Specification - Extended

HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes DSTU Release 2.1 - US Realm

Document Description

extended per extended per TSC tracker 12437, again with 14128 and jira.hl7.org/browse/TSC-38

Existing Wording

Health Status Evaluations and Outcomes Section [section: identifier urn:oid:2.16.840.1.113883.10.20.22.2.61 (open)] This template represents observations regarding the outcome of care from the interventions used to treat the patient. These observations represent status, at points in time, related to established care plan goals and/or interventions.

Proposed Wording

This section has a combined purpose (similar to how the Assessment and Plan section has a dual purpose). This template represents assessments regarding the evaluation of the patient's health status. These observations represent status, at points in time. It also includes observations regarding the outcome of care from the interventions used to treat the patient, related to established care plan goals and/or interventions. The care planning process is cyclical in nature. Thus, assessment information in this section may represent evaluations at the beginning of a care planning cycle or at the end of a care planning cycle. For example, it may include the initial assessment information used to create the care plan, or it may include the final assessment information used to record the final outcome achieved over the course of delivering the planned care.