CDA Module Mappings for ImportEAP
A step-by-step CDA Import tutorial can be found here.
All of the mappings for CDA Import are based on Consolidated Clinical Document Architecture (C-CDA) 2.1.
Valid Document TypesEAP
CDA Exchange+ supports import of supported sections from all following CDA document types that conform to the C-CDA 2.1 IG:
- "Continuity of Care Document" (template id 2.16.840.1.113883.10.20.22.1.2)
- "Discharge Summary" (template id 2.16.840.1.113883.10.20.22.1.8)
- "History and Physical" (template id 2.16.840.1.113883.10.20.22.1.3)
- "Progress Note" (template id 2.16.840.1.113883.10.20.22.1.9)
- "Transfer Summary" (template id 2.16.840.1.113883.10.20.22.1.13)
- "Consultation Note" (template id 2.16.840.1.113883.10.20.22.1.4)
- "Referral Note" (template id 2.16.840.1.113883.10.20.22.1.14)
- "Care Plan" (template id 2.16.840.1.113883.10.20.22.1.15)
- "Operative Note" (template id 2.16.840.1.113883.10.20.22.1.7)
- "Procedure Note" (template id 2.16.840.1.113883.10.20.22.1.6)
Resources derived from the headerEAP
- recordTarget:
Patient
- author:
Practitioner, Device, PractitionerRole, Organization
- custodian:
Organization
- legalAuthenticator:
Practitioner
- authenticator:
Practitioner
- documentationOf:
Composition.event
- participant:
RelatedPerson
There is currently no support for the following optional header tags:
- dataEnterer
- informant
- informationRecipient
- inFulfillmentOf
- authorization
- componentOf
Valid Section Types and SourcesEAP
Admission Diagnosis SectionEAP
Supported CDA Entries:
- Hospital Admission Diagnosis
- The section is expected to contain a single Hospital Admission Diagnosis entry, which contains one or more nested Problem Observation entries.
- Each Problem Observation entry will be converted to a
Condition resource.
Admission Medications SectionEAP
Supported CDA Entries:
- Admission Medication
- Each Medication Activity entry within a Admission Medication will be converted to a
MedicationStatement resource.
Allergy and Intolerances SectionEAP
Supported CDA Entries:
- Allergy Concern Act
- Each Allergy Concern Act entry will be converted to an
AllergyIntolerance resource.
Assessment and Plan SectionEAP
Supported CDA Entries:
- Planned Act
- Each Act Observation entry will be converted to a
ServiceRequest resource.
Care Team SectionEAP
Supported CDA Entries:
The Care Team section as a whole will be converted to a CareTeam resource.
- Care Team Performer Act
- Each Care Team Performer Act entry will be converted to a
Practitioner resource and added to the CareTeam as a participant.
Discharge Diagnosis SectionEAP
Supported CDA Entries:
- Hospital Discharge Diagnosis
- The section is expected to contain a single Hospital Discharge Diagnosis entry, which contains one or more nested Problem Observation entries.
- Each Problem Observation entry will be converted to a
Condition resource.
Discharge Medication SectionEAP
Supported CDA Entries:
- Discharge Medication
- Each Medication Activity entry within a Discharge Medication will be converted to a
MedicationStatement resource.
Encounters SectionEAP
Supported CDA Entries:
- Encounter Activity
- Each Encounter Activity entry will be converted to an
Encounter resource.
Family History SectionEAP
Supported CDA Entries:
- Family History Observation
- Each Family History Observation entry will be converted to a
FamilyMemberHistory resource.
Functional Status SectionEAP
Supported CDA Entries:
- Functional Status Observation
- Each Functional Status Observation entry will be converted to an
Observation resource.
- Self-Care Activities (ADL and IADL)
- Each Self-Care Activities (ADL and IADL) entry will be converted to an
Observation resource.
- Disability Status Observation
- Each Disability Status Observation entry will be converted to an
Observation resource.
Goals Section EAP
Supported CDA Entries:
- Goal Observation
- Each Goal Observation entry will be converted to a
Goal resource.
Immunizations SectionEAP
Supported CDA Entries:
- Immunization Activity
- Each Immunization Activity entry will be converted to an
Immunization resource.
Medical Equipment SectionEAP
Supported CDA Entries:
- Procedure Activity Procedure
- Each Procedure Activity Procedure entry will be converted to a
Procedure resource.
Medications SectionEAP
Supported CDA Entries:
- Medication Activity
- Each Medication Activity entry with
moodCode="EVN" will be converted to a MedicationStatement resource. Each Medication Activity entry with moodCode="INT" will be converted to a MedicationRequest resource. Entries with other values of the moodCode attribute are not supported.
Mental Status SectionEAP
Supported CDA Entries:
- Mental Status Organizer
- Each of the Mental Status Observation entries contained in the Mental Status Organizer will be converted to an
Observation resource.
- Assessment Scale Observation
- Each Assessment Scale Observation entry will be converted to an
Observation resource.
- Assessment Scale Supporting Observation
- Each Assessment Scale Supporting Observation contained in the Assessment Scale Observation will be converted into an
Observation resource and referenced in the Assessment Scale Observation Observation.hasMember property.
