Consolidated CCD Template Type Number Header/Section Contents
from CDAR2_IG_IHE_CONDOL_R1_U1_2012MAY.DOCX
Requirements MIECHV Data Elements LPH HIE Workgroup Demographic Elements PH-DOCS CHAMP CareFacts
Document Header                  
  Header 2.2.1 RecordTarget/patientRole[1]            
Note: content elements in bold are required elements of the CDA/CCD     id This patientRole SHALL  contain at least one [1..*] id ID for Public Health Software or other personal health record patient_id   client_number ClientID
Note: MIECHV data elements with an asterisk should not be accessible by MDH MIECHV staff     addr
(more than one set of addr values may be used)[2]
This patientRole SHALL  contain at least one [1..*] addr
SHALL  be a conformant  US Realm Address (AD.US.FIELDED) 
--  NI (No Information in MIECHV, but does exist in Public Health Software - required for other applications)        
    @use SHOULD  contain @use, which SHALL  be selected from ValueSet PostalAddressUse   Home or Mailing PADDRESS_NAME    
    StreetAddressLine SHALL  contain at least one and not more than four [1..4]    address PADDRESS_LINE
PADDRESS_UNIT
address_1
address_2
ClientAddressLine1
            type_of_home (As used in CDA is different from workgroup discussed: re: need set description of values: age of home, built pefore 1978, etc.) housing_type  
            geocode_home_address      
    city SHALL  contain exactly one [1..1]   city PADDRESS_CITY city ClientCity
            county PADDRESS_COUNTY   ClientCountySC
    state SHOULD  contain exactly one [1..1] state
State is required if the country is US. If country is not specified, it's assumed to be US. 
  state PADDRESS_STATE state_code ClientState
    postalCode SHOULD  contain exactly one [1..1]
PostalCode is required if the country is US. If country is not specified, it's assumed  to be US.
  zip PADDRESS_ZIP5
PADDRESS_ZIP4
zip_code  
    country SHOULD  contain zero or one [0..1] country, which SHALL  be selected from ValueSet CountryValueSet          
      telecom This patientRole SHALL  contain at least one [1..*] telecom
Such telecoms SHOULD  contain @use
--  NI (No Information in MIECHV, but does exist in Public Health Software)        
      @use SHOULD  contain @use, which SHALL  be selected from ValueSet Telecom Use (US Realm Header)   Type of phone      
      value            
      @use     Type of phone CLIENT_PHONE_DESC1  
      value       CLIENT_PHONE1
CLIENT_PHONE_EXT1
home_phone ClientPhone
      @use     Type of phone CLIENT_PHONE_DESC2  
      value       CLIENT_PHONE2
CLIENT_PHONE_EXT2
cell_phone
      @use     Type of phone CLIENT_PHONE_DESC3    
      value       CLIENT_PHONE3
CLIENT_PHONE_EXT3
work_phone  
      @use     Type of email address      
      value       CLIENT_EMAIL email  
      @use     Type of email address      
      value          
  Header 2.2.1.1 Patient[3]            
      Name[4] SHALL  contain exactly one [1..1] name            
      prefix MAY contain zero or more [0..*] prefix    prefix      
      given SHALL contain at least one [1..*] given Fname (char)* first_name CLIENT_FIRST_NAME First_name ClientFirstName 
      given qualifer="IN" The second occurrence of given (given[2]) if provided, SHALL include middle name or middle initial  Minitial (char)* middle_name CLIENT_MIDDLE_NAME Middle_initial ClientMiddleInitial
      family SHALL contain exactly one [1..1] family  Lname (char)* last_name CLIENT_LAST_NAME Last_name ClientLastName
      suffix   suffix      
      administrativeGenderCode SHALL  contain exactly one [1..1]  Gender gender CLIENT_SEX gender ClientGenderSC
      birthTime
SHALL  contain exactly one [1..1] birthTime
a.  SHALL  be precise to year (CONF:5299). b.   SHOULD  be precise to day
<birthTime value="19541125"/> 
Dbirth date of birth CLIENT_BIRTHDATE Born_on ClientBirthDate
      maritalStatusCode SHOULD  contain zero or one [0..1]
SHALL  be selected from ValueSet HL7 Marital Status
--  NI marital_status   marital_status ClientMaritalStatusSC
      religious AffiliationCode MAY  contain zero or one [0..1]
SHALL  be selected from ValueSet HL7 Religious Affiliation
--  NI       AdmitReligionSC?
      raceCode MAY  contain zero or one [0..1]
SHALL  be selected from ValueSet Race
Race race RACE_CODE race ClientPrimaryRaceSC
      sdtc:raceCode
(Secondary race Code)
MAY  contain zero or one [0..1]          
      ethnicGroupCode MAY  contain zero or one [0..1]
SHALL  be selected from ValueSet HITSP Ethnicity Value Set
Ethnicity (Yes=Hispanic) ethnicity ETHNICITY_CODE ethnicity ClientEthnicitySC
          MIECHV PrimaryKey?        
          ID* (MIECHV identifier for individual in other applications such as ETO)        
    2.2.1.2 Guardian   --  NI        
      code            
      addr            
      telecom            
      guardianPerson            
      name            
    2.2.1.3  Birthplace MAY  contain zero or one [0..1]  --  NI        
      place SHALL  contain exactly one [1..1]           
      addr SHALL  contain exactly one [1..1]          
    @use SHOULD  contain @use, which SHALL  be selected from ValueSet PostalAddressUse          
    StreetAddressLine SHALL  contain at least one and not more than four [1..4]           
    city SHALL  contain exactly one [1..1]          
    state If country is US, this addr SHALL  contain exactly one [1..1] state          
    postalCode MAY  contain zero or one [0..1]           
    country SHOULD  contain zero or one [0..1] country, which SHALL  be selected from ValueSet CountryValueSet          
    2.2.1.4 LanguageCommunication SHOULD  contain zero or more [0..*]
languageCommunication
  language_spoken
language_written

