39.3.1CDA Module Mappings for Export

Experimental

All code examples in this document assume that you are in your generateCdaExchangeComposition function and already have the following line in your code:
var composition = ResourceBuilder.build('Composition');

39.3.2Valid Document Types

Experimental

• "Continuity Of Care Document"
• "Discharge Summary"

To set your document to any of the following types in your cda template, use composition.setType(documentType).

The document type should be specified as a Coding: composition.setType('http://LOINC.org|34133-9').

For backward compatibility, Smile also supports the specification of document types from the C-CDA R2.1 IG by name rather than coding. These names can be expressed either in camel case or in snake case.

Example: composition.setType('ContinuityOfCareDocument')

Example: composition.setType('CONTINUITY_OF_CARE_DOCUMENT')

39.3.3Valid Resources for the header

Experimental

• recordTarget: Patient
• author: Device
• custodian: Organization
• documentationOf: Encounter

There is currently no support for the following optional header tags:

• dataEnterer
• informant
• informationRecipient
• legalAuthenticator
• authenticator
• participant
• inFulfillmentOf
• authorization
• componentOf

39.3.4Valid Section Types and Sources

Experimental

• "admissiondiagnosis"
• "admissionmedication"
• "advancedirective"
• "allergyintolerance"
• "assessment"
• "assessmentandplan"
• "careplan"
• "careteam"
• "chiefcomplaint"
• "chiefcomplaintandreasonforvisit"
• "dischargediagnosis"
• "dischargemedication"
• "encounter"
• "familyhistory"
• "functionalstatus"
• "generalstatus"
• "goal"
• "healthconcern"
• "hospitalcourse"
• "hospitaldischargeinstruction"
• "historyofpresentillness"
• "immunization"
• "instruction"
• "medicalequipment"
• "medication"
• "mentalstatus"
• "note"
• "nutrition"
• "objective"
• "pastmedicalhistory"
• "payer"
• "problem"
• "procedure"
• "reasonforreferral"
• "reasonforvisit"
• "result"
• "reviewofsystems"
• "socialhistory"
• "subjective"
• "vitalsign"

To add a section to your cda template, use composition.addSection(sectionType).

Example: var medicationSection = composition.addSection("medication");

39.3.5Applicable To All Sections

Experimental

The following resources are available to all sections listed.

Acceptable FHIR resources:

• DocumentReference
  • A Note Activity Act entry will be created for each DocumentReference in the section entry.

39.3.6Admission Diagnosis Section

Experimental

Acceptable FHIR resources:

• Condition
  • A Problem Observation entry will be created for each Condition in the section. These Problem Observations will be nested within a single Hospital Admission Diagnosis entry.

39.3.7Admission Medication Section

Experimental

Acceptable FHIR resources:

• MedicationStatement
  • An Admission Medication entry will be created for every Condition resource entry in the section.

39.3.8Allergy and Intolerances Section

Experimental

Acceptable FHIR resources:

• AllergyIntolerance
  • An Allergy Concern Act entry will be created for each Coding with system RxNorm found in AllergyIntolerance.code

39.3.9Assessment and Plan Section

Experimental

Acceptable FHIR resources:

• ServiceRequest
  • A Planned Act entry will be created for each ServiceRequest in the Assessment and Plan Composition Section.

39.3.10Encounters Section

Experimental

Acceptable FHIR resources:

• Encounter
  • An Encounter Activity entry will be created for each Encounter in the section.

39.3.11Care Team Section

Experimental

Acceptable FHIR resources:

• CareTeam
  • A CareTeam entry will be created for the CareTeam resource.
• Practitioner
  • A CareTeam performer act will be created for each practitioner in the CareTeam participant.

39.3.12Discharge Medication Section

Experimental

Acceptable FHIR resources:

• MedicationStatement
  • A Discharge Medication entry will be created for every MedicationStatement resource entry in the section.

39.3.13Family History Section

Experimental

Acceptable FHIR resources:

• FamilyMemberHistory
  • A Family History entry will be created for each FamilyMemberHistory in the section.

