Care Team In Transition of Care Documents


Approval Status

  • Approval Status: Approved
  • Example Task Force: 12/22/2016
  • SDWG: 2/2/2017

C-CDA 2.1 Example:

  • serviceEvent and Performer
  • N/A

Reference to full CDA sample:

  • Empty CCD

Validation location

Comments

  • This is an example of how to include Care Team information for 170.315_b1 Ambulatory test data

Certification

  • ONC

Custodian

  • George Cole

Keywords

  • Care Team, transition of care test data

Permalink

  • 4e1047540ebbd74205b20a81bed34143f4d4b3fa

Links

Example: download example view on GitHub

<!-- Transition of Care snip to show Care Team from test data for 170.315_b1 Ambulatory
    
B)	Relevant Information regarding the Visit
Care Team
•	Dr Albert Davis, 2472 Rocky place, Beaverton, OR 97006
•	Tracy Davis, 555-555-1002, 2472 Rocky place, Beaverton, OR 97006

This example includes members of the Care Team in the documentationOf/serviceEvent.

From C-CDA R2.1 we have this statement:
	A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent.
	
and for serviceEvent/performer the guide says:
	The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient’s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors
	
For single encounter events, the guide says:
	If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. The componentOf/encompassingEncounter may be used to document any subset of the providers on the care team that were active participants in the encounter.
 -->
<documentationOf>
    <serviceEvent classCode="PCPR">
        <id extension="5283815" root="1.3.6.1.4.1.22812.4.99930.4.3.8"/>
        <!-- The service event being documented is shown as happening from 10 - 10:30am Eastern on 6/22/2015. 
			     The date is in the Test Data for §170.315(b)(1) Transitions of care the test data. -->
        <effectiveTime>
            <low value="20150622100000-0600"/>
            <high value="20150622103000-0600"/>
        </effectiveTime>
        <!-- Preferably, the patient’s key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
					there are two Care Team members, so two performer elements. 
								 -->
        <performer typeCode="PRF">
            <!-- we infer from the test data description that Dr Davis is the PCP -->
            <!-- MAY provide functionCode -->
            <functionCode codeSystem="2.16.840.1.113883.5.88" code="PCP" displayName="Primary Care Physician"/>
            <!-- we do not know how long Dr Davis has been associated with the patient	-->
            <time>
                <low nullFlavor="UNK"/>
            </time>
            <assignedEntity>
                <!-- a fake NPI number -->
                <id extension="1111111111" root="2.16.840.1.113883.4.6"/>
                <!-- optional, and NOT in Test data: a code from the NUCC Health Care Provider taxonomy showing this is an an internal medicine provider -->
                <code codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC Health Care Provider Taxonomy" code="207R00000X" displayName="Internal Medicine"/>
                <!-- work address -->
                <addr use="WP">
                    <streetAddressLine>Neighborhood Physicians Practice</streetAddressLine>
                    <streetAddressLine>2472 Rocky place</streetAddressLine>
                    <city>Beaverton</city>
                    <state>OR</state>
                    <postalCode>97006</postalCode>
                    <country>US</country>
                </addr>
                <assignedPerson>
                    <name>
                        <prefix qualifier="TITLE">Dr</prefix>						
                        <given>Albert</given>
                        <family>Davis</family>
                    </name>
                </assignedPerson>
            </assignedEntity>
        </performer>
        <performer typeCode="PRF">
            <time>
                <low nullFlavor="UNK"/>
            </time>
            <assignedEntity>
                <!-- this provider has an id, but it is not an NPI  -->
                <id extension="91138" root="1.3.6.1.4.1.22812.4.99930.4"/>
                <!-- optional, and NOT in test data: the provider is a Registered Nurse -->
                <code codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC Health Care Provider Taxonomy" code="163W00000X" displayName="Registered Nurse"/>
                <addr use="WP">
                    <streetAddressLine>Neighborhood Physicians Practice</streetAddressLine>
                    <streetAddressLine>2472 Rocky place</streetAddressLine>
                    <city>Beaverton</city>
                    <state>OR</state>
                    <postalCode>97006</postalCode>
                    <country>US</country>
                </addr>
                <telecom value="tel:+1-(555)555-1002" use="WP"/>
                <assignedPerson>
                    <name>
                        <given>Tracy</given>
                        <family>Davis</family>
                    </name>
                </assignedPerson>
            </assignedEntity>
        </performer>
    </serviceEvent>
</documentationOf>
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