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

Interventions Section (V3) [section: identifier urn:hl7ii:2.16.840.1.113883.10.20.21.2.3:2015-08-01 (open)] This template represents Interventions. Interventions are actions taken to maximize the prospects of the goals of care for the patient, including the removal of barriers to success. Interventions can be planned, ordered, historical, etc. Interventions include actions that may be ongoing (e.g., maintenance medications that the patient is taking, or monitoring the patient’s health status or the status of an intervention). Instructions are nested within interventions and may include self-care instructions. Instructions are information or directions to the patient and other providers including how to care for the individual’s condition, what to do at home, when to call for help, any additional appointments, testing, and changes to the medication list or medication instructions, clinical guidelines and a summary of best practice. Used by Care Plan Document and Progress Note Document.

Proposed Wording

Patient Care WG has requested to have the name of this template modified to "Activities". Currently the purpose of the template include activities that are not Interventions. Specifically, activities to monitor the patient's health status, or the status of an intervention, are not themselves interventions. The Patient Care WG agrees with the purpose for the template, but requests to have the name of the template adjusted to be "Activities" since some of the care activities are not interventions.