Transitions of Care
Clinical Element Data Dictionary
(ToC CEDD)
February 2012 Release, Version 2.0
Office of the National Coordinator for Health IT
Standards & Interoperability Framework
Transitions of Care CEDD
Revision History
Document Version
1.0
2.0
Date
12/1/11
2/29/12
Document Revision Description
Includes A data elements approved by Initiative
Includes B & C data elements approved by Initiative
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Table of Contents
Overview ....................................................................................................................................................... 6
Audience ................................................................................................................................................... 6
Requisite Knowledge............................................................................................................................. 6
Introduction .................................................................................................................................................. 7
S&I Framework Background ..................................................................................................................... 7
ToC Initiative Overview ............................................................................................................................. 7
ToC CEDD Primer....................................................................................................................................... 8
ToC CEDD Origin........................................................................................................................................ 8
ToC CEDD Data Breakdown....................................................................................................................... 9
ToC Key Information Exchanges............................................................................................................ 9
ToC CEDD Objects ............................................................................................................................... 10
ToC CEDD Object Relationships .......................................................................................................... 12
ToC CEDD Data Elements .................................................................................................................... 13
ToC CEDD Vocabularies and Value Sets .................................................................................................. 15
Relevant Usage of the ToC CEDD ............................................................................................................ 16
ToC Scenario 1 User Story 1 ................................................................................................................ 17
ToC Scenario 1 User Story 2 ................................................................................................................ 17
ToC Scenario 2 User Story 1 ................................................................................................................ 18
ToC Scenario 2 User Story 2 ................................................................................................................ 18
Recommendations for S&I CEDD ................................................................................................................ 18
ToC CEDD Key Information Exchanges........................................................................................................ 19
ToC CEDD Key Information Exchange Summary ..................................................................................... 19
Consultation Request including Clinical Summary.............................................................................. 19
Consultation Summary........................................................................................................................ 20
Discharge Instructions......................................................................................................................... 21
Discharge Summary ............................................................................................................................ 22
ToC CEDD Objects ....................................................................................................................................... 24
ToC CEDD Objects in Detail ..................................................................................................................... 24
Admitting and Discharging Diagnoses ................................................................................................ 25
Allergies and Intolerances ................................................................................................................... 26
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Behavioral Health History ................................................................................................................... 29
Care Team Members........................................................................................................................... 32
Consult(s) Assessments and Plan(s) Recommendations..................................................................... 33
Culturally Sensitive Patient Care ......................................................................................................... 34
Demographics ..................................................................................................................................... 36
Diet and Nutrition ............................................................................................................................... 37
Encounters .......................................................................................................................................... 40
Existence of Advance Directives ......................................................................................................... 42
Family History ..................................................................................................................................... 43
General Results ................................................................................................................................... 45
Goals ................................................................................................................................................... 46
History of Present Illness .................................................................................................................... 48
Immunization History.......................................................................................................................... 49
Invasive & Non-Invasive Procedures................................................................................................... 51
Medical Equipment ............................................................................................................................. 54
Medical History ................................................................................................................................... 55
Medications List .................................................................................................................................. 56
Operative Summary ............................................................................................................................ 61
Patient Contact Information ............................................................................................................... 62
Patient Information............................................................................................................................. 64
Patient Instructions ............................................................................................................................. 66
Payer Information ............................................................................................................................... 67
Physical Activity................................................................................................................................... 69
Physical Exam ...................................................................................................................................... 70
Primary Care and Designated Providers ............................................................................................. 71
Problems List ....................................................................................................................................... 73
Reason for Consult Request ................................................................................................................ 75
Review of Systems .............................................................................................................................. 77
Social History....................................................................................................................................... 78
Support Contacts ................................................................................................................................ 78
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Surgical/Procedural History ................................................................................................................ 80
Women’s Health ................................................................................................................................. 81
Vital Signs ............................................................................................................................................ 82
Appendix A: CEDD Object Model Examples ................................................................................................ 85
Demographics Object Model Example.................................................................................................... 85
Consultation Request including Clinical Summary Object Model Example ............................................ 86
Consultation Summary Object Model Example ...................................................................................... 87
Discharge Instructions Object Model Example ....................................................................................... 88
Discharge Summary Object Model Example ........................................................................................... 89
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Overview
A data dictionary is a repository of data elements, their corresponding definitions, and attributes of the
clinical information that is used in a clinical context. The dictionary lists the data elements and
corresponding definitions that are needed to convey the clinical perspective in a manner that is
understandable to a variety of stakeholders, including functional and technical experts. Additionally,
these data elements support the electronic exchange of health information through a core set of
unambiguously-defined data elements that promote semantic compatibility.
The Transitions of Care (ToC) Clinical Element Data Dictionary (CEDD) represents the clinician
perspective of clinical data required in care transitions to fulfill the ToC Use Case. In this document, the
initial sections are to provide explicit guidance to stakeholders who may not have any exposure to the
ToC initiative or the underlying mission of the ToC CEDD. Subsequent sections are focused on the more
technical specifications recommended for the exchange of ToC CEDD Data Elements, including data
types, references to HL7 CDA, and applicable value sets.
Audience
The intended audience for the ToC CEDD includes the following stakeholders:
Stakeholder
Providers and Specialists
Care Coordinators
Electronic Health Record (EHR) Vendors
Personal Health Record (PHR) Vendors
Usage of CEDD
Provides a clinical perspective and view into care transition
data relevant to providers and specialists.
Ensures that in each care transition, the relevant clinical
data that is needed by the care coordinator is available.
Provides EHR vendors a view into the type of the clinical
data needed to support each care transition.
Provides PHR vendors a view into the type of patient-level
data that care transitions produce and that may be
requested from patients.
Requisite Knowledge
Readers are encouraged to have knowledge of the following concepts in order to best understand the
intended usage of the ToC CEDD:
 Knowledge of Health Level Seven International (HL7) Clinical Document Architecture (CDA) R2.
This is critically important as CDA served as the foundation for ToC CEDD.
 Knowledge of the ISO 21090 HL7 data type and CDA specifications. An overview of applicable
data types is provided in the Usage of HL7/ISO Data Types section of this document
 Knowledge and functions of the Transitions of Care Initiative
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Introduction
S&I Framework Background
In support of the national objectives for healthcare reform, the Office of the National Coordinator for
Health Information Technology (ONC) Standards and Interoperability (S&I) Framework has sponsored
the development of harmonized interoperability specifications. These specifications are designed to
support national health initiatives and healthcare priorities, including Meaningful Use, the Nationwide
Health Information Network, and the ongoing mission to improve health care delivery, advance care
coordination, and reduce costs to realize better population health.
The S&I Framework is comprised of several initiatives, each focusing on a single challenge with a set of
value-creating goals and outcomes to enhance the efficiency and effectiveness of healthcare delivery.
The Transitions of Care (ToC) Initiative was among the first initiatives launched by the S&I Framework.
The ToC Initiative focuses on empowering patients, engaging the clinician, and enabling health
information exchange in support of national health initiatives.
ToC Initiative Overview
The purpose of the Transitions of Care initiative is to improve the exchange of core clinical information
among providers, patients and other authorized entities electronically, in support of meaningful use and
IOM-identified needs for improvement in the quality of care. The ToC Initiative is motivated by one very
compelling question:
What if every care transition was accompanied by an
unambiguously-defined core set of high-quality clinical data?
Key Functions of the ToC Initiative:
 Focus on core clinical content that could inform complete reconciled medication, problem,
medication reaction, laboratory results, etc.;
 Build on existing standards to accelerate results;
 Work with the healthcare community to lower the implementation burden; and
 Guide decision-making based on the requirements of meaningful use and IOM-identified needs
for improvement in the quality of care.
Key Outputs of the ToC Initiative:
 Unambiguous definition of the core clinical elements that should be included in care transitions
 Definition of four key clinical Constructs that provide guidance on the exchange of information
in the event of a patient care transition
 Agreement on a single standard in support of Meaningful Use requirements, which minimizes
interoperability errors and streamlines patient care coordination
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 Tools and resources to lower the barrier for implementation
ToC CEDD Primer
In addition to addressing the need for an unambiguously-defined core set of clinical data, the ToC 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 ToC CEDD is that it:
a. Provides a view for clinicians into the type of data needed to support each care transition
b. Provides implementers and vendors an idea of how to store and exchange that data
c. Serves as a logical view of the common data model that underlies all care transitions
In practice, it will manifest itself as physical data within an organization engaged in care transitions. 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 supporting the S&I
Framework mission, including:





National E-Health Transition Authority (NEHTA)
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 ToC
CEDD Objects and to help define the structure of the dictionary. It was not the intention in the
development of the ToC CEDD to specifically adopt an information model already in use, nor to redefine
existing information models – the objective was to leverage previous work 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 ToC Initiative specifications, the need for a common information model
became apparent during analysis of existing standards and barriers to electronic exchange of
information. While common data elements existed between the ToC Selected Standard, HL7 Clinical
Document Architecture (CDA), other applicable standards, and various health care information models,
ambiguous definitions prevented accurate harmonization for an interoperable standard.
To best demonstrate the complex relationships between data elements and objects, the Initiative
initially pursued the development of a Clinical Information Model (CIM), which combined the traditional
data dictionary model with a logical model. The resulting CIM was the harmonization of the clinical
requirements for the ToC Use Case Scenarios, the CDA, and other applicable standards for a harmonized
care transition information model.
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As an important output of the ToC Initiative, the CIM is best represented in the form of a data
dictionary. The transition ensured 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 representation, the ToC CIM is now referred to as the ToC CEDD, but maintains the
important modeling properties to best serve as an artifact for reuse and a tool for implementers. The
following section outlines these modeling properties, as employed by the ToC CEDD.
ToC CEDD Data Breakdown
A complete ToC CEDD concept includes Key Information Exchanges, ToC CEDD Objects and ToC CEDD
Data Elements. These terms may also collectively be referred to as the ToC CEDD Data Structure, a
figurative term used to outline the dependencies between these three concepts. Figure 1 provides an
overview of this CEDD Data Structure:
Figure 1 - ToC CEDD Data Structure
For clinicians, this section may be useful to help understand how the ToC CEDD is structured. Additional
Object representations may be found in Appendix A to assist in understanding ToC CEDD data concepts.
ToC Key Information Exchanges
ToC CEDD Key Information Exchanges contain the clinical information to meet the functional
requirements of the ToC Use Case defined actors. The ToC Use Case defines four clinical constructs
represented through ToC CEDD Key Information Exchanges.
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Characteristic
ToC CEDD Key
Information
Exchange
Definition
ToC Reference
Description of the Characteristic
A clinically-relevant name for this ToC Key Information Exchange. This name
should be understandable to clinicians.
A clinically-relevant definition of the ToC CEDD Object.
References the ToC Use Case Scenario defining the Key Information Exchange
The ToC CEDD Key Information Exchanges are groupings of ToC CEDD Objects, but for ease of
understanding are highlighted in the ToC CEDD to provide implementers an origination point for ToC
constructs to be implemented through the ToC CDA Consolidation Companion Guide. To assist in
traceability, parent and child object designations for objects reflect relationships to the ToC Key
Information Exchanges. Figure 2 depicts a rudimentary example of how a Key Information Exchange is
structured.
Key Information Exchange
Discharge Summary
Medications
List
Consult(s)
Assessment(s) &
Plan(s)
Recommendations
Existence of
Advance
Directives
Immunization
History
Allergies and
Intolerances
Problems List
Medical
Equipment
Demographics
Figure 2 - Key Information Exchange
ToC CEDD Objects are intended to be used primarily for requirements traceability, meaning that they
are intended to map clinical data to the requirements of a use case. Because this representation of the
ToC CEDD is CDA-based, the primary level of traceability is from the ToC CEDD to the ToC Key
Information Exchanges defined in the ToC Use Case.
ToC CEDD Objects
A ToC CEDD Object represents a specific entity within a logical data model. Each ToC 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 is
specifically targeted to stakeholders involved in care transitions processes.
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A key differential with ToC CEDD Objects is that they are not tied to any specific underlying information
model. Thus, as an example, a ToC CEDD Object is not tied to the HL7 Reference Information Model
(RIM), although it may use concepts or terms that are similar to the RIM. As noted in the previous
section, the independence of ToC CEDD Objects from an underlying standard provides the flexibility for
ToC CEDD Objects to be reused in other contexts.
For ToC CEDD Objects, several key pieces of information are defined to assist in understanding clinical
meaning. ToC CEDD Object characteristics are summarized in the following table:
Characteristic
ToC Priority
ToC CEDD Object
Name
Object Definition
Examples and
CDA ID
References
Description of the Characteristic
The priority of this ToC CEDD Object. Please reference the ToC CEDD Priorities
section to understand their application.
A clinically-relevant name for this ToC CEDD Object. This name should be
understandable to clinicians.
A clinically-relevant definition of the ToC CEDD Object. Additional usage
guidance may also be included in italics.
Provides real-world clinical examples to provide context for usage as well as
listing CDA-specific references for Document, Section, and Entry IDs
ToC CEDD Priorities
ToC CEDD Priorities were used to prioritize the development of the ToC CEDD and determined the key
clinical information needed for exchange during care transitions within the scope of the ToC Use Case.
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 following table
summarizes the ToC CEDD Priorities and their applicability:
ToC CEDD
Priority
"A"
"B"
Description of Priority





