EHI Export

Centriq CCDA Data

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