CARE PLAN FRAMEWORK

A Care Plan is a consensus-driven dynamic plan that represents a patient’s and Care Team Member’s prioritized concerns, goals, and planned interventions.

The Consultation Note is generated by a request from a clinician for an opinion or advice from another clinician.

This document type was originally based on the Continuity of Care Document (CCD) Release 1.

The Discharge Summary is a document which synopsizes a patient’s admission to a hospital, LTPAC provider, or other setting.

A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient.

The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies.

A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields.

This template represents a patient’s clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter.

A Referral Note communicates pertinent information from a provider who is requesting services of another provider of clinical or non-clinical services.

This document describes constraints on the Clinical Document Architecture (CDA) header and body elements for a Transfer Summary.

An Unstructured Document (UD) document type can (1) include unstructured content, such as a graphic, directly in a text element with a mediaType attribute, or (2) reference a single document file, such as a word-processing document using a text/reference element.

This template defines constraints that represent common administrative and demographic concepts for US Realm CDA documents.

This template is designed to be used in conjunction with the US Realm Header.

This template represents Activities.

This section contains a narrative description of the problems or diagnoses identified by the clinician at the time of the patient’s admission.

The section contains the medications taken by the patient prior to and at the time of admission to the facility.

This section contains information describing the patient’s advance directives.

This section lists and describes any medication allergies, adverse reactions, idiosyncratic reactions, anaphylaxis/anaphylactoid reactions to food items, and metabolic variations or adverse reactions/allergies to other substances (such as latex, iodine, tape adhesives).

The Anesthesia Section records the type of anesthesia (e.

This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient.

The Assessment Section (also referred to as “impression” or “diagnoses” outside of the context of CDA) represents the clinician’s conclusions and working assumptions that will guide treatment of the patient.

The Care Team Section is used to share historical and current Care Team information.

This section records the patient’s chief complaint (the patient’s own description) and/or the reason for the patient’s visit (the provider’s description of the reason for visit).

This section records the patient’s chief complaint (the patient’s own description).

This section contains problems that occurred during or around the time of a procedure.

The Course of Care section describes what happened during the course of an encounter.

This template represents problems or diagnoses present at the time of discharge which occurred during the hospitalization.

This section contains the medications the patient is intended to take or stop after discharge.

This section lists and describes any healthcare encounters pertinent to the patient’s current health status or historical health history.

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 Functional Status Section contains observations and assessments of a patient’s physical abilities.

The General Status section describes general observations and readily observable attributes of the patient, including affect and demeanor, apparent age compared to actual age, gender, ethnicity, nutritional status based on appearance, body build and habitus (e.

This template represents patient Goals.

This section contains data describing an interest or worry about a health state or process that could possibly require attention, intervention, or management.

This template represents observations regarding the outcome of care from the interventions used to treat the patient.

The History of Present Illness section describes the history related to the reason for the encounter.

The Hospital Consultations Section records consultations that occurred during the admission.

The Hospital Course Section describes the sequence of events from admission to discharge in a hospital facility.

The Hospital Discharge Instructions Section records instructions at discharge.

The Hospital Discharge Physical Section records a narrative description of the patient’s physical findings.

This section records the results of observations generated by laboratories, imaging procedures, and other procedures.

The Immunizations Section defines a patient’s current immunization status and pertinent immunization history.

The Instructions Section records instructions given to a patient.

The Medical History Section describes all aspects of the medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information.

This section defines a patient’s implanted and external health and medical devices and equipment.

The Medications Administered Section usually resides inside a Procedure Note describing a procedure.

The Medications Section contains a patient’s current medications and pertinent medication history.

The Mental Status Section contains observations and evaluations related to a patient’s psychological and mental competency and deficits.

The Notes Section allow for inclusion of clinical documentation which does not fit precisely within any other C-CDA section.

The Nutrition Section represents diet and nutrition information including special diet requirements and restrictions (e.

The Objective Section contains data about the patient gathered through tests, measures, or observations that produce a quantified or categorized result.