Interpreter needed
     
      languageCode SHALL contain exactly one [1..1]
selected from ValueSet Language
PrimLang   LANGUAGE_CODE language_1 ClientPrimarySpokenLanguageSC
      modeCode MAY contain zero or one [0..1]
selected from ValueSet HL7 LanguageAbilityMode
         
      proficiencyLevelCode SHOULD contain zero or one [0..1]
selected from ValueSet LanguageAbilityProficiency
         
      preferenceInd MAY contain zero or one [0..1]            
      2.2.9 Participant (Support)            
  Header   2.2.1.5 ProviderOrganization    
  Header   2.2.2 Author    
      2.2.3 DataEnterer    
      2.2.4 Informant    
      2.2.5 Custodian (of document)    
  Header   2.2.6 InformationRecipient    
      2.2.7 LegalAuthenticator    
      2.2.8 Authenticator    
      2.2.10 InFulfillmentOf    
      2.2.11 DocumentationOf/ serviceEvent    
      2.2.12 Authorization/consent    
      2.2.13 ComponentOf    
Continuity of Care Document (CCD) document        
Advance Directives Section (entries optional) section   Contains 1 entry    
Allergies Section (entries required) section   Contains 52 entries    
Encounters Section (entries optional) section   Contains 8 entries    
Family History Section section   Contains 4 entries    
Functional Status Section section   Contains 35 entries    
Immunizations Section (entries optional) section   Contains 68 entries    
Medical Equipment Section section   Contains 2 entries    
Medications Section (entries required) section   Contains 23 entries    
Payers Section section   Contains 2 entries    
Plan of Care Section section   Contains  9 entries    
Problem Section (entries required) section   Contains 5 entries    
Procedures Section (entries required) section   Contains 79 entries    
Results Section (entries required) section   Contains 2 entries    
Social History Section section   Contains 4 entries    
Vital Signs Section (entries optional) section   Contains 2 entries    

[1]
Kathy Grantham:
CDAR pg. 44
[2]
Kathy Grantham:
CDAR2 page 69
[3]
Kathy Grantham:
CDAR pg. 47
[4]
Kathy Grantham:
CDAR pg. 71