 0 Table of Contents |
  1 IG Home Page |
  2 USCDI |
  3 General Guidance |
  4 Screening And Assessments |
  5 Supporting Guidance |
  6 Validation |
  7 How To Read |
  8 Downloads |
  9 Terminology |
  10 Change Log |
  11 Artifacts Summary |
   11.1 Care Plan |
   11.2 Consultation Note |
   11.3 Continuity of Care Document (CCD) |
   11.4 Discharge Summary |
   11.5 History and Physical |
   11.6 Operative Note |
   11.7 Procedure Note |
   11.8 Progress Note |
   11.9 Referral Note |
   11.10 Transfer Summary |
   11.11 Unstructured Document |
   11.12 US Realm Header |
   11.13 US Realm Header for Patient Generated Document |
   11.14 Activities Section |
   11.15 Admission Diagnosis Section |
   11.16 Admission Medications Section (entries optional) |
   11.17 Advance Directives Section |
   11.18 Allergies and Intolerances Section |
   11.19 Anesthesia Section |
   11.20 Assessment and Plan Section |
   11.21 Assessment Section |
   11.22 Care Teams Section |
   11.23 Chief Complaint and Reason for Visit Section |
   11.24 Chief Complaint Section |
   11.25 Complications Section |
   11.26 Course of Care Section |
   11.27 Discharge Diagnosis Section |
   11.28 Discharge Medications Section |
   11.29 Encounters Section |
   11.30 Family History Section |
   11.31 Functional Status Section |
   11.32 General Status Section |
   11.33 Goals Section |
   11.34 Health Concerns Section |
   11.35 Health Status Evaluations and Outcomes Section |
   11.36 History of Present Illness Section |
   11.37 Hospital Consultations Section |
   11.38 Hospital Course Section |
   11.39 Hospital Discharge Instructions Section |
   11.40 Hospital Discharge Physical Section |
   11.41 Hospital Discharge Studies Summary Section |
   11.42 Immunizations Section |
   11.43 Instructions Section |
   11.44 Medical (General) History Section |
   11.45 Medical Equipment Section |
   11.46 Medications Administered Section |
   11.47 Medications Section |
   11.48 Mental Status Section |
   11.49 Notes Section |
   11.50 Nutrition Section |
   11.51 Objective Section |
   11.52 Operative Note Fluids Section |
   11.53 Operative Note Surgical Procedure Section |
   11.54 Past Medical History |
   11.55 Payers Section |
   11.56 Physical Exam Section |
   11.57 Plan of Treatment Section |
   11.58 Planned Procedure Section |
   11.59 Postoperative Diagnosis Section |
   11.60 Postprocedure Diagnosis Section |
   11.61 Preoperative Diagnosis Section |
   11.62 Problem Section |
   11.63 Procedure Description Section |
   11.64 Procedure Disposition Section |
   11.65 Procedure Estimated Blood Loss Section |
   11.66 Procedure Findings Section |
   11.67 Procedure Implants Section |
   11.68 Procedure Indications Section |
   11.69 Procedure Specimens Taken Section |
   11.70 Procedures Section |
   11.71 Reason for Referral Section |
   11.72 Reason for Visit Section |
   11.73 Results Section |
   11.74 Review of Systems Section |
   11.75 Social History Section |
   11.76 Subjective Section |
   11.77 Surgical Drains Section |
   11.78 Vital Signs Section |
   11.79 Admission Medication |
   11.80 Advance Directive Observation |
   11.81 Advance Directive Organizer |
   11.82 Age Observation |
   11.83 Allergy - Intolerance Observation |
   11.84 Allergy Concern Act |
   11.85 Allergy Status Observation |
   11.86 Assessment Scale Observation |
   11.87 Assessment Scale Supporting Observation |
   11.88 Authorization Activity |
   11.89 Average Blood Pressure Organizer |
   11.90 Basic Industry Observation |
   11.91 Basic Occupation Observation |
   11.92 Birth Sex Observation |
   11.93 Brand Name Observation |
   11.94 Care Experience Preference |
   11.95 Care Team Member Act |
   11.96 Care Team Member Schedule Observation |
   11.97 Care Team Organizer |
   11.98 Care Team Type Observation |
   11.99 Caregiver Characteristics |
   11.100 Catalog Number Observation |
   11.101 Characteristics of Home Environment |
   11.102 Comment Activity |
   11.103 Company Name Observation |
   11.104 Coverage Activity |
   11.105 Criticality Observation |
