ToC+-+Dataset+Considerations

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**Please view the Final Use Case page for the most recent version of this section.**

//Note: The Dataset Considerations section is now 13.0 instead of 14.0 because of the deletion of the separate User Story section.//

13.0 Dataset Considerations
The following summaries are described in the previous user stories.
 * Discharge Summary
 * Discharge Instructions
 * Clinical Summary including Consultation Request
 * Clinical Summary

The Sub-Workgroup did not describe standard content of summaries such as:
 * Patient identity.
 * Data to insure transport of the content.
 * Security, auditing and other policy content.
 * Other procedural overhead, etc.

The following tables describe the sections and data expected to be found in these clinical summaries:
 * All of the data in the tables may not be clinically relevant in all situations
 * Some clinical situations may require additional data not included in the tables
 * Meaningful Use may only require a subset of the data


 * Dataset for Discharge Instructions:**

Discharge Instruction always includes standard basic dataset:
 * Demographic information, active reconciled medication list (with doses and sig), allergy list, problem list.

Discharge Instruction contains also dataset relevant to the discharge summary/discharge instructions context:
 * Follow up/plan of care (e.g., CCD/83 Plan of Care (What patient can do)): Prospective looking sections (Treatment Plan), treatments, diet, activities, alerts for conditions, future visits (may include several depending on condition) including appointment established. Patient education and information on medication (tied to alerts), disease process, wound care, condition based special considerations, etc.) etc.

Message contains variable dataset relevant to the hospitalization (selected by the clinician who prepared the discharge summary):
 * Examples:
 * Procedures during hospitalization
 * Selected medications administered during hospitalization
 * Selected vital signs
 * Emergency contact information
 * Relevant results, reports
 * Wound care (if applicable)
 * Etc.

Whether a Healthcare Proxy has been invoked || 1. Goals. 2. Results yet to be received and procedures to be followed up on. 3. Active and scheduled interventions and orders (short term direct instructions \[e.g. Vital sign checks, labs, etc.\] - in the long run as validated by the patient and those contributed by the patient/caregiver). 4. Education Resources/Materials - Patient education needed. To include classes, educational sessions, and printed materials along with steps to a specific need. 5a. Diet and Diet/Fluid Restrictions: All instructions that describe the expected diet. b. Restrictions: List of limitations being placed on the diet 6a. Fluids Management (C/N): All instructions that describe the expected fluids and method of administration. b. Restrictions: List of limitations being placed on fluids 7. Activity/Exercise **NOTES. Instructions may be more detailed if sent to another provider.** - Yes/No - has the discharge instruction been reviewed with the patient? - Yes/No - has the discharge instruction been accepted by the patient, if no then how addressed ||
 * **Ref** || **Section** || **Content** || **Additional Notes** ||
 * T.CC.1 || Personal Information || Name, DOB, Next of Kin, Address, Phone Number, Gender, Marital Status, Religion, Race, Ethnicity ||  ||
 * T.CC.5 || Allergies and Other Adverse Reactions || Allergy Type; and Date, Substance intolerance, Associated Adverse Events || List of allergies which might include allergy to what (e.g., medication. food, environment). Sensitivity. Past and those that have arisen ||
 * T.CC.6 || Problem List || Current Diseases & Conditions monitored for the patient and status || * List of problems/complaints (what was diagnosis, complaint and/or descriptor of problem/complaints, symptoms).
 * How do these problems/complaints impact interventions, orders or instructions. ||
 * T.CC.16 || Hospital Discharge Medications || Medications names, doses, frequency, route ordered for the patient for after discharge. || * Include the reconciled active medications including time of last dose and whether patient was sent with samples of the medication(s)
 * **NOTES. Instructions may be more detailed if sent to another provider.** ||
 * T.CC.18 || Advance Directives || A summary of patient's expectations for care || Yes/No - Target is to trigger a conversation.
 * T.CC.20 || Immunizations || Immunizations name, dose, route, date administered to the patient || Comprehensive list of immunizations received during the hospital stay ||
 * T.CC.21 || Plan of Care || Proposed interventions and procedures for patient || Subsections include the following (1-7)
 * T.CC.22 || Medical Equipment - includes assistive devices and is related to functional status || Implanted and External Medical Devices; Dates || * List of devices and where the device is to be secured/prescribed/embedded.
 * Duration of medical devices.
 * History of devices (recalls, S/N, etc.)
 * Includes reading glasses, hearing aids, dental appliances, etc. ||
 * ADDED || Patient Risks || Falls, Elopement, etc || * Strategies to mitigate patient risks ||
 * ADDED || Risks to Others || Contagion, Violent Behavior || * Isolation Requirements, etc ||
 * ADDED || Electronic Links ||  || Links to provider or other computer applications for patient results, summaries, etc. ||
 * ADDED || Patient Oriented Embarkation Checklist ||  || List of facility dependent patient oriented items (e.g., pain scale at discharge, last ECG, etc.) ||
 * ADDED || Functional Status (O/N) - ||  || End state/goal expressed/Projected change in functional status (will relate to the goals identified) ||


