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HITSP/C83: HITSP CDA Content Modules Component


1. Introduction

1.1 Overview

The purpose of the Healthcare Information Technology Standards Panel (HITSP) CDA Content Modules Component is to define the library of Components that may be used by CDA-based constructs developed by HITSP and others in standards based exchanges. The Components are organized into modules to simplify navigation. These modules are organized along the same principals as the HL7 Continuity of Care Document.

The data elements found in these modules are based on HL7 CDA Implementation Guides and the IHE PCC Technical Framework Volume II, Release 5 and its related supplements. These guides contain specifications for document sections that are consistent with all clinical documents currently selected for HITSP constructs.

1.2 Copyright Permissions

COPYRIGHT NOTICE
© 2010 ANSI. This material may be copied without permission from ANSI only if and to the extent that the text is not altered in any fashion and ANSI's copyright is clearly noted.
Certain materials contained in this Interoperability Specification are reproduced from HL7 Version 3 Standard: Core Principals with permission of Health Level Seven, Inc. No part of the material may be copied or reproduced in any form outside of the Interoperability Specification documents, including an electronic retrieval system, or made available on the Internet without the prior written permission of Health Level Seven, Inc. Copies of standards included in this Interoperability Specification may be purchased from the Health Level Seven, Inc. Material drawn from these standards is credited where used.

1.3 Reference Documents

A list of key reference documents and background material is provided in the table below. HITSP-maintained reference documents can be retrieved from the HITSP Web Site.

Reference Document Document Description
HITSP Acronyms List Exit Disclaimer [publicaa.ansi.org] Lists and defines the acronyms used in this document
HITSP Glossary Exit Disclaimer [publicaa.ansi.org] Provides definitions for relevant terms used by HITSP documents
TN901 - Clinical Documents TN901 is a reference document that provides the overall context for use of the HITSP Care Management and Health Records constructs
TN903 - Data Architecture TN903 is a reference document that provides the overall context for use of the HITSP Data Architecture constructs

1.4 Conformance

This section describes the conformance criteria, which are objective statements of requirements that can be used to determine if a specific behavior, function, interface, or code set has been implemented correctly.

1.4.1 Conformance Criteria

In order to claim conformance to this construct specification, an implementation must satisfy all the requirements and mandatory statements listed in this specification, the associated HITSP Interoperability Specification or Capability, its associated construct specifications, as well as conformance criteria from the selected base and composite standards. A conformant system must also implement all of the required interfaces within the scope, subset or implementation option that is selected from the associated Interoperability Specification.Claims of conformance may only be made for the overall HITSP Interoperability Specification or Capability with which this construct is associated.

1.4.2 Conformance Scoping, Subsetting and Options

A HITSP Interoperability Specification or Capability must be implemented in its entirety for an implementation to claim conformance to the specification. HITSP may define the permissibility for interface scoping, subsetting or implementation options by which the specification may be implemented in a limited manner. Such scoping, subsetting and options may extend to associated constructs, such as this construct. This construct must implement all requirements within the selected scope, subset or options as defined in the associated Interoperability Specification or Capability to claim conformance.

1.4.3 Use of Vocabulary Recommended to Support ARRA HITECH

This HITSP Component has been modified to support vocabularies allowed for meaningful use and other American Recovery and Reinvestment ACT (ARRA) HITECH requirements for all Components that rely upon it.

In almost all cases, coded values in the HITSP/C83 specifications are either optional (O) or required if known (R2) instead of required (R). In these cases, it is permissible to include a <code> element1 using a nullFlavor of UNK indicating that the information is unknown, and include <translation> The following example shows a case where the elements which indicate codes from other code systems

The following example shows a case where the <value> element in a condition entry includes the optional coded value for the Problem Code data element.

                                            <!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
                                            <observation classCode='OBS' moodCode='EVN'>
                                                <templateId root='2.16.840.1.113883.10.20.1.28'/> 
                                                    ...
                                                <value xsi:type='CD' code='37796009' displayName='Migraine'
                                                    codeSystem='2.16.840.1.113883.96' codeSystemName='SNOMED CT'/>
                                            </observation>
                                        

Because Problem Code is optional, the following is also a legal rendition for the <value> element. The value element is present; it just does not include the optional coded concept.

