ONC Standards and Interoperability (S&I) Framework
Transitions of Care (ToC)
Clinical Element Data Dictionary (CEDD)
Version 1.0
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Contents
Overview of S&I Framework Clinical Element Data Dictionary .................................................................... 4
Audience ................................................................................................................................................... 4
Prerequisites ............................................................................................................................................. 4
Assumptions.............................................................................................................................................. 5
Introduction .................................................................................................................................................. 5
CEDD Concepts (TOC Object Model)............................................................................................................. 6
Key Information Exchange ........................................................................................................................ 7
CEDD Object .............................................................................................................................................. 9
CEDD Data Elements ............................................................................................................................... 10
Understanding CEDD Priorities ............................................................................................................... 11
Usage of ISO/HL7 Data Types ................................................................................................................. 11
The Structure Data Type ......................................................................................................................... 13
Usage of Data Element Sets .................................................................................................................... 13
CEDD Constraints ........................................................................................................................................ 14
CEDD Conformance Statements ............................................................................................................. 14
Vocabulary Recommendations .................................................................. Error! Bookmark not defined.
Usage of the CEDD ...................................................................................................................................... 16
S&I Clinical Data Element Dictionary .......................................................................................................... 18
ToC CEDD Object Summary .................................................................................................................... 19
CEDD Objects (In Detail) ......................................................................................................................... 39
Active Medication List ......................................................................................................................... 40
Active Problem List ............................................................................................................................. 48
Admitting and Discharging Diagnoses ................................................................................................ 49
Allergies and Intolerances ................................................................................................................... 50
Behavioral Health History ................................................................................................................... 53
Consultation Request including Clinical Summary CEDD Object ........................................................ 57
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Consultation Summary CEDD Object .................................................................................................. 59
Culturally Sensitive Patient Care ......................................................................................................... 61
Demographics CEDD Object ................................................................................................................ 63
Diet ...................................................................................................................................................... 67
Discharge Instructions CEDD Object ................................................................................................... 73
Discharge Summary CEDD Object ....................................................................................................... 74
Discontinued Medications .................................................................................................................. 75
Equipment ........................................................................................................................................... 76
Existence of Advanced Directives ....................................................................................................... 77
Family History ..................................................................................................................................... 78
Goals ................................................................................................................................................... 80
History Present Illness......................................................................................................................... 83
Immunization History.......................................................................................................................... 83
Medical History ................................................................................................................................... 85
Medication History.............................................................................................................................. 85
Operative Summary ............................................................................................................................ 86
Patient Contact Information ............................................................................................................... 86
Patient Information............................................................................................................................. 89
Patient Instructions ............................................................................................................................. 91
Payer Information ............................................................................................................................... 92
Physical Activity................................................................................................................................... 92
Physical Exam ...................................................................................................................................... 95
Primary Care Physicians and Designated Providers ............................................................................ 95
Reason for Consult Request ................................................................................................................ 97
Social Determinants of Health ............................................................... Error! Bookmark not defined.
Social History....................................................................................................................................... 98
Support Contacts ................................................................................................................................ 99
Surgical/Procedure History ............................................................................................................... 100
S&I Framework Summary CEDD Object ............................................................................................ 101
Vital Signs .......................................................................................................................................... 102
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Overview of Transitions of Care Clinical Element Data
Dictionary
This guide is an overview of the Transitions of Care (ToC) Clinical Element Data Dictionary (CEDD). The
ToC CEDD is structured to support the perspective on data of clinicians and health care delivery
participants, designed for readability and ease of understanding. Several of the initial sections are
explanatory and provide explicit guidance to stakeholders who may not have any exposure to the S&I
Framework initiative or the underlying mission of the CEDD. Other sections are focused on the more
technical concepts surrounding the CEDD, including objects and attributes, and how the CEDD is
structured to promote a clinician’s understanding of care transitions.
Please ensure you review the introductory sections prior to reviewing the usage and data dictionary of
the ToC CEDD.
Audience
The intended audience for the ToC CEDD includes the following stakeholders, who are the core of the
value proposition for the CEDD:
Stakeholder
Usage of a CEDD
Providers and Specialists
Provide a clinical perspective and view into care transition
data relevant to providers and specialists.
Care coordinators
Ensures that in each care transition, the relevant clinical
data that is needed by the care coordinator is available.
Electronic Health Record (EHR) Vendors
Gives EHR vendors an idea of the clinical data they need to
support each care transition.
Personal Health Record (PHR) Vendors
Gives PHR vendors a view into the type of patient-level data
that care transitions produce, and may be requested from
patients.
Prerequisites
There are several prerequisites for usage of the ToC CEDD:


An organization should have knowledge of the Health Level Seven International (HL7) Clinical
Document Architecture (CDA). This is critically important as the CDA serves as the foundation for
the ToC CEDD and its objects/data elements.
An organization should have knowledge of the ISO/HL7 datatypes. CEDD Data Elements are
expressed using ISO/HL7 datatypes proposed by the members of the S&I Framework S&I
Framework Initiative.
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Assumptions
There are several assumptions built into the CEDD that are important to recognize:
1. The CEDD is not a physical “thing”. It is intended to be a logical representation and is thus
represented as a data model for that purpose.
2. ISO and CDA datatypes are used in the CEDD representation, to allow for the common
transformation of CDA documents to CEDD objects and vice versa.
3. CEDD Objects are intended to be used primarily for requirements traceability. This means it is
intended to map clinical data to the requirements of a use case. Because this initial
representation of the CEDD is CDA-based, the primary level of traceability is from the CEDD to
the key information exchanges defined in the S&I Framework Use Case.
4. The CEDD is NOT intended to provide an overlay for the HL7 RIM. As such, RIM objects are not
represented in the CEDD in any form.
5. The CEDD is NOT based on an underlying information model, which limits its usage outside the
scope intended.
6. The modeling notation used is Information Exchange (IE), used as part of an ERD.
Introduction
The Transitions of Care Clinical Element Data Dictionary (CEDD) is intended to serve as a logical overlay
and neutral representation of the data needed to support care transitions. The value proposition
inherent in the CEDD is that it provides a view for clinicians into the type of data needed to support each
care transition, and gives implementers and vendors an idea of how to store and exchange that data.
The ToC CEDD 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.
The ToC CEDD is not intended to be a “pure” Clinical Element Data Dictionary. This means it is not tied to
an underlying data model (such as the HL7 RIM). Its focus is on providing a clear view for a clinician on
the data they are accustomed to viewing 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 CEDD, this means mapping to the underlying CDA on which
entity (known as a CEDD Object and defined here) 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 CEDD objects. This is a longer-term goal that will require further testing and
analysis of the ToC CEDD.
The work on the ToC CEDD was guided by practicing clinicians and other implementers who were
interested in creating a simple, easy to understand model for functional stakeholders to use. The ToC
CEDD also draws heavily from best practices and models defined by several organizations involved in the
S&I Framework, including:

National E-Health Transition Authority (NEHTA)
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



Federal Health Information Model (FHIM)
HL7 Version 3
GE/Intermountain Healthcare Clinical Element Models (CEM)
Quality Data Model (QDM)
Specific sources of information were drawn from the existing work of these organizations to create
underlying CEDD Objects and to help define the structure. It was not the intention in the development
of the ToC CEDD to specifically adopt an information model already in use, or to redefine existing
information models, but simply to draw from previous work already done to create a new type of
representation specifically targeted to the requirements of clinicians who may not have a deep
understanding of care transition data, its structure, and its flow.
ToC CEDD Origin
Throughout the development of Transitions of Care(TOC) Initiative specifications, the need for a
common information model became apparent during analysis of existing standards and barriers to
electronic exchange. While common data elements existed between standards and other models,
ambiguous definitions prevented accurate harmonization for an interoperable standard.
To best demonstrate the complex relationships between data elements and objects, the Initiative
pursued the development of a Clinical Information Model (CIM) which combines the traditional data
dictionary model with a logical model. Commonly referred to as an ontology, this type of model does
not depend on a rigid parent/child hierarchical structure and data elements or objects may inherit
attributes from more than one parent. This abstract approach represented initially through both a UML
model and corresponding document, promotes greater reuse of data elements and allows implementers
to manipulate the model while maintaining the same definitions and attributes of data elements.
As an important output of the TOC Initiative, the CIM is best represented in the form of a data
dictionary. The transition ensures a clear representation of data elements supporting the TOC use case
while maintaining the level of abstraction necessary to support various business needs. In congruence
with this change in model and representation, the TOC CIM will now be referred to the TOC CEDD and
only be offered in the form of a document. Eventually the TOC CEDD will be used as a basis to develop
the S&I CEDD, which will be used to capture the data elements across each of the S&I Framework
Initiatives.
CEDD Object Model
A complete CEDD concept includes Key Information Exchanges, CEDD Objects and CEDD Data Elements.
It is important to understand these terms prior to reviewing the CEDD itself. These terms may also
collectively be referred to as the “CEDD Object Model”, a figurative term used to outline the
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dependencies between these 3 concepts. The following figure provides an overview of this object model
“structure”
Many of these concepts are analogous to existing data modeling terms. For clinicians, this section may
be useful to help understand how the ToC CEDD is structured.
Key Information Exchange
A key information exchange is the set of functional requirements that CEDD objects “trace” to. The key
information exchange forms the basis for new CEDD objects that may be needed to fulfill clinical
requirements that may come from the S&I Framework or from other sources of requirements within
healthcare. The key information exchanges specific to care transitions can be found here.
The following figure shows how a Discharge Summary key information exchange is structured:
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Example
The Transitions of Care Use Case defines 4 key information exchanges that must be met to
satisfy the clinical requirements of the use case’s defined actors. Each of these 4 key
information exchanges is mapped to specific CEDD objects.
Because the CEDD is designed for reuse, each of the CEDD objects are intended for reuse outside the
scope of the ToC CEDD. This is due to the fact that the CEDD is logical – the CEDD objects are not
designed to “force” conformance but simply capture the key data elements needed to exchange a
bucket of information. Each bucket of information can be combined with other buckets to produce a key
information exchange.
In the context of other use cases and other standards, this is an important concept to understand. CEDD
objects can logically be subsetted or extended depending on the requirements needed for the use case.
Subsetting in this case means taking a subset of the CEDD Object to be used as clinical data, while
extending means adding additional data elements to the CEDD Object depending on the care transition
or clinical setting. CEDD objects can be extended or subsetted based on 2 factors – priority and
requirements traceability (these will be discussed further in a later version of the ToC CEDD).
Example
A Discharge Instructions Key Information Exchange specifies a Demographics CEDD Object. However,
the object will contain both A data elements and C data elements. These elements can be sent
Furthermore, the buckets do not have to be dependent on the underlying standard. This extension and
depending on the rules for CEDD priorities, and a subset of the Discharge Instructions can be sent if
subsetting is separate from the underlying standard used (discussed in the Data Element Set section of
certain information is not available from the EHR.
this document)
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Example:
The Provider Directory Use Case creates a set of requirements surrounding Demographic data. This
can be mapped to the Demographics CEDD Object, which can be extended or subsetted depending
on the requirements of the use case. Because the Demographics CEDD object is only logically
attached to the underlying standard, changes can be made by the Provider Directory initiative to
create a new CEDD for Provider Directory that reuses CEDD objects used in another initiative.
CEDD Object
A CEDD Object represents a specific entity within a logical data model. Each CEDD Object is designed to
map to an underlying concept that is of some familiarity to practicing clinicians and specialists, and other
stakeholders who may be involved in healthcare organizations. The ToC CEDD specifically is targeted to
those clinicians and specialists who may be involved in care transitions processes.
A key differential with CEDD Objects is that they are not tied to any specific underlying information
model. Thus, as an example, a CEDD Object is not tied to the HL7 RIM, although it may use concepts or
terms that are similar to the RIM. As noted in the previous section, this avoidance of connection to an
underlying standard (and adherence to respect for the underlying standard) allows CEDD objects to be
reused in other contexts.
CEDD Objects are intended to capture a real-world clinical concept and display it in a manner that is
understandable to clinicians, patients, and other stakeholders who may be involved in a care transition.
This means that CEDD objects are not intended to be represented as physical objects, meaning the
representation of how data is stored within a physical data store.
For CEDD Objects, several key pieces of information are defined to assist in understanding clinical
meaning. They are summarized in the following table:
Characteristic
Description of the Characteristic
Name
A clinically-relevant name for this CEDD Object – should be
understandable to clinicians
Definition
A clinically-relevant definition of the CEDD Object
CDA ID References
Captures CDA specific references for Document, Section, and Entry ids
CEDD Object Priority
The priority of this ToC CEDD Object- please review the next section on
CEDD Priorities to understand how these priorities are created
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CEDD Data Elements
A CEDD Data Element is an attribute of a CEDD Object.
There are several rules associated with CEDD Data Elements:



Aligned to underlying data element from the CDA, if possible
Aligned to Transitions of Care Data Element Sets, if possible
Have proposed datatypes
For CEDD Data Elements, several key pieces of information are defined to assist in understanding clinical
meaning:
Characteristic
Description of the Characteristic
Name
A clinically-relevant name for this CEDD Data Element – should be
understandable to clinicians
Definition
A clinically-relevant definition of the CEDD data element
Datatype
A possible datatype that can be used to represent this CEDD data
element – aligned to the underlying CDA datatype
Examples and guidance
Provides examples of what this clinical term means and guidance on
value sets and vocabularies
Data Element Priority
The priority of this ToC CEDD Data Element – please review the next
section on CEDD Priorities to understand how these priorities are
created
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Understanding CEDD Priorities
CEDD priorities are used to capture the specific priorities of both CEDD Objects and CEDD Data
Elements. These priorities have been reviewed by clinicians and other stakeholders involved in care
planning and care transitions within healthcare organizations throughout the United States. The ToC
CEDD defines specific priorities surrounding data to help in determining what key information needs to
be exchanged in each type of care transition. The following table summarizes the priorities and their
applicability:
Classifications of CEDD Priorities
CEDD Data Element
Priority
"A" Data Elements
Description of Priority






"B" Data Elements

"C" Data Elements


Core data exchanged with every transition of care
These may be automated by the edge system (EHR)
"A" data elements have validated data models
Required indicates that every clinical document created must have core data
elements
NB subsets of categories of "additional" data elements (e.g. several results from
the hundreds that may be in the EHR database for a patient) can be added by the
clinician end user to the Direct Message depending on the clinical circumstance.
The variable data elements are selectively added to prevent information overload
by the recipient clinician (e.g. a recipient clinician receiving several hundred
results for a patient following an extended hospital stay would lead to the
recipient clinician being data overloaded and not caring for the patient as
effectively as in the circumstances of receiving the selected 2 or three results that
would be helpful to the PCP for efficient care and management of the patient).
Selected "B" data elements are either very frequently required in most transition
of care circumstances (e.g. results) and/or are regularly captured in many EHR
systems as discrete data.
Variable data needed by the end user in some transition of care circumstances
Selected "C" data elements are either less frequently required in most transition
of care circumstances and/or are not currently captured in many EHR systems as
discrete data
Usage of ISO/HL7 Data Types
A core set of datatypes is needed to support the representation of the CEDD. The reason for this is that
the ToC CEDD is not based on any underlying information model, and thus has to use a set of datatypes
from some source to represent data logically. The ToC CEDD adopted the ISO/HL7 datatypes that are
commonly used as part of the HL7 RIM and the HL7 CDA. A list of these datatypes can be found here:
http://www.hl7.org/v3ballot2009sep/html/infrastructure/datatypes_r2/datatypes_r2.htm
It should be noted that several of the datatypes referenced in this list are specific to the HL7 CDA. As
noted, a user of the ToC CEDD should have basic knowledge of the CDA if at all possible.
