Outpatient Encounter with Diagnoses

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 5/7/2015
  • SDWG: 5/28/2015
  • SDWG C-CDA R2.1 Upgrade: 2/2/2017

C-CDA 2.1 Example:

  • 2.16.840.1.113883.10.20.22.2.22.1:2015-08-01
  • 2.16.840.1.113883.10.20.22.4.49:2015-08-01
  • 2.16.840.1.113883.10.20.22.4.32
  • 2.16.840.1.113883.10.20.22.4.80:2015-08-01
  • 2.16.840.1.113883.10.20.22.4.4:2015-08-01
  • 2.16.840.1.113883.10.20.22.4.6

Reference to full CDA sample:

  • Encounter in empty CCD

Validation location

Comments

  • This example illustrates how to structure Encounter Diagnosis for the 170.314(b)(2) Transitions of care - L) Encounter Diagnosis

Custodian

  • Lisa Nelson (GitHub: lisarnelson)

Certification

  • ONC

Keywords

  • Outpatient Visit, Encounter Diagnoses, performer, visit location

Permalink

Links

 

Example: download example view on GitHub 

<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" displayName="Encounters"/>
    <title>ENCOUNTERS</title>
    <text>
        <table border="1" width="100%">
            <thead>
                <tr>
                    <th>Encounter</th>
                    <th>Performer</th>
                    <th>Location</th>
                    <th>Encounter date</th>
                    <th>Diagnosis</th>
                    <th>Diagnosis Status</th>
                </tr>
            </thead>
            <tbody>
                <tr ID="Encounter1">
                    <td ID="Encounter1_type">Office outpatient visit</td>
                    <td>Dr. Samir Kahn <content ID="Encounter1_performer_type">Internal Medicine</content> </td>
                    <td>Community Urgent Care (Urgent Care Center)
                        <paragraph>1004 Healthcare Dr.</paragraph>
                        <paragraph>Portland, OR  97005</paragraph>
                    </td>
                    <td>August 15, 2012</td>
                    <td ID="Encounter1_diagnosis">Costal Chondritis</td>
                    <td ID="Encounter1_diagnosis_status">Active</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"/>
            <!-- Selected reasonable encounter/code. Not in test data -->
            <code code="99213" displayName="Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter."
                codeSystemName="CPT" codeSystem="2.16.840.1.113883.6.12"
                codeSystemVersion="4">
                <originalText><reference value="#Encounter1_type"/>
                </originalText>
            </code>
            <text><reference value="#Encounter1" /></text>
            <!-- August 15, 2012 - added time (pacific time) since but not present in test data -->
            <effectiveTime value="201208151000-0800"/>
            <!-- Not specified in test data, but could infer Dr. Khan from the test scenario narrative-->
            <performer>
                <assignedEntity>
                    <!-- Fake Provider NPI "12345678910" -->
                    <id root="2.16.840.1.113883.4.6" extension="12345678910"/>
                    <code code="207R00000X" codeSystem="2.16.840.1.113883.6.101"
                        codeSystemName="Health Care Provider Taxonomy" 
                        displayName="Allopathic &amp; Osteopathic Physicians; Internal Medicine">
                        <originalText><reference value="Encounter1_performer_type" /></originalText>
                    </code>
                    <assignedPerson>
                        <name>
                            <prefix>Dr.</prefix>
                            <given>Samir</given>
                            <family>Khan</family>
                            <!--  Could alternately use <suffix>MD</suffix> -->
                        </name>                                        
                    </assignedPerson>
                </assignedEntity>
            </performer>
            <participant typeCode="LOC">
                <!-- Location is inferred from the care team address in test data -->
                <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="HealthcareServiceLocation"
                        displayName="Urgent Care Center"/>
                    <addr>
                        <streetAddressLine>1004 Healthcare Dr.</streetAddressLine>
                        <city>Portland</city>
                        <state>OR</state>
                        <postalCode>97005</postalCode>
                    </addr>
                    <telecom value="tel:+1(555)555-1004"/>
                    <playingEntity classCode="PLC">
                        <name>Get Well Clinic</name>
                    </playingEntity>
                </participantRole>
            </participant>
            <entryRelationship typeCode="REFR">
                <act classCode="ACT" moodCode="EVN">
                    <!-- Encounter Diagnosis -->
                    <templateId root="2.16.840.1.113883.10.20.22.4.80" extension="2015-08-01" />
                    <templateId root="2.16.840.1.113883.10.20.22.4.80"/>
                    <code code="29308-4" displayName="Diagnosis"
                        codeSystem="2.16.840.1.113883.6.1"
                        codeSystemName="LOINC"/>
                    <!-- This example uses the Problem Status Observation to represent status of the diagnosis.
                                     The statusCode of the encounter diagnosis is an alternative approach.-->
                    <entryRelationship typeCode="SUBJ">
                        <observation classCode="OBS" moodCode="EVN">
                            <!-- Problem Observation -->
                            <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01" />
                            <templateId root="2.16.840.1.113883.10.20.22.4.4"/>
                            <id root="db734647-fc99-424c-a864-7e3cda82e704"/>
                            <code code="282291009" displayName="Diagnosis interpretation" codeSystem="2.16.840.1.113883.6.96"
                                codeSystemName="SNOMED CT">
                                <translation code="29308-4" displayName="Diagnosis" codeSystem="2.16.840.1.113883.6.1"
                                    codeSystemName="LOINC"/>
                            </code>
                            <statusCode code="completed"/>
                            <!-- This same data may be represented in the Problem List -->
                            <effectiveTime>
                                <low value="20120815"/>
                            </effectiveTime>
                            <!-- Test data is SNOMED but in practice this is probably an ICD9/10 code -->
                            <value xsi:type="CD" code="64109004" displayName="Costal chondritis"
                                codeSystem="2.16.840.1.113883.6.96">
                                <originalText><reference value="#Encounter1_diagnosis" /></originalText>
                            </value>
                            <entryRelationship typeCode="REFR">
                                <observation classCode="OBS" moodCode="EVN"> 
                                    <!-- Problem Status which is strange on an encounter diagnosis but 
                                                         included due to the test data -->
                                    <!-- C-CDA R2.0 deprecated this template -->
                                    <templateId root="2.16.840.1.113883.10.20.22.4.6"/>
                                    <code code="33999-4" displayName="Status"
                                        codeSystem="2.16.840.1.113883.6.1"
                                        codeSystemName="LOINC"/>
                                    <statusCode code="completed"/>
                                    <value xsi:type="CD" code="55561003" displayName="Active"
                                        codeSystem="2.16.840.1.113883.6.96">
                                        <originalText><reference value="#Encounter1_diagnosis_status" /></originalText>
                                    </value>
                                </observation>                                             
                            </entryRelationship>
                        </observation>
                    </entryRelationship>
                </act>
            </entryRelationship>
        </encounter>
    </entry>
</section>

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