Core data exchanged with every transition of care
These may be automated by the edge system (EHR)
"A" objects have validated data models
Required indicates that every clinical document created must have core objects
NB subsets of categories of "additional" objects (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 objects 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" objects are either very frequently required in most transition of care
circumstances (e.g. results) and/or are regularly captured in many EHR systems as
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ToC CEDD
Priority
"C"
Description of Priority
discrete data.
 Variable data needed by the end user in some transition of care circumstances
 Selected "C" objects are either less frequently required in most transition of care
circumstances and/or are not currently captured in many EHR systems as discrete data
It is important to understand that ToC CEDD Priorities served primarily to assist clinicians in building out
the initial ToC Clinical Information Model (previously addressed in Origin of the ToC CEDD). Designation
of priorities allowed development of specific objects and data elements to occur in a fashion to reflect
the priorities of clinical information needs during a care transition instance. While priorities were initially
assigned at both the object and data element level, they are utilized in this version of the ToC CEDD only
at the object level, to provide traceability and for reference by implementers seeking to reuse ToC CEDD
Objects in CDA documents.
ToC CEDD Object Relationships
ToC CEDD Objects are intended to capture a real-world clinical concept and are not intended to be
represented as physical objects, meaning the representation of how data is stored within a physical data
store. To convey relationships between specific entities, ToC CEDD Objects contain properties reflecting
designation as a parent or child object. However, as noted in the Origin of the ToC CEDD, the abstract
nature of the ToC CEDD prevents dependence on a rigid parent/child hierarchical structure, and data
elements or objects may inherit attributes from more than one parent. Similarly, objects may
incorporate specific attributes rather than all attributes of another object. These properties are further
detailed in the following sections, and specific designations are listed within individual ToC CEDD Object
summaries as applicable. Figure 3 depicts the parent-child relationship of ToC CEDD Objects and the
related ToC CEDD Data Elements, using Admitting and Discharging Diagnoses as an example:
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Figure 3 - Admitting and Discharging Diagnoses - CEDD Data Concept Example
ToC CEDD Data Elements
A ToC CEDD Data Element is an attribute of a ToC CEDD Object. For ToC CEDD Data Elements, several
key pieces of information are defined to assist in understanding clinical meaning:
Characteristic
Data Element Name
Data Element Definition
Clinical Example
HL7/ISO Data Type
CDA Reference
Expected Value Set
Description of the Characteristic
A clinically-relevant name for this ToC CEDD
Data Element. This name should be
understandable to clinicians.
A clinically-relevant definition of the ToC
CEDD Data Element. Additional usage
guidance may also be included in italics.
Provides real-world clinical examples to
provide context for usage.
A possible data type that may be used to
represent this ToC CEDD Data Element. They
are aligned to the ToC Recommended
Standard: HL7 CDA.
Representation of the ToC CEDD Data
Element through HL7 CDA.
Identifies the section of an applicable value
Stakeholders
All
All
Providers/Specialists and
Care Coordinators
EHR Vendors and
PHR Vendors
EHR Vendors and
PHR Vendors
EHR Vendors and
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Characteristic
Description of the Characteristic
set made available through the S&I
Framework CEDD Value Set Index.
Stakeholders
PHR Vendors
Usage of HL7/ISO Data Types
A core set of data types is needed to support the representation of the ToC 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 data
types from a source to represent data logically. The ToC CEDD adopted the ISO/HL7 data types that are
commonly used as part of the HL7 RIM and the HL7 CDA.
The ISO 21090 Healthcare Data Type Standard provides a set of data type definitions for representing
and exchanging basic concepts that are encountered in healthcare environments, and specifies a
collection of healthcare-related data types suitable for use in a number of healthcare-related
information environments. This standard is a culmination of a large-scale joint effort among standards
bodies, such as HL7 and ISO, and has been reviewed by experts in the field.
It should be noted that several of the data types 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. The following table provides an
overview of the data types used in the ToC CEDD:
ISO/HL7
Data Type
AD
Description
Usage
Address
Used to capture a physical address
Used to capture phone numbers and email
addresses
Used to capture the name of a person
TN
Telephone Number
PN
Person Name
Coded Element with formatted
values
CF
ED
Encapsulated Data
BAG
Bag
SET
Set
HIST
History
LIST
IVL
IVL_TS
CS
List Sequence
Interval
Interval – Timestamp
Coded – Simple Value
PQ
Physical Quantity
CE
Coded Element
Similar to CE but with formatted values
Used to capture text and multimedia that may be
included in a care transition
Used to capture a an unordered, multiple
collection of things
Used to represent an unordered collection type
that stores unique elements
Used to capture historical items about something
or set of things
Used to store ordered, non-unique elements
Used to capture an interval of things
Used to capture an interval of time
Used to capture a simple set of codes
Used to capture information about quantities,
through a value and a unit of measure
Used to capture a specific coded element or set
of coded elements
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ISO/HL7
Data Type
Description
BL
Boolean
DATE
Date
Used to capture Boolean information (i.e.
true/false, yes/no)
Used to capture a date
II
Instance Identifier
Used to identify a unique instance of some thing
INTEGER
Integer
EN
Entity Name
Used to capture a number
Used to capture the name of an individual or
organization
Usage
Structure Data Type
In addition, the ToC CEDD defines a Structure data type. This data type 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 ToC CEDD). It is important to note that many of the ToC CEDD Data Elements
can potentially be expressed using multiple data types. This is one of the foundational principles of the
ToC 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 data type can be made by implementers and vendors, depending on the base derived data
type within their environment.
Example: The Physical Activity Assessment Data Element has a data type of LIST (List Sequence), but
data types of CE (Coded Entries), SET, or ED (Encapsulated Data) may also be assigned to best fit the
needs of an organization.
ToC CEDD Vocabularies and Value Sets
ToC CEDD Objects use terms that are drawn from several code systems. These controlled vocabularies
are defined in various supporting specifications, and may be maintained by other entities, 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 ToC CEDD Objects and ToC CEDD Data Elements. Specific value sets
are available through the S&I Framework CEDD Value Set Index on the S&I Framework CEDD Value Set
Index wiki page. Value sets are listed at ToC CEDD Data Element level and indicate applicable sections
within the S&I Framework CEDD Value Set Index.
Overall, the ToC CEDD aligns to the recommendations of the Health IT Standards Committee (HITSC) for
data elements that have associated vocabulary/code set requirements. The following table captures the
high-level recommendations from this committee:
ToC CEDD Object
Physical Exam
Family History
ToC CEDD Data Elements
Component
Observation
Component
Vocabulary Recommendation
LOINC
SNOMED-CT
LOINC
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ToC CEDD Object
Active Medication List
Procedures
Problem List
Equipment
Culturally Sensitive Patient Care
Payer Information
ToC CEDD Data Elements
Response
Active Medication List
Procedure
Problem
Equipment
Race
Gender
Language
Primary Payer Information
Secondary Payer Information
Vocabulary Recommendation
SNOMED-CT
RxNORM
SNOMED-CT
SNOMED-CT
SNOMED-CT
PHIN-VADS
HL7
ISO 639-2
ASC X12
ASC X12
For the ToC CEDD, additional vocabularies and value sets can be reused from the National Library of
Medicine (NLM) mappings and subsets available through the Unified Medical Language System (UMLS).
Example: An implementer may wish to implement a discharge summary using an existing vocabulary
already implemented within their environment. The ToC 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 HITSC Vocabulary Task Force.
Relevant Usage of the ToC CEDD
Associated usage diagrams for the ToC CEDD are provided to give context to implementers and clinicians
about different usage scenarios for the ToC CEDD. This section specifically highlights the four ToC Use
Case Scenarios outlined in the S&I Framework Transitions of Care Use Case.
Please note all diagram references to “CIM Objects” are in reality to “CEDD Objects.”
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ToC Scenario 1 User Story 1
ToC Scenario 1 User Story 2
ToC Scenario 2 User Story 1
ToC Scenario 2 User Story 2
Recommendations for S&I CEDD
ToC CEDD Data Elements with an “A” priority designation were accepted for inclusion in the S&I CEDD in
December 2011 and comprise the January release of the S&I Framework CEDD. ToC CEDD Data Elements
included within this version of the ToC CEDD for recommendation to the S&I Framework CEDD are
highlighted in light red to indicate consensus by ToC, but are recommended for consensus by the S&I
CEDD WG, and subsequent inclusion in the S&I Framework CEDD. For more information on the
recommendations process, please reference the S&I CEDD Cross-Initiative WG wiki.
Office of the National Coordinator for Health IT
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ToC CEDD
ToC CEDD Key Information Exchanges
ToC CEDD Key Information Exchange Summary
The following table summarizes each of the ToC CEDD Key Information Exchanges in alphabetical order. This table may be used to reference ToC
CEDD Objects comprising ToC CEDD Key Information Exchanges. It is important to note that ToC CEDD Key Information Exchanges are ToC CEDD
Objects, but for ease of understanding, have been highlighted in this section to provide implementers an origination point for ToC constructs to
be implemented through the ToC CDA Consolidation Companion Guide. Certain ToC CEDD Objects may not be listed as part of a ToC CEDD Key
Information Exchange, but applicable relationships are indicated within individual ToC CEDD Objects. Other ToC CEDD Objects that are not listed
as part of a ToC CEDD Key Information Exchanges or as other related objects are for future development by any interested party.
Consultation Request including Clinical Summary
Key Information Exchange
Consultation Request
including
Clinical Summary
Consultation Request including Clinical Summary Key Information Exchange
Definition
This information exchange would include a standard set of data including demographic
information, active reconciled medication list (with doses and sig), allergy list and problem list.
The Clinical Summary may also contain variable data relevant to the context of the request. In
addition, this document also includes a PCP-selected referral-specific variable dataset.
ToC Reference
ToC Scenario 1
User Story 2
ToC Scenario 2
User Story 2
Consultation Request including Clinical Summary Parent Object
ToC Priority
Child Objects
A
Allergies and Intolerances
B
Consultant(s) Assessment(s) and Plan(s) Recommendations
A
Demographics
B
Encounters
A
Existence of Advance Directives
B
Family History
B
General Results
B
History Present Illness
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Consultation Request including Clinical Summary Parent Object
ToC Priority
Child Objects
A
Immunization History
B
Invasive and Non-Invasive Procedures
C
Medical Equipment
B
Medical History
A
Medications List
A
Payer Information
B
Physical Exam
B
Problems List
B
Reason for Consult Request
B
Social History
B
Surgical/Procedural History
B
Vital Signs
Consultation Summary
Key Information Exchange
Consultation Summary
Consultation Summary Key Information Exchange
Definition
This information exchange will include a standard data set including demographic information,
active reconciled medication list (with doses and sig), allergy list and problem list. This
information exchange would also contain variable data relevant to the context of the request.
ToC Priority
A
B
A
B
A
ToC Reference
ToC Scenario 1
User Story 2
Consultation Summary Parent Object
Child Objects
Allergies and Intolerances
Consult(s) Assessment(s) and Plan(s) Recommendations
Demographics
Encounters
Existence of Advance Directives
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ToC Priority
B
B
B
A
B
C
B
A
A
B
B
B
B
B
B
Consultation Summary Parent Object
Child Objects
Family History
General Results
History Present Illness
Immunization History
Invasive and Non-Invasive Procedures
Medical Equipment
Medical History
Medications List
Payer Information
Physical Exam
Problems List
Reason for Consult Request
Social History
Surgical/Procedural History
Vital Signs
Discharge Instructions
Key Information Exchange
Discharge Instructions
Discharge Instructions Key Information Exchange
Definition
This information exchange 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.
ToC Priority
A
ToC Reference
ToC Scenario 1
User Story 1
ToC Scenario 2
User Story 1
Discharge Instructions Parent Object
Child Objects
Allergies and Intolerances
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ToC Priority
B
A
A
A
C
A
B
Discharge Instructions Parent Object
Child Objects
Consult(s) Assessment(s) and Plan(s) Recommendations
Demographics
Existence of Advance Directives
Immunization History
Medical Equipment
Medications List
Problems List
Discharge Summary
Key Information Exchange
Discharge Summary
Discharge Summary Key Information Exchange
Definition
This information exchange 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 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.
ToC Priority
B
A
B
B
A
B
ToC Reference
ToC Scenario 2
User Story 1
Discharge Summary Parent Object
Child Objects
Admitting and Discharging Diagnoses
Allergies and Intolerances
Consult(s) Assessment(s) and Plan(s) Recommendations
Diet and Nutrition
Demographics
Encounters
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ToC Priority
A
B
B
B
A
B
C
B
A
A
B
B
B
B
B
B
Discharge Summary Parent Object
Child Objects
Existence of Advance Directives
Family History
General Results
History Present Illness
Immunization History
Invasive and Non-Invasive Procedures
Medical Equipment
Medical History
Medications List
Payer Information
Physical Exam
Problems List
Review of Systems
Social History
Surgical/Procedural History
Vital Signs
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ToC CEDD Objects
ToC CEDD Objects in Detail
Within this section, ToC CEDD Objects are listed alphabetically and contain a summary and details at the ToC CEDD Data Element level. Each ToC
CEDD Object summary includes a definition, CDA ID references, clinical applications, and logical relationships to other ToC CEDD Objects.
 ISO/HL7 Data Type: Please note that B and C Priority Objects may require more work to finalizing typing of included data elements.
Further explanation on data types is provided in the Usage of HL7/ISO Data Types section.
 Examples and guidance are provided including clinically relevant terminology from CDA as well as potential vocabularies and value sets
to use in storing these ToC CEDD Data Elements. Sections of the S&I Framework CEDD Value Set Index indicate ToC recommended value
sets.
 Structure is listed as the data type of child objects.
For certain data elements, examples and guidance information may be missing due to the following reasons:
 A clinical example may be deemed unnecessary due to direct inference from data element name
 Structure may be listed as a data type due to insufficient development at the time of this ToC CEDD version publication.
 A CDA reference may not be listed due to alignment with a CDA section rather than entry, an accurate equivalent may not exist in CDA at
this time, or may not have been developed by the time of this ToC CEDD version publication
 Expected value sets may not listed for certain coded entries due to the controlled nature of applicable vocabularies
For the aforementioned reasons, blank entry fields are denoted through light grey coloring to signify recognition of the known missing,
insufficient, or unavailable information.
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Admitting and Discharging Diagnoses
Definition
Admitting Diagnoses are
the diagnoses assigned 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.
Admitting and Discharging Diagnoses Object Summary
Clinical Application
CDA ID Reference(s)
Admitting Diagnoses: Diabetic
Ketoacidosis, Type II Diabetes,
Hyperlipidemia, Obesity,
Noncompliance Discharge
Diagnoses: Type II Diabetes,
Hyperlipidemia, and Obesity.
Admitting and discharge diagnosis
2.16.840.1.113883.10.20.22.2.24
might or might not be the same.
Admitting diagnosis might often be
prospective or might be a chief
complaint that represents a health
concern or symptom, e.g. chest
pain.
Admitting and Discharging Diagnoses Object in Detail
Data Element
ISO/HL7
Data Element Definition
Clinical Example
Name
Data Type
Hospital
The diagnosis(es) that was the reason
Admission
for hospitalization at the time of
Appendicitis
CD
Diagnosis
hospitalization
The diagnosis(es) determined to be
Hospital
the reason for hospitalization at the
Myocardial infarction,
Discharge
time of discharge (this may be the
CD
90% occlusion of the LAD
Diagnosis
same or different from the hospital
admission diagnosis
Prospect of recovery as anticipated
Critical, Guarded, fair,
Patient Conditions
CS
from the usual course of disease or
stable, good
Parent Objects