   11.106 Cultural and Religious Observation |
   11.107 Date of Diagnosis Act |
   11.108 Deceased Observation |
   11.109 Device Identifier Observation |
   11.110 Disability Status Observation |
   11.111 Discharge Medication |
   11.112 Distinct Identification Code Observation |
   11.113 Drug Monitoring Act |
   11.114 Drug Vehicle |
   11.115 Encounter Activity |
   11.116 Encounter Diagnosis |
   11.117 Entry Reference |
   11.118 Estimated Date of Delivery |
   11.119 Expiration Date Observation |
   11.120 External Document Reference |
   11.121 Family History Death Observation |
   11.122 Family History Observation |
   11.123 Family History Organizer |
   11.124 Functional Status Observation |
   11.125 Functional Status Organizer |
   11.126 Gender Identity Observation |
   11.127 Goal Observation |
   11.128 Handoff Communication Participants |
   11.129 Health Concern Act |
   11.130 Health Status Observation |
   11.131 Highest Pressure Ulcer Stage |
   11.132 Hospital Admission Diagnosis |
   11.133 Hospital Discharge Diagnosis |
   11.134 Immunization Activity |
   11.135 Immunization Medication Information |
   11.136 Immunization Not Given Reason |
   11.137 Implantable Device Status Observation |
   11.138 Indication |
   11.139 Instruction |
   11.140 Intervention Act |
   11.141 Latex Safety Observation |
   11.142 Longitudinal Care Wound Observation |
   11.143 Lot or Batch Number Observation |
   11.144 Manufacturing Date Observation |
   11.145 Medical Equipment Organizer |
   11.146 Medication Activity |
   11.147 Medication Adherence |
   11.148 Medication Dispense |
   11.149 Medication Free Text Sig |
   11.150 Medication Information |
   11.151 Medication Supply Order |
   11.152 Mental Status Observation |
   11.153 Mental Status Organizer |
   11.154 Model Number Observation |
   11.155 MRI Safety Observation |
   11.156 Non-Medicinal Supply Activity |
   11.157 Note Activity |
   11.158 Number of Pressure Ulcers Observation |
   11.159 Nutrition Assessment |
   11.160 Nutrition Recommendation |
   11.161 Nutritional Status Observation |
   11.162 Outcome Observation |
   11.163 Patient Referral Act |
   11.164 Planned Coverage |
   11.165 Planned Encounter |
   11.166 Planned Immunization Activity |
   11.167 Planned Intervention Act |
   11.168 Planned Medication Activity |
   11.169 Planned Procedure |
   11.170 Planned Supply |
   11.171 Policy Activity |
   11.172 Postprocedure Diagnosis |
   11.173 Precondition for Substance Administration |
   11.174 Pregnancy Intention in Next Year |
   11.175 Pregnancy Observation |
   11.176 Preoperative Diagnosis |
   11.177 Priority Preference |
   11.178 Problem Concern Act |
   11.179 Problem Observation |
   11.180 Problem Status |
   11.181 Procedure Activity Procedure |
   11.182 Product Instance |
   11.183 Prognosis Observation |
   11.184 Progress Toward Goal Observation |
   11.185 Reaction Observation |
   11.186 Reason |
   11.187 Result Observation |
   11.188 Result Organizer |
   11.189 Risk Concern Act |
   11.190 Section Time Range Observation |
   11.191 Self-Care Activities (ADL and IADL) |
   11.192 Sensory Status |
   11.193 Serial Number Observation |
   11.194 Service Delivery Location |
   11.195 Severity Observation |
   11.196 Sex Observation |
   11.197 Sexual Orientation Observation |
   11.198 Smoking Status |
   11.199 Social History Observation |
   11.200 Specimen Collection Procedure |
   11.201 Specimen Condition Observation |
   11.202 Substance Administered Act |
   11.203 Substance or Device Allergy - Intolerance Observation |
   11.204 Treatment Intervention Preference |
   11.205 Tribal Affiliation Observation |
   11.206 UDI Organizer |
   11.207 Vital Sign Observation |
   11.208 Vital Signs Organizer |
   11.209 Wound Characteristic |
   11.210 Wound Measurement Observation |
   11.211 Author Participation |
   11.212 Provenance - Assembler Participation |
   11.213 Provenance - Author Participation |
   11.214 Related Person Relationship and Name Participant |
   11.215 US Realm Address |
