2.2.1.1 |
Payers Section |
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.). |
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 |
Insurance Provider |
See HITSP/C83 Section 2.2.1.1 Payers Section |
|
2.2.1.2 |
Allergies and Other Adverse Reactions Section |
The Allergies and Other Adverse Reactions Section contains data on the substance intolerances and the associated adverse reactions suffered by the patient. At a minimum, currently active and any relevant historical allergies and adverse reactions shall be listed. |
2.16.840.1.113883.3.88.11.83.102 |
Allergy / Drug Sensitivity |
See HITSP/C83 Section 2.2.1.2 Allergies and Other Adverse Reactions Section |
C83-[CT-102-1] |
The allergies and other adverse reactions section SHALL include entries from the Allergy/Drug Sensitivity |
C83-[CT-102-2] |
This section SHALL conform to the IHE Allergies and Other Adverse Reactions Section template, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.13 |
|
2.2.1.3 |
Problem List Section |
The Problem List Section contains data on the problems currently being monitored for the patient. |
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 |
C83-[CT-104-1] |
The History of Past Illness section SHALL include entries from the Condition module. |
C83-[CT-104-2] |
This section SHALL conform to the IHE History of Past Illness Section template, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.8 |
C83-[CT-104-3] |
This section SHALL conform to the HL7 History and Physical Note and HL7 Consultation Note implementation guide requirements for this section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.2.9 |
Condition |
See HITSP/C83 Section 2.2.1.3 Problem List Section |
|
2.2.1.4 |
History of Past Illness Section |
The History of Past Illness Section contains data about problems the patient suffered in the past. |
2.16.840.1.113883.3.88.11.83.104 |
C83-[CT-104-1] |
The History of Past Illness section SHALL include entries from the Condition module. |
C83-[CT-104-2] |
This section SHALL conform to the IHE History of Past Illness Section template, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.8 |
C83-[CT-104-3] |
This section SHALL conform to the HL7 History and Physical Note and HL7 Consultation Note implementation guide requirements for this section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.2.9 |
|
2.2.1.5 |
Chief Complaint Section |
The Chief Complaint Section contains information about the patient's chief complaint. |
2.16.840.1.113883.3.88.11.83.105 |
C83-[CT-105-1] |
This section SHALL conform to the IHE Chief Complaint Section template, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 |
C83-[CT-105-2] |
This section SHALL conform to the HL7 History and Physical Note requirements for this section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.2.8 |
C83-[CT-105-3] |
The Chief Complaint section MAY include an entry from the Condition |
|
2.2.1.6 |
Reason for Referral Section |
The Reason for Referral Section contains information about the reason that the patient is being referred. |
2.16.840.1.113883.3.88.11.83.106 |
C83-[CT-106-1] |
This section SHALL conform to the IHE Reason for Referral Section template, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.1. |
C83-[CT-106-2] |
This section SHALL conform to the HL7 Consultation Note requirements for this section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.4.8 |
C83-[CT-106-3] |
This section MAY conform to the IHE Coded Reason for Referral Section template, in which case it SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.2 to indicate conformance. |
C83-[CT-106-4] |
The Reason for Referral section MAY include entries from the Condition module or actual events recorded using Result module to provide the reason for referral in coded form. |
|
2.2.1.7 |
History of Present Illness Section |
The History of Present Illness Section contains information about the sequence of events preceding the patient's current complaints. |
2.16.840.1.113883.3.88.11.83.107 |
C83-[CT-107-1] |
This section SHALL conform to the IHE History of Present Illness Section template, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.4. |
|
2.2.1.8 |
List of Surgeries Section |
The List of Surgeries Section provides a list of surgeries the patient has received. |
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. |
Procedure |
See HITSP/C83 Section 2.2.1.8 List of Surgeries Section |
|
2.2.1.9 |
Functional Status Section |
The Functional Status Section provides information about the capability of the patient to perform acts of daily living. |
2.16.840.1.113883.3.88.11.83.109 |
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 |
|
2.2.1.10 |
Hospital Admission Diagnosis Section |
The Hospital Admission Diagnosis Section contains information about the primary reason for admission to a hospital facility. |
2.16.840.1.113883.3.88.11.83.110 |
C83-[CT-110-1] |
This section SHALL conform to the IHE Hospital Admission Diagnosis section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.3 |
C83-[CT-110-2] |
The Hospital Admission Diagnosis section SHALL include an entry from the Condition module to provide the admission diagnosis in coded form |
|
2.2.1.11 |
Discharge Diagnosis Section |
The Discharge Diagnosis Section contains information about the conditions identified during the hospital stay that either need to be monitored after discharge from the hospital and/or where resolved during the hospital course. |
2.16.840.1.113883.3.88.11.83.111 |
C83-[CT-111-1] |
This section SHALL conform to the IHE Hospital Discharge Diagnosis section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.7 |
C83-[CT-111-2] |
The Discharge Diagnosis section SHALL include entries from the Condition module to provide the discharge diagnosis in coded form |
|
2.2.1.12 |
Medications Section |
The Medications Section contains information about the relevant medications for the patient. At a minimum, the currently active medications should be listed. |
