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Goals

  • Confirmation of ONC understanding of USCDI Design in US Core and C-CDA that is going to ballot

Resources:

USCDI v5 Design Review Table

  

 

US Core

QA - ONC Assessment of Ballot Design in US Core

 

C-CDA

QA - ONC Assessment of Ballot Design in C-CDA

CategoryFields

Profile

USCDI Terminology Present?

(Do Terminology bindings agree with what is declared in USCDI)

ASTP agrees Design covers USCDI Definition?

(Yes/No and Date)

Template

USCDI Terminology Present?

(Do Terminology bindings agree with what is declared in USCDI)

ASTP agees Design covers USCDI Definition?

(Yes/No and Date)

Clinical Notes









Emergency Department Note

Operative Note

US Core Document Reference ProfileYes - the 2 LOINC codes added to minumum set servers SHALL support declared on the Clinical Notes Guidance page
Note ActivityYes - the LOINC codes are already present in the existing Note Types value set. Template description update to reflect USCDI Narrative Note Types19-Nov-24: Yes
Immunizations







Lot NumberUS Core Immunization ProfileNA
Immunization Medication InformationNA19-Nov-24: Yes
Observations







Advance Directive Observation

US Core Observation ADI Documentation Profile

US Core ADI DocumentReference Profile

NA
NA19-Nov-24: Yes

Sex Parameter for Clinical UseSex Parameter for Clinical Use used in US Core patient

Sex Parameter For Clinical Use Observation

Yes - LOINC: 99501-9 Sex parameter for clinical use

And THO set Sex Parameter for Clinical Use

19-Nov-24: Yes
Order







Medication OrderUS Core MedicationRequest ProfileNA

Medication Order: RxNorm - Yes - see Medication Clinical Drug in Medication Information

19-Nov-24: Yes

Laboratory Order


Laboratory Order - Planned Procedure

NA (Note "Additonal" binding provided Common LOINC Lab Codes)19-Nov-24: Yes

Diagnositic Imaging Order


Diagnostic Imaging Order - Planned Procedure

NA (Note "Additonal" binding provided Radiology Procedures19-Nov-24: Yes

Clinical Test Order


Clinical Test Order - Planned Procedure

NA (Note "Additonal" binding provided Clinical Tests19-Nov-24: Yes

Procedure Order


Procedure Order - Planned Procedure

NA (Note Procedure.code bound to same set as Procedure: US Core Procedure Codes)19-Nov-24: Yes
Patient Demographics/Information







Interpreter Needed


Interpreter Needed Observation

Yes - LOINC or SNOMED:



Pronouns


Individual Pronoun Observation

NA

  • LOINC 90779-2 Personal pronouns reported
  • Answer Set LOINC  THO Set:  Personal Pronouns




Name to Use


US Realm Patient Name (PTN.US.FIELDED)

NA


Provenance







Author


Provenance - Author Participation NA

Author Role


Provenance - Author Participation (author.code)

NA

Additional Bindings:


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