Discharge
Summary
Encounters
CDA Reference
Child Objects

Problems List
Expected Value Set
1.14 Care
Transition- Problem
Value Set
1.14 Care
Transition- Problem
Value Set
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Data Element
Name
Problem
Observations
Reason for
Admission
Admitting and Discharging Diagnoses Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
peculiarities of the case
All of the patients active
Problems List Object
Structure
medical problems
Narrative description of the primary
Chest Pain
ED
reason for admission to a facility
CDA Reference
Expected Value Set
Allergies and Intolerances
Definition
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).
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.
Allergies and Intolerances Object Summary
Clinical Application
CDA ID Reference(s)
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.
Parent Objects

2.16.840.1.113883.10.20.21.2.6.1
2.16.840.1.113883.10.20.21.2.6.



Child Objects
Consultation
Request
including
Clinical
Summary
Consultation
Summary
Discharge
Instructions
Discharge
Summary
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Data Element
Name
A/I Attributes
Environmental
Allergens
Food Allergens
List of Reactions
Medication
Intolerance
Reaction
Attributes
Reaction Date
Allergies and Intolerances Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
Veracity of the data based on source
Older patient has been
and details available about index
told that had a Rx as a
reaction(e.g. older patient has been
child vs. clinician has
told that had a Rx as a child vs.
ED
healthcare professional
clinician has healthcare professional
documentation of an
documentation of an anaphylactic
anaphylactic episode
episode)
Examples of
A list of associated environment
environmental allergens
allergens for the medication includes
CE
include latex, pollen,
seasonal allergens.
animal dander, etc...
A list of associated food allergens for
the medication
A list of reactions from
allergies/intolerances
Medication (ingredient or class code,
if available) that has been attributed
to an allergic reaction or intolerance,
or drug code if attribution to
ingredient or class is unavailable
Clinical statement detailing an
undesired symptom, finding, etc., due
to an administered or exposed
substance.
Date when this particular Intolerance
Condition or Allergy first manifested
Examples of food
allergens include shellfish,
eggs, peanuts, etc.
(e.g. anaphylaxis), nausea,
morbilliform skin rash
e.g. Opiates
Includes medications,
biologicals, herbal
supplements, OTCs,
vaccine, etc.
Acute generalized
peritonitis (disorder)
CDA Reference
Product Coded
CE
Product Coded
LIST
Reaction FreeText
ED
Product FreeText
CE
Reaction Coded
Expected Value Set
1.3 Allergy/Adverse
Event Food and
Other Allergens
Value Set
1.3 Allergy/Adverse
Event Food and
Other Allergens
Value Set
1.4 Allergy/Adverse
Event Reaction
Value Set
TS
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Reaction
Identified By
Allergies and Intolerances Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
itself or was confirmed via testing if it
had not yet manifested itself.
e.g. patient, provider, care
Who reported the reaction
EN
taker
Reaction Type
Describes type of reaction
Data Element
Name
Severity
Attributes
Clinical statement detailing severity of
a specific reaction
Severity of
Intolerance or
Allergy
Severity associated with the reaction.
This is a description of the level of
severity of the allergy or intolerance
Propensity to adverse
reactions (disorder)
Mild to moderate
(qualifier value)
A patient was treated in
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
CDA Reference
CE
CD
Severity Coded
ED
Severity FreeText
Expected Value Set
1.5 Allergy/Adverse
Event Type Value
Set
1.19 Care TransitionSeverity Value Set
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Behavioral Health History
Definition
Specifies the summary
report intended to
exchange selected
information relevant across
specialties. It may not
include the details of an
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.
Data Element
Name
Confidentiality
Code
DSM Axis 1
Behavioral Health Object Summary
Clinical Application
CDA ID Reference(s)
Parent Objects
Child Objects
History of conditions or episodes
that would fall in the behavioral
health domain, such as a history of
depression treated by the patients
previous PCP with antidepressant
medications and an inpatient stay
in a behavioral health facility.
Behavioral Health History Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
This attribute is used to specify that
the content of this clinical document is
INTEGER
sensitive because it contains
Behavioral Health information
The DSM-IV organizes each psychiatric
diagnosis into five dimensions (axes)
Structure
relating to different aspects of
CDA Reference
Expected Value Set
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Data Element
Name
Behavioral Health History Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
disorder or disability:
CDA Reference
Expected Value Set
Axis I: Clinical disorders, including
major mental disorders, and learning
disorders
The DSM-IV organizes each psychiatric
diagnosis into five dimensions (axes)
relating to different aspects of
disorder or disability:
DSM Axis 2
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 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 disability:
Structure
Structure
Structure
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Data Element
Name
DSM Axis 5
Environmental
Factors
GAF Score
Behavioral Health History Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
Axis IV: Psychosocial and
environmental factors contributing to
the disorder
The DSM-IV organizes each psychiatric
diagnosis into five dimensions (axes)
relating to different aspects of
disorder or disability:
Structure
Axis V: Global Assessment of
Functioning or Children's Global
Assessment Scale for children and
teens under the age of 18
Description of environmental factors
Structure
affecting patient
Global Assessment of Functioning
(GAF)
Range from 0-100, e.g. 50 INT
CDA Reference
Expected Value Set
Part of the diagnosis on Axis 5
Homicidal
Ideation
Clinical statement describing patient
thoughts about homicide
Suicidal Ideation
Clinical statement describing patient
thoughts about suicide
Treatment
Referral
Description of specialized treatment
referrals
Patient reports fantasizing
about killing his spouse
with his gun.
Patient reports thinking
about jumping out of a
window of a high story
building
HIST
HIST
Structure
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Care Team Members
Definition
A list of the care team
members and their role in
the patient’s care.
Care Team Members Object Summary
Clinical Application
CDA ID Reference(s)
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.
Parent Objects
Child Objects


