Outpatient Encounter Patient Disenrolled

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Example metadata last updated 2017-12-11 19:21:14.373000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 11/17/2016
  • SDWG: 2/2/2016

SITE C-CDA Validator

Comments:

  • This is an example of an outpatient visit discharge disposition. In order to support a local Discharge Disposition code the dischargeDisposition contains the "OTH" nullFlavor.

Custodian: Lisa Nelson (GitHub: lisarnelson)

Full sample: Encounter in empty CCD

Example: download example view on GitHub

<!-- ************************ ENCOUNTERS *********************** -->
<component>
    <section>
        <!-- *** Encounters section (entries required) (V3) *** -->
        <templateId root="2.16.840.1.113883.10.20.22.2.22.1" extension="2015-08-01"/>
        <templateId root="2.16.840.1.113883.10.20.22.2.22.1"/>
        <code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
        <title>ENCOUNTERS</title>
        <text>
            <table border="1" width="100%">
                <thead>
                    <tr>
                        <th>Encounter</th>
                        <th>Performer</th>
                        <th>Location</th>
                        <th>Date</th>
                        <th>Discharge Disposition</th>
                        <th>Location</th>
                    </tr>
                </thead>
                <tbody>
                    <tr ID="Encounter1">
                        <td ID="Encounter1_Type"> Checkup Examination </td>
                        <td>Performer Name</td>
                        <td>Community Urgent Care 1007 Health Drive, Portland OR</td>
                        <td>September 27, 2012 at 1:00pm</td>
                        <td ID="Encounter1_DischargeDispositionCode">Disenrolled</td>
                        <td ID="Encounter1_DischargedToLoc">N/A</td>
                    </tr>
                </tbody>
            </table>
        </text>
        <entry typeCode="DRIV">
            <encounter classCode="ENC" moodCode="EVN">
                <!-- ** Encounter Activity (V3) ** -->
                <templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01"/>
                <templateId root="2.16.840.1.113883.10.20.22.4.49"/>
                <id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
                <code code="99213" displayName="Office outpatient visit 15 minutes" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12">
                    <originalText>
                        <reference value="#Encounter1_Type"/>
                    </originalText>
                    <!-- MAY MAY contain zero or one [0..1] translation (CONF:1198-32323)
									The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) valueset to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) valueset.
								<translation code="AMB" codeSystem="2.16.840.1.113883.5.4" displayName="Ambulatory" codeSystemName="HL7 ActEncounterCode"/>
								-->
                </code>
                <text>
                    <reference value="#Encounter1"/>
                </text>
                <effectiveTime value="201209271300+0500"/>
                <!--  This shows use of the discharge disposition extension AND shows using both the suggested encoding from C-CDA R2.1 and some local Good Health Hospital codes. -->
                <sdtc:dischargeDispositionCode nullFlavor="OTH">
                    <originalText>
                        <reference value="#Encounter1_DischargeDispositionCode"></reference>
                    </originalText>
                    <!-- Good Health Hospital (local OID) to represent their local code system. -->
                    <translation code="DE" codeSystem="2.16.840.1.113883.19.5" codeSystemName="Community Urgent Care Local Discharge Code" displayName="Disenrolled"/>
                </sdtc:dischargeDispositionCode>
                <performer>
                    <assignedEntity>
                        <!-- Provider NPI "333444555" -->
                        <id extension="333444555" root="2.16.840.1.113883.4.6"/>
                        <code code="59058001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="General Physician"/>
                    </assignedEntity>
                </performer>
                <participant typeCode="LOC">
                    <participantRole classCode="SDLOC">
                        <templateId root="2.16.840.1.113883.10.20.22.4.32"/>
                        <!-- Service Delivery Location template -->
                        <code code="1160-1" codeSystem="2.16.840.1.113883.6.259" codeSystemName="HL7 HealthcareServiceLocation" displayName="Urgent Care Center"/>
                        <addr>
                            <streetAddressLine>1007 Health Drive</streetAddressLine>
                            <city>Portland</city>
                            <state>OR</state>
                            <postalCode>99123</postalCode>
                            <country>US</country>
                        </addr>
                        <telecom use="WP" value="tel: +1(555)555-1030"/>
                        <playingEntity classCode="PLC">
                            <name>Community Urgent Care</name>
                        </playingEntity>
                    </participantRole>
                </participant>
		<entryRelationship typeCode="RSON">
                    <!-- ** Indivcation (V2) ** -->
                    <observation classCode="OBS" moodCode="EVN">
                        <templateId root="2.16.840.1.113883.10.20.22.4.19" extension="2014-06-09"/>
                        <templateId root="2.16.840.1.113883.10.20.22.4.19"/>
                        <id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/>
                        <!-- code is required; MAY be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2014-09-02 (CONF:1098-31229) -->
                        <code code="404684003" displayName="Finding" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96">
                            <!--  of course this MAY be present 
										<translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Clinical finding"/>-->
                        </code>
                        <statusCode code="completed"/>
                        <effectiveTime>
                            <low value="201209251130+0500"/>
                        </effectiveTime>
                        <value xsi:type="CD" code="233604007" displayName="Pneumonia" codeSystem="2.16.840.1.113883.6.96"/>
                    </observation>
                </entryRelationship>
            </encounter>
        </entry>
    </section>
</component>
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