
needed to convey the clinical reality in a fashion that is
understandable to both clinical domain experts and modelers.
These models have the potential for being used as part of
electronic health information exchange including EMR's,
EHR's, Telehealth applications, medical devices, analytics,
decision support among others.
Continuity of Care Record - is a patient health summary
standard. It is a way to create flexible documents that contain
the most relevant and timely core health information about a
patient, and to send these electronically from one caregiver
to another. It contains various sections such as patient
demographics, insurance information, diagnosis and problem
list, medications, allergies and care plan. These represent a
"snapshot" of a patient's health data that can be useful or
possibly lifesaving, if available at the time of clinical
encounter.
Clinical Document Architecture - an XML based markup
standard intended to specify the encoding, structure and
semantics of clinical documents for exchange
Under the Information Technology Management Reform Act
(Public Law 104-106), the Secretary of Commerce approves
standards and guidelines that are developed by the National
Institute of Standards and Technology (NIST) for Federal
computer systems. These standards and guidelines are issued
by NIST as Federal Information Processing Standards (FIPS)
for use government-wide. NIST develops FIPS when there are
compelling Federal government requirements such as for
security and interoperability and there are no acceptable
industry standards or solutions.
The American National Standards Institute (ANSI) Healthcare
Information Technology Standards Panel; a body created in
2005 in an effort to promote interoperability and
harmonization of healthcare information technology through
standards that would serve as a cooperative partnership
between the public and private sectors.
Health Level Seven International (HL7) is a not-for-profit,
ANSI-accredited standards developing organization dedicated
to providing a comprehensive framework and related
standards for the exchange, integration, sharing, and retrieval
of electronic health information that supports clinical practice
and the management, delivery and evaluation of health
services.
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Created on 8/31/2011
Source
http://wiki.siframework.org/
ToC+Glossary+of+Terms
http://wiki.siframework.org/
ToC+Glossary+of+Terms
http://wiki.siframework.org/
ToC+Glossary+of+Terms
http://www.itl.nist.gov/fipsp
ubs/geninfo.htm
http://wiki.siframework.org/
ToC+Glossary+of+Terms
http://www.hl7.org/about
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Acronym
LOINC
OIP
SNOMED-CT
Definition of Acronym
Source
Logical Observation Identifiers Names and Codes (LOINC) is a
database and universal standard for identifying medical
laboratory observations. It was developed and is maintained
by the Regenstrief Institute, a US non-profit medical research
organization, in 1994. LOINC was created in response to the
demand for an electronic database for clinical care and
management and is publicly available at no cost.
http://wiki.siframework.org/
ToC+Glossary+of+Terms
ONC Initiative Partner (commonly referred to as OIP) is any
organization involved in the following ONC programs: State
HIE Programs, Beacon Communities, Challenge Grantees,
Standards and Interoperability (S&I) Framework.
Systemized Nomenclature of Medicine - is a systematically
organized computer processable collection of medical
terminology covering most areas of clinical information such
as diseases, findings, procedures, microorganisms,
pharmaceuticals etc.
http://wiki.siframework.org/
ToC+Glossary+of+Terms
http://wiki.siframework.org/
ToC+Glossary+of+Terms
7. Appendix C – Recommended Value Sets
This appendix contains recommended value sets drawn from work with the Health IT Standards Committee,
Beacon Communities, and State HIE programs. These value sets have also been drawn from the Consolidated CDA
Guide and its supporting value sets.
The following rules apply in the use of these value sets:



Wherever possible, this guidance will adhere to the recommendations of the Health IT Standards
Committee on vocabularies and controlled terminologies. In those cases where a value set that aligns to
these recommendations cannot be found, an alternative value set is proposed that may use a different
vocabulary.
Implementers from the ONC Beacon Communities and ONC State HIE Programs (sometimes referred to as
ONC Initiative Partners, or OIPs) have provided value set recommendations in some areas where
implementers wish to provide a set of most commonly used codes
In almost all cases, the value set adopted has been aligned to the Consolidated CDA Guide.
Advance Directive Type Recommended Value Set
In alignment with the CDA Consolidation Guide, the Transitions of Care Initiative recommends the following value
set for coding Advance Directive types.
Code
52765003
61420007
71388002
78823007
Name
Intubation
Tube Feedings
Other Directive
Life Support
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Code
89666000
225204009
281789004
304251008
Name
CPR
IV Fluid and Support
Antibiotics
Resuscitation
Allergy/Adverse Event Food and Other Allergens Value Set
The value set for coding Food and other allergens in a care transition is to use any ingredient name drawn from the
FDA Structured Product Labeling (SPL) subset

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Allergy/Adverse Event Reaction Value Set
Any problem drawn from the VA/KP Problem List Subset of SNOMED CT may be used. This set of SNOMED terms
and codes is freely reusable worldwide without licensing or intellectual property restrictions.
http://evs.nci.nih.gov/ftp1/FDA/ProblemList/

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Allergy/Adverse Event Type Value Set
The value set used to code for allergy and/or adverse event type in a care transition uses the following list of
SNOMED-CT concept codes, which describe the type of product and intolerance suffered by the patient:
Concept Name
Propensity to adverse reactions (disorder)
Propensity to adverse reactions to substance (disorder)
Propensity to adverse reactions to drug (disorder)
Propensity to adverse reactions to food (disorder)
Allergy to substance (disorder)
Drug allergy (disorder)
Drug intolerance (disorder)
Food intolerance (disorder)
Propensity to adverse reactions (disorder)

Concept Code (SNOMED-CT)
420134006
418038007
419511003
418471000
419199007
416098002
59037007
235719002
420134006
NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Care Transition – Body Site Value Set
The value set for representing a Body Site in a care transition contains values descending from the SNOMED-CT
Anatomical Structure (91723000) hierarchy or Acquired body structure (body structure) (280115004) or
Anatomical site notations for tumor staging (body structure) (258331007) or Body structure, altered from its
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Health Information Technology
original anatomical structure (morphologic abnormality) (118956008) or Physical anatomical entity (body
structure) (91722005) This indicates the anatomical site.
The Body Site value set can be accessed directly from NLM UMLS at the following location:
http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Care Transition – Contact Type Value Set
For a care transition, the value set to use for identifying family relationships is the HL7 RoleClassCode. This
represents the type of individual support provided, such as immediate emergency contacts, next of kin, family
relations, guardians, agents, et cetera
HL7 RoleClass Code
PRS
NOK
CAREGIVER
AGNT
GUAR
ECON
Usage Note
personal relationship
next of kin
caregiver
agent
guarantor
emergency contact
Care Transition – Country Value Set
The value set for coding a country is to use any ISO 3166-1 Codes for the representation of names of countries and
their subdivisions: Part 1 Countries.
The codes are available here: http://www.iso.org/iso/country_codes/iso_3166_code_lists.htm

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Care Transition – Medication Brand Name Value Set
The value set for a Medication Brand Name in a care transition uses any RxNorm normal forms for concepts type of
Brand Name or Brand Name Packs. The Brand name concepts can be found in the RxNORM file RXCONSO.RRF
selecting all terms where SAB=RXNORM (selecting the normal forms), and TTY=BN (selecting the brand names) or
TTY=BPCK (selecting the brand name packs)

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Care Transition - Medication Clinical Drug Name Value Set
The value set for a Medication Clinical Drug Name in a care transition uses any RxNorm normal forms for concepts
type of Ingredient Name or Generic Packs.
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Page 46 of 111
Last Updated on 11/15/2011
Office of the National Coordinator for
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The ingredient name concepts can be found in the RxNORM file RXCONSO.RRF selecting all terms where
SAB=RXNORM (selecting the normal forms), and TTY=IN (selecting the ingredient names) or TTY=GPCK (selecting
the generic packs)

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Care Transition - Medication Drug Class Value Set
The value set for a care transition is to use any NDF-RT Code drawn from the following NDF-RT SPL Subsets:



Mechanism of Action
Physiologic Effect
Structural Class
These subsets can be accessed at the following location: http://evs.nci.nih.gov/ftp1/FDA/ndfrt/

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Care Transition – Patient Class Value Set

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Concept
Code
Concept Name
EMER
Emergency
IMP
Inpatient Encounter
AMB
Ambulatory
Definition
A patient encounter that takes place at a dedicated healthcare service
delivery location where the patient receives immediate evaluation and
treatment, provided until the patient can be discharged or responsibility for
the patient's care is transferred elsewhere (for example, the patient could
be admitted as an inpatient or transferred to another facility.)
A patient encounter where a patient is admitted by a hospital or equivalent
facility, assigned to a location where patients generally stay at least
overnight and provided with room, board, and continuous nursing service
A comprehensive term for healthcare provided in a healthcare facility (e.g.,
a practitioners office, clinic setting, or hospital) on a nonresident basis. The
term ambulatory usually implies that the patient has come to the location
and is not assigned to a bed. Sometimes referred to as an outpatient
encounter
Care Transition – Postal Code Value Set
The value set for a postal code in a care transition is to use any United States Postal Service (USPS) postal code.
The codes are available here: http://zip4.usps.com/zip4/welcome.jsp

