Reason for Visit C-CDA Coded Social History Results (entries O[0..1] C-CDA Ocular Physical Exam optional) Review of Systems R[0..1] GEE, C-CDA Assessment and Plan Social History R[0..1] GEE, C-CDA, IRIS REGISTRY Signs (entries O[0..1] C-CDA, IRIS optional) REGISTRY Encounters (entries O[0..1] IRIS REGISTRY optional) Functional Status R[0..1] GEE Healthcare Providers R[0..1] GEE, IRIS REGISTRY and Pharmacies 3 Instructions O[0..1] IRIS REGISTRY List of Surgeries R[0..1] GEE Coded List of O[0..1] GEE Surgeries Medications (entries R[0..1] GEE, IRIS REGISTRY required) Ocular History R[0..1] GEE, IRIS REGISTRY Ocular Physical M[1..1] GEE, IRIS REGISTRY Exam Ophthalmic R[0..1] GEE, IRIS REGISTRY Medications Problem (entries R[0..1] GEE, IRIS REGISTRY required) *Shall include an Assessment and Plan Section or an (Assessment Section and a Plan Section). Shall Not include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present. **Shall Not include a combined Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section. ***Shall include a Reason for Referral or Reason for Visit section.
Reason for Visit C-CDA Coded Social History Results (entries optional) O[0..1] C-CDA Ocular Physical Exam Review of Systems R[0..1] GEE, C-CDA Assessment and Plan Social History R[0..1] GEE, C-CDA, IRIS REGISTRY Signs (entries optional) O[0..1] C-CDA, IRIS REGISTRY Encounters (entries optional) O[0..1] IRIS REGISTRY Functional Status R[0..1] GEE Healthcare Providers and Pharmacies R[0..1] GEE, IRIS REGISTRY Instructions O[0..1] IRIS REGISTRY List of Surgeries R[0..1] GEE Coded List of Surgeries O[0..1] GEE Medications (entries required) R[0..1] GEE, IRIS REGISTRY Ocular History R[0..1] GEE, IRIS REGISTRY Ocular Physical Exam M[1..1] GEE, IRIS REGISTRY Ophthalmic Medications R[0..1] GEE, IRIS REGISTRY Problem (entries required) R[0..1] GEE, IRIS REGISTRY *Shall include an Assessment and Plan Section or an (Assessment Section and a Plan Section). Shall Not include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present. **Shall Not include a combined Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section. ***Shall include a Reason for Referral or Reason for Visit section. 3
IHE_EyeCare_Supp_CCDA_GEE_TI_v0.1.docx