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NAACCR Data Item # | NAACCR Data Item Name | Use Case Data Element Name | Definition | USCDI V1 Data Class | USCDI V1 Data Element | US Core Profile / FHIR Resource | US Core / FHIR element | Sample Value | Sample Value Display Name | Code System OID | Code System Name | Value Set OID | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2110 | Date Case Report Exported | Date Report Generated | effectiveTime (Date Document was Generated) |
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| ? | CDA Element: setId |
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| Version Number | CDA Element: Version Number |
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| 1 |
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2508 | EHR Vendor Name | EHR Vendor Name | The name of the software vendor for the EHR that created the report | Provenance | us-core-provenance | us-core-provenance.agent:ProvenanceTransmitter.who(Device).manufacturer WHERE Provenance.agent:ProvenanceTransmitter.type=composer | Epic | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2508 | EHR Software Name | EHR Software Name | The name of the software that created the report | Provenance | us-core-provenance | us-core-provenance.agent:ProvenanceTransmitter.who(Device).deviceName WHERE Provenance.agent:ProvenanceTransmitter.type=composer | Beacon | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2508 | EHR Software Version | EHR Software Version | The version number of the software that created the report | Provenance | us-core-provenance | us-core-provenance.agent:ProvenanceTransmitter.who(Device).version WHERE Provenance.agent:ProvenanceTransmitter.type=composer | V 1.4 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Patient Information | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2330 | Name--Last | Patient Last Name | Last name of the patient. | Patient Demographics | Last Name | US Core Patient Profile | Patientus-core-patient | us-core-patient.name.family | Shepherd |
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2240 | Name--First | Patient First Name | First name of the patient. | Patient Demographics | First NameUS Core Patient Profile | us-core-patient | Patient.name.given | Meredith |
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2250 | Name--Middle | Patient Middle Name | Middle name or, if middle name is unavailable, middle initial of the patient. | Patient Demographics | Middle NameUS Core Patient Profile | us-core-patient | Patient.name.given | Lynn |
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2390 2280 | Name--Birth Surname Name--Alias | Patient Name Use | Identifies the purpose for this name | Patient Demographics | Previous Name | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2270 | Name--Suffix | Patient Suffix | Title that follows a patient's last name, such as a generation order or credential status (e.g., "MD," "Jr."). | Patient Demographics | SuffixUS Core Patient Profile | us-core-patient | Patient.name.suffix |
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2350 2355 | Addr Current--No & Street Addr Current--Supplementl | Patient Street Address | The number and street address or the rural mailing address of the patient’s current usual residence. This can be used to generate a follow-up inquiry and must correspond to other fields in the current address. If the patient has multiple tumors, the current address should be the same. | Patient Demographics | Current AddressUS Core Patient Profile | us-core-patient | Patient.address.line | 111 Main Street |
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1810 | Addr Current--City | Patient Address City | Name of city of the patient’s current usual residence. If the patient has multiple tumors, the current city of residence should be the same for all tumors. | Patient Demographics | Current AddressUS Core Patient Profile | us-core-patient | Patient.address.city | Seattle |
| 2.16.840.1.113883.6.245 | U.S. Board on Geographic Names (USGS - GNIS) | 2.16.840.1.114222.4.11.973 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1820 | Addr Current--State | Patient Address State | USPS abbreviation for the state, territory, commonwealth, U.S. possession, or CanadaPost abbreviation for the Canadian province/territory of the patient’s current usual residence. If the patient has multiple tumors, the current state of residence should be the same for all tumors. | Patient Demographics | Current AddressUS Core Patient Profile | us-core-patient | Patient.address.state | WA |
| 2.16.840.1.113883.6.92 | FIPS 5-2 (State) | 2.16.840.1.113883.3.88.12.80.1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1830 | Addr Current—Postal Code | Patient Address Zip Code | Postal code for the address of the patient’s current usual residence. If the patient has multiple tumors, the postal codes should be the same. For U.S. residents, use either the 5-digit or the extended 9-digit ZIP code. Blanks follow the 5-digit code. For Canadian residents, use the 6-character alphanumeric postal code. Blanks follow the 6-character code. When available, enter postal code for other countries. | Patient Demographics | Current AddressUS Core Patient Profile | us-core-patient | Patient.address.postalCode | 98101 |
| 2.16.840.1.113883.6.231 | USPostalCodes | 2.16.840.1.113883.3.88.12.80.2 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1832 | Addr Current--Country | Patient Address Country | Country code for the address of patient’s current usual residence. If the patient has multiple tumors, the current country of residence should be the same for all tumors. | Patient Demographics | Current AddressUS Core Patient Profile | us-core-patient | Patient.address.country | US |
| 2.16.840.1.113883.3.88.12.80.63 | Country | 2.16.840.1.113883.3.88.12.80.63 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Note: Doesn't map directly, but very important in determining current address vs. address at diagnosis | Patient Address Start Date | Address start date | Patient Demographics | Current Address or Previous Address? | US Core Patient Profileus-core-patient | Patient.address.period | June 23, 2005 |
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| Note: Doesn't map directly, but very important in determining current address vs. address at diagnosis | Patient Address End Date | address end date | Patient Demographics | Current Address or Previous Address? | US Core Patient Profileus-core-patient | Patient.address.period | nullFlavor="NA" |
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2360 | Telephone | Patient Phone Number | Current telephone number with area code for the patient. Number is entered without dashes. Includes codes (in addition to valid telephone number). | Patient Demographics | Phone NumberUS Core Patient Profile | us-core-patient | Patient.telecom.value | (206)555-1313 |
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220 | Sex | Patient Gender | Administrative Gender - the gender that the patient is considered to have for administration and record keeping purposes. | US Core Patient Profileus-core-patient | Patient.gender | F | Female | 2.16.840.1.113883.5.1 | AdministrativeGender | 2.16.840.1.113883.1.11.1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