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The following table provides an overview of the datatypes used in the ToC CEDD:
ISO/HL7
Datatype
Description
Usage
AD
Address
Used to capture a physical address
TN
Telephone Number
Used to capture phone numbers and email
addresses
PN
Person Name
Used to capture the name of a person
CF
Coded Element with formatted
values
Similar to CE but with formatted values
ED
Encapsulated Data
Used to capture text and multimedia that may be
included in a care transition
BAG
Bag
Used to capture a an unordered, multiple
collection of things
SET
Set
Used to represent an unordered collection type
that stores unique elements
HIST
History
Used to capture historical items about something
or set of things
LIST
List Sequence
Used to store ordered, non-unique elements
IVL
Interval
Used to capture an interval of things
IVL_TS
Interval – Timestamp
Used to capture an interval of time
CS
Coded – Simple Value
Used to capture a simple set of codes
PQ
Physical Quantity
Used to capture information about quantities,
through a value and a unit of measure
CE
Coded Element
Used to capture a specific coded element or set
of coded elements
BL
Boolean
Used to capture Boolean information (true/false,
yes/no, etc…)
DATE
Date
Used to capture a date
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II
Instance Identifier
Used to identify a unique instance of some thing
INTEGER
Integer
Used to capture a number
EN
Entity Name
Used to capture the name of an individual or
organization
The Structure Data Type
In addition, the ToC CEDD defines a Structure datatype. This datatype is used in those cases where the
data assembled might be another object or discrete set of data that is assembled somewhere else
(outside the scope of the CEDD). It is important to note that many of the CEDD data elements can
potentially be expressed using multiple data types. This is one of the foundational principles of the CEDD
itself; it is not meant to be prescriptive or to require conformance, it is simply meant to serve as a tool
to represent the perspective of the clinician. As such, design decisions surrounding a Structure datatype
can be made by implementers and vendors depending on the base derived datatype within their
environment.
Each version of the ToC CEDD further clarifies the proposed datatypes to be used for each CEDD Data
Element, so it is expected that as the ToC CEDD evolves, additional detail will be offered for those CEDD
Data Elements defined with a datatype of Structure. Specific focus was concentrated in this initial
version of the CEDD on the "A" Data Elements.
Example:
The Dose CEDD Data Element has a datatype of PQ (Physical Quantity), a common data type used to
capture dosage quantities in the CDA.
Usage of Data Element Sets
This implementation guidance on Data Element Sets (DES) is provided to allow for the reuse of common
data elements defined in the S&I Framework. Data Element Sets are used to describe common data
elements that may be reused across multiple settings among multiple S&I Framework initiatives. A DES
can be used to provide a common set of elements that are used to capture information.
Difference between a DES and a CEDD Object
An important difference between a DES and a CEDD Object is that a DES is designed to support technical
reuse within the Transitions of Care. A CEDD object is designed to support clinical reuse within the
Transitions of Care.
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CEDD Constraints
It is important to note that the only constraints on the CEDD itself are “priorities” of CEDD Objects and
CEDD Data Elements. These constraints for the ToC CEDD are as follows:




All A CEDD Data Elements must be sent as part of each care transition.
All B CEDD Data Elements must be sent as part of each care transition if they are readily
available and can be generated by the EHR
All C CEDD Data Elements can be sent if available and if they can be generated
All D CEDD Data Elements can be sent if available and if the EHR can actually generate them
The reason for making CEDD constraints flexible is that different CEDD’s may have different constraints
to be applied to the same CEDD Object. For example, a CEDD Object might be an "A" Data Element in
one S&I Framework initiative, but CEDD requirements for another S&I Framework Initiative might
express a similar CEDD Object as a "C" data element.
CEDD Conformance Statements
The CEDD does not contain explicit conformance language that would list a set of conformance
statements. There are several reasons for this:




The CEDD is not a ballotable specification (meaning it is not owned by an SDO) and is not
intended to serve as a standard or as an information model to be used outside the context of
the S&I Framework
The CEDD is informative and not normative - it is intended to serve as guidance and not be
prescriptive. Being informative means that the CEDD DOES NOT set out requirements, rules, or
conformance statements.
The CEDD is intended to be used for requirements traceability and is not normally implemented
on its own (although it is possible to build an object-oriented model). The key rule of the CEDD is
that while it can be tied to multiple implementation models and technologies, it is not intended
to be tied to one specifically.
The intention is for implementers to use the underlying conformance language of their chosen
implementation technology combined with CEDD objects to ensure conformance.
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Subsequent iterations of the ToC CEDD may include more explicit conformance language that is
developed based on implementer feedback.
Example of CDA constraint reuse:
A constraint applied in the CDA for Allergy/Alert Observation section is brought up to the Allergy
and Intolerance CEDD object. The conformance statement:
SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet
2.16.840.1.113883.3.88.12.3221.6.2 Allergy/Adverse Event Type DYNAMIC (CONF:7383). \
applies to the Allergy and Intolerance CEDD Object.
It is also expected that because the CEDD is a logical overlay of a physical data store, the CEDD would be
subject to the constraints of the physical data model(s). Claims of conformance may also be made for
the CEDD Object itself for each key information exchange.
Example of CEDD Object conformance
The CEDD object “Social History” would inherit all of the conformance statements specific to the
Social History in the CDA consolidation guide. An implementer would review the Social History
Section-level template (2.16.840.1.113883.10.20.22.2.17) and would need to conform to this
statement:
The Social History section MAY contain clinical statements. If present, the clinical statements SHALL
conform to the social history observations.
CEDD Vocabularies and Value Sets
CEDD Objects use terms from several code systems. These controlled vocabularies are defined in various
supporting specifications and may be maintained by other bodies, as is the case for the LOINC® and
SNOMED CT® vocabularies.
As a general rule, the vocabularies and value sets defined in the CDA are inherited by CEDD objects and
CEDD data elements.
The ToC CEDD aligns to the recommendations of the Health IT Standards Committee for those CEDD
objects that have associated vocabulary/code set requirements. The following table captures the
high-level recommendations from this committee:
CEDD Object
Physical Exam
CEDD Data Elements
Component
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Vocabulary Recommendation
LOINC
ONC Standards and Interoperability (S&I) Framework
Observation
SNOMED-CT
Component
LOINC
Response
SNOMED-CT
Active Medication List
Active Medication List
RxNORM
Procedures
Procedure
SNOMED-CT
Problem List
Problem
SNOMED-CT
Equipment
Equipment
SNOMED-CT
Culturally Sensitive Patient Care
Race
PHIN-VADS
Gender
HL7
Language
ISO 639-2
Primary Payer Information
ASC X12
Secondary Payer Information
ASC X12
Family History
Payer Information
For the ToC CEDD, additional vocabularies and value sets can be reused from the NLM mappings and
subsets available through UMLS.
Example:
An implementer may wish to implement a discharge summary using an existing vocabulary already
implemented within their environment. The CEDD Object “Problem List” does not exclude the use of
this vocabulary, so long as an accurate mapping exists back to the SNOMED-CT recommendation
provided by the Health IT Standards Committee Vocabulary Task Force.
Usage of the CEDD
In this visual, usage of the CEDD in various implementation geographies is outlined. This graphic is
provided to explain how the S&I Framework Clinical Element Data Dictionary (CEDD) can be used in
support of reference implementations and other working environments, together with the underlying
key information exchanges.
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Transport specifications would not actually “use” CEDD Objects; they would use the CEDD to provide
traceability to the requirements they have for information exchange. In this way, the CEDD can serve as
a key tool to verify whether information is being exchanged in support of the clinical perspective.
Examples of CEDD Usage
In the following figure, the use of the CEDD is outlined, together with the methods of health information
exchange and the underlying standard. This figure is a key high-level view of the intention for the CEDD,
which is to link the requirements of the clinician to an underlying standard and a method of transporting
clinical data:
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Transitions of Care Clinical Data Element Dictionary
Because the ToC CEDD is designed to represent a conceptual representation of clinical data, it serves as
a data dictionary for all ToC initiatives.
The following sections contain specific tables that capture information about the ToC CEDD in a tabular
format for easy lookup of important guidance, such as
1. Underlying Definition and Supported Datatypes
2. Priority of the CEDD Object
3. Clinical Examples (highlighted in Bold) to help understand the clinical meaning of the CEDD
Objects and CEDD Data Elements
A summary of the ToC CEDD structure is outlined below



ToC CEDD Object Summary – summarizing each of the ToC CEDD Objects
CEDD Object Detail – individual details about each CEDD Object
ToC CEDD Data Element Summary – summarizing each of the ToC CEDD Data Elements
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ToC CEDD Object Summary
The following table summarizes each of the ToC CEDD Objects in alphabetical order. This table is formatted in data dictionary format to allow for
the quick lookup of specific CDA template ID’s for CEDD objects
Important notes are listed below:


This table can be used to lookup CEDD Object priorities
This table will also capture the relevant CDA Template ID’s for each CEDD Object
To lookup CDA Section and Entry-Level ID’s, refer to the Key Information Exchange Summary
ToC CEDD Objects
CEDD Object
Name
Activities of Daily
Living (ADL)
CEDD Object
Definition
Activities of daily living are the functional tasks
of everyday life, oriented toward caring for
one's own body. ADLs focus on only those
activities a person needs to be able to perform
for him/herself to maintain dignity.
Can be segmented further into Instrumental
activities of daily living (IADL) which are complex
activities that support daily life in the home and
community. Ability to do them allows a person
to function independent of the assistance of
others.
A list of medications that patient should be
taking or an entry of no known medications.
Active Medication List
Clinical Example
ADL Examples are: eating & drinking, toileting,
bathing, grooming, and ambulating.
IADL Examples are: using a checkbook, taking
medication, planning & preparing meals; safely
using car, taxi, or public transportation;
housekeeping; laundry, grocery shopping.
The list of all of the medications that the patient
is taking, or has been prescribed, and the patient
is thought to be taking. If a clinician reads the
The list of medications includes compounds that patient a list of their medications and the patient
reports that they actually stopped taking
the patient may be taking (e.g. herbals) The
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
19
CEDD Object
Priority
"C" Data
Elements Care Plan
Data
"A" Data
Element (core
data
exchanged
with every
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
CEDD Object
Definition
metadata for the Active Medication List is to
include: the clinician that last ordered the
medication with the date/time stamp of when
the medication was last ordered, and whether
or not the Active Medication List was reconciled
during this encounter and if so by whom, and if
not when last reconciled and by whom.
Clinical Example
medication “X”, medication X would be removed
from the list. D/C reconciliation would include
consideration of the pre-hospitalization
medications and whether these need to be
continued or stopped.
CEDD Object
Priority
transition)
What clinician sending the message has
determined to be the patient's active problems
and/or diagnoses or determination of no known
problems - this list may be reconciled at each
care transition.
Active Problem List
Admitting and
The metadata for the problem list is to include:
the clinician that assigned the problem to the
problem list with the date/time stamp of when
the problem was assigned, the start date or
onset of the problem, whether or not the
problem list was reconciled during this
encounter and if so by whom, and whether any
problems were changed during this encounter.
All of the chronic problems or health issues that
the patient’s treating clinicians have determined
to be chronic noteworthy problems, e.g. this list
may include chronic health problems like chronic
obstructive pulmonary disease as well as
problems such as tobacco use disorder.
"A" Data
Element (core
data
exchanged
with every
transition)
For example, one problem might be removed
from the active problem list during an encounter
and another assigned. The removed problem
would be visible to the next recipient clinician as
removed from the problem list in the previous
encounter.
Admitting Diagnoses are the diagnoses assigned Admitting Diagnoses: Diabetic Ketoacidosis, Type "B" Data
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
20
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
Discharging Diagnoses
CEDD Object
Definition
to a patient at the time of admission to a facility.
Discharge Diagnoses are the diagnoses assigned
to a patient on discharge from a facility. These
terms are consistent with admission to a facility
and not applicable to the ambulatory
environment
Captures a list of known allergies and
intolerances, or no known allergies and
intolerances. Allergic reactions occur when
patients are exposed to an allergen an allergen
can be a medication or an environmental
compound (e.g. food, or pollen).
Allergies and
Intolerances
Anticipatory Guidance
Behavioral Health
History
Patients may also have adverse reactions to
substances that are not true allergic reactions,
known as intolerances. This list is comprised of
the agents causing the allergic reaction or
intolerance. An example of intolerance is a
patient that takes an antibiotic and becomes
nauseous.
This is education and support relative to a
patient's needs regarding both their health
conditions and encouraging health maintenance
and wellness
Specifies the summary report intended to
exchange selected information relevant across
specialties. It may not include the details of an
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
21
CEDD Object
Priority
II Diabetes, Hyperlipidemia, Obesity,
Elements
Noncompliance
from Hospital
Discharge Diagnoses: Type II Diabetes,
to PCP or
Hyperlipidemia, Obesity. Admitting and discharge other facility
diagnosis might or might not be the same.
(e.g. long
Admitting diagnosis might often be prospective
term care
or might be a chief complaint that represents a
facility)
health concern or symptom, e.g. chest pain.
Clinical Example
Allergic reactions occur when patients are
exposed to an allergen an allergen can be a
medication or an environmental compound (e.g.
food, or pollen). Patients may also have
adverse reactions to substances that are not true
allergic reactions, known as intolerances. A
patient with an allergic reaction to shellfish may
develop anaphylactic shock after ingesting
shellfish
Would include advice from a pediatrician about
home safety, e.g. storage of household chemicals
or advice from an allergist to an asthmatic
patient to avoid second hand cigarette smoke
exposure.
History of conditions or episodes that would fall
in the behavioral health domain, such as a history
of depression treated by the patients previous
"A" Data
Element (core
data
exchanged
with every
transition)
"C" Data
Elements Care Plan
Data
B" Data
Elements for
PCP to
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
CEDD Object
Definition
assessment but it will contain many data
elements that are based on the information
collected through the assessment and
generated from its processing. May often
include information that would be considered
sensitive information.
Clinical Example
PCP with antidepressant medications and an
inpatient stay in a behavioral health facility.
CEDD Object
Priority
Specialist with
Consultation
Request
"B" Data
Elements
from Hospital
to PCP or
other facility
(e.g. long
term care
facility)
"B" Data
Elements to
Patient:
Data
Exchange to
PHR
Care Team Members
Consultant(s)
A list of the care team members and their role in
the patient’s care. In an advanced primary care
model the care team would include anyone
actively involved in the patient's care such as
the PCMH team, the patient’s designees,
entities providing care and all additional
caregivers designated by the PCP or designated
provider (including those outside the patient’s
primary care practice that they have a
relationship with and/or are referred to).
Core (or A) data elements include diagnoses (on Patient’s thyroid nodule FNA demonstrated
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
22
"B" Data
Elements Care Plan
Data Resides
in PCP System
e.g. Advanced
Primary Care
Team System
"B" Data
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
Assessment(s) and
Plan(s)
Recommendations
CEDD Object
Clinical Example
Definition
the active problem list) and medications (on the follicular thyroid cancer; patient has been
active medication list) entered by the
scheduled for surgery in one month.
consultant.
These data elements include any non-Core
assessments, plans, and orders, including free
text of the consultants assessments and plan
recommendations
CEDD Object
Priority
Elements
from Hospital
to PCP or
other facility
(e.g. long
term care
facility
"B" Data
Elements to
Patient:
Data
Exchange to
PHR
Consultation Request
including Clinical
Summary
The Consultation Request including Clinical
Summary CEDD Object would include a standard
set of data including demographic information,
active reconciled medication list (with doses and
sig), allergy list and problem list. This data set
may also contain variable data relevant to the
context of the request. In addition, this
information exchange also includes a
PCP-selected referral-specific variable dataset.