Encounters
Primary Care
and
Designated
Providers
Care Team Members Object in Detail
Data Element
Name
Care Team
Provider
Care Team Roles
Care Team
Member ID
Data Element Definition
Provider information from Primary
Care Physicians and Designated
Providers
The role on the care team
Includes non-physician providers such
as physical therapist, LCSW,
nutritionist, who might be part of care
team.
Provider Index number
Clinical Example
ISO/HL7
Data Type
CDA Reference
Expected Value Set
Structure
PCP, embedded care
manager, social worker,
specialist consulting
physician, etc.
ED
Unique identifier, such as
NPI for providers
II
Provider Role
Free Text
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Consult(s) Assessments and Plan(s) Recommendations
Consult(s) Assessments and Plan(s) Object Summary
Clinical Application
CDA ID Reference(s)
Definition
Contains information as
part of a patient
assessment that was
performed, plan of care
recommendations, and/or
consultation reasons
Data Element
Name
Assessment
Narrative
Assessment or
Recommendation
Date
Author
List of Associated
Medications
Plan of Care Goals
These data elements include any
non-core assessments, plans, and
orders, including free text of the
consultant's assessments and plan
recommendations.
2.16.840.1.113883.10.20.22.1.9
Parent Objects
 Consultation
Request
including
Clinical
Summary
 Consultation
Summary
 Discharge
Instructions
 Discharge
Summary
Consult(s) Assessments and Plan(s) Recommendations Object in Detail
ISO/HL7
CDA Reference
Data Element Definition
Clinical Example
Data Type
The clinician's conclusions and
working assumptions that will guide
ST
treatment of the patient.
Date of assessment or care plan
establishment
TS
Specific clinician author of care plan or
assessment
PN
Medications List Object
Structure
Goals Object
Structure
Child Objects




Goals
Invasive and
Non-Invasive
Procedures
Medications
List
Reason for
Consult
Request
Expected Value Set
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Data Element
Name
Plan of Care
Procedure
Provisional
Diagnosis
Request Reason
Status of
Recommendation
Consult(s) Assessments and Plan(s) Recommendations Object in Detail
ISO/HL7
CDA Reference
Data Element Definition
Clinical Example
Data Type
Invasive and Non-Invasive Procedures
Structure
Object
Description of unconfirmed diagnosis
to be addressed through assessment
CD
or plan
Reason for Consult Request Object
Structure
Describes state of assessment or plan
Proposal, request, etc.
CS
recommendation
Expected Value Set
1.14 Care
Transition- Problem
Value Set
Culturally Sensitive Patient Care
Definition
Information specific to the
patient's cultural, religious,
and educational
background.
Data Element
Name
Confidentiality
Code
Disability
Educational Level
Culturally Sensitive Patient Care Object Summary
Clinical Application
CDA ID Reference(s)
Patient’s thyroid nodule FNA
demonstrated follicular thyroid
2.16.840.1.113883.10.20.21.1.1
cancer; patient has been scheduled [US Realm Document Header]
for surgery in one month.
Culturally Sensitive Patient Care Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
This field contains information about
e.g. highly sensitive, not
the level of security and/or sensitivity
CE
sensitive, sensitive
surrounding the order
The disability status of the patient
Deaf
CE
Acceptable values for this data
Graduate Degree
CE
element include the following
Parent Objects

Child Objects
Demographics
CDA Reference
Expected Value Set
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Data Element
Name
Ethnicity
Language
Race
Religion
Culturally Sensitive Patient Care Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
(Advanced Degree, College Graduate,
Some College, High School Graduate,
Elementary)
Ethnicity is a term that extends the
Latino
CE
concept of race. The coding of
ethnicity is aligned with public health
and other federal reporting standards
of the CDC and the Census Bureau
Language will be identified as spoken, Arabic
CE
written, or understood; but no
attempt will be made to assess
proficiency. The 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 constant over that
patient's lifetime. The coding of race is
aligned with public health and other
federal reporting standards of the
Asian
CE
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.
Religious affiliation of the patient
Catholic
CE
CDA Reference
Expected Value Set
Ethnicity
Language
Race
Religious
Affiliation
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Demographics
Demographics Object Summary
Clinical Application
CDA ID Reference(s)
Definition
Parent Objects


The Demographics CEDD
Object would assemble
multiple child objects into a
Demographics parent
object
Captures relevant patient
information at an instance of care
2.16.840.1.113883.10.20.21.1.1
[US Realm Document Header]



Consultation
Request
including
Clinical
Summary
Consultation
Summary
Discharge
Instructions
Discharge
Summary




Child Objects
Culturally
Sensitive
Patient Care
Existence of
Advance
Directives
Patient
Contact
Information
Patient
Information
Payer
Information
Demographics Object in Detail
Data Element
Name
ID
Patient Advance
Directives
Patient Contact
Information
Patient Cultural
Sensitive
Information
Data Element Definition
Clinical Example
ISO/HL7
Data Type
A unique identifier for the
Demographics CEDD Object
II
Existence of Advance Directives Object
Structure
Patient Contact Information Object
Structure
Culturally Sensitive Patient Care
Object
Structure
CDA Reference
Expected Value Set
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Demographics Object in Detail
Data Element
Name
Patient
Information
Patient Payer
Information
Data Element Definition
Patient Providers
Patient Support
Contacts
Clinical Example
ISO/HL7
Data Type
Patient Information Object
Structure
Payer Information Object
Structure
Primary Care and Designated
Providers Object
Structure
Support Contacts Object
Structure
CDA Reference
Expected Value Set
Diet and Nutrition
Definition
Information specific to the
patient's cultural, religious,
and educational
background.
Diet and Nutrition Object Summary
Clinical Application
CDA ID Reference(s)
Patient’s thyroid nodule FNA
demonstrated follicular thyroid
2.16.840.1.113883.10.20.21.1.1
cancer; patient has been scheduled [US Realm Document Header]
for surgery in one month.
Parent Objects

Child Objects
Discharge
Summary
Diet and Nutrition Object in Detail
Data Element
Name
Diet Description
Data Element Definition
Narrative of the recommended diet or
daily nutrient intake
Clinical Example
ISO/HL7
Data Type
CDA Reference
Expected Value Set
General Healthful Diet;
80 gm protein +
Consistent Carbohydrate +
ED
2g sodium + 2g potassium
+ 800-1000mg Phosphorus
+ 1500 mL Fluid Restricted
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Diet and Nutrition Object in Detail
Data Element
Name
Diet Type Code
Discharge Diet
Food Type Code
Nutrition
Assessment
Nutrition Care
Provider
Nutrient
Modification
Required
ISO/HL7
Data Type
Data Element Definition
Clinical Example
Set of codes that controls the type of
diet modification that a patient should
receive or follow
Records a narrative description of the
expectations for diet, including
proposals, goals, and order requests for
monitoring, tracking, or improving the
dietary control of the patient, used in a
discharge from a facility such as an
emergency department, hospital, or
nursing home.
DASH (Dietary Approaches
to Stop Hypertension),
Kosher, or Vegan
LIST
Low-fat, low-salt, cardiac
diet
ED
Patient undergoing
treatment and
rehabilitation following a
stroke may require honeythickened liquids, ground
meats and chopped
vegetables
CE
BMI:22
PQ
Indicates what type of food, such as
meats, or liquids, which require a
texture modification
Anthropometric measurement
outcomes
Nutrition professional (RD) responsible
for completing the request nutrition
consult and developing the nutrition
prescription, and nutrition plan of care
Indicator specifying whether the
patient/client requires a therapeutic or
modified diet
to eliminate, decrease, or
CDA Reference
Expected Value Set
EN
Diabetic patient requires
controlled intake of
carbohydrates.
BL
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Diet and Nutrition Object in Detail
Data Element
Name
Data Element Definition
Clinical Example
ISO/HL7
Data Type
CDA Reference
Expected Value Set
increase certain substances in the diet
(e.g., sodium, potassium)
Nutrition
Monitoring and
Evaluation
Nutrient Type
Code
Narrative includes both patient
evaluation of goals, re-assessment of
existing parameters and evaluation
Patient has reduced
sodium and cholesterol
consumption and reduced
BMI from 30 to 27.
Outcomes over past 9
months reflect a reduction
in BP and LDL .
ED
Code which identifies the nutrient
which is to be modified
Sodium or Protein
CE
Nutrition
Observation
Food and nutrition related observation
narrative of indicators which are used
to evaluate the nutritional status of the
patient.
Nutrition
Diagnosis
Identification and labeling of a nutrition
problem that a food and nutrition
professional is responsible for treating
independently
Nutrition
Intervention
Purposefully planned actions intended
to positively change a nutrition-related
behavior, environmental condition, or
aspect of health status for an individual
Three-day food record
reflects patient has been
severely restricted in
protein/kcalorie intake.
Average intake was 1250
kcal, 30 grams protein.
Biting/Chewing
(masticatory) difficulty
(SNOMED CT CID
175130015 ) related to
xerostomia as evidenced
by Speech Language
Pathologist evaluation.
Adaptive equipment for
feeding assistance
ED
CE
ED
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Diet and Nutrition Object in Detail
Data Element
Name
Data Element Definition
Clinical Example
Nutrition
Prescription
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 nutrition
diagnosis.
Recommend patient
consume 2000 calories, 80
grams protein per day for
optimal wound healing.
ED
Biochemical Data, Medical Tests and
Procedures and tests
Lab data: electrolytes,
glucose; Tests: gastric
emptying time, resting
metabolic rate
PQ
Nutrition Results
PES Statement
Quantity of
Nutrient
Describes Problem/Etiology
Signs/Symptoms
Indicates how much of the nutrient is
being ordered or recommended
ISO/HL7
Data Type
CDA Reference
Expected Value Set
ED
PQ
Encounters
Definition
Captures the details of a
specific patient encounter
event.
Encounters Object Summary
Clinical Application
CDA ID Reference(s)
Details information on the
encounter event and captures the
patient health information relevant
to the encounter event.
2.16.840.1.113883.10.20.22.2.22
Parent Objects
 Consultation
Request
including
Clinical
Summary
 Consultation
Summary
 Discharge
Child Objects


Care Team
Members
Problems List
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Definition
Encounters Object Summary
Clinical Application
CDA ID Reference(s)
Parent Objects
Instructions
 Discharge
Summary
Child Objects
Encounters Object in Detail
Data Element
Name
Encounter
Attributes
Encounter Care
Team
Encounter
Date/Time
Encounter ID
Encounter
Problem List
Encounter
Provider
Encounter Type
Patient Class
ISO/HL7
Data Type
CDA Reference
Narrative describing the encounter;
ED
Encounter Free
Text
Care Team Member Object
Structure
Data Element Definition
Clinical Example
Date and time of the encounter
May include duration if pertinent
An identifier for the encounter event
TS
II
Expected Value Set
Encounter
Date/Time
Encounter ID
Problems List Object
Structure
Name and other information for the
person or organization that performed
or hosted the encounter
EN
Encounter
Provider
Describes the type of encounter
Out Patient Office Visit
CE
Encounter Type
Categorizes patients by the site where
the encounter occurred.
Emergency, Inpatient
CE
Patient Class
1.21 Encounter Type
Value Set
1.12 Care TransitionPatient Class Value
Set
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Existence of Advance Directives
Existence of Advance Directives Object Summary
Clinical Application
CDA ID Reference(s)
Definition
Captures the existence of
advanced directives for a
patient; simply whether or
not the patient had
advanced directives is
relevant, but type is also
able to be specified
Data Element
Name
Advanced
Directives
Existence
Advance
Directive Owner
Advance
Directive Range
Advance
Directive Type
Patient has discussed advanced
directives with one of their treating
clinicians, made decisions about
their wishes and completed an AD
form.
2.16.840.1.113883.10.20.22.2.21
Existence of Advance Directives Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
Describes the type of the advance
directive
Name, address, or other contact
information of the person for the
person or organization that can
provide a copy of the document
The effective date of the advance
directive
Coded value indicating the type of
advance directive
Life Support
Parent Objects
 Consultation
Request
including
Clinical
Summary
 Consultation
Summary
 Discharge
Instructions
 Discharge
Summary
 Demographics
CDA Reference
ED
Advance
Directive Free
Text Type
EN
Custodian of the
Document
TS
Effective Date
CE
Advance
Directive Type
Child Objects
Expected Value Set
1.2 Advance
Directive Type Value
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Existence of Advance Directives Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
Data Element
Name
CDA Reference
Expected Value Set
Set
Family History
Definition
The patient's family history
data elements which are
not a summary, as the
sending physician may
want to select specific
elements for inclusion.
Family History Object Summary
Clinical Application
CDA ID Reference(s)
Patient has a family history
significant for: mother died of
colon cancer at age 48, maternal
grandmother, paternal
2.16.840.1.113883.10.20.22.2.15
grandfather, and father with
hypertension; maternal
grandfather with unknown cancer,
deceased age 52.
Parent Objects


