CDA+-+Non-consolidated+TemplateIds

=Section Templates=

Objective
The Objective section contains data about the patient gathered through tests, measures, or observations that produce a quantified or categorized result. It includes important and relevant positive and negative test results, physical findings, review of systems, and other measurements and observations.
 * **CONF-**PRGN-1 : A Progress Note may contain exactly one and SHALL NOT contain more than one Objective section (templateId 2.16.840.1.113883.10.20.21.2.1).
 * **CONF-**PRGN-2 : A section/code element SHALL be present where the value for @code is 61149-1 OBJECTIVE DATA 2.16.840.1.113883.6.1 LOINC static.


 * Figure 11: Objective section example**

Interventions
The Interventions section contains information about the specific interventions provided during the healthcare visit. Depending on the type of intervention(s) provided (procedural, education, application of assistive equipment, etc.), the details will vary but may include specification of frequency, intensity, and duration. Interventions can be encoded using the [|CCD Procedure Activity].
 * **CONF-**PRGN-3 : A Progress Note may contain exactly one and SHALL NOT contain more than one Interventions section (templateId 2.16.840.1.113883.10.20.21.2.3).
 * **CONF-**PRGN-4 : A section/code element SHALL be present where the value for @code is 62387-6 INTERVENTIONS PROVIDED 2.16.840.1.113883.6.1 LOINC static.
 * **CONF-**PRGN-5 : The Interventions section MAY contain clinical statements. If present, the clinical statements SHOULD conform to the [|CCD Procedure Activity] template (2.16.840.1.113883.10.20.1.29)


 * Figure 12: Interventions section example**

Assessment and Plan
A Progress Note contains either discrete sections for Assessment and for Plan or a single section combining the two (Assessment and Plan). The sections may be combined or separated to meet local policy requirements.

The **Assessment** section (also called impression or diagnoses) represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The assessment formulates a specific plan or set of recommendations. The assessment may be a list of specific disease entities or a narrative block.

The **Plan** section contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current care of the patient should be listed unless constrained due to privacy issues. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders. Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and health-care quality improvements, including widely accepted performance measures. The plan may also indicate that patient education was given or will be provided.
 * **CONF-**PRGN-6: When the Assessment and Plan are recorded separately, there shall be a section where the value for section/code shall be 51848-0 ASSESSMENT 2.16.840.1.113883.6.1 LOINC STATIC and the templateId shall be 2.16.840.1.113883.10.20.18.2.13; and there shall be a section where the value for section/code shall be 18776-5 PLAN 2.16.840.1.113883.6.1 LOINC STATIC and the templateId shall be *2.16.840.1.113883.10.20.1.10; and there shall not be a section where the value for section/code is 51847-2 ASSESSMENT AND PLAN 2.16.840.1.113883.6.1 LOINC STATIC.
 * **CONF-**PRGN-7: When the Assessment and Plan and are recorded together, the value for section/code shall be 51847-2 ASSESSMENT AND PLAN 2.16.840.1.113883.6.1 LOINC STATIC and the templateId shall be 2.16.840.1.113883.10.20.18.2.14; and there shall not be a section where the value for section/code is 51848-0 ASSESSMENT; and there shall not be a section where the value for section/code is 18776-5 PLAN.
 * Figure 7: Assessment and plan section example**