240 | Date of Birth | Patient date of birth | Date of birth of the patient. | Patient Demographics | Date of BirthUS Core Patient Profile | us-core-patient | Patient.birthDate | February 20, 1960 |
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2300 | Medical Record Number | Patient medical record number | Records medical record number used by the facility to identify the patient. |
| US Core Patient Profile | us-core-patient | Patient.identifier.value | 979746186 |
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| Patient identifier type | Patient Identifier System | Establishes the namespace for the value - that is, a URL that describes a set values that are unique. |
| US Core Patient Profile | us-core-patient | Patient.identifier.type=MRsystem | MR |
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2320 | Social Security Number | Patient Social Security Number | Records patient’s social security number. The number is entered without dashes and without any letter suffix. This is not always identical to the Medicare claim number. |
| US Core Patient Profile | us-core-patient | Patient.identifier.value | 333-44-5555 |
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| Patient identifier type | Patient Identifier System | Establishes the namespace for the value - that is, a URL that describes a set values that are unique. |
| US Core Patient Profile | us-core-patient | Patient.identifier.type=?system=http://hl7.org/fhir/sid/us-ssn |
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2315 | Medicare Beneficiary Identifier | Patient Medicare Beneficiary number | Congress passed the Medicare Access and CHIP Reauthorization ACT to remove Social Security Number (SSN) from Medicare ID card and replace the existing Medicare Health Insurance Claim Numbers with a Medicare Beneficiary Identifier (MBI). The MBI will be a randomly generated identifier that will not include a SSN or any personal identifiable information. |
| US Core Patient Profile | us-core-patient | Patient.identifier.value |
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| Patient identifier type | Patient Identifier System | Establishes the namespace for the value - that is, a URL that describes a set values that are unique. |
| US Core Patient Profile | us-core-patient | Patient.identifier.type=SBsystem=http://hl7.org/fhir/sid/us-mbi | SB |
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160 | Race 1 | Patient first reported race | A person's self-identification with one or more social groups. | Patient Demographics | RaceUS Core Patient Profile | us-core-patient | Patient.us-core-race.extension:ombCategory AND/OR Patient.us-core-race.extension:detailed | 2054-5 | Black or African American | 2.16.840.1.113883.6.238 | Race & Ethnicity - CDC | 2.16.840.1.113883.1.11.14914 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
190 | Spanish/Hispanic Origin | Patient Ethnicity | A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race | Patient Demographics | EthnicityUS Core Patient Profile | us-core-patient | Patient.us-core-ethnicity.extension:ombCategory AND/OR Patient.us-core-ethnicity.extension:detailed | 2186-5 | Not Hispanic or Latino | 2.16.840.1.113883.6.238 | Race & Ethnicity - CDC | 2.16.840.1.114222.4.11.837 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
252 | Birthplace--State | Patient State of Birth | USPS abbreviation for the state, territory or U.S. possession. |
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| Patient | FHIR Extension: birthPlace.address.state | PA |
| 2.16.840.1.113883.6.92 | FIPS 5-2 (State) | 2.16.840.1.113883.3.88.12.80.1 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
254 | Birthplace--Country | Patient Country of Birth | The country in which the patient was born. |
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| Patient | FHIR Extension: birthPlace.address.country | US |
| 2.16.840.1.113883.3.88.12.80.63 | Country | 2.16.840.1.113883.3.88.12.80.63 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
150 | Marital Status at DX | Patient Marital Status | Code for the patient’s marital status. (removed the NAACCR requirement that it's status at time of diagnosis) |
| US Core Patient Profile | us-core-patient | Patient.maritalStatus | M | Married | 2.16.840.1.113883.5.2 | MaritalStatus | 2.16.840.1.113883.1.11.12212 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1760 | Vital Status | Vital Status | Vital status (dead or alive) of the patient as of the date entered in Date of Last Contact [1750]. If the patient has multiple tumors, vital status should be the same for all tumors. |
| Patient | us-core-patient | Patient.deceasedBoolean | false |
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| Date of First Contact | Date of Patient First Visit | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Date of the patient's first visit with the reporting provider |
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| eICR Encounter | period.start |
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| 1750 | Date of Last Contact | Date of Death | Date of last contact with the patient, or date of death. If the patient has multiple tumors, Date of Last Contact should be the same for all tumors. |
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| Patient Smoking Status | Current smoking status | Smoking Status | Smoking Status | US Core Smoking Status Observation Profile | Observation.valueCodeableConcept.code | 8517006 | Former smoker | 2.16.840.1.113883.6.96 | SNOMED CT | 2.16.840.1.113883.11.20.9.38 |
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| Patient Smoking Status Date | Date patient's smoking status was recorded |
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| US Core Smoking Status Observation Profile | Observation.effective[x] | <date of the encounter> |
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| us-core-patient | Patient.deceasedDateTime |
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2475 | NPI--Physician--Follow-Up | Primary Care Physician NPI | The NPI (National Provider Identifier) code for the physician currently responsible for the patient's medical care. | us-core-patient | Patient.generalPractitioner(US Core).identifier:NPI | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
545 | NPI--Reporting Facility | Reporting Facility NPI | The NPI (National Provider Identifier) code for the facility submitting the data in the record. | us-core-patient | us-core-patient.managingOrganization(US CoreOrganization).identifier:NPI Provenance.agent.who.US Core Practitioner Profile. AND Provenance.agent.type=author or transmitter? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Encounter Information | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Note: Doesn't map directly, but important for context for other elements | Encounter period | The start and end times of the encounter. |
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| US Core Encounter Profile | Encounter.period |
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| Classification of Pt, Encounter | inpatient | outpatient | ambulatory | emergency +. |
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| US Core Encounter Profile | Encounter.class |
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| Encounter subject | The patient or group present at the encounter. |
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| US Core Encounter Profile | Encounter.subject |