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Page 47 of 111
Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
Care Transition - Problem Value Set
The Health IT Standards Committee recommends the use of SNOMED-CT to capture problems. It is expected,
howver, that during a care transition, there may be multiple codes used from different terminologies, including
ICD-9 and ICD-10.
The value set specified for Problems in a care transition is based off SNOMED-CT and includes ICD-9 and ICD-10
codes for common problems. For SNOMED-CT, the value set is limited to terms descending from the Clinical
Findings (404684003) or Situation with Explicit Context (243796009) hierarchies.
This value set is not intended to be comprehensive but represents the recommendations for specific codes that are
common to an active problem list. Implementers should note that a list of ICD-9, ICD-10 and SNOMED-CT codes are
provided for commonly used problems.
Figure 1: Care Transition – Problem Value Set Table
Problem Name
Acute Respiratory
Failure
Asthma
Chronic Kidney Disease
Congestive Heart Failure
COPD
Cystic Fibrosis
Depression screening
Diabetes
Diabetes
Diabetes
Problem Codes
Code Set
518.84
ICD-9
493.0, 493.1, 493.2, 493.8, 493.9, 495.8
585.1-6
428
496
277.00, 277.01, 277.02, 277.03, 277.09
V79.0
250, 250.0, 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12,
250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33,
250.4, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53,
250.60, 250.61, 250.62, 250.63, 250.7, 250.70, 250.71, 250.72, 250.73,
250.8, 250.80, 250.81, 250.82, 250.83, 250.9, 250.90, 250.91, 250.92,
250.93, 357.2, 362.0, 362.01, 362.02, 362.03, 362.04, 362.05, 362.06,
362.07, 366.41, 648.0, 648.00, 648.01, 648.02, 648.03, 648.04
31, E10.36, E11.36, E11.9, E13, E13.32, E13.33, E13.34, E13.35, E13.43,
O24.42
111552007, 111558006, 11530004, 123763000, 127013003, 127014009,
190321005, 190328004, 190330002, 190331003, 190336008, 190353001,
190361006, 190368000, 190369008, 190371008, 190372001, 190383005,
190389009, 190390000, 190392008, 190406000, 190407009, 190410002,
190411003, 190412005, 190416001, 190417004, 190418009, 190419001,
190422004, 193184006, 197605007, 198609003, 199223000, 199227004,
199229001, 199230006, 199231005, 199234002, 201250006, 201251005,
201252003, 23045005, 230572002, 230577008, 237599002, 237600004,
237601000, 237604008, 237613005, 237618001, 237619009, 237627000,
25907005, 26298008, 267379000, 267380002, 2751001, 275918005,
28032008, 28453007, 290002008, 309426007, 310387003, 311366001,
312912001, 313435000, 313436004, 314537004, 314771006, 314772004,
314893005, 314902007, 314903002, 33559001, 34140002, 359611005,
359638003, 359642000, 360546002, 371087003, 38542009, 39058009,
39181008, 408539000, 408540003, 413183008, 414890007, 414906009,
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
ICD-9
ICD-9
ICD-9
ICD-9
ICD-9
ICD-9
ICD-9
ICD-10
SNOMEDCT
Page 48 of 111
Last Updated on 11/15/2011
Office of the National Coordinator for
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Problem Name
Diabetes (Exclusion)
Diabetic Retinopathy
Diabetic Retinopathy
Diabetic Retinopathy
Emphysema
Gestational Diabetes
Gestational Diabetes
Gestational Diabetes
Hypertension
Hyperlipidemia
Ischemic Vascular
Disease
Microalbuminuria
Nephropathy
Nephropathy
Nephropathy
Problem Codes
420414003, 420422005, 421750000, 421847006, 421895002, 422183001,
422228004, 422275004, 423263001, 424736006, 424989000, 425159004,
425442003, 426705001, 426875007, 427089005, 428896009, 42954008,
44054006, 4627003, 46635009, 50620007, 51002006, 5368009,
54181000, 57886004, 59079001, 5969009, 70694009, 73211009,
74263009, 75524006, 75682002, 76751001, 81531005, 81830002,
8801005, 91352004, 9859006
648.8, 249, 251.8, 962
E10.3, E10.31, E10.311, E10.319, E11.31, E11.311, E11.319, E11.32,
E11.321, E11.329, E11.33, E11.331, E11.339, E11.34, E11.341, E11.349
193349004, 193350004, 232020009, 232021008, 232022001, 232023006,
25093002, 25412000, 311782002, 312903003, 312904009, 312905005,
312906006, 312907002, 312908007, 312909004, 312912001, 314010006,
314011005, 314014002, 314015001, 390834004, 399625000, 399862001,
399863006, 399864000, 399865004, 399866003, 399868002, 399869005,
399870006, 399871005, 399872003, 399873008, 399874002, 399875001,
399876000, 399877009, 408409007, 408410002, 408411003, 408412005,
408413000, 408414006, 408415007, 408416008, 414892004, 414894003,
414908005, 414910007, 417677008, 420486006, 420789003, 421779007,
422034002, 4855003, 59276001, 62585004
362.01, 362.02, 362.03, 362.04, 362.05, 362.06
491.20-491.22, 518.20, 506.4, 518.1, 998.81, 958.7
648.8, 648.80, 648.81, 648.82, 648.83, 648.84
R73.02, R73.09
11687002, 420491007, 420738003, 420989005, 421223006, 421389009,
421443003, 422155003, 46894009, 71546005, 75022004
401.-405.XX
272.X
411, 413, 414.0, 414.2, 414.8, 414.9, 429.2, 433-434, 440.1, 440.2, 440.4,
444, 445
791.0
250.4, 250.40, 250.41, 250.42, 250.43, 403, 403.0, 403.00, 403.01, 403.1,
403.10, 403.11, 403.9, 403.90, 403.91, 404, 404.0, 404.00, 404.01, 404.02,
404.03, 404.1, 404.10, 404.11, 404.12, 404.13, 404.9, 404.90, 404.91,
404.92, 404.93, 405.01, 405.11, 405.91, 580, 580.0, 580.4, 580.8, 580.81,
580.89, 580.9, 581, 581.0, 581.1, 581.2, 581.3, 581.8, 581.81, 581.89,
581.9, 582, 582.0, 582.1, 582.2, 582.4, 582.8, 582.81, 582.89, 582.9, 583,
583.0, 583.1, 583.2, 583.4, 583.6, 583.7, 583.8, 583.81, 583.89, 583.9,
584, 584.5, 584.6, 584.7, 584.8, 584.9, 585, 585.1, 585.2, 585.3, 585.4,
585.5, 585.6, 585.9, 586, 587, 588, 588.0, 588.1, 588.8, 588.81, 588.89,
588.9, 753.0, 753.1, 753.10, 753.11, 753.12, 753.13, 753.14, 753.15,
753.16, 753.17, 753.19, 791.0, V42.0, V45.1, V45.11, V45.12, V56, V56.0,
V56.1, V56.2, V56.3, V56.31, V56.32, V56.8
G56, G56.8, G56.80, G56.81, G56.82, G56.9, G56.90, G56.91, G56.92, G57,
G57.8, G57.80, G57.81, G57.82, G57.9, G57.90, G57.91, G57.92, G58,
G58.0, G58.7, G58.8, G58.9, G59, G61, G61.0, G61.1, G61.8, G61.81,
G61.89, G61.9, G62, G62.0, G62.9
193003, 290006, 1426004, 1592005, 1776003, 2900003, 3321001,
4292005, 4390004, 4451004, 4495005, 4576001, 4676006, 5397007,
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Code Set
ICD-9
ICD-10
SNOMEDCT
ICD-9
ICD-9
ICD-9
ICD-10
SNOMEDCT
ICD-9
ICD-9
ICD-9
ICD-9
ICD-9
ICD-10
SNOMEDCT
Page 49 of 111
Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
Problem Name
Problem Codes
5753006, 6134000, 7703001, 7724006, 8199003, 8436004, 8468007,
8964003, 8996006, 9918001, 10123006, 10697004, 10833000, 11013005,
11026009, 11109001, 11659006, 12897005, 13010001, 13335004,
13530005, 13886001, 13889008, 14178006, 14343001, 14669001,
14853005, 14973001, 15842009, 16147005, 16297002, 16507009,
16652001, 16756008, 16934004, 17121006, 17380002, 17901006,
18417009, 18796000, 19351000, 20341008, 20483002, 20917003,
21764004, 21952001, 22011005, 22702000, 22846003, 23697004,
23754003, 24790002, 25646005, 25765006, 25821008, 26235008,
26367008, 27174002, 28196006, 28545001, 28770003, 28918009,
29908007, 30124006, 30275001, 30295007, 31005002, 32093003,
32278006, 32659003, 32916005, 33561005, 33763006, 34165000,
35455006, 35546006, 36171008, 36184004, 36225005, 36388008,
36402006, 36473002, 36568005, 36689008, 36891003, 37133005,
37183000, 37891007, 38481006, 39018007, 39291006, 39734002,
40095003, 40233000, 40488004, 40894000, 41305006, 41729002,
41962002, 42399005, 42496002, 42927005, 43064006, 43258006,
43629001, 43738009, 44323002, 44513007, 44730006, 45281005,
45456005, 45646000, 45743004, 45812003, 45816000, 46177005,
46395002, 48061001, 48631008, 48638002, 48655003, 48713002,
48796009, 49008000, 49220004, 49809007, 50581000, 50909009,
51055000, 51292008, 51677000, 52042003, 52254009, 52342006,
52777008, 52845002, 53378008, 53556002, 54155004, 54181000,
54480007, 54781007, 54879000, 54967001, 55006001, 55536001,
55655006, 55856005, 56108007, 56346006, 57088004, 57469000,
57557005, 57684003, 57965003, 58276006, 58574008, 58797008,
59400006, 59530001, 59758007, 59780005, 60989005, 61474001,
61598006, 61680002, 61852001, 62216007, 62240004, 63510008,
64323009, 65127006, 65443008, 66993009, 67132008, 68815009,
69718008, 70092007, 71064009, 71110009, 71275003, 71909003,
72613009, 73030000, 73286009, 73305009, 74594005, 75030003,
75150001, 75652008, 75712001, 76224000, 76521009, 76910007,
77186001, 77624000, 77945009, 78209002, 78311009, 78544004,
79385002, 80902009, 81363003, 81896006, 81986001, 81987005,
82525005, 83563007, 83850008, 83866005, 84121007, 85020001,
85487008, 85901000, 86210009, 86234004, 86235003, 86249007,
86463003, 86564006, 87571007, 88102009, 88380005, 88531004,
90241004, 90493000, 90688005, 90708001, 91003006, 92165001,
92624000, 92921005, 92975004, 93290000, 93425004, 94889006,
95444008, 95474000, 95568003, 95570007, 95571006, 95572004,
95575002, 95577005, 95578000, 95579008, 95580006, 95582003,
95889002, 102455002, 105999006, 106000008, 109477002, 110996009,
111395007, 111403005, 111404004, 111406002, 111407006, 112066009,
118951003, 123609007, 123610002, 123611003, 123612005, 123752003,
123753008, 123755001, 124147007, 126874009, 126880001, 126881002,
127013003, 128996006, 129128006, 168041003, 187144000, 188250002,
188251003, 194774006, 194780003, 194781004, 197577008, 197589005,
197590001, 197591002, 197593004, 197594005, 197595006, 197596007,
197597003, 197598008, 197599000, 197600002, 197601003, 197603000,
197605007, 197606008, 197607004, 197627003, 197628008, 197629000,
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Code Set
Page 50 of 111
Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
Problem Name
Problem Codes
197650009, 197659005, 197660000, 197661001, 197663003, 197664009,
197670003, 197671004, 197679002, 197688006, 197707007, 197708002,
197712008, 197738008, 197739000, 197752005, 197753000, 197801000,
197802007, 197813005, 197817006, 197820003, 198841006, 198842004,
198843009, 198844003, 198845002, 198846001, 198949009, 199110003,
199132007, 199134008, 199135009, 199136005, 199137001, 200117009,
200118004, 204938007, 204941003, 204942005, 204949001, 204950001,
204957003, 204962002, 204980006, 204984002, 204985001, 210197003,
210207004, 210811000, 213231008, 226309007, 230970001, 236367002,
236369004, 236374007, 236376009, 236377000, 236380004, 236381000,
236382007, 236383002, 236384008, 236385009, 236395002, 236402009,
236403004, 236404005, 236405006, 236406007, 236423003, 236424009,
236425005, 236428007, 236429004, 236430009, 236431008, 236432001,
236433006, 236434000, 236435004, 236436003, 236437007, 236438002,
236439005, 236441006, 236442004, 236443009, 236444003, 236445002,
236448000, 236452000, 236453005, 236454004, 236455003, 236456002,
236457006, 236460004, 236461000, 236463002, 236464008, 236467001,
236469003, 236470002, 236471003, 236472005, 236474006, 236475007,
236477004, 236478009, 236479001, 236480003, 236481004, 236482006,
236483001, 236484007, 236485008, 236486009, 236487000, 236488005,
236490006, 236491005, 236492003, 236493008, 236495001, 236498004,
236499007, 236500003, 236502006, 236503001, 236504007, 236505008,
236506009, 236507000, 236508005, 236511006, 236514003, 236515002,
236516001, 236517005, 236518000, 236519008, 236520002, 236521003,
236522005, 236523000, 236526008, 236527004, 236528009, 236530006,
236531005, 236532003, 236534002, 236535001, 236569000, 236570004,
236583003, 236584009, 236586006, 236587002, 236590008, 236592000,
236614007, 236708007, 236710009, 236713006, 237230004, 239932005,
240317003, 253860008, 253862000, 253864004, 253865003, 253866002,
253867006, 253869009, 253872002, 253875000, 253876004, 253881008,
253883006, 253886003, 254914004, 254915003, 254916002, 254919009,
254920003, 254922006, 254923001, 254924007, 262612001, 262891006,
262893009, 262894003, 262900003, 266549004, 266556005, 267430007,
268232000, 268234004, 268854008, 269257004, 269301005, 269489006,
270494003, 270517006, 271387005, 271432005, 274401005, 275408006,
275510005, 276583007, 276584001, 276585000, 276586004, 276627004,
277010001, 277011002, 278531007, 282348002, 282664001, 283905005,
288004005, 289923007, 298127003, 301814009, 302233006, 302849000,
302910002, 302922004, 307309005, 307532008, 307604008, 307618001,
309426007, 309785008, 310387003, 311366001, 311496007, 359563005,
361146001, 361147005, 361264003, 363224005, 363234001, 363287001,
363288006, 363518003, 367540006, 370488005, 370493008, 370494002,
371011007, 371019009, 371020003, 373421000, 373422007, 373584008,
373585009, 373599008, 399094007, 399190000, 399340005, 405573009,
405584002, 420279001, 421893009, 422593004, 423322005, 423533009,
423919000, 425369003, 425384007, 425414000, 425455002, 426136000,
427555000, 427649000, 428255004, 428720002, 429224003, 429489008,
430535006, 431480000, 431501001, 431855005, 431856006, 431857002,
432294000, 432461000, 433036004, 433144002, 433146000, 433229006,
438783006, 439990003, 440018001, 441815006
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Code Set
Page 51 of 111
Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
Problem Name
Obesity
Polycystic ovaries
Polycystic ovaries
278
256.4
E28.2
Polycystic ovaries
69878008
Pregnancy (normal)
Problem Codes
Code Set
ICD-9
ICD-9
ICD-10
SNOMEDCT
630, 631, 632, 633.00, 633.01, 633.10, 633.11, 633.20, 633.21, 633.80,
633.81, 633.90, 633.91, 634.00, 634.01, 634.02, 634.10, 634.11, 634.12,
634.20, 634.21, 634.22, 34.30, 634.31, 634.32, 634.40, 634.41, 634.42,
634.50, 634.51, 634.52, 634.60, 634.61, 634.62, 634.70, 634.71, 634.72,
634.80, 634.81, 634.82, 634.90, 634.91, 634.92, 635.00, 635.01, 635.02,
635.10, 635.11, 635.12, 635.20, 635.21, 635.22, 635.30, 635.31, 635.32,
635.40, 635.41, 635.42, 635.50, 635.51, 635.52, 635.60, 635.61, 635.62,
635.70, 635.71, 635.72, 635.80, 635.81, 635.82, 635.90, 635.91, 635.92,
636.00, 636.01, 636.02, 636.10, 636.11, 636.12, 636.20, 636.21, 636.22,
636.30, 636.31, 636.32, 636.40, 636.41, 636.42, 636.50, 636.51, 636.52,
636.60, 636.61, 636.62, 636.70, 636.71, 636.72, 636.80, 636.81, 636.82,
636.90, 636.91, 636.92, 637.00, 637.01, 637.02, 637.10, 637.11, 637.12,
637.20, 637.21, 637.22, 637.30, 637.31, 637.32, 637.40, 637.41, 637.42,
637.50, 637.51, 637.52, 637.60, 637.61, 637.62, 637.70, 637.71, 637.72,
637.80, 637.81, 637.82, 637.90, 637.91, 637.92, 638.0, 638.1, 638.2,
638.3, 638.4, 638.5, 638.6, 638.7, 638.8, 638.9, 639.0, 639.1, 639.2, 639.3,
639.4, 639.5, 639.6, 639.8, 639.9, 640.00, 640.01, 640.03, 640.80, 640.81,
640.83, 640.90, 640.91, 640.93, 641.00, 641.01, 641.03, 641.10, 641.11,
641.13, 641.20, 641.21, 641.23, 641.30, 641.31, 641.33, 641.80, 641.81,
641.83, 641.90, 641.91, 641.93, 642.00, 642.01, 642.02, 642.03, 642.04,
642.10, 642.11, 642.12, 642.13, 642.14, 642.20, 642.21, 642.22, 642.23,
642.24, 642.30, 642.31, 642.32, 642.33, 642.34, 642.40, 642.41, 642.42,
642.43, 642.44, 642.50, 642.51, 642.52, 642.53, 642.54, 642.60, 642.61,
642.62, 642.63, 642.64, 642.70, 642.71, 642.72, 642.73, 642.74, 642.90,
642.91, 642.92, 642.93, 642.94, 643.00, 643.01, 643.03, 643.10, 643.11,
643.13, 643.20, 643.21, 643.23, 643.80, 643.81, 643.83, 643.90, 643.91,
643.93, 644.00, 644.03, 644.10, 644.13, 644.20, 644.21, 645.10, 645.11,
642.13, 645.20, 645.21, 645.23, 646.00, 646.01, 646.03, 646.10, 646.11,
646.12, 646.13, 646.14, 646.20, 646.21, 646.22, 646.23, 646.24, 646.30,
646.31, 646.33, 646.40, 646.41, 646.42, 646.43, 646.44, 646.50, 646.51,
646.52, 646.53, 646.54, 646.60, 646.61, 646.62, 646.63, 646.64, 646.70,
646.71, 646.73, 646.80, 646.81, 646.82, 646.83, 646.84, 646.90, 646.91,
646.93, 647.00, 647.01, 647.02, 647.03, 647.04, 647.10, 647.11, 647.12,
647.13, 647.14, 647.20, 647.21, 647.22, 647.23, 647.24, 647.30, 647.31,
647.32, 647.33, 647.34, 647.40, 647.41, 647.42, 647.43, 647.44, 647.50,
647.51, 647.52, 647.53, 647.54, 647.60, 647.61, 647.62, 647.63, 647.64,
647.80, 647.81, 647.82, 647.83, 647.84, 647.90, 647.91, 647.92, 647.93,
647.94, 648.00, 648.01, 648.02, 648.03, 648.04, 648.10, 648.11, 648.12,
648.13, 648.14, 648.20, 648.21, 648.22, 648.23, 648.24, 648.30, 648.31,
648.32, 648.33, 648.34, 648.40, 648.41, 648.42, 648.43, 648.44, 648.50,
648.51, 648.52, 648.53, 648.54, 648.60, 648.61, 648.62, 648.63, 648.64,
648.70, 648.71, 648.72, 648.73, 648.74, 648.80, 648.81, 648.82, 648.83,
648.84, 648.90, 648.91, 648.92, 648.93, 648.94, 649.00, 649.01, 649.02,
649.03, 649.04, 649.10, 649.11, 649.12, 649.13, 649.14, 649.20, 649.21,
649.22, 649.23, 649.24, 649.30, 649.31, 649.32, 649.33, 649.34, 649.40,
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
ICD-9
Page 52 of 111
Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
Problem Name
Problem Codes
649.41, 649.42, 649.43, 649.44, 649.50, 649.51, 649.53, 649.60, 649.61,
649.62, 649.63, 649.64, 649.70, 649.71, 649.73, 650, 651.00, 651.01,
651.03, 651.10, 651.11, 651.13, 651.20, 651.21, 651.23, 651.30, 651.31,
651.33, 651.40, 651.41, 651.43, 651.50, 651.51, 651.53, 651.60, 651.61,
651.63, 651.70, 651.71, 651.73, 651.80, 651.81, 651.83, 651.90, 651.91,
651.93, 652.00, 652.01, 652.03, 652.10, 652.11, 652.13, 652.20, 652.21,
652.23, 652.30, 652.31, 652.33, 652.40, 652.41, 652.43, 652.50, 652.51,
652.53, 652.60, 652.61, 652.63, 652.70, 652.71, 652.73, 652.80, 652.81,
652.83, 652.90, 652.91, 652.93, 653.00, 653.01, 653.03, 653.10, 653.11,
653.13, 653.20, 653.21, 653.23, 653.30, 653.31, 653.33, 653.40, 653.41,
653.43, 653.50, 653.51, 653.53, 653.60, 653.61, 653.63, 653.70, 653.71,
653.73, 653.80, 653.81, 653.83, 653.90, 653.91, 653.93, 654.00, 654.01,
654.02, 654.03, 654.04, 654.10, 654.11, 654.12, 654.13, 654.14, 654.20,
654.21, 654.23, 654.30, 654.31, 654.32, 654.33, 654.34, 654.40, 654.41,
654.42, 654.43, 654.44, 654.50, 654.51, 654.52, 654.53, 654.54, 654.60,
654.61, 654.62, 654.63, 654.64, 654.70, 654.71, 654.72, 654.73, 654.74,
654.80, 654.81, 654.82, 654.83, 654.84, 654.90, 654.91, 654.92, 654.93,
654.94, 655.00, 655.01, 655.03, 655.10, 655.11, 655.13, 655.20, 655.21,
655.23, 655.30, 655.31, 655.33, 655.40, 655.41, 655.43, 655.50, 655.51,
655.53, 655.60, 655.61, 655.63, 655.70, 655.71, 655.73, 655.80, 655.81,
655.83, 655.90, 655.91, 655.93, 656.00, 656.01, 656.03, 656.10, 656.11,
656.13, 656.20, 656.21, 656.23, 656.30, 656.31, 656.33, 656.40, 656.41,
656.43, 656.50, 656.51, 656.53, 656.60, 656.61, 656.63, 656.70, 656.71,
656.73, 656.80, 656.81, 656.83, 656.90, 656.91, 656.93, 657.00, 657.01,
657.03, 658.00, 658.01, 658.03, 658.10, 658.11, 658.13, 658.20, 658.21,
658.23, 658.30, 658.31, 658.33, 658.40, 658.41, 658.43, 658.80, 658.81,
658.83, 658.90, 658.91, 658.93, 659.00, 659.01, 659.03, 659.10, 659.11,
659.13, 659.20, 659.21, 659.23, 659.30, 659.31, 659.33, 659.40, 659.41,
659.43, 659.50, 659.51, 659.53, 659.60, 659.61, 659.63, 659.70, 659.71,
659.73, 659.80, 659.81, 659.83, 659.90, 659.91, 659.93, 660.00, 660.01,
660.03, 660.10, 660.11, 660.13, 660.20, 660.21, 660.23, 660.30, 660.31,
660.33, 660.40, 660.41, 660.43, 660.50, 660.51, 660.53, 660.60, 660.61,
660.63, 660.70, 660.71, 660.73, 660.80, 660.81, 660.83, 660.90, 660.91,
660.93, 661.00, 661.01, 661.03, 661.10, 661.11, 661.13, 661.20, 661.21,
661.23, 661.30, 661.31, 661.33, 661.40, 661.41, 661.43, 661.90, 661.91,
661.93, 662.00, 662.01, 662.03, 662.10, 662.11, 662.13, 662.20, 662.21,
662.23, 662.30, 662.31, 662.33, 663.00, 663.01, 663.03, 663.10, 663.11,
663.13, 663.20, 663.21, 663.23, 663.30, 663.31, 663.33, 663.40, 663.41,
663.43, 663.50, 663.51, 663.53, 663.60, 663.61, 663.63, 663.80, 663.81,
663.83, 663.90, 663.91, 663.93, 664.00, 664.01, 664.04, 664.10, 664.11,
664.14, 664.20, 664.21, 664.24, 664.30, 664.31, 664.34, 664.40, 664.41,
664.44, 664.50, 664.51, 664.54, 664.60, 664.61, 664.64, 664.80, 664.81,
664.84, 664.90, 664.91, 664.94, 665.00, 665.01, 665.03, 665.10, 665.11,
665.20, 665.22, 665.24, 665.30, 665.31, 665.34, 665.40, 665.41, 665.44,
665.50, 665.51, 665.54, 665.60, 665.61, 665.64, 665.70, 665.71, 665.72,
665.74, 665.80, 665.81, 665.82, 665.83, 665.84, 665.90, 665.91, 665.92,
665.93, 665.94, 666.00, 666.02, 666.04, 666.10, 666.12, 666.14, 666.20,
666.22, 666.24, 666.30, 666.32, 666.34, 667.00, 667.02, 667.04, 667.10,
667.12, 667.14, 668.00, 668.01, 668.02, 668.03, 668.04, 668.10, 668.11,
668.12, 668.13, 668.14, 668.20, 668.21, 668.22, 668.23, 668.24, 668.80,
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Code Set
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Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
Problem Name
PregProblem nancy
(normal)
Steroid Induced
Diabetes
Steroid Induced
Diabetes
Steroid Induced
Diabetes
Steroid Induced
Diabetes
Tobacco Use
Problem Codes
668.81, 668.82, 668.83, 668.84, 668.90, 668.91, 668.92, 668.93, 668.94,
669.00, 669.01, 669.02, 669.03, 669.04, 669.10, 669.11, 669.12, 669.13,
669.14, 669.20, 669.21, 669.22, 669.23, 669.24, 669.30, 669.32, 669.34,
669.40, 669.41, 669.42, 669.43, 669.44, 669.50, 669.51, 669.60, 669.61,
669.70, 669.71, 669.80, 669.81, 669.82, 669.83, 669.84, 669.90, 669.91,
669.92, 669.93, 669.94, 670.00, 670.02, 670.04, 670.10, 670.12, 670.14,
670.20, 670.22, 670.24, 670.30, 670.32, 670.34, 670.80, 670.82, 670.84,
671.00, 671.01, 671.02, 671.03, 671.04, 671.10, 671.11, 671.12, 671.13,
671.14, 671.20, 671.21, 671.22, 671.23, 671.24, 671.30, 671.31, 671.33,
671.40, 671.42, 671.44, 671.50, 671.51, 671.52, 671.53, 671.54, 671.80,
671.81, 671.82, 671.83, 671.84, 671.90, 671.91, 671.92, 671.93, 671.94,
672.00, 672.02, 672.04, 673.00, 673.01, 673.02, 673.03, 673.04, 673.10,
673.11, 673.12, 673.13, 673.14, 673.20, 673.21, 673.22, 673.23, 673.24,
673.30, 673.31, 673.32, 673.33, 673.34, 673.80, 673.81, 673.82, 673.83,
673.84, 674.00, 674.01, 674.02, 674.03, 674.04, 674.10, 674.12, 674.14,
674.20, 674.22, 674.24, 674.30, 674.32, 674.34, 674.40, 674.42, 674.44,
674.50, 674.51, 674.52, 674.53, 674.54, 674.80, 674.82, 674.84, 674.90,
674.92, 674.94, 675.00, 675.01, 675.02, 675.03, 675.04, 675.10, 675.11,
675.12, 675.13, 675.14, 675.20, 675.21, 675.22, 675.23, 675.24, 675.80,
675.81, 675.82, 675.83, 675.84, 675.90, 675.91, 675.92, 675.93, 675.94,
676.00, 676.01, 676.02, 676.03, 676.04, 676.10, 676.11, 676.12, 676.13,
676.14, 676.20, 676.21, 676.22, 676.23, 676.24, 676.30, 676.31, 676.32,
676.33, 676.34, 676.40, 676.41, 676.42, 676.43, 676.44, 676.50, 676.51,
676.52, 676.53, 676.54, 676.60, 676.61, 676.62, 676.63, 676.64, 676.80,
676.81, 676.82, 676.83, 676.84, 676.90, 676.91, 676.92, 676.93, 676.94,
V22.0, V22.1, V22.2, V23.0, V23.1, V23.2, V23.3, V23.41, V23.49, V23.5,
V23.7, V23.81, V23.82, V23.83, V23.84, V23.85, V23.86, V23.89, V23.9,
V28.0, V28.1, V28.2, V28.3, V28.4, V28.5, V28.6, V28.81, V28.82, V28.89,
V28.9
16356006, 198624007, 198626009, 198627000, 239101008, 289908002,
31601007, 34801009, 38720006, 41991004, 43990006, 44782008,
60000008, 60810003, 64254006, 65147003, 69532007, 79290002,
79586000, 80997009, 82661006, 87605005, 90968009, 9899009
249, 249.0
249.00, 249.01, 249.1, 249.10, 249.11, 249.2, 249.20, 249.21, 249.3,
249.30, 249.31, 249.4, 249.40, 249.41, 249.5, 249.50, 249.51, 249.6,
249.60, 249.61, 249.7, 249.70, 249.71, 249.8, 249.80, 249.81, 249.9,
249.90, 249.91, 251.8, 962.0
E08, E10, T38
190416008, 190447002, 53126001
305.1, 649.0x, 989.84
Code Set
SNOMEDCT
ICD-9
ICD-9
ICD-10
SNOMEDCT
ICD-9
Care Transition – Provider Role Value Set
The value set for a Provider Role in a care transition uses the HL7 2.5.1 vocabulary specified in the Consolidated
CDA Guide for Provider Role.
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Care Transition – Provider Type Value Set
The value set for a Provider Type in a care transition uses the National Uniform Claim Committee (NUCC) Health
Care Provider Taxonomy. This Provider Type value set classifies providers according to the type of license or
accreditation they hold or the service they provide.
The value set can be located here:
http://www.nucc.org/index.php?option=com_content&task=view&id=14&Itemid=40
A list of the most common provider types is provided below. At this time, the concept codes are not available from
NUCC and this table outlines the high level “Provider Type” classification only:
Provider Type Concept Name
Behavioral Health & Social
Service Providers
Chiropractic Providers
Dental Providers
Dietary and Nutritional Service
Providers
Emergency Medical Service
Providers
Eye and Vision Service Providers
Nursing Service Providers
Pharmacy Service Providers
(Individuals)
Allopathic & Osteopathic
Physicians
Podiatric Medicine and Surgery
Providers
Respiratory, Developmental,
Rehabilitative and Restorative
Service Providers
Definition
Broad classification aggregating providers who are trained and educated to
perform services related to behavioral health, mental health, and counseling
and may be licensed or practice within the scope or licensure or training
A provider qualified by a Doctor of Chiropractic (D.C.) licensed by the State and
who practices chiropractic medicine -that discipline within the healing arts
which deals with the nervous system and its relationship to the spinal column
and its interrelationship with other body systems
Broad category to identify practitioners who render services related the
practice of dentistry. Dentistry is defined as the evaluation, diagnosis,
prevention and/or treatment (nonsurgical, surgical or related procedures) of
diseases, disorders and/or conditions of the oral cavity, maxillofacial area
and/or the adjacent and associated structures and their impact on the human
body; provided by a dentist, within the scope of his/her education, training and
experience, in accordance with the ethics of the profession and applicable law
Broad category defining practitioners who help prevent and treat illness by
promoting healthy eating habits, scientifically evaluating diets and suggesting
modifications. They may also assess the nutritional needs of patients, develop
and implement nutritional care plans
Broad category for individuals who complete additional training and education
in the area of pre-hospital emergency services and are licensed and/or practice
within the scope of that training
Broad category grouping individuals who renders services related to the human
eye and visual systems, but are not an allopathic or osteopathic physicians
Providers who are trained and educated to perform and administer services
related to health promotion, disease prevention, acute and chronic care,
spiritual guidance and comfort for healing and health, restoration of health and
health maintenance across the life span
A broad category grouping providers who render services relating to the
preparation and dispensing of drugs
A broad category grouping state licensed providers in allopathic or osteopathic
medicine whose scope of practice is determined by education
Broad category grouping licensed providers who renders services related to the
human foot
A provider who is trained and educated to perform services related to
respiratory care, physical therapy, occupational therapy, developmental
therapy, rehabilitation and restorative services and may be licensed, certified
Transitions of Care – Discharge Summary Guide
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Provider Type Concept Name
Speech, Language and Hearing
Providers
Agencies
Ambulatory Health Care
Facilities
Hospitals
Laboratories
Managed Care Organizations
Nursing & Custodial Care
Facilities
Residential Treatment Facilities
Suppliers
Physician Assistants & Advanced
Practice Nursing Providers
Nursing Service Related
Providers
Definition
or practice within the scope of training
A provider who renders services to improve communicative skills of people
with language, speech and hearing impairments
A non-facility provider that renders outpatient outreach services that are not
provided at a specific location. The licensure or registration is assigned to the
agency rather than to the individual practitioners as would be the case in a
group practice
A facility or distinct part of one used for the diagnosis and treatment of
outpatients. "Clinic/Center" is irregularly defined, sometimes being limited to
organizations serving specialized treatment requirements or distinct
patient/client groups (e.g., radiology, poor, and public health)
A healthcare organization that has a governing body, an organized medical
staff and professional staff and inpatient facilities and provides medical nursing
and related services for ill and injured patients 24 hrs per day, seven days per
week. For licensing purposes, each state has its own definition of hospital
A room or building equipped for scientific experimentation, research, testing,
or clinical studies of materials, fluids, or tissues obtained from patients
Not Available
Broad category identifying licensed facilities with inpatient beds specializing in
nursing and custodial care
Live in facilities where patients or clients, who because of their physical,
mental, or emotional condition, are not able to live independently, and who
receive treatment appropriate to their particular needs in a less restrictive
environment than an inpatient facility. For example, an RTC may provide
educational training and therapy for children with emotional disturbances or
continuing care and therapy for people with severe mental handicaps
Suppliers, pharmacies, and other healthcare providers who supply healthcare
related products or medications and associated professional and
administrative services
A broad grouping of providers who are: 1) trained, educated, and certified to
perform basic medical and minor surgical services (or to assist the physician in
performance of more complex services) under general physician supervision;
and 2) trained, educated at a post-graduate level, and certified to perform
autonomous and specialized roles as nurse practitioners, midwives, nurse
anesthetists, or clinical nurse specialists
Providers not otherwise classified, who perform or administer services in or
related to the delivery or research of healthcare services, disease, and
restoration of health. An individual provider who is not represented in one of
the identified categories but whose data may be needed for clinical,
operational or administrative processes
Care Transition – Relationship Value Set
For a care transition, the value set to use for identifying family relationships is the HL7 RoleCode.
A Personal Relationship in this value set records the role of a person in relation to another person. This value set is
to be used when recording the relationships between different people who are not necessarily related by family
ties, but also includes family relationships
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Created on 8/31/2011
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HL7 RoleClass Code
PRS
NOK
CAREGIVER
AGNT
GUAR
ECON
Usage Note
personal relationship
next of kin
caregiver
agent
guarantor
emergency contact
Care Transition - Severity Value Set
The value set for severity of an allergy, adverse event or problem in a care transition uses the following list of
SNOMED-CT concept codes, that describes the severity being experienced:

