Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information. MDS Summary Items To C32-CCD

12/01/2011

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

MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
A     Identification Information N/A        
  A0200   Type of provider TRUE   Encounter C32-[CT1--5] O N
  A0310A   Type of assessment: OBRA TRUE 99 - Not OBRA required assessment/tracking Information Source C32-[CT1--8] R Y
  A0500A   Resident first name TRUE   Person Information C32-[CT1--12] R N
  A0500B   Resident middle initial TRUE   Person Information C32-[CT1--12] R N
  A0500C   Resident last name TRUE   Person Information C32-[CT1--12] R N
  A0500D   Resident name suffix TRUE   Person Information C32-[CT1--12] R N
  A0600A   Social Security Number TRUE   Person Information C32-[CT1--12] R N
  A0700   Resident Medicaid number TRUE   Insurance Provider C32-[CT1--9] O N
  A0800   Gender TRUE   Person Information C32-[CT1--12] R N
  A0900   Birthdate TRUE   Person Information C32-[CT1--12] R N
  A1000A   Ethnicity: American Indian or Alaska Native TRUE   Person Information C32-[CT1--12] R N
  A1000B   Ethnicity: Asian TRUE   Person Information C32-[CT1--12] R N
  A1000C   Ethnicity: Black or African American TRUE   Person Information C32-[CT1--12] R N
  A1000D   Ethnicity: Hispanic or Latino TRUE   Person Information C32-[CT1--12] R N
  A1000E   Ethnicity: Native Hawaiian/Pacific Islander TRUE   Person Information C32-[CT1--12] R N
  A1000F   Ethnicity: White TRUE   Person Information C32-[CT1--12] R N
  A1100A   Does the resident need or want an interpreter TRUE 0 - No;
9 - Unable to determine
Language Spoken C32-[CT1--10] R2 Y
  A1100B   Preferred language TRUE   Language Spoken C32-[CT1--10] R2 Y
  A1200   Marital status TRUE   Person Information C32-[CT1--12] R N
  A1300A MDCL_REC_NUM Medical record number TRUE   Person Information C32-[CT1--12] R N
  A1300C PREFRD_NAME Name by which resident prefers to be addressed TRUE   Person Information C32-[CT1--12] R N
  A1300D   Lifetime occupation(s) TRUE   "Social History" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  A1550A   MR/DD status: Down syndrome TRUE   Condition C32-[CT1--4] O N
  A1550B   MR/DD status: Autism TRUE   Condition C32-[CT1--4] O N
  A1550C   MR/DD status: Epilepsy TRUE   Condition C32-[CT1--4] O N
  A1550D   MR/DD status: other organic MR/DD condition TRUE   Condition C32-[CT1--4] O N
  A1550E   MR/DD status: MR/DD with no organic condition TRUE   Condition C32-[CT1--4] O N
  A1600   Entry date (date of admission/reentry in facility) TRUE   Encounter C32-[CT1--5] O N
  A1700   Type of entry TRUE   Encounter C32-[CT1--5] O N
  A1800   Entered from TRUE 99 - Other Encounter C32-[CT1--5] O N
  A2000   Discharge date TRUE   Encounter C32-[CT1--5] O N
  A2100   Discharge status TRUE 99 - Other Encounter C32-[CT1--5] O N
  A2300   Assessment reference date TRUE   Information Source C32-[CT1--8] R Y
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
B     Hearing, Speech, and Vision N/A        
  B0100   Comatose TRUE 0 - No "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  B0200   Hearing TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  B0300   Hearing aid TRUE 0 - No "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  B0600   Speech clarity TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  B0700   Makes self understood TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  B0800   Ability to understand others TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  B1000   Vision TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  B1200   Corrective lenses TRUE 0 - No "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
C     Cognitive Patterns N/A        
  C0500   BIMS res interview: summary score TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  C0700   Staff asmt mental status: short-term memory OK TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  C0800   Staff asmt mental status: long-term memory OK TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  C0900A   Staff asmt mental status: recall current season TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  C0900B   Staff asmt mental status: recall location of room TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  C0900C   Staff asmt mental status: recall staff names/faces TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  C0900D   Staff asmt mental status: recall in nursing home TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  C1000   Cognitive skills for daily decision making TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  C1300A   Signs of delirium: inattention TRUE 0 - Behavior not present "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  C1300B   Signs of delirium: disorganized thinking TRUE 0 - Behavior not present "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  C1300C   Signs of delirium: altered level of consciousness TRUE 0 - Behavior not present "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  C1300D   Signs of delirium: psychomotor retardation TRUE 0 - Behavior not present "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  C1600   Acute onset mental status change TRUE 0 - No "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
D     Section D - Mood N/A        
  D0300   PHQ res: total mood severity score TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  D0600   PHQ staff: total mood score TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
E     Section E - Behavior N/A        