Child Objects
Consultation
Request
including
Clinical
Summary
Consultation
Summary
Family History Object in Detail
Data Element
Name
Family History
Genetic Relative
Administrative
Gender
Data Element Definition
Textual description about the
problems, diagnoses, and genetic
markers found in genetic relatives. This
field may be used to capture
unstructured or structured family
history information recorded in clinical
records.
gender (i.e., the behavioral, cultural, or
psychological traits typically associated
with one sex) of the genetic relative as
ISO/HL7
Data Type
CDA Reference
Maternal Grandmother
with history of Alzheimer's
Dementia; Paternal
Grandfather with CAD and
HTN, deceased MI age 58
HIST
Family Member
Information
Female
CE
Family Member
Administrative
Gender
Clinical Example
Expected Value Set
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Family History Object in Detail
Data Element
Name
Data Element Definition
Clinical Example
ISO/HL7
Data Type
Patient has had individual
genome analysis that
revealed BRACA 1
Structure
CDA Reference
Expected Value Set
defined for administrative purposes
Genetic Marker
Description
Description of risk-related genetic
markers identified in this individual.
Genetice
Relative Age at
Death
Represents the subject's age at onset of
an event or observation
Genetic Relative
Cause of Death
Observation
Indicates that a particular problem was
the cause of death of the family
member
Genetic Relative
Condition
Condition is the generic term used in
the model to designate conditions,
problems, diagnoses, etc.
Genetic Relative
Date of Birth
Date of birth of the genetic relative
Genetic Relative
Ethnicity
The cultural heritage with which the
genetic relative identifies themselves
PQ
Family Member
Age (at death)
A common scenario is that
a patient will know the
age of a relative when the
relative had a certain
condition or when the
relative died, but will not
know the actual year (e.g.,
"grandpa died of a heart
attack at the age of 50").
Often times, neither
precise dates nor ages are
known (e.g. "cousin died
of congenital heart
disease as an infant").
CD
Family Member
Cause of Death
"cousin has systemic lupus
erythematosus"
CE
Family Member
Condition
TS
Latino
CE
Family Member
Date of Birth
Family Member
Ethnicity
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Family History Object in Detail
Data Element
Name
Data Element Definition
Clinical Example
ISO/HL7
Data Type
Details about problems or diagnoses
for this genetic relative.
Specifies if the family member is a twin,
triplet etc. and whether identical or
fraternal
Clinical Example: Type II
Diabetes
Structure
Patient is second of a twin
birth
CF
Genetic Relative
Problem Status
Status of the genetic relative’s problem
Active, inactive
CS
Genetic Relative
Name
Name of family member. For privacy
reasons this may not be appropriate for
sharing or public display and in this
situation the 'label' should be used.
John Doe
PN
Genetic Relative
Race
Race of the genetic relative
Asian
CE
Genetic Relative
Relationship
The relationship of the genetic relative
to the individual.
Clinical Example: Mother
CE
Genetic Relative
Medical History
Genetic Relative
Multiple Birth
Status
CDA Reference
Expected Value Set
Family Member
Medical History
Family Member
Multiple Birth
Status
Family Member
Problem Status
Family Member
Name
Family Member
Race
Family Member
Relationship
General Results
Definition
The patient's family history
data elements which are
not a summary, as the
sending physician may
want to select specific
elements for inclusion.
General Results Object Summary
Clinical Application
CDA ID Reference(s)
Patient has a family history
significant for: mother died of
colon cancer at age 48, maternal
grandmother, paternal
2.16.840.1.113883.10.20.22.2.15
grandfather, and father with
hypertension; maternal
grandfather with unknown cancer,
deceased age 52.
Parent Objects
Consultation
Request
including
Clinical
Summary
 Consultation
Summary
 Discharge
Child Objects

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General Results Object Summary
Clinical Application
CDA ID Reference(s)
Definition
Parent Objects
Summary
Child Objects
General Results Object in Detail
Data Element
Name
Data Element Definition
Result Type
Coded representation of the
observation performed
Result Narrative
Description of type of results
Date Result
Obtained
Date and time of the results
Result Status
Status of this observation
Result
Interpretation
Result Value
An abbreviated interpretation of the
observation
Value of the result
Result Reference
Range
Reference range for the observation
Clinical Example
Hematology, Chemistry,
Nuclear Medicine
microscopic examination
of the tissue received
marked "lung biosy"
shows adenocarcinoma
ISO/HL7
Data Type
CDA Reference
Expected Value Set
CD
Result Type
1.40 Results Value
Set
ED
TS
Result
Date/Time
Active, aborted
CS
Result Status
Normal, high
CE
13.2 g/dl
PQ
M 13-18 g/dl; F 12-16 g/dl
1.39 Result Status
Value Set
Result
Interpretation
Result Value
Result
Reference
Range
Goals
Definition
This is a list of the healthrelated goals, such as
Goals Object Summary
Clinical Application
CDA ID Reference(s)
The patient and the clinician have
discussed and agree on the
Parent Objects
 Consult(s)
Assessment(s)
Child Objects
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Definition
smoking cessation agreed
upon by the patient and
the physician.
Goals Object Summary
Clinical Application
CDA ID Reference(s)
patient’s goal of 5 lbs. of weight
loss over the next 2 months. Goals
might or might not have a time
frame. For example, maintaining an
HgbA1 below a certain level might
be a goal for a diabetic.
Parent Objects
and Plan(s)
Recommendations
Child Objects
Goals Object in Detail
Data Element
Name
Author
Data Element Definition
The person who records the goal.
What actually happens. Quantifiable
Actual Outcome measureable finding, observation or
result
What is expected to happen.
Desired Outcome Quantifiable measurable description
added to Goal description.
Goal agreed to
by
Any person who agrees to supporting
the goal
Goal Category
The goal type
Goal Description
Goal Established
date/time
The human readable text describing
what is expected to happen
Date and time goal is
entered/identified
Clinical Example
ISO/HL7
Data Type
Nurse, PT, patient, MD.
The MD records goal for
patient to ambulate.
PN
Patient Ambulated 15
feet.
ED
Ambulate 20 feet.
Structure
Nurse, PT, patient, MD,
Patient agrees to goal of
walking 20 feet.
Activity, Diet, medication,
learning etc.
Patient will ambulate
CDA Reference
Expected Value Set
PN
ST
ST
TS
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Goals Object in Detail
Data Element
Name
Data Element Definition
Clinical Example
Goal Intent
The overarching outcome targeted
Patient will return to
baseline status of full free
unlimited ambulation
state as prior to admission
Goal Priority
The ranking of the goal compared to
other goals
1, 2, 3, etc…
Goal Reviewed
by
Goal Revised By
Goal Status
Goal Target
Date/Time
Any person who reviews the goal
Any person who edits or refines the
goal
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.
Nurse reviews goal of
patient’s ambulation goal
as set and refined by MD
and PT
PT refines goal to patient
will ambulate 20 feet
ISO/HL7
Data Type
ED
INT
CDA Reference
Expected Value Set
PN
PN
The goal is Met, not met,
in progress, or on hold.
CS
May be specific end date,
or may have a range date
(beginning and end)
IVL_TS
History of Present Illness
Definition
In a medical encounter, a
history of the present
illness (abbreviated HPI) [1]
(termed history of
presenting complaint (HPC)
in the UK) refers to a
History of Present Illness Object Summary
Clinical Application
CDA ID Reference(s)
Patient reports having new onset
chest pain described as a dull pain
like an elephant sitting on his chest.
1.3.6.1.4.1.19376.1.5.3.1.3.4
Pain radiates down the arm, is
relieved with rest, began 1 week
ago, and lasts for minutes. Pain is
Parent Objects
 Consultation
Request
including
Clinical
Summary
 Consultation
Child Objects
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Definition
detailed interview
prompted by the chief
complaint or presenting
symptom (for example,
pain).
Data Element
Name
History of
Present Illness
History of Present Illness Object Summary
Clinical Application
CDA ID Reference(s)
brought on with stress or climbing
stairs.
History of Present Illness Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
Patient presents with a 24
hour history of urinary
frequency, urgency, and
painful urination. She
Historical details leading up to and
reports that she had
pertaining to the patient’s current
sexual intercourse with a
HIST
complaint or reason for seeking
new male partner ~ 48
medical care
hours ago and denies
fevers, abdominal, or flank
pain, urinary or vaginal
bleeding
Parent Objects
Summary
 Discharge
Summary
CDA Reference
Child Objects
Expected Value Set
Immunization History
Definition
A list of the immunizations
that the patient has
received including date of
immunization, where the
Immunization History Object Summary
Clinical Application
CDA ID Reference(s)
The patient’s immunization history
includes BCG, or bacille Calmette2.16.840.1.113883.10.20.22.2.2.1
Guérin which is a vaccine for TB, as 2.16.840.1.113883.10.20.22.2.2
an infant.
Parent Objects

Child Objects
Consultation
Request
including
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Definition
immunization was
administered if known, and
lot or batch number if
available.
Immunization History Object Summary
Clinical Application
CDA ID Reference(s)
Parent Objects
Clinical
Summary
 Consultation
Summary
 Discharge
Instructions
 Discharge
Summary
Child Objects
Immunization History Object in Detail
Data Element
Name
Category of
Immunization
Data Element Definition
Clinical Example
ISO/HL7
Data Type
CDA Reference
Expected Value Set
CE
Coded Product
Name
1.25 Immunizations
Administered
Vaccine Value Set
TS
Administered
Date
ST
Lot Number
What the immunization is for
Potential for exposure to
pertussis
ED
Contraindication
Reason to not give the immunization in
the future due to previous reaction or
other existing condition
Allergy to component or
immunodeficiency state
BL
Immunization
Administered
Coded immunization description from a
controlled vocabulary
Immunization
Date
Immunization
Lot Number
Immunization
Manufacturer
Name
Immunization
The date and time the immunization
was administered
The manufacturer’s production lot
number for the administered product
Cholera
Manufacturer of immunization
Sanofi Pasteur
ED
Free Text
Product Name
Indicates which type of series the
Current valid values are
IVL_INT
Medication
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Immunization History Object in Detail
Data Element
Name
Series Number
Immunization
Facility
Immunization
Performer
Immunization
Route
Observed
Reaction
Site of Delivery
Refusal Reason
Data Element Definition
patient has been given.
Clinical Example
ISO/HL7
Data Type
Series 1 through 8,
Partially complete,
booster, or complete
EN
Person who administered the
immunization
PN
The response of cells or tissues to an
antigen, as in a test for immunization
Body site where immunization was
administered
Documents the rationale for the
patient declining an immunization
Intranasal, subcutaneous,
intradermal
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
Expected Value Set
Series Number
Facility performing immunization
How immunization is administered
CDA Reference
Performer
1.30 Medication
Route Value Set
CE
COLL
Reaction
Left deltoid arm
CE
Site
"Vaccine safety concerns"
CE
Refusal Reason
1.4 Allergy/Adverse
Reaction Value Set
1.6 Care TransitionBody Site Value Set
1.26 Immunization
Reason Value Set
Invasive & Non-Invasive Procedures
Definition
A listing of all invasive and
non-invasive procedures
for a patient.
Invasive and Non-Invasive Procedures Object Summary
Clinical Application
CDA ID Reference(s)
Defines all interventional, surgical,
diagnostic, or therapeutic
2.16.840.1.113883.10.20.22.2.7.1
procedures or treatments pertinent
Parent Objects

