EHI Export
Centriq generates an R2.1 Consolidated-CDA document that contains the following. Select the section name to view the standard details.
| Section | Description | Centriq Data Source(s) |
|---|---|---|
| US Realm General Header | The header contains demographic data collected at the time of admissions. Name, address, and communication details are some of the information provided in this section. | Patient Registration |
| Allergies and Intolerances | Medication and Environmental allergies, including reactions, for a patient. Allergies are coded to RXNORM or SNOMED-CT depending on how the medication is managed by the facility. | Medical History > Allergies |
| Assessment | The clinician's conclusions and working assumptions that will guide treatment of the patient. | Patient Chart > Notes > Assessment |
| Plan of Treatment | Listing of future orders, diagnostic tests, and appointments for a patient. | CPOE > Future Orders, Scheduler, ePrescribing, Notes > Plan of Treatment |
| Care Team Members | Listing of the patient's care team: primary care, consulting physician, and personal care member. | Patient Chart > Care Team |
| Clinical Notes | Chart Notes entered by staff members to document details about the visit. These could include initial assessment, progress notes, and transcribed documents. | Notes and Transcription |
| Mental Status | Observations and evaluations related to a patient's psychological and mental competency. Includes PHQ-2 and PHQ-9 Depression screens. Information can be coded to SNOMED-CT. | Patient Chart > Problems > Impairments |
| Encounter Diagnosis | The list of medical conditions (coded diagnoses) that were addressed during the visit. | Patient Registration > Visit > Diagnosis |
| Functional Status | Patient's physical abilities to perform daily tasks. Information coded to SNOMED-CT. | Patient Chart > Problems > Impairments |
| Goals | A defined outcome or condition to be achieved in the process of patient care. These goals are associated to the patient's problem list. | Patient Chart > Problems > Goals |
| Health Concerns | A health-related matter that is of interest. Health Concerns are marked on the patient's problem list. | Patient Chart > Problems (Health Concern indicated) |
| Hospital Discharge Instructions | Care Instructions given to the patient at the time of discharge. This information is narrative in nature. | Patient Chart > Chart Note |
| Immunizations | The patient's immunization history collected during an encounter, which can include medications administered. | Medical History > Immunizations |
| Medical Equipment (Implants) | Equipment relevant to the diagnosis, care, or treatment of a patient. Devices applied to, or placed in, the patient. This information may include Unique Device Identifier value and includes manufacturer information if collected. | Medical History > Implant Log |
| Medications | The patient's current medications and pertinent medication history. Medications managed by the facility will contain an RxNorm and NDC value. | Medical History > Home Medications |
| Problem List | Listing of the patient’s problems collected in Medical History. Problems will include the SNOMED-CT code and ICD-10 value. | Patient Chart > Problems |
| Procedures | Orders placed on the patient during an encounter. Procedure will contain either a SNOMED-CT or LOINC code if defined. | Patient Chart > Orders Tracking |
| Reason for Referral | Describes the clinical reason why a provider is sending a patient to another provider for care and provides provider details if available. | Work Center > Referral Management |
| Results | Patient's Laboratory and Diagnostic results for the encounter. Lab tests are coded to LOINC. | Patient Chart > Results, Patient Chart > Documents > Radiology Results |
| Social History | Collection of data that influence a patient's physical, psychological, or emotional health, such as Smoking Status, Financial Resource Strain, Education Level, Physical Activity, Travel History, etc. | Patient Chart > Social Profile > all sub-sections |
| Vital Signs | Contains relevant vital signs, such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, and temperature. Information is coded using LOINC codes. | Patient Chart > Vitals |