  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 Existence Observation |
| 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 Individual Pronoun Observation |
| 11.140 Instruction Observation |
| 11.141 Interpreter Needed Observation |
| 11.142 Intervention Act |
| 11.143 Latex Safety Observation |
| 11.144 Longitudinal Care Wound Observation |
| 11.145 Lot or Batch Number Observation |
| 11.146 Manufacturing Date Observation |
| 11.147 Medical Equipment Organizer |
| 11.148 Medication Activity |
| 11.149 Medication Adherence |
| 11.150 Medication Dispense |
| 11.151 Medication Free Text Sig |
| 11.152 Medication Information |
| 11.153 Medication Supply Order |
| 11.154 Mental Status Observation |
| 11.155 Mental Status Organizer |
| 11.156 Model Number Observation |
| 11.157 MRI Safety Observation |
| 11.158 Non-Medicinal Supply Activity |
| 11.159 Note Activity |
| 11.160 Number of Pressure Ulcers Observation |
| 11.161 Nutrition Assessment |
| 11.162 Nutrition Recommendation |
| 11.163 Nutritional Status Observation |
| 11.164 Outcome Observation |
| 11.165 Patient Referral Act |
| 11.166 Planned Coverage |
| 11.167 Planned Encounter |
| 11.168 Planned Immunization Activity |
| 11.169 Planned Intervention Act |
| 11.170 Planned Medication Activity |
| 11.171 Planned Procedure |
| 11.172 Planned Supply |
| 11.173 Policy Activity |
| 11.174 Postprocedure Diagnosis |
| 11.175 Precondition for Substance Administration |
| 11.176 Pregnancy Intention in Next Year |
| 11.177 Pregnancy Status Observation |
| 11.178 Preoperative Diagnosis |
| 11.179 Priority Preference |
| 11.180 Problem Concern Act |
| 11.181 Problem Observation |
| 11.182 Problem Status |
| 11.183 Procedure Activity Procedure |
| 11.184 Product Instance |
| 11.185 Prognosis Observation |
| 11.186 Progress Toward Goal Observation |
| 11.187 Reaction Observation |
| 11.188 Reason |
| 11.189 Result Observation |
| 11.190 Result Organizer |
| 11.191 Risk Concern Act |
| 11.192 Section Time Range Observation |
| 11.193 Self-Care Activities (ADL and IADL) |
| 11.194 Sensory Status |
| 11.195 Serial Number Observation |
| 11.196 Service Delivery Location |
| 11.197 Severity Observation |
| 11.198 Sex Observation |
| 11.199 Sex Parameter For Clinical Use Observation |
| 11.200 Sexual Orientation Observation |
| 11.201 Smoking Status |
| 11.202 Social History Observation |
| 11.203 Specimen Collection Procedure |
| 11.204 Specimen Condition Observation |
| 11.205 Substance Administered Act |
| 11.206 Substance or Device Allergy - Intolerance Observation |
| 11.207 Treatment Intervention Preference |
| 11.208 Tribal Affiliation Observation |
| 11.209 UDI Organizer |
| 11.210 Vital Sign Observation |
| 11.211 Vital Signs Organizer |
| 11.212 Wound Characteristic |
| 11.213 Wound Measurement Observation |
| 11.214 Author Participation |
| 11.215 Provenance - Assembler Participation |
| 11.216 Provenance - Author Participation |
| 11.217 Related Person Relationship and Name Participant |
| 11.218 US Realm Address |
| 11.219 US Realm Date and Time - Interval |
| 11.220 US Realm Date and Time - Point in Time |
| 11.221 US Realm Patient Name (PTN.US.FIELDED) |
| 11.222 US Realm Person Name (PN.US.FIELDED) |
| 11.223 Advance Directive Organizer |
| 11.224 Instruction Activity |
| 11.225 Smoking Status - Meaningful Use |
| 11.226 Tobacco Use |
| 11.227 Example of Allergy Intolerance to Food Egg |
| 11.228 Admission Diagnosis Section Example |
| 11.229 Admission Medication example |
| 11.230 Advance Directive Existance Observation Example |
| 11.231 Advance Directive Observation Example |
| 11.232 Advance Directives Section Example |
| 11.233 Age Observation Example |
| 11.234 Allergies and Intolerances Section Example |
| 11.235 Allergy Concern Act Example |
| 11.236 Allergy Intolerance Observation Medication Example |
| 11.237 Allergy Intolerance Observation Drug Class Example |
