July 8, 2009

Version 1.1

HITSP CDA Content Modules Component

Submitted to:

Healthcare Information Technology Standards Panel

Submitted by:

Care Management and Health Records Domain Technical Committee

Document Change History

Version Number	Description of Change	Name of Author	Date Published
	Template V2.4	Project Team	July 31, 2008
0.0.1	Review Copy	Care Management and Health Records Domain Technical Committee	September 26, 2008
0.0.2	Review Copy	Care Management and Health Records Domain Technical Committee	December 10, 2008
1.0	Released for Implementation	Care Management and Health Records Domain Technical Committee	December 18, 2008
	Template V2.5	Project Team	June 30, 2009
1.0.1	Review Copy	Care Management and Health Records Domain Technical Committee	June 30, 2009
1.1	Released for Implementation	Care Management and Health Records Domain Technical Committee	July 8, 2009

Table of Contents

1.0 Introduction. 7

1.1 Overview. 7

1.2 Copyright Permissions. 7

1.3 Reference Documents. 7

1.4 Conformance. 7

1.4.1 Conformance Criteria. 7

1.4.2 Conformance Scoping, Subsetting and Options. 8

1.5 Document Conventions. 8

1.5.1 Key Words. 8

1.5.2 Constraints. 8

2.0 Component Definition. 9

2.1 Context Overview. 9

2.1.1 Component Constraints. 10

2.1.2 HITSP Data Elements. 11

2.1.3 Component Dependencies. 31

2.2 Rules for Implementing Components in CDA. 32

2.2.1 CDA Sections. 34

2.2.2 Entry Content Modules. 41

2.3 Standards. 97

2.3.1 Regulatory Guidance. 97

2.3.2 Selected Standards. 97

2.3.3 Informative Reference Standards. 98

3.0 Appendix. 99

3.1 HITSP Constraints Defined in this Document 99

3.2 Template Identifiers. 112

4.0 Document Updates. 115

4.1 December 10, 2008. 115

4.1.1 Global 115

4.1.2 Section 2.1 Contect Overview. 115

4.1.3 Section 2.2 Rules for Implementing. 116

4.1.4 Section 2.2.1.x Section Content Modules. 116

4.1.5 Section 2.2.1.23 Assessments and Plan Section. 116

4.1.6 Section 2.2.1.28 Medical equipment Section. 116

4.1.7 Section 2.2.2.5 Insurance Provider 116

4.1.8 Section 2.2.2.7 Condition. 116

4.1.9 Section 2.2.2.11 Comment 116

4.1.10 Section 2.2.2.15.2 Results Type. 116

4.1.11 Section 2.2.2.17 Procedure. 116

4.1.12 Section 2.2.2.18 Family History. 116

4.1.13 Section 2.2.2.19 Social History. 116

4.1.14 Section 2.3.2 Selected standards. 117

4.2 December 18, 2008. 117

4.3 June 30, 2009. 117

4.4 July 8, 2009. 118

Figures and Tables

Figure 2-1 Rules for Implementing Clinical Documents. 33

Figure 2-2 Person Name Example. 43

Figure 2-3 Address Example. 44

Figure 2-4 Telephone Numbers and E-mail Addresses Example. 45

Figure 2-5 Gender Code Examples. 45

Figure 2-6 Marital Status Example. 46

Figure 2-7 Race Coding Example. 46

Figure 2-8 Ethnicity Coding Example. 46

Figure 2-9 Religious Affiliation Example. 46

Figure 2-10 Language Communication Examples. 47

Figure 2-11 Support Examples. 49

Figure 2-12 Contact Type Examples. 49

Figure 2-13 Healthcare Provider Example. 51

Figure 2-14 Insurance Provider Examples. 54

Figure 2-15 Group Number Example. 55

Figure 2-16 Health Insurance Type Example. 55

Figure 2-17 Payer Example. 56

Figure 2-18 Member Information Examples. 57

Figure 2-19 Subscriber Information Example. 58

Figure 2-20 Health Plan Example. 59

Figure 2-21 Allergies and Drug Sensitivities Example. 61

Figure 2-22 Problem Date Examples. 64

Figure 2-23 Problem Type Example. 64

Figure 2-24 Problem Name Example. 64

Figure 2-25 Problem Code Example. 65

Figure 2-26 Treating Provider Example. 65

Figure 2-27 Free Text Sig Example. 68

Figure 2-28 Administration Timing Examples. 69

Figure 2-29 Route of Administration Example. 70

Figure 2-30 Dose Examples. 70

Figure 2-31 Product Form Example. 71

Figure 2-32 Delivery Method. 71

Figure 2-33 Medication Information Example. 72

Figure 2-34 Type of Medication. 73

Figure 2-35 Status of Medication Example. 74

Figure 2-36 Indication Example. 74

Figure 2-37 Patient Instructions Example. 75

Figure 2-38 Vehicle Example. 75

Figure 2-39 Order Information Examples. 77

Figure 2-40 Fills Example. 78

Figure 2-41 Quantity Ordered Examples. 78

Figure 2-42 Fulfillment Instructions Example. 79

Figure 2-43 Prescription Number Example. 79

Figure 2-44 Pregnancy Coding Example. 81

Figure 2-45 Comment Example. 82

Figure 2-46 Advance Directive Example. 84

Figure 2-47 Immunization Example. 86

Figure 2-48 Results Example. 88

Figure 2-49 Encounters Example. 90

Figure 2-50 Family History Example. 94

Figure 2-51 Pedigree Example. 95

Figure 2-52 Age Example. 96

Figure 2-53 Cause of Death Example. 97

Table 1-1 Reference Documents. 8

Table 2-1 Module Categories. 10

Table 2-2 Data Element Definition. 11

Table 2-3 Person Information Data Mapping Table Definitions. 12

Table 2-4 Person Information Data Mapping Table Definitions Patient Information Event Entry. 12