The Operative Note Fluids Section may be used to record fluids administered during the surgical procedure.

The Operative Note Surgical Procedure Section can be used to restate the procedures performed if appropriate for an enterprise workflow.

This section contains a record of the patient’s past complaints, problems, and diagnoses.

The Payers Section contains data on the patient’s payers, whether “third party” insurance, self-pay, other payer or guarantor, or some combination of payers, and is used to define which entity is the responsible fiduciary for the financial aspects of a patient’s care.

The section includes direct observations made by a clinician.

This section, formerly known as “Plan of Care”, contains data that define pending orders, interventions, encounters, services, and procedures for the patient.

This section contains the procedure(s) that a clinician planned based on the preoperative assessment.

The Postoperative Diagnosis Section records the diagnosis or diagnoses discovered or confirmed during the surgery.

The Postprocedure Diagnosis Section records the diagnosis or diagnoses discovered or confirmed during the procedure.

The Preoperative Diagnosis Section records the surgical diagnoses assigned to the patient before the surgical procedure which are the reason for the surgery.

This section lists and describes all relevant clinical problems at the time the document is generated.

The Procedure Description section records the particulars of the procedure and may include procedure site preparation, surgical site preparation, pertinent details related to sedation/anesthesia, pertinent details related to measurements and markings, procedure times, medications administered, estimated blood loss, specimens removed, implants, instrumentation, sponge counts, tissue manipulation, wound closure, sutures used, vital signs and other monitoring data.

The Procedure Disposition Section records the status and condition of the patient at the completion of the procedure or surgery.

The Procedure Estimated Blood Loss Section may be a subsection of another section such as the Procedure Description Section.

The Procedure Findings Section records clinically significant observations confirmed or discovered during a procedure or surgery.

The Procedure Implants Section records any materials placed during the procedure including stents, tubes, and drains.

This section contains the reason(s) for the procedure or surgery.

The Procedure Specimens Taken Section records the tissues, objects, or samples taken from the patient during the procedure including biopsies, aspiration fluid, or other samples sent for pathological analysis.

This section describes all historical or current interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient at the time the document is generated.

This section describes the clinical reason why a provider is sending a patient to another provider for care.

This section records the patient’s reason for the patient’s visit (as documented by the provider).

The Results Section contains observations of results generated by laboratories, imaging procedures, and other procedures.

The Review of Systems Section contains a relevant collection of symptoms and functions systematically gathered by a clinician.

This section contains social history data that influence a patient’s physical, psychological or emotional health (e.

The Subjective Section describes in a narrative format the patient’s current condition and/or interval changes as reported by the patient or by the patient’s guardian or another informant.

The Surgical Drains Section may be used to record drains placed during the surgical procedure.

The Vital Signs Section contains relevant vital signs for the context and use case of the document type, such as blood pressure (including average blood pressure), heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area.

This template represents the medications taken by the patient prior to and at the time of admission.

An Advance Directive Observation template is used to record information about a document authored by the person and containing goals, preferences, and priorities for care.

This clinical statement groups a set of advance directive observations documented together at a single point in time, and relevant during the episode of care being documented.

This Age Observation represents the subject’s age at onset of an event or observation.

This template reflects a discrete observation about a patient’s allergy or intolerance.

This template reflects an ongoing concern on behalf of the provider that placed the allergy on a patient’s allergy list.

This template represents the clinical status attributed to the allergy or intolerance.

An assessment scale is a collection of observations that together can yield a calculated or non-calculated summary evaluation of a one or more conditions.

An Assessment Scale Supporting Observation represents the components of a scale used in an Assessment Scale Observation.

An Authorization Activity represents authorizations or pre-authorizations currently active for the patient for the particular payer.

This template represents a simple observation about the type of business that compensates for work or assigns work to an unpaid worker or volunteer (e.

This template represents a simple observation about the type of work (e.

This observation represents the sex of the patient at birth.

This template is intended to be used in addition to the Product Instance template to exchange the Brand Name.

This Care Experience Preference template represents a person’s care preferences during their care and treatment.

