CCDA – R2 – PROGRESS NOTE

As we specified earlier in the blog there are various versions of CCDA documents. HL7 standards defines them as Consolidated Clinical Document Architecture. There are various other ways these documents are diversified such as Transfer Of Care, Procedural based and Plan Of Care based.

What is Progress Notes CCDA?

This blog post is about breaking down the PROGRESS NOTE based CCDA document. First we need to understand what is Progress Notes CCDA?. When a patient is in-patient (admitted in a hospital) or if the patient is diagnosed for certain prolonged illness or disease then the physician may need to use the Progress Notes of that Particular patient to identify the progress that the patient has made undergoing the treatment.

Real time example of Progress Notes CCDA?

Best example of a Progress Notes needed in real time would be the example of a patient who is diagnosed with the type-2  or common diabetic. The particular patient has to give the blood test in a quarterly basis and the physician will have to keep track of  the progress made by the patient with his/her sugar control level or LDL  cholesterol control level. In this case The physician definitely needed a Progress Notes CCDA.

What are all the sections does the Progress Notes CCDA contain?

  1. Allergies, Adverse Reaction, Alerts:

This section contains information about the allergies and reactions to the allergy that a patient undergoes. This will also contain information about the patient who may/may not be allergic to certain drugs that will be used for treating particular problem for the patient.

Each and every specific section as usual starts with a <component> tag followed by <section> tag. So With in one <component><section> there will be multiple <entry> tag. each <entry> tag denotes a particular allergy and reactions of the patient.

The syntax of the <entry> tag will be <entry typeCode = “”>  usually the typeCode will be filled with certain bunch of known values.

Meaningfully what does the typeCode do?.  The final significant use of typeCode is to describe the relationships inside the clinical statement which can be any of those specified below

typeCode_Meaning

Sometime your <entry typeCode=”DRIV”>. When CCD(A) sets the typeCode to DRIV, then there is an implicit assertion here: the narrative content of the CDA Section that contains the problems must be generated from the data – so you couldn’t build this by taking some existing narrative that may contain additional information not found in the entries – or (as is commonly done) adding additional information in the narrative that is not in the data to save figuring out how to represent it in the data.

Sample Allergy Section of Progress Notes CCDA:

<component>
<section>
<templateId root=”2.16.840.1.113883.10.20.22.2.6″ extension=”2014-06-09″/>
<code code=”48765-2″ codeSystem=”2.16.840.1.113883.6.1″ codeSystemName=”LOINC”/>
<title>ALLERGIES AND ADVERSE REACTIONS</title>

<! — Begin human readable format –>
<text>
<table border=”1″ width=”100%”>
<thead>
<tr>
<th>Substance</th>
<th>Reaction</th>
</tr>
</thead>
<tbody>
<tr>
<td ID=”substance1″>Penicillin</td>
<td ID=”reaction1″>Nausea</td>
</tr>
<tr>
<td ID=”substance2″>Codeine</td>
<td ID=”reaction2″>Wheezing</td>
</tr>
</tbody>
</table>
</text>
<! — End human readable format –>