  E0100A   Psychosis: hallucinations TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  E0100B   Psychosis: delusions TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  E0200A   Physical behav symptoms directed toward others TRUE 0 - Behavior not exhibited "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  E0200B   Verbal behav symptoms directed toward others TRUE 0 - Behavior not exhibited "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  E0200C   Other behav symptoms not directed toward others TRUE 0 - Behavior not exhibited "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  E0500A   Behav symptoms put res at risk for illness/injury TRUE 0 - No "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  E0500B   Behav symptoms interfere with resident care TRUE 0 - No "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  E0500C   Behav symptoms interfere with social activities TRUE 0 - No "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  E0600A   Behav symptoms put others at risk for injury TRUE 0 - No "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  E0600B   Behav symptoms intrude on privacy of others TRUE 0 - No "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  E0600C   Behav symptoms disrupt care or living environment TRUE 0 - No "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  E0800   Rejection of care: presence and frequency TRUE 0 - Behavior not exhibited "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  E0900   Wandering: presence and frequency TRUE 0 - Behavior not exhibited "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  E1100   Change in behavioral or other symptoms TRUE 0 - Same;
9 - N/A because no prior MDS assessment
"Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
F     Section F - Preferences for Customary Routine and Activities N/A        
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
G     Section G - Functional Status N/A        
  G0110A1   Bed mobility: self-performance TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  G0110B1   Transfer: self-performance TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  G0110C1   Walk in room: self-performance TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  G0110E1   Locomotion on unit: self-performance TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  G0110H1   Eating: self-performance TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  G0110I1   Toilet use: self-performance TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  G0110J1   Personal hygiene: self-performance TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  G0400A   ROM limitation: upper extremity TRUE 0 - No impairment "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  G0400B   ROM limitation: lower extremity TRUE 0 - No impairment "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  G0600A   Mobility devices: cane/crutch TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  G0600B   Mobility devices: walker TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  G0600C   Mobility devices: wheelchair (manual or electric) TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  G0600D   Mobility devices: limb prosthesis TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
H     Section H - Bladder and Bowel N/A        
  H0100A   Appliances: indwelling catheter TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  H0100B   Appliances: external catheter TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  H0100C   Appliances: ostomy TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  H0100D   Appliances: intermittent catheterization TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  H0200C   Urinary toileting program: current program/trial TRUE 0 - No "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  H0300   Urinary continence TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  H0400   Bowel continence TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  H0500   Bowel toileting program being used TRUE 0 - No "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  H0600   Constipation TRUE 0 - No "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
I     Section I - Active Disease Diagnosis N/A        
  I0100   Cancer (with or without metastasis) TRUE   Condition C32-[CT1--4] O N
  I0200   Anemia TRUE   Condition C32-[CT1--4] O N
  I0300   Atrial fibrillation and other dysrhythmias TRUE   Condition C32-[CT1--4] O N
  I0400   Coronary artery disease (CAD) TRUE   Condition C32-[CT1--4] O N
  I0500   Deep venous thrombosis (DVT), PE, or PTE TRUE   Condition C32-[CT1--4] O N
  I0600   Heart failure TRUE   Condition C32-[CT1--4] O N
  I0700   Hypertension TRUE   Condition C32-[CT1--4] O N
  I0800   Orthostatic hypotension TRUE   Condition C32-[CT1--4] O N
  I0900   Peripheral vascular disease (PVD) or PAD TRUE   Condition C32-[CT1--4] O N
  I1100   Cirrhosis TRUE   Condition C32-[CT1--4] O N
  I1200   Gastroesophageal reflux disease (GERD) or ulcer TRUE   Condition C32-[CT1--4] O N
  I1300   Ulcerative colitis, Crohn’s, inflam bowel disease TRUE   Condition C32-[CT1--4] O N
  I1400   Benign prostatic hyperplasia (BPH) TRUE   Condition C32-[CT1--4] O N
  I1500   Renal insufficiency, renal failure, ESRD TRUE   Condition C32-[CT1--4] O N
  I1550   Neurogenic bladder TRUE   Condition C32-[CT1--4] O N
  I1650   Obstructive uropathy TRUE   Condition C32-[CT1--4] O N
  I1700   Multidrug resistant organism (MDRO) TRUE   Condition C32-[CT1--4] O N
  I2000   Pneumonia TRUE   Condition C32-[CT1--4] O N
  I2100   Septicemia TRUE   Condition C32-[CT1--4] O N
  I2200   Tuberculosis TRUE   Condition C32-[CT1--4] O N
  I2300   Urinary tract infection (UTI) (LAST 30 DAYS) TRUE   Condition C32-[CT1--4] O N
  I2400   Viral hepatitis (includes type A, B, C, D, and E) TRUE   Condition C32-[CT1--4] O N
  I2500   Wound infection (other than foot) TRUE   Condition C32-[CT1--4] O N
  I2900   Diabetes mellitus (DM) TRUE   Condition C32-[CT1--4] O N
  I3100   Hyponatremia TRUE   Condition C32-[CT1--4] O N
  I3200   Hyperkalemia TRUE   Condition C32-[CT1--4] O N
