CCDA CCDA Care Plan Document Type Health Concern

C-CDA

C-CDA Care Plan Document Type • Health Concern Section (Required) • Goals Section (Required) • Interventions Section (Optional) • Health Status Evaluations and Outcomes Section (Optional)

C-CDA Care Plan Linkages Health Concern Related Milestone Goal Resulting Goal Reference Health Status Evaluation and Outcome Reference Intervention Reference

MU 2015 Test Data CXD: Health Concern Vital Sign Weight Observation Related CXD: Goal Keep weight under 95 kg. Reference Resulting CXD: Outcome Reference CXD: Intervention a. Intervention. Act #1: i. Nutrition Recommendations: 1. Follow dietary regime as discussed , 182922004 – Dietary Regime (SNOMED-CT) 2. Read about nutrition as discussed, 61310001 – Nutrition Education procedure, (SNOMED-CT) ii. Refers to the Goal Observation for Weight. Reference a. Outcome Observation #1: i. Refers to Goal Observation for Weight ii. Refers to the Intervention Act #1 iii. Progress Towards Goal of Weight – Goal Not Achieved as of 6/22/2015

Care. Plan Addresses Context related. Plan Care. Team Condition Encounter/Episode. Of Care Incoming. Referral Indication Referral. Request Condition Note Addresses Support Activity OR Goal Activity Detail Outcome Result Addresses Result. Reference Any Procedure Action. Resulting Product definition Reference Product. Reference Plan. Definition| Questionnaire Condition Medication|Substance Procedure. Request Etc. Procedure Medication. Statement Etc. FHIR DSTU 2 Care Plan Linkages Evidence Encounter/Episode Of. Care Any Detail Observation Medication Observation Condition Medication Goal Context Note Medication. Request Any Reason. Reference Plan. Definition| Questionnaire Observation Procedure. Request Procedure Etc.