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| Encounter Identifier | Identifier(s) by which this encounter is known. |
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| US Core Encounter Profile | Encounter.identifier.value |
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| Encounter participant type | Role of participant in encounter. |
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| US Core Encounter Profile | Encounter.participant.type |
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| Primary participant responsible for encounter | Encounter principal performer of service. |
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| US Core Encounter Profile | Encounter.participant.type=PPRF |
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| Participant overseeing the encounter | Participant overseeing the encounter |
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| US Core Encounter Profile | Encounter.participant.type=ATND |
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| Encounter participant individual | Persons involved in the encounter other than the patient. Reference(US Core Practitioner Profile) |
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| US Core Encounter Profile | Encounter.participant.individual |
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| Encounter primary performer NPI | NPI of encounter principal performer. |
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| US Core Encounter Profile | Encounter.participant.individual.Practitioner.identifier:NPI |
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| Encounter primary performer nameNPI | Name NPI of encounter principal performer. |
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| US Core Encounter Profile | Encounter.participant.individual.Practitioner.nameidentifier:NPI |
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| Encounter primary performer professional rolename | Professional role Name of encounter principal performer. |
| ? | US Core Encounter Profile | Encounter.participant.individual.PractitionerRolePractitioner.codename |
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| Encounter location address | The location where the encounter takes place. |
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| US Core Encounter Profile | Encounter.location.location.address |
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| Encounter location NPI | The NPI Number for the facility where the encounter takes place |
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630 | Primary Payer at DX | Primary payer type | The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization. |
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| US Core Encounter Profile | Encounter.account.coverage.type |
| BC Managed Care or equivalent |
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580 | Date of First Contact | Date of Patient First Visit | Date of the patient's first visit with the reporting provider | us-core-encounter | period.start | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Encounter Diagnosis | Enounter diagnosis. | us-core-encounter | diagnosis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Encounter Service Provider | The organization (facility) responsible for this encounter | us-core-encounter | serviceProvider | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Encounter Reason Code | Coded reason the encounter takes place | us-core-encounter | reasonCode | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Encounter Reason Reference | Reason the encounter takes place (reference) | us-core-encounter | reasonReference | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Provider Information | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Practitioner Name | The full name of the physician playing a specific role for the patient during diagnosis and/or treatment for this cancer. | Care Team Members |
| USCorePractitionerProfile | Practitionerus-core-practitioner | us-core-practitioner.name.text | Alex Karev, MD |
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| Practitioner Last Name | The last name of the physician playing a specific role for the patient during diagnosis and/or treatment for this cancer. | Care Team Members |
| USCorePractitionerProfile | Practitionerus-core-practitioner | us-core-practitioner.name.family | Karev |
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| Practitioner First Name | The first name of the physician playing a specific role for the patient during diagnosis and/or treatment for this cancer. | Care Team Members |
| USCorePractitionerProfile | Practitionerus-core-practitioner | us-core-practitioner.name.given | Alex |
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Practitioner Address | The address of the physician playing a specific role for the patient during diagnosis and/or treatment for this cancer.Care Team Memberscancer. | Care Team Members | us-core-practitioner | us-core-practitioner.address | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Practitioner Street Address | The street address of the physician playing a specific role for the patient during diagnosis and/or treatment for this cancer. | Care Team Members |
| USCorePractitionerProfile | Practitionerus-core-practitioner | us-core-practitioner.address.line | 999 Ellis Way |
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| Practitioner Address City | The city of the physician playing a specific role for the patient during diagnosis and/or treatment for this cancer. | Care Team Members |
| USCorePractitionerProfile | Practitionerus-core-practitioner | us-core-practitioner.address.city | Seattle |
| 2.16.840.1.113883.6.245 | U.S. Board on Geographic Names (USGS - GNIS) | 2.16.840.1.114222.4.11.973 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Practitioner Address State | the State of the physician playing a specific role for the patient during diagnosis and/or treatment for this cancer. | Care Team Members |
| USCorePractitionerProfile | Practitionerus-core-practitioner | us-core-practitioner.address.state | WA |
| 2.16.840.1.113883.6.92 | FIPS 5-2 (State) | 2.16.840.1.113883.3.88.12.80.1 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Practitioner Address Postal Code | The postal code of the physician playing a specific role for the patient during diagnosis and/or treatment for this cancer. | Care Team Members |
| USCorePractitionerProfile | Practitionerus-core-practitioner | us-core-practitioner.address.postalCode | 98101 |
| 2.16.840.1.113883.6.231 | USPostalCodes | 2.16.840.1.113883.3.88.12.80.2 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Practitioner Address Country | The country of the physician playing a specific role for the patient during diagnosis and/or treatment for this cancer. | Care Team Members |
| USCorePractitionerProfile | Practitionerus-core-practitioner | us-core-practitioner.address.country | US |
| 2.16.840.1.113883.3.88.12.80.63 | Country | 2.16.840.1.113883.3.88.12.80.63 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Practitioner Email Address | The email of the physician playing a specific role for the patient during diagnosis and/or treatment for this cancer. | Care Team Members | Provenance and/or Care Team Members? |
| us-core-practitioner | us-core-practitioner.telecom.ContactPoint.value WHERE system=email |