  I3300   Hyperlipidemia (e.g.,  hypercholesterolemia) TRUE   Condition C32-[CT1--4] O N
  I3400   Thyroid disorder TRUE   Condition C32-[CT1--4] O N
  I3700   Arthritis TRUE   Condition C32-[CT1--4] O N
  I3800   Osteoporosis TRUE   Condition C32-[CT1--4] O N
  I3900   Hip fracture TRUE   Condition C32-[CT1--4] O N
  I4000   Other fracture TRUE   Condition C32-[CT1--4] O N
  I4200   Alzheimer's disease TRUE   Condition C32-[CT1--4] O N
  I4300   Aphasia TRUE   Condition C32-[CT1--4] O N
  I4400   Cerebral palsy TRUE   Condition C32-[CT1--4] O N
  I4500   Cerebrovascular accident (CVA), TIA, or stroke TRUE   Condition C32-[CT1--4] O N
  I4800   Dementia TRUE   Condition C32-[CT1--4] O N
  I4900   Hemiplegia or hemiparesis TRUE   Condition C32-[CT1--4] O N
  I5000   Paraplegia TRUE   Condition C32-[CT1--4] O N
  I5100   Quadriplegia TRUE   Condition C32-[CT1--4] O N
  I5200   Multiple sclerosis TRUE   Condition C32-[CT1--4] O N
  I5250   Huntington's disease TRUE   Condition C32-[CT1--4] O N
  I5300   Parkinson's disease TRUE   Condition C32-[CT1--4] O N
  I5350   Tourette's syndrome TRUE   Condition C32-[CT1--4] O N
  I5400   Seizure disorder or epilepsy TRUE   Condition C32-[CT1--4] O N
  I5500   Traumatic brain injury (TBI) TRUE   Condition C32-[CT1--4] O N
  I5600   Malnutrition (protein, calorie), risk of malnutrit TRUE   Condition C32-[CT1--4] O N
  I5700   Anxiety disorder TRUE   Condition C32-[CT1--4] O N
  I5800   Depression (other than bipolar) TRUE   Condition C32-[CT1--4] O N
  I5900   Manic depression (bipolar disease) TRUE   Condition C32-[CT1--4] O N
  I5950   Psychotic disorder (other than schizophrenia) TRUE   Condition C32-[CT1--4] O N
  I6000   Schizophrenia TRUE   Condition C32-[CT1--4] O N
  I6100   Post-traumatic stress disorder (PTSD) TRUE   Condition C32-[CT1--4] O N
  I6200   Asthma (COPD) or chronic lung disease TRUE   Condition C32-[CT1--4] O N
  I6300   Respiratory failure TRUE   Condition C32-[CT1--4] O N
  I6500   Cataracts, glaucoma, or macular degeneration TRUE   Condition C32-[CT1--4] O N
  I8000A   Additional active ICD diagnosis 1 TRUE   Condition C32-[CT1--4] O N
  I8000B   Additional active ICD diagnosis 2 TRUE   Condition C32-[CT1--4] O N
  I8000C   Additional active ICD diagnosis 3 TRUE   Condition C32-[CT1--4] O N
  I8000D   Additional active ICD diagnosis 4 TRUE   Condition C32-[CT1--4] O N
  I8000E   Additional active ICD diagnosis 5 TRUE   Condition C32-[CT1--4] O N
  I8000F   Additional active ICD diagnosis 6 TRUE   Condition C32-[CT1--4] O N
  I8000G   Additional active ICD diagnosis 7 TRUE   Condition C32-[CT1--4] O N
  I8000H   Additional active ICD diagnosis 8 TRUE   Condition C32-[CT1--4] O N
  I8000I   Additional active ICD diagnosis 9 TRUE   Condition C32-[CT1--4] O N
  I8000J   Additional active ICD diagnosis 10 TRUE   Condition C32-[CT1--4] O N
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
J     Section J - Health Conditions N/A        
  J0100A   Pain: been on scheduled pain med regimen TRUE 0 - No Condition C32-[CT1--4] O N
  J0400   Res pain interview: frequency TRUE 9 - Unable to answer Condition C32-[CT1--4] O N
  J0600A   Res pain interview: intensity rating scale TRUE   Condition C32-[CT1--4] O N
  J0600B   Res pain interview: verbal descriptor scale TRUE 9 - Unable to answer Condition C32-[CT1--4] O N
  J1100A   Short breath/trouble breathing: with exertion TRUE   Condition C32-[CT1--4] O N
  J1100B   Short breath/trouble breathing: sitting at rest TRUE   Condition C32-[CT1--4] O N
  J1100C   Short breath/trouble breathing: lying flat TRUE   Condition C32-[CT1--4] O N
  J1300   Current tobacco use TRUE 0 - No Condition C32-[CT1--4] O N
  J1400   Prognosis: life expectancy of less than 6 months TRUE 0 - No Condition C32-[CT1--4] O N
  J1700A   Fall history: fall during month before admission TRUE 0 - No;
9 - Unable to determine
Condition C32-[CT1--4] O N
  J1700B   Fall history: fall 2-6 months before admission TRUE 0 - No;
9 - Unable to determine
Condition C32-[CT1--4] O N
  J1700C   Fall history: fracture from fall 6 month pre admit TRUE 0 - No;
9 - Unable to determine
Condition C32-[CT1--4] O N
  J1800   Falls since admit/prior asmt: any falls TRUE 0 - No Condition C32-[CT1--4] O N
  J1900B   Falls since admit/prior asmt: injury (not major) TRUE 0 - None Condition C32-[CT1--4] O N
  J1900C   Falls since admit/prior asmt: major injury TRUE 0 - None Condition C32-[CT1--4] O N
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
K     Section K - Swallowing/ Nutritional Status N/A        
  K0100A   Swallow disorder: loss liquids/solids from mouth TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  K0100B   Swallow disorder: holds food in mouth/cheeks TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  K0100C   Swallow disorder: cough/choke with meals/meds TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  K0100D   Swallow disorder: difficulty or pain swallowing TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  K0200A   Height (in inches) TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  K0200B   Weight (in pounds) TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  K0300   Weight loss TRUE 0 - No, or unknown "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  K0500A   Nutritional approaches: parenteral /IV feeding TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  K0500B   Nutritional approaches: feeding tube TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  K0500C   Nutritional approaches: mechanically altered diet TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  K0500D   Nutritional approaches: therapeutic diet TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
L     Section L - Oral/Dental Status N/A        