This template is used to represent a member of the care team.

This template represents the schedule of when the care team member participates on the care team.

This organizer template contains information about a single care team.

This template is used to express the care team type.

This clinical statement represents a caregiver’s willingness to provide care and the abilities of that caregiver to provide assistance to a patient in relation to a specific need.

This template is intended to be used in addition to the Product Instance template urn:oid:2.

This template represents the patient’s home environment including, but not limited to, type of residence (trailer, single family home, assisted living), living arrangement (e.

Comments are free text data that cannot otherwise be recorded using data elements already defined by this specification.

This template is intended to be used in addition to the Product Instance template urn:oid:2.

A Coverage Activity groups the policy and authorization acts within a Payers Section to order the payment sources.

This observation represents the gravity of the potential risk for future life-threatening adverse reactions when exposed to a substance known to cause an adverse reaction in that individual.

This template represents a patient’s spiritual, religious, and cultural belief practices, such as a kosher diet or fasting ritual.

This template represents the earliest date of diagnosis, which is the date of first determination by a qualified professional of the presence of a problem or condition affecting a patient.

This template represents the observation that a patient has died.

This template is intended to be used in addition to the Product Instance template urn:oid:2.

This template represents an assessment of patients perception of their physical, cognitive, intellectual, or psychiatric disabilities.

This template represents medications that the patient is intended to take (or stop) after discharge.

This template is intended to be used in addition to the Product Instance template urn:oid:2.

This template represents the act of monitoring the patient’s medication and includes a participation to record the person responsible for monitoring the medication.

This template represents the vehicle (e.

This clinical statement describes an interaction between a patient and clinician.

This template wraps relevant problems or diagnoses at the close of a visit or that need to be followed after the visit.

This template represents the act of referencing another entry in the same CDA document instance.

This clinical statement represents the anticipated date when a woman will give birth.

This template is intended to be used in addition to the Product Instance template urn:oid:2.

Where it is necessary to reference an external clinical document, the External Document Reference template can be used to reference this external document.

This clinical statement records whether the family member is deceased.

Family History Observations related to a particular family member are contained within a Family History Organizer.

The Family History Organizer associates a set of observations with a family member.

This template represents the patient’s physical function (e.

This template groups related functional status observations into categories (e.

This observation represents the gender identity of the patient, defined as:

> “Ones basic sense of being male, female, or other gender (for example, transgender or gender queer).

This template represents a patient health goal.

This template represents the sender (author) and receivers (participants) of a handoff communication in a plan of treatment.

This template represents a health concern.

This template represents information about the overall health status of the patient.

This observation contains a description of the wound tissue of the most severe or highest staged pressure ulcer observed on a patient.

This template represents problems or diagnoses identified by the clinician at the time of the patient’s admission.

This template represents problems or diagnoses present at the time of discharge which occurred during the hospitalization or need to be monitored after hospitalization.

An Immunization Activity describes immunization substance administrations that have actually occurred or are intended to occur.

The Immunization Medication Information represents product information about the immunization substance.

The Immunization Refusal Reason documents the rationale for the patient declining an immunization.

This template is intended to be used in addition to the Product Instance template urn:oid:2.

This template represents the rationale for an action such as an encounter, a medication administration, or a procedure.

The Instruction template can be used in several ways, such as to record patient instructions within a Medication Activity or to record fill instructions within a supply order.

This template represents an Intervention Act.

This template is intended to be used in addition to the Product Instance template urn:oid:2.

This template represents acquired or surgical wounds and is not intended to encompass all wound types.

This template is intended to be used in addition to the Product Instance template urn:oid:2.

This template is intended to be used in addition to the Product Instance template urn:oid:2.

This template represents a set of current or historical medical devices, supplies, aids and equipment used by the patient.

A Medication Activity describes substance administrations that have actually occurred (e.

This profile represents whether a medication has been consumed according to instructions.

This template records the act of supplying medications (i.

The template is available to explicitly identify the free text Sig within each medication.

A medication should be recorded as a pre-coordinated ingredient + strength + dose form (e.

