  0 Table of Contents |
  1 IG Home Page |
| 2 USCDI |
| 3 General Guidance |
| 4 Screening And Assessments |
| 5 Supporting Guidance |
| 6 Validation |
| 7 How To Read |
| 8 Downloads |
| 9 Terminology |
| 10 Change Log |
 11 Artifacts Summary |
 11.1 Care Plan |
| 11.2 Consultation Note |
| 11.3 Continuity of Care Document (CCD) |
| 11.4 Discharge Summary |
| 11.5 History and Physical |
| 11.6 Operative Note |
| 11.7 Procedure Note |
| 11.8 Progress Note |
| 11.9 Referral Note |
| 11.10 Transfer Summary |
| 11.11 Unstructured Document |
| 11.12 US Realm Header |
| 11.13 US Realm Header for Patient Generated Document |
| 11.14 Activities Section |
| 11.15 Admission Diagnosis Section |
| 11.16 Admission Medications Section (entries optional) |
| 11.17 Advance Directives Section |
| 11.18 Allergies and Intolerances Section |
| 11.19 Anesthesia Section |
| 11.20 Assessment and Plan Section |
| 11.21 Assessment Section |
| 11.22 Care Teams Section |
| 11.23 Chief Complaint and Reason for Visit Section |
| 11.24 Chief Complaint Section |
| 11.25 Complications Section |
| 11.26 Course of Care Section |
| 11.27 Discharge Diagnosis Section |
| 11.28 Discharge Medications Section |
| 11.29 Encounters Section |
| 11.30 Family History Section |
| 11.31 Functional Status Section |
| 11.32 General Status Section |
| 11.33 Goals Section |
| 11.34 Health Concerns Section |
| 11.35 Health Status Evaluations and Outcomes Section |
| 11.36 History of Present Illness Section |
| 11.37 Hospital Consultations Section |
| 11.38 Hospital Course Section |
| 11.39 Hospital Discharge Instructions Section |
| 11.40 Hospital Discharge Physical Section |
| 11.41 Hospital Discharge Studies Summary Section |
| 11.42 Immunizations Section |
| 11.43 Instructions Section |
| 11.44 Medical (General) History Section |
| 11.45 Medical Equipment Section |
| 11.46 Medications Administered Section |
| 11.47 Medications Section |
| 11.48 Mental Status Section |
| 11.49 Notes Section |
| 11.50 Nutrition Section |
| 11.51 Objective Section |
| 11.52 Operative Note Fluids Section |
| 11.53 Operative Note Surgical Procedure Section |
| 11.54 Past Medical History |
| 11.55 Payers Section |
| 11.56 Physical Exam Section |
| 11.57 Plan of Treatment Section |
| 11.58 Planned Procedure Section |
| 11.59 Postoperative Diagnosis Section |
| 11.60 Postprocedure Diagnosis Section |
| 11.61 Preoperative Diagnosis Section |
| 11.62 Problem Section |
| 11.63 Procedure Description Section |
| 11.64 Procedure Disposition Section |
| 11.65 Procedure Estimated Blood Loss Section |
| 11.66 Procedure Findings Section |
| 11.67 Procedure Implants Section |
| 11.68 Procedure Indications Section |
| 11.69 Procedure Specimens Taken Section |
| 11.70 Procedures Section |
| 11.71 Reason for Referral Section |
| 11.72 Reason for Visit Section |
| 11.73 Results Section |
| 11.74 Review of Systems Section |
| 11.75 Social History Section |
| 11.76 Subjective Section |
| 11.77 Surgical Drains Section |
| 11.78 Vital Signs Section |
| 11.79 Admission Medication |
| 11.80 Advance Directive Observation |
| 11.81 Advance Directive Organizer |
| 11.82 Age Observation |
| 11.83 Allergy - Intolerance Observation |
| 11.84 Allergy Concern Act |
| 11.85 Allergy Status Observation |
| 11.86 Assessment Scale Observation |
| 11.87 Assessment Scale Supporting Observation |
| 11.88 Authorization Activity |
| 11.89 Average Blood Pressure Organizer |
| 11.90 Basic Industry Observation |
| 11.91 Basic Occupation Observation |
| 11.92 Birth Sex Observation |
| 11.93 Brand Name Observation |
| 11.94 Care Experience Preference |
| 11.95 Care Team Member Act |
| 11.96 Care Team Member Schedule Observation |
| 11.97 Care Team Organizer |
| 11.98 Care Team Type Observation |
| 11.99 Caregiver Characteristics |
| 11.100 Catalog Number Observation |
| 11.101 Characteristics of Home Environment |
| 11.102 Comment Activity |
| 11.103 Company Name Observation |
| 11.104 Coverage Activity |
| 11.105 Criticality Observation |