| 11.238 Allergy Intolerance Observation Non-Medication Example |
| 11.239 Anesthesia Section Example |
| 11.240 Assessment and Plan Section Example |
| 11.241 Assessment Scale Observation Example |
| 11.242 Assessment Scale Supporting Observation Example |
| 11.243 Assessment Section Example |
| 11.244 Author Participation Example |
| 11.245 Authorization Activity Example |
| 11.246 Basic Industry Observation Example |
| 11.247 Basic Occupation Observation Example |
| 11.248 Birth Sex Observation Example |
| 11.249 Birth Sex Observation Example with Null Flavor |
| 11.250 Brand Name Observation Example |
| 11.251 Care Plan Caregiver participant Example |
| 11.252 Care Plan Patient authenticator Example |
| 11.253 Care Plan performer Example |
| 11.254 Care Plan relatedDocument Example |
| 11.255 Care Plan Review Example |
| 11.256 Care Plan Complete Header Example |
| 11.257 Care Team Member Act Example |
| 11.258 Care Team Member Schedule Observation Example |
| 11.259 Care Team Organizer Example |
| 11.260 Care Teams Section Example |
| 11.261 Care Team Type Observation Example |
| 11.262 Catalog Number Observation Example |
| 11.263 Caregiver Characteristics Example |
| 11.264 Characteristics of Home Environment Example |
| 11.265 Chief Complaint and Reason for Visit Section Example |
| 11.266 Chief Complaint Section Example |
| 11.267 Comment Activity Example |
| 11.268 Company Name Observation Example |
| 11.269 Complications Section Example |
| 11.270 Continuity Of Care Document Complete Header Example |
| 11.271 Continuity Of Care Document Author Example |
| 11.272 Continuity Of Care Document Performer |
| 11.273 Continuity Of Care Document serviceEvent Example |
| 11.274 Consultation Note Complete Header Example |
| 11.275 Consultation Note Callback participant Example |
| 11.276 Consultation Note inFulfillmentOf Example |
| 11.277 Course of Care Section Example |
| 11.278 Coverage Activity Example |
| 11.279 Criticality Observation Example |
| 11.280 Cultural and Religious Observation Example |
| 11.281 Date of Diagnosis Act Example |
| 11.282 Deceased Observation Example |
| 11.283 Device Identifier Observation Example |
| 11.284 Diagnosis Reference Example |
| 11.285 Disability Status Observation Example |
| 11.286 Discharge Diagnosis Example |
| 11.287 Discharge Medication Example |
| 11.288 Discharge Medications Section Example |
| 11.289 Discharge Summary Complete Header Example |
| 11.290 Discharge Summary encompassingEncounter Example |
| 11.291 Distinct Identification Code Observation Example |
| 11.292 Drug Monitoring Act Example |
| 11.293 Drug Vehicle Example |
| 11.294 Encounter Activity Example |
| 11.295 Encounter Diagnosis Example |
| 11.296 Encounters Section Example |
| 11.297 Entry Reference Example |
| 11.298 Estimated Date of Delivery Example |
| 11.299 Expiration Date Observation Example |
| 11.300 External Document Reference Example |
| 11.301 Family History Death Observation Example |
| 11.302 Family History Observation Example |
| 11.303 Family History Organizer Example |
| 11.304 Family History Section Example |
| 11.305 Functional Status Observation Example |
| 11.306 Functional Status Organizer Example |
| 11.307 Functional Status Section Example |
| 11.308 Gender Identity Observation Example |
| 11.309 Gender Identity Observation NullFlavor Example |
| 11.310 General Status Section Example |
| 11.311 Goal Observation Example |
| 11.312 Goals Section Example |
| 11.313 Handoff Communication Participants Example |
| 11.314 Health Concern Act Example |
| 11.315 Health Concerns Section Example |
| 11.316 Health Status Evalutations and Outcomes Section Example |
| 11.317 Health Status Observation Example |
| 11.318 Highest Pressure Ulcer Stage Example |
| 11.319 History and Physical Encompassing Encounter Example |
| 11.320 History and Physical Complete Header Example |