39.3.14Functional Status Section

Experimental

Acceptable FHIR resources:

• Observation
  • If an Observation has the LOINC code 54522-8, a Functional Status Observation entry will be created.
  • If it has the LOINC code 89571-4, a Disability Status Observation entry will be created.
  • Otherwise, Self-Care Activities (ADL and IADL) entry will be created.
• Any resources that are grouped together within a sub-section of the FHIR Composition.section will be grouped together within a CDA Functional Status Organizer entry.

39.3.15Goals Section

Experimental

Acceptable FHIR resources:

• Goal
  • A Goal Observation entry will be created for each Goal in the section.

39.3.16Immunizations Section

Experimental

Acceptable FHIR resources:

• Immunization
  • An Immunization Activity entry with moodCode="EVN" will be created for each Immunization in the section.
• ImmunizationRecommendation
  • An Immunization Activity entry with moodCode="INT" will be created for each ImmunizationRecommendation in the section.

39.3.17Medical Equipment Section

Experimental

Acceptable FHIR resources:

• Procedure
  • A Procedure Activity Procedure entry will be created for each Procedure in the section.

39.3.18Medications Section

Experimental

Acceptable FHIR resources:

• MedicationStatement
  • A Substance Administration entry with moodCode="EVN" will be created for each MedicationStatement.
• MedicationRequest
  • A Substance Administration entry with moodCode="INT"will be created for each MedicationRequest.

39.3.19Mental Status Section

Experimental

Acceptable FHIR resources:

• Observation
  • For each nested Observation resource entry in the Composition's Mental Status Section sub-section(s) will be rendered as a separate Mental Status Organizer. The section and sub-section model of the FHIR Composition will help render grouped Mental Status Observation entries.

39.3.20Past Medical History Section

Experimental

Acceptable FHIR resources:

• Condition
  • A Problem Observation entry will be created for each Condition in the section. These Problem Observations will be nested directly under the section.

39.3.21Payer Section

Experimental

Acceptable FHIR resources:

• Coverage
  • For each nested Coverage resource entry in the Composition's Payers Section sub-section(s). Each sub-section will be rendered as a separate Coverage Activity. The section and sub-section model of the FHIR Composition will help render grouped Coverage Activity entries.

39.3.22Plan of Treatment Section

Experimental

Acceptable FHIR resources:

• Encounter
  • A Planned Encounter entry will be created for each Encounter in the Plan Of Treatment Composition Section.
• MedicationRequest
  • A Planned Medication Activity entry will be created for each MedicationRequest in the Plan Of Treatment Composition Section.
• ServiceRequest
  • A Planned Observation entry will be created for each ServiceRequest in the Plan Of Treatment Composition Section.

39.3.23Problem Section

Experimental

Acceptable FHIR resources:

• Condition
  • A Problem Concern Act will be created for each Condition resource.
  • The nested Problem Concern Observation will contain the identifier from an Encounter or EpisodeOfCare in Condition.context. If no context is present, a random identifier will be assigned for the Problem Concern Observation.

39.3.24Procedures Section

Experimental

Acceptable FHIR resources:

• Procedure
  • An entry will be created for each Procedure in the section.

39.3.25Reason For Referral Section

Experimental

Acceptable FHIR resources:

• ServiceRequest
  • A Patient Referral Act entry will be created for each ServiceRequest in the section.

39.3.26Results Section

Experimental

Acceptable FHIR resources:

• DiagnosticReport
  • A Results Organizer will be created for each Diagnostic Report.
  • All Observations referenced in DiagnosticReport.result will be collected.
  • For each Observation, a Result Observation will be nested in the Results Organizer for each value present in Observation.value and every Observation.component.value
• Observation
  • A Results Organizer will be created for each Observation that was not collected for a Diagnostic Report.
  • A Result Observation will be nested in the Results Organizer for each value present in Observation.value and every Observation.component.value

Only values of type valueQuantity, valueCodeableConcept, and valueString will be read.

39.3.27Social History Section

Experimental

Acceptable FHIR resources:

• Observation
  • If an observation with LOINC code 11367-0 is present, a Tobacco Use entry will be created.
  • If an observation with LOINC code 72166-2 is present, a Smoking Status Meaningful Use entry will be created.
  • If an observation with LOINC code 75274-1 is present, a Characteristics of Residence entry will be created.
  • If an observation with LOINC code 75281-6 is present, a Cultural and Religious Observation entry will be created.
  • If an observation with LOINC code 82810-3 is present, a Pregnancy Observation entry will be created.
  • If an observation with LOINC code 86645-9 is present, a Pregnancy Intention in Next Year entry will be created.
  • If an observation with LOINC code 76690-7 is present, a Sexual Orientation Observation entry will be created.
  • If any other code is present, a Social History Observation entry will be created.