| 11.106 Cultural and Religious Observation |
| 11.107 Date of Diagnosis Act |
| 11.108 Deceased Observation |
| 11.109 Device Identifier Observation |
| 11.110 Disability Status Observation |
| 11.111 Discharge Medication |
| 11.112 Distinct Identification Code Observation |
| 11.113 Drug Monitoring Act |
| 11.114 Drug Vehicle |
| 11.115 Encounter Activity |
| 11.116 Encounter Diagnosis |
| 11.117 Entry Reference |
| 11.118 Estimated Date of Delivery |
| 11.119 Expiration Date Observation |
| 11.120 External Document Reference |
| 11.121 Family History Death Observation |
| 11.122 Family History Observation |
| 11.123 Family History Organizer |
| 11.124 Functional Status Observation |
| 11.125 Functional Status Organizer |
| 11.126 Gender Identity Observation |
| 11.127 Goal Observation |
| 11.128 Handoff Communication Participants |
| 11.129 Health Concern Act |
| 11.130 Health Status Observation |
| 11.131 Highest Pressure Ulcer Stage |
| 11.132 Hospital Admission Diagnosis |
| 11.133 Hospital Discharge Diagnosis |
| 11.134 Immunization Activity |
| 11.135 Immunization Medication Information |
| 11.136 Immunization Not Given Reason |
| 11.137 Implantable Device Status Observation |
| 11.138 Indication |
| 11.139 Instruction |
| 11.140 Intervention Act |
| 11.141 Latex Safety Observation |
| 11.142 Longitudinal Care Wound Observation |
| 11.143 Lot or Batch Number Observation |
| 11.144 Manufacturing Date Observation |
| 11.145 Medical Equipment Organizer |
| 11.146 Medication Activity |
| 11.147 Medication Adherence |
| 11.148 Medication Dispense |
| 11.149 Medication Free Text Sig |
| 11.150 Medication Information |
| 11.151 Medication Supply Order |
| 11.152 Mental Status Observation |
| 11.153 Mental Status Organizer |
| 11.154 Model Number Observation |
| 11.155 MRI Safety Observation |
| 11.156 Non-Medicinal Supply Activity |
| 11.157 Note Activity |
| 11.158 Number of Pressure Ulcers Observation |
| 11.159 Nutrition Assessment |
| 11.160 Nutrition Recommendation |
| 11.161 Nutritional Status Observation |
| 11.162 Outcome Observation |
| 11.163 Patient Referral Act |
| 11.164 Planned Coverage |
| 11.165 Planned Encounter |
| 11.166 Planned Immunization Activity |
| 11.167 Planned Intervention Act |
| 11.168 Planned Medication Activity |
| 11.169 Planned Procedure |
| 11.170 Planned Supply |
| 11.171 Policy Activity |
| 11.172 Postprocedure Diagnosis |
| 11.173 Precondition for Substance Administration |
| 11.174 Pregnancy Intention in Next Year |
| 11.175 Pregnancy Observation |
| 11.176 Preoperative Diagnosis |
| 11.177 Priority Preference |
| 11.178 Problem Concern Act |
| 11.179 Problem Observation |
| 11.180 Problem Status |
| 11.181 Procedure Activity Procedure |
| 11.182 Product Instance |
| 11.183 Prognosis Observation |
| 11.184 Progress Toward Goal Observation |
| 11.185 Reaction Observation |
| 11.186 Reason |
| 11.187 Result Observation |
| 11.188 Result Organizer |
| 11.189 Risk Concern Act |
| 11.190 Section Time Range Observation |
| 11.191 Self-Care Activities (ADL and IADL) |
| 11.192 Sensory Status |
| 11.193 Serial Number Observation |
| 11.194 Service Delivery Location |
| 11.195 Severity Observation |
| 11.196 Sex Observation |
| 11.197 Sexual Orientation Observation |
| 11.198 Smoking Status |
| 11.199 Social History Observation |
| 11.200 Specimen Collection Procedure |
| 11.201 Specimen Condition Observation |
| 11.202 Substance Administered Act |
| 11.203 Substance or Device Allergy - Intolerance Observation |
| 11.204 Treatment Intervention Preference |
| 11.205 Tribal Affiliation Observation |
| 11.206 UDI Organizer |
| 11.207 Vital Sign Observation |
| 11.208 Vital Signs Organizer |
| 11.209 Wound Characteristic |
| 11.210 Wound Measurement Observation |
| 11.211 Author Participation |
| 11.212 Provenance - Assembler Participation |
| 11.213 Provenance - Author Participation |
| 11.214 Related Person Relationship and Name Participant |
| 11.215 US Realm Address |
| 11.216 US Realm Date and Time - Interval |
