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Indication that a medication should be taken by or given to the patient after being discharged from an encounter.

Medications (including medications with dose): RxNORM Medication Route: SNOMED (i.e. OID: 2.16.840.1.113883.3.117.1.7.1.222) Negation Rationale (reason codes): SNOMED (i.e. OID: 2.16.840.1.113883.3.117.1.7.1.93) https://vsac.nlm.nih.gov/valueset/expansions?pr=ecqm Negation Rationale: https://www.hl7.org/fhir/valueset-reason-medication-not-given-codes.html , http://hl7.org/fhir/us/qicore/ValueSet-qicore-negation-reason.html

Who was responsible for asserting the observed value as "true". Many observations will be asserted by a clinician in the care of a patient, but this data element also explicitly allows record of patients, caregivers, and other entities as the source. Such information is crucial for understanding context for observations derived from patient reported outcomes measures. Data Type: Reference (Practitioner, PractitionerRole, Organization, CareTeam, Patient, RelatedPerson). This data element may be a pointer into a record in another table/structure that contains more metadata about the performer. In other contexts, it may be a data type that carries all of the requisite identifying information "inline", such as the XCN (Extended Composite ID Number and Name for Persons) data type used in HL7 v2 OBX-16.

Vocabulary Standard: No single vocabulary covers the content necessary for representing all aspects of observation reporting (observation identifiers, coded observation values, computable units of measure, etc). Yet, the collection of core vocabularies needed are sufficiently mature. [Observation: Code] LOINC was specifically designed to fulfill the need for a freely available standard for identifying observations. More than 25 years later, it now contains a rich catalog of variables, answer lists, and the collections that contain them. [Observation: Value.units] UCUM was specifically designed to fulfill the need for a freely available standard of computable units of measure. [Observation: Value.code] • If the observation represents a validated assessment instrument (e.g. survey) item and the value is a CodeableConcept, then Observation.value.code SHALL be drawn from LOINC. • If the observation pertains to clinical genetics, then other terminologies or syntaxes may be used as appropriate, e.g. HGVS, ClinVar, etc. • If the observation represents a human phenotype, then the Observation.value MAY be drawn from the Human Phenotype Ontology • If the observation has a nominal or ordinal scale value and the Observation.value exists in SNOMED CT, then SNOMED CT MAY be used Exchange and Analytic CDM specifications: HL7 Version 2: Chapter 7 C-CDA: Results Section (entries required): 2.16.840.1.113883.10.20.22.2.3.1 FHIR: Observation OMOP: Measurement, Observation PCORnet CDM: LAB_RESULT_CM, PRO_CM, OBS_CLIN, OBS_GEN

The patient, or group of patients, location, or device this Observation is about and into whose record the observation is placed. Note: Additional structures are needed to handle situations where the actual focus of the Observation is different from the subject (or a sample of, part, or region of the subject). For example, a measurement on a fetus that is placed in the mother's record. Data Type: Reference (Patient, Group, Device, or Location). This data element is typically a pointer into a record in another table/structure that contains more metadata about the subject. Note: This Data Element (Observation.subject) would typically point to a record/instance of the Patient Demographics Data Class, though Observations can be recorded for other “units of analysis” (such as a geographic area, group of subjects, etc). The exact mechanism for specifying this linkage is not prescribed, but the purpose of this Data Element is to establish that the ability to communicate “who the observation is about” must be supported.

Vocabulary Standard: No single vocabulary covers the content necessary for representing all aspects of observation reporting (observation identifiers, coded observation values, computable units of measure, etc). Yet, the collection of core vocabularies needed are sufficiently mature. [Observation: Code] LOINC was specifically designed to fulfill the need for a freely available standard for identifying observations. More than 25 years later, it now contains a rich catalog of variables, answer lists, and the collections that contain them. [Observation: Value.units] UCUM was specifically designed to fulfill the need for a freely available standard of computable units of measure. [Observation: Value.code] • If the observation represents a validated assessment instrument (e.g. survey) item and the value is a CodeableConcept, then Observation.value.code SHALL be drawn from LOINC. • If the observation pertains to clinical genetics, then other terminologies or syntaxes may be used as appropriate, e.g. HGVS, ClinVar, etc. • If the observation represents a human phenotype, then the Observation.value MAY be drawn from the Human Phenotype Ontology • If the observation has a nominal or ordinal scale value and the Observation.value exists in SNOMED CT, then SNOMED CT MAY be used Exchange and Analytic CDM specifications: HL7 Version 2: Chapter 7 C-CDA: Results Section (entries required): 2.16.840.1.113883.10.20.22.2.3.1 FHIR: Observation OMOP: Measurement, Observation PCORnet CDM: LAB_RESULT_CM, PRO_CM, OBS_CLIN, OBS_GEN