2.16.840.1.113883.3.88.11.83.112 |
C83-[CT-112-1] |
This section SHALL conform to the IHE Medications section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.19 |
C83-[CT-112-2] |
The Medications Section SHALL include entries from the Medication module to provide the relevant medications in coded form |
Medication - Prescription and Non-Prescription |
See HITSP/C83 Section 2.2.1.12 Medications Section |
|
2.2.1.13 |
Admission Medications History Section |
The Admission Medications Section contains information about the relevant medications of a patient prior to admission to a facility. |
2.16.840.1.113883.3.88.11.83.113 |
C83-[CT-113-1] |
This section SHALL conform to the IHE Admission Medications History section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.20 |
C83-[CT-113-2] |
The Admission Medications History section SHALL include entries from the Medication module to provide the relevant medications of a patient prior to admission in coded form |
|
2.2.1.14 |
Hospital Discharge Medications Section |
The Hospital Discharge Medications Section contains information about the relevant medications of the medications ordered for the patient for use after discharge from the hospital. |
2.16.840.1.113883.3.88.11.83.114 |
C83-[CT-114-1] |
This section SHALL conform to the IHE Hospital Discharge Medications Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.22 |
C83-[CT-114-2] |
The Hospital Discharge Medications section SHALL include entries from the Medication module to provide the relevant medications of the medications ordered for the patient for use after discharge in coded form |
|
2.2.1.15 |
Medications Administered Section |
The Medications Administered Section contains information about the relevant medications administered to a patient during the course of an encounter. |
2.16.840.1.113883.3.88.11.83.115 |
C83-[CT-115-1] |
This section SHALL conform to the IHE Medications Administered Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.21 |
C83-[CT-115-2] |
The Medications Administered Section SHALL include entries from the Medication module to provide the relevant medications administered to a patient in coded form |
|
2.2.1.16 |
Advance Directives Section |
The Advance Directives Section contains information that defines the patient's expectations and requests for care along with the locations of the documents. |
2.16.840.1.113883.3.88.11.83.116 |
C83-[CT-116-1] |
This section SHALL conform to the IHE Coded Advance Directives Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.35 |
C83-[CT-116-2] |
The Advance Directives Section SHALL include entries from the Advance Directive module |
|
2.2.1.17 |
Immunizations Section |
The Immunizations Section contains information describing the immunizations administered to the patient. |
2.16.840.1.113883.3.88.11.83.117 |
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 |
Immunization |
See HITSP/C83 Section 2.2.1.17 Immunizations Section |
|
2.2.1.18 |
Physical Examination Section |
The Physical Examination Section contains information describing the physical findings. |
2.16.840.1.113883.3.88.11.83.118 |
C83-[CT-118-1] |
This section SHALL conform to the IHE Physical Examination Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.9.15 |
C83-[CT-118-2] |
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 2.16.840.1.113883.10.20.2.10 |
C83-[CT-118-3] |
The Physical Examination Section SHOULD contain Condition entries conforming to the Condition module |
C83-[CT-118-4] |
Condition entries appearing in the physical examination section SHALL conform the Condition module and SHOULD restrict the Condition Type as FINDING (404684003)or FUNCTIONAL LIMITATION (248536006) from the SNOMED CT Code System |
|
2.2.1.19 |
Vital Signs Section |
The Vital Signs Section contains information documenting the patient vital signs. |
2.16.840.1.113883.3.88.11.83.119 |
C83-[CT-119-1] |
This section SHALL conform to the IHE Coded Vital Signs Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 |
C83-[CT-119-2] |
The Vital Signs Section SHALL contain entries conforming to the Vital Sign module |
Vital Sign |
See HITSP/C83 Section 2.2.1.19 Vital Signs Section |
|
2.2.1.20 |
Review of Systems Section |
The Review of Systems Section contains information describing patient responses to questions about the function of various body systems. |
2.16.840.1.113883.3.88.11.83.120 |
C83-[CT-120-1] |
This section SHALL conform to the IHE Review of Systems Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.18 |
C83-[CT-120-2] |
This section SHALL conform to the HL7 Consultation Note requirements for this section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.4.10 |
|
2.2.1.21 |
Hospital Course Section |
The Hospital Course Section contains information about of the sequence of events from admission to discharge in a hospital facility. |
2.16.840.1.113883.3.88.11.83.121 |
C83-[CT-121-1] |
This section SHALL conform to the IHE Hospital Course Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.5 |
|
2.2.1.22 |
Diagnostic Results Section |
The Diagnostic Results Section contains information about the results from diagnostic procedures the patient received. |
2.16.840.1.113883.3.88.11.83.122 |
C83-[CT-122-1] |
This section SHALL conform to the IHE Coded Results Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.28 |
C83-[CT-122-2] |
The Diagnostic Results Section SHALL include entries from the Procedure module to indicate the diagnostic procedure, and the events recorded using the Result module to provide the results of that procedure |
Results |
See HITSP/C83 Section 2.2.1.22 Diagnostic Results Section |
|
2.2.1.23 |
Assessment and Plan Section |
The Assessment and Plan Section contains information about the assessment of the patient's condition and expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient.
