Continuity of Care Document+

Template ID

TBD

Reference(s)

HL7 Continuity Of Care Document

Base Template (IS-A)

Continuity of Care Document

Document Code

LOINC: 34133-9 (SUMMARIZATION OF EPISODE NOTE)

XDS Format Code

IHE Format Code: urn:ad:ohie:ccd+:2014Change this to CCD

XDS Type Code

LOINC: 34133-9

Description

The Continuity of Care Document+ template is an OpenHIE specific document template which encapsulates the constraints of HL7 CCD adding additional sections to represent a more complete view of the patient.

Expected Sections

Section

Template ID

Reference

Visit Summary Flow sheet

1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2

3.3.2.5

History of Surgical Procedures

1.3.6.1.4.1.19376.1.5.3.1.1.16.2.2

Coded Antenatal Testing and Surveillance

1.3.6.1.4.1.19376.1.5.3.1.1.21.2.5.1

3.3.2.4

Allergies and Other Adverse Reactions

1.3.6.1.4.1.19376.1.5.3.1.3.13

3.3.2.3

Medications

1.3.6.1.4.1.19376.1.5.3.1.3.19

3.3.2.12

Care Plan

1.3.6.1.4.1.19376.1.5.3.1.3.31

Advance Directives

1.3.6.1.4.1.19376.1.5.3.1.3.34 or 1.3.6.1.4.1.19376.1.5.3.1.3.35

3.3.2.2

Problems

1.3.6.1.4.1.19376.1.5.3.1.3.6

3.3.2.1

Vital Signs

1.3.6.1.4.1.19376.1.5.3.1.3.25 or 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2

3.3.2.17

Family History

1.3.6.1.4.1.19376.1.5.3.1.3.14 or 1.3.6.1.4.1.19376.1.5.3.1.3.15

3.3.2.9

Social History

1.3.6.1.4.1.19376.1.5.3.1.3.16 or 1.3.6.1.4.1.19376.1.5.3.1.3.16.1

3.3.2.15

Results

1.3.6.1.4.1.19376.1.5.3.1.3.27 or 1.3.6.1.4.1.19376.1.5.3.1.3.28

3.3.2.7

History of Present Illness

1.3.6.1.4.1.19376.1.5.3.1.3.4

History of Past Illness

1.3.6.1.4.1.19376.1.5.3.1.3.8

3.3.2.10

Pregnancy History

1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4

3.3.2.14

Immunizations

1.3.6.1.4.1.19376.1.5.3.1.3.23

3.3.2.11

Procedures

2.16.840.1.113883.10.20.1.12

3.3.2.15

OpenSHR Implementation Notes

Additional Constraints

• This document type cannot currently be imported by OpenSHR.

Notes

• This document will contain the aggregate information of each section provided by one of APHP, APS, IC or XDS-MS documents imported with corresponding sections.
  
• This document type is currently only supported for export.

Specification

<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" classCode="DOCCLIN" moodCode="EVN">
<realmCode code="UV"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="TBD"/>
<id root="1.2.3.4.5.6.9.100.2" extension="2-20141027135823"/>
<code code="34133-9" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="SUMMARIZATION OF EPISODE NOTE"/>
<title language="en-US">SUMARIZATION OF EPISODE NOTE</title>
<effectiveTime value=""/>
<confidentialityCode code="" codeSystem="2.16.840.1.113883.5.25" codeSystemName="x_BasicConfidentialityKind"/>
<languageCode code=""/>
<!-- 1..1 Authors -->
<recordTarget typeCode="RCT" contextControlCode="OP">
<patientRole classCode="PAT">
...
</patientRole>
</recordTarget>
<!-- 1..n Authors -->
<author typeCode="AUT" contextControlCode="OP">
<time value=""/>
<assignedAuthor classCode="ASSIGNED">
...
</assignedAuthor>
</author>
<!-- 1..1 Custodial Organization -->
<custodian typeCode="CST">
<assignedCustodian classCode="ASSIGNED">
<representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
...
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<!-- 0..n Participants -->
<participant typeCode="IND">
<time value=""/>
<associatedEntity classCode="PRS">
...
</associatedEntity>
</participant>
<!-- 1..n Documentation Of -->
<documentationOf typeCode="DOC">
<serviceEvent classCode="PCPR" moodCode="EVN">
<effectiveTime>
<low value=""/>
<high value=""/>
</effectiveTime>
</serviceEvent>
</documentationOf>
<!-- 1..1 Component -->
<component typeCode="COMP" contextConductionInd="true">
<!-- Must be structured body -->
<structuredBody classCode="DOCBODY" moodCode="EVN">

<!-- 1..n Components -->
<component typeCode="COMP" contextConductionInd="true">
<!-- 1..1 Section -->
<section classCode="DOCSECT" moodCode="EVN">
...
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>