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| Practitioner Telephone Number | The telephone number of the physician playing a specific role for the patient during diagnosis and/or treatment for this cancer. | Care Team Members |
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| us-core-practitioner | us-core-practitioner.telecom.ContactPoint.value WHERE system=phone | (206) 555-3921 |
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Provider Role | The role of the provider, which would apply to each of the individual provider types (above) | Care Team Members |
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| us-ph-practitionerrole | us-ph-practitionerrole.specialty |
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2495 | NPI--Physician 3 | Practitioner Specialty NPI | The NPI (National Provider Identifier) code for another physician (e.g., managing provider, radiation oncologist, medical oncologist) involved in the care of the patient. | Care Team Members |
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| Primary Cancer Condition | 1770 | Cancer Status | Cancer Condition Clinical Status | The clinical status of the condition. | Problems | Problems | us-core-condition | us-core-condition.clinicalStatus | active |
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| 390 | Date of Diagnosis | Cancer (Primary) Date of Diagnosis | Date of initial diagnosis by a recognized medical practitioner | Problems | Problems | Document Reference or Diagnostic Report or Condition |
| January 26, 2018of the patient. | Care Team Members |
| us-core-practitioner | Practitioner.identifier:NPI |
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| Doesn't map to a SINGLE item | Cancer (Primary) Diagnosis Code | Code for the cancer diagnosis being reported | Problems | Problems | Condition |
| 408643008 | Infiltrating duct carcinoma of breast (disorder) | 2.16.840.1.113883.6.96 | SNOMED CT | Needs to be developed |
| Doesn't map to a SINGLE item | Cancer Diagnosis Code | Code for the cancer diagnosis being reported | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| C50.411 | Malignant neoplasm of upper-outer quadrant of right female breast | 2.16.840.1.113883.6.90 | ICD-10-CM | Have list of values in emarc; will need to publish as value set | 522 523 | Histologic Type ICD-O-3 Behavior Code ICD-O-3 | Cancer (Primary) Histology/Behavior | The histologic type and behavior (morphology) of the tumor | Problems | Problems | Condition |
| 8500/3 OR 8500 | Infiltrating duct carcinoma, NOS | 2.16.840.1.113883.6.43.1 | ICD-O-3 | Is there a way for us to create a VS to restrict these to only the Morphology codes? |
| Histologic Type ICD-O-3 Behavior Code ICD-O-3 | Cancer (Primary) Histology/Behavior | The histologic type and behavior (morphology) of the tumor | Problems | Problems | Condition |
| 82711006 | Infiltrating duct carcinomaPrimary Cancer Condition | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1770 | Cancer Status | Cancer Condition Clinical Status | The clinical status of the condition. | Problems | Problems | us-core-condition | us-core-condition.clinicalStatus | active |
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390 | Date of Diagnosis | Cancer (Primary) Date of Diagnosis | Date of initial diagnosis by a recognized medical practitioner | Problems | Problems | us-core-condition | us-core-condition.onsetDateTime | January 26, 2018 |
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| Doesn't map to a SINGLE item | Cancer (Primary) Diagnosis Code | Code for the cancer diagnosis being reported | Problems | Problems | us-core-condition | us-core-condition.code | 408643008 | Infiltrating duct carcinoma of breast (disorder) | 2.16.840.1.113883.6.96 | SNOMED CT | 2.16.840.1.114222.4.11.7256 | 490 | Diagnostic Confirmation ICD-O-3 | Cancer (Primary) Evidence Type (Diagnostic Confirmation) | Code for the best method of diagnostic confirmation of the cancer being reported at any time in the patient’s history. | Problems | Problems | Condition |
| 1 | Positive histology | 2.16.840.1.113883.3.520.3.3 | NAACCR Diagnostic Confirmation | Needs to be developed | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Doesn't map to a SINGLE item | Cancer Diagnosis Code | Code for the cancer diagnosis being reported |
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| C50.411 | Malignant neoplasm of upper-outer quadrant of right female breast | 2.16.840.1.113883.3.520.4.3 | 400 | Primary Site6.90 | ICD-10-CM | Have list of values in emarc; will need to publish as value set | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
522 523 | Histologic Type ICD-O-3 Behavior Code ICD-O-3 | Cancer (Primary) Primary SiteCode for the primary site Histology/Behavior | The histologic type and behavior (morphology) of the tumor being reported | Problems | ProblemsCondition |
| C50.4 | Upper-outer quadrant of breast8500/3 OR 8500 | Infiltrating duct carcinoma, NOS | 2.16.840.1.113883.6.43.1 | ICD-O-3 | Is there a way for us to create a VS to restrict these to only the Topography Morphology codes? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Primary Site | Histologic Type ICD-O-3 Behavior Code ICD-O-3 | Cancer (Primary) Primary Site |
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| Histology/Behavior | The histologic type and behavior (morphology) of the tumor | Problems | Problems |
| 82711006 | 110496004 | Upper outer quadrant of right breast | Infiltrating duct carcinoma | 2.16.840.1.113883.6.96 | SNOMED CT | 2.16.840.1.113883114222.34.88.12.3221.8.9 | 410 | Laterality11.7256 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
490 | Diagnostic Confirmation ICD-O-3 | Cancer (Primary) Evidence Type (Diagnostic Confirmation) Laterality | The side of a paired organ, or the side of the body on which the reportable tumor originated | Problems |
| Condition |
| 24028007 | Right (qualifier value) | Code for the best method of diagnostic confirmation of the cancer being reported at any time in the patient’s history. | Problems | Problems |
| 1 | Positive histology | 2.16.840.1.113883.3.6520.3.96SNOMED CT3 | NAACCR Diagnostic Confirmation | 2.16.840.1.113883.3.520.4.22 | Secondary Cancer Condition | Cancer (Secondary) Date of Diagnosis | The date of onset of metastases | Cancer (Secondary) Diagnosis Code | Code for the cancer that has spread (metastasized) from the place where it first started to another part of the body | Cancer (Secondary) Histology/Behavior | The histologic type and behavior (morphology) of the metastatic tumor | Cancer (Secondary) Histology/Behavior | The histologic type and behavior (morphology) of the metastatic tumor | Cancer (Secondary) Primary Site | Code for the metastatic site of the tumor being reported | Cancer (Secondary) Primary Site | Code for the metastatic site of the tumor being reported | Cancer (Secondary3 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
400 | Primary Site | Cancer (Primary) Primary Site | Code for the primary site of the tumor being reported | Problems | Problems |
| C50.4 | Upper-outer quadrant of breast | 2.16.840.1.113883.6.43.1 | ICD-O-3 | Is there a way for us to create a VS to restrict these to only the Topography codes? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Primary Site | Cancer (Primary) Primary Site |