The Consultation Request including Clinical
Summary CEDD Object is a logical
representation of the Consultation Request
including Clinical Summary information
exchange expressed in the S&I Framework S&I
Framework Use Case.
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
23
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
CEDD Object
Definition
The Consultation Summary is a CEDD object that
represents a standard data set including
demographic information, active reconciled
medication list (with doses and sig), allergy list
and problem list, and would also contain
variable data relevant to the context of the
Consultation Summary
request.
Clinical Example
CEDD Object
Priority
The Consultation Summary CEDD Object is a
logical representation of the Consultation
Summary expressed in the S&I Framework S&I
Framework Use Case.
Culturally Sensitive
Patient Care
Demographics
Diet
"A" Data
Element (core
data
A patient who is a Jehovah’s witnesses refuses to
exchanged
undergo a blood transfusion.
with every
transition)
Information specific to the patient's cultural,
religious, and educational background.
The Demographics CEDD object would assemble
multiple child CEDD objects into a Demographics
parent CEDD object
The diet that has been ordered or
recommended by the clinician. (Distinct from
the diet that the patient reports they follow, e.g.
a vegetarian diet). Diet appears in 2 places.
Patient is advised to follow a low salt, low fat and
The first is the diet that has been “ordered” or
reduced calorie diet.
recommended by the clinician. The second is the
diet that the patient is actually consuming. This
second instance will be for patient
self-monitoring.
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
24
“B” Data
Elements for
PCP to
Specialist with
Consultation
Request
(including
closed loop
referral)
“B” Data
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
Diet Narrative
CEDD Object
Definition
Clinical Example
This section records a narrative description of
the expectations for diet and nutrition including
nutrition prescription, proposals, goals, and
order requests for monitoring, tracking, or
improving the nutritional status of the patient,
used in a discharge from a facility such as an
emergency department, hospital, or nursing
home.
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
25
CEDD Object
Priority
Elements
from Hospital
to PCP or
other facility
(e.g. long
term care or
sub-acute
care)
“B” Data
Elements to
Patient: Data
Exchange to a
PHR.
“B” Data
Elements for
PCP to
Specialist with
Consultation
Request
(including
closed loop
referral)
“B” Data
Elements
from Hospital
to PCP or
other facility
(e.g. long
term care or
sub-acute
care)
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
Discharge Instructions
Discharge Summary
CEDD Object
Definition
Clinical Example
The Discharge Instructions CEDD Object would
include a standard data set including
demographic information, active reconciled
medication list (with doses and sig), allergy list
and problem list. Discharge Instructions also
contains dataset relevant to the Discharge
Summary/Discharge Instructions context which
includes follow-up/plan of care.
The Discharge Instructions CEDD Object is a
logical representation of the Discharge
Instructions expressed in the S&I Framework S&I
Framework Use Case.
The Discharge Summary CEDD Object would
contain 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
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
26
CEDD Object
Priority
“B” Data
Elements to
Patient: Data
Exchange to a
PHR.
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
CEDD Object
Definition
Instruction as well as the Discharge Summary.
Discharge summary content examples include
demographic information, active reconciled
medication list (with doses and sig), allergy list,
problem list, and reason for admission.
Clinical Example
CEDD Object
Priority
The Discharge Summary CEDD Object is a logical
representation of the Discharge Summary
expressed in the S&I Framework S&I Framework
Use Case.
This includes all discontinued medications with a
date time stamp of when the medication was
discontinued and the reason for discontinuation
(if available).
Discontinued
Medications
Equipment
Existence of Advanced
Directives
"A" Data
If the medication had been discontinued during Patient reports that a new medication is making Element (core
the specific care transition encounter this would them feel queasy, the medication is discontinued data
be evident from the date time stamp of
and is removed from the active medication list
exchanged
discontinuation. This should include
and added to the discontinued medication list
with every
medications that were just discontinued, but
transition)
might still be physiologically active in the
patient's system. There should be a date and
time stamp of discontinuation with each
discontinued medication.
"C" Data
Durable Medical Equipment (DME), and any
Elements crutches, neck brace, cane
other equipment ordered for the patient
Care Plan
Data
Captures the existence of advanced directives
The patient has discussed advanced directives
"A" Data
for a patient; simply whether or not the patient with one of their treating clinicians, made
Element (core
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
27
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
CEDD Object
Definition
had advanced directives not what they are.
Clinical Example
decisions about their wishes and completed an
AD form.
Patient has a family history significant for:
mother died of colon cancer at age 48, maternal
grandmother, paternal grandfather, and father
with hypertension; maternal grandfather with
unknown cancer, deceased age 52.
The patient's family history data elements
Family History
Not a summary, as the sending physician may
want to select specific elements for inclusion.
CEDD Object
Priority
data
exchanged
with every
transition)
B" Data
Elements for
PCP to
Specialist with
Consultation
Request
"B" Data
Elements
from Hospital
to PCP or
other facility
(e.g. long
term care
facility)
"B" Data
Elements to
Patient:
Data
Exchange to
PHR
Follow-up
Appointments
Patient has an appointment 8/10/11 at 10 AM
with her PCP and an appointment 8/20/11with
for PT
All of the patients scheduled future
appointments
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
28
"C" Data
Elements Care Plan
Data
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
CEDD Object
Definition
Goals
This is a list of the health-related goals, such as
smoking cessation agreed upon by the patient
and the physician
Health Literacy
Information on the degree to which individuals
have the capacity to obtain, process, and
understand basic health information and
services needed to make appropriate health
decisions
Health Maintenance
The education, scheduled or anticipated tests
and studies, and self-monitoring activities
related to Health maintenance
History Present Illness
CEDD Object
Priority
"B" Data
Elements The patient and the clinician have discussed and
Care Plan
agree on the patient’s goal of 5 lbs of weight loss
Data Resides
over the next 2 months. Goals might or might not
in PCP System
have a time frame. For example, maintaining a
e.g. Advanced
HgbA1 below a certain level might be a goal for a
Primary Care
diabetic.
Team System
Clinical Example
Patient is able to understand health information
provided at the 9th grade level
"C" Data
Elements Care Plan
Data
"C" Data
Elements Care Plan
Data
B" Data
Elements for
PCP to
Specialist with
In a medical encounter, a history of the present Patient reports having new onset chest pain
Consultation
illness (abbreviated HPI)[1] (termed history of
described as a dull pain like an elephant sitting on
Request
presenting complaint (HPC) in the UK) refers to a his chest. Pain radiates down the arm, is
detailed interview prompted by the chief
relieved with rest, began 1 week ago, and lasts
"B" Data
complaint or presenting symptom (for example, for minutes. Pain is brought on with stress or
Elements
pain).
climbing stairs.
from Hospital
to PCP or
other facility
(e.g. long
Mammogram, Pap test, colonoscopy or patient
tracking of a regular exercise routine
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
29
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
CEDD Object
Definition
Clinical Example
CEDD Object
Priority
term care
facility)
"B" Data
Elements to
Patient:
Data
Exchange to
PHR
"B" Data
Elements for
PCP to
Specialist with
Consultation
Request
Immunization History
A list of the immunizations that the patient has
received including date of immunization, where
the immunization was administered if known,
and lot or batch number if available
The patient’s immunization history includes
includes BCG, or bacille Calmette-Guérin, is a
vaccine for TB, as an infant.
"B" Data
Elements
from Hospital
to PCP or
other facility
(e.g. long
term care
facility)
"B" Data
Elements to
Patient:
Data
Exchange to
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
30
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
Invasive and
Non-Invasive
Procedures
Medical History
CEDD Object
Definition
Clinical Example
CEDD Object
Priority
PHR
"C" Data
Elements Care Plan
Data
B" Data
Elements for
PCP to
Specialist with
Consultation
Request
A listing of invasive and non-invasive procedures
for a patient.
"B" Data
Elements
from Hospital
to PCP or
Patient with a past medical history of gallstones x
other facility
2 episodes which resolved post cholecystectomy
(e.g. long
term care
facility)
The patient's previous medical problems
"B" Data
Elements to
Patient:
Data
Exchange to
PHR
Medication History
The patient's previous medications that are no
longer on the active medication list, including
A list of the patient’s discontinued medications,
e.g. prior courses of antibiotics, previous oral
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
31
"B" Data
Elements for
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
CEDD Object
Definition
stop and start dates and reason for
discontinuation if known
Clinical Example
birth control medications, previous lower doses
of antihypertensive medications that have been
changed to higher doses. (Distinct from a
medication history service that might provide an
aggregation of a patient’s known recent
medications based on pharmacy fill data, claims
history, and other data sources)
CEDD Object
Priority
PCP to
Specialist with
Consultation
Request
"B" Data
Elements
from Hospital
to PCP or
other facility
(e.g. long
term care
facility)
"B" Data
Elements to
Patient:
Data
Exchange to
PHR
Operative Summary
"B" Data
Elements
from Hospital
to PCP or
other facility
(e.g. long
term care
facility)
Operative Report
"B" Data
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
32
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
CEDD Object
Definition
Clinical Example
CEDD Object
Priority
Elements to
Patient:
Data
Exchange to
PHR
Outcome of
Allergy/Intolerance
Specific outcomes that result from an allergy
and/or intolerance
"D"Elements
The patient in treated with Benadryl and steroids
- Care Plan
and discharged to home
Data
Patient Consent
Directive
The record of a healthcare consumer¡¦s privacy
policy that grants or withholds consent for:
 one or more principals (identified entity
or role)
 performing one or more operations
(e.g., collect, access, use, disclose,
amend, or delete)
 purposes such as Treatment, Payment,
Operations, Research, Public Health,
Quality Measures, Health Status
Evaluation by third parties, or Marketing
 certain conditions, e.g., when
unconscious
 a specified time period, e.g., effective
and expiry dates
 a certain context, e.g., in an emergency
Patient has been explained the risks and benefits
of the procedure that include: xxx, yyy, zzz, and
potentially death, and has consented to the
procedure
Patient Contact
Information
Main contact information for the patient,
including telecommunications and physical
addresses. Also includes information on if the
patient has a Direct-specific electronic endpoint
address and has text messaging enabled.
"A" Data
Element (core
The clinical information that the patient provides data
about how to reach them
exchanged
with every
transition)
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
33
"C" Data
Elements PCP to
Specialist with
Consultation
Request
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
Patient Information
Patient Instructions
CEDD Object
Definition
CEDD Object
Priority
"A" Data
Element (core
Information used to specifically help in the
data
identification of the patient.
exchanged
with every
transition)
"B" Data
The patient’s wound care instructions included
Elements washing the wound daily with warm soapy water,
Care Plan
drying the area completely, applying a film of
Information provided to the patient by the care
Data Resides
petroleum jelly over the wound and applying a
team members detailing what the patient needs
in PCP System
fresh bandage loosely to cover the wound.
to do regarding their healthcare.
e.g. Advanced
Proposed MU Stage II also calls out some data for
Primary Care
hospital discharge instructions, e.g. diet and
Team System
activity.
Patient
Self-Management
Activities to be performed by the patient to
manage specific problems (e.g. recording of
food consumed in a patient trying to modify
their weight)
Payer Information
Primary and secondary insurance provider
information applicable to the patient.
Pending Tests and
Procedures
Clinical Example
(e.g. recording of food consumed in a patient
trying to modify their weight)
e.g. the patient had blood drawn for a Russell
Viper Venom that needed to be sent to a special
lab and the results are not back yet. The
patient had a fasting Lipid panel ordered, but as
the patient has eaten he will need to return
tomorrow in a fasting state to have the blood
Those tests and procedures that have been
ordered but not completed
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
34
"C" Data
Elements Care Plan
Data
"A" Data
Element (core
data
exchanged
with every
transition)
"B" Data
Elements for
PCP to
Specialist with
Consultation
Request
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
CEDD Object
Definition
Clinical Example
CEDD Object
Priority
drawn.
"B" Data
Elements
from Hospital
to PCP or
other facility
(e.g. long
term care
facility
"B" Data
Elements to
Patient:
Data
Exchange to
PHR
Physical Activity
Physical Exam
Primary Care
The provider recommended physical activity to
the patient, e.g. ambulate with a cane
Physical examination or clinical examination is
the process by which a doctor investigates the
body of a patient for signs of disease. It
generally follows the taking of the medical
history — an account of the symptoms as
experienced by the patient. Together with the
medical history, the physical examination aids in
determining the correct diagnosis and devising
the treatment plan
A list of the primary care physicians applicable
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
35
Patient to ambulate using a 4 point walker
"C" Data
Elements Care Plan
Data
Pupils equal reactive to light and
accommodation; equal ocular movements Intact,
2+ lower extremity edema; Heart: regular rate
and rhythm
"B" Data
Elements for
PCP to
Specialist with
Consultation
Request
"A" Data
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
Physicians and
Designated Providers
CEDD Object
Definition
to the patient, as well as other designated
providers and specialists who may work with the
patient. This list will include information about
the provider's specializations and whether they
are part of the patient's care team.
Clinical Example
CEDD Object
Priority
Element (core
data
exchanged
with every
transition)
Part of the Demographics CEDD Object
"B" Data
Elements for
PCP to
Specialist with
Consultation
Request
Reason for Consult
Request
The reason that one physician or other clinical
professional is asking for the specialty opinion or
action of another physician or other clinical
professional. This generally includes context
The patient has a large left sided thyroid nodule;
specific patient history and the issues that the
please evaluate and perform a fine needle
requesting physician wants the consulting
aspiration if deemed appropriate
physician to address, or the activities that the
requesting physician or other clinical
professional wants the consulting physician or
other clinical professional to perform.
Restorative Care
Would include programs and treatments aimed
at rehabilitation or restoring a patient to a
greater level of function after an episode of
illness or a surgery, e.g. a prescribed course of
physical therapy, a course of home care, or a
self-management program.
Review of Systems
"B" Data
Subjective patient supplied information
Patient denies change in bowel habits, black stool Elements
regarding the patient's different bodily systems. or bright red blood per rectum.
from Hospital
to PCP or
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
36
"B" Data
Elements to
Patient:
Data
Exchange to
PHR
Would require identification of an appropriate
set of data elements, value set(s), and
terminology
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
CEDD Object
Definition
Clinical Example
CEDD Object
Priority
other facility
(e.g. long
term care
facility)
"B" Data
Elements to
Patient:
Data
Exchange to
PHR
The patient's social situation that will determine
their ability to access, understand and comply
Social Determinants of
with their healthcare recommendations, e.g.
Health
patient is uninsured and cannot afford their
medication.
Social History
Patient is unable to afford the copay for their
medicine. Patient was evicted and is currently
living on the street, therefore unable to perform
required wound changes
Subjective patient supplied information that
addresses occupational and recreational aspects
Patient smokes 2 packs of cigarettes per day for
of the patient's personal life that have the
20 years.
potential to be clinically significant, e.g. sexual
history, smoking history, etc...