| 11.321 History Of Present Illness Example |
| 11.322 Hospital Admission Diagnosis Example |
| 11.323 Hospital Consultations Section Example |
| 11.324 Hospital Course Section Example |
| 11.325 Hospital Discharge Diagnosis Example |
| 11.326 Hospital Discharge Instructions Section Example |
| 11.327 Hospital Discharge Physical Section Example |
| 11.328 Hospital Discharge Studies Summary Section Example |
| 11.329 Immunization Activity Example |
| 11.330 Immunization Medication Information Example |
| 11.331 Immunization Not Given Reason Example |
| 11.332 Immunizations Section Example |
| 11.333 Implantable Device Status Observation Example |
| 11.334 Indication Example |
| 11.335 Instructions Section Example |
| 11.336 Instruction Example |
| 11.337 Intervention Act Example |
| 11.338 Latex Safety Observation Example |
| 11.339 Longitudinal Care Wound Observation Example |
| 11.340 Lot or Batch Number Observation Example |
| 11.341 Manufacturing Date Observation Example |
| 11.342 Medical Equipment Organizer Example |
| 11.343 Medical Equipment Section Example |
| 11.344 Medication Activity Example |
| 11.345 Medication Adherence Example |
| 11.346 Medication Adherence NullFlavor Example |
| 11.347 Medication Dispense Example |
| 11.348 Medication Free Text Sig Example |
| 11.349 Medication Information Example |
| 11.350 Medication Supply Order Example |
| 11.351 Medications Administered Section Example |
| 11.352 Medications Section Example |
| 11.353 Mental Status Observation Example |
| 11.354 Mental Status Organizer Example |
| 11.355 Mental Status Section Example |
| 11.356 Model Number Observation Example |
| 11.357 MRI Safety Observation Example |
| 11.358 No Known Medications Example |
| 11.359 No Known Problem Section Example |
| 11.360 Non-Medicinal Supply Activity Example |
| 11.361 Note Activity Entry Relationship Example |
| 11.362 Note Activity Standalone Example |
| 11.363 nonXML Body Example with Compressed Content |
| 11.364 nonXML Body Example with Embedded Content |
| 11.365 nonXML Body Example with Referenced Content |
| 11.366 Number of Pressure Ulcers Observation Example |
| 11.367 Nutrition Assessment Example |
| 11.368 Nutrition Recommendation Example |
| 11.369 Nutrition Section Example |
| 11.370 Nutritional Status Observation Example |
| 11.371 Objective Section Example |
| 11.372 Operative Note Complete Header Example |
| 11.373 Operative Note performer Example |
| 11.374 Operative Note serviceEvent Example |
| 11.375 Operative Note Fluids Section Example |
| 11.376 Operative Note Surgical Procedure Section Example |
| 11.377 Outcome Observation Example |
| 11.378 Past Medical History Example |
| 11.379 Patient Generated Document authenticator |
| 11.380 Patient Generated Document author device Example |
| 11.381 Patient Generated Document author |
| 11.382 Patient Generated Document custodian Example |
| 11.383 Patient Generated Document dataEnterer |
| 11.384 Patient Generated Document informant Example informant |
| 11.385 Patient Generated Document informant RelEnt Example |
| 11.386 Patient Generated Document informationRecipient Example |
| 11.387 Patient Generated Document inFulfillmentOf Example |
| 11.388 Patient Generated Document legalAuthenticator Example |
| 11.389 Patient Generated Document participant Example |
| 11.390 Patient Generated Document recordTarget |
| 11.391 Patient Referral Act Example |
| 11.392 Payers Section Example |
| 11.393 Physical Exam Section Example |
| 11.394 Plan of Treatment Section Example |
| 11.395 Planned Coverage Example |
| 11.396 Planned Encounter Example |
| 11.397 Planned Immunization Activity Example |
| 11.398 Planned Intervention Activity Example |
| 11.399 Planned Medication Activity Example |
| 11.400 Planned Procedure Section Example |
| 11.401 Planned Procedure Example |
| 11.402 Planned Supply Example |