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| us-core-condition | us-core-conditionbodySite | 110496004 | Upper outer quadrant of right breast | 2.16.840.1.113883.6.96 | SNOMED CT | 2.16.840.1.113883.3.88.12.3221.8.9 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
410 | Laterality | Cancer (Primary) Laterality | The side of a paired organ, or the side of the body on which the reportable metastatic tumor originated | Cancer Stage Group | Cancer Stage Group Code | Indication of whether the stage group, T, N, M is clinical or pathological. | No mapping, but can be used to determine stage at diagnosis | Cancer Date TNM Clinical Stage Assigned | Date/time TNM clinical stage information was assigned | Problems | Condition |
| February 11, 2018 | 1060 | TNM Edition Number | Cancer TNM Stage Edition/Version Number | The edition of the AJCC manual used to stage the cancer | Problems |
| Condition | 1004 1014 | AJCC TNM Clin Stage Group AJCC TNM Path Stage Group | Cancer TNM Clinical Stage Group | Detailed site-specific codes for the clinical stage group as defined by AJCC | Problems |
| Condition |
| IIIA OR 3A |
| 2.16.840.1.113883.3.520.3.18 | TNM 8. Edition | 2.16.840.1.113883.3.520.4.30 | 1001 1011 | AJCC TNM Clin T AJCC TNM Path T | Cancer TNM Tumor | Detailed site-specific codes for the tumor (T) as defined by AJCC | Problems |
| Condition |
| cT2 or c2 |
| 2.16.840.1.113883.3.520.3.18 | TNM 8. Edition | 2.16.840.1.113883.3.520.4.32 | 1002 1012 | AJCC TNM Clin N AJCC TNM Path N | Cancer TNM Nodes | Detailed site-specific codes for the nodes (N) as defined by AJCC | Problems |
| Condition |
| cN2 OR c2 |
| 2.16.840.1.113883.3.520.3.18 | TNM 8. Edition | 2.16.840.1.113883.3.520.4.33 | 1003 1013 | AJCC TNM Clin M AJCC TNM Path M | Cancer TNM Clinical Metastases24028007 | Right (qualifier value) | 2.16.840.1.113883.6.96 | SNOMED CT | 2.16.840.1.113883.3.520.4.22 | ||||||||||||||||||||||||||||||||||||||||||||||||||
Secondary Cancer Condition | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Cancer (Secondary) Date of Diagnosis | The date of onset of metastases | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Cancer (Secondary) Diagnosis Code | Code for the cancer that has spread (metastasized) from the place where it first started to another part of the body | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Cancer (Secondary) Histology/Behavior | The histologic type and behavior (morphology) of the metastatic tumor | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Cancer (Secondary) Histology/Behavior | The histologic type and behavior (morphology) of the metastatic tumor | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Cancer (Secondary) Primary Site | Code for the metastatic site of the tumor being reported | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Cancer (Secondary) Primary Site | Code for the metastatic site of the tumor being reported | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Cancer (Secondary) Laterality | The side of a paired organ, or the side of the body on which the reportable metastatic tumor originated | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Cancer Stage Group | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Cancer Stage Group Code | Indication of whether the stage group, T, N, M is clinical or pathological. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No mapping, but can be used to determine stage at diagnosis | Cancer Date TNM Clinical Stage Assigned | Date/time TNM clinical stage information was assigned | Problems |
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| February 11, 2018 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1060 | TNM Edition Number | Cancer TNM Stage Edition/Version Number | The edition of the AJCC manual used to stage the cancer | Problems |
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1004 1014 | AJCC TNM Clin Stage Group AJCC TNM Path Stage Group | Cancer TNM Clinical Stage Group | Detailed site-specific codes for the metastases (M) clinical stage group as defined by AJCC AJCC | Problems |
| Condition |
| cM0 IIIA OR c03A |
| 2.16.840.1.113883.3.520.3.18 | TNM 8. Edition | 2.16.840.1.113883.3.520.4.34 | Medications (Treatment) |
| Does not map, but might be similar concept in FHIR that we need to use. | Medication Status | Indicates whether the medication was prescribed, administered, etc. (Discuss with the WG--what do we want to capture for systemic therapy/meds?) | Medications30 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1001 1011 | AJCC TNM Clin T AJCC TNM Path T | Cancer TNM Tumor | Detailed site-specific codes for the tumor (T) as defined by AJCC | Problems |
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| cT2 or c2 | EVN |
| 2.16.840.1.113883.5.1001ActMood.3.520.3.18 | TNM 8. Edition | 2.16.840.1.113883.113.20520.94.1832 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1390 | RX Summ--Chemo | Medication prescribed code | Code (with associated name) for the medication that was prescribed | Medications | Medications |
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| 1720960 | 122010021230 | RX Date Chemo | Date medication prescribed | Date medication was prescribed | Medications |
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| 26.3 ML gemcitabine 38 MG/ML Injection1012 | AJCC TNM Clin N AJCC TNM Path N | Cancer TNM Nodes | Detailed site-specific codes for the nodes (N) as defined by AJCC | Problems |
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| cN2 OR c2 |
| 2.16.840.1.113883.6.88RxNorm3.520.3.18 | TNM 8. Edition | 2.16.840.1.113762113883.3.1520.4.1010.4 |
| Does not map; ask WG whether to keep | Medication prescribed dose | Dose for the medication that was prescribed |
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| 2225 |
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| Does not map; ask WG whether to keep | Medication prescribed dose units | Units of measure for the medication that was prescribed |
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| 33 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1003 1013 | AJCC TNM Clin M AJCC TNM Path M | Cancer TNM Clinical Metastases | Detailed site-specific codes for the metastases (M) as defined by AJCC | Problems |
| cM0 OR c0 |
| 2.16.840.1.113883.3.520.3.18 | TNM 8. Edition | 2.16.840.1.113883.3.520.4.34 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Problems | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3780, 3782, 3784, 3786, 3788, 3790, 3792, 3794, 3796, 3798 | Secondary Diagnosis 1-10 | Patient Problem Code | Records the patient’s preexisting medical conditions, factors influencing health status, and/or complications for the treatment of this cancer. | Problems | Problems | us-core-condition | us-core-condition.code | 44054006 | Diabetes mellitus type 2 | 2.16.840.1.113883.6.896 | UCUMSNOMED CT | 2.16.840.1.113883.3.88.112.11.12839 |
| RX Date Chemo | Date medication administered | A specific date/time or interval of time during which the medication administration took place. |
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| RX Summ--Chemo | Medication administered code | Identifies the code (with associated name) for the medication that was administered. |
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| Does not map; ask WG whether to keep | Medication administered dose | Dose for the medication that was administered |