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Consultation
Request
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Definition
Data Element
Name
Entity
Performing
Procedure
Entity
Performing
Procedure
Address
Entity
Performing
Procedure Phone
Number
Invasive and Non-Invasive Procedures Object Summary
Clinical Application
CDA ID Reference(s)
to the patient historically at the
time the document is generated.
May contain all procedures for the
period of time being summarized,
but should include notable
procedures.
Invasive and Non-Invasive Procedures Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
Identifies the location where the
procedure was performed
Critical Care Unit
AD
Phone number of entity performing the
procedure
TN
Invasiveness of
Procedure
Describes invasiveness of the
procedure
Procedure
Records clinically significant
CDA Reference
Child Objects
Expected Value Set
EN
Address of entity performing the
procedure
Non-invasive (ex:
abdominal sonogram),
minimally invasive (ex:
endoscopy), invasive
(open surgery)
Necrotic left ovarian cyst
Parent Objects
including
Clinical
Summary
 Consultation
Summary
 Discharge
Summary
CS
ED
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Data Element
Name
Findings
Procedure
Implants
Procedure
Narrative
Procedure
Performed
Procedure
Provider
Procedure
Specimens Taken
Procedure Time
Site of Procedure
Invasive and Non-Invasive Procedures Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
observations confirmed or discovered
was discovered and
during the procedure or surgery.
removed
Records any materials placed during
A doohickey pacemaker,
the procedure including stents, tubes,
number 3975359 was
ED
and drains.
placed
A 6 mm sessile polyp was
found in the ascending
colon and removed by
Narrative to further describe the
snare, no cautery.
ED
procedure
Bleeding was controlled.
Moderate diverticulosis
and hemorrhoids were
incidentally noted.
This code could come
Contains a code indicating a procedure from various coding
or a non-procedural event involving the systems; typically the
CD
patient
Common Procedure
Terminology (CPT)
Provider performing procedure
Records the tissues, objects, or samples
taken from the patient during the
procedure including biopsies,
aspiration fluid, or other samples sent
for pathological analysis
Date and time of procedure, may
include duration
Anatomical site where procedure is
PN
a .01x .02 cm biopsy was
taken from the left
ventricle
Expected Value Set
Procedure Free
Text Type
Procedure Type
1.34 Procedure
Value Set
Procedure
Provider
ED
IVL_TS
Skin biopsy of the left
CDA Reference
CD
Procedure
Date/Time
Body Site
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Data Element
Name
Times Performed
Invasive and Non-Invasive Procedures Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
performed
eyelid
Indicates the number of times this
procedure was performed for the
patient at one setting
During the laparoscopic
Most procedures are only performed
thermal liver tumor
(and recorded) once; this property
INT
ablation 3 different areas
allows for the recording of multiple
of tumor were ablated
procedures in order to remove the
necessity to record the same procedure
multiple times.
CDA Reference
Expected Value Set
Body Site Value Set
Medical Equipment
Definition
Medical Equipment Object Summary
Clinical Application
CDA ID Reference(s)
Durable Medical Equipment
Crutches, neck brace or cane
(DME), and any other
ordered for the patient
equipment ordered for the
patient.
2.16.840.1.113883.10.20.22.2.23
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 Consultation
Request
including
Clinical
Summary
 Consultation
Summary
 Discharge
Instructions
 Discharge
Summary
Child Objects
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Medical Equipment Object in Detail
Data Element
Name
Equipment Code
Equipment Date
Acquired
Equipment Date
Disposed
Equipment ID
Equipment
Model Name
Equipment
Owner
Equipment
Software Name
Equipment
Software Version
Equipment
Status
Quantity of
Equipment
Data Element Definition
Clinical Example
Coded manufacturer name
Date and time equipment was installed
or affixed
Date and time equipment was removed
or uninstalled
Unique identifier for the device
The human designated moniker for a
device, assigned by the manufacturer
Entity or person who owns the device
CDA Reference
Expected Value Set
Playing Device
DATE
II
CK
EN
The moniker, version and release of the
software that operates the device as
assigned by the software manufacturer
or developer
Version of the equipment software
Describes state or condition of
equipment
Number of devices identified by the
Equipment ID
ISO/HL7
Data Type
CE
DATE
CK
INT
Activated; New
CS
PQ
Quantity
Medical History
Definition
The patient's previous
medical problems.
Medical History Object Summary
Clinical Application
CDA ID Reference(s)
Patient with a past medical history
of gallstones x 2 episodes which
2.16.840.1.113883.10.20.22.2.20
resolved post cholecystectomy

Parent Objects
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Child Objects
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Medical History Object Summary
Clinical Application
CDA ID Reference(s)
Definition
Parent Objects
Clinical
Summary
 Consultation
Summary
 Discharge
Summary
Child Objects
Medical History Object in Detail
Data Element
Name
Medical History
Data Element Definition
Describes all aspects of the medical
history of the patient even if not
pertinent to the current encounter
The history may be limited to
information pertinent to the current
procedure or may be more
comprehensive. The history may be
reported as a collection of random
clinical statements or it may be
reported categorically.
Clinical Example
Patient has a history of
asthma with 3 episodes of
hospitalization, 2 of which
resulted in intubation,
both for less than 72
hours.
ISO/HL7
Data Type
CDA Reference
Expected Value Set
LIST
Medications List
Definition
A list of medications that
patient should be taking or
an entry of no known
medications. The list of
Medications List Object Summary
Clinical Application
CDA ID Reference(s)
The list of all of the medications
2.16.840.1.113883.10.20.22.2.1.1
that the patient is taking, or has
2.16.840.1.113883.10.20.22.2.1
been prescribed, and the patient is
2.16.840.1.113883.10.20.22.2.38
thought to be taking. If a clinician
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Definition
medications includes
compounds that the
patient may be taking (e.g.
herbals).
The metadata for the
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
Medication List was
reconciled during this
encounter and if so by
whom, and if not when last
reconciled and by whom.
Medications List Object Summary
Clinical Application
CDA ID Reference(s)
reads the patient a list of their
medications and the patient
reports that they actually stopped
taking medication “X”, medication
X would be removed from the list.
D/C reconciliation would include
consideration of the prehospitalization medications and
whether these need to be
continued or stopped.
Parent Objects
Summary
 Consultation
Summary
 Discharge
Instructions
 Discharge
Summary
Child Objects
Medications List Object in Detail
Data Element
Name
Data Element Definition
Active
Medications
A list of clinically relevant medications.
Includes: PRN Medication List, Active
Medications (Held for Period of Time),
Medications that patient was exposed
to, now discontinued, but still clinically
relevant, Software need – document
the delta
Clinical Example
Lipitor 20 mg
ISO/HL7
Data Type
CDA Reference
Expected Value Set
CE
Coded Product
Name, Coded
Brand Name,
Free Text
Product Name,
Free Text Brand
Name
1.9 Care TransitionMedication Brand
Name
1.10 Care
TransitionsMedication Clinical
Drug Name
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Medications List Object in Detail
Data Element
Name
Data Element Definition
Clinical Example
ISO/HL7
Data Type
CDA Reference
Includes ICD-9 codes and/or SNOMED
codes
Associated
Assessment
Reason the provider prescribed the
medication
Changed
Medications
Medications that have been modified
in this encounter, i.e. dosage
adjustments
Date Of
Reconciliation
The date of the last active medication
list reconciliation
Discontinued
Medications
Medications that have been
discontinued
Expected Value Set
1.11 Care TransitionMedication Drug
Class
Hyperlipidemia: Lipitor
Lipitor 10 mg
discontinued; Lipitor 20
mg prescribed
BAG
CE
Indication
Coded Product
Name, Coded
Brand Name,
Free Text
Product Name,
Free Text Brand
Name
1.9 Care TransitionMedication Brand
Name
1.10 Care
TransitionsMedication Clinical
Drug Name
1.11 Care TransitionMedication Drug
Class
Coded Product
Name, Coded
Brand Name,
Free Text
Product Name,
Free Text Brand
Name
1.9 Care TransitionMedication Brand
Name
1.10 Care
TransitionsMedication Clinical
Drug Name
1.11 Care TransitionMedication Drug
Class Value Set:
Medication Brand
DATE
Lipitor 10 mg discontinued
CE
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Medications List Object in Detail
Data Element
Name
Data Element Definition
Clinical Example
ISO/HL7
Data Type
CDA Reference
Expected Value Set
Name
Dose
Duration of
Administration
Frequency of
Administration
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 amount of the form to take. For
example Medication XXX 500 mg,
tablets; take ½ tablet, administration
500 mg tablet
unit (e.g., tablet), or an amount of
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 if it is time
For 10 days
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 include event6 hours while awake
related information (e.g., 1 hour
before meals, in the morning, at
bedtime). Complimentary to Interval,
although equivalent expressions may
PQ
Dose
IVL
Duration
IVL_TS
Frequency
1.9 Care TransitionMedication Brand
Name
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Medications List Object in Detail
Data Element
Name
Data Element Definition
ISO/HL7
Data Type
CDA Reference
CE
Product Form
Prescription, over the
counter drug
CE
Type of
Medication
Store in the refrigerator.
Take with food.
ED
Patient
Instructions
PN
Ordering
Provider
PN
Provider
Clinical Example
Expected Value Set
have different implications (e.g., every
8 hours versus 3 times a day)
Medication
Attributes
Medication Type
Patient
Instructions
Prescriber
Reconciled By
Route of
Administration
This is the physical form of the
Tablet, capsule, liquid or
product as presented to the individual. ointment
Classification based on how the
medication is marketed
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 medication is
received by the patient (e.g., by
mouth, intravenously, topically, etc.)
By mouth; or apply to skin
in area of rash
CE
Route
Amputation stump
CE
Site
Start Date
Used to express the start date for a
medication
TS
Indicate
Medication
Started
Status of
Indicate if the active medication list
CS
Site of Delivery
The anatomic site where the medication is
administered.
Usually applicable to injected or topical
products
1.29 Medication
Product Form Value
Set
1.31 Medication
Type Value Set
1.30 Medication
Route Value Set
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Medications List Object in Detail
Data Element
Name
Reconciliation
Stop Date
Vehicle for
Delivery
When to Take
Data Element Definition
has been reconciled
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 stop, such as antibiotic
treatment, etc.
Non-active ingredient(s), or
substances not of therapeutic interest,
in which the active ingredients are
dispersed. Most often applied to liquid
products where the major fluid
component is considered the vehicle.
For PRN meds this information would
be take when you are experiencing
the system, e.g. take you
nitroglycerine when you are
experiencing chest pain
ISO/HL7
Data Type
CDA Reference
TS
Indicate
Medication
Stopped
Normal Saline is the
vehicle in “Ampicillin
150mg in 50ml NS”;
Aquaphor is the vehicle in
“10% LCD in Aquaphor”
CE
Vehicle
At bedtime daily
IVL_TS
Administration
Timing
Clinical Example
Expected Value Set
1.28 Medication
Method for Delivery
Value Set
Operative Summary
Definition
Operative report containing
details on operation
performed and diagnoses
pre and post operation.
Operative Summary Object Summary
Clinical Application
CDA ID Reference(s)
Operative Report
Parent Objects
Child Objects
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Operative Summary Object in Detail
Data Element
Name
Postoperative
Diagnosis
Preoperative
Diagnosis
Operative
Procedure
Operative
Summary
Narrative
Data Element Definition
Records the diagnosis or diagnoses
discovered or confirmed through the
surgery
Records the surgical diagnosis or
diagnoses assigned to the patient
before the surgical procedure and is to
be confirmed through the surgery
The operative procedure that was
performed
Narrative of the operation(s)
performed
Clinical Example
ISO/HL7
Data Type
CDA Reference
Expected Value Set
Acute cholecystitis and
cholelithiasis
CD
1.14 Care
Transition- Problem
Value Set
Acute cholecystitis and
cholelithiasis
CD
1.14 Care
Transition- Problem
Value Set
laparascopic
cholecystectomy
The Hasson cannula was
reinserted and the
remaining port sites
inspected and removed
under direct vision
CE
ED
Patient Contact Information
Definition
Main contact information
for the patient, including
telecommunications and
physical addresses. Also
includes information on if
the patient has a Directspecific electronic endpoint
address and has text
messaging enabled.
Patient Contact Object Summary
Clinical Application
CDA ID Reference(s)
The clinical information that the
patient provides about how to
reach them.
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Parent Objects