39.3.28General Status Section

Experimental

• A Composition's General Status narrative-only section will be converted to a component entry with the narrative text from the section.

39.3.29History of Present Illness Section

Experimental

• A Composition's History of Present Illness narrative-only section will be converted to a component entry with the narrative text from the section.

39.3.30Objective Section

Experimental

• A Composition's Objective narrative-only section will be converted to a component entry with the narrative text from the section.

39.3.31Review of Systems Section

Experimental

• A Review of Systems narrative-only section will be converted to a component entry with the narrative text from the section.

39.3.32Subjective Section

Experimental

• A Composition's Subjective narrative-only section will be converted to a component entry with the narrative text from the section.

39.3.33Vital Signs Section

Experimental

Acceptable FHIR resources:

• Observation
  • The CDA Exchange v2 module expects Observations to be grouped together in nested sections of the Vital Signs section. A Vital Signs Organizer will be created for each nested section, containing one Vital Sign Observation entry for each Observation in that nested section.
  • If any Observations exist as direct entries of the top-level section, all of the corresponding Vital Sign Observations will be grouped in a single Vital Signs Organizer. This is not a recommended pattern.

    let vitalSection = composition.addSection("vitalsign");
    
    // All of these Observations will be clustered in a single Vital Signs Organizer
    let topLevelList = Fhir
        .search()
        .forResource('Observation')
        .where('subject', subject)
        .where('category', 'vital-signs')
        .where([some suitable filter])
        .asList();
    vitalSection.addSection().populate(topLevelList);

    // All of these Observations will be clustered in a second Vital Signs Organizer
    let clusteredList = Fhir
        .search()
        .forResource('Observation')
        .where('subject', subject)
        .where('category', 'vital-signs')
        .where([some other suitable filter])
        .asList();
    vitalSection.addSection().populate(clusteredList);

39.3.34Note Section

Experimental

Acceptable FHIR resources:

• DocumentReference
  • A note entry will be created for each DocumentReference in the section

39.3.35Discharge Diagnosis Section

Experimental

Acceptable FHIR resources:

• Condition
  • A Problem Observation entry will be created for each Condition in the section. These Problem Observations will be nested within a single Hospital Discharge Diagnosis entry.

39.3.36Chief Complaint Section

Experimental

• A Composition's Chief Complaint narrative-only section will be converted to a component entry with the narrative text from the section.

39.3.37Reason for Visit Section

Experimental

• A Composition's Reason for Visit narrative-only section will be converted to a component entry with the narrative text from the section.

39.3.38Chief Complaint and Reason for Visit Section

Experimental

• A Composition's Chief Complaint and Reason for Visit narrative-only section will be converted to a component entry with the narrative text from the section.

39.3.39Hospital Course Section

Experimental

• A Composition's Hospital Course narrative-only section will be converted to a component entry with the narrative text from the section.

39.3.40Hospital Discharge Instructions Section

Experimental

• A Composition's Hospital Discharge Instructions narrative-only section will be converted to a component entry with the narrative text from the section.

39.3.41Instructions Section

Experimental

• A Composition's Instructions narrative-only section will be converted to a component entry with the narrative text from the section.

39.3.42Nutrition Section

Experimental

• A Composition's Nutrition narrative-only section will be converted to a component entry with the narrative text from the section.

39.3.43Assessment Section

Experimental

• A Composition's Assessment narrative-only section will be converted to a component entry with the narrative text from the section.

39.3.44Advance Directives Section

Experimental

• A Composition's Advance Directives narrative-only section will be converted to a component entry with the narrative text from the section.

39.3.45Health Concerns Section

Experimental

Acceptable FHIR resources:

• Condition
  • Health Concern Act will be created for each entry in the section. A Problem Observation entryRelationship will be created and nested in the Health Concern Act for each Condition resource in the sub-section.