Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information. CCD Sequence -- OASIS Summary Items

12/01/2011

[NOTE: This table was split in half because of the size for HTML & PDF versions.]

CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD HEADER
Header M0014_BRANCH_STATE   Branch State TRUE   --- --- ---
Header M0016_BRANCH_ID   Branch ID (Optional) TRUE   --- --- ---
Header M0020_PAT_ID   Patient ID Number TRUE   Person Information C32-[CT1--12] R N
Header M0040_PAT_FNAME   Patient's First Name TRUE   Person Information C32-[CT1--12] R N
Header M0040_PAT_MI   Patient's Middle Initial TRUE   Person Information C32-[CT1--12] R N
Header M0040_PAT_LNAME   Patient's Last Name TRUE   Person Information C32-[CT1--12] R N
Header M0040_PAT_SUFFIX   Patient's Suffix TRUE   Person Information C32-[CT1--12] R N
Header M0050_PAT_ST   Patient State of Residence TRUE   Person Information C32-[CT1--12] R N
Header M0060_PAT_ZIP   Patient Zip Code TRUE   Person Information C32-[CT1--12] R N
Header M0064_SSN   Patient's Social Security Number TRUE   Person Information C32-[CT1--12] R N
Header M0066_PAT_BIRTH_DT   Date of Birth TRUE   Person Information C32-[CT1--12] R N
Header M0069_PAT_GENDER   Gender TRUE   Person Information C32-[CT1--12] R N
Header M0140_ETHNIC_AI_AN 1 Race/Ethnicity: American Indian or Alaska Native TRUE   Person Information C32-[CT1--12] R N
Header M0140_ETHNIC_ASIAN 2 Race/Ethnicity: Asian TRUE   Person Information C32-[CT1--12] R N
Header M0140_ETHNIC_BLACK 3 Race/Ethnicity: Black or African-American TRUE   Person Information C32-[CT1--12] R N
Header M0140_ETHNIC_HISP 4 Race/Ethnicity: Hispanic or Latino TRUE   Person Information C32-[CT1--12] R N
Header M0140_ETHNIC_NH_PI 5 Race/Ethnicity: Native Hawaiian or Pacific Islander TRUE   Person Information C32-[CT1--12] R N
Header M0140_ETHNIC_WHITE 6 Race/Ethnicity: White TRUE   Person Information C32-[CT1--12] R N
Header M0090_INFO_COMPLETED_DT   Date Assessment Completed TRUE   Information Source C32-[CT1--8] R Y
Header M0100_ASSMT_REASON   Reason for Assessment TRUE   Information Source C32-[CT1--8] R Y
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY -- PAYERS SECTION
Payer M0063_MEDICARE_NUM   Medicare Number, Including Suffix TRUE   Insurance Provider C32-[CT1--9] O N
Payer M0065_MEDICAID_NUM   Medicaid Number TRUE   Insurance Provider C32-[CT1--9] O N
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY -- ADVANCE DIRECTIVES SECTION
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY -- SUPPORT SECTION
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY -- FUNCTIONAL STATUS SECTION
                 