 * Dataset for Discharge Summary**

Discharge Summary Contents: Both basic standard dataset and discharge context relevant dataset are determined by the discharging provider organization in accordance with local policy, regulations and law. The receiving provider through its EHR system may determine how to incorporate and present the Discharge Summary.

Notwithstanding the Discharge Summary should always include standard basic dataset. At discharge the summary might include content for the Discharge Instruction as well as Discharge Summary. Discharge Summary content includes:
 * Demographic information, active reconciled medication list (with doses and sig), allergy list, problem list, and reason for admission.

Message contains variable dataset relevant to the hospitalization (selected by the clinician who prepared the discharge message). Examples:
 * Procedures during hospitalization
 * Relevant results, reports
 * Wound care (if applicable)
 * Etc.

Hospital and ED discharge is also the focus of several other efforts including individuals and institutions involved in ToC. For instance, the HIE Challenge Grants, Improving Massachusetts Post-Acute Care Transfers (IMPACT). Input was provided by Keith Boone; (http://motorcycleguy.blogspot.com/2010/11/circle-never-ends.html). Consideration was given to HITSP C32 Version 2.5, Meaningful Use EHR certification requirement and CDA Consolidation. Along with input from the Use Case Simplification and Discharge Instruction Sub Workgroups the following recommended sections and data are included in the Discharge Summary. The sections with a † are also found in the HITSP C48 Encounter Document Using IHE Medical Summary (XDS-MS) Component.