  L0200A   Dental: broken or loosely fitting denture TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  L0200B   Dental: no natural teeth or tooth fragment(s) TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  L0200C   Dental: abnormal mouth tissue TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  L0200D   Dental: cavity or broken natural teeth TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  L0200E   Dental: inflamed/bleeding gums or loose teeth TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
  L0200F   Dental: pain, discomfort, difficulty chewing TRUE   "Functional Status" is not included in HITSP C32 Table 2-3 (Content Modules) --- ---
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
M     Section M - Skin Conditions N/A        
  M0150   Is resident at risk of developing pressure ulcer TRUE 0 - No Condition C32-[CT1--4] O N
  M0210   Resident has Stage 1 or higher pressure ulcers TRUE 0 - No Condition C32-[CT1--4] O N
  M0300A   Stage 1 pressure ulcers: number present TRUE 0 Condition C32-[CT1--4] O N
  M0300B1   Stage 2 pressure ulcers: number present TRUE 0 Condition C32-[CT1--4] O N
  M0300B2   Stage 2 pressure ulcers: number at admit/reentry TRUE 0 Condition C32-[CT1--4] O N
  M0300B3   Stage 2 pressure ulcers: date of oldest TRUE   Condition C32-[CT1--4] O N
  M0300C1   Stage 3 pressure ulcers: number present TRUE 0 Condition C32-[CT1--4] O N
  M0300C2   Stage 3 pressure ulcers: number at admit/reentry TRUE 0 Condition C32-[CT1--4] O N
  M0300D1   Stage 4 pressure ulcers: number present TRUE 0 Condition C32-[CT1--4] O N
  M0300D2   Stage 4 pressure ulcers: number at admit/reentry TRUE 0 Condition C32-[CT1--4] O N
  M0300E1   Unstaged due to dressing: number present TRUE 0 Condition C32-[CT1--4] O N
  M0300E2   Unstaged due to dressing: number at admit/reentry TRUE 0 Condition C32-[CT1--4] O N
  M0300F1   Unstaged slough/eschar: number present TRUE 0 Condition C32-[CT1--4] O N
  M0300F2   Unstaged slough/eschar: number at admit/reentry TRUE 0 Condition C32-[CT1--4] O N
  M0300G1   Unstageable - deep tissue: number present TRUE 0 Condition C32-[CT1--4] O N
  M0300G2   Unstageable - deep tissue: number at admit/reentry TRUE 0 Condition C32-[CT1--4] O N
  M0610A   Stage 3 or 4 pressure ulcer longest length TRUE   Condition C32-[CT1--4] O N
  M0610B   Stage 3 or 4 pressure ulcer width (same ulcer) TRUE   Condition C32-[CT1--4] O N
  M0610C   Stage 3 or 4 pressure ulcer depth (same ulcer) TRUE   Condition C32-[CT1--4] O N
  M0800A   Worsened since prior asmt: Stage 2 pressure ulcers TRUE 0 Condition C32-[CT1--4] O N
  M0800B   Worsened since prior asmt: Stage 3 pressure ulcers TRUE 0 Condition C32-[CT1--4] O N
  M0800C   Worsened since prior asmt: Stage 4 pressure ulcers TRUE 0 Condition C32-[CT1--4] O N
  M1030   Number of venous and arterial ulcers TRUE 0 Condition C32-[CT1--4] O N
  M1040A   Other skin probs: infection of the foot TRUE   Condition C32-[CT1--4] O N
  M1040B   Other skin probs: diabetic foot ulcer(s) TRUE   Condition C32-[CT1--4] O N
  M1040C   Other skin probs: other open lesion(s) on the foot TRUE   Condition C32-[CT1--4] O N
  M1040D   Other skin probs: lesions not ulcers, rashes, cuts TRUE   Condition C32-[CT1--4] O N
  M1040E   Other skin probs: surgical wound(s) TRUE   Condition C32-[CT1--4] O N
  M1040F   Other skin probs: burn(s) (second or third degree) TRUE   Condition C32-[CT1--4] O N
  M1200A   Skin/ulcer treat: pressure reduce device for chair TRUE   Procedure C32-[CT1--15] O N
  M1200B   Skin/ulcer treat: pressure reducing device for bed TRUE   Procedure C32-[CT1--15] O N
  M1200C   Skin/ulcer treat: turning/repositioning TRUE   Procedure C32-[CT1--15] O N
  M1200D   Skin/ulcer treat: nutrition/hydration TRUE   Procedure C32-[CT1--15] O N
  M1200E   Skin/ulcer treat: ulcer care TRUE   Procedure C32-[CT1--15] O N
  M1200F   Skin/ulcer treat: surgical wound care TRUE   Procedure C32-[CT1--15] O N
  M1200G   Skin/ulcer treat: application of dressings TRUE   Procedure C32-[CT1--15] O N
  M1200H   Skin/ulcer treat: apply ointments/medications TRUE   Procedure C32-[CT1--15] O N
  M1200I   Skin/ulcer treat: apply dressings to feet TRUE   Procedure C32-[CT1--15] O N
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
N     Section N - Medications N/A        
  N0350A   Insulin: insulin injections TRUE   --- --- ---
  N0400A   Medications: antipsychotic TRUE   --- --- ---
  N0400B   Medications: antianxiety TRUE   --- --- ---
  N0400C   Medications: antidepressant TRUE   --- --- ---
  N0400D   Medications: hypnotic TRUE   --- --- ---
  N0400E   Medications: anticoagulant TRUE   --- --- ---
  N0400F   Medications: antibiotic TRUE   --- --- ---
  N0400G   Medications: diuretic TRUE   --- --- ---
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
O     Section O - Special Treatments and Procedures N/A        
  O0100A2   Treatment: chemotherapy - while resident TRUE   Procedure C32-[CT1--15] O N
  O0100B2   Treatment: radiation - while resident TRUE   Procedure C32-[CT1--15] O N
  O0100C2   Treatment: oxygen therapy - while resident TRUE   Procedure C32-[CT1--15] O N
  O0100D2   Treatment: suctioning - while resident TRUE   Procedure C32-[CT1--15] O N
  O0100E2   Treatment: tracheostomy care - while resident TRUE   Procedure C32-[CT1--15] O N
  O0100F2   Treatment: vent/respirator - while resident TRUE   Procedure C32-[CT1--15] O N
  O0100G2   Treatment: BIPAP/CPAP - while resident TRUE   Procedure C32-[CT1--15] O N
  O0100H2   Treatment: IV medications - while resident TRUE   Procedure C32-[CT1--15] O N
  O0100I2   Treatment: transfusions - while resident TRUE   Procedure C32-[CT1--15] O N
  O0100J2   Treatment: dialysis - while resident TRUE   Procedure C32-[CT1--15] O N
  O0100K2   Treatment: hospice care - while resident TRUE   Procedure C32-[CT1--15] O N
  O0100L2   Treatment: respite care - while resident TRUE   Procedure C32-[CT1--15] O N