Functional Status M1200_VISION   Sensory Status: Vision TRUE 0 - Normal vision "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1210_HEARG_ABLTY   Ability To Hear TRUE 0 - Adequates
UK - Unable to assess hearing
"Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1220_UNDRSTG_VERBAL_CNTNT   Understanding Of Verbal Content In Patient's Own Language TRUE 0 - Understands
UK - Unable to assess understanding
"Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1230_SPEECH   Sensory Status: Speech TRUE 0 - Expresses complex ideas, feelings, and needs clearly "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1610_UR_INCONT   Urinary Incontinence or Urinary Catheter Present TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1615_INCNTNT_TIMING   When Urinary Incontinence Occurs TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1620_BWL_INCONT   Bowel Incontinence Frequency TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1700_COG_FUNCTION   Cognitive Functioning TRUE 0 - Alert/oriented "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1710_WHEN_CONFUSED   When Confused (Reported or Observed) TRUE 0 - Never "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1720_WHEN_ANXIOUS   When Anxious (Reported or Observed) TRUE 0 - None of the time "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1730_STDZ_DPRSN_SCRNG   Has The Patient Been Screened For Depression Using Stdzed Screen Tool TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1730_PHQ2_LACK_INTRST 1a PHQ2 Pfizer Little Interest Or Pleasure In Doing Things TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1730_PHQ2_DPRSN 1b PHQ2 Pfizer Feeling Down, Depressed Or Hopeless TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1740   Cognitive, behavorial, and psychiatric symptoms that are demonstrated at least once a week (Reported or Observed): TRUE 7 - None of the Above "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1745_BEH_PROB_FREQ   Frequency of Behavior Problems TRUE 0 - Never "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1800_CUR_GROOMING   Current: Grooming TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1810_CUR_DRESS_UPPER   Current: Dress Upper Body TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1820_CUR_DRESS_LOWER   Current: Dress Lower Body TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1830_CRNT_BATHG   Current: Bathing TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1840_CUR_TOILTG   Current: Toileting TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1845_CUR_TOILTG_HYGN   Current: Toileting Hygiene TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1850_CUR_TRNSFRNG   Current: Transferring TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1860_CRNT_AMBLTN   Current: Ambulation TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1870_CUR_FEEDING   Current: Feeding TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1880_CUR_PREP_LT_MEALS   Current: Prepare Light Meals TRUE 0 - Able to independently prepare all light meals "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1890_CUR_PHONE_USE   Current: Telephone Use TRUE 0 - Able to dial numbers and answer calls appropriately and as desired. "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M1910_MLT_FCTR_FALL_RISK_ASMT   Has Patient Had A Multi-factor Fall Risk Assessment? TRUE 0 - No multi-factor falls risk assessment conducted
1 - Yes, and it does not indicate a risk for falls
"Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M2020_CRNT_MGMT_ORAL_MDCTN   Current: Management Of Oral Medications TRUE 0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.
NA - No oral medications prescribed.
"Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M2030_CRNT_MGMT_INJCTN_MDCTN   Current: Management Of Injectable Medications TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M2100_CARE_TYPE_SRC_ADL a Care Mgmt, Types And Sources Of Assist: ADL TRUE 0 - No assistance needed in this area "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M2100_CARE_TYPE_SRC_IADL b Care Mgmt, Types And Sources Of Assist: IADL TRUE 0 - No assistance needed in this area "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M2100_CARE_TYPE_SRC_MDCTN c Care Mgmt, Types And Sources Of Assist: Medication Admin TRUE 0 - No assistance needed in this area "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M2100_CARE_TYPE_SRC_PRCDR d Care Mgmt, Types And Sources Of Assist: Med Procs Tx TRUE 0 - No assistance needed in this area "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M2100_CARE_TYPE_SRC_EQUIP e Care Mgmt, Types And Sources Of Assist: Equipment TRUE 0 - No assistance needed in this area "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M2100_CARE_TYPE_SRC_SPRVSN f Care Mgmt, Types And Sources Of Assist: Supervision And Safety TRUE 0 - No assistance needed in this area "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M2100_CARE_TYPE_SRC_ADVCY g Care Mgmt, Types And Sources Of Assist: Advocacy Or Facilitation TRUE 0 - No assistance needed in this area "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
Functional Status M2110_ADL_IADL_ASTNC_FREQ   How Often Recv ADL Or IADL Assistance From Any TRUE 5 - No assistance received
UK - Unknown
"Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY -- PROBLEMS SECTION
Problems M1010   Inpatient Diagnosis TRUE   Condition C32-[CT1--4] O N
Problems M1016   Diagnosis Requiring Regimen Change TRUE   Condition C32-[CT1--4] O N
Problems M1020_PRIMARY_DIAG_ICD a Primary Diagnosis ICD Code TRUE   Condition C32-[CT1--4] O N
Problems M1022_OTH_DIAG1_ICD b Other Diagnosis 1: ICD Code TRUE   Condition C32-[CT1--4] O N
Problems M1022_OTH_DIAG2_ICD c Other Diagnosis 2: ICD Code TRUE   Condition C32-[CT1--4] O N
Problems M1022_OTH_DIAG3_ICD d Other Diagnosis 3: ICD Code TRUE   Condition C32-[CT1--4] O N