   11.216 US Realm Date and Time - Interval |
   11.217 US Realm Date and Time - Point in Time |
   11.218 US Realm Patient Name (PTN.US.FIELDED) |
   11.219 US Realm Person Name (PN.US.FIELDED) |
   11.220 Smoking Status - Meaningful Use |
   11.221 Tobacco Use |
   11.222 Example of Allergy Intolerance to Food Egg |
   11.223 Admission Diagnosis Section Example |
   11.224 Admission Medication example |
   11.225 Advance Directive Observation Example |
   11.226 Advance Directive Organizer Example |
   11.227 Advance Directives Section Example |
   11.228 Age Observation Example |
   11.229 Allergies and Intolerances Section Example |
   11.230 Allergy Concern Act Example |
   11.231 Allergy Intolerance Observation Medication Example |
   11.232 Allergy Intolerance Observation Drug Class Example |
   11.233 Allergy Intolerance Observation Non-Medication Example |
   11.234 Anesthesia Section Example |
   11.235 Assessment and Plan Section Example |
   11.236 Assessment Scale Observation Example |
   11.237 Assessment Scale Supporting Observation Example |
   11.238 Assessment Section Example |
   11.239 Author Participation Example |
   11.240 Authorization Activity Example |
   11.241 Basic Industry Observation Example |
   11.242 Basic Occupation Observation Example |
   11.243 Birth Sex Observation Example |
   11.244 Brand Name Observation Example |
   11.245 Care Plan Caregiver participant Example |
   11.246 Care Plan Patient authenticator Example |
   11.247 Care Plan performer Example |
   11.248 Care Plan relatedDocument Example |
   11.249 Care Plan Review Example |
   11.250 Care Plan Complete Header Example |
   11.251 Care Team Member Act Example |
   11.252 Care Team Member Schedule Observation Example |
   11.253 Care Team Organizer Example |
   11.254 Care Teams Section Example |
   11.255 Care Team Type Observation Example |
   11.256 Catalog Number Observation Example |
   11.257 Caregiver Characteristics Example |
   11.258 Characteristics of Home Environment Example |
   11.259 Chief Complaint and Reason for Visit Section Example |
   11.260 Chief Complaint Section Example |
   11.261 Comment Activity Example |
   11.262 Company Name Observation Example |
   11.263 Complications Section Example |
   11.264 Continuity Of Care Document Complete Header Example |
   11.265 Continuity Of Care Document Author Example |
   11.266 Continuity Of Care Document Performer |
   11.267 Continuity Of Care Document serviceEvent Example |
   11.268 Consultation Note Complete Header Example |
   11.269 Consultation Note Callback participant Example |
   11.270 Consultation Note inFulfillmentOf Example |
   11.271 Course of Care Section Example |
   11.272 Coverage Activity Example |
   11.273 Criticality Observation Example |
   11.274 Cultural and Religious Observation Example |
   11.275 Date of Diagnosis Act Example |
   11.276 Deceased Observation Example |
   11.277 Device Identifier Observation Example |
   11.278 Diagnosis Reference Example |
   11.279 Disability Status Observation Example |
   11.280 Discharge Diagnosis Example |
   11.281 Discharge Medication Example |
   11.282 Discharge Medications Section Example |
   11.283 Discharge Summary Complete Header Example |
   11.284 Discharge Summary encompassingEncounter Example |
   11.285 Distinct Identification Code Observation Example |
   11.286 Drug Monitoring Act Example |
   11.287 Drug Vehicle Example |
   11.288 Encounter Activity Example |
   11.289 Encounter Diagnosis Example |
   11.290 Encounters Section Example |
   11.291 Entry Reference Example |
   11.292 Estimated Date of Delivery Example |
   11.293 Expiration Date Observation Example |
   11.294 External Document Reference Example |
   11.295 Family History Death Observation Example |
   11.296 Family History Observation Example |
   11.297 Family History Organizer Example |
   11.298 Family History Section Example |
   11.299 Functional Status Observation Example |
   11.300 Functional Status Organizer Example |
   11.301 Functional Status Section Example |
   11.302 Gender Identity Observation Example |