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
37
"C" Data
Elements Care Plan
Data
B" Data
Elements for
PCP to
Specialist with
Consultation
Request
"B" Data
Elements
from Hospital
to PCP or
other facility
(e.g. long
term care
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
CEDD Object
Definition
Clinical Example
CEDD Object
Priority
facility)
"B" Data
Elements to
Patient:
Data
Exchange to
PHR
Support Contacts
"A" Data
Element (core
data
exchanged
with every
transition)
B" Data
Elements for
PCP to
Specialist with
Consultation
Request
A list of the primary and secondary caregiver
contacts and their relevant information
Part of the Demographics CEDD Object
Surgical/Procedure
History
The previous surgery and procedures that a
patient has had
Cholecystectomy 1995
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"B" Data
Elements
from Hospital
to PCP or
other facility
(e.g. long
term care
facility)
ONC Standards and Interoperability (S&I) Framework
ToC CEDD Objects
CEDD Object
Name
S&I Framework
Summary
Vital Signs
CEDD Object
Definition
Clinical Example
CEDD Object
Priority
"B" Data
Elements to
Patient:
Data
Exchange to
PHR
High level CEDD Object used to incorporate all
key information exchanges associated with the
S&I Framework S&I Framework Use Case
Vital signs are measures of various physiological Blood pressure 120/80, Temp 99 F; Height 5’ 3”,
statistics, often taken by health professionals, in Weight 113; Respiratory Rate 14, Heart Rate 60.
order to assess the most basic body functions
"B" Data
Elements for
PCP to
Specialist with
Consultation
Request
"B" Data
Elements to
Patient:
Data
Exchange to
PHR
CEDD Objects (In Detail)
Within this section, each CEDD object is detailed at the CEDD Data element level. This table provides further context into the priority of specific
CEDD Data Elements so that CEDD objects that are structured within an EHR or other health information system can also be prioritized. Specific
columns to note include:
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ONC Standards and Interoperability (S&I) Framework


ISO/HL7 Datatypes – note that these datatypes are proposed in Version 1.3 of the ToC CEDD. The B and C Priority data elements may
require more work to finalizing typing of the data elements.
Examples and guidance are provided – clinically relevant terminology is given, as well as potential vocabularies and value sets to use in
storing these CEDD data elements.
Activities of Daily Living
Activities of Daily Living
Name of Data Element
Definition of Data Element
ADLs
List of functional tasks of
everyday life, oriented
toward caring for one's
own body.
IADLs
Instrumental activities of
daily living (IADL) are
complex activities that
support daily life in the
home and
community. Ability to do
them allows a person to
function independent of
the assistance of others.
ISO/HL7 Datatype
Examples and
Data Element Priority
Guidance
Examples are: eating &
"C" Data Element (data
drinking, toileting, bathing, dependent on transition of
grooming, and
care)
ambulating. ADLs focus
on only those activities a
person needs to be able to
perform for him/herself to
maintain dignity.
Examples are: using a
checkbook, taking
medication, planning &
preparing meals; safely
using car, taxi, or public
transportation;
housekeeping; laundry,
grocery shopping.
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"C" Data Element (data
dependent on transition of
care)
ONC Standards and Interoperability (S&I) Framework
Activities of Daily Living
Name of Data Element
Index of Independence ADL Scale
IADL Scale (Lawton)
Definition of Data Element
ISO/HL7 Datatype
The Index of Independence
in Activities of Daily Living
(Katz Index of ADL) was
developed to evaluate
changes in these
populations, assessing a
patient's overall
performance of six
self-care functions. It can
be used to assess the need
for care as well as the
progression of illness and
the effectiveness of
treatment and
rehabilitation.
Examples and
Guidance
A score out of 6 assigned
to patient relating to six
self-care functions:
Data Element Priority
"C" Data Element (data
dependent on transition of
care)
bathing, dressing, toileting,
transferring, continence,
and feeding
The IADL scale is a brief
tool that aids in the
formulation,
implementation, and
evaluation of treatment
plans. It is useful in elderly
community populations
and provides information
about a patient's need for
support services.
A summary score of 0-5 is
provided for men and 0-8
is provided for women
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"C" Data Element (data
dependent on transition of
care)
ONC Standards and Interoperability (S&I) Framework
Active Medication List
Active Medication List
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
A list of clinically relevant
medications, including:
Active Medication List ID
Associated Assessment
Changed Medications
PRN Medication List
Active Medications (Held
for Period of Time)
LIST (Sequence)
Medications that patient
was exposed to, now
discontinued, but still
clinically relevant
Software need – document
the delta
"A" Data Element (core
data exchanged with every
transition)
Clinical Example:
Hyperlipidemia: Lipitor
Reason the provider
prescribed the medication
BAG (Bag)
Medications that have
been modified in this
encounter, i.e. dosage
adjustments
CE (Coded element)
Includes ICD-9 codes
and/or SNOMED codes
Clinical Example: Lipitor 10
mg discontinued; Lipitor 20
mg prescribed
Value Set: Medication
"A" Data Element (core
Brand Name
data exchanged with every
2.16.840.1.113883.3.88.12. transition)
80.16
Code System(s): rxNorm
2.16.840.1.113883.6.88
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"A" Data Element (core
data exchanged with every
transition)
ONC Standards and Interoperability (S&I) Framework
Active Medication List
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Value Set: Medication Drug
Class
2.16.840.1.113883.3.88.12.
80.18
Code System(s): NDF-RT
2.16.840.1.113883.3.26.1.5
Value Set: Medication
Clinical Drug
2.16.840.1.113883.3.88.12.
80.17
Code System(s): RxNorm
2.16.840.1.113883.6.88
Date Of Reconciliation
The date of the last active
medication list
reconciliation
"A" Data Element (core
data exchanged with every
transition)
DATE
Clinical Example: Lipitor 10
mg discontinued
Discontinued Medications
Medications that have
been discontinued
CE (Coded element)
Value Set: Medication
Brand Name
"A" Data Element (core
2.16.840.1.113883.3.88.12. data exchanged with every
80.16
transition)
Code System(s): rxNorm
2.16.840.1.113883.6.88
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ONC Standards and Interoperability (S&I) Framework
Active Medication List
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Value Set: Medication Drug
Class
2.16.840.1.113883.3.88.12.
80.18
Data Element Priority
Code System(s): NDF-RT
2.16.840.1.113883.3.26.1.5
Value Set: Medication
Clinical Drug
2.16.840.1.113883.3.88.12.
80.17
Code System(s): RxNorm
2.16.840.1.113883.6.88
Dose
The amount of the product
to be given. This includes a
dose in measurable units
(e.g., milliliters, or mg), the
form (or administrative
unit (e.g. tablets,
suppository, etc...), and the PQ
amount of the form to
take. For example
Medication XXX 500 mg,
tablets; take ½ tablet,
administration unit (e.g.,
tablet), or an amount of
Clinical Example: 500 mg
tablet
Value Set: Medication
Brand Name
2.16.840.1.113883.3.88.12. "A" Data Element (core
80.16
data exchanged with every
transition)
Code System(s): rxNorm
2.16.840.1.113883.6.88
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ONC Standards and Interoperability (S&I) Framework
Active Medication List
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
active ingredient (e.g., 250
mg). May define a variable
dose, dose range or dose
options based upon
identified criteria (see Dose
Indicator)
Need to have both the
"dose" as well as the form
or administration unit.
The period of time that you
are to take the medication
Duration of Administration
IVL (Interval)
if it is time limited, e.g.
take abx for 10 days
Defines how often the
medication is to be
administered as events per
unit of time. Often
expressed as the number
of times per day (e.g., four
times a day), but may also
Frequency of
include event-related
IVL_TS
Administration
information (e.g., 1 hour
before meals, in the
morning, at bedtime).
Complimentary to Interval,
although equivalent
expressions may have
different implications (e.g.,
Clinical Example: for 10
days
Clinical Example:
6 hours while awake
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"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
transition)
ONC Standards and Interoperability (S&I) Framework
Active Medication List
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
every 8 hours versus 3
times a day)
Medication Attributes
This is the physical form of
the product as presented
to the individual. For
example: tablet, capsule,
liquid or ointment
Value Set: Medication
Product Form
2.16.840.1.113883.3.88.12.
3221.8.11
CE (Coded element)
Code System(s): National
Cancer Institute (NCI)
Thesaurus
2.16.840.1.113883.3.26.1.1
"A" Data Element (core
data exchanged with every
transition)
Medication Delivery
Method
Patient Instructions
Prescriber
Reconciled By
Route of Administration
Instructions to the patient
that are not traditionally
part of the Sig. For
example, “keep in the
refrigerator.” More
extensive patient
education materials can
also be included
The person that wrote this
order/prescription (may
include both a name and
an identifier)
The name of the individual
who last reconciled the
active medication list
Indicates how the
Clinical example:
ED (Encapsulated Data)
Store in the refrigerator.
Take with food.
"A" Data Element (core
data exchanged with every
transition)
EN (Entity Name)
EN (Entity Name)
CE (Coded element)
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"A" Data Element (core
data exchanged with every
transition)
Clinical Example:
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
ONC Standards and Interoperability (S&I) Framework
Active Medication List
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
medication is received by
the patient (e.g., by mouth,
intravenously, topically,
etc.)
Examples and
Guidance
by mouth; or apply to skin
in area of rash
Data Element Priority
data exchanged with every
transition)
Value Set: Medication
Route FDA Value Set
2.16.840.1.113883.3.88.12.
3221.8.7
Code System(s): National
Cancer Institute (NCI)
Thesaurus
2.16.840.1.113883.3.26.1.1
Site of Delivery
Start Date
Used to express the start
date for a medication
Status of Reconciliation
Is the active medication list
CE (Coded element)
reconciled?
Stop Date
Used to express a "hard
stop," such as the last Sig
sequence in a tapering
dose, where the last
sequence is 'then D/C' or
where the therapy/drug is
used to treat a condition
and that treatment is for a
fixed duration with a hard
DATE
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
transition)
DATE
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ONC Standards and Interoperability (S&I) Framework
Active Medication List
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
stop, such as antibiotic
treatment, etc
Vehicle for Delivery
When to Take
For PRN meds this
information would be take
when you are experiencing
IVL_TS
the system, e.g. take you
nitroglycerine when you
are experiencing chest pain
Clinical Example:
at bedtime daily
"A" Data Element (core
data exchanged with every
transition)
Active Problem List
Active Problem List
Name of Data Element
Active Problem Attributes
Definition of Data Element
List of coded values
capturing problem health
status
ISO/HL7 Datatype
CS (Coded Simple Value)
Examples and
Data Element Priority
Guidance
Value Set:
"A" Data Element (core
ProblemHealthStatusCode data exchanged with every
2.16.840.1.113883.1.11.20. transition)
12
Code System: SNOMED CT
2.16.840.1.113883.6.96
Active Problem List ID
Active Problem Name
Actual name of the
problem
Active Problem Type
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ONC Standards and Interoperability (S&I) Framework
Active Problem List
Name of Data Element
Problem Assignee
Problem Assignee ID
Reconciled By
Reconciliation Date
Reconciliation Status
Start Date Of Problem
Definition of Data Element
The person that entered
the problem in the EHR
date/time stamped
Who reconciled the
problem list
ISO/HL7 Datatype
Examples and
Guidance
EN (Entity Name)
"A" Data Element (core
data exchanged with every
transition)
INT (Integer)
EN (Entity Name)
The date/time stamp for
the last reconciliation of
the problem list
Has the problem list been
reconciled?
DATE
This is the range of time of
which the problem was
active for the patient or
subject
DATE
Data Element Priority
"A" Data Element (core
data exchanged with every
transition)
CE (Coded element)
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
transition)
Includes the date of onset
Admitting and Discharging Diagnoses
Admitting and Discharging Diagnoses
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Diagnosis List ID
Diagnosis Name
Diagnosis Code
Patient Conditions
Problem Observation
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Examples and
Guidance
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Allergies and Intolerances
Allergies and Intolerances
Name of Data Element
A/I Attributes
Definition of Data Element
Severity, Veracity of the
data based on source and
details available about
index reaction(e.g. older
patient has been told that
had a rxn as a child vs.
clinician has healthcare
professional
documentation of an
anaphylactic episode)
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Clinical Example:
ED (Encapsulated Data)
older patient has been told
that had a rxn as a child vs.
clinician has healthcare
professional
documentation of an
anaphylactic episode
Active Allergy List ID
Environmental Allergens
A list of associated
environment allergens for
the medication
Value Set: Allergy/Adverse
Event Type
2.16.840.1.113883.3.88.12.
3221.6.2
CE (Coded element)
Includes seasonal allergens
Food Allergens
A list of associated food
allergens for the
medication
CE (Coded element)
"A" Data Element (core
Code System(s): SNOMED
data exchanged with every
CT 2.16.840.1.113883.6.96
transition)
Examples of environmental
allergens include latex,
pollen, animal dander,
etc...
Value Set: Allergy/Adverse
Event Type
"A" Data Element (core
2.16.840.1.113883.3.88.12.
data exchanged with every
3221.6.2
transition)
Code System(s): SNOMED
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ONC Standards and Interoperability (S&I) Framework
Allergies and Intolerances
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
CT 2.16.840.1.113883.6.96
Data Element Priority
Examples of food allergens
include shellfish, eggs,
peanuts, etc.
Clinical Example:
List of Reactions
Medication Intolerances
Reaction Attributes
Reaction Date
Reaction Identified By
Reaction Type
Severity Attributes
Severity of Intolerance or
A list of reactions from
allergies/intolerances
LIST (Sequence)
Medication (ingredient or
class code, if available) that
has been attributed to an
allergic reaction or
ED (Encapsulated Data)
intolerance, or drug code if
attribution to ingredient or
class is unavailable
Severity of an individual
episode
Date when this particular
Intolerance Condition or
Allergy first manifested
TIMESTAMP()
itself or was confirmed via
testing if it had not yet
manifested itself.
Who reported the reaction
(e.g. patient, provider, care EN (Entity Name)
taker)
Severity associated with
CE (Coded element)
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(e.g. anaphylaxis), nausea,
morbilliform skin rash
Clinical Example: e.g.
Opiates
Includes medications,
biologicals, herbal
supplements, OTCs,
vaccine, etc.
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
transition)
Clinical Example:
"A" Data Element (core
ONC Standards and Interoperability (S&I) Framework
Allergies and Intolerances
Name of Data Element
Allergy
Definition of Data Element
ISO/HL7 Datatype
the reaction. This is a
description of the level of
severity of the allergy or
intolerance
Examples and
Guidance
Data Element Priority
data exchanged with every
A patient was treated in
transition)
the ED and hospitalized
overnight 3 years ago for
severe anaphylaxis 30
minutes after eating
roasted peanuts; six
months ago they ate a dish
served with a utensil that
had been contaminated
with peanut sauce and had
itching of their mouth that
resolved after Benadryl;
their condition is
considered a severe
peanut allergy, even
though they have had a
mild episode on one
occasion
Need to be sure to
distinguish the severity of
the condition (intolerant to
XXX) from the severity of a
specific instance of a
reaction
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ONC Standards and Interoperability (S&I) Framework
Anticipatory Guidance
Anticipatory Guidance
Name of Data Element
Guidance Narrative
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
This is education and
support relative to a
patient's needs regarding
both their health
conditions and
encouraging health
maintenance and wellness
Behavioral Health History
Behavioral Health History
Name of Data Element
DSM Axis 1
DSM Axis 2
Definition of Data Element
ISO/HL7 Datatype
The DSM-IV organizes each
psychiatric diagnosis into
five dimensions (axes)
relating to different
aspects of disorder or
disability:
Structure
Axis I: Clinical disorders,
including major mental
disorders, and learning
disorders
The DSM-IV organizes each
psychiatric diagnosis into
five dimensions (axes)
Structure
relating to different
aspects of disorder or
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Examples and
Guidance
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Behavioral Health History
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
disability:
DSM Axis 3
DSM Axis 4
Axis II: Personality
disorders and intellectual
disabilities (although
developmental disorders,
such as Autism, were
coded on Axis II in the
previous edition, these
disorders are now included
on Axis I)
The DSM-IV organizes each
psychiatric diagnosis into
five dimensions (axes)
relating to different
aspects of disorder or
Structure
disability:
Axis III: Acute medical
conditions and physical
disorders
The DSM-IV organizes each
psychiatric diagnosis into
five dimensions (axes)
relating to different
aspects of disorder or
Structure
disability:
Axis IV: Psychosocial and
environmental factors
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Examples and
Guidance
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Behavioral Health History
Name of Data Element
DSM Axis 5
Definition of Data Element
contributing to the
disorder
The DSM-IV organizes each
psychiatric diagnosis into
five dimensions (axes)
relating to different
aspects of disorder or
disability:
ISO/HL7 Datatype
Examples and
Guidance
Structure
Axis V: Global Assessment
of Functioning or Children's
Global Assessment Scale
for children and teens
under the age of 18
Environmental Factors
Structure
Global Assessment of
Functioning (GAF)
GAF Score
Clinical Example:
INT (Integer)
Part of the diagnosis on
Axis 5
Range from 0-100, e.g. 50
Clinical Example:
Homicidal Ideation
HIST (History)
Patient reports fantasizing
about killing his spouse
with his gun.