An assessment and plan section varies from the plan of care section defined later in that it includes a physician assessment of the patient condition.
Note: Please note that the assessments described in this section are physician assessments of the patient's current condition, and do not include assessments of functional status, or other assessments typically used in nursing. In Implementation Guides currently selected, when both the assessment and plan are documented, they are included together in a single section documenting both. When the physician assessment is not present, only the Plan of Care Section appears. There are no cases where a physician assessment is provided without a plan. |
2.16.840.1.113883.3.88.11.83.123 |
C83-[CT-123-1] |
This section SHALL conform to the IHE Assessment and Plans Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5 |
C83-[CT-123-2] |
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-123-3] |
The Assessments and Plan Section MAY include entries conforming to the Medication, Immunization, Encounter, and Procedure modules to provide information about the intended care plan |
|
2.2.1.24 |
Plan of Care Section |
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. |
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 |
Plan of Care |
See HITSP/C83 Section 2.2.1.24 Plan of Care |
|
2.2.1.25 |
Family History Section |
The Family History Section contains information about the genetic family members, to the extent that they are known, the diseases they suffered from, their ages at death, and other relevant genetic information. |
2.16.840.1.113883.3.88.11.83.125 |
C83-[CT-125-1] |
This section SHALL conform to the IHE Family Medical History Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.14 |
C83-[CT-125-2] |
When used to convey structured family histories, this section SHALL conform to the IHE Coded Family History Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.3.15 C83-[DE-17-CDA-1 |
C83-[CT-125-3] |
When providing structured Family History Information this section SHALL include entries conforming to the Family History module |
|
2.2.1.25.1 |
Procedures Constraints |
No definition given |
N/A |
C83-[DE-17-CDA-1] |
Procedure entries SHALL declare conformance for the procedures module by including a element with the root attribute set to the value 2.16.840.1.113883.3.88.11.83.17 |
C83-[DE-17-CDA-2] |
Procedure entries SHALL declare conformance to the IHE Procedure entry by including a element with the root attribute set to the value 1.3.6.1.4.1.19376.1.5.3.1.4.19 |
|
2.2.1.25.2 |
Body Site Constraints |
No definition given |
N/A |
C83-[DE-17-CDA-3] |
The body site SHALL be coded according as specified in HITSP/C80 Section 2.2.3.2.1 Body Site |
|
2.2.1.26 |
Social History Section |
The Social History Section contains information about the person's beliefs, home life, community life, work life, hobbies, and risky habits. |
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 |
|
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. |
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 element 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 SHALL contain entries conforming to the Encounters module |
Encounter |
See HITSP/C83 Section 2.2.1.27 Encounters Section |
|
2.2.1.28 |
Medical Equipment Section |
The Medical Equipment Section contains information describing a patient's implanted and external medical devices and equipment that their health status depends on, as well as any pertinent equipment or device history. |
2.16.840.1.113883.3.88.11.83.128 |
C83-[CT-128-1] |
This section SHALL conform to the HL7 CCD Medical Equipment Section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.1.7. |
C83-[CT-128-2] |
This section SHALL conform to the IHE Medical Devices Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.5 |
|
2.2.1.29 |
Preoperative Diagnosis Section |
The Preoperative Diagnosis Section records the surgical diagnosis or diagnoses that are assigned to the patient before the surgical procedure, and is the reason for the surgery. The Preoperative Diagnosis is, in the opinion of the surgeon, the diagnosis that will be confirmed during surgery. |
2.16.840.1.113883.3.88.11.83.129 |
C83-[CT-129-1] |
This section SHALL conform to the HL7 Operative Note Preoperative Diagnosis Section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.7.1 |
C83-[CT-129-2] |
This section SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.3.88.11.83.129 |
C83-[CT-129-3] |
The Preoperative Diagnosis Section SHALL contain entries conforming to the Condition module to record the diagnoses |
C83-[CT-129-4] |
The Conditions entries in the preoperative diagnosis section SHALL use the SNOMED CT Code 282291009 (Diagnosis) for the value of data element 7.02 Problem Type |
|
2.2.1.30 |
Postoperative Diagnosis Section |
The Postoperative Diagnosis Section records the diagnosis or diagnoses discovered or confirmed during the surgery. Often it is the same as the Preoperative Diagnosis. |