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Concept Code
255604002
371923003
6736007
371924009
24484000
399166001
Concept Name (Fully Qualified
SNOMED-CT Name)
Mild (qualifier value)
Mild to moderate (qualifier value)
Moderate (severity modifier)
(qualifier value)
Moderate to severe (qualifier value)
Severe (severity modifier) (qualifier
value)
Fatal (qualifier value)
Definition
Usage Notes
Not Available
Not Available
Not Available
Mild
Mild to moderate
Moderate
Not Available
Not Available
Moderate to severe
Severe
Not Available
Fatal
Care Transition – State Value Set
The value set for a coding a state value in a care transition is to use any FIPS 5-2 Codes (Identification of the States,
the District of Columbia and the Outlying Areas of the United States, and Associated Areas Publication # 5-2, May,
1987). The codes are available here: http://www.itl.nist.gov/fipspubs/fip5-2.htm

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Encounter Type Value Set
As stated in the Transitions of Care implementation guidance:
“Per the recommendation of the Health IT Standards Committee, encounters SHOULD be coded using
SNOMED-CT. A full value set in support of this recommendation is under development. The current value
set provided in this implementation guidance is based on the HITSP C80 recommendation to use CPT-4
codes as a transition mechanism towards SNOMED-CT.”
The value set for Encounter Type in a care transition is drawn from the codes of the Current Procedure and
Terminology (CPT) designated for Evaluation and Management (99200 – 99299).
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The following list of most common Encounters and their CPT coded procedure type.
Figure 2: Encounter Type Value Set Table
Encounter Type
Out Patient Office Visit
Hospital Observation Services
Office Consultations
Coded Procedure Type
99201-99205, 99211-99215
99217-99220
99241-99245
Code Set
CPT
CPT
CPT
Health Insurance Subscriber Relationship Value Set

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Concept Code
FAMDEP
FSTUD
HANDIC
INJ
PSTUD
SELF
SPON
STUD
Concept Name
Family dependent
Full-time student
Handicapped dependent
Injured plaintiff
Part-time student
Self
Sponsored dependent
Student
Health Insurance Type Value Set
The current value set specified for Health Insurance Type supports Accredited Standards Committee (ASC) X12
Standards Release 004010. This value set uses the ACS X12 vocabulary for Insurance Type Code (ASC X12 Data
Element 1336.


NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
NOTE: Further updates of this value set will be needed in support of the HIPAA 5010 transition.
Concept Code
12
13
14
15
16
41
42
43
47
AP
C1
Concept Name
Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination period
with an employers group health plan
Medicare Secondary, No-fault Insurance including Auto is Primary
Medicare Secondary Workers Compensation
Medicare Secondary Public Health Service (PHS)or Other Federal Agency
Medicare Secondary Black Lung
Medicare Secondary Veterans Administration
Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
Medicare Secondary, Other Liability Insurance is Primary
Auto Insurance Policy
Commercial
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Concept Code
CO
CP
D
DB
EP
FF
GP
HM
HN
HS
IN
IP
LC
LD
LI
LT
MA
MB
MC
MH
MI
MP
OT
PE
PL
PP
PR
PS
QM
RP
SP
TF
WC
WU
Concept Name
Consolidated Omnibus Budget Reconciliation Act (COBRA)
Medicare Conditionally Primary
Disability
Disability Benefits
Exclusive Provider Organization
Family or Friends
Group Policy
Health Maintenance Organization (HMO)
Health Maintenance Organization (HMO) - Medicare Risk
Special Low Income Medicare Beneficiary
Indemnity
Individual Policy
Long Term Care
Long Term Policy
Life Insurance
Litigation
Medicare Part A
Medicare Part B
Medicaid
Medigap Part A
Medigap Part B
Medicare Primary
Other
Property Insurance – Personal
Personal
Personal Payment (Cash - No Insurance)
Preferred Provider Organization (PPO)
Point of Service (POS)
Qualified Medicare Beneficiary
Property Insurance - Real
Supplemental Policy
Tax Equity Fiscal Responsibility Act (TEFRA)
Workers Compensation
Wrap Up Policy
Ingredient Name Value Set
The value set to identify an ingredient name within a care transition uses unique ingredient identifiers (UNIIs) for
substances in drugs, biologics, foods, and devices.
The value set can be located here:
http://www.fda.gov/ForIndustry/DataStandards/StructuredProductLabeling/ucm162523.htm
Immunizations Administered Vaccines Value Set Recommendation
The Health IT Standards Committee recommends CVX Codes for vaccinations (acknowledging that vaccinations are
treated as medications in some contexts and as a separate category in others). The value set for a care transition
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uses CVX codes to populate the Coded Product Name in the Immunizations Section of the care transition. This
value set provides CVX codes common to a care transition:
CVX Code
54
55
24
19
27
26
29
12
28
20
106
110
50
120
130
01
22
30
52
83
84
85
104
08
42
43
44
45
47
46
49
48
17
51
62
118
86
14
87
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Immunization Description
Adenovirus, type 4
Adenovirus, type 7
Anthrax
BCG
Botulinum antitoxin
Cholera
CMVIG
Diphtheria antitoxin
DT (pediatric)
DTaP
DTaP, 5 pertussis antigens
DTaP-Hep B-IPV
DTaP-Hib
DTaP-Hib-IPV
DTaP-IPV
DTP
DTP-Hib
HBIG
Hep A, adult
Hep A, ped/adol, 2 dose
Hep A, ped/adol, 3 dose
Hep A, unspecified formulation
Hep A-Hep B
Hep B, adolescent or pediatric
Hep B, adolescent/high risk infant
Hep B, adult
Hep B, dialysis
Hep B, unspecified formulation
Hib (HbOC)
Hib (PRP-D)
Hib (PRP-OMP)
Hib (PRP-T)
Hib, unspecified formulation
Hib-Hep B
HPV, quadrivalent
HPV, bivalent
IG
IG, unspecified formulation
IGIV
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CVX Code
135
111
144
140
141
88
16
10
134
39
66
05
32
136
114
03
94
04
07
127
128
125
126
02
23
100
133
33
18
40
90
34
116
119
93
71
06
09
113
115
35
13
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Immunization Description
Influenza, high dose seasonal
Influenza, live, intranasal
Influenza, seasonal, intradermal, preservative free
Influenza, seasonal, injectable, preservative free
Influenza, seasonal, injectable
Influenza, unspecified formulation
Influenza, whole
IPV
Japanese Encephalitis IM
Japanese encephalitis SC
Lyme disease
Measles
Meningococcal MPSV4
Meningococcal MCV4O
Meningococcal MCV4P
MMR
MMRV
M/R
Mumps
Novel influenza-H1N1-09
Novel Influenza-H1N1-09, all formulations
Novel Influenza-H1N1-09, nasal
Novel influenza-H1N1-09, preservative-free
OPV
Plague
Pneumococcal conjugate PCV 7
Pneumococcal conjugate PCV 13
Pneumococcal polysaccharide PPV23
Rabies, intramuscular injection
Rabies, intradermal injection
Rabies, unspecified formulation
RIG
Rotavirus, pentavalent
Rotavirus, monovalent
RSV-MAb
RSV-IGIV
Rubella
Td (adult), adsorbed
Td (adult) preservative free
Tdap
Tetanus toxoid, adsorbed
TIG
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CVX Code
Immunization Description
Typhoid, oral
Typhoid, parenteral
Typhoid, parenteral, AKD (U.S. military)
Typhoid, unspecified formulation
Typhoid, ViCPs
Vaccinia immune globulin
VZIG
Varicella
Yellow fever
Zoster
25
41
53
91
101
79
36
21
37
121
Immunization Reason Value Set

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component with the following change
Concept Code
IMMUNE
Concept Name
Immunity
MEDPREC
Medical precaution
OSTOCK
Out of sToCk
PATOBJ
Patient objection
PHILISOP
Philosophical objection
RELIG
Religious objection
VACEFF
Vaccine efficacy
concerns
VACSAF
Vaccine safety concerns
Definition
Testing has shown that the patient already has
immunity to the agent targeted by the immunization
The patient currently has a medical condition for which
the vaccine is contraindicated or for which precaution is
warranted
There was no supply of the product on hand to perform
the service
The patient or their guardian objects to receiving the
vaccine
The patient or their guardian objects to receiving the
vaccine because of philosophical beliefs
The patient or their guardian objects to receiving the
vaccine on religious grounds
The intended vaccine has expired or is otherwise
believed to no longer be effective
Example: Due to temperature exposure
Medication Fill Status Value Set

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Concept Code
Completed
Concept Name
Completed
Aborted
Aborted
Definition
An Act that has terminated normally after all of its constituents have been
performed
The Act has been terminated prior to the originally intended completion
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Medication Method of Delivery Value Set
The Centers for Medicare and Medicaid Services (CMS) published to the Federal Register July 1, 2010 an Interim
Final Rule (IFR) entitled, "Identification of Backward Compatible Version of Adopted Standard for E-Prescribing and
the Medicare Prescription Drug Program (NCPDP SCRIPT 10.6)." The regulation names NCPDP SCRIPT 10.6 effective
for use July 1, 2010 and continues to support NCPDP SCRIPT 8.1.
Pursuant to this implementation guidance the value set for Medication Method of Delivery in a care transition can
use NCPDP Script 10.6 to code values for delivery method.
Medication Product Form Value Set
This is the physical form of the product as presented to the individual. For example: tablet, capsule, liquid or
ointment. The value set specified for a care transition is to use NCI concept code for pharmaceutical dosage form:
C42636

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Medication Route Value Set
This indicates the method for the medication received by the individual (e.g., by mouth, intravenously, topically,
etc). The value set specified for a care transition is to use NCI concept code for route of administration: C38114

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Medication Type Value Set
For an Active Medication List (as specified in the Transitions of Care Clinical Information Model ), the value set for
Medication Type is based on SNOMED-CT. The following SNOMED-CT concept codes are used:

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Concept Code
329505003
73639000
Concept Name (Fully Qualified SNOMED-CT
Name)
Over the counter products (product)
Prescription drug (product)
Usage Note
Over the counter products
Prescription Drug
Problem Status Value Set
The Health IT Standards Committee recommends the use of SNOMED-CT to capture problems.For an Active
Problem List (as specified in the Transitions of Care Clinical Information Model ), the value set for Problem Status is
derived from SNOMED-CT. The following SNOMED-CT concept codes are used:
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Concept Name
(Fully Qualified
SNOMED-CT
Name)
Concept Code
Definition
The problem has been resolved (as of the time reported) - the problem is
one that still exists for the patient but is not currently a cause for concern
(e.g., diabetes that is under control)
The problem is currently active (as of the time reported) - the problem
exists and is a current cause for concern
The problem is currently inactive (as of the time reported) - the problem
no longer exists as a problem for the patient as of the time of recording
(it may reoccur, but that would be a new instance)
413322009
Resolved
55561003
Active
73425007
Inactive
90734009
7087005
255227004
415684004
410516002
Chronic
Intermittent
Recurrent
Rule out
Ruled out
Problem Type Value Set
The Health IT Standards Committee recommends the use of SNOMED-CT to capture problems. For an Active
Problem List (as specified in the Transitions of Care Clinical Information Model ), the value set for Problem Type is
derived from SNOMED-CT. The following SNOMED-CT concept codes are used:

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Concept Code
404684003
418799008
55607006
409586006
64572001
282291009
248536006
Concept Name (Fully Qualified
SNOMED-CT Name)
Clinical finding (finding)
Finding reported by subject or
history provider (finding)
Problem (finding)
Complaint (finding)
Disease (disorder)
Diagnosis interpretation
(observable entity)
Finding of functional performance
and activity (finding)
Definition
Usage Note
Finding
Symptom
Problem
Complaint
Condition
Diagnosis
Functional limitation
Procedure Value Set
The Health IT Standards Committee recommends SNOMED-CT for procedures. The value set recommended within
the Consolidated CDA Guide, however, is CPT-4. Thus, at this time, a supporting value set for the HITSC Procedure
recommendation CANNOT be provided. The value set used for coding Procedure Types for a care transition is
listed in the following table. The table below lists the most desired CPT Coded Procedure types.
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Figure 3: Procedure Value Set Table
Procedure
Home Services
Well baby/child care visits
Preventive Counseling
Group Counseling
Health Risk Assessment Intervention
Unlisted Preventive Medicine Service
Health & Behavior Assessment/Intervention
(Non-physician only)
Individual psychotherapy
Interactive psychiatric diagnostic interview
examination
Physician educational services in a group
setting
Physical medicine and rehabilitation
Preventive medicine services
Psychiatric diagnostic interview examination
Smoking Cessation Treatment
Smoking and tobacco-use cessation
counseling visit
Smoking Cessation Classes, non-physician
provider
Eye Exams
Eye Exams
Nephropathy-related procedures
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Coded Procedure Type
99341-99345, 99347-99350
99392-99396
99401-99404
99411, 99412
99420
99429
96150-96155
90804-90809
90802
99078
97003
99381-99389
90801
S9075
4000F, 4001F, 4004F, 99406,
99407
S9453
134395001, 390735007,
390847009, 390855002
67028, 67030, 67031, 67036,
67038, 67039, 67040, 67041,
67042, 67043, 67101, 67105,
67107, 67108, 67110, 67112,
67113, 67121, 67141, 67145,
67208, 67210, 67218
, 67220, 67221, 67227, 67228,
92002, 92004, 92012, 92014,
92018, 92019, 92225, 92226,
92230, 92235, 92240, 92250,
92260
11932001, 14684005,
225230008, 225231007,
233575001, 233578004,
233581009, 233582002,
233583007, 233584001,
233585000, 233586004,
233587008, 233588003,
233589006, 233590002,
236434000, 236435004,
238318009, 238319001,
238321006, 238322004,
238323009, 265764009,
302497006, 34897002,
Code Set
CPT
CPT
CPT
CPT
CPT
CPT
CPT
CPT
CPT
CPT
CPT
CPT
CPT
CPT
CPT
CPT
SNOMED CT
CPT
SNOMED-CT
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Procedure
Nephropathy-related procedures
Nephropathy-related procedures
Nephropathy-related procedures
Coded Procedure Type
427053002, 428648006,
46177005, 57274006, 676002,
67970008, 68341005,
71192002, 73257006
Z49, Z49.0, Z49.01, Z49.02,
Z49.3, Z49.31, Z49.32, Z99.2
36145, 36800, 36810, 36815,
36818, 36819-36821, 36831,
36832, 36833, 50300, 50320,
50340, 50360, 50365, 50370,
50380, 90920, 90921, 90924,
90925, 90935, 90937, 90940,
90945, 90947, 90957, 90958,
90959, 90960, 90961, 90962,
90965, 90966, 90969, 90970,
90989, 90993, 90997, 90999,
99512
38.95, 39.27, 39.42, 39.43,
39.53, 39.93, 39.94, 39.95,
54.98, 55.4, 55.5, 55.6
Code Set
ICD-10
CPT-4
ICD-9
Result Type Value Set