Clinical Example:
Suicidal Ideation
HIST (History)
Patient reports thinking
about jumping out of a
window of a high story
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Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Behavioral Health History
Name of Data Element
Definition of Data Element
Treatment Referral
ISO/HL7 Datatype
Examples and
Guidance
building
Data Element Priority
Structure
Care Team Members
Care Team Members
Name of Data Element
Care Team List
(placeholder)
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Examples and
Guidance
Data Element Priority
A list of the care team
members and their role in
the patient's care. In an
advanced primary care
model the care team
would include the PCMH
team, the patient's
designee(s) (if applicable),
and all additional
caregivers (e.g. home
health aide) designated by
the PCP involved in the
patient's care
Consultant(s) Assessment(s) and Plan(s) Recommendation
Consultant(s) Assessment(s) and Plan(s) Recommendation
Name of Data Element
Assessment Narrative
Definition of Data Element
ISO/HL7 Datatype
Core (or A) data elements
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ONC Standards and Interoperability (S&I) Framework
Consultant(s) Assessment(s) and Plan(s) Recommendation
Name of Data Element
(placeholder)
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Examples and
Guidance
Data Element Priority
include diagnoses (on the
active problem list) and
medications (on the active
medication list) entered by
the consultant.
These data elements
include any non-Core
assessments, plans, and
orders, including free text
of the consultants
assessments and plan
recommendations
Consultation Request including Clinical Summary CEDD Object
Consultation Request including Clinical Summary CEDD Object
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Active Allergy List ID
A list of clinically relevant
medications, including:
Active Medication List ID
PRN Medication List
Active Medications (Held
for Period of Time)
Medications that patient
was exposed to, now
discontinued, but still
LIST (Sequence)
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"A" Data Element (core
data exchanged with every
transition)
ONC Standards and Interoperability (S&I) Framework
Consultation Request including Clinical Summary CEDD Object
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
clinically relevant
Software need – document
the delta
Active Problem List ID
Advanced Directive Type
Confidentiality Code
Consultation Request ID
Discontinued Medication
List
Patient Identifiers
Primary Emergency
Contact Name
Primary Insurance Plan ID
Provider NPI
A unique identifier for the
Consultation Request
List of discontinued
medications
An identifier that uniquely
identifies the individual to
which the exchange refers
and connects that
document to the
individual's personal health
record. Potential security
risks associated with use of
SSN or driver's license for
this element suggest that
these should not be used
routinely
The name of the individual
or organization providing
support to the individual
for which this exchange is
produced
National Provider Identifier
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Examples and
Guidance
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Consultation Request including Clinical Summary CEDD Object
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
or NPI is a unique
identification number
issued to healthcare
providers in the United
States
Accessible at:
Secondary Emergency
Contact Name
https://nppes.cms.hhs.gov
/NPPES/NPIRegistryHome.
do
The name of the individual
or organization providing
support to the individual
for which this exchange is
produced
Consultation Summary CEDD Object
Consultation Summary CEDD Object
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Active Allergy List ID
A list of clinically relevant
medications, including:
Active Medication List ID
LIST (Sequence)
PRN Medication List
Active Medications (Held
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"A" Data Element (core
data exchanged with every
transition)
ONC Standards and Interoperability (S&I) Framework
Consultation Summary CEDD Object
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
for Period of Time)
Medications that patient
was exposed to, now
discontinued, but still
clinically relevant
Software need – document
the delta
Active Problem List ID
Advanced Directive Type
Confidentiality Code
Consultation Summary ID
Patient Identifiers
Primary Emergency
Contact Name
A unique identifier for the
Consultation Summary
An identifier that uniquely
identifies the individual to
which the exchange refers
and connects that
document to the
individual's personal health
record. Potential security
risks associated with use of
SSN or driver's license for
this element suggest that
these should not be used
routinely
The name of the individual
or organization providing
support to the individual
for which this exchange is
produced
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Examples and
Guidance
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Consultation Summary CEDD Object
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Primary Insurance Plan ID
Provider NPI
National Provider Identifier
or NPI is a unique
identification number
issued to healthcare
providers in the United
States
Accessible at:
Secondary Emergency
Contact Name
https://nppes.cms.hhs.gov
/NPPES/NPIRegistryHome.
do
The name of the individual
or organization providing
support to the individual
for which this exchange is
produced
Culturally Sensitive Patient Care
Culturally Sensitive Patient Care
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Confidentiality Code
Disability
The disability status of the
patient
CE (Coded element)
Educational Level
Acceptable values for this
data element include the
CE (Coded element)
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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"A" Data Element (core
data exchanged with every
transition)
Clinical Example: Graduate "A" Data Element (core
Degree
data exchanged with every
Clinical Example: Deaf
ONC Standards and Interoperability (S&I) Framework
Culturally Sensitive Patient Care
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
following (Advanced
Degree, College Graduate,
Some College, High School
Graduate, Elementary)
Data Element Priority
transition)
Clinical Example: Latino
Value Set:
Ethnicity
Language
Race
Ethnicity is a term that
extends the concept of
race. The coding of
ethnicity is aligned with
CE (Coded element)
public health and other
federal reporting standards
of the CDC and the Census
Bureau
Language will be identified
as spoken, written, or
understood; but no
attempt will be made to
assess proficiency. The
CE (Coded element)
default language is English,
but English is to be entered
explicitly similar to any
other listed language
Race is usually a single
valued term that may be
CE (Coded element)
constant over that
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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EthnicityGroup
2.16.840.1.113883.1.11.15
"A" Data Element (core
836
data exchanged with every
transition)
Code System(s):
Race and Ethnicity Code
Sets
2.16.840.1.113883.6.238
Clinical Example: Arabic
ValueSet
"A" Data Element (core
2.16.840.1.113883.1.11.11 data exchanged with every
526
transition)
Language Value Set
Clinical Example: of Asian
Pacific descent
"A" Data Element (core
data exchanged with every
transition)
ONC Standards and Interoperability (S&I) Framework
Culturally Sensitive Patient Care
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
patient's lifetime. The
coding of race is aligned
with public health and
other federal reporting
standards of the CDC and
the Census Bureau.
Typically the patient is the
source of the content of
this element. However, the
individual may opt to omit
race.
Examples and
Guidance
Value Set: Race
2.16.840.1.113883.1.11.14
914
Data Element Priority
Code System(s): Race and
Ethnicity - CDC
2.16.840.1.113883.6.238
Clinical Example: Catholic
Religion
Religious affiliation of the
patient
CE (Coded element)
Value Set: Religious
Affiliation
2.16.840.1.113883.1.11.19
"A" Data Element (core
185
data exchanged with every
transition)
Code System(s):
ReligiousAffiliation
2.16.840.1.113883.1.11.19
185
Demographics CEDD Object
Demographics CEDD Object
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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Examples and
Guidance
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Demographics CEDD Object
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Advanced Directive Type
Confidentiality Code
Consultation Summary ID
Demographics ID
Patient Identifiers
Primary Emergency
Contact Name
A unique identifier for the
Consultation Summary
A unique identified for the
Demographics CEDD
Object
II (Instance Identifier)
An identifier that uniquely
identifies the individual to
which the exchange refers
and connects that
document to the
individual's personal health
record. Potential security
risks associated with use of
SSN or driver's license for
this element suggest that
these should not be used
routinely
The name of the individual
or organization providing
support to the individual
for which this exchange is
produced
Primary Insurance Plan ID
Provider NPI
National Provider Identifier
or NPI is a unique
identification number
issued to healthcare
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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Examples and
Guidance
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Demographics CEDD Object
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
providers in the United
States
Accessible at:
Secondary Emergency
Contact Name
https://nppes.cms.hhs.gov
/NPPES/NPIRegistryHome.
do
The name of the individual
or organization providing
support to the individual
for which this exchange is
produced
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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Examples and
Guidance
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Patient Contact Information
Primary Care Physicians and Designated Providers
Patient Home Address: AD (Address)
Patient Home Phone: TN (Telephone Number)
Secondary Email Address: TN (Telephone Number)
Patient Work Phone: TN (Telephone Number)
Patient Cell Phone: TN (Telephone Number)
Primary Email Address: TN (Telephone Number)
Direct Address: TN (Telephone Number)
Patient Portal/PHR Available: BL (Boolean)
Patient Portal/PHR URL: TN (Telephone Number)
Patient Home Phone Text Message Enabled: BL (Boolean)
Patient Cell Phone Text Message Enabled: BL (Boolean)
Patient Work Phone Text Message Enabled: BL (Boolean)
Designated Providers Specialties: CF (Coded element with formatted values)
Designated Providers Names: PN (Person Name)
Designated Provider NPI: II (Instance Identifier)
Designated Provider Contact Information: XAD (Extended Address)
Designated Provider Domain of Management: CF (Coded element with formatted values)
Designated Provider PCMH: EN (Entity Name)
Culturally Sensitive Patient Care
Payer Information
D e mo g ra p hic s
Primary Payer Information: ED (Encapsulated Data)
Secondary Payer Information: ED (Encapsulated Data)
Race: CE (Coded element)
Ethnicity: CE (Coded element)
Religion: CE (Coded element)
Language: CE (Coded element)
Disability: CE (Coded element)
Educational Level: CE (Coded element)
ID: II (Instance Identifier)
Existence of Advanced Directives
Advanced Directives: BL (Boolean)
Support Contacts
Patient Information
Gender: CE (Coded element)
Patient Name: PN (Person Name)
Patient Identifiers: II (Instance Identifier)
Mothers Maiden Name: PN (Person Name)
Marital Status: CE (Coded element)
Date of Birth: DATE
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Primary Emergency Contact Name: PN (Person Name)
Primary Emergency Contact Relationship: CE (Coded element)
Primary Emergency Contact Information: AD (Address)
Secondary Emergency Contact Name: PN (Person Name)
Secondary Emergency Contact Relationship: CE (Coded element)
Secondary Emergency Contact Information: AD (Address)
ONC Standards and Interoperability (S&I) Framework
Diet
Diet
Name of Data Element
Nutrition Assessment
Definition of Data Element
ISO/HL7 Datatype
Food and Nutrition related
indicators which are used
to evaluate the nutritional
status of the patient. Five
general categories used to
evaluate and later assess
outcomes are:
 Food/Nutrition-Relat
ed History Outcomes
(Food & nutrient
intake, food &
CE (Coded Element)
nutrient
administration,
ED (Encapsulated Data)
medication/herbal
PQ (Physical Quantity)
supplement use,
knowledge/beliefs,
food & supplies
availability, physical
activity, nutrition
quality of life)
 Anthropometric
Measurement
Outcomes (height,
weight, body mass
index (BMI), growth
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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Examples and
Guidance
Clinical Examples:
Three-day food record
reflects patient has been
severely restricted in
protein/kcalorie intake.
Average intake was 1250
kcal, 30 grams protein.
BMI:22
Mid-arm muscle
circumference:
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Diet
Name of Data Element
Definition of Data Element



ISO/HL7 Datatype
pattern
indices/percentile
ranks, and weight
history)
Biochemical Data,
Medical Tests and
Procedures (Lab data
(e.g. electrolytes,
glucose) and tests
(e.g. gastric emptying
time, resting
metabolic rate)
Nutrition-Focused
Physical Finding
Outcomes (Physical
appearance, muscle
& fat wasting,
swallow function,
appetite and affect)
Client History
(Personal history,
medical/health/famil
y history, treatments
and
complementary/alter
native medicine use,
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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Examples and
Guidance
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Diet
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
and social history)
Nutrition Diagnosis
Nutrition Intervention
Identification and labeling
of a nutrition problem that
a food and nutrition
professional is responsible
for treating independently.
Typically includes three
categories:
1. Intake (too much or
too little of a food or
nutrient compared to
actual or estimated
needs.)
2. Clinical (nutrition
problems that relate
to medical or physical
conditions)
3. Behavioral-Environme
ntal (knowledge,
attitudes, beliefs,
physical environment,
access to food, or food
safety)
Purposefully planned
Clinical Examples:
Inadequate oral intake
related to intolerance as
evidenced by frequent
nausea and vomiting
prior to admission.
ED (Encapsulated Data) Altered nutrition-related
CE (Coded Element)
laboratory values related
(value set is all of the
to diabetes mellitus as
SNOMED-coded
evidenced by diabetic
interventions in the IDNT ketoacidosis.
list.
Biting/Chewing
(masticatory) difficulty
(SNOMED CT CID
175130015) related to
xerostomia as evidenced
by Speech Language
Pathologist evaluation.
CE (Coded Element)
(value set is all of the
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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Clinical Examples:
Enteral nutrition
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Diet
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
actions intended to
SNOMED-coded
positively change a
interventions in the IDNT
nutrition-related behavior, list.)
environmental condition,
or aspect of health status
for an individual (and his or
her family or caregivers),
target group, or the
community at large. A food
and nutrition professional
works in conjunction with
the patient/client(s) and
other health care
providers, programs, or
agencies during the
nutrition intervention
phase.
solution: 1 Kcal/cc
formula for 1600
Kcal/day
The patient’s individualized
recommended dietary
intake of energy and/or
selected foods or nutrients
based on current reference
standards and dietary
guidelines and the patient’s
health condition and
Clinical Examples:
Recommend Isosource
1.5 tube feeding per
small bowel feeding tube
at 70 ml per hour to
provide 2310 calories (27
Kcal/Kg), and 105 gm
protein (1.2 gm/Kg) per
Adaptive equipment for
feeding assistance.
Nutrition counseling
based on motivational
interviewing strategy.
Includes SNOMED Codes
(IDNT mapped to
SNOMED) and/or LOINC
1.
Nutrition Prescription
CE (Coded Element) or
CF (Coded Element with
formatted values)
or
PQ (Physical Quantity)
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Diet
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
nutrition diagnosis.
This includes the nutrition
recommendation by the
dietitian.
It may not be what the
patient currently
receives. The prescription
is different than the
Nutrition Intervention
because it is more
nutrient-based and
excludes things like
feeding, education,
counseling, coordination of
care.
Examples and
Guidance
day.
Recommend patient
consume 2000 calories,
80 grams protein per day
for optimal wound
healing.
Typically includes a PES
Statement:
Problem/Etiology/Sympt
oms
Patient Instructions
Directions to the patient
which have been agreed
upon between dietitian and ED (Encapsulated Data)
patient and conform to diet
order, goals and care plan.
PES Statement
(Problem/Etiology
Signs/Symptoms)
Problem or Nutrition
Diagnosis Label
(Describes alterations in
ED (Encapsulated Data)
CE (Coded Element)
(value set is all of the
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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Clinical Example:
Reduce intake of refined
carbohydrates, reduce
fat consumption &
increase omega-3 fatty
acid intake per written
guidance.
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Diet
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Examples and
Guidance
Data Element Priority
the patient’s nutritional
SNOMED-coded
status)
interventions in the IDNT
Etiology
list.