                                            <!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
                                            <observation classCode='OBS' moodCode='EVN'>
                                                <templateId root='2.16.840.1.113883.10.20.1.28'/>
                                                    ...
                                                <value xsi:type='CD' nullFlavor='UNK'>
                                                <translation code='346.9' displayName='Migraine'
                                                    codeSystem='2.16.840.1.113883.6.103'
                                                    codeSystemName='ICD-9-CM'/>
                                                </value>
                                            <observation>
                                        

To clarify this, we have changed the mapping for coded information in this specification to be more precise. Where these mappings formerly identified the XML element where the coded information is to be obtained (typically cda:code or cda:value elements), they now identify the specific attribute where the coded information is expected to be present. The effect on the mapping tables is that what was formerly:

CDA Data Location HITSP Data Element Identifier and Name O/R Additional Specification
cda:code 7.02 - Problem Type R2/N 2.2.2.7.3
cda:value 7.04 - Problem Code O/N 2.2.2.7.5

Optionality Legend: "R" for Required, "R2" for Required if known, "O" for Optional and Repeat = "Y" for Yes or "N" for No

Now appears as:

CDA Data Location HITSP Data Element Identifier and Name O/R Additional Specification
cda:code/@code 7.02 - Problem Type R2/N 2.2.2.7.3
cda:value/@code 7.04 - Problem Code O/N 2.2.2.7.5

Optionality Legend: "R" for Required, "R2" for Required if known, "O" for Optional and Repeat = "Y" for Yes or "N" for No

These changes are technical and reflect the original intent of the Care Management and Health Records Domain Technical Committee in the construction of the HITSP/C83 specification. Therefore no template identifiers have been changed where these changes have been made.

In only two cases does this specification require absolute adherence to a specific vocabulary.

CDA Data Location HITSP Data Element Identifier and Name O/R Additional Specification
cda:administrativeGenderCode/@code 1.06 - Gender R2/N 2.2.2.1.4
cda:code/@code 6.02 - Adverse Event Type O/N 2.2.2.6.2

Optionality Legend: "R" for Required, "R2" for Required if known, "O" for Optional and Repeat = "Y" for Yes or "N" for No

  • 1.06 Gender, it was felt that adherence to a vocabulary containing only 3 elements for a commonly understood construct could be met by all producers using the HITSP supplied vocabulary
  • 6.02 Adverse Event Type, producers who are unable to classify allergies according to the HITSP vocabulary SHALL use the code 420134006 Propensity to adverse reactions as the code instead of using nullFlavor='UNK' value. In the context of adverse reactions, this code indicates the presence of an adverse reaction of an unknown type to an unknown substance and is preferable to (and equivalent in meaning to) the use of nullFlavor='UNK'


Vocabulary constraints were relaxed from Required (R) to Required if Known (R2) for the following two data elements and the template identifier was updated to reflect this change:

  • 5.09 - Patient Relationship to Subscriber
  • 5.14 - Financial Responsibility Party Type


Finally, while the requirements for codes on (laboratory) results have not been relaxed, the underlying vocabulary requirements on the result type data element recommend, rather than require specific vocabulary.

1.5 Document Conventions

1.5.1 Key Words

The key words SHALL, SHALL NOT, SHOULD, SHOULD NOT and MAY are to be interpreted as described in RFC 2119 and will appear when used in that fashion in this TYPEFACE.

The key words REQUIRED and OPTIONAL are also to be interpreted as described in RFC 2119 when they are used to indicate the optionality of components used in an exchange.

1.5.2 Constraints

Constraints in this document will appear as shown below.

C83-[DE-7.04-1] The problem type SHALL be coded as specified in HITSP/C80 section 2.2.1.1.4.1.2 Problem Type. The first portion identifies the type of artifact being constrained. The second portion is the identifier for that artifact, and the final portion is the sequence number of the constraint on that artifact within this document. Constraints specific to CDA usage will contain the string CDA before the final number

2.2.1 CDA Sections

Two types of content components are specified in this section, they are:

  • CDA Entries - a collection of Data Elements pertaining to a single instance of the specified concept. For example, the Allergy/Drug Sensitivity Entry Module describes all the Data Elements for one allergy
  • CDA Sections - a collection of Entries pertaining to a single specified concept. For example, the Allergies and Other Adverse Reactions Section can contain a list of allergies (multiple Entry Content Modules)


CDA Sections are typically selected from specifications created by SDOs, such as the HL7 Implementation Guides and IHE Integration Profiles. Definitions for the document sections below are adapted from the IHE Patient Care Coordination Technical Framework, Volume II, Release 5.0, HL7 Implementation Guides for CDA Release 2.0: Consult Note, History and Physical (H&P) Notes, or Operative Note and are used with permission.