Problems M1022_OTH_DIAG4_ICD e Other Diagnosis 4: ICD Code TRUE   Condition C32-[CT1--4] O N
Problems M1022_OTH_DIAG5_ICD f Other Diagnosis 5: ICD Code TRUE   Condition C32-[CT1--4] O N
Problems M1024_PMT_DIAG_ICD_A3 a Case Mix Diagnosis: Primary, Column 3 TRUE   Condition C32-[CT1--4] O N
Problems M1024_PMT_DIAG_ICD_B3 b Case Mix Diagnosis: First Secondary, Column 3 TRUE   Condition C32-[CT1--4] O N
Problems M1024_PMT_DIAG_ICD_C3 c Case Mix Diagnosis: Second Secondary, Column 3 TRUE   Condition C32-[CT1--4] O N
Problems M1024_PMT_DIAG_ICD_D3 d Case Mix Diagnosis: Third Secondary, Column 3 TRUE   Condition C32-[CT1--4] O N
Problems M1024_PMT_DIAG_ICD_E3 e Case Mix Diagnosis: Fourth Secondary, Column 3 TRUE   Condition C32-[CT1--4] O N
Problems M1024_PMT_DIAG_ICD_F3 f Case Mix Diagnosis: Fifth Secondary, Column 3 TRUE   Condition C32-[CT1--4] O N
Problems M1024_PMT_DIAG_ICD_A4 a Case Mix Diagnosis: Primary, Column 4 TRUE   Condition C32-[CT1--4] O N
Problems M1024_PMT_DIAG_ICD_B4 b Case Mix Diagnosis: First Secondary, Column 4 TRUE   Condition C32-[CT1--4] O N
Problems M1024_PMT_DIAG_ICD_C4 c Case Mix Diagnosis: Second Secondary, Column 4 TRUE   Condition C32-[CT1--4] O N
Problems M1024_PMT_DIAG_ICD_D4 d Case Mix Diagnosis: Third Secondary, Column 4 TRUE   Condition C32-[CT1--4] O N
Problems M1024_PMT_DIAG_ICD_E4 e Case Mix Diagnosis: Fourth Secondary, Column 4 TRUE   Condition C32-[CT1--4] O N
Problems M1024_PMT_DIAG_ICD_F4 f Case Mix Diagnosis: Fifth Secondary, Column 4 TRUE   Condition C32-[CT1--4] O N
Problems M1032   Risk for hospitalization TRUE 6 - Other
7 - None of the Above
Condition C32-[CT1--4] O N
Problems M1034_PTNT_OVRAL_STUS   Patient's Overall Status TRUE 0 - Patient stable
1 - Patient temporarily facing high health risk
UK - Unknown
Condition C32-[CT1--4] O N
Problems M1036   Risk factors, either present or past, likely to affect current health status and/or outcome TRUE 5 - None of the Above
UK - Unknown
Condition C32-[CT1--4] O N
Problems M1242_PAIN_FREQ_ACTVTY_MVMT   Frequency Of Pain Interfering With Patient's Activity Or Movement TRUE 0 - Patient has no pain Condition C32-[CT1--4] O N
Problems M1302_RISK_OF_PRSR_ULCR   Does This Patient Have A Risk Of Developing PUs TRUE 0 - No Condition C32-[CT1--4] O N
Problems M1306_UNHLD_STG2_PRSR_ULCR   Patient Has At Least 1 Unhealed PU At Stage 2 Or Higher TRUE 0 - No Condition C32-[CT1--4] O N
Problems M1308_NBR_PRSULC_STG2 a No. Pressure Ulcers - Stage 2 TRUE 0 Condition C32-[CT1--4] O N
Problems M1308_NBR_STG2_AT_SOC_ROC   Number PU Stage 2 At SOC/ROC TRUE 0 Condition C32-[CT1--4] O N
Problems M1308_NBR_PRSULC_STG3 b No. Pressure Ulcers - Stage 3 TRUE 0 Condition C32-[CT1--4] O N
Problems M1308_NBR_STG3_AT_SOC_ROC   Number PU Stage 3 At SOC/ROC TRUE 0 Condition C32-[CT1--4] O N
Problems M1308_NBR_PRSULC_STG4 c No. Pressure Ulcers - Stage 4 TRUE 0 Condition C32-[CT1--4] O N
Problems M1308_NBR_STG4_AT_SOC_ROC   Number PU Stage 4 At SOC/ROC TRUE 0 Condition C32-[CT1--4] O N
Problems M1308_NSTG_DRSG d1 Unstageable Due To Non-removable Dressing Or Device TRUE 0 Condition C32-[CT1--4] O N
Problems M1308_NSTG_DRSG_SOC_ROC   Unstageable Due To Non-removable Dressing Or Device At SOC/ROC TRUE 0 Condition C32-[CT1--4] O N
Problems M1308_NSTG_CVRG d2 Unstageable Due To Coverage By Slough Or Eschar TRUE 0 Condition C32-[CT1--4] O N
Problems M1308_NSTG_CVRG_SOC_ROC   Unstageable Due To Coverage By Slough Or Eschar At SOC/ROC TRUE 0 Condition C32-[CT1--4] O N
Problems M1308_NSTG_DEEP_TISUE d3 Unstageable Due To Suspected Deep Tissue Injury In Evolution TRUE 0 Condition C32-[CT1--4] O N
Problems M1308_NSTG_DEEP_TISUE_SOC_ROC   Unstageable Due To Suspected Deep Tissue Injury In Evolution At SOC/ROC TRUE 0 Condition C32-[CT1--4] O N
Problems M1310_PRSR_ULCR_LNGTH   Head To Toe Length Of Stage III Or IV Pu With Largest Area TRUE   Condition C32-[CT1--4] O N
Problems M1312_PRSR_ULCR_WDTH   Width At Right Angles Of Stage III Or IV Pu With Largest Area TRUE   Condition C32-[CT1--4] O N
Problems M1314_PRSR_ULCR_DEPTH   Depth Of Stage III Or IV Pu With Largest Area TRUE   Condition C32-[CT1--4] O N
Problems M1320_STUS_PRBLM_PRSR_ULCR   Status Of Most Problematic Pressure Ulcer TRUE   Condition C32-[CT1--4] O N
Problems M1322_NBR_PRSULC_STG1   No. Pressure Ulcers - Stage 1 TRUE 0 Condition C32-[CT1--4] O N
Problems M1332_NUM_STAS_ULCR   No. Stasis Ulcers TRUE   Condition C32-[CT1--4] O N
Problems M1334_STUS_PRBLM_STAS_ULCR   Status Of Most Problematic Stasis Ulcer TRUE   Condition C32-[CT1--4] O N
Problems M1340_SRGCL_WND_PRSNT   Does This Patient Have A Surgical Wound TRUE 0 - No Condition C32-[CT1--4] O N
Problems M1342_STUS_PRBLM_SRGCL_WND   Status Of Most Problematic Surgical Wound TRUE   Condition C32-[CT1--4] O N
Problems M1350_LESION_OPEN_WND   Has Skin Lesion Or Open Wound TRUE 0 - No Condition C32-[CT1--4] O N
Problems M1400_WHEN_DYSPNEIC   When Dyspneic TRUE 0 - Patient is not short of breath Condition C32-[CT1--4] O N
Problems M1500_SYMTM_HRT_FAILR_PTNTS   Symptoms In Heart Failure Patients TRUE 0 - No
NA - Patient does not have diagnosis of heart failure
Condition C32-[CT1--4] O N
Problems M1600_UTI   Treated for Urinary Tract Infection in Past 14 Days TRUE 0 - No
UK - Unknown
Condition C32-[CT1--4] O N
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY - FAMILY HISTORY SECTION
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY -- SOCIAL HISTORY SECTION
Social History M1100_PTNT_LVG_STUTN   Patient Living Situation TRUE   "Social History" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY -- ALERTS SECTION
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY -- MEDICATIONS SECTION
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY -- MEDICAL EQUIPMENT SECTION
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY -- IMMUNIZATIONS
                 