Table 2-5 Person Information Data Mapping Table Definitions: Personal Information. 13

Table 2-6 Language Spoken Data Mapping Table Definitions. 14

Table 2-7 Support Data Mapping Table Definitions: Support 14

Table 2-8 Support Data Mapping Table Definitions: Contact 14

Table 2-9 Healthcare Providers Data Mapping Table Definitions: Provider 15

Table 2-10 Healthcare Providers Data Mapping Table Definitions: Provider Entity. 15

Table 2-11 Insurance Provider Data Mapping Table Definitions: Payment Provider Event Entry. 16

Table 2-12 Insurance Provider Data Mapping Table Definitions: Payer 16

Table 2-13 Insurance Provider Data Mapping Table Definitions: Patient 17

Table 2-14 Insurance Provider Data Mapping Table Definitions: Patient Information. 18

Table 2-15 Insurance Provider Data Mapping Table Definitions: Patient 18

Table 2-16 Insurance Provider Data Mapping Table Definitions: Subscriber Information. 19

Table 2-17 Insurance Provider Data Mapping Table Definitions: Guarantor Information. 20

Table 2-18 Insurance Provider Data Mapping Table Definitions: Health Plan. 20

Table 2-19 Allergy/Drug Sensitivity Data Mapping Table Definitions: Adverse Event Entry. 21

Table 2-20 Allergy/Drug Sensitivity Data Mapping Table Definitions: Product 21

Table 2-21 Allergy/Drug Sensitivity Data Mapping Table Definitions: Reaction. 21

Table 2-22 Allergy/Drug Sensitivity Data Mapping Table Definitions: Severity. 21

Table 2-23 Conditions Data Mapping Table Problem Event Entry. 22

Table 2-24 Medication - Prescription and Non-Prescription Data Mapping Table Definitions: Administration Information Event Entry. 22

Table 2-25 Medication - Prescription and Non-Prescription Data Mapping Table Definitions: Medication Information 24

Table 2-26 Medication - Prescription and Non-Prescription Data Mapping Table Definitions: Order Information 25

Table 2-27 Pregnancy Data Mapping Table Definitions. 26

Table 2-28 Information Source Data Mapping Table Definitions: Author 26

Table 2-29 Information Source Data Mapping Table Definitions: Information Source. 26

Table 2-30 Advance Directives Data Mapping Table Definitions. 27

Table 2-31 Immunizations Data Mapping Table Definitions: Immunization Event Entry. 27

Table 2-32 Immunizations Data Mapping Table Definitions: Medication Information. 27

Table 2-33 Vital Signs Data Mapping Table Definitions. 28

Table 2-34 Results Data Mapping Table Definitions: Result Event Entry. 28

Table 2-35 Encounters Data Mapping Table Definitions: Encounter Event Entry. 29

Table 2-36 Procedure Data Mapping Table Definitions. 29

Table 2-37 Family History Data Mapping Table Definitions. 30

Table 2-38 Social History Data Mapping Table Definitions: Social History Event Entry. 32

Table 2-39 Component Dependencies. 33

Table 2-40 Mapping Tables Conventions. 34

Table 2-41 Optionality. 35

Table 2-42 Repeatability. 35

Table 2-43 Person Information Data Mapping Table Requirements. 43

Table 2-44 Language Spoken Data Mapping Table - Requirements. 47

Table 2-45 Support Data Mapping Table Requirements. 48

Table 2-46 Healthcare Providers Data Mapping Table Requirements. 50

Table 2-47 Insurance Provider Data Mapping Table Requirements. 52

Table 2-48 Allergy/Drug Sensitivity Data Mapping Table Requirements. 60

Table 2-49 Conditions Data Mapping Table Requirements. 62

Table 2-50 Medication Prescription and Non-Prescription Data Mapping Table Requirements. 66

Table 2-51 Pregnancy Data Mapping Table Requirements. 81

Table 2-52 Information Source Data Mapping Table Requirements. 81

Table 2-53 Comments Data Mapping Table Definitions: Author 82

Table 2-54 Comments Data Mapping Table Requirements. 82

Table 2-55 Advance Directives Data Mapping Table Requirements. 83

Table 2-56 Immunizations Data Mapping Table Requirements. 85

Table 2-57 Vital Signs Data Mapping Table Requirements. 87

Table 2-58 Results Data Mapping Table Requirements. 88

Table 2-59 Encounters Data Mapping Table Requirements. 89

Table 2-60 Procedure Data Mapping Table - Requirements. 91

Table 2-61 Family History Data Mapping Table Requirements. 92

Table 2-62 Social History Mapping Table - Requirements. 98

Table 2-63 Regulatory Guidance. 98

Table 2-64 Selected Standards. 98

Table 2-65 Informative Reference Standards. 99

Table 3-1 Template Identifiers. 113