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component without change
Concept Code
completed
Concept Name
Completed
aborted
active
cancelled
held
Aborted
Active
Cancelled
Held
new
suspended
New
Suspended
Definition
An Act that has terminated normally after all of its constituents have been
performed
The Act has been terminated prior to the originally intended completion
The Act can be performed or is being performed
The Act has been abandoned before activation
An Act that is still in the preparatory stages has been put aside. No action
can occur until the Act is released
An Act that is in the preparatory stages and may not yet be acted upon
An Act that has been activated (actions could or have been performed
against it), but has been temporarily disabled. No further action should be
taken against it until it is released
Results Value Set
The value set to use for Results in a care transition is based on LOINC. The table contains a recommended selection
of LOINC result codes that can be used to populate a Results Section.
Figure 4: Results Codes Table
Result Text
24 hour Urine Creatinine Clearance
ALT/SGPT
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Created on 8/31/2011
Result Code (LOINC)
2162-6, 14399-0, 14682-9
1742-6
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Result Text
AST/SGOT
BNP
BUN
Chol/HDL Ratio
Creatinine
Digoxin level
Estimated Average Glucose
FBS
Fe
Fecal Occult Blood Test (FOBT)
Ferritin
Folate
Glucose Random
Glucose
HBA1c
Hct
HDL
Hep B Surface Antibody
Hep C Antibody
Hgb
INR
iPTH
Iron Saturation
LDL
LDL/HDL Ratio
LVEF
Micro albumin / Creatinine Ratio
Platelets
PSA
RBC count
Serum Albumin
Serum Calcium
Serum Chloride
Serum CPK
Serum Creatinine
Serum Lead Level
Serum Magnesium
Serum Phosphorus
Serum Potassium
Serum Sodium
TIBC
Total Cholesterol
Triglycerides
TSH
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Result Code (LOINC)
1920-8
42637-9
3094-0
9830-1
2161-8
27353-2
2335-8
2276-4
2284-8
10966-0, 15076-3, 22705-8,
2339-0, 2341-6, 2349-9, 2350-7,
2351-5, 5914-7
4548-4, 4549-2, 17855-8, 178568
4544-3
2086-7, 2085-9
718-7
6301-6
2090-9, 2089-1, 18262-6, 134577
11054-4
30000-4
2857-1
789-8
1751-7
17861-6
2075-0
2157-6
2160-0
19123-9
2777-1
2823-3
2951-2
2500-7
2565-0
3049-4
3016-3
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Result Text
Urine Collection Duration
Urine Dip Stick
Urine Micro albumin
Urine Volume
Vitamin B12
WBC count
Tobacco Assessment
Tobacco Cessation Intervention
Tobacco Counseling
Nephropathy screening
Patient Health Questionnaire (PHQ-2)
Patient Health Questionnaire (PHQ-2)
PHQ-2 total score
Result Code (LOINC)
13362-9
20454-5, 50561-0, 53525-2,
5804-0
28009-9
6690-2
11218-5, 12842-1, 13705-9,
13801-6, 14585-4, 14956-7,
14957-5, 14958-3, 14959-1,
1753-3, 1754-1, 1755-8, 1757-4,
18373-1, 20621-9, 21059-1,
21482-5, 26801-1, 27298-9,
2887-8, 2888-6, 2889-4, 2890-2,
30000-4, 30001-2, 30003-8,
32209-9, 32294-1, 32551-4,
34366-5, 35663-4, 40486-3,
40662-9, 40663-7, 43605-5,
43606-3, 43607-1, 44292-1,
47558-2, 49023-5, 50949-7,
53121-0, 53530-2, 53531-0,
53532-8, 9318-7
55757-9
58120-7
55758-7
Social History Type Value Set
Figure 5: Social History Type Value Set
Code
229819007
256235009
160573003
364393001
364703007
425400000
363908000
228272008
Name
Tobacco use and exposure (observable entity)
Exercise (observable entity)
Alcohol intake (observable entity)
Nutritional observable (observable entity)
Employment detail (observable entity)
Toxic exposure status (observable entity)
Details of drug misuse behavior (observable entity)
Health-related behavior (observable entity)
Usage Note
Smoking
Exercise
ETOH (Alcohol) Use
Diet
Employment
Toxic Exposure
Drug Use
Other Social History
Vital Signs Result Type Value Set
The Transitions of Care Initiative recommends the use of LOINC to capture a core set of Vital Signs Results. These
vital sign values are captured in the Vital Sign Result Type of the Vital Signs Section.
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The following value set is derived from HITSP C80 and includes BMI measurements as a vital sign observation.