Immunizations M1040_INFLNZ_RCVD_AGNCY   Influenza Vaccine: Did Patient Receive The Influenza Vaccine TRUE 0 - No Immunization C32-[CT1--7] O N
Immunizations M1045_INFLNZ_RSN_NOT_RCVD   Influenza Vaccine: Reason Not Received In Agency TRUE 7 - None of the Above Immunization C32-[CT1--7] O N
Immunizations M1050_PPV_RCVD_AGNCY   Pneumococcal Vaccine: Did Patient Receive The Influenza Vaccine TRUE 0 - No Immunization C32-[CT1--7] O N
Immunizations M1055_PPV_RSN_NOT_RCVD_AGNCY   Pneumococcal Vaccine: Reason Not Received In Agency TRUE 5 - None of the Above Immunization C32-[CT1--7] O N
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY -- VITAL SIGNS SECTOIN
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY -- RESULTS SECTION
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY -- PROCEDURES SECTION
Procedures M1030   Therapies the patient receives at home TRUE 4 - None of the Above Procedure C32-[CT1--15] O N
Procedures M1410   Respiratory treatments utilized at home: TRUE 4 - None of the Above Procedure C32-[CT1--15] O N
Procedures M2400_INTRVTN_SMRY_DBTS_FT a Intervention Synopsis: Diabetic Foot Care TRUE 0 - No
NA - Patient is not diabetic or is bilateral amputee
Procedure C32-[CT1--15] O N
Procedures M2400_INTRVTN_SMRY_FALL_PRVNT b Intervention Synopsis: Falls Prevention Intervention TRUE 0 - No
NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment
Procedure C32-[CT1--15] O N
Procedures M2400_INTRVTN_SMRY_DPRSN c Intervention Synopsis: Depression Intervention TRUE 0 - No
NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment
Procedure C32-[CT1--15] O N
Procedures M2400_INTRVTN_SMRY_PAIN_MNTR d Intervention Synopsis: Intervention To Monitor And Mitigate Pain TRUE 0 - No
NA - Formal assessment did not indicate pain since the last OASIS assessment
Procedure C32-[CT1--15] O N
Procedures M2400_INTRVTN_SMRY_PRSULC_PRVN e Intervention Synopsis: Intervention To Prevent Pressure Ulcers TRUE 0 - No
NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment
Procedure C32-[CT1--15] O N
Procedures M2400_INTRVTN_SMRY_PRSULC_WET f Intervention Synopsis: Pressure Ulcer Treatment Based On Moist Wound Treatment TRUE 0 - No
NA - Dressings that support the principles of moist wound healing not indicated for this patient’s pressure ulcers OR patient has no pressure ulcers with need for moist wound healing
Procedure C32-[CT1--15] O N
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY -- ENCOUNTERS SECTION
Encounter M0030_START_CARE_DT   Start of Care Date TRUE   Encounter C32-[CT1--5] O N
Encounter M0032_ROC_DT   Resumption of Care Date TRUE   Encounter C32-[CT1--5] O N
Encounter M1000   Inpatient discharge facility TRUE 7 -Past 14 Days: Dschrgd From Other
N/A - Past 14 Days: Not Discharged from Inpatient Facility
Encounter C32-[CT1--5] O N
Encounter M1005_INP_DISCHARGE_DT   Most Recent Inpatient Discharge Date TRUE   Encounter C32-[CT1--5] O N
Encounter M2300_EMER_USE_AFTR_LAST_ASMT   Emergent Care: Use Since Last Oasis Data Collection TRUE 0 - No
UK - Unknown
Encounter C32-[CT1--5] O N
Encounter M2310   Reason for emergent care TRUE 19 - Other than above reasons
UK - Reason Unknown
Encounter C32-[CT1--5] O N
Encounter M2410_INPAT_FACILITY   Inpatient Facility TRUE NA - No inpatient facility admission Encounter C32-[CT1--5] O N
Encounter M2420_DSCHRG_DISP   Discharge Disposition TRUE 4 - Unknown because patient moved to a geographic location not served by this agency
UK - Other Unknown
Encounter C32-[CT1--5] O N
Encounter M2430   Reason for hospitalization TRUE 20 - Other than above reasons
UK - Reason Unknown
Encounter C32-[CT1--5] O N
Encounter M2440   Reason for nursing home admission TRUE 6 - Other
UK - Unknown
Encounter C32-[CT1--5] O N
Encounter M0903_LAST_HOME_VISIT   Date of Last Home Visit TRUE   Encounter C32-[CT1--5] O N
Encounter M0906_DC_TRAN_DTH_DT   Discharge, Transfer, Death Date TRUE   Encounter C32-[CT1--5] O N
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY -- PLAN OF CARE SECTION
                 
