HL7 CDA® R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Nutrition, Release 1 - US Realm

DESCRIPTION

This specification has been retired. Please see: C-CDA (HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes) for the current C-CDA templates.

 

This document describes constraints on the Clinical Document Architecture Release 2 (CDA R2) header and body elements that are derived from requirements set forth by the Academy of Nutrition and Dietetics Nutrition Care Process and Health Level Seven (HL7) stakeholder workgroups. The NCP is used by Registered Dietitians Nutritionists (RDN) and other nutrition and dietetics professionals as a systematic approach to providing high quality nutrition care. Templates in this guide are specific to the four steps of the Nutrition Care Process: Nutrition Assessment and Reassessment, Nutrition Diagnosis, Nutrition Intervention, and Nutrition Monitoring and Evaluation. These templates are intended to promote nutrition interoperability across care settings and will create information suitable for reuse in transitions of care, quality measurement, public health reporting, research, and reimbursement.

 

ALTERNATIVE NAMES

HL7 CDA® R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Nutrition, Release 1 - US Realm may also go by the following names or acronyms:

TARGETS

• Quality Reporting Agencies
• Standards Development Organizations (SDOs)
• EHR, PHR Vendors
• Health Care IT Vendors
• Lab Vendors
• HIS Vendors
• Healthcare Institutions (hospitals, long term care, home care, mental health)
• Registered Dietitians/Nutritionists

 

BENEFITS

• Creates a standardized approach to document the Nutrition Care Process, including the steps:
  • Nutrition Assessment
  • Nutrition Diagnosis
  • Nutrition Interventions
  • Nutrition Monitoring
• Promotes nutrition interoperability across care settings and creates information suitable for reuse in transitions of care, quality measurement, public health reporting, research, and reimbursement.

 

IMPLEMENTATIONS/CASE STUDIES

• Patients First (Peter Jordan, Solutions Architect) peter.jordan@patientsfirst.org.nz)
• Janie Appleseed (Lisa R. Nelson) Lisarnelson@cox.net
• UPMC Presbyterian – Shadyside (Susan Evanchak, Nutrition Data Manager, Pittsburg, PA 15232) evanchakse@upmc.edu

DEVELOPMENT BACKGROUND

This document is to be used in conjunction with the C-CDA R2.1 Implementation Guide. The C-CDA R2.1 Implementation Guide contains templates which are not a part of this supplemental guide but are critical in successfully implementing the Nutrition Care Plan CDA document. This includes all implied templates, which fall under the C-CDA Care Plan (V2). Within the C-CDA Care Plan, there is a Goals section which is critical in the nutrition care process but is not a part of this supplemental template implementation guide.

The Nutrition Care Plan document is based off the coordinated efforts to include nutrition content in health IT standards, regulations, and policy which began in 2009, when the Academy embarked on aligning nutrition care as part of health care delivery using EHRs and other health IT. The foundation for nutrition care was based upon the Nutrition Care Process Model, and established terminology which provides appropriate definitions for each term used in each specific stage.

 

RELATED DOCUMENTS

HL7 CDA® R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Nutrition, Release 1 - US Realm

STU DOCUMENTS

HL7 CDA® R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Nutrition, Release 1 - US Realm

Expiration May 2024

(Download)

TOPICS

• Care Provision
• Nutrition
• Patient Care

BALLOT TYPE

• STU

STATUS DATE

2018-07-23

RESPONSIBLE WORK GROUP

STAKEHOLDERS

• EHR, PHR Vendors
• Health Care IT Vendors
• Healthcare Institutions
• HIS Vendors
• Quality Reporting Agencies
• Standards Development Organizations (SDOs)

FAMILY

• CDA

CURRENT STATE

• Retired

REALM

• US Realm