33.4.1CDA Module Mappings for Import
Experimental

 

All of the mappings for CDA Import are based on the Consolidated CDA Templates for Clinical Notes Release 2.1.

33.4.2Valid Document Types
Experimental

 
  • "Continuity of Care Document" (template id 2.16.840.1.113883.10.20.22.1.2)
  • "Discharge Summary" (template id 2.16.840.1.113883.10.20.22.1.8)

33.4.3Resources derived from the header
Experimental

 
  • recordTarget: Patient
  • author: Practitioner
  • custodian: Organization
  • legalAuthenticator: Practitioner
  • authenticator: Practitioner
  • documentationOf: Composition.event

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

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

33.4.4Valid Section Types and Sources
Experimental

 

33.4.5Admission Diagnosis Section
Experimental

 

Supported CDA Entries:

  • Hospital Admission Diagnosis
    • The section is expected to contain a single Hospital Admission Diagnosis entry, which contains one or more nested Problem Observation entries.
    • Each Problem Observation entry will be converted to a Condition resource.

33.4.6Admission Medication Section
Experimental

 

Supported CDA Entries:

  • Admission Medication
    • Each Medication Activity entry within a Admission Medication will be converted to a MedicationStatement resource.

33.4.7Allergy and Intolerances Section
Experimental

 

Supported CDA Entries:

  • Allergy Concern Act
    • Each Allergy Concern Act entry will be converted to an AllergyIntolerance resource.

33.4.8Care Plan Section
Experimental

 

Supported CDA Entries:

The Care Plan section as a whole will be converted to a CarePlan resource.

33.4.9Care Team Section
Experimental

 

Supported CDA Entries:

The Care Team section as a whole will be converted to a CareTeam resource.

  • Care Team Performer Act
    • Each Care Team Performer Act entry will be converted to a Practitioner resource and added to the CareTeam as a participant.

33.4.10Discharge Diagnosis Section
Experimental

 

Supported CDA Entries:

  • Hospital Discharge Diagnosis
    • The section is expected to contain a single Hospital Discharge Diagnosis entry, which contains one or more nested Problem Observation entries.
    • Each Problem Observation entry will be converted to a Condition resource.

33.4.11Discharge Medication Section
Experimental

 

Supported CDA Entries:

  • Discharge Medication
    • Each Medication Activity entry within a Discharge Medication will be converted to a MedicationStatement resource.

33.4.12Encounters Section
Experimental

 

Supported CDA Entries:

  • Encounter Activity
    • Each Encounter Activity entry will be converted to an Encounter resource.

33.4.13Family History Section
Experimental

 

Supported CDA Entries:

  • Family History Observation
    • Each Family History Observation entry will be converted to a FamilyMemberHistory resource.

33.4.14Functional Status Section
Experimental

 

Supported CDA Entries:

  • Functional Status Observation
    • Each Functional Status Observation entry will be converted to an Observation resource.

33.4.15Goals Section
Experimental

 

Supported CDA Entries:

  • Goal Observation
    • Each Goal Observation entry will be converted to a Goal resource.

33.4.16Health Concerns Section
Experimental

 

Supported CDA Entries:

  • Health Status Observation
    • Each Health Status Observation entry will be converted to an Observation resource.
  • Health Concern Act
    • Each Health Concern Act entry will be converted to a Condition resource.

33.4.17Immunizations Section
Experimental

 

Supported CDA Entries:

  • Immunization Activity
    • Each Immunization Activity entry will be converted to an Immunization resource.

33.4.18Medical Equipment Section
Experimental

 

Supported CDA Entries:

  • Procedure Activity Procedure
    • Each Procedure Activity Procedure entry will be converted to a Procedure resource.

33.4.19Medications Section
Experimental

 

Supported CDA Entries:

  • Medication Activity
    • Each Medication Activity entry with moodCode="EVN" will be converted to a MedicationStatement resource. Each Medication Activity entry with moodCode="INT" will be converted to a MedicationRequest resource. Entries with other values of the moodCode attribute are not supported.

33.4.20Medications Administered Section
Experimental

 

Supported CDA Entries:

  • Medication Activity
    • Each Medication Activity entry will be converted to a MedicationStatement resource.