  O0100M2   Treatment: isolate/quarantine - while resident TRUE   Procedure C32-[CT1--15] O N
  O0250A   Was influenza vaccine received TRUE   Immunization C32-[CT1--7] O N
  O0250B   Date influenza vaccine received. TRUE   Immunization C32-[CT1--7] O N
  O0250C   If influenza vaccine not received, state reason TRUE 9 - None of the above Immunization C32-[CT1--7] O N
  O0300A   Is pneumococcal vaccination up to date TRUE   Immunization C32-[CT1--7] O N
  O0300B   If pneumococcal vacc not received, state reason TRUE   Immunization C32-[CT1--7] O N
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
P     Section P - Restraints N/A        
  P0100A   Restraints used in bed: bed rail TRUE 0 - Not used Procedure C32-[CT1--15] O N
  P0100B   Restraints used in bed: trunk restraint TRUE 0 - Not used Procedure C32-[CT1--15] O N
  P0100C   Restraints used in bed: limb restraint TRUE 0 - Not used Procedure C32-[CT1--15] O N
  P0100D   Restraints used in bed: other TRUE 0 - Not used Procedure C32-[CT1--15] O N
  P0100E   Restraints in chair/out of bed: trunk restraint TRUE 0 - Not used Procedure C32-[CT1--15] O N
  P0100F   Restraints in chair/out of bed: limb restraint TRUE 0 - Not used Procedure C32-[CT1--15] O N
  P0100G   Restraints in chair/out of bed: chair stops rising TRUE 0 - Not used Procedure C32-[CT1--15] O N
  P0100H   Restraints in chair/out of bed: other TRUE 0 - Not used Procedure C32-[CT1--15] O N
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
Q     Section Q - Participation in Assessment and Goal Setting N/A        
  Q0400B   Determination regarding discharge to community TRUE   Plan of Care C32-[CT1--13] O N
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
T     Therapy Supplement for Medicare PPS N/A        
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
V       N/A        
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
X       N/A        
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
Z     Assessment Administration N/A        
  Z0500B   Date RN signed assessment as complete TRUE   Information Source C32-[CT1--8] R Y
MDS ITEMS FINAL SUMMARY ITEM 2 Response(s) Triggering Omission of MDS Question from Summary HITSP C32 ENTRY CONTENT MODULES
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
Content Module/ C32 Constraint ID Content Module -- Optionality Content Module -- Repeatable
OTHER       N/A        

 

HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
A                  
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.
- 16.05 - Encounter Provider
R2 Y 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
16.05 - Encounter Provider: Name and other information for the person or organization performed or hosted the Encounter No Encounter Header 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 The MDS3.0 does not have a corresponding item for 16.01 - Encounter ID.
Note: KeyHIE CCD Section assignment reflects mapping at MDS3.0 question level vs. mapping at MDS3.0 section level.
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 Header Header Issue:
Item requires additional review. Present mapping is a forced fit.
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 Header Header  
Section 2.2.2.1 (Personal Information): see row #48
- 1.05 - Person Name
R Y C83 - 2.2.2.1.1 N/A 1.05 - Person Name: See row #48 No Header Header  
Section 2.2.2.1 (Personal Information): see row #48
- 1.05 - Person Name
R Y C83 - 2.2.2.1.1 N/A 1.05 - Person Name: See row #48 No Header Header  
Section 2.2.2.1 (Personal Information): see row #48
- 1.05 - Person Name
R Y C83 - 2.2.2.1.1 N/A 1.05 - Person Name: See row #48 No Header Header  
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 Header Header Issues:
1) Data element #1.02-Person ID is not repeatable, however both the SSN and medical record number have been selected for the Summary. Since the medical record number is an Optional field on the MDS and may not be present, general guidance is needed that balances the HITSP concerns over use of the SSN and available data for a Person ID. 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. The MDS3.0 does not support data elements #1.03 and #1.04.
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 Payers Header Issue:
The inclusion of this MDS3.0 item may need to be re-evaluated as the ONLY payer indicated will be Medicaid.
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 Header Header Issue:
The MDS3.0 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.
- 1.07 - 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 Header Header  
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 Header Header 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 the MDS3.0.
Section 2.2.2.1 (Personal Information): see row #59
- 1.10 – Race
O Y C83 - 2.2.2.1.6 N/A 1.10 – Race: See row #59 Yes - See row #59 Header Header Issue:
See row #59
Section 2.2.2.1 (Personal Information): see row #59
- 1.10 – Race
O Y C83 - 2.2.2.1.6 N/A 1.10 – Race: See row #59 Yes - See row #59 Header Header Issue:
See row #59
Section 2.2.2.1 (Personal Information): see row #59
- 1.11 – Ethnicity
O N 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 Header Header  
Section 2.2.2.1 (Personal Information): see row #59
- 1.10 – Race
O Y C83 - 2.2.2.1.6 N/A 1.10 – Race: See row #59 Yes - See row #59 Header Header Issue:
See row #59
Section 2.2.2.1 (Personal Information): see row #59
- 1.10 – Race
O Y C83 - 2.2.2.1.6 N/A 1.10 – Race: See row #59 Yes - See row #59 Header Header Issue:
See row #59
Section 2.2.2.2 (Language Spoken) states: Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. This module contains the primary and secondary languages of communication for the patient. The template identifier for this module is 2.16.840.1.113883.3.88.11.83.2.