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| Does not map; ask WG whether to keep | Medication administered dose units | Units of measure for the medication that was administered |
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| Medication Reason | We need a way to link medications to the correct cancer diagnosis when there is more than one cancer diagnosis in the same report. Note: will there multiple cancer diagnoses in the same FHIR bundle, or would they each be sent in a separate bundle, in which case this linkage is not needed? (A code indicating why the medication was given.) |
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| Problems |
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| Patient Problem Onset Date | Date of onset of the patient’s preexisting medical conditions, factors influencing health status, and/or complications for the treatment of this cancer | Problems |
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| May 12, 1990 |
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| 3780, 3782, 3784, 3786, 3788, 3790, 3792, 3794, 3796, 3798 | Secondary Diagnosis 1-10 | Patient Problem Code | Records the patient’s preexisting medical conditions, factors influencing health status, and/or complications for the treatment of this cancer. | Problems | Problems |
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| 44054006 | Diabetes mellitus type 2 | 2.16.840.1.113883.6.96 | SNOMED CT3221.7.4 | |||||||||||||
3780, 3782, 3784, 3786, 3788, 3790, 3792, 3794, 3796, 3798 | Secondary Diagnosis 1-10 | Patient Problem Code |
| us-core-condition | us-core-condition.code | E11.9 | Type 2 diabetes mellitus without complications | 2.16.840.1.113883.6.90 | ICD-10-CM | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Problem Clinical Status | The clinical status of the condition. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Problem Verification Status | The verification status to support the clinical status of the condition. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Problem Category | A category assigned to the condition. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Problem Subject | Indicates the patient or group who the condition record is associated with. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Lab Results | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Laboratory Test/Panel Code | The test (or panel of tests) that was performed relevant to the cancer diagnosis . A LOINC SHALL be used if the concept is present in LOINC. | Laboratory | Tests | us-core-observation-lab | us-core-observation-lab.code | 10480-2 | Estrogen+Progesterone receptor Ag [Presence] in Tissue by Immune stain | 2.16.840.1.113883.6.1 | LOINC | Value set to be developed to restrict to cancer-related (or can we do a "blacklist" approach--which tests are NOT wanted) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Laboratory Test Result Status | The status of the result value |
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| us-core-observation-lab | us-core-observation-lab.status | completed |
| 2.16.840.1.113883.5.14 | ActStatus | 2.16.840.1.113883.11.20.9.39 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Laboratory Test Performed Date | Date test was performed | Laboratory |
| us-core-observation-lab | us-core-observation-lab.effective[x] | January 26, 2018 |
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| Laboratory Result Value | The Laboratory result value. | Laboratory | Values/Results | us-core-observation-lab | us-core-observation-lab.valueQuantity.value | Positive |
| 2.16.840.1.113883.3.88.12.3221.7.4 | 3780, 3782, 3784, 3786, 3788, 3790, 3792, 3794, 3796, 3798 | Secondary Diagnosis 1-10 | Patient Problem Code |
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| E11.9 | Type 2 diabetes mellitus without complications6.96 | SNOMED CT |
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| Laboratory Result Units of Measure | Units of measure for the laboratory result value. | Laboratory | Values/Results | us-core-observation-lab | us-core-observation-lab.valueQuantity.unit |
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| 2.16.840.1.113883.6.8 | UCUM | 2.16.840.1.113883.6.90 | ICD-10-CM | 1.11.12839 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Procedures | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1290 | RX Summ--Surg Prim Site | Procedure Code | Procedure to the primary site performed as part of the first course of treatment. | Procedures | Procedures |
| us-core-procedure | us-core-procedure.code | 442963006 | Percutaneous needle biopsy of breast using ultrasound guidance | 2.16.840.1.113883.6.96 | SNOMED CT | Is there a value set for procedures? If not, should/can we create one? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1290 | RX Summ--Surg Prim Site | Procedure Code |
| Procedures | Procedures |
| us-core-procedure | us-core-procedure.code | 19083 | Biopsy, breast, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance | 2.16.840.1.113883.6.12 | CPT-4 | We can't publish a CPT value set. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1290 | RX Summ--Surg Prim Site | Procedure Code |
| Procedures | Procedures |
| us-core-procedure | us-core-procedure.code | 0HBT3ZX | Excision of Right Breast, Percutaneous Approach, Diagnostic | 2.16.840.1.113883.6.4 | ICD10 PCS | See item in TFS for value set | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1200 | RX Date Surg | Procedure Performed Date | Date/time of the procedure to the primary site performed as part of the first course of treatment. | Procedures |
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| us-core-procedure | us-core-procedure.performedDateTime | January 26, 2018 |
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| Procedure Performed Facility | Facility (NPI/Name) where the procedure was performed |
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| us-core-procedure | us-core-procedure.performer.actor.Organization.identifier |
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| Procedure Reason | We need a way to link procedures to the correct cancer diagnosis when there is more than one cancer diagnosis in the same report. Note: will there multiple cancer diagnoses in the same FHIR bundle, or would they each be sent in a separate bundle, in which case this linkage is not needed? |
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| Code | The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text. |
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| us-core-procedure | us-core-procedure.reasonReference.Condition us-core-procedure.reasonCode |
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Radiation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1506 | Phase 1 Radiation Treatment Modality | Radiation Code | Identifies the radiation modality administered during the first phase of radiation treatment delivered as part of the first course of treatment | Procedures? | Procedures? |
| us-core-procedure | us-core-procedure.code | 77412 | Radiation treatment delivery, ≥ 1 MeV; complex | 2.16.840.1.113883.6.14 | HCPCS | 2.16.840.1.113883.3.520.4.23; but we can't publish the CPT codes in this value set. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1506 | Phase 1 Radiation Treatment Modality | Radiation Code |
| Procedures |
|