<entry typeCode=”DRIV”>
<act classCode=”ACT” moodCode=”EVN”>
<templateId root=”2.16.840.1.113883.10.20.22.4.30″ extension=”2014-06-09″/>
<id root=”36e3e930-7b14-11db-9fe1-0800200c9a66″/>
<code code=”CONC” codeSystem=”2.16.840.1.113883.5.6″/>
<statusCode code=”active”/>
<effectiveTime>
<low value=”199805011145-0800″/>
</effectiveTime>
<author typeCode=”AUT”>
<templateId root=”2.16.840.1.113883.10.20.22.4.119″/>
<time value=”199805011145-0800″/>
<assignedAuthor>
<id extension=”555555555″ root=”2.16.840.1.113883.4.6″/>
<code code=”207QA0505X” displayName=”Adult Medicine” codeSystem=”2.16.840.1.113883.6.101″ codeSystemName=”Healthcare Provider Taxonomy (HIPAA)”/>
<addr>
<streetAddressLine>1004 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use=”WP” value=”tel:+1(555)-1004″/>
<assignedPerson>
<name>
<given>Patricia</given>
<given qualifier=”CL”>Patty</given>
<family>Primary</family>
<suffix qualifier=”AC”>M.D.</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<entryRelationship typeCode=”SUBJ”>
<observation classCode=”OBS” moodCode=”EVN”>
<templateId root=”2.16.840.1.113883.10.20.22.4.7″ extension=”2014-06-09″/>
<id root=”4adc1020-7b14-11db-9fe1-0800200c9a66″/>
<code code=”ASSERTION” codeSystem=”2.16.840.1.113883.5.4″/>
<text>
<reference value=”#allergytype1″/>
</text>
<statusCode code=”completed”/>
<effectiveTime>
<low value=”19980501″/>
</effectiveTime>
<value xsi:type=”CD” code=”419199007″ displayName=”Allergy to substance” codeSystem=”2.16.840.1.113883.6.96″ codeSystemName=”SNOMED CT”/>
<author typeCode=”AUT”>
<templateId root=”2.16.840.1.113883.10.20.22.4.119″/>
<time value=”199805011145-0800″/>
<assignedAuthor>
<id extension=”222223333″ root=”2.16.840.1.113883.4.6″/>
<code code=”207KA0200X” displayName=”Allergy” codeSystem=”2.16.840.1.113883.6.101″ codeSystemName=”Healthcare Provider Taxonomy (HIPAA)”/>
</assignedAuthor>
</author>
<participant typeCode=”CSM”>
<participantRole classCode=”MANU”>
<playingEntity classCode=”MMAT”>
<code code=”70618″ displayName=”Penicillin” codeSystem=”2.16.840.1.113883.6.88″ codeSystemName=”RxNorm”/>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode=”MFST” inversionInd=”true”>
<observation classCode=”OBS” moodCode=”EVN”>
<templateId root=”2.16.840.1.113883.10.20.22.4.9″ extension=”2014-06-09″/>
<id root=”4adc1020-7b14-11db-9fe1-0800200c9a64″/>
<code code=”ASSERTION” codeSystem=”2.16.840.1.113883.5.4″/>
<text>
<reference value=”#reaction1″/>
</text>
<statusCode code=”completed”/>
<effectiveTime>
<low value=”200802260805-0800″/>
<high value=”200802281205-0800″/>
</effectiveTime>
<value xsi:type=”CD” code=”422587007″ codeSystem=”2.16.840.1.113883.6.96″ displayName=”Nausea”/>
<entryRelationship typeCode=”SUBJ” inversionInd=”true”>
<observation classCode=”OBS” moodCode=”EVN”>
<templateId root=”2.16.840.1.113883.10.20.22.4.8″ extension=”2014-06-09″/>
<code code=”SEV” displayName=”Severity Observation” codeSystem=”2.16.840.1.113883.5.4″ codeSystemName=”ActCode”/>
<statusCode code=”completed”/>
<value xsi:type=”CD” code=”255604002″ displayName=”Mild” codeSystem=”2.16.840.1.113883.6.96″ codeSystemName=”SNOMED CT”/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
<entryRelationship typeCode=”SUBJ” inversionInd=”true”>
<observation classCode=”OBS” moodCode=”EVN”>
<templateId root=”2.16.840.1.113883.10.20.22.4.8″ extension=”2014-06-09″/>
<code code=”SEV” displayName=”Severity Observation” codeSystem=”2.16.840.1.113883.5.4″ codeSystemName=”ActCode”/>
<text>
<reference value=”#allergyseverity1″/>
</text>
<statusCode code=”completed”/>
<value xsi:type=”CD” code=”371924009″ displayName=”Moderate to severe” codeSystem=”2.16.840.1.113883.6.96″ codeSystemName=”SNOMED CT”/>
</observation>
</entryRelationship>
</act>

</entry>

</section>
</component>

 

 

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