Child Objects
Demographics
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Data Element
Name
Patient DirectEnabled Address
Patient Home
Address
Patient Home
Phone
Patient Home
Phone Text
Message Enabled
Patient
Portal/PHR
Available
Patient
Portal/PHR URL
Patient Work
Phone
Patient Work
Phone Text
Message Enabled
Primary Email
Address
Secondary Email
Patient Contact Information Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
The electronic endpoint address of the
TN
patient
CDA Reference
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
Person Address
A telephone number (voice or fax),
TN
Patient
Phone/Email/URL
Is text messaging enabled on the
patient's home phone?
BL
Is a patient portal or PHR available?
BL
The URL of the patient portal or URI of
the PHR
TN
A telephone number (voice or fax),
TN
Is text messaging enabled on the
patient's work phone?
BL
Primary email address for the patient
TN
Secondary email address for the
TN
Expected Value Set
1.8 Care TransitionCountry Value Set
1.13 Care
Transition- Postal
Code Value Set
1.20 Care
Transition- State
Value Set
Patient
Phone/Email/URL
Patient
Phone/Email/URL
Patient
Phone/Email/URL
Patient
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Data Element
Name
Address
Patient Contact Information Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
patient (may be a work-related email
address)
CDA Reference
Expected Value Set
Phone/Email/URL
Patient Information
Definition
Information used to
specifically help in the
identification of the
patient.
Patient Information Object Summary
Clinical Application
CDA ID Reference(s)
Content identifies the patient
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Parent Objects

Child Objects
Demographics
Patient Information Object in Detail
Data Element
Name
Mothers Maiden
Name
Patient Date of
Birth
Patient
Administrative
Data Element Definition
The family name under 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 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
Gender (i.e., the behavioral, cultural, or
psychological traits typically associated
Clinical Example
ISO/HL7
Data Type
CDA Reference
PN
Mother’s
Maiden Name
TS
Person Date of
Birth
CE
Gender
Expected Value Set
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Patient Information Object in Detail
Data Element
Name
Gender
Patient
Identifiers
Patient Marital
Status
Patient Name
Data Element Definition
with one sex) as defined for
administrative purposes
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
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
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 produced. Former
values might be part of the personal
and social history
The individual to whom the exchange
refers. Multiple names are allowed to
Clinical Example
Married Polygamous; Civil
Union; Single; Divorced;
Widowed
ISO/HL7
Data Type
CDA Reference
II
Person ID
CE
Marital Status
PN
Person Name
Expected Value Set
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Patient Information Object in Detail
Data Element
Name
Data Element Definition
Clinical Example
ISO/HL7
Data Type
CDA Reference
Expected Value Set
retain birth name, maiden name, legal
names and aliases as required
Patient Instructions
Definition
Information provided to
the patient by the care
team members detailing
what the patient needs to
do regarding their
healthcare.
Patient Instructions Object Summary
Clinical Application
CDA ID Reference(s)
The patient’s wound care
instructions including washing the
wound daily with warm soapy
water, drying the area completely,
applying a film of petroleum jelly
over the wound and applying a
fresh bandage loosely to cover the
wound.
Parent Objects
Child Objects
Patient Instructions Object in Detail
Data Element
Name
Patient
Instructions
Narrative
Instruction
Delivery Method
Instructions Type
Definition
Records instructions given to a patient.
Manner in which instructions were
provided
Defines the application of instructions.
Clinical Example
ISO/HL7
Data Type
Drink at least 8, 8 oz,
glasses of H2O per day
ED
Verbal
ED
Patient Education
CD
CDA Reference
Expected Value Set
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Payer Information
Payer Information Object Summary
Clinical Application
CDA ID Reference(s)
Definition
Primary and secondary
insurance provider
information applicable to
the patient.
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Parent Objects
 Consultation
Request
including
Clinical
Summary
 Consultation
Summary
 Discharge
Summary
Child Objects
CDA Reference
Expected Value Set
Payer Information Object in Detail
Data Element
Name
Definition
Clinical Example
ISO/HL7
Data Type
Name of Payer
The name of the insurance company
EN
Insurance
Company Name
Patient Member
ID
The identifier assigned by the health
insurance payer to the patient
INT
Member ID
Patient
Relationship to
Subscriber
Specifies only if patient is the
subscriber or dependent is within the
context of the specified health plan
CE
Patient
Relationship to
Subscriber
Primary Payer
Address
The official mailing address to which
written correspondence is to be
directed
AD
The policy or group contract number
ED
Primary Payer
1.22 Health
Insurance
Subscriber
Relationship Value
Set
Health Plan
Insurance
Information
Source Address
Group Number
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Payer Information Object in Detail
Data Element
Name
Group Number
Primary Payer
Type
Definition
Clinical Example
ISO/HL7
Data Type
CDA Reference
Expected Value Set
identifying the contract between a
health plan sponsor and the health
plan.
This is not a number that uniquely
identifies either the subscriber or
person covered by the health insurance
The type of primary health plan
covering the individual
Health Insurance
Type
PPO, HMO, POS, etc.
Secondary Payer
Address
The official mailing address to which
written correspondence is to be
directed
AD
Health Plan
Insurance
Information
Source Address
Secondary Payer
Group Number
The policy or group contract number
identifying the contract between a
health plan sponsor and the health
plan.
This is not a number that uniquely
identifies either the subscriber or
person covered by the health insurance
ED
Group Number
TN
Health Plan
Insurance
Information
Source
Phone/Email/URL
Secondary Payer
Phone
Secondary payer’s contact number
Secondary Payer
Type
The type of secondary health plan
covering the individual
PPO, HMO, POS, etc.
Health Insurance
Type
1.23 Health
Insurance Type
Value Set
1.23 Health
Insurance Type
Value Set
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Physical Activity
Definition
The provider
recommended physical
activity to the patient.
Physical Activity Object Summary
Clinical Application
CDA ID Reference(s)
Parent Objects
Child Objects
Patient to ambulate using a 4 point
walker
Physical Activity Object in Detail
Data Element
Name
Data Element Definition
Activity
Motivation
Patient’s perception and/or willingness
that they need to increase their
exercise intervals, intensity or total
weekly commitment to physical
activity.
Exercise Vital
Sign (EVS)
Physical Activity
Assessment
A computable value which translates
into “minutes/week” of physical
activity.
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
Clinical Example
Example: “Yes, I need to
increase my
activity/exercise”
Answer: Yes/No/Unsure
Example:
1. Patient states they
typically exercise 4
days/week.
2. Patient states they
typically walk 15
minutes/day.
EHR Calculates: days x
minutes/day =
minutes/week.
Assessment can be
completed in terms of
frequency, duration,
intensity, and type of
activity using objective or
ISO/HL7
Data Type
CDA Reference
Expected Value Set
BL
IVL_TS
LIST
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Physical Activity Object in Detail
Data Element
Name
Data Element Definition
fitness and overall health
Clinical Example
ISO/HL7
Data Type
CDA Reference
Expected Value Set
self-reported measures.
Physical Exam
Definition
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.
Physical Exam Object Summary
Clinical Application
CDA ID Reference(s)
Parent Objects

Pupils equal reactive to light and
accommodation; equal ocular
movements Intact, 2+ lower
extremity edema; Heart: regular
rate and rhythm.
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

Child Objects
Consultation
Request
including
Clinical
Summary
Consultation
Summary
Discharge
Summary
Physical Exam Object in Detail
Data Element
Name
Physical Exam
Component
Data Element Definition
Device used by the clinician to make
observation
Clinical Example
Stethoscope
ISO/HL7
Data Type
CDA Reference
Expected Value Set
Structure
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Physical Exam Object in Detail
Data Element
Name
Data Element Definition
Clinical Example
Physical Exam
Narrative
Direct observations made by the
clinician
Pupils equal round and
reactive to light and
accomodation;
The examination may be
reported as a collection of
random clinical
statements or it may be
reported categorically
Physical
Observations
Observations made by the examining
clinician using inspection, palpation,
auscultation, and percussion
All normal to examination
ISO/HL7
Data Type
HIST
CE
CDA Reference
Expected Value Set
Primary Care and Designated Providers
Definition
A list of the primary care
physicians applicable to the
patient, as well as other
designated providers and
specialists who may work
with the patient.
Data Element
Name
Provider Domain
Primary Care and Desginated Providers Object Summary
Clinical Application
CDA ID Reference(s)
This list will include information
about the provider's specializations
and whether they are part of the
patient's care team.
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Primary Care and Designated Providers Object
ISO/HL7
Data Element Definition
Clinical Example
Data Type
Provider role uses a coded value to
Behavioral Health & Social CF
Parent Objects

Child Objects
Demographics
CDA Reference
Provider Role
Expected Value Set
1.15 Care
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Data Element
Name
of Management
Provider Fax
Number
Provider Name
Provider NPI
Provider Patient
Identifier
Provider PCMH
Provider Phone
Number
Provider Portal
URL
Provider Primary
Primary Care and Designated Providers Object
ISO/HL7
Data Element Definition
Clinical Example
Data Type
classify providers according to the role Service Providers
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 the information
often required during patient
registration, identifying the patient's
primary care provider, the referring
physician or other consultant involved
in the care of the patient
The fax number of the provider’s
TN
organization
The name of the provider
National Provider Identifier or NPI is a
unique identification number issued to
healthcare providers in the United
States
The identifier used by the provider to
identify the patient’s medical record
PN
II
Expected Value Set
Transition- Provider
Role Value Set
Provider
Phone/Email/URL
Encounter
Provider
National Provider
ID
II
The patient's PCMH
EN
The provider’s contact phone number
TN
The URL of the provider’s patient
portal
The mailing address to which written
CDA Reference
TN
AD
Provider’s
Organization
Name
Provider
Phone/Email/URL
Provider
Phone/Email/URL
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Data Element
Name
Address
Provider Primary
Email Address
Primary Care and Designated Providers Object
ISO/HL7
Data Element Definition
Clinical Example
Data Type
correspondence to this provider
should be directed
The primary email for contact
purposes
Provider
Secondary
Address
The mailing address for the provider if
the primary address is unavailable.
Provider
Specialties
Provider type classifies providers
according to the type of license or
accreditation they hold or the service
they provide
physician, dentist,
pharmacist, etc.
CDA Reference
Expected Value Set
Country Value Set
1.13 Care
Transition- Postal
Code Value Set
1.20 Care
Transition- State
Value Set
TN
Provider
Phone/Email/URL
TN
1.8 Care TransitionCountry Value Set
1.13 Care
Provider
Transition- Postal
Phone/Email/URL Code Value Set
1.20 Care
Transition- State
Value Set
CF
1.16 Care
Transition- Provider
Type Value Set
Provider Type
Problems List
Definition
What clinician sending the
message has determined to
be the patient's active
Problems List Object Summary
Clinical Application
CDA ID Reference(s)
All of the chronic problems or
health issues that the patient’s
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Parent Objects
 Consultation
Request
including
Child Objects
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Definition
problems and/or diagnoses
or determination of no
known problems - this list
may be reconciled at each
care transition.
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.
Problems List Object Summary
Clinical Application
CDA ID Reference(s)
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).
Parent Objects
Clinical
Summary
 Consultation
Summary
 Discharge
Instructions
 Discharge
Summary
 Encounters
Child Objects
Problems List Object in Detail
Data Element
Name
Active Problem
Attributes
Active Problem
Name
Data Element Definition
Clinical Example
ISO/HL7
Data Type
CDA Reference
Expected Value Set
1.14 Care TransitionProblem Value Set
List of coded values capturing problem
health status
Asthma
CD
Problem Code
Actual name of the problem
No known problems
ED
Problem Name
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Problems List Object in Detail
Data Element
Name
Active Problem
Type
Problem Assignee
Problem Assignee
ID
Reconciled By
Reconciliation
Date
Reconciliation
Status
Start Date Of
Problem
Data Element Definition
Indicates the level of medical
judgment used to determine the
existence of a problem
The person that entered the problem
in the EHR date/time stamped
Identifier for the person that entered
the problem in the EHR
Who reconciled the problem list
The date/time stamp for the last
reconciliation of the problem list
Clinical Example
Complaint
ISO/HL7
Data Type
CDA Reference
Expected Value Set
CD
Problem Type
1.33 Problem Type
Value Set
PN
II
Treating
Provider
Treating
Provider ID
PN
TS
Has the problem list been reconciled?
Boolean
This is the range of time of which the
problem was active for the patient
Includes the date of onset
IVL_TS
Problem Date
Reason for Consult Request
Definition
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 specific patient
Reason for Consult Request Object Summary
Clinical Application
CDA ID Reference(s)
Parent Objects