This template records the intent to supply a patient with medications.

The Mental Status Observation template represents an observation about mental status that can come from a broad range of subjective and objective information (including measured data) to address those categories described in the Mental Status Section.

The Mental Status Organizer template may be used to group related Mental Status Observations (e.

This template is intended to be used in addition to the Product Instance template urn:oid:2.

This template is intended to be used in addition to the Product Instance template urn:oid:2.

This template represents equipment supplied to the patient (e.

The Note Activity represents a clinical note.

This template represents the number of pressure ulcers observed at a particular stage.

This template represents the patient’s nutrition abilities and habits including intake, diet requirements or diet followed.

This template represents nutrition regimens (e.

This template describes the overall nutritional status of the patient including findings related to nutritional status.

This template represents the outcome of care resulting from the interventions used to treat the patient.

This template represents the type of referral (e.

This template represents planned acts that are not classified as an observation or a procedure according to the HL7 RIM.

This template represents the insurance coverage intended to cover an act or procedure.

This template represents a planned or ordered encounter.

This template represents planned immunizations.

This template represents a Planned Intervention Act.

This template represents planned medication activities.

This template represents planned observations that result in new information about the patient which cannot be classified as a procedure according to the HL7 RIM, i.

This template represents planned alterations of the patient’s physical condition.

This template represents both medicinal and non-medicinal supplies ordered, requested, or intended for the patient (e.

A policy activity represents the policy or program providing the coverage.

This template represents the diagnosis or diagnoses discovered or confirmed during the procedure.

A criterion for administration can be used to record that the medication is to be administered only when the associated criteria are met.

This template represents a patient’s reported intention or desire in the next year to either become pregnant or prevent a future pregnancy.

This clinical statement represents current and/or prior pregnancy dates enabling investigators to determine if the subject of the case report was pregnant during the course of a condition.

This template represents the surgical diagnosis or diagnoses assigned to the patient before the surgical procedure and is the reason for the surgery.

This template represents priority preferences chosen by a patient or a care provider.

This template reflects an ongoing concern on behalf of the provider that placed the concern on a patient’s problem list.

This template reflects a discrete observation about a patient’s problem.

The Problem Status records the clinical status attributed to the problem.

This template is used to represent the details of current and historical procedures performed on or for a patient.

This clinical statement represents a particular device that was placed in a patient or used as part of a procedure or other act.

This template represents the patient’s prognosis, which must be associated with a problem observation.

This template represents a patient’s progress toward a goal.

This clinical statement represents the response to an undesired symptom, finding, etc.

This template describes the thought process or justification for an action or for not performing an action.

This template represents the results of a laboratory, radiology, or other study performed on a patient.

This template provides a mechanism for grouping result observations.

This template represents a risk concern.

This observation represents the date and time range of the information contained in a section.

This template represents a patient’s daily self-care ability.

This template represents a patient’s sensory or speech ability.

This template is intended to be used in addition to the Product Instance template urn:oid:2.

This clinical statement represents the location of a service event where an act, observation or procedure took place.

This clinical statement represents the gravity of the problem, such as allergy or reaction, in terms of its actual or potential impact on the patient.

This Sex Observation template is used to reflect the documentation of a person’s sex.

This observation represents the sexual orientation of the patient, defined as:

> A persons identification of their emotional, romantic, sexual, or affectional attraction to another person.

This template represents the current smoking status of the patient as specified in Meaningful Use (MU) Stage 2 requirements.

This template represents a patient’s job (occupation and industry), lifestyle, and environmental health risk factors.

This template represents clinical information about the specimen including when it was collected, the type and source of specimen, as well as related observations regarding the specimen.

This template conveys the condition (mode or state of being) that describes the nature of the specimen.

This template describes a reason the specimen was rejected for the specified observation/result/analysis.

This template represents the administration course in a series.

This template reflects a discrete observation about a patient’s allergy or intolerance to a substance or device.

This template represents a patient’s tobacco use.

