Comparison of clinical content for XDS-MS Discharge document. Not a test for document structure.

Header Data (For Reference Only)

id	MSDischarge_2010-1
title	IHE Connectathon XDSMS Discharge
LOINC code	18842-5
Patient Name	George Washington
Patient ID	20_2010-1

Required Sections

PCC TF: 6.3.3.2.3 Active Problems 1.3.6.1.4.1.19376.1.5.3.1.3.6

LOINC: 11450-4 PROBLEM LIST

Element	Provided	Expected
id/root	1.3.6.1.4.1.21367.2010.1.2.777	id/root
id/extension	ActiveProblems_2010-1	id/extension
code/code	11450-4	11450-4
code/codeSystem	2.16.840.1.113883.6.1	2.16.840.1.113883.6.1
title	Active Problems	title
Text	Patient has Lung Cancer. Patient has Depression.	Patient has Lung Cancer. Patient has Depression.

PCC TF: 6.3.3.2.5 History of Past Illness 1.3.6.1.4.1.19376.1.5.3.1.3.8

LOINC: 11348-0 HISTORY OF PAST ILLNESS

Element	Provided	Expected
id/root	1.3.6.1.4.1.21367.2010.1.2.777	id/root
id/extension	HistoryOfPastIllness_2010-1	id/extension
code/code	11348-0	11348-0
code/codeSystem	2.16.840.1.113883.6.1	2.16.840.1.113883.6.1
title	History of Past Illness	title
Text	Patient was diagnosed with Depression. Patient was diagnosed with Lung Cancer.	Patient was diagnosed with Depression. Patient was diagnosed with Lung Cancer.

PCC TF: 6.3.3.2.4 Discharge Diagnosis 1.3.6.1.4.1.19376.1.5.3.1.3.7

LOINC: 11535-2 HOSPITAL DISCHARGE DX

Element	Provided	Expected
id/root	1.3.6.1.4.1.21367.2010.1.2.777	id/root
id/extension	DischargeDiagnosis_2010-1	id/extension
code/code	11535-2	11535-2
code/codeSystem	2.16.840.1.113883.6.1	2.16.840.1.113883.6.1
title	Discharge Diagnosis	title
Text	Adverse Reaction to Medication.	Adverse Reaction to Medication.

PCC TF: 6.3.3.1.4 Hospital Admission Diagnosis 1.3.6.1.4.1.19376.1.5.3.1.3.3

LOINC: 46241-6 HOSPITAL ADMISSION DX

Element	Provided	Expected
id/root	1.3.6.1.4.1.21367.2010.1.2.777	id/root
id/extension	HospitalAdmissionDiagnosis_2010-1	id/extension
code/code	46241-6	46241-6
code/codeSystem	2.16.840.1.113883.6.1	2.16.840.1.113883.6.1
title	Hospital Admission Diagnosis	title
Text	Patient was admitted for observation after suspecting an adverse reaction to recently prescribed antidepressant (Lexapro).	Patient was admitted for observation after suspecting an adverse reaction to recently prescribed antidepressant (Lexapro).

PCC TF: 6.3.3.3.4 Hospital Discharge Medications 1.3.6.1.4.1.19376.1.5.3.1.3.22

LOINC: 10183-2 HOSPITAL DISCHARGE MEDICATIONS

Element	Provided	Expected
id/root	1.3.6.1.4.1.21367.2010.1.2.777	id/root
id/extension	HospitalDischargeMedications_2010-1	id/extension
code/code	10183-2	10183-2
code/codeSystem	2.16.840.1.113883.6.1	2.16.840.1.113883.6.1
title	Hospital Discharge Medications	title
Text	Discharge Medication List includes: Cymbalta for depression. Lexapro is to be stopped. Patient may resume taking other medications as prescribed.	Discharge Medication List includes: Cymbalta for depression. Lexapro is to be stopped. Patient may resume taking other medications as prescribed.

PCC TF: 6.3.3.2.11 Allergies and Other Adverse Reactions 1.3.6.1.4.1.19376.1.5.3.1.3.13

LOINC: 48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS

Element	Provided	Expected
id/root	1.3.6.1.4.1.21367.2010.1.2.777	id/root
id/extension	AllergiesAndOtherAdverseReactions_2010-1	id/extension
code/code	48765-2	48765-2
code/codeSystem	2.16.840.1.113883.6.1	2.16.840.1.113883.6.1
title	Allergies and Adverse Reactions	title
Text	Active Drug Allergy: The patient has an adverse reaction to LEXAPRO(Escitalopram) which involved Hallucinations. The problem began on October 18, 2011.	Active Drug Allergy: The patient has an adverse reaction to LEXAPRO(Escitalopram) which involved Hallucinations. The problem began on October 18, 2011.

PCC TF: 6.3.3.2.2 Hospital Course 1.3.6.1.4.1.19376.1.5.3.1.3.5

LOINC: 8648-8 HOSPITAL COURSE

Element	Provided	Expected
id/root	1.3.6.1.4.1.21367.2010.1.2.777	id/root
id/extension	HospitalCourse_2010-1	id/extension
code/code	8648-8	8648-8
code/codeSystem	2.16.840.1.113883.6.1	2.16.840.1.113883.6.1
title	Hospital Course	title
Text	The Patient's medications were changed. Cymbalta was given in place of Lexapro. The Patient was monitored for 48 hours.	The Patient's medications were changed. Cymbalta was given in place of Lexapro. The Patient was monitored for 48 hours.

CDA Sup: 6.3.3.6.1 Care Plan 1.3.6.1.4.1.19376.1.5.3.1.3.31

LOINC: 18776-5 PATIENT PLAN OF CARE

Element	Provided	Expected
id/root	1.3.6.1.4.1.21367.2010.1.2.777	id/root
id/extension	CarePlan_2010-1	id/extension
code/code	18776-5	18776-5
code/codeSystem	2.16.840.1.113883.6.1	2.16.840.1.113883.6.1
title	CARE PLAN	title
Text	Continue to watch for signs of mental status change over the next 3-5 days. Report any change in status to your primary care physician.	Continue to watch for signs of mental status change over the next 3-5 days. Report any change in status to your primary care physician.