Plan of Care M2250_PLAN_SMRY_DBTS_FT_CARE b Plan Of Care Synopsis: Diabetic Foot Care TRUE 0 - No
NA - Patient is not diabetic or is bilateral amputee
Plan of Care C32-[CT1--13] O N
Plan of Care M2250_PLAN_SMRY_FALL_PRVNT c Plan Of Care Synopsis: Falls Prevention Interventions TRUE 0 - No
NA - Patient is not assessed to be at risk for falls
Plan of Care C32-[CT1--13] O N
Plan of Care M2250_PLAN_SMRY_DPRSN_INTRVTN d Plan Of Care Synopsis: Depression Interventions TRUE 0 - No
NA - Patient is not assessed to be at risk for falls
Plan of Care C32-[CT1--13] O N
Plan of Care M2250_PLAN_SMRY_PRSULC_PRVNT f Plan Of Care Synopsis: PU Prevention TRUE 0 - No
NA - Patient is not assessed to be at risk for pressure ulcers
Plan of Care C32-[CT1--13] O N
Plan of Care M2250_PLAN_SMRY_PRSULC_TRTMT g Plan Of Care Synopsis: PU Moist Treatment TRUE 0 - No
NA - Patient has no pressure ulcers with need for moist wound healing
Plan of Care C32-[CT1--13] O N
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
CCD BODY -- HEALTH CARE PROVIDERS SECTION
Healthcare Providers M0018_PHYSICIAN_ID   Primary Referring Physician National Provider ID (NPI) TRUE   C32-[CT1--6] Healthcare Provider O Y
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
 
CCD SECTION NOT ASSIGNED DUE TO INCOMPATIBILITY OF MDS ITEM AND CCD REQUIREMENTS
                 
                 
CCD SECTION
Per Review Team Recommendation
OASIS ITEMS FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
CMS Question ID Answer CMS Description
Rose Shading ndicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
 
CCD SECTIONS NOT MAPPED -- MDS ADMINISTRATIVE ITEMS NOT APPLICABLE TO MDS PATIENT ASSESSMENT SUMMARY
                 
                 

 

HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD HEADER
--- --- --- --- --- --- --- Issue:
Verify whether this should be mapped to the CCD Header or to the Healthcare Provider Section
--- --- --- --- --- --- --- Issue:
Verify whether this should be mapped to the CCD Header or to the Healthcare Provider Section
Section 2.2.2.1 (Personal Information) states: Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. Additional constraints applicable to this information can be found in the Continuity of Care Document Section 2.5.
-- 1.02 - Person ID
R N N/A N/A 1.02 - Person ID:
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.
No  
Section 2.2.2.1 (Personal Information) states: Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. Additional constraints applicable to this information can be found in the Continuity of Care Document Section 2.5.
-- 1.05 - Person Name
R Y C83 - 2.2.2.1.1 N/A 1.05 - Person Name:
The individual to whom the exchange refers. Multiple names are allowed to retain birth name, maiden name, legal names and aliases as required.
No  
Section 2.2.2.1 (Personal Information):
See row #8
-- 1.05 - Person Name
R Y C83 - 2.2.2.1.1 N/A 1.05 - Person Name:
See row #8
No  
Section 2.2.2.1 (Personal Information):
See row #8
-- 1.05 - Person Name
R Y C83 - 2.2.2.1.1 N/A 1.05 - Person Name:
See row #8
No  
Section 2.2.2.1 (Personal Information):
See row #8
-- 1.05 - Person Name
R Y C83 - 2.2.2.1.1 N/A 1.05 - Person Name:
See row #8
No  
Section 2.2.2.1 (Personal Information) states: Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. Additional constraints applicable to this information can be found in the Continuity of Care Document Section 2.5.
-- 1.03 - Person Address
R Y C83 - 2.2.2.1.2 N/A 1.03 - Person Address:
The current address of the individual to which the exchange refers. Multiple addresses are allowed and the work address may be a method of disclosing the employer.
C154-[DE-1.03-1] The state part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.1 State
C154-[DE-1.03-2] The postal code part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.2 Postal Code
C154-[DE-1.03-3] The country part of an address SHALL be recorded using HITSP/C80 Section 2.2.1.1.3 Country
Issue:
Verify whether the address components captured in OASIS (state of residence and zip code) provides sufficient information to comply with the Address constraints specified at C83 - 2.2.2.1.2
Section 2.2.2.1 (Personal Information):
See row #12
-- 1.03 - Person Address
R Y C83 - 2.2.2.1.2 N/A 1.03 - Person Address:
See row #12
See row #12 Issue:
See row #12
Section 2.2.2.1 (Personal Information) states: Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. Additional constraints applicable to this information can be found in the Continuity of Care Document Section 2.5.
-- 1.02 - Person ID
R N N/A N/A 1.02 - Person ID:
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.
No Issues:
1) Data element #1.02-Person ID is not repeatable, however both the SSN and patient ID number have been selected for the Summary.
2) "Patient Information Entry" is required in the "Personal Information" Component Module.  Required data elements for "Patient Information Entry" include #1.02-Person ID, #1.03-Person Address, and #1.04-Person Phone/ e-mail/ URL.  OASIS does not support data element #1.04.
Section 2.2.2.1 (Personal Information) states: Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. Additional constraints applicable to this information can be found in the Continuity of Care Document Section 2.5.
-- 1.07 - Person Date of Birth
R N N/A N/A 1.07 - Person Date of Birth:
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.
No  
Section 2.2.2.1 (Personal Information) states: Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. Additional constraints applicable to this information can be found in the Continuity of Care Document Section 2.5.
-- 1.06 – Gender
R N C83 - 2.2.2.1.4 N/A 1.06 – Gender:
Gender is used to refer to administrative sex rather than biological sex and therefore should easily be classified into female and male. It is included in the exchange for purposes of linking to insurance information and other patient identification linkages and the value chosen by the patient should reflect the information under which any insurance or financial information will be filed, as well as the same information given to other healthcare providers, institutions or health data exchange networks.
C154-[DE-1.06-1] Gender SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.1. Administrative Gender Issue:
The OASIS data set does not fully support the HITSP value set for "administrative gender" detailed in C-80 Table 2-38.  The "Undifferentiated" value is not available in the MDS3.0
Section 2.2.2.1 (Personal Information) states: Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. Additional constraints applicable to this information can be found in the Continuity of Care Document Section 2.5.
-- 1.10 – Race
O Y C83 - 2.2.2.1.6 N/A 1.10 – Race:
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 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. In this event, some healthcare organizations that receive the Summary Document may choose to enter an observed race as their current practice for manual registration. Such organization observed race data should be differentiated from patient sourced data in the patient's registration summary
C154-[DE-1.10-1] Race SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.7 Race Issue:
The Race value set identified in HITSP/C80 Section 2.2.1.2.7 includes the value "Other Race".  This value is not supported by OASIS.
Section 2.2.2.1 (Personal Information):
See row #20
-- 1.10 – Race
O Y C83 - 2.2.2.1.6 N/A 1.10 – Race:
See row #20
Yes -
See row #20
Issue:
See row #20
Section 2.2.2.1 (Personal Information):
See row #20
-- 1.10 – Race
O Y C83 - 2.2.2.1.6 N/A 1.10 – Race:
See row #20
Yes -
See row #20
Issue:
See row #20
Section 2.2.2.1 (Personal Information):
See row #20
-- 1.11 – Ethnicity
O Y C83 - 2.2.2.1.7 N/A 1.11 – Ethnicity:
Ethnicity is a term that extends the concept of race. The coding of ethnicity is aligned with public health and other federal reporting standards of the CDC and the Census Bureau
C154-[DE-1.11-1] Ethnicity SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.2 Ethnicity  
Section 2.2.2.1 (Personal Information):
See row #20
-- 1.10 – Race
O Y C83 - 2.2.2.1.6 N/A 1.10 – Race:
See row #20
Yes -
See row #20
Issue:
See row #20
Section 2.2.2.1 (Personal Information):
See row #20
-- 1.10 – Race
O Y C83 - 2.2.2.1.6 N/A 1.10 – Race:
See row #20
Yes -
See row #20
Issue:
See row #20
Section 2.2.2.10 (Information Source) states:  This module contains information about the original author to be supplied and for a reference to the original document to be provided. This module may be applied to all other entry Content Modules. See the HL7 Continuity of Care Document Section 5.2 for constraints applicable to this module.
-- 10.01 - Author Time
R N N/A N/A 10.01 - Author Time:
The time at which this information was created
No Issue:
In addition to the Author Name, required data elements for the "Information Source" Component Module "Author" include 10.02-Author Time and 10.04-Reference Document ID.  The OASIS data specificiations do not capture the Author Name nor a document ID.
Section 2.2.2.10 (Information Source) states:  This module contains information about the original author to be supplied and for a reference to the original document to be provided. This module may be applied to all other entry Content Modules. See the HL7 Continuity of Care Document Section 5.2 for constraints applicable to this module.
-- 10.03 - Reference
R N N/A N/A 10.03 - Reference:
A reference to the original document from which this information was obtained
No Issue:
Item requires additional review.  Present mapping is a forced fit.
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY -- PAYERS SECTION
Section 2.2.2.5 (Insurance Provider) states: Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.1.2.1.2 for constraints applicable to these data elements. Each unique instance of a payer or party with financial responsibility will include all the pertinent data needed to contact, bill to and collect from that party. The template identifier for these entries is 2.16.840.1.113883.3.88.11.83.5.1.
-- 5.08 - Member ID
R2 N C83 - 2.2.2.5.9 Section #2.2.1.1 (Payers Section) states: The Payers Section contains data on the patient’s payers, whether a ‘third party’ insurance, self-pay, other payer or guarantor, or some combination. At a minimum, the patient's pertinent current payment sources should be listed. If no payment sources are supplied, the reason shall be supplied as free text in the narrative block (e.g., Not Insured, Payer Unknown, Medicare Pending, etc.).
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.101.1
-- C83-[CT-101-1] - This section SHALL conform to the IHE Payers Section template, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7
-- C83-[CT-101-2] - The payers section SHALL include entries from the Insurance Provider module when this information is known
5.08 - Member ID
The identifier assigned by the health plan to the patient who is covered by the health plan. When the patient is the actual member or health plan contract holder (the true subscriber) and not a dependent of the subscriber, it is the same as the Subscriber ID. A related spouse, child, or dependent may not have a unique identification number of their own
No  
Section 2.2.2.5 (Insurance Provider):
See row #42
-- 5.08 - Member ID
      Section #2.2.1.1 (Payers Section):
See row #42
5.08 - Member ID
See row #42
No  
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY -- ADVANCE DIRECTIVES SECTION
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY -- SUPPORT SECTION
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY -- FUNCTIONAL STATUS SECTION
Section #2.2.2.21 (Functional Status) states: No CDA document mappings have been defined at this time. --- --- --- Section #2.2.1.9 (Functional Status) states:
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.109
-- The Functional Status Section provides information about the capability of the patient to perform acts of daily living.
-- C83-[CT-109-1] This section SHALL conform to the Continuity of Care Document Functional Status section described in section 3.4 of the CCD specification, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.1.5
The functional status module contains data defining the patient's functional status with respect to Ambulatory ability, Mental status or competency, Activities of Daily Living, including bathing, dressing, feeding, grooming, Home/living situation having an effect on the health status of the patient or their Ability to care for themselves.
The definition of this Module is for future development.
Functional Status Issue:
HITSP has not defined a Content Module nor Data Elements for Functional Status.
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
Section #2.2.2.21 (Functional Status):
See Row #63
--- --- --- Section #2.2.1.9 (Functional Status):
See Row #63
See Row #63 --- Issue:
See Row #63
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY -- PROBLEMS SECTION
Section 2.2.2.7 (Condition) states: Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.5 for constraints applicable to these data elements.  The template identifier for this module is 2.16.840.1.113883.3.88.11.83.7
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section) states:
The Problem List Section contains data on the problems currently being monitored for the patient.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.103
-- C83-[CT-103-1]: The problem list section SHALL include entries from the Condition module
-- C83-[CT-103-2]: This section SHALL conform to the IHE Active Problems Section template, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.6
7.04 - Problem Code
This value is a code describing the problem according to a specific vocabulary of problems
C154-[DE-7.04-1] The problem SHALL be coded as specified in HITSP/C80 Section 2.2.3.1.1 Problem  
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition):
See row #326
-- 7.04 - Problem Code
O N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section):
See row #326
7.04 - Problem Code
See row #326
YES -
See row #326
 