33.4.21Mental Status Section
Experimental

 

Supported CDA Entries:

  • Mental Status Organizer
    • Each of the Mental Status Observation entries contained in the Mental Status Organizer will be converted to an Observation resource.
  • Assessment Scale Observation
    • Each Assessment Scale Observation entry will be converted to an Observation resource.
  • Assessment Scale Supporting Observation
    • Each Assessment Scale Supporting Observation contained in the Assessment Scale Observation will be converted into an Observation resource and referenced in the Assessment Scale Observation Observation.hasMember property.

33.4.22Past Medical History Section
Experimental

 

Supported CDA Entries:

  • Past Medical History
    • The section is expected to contain one or more nested Problem Observation entries.
    • Each Problem Observation entry will be converted to a Condition resource.

33.4.23Payer Section
Experimental

 

Supported CDA Entries:

  • Coverage Activity
    • Each Policy Activity contained within a Coverage Activity entry will be converted to a Coverage resource.

33.4.24General Status Section
Experimental

 
  • A General Status narrative-only section will be created within the Composition resource

33.4.25History of Present Illness Section
Experimental

 
  • A History of Present Illness narrative-only section will be created within the Composition resource

33.4.26Review of Systems Section
Experimental

 
  • A Review of Systems narrative-only section will be created within the Composition resource

33.4.27Plan of Treatment Section
Experimental

 

Supported CDA Entries:

  • Planned Observation
    • Each Planned Observation entry will be converted to a ServiceRequest resource.
  • Planned Encounter
    • Each Encounter Observation entry will be converted to a Encounter resource.
  • Planned Act
    • Each Act Observation entry will be converted to a ServiceRequest resource.
  • Planned Procedure
    • Each Planned Procedure entry will be converted to a ServiceRequest resource.
  • Planned Medication
    • Each Planned Medication entry will be converted to a MedicationRequest resource.
  • Planned Immunization
    • Each Planned Immunization entry will be converted to a MedicationRequest resource.

33.4.28Problem Section
Experimental

 

Supported CDA Entries:

  • Problem Concern Act
    • Each Problem Concern Act entry will be converted to a Condition resource.
  • Health Status Observation
    • The Health Status Observation entry is not supported.

33.4.29Procedures Section
Experimental

 

Supported CDA Entries:

  • Procedure Activity Procedure
    • Each Procedure Activity Procedure entry will be converted to a Procedure resource.

33.4.30Results Section
Experimental

 

Supported CDA Entries:

  • Result Organizer
    • Each Result Organizer entry will be converted to a DiagnosticReport resource.
    • Any Result Observation entry within the Result Organizer will be converted to an Observation resource and added to the result list of the DiagnosticReport.

33.4.31Social History Section
Experimental

 

Supported CDA Entries:

  • Pregnancy Observation
  • Caregiver Characteristics
  • Characteristics of Home Environment
  • Cultural and Religious Observation
  • Smoking Status - Meaningful Use
  • Tobacco Use
  • Social History Observation
    • Each entry in the section will be converted to an Observation resource.

33.4.32Vital Signs Section
Experimental

 

Supported CDA Entries:

  • Vital Signs Organizer
    • Each Vital Sign Organizer entry in the section will be converted to a nested section within the Composition.section.
    • Each Vital Sign Observation entry within a Vital Signs Organizer will be converted to an Observation resource within the corresponding nested section.

33.4.33Note Section
Experimental

 

Supported CDA Entries:

  • Note Act
    • Each Note Act will be converted to a DocumentReference resource
    • Currently only supports note sections with the LOINC code 34109-9, but individual Note Acts can have more specific codes.

33.4.34Admission Medications Section
Experimental

 

Supported CDA Entries:

  • Admission Medication
    • The section is expected to contain a single Admission Medication entry, which contains one or more nested Medication Activity entries.
    • Each Medication Activity entry will be converted to a MedicationStatement resource.

33.4.35Discharge Medications Section
Experimental

 

Supported CDA Entries:

  • Discharge Medication
    • The section is expected to contain a single Discharge Medication entry, which contains one or more nested Medication Activity entries.
    • Each Medication Activity entry will be converted to a MedicationStatement resource.