- 2.01 – Language
R Y C83 - 2.2.2.2.1 N/A 2.01 – Language Language will be identified as spoken, written, or understood; but no attempt will be made to assess proficiency. The default language is English, but English is to be entered explicitly similar to any other listed language ● C154-[DE-2.01-1] Language SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.9 Language
- C154-[DE-2.01-2] Sign language SHALL be treated as a separate language
Header Header Issue:
This MDS3.0 item seems most appropriate for the "Language Spoken" component module. However, review of HITSP, CCD and CDA documentation seems to indicate that such an intuitive match is not supported in the requirements. This item will likely need to be reclassified.
Section 2.2.2.2 (Language Spoken) states: Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. This module contains the primary and secondary languages of communication for the patient. The template identifier for this module is 2.16.840.1.113883.3.88.11.83.2.
- 2.01 – Language
R Y C83 - 2.2.2.2.1 N/A 2.01 – Language Language will be identified as spoken, written, or understood; but no attempt will be made to assess proficiency. The default language is English, but English is to be entered explicitly similar to any other listed language ● C154-[DE-2.01-1] Language SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.9 Language
- C154-[DE-2.01-2] Sign language SHALL be treated as a separate language
Header Header  
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.
- 1.08 - Marital Status
R Y C83 - 2.2.2.1.5 N/A 1.08 - Marital Status: A value representing the domestic partnership status of a person. Marital status is important in determining insurance eligibility and other legal arrangements surrounding care. Marital status often changes during a patient's lifetime so the data should relate to the effective date of the patient data object and not be entered with multiple values like an address or contact number. This element should only have one instance reflecting the current status of the individual at the time the Exchange is produced. Former values might be part of the personal and social history C154-[DE-1.08-1] Marital Status SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.3.2 Marital Status CDA and HLV3 Header Header Issue:
While the value set for marital status found in HITSP/C80 Section 2.2.1.2.3 supports the five marital status values of the MDS3.0, the MDS3.0 does not address all marital status values found in the HITSP C80 marital status value set.
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 Header Header Issue:
See row #52
Section 2.2.2.1 (Personal Information): see row #48
- 1.05 - Person Name
R Y C83 - 2.2.2.1.1 N/A 1.05 - Person Name: See row #48 No Header Header  
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 Social History Header Note: KeyHIE CCD Section assignment reflects mapping at MDS3.0 question level vs. mapping at MDS3.0 section level.
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 Problems Header Note: KeyHIE CCD Section assignment reflects mapping at MDS3.0 question level vs. mapping at MDS3.0 section level.
Section 2.2.2.7 (Condition): See row #84
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #84 7.03 - Problem Name See row #84 No Problems Header Note: KeyHIE CCD Section assignment reflects mapping at MDS3.0 question level vs. mapping at MDS3.0 section level.
Section 2.2.2.7 (Condition): See row #84
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #84 7.03 - Problem Name See row #84 No Problems Header Note: KeyHIE CCD Section assignment reflects mapping at MDS3.0 question level vs. mapping at MDS3.0 section level.
Section 2.2.2.7 (Condition): See row #84
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #84 7.03 - Problem Name See row #84 No Problems Header Note: KeyHIE CCD Section assignment reflects mapping at MDS3.0 question level vs. mapping at MDS3.0 section level.
Section 2.2.2.7 (Condition): See row #84
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #84 7.03 - Problem Name See row #84 No Problems Header Note: KeyHIE CCD Section assignment reflects mapping at MDS3.0 question level vs. mapping at MDS3.0 section level.
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 Encounter Header 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 The MDS3.0 does not have a corresponding item for 16.01 - Encounter ID.
Note: KeyHIE CCD Section assignment reflects mapping at MDS3.0 question level vs. mapping at MDS3.0 section level.
Section #2.2.2.16 (Encounter): See row #90
- 16.03 - Encounter Free Text Type
R N N/A Section #2.2.1.27 (Encounters Section): See row #90 16.03 - Encounter Free Text Type:Free text describing the Encounter Type No Encounter Header Issue:
See row #90
Note: See row #90
Section #2.2.2.16 (Encounter): See row #90
- 16.06 - Admission Source
O N N/A Section #2.2.1.27 (Encounters Section): See row #90 16.06 - Admission Source:Identifies where the patient was admitted C154-[DE-16.06-1] The Admission Source SHALL be coded as specified in HITSP/C80 Section 2.2.3.9.1 Admission Source Encounter Header Issue:
See row #90
Note: See row #90
Section #2.2.2.16 (Encounter): See row #90
- 16.04 - Encounter Date / Time
R N N/A Section #2.2.1.27 (Encounters Section): See row #90 16.04 - Encounter Date/Time:The date and time of the Encounter, including duration if pertinent No Encounter Header Issue:
See row #90
Note: See row #90
Section #2.2.2.16 (Encounter): See row #90
- 16.09 - Discharge Disposition
O N N/A Section #2.2.1.27 (Encounters Section): See row #90 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 Encounter Header Issue:
See row #90
Note: See row #90
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 Header Header Issue:
Item requires additional review. Present mapping is a forced fit.