2.16.840.1.113883.3.88.11.83.130 |
C83-[CT-130-1] |
This section SHALL conform to the HL7 Operative Note Postoperative Diagnosis Section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.7.2 |
C83-[CT-130-2] |
This section SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.3.88.11.83.130 |
C83-[CT-130-3] |
The Postoperative Diagnosis Section SHALL contain entries conforming to the Condition module to record the diagnoses |
C83-[CT-130-4] |
The Conditions entries in the Postoperative Diagnosis Section SHALL use the SNOMED CT Code 282291009 (Diagnosis) for the value of data element 7.02 Problem Type |
|
2.2.1.31 |
Surgery Description Section |
The Operative Note Surgery Description Section records the particulars of the surgery with an extensive narrative describing the surgery. |
2.16.840.1.113883.10.20.7.3 |
C83-[CT-131-1] |
This section SHALL conform to the HL7 Operative Note Postoperative Diagnosis Section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.7.3. |
|
2.2.1.32 |
Surgical Operation Note Findings Section |
The Surgical Operation Note Findings Section records clinically significant observations confirmed or discovered during the surgery. |
2.16.840.1.113883.3.88.11.83.132 |
C83-[CT-132-1] |
This section SHALL conform to the HL7 Operative Note Findings Section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.7.4 |
C83-[CT-132-2] |
The Surgical Operation Note Findings Section SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.3.88.11.83.132 |
C83-[CT-132-3] |
Surgical Operative Note Findings MAY be present and shall be recorded in entries conforming to the Condition module to record any findings |
|
2.2.1.33 |
Anesthesia Section |
The Anesthesia Section briefly records the type of anesthesia (e.g., general or local) and may state the actual agent used. |
2.16.840.1.113883.3.88.11.83.133 |
C83-[CT-133-1] |
This section SHALL conform to the HL7 Operative Note Anesthesia Section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.7.5 |
C83-[CT-133-2] |
The Anesthesia Section SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.3.88.11.83.133 |
C83-[CT-133-3] |
Structured entries describing anesthesia used MAY be present and shall be recorded using entries conforming to the Medication or Procedures module to record any the anesthesia substance or procedure used. |
|
2.2.1.34 |
Estimated Blood Loss Section |
The Estimated Blood Loss Section records the approximate amount of blood that the patient lost during the surgery. |
2.16.840.1.113883.3.88.11.83.134 |
C83-[CT-134-1] |
This section SHALL conform to the HL7 Operative Note Estimated Blood Loss Section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.7.6 |
|
2.2.1.35 |
Specimens Removed |
The Specimens Removed Section records the tissues, objects, or samples taken from the patient during surgery. |
2.16.840.1.113883.10.20.7.7 |
C83-[CT-135-1] |
This section SHALL conform to the HL7 Operative Note Specimens Removed Section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.7.7. |
|
2.2.1.36 |
Complications Section |
The Complications Section records problems that occurred during surgery. The complications may have been known risks or unanticipated problems. |
2.16.840.1.113883.10.20.7.10 |
C83-[CT-136-1] |
This section SHALL conform to the HL7 Operative Note Complications Section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.7.10. |
C83-[CT-136-2] |
Structured entries describing complications May be present and SHALL contain entries conforming to the Condition module. |
|
2.2.1.37 |
Planned Procedure Section |
The Planned Procedure Section records the procedure(s) that the surgeon thought would need to be done based on the preoperative assessment. |
2.16.840.1.113883.3.88.11.83.137 |
C83-[CT-137-1] |
This section SHALL conform to the HL7 Operative Note Planned Procedure Section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.7.8 |
C83-[CT-137-2] |
The Planned Procedure Section SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.3.88.11.83.137 |
C83-[CT-137-3] |
The Planned Procedure Section SHALL contain at least one entry conforming to the Procedures module to record the planned procedure |
|
2.2.1.38 |
Indications Section |
The Indications Section records further details about the reason for the surgery. |
2.16.840.1.113883.10.20.7.9 |
C83-[CT-138-1] |
This section SHALL conform to the HL7 Operative Note Indications Section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.7.9 |
C83-[CT-138-2] |
Structured indications entries MAY be present and SHALL conform to the Condition module |
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2.2.1.39 |
Disposition Section |
The Disposition Section records the status and condition of the patient at the completion of the surgery. It often also states where the patent was transferred to for the next level of care. |
2.16.840.1.113883.10.20.7.11 |
C83-[CT-139-1] |
This section SHALL conform to the HL7 Operative Note Dispositions Section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.7.11 |