The patient has a large left sided
thyroid nodule; please evaluate
and perform a fine needle
aspiration if deemed appropriate.
1.3.6.1.4.1.19376.1.5.3.1.3.1


Child Objects
Consultation
Request
including
Clinical
Summary
Consultation
Summary
Consult(s)
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Definition
history and the issues that
the requesting physician
wants the consulting
physician to address, or the
activities that the
requesting physician or
other clinical professional
wants the consulting
physician or other clinical
professional to perform.
Data Element
Name
Provisional
Diagnosis
Requested
Procedure
Reason for Consult Request Object Summary
Clinical Application
CDA ID Reference(s)
Reason for Consult Request Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
Description of unconfirmed diagnosis
A procedure that is requested as part
of this order.
Request Reason
Reason for consult/procedure
encounter request
Request Type
Indicates the type of request
Sore throat or back pain
FN Interactive psychiatric
diagnostic interview
examination A of the
thyroid nodule
Examples are "Medical
Necessity", "Patient's
Request" and
"Dependency". Note:
medical reason(s) for the
consult are specified as
associated diagnoses.
Consult, procedure
Parent Objects
Assessment(s)
and Plan(s)
Recommendations
Child Objects
CDA Reference
Expected Value Set
CE
Procedure Type
1.34 Procedure
Value Set
CE
Reason for Visit
ED
ED
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Data Element
Name
Source of
Request
Reason for Consult Request Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
Identifies the source of the consult
Community, Other facility EN
request
CDA Reference
Expected Value Set
Facility Name
Review of Systems
Definition
Subjective patient supplied
information regarding the
patient's different bodily
systems.
Review of Systems Object Summary
Clinical Application
CDA ID Reference(s)
Patient denies change in bowel
habits, black stool or bright red
1.3.6.1.4.1.19376.1.5.3.1.3.18
blood per rectum.
Parent Objects

Child Objects
Discharge
Summary
Review of Systems Object in Detail
Data Element
Name
Data Element Definition
Review of
Systems
Narrative
Relevant collection of symptoms and
functions systematically gathered by a
clinician.
Includes symptoms the patient is
currently experiencing, some of which
were not elicited during the history of
present illness, as well as a potentially
large number of pertinent negatives,
for example, symptoms that the patient
denied experiencing.
Clinical Example
ISO/HL7
Data Type
CDA Reference
Expected Value Set
Patient denies recent
history of fever or malaise.
Positive for weakness and
shortness of breath. One
episode of melena. No
ED
recent headaches. Positive
for osteoarthritis in hips,
knees and hands.
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Social History
Definition
Subjective patient supplied
information that addresses
occupational and
recreational aspects of the
patient's personal life that
have the potential to be
clinically significant such as
sexual history, smoking
history and ETOH.
Social History Object Summary
Clinical Application
CDA ID Reference(s)
Patient smokes 2 packs of
cigarettes per day for 20 years.
2.16.840.1.113883.10.20.22.2.17
Parent Objects
 Consultation
Request
including
Clinical
Summary
 Consultation
Summary
 Discharge
Summary
Child Objects
Social History Object in Detail
Data Element
Name
Social History
Details
Social History
Attribute Status
Social History
Range
Social History
Type
Data Element Definition
Clinical Example
Narrative description of social
situation.
Describes current state of social
attribute
Range of time the social attribute was
active for the patient
Active
Coded entry for type of social attribute
Alcohol intake (observable
entity)
ISO/HL7
Data Type
ED
ST
IVL_TS
CD
CDA Reference
Expected Value Set
Social History
Free Text
Social History
Observed Value
Social History
Date
Social History
Type
1.41 Social History
Type Value Set
Support Contacts
Definition
A list of the primary and
Support Contacts Object Summary
Clinical Application
CDA ID Reference(s)
2.16.840.1.113883.10.20.21.1.1

Parent Objects
Demographics
Child Objects
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Definition
secondary caregiver
contacts and their relevant
information.
Support Contacts Object Summary
Clinical Application
CDA ID Reference(s)
[US Realm Document Header]
Parent Objects
Child Objects
Support Contacts Object in Detail
Data Element
Name
Data Element Definition
Contact Type
Identifies the relationship of the
support contact to the patient
Primary
Emergency
Contact Address
Primary
Emergency
Contact Name
Primary
Emergency
Contact Phone
Primary
Emergency
Contact
Relationship
Secondary
Emergency
Contact Address
Clinical Example
CDA Reference
CE
Contact Type
AD
Contact Address
PN
Contact Name
Phone number of the primary
emergency contact
TN
Contact
Phone/Email/URL
Identifies the relationship of the
contact person to the individual for
which this exchange refers
ED
Contact
Relationship
The address of the contact individual or
organization providing support to the
individual for which this exchange is
AD
Contact Address
The address of the contact individual or
organization 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
Next of kin
ISO/HL7
Data Type
Expected Value Set
1.18 Care TransitionRelationship Value
Set
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Support Contacts Object in Detail
Data Element
Name
Secondary
Emergency
Contact Name
Secondary
Emergency
Contact Phone
Secondary
Emergency
Contact
Relationship
Data Element Definition
produced
The name of the individual or
organization providing support to the
individual for which this exchange is
produced
Clinical Example
ISO/HL7
Data Type
CDA Reference
PN
Contact Name
Phone number of secondary
emergency contact
TN
Contact
Phone/Email/URL
Identifies the relationship of the
contact person to the individual for
which this exchange refers
ED
Contact
Relationship
Expected Value Set
Surgical/Procedural History
Definition
The previous surgery and
procedures that a patient
has had.
Surgical/Procedural History Object Summary
Clinical Application
CDA ID Reference(s)
Patient had cholecystectomy in
1995.
2.16.840.1.113883.10.20.22.2.7
Parent Objects
 Consultation
Request
including
Clinical
Summary
 Consultation
Summary
 Discharge
Summary
Child Objects
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Data Element
Name
Procedure
History
Surgical History
Surgical/Procedural History Object in Detail
ISO/HL7
Data Element Definition
Clinical Example
Data Type
Listing of the patient’s procedure
HIST
history
Listing of the patient’s surgical history
HIST
CDA Reference
Expected Value Set
Women’s Health
Definition
Pertinent information of
women's health case
summarization of a patient
Women’s Health Object Summary
Clinical Application
CDA ID Reference(s)
Captures information of health
history specific to women
including, scheduled or anticipated
tests and studies such as
mammograms, pap tests, etc.
Parent Objects
Child Objects
Women’s Health Object in Detail
Data Element
Name
Pregnancy Status
History of Sexual
Trauma
Pap Regimen
Pap Regimen
Start Date
Genetic Relative
Data Element Definition
Indicates whether the patient is
currently pregnant.
Indicates whether the patient has
experienced any sexual trauma (rape,
sexual assault, etc.) as a civilian.
Identifies the current Pap regimen for
the patient.
The date on which the patient began or
will begin her current PAP regimen.
Indicates whether the patient or the
Clinical Example
Possible values include:
Yes, No, Declined to
answer, Unknown.
ISO/HL7
Data Type
CDA Reference
ED
Pregnancy
Expected Value Set
CS
CF
TS
Possible values include:
Structure
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Women’s Health Object in Detail
Data Element
Name
Breast Cancer
Status
Data Element Definition
one of the patient's relatives have had
breast cancer.
Identifies the current or next breast
Breast Treatment procedure or treatment recommended
for this patient.
The date when the current or next
Breast Treatment
breast procedure or treatment should
Date
be completed.
Identifies the current or next cervical
Cervical
procedure or treatment recommended
Treatment
for this patient.
The date when the current or next
Cervical
cervical procedure or treatment should
Treatment Date
be completed.
An indication of whether the patient
DES Daughter
was exposed to diethylstilbestrol (DES)
in utero.
Clinical Example
ISO/HL7
Data Type
CDA Reference
Expected Value Set
No family history, 2nd
degree relative, 1st
degree relative, 3: More
than one 1st degree
relatives, Personal history,
or Unknown.
Structure
TS
Structure
TS
Possible values include:
Yes, No, or Unknown.
Structure
Vital Signs
Definition
Vital signs are measures of
various physiological
Vital Signs Object Summary
Clinical Application
CDA ID Reference(s)
Patient's blood pressure is 120/80, 2.16.840.1.113883.10.20.22.2.4.1
Temp 99 F, Height 5’ 3”, Weight
2.16.840.1.113883.10.20.22.2.4

Parent Objects
Consultation
Request
Child Objects
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Definition
statistics, often taken by
health professionals, in
order to assess the most
basic body functions.
Vital Signs Object Summary
Clinical Application
CDA ID Reference(s)
113, Respiratory Rate 14 and Heart
Rate 60.
Parent Objects
including
Clinical
Summary
 Consultation
Summary
 Discharge
Summary
Child Objects
ISO/HL7
Data Type
CDA Reference
Expected Value Set
CE
Site
Vital Signs Object in Detail
Data Element
Name
Body Site
Device
Observation
Method
Data Element Definition
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.
Identifies the device used to measure
the vital sign.
Indicates Medical Equipment Object
A code that provides additional detail
about the means or technique used to
ascertain the observation.
Observation
Range
Reference range for the vital sign
observation
Observation
Time
The date/time on which the
measurement was taken.
Provides an indication of the state of
the patient at the time of the
Patient State
Clinical Example
1.6 Care TransitionBody Site Value Set
Structure
CK
IVL
TS
Standing blood pressure
can be significantly
Vital Sign Result
Reference
Range
Vital Sign Result
Date/Time
ED
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Vital Signs Object in Detail
Data Element
Name
Data Element Definition
observation. For example, a blood
pressure may be taken while the
patient is exercising or at rest.
Status
Vital Sign ID
Vital Sign Type
Indicates the status of the Vital Signs
measurement record
Uniquely identifies the Vital Signs
measurement.
Indicates which Vital Sign was
measured. From a code set of
allowable Vital Sign codes.
Clinical Example
ISO/HL7
Data Type
CDA Reference
Expected Value Set
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.
CS
II
Heart Beat
CK
Vital Sign Result
Status
Vital Sign Result
ID
Vital Sign Result
Type
1.42 Vital Signs
Result Type
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Appendix A: CEDD Object Model Examples
Demographics Object Model Example
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)
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
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)
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Consultation Request including Clinical Summary Object Model Example
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 Summa 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 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)
Discontinued Medication List: LIST (Sequence)
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)
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Consultation Summary Object Model Example
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 nsulta tio n Summa ry
Consultation Summary 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
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 Medication List
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)
Primary Payer Information: ED (Encapsulated Data)
Secondary Payer Information: ED (Encapsulated Data)
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Discharge Instructions Object Model Example
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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Discharge Summary Object Model Example
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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