(Cause/Contributing factors
linked to the nutrition
diagnosis )
Signs/Symptoms (Data
used to determine that the
patient has the nutrition
diagnosis specified, linked
to etiology)
Diet Narrative
Diet Narrative
Name of Data Element
Diet Description
Definition of Data Element
ISO/HL7 Datatype
Examples:
General Healthful Diet;
or
“80 gm protein +
Consistent Carbohydrate
+ 2g sodium + 2g
potassium + 800-1000mg
Phosphorus + 1500 ml
Fluid Restricted “
Narrative description of
the recommended diet
or daily nutrient intake
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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B
ONC Standards and Interoperability (S&I) Framework
Diet Narrative
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Or Per IHE: LOINC
42344-2 Discharge Diet
Diet Type Code
(dietType)
NPO Flag
(isNPO)
A code that controls the
CE (Coded Element)
type of diet that a
patient should receive of
Note: Local codes only
follow, e.g., Cultural
at present
Preference,
Portion Size, Timing.
Indicator specifying that
patient should not
receive food or drink.
NPO (nil per os) or NBM
(nothing by mouth) is a
medical order to
withhold food and
liquids
E.g., DASH (Dietary
Approaches to Stop
Hypertension), Kosher,
Vegan, 6 Small Meals
B
Patient test home and
told to return tomorrow
for a surgical procedure
or test may be instructed
not to eat or drink
anything after midnight.
BL (Boolean)
B
E.g., NPO (nil per os) or
NBM (nothing by mouth)
is a diet type code for a
medical order to
withhold food and
liquids
Discharge Instructions CEDD Object
Discharge Instructions CEDD Object
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
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Examples and
Guidance
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Discharge Instructions CEDD Object
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Active Allergy List ID
A list of clinically relevant
medications, including:
Active Medication List ID
PRN Medication List
Active Medications (Held
for Period of Time)
LIST (Sequence)
Medications that patient
was exposed to, now
discontinued, but still
clinically relevant
Software need – document
the delta
"A" Data Element (core
data exchanged with every
transition)
Active Problem List ID
Advanced Directive Type
Discharge Instructions ID
A unique identifier for the
Discharge Instructions
II (Instance Identifier)
Discharge Summary CEDD Object
Discharge Summary CEDD Object
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Active Allergy List ID
A list of clinically relevant
medications, including:
Active Medication List ID
LIST (Sequence)
PRN Medication List
Active Medications (Held
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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"A" Data Element (core
data exchanged with every
transition)
ONC Standards and Interoperability (S&I) Framework
Discharge Summary CEDD Object
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Examples and
Guidance
Data Element Priority
Examples and
Guidance
Data Element Priority
for Period of Time)
Medications that patient
was exposed to, now
discontinued, but still
clinically relevant
Software need – document
the delta
Active Problem List ID
Advanced Directive Type
Discharge Summary ID
A unique identifier for the
Discharge Summary
II (Instance Identifier)
Discontinued Medications
Discontinued Medications
Name of Data Element
Definition of Data Element
Discontinued Medication
List ID
List of Discontinued
Medications
List of discontinued
medications
ISO/HL7 Datatype
LIST (Sequence)
Encounter History
Encounter History
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Class of Facility
Class of Patient
Date and Time of Arrival
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ONC Standards and Interoperability (S&I) Framework
Encounter History
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Disposition at Discharge
Encounter ID
Encounter Type
Encounter Attributes
Encounter Provider
Reason for Admission
Source of Admission
Type of Admission
Equipment
Equipment
Name of Data Element
Equipment Code
Equipment Date Acquired
Equipment Date Disposed
Equipment ID
CK (Composite ID with
check digit)
Source: Federal Health
Information Model (FHIM) Durable Medical
Equipment
The moniker, version and
release of the software
that operates the device as CK (Composite ID with
Equipment Software Name
assigned by the software
check digit)
manufacturer or
developer.
Source: Federal Health
Information Model (FHIM) Durable Medical
Equipment
Equipment Model Name
The human designated
moniker for a device,
assigned by the
manufacturer
Equipment Owner
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ONC Standards and Interoperability (S&I) Framework
Equipment
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Equipment Software
Version
Equipment Status
Quantity
Existence of Advanced Directives
Existence of Advanced Directives
Name of Data Element
Definition of Data Element
Advanced Directive
Existence
This is a coded value
BL (Boolean)
describing the type of the
Advance Directive.
Specifically asks: Has an
Advanced Directive has
been signed by the patient,
and is contained in records.
"A" Data Element (core
data exchanged with every
transition)
Advance Directive Owner
Advance Directive Range
Advance Directive Type
Facility
Facility
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Class of Facility
Facility ID
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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Examples and
Guidance
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Facility
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Facility Name
Family History
Family History
Name of Data Element
Family History Summary
Textual description about
the problems, diagnoses,
and genetic markers found
in genetic relatives. This
HIST (History)
field may be used to
capture unstructured
family history information
recorded in clinical records.
Family History Survey
Question
Family History Survey
Response
Structure
Structure
Description of risk-related
Genetic Marker Description genetic markers identified
in this individual.
Genetic Relative Age
Genetic Relative Age at
Birth
Genetic Relative Age at
Clinical Example:
Patient has had individual
genome analysis that
revealed a genetic marker
clearly established to
represent an increased risk
of breast cancer
Structure
INT (Integer)
INT (Integer)
Age of the genetic relative
INT (Integer)
Clinical Example: deceased
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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ONC Standards and Interoperability (S&I) Framework
Family History
Name of Data Element
Death
Genetic Relative Cause of
Death
Genetic Relative Date of
Birth
Genetic Relative Ethnicity
Genetic Relative Gender
Genetic Relative Medical
History
Genetic Relative Name
Definition of Data Element
ISO/HL7 Datatype
at death.
Examples and
Guidance
Data Element Priority
age 45
DATE
Details about problems or
diagnoses for this genetic
Structure
relative.
Name of family member.
For privacy reasons this
may not be appropriate for
PN
sharing or public display
and in this situation the
'label' should be used.
Clinical Example: Type II
Diabetes
Genetic Relative Race
Genetic Relative
Relationship
The relationship of the
genetic relative to the
individual. Coding of the
relationship with a
terminology is preferred,
where possible.
CE (Coded element)
Clinical Example: Mother
Follow-Up Appointments
Follow-Up Appointments
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Appointment Details
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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Examples and
Guidance
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Follow-Up Appointments
Name of Data Element
Definition of Data Element
Appointment ID
Scheduled Date of
Appointment
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Examples and
Guidance
Data Element Priority
DATE
General Results
General Results
Name of Data Element
Definition of Data Element
Date Results Obtained
Reference Range for Result
Result Assessment
Result Attributes
Result ID
Type of Result
ISO/HL7 Datatype
DATE
Goals
Goals
Name of Data Element
Author
Actual Outcome
Definition of Data Element
ISO/HL7 Datatype
The person who originates,
writes, the goal.
What actually happens.
Quantifiable measureable
finding, observation or
Examples and
Guidance
Nurse, PT, patient, MD.
The MD writes goal for
patient to ambulate.
Patient Ambulated 15 feet.
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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Data Element Priority
“B”
“B”
ONC Standards and Interoperability (S&I) Framework
Goals
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
result
Desired Outcome
What is expected to
happen. Quantifiable
measurable description
added to Goal description.
Ambulate 20 feet.
“B”
Goal agreed to by
Any person who agrees to
supporting the goal
Nurse, PT, patient, MD,
Patient agrees to goal of
walking 20 feet.
“B”
Goal Category
The goal type
Activity, Diet, medication,
learning etc.
Saba care
components.
“B”
Goal Description
The human readable text
describing what is expected
to happen
Patient will ambulate
“B”
Goal established date/time Date and time goal is
entered/identified
Need example
“B”
Goal ID
A unique identifier for the
Goal
SNOMED CT,
“B”
The overarching outcome
targeted
Patient will return to
baseline status of full free
unlimited ambulation state
Goal Intent
(CDA) Moodcode = GOL
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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“B”
ONC Standards and Interoperability (S&I) Framework
Goals
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
as prior to admission
Data Element Priority
Goal Priority
The ranking of the goal
compared to other goals
1, 2, 3, etc…
“B”
Goal refined/edited by
Any person who edits or
refines the goal
PT refines goal to patient
will ambulate 20 feet
“B”
Goal reviewed
by/acknowledged
Any person who reviews
the goal
Nurse reviews goal of
patient’s ambulation goal
as set and refined by MD
and PT
“B”
The goal is Met, not met, in
progress, or on hold.
“B”
Need example
“B”
Goal Status
Goal Target Date/Time
The particular stage within the defined goal
process (based on QDM/NQF status definition
draft October 2011)
 The date and time when
the measurement should
be taken, goal should be
reached.
 May be specific end date,
or may have a range date
(beginning and end)
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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ONC Standards and Interoperability (S&I) Framework
Health Literacy
Health Literacy
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Definition of Data Element
ISO/HL7 Datatype
Health Literacy Score
Methodology Used for
Health Literacy
Source of Health Literacy
Score
Health Maintenance
Health Maintenance
Name of Data Element
History of Present Illness
History of Present Illness
Name of Data Element
Medical Diagnosis
HIST (History)
Examples and
Guidance
Clinical Example: e.g.
Congestive Heart Failure
Data Element Priority
Examples and
Guidance
Clinical Example: Severe
skin rubor, calor, and
Data Element Priority
Immunization History
Immunization History
Name of Data Element
Contraindication
Definition of Data Element
Contraindication is the
indicator if this
ISO/HL7 Datatype
BOOLEAN
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
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ONC Standards and Interoperability (S&I) Framework
Immunization History
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
immunization should be
continued or should be
stopped due to an adverse
reaction being observed.
Examples and
Guidance
edema
Immunization Attributes
Category of Immunization
Date Immunization
Delivered
Immunization History ID
What the immunization is
for
The date and time the
immunization was given.
Unique id given to the
immunization test
CK (Composite ID with
check digit)
Clinical Example: Pertussis
DATE
II (Instance Identifier)
Immunization Lot ID
Immunization Series
Observed Reaction
Indicates which type of
series the patient has been
given. Current valid values CK (Composite ID with
are Series 1 through 8,
check digit)
Partially complete, booster,
or complete
The response of cells or
tissues to an antigen, as in
a test for immunization
COLL (Collection)
Reason for Administration
Refusal
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
84
Clinical Example: The
observed response to an
antigen which would
normally be a description
of skin reaction including
size and time since test was
applied, as in a test for
immunization to be given
or for tuberculosis
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Invasive and Non-Invasive Procedures
Invasive and Non-Invasive Procedures
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Examples and
Guidance
Data Element Priority
Entity Performing
Procedure
Invasiveness of Procedure
Procedure ID
Unique identifier for the
procedure
Procedure Narrative
Site of Procedure
Type of Procedure
Performed
Medical History
Medical History
Name of Data Element
Definition of Data Element
Medical History Narrative
ED (Encapsulated Data)
Medication History
Medication History
Name of Data Element
Definition of Data Element
Medication History
Narrative
ISO/HL7 Datatype
HIST (History)
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
85
ONC Standards and Interoperability (S&I) Framework
Operative Summary
Operative Summary
Name of Data Element
Definition of Data Element
Operative Summary
Narrative
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
HIST (History)
Outcome of Allergy/Intolerance
Outcome of Allergy/Intolerance
Name of Data Element
Definition of Data Element
Patient Consent Directive
Patient Consent Directive
Name of Data Element
Definition of Data Element
Patient Contact Information
Patient Contact Information
Name of Data Element
Definition of Data Element
Direct Address
The electronic endpoint
address of the patient
TN (Telephone Number)
Patient Cell Phone
A telephone number
(mobile)
TN (Telephone Number)
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
86
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
transition)
ONC Standards and Interoperability (S&I) Framework
Patient Contact Information
Name of Data Element
Definition of Data Element
Patient Cell Phone Text
Message Enabled
Patient Direct-Enabled
Address
Is text messaging enabled
on the patient's cell
phone?
The electronic endpoint
address of the patient
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
"A" Data Element (core
data exchanged with every
transition)
BL (Boolean)
Value Set: State Value Set
2.16.840.1.113883.3.88.12.
80.1
Code System(s): FIPS 5-2
(State)
2.16.840.1.113883.6.92
Patient Home Address
The current address of the
individual to which the
exchange refers. Multiple
addresses are allowed and
the work address may be a
method of disclosing the
employer
AD (Address)
Value Set: Postal Code
Value Set
2.16.840.1.113883.3.88.12.
80.2
"A" Data Element (core
data exchanged with every
Code System(s): US Postal transition)
Codes
Value Set: Country Value
Set
2.16.840.1.113883.3.88.12.
80.63
Code System(s): ISO 3166-1
Country Codes: 1.0.3166.1
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
87
ONC Standards and Interoperability (S&I) Framework
Patient Contact Information
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Patient Home Phone
A telephone number (voice
TN (Telephone Number)
or fax),
Patient Home Phone Text
Message Enabled
Is text messaging enabled
on the patient's home
phone?
BL (Boolean)
Patient Portal/PHR
Available
Is a patient portal or PHR
available?
BL (Boolean)
Patient Portal/PHR URL
The URL of the patient
portal or URI of the PHR
TN (Telephone Number)
Patient Work Phone
A telephone number (voice
TN (Telephone Number)
or fax),
Patient Work Phone Text
Message Enabled
Is text messaging enabled
on the patient's work
phone?
BL (Boolean)
Primary Email Address
Primary email address for
the patient
TN (Telephone Number)
Secondary Email Address
Secondary email address
for the patient (may be a
work-related email
address)
TN (Telephone Number)
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
88
Examples and
Guidance
Data Element Priority
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
transition)
ONC Standards and Interoperability (S&I) Framework
Patient Information
Patient Information
Name of Data Element
Mothers Maiden Name
Patient Date of Birth
Patient Gender
Patient Identifiers
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
"A" Data Element (core
data exchanged with every
transition)
The family name under
PN (Person Name)
which the Mother was born
The date and time of birth
of the individual to which
this Exchange refers. The
date of birth is typically a
key patient identifier
variable and used to enable
DATE
computation of age at the
effective date of any other
data element. It is assumed
to be unique and fixed
throughout the patient's
lifetime
The date and time of birth
of the individual to which
this Exchange refers. The
date of birth is typically a
key patient identifier
variable and used to enable
CE (Coded element)
computation of age at the
effective date of any other
data element. It is assumed
to be unique and fixed
throughout the patient's
lifetime
An identifier that uniquely
II (Instance Identifier)
identifies the individual to
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
89
Data Element Priority
"A" Data Element (core
Should include Month, Day,
data exchanged with every
Year
transition)
Value Set: Administrative
Gender (HL7 V3)
2.16.840.1.113883.1.11.1
Code System(s):
AdministrativeGender
2.16.840.1.113883.5.1
"A" Data Element (core
data exchanged with every
transition)
Everything currently legally "A" Data Element (core
used in an MPI algorithm, data exchanged with every
ONC Standards and Interoperability (S&I) Framework
Patient Information
Name of Data Element
Patient Marital Status
Definition of Data Element
ISO/HL7 Datatype
which the exchange refers
and connects that
document to the
individual's personal health
record. Potential security
risks associated with use of
SSN or driver's license for
this element suggest that
these should not be used
routinely
A value representing the
domestic partnership
status of a person. Marital
status is important in
determining insurance
eligibility and other legal
arrangements surrounding
care. Marital status often
changes during a patient's
lifetime so the data should
CE (Coded element)
relate to the effective date
of the patient data object
and not be entered with
multiple values like an
address or contact number.