NOTE: This value set is adopted from HITSP C80 - Clinical Document and Message Terminology
Component with the following change
o Includes BMI measurements as a vital sign observation.
LOINC Concept Code
9279-1
8867-4
2710-2
8480-6
8462-4
8310-5
8302-2
8306-3
8287-5
3141-9
39156-5
41909-3
Description of Vital Sign
Respiration Rate
Heart Beat
Oxygen Saturation
Intravascular Systolic
Intravascular Diastolic
Body Temperature
Body Height (Measured)
Body Height (Lying)
Circumference Occipital Frontal (Tape Measure)
Body Weight (Measured)
Body-Mass-Index measurement
Body-Mass-Index
8. Appendix D – XML Examples for Discharge Summary
A series of sample XML schemas are provided to help guide the development of CDA-conformant documents.
Sample CDA Header XML Schema
http://xreg2.nist.gov:8080/hitspValidation/schema/cdar2c32/infrastructure/cda/C32_CDA.xsd">
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.10.20.1"/>
<id root="6858a017-39c1-4153-bbd4-eaedac72a0e7"/>
<code code="34133-9" displayName="Summarization of episode note" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<title> Continuity of Care Document from “HIE Name”</title>
<effectiveTime value="20081120161000+1400"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
Sample RecordTarget XML Schema
<recordTarget typeCode="RCT" contextControlCode="OP">
<patientRole>
<id extension="#########"/>
<addr use="HP">
<streetAddressLine>15 New Kidney St. </streetAddressLine>
<city>Richmond</city>
<state>VA</state>
<postalCode>22222</postalCode>
</addr>
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<telecom use="HP" value="tel:+1-703-555-1212"/>
<telecom use="WP" value="tel:+1-703-555-2323"/>
<patient>
<name use="L">
<given qualifier="CL">Jane</given>
<given qualifier="CL">M</given>
<family qualifier="BR">Snow</family>
</name>
<administrativeGenderCode code="F" displayName="Female" codeSystem="2.16.840.1.113883.5.1"
codeSystemName="HL7 AdministrativeGenderCode"/>
<birthTime value="19610821"/>
</patient>
</patientRole>
</recordTarget>
Sample Author XML Schema
<author>
<time value="20080731142500"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6.1013905751"/>
<addr>
<streetAddressLine>612 Wharf Ave.</streetAddressLine>
<city>Fairfax</city>
<state>VA</state>
<postalCode>20151</postalCode>
</addr>
<telecom use="HP" value="tel:+1-703-555-0033"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>John</given>
<family>Lee</family>
</name>
</assignedPerson>
<<representedOrganization>
<id root="2.16.840.1.113883.X.XXX"/>
<name>Hospital Name</name>
<</representedOrganization>
</assignedAuthor>
</author>
Sample Informant XML Schema
<informant>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<addr>
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
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<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom value="tel:(555)555-1003"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</informant>
<informant>
<relatedEntity classCode='PROV'>
<code code='208D00000X' codeSystem="2.16.840.1.113883.11.19465"/>
<relatedPerson>
<name>
<given>Adam</given>
<family>Everyman</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
Sample Custodian XML Schema
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="2.16.840.1.113883.X.X.XXXX"/>
<name>Smith Medical Center</name>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
Sample Participant XML Schema
<participant typeCode="IND" contextControlCode="OP">
<templateId root="2.16.840.1.113883.3.88.11.32.3"/>
<time/>
<associatedEntity classCode="PRS">
<code code="DAU" displayName="Daughter" codeSystem="2.16.840.1.113883.5.111"
codeSystemName="HL7 RoleCode"/>
<addr use="HP">
<streetAddressLine>612 Wharf Ave.</streetAddressLine>
<city>Fairfax</city>
<state>VA</state>
<postalCode>20151</postalCode>
</addr>
<telecom use="HP" value="tel:+1-703-555-0033"/>
<telecom use="WP" value="tel:+1-703-555-3434"/>
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<telecom value="mailto:Janet_Snow@email.com"/>
<associatedPerson>
<name>
<given>Janet</given>
<family>Snow</family>
<suffix/>
</name>
</associatedPerson>
</associatedEntity>
</participant>
Sample DocumentationOf XML Schema
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="20000101"/>
<high value="20080731"/>
</effectiveTime>
<performer typeCode="PRF">
<templateId root="2.16.840.1.113883.3.88.11.32.4"/>
<functionCode code="PP" displayName="Primary Care Provider"
codeSystem="2.16.840.1.113883.12.443" codeSystemName="Provider Role">
<originalText>Primary Care Provider</originalText>
</functionCode>
<time>
<low value="20020101"/>
<high nullFlavor="UNK"/>
</time>
<assignedEntity>
<id root="2.16.840.1.113883.4.6.1013905751" extension="Provider ID"/>
<code code="280000000X" displayName="Hospitals"
codeSystem="2.16.840.1.113883.6.101" codeSystemName="ProviderCodes"/>
<addr use="WP">
<streetAddressLine>10 St. Sample Boulevard </streetAddressLine>
<city>Example</city>
<state>VA</state>
<postalCode>11111</postalCode>
</addr>
<addr use="WP">
<streetAddressLine>123 West Cove Alley</streetAddressLine>
<streetAddressLine>Suite #22</streetAddressLine>
<city>Richmond</city>
<state>VA</state>
<postalCode>11111</postalCode>
</addr>
<telecom use="WP" value="tel:+1-888-555-1111"/>
<telecom value="mailto:H.Cohen.MD@SFMC.com"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
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<given>Harry</given>
<given>R</given>
<family>Cohen</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.4.6.2649871"/>
<name>St. George Medical Center</name>
</representedOrganization>
<sdtc:patient>
<sdtc:id root="78A150ED-B890-49dc-B716-5EC0027B3983" extension="11224433"/>
</sdtc:patient>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
Sample Advance Directives XML Schema
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.1"/>
<code code="42348-3" displayName="Advance directives"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Advance Directives</title>
<text>
<content ID="Direct-1">
Herein I, Jane Mertle Snow write this document as a directive regarding my medical care. In the following sections,
put the initials of your name in the blank spaces by the choices you want. PART 1. My Durable Power of Attorney
for Health Care _SMT__ I appoint this person to make decisions about my medical care if there ever comes a time
when I cannot make those decisions myself. I want the person I have appointed, my doctors, my family and others
to be guided by the decisions I have made in the parts of the form that follow. Name: Sarah Marie
Thompson/Daughter Home telephone:301-555-1415 Work telephone: 301-555-1514 Address: 12 East Main New
Market, MD 21774 If the person above cannot or will not make decisions for me, I appoint this person: Name:
Bradley John Snow/Son Home telephone: 301-555-6677 Work telephone: 301-666-4545
Address: 3453 Hallow Way Baltimore, MD
</content>
</text>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.17 "/>
<id root="ec78a751-5994-4910-ada5-ef402937837d"/>
<code code="304251008" displayName="Resuscitation"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<originalText>
<reference value="#Direct-1"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20050101"/>
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<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="304253006" displayName="Do Not Resuscitate"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<participant typeCode="CST">
<participantRole classCode="AGNT">
<addr use="">
<streetAddressLine/>
<city/>
<state/>
<postalCode/>
</addr>
<telecom use="HP" value="tel:+1-301-555-1234"/>
<playingEntity>
<name>
<given>Emily</given>
<given>X.</given>
<family>Green</family>
<suffix/>
</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.37"/>
<code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="425392003" displayName="Current and Verified"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
</observation>
</entry>
</section>
</component>
Sample Allergy XML Schema
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.2"/>
<code code="48765-2" displayName="Allergies, adverse reactions, alerts"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Allergies and Adverse Reactions</title>
<text>
<content ID="allergy_comment-1">No known allergies. </content>
</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.20.1.27"/>
<templateId root="2.16.840.1.113883.3.88.11.32.6"/>
<id root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code nullFlavor="NA"/>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.40"/>
<templateId root="2.16.840.1.113883.3.88.11.32.12"/>
<code code="48767-8" displayName="Annotation Comment"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#allergy_comment-1"/>
</text>
<statusCode code="completed"/>
<author>
<time value="20080101"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6.1013905751"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Randall</given>
<family>Ford</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
</act>
</entryRelationship>
</act>
</entry>
</section>
</component>
Sample Problems XML Schema
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.11"></templateId>
<code code="11450-4" displayName="Problem list" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" />
<title>Problem list</title>
<text></text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.27" />
<id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7" />
<code nullFlavor="UNK" />
<performer typeCode="PRF">
<time>
<low value="20060601" />
<high value="20080924" />
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</time>
<assignedEntity>
<id root="78A150ED-B890-49dc-B716-5EC0027B3982" extension="ProviderID" />
<code code="280000000X" displayName="Hospitals"
codeSystem="2.16.840.1.113883.6.101" codeSystemName="ProviderCodes" />
<addr use="WP">
<streetAddressLine>145 Applecross Road</streetAddressLine>
<streetAddressLine></streetAddressLine>
<city>Southern Pines</city>
<state>NC</state>
<postalCode>28388</postalCode>
</addr>
<assignedPerson>
<name>
<prefix>Dr. </prefix>
<given>Shirley</given>
<given />
<family>Jordan</family>
</name>
</assignedPerson>
<representedOrganization>
<name>Southern Pines Women's Health Center</name>
</representedOrganization>
<sdtc:patient xmlns:sdtc="urn:hl7-org:sdtc">
<sdtc:id root="78A150ED-ZZ23-49dc-B716-5EC0027B3983" extension="33445566" />
</sdtc:patient>
</assignedEntity>
</performer>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28" />
<id root="ab1791b0-5c71-11db-b0de-0800200c9a66" />
<code code="282291009" displayName="Diagnosis"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"></code>
<text>
<reference value="#prob-1" />
</text>
<statusCode code="completed" />
<!--Problem Date-->
<effectiveTime>
<low value="20080915" />
<high nullFlavor="UNK" />
</effectiveTime>
<!--Problem Code-->
<value xsi:type="CD" code="174.0" displayName="Malignant neoplasm of female breast"
codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD9"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" />
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<!--20.1.50 = problem status observation 20.1.57 = conformant status observation-->
<templateId root="2.16.840.1.113883.10.20.1.50"></templateId>
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<code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" />
<statusCode code="completed" />
<value xsi:type="CE" code="55561003" displayName="Active"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" />
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="DRIV">
<!--Condition Module-->
<act classCode="ACT" moodCode="EVN">
<!--TemplateId 20.1.27 = CCD Problem Act 11.32.7 = C32 Condition Module-->
<templateId root="2.16.840.1.113883.10.20.1.27" />
<id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7" />
<code nullFlavor="NA" />
<!--Primary Care Physician-->
<performer typeCode="PRF">
<time>
<low value="20060509"></low>
<high value="20080801" />
</time>
<assignedEntity>
<id root="2.16.840.1.113883.4.6.15597815751" extension="Provider ID" />
<!-- OID is Dr. Orbit's NPI -->
<code code="261QM2500X" displayName="Medical Specialty"
codeSystem="2.16.840.1.113883.6.101" codeSystemName="ProviderCodes" />
<addr use="WP">
<streetAddressLine>155 Memorial Drive</streetAddressLine>
<streetAddressLine></streetAddressLine>
<city>Ironton</city>
<state>OH</state>
<postalCode>11111</postalCode>
</addr>
<telecom use="WP" value="tel:+1-888-555-5555" />
<assignedPerson>
<name>
<prefix>Dr</prefix>
<given>George</given>
<given>E.</given>
<family>Orbit</family>
</name>
</assignedPerson>
<representedOrganization>
<name>Smith Regional Hospital</name>
</representedOrganization>
<sdtc:patient xmlns:sdtc="urn:hl7-org:sdtc">
<!--The ID is how the doctor identifies the patient's record. Patient's MRN under the
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provider producing the CCD/C32-->
<sdtc:id root="78A150ED-ZZ12-49dc-B716-5EC0027B3983" extension="11223344" />
</sdtc:patient>
</assignedEntity>
</performer>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- Problem observation template -->
<templateId root="2.16.840.1.113883.10.20.1.28" />
<id root="ab1791b0-5c71-11db-b0de-0800200c9a66" />
<!--Problem Type (and description)-->
<code code="418799008" displayName="Symptom"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"></code>
<text>
<reference value="#prob-1" />
</text>
<statusCode code="completed" />
<!--Problem Date-->
<effectiveTime>
<low value="20080910" />
<high nullFlavor="UNK" />
</effectiveTime>
<value xsi:type="CD" code="198.2" displayName="Skin, Skin of breast"
codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD9"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" />
<!--Problem Status-->
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<!--20.1.50 = problem status observation 20.1.57 = conformant status observation-->
<templateId root="2.16.840.1.113883.10.20.1.50"></templateId>
<code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" />
<statusCode code="completed" />
<!--Problem Status-->
<value xsi:type="CE" code="55561003" displayName="Active"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" />
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
Sample Medication XML Schema
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.8"/>
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<code code="10160-0" displayName="History of medication use"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Medication</title>
<text/>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<templateId root="2.16.840.1.113883.3.88.11.32.8"/>
<id root="cdbd5b05-6cde-11db-9fe1-0800200c9a66"/>
<text>
<reference value="#sig-1"/>
</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS" nullFlavor="UNK"/>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
<period value="12" unit="h"/>
</effectiveTime>
<routeCode code="C38288" displayName="Oral"
codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus"/>
<approachSiteCode code=" 21082005 " displayName="Mouth"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<doseQuantity value="1" unit="{INHALATION}"/>
<maxDoseQuantity xsi:type="RTO_PQ_PQ">
<numerator value="6"/>
<denominator value="1"/>
</maxDoseQuantity>
<administrationUnitCode code="C38216" displayName="Tablet"
codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus"/>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<templateId root="2.16.840.1.113883.3.88.11.32.9"/>
<manufacturedMaterial classCode="MMAT">
<code code="51947-0696" displayName="Levothyroxine"
codeSystem="2.16.840.1.113883.6.69" codeSystemName="NDC">
<originalText>
<reference value="#medication-1"/>
</originalText>
<translation code="PLACE_HOLDER" displayName="PLACE_HOLDER"
codeSystem="2.16.840.1.113883.6.88" codeSystemName="PLACE_HOLDER"/>
</code>
<name>Levothyroxine</name>
</manufacturedMaterial>
<manufacturerOrganization>
<name>GlaxoC3POKline</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<code code="N0000006601" displayName="Lactose"
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codeSystem="2.16.840.1.113883.4.209" codeSystemName="NDF-RT"/>
<playingEntity classCode="MMAT">
<code/>
<name/>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.3.88.11.32.10"/>
<code code="73639000" displayName="Prescription Drug"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.47"/>
<code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<value xsi:type="CE" code="55561003" displayName="Active"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28"/>
<code code=" 312453004 " displayName="Asthma - currently active"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#indication-1"/>
</text>
<statusCode code="completed"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ">
<act classCode="ACT" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.1.49"/>
<code nullFlavor="UNK"/>
<text>
<reference value="#patient-instruction-1"/>
</text>
</act>
</entryRelationship>
<entryRelationship typeCode="CAUS">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.54"/>
<code nullFlavor="UNK"/>
<text>
<reference value="#reaction-1"/>
</text>
<statusCode code="completed"/>
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</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<supply classCode="SPLY" moodCode="INT">
<templateId root="2.16.840.1.113883.3.88.11.32.11"/>
<id root="14ED7742-2428-4e2c-9446-A9B0D0075272"
extension="20097864565331453252"/>
<effectiveTime value="20081109"/>
<repeatNumber value="6"/>
<quantity value="1"/>
<author>
<time value="20080604"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6.1013905751" extension="Provider ID"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Harry</given>
<given>R</given>
<family>Cohen</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<act classCode="ACT" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.1.43"/>
<code/>
<text>
<reference value="#fulfillment-instruction1"/>
</text>
</act>
</entryRelationship>
</supply>
</entryRelationship>
<entryRelationship typeCode="REFR">
<sequenceNumber value="4"/>
<supply classCode="SPLY" moodCode="EVN">
<id root="14ED7742-2428-4e2c-9446-A9B0D0075272" extension="321654-7746816180"/>
<statusCode code="completed"/>
<effectiveTime value="20081109"/>
<quantity value="1" unit="tablet"/>
<performer>
<assignedEntity>
<id root="2.16.840.1.113883.4.6.1013905751"/>
<addr use="WP">
<streetAddressLine>330 Brookline</streetAddressLine>
<streetAddressLine/>
<city>New Market</city>
<state>MA</state>
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<postalCode>02215</postalCode>
</addr>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Harry</given>
<given>R</given>
<family>Cohen</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.4.6.2649871"/>
<name>St. Francis Medical Center</name>
</representedOrganization>
</assignedEntity>
</performer>
</supply>
</entryRelationship>
<precondition>
<criterion/>
</precondition>
</substanceAdministration>
</entry>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<templateId root="2.16.840.1.113883.3.88.11.32.8"/>
<id root="cdbd5b05-6cde-11db-9fe1-0800200c9a66"/>
<text>
<reference value="#sig-1"/>
</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS" nullFlavor="UNK"/>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
period value="12" unit="h"/>
</effectiveTime>
<routeCode code="C38288" displayName="Oral"
codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus"/>
<approachSiteCode code=" 21082005 " displayName="Mouth"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<doseQuantity value="500" unit="mg"/>
<maxDoseQuantity xsi:type="RTO_PQ_PQ">
<numerator value="1"/>
<denominator value="1"/>
</maxDoseQuantity>
<administrationUnitCode code="C38216" displayName="Tablet"
codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus"/>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<templateId root="2.16.840.1.113883.3.88.11.32.9"/>
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<manufacturedMaterial classCode="MMAT">
<code code="51947-0696" displayName="Cefuroxime"
codeSystem="2.16.840.1.113883.6.69" codeSystemName="NDC">
<originalText>
<reference value="#medication-1"/>
</originalText>
<translation code="PLACE_HOLDER" displayName="PLACE_HOLDER"
codeSystem="2.16.840.1.113883.6.88" codeSystemName="PLACE_HOLDER"/>
</code>
<name>Cefuroxime</name>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Glaxo Smith Kline </name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<code code="N0000006601" displayName="Lactose"
codeSystem="2.16.840.1.113883.4.209" codeSystemName="NDF-RT"/>
<playingEntity classCode="MMAT">
<code/>
<name/>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.3.88.11.32.10"/>
<code code="73639000" displayName="Prescription Drug"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.47"/>
<code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1"
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<value xsi:type="CE" code="55561003" displayName="Active"
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</entryRelationship>
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28"/>
<code code=" 312453004 " displayName="Infection - currently active"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#indication-1"/>
</text>
<statusCode code="completed"/>
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Office of the National Coordinator for