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
B                  
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 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 #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
C                  
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
D                  
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
E                  
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
F                  
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
G                  
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
H                  
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
I                  
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 Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
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 Problems Problems  
Section 2.2.2.7 (Condition): See row #899
- 7.03 - Problem Code
R N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section): See row #899 7.03 - Problem Code See row #899 Yes - See row #899 Problems Problems  
Section 2.2.2.7 (Condition): See row #899
- 7.03 - Problem Code
R N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section): See row #899 7.03 - Problem Code See row #899 Yes - See row #899 Problems Problems  
Section 2.2.2.7 (Condition): See row #899
- 7.03 - Problem Code
R N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section): See row #899 7.03 - Problem Code See row #899 Yes - See row #899 Problems Problems  
Section 2.2.2.7 (Condition): See row #899
- 7.03 - Problem Code
R N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section): See row #899 7.03 - Problem Code See row #899 Yes - See row #899 Problems Problems  
Section 2.2.2.7 (Condition): See row #899
- 7.03 - Problem Code
R N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section): See row #899 7.03 - Problem Code See row #899 Yes - See row #899 Problems Problems  
Section 2.2.2.7 (Condition): See row #899
- 7.03 - Problem Code
R N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section): See row #899 7.03 - Problem Code See row #899 Yes - See row #899 Problems Problems  
Section 2.2.2.7 (Condition): See row #899
- 7.03 - Problem Code
R N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section): See row #899 7.03 - Problem Code See row #899 Yes - See row #899 Problems Problems  
Section 2.2.2.7 (Condition): See row #899
- 7.03 - Problem Code
R N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section): See row #899 7.03 - Problem Code See row #899 Yes - See row #899 Problems Problems  
Section 2.2.2.7 (Condition): See row #899
- 7.03 - Problem Code
R N C83 - 2.2.2.7.5 Section #2.2.1.3 (Problem List Section): See row #899 7.03 - Problem Code See row #899 Yes - See row #899 Problems Problems  
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
J                  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
K                  
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
L                  
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
Section #2.2.2.21 (Functional Status): See Row #122 --- --- --- Section #2.2.1.9 (Functional Status): See Row #122 See Row #122 --- Functional Status Functional Status Issue:
See Row #122
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
M                  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
Section 2.2.2.7 (Condition): See row #842
- 7.03 - Problem Name
R N C83 - 2.2.2.7.4 Section #2.2.1.3 (Problem List Section): See row #842 7.03 - Problem Name See row #842 No Problems Problems  
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 Procedures Problems 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 MDS 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 The MDS3.0 does not have a corresponding item for 17.01 - Procedure ID.
Note: KeyHIE CCD Section assignment reflects mapping at MDS3.0 question level vs. mapping at MDS3.0 section level.
Section 2.2.2.17 (Procedure): See row #1084
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1084 17.03 - Procedure Free Text Type: Free text describing the Procedure No Procedures Problems Issues:
See row #1084
Note: See row #1084
Section 2.2.2.17 (Procedure): See row #1084
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1084 17.03 - Procedure Free Text Type: Free text describing the Procedure No Procedures Problems Issues:
See row #1084
Note: See row #1084
Section 2.2.2.17 (Procedure): See row #1084
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1084 17.03 - Procedure Free Text Type: Free text describing the Procedure No Procedures Problems Issues:
See row #1084
Note: See row #1084
Section 2.2.2.17 (Procedure): See row #1084
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1084 17.03 - Procedure Free Text Type: Free text describing the Procedure No Procedures Problems Issues:
See row #1084
Note: See row #1084
Section 2.2.2.17 (Procedure): See row #1084
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1084 17.03 - Procedure Free Text Type: Free text describing the Procedure No Procedures Problems Issues:
See row #1084
Note: See row #1084
Section 2.2.2.17 (Procedure): See row #1084
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1084 17.03 - Procedure Free Text Type: Free text describing the Procedure No Procedures Problems Issues:
See row #1084
Note: See row #1084
Section 2.2.2.17 (Procedure): See row #1084
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1084 17.03 - Procedure Free Text Type: Free text describing the Procedure No Procedures Problems Issues:
See row #1084
Note: See row #1084
Section 2.2.2.17 (Procedure): See row #1084
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1084 17.03 - Procedure Free Text Type: Free text describing the Procedure No Procedures Problems Issues:
See row #1084
Note: See row #1084
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
N                  
--- --- --- --- --- --- --- ? N/A Issue:
Further work is required on representation of relevant medication information found in the MDS3.0. The MDS3.0 information is not compatible with the C83 "Medication-Prescription and Non-Prescription" Content Module. Data element #8.15-Free Text Product Name is required medication information.
--- --- --- --- --- --- --- ? N/A Issue:
See row #1096
--- --- --- --- --- --- --- ? N/A Issue:
See row #1096
--- --- --- --- --- --- --- ? N/A Issue:
See row #1096
--- --- --- --- --- --- --- ? N/A Issue:
See row #1096
--- --- --- --- --- --- --- ? N/A Issue:
See row #1096
--- --- --- --- --- --- --- ? N/A Issue:
See row #1096
--- --- --- --- --- --- --- ? N/A Issue:
See row #1096
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
O                  
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 Procedures Procedures 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 MDS 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 The MDS3.0 does not have a corresponding item for 17.01 - Procedure ID.