This element should only
have one instance
reflecting the current
status of the individual at
the time the Exchange is
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
90
Examples and
Data Element Priority
Guidance
e.g. Reconciling and
transition)
Managing EMPI and AHIMA
reference documentation
Value Set: HL7 Marital
Status
2.16.840.1.113883.1.11.12
212
Code System(s): HL7
MaritalStatus
2.16.840.1.113883.5.2
Values include: Married
Polygamous; Civil Union;
Single; Divorced; Widowed
"A" Data Element (core
data exchanged with every
transition)
ONC Standards and Interoperability (S&I) Framework
Patient Information
Name of Data Element
Patient Name
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
produced. Former values
might be part of the
personal and social history
The individual to whom the
exchange refers. Multiple
names are allowed to
PN (Person Name)
retain birth name, maiden
name, legal names and
aliases as required
Data Element Priority
"A" Data Element (core
data exchanged with every
transition)
Patient Instructions
Patient Instructions
Name of Data Element
Definition of Data Element
Patient Instructions
Narrative
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Examples and
Guidance
Data Element Priority
ED (Encapsulated Data)
Patient Self-Management
Patient Self-Management
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
91
ONC Standards and Interoperability (S&I) Framework
Payer Information
Payer Information
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Insurance Source Address
Insurance Source Email
Insurance Source Phone
Insurance Source URL
Insurance Type
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
transition)
Primary Insurance Plan ID
Secondary Insurance Plan
ID
Subscriber ID
Pending Tests and Procedures
Pending Tests and Procedures
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Assigned Entity
Context of Test/Procedure
Test/Procedure ID
Test/Procedure Status
Physical Activity
Physical Activity
Name of Data Element
Definition of Data Element
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
92
ONC Standards and Interoperability (S&I) Framework
Physical Activity
Name of Data Element
Activity Motivation
Exercise Vital Sign (EVS)
Definition of Data Element
ISO/HL7 Datatype
Patient’s perception and/or
willingness that they need
to increase their exercise
intervals, intensity or total
weekly commitment to
physical activity.
Examples and
Guidance
Example: “Yes, I need to
increase my
activity/exercise”
Answer: Yes/No/Unsure
A computable value which
translates into
“minutes/week” of physical
activity.
Example:
1. Patient states they
typically exercise 4
days/week. (Answer
range is 0-7)
2. Patient states they
typically walk 15
minutes/day.
“1. How many days a week
of moderate to strenuous
exercise, like a brisk walk,
do you typically do?”
EHR Calculates: days x
minutes/day =
minutes/week.
2. On those days that you
engage in moderate to
strenuous exercise, how
many minutes, on average,
do you exercise at this
level?
<150 minutes/week
(Adults) or
<420 minutes/week
(Children)
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
93
Data Element Priority
"C" Data Element (data
dependent on transition of
care)
"C" Data Element (data
dependent on transition of
care)
ONC Standards and Interoperability (S&I) Framework
Physical Activity
Name of Data Element
Physical Activity
Assessment
Definition of Data Element
ISO/HL7 Datatype
A physical activity
assessment is an evaluation
of a person's body
movement that works
muscles and uses more
energy than when at rest
or that enhances or
maintains physical fitness
and overall health.
Assessment can be
completed in terms of
frequency, duration,
intensity, and type of
activity using objective
(e.g., accelerometer) or
self-reported measures.
Examples and
Guidance
is criteria for referral for
physical activity/exercise
referral.
Data Element Priority
Assessment Example:
"C" Data Element (data
dependent on transition of
self-reported measures
using the Exercise Vital Sign care)
(EVS).
Can include additional data
elements based upon
clinician entered or
machine readable
assessment parameters.
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
94
ONC Standards and Interoperability (S&I) Framework
Physical Exam
Physical Exam
Name of Data Element
Definition of Data Element
Physical Exam Component
Physical Exam Narrative
Physical Exam Observation
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Examples and
Guidance
Data Element Priority
Structure
HIST (History)
Structure
Primary Care and Designated Providers
Primary Care and Designated Providers
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Provider Designation
Provider Domain of
Management
Provider Fax Number
Provider Name
Provider role uses a coded
value to classify providers
according to the role they
play in the healthcare of
the patient and comes
from a very limited set of
values. The purpose of this
data element is to express CF (Coded element with
the information often
formatted values)
required during patient
registration, identifying the
patient's primary care
provider, the referring
physician or other
consultant involved in the
care of the patient
"A" Data Element (core
data exchanged with every
transition)
The name of the provider
"A" Data Element (core
PN (Person Name)
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
95
ONC Standards and Interoperability (S&I) Framework
Primary Care and Designated Providers
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
data exchanged with every
transition)
Provider NPI
National Provider Identifier
or NPI is a unique
identification number
issued to healthcare
providers in the United
States
II (Instance Identifier)
Accessible at:
Provider PCMH
https://nppes.cms.hhs.gov/
NPPES/NPIRegistryHome.d
o
The identifier used by this
provider to identify the
EN (Entity Name)
patient's PCMH
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
transition)
Provider Phone Number
Provider Portal URL
Provider Primary Address
The mailing address to
which written
XAD (Extended Address)
correspondence to this
provider should be directed
"A" Data Element (core
data exchanged with every
transition)
Provider Primary Email
Address
Provider Secondary
Address
Provider Specialties
Provider type classifies
providers according to the
type of license or
CF (Coded element with
formatted values)
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
96
Value Set: Provider Type
"A" Data Element (core
2.16.840.1.113883.3.88.12. data exchanged with every
3221.4
transition)
ONC Standards and Interoperability (S&I) Framework
Primary Care and Designated Providers
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
accreditation they hold
(e.g. physician, dentist,
pharmacist, etc.) or the
service they provide
Examples and
Guidance
Data Element Priority
Code System(s): Health
Care Provider Taxonomy
2.16.840.1.113883.6.101
Reason for Consult Request
Reason for Consult Request
Name of Data Element
Definition of Data Element
Provisional Diagnosis
Request Reason
Requested Procedure
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
ED (Encapsulated Data)
Reason for
consult/procedure request
A procedure that is
requested as part of this
order.
CE (Coded element)
"A" Data Element
CE (Coded element)
Restorative Care
Restorative Care
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Restorative Care Narrative
Review of Systems
Review of Systems
Name of Data Element
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
97
ONC Standards and Interoperability (S&I) Framework
Review of Systems
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Examples and
Guidance
Data Element Priority
Systems Review Attributes
Systems Review Narrative
Social Determinants of Health
Social Determinants of Health
Name of Data Element
Definition of Data Element
Social Determinant
Attributes
Social Determinant
Narrative
Social Determinant Source
ED (Encapsulated Data)
Social History
Social History
Name of Data Element
Social History Additional
Details
Social History Attributes
Social History Range
Social History Type
Definition of Data Element
ISO/HL7 Datatype
Additional structured
details
HIST (History)
Narrative description of
social situation. This data
element may be used to
capture textual
descriptions about Social
History within existing
clinical software
HIST (History)
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
98
ONC Standards and Interoperability (S&I) Framework
Social History
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
applications.
Support Contacts
Support Contacts
Name of Data Element
Definition of Data Element
Contact Type
The address of the contact
individual or organization
Primary Emergency Contact
providing support to the
Address
individual for which this
exchange is produced
The name of the individual
or organization providing
Primary Emergency Contact
support to the individual
Name
for which this exchange is
produced
Primary Emergency Contact
Phone
AD (Address)
"A" Data Element (core
data exchanged with every
transition)
PN (Person Name)
"A" Data Element (core
data exchanged with every
transition)
Identifies the relationship
Primary Emergency Contact of the contact person to
Relationship
the individual for which
this exchange refers
CE (Coded element)
Secondary Emergency
Contact Address
AD (Address)
The address of the contact
individual or organization
Value Set: Personal
Relationship Role Type
2.16.840.1.113883.1.11.19
563
Code System(s): Role Code
2.16.840.1.113883.5.111
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
99
"A" Data Element (core
data exchanged with every
transition)
"A" Data Element (core
data exchanged with every
ONC Standards and Interoperability (S&I) Framework
Support Contacts
Name of Data Element
Secondary Emergency
Contact Name
Definition of Data Element
providing support to the
individual for which this
exchange is produced
The name of the individual
or organization providing
support to the individual
for which this exchange is
produced
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
transition)
"A" Data Element (core
data exchanged with every
transition)
PN (Person Name)
Secondary Emergency
Contact Phone
Secondary Emergency
Contact Relationship
Identifies the relationship
of the contact person to
the individual for which
this exchange refers
CE (Coded element)
Value Set: Personal
Relationship Role Type
2.16.840.1.113883.1.11.19
563
"A" Data Element (core
data exchanged with every
transition)
Code System(s): Role Code
2.16.840.1.113883.5.111
Surgical/Procedure History
Surgical/Procedure History
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
External Reference ID
Surgical History ID
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
100
Examples and
Guidance
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Transitions of Care Summary CEDD Object
S&I Framework Summary CEDD Object
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
Data Element Priority
Active Allergy List ID
A list of clinically relevant
medications, including:
Active Medication List ID
Active Problem List ID
Discontinued Medication
ID
Demographics ID
PRN Medication List
Active Medications (Held
for Period of Time)
LIST (Sequence)
Medications that patient
was exposed to, now
discontinued, but still
clinically relevant
Software need – document
the delta
List of discontinued
medications
A unique identified for the
LIST (Sequence)
Demographics CEDD Object
Diagnosis List ID
Goals ID
Transitions of Care
Summary ID
"A" Data Element (core
data exchanged with every
transition)
A unique identifier for the
summary entity that may
contain one or more of the
other entities defined in
II (Instance Identifier)
the Transitions of Care
Clinical Element Data
Dictionary (CEDD)
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
101
"A" Data Element (core
data exchanged with every
transition)
ONC Standards and Interoperability (S&I) Framework
Vital Signs
Vital Signs
Name of Data Element
Body Site
Device
Observation List
Observation Method
Observation Range
Observation Time
Definition of Data Element
ISO/HL7 Datatype
Indicates the anatomical
site - intended to be
specified as left arm, right
arm, left leg, etc. May
also indicate whether
patient is sitting, standing,
supine.
CHAR(18)
Identifies the device used
to measure the vital sign.
VARCHAR()
Indicates which Vital Sign
was measured. From a
code set of allowable Vital
Sign codes.
A code that provides
additional detail about the
means or technique used
to ascertain the
observation.
The date/time on which
Examples and
Guidance
Value Set: Body Site Value
Set
2.16.840.1.113883.3.88.12.
3221.8.9
Code System(s): SNOMED
CT 2.16.840.1.113883.6.96
This would include cuff size
for blood pressure, which is
critical for sake of
comparison or
interpretation. A blood
pressure cuff should be 2/3
size of upper arm, which in
some individuals requires a
"leg cuff". Using a cuff
that is too small causes an
erroneously high reading.
CK (Composite ID with
check digit)
CK (Composite ID with
check digit)
DATE
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
102
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Vital Signs
Name of Data Element
Definition of Data Element
ISO/HL7 Datatype
Examples and
Guidance
the measurement was
taken.
Patient State
Status
Telehealth Monitor
Vital Sign ID
Provides an indication of
the state of the patient at
the time of the
observation. For example,
a blood pressure may be
taken while the patient is
exercising or at rest.
Standing blood pressure
can be significantly
different from supine and
may, for example be an
indication of a medication
side effect as some blood
pressure medications can
cause a dangerous drop in
blood pressure on standing
which could cause falls and
injury.
VARCHAR()
Indicates the status of the
Vital Signs measurement
VARCHAR()
record
The Home TeleHealth
Monitor Equipment used
VARCHAR()
by the patient.
Uniquely identifies the Vital
INTEGER
Signs measurement.