This Treatment Intervention Preference template represents personal health goals, preferences, and priorities for medical treatments or interventions in the event of a future health scenario where a person is unable to make medical decisions because of a serious illness or injury.

This template represents the tribe or band that an individual associates with, within the United States.

This template is nested in an entryRelationship/Procedure Activity Procedure to record all the UDI-related templates to exchange the parsed UDI data elements and associated data.

This template represents measurement of common vital signs.

This template provides a mechanism for grouping vital signs (e.

This template represents characteristics of a wound (e.

This template represents the Wound Measurement Observations of wound width, depth and length.

This template represents the Author Participation (including the author timestamp).

This template represents the organization that supported generation of a CDA document.

This template represents the key information to record Provenance in an Author Participation.

This template represents a generic participant person that has a relationship to the patient.

Reusable address template, for use in US Realm documents

The US Realm Clinical Document Date and Time datatype flavor records date and time information.

The US Realm Clinical Document Date and Time datatype flavor records date and time information.

The US Realm Patient Name datatype flavor is a set of reusable constraints that can be used for the patient or any other person.

The US Realm Clinical Document Person Name datatype flavor is a set of reusable constraints that can be used for Persons.

Example of an allergy to egg

Admission Diagnosis Section example

Admission Medication example

Advance Directive Observation example

Advance Directive Organizer example

Advance Directives Section example

Age Observation example

Allergies and Intolerances Section example

Allergy Concern Act example

Allergy Intolerance Observation example

Anesthesia Section example

Assessment and Plan Section example

Assessment Scale Observation example

Assessment Scale Supporting Observation example

Assessment Section example

Author Participation example

Authorization Activity example

Basic Industry Observation example

Basic Occupation example

Birth Sex Obseration example

Brand Name Observation example

Care Plan Caregiver participant example

Care Plan Patient authenticator example

Care Plan performer example

Care Plan relatedDocument example

Care Plan Review example

Care Plan Complete example

Care Team Member Act example

Care Team Member Schedule Observation example

Care Team Organizer example

Care Teams Section example

Care Team Type Observation example

Catalog Number Observation example

Caregiver Characteristics example

Characteristics of Home Environment example

Chief Complaint and Reason for Visit Section example

Chief Complaint Section example

Comment Activity example

Company Name Observation example

Complications Section example

Continuity Of Care Document Author example

Continuity Of Care Document Performer example

Continuity Of Care Document serviceEvent example

Consultation Note Complete Example

Consultation Note Callback participant example

Consultation Note inFulfillmentOf example

Course of Care Section example

Coverage Activity example

Criticality Observation example

Cultural and Religious Observation example

Date of Diagnosis Act example

Deceased Observation example

Device Identifier Observation example

Diagnosis Reference example

Disability Status Observation Example

Discharge Diagnosis example

Discharge Medication example

Discharge Medications Section example

Discharge Summary (encompassingEncounter) example

Distinct Identification Code Observation example

Drug Monitoring Act example

Drug Vehicle example

Encounter Activity example

Encounter Diagnosis example

Encounters Section example

Entry Reference example

Estimated Date of Delivery example

example

External Document Reference example

Family History Death Observation example

Family History Observation example

Family History Organizer example

Family History Section example

Functional Status Observation example

Functional Status Organizer example

Functional Status Section example

Gender Identity Observation example

General Status Section example

Goal Observation example

Goals Section example

Handoff Communication Participants example

Health Concern Act example

Health Concerns Section example

Health Status Evaluations and Outcomes Section example

Health Status Observation example

Highest Pressure Ulcer Stage example

History and Physical Encompassing Encounter example

History of Present Illness example

Hospital Admission Diagnosis example

Hospital Consultations Section example

Hospital Course Section example

Hospital Discharge Diagnosis example

Hospital Discharge InstructionsSection example

Hospital Discharge Physical Section example

Hospital Discharge Studies Summary Section example

Immunization Activity example

Immunization Medication Information example

Immunization Refusal Reason example

