ToC+CIM+Core+Data+Elements

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The data elements listed below indicate the core data elements for all transition of care settings. Additional information can be exchanged during transitions of care, but they may not be essential for all care transitions. For additional information on the classification of data elements, see ToC Classification of Data Elements. To download a copy of the original document, click here: Data Element Category.


 * Notes included for Standards Analysis WG
 * Note: Privacy and security are important, but out of scope for this WG.

**Patient Information**

 * Name: Last Name, Middle Name, First Name *Note: Accommodate additional names: Given Name/Family Name/Suffix/Prefix
 * Gender (Administrative)
 * Patient Identifiers (everything currently legally used in an MPI algorithm, e.g. Reconciling and Managing EMPI and AHIMA reference documentation)
 * Mother’s Maiden Name
 * Marital Status: Married; Married Polygamous; Civil Union; Single; Divorced; Widowed
 * Date of Birth: Month, Day, Year

**Culturally Sensitive Patient Care**

 * Race (value set included, insert coding term)
 * Ethnicity (value set included, insert coding term)
 * Religion (value set included, insert coding term)
 * Language (value set included, insert coding term)
 * Disability (value set included, insert coding term)
 * Educational Level (value set included, insert coding term)

**Patient Contact Information (indicate the preferred method of communication)**

 * Home Address
 * Home Phone
 * Text Message (Yes or No)
 * Cell Phone
 * Text Message (Yes or No)
 * Work Phone
 * Text Message (Yes or No)
 * Primary Email Address
 * Secondary Email Address
 * DIRECT Address
 * Patient Portal/PHR
 * URL, if Yes

**Existence of Advanced Directives**
(Yes or No)
 * Note: Has an advanced Directive has been signed by the patient, and is contained in records

**Primary Care Physician (PCP) and Designated Providers**
PCP and Designated Providers
 * Names
 * Patient’s Medical Home (where the patient sees their PCP or designated providers)
 * Specialties
 * National Provider Identifiers (NPI)
 * Domain of Management
 * Contact Information

**Support Contacts**

 * Emergency Contact (Primary)
 * Name
 * Relationship (Friend, Relative or Other)
 * Contact Information
 * Emergency Contact (Secondary)
 * Name
 * Relationship (Friend, Relative or Other)
 * Contact Information

**Payer Information**

 * Insurance (Primary)
 * Information
 * Insurance (Secondary)
 * Information

**Active Medication List**

 * Notes on Active Medication List**
 * Reconciliation means that the provider who upon completion of their care of the patient sends an active medication list either having reviewed the original active medication list relative to any new prescribed or changes to medications and reconciled the active medication list or not. (provide examples) Assuming reconciliation, discontinued medications would be available separately, not as part of the active medication list.

Q. What does it mean for a medication to be active? – clinically relevant medications

Active Medications Going Forward List includes:


 * PRN Medication List
 * Active Medications (Held for Period of Time)
 * Medications that patient was exposed to, now discontinued, but still clinically relevant
 * Software need – document the delta

**Data Elements**
 * Active Medication List
 * Reconciled (Yes/No)
 * If Yes, Date of Reconciliation
 * Reconciled by? Date/Time Stamp
 * Discontinued Medication in this encounter
 * Changed Medication
 * Medication Code (coded field that includes text) *Note: Appropriate coding system, not medication
 * Dose (must be able to include variable dosages e.g. sliding scales, etc.)
 * When to take (Sig)
 * Frequency (Sig)
 * Route (Sig)
 * Duration (Sig)
 * Patient Instructions
 * PRN (Sig)
 * Start Date
 * Stop Date, if applicable
 * Prescriber
 * Associated Assessment (ICD code, SNOMED) *Note: Reason the provider prescribed the medication

**Active Problem List**

 * Note: What clinician sending the message has determined to be the patient’s active problems and/or diagnoses or determination of no known problems – this list may be reconciled at each ToC.
 * Coded Problem(s) or no known problem(s)
 * Start Date (or date of onset) of problem(s)
 * Clinician who added it to the problem list (include date/time stamp)
 * Reconciled (Yes or No)
 * Reconciled by? Date/Time Stamp
 * Resolved and/or changed problems in this encounter

**Intolerances including Allergies**

 * Medication (ingredient or class code, if available) that has been attributed to an allergic reaction or intolerance, or drug code if attribution to ingredient or class is unavailable *Note: Includes medications, biologicals, herbal supplements, OTCs, vaccine, etc.
 * Environmental Allergens *Note: Examples of environmental allergens include latex, pollen, animal dander, etc.
 * Food Allergens *Note: Examples of food allergens include shellfish, eggs, peanuts, etc.
 * Reaction (can have multiples)
 * Severity associated with the reaction
 * Date Identified
 * Who Reported (e.g. patient, provider, care taker) *Note: Not required for clinician to fill field

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