   11.303 General Status Section Example |
   11.304 Goal Observation Example |
   11.305 Goals Section Example |
   11.306 Handoff Communication Participants Example |
   11.307 Health Concern Act Example |
   11.308 Health Concerns Section Example |
   11.309 Health Status Evalutations and Outcomes Section Example |
   11.310 Health Status Observation Example |
   11.311 Highest Pressure Ulcer Stage Example |
   11.312 History and Physical Encompassing Encounter Example |
   11.313 History and Physical Complete Header Example |
   11.314 History Of Present Illness Example |
   11.315 Hospital Admission Diagnosis Example |
   11.316 Hospital Consultations Section Example |
   11.317 Hospital Course Section Example |
   11.318 Hospital Discharge Diagnosis Example |
   11.319 Hospital Discharge Instructions Section Example |
   11.320 Hospital Discharge Physical Section Example |
   11.321 Hospital Discharge Studies Summary Section Example |
   11.322 Immunization Activity Example |
   11.323 Immunization Medication Information Example |
   11.324 Immunization Not Given Reason Example |
   11.325 Immunizations Section Example |
   11.326 Implantable Device Status Observation Example |
   11.327 Indication Example |
   11.328 Instructions Section Example |
   11.329 Instruction Example |
   11.330 Intervention Act Example |
   11.331 Latex Safety Observation Example |
   11.332 Longitudinal Care Wound Observation Example |
   11.333 Lot or Batch Number Observation Example |
   11.334 Manufacturing Date Observation Example |
   11.335 Medical Equipment Organizer Example |
   11.336 Medical Equipment Section Example |
   11.337 Medication Activity Example |
   11.338 Medication Adherence Example |
   11.339 Medication Dispense Example |
   11.340 Medication Free Text Sig Example |
   11.341 Medication Information Example |
   11.342 Medication Supply Order Example |
   11.343 Medications Administered Section Example |
   11.344 Medications Section Example |
   11.345 Mental Status Observation Example |
   11.346 Mental Status Organizer Example |
   11.347 Mental Status Section Example |
   11.348 Model Number Observation Example |
   11.349 MRI Safety Observation Example |
   11.350 No Known Medications Example |
   11.351 No Known Problem Section Example |
   11.352 Non-Medicinal Supply Activity Example |
   11.353 Note Activity Entry Relationship Example |
   11.354 Note Activity Standalone Example |
   11.355 nonXML Body Example with Compressed Content |
   11.356 nonXML Body Example with Embedded Content |
   11.357 nonXML Body Example with Referenced Content |
   11.358 Number of Pressure Ulcers Observation Example |
   11.359 Nutrition Assessment Example |
   11.360 Nutrition Recommendation Example |
   11.361 Nutrition Section Example |
   11.362 Nutritional Status Observation Example |
   11.363 Objective Section Example |
   11.364 Operative Note Complete Header Example |
   11.365 Operative Note performer Example |
   11.366 Operative Note serviceEvent Example |
   11.367 Operative Note Fluids Section Example |
   11.368 Operative Note Surgical Procedure Section Example |
   11.369 Outcome Observation Example |
   11.370 Past Medical History Example |
   11.371 Patient Generated Document authenticator |
   11.372 Patient Generated Document author device Example |
   11.373 Patient Generated Document author |
   11.374 Patient Generated Document custodian Example |
   11.375 Patient Generated Document dataEnterer |
   11.376 Patient Generated Document informant Example informant |
   11.377 Patient Generated Document informant RelEnt Example |
   11.378 Patient Generated Document informationRecipient Example |
   11.379 Patient Generated Document inFulfillmentOf Example |
   11.380 Patient Generated Document legalAuthenticator Example |
   11.381 Patient Generated Document participant Example |
   11.382 Patient Generated Document recordTarget |
   11.383 Patient Referral Act Example |
   11.384 Payers Section Example |
   11.385 Physical Exam Section Example |
   11.386 Plan of Treatment Section Example |