Past Medical History SectionEAP
Supported CDA Entries:
- Past Medical History
- The section is expected to contain one or more nested Problem Observation entries.
- Each Problem Observation entry will be converted to a
Condition resource.
Payer SectionEAP
Supported CDA Entries:
- Coverage Activity
- Each Policy Activity contained within a Coverage Activity entry will be converted to a
Coverage resource.
Course of Care SectionEAP
- A Course of Care narrative-only section will be created within the
Composition resource
General Status SectionEAP
- A General Status narrative-only section will be created within the
Composition resource
Health Status Evaluations and Outcomes SectionEAP
- A Health Status Evaluations/Outcomes narrative-only section will be created within the
Composition resource
History of Present Illness SectionEAP
- A History of Present Illness narrative-only section will be created within the
Composition resource
Interventions SectionEAP
- An Interventions narrative-only section will be created within the
Composition resource
Objective SectionEAP
- An Objective narrative-only section will be created within the
Composition resource
Physical Exam SectionEAP
- A Physical Exam narrative-only section will be created within the
Composition resource
Review of Systems SectionEAP
- A Review of Systems narrative-only section will be created within the
Composition resource
Subjective SectionEAP
- A Subjective narrative-only section will be created within the
Composition resource
Plan of Treatment SectionEAP
Supported CDA Entries:
- Planned Observation
- Each Planned Observation entry will be converted to a
ServiceRequest resource.
- Planned Encounter
- Each Encounter Observation entry will be converted to a
Encounter resource.
- Planned Act
- Each Act Observation entry will be converted to a
ServiceRequest resource.
- Planned Procedure
- Each Planned Procedure entry will be converted to a
ServiceRequest resource.
- Planned Medication
- Each Planned Medication entry will be converted to a
MedicationRequest resource.
- Planned Immunization
- Each Planned Immunization entry will be converted to a
MedicationRequest resource.
Problem SectionEAP
Supported CDA Entries:
- Problem Concern Act
- Each Problem Concern Act entry will be converted to a
Condition resource.
- Health Status Observation
- The Health Status Observation entry is not supported.
Procedures SectionEAP
Supported CDA Entries:
- Procedure Activity Procedure
- Each Procedure Activity Procedure entry will be converted to a
Procedure resource.
Reason for Referral SectionEAP
Supported CDA Entries:
- Patient Referral Act
- Each Patient Referral Act entry will be converted to a
ServiceRequest resource.
Results SectionEAP
Supported CDA Entries:
- Result Organizer
- Each Result Organizer entry will be converted to a
DiagnosticReport resource.
- Any Result Observation entry within the Result Organizer will be converted to an
Observation resource and added to the result list of the DiagnosticReport.
Social History SectionEAP
Supported CDA Entries:
- Pregnancy Observation
- Caregiver Characteristics
- Characteristics of Home Environment
- Cultural and Religious Observation
- Smoking Status - Meaningful Use
- Tobacco Use
- Birth Sex Observation
- Gender Identity Observation
- Sexual Orientation Observation
- Pregnancy Intention in Next Year
- Basic Occupation Observation
- Basic Industry Observation
- Assessment Scale Observation
- Social History Observation
- Each entry in the section will be converted to an
Observation resource.
Vital Signs SectionEAP
Supported CDA Entries:
- Vital Signs Organizer
- Each Vital Sign Organizer entry in the section will be converted to a nested section within the
Composition.section.
- Each Vital Sign Observation entry within a Vital Signs Organizer will be converted to an
Observation resource within the corresponding nested section.
Note SectionEAP
Supported CDA Entries:
- Note Act
- Each Note Act will be converted to a
DocumentReference resource
- Currently only supports note sections with the LOINC code
34109-9, but individual Note Acts can have more specific codes.
Chief Complaint SectionEAP
- A Chief Complaint narrative-only section will be created within the
Composition resource
Reason for Visit SectionEAP
- A Reason for Visit narrative-only section will be created within the
Composition resource
Chief Complaint and Reason for Visit SectionEAP
- A Chief Complaint and Reason for Visit narrative-only section will be created within the
Composition resource
Hospital Consultations SectionEAP
- A Hospital Consultations narrative-only section will be created within the
Composition resource
Hospital Course SectionEAP
- A Hospital Course narrative-only section will be created within the
Composition resource
Hospital Discharge Instructions SectionEAP
- A Hospital Discharge Instructions narrative-only section will be created within the
Composition resource
Hospital Discharge Physical SectionEAP
- A Hospital Discharge Physical narrative-only section will be created within the
Composition resource
Hospital Discharge Studies Summary SectionEAP
- A Hospital Discharge Studies Summary narrative-only section will be created within the
Composition resource
Instructions SectionEAP
- An Instructions narrative-only section will be created within the
Composition resource
Nutrition SectionEAP
- A Nutrition narrative-only section will be created within the
Composition resource
Assessment SectionEAP
- An Assessment narrative-only section will be created within the
Composition resource
Advance Directives SectionEAP
- An Advance Directives narrative-only section will be created within the
Composition resource
Health Concerns SectionEAP
Supported CDA Entries:
- Health Concern Act
- Each Health Concern Act will contain a Problem Observation entryRelationship
- Each Problem Observation entryRelationship will be converted to a
Condition resource