Please note that we have added template identifiers to each of the sections that follow. These template identifiers are recommended to be used in exchanges, but are not required due to restrictions on major change. It is possible that these identifiers could be required in future editions of this specification.

CDA Sections CDA Entries
2.2.1.1 Payers Section 2.2.2.1 Personal Information
2.2.1.2 Allergies and Other Adverse Reactions Section 2.2.2.2 Language Spoken
2.2.1.3 Problem List Section 2.2.2.3 Support
2.2.1.4 History of Past Illness Section 2.2.2.4 Healthcare Provider
2.2.1.5 Chief Complaint Section 2.2.2.5 Insurance Provider
2.2.1.6 Reason for Referral Section 2.2.2.6 Allergy/Drug Sensitivity
2.2.1.7 History of Present Illness Section 2.2.2.7 Condition
2.2.1.8 List of Surgeries Section 2.2.2.8 Medication
2.2.1.9 Functional Status Section 2.2.2.9 Pregnancy
2.2.1.10 Hospital Admission Diagnosis Section 2.2.2.10 Information Source
2.2.1.11 Discharge Diagnosis Section 2.2.2.11 Comment
2.2.1.12 Medications Section 2.2.2.12 Advance Directive
2.2.1.13 Admission Medications History Section 2.2.2.13 Immunization
2.2.1.14 Hospital Discharge Medications Section 2.2.2.14 Vital Sign
2.2.1.15 Medications Administered Section 2.2.2.15 Result
2.2.1.16 Advance Directives Section 2.2.2.16 Encounter
2.2.1.17 Immunizations Section 2.2.2.17 Procedure
2.2.1.18 Physical Examination Section 2.2.2.18 Family History
2.2.1.19 Vital Signs Section 2.2.2.19 Social History
2.2.1.20 Review of Systems Section 2.2.2.20 Medical Equipment
2.2.1.21 Hospital Course Section 2.2.2.21 Functional Status
2.2.1.22 Diagnostic Results Section 2.2.2.22 Plan Of Care
2.2.1.23 Assessment and Plan Section
2.2.1.24 Plan of Care Section
2.2.1.25 Family History Section
2.2.1.26 Social History Section
2.2.1.27 Encounters Section
2.2.1.28 Medical Equipment Section
2.2.1.29 Preoperative Diagnosis Section
2.2.1.30 Postoperative Diagnosis Section
2.2.1.31 Surgery Description Section
2.2.1.32 Surgical Operation Note Findings Section
2.2.1.33 Anesthesia Section
2.2.1.34 Estimated Blood Loss Section
2.2.1.35 Specimens Section
2.2.1.36 Complications Section
2.2.1.37 Planned Procedure Section
2.2.1.38 Indications Section
2.2.1.39 Disposition Section
2.2.1.40 Operative Note Fluids Section
2.2.1.41 Operative Note Surgical Procedure Section
2.2.1.42 Surgical Drains Section
2.2.1.43 Implants Section
2.2.1.44 Assessments Section
2.2.1.45 Procedures and Interventions Section
2.2.1.46 Provider Orders Section
2.2.1.47 Questionnaire Assessment Section
Download an excel spreadsheet containing all HITSP C83 Entry Content Modules and CDA Sections
Reference Title Definition Template ID Constraint(s)
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
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
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
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.
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
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
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
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
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
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
Reference Title Definition Template ID
2.2.2.1 Personal Information 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 2.16.840.1.113883.3.88.11.83.1
2.2.2.2 Language Spoken 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. 2.16.840.1.113883.3.88.11.83.2
2.2.2.3 Support Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. At a minimum, key support contacts relative to healthcare decisions, including next of kin, should be included. If no healthcare providers are supplied, the reason should be supplied as free text in the narrative block (e.g., Unknown, etc). See the HL7 Continuity of Care Document Section 3.3 for constraints applicable to these data elements. 2.16.840.1.113883.3.88.11.83.3
2.2.2.4 Healthcare Provider Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. These entries contain the healthcare providers involved in the current or pertinent historical care of the patient. See the HL7 Continuity of Care Document Section 3.17 for constraints applicable to these data elements. If no healthcare providers are supplied, the reason shall be supplied as free text in the narrative block (e.g., No Providers, Provider Unknown, etc.). 2.16.840.1.113883.3.88.11.83.4
2.2.2.5 Insurance Provider 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. 2.16.840.1.113883.3.88.11.83.5.1
2.2.2.6 Allergy/Drug Sensitivity Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.8 for constraints applicable to these data elements. 2.16.840.1.113883.3.88.11.83.6
2.2.2.7 Condition 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. 2.16.840.1.113883.3.88.11.83.7
2.2.2.8 Medication Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.9 for constraints applicable to these data elements. 2.16.840.1.113883.3.88.11.83.8