The time or time-period the observed value is asserted as being true. For biological subjects (e.g. human patients) this is typically called the "physiologically relevant time", which is usually either the time of the procedure or of specimen collection. Very often the source of the date/time information is not known, only the date/time itself. Data Type: variable. Allowable data types include: dateTime, Period, Timing, instant Note: An observation time is essential for understanding the context and clinical meaning of an observation. For nationwide interoperability, systems must support the ability to representing this time, even if it is not present for all observations.

Vocabulary Standard: No single vocabulary covers the content necessary for representing all aspects of observation reporting (observation identifiers, coded observation values, computable units of measure, etc). Yet, the collection of core vocabularies needed are sufficiently mature. [Observation: Code] LOINC was specifically designed to fulfill the need for a freely available standard for identifying observations. More than 25 years later, it now contains a rich catalog of variables, answer lists, and the collections that contain them. [Observation: Value.units] UCUM was specifically designed to fulfill the need for a freely available standard of computable units of measure. [Observation: Value.code] • If the observation represents a validated assessment instrument (e.g. survey) item and the value is a CodeableConcept, then Observation.value.code SHALL be drawn from LOINC. • If the observation pertains to clinical genetics, then other terminologies or syntaxes may be used as appropriate, e.g. HGVS, ClinVar, etc. • If the observation represents a human phenotype, then the Observation.value MAY be drawn from the Human Phenotype Ontology • If the observation has a nominal or ordinal scale value and the Observation.value exists in SNOMED CT, then SNOMED CT MAY be used Exchange and Analytic CDM specifications: HL7 Version 2: Chapter 7 C-CDA: Results Section (entries required): 2.16.840.1.113883.10.20.22.2.3.1 FHIR: Observation OMOP: Measurement, Observation PCORnet CDM: LAB_RESULT_CM, PRO_CM, OBS_CLIN, OBS_GEN

The concept identifying what was tested, measured, or observed. Data Type: CodeableConcept Permissible Values: The observation identifier SHALL be from LOINC if the concept is present in LOINC.

Vocabulary Standard: No single vocabulary covers the content necessary for representing all aspects of observation reporting (observation identifiers, coded observation values, computable units of measure, etc). Yet, the collection of core vocabularies needed are sufficiently mature. [Observation: Code] LOINC was specifically designed to fulfill the need for a freely available standard for identifying observations. More than 25 years later, it now contains a rich catalog of variables, answer lists, and the collections that contain them. [Observation: Value.units] UCUM was specifically designed to fulfill the need for a freely available standard of computable units of measure. [Observation: Value.code] • If the observation represents a validated assessment instrument (e.g. survey) item and the value is a CodeableConcept, then Observation.value.code SHALL be drawn from LOINC. • If the observation pertains to clinical genetics, then other terminologies or syntaxes may be used as appropriate, e.g. HGVS, ClinVar, etc. • If the observation represents a human phenotype, then the Observation.value MAY be drawn from the Human Phenotype Ontology • If the observation has a nominal or ordinal scale value and the Observation.value exists in SNOMED CT, then SNOMED CT MAY be used Exchange and Analytic CDM specifications: HL7 Version 2: Chapter 7 C-CDA: Results Section (entries required): 2.16.840.1.113883.10.20.22.2.3.1 FHIR: Observation OMOP: Measurement, Observation PCORnet CDM: LAB_RESULT_CM, PRO_CM, OBS_CLIN, OBS_GEN