Section 2.2.2.17 (Procedure): See row #1108
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1108 17.03 - Procedure Free Text Type: See row #1108 No Procedures Procedures Issues:
See row #1108
Section 2.2.2.17 (Procedure): See row #1108
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1108 17.03 - Procedure Free Text Type: See row #1108 No Procedures Procedures Issues:
See row #1108
Section 2.2.2.17 (Procedure): See row #1108
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1108 17.03 - Procedure Free Text Type: See row #1108 No Procedures Procedures Issues:
See row #1108
Section 2.2.2.17 (Procedure): See row #1108
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1108 17.03 - Procedure Free Text Type: See row #1108 No Procedures Procedures Issues:
See row #1108
Section 2.2.2.17 (Procedure): See row #1108
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1108 17.03 - Procedure Free Text Type: See row #1108 No Procedures Procedures Issues:
See row #1108
Section 2.2.2.17 (Procedure): See row #1108
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1108 17.03 - Procedure Free Text Type: See row #1108 No Procedures Procedures Issues:
See row #1108
Section 2.2.2.17 (Procedure): See row #1108
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1108 17.03 - Procedure Free Text Type: See row #1108 No Procedures Procedures Issues:
See row #1108
Section 2.2.2.17 (Procedure): See row #1108
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1108 17.03 - Procedure Free Text Type: See row #1108 No Procedures Procedures Issues:
See row #1108
Section 2.2.2.17 (Procedure): See row #1108
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1108 17.03 - Procedure Free Text Type: See row #1108 No Procedures Procedures Issues:
See row #1108
Section 2.2.2.17 (Procedure): See row #1108
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1108 17.03 - Procedure Free Text Type: See row #1108 No Procedures Procedures Issues:
See row #1108
Section 2.2.2.17 (Procedure): See row #1108
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1108 17.03 - Procedure Free Text Type: See row #1108 No Procedures Procedures Issues:
See row #1108
Section 2.2.2.17 (Procedure): See row #1108
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1108 17.03 - Procedure Free Text Type: See row #1108 No Procedures Procedures Issues:
See row #1108
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. Immunizations Procedures 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 Data element #13.01 will need to be triggered based on MDS3.0 item O0250C.
Note: KeyHIE CCD Section assignment reflects mapping at MDS3.0 question level vs. mapping at MDS3.0 section level.
Section 2.2.2.13 (Immunizations): See row #1134
- 13.02 - Administered Date
O N N/A Section #2.2.1.17 (Immunizations Section): See row #1134 13.02 - Administered Date: The date and time of substance was administered or refused, i.e., when the immunization was administered to the patient, or refused by the patient or patient caregiver. No Immunizations Procedures Issue:
See row #1134
Note: See row #1134
Section 2.2.2.13 (Immunizations): See row #1134
- 13.10 - Refusal Reason
R2 N C83 - 2.2.2.13.2 Section #2.2.1.17 (Immunizations Section): See row #1134 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 Immunizations Procedures Issue:
1) See row #1134 2) The HITSP value set for "No Immunization Reason" detailed in C80 Table 2-90 does not fully support the MDS3.0 responses for this question (i.e., "Resident not in facility during this year's flu season", "Received outside of this facility", "Not offered").
Note: See row #1134
No appropriate match       Section #2.2.1.17 (Immunizations Section): See row #1134 No appropriate match   Immunizations Procedures Issue:
1) See row #1134 2) The format of the MDS3.0 pneumococcal vaccination data item does not lend itself to parameters of the C83 Immunization Content module data elements.
Note: See row #1134
Section 2.2.2.13 (Immunizations): See row #1134
- 13.10 - Refusal Reason
R2 N C83 - 2.2.2.13.2 Section #2.2.1.17 (Immunizations Section): See row #1134 13.10 - Refusal Reason: See row #1138 Yes - see row #1138 Immunizations Procedures Issue:
See row #1138
Note: See row #1138
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
P                  
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 Procedures N/A 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 MDS 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 The MDS3.0 does not have a corresponding item for 17.01 - Procedure ID.
Note: KeyHIE CCD Section assignment reflects mapping at MDS3.0 question level vs. mapping at MDS3.0 section level.
Section 2.2.2.17 (Procedure): See row #1192
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1192 17.03 - Procedure Free Text Type: Free text describing the Procedure No Procedures N/A Issues:
See row #1192
Note: See row #1192
Section 2.2.2.17 (Procedure): See row #1192
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1192 17.03 - Procedure Free Text Type: Free text describing the Procedure No Procedures N/A Issues:
See row #1192
Note: See row #1192
Section 2.2.2.17 (Procedure): See row #1192
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1192 17.03 - Procedure Free Text Type: Free text describing the Procedure No Procedures N/A Issues:
See row #1192
Note: See row #1192
Section 2.2.2.17 (Procedure): See row #1192
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1192 17.03 - Procedure Free Text Type: Free text describing the Procedure No Procedures N/A Issues:
See row #1192
Note: See row #1192
Section 2.2.2.17 (Procedure): See row #1192
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1192 17.03 - Procedure Free Text Type: Free text describing the Procedure No Procedures N/A Issues:
See row #1192
Note: See row #1192
Section 2.2.2.17 (Procedure): See row #1192
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1192 17.03 - Procedure Free Text Type: Free text describing the Procedure No Procedures N/A Issues:
See row #1192
Note: See row #1192
Section 2.2.2.17 (Procedure): See row #1192
- 17.03 - Procedure Free Text Type
R N N/A Section #2.2.1.8 (List of Surgeries Section): See row #1192 17.03 - Procedure Free Text Type: Free text describing the Procedure No Procedures N/A Issues:
See row #1192
Note: See row #1192
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
Q                  
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. --- Plan of Care N/A 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 MDS item.
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
T                  
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
V                  
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
X                  
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
Z                  
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 Header Header 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 MDS3.0 data specificiations do not capture the Author Name (item Z0500A on MDS3.0 form) nor a document ID.
HITSP C83 DATA MAPPING REQUIREMENTS HITSP C154 DATA DICTIONARY CCD SECTION ISSUES/ COMMENTS
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 Per Review Team Recommendation Per MDS CCD Representation Guide
(Draft 3/24/09)
OTHER                  

 

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