[act: identifier urn:oid:2.16.840.1.113883.10.20.35.4.2 (open)]
Table 46: Encounter Order (CDP1) Contexts (Draft Final)
Contained By: Contains:
Orders Placed Section (CDP1) (required) Author Participation Indication (V2) Priority Preference Service Delivery Location
This template represents an encounter order. The type of encounter (e.g. comprehensive outpatient visit) is represented. Clinicians participating in the encounter and the location of the ordered encounter may be captured.
The priority of the activity to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the encounter did take place or is intended to take place.
Entries using the Encounter Order template must be placed orders (moodCode = RQO), with a status (statusCode) of “active” or “completed”.
Author Participation is required and indicates the provider who placed the order and the time when the order was placed
The Encounter Order (CDP1) template conforms to the C-CDA R2 Planned Encounter (V2) template (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.40:2014- 06-09) with the following additional constraints:
1) moodCode = RQO.
2) statusCode = “active” or “completed”.
3) effectiveTime is the time when the encounter did take place (statusCode “completed”) or is intended to take place (statusCode “active”).
Table 47: Encounter Order (CDP1) Constraints Overview (Draft Final)
XPath Card. Verb Data
Type CONF# Fixed Value
encounter (identifier: urn:oid:2.16.840.1.113883.10.20.35.4.2)
@classCode 1..1 SHALL CDP1-3601 2.16.840.1.113883.5.6 (HL7ActClass) = ENC @moodCode 1..1 SHALL CDP1-3602 2.16.840.1.113883.5.1001 (ActMood)= RQO templateId 1..1 SHALL CDP1-3603
@root 1..1 SHALL CDP1-3604 2.16.840.1.113883.10.20.35.4.2
id 1..* SHALL CDP1-3605
code 1..1 SHALL CDP1-3606
statusCode 1..1 SHALL CDP1-3608
@code 1..1 SHALL CDP1-3609 2.16.840.1.113883.10.20.35.6.1 (ActStatus2) effectiveTime 0..1 SHOULD CDP1-3610
performer 0..* MAY CDP1-3611 assignedEntity 1..1 SHALL CDP1-3612
author 1..1 SHALL CDP1-3613 Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) participant 0..* MAY CDP1-3614
@typeCode 1..1 SHALL CDP1-3615 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = LOC participantRole 1..1 SHALL CDP1-3616 Service Delivery Location (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.32) entryRelationship 0..* MAY CDP1-3619
@typeCode 1..1 SHALL CDP1-3620 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = REFR observation 1..1 SHALL CDP1-3621 Priority Preference (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.143) entryRelationship 0..* MAY CDP1-3622
@typeCode 1..1 SHALL CDP1-3623 2.16.840.1.113883.5.1002 (HL7ActRelationshipType) = RSON observation 1..1 SHALL CDP1-3624 Indication (V2) (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2 014-06-09)
1. Conforms to Planned Encounter (V2) template (identifier:
urn:hl7ii:2.16.840.1.113883.10.20.22.4.40:2014-06-06).
2. SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: HL7ActClass
2.16.840.1.113883.5.6 STATIC) (CONF:CDP1-3601).
3. SHALL contain exactly one [1..1] @moodCode = “RQO” (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:CDP1-3602).
4. SHALL contain exactly one [1..1] templateId (CONF:CDP1-3603) such that it a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.35.4.2" (CONF:CDP1-3604).
Records the type of encounter ordered.
6. SHALL contain exactly one [1..1] code (CONF:CDP1-3606)
a. which SHOULD be selected from ValueSet Encounter _Ordered
2.16.840.1.113883.10.20.35.6.2 DYNAMIC (CONF:CDP1-3607).
7. SHALL contain exactly one [1..1] statusCode (CONF:CDP1-3608).
a. This statusCode SHALL contain exactly one [1..1] @code, which SHALL be
selected from ValueSet ActStatus2 2.16.840.1.113883.10.20.35.6.1
STATIC (CONF:CDP1-3609).
The effectiveTime indicates the time when the encounter did or should occur. 8. SHOULD contain zero or one [0..1] effectiveTime (CONF:CDP1-3610). Performers represent clinicians who are responsible for assessing and treating the patient.
9. MAY contain zero or more [0..*] performer (CONF:CDP1-3611) such that it a. SHALL contain exactly one [1..1] assignedEntity (CONF:CDP1-3612). The author in an ordered encounter represents the clinician who ordered the encounter and the time is the time the order was placed.
10. SHALL contain exactly one [1..1] Author Participation (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:CDP1-3613).
The location participation captures where the ordered encounter may take place. 11. MAY contain zero or more [0..*] participant (CONF:CDP1-3614) such that it
a. SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:CDP1-
3615).
b. SHALL contain exactly one [1..1] Service Delivery Location
(identifier: urn:oid:2.16.840.1.113883.10.20.22.4.32) (CONF:CDP1-3616).
The entryRelationship represents the priority that a patient or provider places on the encounter.
12. MAY contain zero or more [0..*] entryRelationship (CONF:CDP1-3619) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem:
HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:CDP1-
3620).
b. SHALL contain exactly one [1..1] Priority Preference (identifier:
urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:CDP1-3621).
The following entryRelationship captures the reason for the ordered encounter. 13. MAY contain zero or more [0..*] entryRelationship (CONF:CDP1-3622) such that it
a. SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:CDP1-3623).
b. SHALL contain exactly one [1..1] Indication (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:CDP1-3624).
