 |
Return to detail page at www.hitsp.org | HITSP/C84 |
| Prev TOC Next |
| HOME | ABOUT | MEMBERSHIP | NEWS & ANNOUNCEMENTS | MEETINGS | FAQ | CONTACT US | | Powered by American National Standards Institute |
|
Return to detail page at www.hitsp.org | HITSP/C84 |
| Prev TOC Next |
The HL7 Health Level Seven (HL7) Implementation Guide for CDA Release 2: Consultation Note describes its purpose as:
The text for the HL7 specification begins here:
This standard specifies constraints on CDA R2 for Consultation Notes. It re-uses section and entry-level templates created for CCD and for the History and Physical DSTU. For the purpose of this Implementation Guide, a consultation visit is defined by the evaluation and management guidelines for a consultation established by the Centers for Medicare and Medicaid Services (CMS). According to those guidelines, a Consultation Note must be generated as a result of a physician or non-physician practitioners (NPP) request for an opinion or advice from another physician or NPP.
Consultations must involve face-to-face time with the patient or fall under guidelines for telemedicine visits.
A Consultation Note must be provided to the referring physician or NPP and must include the reason for the referral, history of present illness, physical examination, and decision-making component (assessment and plan).
The text for the HL7 specification ends here.
And, as stated in the Health Level Seven (HL7) Implementation Guide for CDA Release 2: History and Physical (H&P) Notes:
The text for the HL7 specification begins here:
A History and Physical (H&P) Note is a two-part medical report which documents the current and past conditions of the patient. It contains both subjective and objective information and forms the basis of most treatment plans. The first half of the report includes subjective information, typically supplied by the patient or their caregiver, about the current medical problem or the reason for the patient encounter. This information is followed by a description of any past or ongoing medical issues, including current medications and allergies. Information is also obtained about the patient's lifestyle, habits, and diseases among family members.
The second half of the report contains objective information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures. The report ends with the clinician's assessment of the patient's situation and the intended plan to address those issues. A History and Physical Examination is required upon hospital admission as well as before operative procedures. An initial evaluation in an ambulatory setting is often documented in the form of a History and Physical Note.
The text for the HL7 specification ends here.
Table 2-1 Component Constraints
|
Constraint |
Constraint Section |
|
No applicable constraints |
Table 2-2 Component Dependencies
|
Standard/HITSP Component |
Depends On |
Dependency Type |
Purpose |
|
HITSP/C84 Consult and History & Physical Note |
HITSP /C83 CDA Content Modules |
General |
Identifies Content Modules constrained by this Component to be applied within the exchange |
The following section documents the content of the Component. It provides the basics elements and secondary standards that are supported by this Component and the constraints that are being placed on those standards. Specifically, it describes the subset or constraints that are required for this Component, and the minimum attributes of the Component as it relates to the base or composite standards on which it is based [1] .
This section describes the specific data elements used by this Component. Due to the potentially large number of data elements in a particular standard, only the fields that HITSP is constraining differently from the standard will be described here.
For all constraints applied to the data the reader must refer to:
Health Level Seven (HL7) Implementation Guide for CDA Release 2: History and Physical (H&P) Notes
Health Level Seven (HL7) Implementation Guide for CDA Release 2: Consultation Note
The HITSP constraints defined in Table 2-3 and Table 2-4
The following sections describe the content modules for the Consultation and History and Physical.
C84-[CT1-20] Implementations of this Component SHALL support the Consultation Note Content Modules as defined by Health Level Seven (HL7) Implementation Guide for CDA Release 2: Consultation Note. Implementation SHALL also support the HITSP constraints specified in Table 2-3
C84-[CT1-21] Implementations of this Component SHALL use the document type code: 11488-4 Consultation Note
C84-[CT1-22] Implementations of this Component SHALL contain a structuredBody element
C84-[CT1-23] inFulfillmentOf/order/id SHALL contain the order identifier of the referring physician referral request order
The template identifier for this 2.16.840.1.113883.3.88.11.84.1.
Table 2-3 Consultation Note Content Modules
|
Constraint ID |
Content Module |
HITSP Optional Entry [2] |
HITSP Repeatable Entry [3] |
Specification Reference |
|
Active Problems |
R |
N |
||
|
Advance Directives |
R |
N |
||
|
Allergies |
R |
N |
See HITSP/C83 Section 2.2.1.2 Allergies and Other Adverse Reactions Section |
|
|
Current Meds |
R |
N |
||
|
Family History |
R2 |
N |
||
|
Functional Status |
R2 |
N |
||
|
History Present Illness |
R |
N |
See HITSP/C83 Section 2.2.1.7 History of Present Illness Section |
|
|
Immunizations |
R2 |
N |
||
|
List of Surgeries |
R2 |
N |
||
|
Person Information |
R |
N |
||
|
Pertinent Insurance Information |
R2 |
N |
||
|
Physical Exam |
R2 |
N |
||
|
Plan of Care |
R |
N |
||
|
Reason for Referral |
R |
N |
||
|
Relevant Diagnostic Surgical Procedures/Clinical Reports and Relevant Diagnostic Test and Reports |
R2 |
N |
||
|
Resolved Problems |
R2 |
N |
See HITSP/C83 Section 2.2.1.4 History of Past Illness Section |
|
|
Review of Systems |
O |
N |
||
|
Social History |
R2 |
N |
||
|
Vital Signs |
R2 |
N |
C84-[CT2-16] Implementations of this Component SHALL support the History and Physical Content Modules as defined by Health Level Seven (HL7) Implementation Guide for CDA Release 2: History and Physical (H&P) Notes. Implementation shall also support the HITSP constraints specified in Table 2-4.