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2.2.1.40 |
Operative Note Fluids Section |
The Operative Note Fluids Section may be used to record fluids administered during the surgical procedure. |
2.16.840.1.113883.10.20.7.12 |
C83-[CT-140-1] |
This section SHALL conform to the HL7 Operative Note Fluids Section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.7.12 |
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2.2.1.41 |
Operative Note Surgical Procedure Section |
The Operative Note Surgical Procedure Section may be used to restate the procedures performed if appropriate for an enterprise workflow. |
2.16.840.1.113883.10.20.7.14 |
C83-[CT-141-1 |
This section SHALL conform to the HL7 Operative Note Surgical Procedure Section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.7.14. |
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2.2.1.42 |
Surgical Drains Section |
The Surgical Drains Section may be used to record drains placed during the surgical procedure. |
2.16.840.1.113883.10.20.7.13 |
C83-[CT-142-1] |
This section SHALL conform to the HL7 Operative Note Surgical Drains, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.7.13 |
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2.2.1.43 |
Implants Section |
The Implants Section may be used to record implants placed during the surgical procedure. |
2.16.840.1.113883.10.20.7.15 |
C83-[CT-143-1] |
This section SHALL conform to the HL7 Operative Note Dispositions Section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.10.20.7.15 C83-[CT-144-1 |
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2.2.1.44 |
Assessments Section |
The Assessments Section may be used to record assessments of the patient status. |
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4 |
C83-[CT-144-1] |
This section SHALL conform to the IHE Assessments Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4 |
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2.2.1.45 |
Procedures and Interventions Section |
The Procedures and Interventions Section may be used to record the procedures and interventions that have been performed. |
2.16.840.1.113883.3.88.11.83.145 |
C83-[CT-145-1] |
This section SHALL conform to the IHE Procedures and Interventions Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 |
C83-[CT-145-2] |
The Procedures and Assessments Section SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.3.88.11.83.144 |
C83-[CT-145-3] |
This section SHALL contain entries describing procedures using the Procedure module |
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2.2.1.46 |
Provider Orders Section |
The Provider Orders Section may be used to record orders that are to be implemented, including any orders for treatment (e.g., medications, therapy, et cetera), monitoring (testing, monitoring, etc.), education and follow-up care. |
2.16.840.1.113883.3.88.11.83.146 |
C83-[CT-146-1] |
This section SHALL conform to the IHE Provider Orders Section, and SHALL contain a templateId element whose root attribute is 1.3.6.1.4.1.19376.1.5.3.1.1.20.2.1. |
C83-[CT-146-2] |
This section SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.3.88.11.83.146 |
C83-[CT-146-3] |
Entries for medications, encounters, procedures or results found in this section shall conform to the specifications for the Medication, Encounter, Procedure and Result modules |
C83-[CT-146-4] |
Entries for medications, encounters, procedures or results found in this section shall have */@moodCode = INT or PRP as allowed by those modules to indicate that these are activities intended as part of the care plan, rather than actual events that have occurred C83-[DE-17-CDA-1 |
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2.2.1.47 |
Questionnaire Assessment Section |
The Questionnaire Assessment Section contains tools/instruments structured in a question/answer- format that are used in various healthcare settings to document (or provide information to assess) the patient's overall clinical status, functional status, treatment given, or other patient status or care. |
2.16.840.1.113883.3.88.11.83.147 |
C83-[CT-147-1] |
Conforming sections SHALL contain a element whose root attribute is 2.16.840.1.113883.3.88.11.83.147 |
C83-[CT-147-2] |
Conforming sections SHALL contain one element valued as the name of the specific assessment instrument |
C83-[CT-147-3] |
Conforming sections SHALL use LOINC ® codes where available to identify the divisions, topics, domains and associated questions of the assessment instrument |
C83-[CT-147-4] |
Conforming sections SHALL contain a local system code in the element when LOINC codes are not available to identify the divisions, topics, domains and associated questions in relation to how they are used and the answers. It may be provided otherwise |
C83-[CT-147-5] |
Conforming sections SHALL represent answers in conformance with the Result module |
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