| 11.217 US Realm Date and Time - Point in Time |
| 11.218 US Realm Patient Name (PTN.US.FIELDED) |
| 11.219 US Realm Person Name (PN.US.FIELDED) |
| 11.220 Smoking Status - Meaningful Use |
| 11.221 Tobacco Use |
| 11.222 Example of Allergy Intolerance to Food Egg |
| 11.223 Admission Diagnosis Section Example |
| 11.224 Admission Medication example |
| 11.225 Advance Directive Observation Example |
| 11.226 Advance Directive Organizer Example |
| 11.227 Advance Directives Section Example |
| 11.228 Age Observation Example |
| 11.229 Allergies and Intolerances Section Example |
| 11.230 Allergy Concern Act Example |
| 11.231 Allergy Intolerance Observation Medication Example |
| 11.232 Allergy Intolerance Observation Drug Class Example |
| 11.233 Allergy Intolerance Observation Non-Medication Example |
| 11.234 Anesthesia Section Example |
| 11.235 Assessment and Plan Section Example |
| 11.236 Assessment Scale Observation Example |
| 11.237 Assessment Scale Supporting Observation Example |
| 11.238 Assessment Section Example |
| 11.239 Author Participation Example |
| 11.240 Authorization Activity Example |
| 11.241 Basic Industry Observation Example |
| 11.242 Basic Occupation Observation Example |
| 11.243 Birth Sex Observation Example |
| 11.244 Brand Name Observation Example |
| 11.245 Care Plan Caregiver participant Example |
| 11.246 Care Plan Patient authenticator Example |
| 11.247 Care Plan performer Example |
| 11.248 Care Plan relatedDocument Example |
| 11.249 Care Plan Review Example |
| 11.250 Care Plan Complete Header Example |
| 11.251 Care Team Member Act Example |
| 11.252 Care Team Member Schedule Observation Example |
| 11.253 Care Team Organizer Example |
| 11.254 Care Teams Section Example |
| 11.255 Care Team Type Observation Example |
| 11.256 Catalog Number Observation Example |
| 11.257 Caregiver Characteristics Example |
| 11.258 Characteristics of Home Environment Example |
| 11.259 Chief Complaint and Reason for Visit Section Example |
| 11.260 Chief Complaint Section Example |
| 11.261 Comment Activity Example |
| 11.262 Company Name Observation Example |
| 11.263 Complications Section Example |
| 11.264 Continuity Of Care Document Complete Header Example |
| 11.265 Continuity Of Care Document Author Example |
| 11.266 Continuity Of Care Document Performer |
| 11.267 Continuity Of Care Document serviceEvent Example |
| 11.268 Consultation Note Complete Header Example |
| 11.269 Consultation Note Callback participant Example |
| 11.270 Consultation Note inFulfillmentOf Example |
| 11.271 Course of Care Section Example |
| 11.272 Coverage Activity Example |
| 11.273 Criticality Observation Example |
| 11.274 Cultural and Religious Observation Example |
| 11.275 Date of Diagnosis Act Example |
| 11.276 Deceased Observation Example |
| 11.277 Device Identifier Observation Example |
| 11.278 Diagnosis Reference Example |
| 11.279 Disability Status Observation Example |
| 11.280 Discharge Diagnosis Example |
| 11.281 Discharge Medication Example |
| 11.282 Discharge Medications Section Example |
| 11.283 Discharge Summary Complete Header Example |
| 11.284 Discharge Summary encompassingEncounter Example |
| 11.285 Distinct Identification Code Observation Example |
| 11.286 Drug Monitoring Act Example |
| 11.287 Drug Vehicle Example |
| 11.288 Encounter Activity Example |
| 11.289 Encounter Diagnosis Example |
| 11.290 Encounters Section Example |
| 11.291 Entry Reference Example |
| 11.292 Estimated Date of Delivery Example |
| 11.293 Expiration Date Observation Example |
| 11.294 External Document Reference Example |
| 11.295 Family History Death Observation Example |
| 11.296 Family History Observation Example |
| 11.297 Family History Organizer Example |
| 11.298 Family History Section Example |
| 11.299 Functional Status Observation Example |
| 11.300 Functional Status Organizer Example |
| 11.301 Functional Status Section Example |
| 11.302 Gender Identity Observation Example |
| 11.303 General Status Section Example |