Immunizations Section example

Implantable Device Status Observation example

Indication example

Instructions Section example

Instruction example

Intervention Act example

Latex Safety Observation example

Longitudinal Care Wound Observation example

Lot or Batch Number Observation example

Manufacturing Date Observation example

Medical Equipment Organizer example

Medical Equipment Section example

Medication Activity example

Medication Dispense example

Medication Free Text Sig example

Medication Information example

Medication Supply Order example

Medications Administered Section example

Medications Section example

Mental Status Observation example

Mental Status Organizer example

Mental Status Section example

Model Number Observation example

MRI Safety Observation example

No Known Medications example

No Known Problem Section example

Non-Medicinal Supply Activity example

Note Activity example

Note Activity example

nonXMLBody Example with Compressed Content

nonXMLBody Example with Embedded Content

nonXMLBody Example with Referenced Content

Number of Pressure Ulcers Observation example

Nutrition Assessment example

Nutrition Recommendation example

Nutrition Section example

Nutritional Status Observation example

Objective Section example

Operative Note performer example

Operative Note serviceEvent example

Operative Note Fluids Section example

Operative Note Surgical Procedure Section example

Outcome Observation example

Past Medical History example

Patient Generated Document authenticator example

Patient Generated Document author device example

Patient Generated Document author example

PPatient Generated Document custodian example

Patient Generated Document dataEnterer example

Patient Generated Document informant Example informant

Patient Generated Document informant RelEnt example

Patient Generated Document informationRecipient example

Patient Generated Document inFulfillmentOf example

PPatient Generated Document legalAuthenticator example

Patient Generated Document participant example

Patient Generated Document recordTarget example

Patient Referral Act example

Payers Section example

Physical Exam Section example

Plan of Treatment Section example

Planned Act example Example

Planned Coverage example

Planned Encounter example

Planned Immunization Activity example

Planned Intervention Activity example

Planned Medication Activity example

Planned Observation example

Planned Procedure Section example

Planned Procedure example

Planned Supply example

Policy Activity example

Postoperative Diagnosis Section example

Postprocedure Diagnosis Section example

Precondition for Substance Administration example

Pregnancy Intention in Next Year example

Pregnancy Observation example

Preoperative Diagnosis Section example

Preoperative Diagnosis example

Priority Preference example

Problem Concern Act example

Problem Observation example

Problem Observation with Post-Coordinated SNOMED example

Problem Section example

Procedure Note performer example

Procedure Note serviceEvent example

Procedure Activity Procedure example

Procedure Description Section example

Procedure Disposition Section example

Procedure Estimated Blood Loss Section example

Procedure Findings Section dexample

Procedure Implants Section example

Procedure Indications Section example

Procedure Specimens Taken Section example

Procedures Section example

Product Instance example

Prognosis Coded example

Prognosis Free Text example

Progress Note encompassingEncounter example

Progress Note serviceEvent example

Progress Toward Goal Observation example

Provenance - Assembler Participation example

Provenance - Author Participation example

Reaction Observation example

Reason example

Reason For Referral example

Reason for Visit Section example

Referral Note Callback Contact example

Referral Note Caregiver example

Referral Note informationRecipient example

Related Person Relationship and Name Participant example

Result Observation example

Result Organizer example

Results Section example

Review of Systems Section example

Risk Concern Act example

Self-Care Activities (ADL and IADL) example

Sensory Status example

Serial Number Observation example

Service Delivery Location example

Severity Observation example

Sexual Orientation Observation example

Smoking Status - Meaningful Use example

Social History Observation example

Social History Section example

Subjective Section example

Substance Administered Act example

Surgical Drains Section example

Tobacco Use example

Transfer Summary Callback Contact example

Transfer Summary participant (Support) example

Tribal Affiliation Observation example

UDI Organizer example

US Realm Address example

US Realm Date and Time example

US Realm Date and Time Interval example

US Realm Header example

US Realm Person Name example

Vital Sign Observation example

Vital Sign Observation example of average blood pressure

Vital Signs Organizer example

Vital Signs Section example - including Average Blood Pressure

Wound Characteristic example

Wound Measurement Observation example

These codes are used to convey the patient discharge status.