| Procedures | us-core-procedure | us-core-procedure.code | 448385000 | Megavoltage radiation therapy using photons | 2.16.840.1.113883.6.96 | SNOMED CT | 2.16.840.1.113883.3.520.4.23 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1506 | Phase 1 Radiation Treatment Modality | Radiation Code |
| Procedures |
|
| Procedures | us-core-procedure | us-core-procedure.code | DM011ZZ | Beam Radiation of Right Breast using Photons 1 - 10 MeV | 2.16.840.1.113883.6.4 | ICD10 PCS | 2.16.840.1.113883.3.520.4.23 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1210 | RX Date Radiation | Radiation Administered Start Date | Date on which radiation therapy began at any facility that is part of the first course of treatment. | Procedures? |
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| us-core-procedure | us-core-procedure.performedDateTime | 09/14/2018 |
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| Radiation Reason Code | The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text. |
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| us-core-procedure | us-core-procedure.reasonReference.Condition? |
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| Radiation Reason | We need a way to link radiation procedures to the correct cancer diagnosis when there is more than one cancer diagnosis in the same report. Note: will there multiple cancer diagnoses in the same FHIR bundle, or would they each be sent in a separate bundle, in which case this linkage is not needed? |
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| Lab Results |
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| Laboratory Test/Panel Code | The test (or panel of tests) that was performed relevant to the cancer diagnosis . A LOINC SHALL be used if the concept is present in LOINC. | Laboratory | Tests |
|
| 10480-2 | Estrogen+Progesterone receptor Ag [Presence] in Tissue by Immune stain | 2.16.840.1.113883.6.1 | LOINC | Value set to be developed to restrict to cancer-related (or can we do a "blacklist" approach--which tests are NOT wanted) |
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| Laboratory Test Result Status | The status of the result value |
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| completed |
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| Radiation Reason Reference | The justification of why the procedure was performed. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Radiation Intent | The purpose of a procedure. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1531 | Radiation Treatment Discontinued Early | Radiation Termination Reason | A code explaining the unplanned or premature termination, or normal completion, of a plan of treatment, course of medication, or research study. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Prescribed Medication Information | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1220 | RX Date Chemo | Date medication prescribed | Date medication was prescribed | Medications |
| us-core-medicationrequest | us-core-medicationrequest.authoredOn |
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1390 | RX Summ--Chemo | Medication prescribed code | Code (with associated name) for the medication that was prescribed | Medications | Medications | us-core-medicationrequest | us-core-medicationrequest.medicationCodeableConcept | 1720960 | 26.3 ML gemcitabine 38 MG/ML Injection | 2.16.840.1.113883.56.1488 | ActStatusRxNorm | 2.16.840.1.113883113762.111.204.91010.39 |
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| Laboratory Test Performed Date | Date test was performed | Laboratory |
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| January 26, 2018 |
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| Laboratory Result Value | The Laboratory result value. | Laboratory | Values/Results |
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| Positive |
| 2.16.840.1.113883.6.96 | SNOMED CT |
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| Laboratory Result Units of Measure | Units of measure for the laboratory result value. | Laboratory | Values/Results |
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| 2.16.840.1.113883.6.8 | UCUM | 2.16.840.1.113883.1.11.12839 | Employment History |
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| Patient Industry Period | Date patient's industry code was recorded |
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| April 1985-present |
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| 272 | Census Ind Code 2010 CDC | Patient Industry Code | Code for the patient's usual industry, using U.S. Census Bureau codes and NIOSH non-paid worker codes4 | |||||||||||||||||||||||||||||||||||||||||||||||
Medication Prescribed Reason Code | The reason or the indication for ordering or not ordering the medication. | us-core-medicationrequest | us-core-medicationrequest.reasonCode AND | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Medication Prescribed Reason Reference | Condition or observation that supports why the medication was ordered. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Medication Prescribed Reason Reference | Condition or observation that supports why the medication was ordered. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Administered Medication Information | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| RX Date Chemo | Date medication administered | A specific date/time or interval of time during which the medication administration took place. |
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| MedicationAdministration | MedicationAdministration.effectiveDateTime |
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| RX Summ--Chemo | Medication administered code | Identifies the code (with associated name) for the medication that was administered. |
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| MedicationAdministration | MedicationAdministration.medication[x] |
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| 6570 | Motion pictures and video industries | 2.16.840.1.114222.4.5.315 | Industry CDC Census 2010 | 2.16.840.1.114222.4.11.7187 |
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| Patient Occupation Period | Date patient's occupation code was recordedMedication Administered Reason Code | A code indicating why the medication was given. |
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| MedicationAdministration | MedicationAdministration.reasonCode |
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| April 1985-present |
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| 282 | Census Occ | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Medication Administered Reason Reference | Condition or observation that supports why the medication was administered. | MedicationAdministration | MedicationAdministration.reasonReference.Condition | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Medication Administered Reason Reference | Condition or observation that supports why the medication was administered. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Employment History | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
272 | Census Ind Code 2010 CDC | Patient Occupation Industry Code | Code for the patient's usual occupationindustry, using U.S. Census Bureau codes and NIOSH non-paid worker codes |
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| 2700 | Actors | 2.16.840.1.114222.4.5.314 | Occupation CDC Census 2010 | 2.16.840.1.114222.4.11.7186 | Vital Signsand NIOSH non-paid worker codes |