Section 2.2.2.7 (Condition) states: Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.5 for constraints applicable to these data elements.  The template identifier for this module is 2.16.840.1.113883.3.88.11.83.7
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section) states:
The Problem List Section contains data on the problems currently being monitored for the patient.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.103
-- C83-[CT-103-1]: The problem list section SHALL include entries from the Condition module
-- C83-[CT-103-2]: This section SHALL conform to the IHE Active Problems Section template, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.6
7.03 - Problem Name
This is a text description of the problem suffered
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
Section 2.2.2.7 (Condition):
See row #405
-- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section):
See row #405
7.03 - Problem Name
See row #405
No  
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY - FAMILY HISTORY SECTION
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY -- SOCIAL HISTORY SECTION
Section #2.2.2.19 (Social History) states: Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.7 for constraints applicable to these data elements.
-- 19.03 - Social History Free Text
R N N/A Section #2.2.1.26 (Social History Section) states: The Social History Section contains information about the person’s beliefs, home life, community life, work life, hobbies, and risky habits.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.126
-- C83-[CT-126-1] This section SHALL conform to the IHE Social History Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.16
-- C83-[CT-126-2] The Social History Section MAY contain entries conforming to the Social History module
19.03 - Social History Free Text
This is a text description of the social history
No  
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY -- ALERTS SECTION
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY -- MEDICATIONS SECTION
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY -- MEDICAL EQUIPMENT SECTION
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY -- IMMUNIZATIONS
Section 2.2.2.13 (Immunizations) states: Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.11 for constraints applicable to these data elements. This module contains data describing the patient's immunization history. The HL7 Continuity of Care (CCD) Implementation Guide defines Immunizations using the same data objects and constraints as for Medications. See the HL7 Continuity of Care Document, Sections 3.9 Medications and 3.11 Immunizations; and also the Medication module Section 2.2.2.8 of this construct for constraints applicable to this module.
The template identifier for this module is 2.16.840.1.113883.3.88.11.83.13.
-- 13.07 - Free Text Product Name
R N N/A Section #2.2.1.17 (Immunizations Section):
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.117
-- The Immunizations Section contains information describing the immunizations administered to the patient.
-- C83-[CT-117-1] This section SHALL conform to the IHE Immunizations Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.23
-- C83-[CT-117-2] The Immunizations Section SHALL include entries from the Immunization module
13.07 - Free Text Product Name:
The name of the substance or product without reference to a specific vendor (e.g., generic or other non-proprietary name). If a Coded Product Name is present, this is the text associated with the coded concept.
C154-[DE-13.07-1] This SHOULD be sufficient for a provider to identify a medication, and MAY include additional information such as strength, dose form, etc. If the name of the product is unknown, the type, purpose or other description MAY be supplied. Issue:
Per C83 Section #2.2.2.13, Table 2-18, data elements required for an "Immunization Event Entry" include:
-- 13.01 - Refusal (Indicator)
-- 13.07 - Free Text Product Name
Verify that "Flu Vaccine" is adequate as a "product name"
Section 2.2.2.13 (Immunizations):
See row #556
-- 13.10 - Refusal Reason
R2 N C83 - 2.2.2.13.2 Section #2.2.1.17 (Immunizations Section):
See row #556
13.10 - Refusal Reason:
When an immunization is refused, this provides a coded representation of the reason for refusing the immunization
C154-[DE-13.10-1] The reason for refusal SHALL be coded as specified in HITSP/C80 Section 2.2.3.5.3 No Immunization Reason Issue:
1) See row #556
2) The HITSP value set for "No Immunization Reason" detailed in C80 Table 2-90 does not fully support the OASIS responses for this question (i.e., "Received from another health care provider (e.g., physician)", "Received from your agency previously during this year’s flu season", "Not indicated; patient does not meet age/condition guidelines for influenza vaccine").
Section 2.2.2.13 (Immunizations):
See row #556
-- 13.07 - Free Text Product Name
R N N/A Section #2.2.1.17 (Immunizations Section):
See row #556
13.07 - Free Text Product Name:
The name of the substance or product without reference to a specific vendor (e.g., generic or other non-proprietary name). If a Coded Product Name is present, this is the text associated with the coded concept.
C154-[DE-13.07-1] This SHOULD be sufficient for a provider to identify a medication, and MAY include additional information such as strength, dose form, etc. If the name of the product is unknown, the type, purpose or other description MAY be supplied. Issue:
Per C83 Section #2.2.2.13, Table 2-18, data elements required for an "Immunization Event Entry" include:
-- 13.01 - Refusal (Indicator)
-- 13.07 - Free Text Product Name
Verify that "Flu Vaccine" is adequate as a "product name"
Section 2.2.2.13 (Immunizations):
See row #556
-- 13.10 - Refusal Reason
R2 N C83 - 2.2.2.13.2 Section #2.2.1.17 (Immunizations Section):
See row #556
13.10 - Refusal Reason:
When an immunization is refused, this provides a coded representation of the reason for refusing the immunization
C154-[DE-13.10-1] The reason for refusal SHALL be coded as specified in HITSP/C80 Section 2.2.3.5.3 No Immunization Reason Issue:
1) See row #556
2) The HITSP value set for "No Immunization Reason" detailed in C80 Table 2-90 does not fully support the OASIS responses for this question (i.e., "Patient has received PPV in the past", "Not indicated; patient does not meet age/condition guidelines for influenza vaccine", "None of the above").
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY -- VITAL SIGNS SECTION
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY -- RESULTS SECTION
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY -- PROCEDURES SECTION
Section 2.2.2.17 (Procedure) states: Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.14 for constraints applicable to these data elements.
This section defines a coded entry describing a procedure performed on a patient. The template identifier for this module is 2.16.840.1.113883.3.88.11.83.17.
-- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section) states:
The List of Surgeries Section provides a list of surgeries the patient has received.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.108
-- C83-[CT-108-1] This section SHALL conform to the IHE Coded List of Surgeries template, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.12
-- C83-[CT-108-2] The list of surgeries section SHALL include entries from the Procedure module
17.03 - Procedure Free Text Type: Free text describing the Procedure No Issues:
1) Table 2-3 (Content Modules) in the HITSP C32 publication lists C83 Section 2.2.1.8 (List of Surgeries Section) as the "Specification Reference" for the Procedure content module.  This poses a potential problem for compliance with C32 specifications as the OASIS items designated for capture in the procedure section of the CCD are treatments and services, but NOT surgeries.
2) Per C83 Section #2.2.2.17, Table 2-22, data elements required for "Procedures" include:
-- 17.01 - Procedure ID
-- 17.03 - Procedure Free Text Type
OASIS does not have a corresponding item for 17.01 - Procedure ID.
Section 2.2.2.17 (Procedure):
See row #587
-- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section):
See row #587
17.03 - Procedure Free Text Type: Free text describing the Procedure No Issues:
See row #587
Section 2.2.2.17 (Procedure):
See row #587
-- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section):
See row #587
17.03 - Procedure Free Text Type: Free text describing the Procedure No Issues:
See row #587
Section 2.2.2.17 (Procedure):
See row #587
-- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section):
See row #587
17.03 - Procedure Free Text Type: Free text describing the Procedure No Issues:
See row #587
Section 2.2.2.17 (Procedure):
See row #587
-- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section):
See row #587
17.03 - Procedure Free Text Type: Free text describing the Procedure No Issues:
See row #587
Section 2.2.2.17 (Procedure):
See row #587
-- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section):
See row #587
17.03 - Procedure Free Text Type: Free text describing the Procedure No Issues:
See row #587
Section 2.2.2.17 (Procedure):
See row #587
-- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section):
See row #587
17.03 - Procedure Free Text Type: Free text describing the Procedure No Issues:
See row #587
Section 2.2.2.17 (Procedure):
See row #587
-- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section):
See row #587
17.03 - Procedure Free Text Type: Free text describing the Procedure No Issues:
See row #587
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY -- ENCOUNTERS SECTION
Section #2.2.2.16 (Encounter):
Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.15 for constraints applicable to these data elements. The encounter entry contains data describing the interactions between the patient and clinicians. Interaction includes both in-person and non-in-person encounters such as telephone and e-mail communication.
The template identifier for this module is 2.16.840.1.113883.3.88.11.83.16.
-- 16.04 - Encounter Date / Time
R N N/A Section #2.2.1.27 (Encounters Section): The Encounters Section contains information describing the patient history of encounters. At a minimum, current and pertinent historical encounters should be included; a full encounter history may be included.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.127
-- C83-[CT-127-1] This section SHALL conform to the IHE Encounters History Section, and SHALL contain a templateId whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
-- C83-[CT-127-2] The Encounters Section element SHALL contain entries conforming to the Encounters module
16.04 - Encounter Date / Time:
The date and time of the Encounter, including duration if pertinent
No Issue:
1) OASIS captures both a start of care and resumption of care date however, the "encounter date/time" data element is not repeatable
2) Per C83 Section #2.2.2.16, Table 2-21, data elements required for an "Encounter Event Entry" include:
-- 16.01 - Encounter ID
-- 16.03 - Encounter Free Text Type
-- 16.04 - Encounter Date / Time
OASIS does not have a corresponding item for 16.01 - Encounter ID.
Section #2.2.2.16 (Encounter):
Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.15 for constraints applicable to these data elements. The encounter entry contains data describing the interactions between the patient and clinicians. Interaction includes both in-person and non-in-person encounters such as telephone and e-mail communication.
The template identifier for this module is 2.16.840.1.113883.3.88.11.83.16.
-- 16.04 - Encounter Date / Time
R N N/A Section #2.2.1.27 (Encounters Section): The Encounters Section contains information describing the patient history of encounters. At a minimum, current and pertinent historical encounters should be included; a full encounter history may be included.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.127
-- C83-[CT-127-1] This section SHALL conform to the IHE Encounters History Section, and SHALL contain a templateId whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
-- C83-[CT-127-2] The Encounters Section element SHALL contain entries conforming to the Encounters module
16.04 - Encounter Date / Time:
The date and time of the Encounter, including duration if pertinent
No Issue:
1) OASIS captures both a start of care and resumption of care date however, the "encounter date/time" data element is not repeatable
2) Per C83 Section #2.2.2.16, Table 2-21, data elements required for an "Encounter Event Entry" include:
-- 16.01 - Encounter ID
-- 16.03 - Encounter Free Text Type
-- 16.04 - Encounter Date / Time
OASIS does not have a corresponding item for 16.01 - Encounter ID.
No appropriate match       Section #2.2.1.27 (Encounters Section): The Encounters Section contains information describing the patient history of encounters. At a minimum, current and pertinent historical encounters should be included; a full encounter history may be included.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.127
-- C83-[CT-127-1] This section SHALL conform to the IHE Encounters History Section, and SHALL contain a templateId whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
-- C83-[CT-127-2] The Encounters Section element SHALL contain entries conforming to the Encounters module
No appropriate match   Issue:
1) There does not appear to be an appropriate Encounter data element for this OASIS item.  OASIS question M1000 captures the types of inpatient facilities from which the client was discharged in the past 14 days, but the encounter dates associated with these stays are not captured.
2) Per C83 Section #2.2.2.16, Table 2-21, data elements required for an "Encounter Event Entry" include:
-- 16.01 - Encounter ID
-- 16.03 - Encounter Free Text Type
-- 16.04 - Encounter Date / Time
The OASIS does not have a corresponding item for 16.01 - Encounter ID.
Section #2.2.2.16 (Encounter):
Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.15 for constraints applicable to these data elements. The encounter entry contains data describing the interactions between the patient and clinicians. Interaction includes both in-person and non-in-person encounters such as telephone and e-mail communication.
The template identifier for this module is 2.16.840.1.113883.3.88.11.83.16.
-- 16.04 - Encounter Date / Time
R N N/A Section #2.2.1.27 (Encounters Section): The Encounters Section contains information describing the patient history of encounters. At a minimum, current and pertinent historical encounters should be included; a full encounter history may be included.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.127
-- C83-[CT-127-1] This section SHALL conform to the IHE Encounters History Section, and SHALL contain a templateId whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
-- C83-[CT-127-2] The Encounters Section element SHALL contain entries conforming to the Encounters module
16.04 - Encounter Date / Time:
The date and time of the Encounter, including duration if pertinent
No Issue:
1) Need to verify how the preceding inpatient discharge date is captured if the "encounter date/time" data element is not repeatable
2) Per C83 Section #2.2.2.16, Table 2-21, data elements required for an "Encounter Event Entry" include:
-- 16.01 - Encounter ID
-- 16.03 - Encounter Free Text Type
-- 16.04 - Encounter Date / Time
The OASIS does not have a corresponding item for 16.01 - Encounter ID.
No appropriate match       Section #2.2.1.27 (Encounters Section): The Encounters Section contains information describing the patient history of encounters. At a minimum, current and pertinent historical encounters should be included; a full encounter history may be included.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.127
-- C83-[CT-127-1] This section SHALL conform to the IHE Encounters History Section, and SHALL contain a templateId whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
-- C83-[CT-127-2] The Encounters Section element SHALL contain entries conforming to the Encounters module
No appropriate match   Issue:
There does not appear to be an appropriate Encounter data element for this OASIS item.  The OASIS form does not capture encounter dates for the ER visit(s).
No appropriate match       Section #2.2.1.27 (Encounters Section): The Encounters Section contains information describing the patient history of encounters. At a minimum, current and pertinent historical encounters should be included; a full encounter history may be included.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.127
-- C83-[CT-127-1] This section SHALL conform to the IHE Encounters History Section, and SHALL contain a templateId whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
-- C83-[CT-127-2] The Encounters Section element SHALL contain entries conforming to the Encounters module
No appropriate match   Issue:
There does not appear to be an appropriate Encounter data element for this OASIS item.  The OASIS form does not capture encounter dates for the ER visit(s).
Section #2.2.2.16 (Encounter):
Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.15 for constraints applicable to these data elements. The encounter entry contains data describing the interactions between the patient and clinicians. Interaction includes both in-person and non-in-person encounters such as telephone and e-mail communication.
The template identifier for this module is 2.16.840.1.113883.3.88.11.83.16.
-- 16.09 - Discharge Disposition
O N N/A Section #2.2.1.27 (Encounters Section): The Encounters Section contains information describing the patient history of encounters. At a minimum, current and pertinent historical encounters should be included; a full encounter history may be included.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.127
-- C83-[CT-127-1] This section SHALL conform to the IHE Encounters History Section, and SHALL contain a templateId whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
-- C83-[CT-127-2] The Encounters Section element SHALL contain entries conforming to the Encounters module
16.09 - Discharge Disposition
Discharge Disposition (sometimes called “Discharge Status”) is the person's anticipated location or status following the encounter (e.g. death, transfer to home/hospice/snf/AMA) – uses standard claims-based codes
C154-[DE-16.09-1] The Discharge Disposition SHALL be coded as specified in HITSP/C80 Section 2.2.3.9.4 Discharge Disposition Issue:
Per C83 Section #2.2.2.16, Table 2-21, data elements required for an "Encounter Event Entry" include:
-- 16.01 - Encounter ID
-- 16.03 - Encounter Free Text Type
-- 16.04 - Encounter Date / Time
OASIS does not have a corresponding item for 16.01 - Encounter ID.
Section #2.2.2.16 (Encounter):
Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.15 for constraints applicable to these data elements. The encounter entry contains data describing the interactions between the patient and clinicians. Interaction includes both in-person and non-in-person encounters such as telephone and e-mail communication.
The template identifier for this module is 2.16.840.1.113883.3.88.11.83.16.
-- 16.09 - Discharge Disposition