Vital Sign Type
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
103
Data Element Priority
ONC Standards and Interoperability (S&I) Framework
Culturally Sensitive Patient Care
Existence of Advanced Directives
Advanced Directives: BL (Boolean)
Payer Information
Race: CE (Coded element)
Ethnicity: CE (Coded element)
Religion: CE (Coded element)
Language: CE (Coded element)
Disability: CE (Coded element)
Educational Level: CE (Coded element)
Active Medication List
Primary Payer Information: ED (Encapsulated Data)
Secondary Payer Information: ED (Encapsulated Data)
Support Contacts
Primary Emergency Contact Name: PN (Person Name)
Primary Emergency Contact Relationship: CE (Coded element)
Primary Emergency Contact Information: AD (Address)
Secondary Emergency Contact Name: PN (Person Name)
Secondary Emergency Contact Relationship: CE (Coded element)
Secondary Emergency Contact Information: AD (Address)
Co ns ulta tio n R e q ue s t inc lud ing Clinic a l S umma ry
Patient Contact Information
Consultation Request ID: II (Instance Identifier)
Active Medication List: LIST (Sequence)
Date Of Reconciliation: DATE
Status of Reconciliation: CE (Coded element)
Reconciled By: EN (Entity Name)
Discontinued Medications: CE (Coded element)
Changed Medications: CE (Coded element)
Medication Code: CE (Coded element)
Dose: PQ
Frequency: IVL_TS
When to Take: IVL_TS
Duration: IVL (Interval)
Route: CE (Coded element)
Patient Instructions: ED (Encapsulated Data)
Start Date: DATE
Stop Date: DATE
Prescriber: EN (Entity Name)
Associated Assessment: BAG (Bag)
Allergies and Intolerances
Patient Home Address: AD (Address)
Patient Home Phone: TN (Telephone Number)
Secondary Email Address: TN (Telephone Number)
Patient Work Phone: TN (Telephone Number)
Patient Cell Phone: TN (Telephone Number)
Primary Email Address: TN (Telephone Number)
Direct Address: TN (Telephone Number)
Patient Portal/PHR Available: BL (Boolean)
Patient Portal/PHR URL: TN (Telephone Number)
Patient Home Phone Text Message Enabled: BL (Boolean)
Patient Cell Phone Text Message Enabled: BL (Boolean)
Patient Work Phone Text Message Enabled: BL (Boolean)
Medication Intolerance: ED (Encapsulated Data)
All Environmental Allergens: CE (Coded element)
All Food Allergens: CE (Coded element)
Reaction Attributes: ED (Encapsulated Data)
Reaction Date: TIMESTAMP()
Severity of Intolerance or Allergy: CE (Coded element)
Reaction Identified By: EN (Entity Name)
A/I Attributes: ED (Encapsulated Data)
List of Reactions: LIST (Sequence)
Patient Information
Primary Care Physicians and Designated Providers
Active Problem List
Discontinued Medications
Designated
Designated
Designated
Designated
Designated
Designated
Providers Specialties: CF (Coded element with formatted values)
Providers Names: PN (Person Name)
Provider NPI: II (Instance Identifier)
Provider Contact Information: XAD (Extended Address)
Provider Domain of Management: CF (Coded element with formatted values)
Provider PCMH: EN (Entity Name)
Discontinued Medication List: LIST (Sequence)
Transitions of Care Clinical Element Data Dictionary (CEDD) Workgroup
104
Gender: CE (Coded element)
Patient Name: PN (Person Name)
Patient Identifiers: II (Instance Identifier)
Mothers Maiden Name: PN (Person Name)
Marital Status: CE (Coded element)
Date of Birth: DATE
Start Date Of Problem: DATE
Problem Assignee: EN (Entity Name)
Active Codes: CS (Coded Simple Value)
Reconciliation Status: CE (Coded element)
Reconciliation Date: DATE
Reconciled By: EN (Entity Name)
ONC Standards and Interoperability (S&I) Framework
Patient Contact Information
Culturally Sensitive Patient Care
Existence of Advanced Directives
Advanced Directives: BL (Boolean)
Race: CE (Coded element)
Ethnicity: CE (Coded element)
Religion: CE (Coded element)
Language: CE (Coded element)
Disability: CE (Coded element)
Educational Level: CE (Coded element)
Patient Home Address: AD (Address)
Patient Home Phone: TN (Telephone Number)
Secondary Email Address: TN (Telephone Number)
Patient Work Phone: TN (Telephone Number)
Patient Cell Phone: TN (Telephone Number)
Primary Email Address: TN (Telephone Number)
Direct Address: TN (Telephone Number)
Patient Portal/PHR Available: BL (Boolean)
Patient Portal/PHR URL: TN (Telephone Number)
Patient Home Phone Text Message Enabled: BL (Boolean)
Patient Cell Phone Text Message Enabled: BL (Boolean)
Patient Work Phone Text Message Enabled: BL (Boolean)
Support Contacts
Primary Emergency Contact Name: PN (Person Name)
Primary Emergency Contact Relationship: CE (Coded element)
Primary Emergency Contact Information: AD (Address)
Secondary Emergency Contact Name: PN (Person Name)
Secondary Emergency Contact Relationship: CE (Coded element)
Secondary Emergency Contact Information: AD (Address)
Co ns ulta tio n Summa ry
Consultation Summary ID: II (Instance Identifier)
Active Medication List
Active Medication List: LIST (Sequence)
Date Of Reconciliation: DATE
Status of Reconciliation: CE (Coded element)
Reconciled By: EN (Entity Name)
Discontinued Medications: CE (Coded element)
Changed Medications: CE (Coded element)
Medication Code: CE (Coded element)
Dose: PQ
Frequency: IVL_TS
When to Take: IVL_TS
Duration: IVL (Interval)
Route: CE (Coded element)
Patient Instructions: ED (Encapsulated Data)
Start Date: DATE
Stop Date: DATE
Prescriber: EN (Entity Name)
Associated Assessment: BAG (Bag)
Allergies and Intolerances
Medication Intolerance: ED (Encapsulated Data)
All Environmental Allergens: CE (Coded element)
All Food Allergens: CE (Coded element)
Reaction Attributes: ED (Encapsulated Data)
Reaction Date: TIMESTAMP()
Severity of Intolerance or Allergy: CE (Coded element)
Reaction Identified By: EN (Entity Name)
A/I Attributes: ED (Encapsulated Data)
List of Reactions: LIST (Sequence)
Patient Information
Gender: CE (Coded element)
Patient Name: PN (Person Name)
Patient Identifiers: II (Instance Identifier)
Mothers Maiden Name: PN (Person Name)
Marital Status: CE (Coded element)
Date of Birth: DATE
Primary Care Physicians and Designated Providers
Active Problem List
Payer Information
Designated Providers Specialties: CF (Coded element with formatted values)
Designated Providers Names: PN (Person Name)
Designated Provider NPI: II (Instance Identifier)
Designated Provider Contact Information: XAD (Extended Address)
Designated Provider Domain of Management: CF (Coded element with formatted values)
Designated Provider PCMH: EN (Entity Name)
Start Date Of Problem: DATE
Problem Assignee: EN (Entity Name)
Active Codes: CS (Coded Simple Value)
Reconciliation Status: CE (Coded element)
Reconciliation Date: DATE
Reconciled By: EN (Entity Name)
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Primary Payer Information: ED (Encapsulated Data)
Secondary Payer Information: ED (Encapsulated Data)
ONC Standards and Interoperability (S&I) Framework
Patient Contact Information
Primary Care Physicians and Designated Providers
Patient Home Address: AD (Address)
Patient Home Phone: TN (Telephone Number)
Secondary Email Address: TN (Telephone Number)
Patient Work Phone: TN (Telephone Number)
Patient Cell Phone: TN (Telephone Number)
Primary Email Address: TN (Telephone Number)
Direct Address: TN (Telephone Number)
Patient Portal/PHR Available: BL (Boolean)
Patient Portal/PHR URL: TN (Telephone Number)
Patient Home Phone Text Message Enabled: BL (Boolean)
Patient Cell Phone Text Message Enabled: BL (Boolean)
Patient Work Phone Text Message Enabled: BL (Boolean)
Designated Providers Specialties: CF (Coded element with formatted values)
Designated Providers Names: PN (Person Name)
Designated Provider NPI: II (Instance Identifier)
Designated Provider Contact Information: XAD (Extended Address)
Designated Provider Domain of Management: CF (Coded element with formatted values)
Designated Provider PCMH: EN (Entity Name)
Culturally Sensitive Patient Care
Payer Information
D e mo g ra p hic s
Primary Payer Information: ED (Encapsulated Data)
Secondary Payer Information: ED (Encapsulated Data)
Race: CE (Coded element)
Ethnicity: CE (Coded element)
Religion: CE (Coded element)
Language: CE (Coded element)
Disability: CE (Coded element)
Educational Level: CE (Coded element)
ID: II (Instance Identifier)
Existence of Advanced Directives
Advanced Directives: BL (Boolean)
Support Contacts
Patient Information
Gender: CE (Coded element)
Patient Name: PN (Person Name)
Patient Identifiers: II (Instance Identifier)
Mothers Maiden Name: PN (Person Name)
Marital Status: CE (Coded element)
Date of Birth: DATE
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Primary Emergency Contact Name: PN (Person Name)
Primary Emergency Contact Relationship: CE (Coded element)
Primary Emergency Contact Information: AD (Address)
Secondary Emergency Contact Name: PN (Person Name)
Secondary Emergency Contact Relationship: CE (Coded element)
Secondary Emergency Contact Information: AD (Address)
ONC Standards and Interoperability (S&I) Framework
Active Medication List
Active Medication List: LIST (Sequence)
Date Of Reconciliation: DATE
Status of Reconciliation: CE (Coded element)
Reconciled By: EN (Entity Name)
Discontinued Medications: CE (Coded element)
Changed Medications: CE (Coded element)
Medication Code: CE (Coded element)
Dose: PQ
Frequency: IVL_TS
When to Take: IVL_TS
Duration: IVL (Interval)
Route: CE (Coded element)
Patient Instructions: ED (Encapsulated Data)
Start Date: DATE
Stop Date: DATE
Prescriber: EN (Entity Name)
Associated Assessment: BAG (Bag)
Existence of Advanced Directives
Advanced Directives: BL (Boolean)
D is c ha rg e Ins truc tio ns
Discharge Instructions ID: II (Instance Identifier)
Allergies and Intolerances
Active Problem List
Start Date Of Problem: DATE
Problem Assignee: EN (Entity Name)
Active Codes: CS (Coded Simple Value)
Reconciliation Status: CE (Coded element)
Reconciliation Date: DATE
Reconciled By: EN (Entity Name)
Medication Intolerance: ED (Encapsulated Data)
All Environmental Allergens: CE (Coded element)
All Food Allergens: CE (Coded element)
Reaction Attributes: ED (Encapsulated Data)
Reaction Date: TIMESTAMP()
Severity of Intolerance or Allergy: CE (Coded element)
Reaction Identified By: EN (Entity Name)
A/I Attributes: ED (Encapsulated Data)
List of Reactions: LIST (Sequence)
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ONC Standards and Interoperability (S&I) Framework
Active Medication List
Active Medication List: LIST (Sequence)
Date Of Reconciliation: DATE
Status of Reconciliation: CE (Coded element)
Reconciled By: EN (Entity Name)
Discontinued Medications: CE (Coded element)
Changed Medications: CE (Coded element)
Medication Code: CE (Coded element)
Dose: PQ
Frequency: IVL_TS
When to Take: IVL_TS
Duration: IVL (Interval)
Route: CE (Coded element)
Patient Instructions: ED (Encapsulated Data)
Start Date: DATE
Stop Date: DATE
Prescriber: EN (Entity Name)
Associated Assessment: BAG (Bag)
Allergies and Intolerances
Medication Intolerance: ED (Encapsulated Data)
All Environmental Allergens: CE (Coded element)
All Food Allergens: CE (Coded element)
Reaction Attributes: ED (Encapsulated Data)
Reaction Date: TIMESTAMP()
Severity of Intolerance or Allergy: CE (Coded element)
Reaction Identified By: EN (Entity Name)
A/I Attributes: ED (Encapsulated Data)
List of Reactions: LIST (Sequence)
Is Contained In /
Contains
D is c ha rg e S umma ry
Is Contained In /
Contains
Discharge Summary ID: II (Instance Identifier)
Is Contained In /
Contains
Active Problem List
Start Date Of Problem: DATE
Problem Assignee: EN (Entity Name)
Active Codes: CS (Coded Simple Value)
Reconciliation Status: CE (Coded element)
Reconciliation Date: DATE
Reconciled By: EN (Entity Name)
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ONC Standards and Interoperability (S&I) Framework
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ONC Standards and Interoperability (S&I) Framework
Active Problem List
Active Medication List
Active Medication List: LIST (Sequence)
Date Of Reconciliation: DATE
Status of Reconciliation: CE (Coded element)
Reconciled By: EN (Entity Name)
Discontinued Medications: CE (Coded element)
Changed Medications: CE (Coded element)
Medication Code: CE (Coded element)
Dose: PQ
Frequency: IVL_TS
When to Take: IVL_TS
Duration: IVL (Interval)
Route: CE (Coded element)
Patient Instructions: ED (Encapsulated Data)
Start Date: DATE
Stop Date: DATE
Prescriber: EN (Entity Name)
Associated Assessment: BAG (Bag)
Discontinued Medications
Start Date Of Problem: DATE
Problem Assignee: EN (Entity Name)
Active Codes: CS (Coded Simple Value)
Reconciliation Status: CE (Coded element)
Reconciliation Date: DATE
Reconciled By: EN (Entity Name)
Is Contained In /
Discontinued Medication List: LIST (Sequence)
Contains
Allergies and Intolerances
Is Contained In /
Contains
Is Contained In /
Contains
Is Contained In /
Contains
T ra ns itio ns o f Ca re Summa ry
ID: II (Instance Identifier)
Patient Contact Information
Patient Home Address: AD (Address)
Patient Home Phone: TN (Telephone Number)
Secondary Email Address: TN (Telephone Number)
Patient Work Phone: TN (Telephone Number)
Patient Cell Phone: TN (Telephone Number)
Primary Email Address: TN (Telephone Number)
Direct Address: TN (Telephone Number)
Patient Portal/PHR Available: BL (Boolean)
Patient Portal/PHR URL: TN (Telephone Number)
Patient Home Phone Text Message Enabled: BL (Boolean)
Patient Cell Phone Text Message Enabled: BL (Boolean)
Patient Work Phone Text Message Enabled: BL (Boolean)
Medication Intolerance: ED (Encapsulated Data)
All Environmental Allergens: CE (Coded element)
All Food Allergens: CE (Coded element)
Reaction Attributes: ED (Encapsulated Data)
Severity of Intolerance or Allergy: CE (Coded element)
Reaction Date: TIMESTAMP()
Reaction Identified By: EN (Entity Name)
A/I Attributes: ED (Encapsulated Data)
List of Reactions: LIST (Sequence)
Primary Care Physicians and Designated Providers
Part of
D e mo g ra p hic s
Designated Providers Specialties: CF (Coded element with formatted values)
Designated Providers Names: PN (Person Name)
Designated Provider NPI: II (Instance Identifier)
Designated Provider Contact Information: XAD (Extended Address)
Designated Provider Domain of Management: CF (Coded element with formatted values)
Designated Provider PCMH: EN (Entity Name)
Part of
ID: II (Instance Identifier)
Part of
Part of
Race: CE (Coded element)
Ethnicity: CE (Coded element)
Religion: CE (Coded element)
Language: CE (Coded element)
Disability: CE (Coded element)
Educational Level: CE (Coded element)
Part of
Payer Information
Primary Payer Information: ED (Encapsulated Data)
Secondary Payer Information: ED (Encapsulated Data)
Existence of Advanced Directives
Culturally Sensitive Patient Care
Part of
Part of
Support Contacts
Advanced Directives: BL (Boolean)
Patient Information
Gender: CE (Coded element)
Patient Name: PN (Person Name)
Patient Identifiers: II (Instance Identifier)
Mothers Maiden Name: PN (Person Name)
Marital Status: CE (Coded element)
Date of Birth: DATE
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Primary Emergency Contact Name: PN (Person Name)
Primary Emergency Contact Relationship: CE (Coded element)
Primary Emergency Contact Information: AD (Address)
Secondary Emergency Contact Name: PN (Person Name)
Secondary Emergency Contact Relationship: CE (Coded element)
Secondary Emergency Contact Information: AD (Address)
ONC Standards and Interoperability (S&I) Framework
Family History
Immunization History
Family History Summary: HIST (History)
Genetic Relative Name: PN
Genetic Relative Age: INT (Integer)
Genetic Relative Relationship: CE (Coded element)
Genetic Relative Medical History: Structure
Genetic Marker Description: Structure
Family History Survey Question: Structure
Family History Survey Response: Structure
Medication History
Immunization ID: II (Instance Identifier)
Immunization Category: CK (Composite ID with check digit)
Immunization Date: DATE
Contraindication: BOOLEAN
Immunization Series: CK (Composite ID with check digit)
Observed Reaction: COLL (Collection)
Vital Signs
Medication History: HIST (History)
History Present Illness
Medical Diagnosis: HIST (History)
Vital Sign ID: INTEGER
Status: VARCHAR()
Observation Time: DATE
Observation List: CK (Composite ID with check digit)
Observation Method: CK (Composite ID with check digit)
Device: VARCHAR()
Patient State: VARCHAR()
Telehealth Monitor: VARCHAR()
Body Site: CHAR(18)
Operative Summary
Behavioral Health History
Operative Summary Narrative: HIST (History)
T ra ns itio ns o f Ca re S umma ry
GAF Score: INTEGER
Suicidal Ideation: HIST (History)
Homicidal Ideation: HIST (History)
DSM Axis 1: Structure
DSM Axis 2: Structure
DSM Axis 3: Structure
DSM Axis 4: Structure
DSM Axis 5: Structure
Confidentiality Code: INTEGER
Environmental Factors: Structure
Treatment Referral: Structure
Consultant(s) Assessment(s) and Plan(s) Recommendations
ID: II (Instance Identifier)
Medical History
Medical History Narrative: ED (Encapsulated Data)
Surgical/Procedure History
Care Team Members
Surgical History: HIST (History)
Procedure History: HIST (History)
Social History
Goals
Social History Description: HIST (History)
Social History Additional Details: HIST (History)
Goal ID: INT (Integer)
Goal Name: ST (String)
Goal Description: ED (Encapsulated Data)
Pending Tests and Procedures
Admitting and Discharging Diagnoses
Admitting Diagnosis: TEXT()
Discharging Diagnosis: TEXT()
Physical Exam
Reason for Consult Request
Patient Instructions
Request Reason: CE (Coded element)
Requested Procedure: CE (Coded element)
Provisional Diagnosis: ED (Encapsulated Data)
Patient Instructions Narrative: ED (Encapsulated Data)
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Physical Exam Narrative: HIST (History)
Physical Exam Component: Structure
Physical Exam Observation: Structure
ONC Standards and Interoperability (S&I) Framework
Patient Consent Directive
Patient Self-Management
Social Determinants of Health
Social Narrative: ED (Encapsulated Data)
T ra ns itio ns o f Ca re S umma ry
Health Maintenance
ID: II (Instance Identifier)
Physical Activity
Physical Activity Narrative: ED (Encapsulated Data)
Invasive and Non-Invasive Procedures
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Health Literacy
ONC Standards and Interoperability (S&I) Framework
Appendix A
ToC CEDD Data Element Set Revision History
CEDD Data Element Set
ADL
Revision
Date
12/10
Goals
12/14
Physical Activity
Diet
12/14
12/14
Diet Narrative
12/14
Revision History
Incorporated
suggestions from
Susan Campbell
Incorporated tabular
suggestions from
Laura Heerman
Langford
Incorporated Lindsey
Hoggle’s Powerpoint
Incorporated Lindsey
Hoggle’s Powerpoint
Revision
Description
Data Elements
Date of Last
Review
12/14
Data Elements
12/14
Data Elements
Data Elements
12/14
12/14
Data Elements
12/14
Sample B Data Element
Sample B Data Element
Sample B Data Element
Sample B Data Element
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