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| Patient Height Code | Patient Height code | Vital Signs | Body height |
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| 8302-2 | Height | 2odh-UsualWork | coding:industryONETSOCDetailODH | 6570 | Motion pictures and video industries | 2.16.840.1.113883114222.4.6.1LOINC5.315 | Industry CDC Census 2010 Industry NAICS Detail (ODH) | 2.16.840.1.113883114222.34.88.12.80.62 |
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| Patient Height Recorded Date | Date patient's height was recorded |
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| <date of the encounter> |
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| Patient Height Value | Patient Height value | Vital Signs | Body height |
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| 162.5 | 11.7187 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Patient Occupation Period | Date patient's occupation code was recorded |
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| odh-UsualWork | component:odh-UsualOccupationDuration.valueQuantity | April 1985-present |
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| Patient Height Units | Patient Height units | Vital Signs | Body height |
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| cm | 282 | Census Occ Code 2010 CDC | Patient Occupation Code | Code for the patient's usual occupation, using U.S. Census Bureau codes and NIOSH non-paid worker codes |
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| odh-UsualWork | coding:occupationONETSOCDetailODH | 2700 | Actors | 2.16.840.1.114222.1138834.6.8UCUM5.314 | Occupation CDC Census 2010 Occupation ONETSOC Detail (ODH) | 2.16.840.1.113883114222.14.11.12839.7186 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Smoking Status | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Patient Weight Code | Patient Weight code | Vital Signs | Body weight |
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| 3141-9 or 29463-7 | Weight Measured or WeightSmoking Status | Current smoking status | Smoking Status | Smoking Status | US Core Smoking Status Observation Profile | Observation.valueCodeableConcept.code | 8517006 | Former smoker | 2.16.840.1.113883.6.196 | LOINCSNOMED CT | 2.16.840.1.113883.311.8820.129.80.6238 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Patient Weight Recorded Smoking Status Date | Date patient's weight smoking status was recorded |
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| US Core Smoking Status Observation Profile | Observation.effective[x] | <date of the encounter> |
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Patient Weight Value | Patient Weight value | Vital Signs | Body weight |
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 72.5 |
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| Patient Weight UnitsHeight Code | Patient Weight unitsHeight code | Vital Signs | Body weight |
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| kg | height | us-core-body-height | us-core-body-height.code.coding.code | 8302-2 | Height | 2.16.840.1.113883.6.81 | UCUMLOINC | 2.16.840.1.113883.3.188.12.1180.12839 | Clinical Notes/Text Fields62 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| TBD | Consultation Note Content | To be discussed with WG--do cancer registries want this? Are they allowed to receive it? | Clinical Notes | Consultation Note | Patient Height Recorded Date | Date patient's height was recorded |
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| us-core-body-height | us-core-body-height.effectiveDateTime | <date of the encounter> |
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| TBD | Discharge Summary Note Content | To be discussed with WG--do cancer registries want this? Are they allowed to receive it? | Clinical Notes | Discharge Summary Note | Patient Height Value | Patient Height value | Vital Signs | Body height | us-core-body-height | us-core-body-height.valueQuantity.value | 162.5 |
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| 2520 | Text--DX Proc--PE | History & Physical Content | To be discussed with WG--do cancer registries want this? Are they allowed to receive it? | Clinical Notes | History & Physical |
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|
| 2530 | Text--DX Proc--X-ray/Scan | Imaging Narrative Content | To be discussed with WG--do cancer registries want this? Are they allowed to receive it? | Clinical Notes | Imaging Narrative |
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| 2550 | Text--DX Proc--Lab Tests | Laboratory Report Narrative Content | To be discussed with WG--do cancer registries want this? Are they allowed to receive it? | Clinical Notes | Laboratory Report Narrative | Patient Height Units | Patient Height units | Vital Signs | Body height | us-core-body-height | us-core-body-height.valueQuantity.unit | cm |
| 2.16.840.1.113883.6.8 | UCUM | 2.16.840.1.113883.1.11.12839 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
| Patient Weight Code | Patient Weight code | Vital Signs | Body weight | us-core-body-weight | us-core-body-weight.code.coding.code | 3141-9 or 29463-7 | Weight Measured or Weight | 2.16.840.1.113883.6.1 | LOINC | 2.16.840.1.113883.3.88.12.80.62 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
| Patient Weight Recorded Date | Date patient's weight was recorded |
|
| us-core-body-weight | us-core-body-weight.effectiveDateTime | <date of the encounter> |
|
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
| 2570 | Text--DX Proc--Path | Pathology Report Narrative Content | To be discussed with WG--do cancer registries want this? Are they allowed to receive it? | Clinical Notes | Pathology Report NarrativePatient Weight Value | Patient Weight value | Vital Signs | Body weight | us-core-body-weight | us-core-body-weight.valueQuantity.value | 72.5 |
|
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
| 2560 | Text--DX Proc--Op | Procedure Note Content | To be discussed with WG--do cancer registries want this? Are they allowed to receive it? | Clinical Notes | Procedure Note |
|
|
|
|
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|
|
| TBD | Progress Note Content | To be discussed with WG--do cancer registries want this? Are they allowed to receive it? Patient Weight Units | Patient Weight units | Vital Signs | Body weight | us-core-body-weight | us-core-body-weight.valueQuantity.unit | kg |
| 2.16.840.1.113883.6.8 | UCUM | 2.16.840.1.113883.1.11.12839 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Clinical Notes/Text Fields | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| TBD | Progress Note Content | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | Clinical Notes | Progress Note |
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|
| 2630 | RX Text--Radiation Other | Radiation Therapy Treatment Summary Content | Text area for manual documentation of information regarding treatment of the tumor being reported with beam radiation. | Clinical Notes | Note: Flag for candidate for submission to ONDEC (new data element)?: |
|
| Patient received 5 MeV radiation treatmentus-core-documentreference | us-core-documentreference.text |
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Table 3: Cancer Reporting Data Elements
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