C84-[CT2-17] Implementations of this Component SHALL use the document type code: 34117-2 History & Physical
C84-[CT2-18] Implementations of this Component SHALL contain a structuredBody element
C84-[CT2-19] When used to respond to a request for consultation, the inFulfillmentOf/order/id SHALL contain the order identifier of the referring physician referral request order
The template identifier for this 2.16.840.1.113883.3.88.11.84.2.
Table 2-4 History and Physical Content Modules
|
Constraint ID |
Content Module |
HITSP Optional Entry [4] |
HITSP Repeatable Entry [5] |
Specification Reference |
|
Allergies |
R |
N |
See HITSP/C83 Section 2.2.1.2 Allergies and Other Adverse Reactions Section |
|
|
Assessment and Plan |
R |
N |
||
|
Chief Complaint |
R |
N |
||
|
Current Meds |
R |
N |
||
|
Family History |
R |
N |
||
|
History Present Illness |
R |
N |
See HITSP/C83 Section 2.2.1.7 History of Present Illness Section |
|
|
Immunization History |
O |
N |
||
|
Person Information |
R |
N |
||
|
Physical Examination |
R |
N |
||
|
Problems |
R |
N |
||
|
Procedure History |
O |
N |
||
|
Relevant Diagnostic Surgical Procedures/Clinical Reports and Relevant Diagnostic Test and Reports |
R |
N |
||
|
Resolved Problems |
R |
N |
See HITSP/C83 Section 2.2.1.4 History of Past Illness Section |
|
|
Review of Systems |
R |
N |
||
|
Social History |
R |
N |
Guidelines and Examples
Examples of these documents may be found via the following links:
Consult Notes: www.hl7.org/dstucomments/showdetail.cfm?dstuid=24
History and Physical Notes: www.hl7.org/dstucomments/showdetail.cfm?dstuid=25
Table 2-5 Regulatory Guidance
|
Standard |
Description |
|
No applicable regulatory guidance |
|
Table 2-6 Selected Standards
|
Standard |
Description |
|
Health Level Seven (HL7) HL7 Version 3 Standard: Clinical Document Architecture (CDA), Release 2 |
The HL7 Clinical Document Architecture is an XML-based document markup standard that specifies the structure and semantics of clinical documents for the purpose of exchange. CDA is one instantiation of HL7's Version 3.0 Reference Information Model (RIM) into a specific message format. Of particular focus for HITSP Interoperability Specifications are message formats for Laboratory Results and Continuity of Care (CCD) documents. Release 2.0 of the HL7 Clinical Document Architecture (CDA) is an extension to the original CDA document markup standard that specifies the structure and semantics of clinical documents for the purpose of exchange. CDA R2 includes a prose document in HTML, XML schemas, data dictionary, and sample CDA documents. CDA R2 further builds upon other HL7 standards beyond just the Version 3.0 Reference Information Model (RIM) and incorporates Version 3.0 Data Structures, Vocabulary, and the XML Implementation Technology Specifications for Data Types and Structures. For more information visit www.hl7.org |
|
Health Level Seven (HL7) Implementation Guide for CDA Release 2.0: Consultation Note |
The HL7 Implementation Guide for CDA Release 2.0: Consultation Note defines additional constraints on the CDA Header and Body used in a Consultation document in the U.S. realm, and provides examples of conforming fragments in the body of the document and an example of a conforming XML instance. For more information visit www.hl7.org |
|
Health Level Seven (HL7) Implementation Guide for CDA Release 2.0: History and Physical (H&P) Notes |
The HL7 Implementation Guide for CDA Release 2.0: History and Physical (H&P) Notes defines additional constraints on the CDA Header and Body used in a History and Physical document in the U.S. realm, and provides examples of conforming fragments in the body of the document and an example of a conforming XML instance. For more information visit www.hl7.org |
Table 2-7 Informative Reference Standards
|
Standard |
Description |
|
Health Level Seven (HL7) Implementation Guide: CDA Release 2 Continuity of Care Document (CCD), April 01, 2007 |
The Continuity of Care Document implementation guide describes constraints on the HL7 Clinical Document Architecture, Release 2 (CDA) specification in accordance with requirements set forward in ASTM E2369-05 Standard Specification for Continuity of Care Record (CCR). The resulting specification, known as the Continuity of Care Document (CCD), is developed as a collaborative effort between ASTM and HL7. It is intended as an alternate implementation to the one specified in ASTM ADJE2369 for those institutions or organizations committed to implementation of the HL7 Clinical Document Architecture. For more information visit www.hl7.org |
|
Return to detail page at www.hitsp.org | HITSP/C84 |
| Prev TOC Next |