| 11.403 Policy Activity Example |
| 11.404 Postoperative Diagnosis Section Example |
| 11.405 Postprocedure Diagnosis Example |
| 11.406 Postprocedure Diagnosis Section Example |
| 11.407 Precondition for Substance Administration Example |
| 11.408 Pregnancy Intention in Next Year Example |
| 11.409 Pregnancy Status Observation Example |
| 11.410 Preoperative Diagnosis Section Example |
| 11.411 Preoperative Diagnosis Example |
| 11.412 Priority Preference Example |
| 11.413 Problem Concern Act Example |
| 11.414 Problem Observation Example |
| 11.415 Problem Observation with Post-Coordinated SNOMED Example |
| 11.416 Problem Section Example |
| 11.417 Procedure Note Complete Header Example |
| 11.418 Procedure Note performer Example |
| 11.419 Procedure Note serviceEvent Example |
| 11.420 Procedure Activity Procedure Example |
| 11.421 Procedure Description Section Example |
| 11.422 Procedure Disposition Section Example |
| 11.423 Procedure Estimated Blood Loss Section Example |
| 11.424 Procedure Findings Section Example |
| 11.425 Procedure Implants Section Example |
| 11.426 Procedure Indications Section Example |
| 11.427 Procedure Specimens Taken Section Example |
| 11.428 Procedures Section Example |
| 11.429 Product Instance Example |
| 11.430 Prognosis Coded Example |
| 11.431 Prognosis Free Text Example |
| 11.432 Progress Note Complete Header Example |
| 11.433 Progress Note encompassingEncounter Example |
| 11.434 Progress Note serviceEvent Example |
| 11.435 Progress Toward Goal Observation Example |
| 11.436 Provenance - Assembler Participation Example |
| 11.437 Provenance - Author Participation Example |
| 11.438 Reaction Observation Example |
| 11.439 Reason Example |
| 11.440 Reason For Referral |
| 11.441 Reason for Visit Section Example |
| 11.442 Referral Note Complete Header Example |
| 11.443 Referral Note Callback Contact Example |
| 11.444 Referral Note Caregiver |
| 11.445 Referral Note informationRecipient Example |
| 11.446 Related Person Relationship and Name Participant Example |
| 11.447 Result Observation Example |
| 11.448 Result Organizer Example |
| 11.449 Results Section Example |
| 11.450 Review Of Systems Section Example |
| 11.451 Risk Concern Act Example |
| 11.452 Self-Care Activities ADL and IADL Example |
| 11.453 Sensory Status Example |
| 11.454 Serial Number Observation Example |
| 11.455 Service Delivery Location Example |
| 11.456 Severity Observation Example |
| 11.457 Sex Observation Example |
| 11.458 Sex Observation Null Flavor Example |
| 11.459 Sexual Orientation Observation Example |
| 11.460 Sexual Orientation Observation Null Flavor Example |
| 11.461 Smoking Status Coded Example |
| 11.462 Smoking Status Quantity Example |
| 11.463 Smoking Status Meaningful Use Example |
| 11.464 Specimen Collection Procedure Example |
| 11.465 Specimen Condition Observation Example |
| 11.466 Social History Section Example |
| 11.467 Subjective Section Example |
| 11.468 Substance Administered Act Example |
| 11.469 Surgical Drains Section Example |
| 11.470 Tobacco Use Example |
| 11.471 Transfer Summary Complete Header Example |
| 11.472 Transfer Summary Callback Contact Example |
| 11.473 Transfer Summary participant (Support) Example |
| 11.474 Tribal Affiliation Observation Example |
| 11.475 UDI Organizer Example |
| 11.476 US Realm Address Example |
| 11.477 US Realm Date and Time Example |
| 11.478 US Realm Date and Time Interval Example |
| 11.479 US Realm Header Example |
| 11.480 US Realm Person Name Example |
| 11.481 Vital Sign Observation Example |
| 11.482 Average Blood Pressure Organizer Example |
| 11.483 Vital Signs Organizer Example |
| 11.484 Vital Signs Section Example |
| 11.485 Wound Characteristic Example |
| 11.486 Wound Measurement Observation Example |
 11.487 NUBC UB-04 FL17 Patient Status |
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