 * **Ref.** || **Section** || **Content** || **Notes by Discharge Instructions SWG** ||
 * T.CC.1 || Personal Information † || Name, DOB, Healthcare Power of Attorney, Address, Phone Number, Gender, Marital Status, Religion, Race, Ethnicity ||  ||
 * T.CC.2 || Contact Information || Contact Name, Contact Number ||  ||
 * T.CC.3 || Insurance Information || Insurance Name, Phone #, Group #, Type, Member #, Subscriber Name, Financial responsibility ||  ||
 * T.CC.4 || Healthcare Provider || Provider Name, Address, Phone Number, Type ||  ||
 * T.CC.5 || Allergies and Other Adverse Reactions † || Allergy Type; and Date || List of allergies which might include allergy to what (e.g., medication. food, environment) ||
 * T.CC.6 || Problem List Active Problems (R/N)/Chief Complaint (overriding problem at the time of discharge) - chronic illness and congenital problems † || Current Diseases & Conditions monitored for the patient and status || * List of problems/complaints (what was diagnosis, complaint and/or descriptor of problem/complaints, symptoms) ||
 * T.CC.7 || History of Past Illness || Diseases & Conditions Patient has suffered in the past ||  ||
 * T.CC.8 || Chief Complaint (see change in T.CC.6 Problem List) || Description of Patient's Complaint (narrative) ||  ||
 * T.CC.9 || Reason for Transfer || Reason Patient is being referred ||  ||
 * T.CC.10 || History of Present Illness † || Sequence of events proceeding patient's disease/condition ||  ||
 * T.CC.11 || List of Surgeries || List of types of surgeries and dates ||  ||
 * T.CC.12 || Hospital Admission Diagnosis † || List of Hospital Diagnosis and dates ||  ||
 * T.CC.13 || Discharge Diagnosis † || Conditions/Diseases identified during hospital stay and dates ||  ||
 * T.CC.14 || Medications || List of Current Medication Names; date, route, dose, frequency || * Include the reconciled active medications ||
 * T.CC.15 || Admission Medications History † || List of historical medication names, dose, route, frequency, date patient has taken previously ||  ||
 * T.CC.16 || Hospital Discharge Medications † || Medications names, doses, frequency, route ordered for the patient for after discharge ||  ||
 * T.CC.17 || Medications Administered † || Medications administered to patient during the course of an encounter; name, dose, route, frequency ||  ||
 * T.CC.18 || Advance Directives † || A summary of patient's expectations for care || * Yes/No, if Yes date of last known
 * Yes/No if **Physician Orders for Life-Sustaining Treatment** (POLST) form returned
 * Where is last known version/original is located ||
 * T.CC.19 || Pregnancy || Pregnant, Yes/NO ||  ||
 * T.CC.20 || Immunizations || Immunizations name, dose, route, date administered to the patient || Comprehensive list of immunizations received during hospital stay. ||
 * T.CC.21 || Physical Examination † || Physical Findings of the Patient; VS, Biometrics, Review of Systems ||  ||
 * T.CC.22 || Vital Signs - Vital Signs (R/N) including Pain Scale Assessment, Smoking Status † || Patient's Vital Signs; Heart rate, Resp Rate, Pulse Ox, Temp, B/P, Pain || Including Pain Scale Assessment, Smoking Status ||
 * T.CC.23 || Review of Systems † || Functions of various body systems; Neuro, Derm, GI, GU, Cardiac, Pulmonary, MS, Repro, Nervous, Endocrine ||  ||
 * T.CC.24 || Hospital Course † || Sequence of (name, diagnosis associated with) events and dates from admission to discharge of hospital stay ||  ||
 * T.CC.25 || Diagnostic Results † || Results and dates of Diagnostic Procedures || Corresponding results to the scheduled procedures and interventions. ||
 * T.CC.26 || Assessment and Plan || Assessment of patients conditions and expectations/goals of care ||  ||
 * T.CC.28 || Family History || Dates with Disease Suffered, Age of Death, other genetic information ||  ||
 * T.CC.29 || Social History || Patient's beliefs, home life, social/risky habits, family life, work history ||  ||
 * T.CC.30 || Encounters || Current and historical encounters; dates ||  ||
 * T.CC.31 || Medical Equipment - Medical Devices (C/N) - includes assistive devices and is related to functional status † || Implanted and External Medical Devices; Dates || * List of devices and where the device is to be secured/embedded.
 * Duration of medical devices.
 * History of devices (recalls, S/N, etc.). ||
 * T.CC.32 || Preoperative Diagnosis || Diagnosis (Date) assigned to patient previously to surgery ||  ||
 * T.CC.33 || Postoperative Diagnosis || Diagnosis (Date) assigned to patient after surgery ||  ||
 * T.CC.34 || Surgery Description || Particulars of Surgery (narrative) (images) ||  ||
 * T.CC.35 || Surgical Operation Note Findings || Clinically significant observations found during surgery ||  ||
 * T.CC.36 || Complications Section || Known risks or unidentified problems ||  ||
 * T.CC.37 || Operative Note Surgical Procedure || Date and Description of Procedure Performed ||  ||
 * † || Discharge Diet ||  || Part of Discharge Instructions ||
 * † || Functional Status ||  || Part of Discharge Instructions ||
 * † || Plan of Care ||  || Part of Discharge Instructions ||

Dataset for Clinical Summary:
The User Stories Sub-Workgroup defined the following clinical summary content.


 * Clinical Summary including Consultation Request Summary**

Clinical Summary always includes //standard// basic dataset:
 * Demographic information, active medication list (with doses and sig), allergy list, problem list, reason for referral, etc.

Clinical Summary contains //variable dataset relevant to the context of the request://


 * Examples:
 * Cover note describing the clinical impetus for the referral
 * For a cardiologist consultation request: cardiology relevant tests and results such as Cardiac Echo results, Holter Monitor results, etc.; cardiology-pertinent family history, social histories, procedures, PE findings, etc..
 * For a dermatologist consultation request: dermatology relevant tests and results such as skin biopsy path report, image of lesion, dermatology pertinent family history, social histories, procedures, PE findings, etc..
 * Specific example:
 * PCP has worked up a patient who has a working diagnosis of Thyroid Cancer and is referring the patient to an Endocrine Surgeon.
 * Summary includes _standard_ basic dataset as above as well as PCP-selected referral-specific variable data set. E.g.:
 * //Pertinent PE finding and history of present illness:// 3 month history of a //2 cm R sided, hard thyroid nodule//
 * //Pertinent results and diagnosis:// FNA done 2/28/11 significant for medullary carcinoma, Calcitonin 2700, CEA 7, TSH, T3 Free T4 all normal
 * //Pertinent Additional Diagnoses Medical /Surgical Hx:// significant only for 3 year history of mild obesity, current BMI 30
 * //Pertinent Family History:// significant for Thyroid cancer mother (unknown type). No family history of MEN Syndromes. No family history of radiation exposure.
 * //PCP referral request and determination of responsibility:// Please evaluate for possible MEN II syndrome, surgery, post-operative care, and any special recommendations. I will assume full care status post the procedure.
 * //Reference to shared information with Patient:// I have reviewed all of the above information with the patient and his wife.
 * //Patient did/did not understand what was communicated//