Health Information Technology
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ">
<act classCode="ACT" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.1.49"/>
<code nullFlavor="UNK"/>
<text>
<reference value="#patient-instruction-1"/>
</text>
</act>
</entryRelationship>
<entryRelationship typeCode="CAUS">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.54"/>
<code nullFlavor="UNK"/>
<text>
<reference value="#reaction-1"/>
</text>
<statusCode code="completed"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<supply classCode="SPLY" moodCode="INT">
<templateId root="2.16.840.1.113883.3.88.11.32.11"/>
<id root="14ED7742-2428-4e2c-9446-A9B0D0075272"
extension="20097864565331453252"/>
<effectiveTime value="20081109"/>
<repeatNumber value="6"/>
<quantity value="1"/>
<author>
<time value="20080604"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6.1013905751" extension="Provider ID"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Harry</given>
<given>R</given>
<family>Cohen</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<act classCode="ACT" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.1.43"/>
<code/>
<text>
<reference value="#fulfillment-instruction1"/>
</text>
</act>
Transitions of Care – Discharge Summary Guide
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Office of the National Coordinator for
Health Information Technology
</entryRelationship>
</supply>
</entryRelationship>
<entryRelationship typeCode="REFR">
<sequenceNumber value="4"/>
<supply classCode="SPLY" moodCode="EVN">
<id root="14ED7742-2428-4e2c-9446-A9B0D0075272" extension="321654-7746816180"/>
<statusCode code="completed"/>
<effectiveTime value="20081109"/>
<quantity value="1" unit="tablet"/>
<performer>
<assignedEntity>
<id root="2.16.840.1.113883.4.6.1013905751"/>
<addr use="WP">
<streetAddressLine>10 Brook</streetAddressLine>
<streetAddressLine/>
<city>New Market</city>
<state>MD</state>
<postalCode>01111</postalCode>
</addr>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Harry</given>
<given>R</given>
<family>Ah</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.4.6.1123"/>
<name>Test Medical Center</name>
</representedOrganization>
</assignedEntity>
</performer>
</supply>
</entryRelationship>
<precondition>
<criterion/>
</precondition>
</substanceAdministration>
</entry>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<templateId root="2.16.840.1.113883.3.88.11.32.8"/>
<id root="cdbd5b05-6cde-11db-9fe1-0800200c9a66"/>
<text>
<reference value="#sig-1"/>
</text>
<statusCode code="completed"/>
Transitions of Care – Discharge Summary Guide
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Office of the National Coordinator for
Health Information Technology
<effectiveTime xsi:type="IVL_TS" nullFlavor="UNK"/>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
<period value="24" unit="h"/>
</effectiveTime>
<routeCode code="C38288" displayName="Oral"
codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus"/>
<approachSiteCode code=" 21082005 " displayName="Mouth"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<doseQuantity value="1" unit="Syrup"/>
<maxDoseQuantity xsi:type="RTO_PQ_PQ">
<numerator value="1"/>
<denominator value="1"/>
</maxDoseQuantity>
<administrationUnitCode code="C38216" displayName="Syrup"
codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus"/>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<templateId root="2.16.840.1.113883.3.88.11.32.9"/>
<manufacturedMaterial classCode="MMAT">
<code code="51947-0696" displayName="Mytussin AC"
codeSystem="2.16.840.1.113883.6.69" codeSystemName="NDC">
<originalText>
<reference value="#medication-1"/>
</originalText>
<translation code="PLACE_HOLDER" displayName="PLACE_HOLDER"
codeSystem="2.16.840.1.113883.6.88" codeSystemName="PLACE_HOLDER"/>
</code>
<name>Mytussin AC</name>
</manufacturedMaterial>
<manufacturerOrganization>
<name>GlaxoC3POKline</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<code code="N0000006601" displayName="Lactose"
codeSystem="2.16.840.1.113883.4.209" codeSystemName="NDF-RT"/>
<playingEntity classCode="MMAT">
<code/>
<name/>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.3.88.11.32.10"/>
<code code="73639000" displayName="Prescription Drug"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
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Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
</entryRelationship>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.47"/>
<code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<value xsi:type="CE" code="55561003" displayName="Active"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28"/>
<code code=" 312453004 " displayName="Expectorant - currently active"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#indication-1"/>
</text>
<statusCode code="completed"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ">
<act classCode="ACT" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.1.49"/>
<code nullFlavor="UNK"/>
<text>
<reference value="#patient-instruction-1"/>
</text>
</act>
</entryRelationship>
<entryRelationship typeCode="CAUS">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.54"/>
<code nullFlavor="UNK"/>
<text>
<reference value="#reaction-1"/>
</text>
<statusCode code="completed"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<supply classCode="SPLY" moodCode="INT">
<templateId root="2.16.840.1.113883.3.88.11.32.11"/>
<id root="14ED7742-2428-4e2c-9446-A9B0D0075272"
extension="20097864565331453252"/>
<effectiveTime value="20081109"/>
<repeatNumber value="1"/>
<quantity value="1"/>
<author>
<time value="20081109"/>
<assignedAuthor>
Transitions of Care – Discharge Summary Guide
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Office of the National Coordinator for
Health Information Technology
<id root="2.16.840.1.113883.4.6.1013905751" extension="Provider ID"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>John</given>
<given/>
<family>Lee</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<act classCode="ACT" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.1.43"/>
<code/>
<text>
<reference value="#fulfillment-instruction1"/>
</text>
</act>
</entryRelationship>
</supply>
</entryRelationship>
<entryRelationship typeCode="REFR">
<sequenceNumber value="4"/>
<supply classCode="SPLY" moodCode="EVN">
<id root="14ED7742-2428-4e2c-9446-A9B0D0075272" extension="321654-7746816180"/>
<statusCode code="completed"/>
<effectiveTime value="20081109"/>
<quantity value="1" unit="Tablespoon"/>
<performer>
<assignedEntity>
<id root="2.16.840.1.113883.4.6.1013905751"/>
<addr use="WP">
<streetAddressLine>885 Washington Street</streetAddressLine>
<streetAddressLine/>
<city>New Market</city>
<state>MD</state>
<postalCode>01111</postalCode>
</addr>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>John</given>
<given/>
<family>Lee</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.4.6.111111"/>
<name>South Comm. Health Center</name>
Transitions of Care – Discharge Summary Guide
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Office of the National Coordinator for
Health Information Technology
</representedOrganization>
</assignedEntity>
</performer>
</supply>
</entryRelationship>
<precondition>
<criterion/>
</precondition>
</substanceAdministration>
</entry>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<templateId root="2.16.840.1.113883.3.88.11.32.8"/>
<id root="cdbd5b05-6cde-11db-9fe1-0800200c9a66"/>
<text>
<reference value="#sig-1"/>
</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS" nullFlavor="UNK"/>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
period value="24" unit="h"/>
</effectiveTime>
<routeCode code="C38288" displayName="Oral"
codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus"/>
<approachSiteCode code=" 21082005 " displayName="Mouth"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<doseQuantity value="1" unit="Inhaler"/>
<maxDoseQuantity xsi:type="RTO_PQ_PQ">
<numerator value="1"/>
<denominator value="1"/>
</maxDoseQuantity>
<administrationUnitCode code="C38216" displayName="Inhaler"
codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus"/>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<templateId root="2.16.840.1.113883.3.88.11.32.9"/>
<manufacturedMaterial classCode="MMAT">
<code code="51947-0696" displayName="Fluticasone-Salmeterol"
codeSystem="2.16.840.1.113883.6.69" codeSystemName="NDC">
<originalText>
<reference value="#medication-1"/>
</originalText>
<translation code="PLACE_HOLDER" displayName="PLACE_HOLDER"
codeSystem="2.16.840.1.113883.6.88" codeSystemName="PLACE_HOLDER"/>
</code>
<name>Fluticasone-Salmeterol</name>
</manufacturedMaterial>
<manufacturerOrganization>
<name>GlaxoC3POKline</name>
Transitions of Care – Discharge Summary Guide
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Office of the National Coordinator for
Health Information Technology
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<code code="N0000006601" displayName="Lactose"
codeSystem="2.16.840.1.113883.4.209" codeSystemName="NDF-RT"/>
<playingEntity classCode="MMAT">
<code/>
<name/>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.3.88.11.32.10"/>
<code code="73639000" displayName="Prescription Drug"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.47"/>
<code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<value xsi:type="CE" code="55561003" displayName="Active"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28"/>
<code code=" 312453004 " displayName="Expectorant - currently active"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#indication-1"/>
</text>
<statusCode code="completed"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ">
<act classCode="ACT" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.1.49"/>
<code nullFlavor="UNK"/>
<text>
<reference value="#patient-instruction-1"/>
</text>
</act>
</entryRelationship>
<entryRelationship typeCode="CAUS">
<observation classCode="OBS" moodCode="EVN">
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
Page 90 of 111
Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
<templateId root="2.16.840.1.113883.10.20.1.54"/>
<code nullFlavor="UNK"/>
<text>
<reference value="#reaction-1"/>
</text>
<statusCode code="completed"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<supply classCode="SPLY" moodCode="INT">
<templateId root="2.16.840.1.113883.3.88.11.32.11"/>
<id root="14ED7742-2428-4e2c-9446-A9B0D0075272"
extension="20097864565331453252"/>
<effectiveTime value="20081109"/>
repeatNumber value="1"/>
<quantity value="1"/>
<author>
<time value="20081109"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6.1013905751" extension="Provider ID"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>John</given>
<given/>
<family>Lee</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<act classCode="ACT" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.1.43"/>
<code/>
<text>
<reference value="#fulfillment-instruction1"/>
</text>
</act>
</entryRelationship>
</supply>
</entryRelationship>
<entryRelationship typeCode="REFR">
<sequenceNumber value="1"/>
<supply classCode="SPLY" moodCode="EVN">
<id root="14ED7742-2428-4e2c-9446-A9B0D0075272" extension="321654-7746816180"/>
<statusCode code="completed"/>
<effectiveTime value="20081109"/>
<quantity value="1" unit="Tablespoon"/>
<performer>
<assignedEntity>
Transitions of Care – Discharge Summary Guide
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Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
<id root="2.16.840.1.113883.4.6.1013905751"/>
<addr use="WP">
<streetAddressLine>885 Washington Street</streetAddressLine>
<streetAddressLine/>
<city>New Market</city>
<state>MD</state>
<postalCode>01111</postalCode>
</addr>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>John</given>
<given/>
<family>Lee</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.4.6.11111"/>
<name>South Comm. Health Center</name>
</representedOrganization>
</assignedEntity>
</performer>
</supply>
</entryRelationship>
<precondition>
<criterion/>
</precondition>
</substanceAdministration>
</entry>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<templateId root="2.16.840.1.113883.3.88.11.32.8"/>
<id root="cdbd5b05-6cde-11db-9fe1-0800200c9a66"/>
<text>
<reference value="#sig-1"/>
</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS" nullFlavor="UNK"/>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
<period value="6" unit="h"/>
</effectiveTime>
<routeCode code="C38288" displayName="Oral"
codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus"/>
<approachSiteCode code=" 21082005 " displayName="Mouth"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<doseQuantity value="1" unit="aerosol"/>
<maxDoseQuantity xsi:type="RTO_PQ_PQ">
<numerator value="1"/>
<denominator value="1"/>
</maxDoseQuantity>
Transitions of Care – Discharge Summary Guide
Created on 8/31/2011
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Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
<administrationUnitCode code="C38216" displayName="Inhaler"
codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus"/>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<templateId root="2.16.840.1.113883.3.88.11.32.9"/>
<manufacturedMaterial classCode="MMAT">
<code code="51947-0696" displayName="Ipratropium Bromide"
codeSystem="2.16.840.1.113883.6.69" codeSystemName="NDC">
<originalText>
<reference value="#medication-1"/>
</originalText>
<translation code="PLACE_HOLDER" displayName="PLACE_HOLDER"
codeSystem="2.16.840.1.113883.6.88" codeSystemName="PLACE_HOLDER"/>
</code>
<name>Ipratropium Bromide</name>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Atrovent</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<code code="N0000006601" displayName="Lactose"
codeSystem="2.16.840.1.113883.4.209" codeSystemName="NDF-RT"/>
<playingEntity classCode="MMAT">
<code/>
<name/>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.3.88.11.32.10"/>
<code code="73639000" displayName="Prescription Drug"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.47"/>
<code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<value xsi:type="CE" code="55561003" displayName="Active"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28"/>
Transitions of Care – Discharge Summary Guide
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Last Updated on 11/15/2011
Office of the National Coordinator for
Health Information Technology
<code code=" 312453004 " displayName="Inhaler - currently active"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#indication-1"/>
</text>
<statusCode code="completed"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ">
<act classCode="ACT" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.1.49"/>
<code nullFlavor="UNK"/>
<text>
<reference value="#patient-instruction-1"/>
</text>
</act>
</entryRelationship>
<entryRelationship typeCode="CAUS">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.54"/>
<code nullFlavor="UNK"/>
<text>
<reference value="#reaction-1"/>
</text>
<statusCode code="completed"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<supply classCode="SPLY" moodCode="INT">
<templateId root="2.16.840.1.113883.3.88.11.32.11"/>
<id root="14ED7742-2428-4e2c-9446-A9B0D0075272"
extension="20097864565331453252"/>
<effectiveTime value="20081109"/>
<repeatNumber value="2"/>
<quantity value="1"/>
<author>
<time value="20081109"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6.1013905751" extension="Provider ID"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>John</given>
<given/>
<family>Lee</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<act classCode="ACT" moodCode="INT">
Transitions of Care – Discharge Summary Guide
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Office of the National Coordinator for
Health Information Technology
<templateId root="2.16.840.1.113883.10.20.1.43"/>
<code/>
<text>
<reference value="#fulfillment-instruction1"/>
</text>
</act>
</entryRelationship>
</supply>
</entryRelationship>
<entryRelationship typeCode="REFR">
<sequenceNumber value="1"/>
<supply classCode="SPLY" moodCode="EVN">
<id root="14ED7742-2428-4e2c-9446-A9B0D0075272" extension="321654-7746816180"/>
<statusCode code="completed"/>
<effectiveTime value="20081109"/>
<quantity value="1" unit="Tablespoon"/>
<performer>
<assignedEntity>
<id root="2.16.840.1.113883.4.6.1013905751"/>
<addr use="WP">
<streetAddressLine>885 Washington Street</streetAddressLine>
<streetAddressLine/>
<city>New Market</city>
<state>MD</state>
<postalCode>01111</postalCode>
</addr>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>John</given>
<given/>
<family>Lee</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.4.6.2649871"/>
<name>South Comm. Health Center</name>
</representedOrganization>
</assignedEntity>
</performer>
</supply>
</entryRelationship>
<precondition>
<criterion/>
</precondition>
</substanceAdministration>
</entry>
</section>
</component>
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Sample Immunization XML Schema
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.6"/>
<code code="11369-6" displayName="History of immunizations"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Immunizations</title>
<text/>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="false">
<templateId root="2.16.840.1.113883.3.88.11.32.14"/>
<id root="cevv5b05-6zae-11wq-0ve1-0822202c9a76"/>
<statusCode code="completed"/>
<effectiveTime value="20080108"/>
<approachSiteCode/>
<doseQuantity/>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<templateId root="2.16.840.1.113883.3.88.11.32.9"/>
<manufacturedMaterial classCode="MMAT" determinerCode="KIND">
<code code="16" displayName="Influenza Virus Vaccine"
codeSystem="2.16.840.1.113883.6.59" codeSystemName="CVX">
<originalText/>
</code>
<name>TIV</name>
<lotNumberText>A1234-ddz</lotNumberText>
</manufacturedMaterial>
<manufacturerOrganization>
<name> GlaxoC3POKline Biologicals</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<performer typeCode="PRF">
<time>
<low value="20070506"/>
</time>
<assignedEntity>
<id root="2.16.840.1.113883.4.6.332789877" extension="Provider ID"/>
<addr use="WP">
<streetAddressLine>227 Medical Court</streetAddressLine>
<streetAddressLine/>
<city>Annapolis</city>
<state>MD</state>
<postalCode>20497</postalCode>
<country>US</country>
</addr>
<telecom value="TEL:+1-301-555-7654"/>
<assignedPerson>
<name>
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<prefix>Dr</prefix>
<given>Sarah</given>
<given/>
<family>Silvarmen</family>
</name>
</assignedPerson>
<representedOrganization>
<name>Orthopedic Associates of Annapolis</name>
</representedOrganization>
</assignedEntity>
</performer>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<code nullFlavor="NA"/>
<text/>
<statusCode/>
<value xsi:type="INT" value="1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="CAUS">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.54"/>
<code nullFlavor="NA"/>
<text>
<reference value="#reaction"/>
</text>
<statusCode code="completed"/>
</observation>
</entryRelationship>
</substanceAdministration>
</entry>
</section>
</component>
Sample Vital Signs XML Schema
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.16"/>
<code code="8716-3" displayName="Vital Signs" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<title>Vital Signs</title>
<text/>
<entry typeCode="DRIV">
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.35"/>
<id root="c6f88320-67ad-11db-bd13-0800200c9a66"/>
<statusCode code="completed"/>
<effectiveTime value="200811091030"/>
<component>
<observation classCode="OBS" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.20.1.31"/>
<id root="c6f88322-67ad-11db-bd13-0800200c9a66"/>
<code code="3141-9" displayName="Body weight" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<text/>
<statusCode code="completed"/>
<effectiveTime value="200811091030"/>
<value xsi:type="PQ" value="110" unit="[lb_av]"/>
<interpretationCode code="N" displayName="Normal"
codeSystem="2.16.840.1.113883.5.83" codeSystemName="Observation Interpretation"/>
<referenceRange>
<observationRange>
<text/>
</observationRange>
</referenceRange>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.31"/>
<templateId root="2.16.840.1.113883.3.88.11.32.15"/>
<id root="c6f88323-67ad-11db-bd13-0800200c9a66"/>
<code code="8480-6" displayName="Systolic BP" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<text/>
<statusCode code="completed"/>
<effectiveTime value="200811091030"/>
<value xsi:type="PQ" value="116" unit="mm[Hg]"/>
<interpretationCode code="N" displayName="Normal"
codeSystem="2.16.840.1.113883.5.83" codeSystemName="Observation Interpretation"/>
<referenceRange>
<observationRange>
<text/>
</observationRange>
</referenceRange>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.31"/>
<templateId root="2.16.840.1.113883.3.88.11.32.15"/>
<id root="c6f88324-67ad-11db-bd13-0800200c9a66"/>
<code code="8462-4" displayName="Diastolic BP" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<text/>
<statusCode code="completed"/>
<effectiveTime value="200811091030"/>
<value xsi:type="PQ" value="72" unit="mm[Hg]"/>
<interpretationCode code="N" displayName="Normal"
codeSystem="2.16.840.1.113883.5.83" codeSystemName="Observation Interpretation"/>
<referenceRange>
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<observationRange>
<text/>