Table 48: Encounter Ordered (Draft Final) Value Set: Encounter Ordered 2.16.840.1.113883.10.20.35.6.2
A value set of SNOMED-CT codes descending from "308335008" patient encounter procedure (procedure). Value Set Source:
http://vtsl.vetmed.vt.edu/TerminologyMgt/RF2Browser/ISA.cfm?SCT_ConceptID=30833500 8
Code Code System Code System OID Print Name
185349003 SNOMED CT 2.16.840.1.113883.6.96 encounter for "check-up" (procedure) 439740005 SNOMED CT 2.16.840.1.113883.6.96 postoperative follow-up visit (procedure) 439708006 SNOMED CT 2.16.840.1.113883.6.96 home visit (procedure)
438515009 SNOMED CT 2.16.840.1.113883.6.96 E-mail encounter from carer (procedure) 14736009 SNOMED CT 2.16.840.1.113883.6.96 patient evaluation and management 4525004 SNOMED CT 2.16.840.1.113883.6.96 emergency department patient visit
12586001 SNOMED CT 2.16.840.1.113883.6.96 physician direction of emergency medical systems 11429006 SNOMED CT 2.16.840.1.113883.6.96 consultation
680007 SNOMED CT 2.16.840.1.113883.6.96 radiation physics consultation
726007 SNOMED CT 2.16.840.1.113883.6.96 pathology consultation, comprehensive, records and specimen with report
Figure 24: Encounter Order (CDP1) Example (Draft Final) <entry>
<encounter moodCode="RQO" classCode="ENC">
<templateId root="2.16.840.1.113883.10.20.35.4.2"/> <!-- Encounter Order CDP1 template -->
<id root="9a6d1bac-17d3-4195-89a4-1121bc809b4d"/> <code code="185349003"
displayName="encounter for check-up (procedure)"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96"> </code> <statusCode code="active"/> <effectiveTime value="20130615"/> <performer> <assignedEntity> ... </performer> <author typeCode="AUT"> <!-- Author Participation --> </author> <entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN"> <!-- Patient Priority Preference-->
<templateId root="2.16.840.1.113883.10.20.22.4.142"/> ...
</observation> </entryRelationship>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN"> <!-- Provider Priority Preference--> ...
</observation> </entryRelationship> </encounter>
</entry>
7.3 Externally Defined CDE (CDP1)
[organizer: templateId 2.16.840.1.113883.10.20.35.4.3 (open)] Table 27: Externally Defined CDE (CDP1) Contexts
Contained By: Contains:
Externally Defined CDE Organizer (CDP1)
This template includes the name – value pairs for externally defined clinical data elements or the information required by an externally defined information/content model to represent name-value pairs in context. The organizer includes all information to identify the specific external template that was used to capture the CDEs. Name- Value pairs or information/content model information must be identified by externally defined XML tags.
Table 28: Externally Defined CDE (CDP1) Constraints Overview
XPath Card. Verb Data
Type CONF# Fixed Value
observation[templateId/@root = '2.16.840.1.113883.10.20.35.4.3’] @classCode 1..1 SHALL CDP1370 1 2.16.840.1.113883.5.6 (HL7ActClass) = OBS @moodCode 1..1 SHALL CDP1370 2 2.16.840.1.113883.5.1001 (ActMood) = EVN templateId 1..1 SHALL CDP1370 3 @root 1..1 SHALL CDP1370 4 2.16.840.1.113883.10.20.35. 4.3 id 1..* SHALL CDP1370 5 code 1..1 SHALL CDP1370 6 name 1..1 SHALL CDP1370 7 @value 1..1 SHALL CDP1370 8 value 1..1 SHALL CDP1370 9 @value 1..1 SHALL CDP1371 0 model 1..1 SHALL CDP1371 1 @value 1..1 SHALL CDP1371 2
1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:CDP1-3701).
2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood 2.16.840.1.113883.5.1001 STATIC) (CONF:CDP1-3702).
3. SHALL contain exactly one [1..1] templateId (CONF:CDP1-3703) such that it a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.35.4.3" (CONF:CDP1-3701). 4. SHALL contain at least one [1..*] id (CONF:CDP1-3704).
5. SHALL contain exactly one [1..1] code (CONF:CDP1-3705).
a. SHOULD be from an externally defined source (see Externally Defined CDE Organizer) or other terminology named by the US Department of Health and Human Services Office of National Coordinator or other federal agency (CONF:CDP1-3706).
6. SHALL contain exactly one [1..1] name (CONF:CDP1-3707).
a. The text SHALL be an XML tagged string that is a name taken from the externally defined source (CONF:CDP1-3708).
a. The value SHALL be an XML tagged string that is value associated with the externally defined name (CONF:CDP1-3710).
8. SHALL contain exactly one [1..1] model (CONF:CDP1-3711).
a. The value SHALL be an XML tagged string that includes elements for name/value pairs and their context based on an externally defined information/content model (CONF:CDP1-3712).
9. SHALL NOT include name and value if model is present (CONF:CDP1-3713). Figure 24: Externally Defined CDE (CDP1) Example
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.35.4.3"/> <id root="7c0704bb-9c40-41b5-9c7d-26b2d59e234f"/> <code code="TBD"
<name>
<CMS=”2.16.840.1.113883.10.20.35.5.111”> This is the question
</ CMS=”2.16.840.1.113883.10.20.35.5.111”> </name>
<value> <answer>
This is the value that was entered by the provider </answer>
</value>
</observation>