 * **Ref.** || **Section** || **Content** || **Additional Notes** ||
 * T.CC.1 || Personal Information || Name, DOB, Next of Kin, Address, Phone Number, Gender, Marital Status, Religion, Race, Ethnicity ||  ||
 * T.CC.2 || Contact Information || Contact Name, Contact Number ||  ||
 * T.CC.3 || Insurance Information || Insurance Name, Phone #, Group #, Type, Member #, Subscriber Name, Financial responsibility ||  ||
 * T.CC.4 || Healthcare Provider || Provider Name, Address, Phone Number, Type ||  ||
 * T.CC.5 || Allergies/Other adverse Reactions || Allergy Type; and Date, Substance intolerance, Associated Adverse Events || List of allergies which might include allergy to what (e.g., medication. food, environment).

Yes/No/Unknown, and if Yes or Unknown how does it affect care

Other history that guide care

Patient supplied information about reaction || Conditions monitored for the patient and status || * List of problems/complaints (what was diagnosis, complaint and/or descriptor of problem/complaints, symptoms). Is a list, of diagnosis, complaints some of these may have been resolved and some are active Vital Signs (R/N) including Pain Scale Assessment, Smoking Status || Patient's Vital Signs ; Heart rate, Resp Rate, Pulse Ox, Temp, B/P, Pain || Instructions regarding the capture of vital signs at points along the care plan and any special instructions regarding how to capture || - All instructions that describe the expected diet.
 * T.CC.6 || Problem List Active Problems (R/N)/Chief Complaint (overriding problem at the time || Current Diseases &
 * How do these problems/complaints impact interventions, orders or instructions. Discharge instructions usually are for the encounter just ending.
 * Patient's perception or description of problems/complaints is usually in notes or history. Not part of a formal problem list. ||
 * T.CC.7 || History of Past Illness || Diseases & Conditions Patient has suffered in the past || May be a list with dates onset and/or resolution ||
 * T.CC.8 || Chief Complaint (see change in T.CC.6 Problem List) || Description of Patient's Complaint (narrative) || If not listed, in the problem list ||
 * T.CC.9 || Reason for Transfer || Reason Patient is being referred || May come from Utilization Review (UR) or Medicare rules, insurance or HMO rules or the patient may be well. ||
 * T.CC.10 || History of Present Illness || Sequence of events proceeding patient's disease/condition ||  ||
 * T.CC.11 || List of Surgeries || List of types of surgeries and dates ||  ||
 * T.CC.12 || Diagnosis || List of Hospital Diagnosis and dates || Current encounter list only ||
 * T.CC.13 || Medications || List of Current Medication Names ; date, route, dose, frequency || * List of prescribed medications or other medications. (Should be the reconciled list (which should have been done on admission))
 * If to be reconciled then list needs to be inclusive of self-administered medications (herbals, over the counter)
 * See notes on medication reconciliation regarding expectations such as discontinued medications from inpatient if not included in discharge summary
 * NOTES: Instructions my be more detailed if sent to another provider ||
 * T.CC.15 || Advance Directives || A summary of patient's expectations for care || * Yes/No, if Yes then date of
 * Yes/No if POLST form returned
 * Where is last known version/original is located
 * Going forward how the "state" and how it affects care ||
 * T.CC.16 || Pregnancy || Pregnant, Yes/NO ||  ||
 * T.CC.17 || Immunizations || Immunizations name, dose, route, date administered to the patient || Comprehensive list of immunizations (have - patient reported, got, need): **list of immunizations necessary to get after discharge.** list of education or information about immunizations they received while hospitalization ||
 * T.CC.18 || Physical Examination || Physical Findings of the Patient; VS, Biometrics, Review of Systems ||  ||
 * T.CC.19 || Vital Signs
 * T.CC.20 || Review of Systems || Functions of various body systems; Neuro, Derm, GI, GU, Cardiac, Pulmonary, MS, Repro, Nervous, Endocrine ||  ||
 * T.CC.21 || Diagnostic Results || Results and dates of Diagnostic Procedures || Corresponding results to the scheduled procedures and interventions. ||
 * T.CC.22 || Plan of CarePlan of Treatment/Treatment Plan/Care Plan (R/N) - Covers the considerations that encompass a range of scopes and/or timeframe (could be a description of a single encounter or across multiple encounters || Proposed interventions and procedures for patient || * Goals.
 * Results yet to be received and procedures to be followed up on.
 * Active interventions and orders (short term direct instructions - in the long run as validated by the patient and those contributed by the patient/caregiver). ||
 * || Education ||  ||   ||
 * || Diet/Diet Restrictions (R/N) ||  || Diet:

Restrictions: - List of limitations being placed on the diet || - All instructions that describe the expected fluids and method of administration.
 * || Fluids Management (Conditional/No) ||  || Fluids:

Restrictions: - List of limitations being placed on fluids || Duration of medical devices.History of devices (recalls/S/N, etc.) || Duration of medical devices.History of devices (recalls/S/N, etc.) || Functional StatusEnd state, Goal Expressed, Projected change in functional status (will relate to the goals identified) ||
 * ||  ||   || Yes/No-has the plan been reviewed with the patient?Yes/No-has the plan been accepted by the patient, if no then how addressed ||
 * T.CC.23 || Family History || Dates with Disease Suffered, Age of Death, other generic information ||  ||
 * T.CC.24 || Social History || Patient’s beliefs, home life, social/risky habits, family life, work history ||  ||
 * T.CC.25 || Encounters || Current and historical encounters; dates ||  ||
 * T.CC.26 || Medical Equipment-includes assistive devices and is related to functional status || Implanted and External Devices; dates || List of devices and where the device is to be secured/prescribed/embedded.
 * T.CC.27 || Preoperative Diagnosis || Diagnosis (date) assigned to patient previously to surgery ||  ||
 * T.CC.28 || Postoperative Diagnosis || Diagnosis (date) assigned to patient after surgery ||  ||
 * T.CC.29 || Surgery Description || Particulars of Surgery (narrative) (images) ||  ||
 * T.CC.30 || Surgical Operation Note Findings || Clinically significant observations found during surgery ||  ||
 * T.CC.31 || Complications Section || Known risks or unidentified problems ||  ||
 * T.CC.32 || Operative Note Surgical Procedure || Date and description of Procedure Performed || List of devices and where the device is to be secured/prescribed/embedded.
 * T.CC.33 || Electronic Links ||  || How to get future results, summaries, etc ||
 * ADDED || Functional Status (Optional/No) ||  || Baseline, current and desired:
 * ADDED || Relevant Diagnostic Surgical Procedures/Clinical Reports and Relevant Diagnostic Test and Reports ||  ||   ||
 * ADDED || Patient Administrative Identifiers ||  ||   ||


 * Consultation Summary for specialist notes:**

Summary always includes //standard// basic dataset:
 * Demographic information, //specialist-reconciled// active medication list (with doses and sig when known), allergy list, //specialist-reconciled// problem list, specialist recommendations, etc.

Summary contains variable dataset relevant to the context of the referral:
 * pertinent findings, test or study results, procedures or operations and reports, indication of any specialty ongoing follow up responsibilities, what has been communicated to the patient, patient’s level of understanding of what was communicated, etc.