The information determined as a result of making the observation. The information carried by Observation.value may take several forms, depending on the nature of the observation. For example, it could be a quantitative result, and ordinal scale value, nominal or categorial value, etc. Data Type: variable. Possible data types include: Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Terminology Standards: The appropriate terminology depends on the observation. A few examples: • If the observation is quantitative, then Observation.value.units SHALL be drawn from UCUM. • If the observation represents a validated assessment instrument (e.g. survey) item and the value is a CodeableConcept, then Observation.value.code SHALL be drawn from LOINC. • If the observation pertains to clinical genetics, then other terminologies or syntaxes may be used as appropriate, e.g. HGVS, ClinVar, etc. • If the observation represents a human phenotype, then the Observation.value MAY be drawn from the Human Phenotype Ontology • If the observation has a nominal or ordinal scale value and the Observation.value exists in SNOMED CT, then SNOMED CT MAY be used.

Vocabulary Standard: No single vocabulary covers the content necessary for representing all aspects of observation reporting (observation identifiers, coded observation values, computable units of measure, etc). Yet, the collection of core vocabularies needed are sufficiently mature. [Observation: Code] LOINC was specifically designed to fulfill the need for a freely available standard for identifying observations. More than 25 years later, it now contains a rich catalog of variables, answer lists, and the collections that contain them. [Observation: Value.units] UCUM was specifically designed to fulfill the need for a freely available standard of computable units of measure. [Observation: Value.code] • If the observation represents a validated assessment instrument (e.g. survey) item and the value is a CodeableConcept, then Observation.value.code SHALL be drawn from LOINC. • If the observation pertains to clinical genetics, then other terminologies or syntaxes may be used as appropriate, e.g. HGVS, ClinVar, etc. • If the observation represents a human phenotype, then the Observation.value MAY be drawn from the Human Phenotype Ontology • If the observation has a nominal or ordinal scale value and the Observation.value exists in SNOMED CT, then SNOMED CT MAY be used Exchange and Analytic CDM specifications: HL7 Version 2: Chapter 7 C-CDA: Results Section (entries required): 2.16.840.1.113883.10.20.22.2.3.1 FHIR: Observation OMOP: Measurement, Observation PCORnet CDM: LAB_RESULT_CM, PRO_CM, OBS_CLIN, OBS_GEN

FHIR Resource: HL7 FHIR R4 MedicationStatement, aka R5 MedicationUsage Data element: MedicationStatement.status; MedicationUsage.takenAsOrdered Values in http://hl7.org/fhir/CodeSystem/medication-statement-status: {active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken} These are defined in terms of taking; i.e., “active” in MedicationRequest means that the prescription can be filled, but in MedicationStatement, means that the patient is taking it. FHIR R5 target is to remove “status” and create “use,” with values { Taking | Taking as directed | Taking not as directed | Not Taking | Unknown (unable to obtain)} AVS/PVS system uses “I am taking this med {As written | Differently | Not taking | Unsure}”

Encounter Status: FHIR Encounter Status: http://hl7.org/fhir/ValueSet/encounter-status Classification of Encounter: V3 Value SetActEncounterCode: http://hl7.org/fhir/ValueSet/v3-ActEncounterCode Encounter Type: FHIR Encounter type: http://www.ama-assn.org/go/cpt Encounter participant type: FHIR Participant type: http://hl7.org/fhir/ValueSet/encounter-participant-type Reason for the encounter: FHIR Encounter Reason Codes: http://hl7.org/fhir/ValueSet/encounter-reason Hospital encounter discharge disposition: FHIR Discharge disposition: http://hl7.org/fhir/ValueSet/encounter-discharge-disposition Expected source(s) of payment for this encounter: FHIR Coverage Type and Self-Pay Codes: http://hl7.org/fhir/R4/valueset-coverage-type.html Encounter chief complaint: FHIR DiagnosisRole: http://hl7.org/fhir/R4/valueset-diagnosis-role.html

NPPES assigns a unique number to each registered provider DEA assigns a number to each requesting and qualified healthcare professional.

NPPES assigns a unique number to each registered provider DEA assigns a number to each requesting and qualified healthcare professional.