   11.387 Planned Coverage Example |
   11.388 Planned Encounter Example |
   11.389 Planned Immunization Activity Example |
   11.390 Planned Intervention Activity Example |
   11.391 Planned Medication Activity Example |
   11.392 Planned Procedure Section Example |
   11.393 Planned Procedure Example |
   11.394 Planned Supply Example |
   11.395 Policy Activity Example |
   11.396 Postoperative Diagnosis Section Example |
   11.397 Postprocedure Diagnosis Example |
   11.398 Postprocedure Diagnosis Section Example |
   11.399 Precondition for Substance Administration Example |
   11.400 Pregnancy Intention in Next Year Example |
   11.401 Pregnancy Observation Example |
   11.402 Preoperative Diagnosis Section Example |
   11.403 Preoperative Diagnosis Example |
   11.404 Priority Preference Example |
   11.405 Problem Concern Act Example |
   11.406 Problem Observation Example |
   11.407 Problem Observation with Post-Coordinated SNOMED Example |
   11.408 Problem Section Example |
   11.409 Procedure Note Complete Header Example |
   11.410 Procedure Note performer Example |
   11.411 Procedure Note serviceEvent Example |
   11.412 Procedure Activity Procedure Example |
   11.413 Procedure Description Section Example |
   11.414 Procedure Disposition Section Example |
   11.415 Procedure Estimated Blood Loss Section Example |
   11.416 Procedure Findings Section Example |
   11.417 Procedure Implants Section Example |
   11.418 Procedure Indications Section Example |
   11.419 Procedure Specimens Taken Section Example |
   11.420 Procedures Section Example |
   11.421 Product Instance Example |
   11.422 Prognosis Coded Example |
   11.423 Prognosis Free Text Example |
   11.424 Progress Note Complete Header Example |
   11.425 Progress Note encompassingEncounter Example |
   11.426 Progress Note serviceEvent Example |
   11.427 Progress Toward Goal Observation Example |
   11.428 Provenance - Assembler Participation Example |
   11.429 Provenance - Author Participation Example |
   11.430 Reaction Observation Example |
   11.431 Reason Example |
   11.432 Reason For Referral |
   11.433 Reason for Visit Section Example |
   11.434 Referral Note Complete Header Example |
   11.435 Referral Note Callback Contact Example |
   11.436 Referral Note Caregiver |
   11.437 Referral Note informationRecipient Example |
   11.438 Related Person Relationship and Name Participant Example |
   11.439 Result Observation Example |
   11.440 Result Organizer Example |
   11.441 Results Section Example |
   11.442 Review Of Systems Section Example |
   11.443 Risk Concern Act Example |
   11.444 Self-Care Activities ADL and IADL Example |
   11.445 Sensory Status Example |
   11.446 Serial Number Observation Example |
   11.447 Service Delivery Location Example |
   11.448 Severity Observation Example |
   11.449 Sexual Orientation Observation Example |
   11.450 Smoking Status Coded Example |
   11.451 Smoking Status Quantity Example |
   11.452 Smoking Status Meaningful Use Example |
   11.453 Specimen Collection Procedure Example |
   11.454 Specimen Condition Observation Example |
   11.455 Social History Section Example |
   11.456 Subjective Section Example |
   11.457 Substance Administered Act Example |
   11.458 Surgical Drains Section Example |
   11.459 Tobacco Use Example |
   11.460 Transfer Summary Complete Header Example |
   11.461 Transfer Summary Callback Contact Example |
   11.462 Transfer Summary participant (Support) Example |
   11.463 Tribal Affiliation Observation Example |
   11.464 UDI Organizer Example |
   11.465 US Realm Address Example |
   11.466 US Realm Date and Time Example |
   11.467 US Realm Date and Time Interval Example |
   11.468 US Realm Header Example |
   11.469 US Realm Person Name Example |
   11.470 Vital Sign Observation Example |
   11.471 Average Blood Pressure Organizer Example |
   11.472 Vital Signs Organizer Example |
   11.473 Vital Signs Section Example |
   11.474 Wound Characteristic Example |
   11.475 Wound Measurement Observation Example |
   11.476 NUBC UB-04 FL17 Patient Status |