O N N/A Section #2.2.1.27 (Encounters Section): The Encounters Section contains information describing the patient history of encounters. At a minimum, current and pertinent historical encounters should be included; a full encounter history may be included.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.127
-- C83-[CT-127-1] This section SHALL conform to the IHE Encounters History Section, and SHALL contain a templateId whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
-- C83-[CT-127-2] The Encounters Section element SHALL contain entries conforming to the Encounters module
16.09 - Discharge Disposition
Discharge Disposition (sometimes called “Discharge Status”) is the person's anticipated location or status following the encounter (e.g. death, transfer to home/hospice/snf/AMA) – uses standard claims-based codes
C154-[DE-16.09-1] The Discharge Disposition SHALL be coded as specified in HITSP/C80 Section 2.2.3.9.4 Discharge Disposition Issue:
Per C83 Section #2.2.2.16, Table 2-21, data elements required for an "Encounter Event Entry" include:
-- 16.01 - Encounter ID
-- 16.03 - Encounter Free Text Type
-- 16.04 - Encounter Date / Time
OASIS does not have a corresponding item for 16.01 - Encounter ID.
No appropriate match       Section #2.2.1.27 (Encounters Section): The Encounters Section contains information describing the patient history of encounters. At a minimum, current and pertinent historical encounters should be included; a full encounter history may be included.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.127
-- C83-[CT-127-1] This section SHALL conform to the IHE Encounters History Section, and SHALL contain a templateId whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
-- C83-[CT-127-2] The Encounters Section element SHALL contain entries conforming to the Encounters module
No appropriate match   Issue:
There does not appear to be an appropriate Encounter data element for this OASIS item.  The OASIS form does not capture encounter dates for the ER visit(s).
No appropriate match       Section #2.2.1.27 (Encounters Section): The Encounters Section contains information describing the patient history of encounters. At a minimum, current and pertinent historical encounters should be included; a full encounter history may be included.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.127
-- C83-[CT-127-1] This section SHALL conform to the IHE Encounters History Section, and SHALL contain a templateId whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
-- C83-[CT-127-2] The Encounters Section element SHALL contain entries conforming to the Encounters module
No appropriate match   Issue:
There does not appear to be an appropriate Encounter data element for this OASIS item.  The OASIS form does not capture encounter dates for the ER visit(s).
Section #2.2.2.16 (Encounter):
Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.15 for constraints applicable to these data elements. The encounter entry contains data describing the interactions between the patient and clinicians. Interaction includes both in-person and non-in-person encounters such as telephone and e-mail communication.
The template identifier for this module is 2.16.840.1.113883.3.88.11.83.16.
-- 16.04 - Encounter Date / Time
R N N/A Section #2.2.1.27 (Encounters Section): The Encounters Section contains information describing the patient history of encounters. At a minimum, current and pertinent historical encounters should be included; a full encounter history may be included.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.127
-- C83-[CT-127-1] This section SHALL conform to the IHE Encounters History Section, and SHALL contain a templateId whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
-- C83-[CT-127-2] The Encounters Section element SHALL contain entries conforming to the Encounters module
16.04 - Encounter Date / Time:
The date and time of the Encounter, including duration if pertinent
No Issue:
1) Need to verify how the preceding inpatient discharge date is captured if the "encounter date/time" data element is not repeatable
2) Per C83 Section #2.2.2.16, Table 2-21, data elements required for an "Encounter Event Entry" include:
-- 16.01 - Encounter ID
-- 16.03 - Encounter Free Text Type
-- 16.04 - Encounter Date / Time
OASIS does not have a corresponding item for 16.01 - Encounter ID.
Section #2.2.2.16 (Encounter):
Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.15 for constraints applicable to these data elements. The encounter entry contains data describing the interactions between the patient and clinicians. Interaction includes both in-person and non-in-person encounters such as telephone and e-mail communication.
The template identifier for this module is 2.16.840.1.113883.3.88.11.83.16.
-- 16.04 - Encounter Date / Time
R N N/A Section #2.2.1.27 (Encounters Section): The Encounters Section contains information describing the patient history of encounters. At a minimum, current and pertinent historical encounters should be included; a full encounter history may be included.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.127
-- C83-[CT-127-1] This section SHALL conform to the IHE Encounters History Section, and SHALL contain a templateId whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3
-- C83-[CT-127-2] The Encounters Section element SHALL contain entries conforming to the Encounters module
16.04 - Encounter Date / Time:
The date and time of the Encounter, including duration if pertinent
No Issue:
Per C83 Section #2.2.2.16, Table 2-21, data elements required for an "Encounter Event Entry" include:
-- 16.01 - Encounter ID
-- 16.03 - Encounter Free Text Type
-- 16.04 - Encounter Date / Time
OASIS does not have a corresponding item for 16.01 - Encounter ID.
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY -- PLAN OF CARE SECTION
Section #2.2.2.22 (Plan of Care):
-- No CDA document mappings have been defined at this time..
-- The template identifier for this module is 2.16.840.1.113883.3.88.11.83.22.
--- --- --- Section #2.2.1.24 (Plan of Care Section) states: The Plan of Care Section contains information about the expectations for care to be provided including proposed interventions and goals for improving the condition of the patient.
-- A plan of care section varies from the assessment and plan section defined above in that it does not include a physician assessment of the patient condition.
-- The template identifier for this section is 2.16.840.1.113883.3.88.11.83.124
-- C83-[CT-124-1] This section SHALL conform to the IHE Care Plan Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.31
-- C83-[CT-124-2] This section SHALL conform to the HL7 History and Physical Note and HL7 Consultation Note requirements for this section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.2.7
-- C83-[CT-124-3] The Plan of Care Section MAY include entries conforming to the Medication , Immunization, Encounter, and Procedure modules to provide information about the intended care plan
There are no HITSP defined data elements that match this MDS item. --- Issues:
1) HITSP has not defined Entry Content Modules for Plan of Care.
2) HITSP has no defined Plan of Care data elements that support this OASIS item.
Section #2.2.2.22 (Plan of Care):
See row #744
--- --- --- Section #2.2.1.24 (Plan of Care Section)
See row #744
There are no HITSP defined data elements that match this MDS item. --- Issues:
See row #744
Section #2.2.2.22 (Plan of Care):
See row #744
--- --- --- Section #2.2.1.24 (Plan of Care Section)
See row #744
There are no HITSP defined data elements that match this MDS item. --- Issues:
See row #744
Section #2.2.2.22 (Plan of Care):
See row #744
--- --- --- Section #2.2.1.24 (Plan of Care Section)
See row #744
There are no HITSP defined data elements that match this MDS item. --- Issues:
See row #744
Section #2.2.2.22 (Plan of Care):
See row #744
--- --- --- Section #2.2.1.24 (Plan of Care Section)
See row #744
There are no HITSP defined data elements that match this MDS item. --- Issues:
See row #744
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
CCD BODY -- HEALTH CARE PROVIDERS SECTION
Section 2.2.2.4 (Healthcare Provider):
Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. These entries contain the healthcare providers involved in the current or pertinent historical care of the patient. See the HL7 Continuity of Care Document Section 3.17 for constraints applicable to these data elements. If no healthcare providers are supplied, the reason shall be supplied as free text in the narrative block (e.g., No Providers, Provider Unknown, etc.).
The template identifier for this module is 2.16.840.1.113883.3.88.11.83.4.
-- 4.10 - National Provider ID
R2 N C83 - 2.2.2.4.4 N/A 4.10 - National Provider ID
National Provider Identifier or NPI is a unique identification number issued to healthcare providers in the United States.
No Issue:
The assignment of this OASIS item to data element 4.10 needs to be verified. The OASIS item is reporting the NPI of the referring physician.
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
 
CCD SECTION NOT ASSIGNED DUE TO INCOMPATIBILITY OF MDS ITEM AND CCD REQUIREMENTS
               
               
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY ISSUES/ NOTES
Data Element Identifier and Name
(per C83 Section #2.2.2.x -- Entry Content Module)
Data Element -- Optionality Data Element -- Repeatable Data Element -- Additional Constraints/ Specifications Rules for Implementing Component in CDA
(per C83 Section #2.2.1.x -- CDA Sections)
Data Element Definition Data Element Constraints
 
CCD SECTIONS NOT MAPPED -- MDS ADMINISTRATIVE ITEMS NOT APPLICABLE TO MDS PATIENT ASSESSMENT SUMMARY
               
               

 

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