</observationRange>
</referenceRange>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.31"/>
<id root="492f6ad3-db26-42f2-b493-ad17ab85cc9b"/>
<code code="8867-4" displayName="Heart Beat" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<text/>
<statusCode code="completed"/>
<effectiveTime value="200811091030"/>
<value xsi:type="PQ" value="53" unit="1"/>
<interpretationCode code="N" displayName="Normal"
codeSystem="2.16.840.1.113883.5.83" codeSystemName="Observation Interpretation"/>
<referenceRange>
<observationRange>
Sample Emergency Encounter XML Schema
<section>
<templateId root="2.16.840.1.113883.10.20.1.3"/>
<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="History of encounters"/>
<title>Encounters</title>
<text>
<content ID="note-1">Name: SNOW, JANE Service Date: DOB: 03/29/1975
Sex: F Age: 33 Billing #: 112121212 Date of Adm: 12/18/2007
CLINICAL DIAGNOSIS: This is an echocardiogram ordered.
<br/><br/> Name: SNOW, JANE Service Date: DOB: 03/29/1975
<br/><br/></content><content ID="note-2"> Name: SNOW, JANE Service Date:
DOB: 03/29/1975 Sex: F Age: 33 Billing #: 112121212 Date of
Adm: 02/08/2008
DISCHARGE SUMMARY ADMISSION DIAGNOSES: 1. Diabetes type 2. 2.
Hypertension.
<br/><br/></content><content ID="note-3">"> Name: SNOW, JANE Service Date:
DOB: 03/29/1975 Sex: F Age: 33 Billing #: 112121212 Date of
Adm: 05/16/2008 OPERATIVE REPORT PROCEDURE: Upper endoscopy.
INDICATION: Anemia, history of heartburn. </content>
</text>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.3.88.11.32.17"/>
<templateId root="2.16.840.1.113883.10.20.1.21"/>
<id root="8e6184b6-2321-4800-97e5-ccb487a104ff"/>
<code code="EMER" codeSystem="2.16.840.1.113883.5.4" codeSystemName="HL7
ActCode" displayName="Emergency"/>
<effectiveTime>
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<low value="20080910"/>
<high nullFlavor="UNK"/>
</effectiveTime>
<performer typeCode="PRF">
<time>
<low value="20080910"/>
<high nullFlavor="UNK"/>
</time>
<assignedEntity>
<id extension="568a4e00-11e0-4194-8052-971e797080e2"
root="2.16.840.1.113883.4.6.1013905751"/>
<code code="280000000X" codeSystem="2.16.840.1.113883.6.101"
codeSystemName="ProviderCodes" displayName="Hospitals"/>
<addr/>
<assignedPerson>
<name>
<family>Smith</family>
<given>John</given>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.3.190"/>
<name>Community Medical Center</name>
</representedOrganization>
<sdtc:patient>
<sdtc:id root="2.16.840.1.113883.3.190" extension="92709368"/>
</sdtc:patient>
</assignedEntity>
</performer>
<participant typeCode="LOC">
<templateId root="2.16.840.1.113883.10.20.1.45"/>
<participantRole classCode="SDLOC">
<code code="PC" codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode"
displayName="Primary Care Clinic"/>
<playingEntity classCode="PLC">
<name>Community Medical Center</name>
</playingEntity>
</participantRole>
</participant>
</encounter>
</entry>
</section>
Sample Inpatient Encounter XML Schema
<section>
<templateId root="2.16.840.1.113883.10.20.1.3"/>
<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="History of encounters"/>
<title>Encounters</title>
<text>
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<content ID="note-1">Name: SNOW, JANE Admitted: 03/27/2009 MR #:
123456789 DOB: 03/29/1975 Account#: 000012345678910 Age: 33
Physician: Smith, Jonnie, MD Location: 12-ee-12 HISTORY OF PRESENT ILLNESS:
This is a 33-year-old smoking female with a~long-standing history of asthma,
polycystic ovarian disease, and suspected~cervical cancer, currently being worked
up. The patient reports that she~took Advair for the first time today, but also took
a couple of other~medications today and had eaten. She then developed some
tightness in her~chest and shortness of breath. She was concerned that she was
having an~anaphylactic type reaction and came into the ED. In the ED, the
patient~was not moving air very well. She was given 3 nebulizer treatments and
a~dose of Solu-Medrol, after which although she improved, she continued to~have
some difficulty breathing. Currently, she is breathing much more~relaxed. She
denies headache, vision changes, chest pain, or~palpitations. Her shortness of
breath has improved. She is having a~cough, nonproductive of sputum. No
nausea, vomiting, constipation,~hematemesis, or hematochezia. No new
rashes.~~PAST MEDICAL HISTORY:~1. Polycystic ovarian disease.~2. Possible
cervical cancer.~3. Asthma.~4. Hypertension.~5. Chronic lower extremity
edema.~6. Suspected diabetes.~~MEDICATIONS:~1. Vicodin on a daily basis.~2.
Advair 250/50.~3. Birth control pills.~4. Lisinopril 20 mg daily.~5. Prozac 40 mg
daily.~6. Cipro 500 mg b.i.d. for bronchitis.~7. Xanax 0.5 mg daily.~8. Restoril 30
mg daily.~9. Spironolactone 50 mg b.i.d.~10. Bentyl 20 mg 4 times a
day.~~ALLERGIES: BACTRIM, LEVAQUIN, and SEAFOOD.~~SOCIAL HISTORY: She
smokes 1-1/2 packs of cigarettes a day. Does not~drink alcohol. She is
unemployed.~~FAMILY HISTORY: Significant for mother with diabetes.~~REVIEW
OF SYSTEMS:~HEENT: No headache, vision changes, ear pain, or sore
throat.~CARDIOVASCULAR: No chest pain or palpitations.~RESPIRATORY: Positive
shortness of breath, but improved. A mild cough,~nonproductive of
sputum.~ABDOMEN: No nausea, vomiting, constipation, hematemesis,
or~hematochezia.~EXTREMITIES: No new edema.~~PHYSICAL
EXAMINATION:~VITAL SIGNS: Temperature is 98.2. Pulse 100. Blood pressure
132/79.~Respiratory rate 20. O2 saturation 96% on room air.~GENERAL: Obese
female, in no acute distress, lying in bed. She appears~comfortable.~HEENT:
Sclerae are anicteric. Mucous membranes are moist. Pharynx
is~________.~NECK: There is no lymphadenopathy.~CARDIOVASCULAR: Slightly
tachycardic. No murmurs, rubs, or gallops.~RESPIRATORY: Expiratory wheezes
noted bilaterally, but improved air~movement.~ABDOMEN: Bowel sounds are
positive. Nontender and nondistended. No~hepatosplenomegaly.~EXTREMITIES:
Trace bilateral lower extremity edema.~~LABORATORY DATA: Sodium 136,
potassium 4.2, chloride 102, bicarbonate 21,~BUN 19, creatinine 1.2, glucose 327.
White blood cell count 16.5. Please~note the patient has been on steroids.
Hemoglobin 12.1, hematocrit 38.3,~and platelets 338, with granulocytes 93%.
CPK is 99. Cardiac enzymes~negative x1.~~ASSESSMENT:~1. Acute asthma
exacerbation, possibly set off by food or some other~allergen.~2.
Hypertension.~3. Diabetes versus steroid-induced hyperglycemia.~~PLAN: At this
time, will start IV Solu-Medrol, jet nebulizers, and~Singulair. Will start sliding
scale insulin. Check a TSH and a hemoglobin~A1c, as well as a lipid panel. At this
point, I am going to go ahead and~continue her Cipro. Will obtain Physical
Therapy and Occupational Therapy~consults. Will provided gastrointestinal and
deep venous thrombosis~prophylaxis.~~
<br/><br/> Name: SNOW, JANE Service Date: DOB: 03/29/1975
<br/><br/></content><content ID="note-2"> Name: SNOW, JANE Service Date:
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DOB: 03/29/1975 Sex: F Age: 33 Billing #: 112121212 Date of
Adm: 02/08/2008
DISCHARGE SUMMARY ADMISSION DIAGNOSES: 1. Diabetes type 2. 2.
Hypertension.
<br/><br/></content><content ID="note-3">"> Name: SNOW, JANE Service Date:
DOB: 03/29/1975 Sex: F Age: 33 Billing #: 112121212 Date of
Adm: 05/16/2008 OPERATIVE REPORT PROCEDURE: Upper endoscopy.
INDICATION: Anemia, history of heartburn. </content>
</text>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.3.88.11.32.17"/>
<templateId root="2.16.840.1.113883.10.20.1.21"/>
<id root="8e6184b6-2321-4800-97e5-ccb487a104ff"/>
<code code="IMP" codeSystem="2.16.840.1.113883.5.4" codeSystemName="HL7 ActCode"
displayName="Inpatient encounter"/>
<originalText>
<reference value="#note-1"/>
</originalText>
<effectiveTime>
<low value="20080910"/>
<high nullFlavor="UNK"/>
</effectiveTime>
<performer typeCode="PRF">
<time>
<low value="20080910"/>
<high nullFlavor="UNK"/>
</time>
<assignedEntity>
<id extension="568a4e00-11e0-4194-8052-971e797080e2"
root="2.16.840.1.113883.4.6.1013905751"/>
<code code="280000000X" codeSystem="2.16.840.1.113883.6.101"
codeSystemName="ProviderCodes" displayName="Hospitals"/>
<addr/>
<assignedPerson>
<name>
<family>Smith</family>
<given>John</given>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.3.190"/>
<name>Community Medical Center</name>
</representedOrganization>
<sdtc:patient>
<sdtc:id root="2.16.840.1.113883.3.190" extension="92709368"/>
</sdtc:patient>
</assignedEntity>
</performer>
<participant typeCode="LOC">
<templateId root="2.16.840.1.113883.10.20.1.45"/>
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<participantRole classCode="SDLOC">
<code code="PC" codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode"
displayName="Primary Care Clinic"/>
<playingEntity classCode="PLC">
<name>Community Medical Center</name>
</playingEntity>
</participantRole>
</participant>
</encounter>
</entry>
</section>
Sample Results XML Schema
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.14"/>
<code code="30954-2" displayName="Relevant diagnostic tests and/or laboratory data"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Results</title>
<text>
<content ID="lab-1">Patient has normal cholesteral</content>
<content ID="lab-2">Yellow</content>
</text>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.31"/>
<id root="57d07056-bd97-4c90-891d-eb716d3170c8"/>
<code code="2093-3" displayName="Cholesterol" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<text>
<reference value="#lab-1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20071022"/>
</effectiveTime>
<value xsi:type="PQ" value="98" unit="mg/dL"/>
<interpretationCode code="N" displayName="Normal"
codeSystem="2.16.840.1.113883.5.83" codeSystemName="Observation Interpretation"/>
<referenceRange>
<observationRange>
<text>55 - 115 mg/dL</text>
</observationRange>
</referenceRange>
</observation>
</entry>
<entry>
<organizer classCode="BATTERY" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.32"/>
<id root="zzz12320-67ad-11db-bd13-0800200c9a66"/>
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<code code="24356-8" displayName="Urinalysis Panel"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<statusCode code="completed"/>
<effectiveTime value="20080918"/>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.31"/>
<id root="2a7cdfe6-13f5-4e36-92f0-9e174837eec1"/>
<code code="86192007" displayName="COLOR OF URINE"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#lab-2"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CV" nullFlavor="NA"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"
codeSystemName="Observation Interpretation" displayName="Normal"/>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.31"/>
<id root="8616ca32-7b5c-4f1c-819a-3336dd61c8b4"/>
<code code="365828000" displayName="SPECIFIC GRAVITY URINE"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<statusCode code="completed"/>
<value xsi:type="PQ" value="1.01" unit="g/ml"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"
codeSystemName="Observation Interpretation" displayName="Normal"/>
<referenceRange>
<observationRange>
<text>1.003-1.030</text>
</observationRange>
</referenceRange>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.31"/>
<id root="329a9130-3ba8-4306-b72f-a58678b8c452"/>
<code code="365723003" displayName="PH URINE" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
<statusCode code="completed"/>
<value xsi:type="PQ" value="6.0"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"
codeSystemName="Observation Interpretation" displayName="Normal"/>
<referenceRange>
<observationRange>
<text>5.0-8.0</text>
</observationRange>
</referenceRange>
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</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.3.88.11.32.16"/>
<id root="8215896c-4f99-4e74-91ac-e52201c06a8d"/>
<code code="365799007" displayName="PROTEIN" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
<text>
<reference value="#lab-82"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CV" nullFlavor="NA"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"
codeSystemName="Observation Interpretation" displayName="Normal"/>
<referenceRange>
<observationRange>
<text>NEG</text>
</observationRange>
</referenceRange>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.3.88.11.32.16"/>
<id root="908b849b-6eb9-448d-a9ec-708c469059ec"/>
<code code="365811003" displayName="GLUCOSE" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
<text>
<reference value="#lab-83"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CV" nullFlavor="NA"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"
codeSystemName="Observation Interpretation" displayName="Normal"/>
<referenceRange>
<observationRange>
<text>NEG</text>
</observationRange>
</referenceRange>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.3.88.11.32.16"/>
<id root="1ddd48a3-2969-4293-9c25-2e0feefbe3a3"/>
<code code="365658008" displayName="KETONE" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
<text>
<reference value="#lab-84"/>
</text>
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<statusCode code="completed"/>
<value xsi:type="CV" nullFlavor="NA"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"
codeSystemName="Observation Interpretation" displayName="Normal"/>
<referenceRange>
<observationRange>
<text>NEG</text>
</observationRange>
</referenceRange>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.3.88.11.32.16"/>
<id root="a4f500b5-7309-405d-8432-c2269abf3487"/>
<code code="275778006" displayName="BILI" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
<text>
<reference value="#lab-85"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CV" nullFlavor="NA"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"
codeSystemName="Observation Interpretation" displayName="Normal"/>
<referenceRange>
<observationRange>
<text>NEG</text>
</observationRange>
</referenceRange>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
Sample Procedures XML Schema
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.12" />
<code code="47519-4" displayName="History of procedures"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
<title>Procedures</title>
<entry typeCode="DRIV">
<procedure classCode="PROC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.29" />
<id root="d512g451-9999-22ec-0gf2-1911311d0b77" />
<code code="V58.11" displayName="Encounter for antineoplastic chemotherapy
&#xD;&#xA; &#xD;&#xA;" codeSystem="2.16.840.1.113883.6.104" codeSystemName="ICD9
Procedures">
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<originalText>
<reference value="#proc-3" />
</originalText>
</code>
<text></text>
<statusCode code="completed" />
<effectiveTime>
<low value="20070211" />
<high value="200609211030" />
</effectiveTime>
<!--Site where procedure was performed-->
<targetSiteCode code="302540006" displayName="Entire thumb"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"></targetSiteCode>
<time>
<low value="200702011000" />
<high value="200702011200" />
</time>
<assignedEntity>
<id root="78A150ED-B890-49dc-B716-5EC0027B3982" extension="ProviderID" />
<code code="280000000X" displayName="Hospitals"
codeSystem="2.16.840.1.113883.6.101" codeSystemName="ProviderCodes" />
<addr use="WP">
<streetAddressLine>145 Applecross Road</streetAddressLine>
<streetAddressLine></streetAddressLine>
<city>Southern Pines</city>
<state>NC</state>
<postalCode>28388</postalCode>
</addr>
<assignedPerson>
<name>
<prefix>Dr. </prefix>
<given>Susan</given>
<given />
<family>Saltz</family>
</name>
</assignedPerson>
<representedOrganization>
<name>Southern Pines Women's Health Center</name>
</representedOrganization>
<sdtc:patient xmlns:sdtc="urn:hl7-org:sdtc">
<sdtc:id root="78A150ED-ZZ23-49dc-B716-5EC0027B3983"
extension="33445999" />
</sdtc:patient>
</assignedEntity>
</performer>
<!--Operative Report-->
</procedure>
</entry>
<entry typeCode="DRIV">
<procedure classCode="PROC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.29" />
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<id root="d512g451-9999-22ec-0gf2-1911311d0b77" />
<code code="V58.11" displayName="Encounter for antineoplastic chemotherapy
&#xD;&#xA; &#xD;&#xA;" codeSystem="2.16.840.1.113883.6.104" codeSystemName="ICD9
Procedures">
<originalText>
<reference value="#proc-3" />
</originalText>
</code>
<statusCode code="completed" />
<effectiveTime>
<low value="20060921000" />
<high value="200609211030" />
</effectiveTime>
<targetSiteCode code="302540006" displayName="Entire thumb"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"></targetSiteCode>
<time>
<low value="200701211000" />
<high value="200701211200" />
</time>
<assignedEntity>
<id root="78A150ED-B890-49dc-B716-5EC0027B3982" extension="ProviderID" />
<code code="280000000X" displayName="Hospitals"
codeSystem="2.16.840.1.113883.6.101" codeSystemName="ProviderCodes" />
<addr use="WP">
<streetAddressLine>145 Applecross Road</streetAddressLine>
<streetAddressLine></streetAddressLine>
<city>Southern Pines</city>
<state>NC</state>
<postalCode>28388</postalCode>
</addr>
<assignedPerson>
<name>
<prefix>Dr. </prefix>
<given>Susan</given>
<given />
<family>Saltz</family>
</name>
</assignedPerson>
<representedOrganization>
<name>Southern Pines Women's Health Center</name>
</representedOrganization>
<sdtc:patient xmlns:sdtc="urn:hl7-org:sdtc">
<sdtc:id root="78A150ED-ZZ23-49dc-B716-5EC0027B3983"
extension="33445999" />
</sdtc:patient>
</assignedEntity>
</performer>
</procedure>
</entry>
<entry typeCode="DRIV">
<procedure classCode="PROC" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.20.1.29" />
<id root="d512g451-9999-22ec-0gf2-1911311d0b77" />
<code code="V58.11" displayName="Encounter for antineoplastic chemotherapy
&#xD;&#xA; &#xD;&#xA;" codeSystem="2.16.840.1.113883.6.104" codeSystemName="ICD9
Procedures">
<originalText>
<reference value="#proc-3" />
</originalText>
</code>
<statusCode code="completed" />
<effectiveTime>
<low value="200612291000" />
<high value="200612291030" />
</effectiveTime>
<targetSiteCode code="302540006" displayName="Entire thumb"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"></targetSiteCode>
<time>
<low value="200702011000" />
<high value="200702011200" />
</time>
<!--Treating Physician-->
<assignedEntity>
<id root="78A150ED-B890-49dc-B716-5EC0027B3982" extension="ProviderID" />
<code code="280000000X" displayName="Hospitals"
codeSystem="2.16.840.1.113883.6.101" codeSystemName="ProviderCodes" />
<addr use="WP">
<streetAddressLine>145 Applecross Road</streetAddressLine>
<streetAddressLine></streetAddressLine>
<city>South Pine</city>
<state>NC</state>
<postalCode>55555</postalCode>
</addr>
<assignedPerson>
<name>
<prefix>Dr. </prefix>
<given>Susan</given>
<given />
<family>Saltz</family>
</name>
</assignedPerson>
<representedOrganization>
<name>Southern Pines Women's Health Center</name>
</representedOrganization>
<sdtc:patient xmlns:sdtc="urn:hl7-org:sdtc">
<sdtc:id root="78A150ED-ZZ23-49dc-B716-5EC0027B3983"
extension="33445999" />
</sdtc:patient>
</assignedEntity>
</performer>
</procedure>
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</entry>
Sample Social History XML Schema
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.15" />
<code code="29762-2" displayName="Social history"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
<title>Social History</title>
<text>
<content ID="socialhistory-1">Recently retired as a day care worker. Immigrated
from China 30 years ago. Husband passed away in 2003. 3 supportive children. Denies
current or history of tobacoo, EtOH, illicits. Exposed to second-hand smoke by
husband.</content>
</text>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.33" />
<id root="a13c6991-5c8b-11db-b0de-0800200c9a66" />
<code code="14679004" displayName="Occupation"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<originalText>
<reference value="#socialhistory-1" />
</originalText>
</code>
<statusCode code="completed" />
<effectiveTime>
<low value="19971203" />
<high value="20001203" />
</effectiveTime>
<value xsi:type="CD" code=" 112271005 " displayName="Assembly Shipment"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" />
</observation>
</entry>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.33" />
<id root="a13c6991-5c8b-11db-b0de-0800200c9a66" />
<code code="257733005" displayName="Activity"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<originalText>
<reference value="#socialhistory-2" />
</originalText>
</code>
<statusCode code="completed" />
<effectiveTime>
<low value="19990615" />
<high value="20060615" />
</effectiveTime>
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<value xsi:type="CD" code="102393008" displayName="Child Care"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" />
</observation>
</entry>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.33" />
<id root="a13c6991-5c8b-11db-b0de-0800200c9a66" />
<code code="257733005" displayName="Activity"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<originalText>
<reference value="#socialhistory-2" />
</originalText>
</code>
<statusCode code="completed" />
<effectiveTime>
<low value="19891101" />
<high value="19960415" />
</effectiveTime>
<value xsi:type="CD" code="102393008" displayName="Kitchen Help"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" />
</observation>
</entry>
</section>
</component>
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