LOINC codes for vitals—date and timestamps collected in standard format

In CCDA 2.1, the Social History Section and Observations recommend use of SNOMED CT codes that are members of the Social History Type Set Definition 2.16.840.1.113883.3.88.12.80.60 Value Set, but there are many other potential codes and code sets to represent values associated with Social Risk Factor assessment, observations, diagnoses and interventions.

LOINC codes are available for gestational age

Encounter Status: FHIR Encounter Status: http://hl7.org/fhir/ValueSet/encounter-status Classification of Encounter: V3 Value SetActEncounterCode: http://hl7.org/fhir/ValueSet/v3-ActEncounterCode Encounter Type: FHIR Encounter type: http://www.ama-assn.org/go/cpt Encounter participant type: FHIR Participant type: http://hl7.org/fhir/ValueSet/encounter-participant-type Reason for the encounter: FHIR Encounter Reason Codes: http://hl7.org/fhir/ValueSet/encounter-reason Hospital encounter discharge disposition: FHIR Discharge disposition: http://hl7.org/fhir/ValueSet/encounter-discharge-disposition Expected source(s) of payment for this encounter: FHIR Coverage Type and Self-Pay Codes: http://hl7.org/fhir/R4/valueset-coverage-type.html Encounter chief complaint: FHIR DiagnosisRole: http://hl7.org/fhir/R4/valueset-diagnosis-role.html

Encounter type/occurrence: SNOMED CT (example, value set OID: 2.16.840.1.113883.3.666.5.307) HCPCS (example, value set OID: 2.16.840.1.113883.3.464.1003.101.12.1087) CPT (example, value set OID: 2.16.840.1.113883.3.464.1003.101.12.1001) HL7 value set, encounter type: https://www.hl7.org/fhir/us/core/ValueSet-us-core-encounter-type.html Encounter Diagnosis/ Primary Diagnosis/Discharge Diagnosis: SNOMED CT ICD-10-CM Discharge Disposition: DischargeDisposition Code System http://terminology.hl7.org/CodeSystem/discharge-disposition Encounter Location: SNOMED HSLOC

Encounter Status: FHIR Encounter Status: http://hl7.org/fhir/ValueSet/encounter-status Classification of Encounter: V3 Value SetActEncounterCode: http://hl7.org/fhir/ValueSet/v3-ActEncounterCode Encounter Type: FHIR Encounter type: http://www.ama-assn.org/go/cpt Encounter participant type: FHIR Participant type: http://hl7.org/fhir/ValueSet/encounter-participant-type Reason for the encounter: FHIR Encounter Reason Codes: http://hl7.org/fhir/ValueSet/encounter-reason Hospital encounter discharge disposition: FHIR Discharge disposition: http://hl7.org/fhir/ValueSet/encounter-discharge-disposition Expected source(s) of payment for this encounter: FHIR Coverage Type and Self-Pay Codes: http://hl7.org/fhir/R4/valueset-coverage-type.html Encounter chief complaint: FHIR DiagnosisRole: http://hl7.org/fhir/R4/valueset-diagnosis-role.html

Encounter Status: FHIR Encounter Status: http://hl7.org/fhir/ValueSet/encounter-status Classification of Encounter: V3 Value SetActEncounterCode: http://hl7.org/fhir/ValueSet/v3-ActEncounterCode Encounter Type: FHIR Encounter type: http://www.ama-assn.org/go/cpt Encounter participant type: FHIR Participant type: http://hl7.org/fhir/ValueSet/encounter-participant-type Reason for the encounter: FHIR Encounter Reason Codes: http://hl7.org/fhir/ValueSet/encounter-reason Hospital encounter discharge disposition: FHIR Discharge disposition: http://hl7.org/fhir/ValueSet/encounter-discharge-disposition Expected source(s) of payment for this encounter: FHIR Coverage Type and Self-Pay Codes: http://hl7.org/fhir/R4/valueset-coverage-type.html Encounter chief complaint: FHIR DiagnosisRole: http://hl7.org/fhir/R4/valueset-diagnosis-role.html

Encompasses non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and other specialty’s procedures.

Logical Observation Identifiers Names and Codes (LOINC®) version 2.71

• Procedure Note (LOINC® code 28570-0)