| 11.304 Goal Observation Example |
| 11.305 Goals Section Example |
| 11.306 Handoff Communication Participants Example |
| 11.307 Health Concern Act Example |
| 11.308 Health Concerns Section Example |
| 11.309 Health Status Evalutations and Outcomes Section Example |
| 11.310 Health Status Observation Example |
| 11.311 Highest Pressure Ulcer Stage Example |
| 11.312 History and Physical Encompassing Encounter Example |
| 11.313 History and Physical Complete Header Example |
| 11.314 History Of Present Illness Example |
| 11.315 Hospital Admission Diagnosis Example |
| 11.316 Hospital Consultations Section Example |
| 11.317 Hospital Course Section Example |
| 11.318 Hospital Discharge Diagnosis Example |
| 11.319 Hospital Discharge Instructions Section Example |
| 11.320 Hospital Discharge Physical Section Example |
| 11.321 Hospital Discharge Studies Summary Section Example |
| 11.322 Immunization Activity Example |
| 11.323 Immunization Medication Information Example |
| 11.324 Immunization Not Given Reason Example |
| 11.325 Immunizations Section Example |
| 11.326 Implantable Device Status Observation Example |
| 11.327 Indication Example |
| 11.328 Instructions Section Example |
| 11.329 Instruction Example |
| 11.330 Intervention Act Example |
| 11.331 Latex Safety Observation Example |
| 11.332 Longitudinal Care Wound Observation Example |
| 11.333 Lot or Batch Number Observation Example |
| 11.334 Manufacturing Date Observation Example |
| 11.335 Medical Equipment Organizer Example |
| 11.336 Medical Equipment Section Example |
| 11.337 Medication Activity Example |
| 11.338 Medication Adherence Example |
| 11.339 Medication Dispense Example |
| 11.340 Medication Free Text Sig Example |
| 11.341 Medication Information Example |
| 11.342 Medication Supply Order Example |
| 11.343 Medications Administered Section Example |
| 11.344 Medications Section Example |
| 11.345 Mental Status Observation Example |
| 11.346 Mental Status Organizer Example |
| 11.347 Mental Status Section Example |
| 11.348 Model Number Observation Example |
| 11.349 MRI Safety Observation Example |
| 11.350 No Known Medications Example |
| 11.351 No Known Problem Section Example |
| 11.352 Non-Medicinal Supply Activity Example |
| 11.353 Note Activity Entry Relationship Example |
| 11.354 Note Activity Standalone Example |
| 11.355 nonXML Body Example with Compressed Content |
| 11.356 nonXML Body Example with Embedded Content |
| 11.357 nonXML Body Example with Referenced Content |
| 11.358 Number of Pressure Ulcers Observation Example |
| 11.359 Nutrition Assessment Example |
| 11.360 Nutrition Recommendation Example |
| 11.361 Nutrition Section Example |
| 11.362 Nutritional Status Observation Example |
| 11.363 Objective Section Example |
| 11.364 Operative Note Complete Header Example |
| 11.365 Operative Note performer Example |
| 11.366 Operative Note serviceEvent Example |
| 11.367 Operative Note Fluids Section Example |
| 11.368 Operative Note Surgical Procedure Section Example |
| 11.369 Outcome Observation Example |
| 11.370 Past Medical History Example |
| 11.371 Patient Generated Document authenticator |
| 11.372 Patient Generated Document author device Example |
| 11.373 Patient Generated Document author |
| 11.374 Patient Generated Document custodian Example |
| 11.375 Patient Generated Document dataEnterer |
| 11.376 Patient Generated Document informant Example informant |
| 11.377 Patient Generated Document informant RelEnt Example |
| 11.378 Patient Generated Document informationRecipient Example |
| 11.379 Patient Generated Document inFulfillmentOf Example |
| 11.380 Patient Generated Document legalAuthenticator Example |
| 11.381 Patient Generated Document participant Example |
| 11.382 Patient Generated Document recordTarget |
| 11.383 Patient Referral Act Example |
| 11.384 Payers Section Example |
| 11.385 Physical Exam Section Example |
| 11.386 Plan of Treatment Section Example |
| 11.387 Planned Coverage Example |
| 11.388 Planned Encounter Example |