Yes/No/Unknown, and if Yes or Unknown how does it affect care. Other history that guide care. Patient supplied information about reaction ||
 * **Ref** || **Section** || **Content** || **Notes by Sub-Workgroup** ||
 * T.CC.1 || Personal Information || Name, DOB, Next of Kin, Address, Phone Number, Gender, Marital Status, Religion, Race, Ethnicity ||  ||
 * T.CC.2 || Contact Information || Contact Name, Contact Number ||  ||
 * T.CC.3 || Insurance Information || Insurance Name, Phone #, Group #, Type, Member #, Subscriber Name, Financial responsibility ||  ||
 * T.CC.4 || Healthcare Provider || Provider Name, Address, Phone Number, Type ||  ||
 * T.CC.5 || Allergies and Other Adverse Reactions || Allergy Type; and Date, Substance Intolerance, Associated Adverse Events || List of allergies which might include allergy to what (e.g., medication. food, environment).
 * T.CC.6 || Problem List || Current Diseases || List of problems/complaints by patient to specialist and what was diagnosis, complaint and/or descriptor of problem/complaints, symptoms ||
 * || Active Problems (R/N)/Chief Complaint (overriding problem at the time of discharge) - chronic illness and congenital problems || Conditions monitored for the patient and status || How do these problems/complaints impact interventions, orders or instructions. ||
 * ||  ||   || Patient's perception or description of problems/complaints - was there discussion with patient? ||
 * T.CC.7 || History of Past Illness || Diseases & Conditions Patient has suffered in the past || Optional if relevant new discovery - resolved problems ||
 * T.CC.8 || Chief Complaint (see change in T.CC.6 Problem List) || Description of Patient's Complaint (narrative) || If patient tells specialist different complaint than was reported by PCP ||
 * T.CC.9 ||  || Reason Patient is being referred ||   ||
 * T.CC.10 || History of Present Illness || Sequence of events proceeding patient's disease/condition || If different or in addition to PCP history ||
 * T.CC.11 || List of Surgeries and Procedures || List of types of surgeries and procedures with date || If any performed by specialist ||
 * T.CC.14 || Medications || List of Current Medication Names ; date, route, dose, frequency || List of prescribed medications or medications administered by specialist ||
 * ||  ||   || If to be reconciled then list needs to be inclusive of self-administered medications (herbals, over the counter) ||
 * T.CC.17 || Medications Administered || Medications administered to patient during the course of an encounter; name, dose, route, frequency || If relevant to referral ||
 * T.CC.18 || Advance Directives || A summary of patient's expectations for care || Yes/No (Optional in context of Consultation) ||
 * T.CC.19 || Pregnancy || Pregnant, Yes/NO || Only if relevant ||
 * T.CC.20 || Immunizations || Immunizations name, dose, route, date administered to the patient || Immunizations administered or recommended by specialist ||
 * T.CC.21 || Physical Examination || Physical Findings of the Patient; VS, Biometrics, Review of Systems || Pertinent postive or negative finding only ||
 * T.CC.22 || Vital Signs || Patient's Vital Signs ; Heart rate, Resp Rate, Pulse Ox, Temp, B/P, Pain || Pertinent postive or negative findings only ||
 * || Vital Signs (R/N) including Pain Scale Assessment, Smoking Status ||  ||   ||
 * T.CC.23 || Review of Systems || Functions of various body systems; Neuro, Derm, GI, GU, Cardiac, Pulmonary, MS, Repro, Nervous, Endocrine || Pertinent postive or negative findings only ||
 * T.CC.25 || Diagnostic Results || Results and dates of Diagnostic Procedures || Corresponding results to the scheduled procedures and interventions. ||
 * T.CC.26 || Assessment and Plan || Assessment of patients conditions and expectations/goals of care || See Plan of Care in regards discussions with patient ||
 * T.CC.27 || Recommended Plan of Care

Plan of Treatment/Treatment Plan/Care Plan (R/N) - Covers the considerations that encompass a range of scopes and/or timeframe (could be a description of a single encounter or across multiple encounters || Proposed interventions and procedures || Goals. Details for follow-up, expectations, as needed.

Active interventions and orders (short term direct instructions - in the long run as validated by the patient and those contributed by the patient/caregiver). ||
 * ||  ||   || Yes/No - has the specialist findings, recommendations and instruction been reviewed with the patient. ||
 * ||  ||   || Yes/No - Have these instruction been accepted by the patient, if no then how addressed ||
 * ||  ||   || Yes/No - Has patient been involved in formulation of plan of care ||
 * || Education || Patient education provided or needed. To included classes, educational sessions, printed materials. || If relevant ||
 * || Fluids Management (Conditional/No) || All instructions that describe the expected fluids and method of administration. || If relevant ||
 * T.CC.28 || Family History || Dates with Disease Suffered, Age of Death, other genetic information || Optional if relevant ||
 * T.CC.29 || Social History || Patient's beliefs, home life, social/risky habits, family life, work history || Optional if relevant ||
 * T.CC.31 || Medical Equipment || Implanted and External Medical Devices; Dates || List of devices and where the device is to be secured/prescribed by specialist. ||
 * || Medical Devices (Conditional/No) - includes assistive devices and is related to functional status ||  || Optional if implanted or applied or with special instructions by specialist ||
 * ||  ||   || History of devices for this patient. ||
 * || Functional Status (Optional/No) -scales, scores || SHOULD be present when any assessments of functional status are performed on the patient || If relevant - Baseline, current and desired:\* Functional status\* End state/goal expressed/Projected change in functional status (will relate to the goals identified) ||
 * || Electronic Links || How to get to future results, summaries, etc. ||  ||

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