2.2.2.9 Pregnancy Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. This section describes a coded entry indicating whether the patient is currently pregnant. N/A
2.2.2.10 Information Source 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. N/A
2.2.2.11 Comment This module contains a comment to be supplied for any other entry Content Modules. See the HL7 Continuity of Care Document Section 4.3 for constraints applicable to this module. 2.16.840.1.113883.3.88.11.83.11
2.2.2.12 Advance Directive Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.2 for constraints applicable to these data elements. This module contains data describing the patient's Advance Directives and any reference to supporting documentation. This section contains data such as the existence of living wills, healthcare proxies and CPR and resuscitation status. The custodian of these documents may be described. See the HL7 Continuity of Care Document Section 3.2 for constraints applicable to this module. 2.16.840.1.113883.3.88.11.83.12
2.2.2.13 Immunization 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. 2.16.840.1.113883.3.88.11.83.13
2.2.2.14 Vital Sign Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.12 for constraints applicable to these data elements. These entries are used to record current and relevant historical vital signs for the patient. Vital Signs are a subset of Results (see Section 2.2.2.15), but are reported in this section to follow clinical conventions. The differentiation between Vital Signs and Results varies by clinical context. Common examples of vital signs include temperature, height, weight, blood pressure, etc. However, some clinical contexts may alter these common vitals, for example in neonatology "height" may be replaced by "crown-to-rump" measurement. 2.16.840.1.113883.3.88.11.83.14
2.2.2.15 Result Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.13 for constraints applicable to these data elements. This module contains current and relevant historical result observations for the patient. The scope of "observations" is broad with the exception of "vital signs" which are contained in the Vital Signs sections (see Section 2.2.2.14 above). The Results section is intended as a summary and not as an official, legally sanctioned report. For example, regulatory requirements for lab reports are not necessarily supported in the following Data Element Definitions. In the case of lab reports, the official report is supported in HITSP/C37 Laboratory Report Document Using IHE XD* Lab. 2.16.840.1.113883.3.88.11.83.15.1
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. 2.16.840.1.113883.3.88.11.83.16
2.2.2.17 Procedure 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. 2.16.840.1.113883.3.88.11.83.17
2.2.2.18 Family History Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.6 for constraints applicable to these data elements. The text for the HL7 CDA Release 2 - Continuity of Care Document (CCD), Section 3.6 Family History, p.33 begins here: This section contains data defining the patient's genetic relatives in terms of possible or relevant health risk factors that have a potential impact on the patient's healthcare risk profile. The text for the HL7 CDA Release 2 - Continuity of Care Document (CCD), Section 3.6 Family History, p.33 ends here. While blood relatives are the focus of family history, this specification recognizes that it is necessary also to communicate information about spouses, partners, and adopted or foster children, in order to clarify the consanguinity of relationships between family members. For family histories recorded in a clinical document the individual who is the focus of the family history is the patient, and represents the index case for the family history. The current concept can be stated as follows: Quoted Material from MedicineNet.com - MedTerms Dictionary starts here: Family: 1. A group of individuals related by blood or marriage or by a feeling of closeness. Family history: The family structure and relationships within the family, including information about diseases in family members. Quoted Material from MedicineNet.com - MedTerms Dictionary ends here. 2.16.840.1.113883.3.88.11.83.18.1
2.2.2.19 Social History 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. The text for the HL7 CDA Release 2 - Continuity of Care Document (CCD), Section 3.7 Social History, p.37.begins here: This section contains data defining the patient's occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation. The text for the HL7 CDA Release 2 - Continuity of Care Document (CCD), Section 3.7 Social History, p.37 ends here. 2.16.840.1.113883.3.88.11.83.19
2.2.2.20 Medical Equipment No CDA document mappings have been defined at this time. 2.16.840.1.113883.3.88.11.83.20
2.2.2.21 Functional Status No CDA document mappings have been defined at this time. 2.16.840.1.113883.3.88.11.83.21
2.2.2.22 Plan Of Care No CDA document mappings have been defined at this time. 2.16.840.1.113883.3.88.11.83.22
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