| 11.389 Planned Immunization Activity Example |
| 11.390 Planned Intervention Activity Example |
| 11.391 Planned Medication Activity Example |
| 11.392 Planned Procedure Section Example |
| 11.393 Planned Procedure Example |
| 11.394 Planned Supply Example |
| 11.395 Policy Activity Example |
| 11.396 Postoperative Diagnosis Section Example |
| 11.397 Postprocedure Diagnosis Example |
| 11.398 Postprocedure Diagnosis Section Example |
| 11.399 Precondition for Substance Administration Example |
| 11.400 Pregnancy Intention in Next Year Example |
| 11.401 Pregnancy Observation Example |
| 11.402 Preoperative Diagnosis Section Example |
| 11.403 Preoperative Diagnosis Example |
| 11.404 Priority Preference Example |
| 11.405 Problem Concern Act Example |
| 11.406 Problem Observation Example |
| 11.407 Problem Observation with Post-Coordinated SNOMED Example |
| 11.408 Problem Section Example |
| 11.409 Procedure Note Complete Header Example |
| 11.410 Procedure Note performer Example |
| 11.411 Procedure Note serviceEvent Example |
| 11.412 Procedure Activity Procedure Example |
| 11.413 Procedure Description Section Example |
| 11.414 Procedure Disposition Section Example |
| 11.415 Procedure Estimated Blood Loss Section Example |
| 11.416 Procedure Findings Section Example |
| 11.417 Procedure Implants Section Example |
| 11.418 Procedure Indications Section Example |
| 11.419 Procedure Specimens Taken Section Example |
| 11.420 Procedures Section Example |
| 11.421 Product Instance Example |
| 11.422 Prognosis Coded Example |
| 11.423 Prognosis Free Text Example |
| 11.424 Progress Note Complete Header Example |
| 11.425 Progress Note encompassingEncounter Example |
| 11.426 Progress Note serviceEvent Example |
| 11.427 Progress Toward Goal Observation Example |
| 11.428 Provenance - Assembler Participation Example |
| 11.429 Provenance - Author Participation Example |
| 11.430 Reaction Observation Example |
| 11.431 Reason Example |
| 11.432 Reason For Referral |
| 11.433 Reason for Visit Section Example |
| 11.434 Referral Note Complete Header Example |
| 11.435 Referral Note Callback Contact Example |
| 11.436 Referral Note Caregiver |
| 11.437 Referral Note informationRecipient Example |
| 11.438 Related Person Relationship and Name Participant Example |
| 11.439 Result Observation Example |
| 11.440 Result Organizer Example |
| 11.441 Results Section Example |
| 11.442 Review Of Systems Section Example |
| 11.443 Risk Concern Act Example |
| 11.444 Self-Care Activities ADL and IADL Example |
| 11.445 Sensory Status Example |
| 11.446 Serial Number Observation Example |
| 11.447 Service Delivery Location Example |
| 11.448 Severity Observation Example |
| 11.449 Sexual Orientation Observation Example |
| 11.450 Smoking Status Coded Example |
| 11.451 Smoking Status Quantity Example |
| 11.452 Smoking Status Meaningful Use Example |
| 11.453 Specimen Collection Procedure Example |
| 11.454 Specimen Condition Observation Example |
| 11.455 Social History Section Example |
| 11.456 Subjective Section Example |
| 11.457 Substance Administered Act Example |
| 11.458 Surgical Drains Section Example |
| 11.459 Tobacco Use Example |
| 11.460 Transfer Summary Complete Header Example |
| 11.461 Transfer Summary Callback Contact Example |
| 11.462 Transfer Summary participant (Support) Example |
| 11.463 Tribal Affiliation Observation Example |
| 11.464 UDI Organizer Example |
| 11.465 US Realm Address Example |
| 11.466 US Realm Date and Time Example |
| 11.467 US Realm Date and Time Interval Example |
| 11.468 US Realm Header Example |
| 11.469 US Realm Person Name Example |
| 11.470 Vital Sign Observation Example |
| 11.471 Average Blood Pressure Organizer Example |
| 11.472 Vital Signs Organizer Example |
| 11.473 Vital Signs Section Example |
| 11.474 Wound Characteristic Example |
| 11.475 Wound Measurement Observation Example |
 11.476 NUBC UB-04 FL17 Patient Status |
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