Clinical Notes Mapping form

This option identifies the document being created as a specific type of CCDA document. Within the XML, the document is tagged with an LOINC code that can be interpreted by receiving organizations. The options for defining the CCDA document include:

• Clinical Summary - general summary
• Consultation Note - note generated by a consultant
• Discharge Summary - note generated at the time of discharge
• History and Physical Note - note generated as part of a History and Physical note
• Progress Note - note generated as the result of an individual visit

This is a free-text field for specifying additional details about the note content and is included in the information shared with the querying organization. For example, if an organization has multiple progress notes across providers, use the CCDA Document Title to indicate a case manger note versus a psychiatrist note. This field is not required.

In CareConnect Inbox the list of available clinical notes shows the CCDA Document Title in the Note Type column.

This option allows organizations to determine which standard sections are appropriate to include in the CCD based on the scope of practice for the individual completing the note. For example, it may not be appropriate for a case manager progress note to include medications. 

Available sections include:

• Allergies and Intolerances
• Medical Equipment
• Social History
• Discharge Diagnosis
• Medications
• Vital Signs
• Immunizations
• Problems
• Results
• Procedures

This option allows the organization to specify whether this is a psychiatry or primary care note. 

Note: Netsmart has provided predefined mappings based on whether the user is completing a psychiatry or primary care note.

This option allows an organization to map fields within the progress note or modeled assessment (or separate tables) to narrative sections within the CCDA document.

Netsmart used the HL7 CCDA standards and USCDI v1 elements defined by the ONC to determine which fields an organization may want to include.

Note: At least one field setting mapping is required. An organization needs to determine which fields to include as individual fields. An organization may choose to put multiple care record fields into a generic Note field (for example, Progress Note) if desired.

CCDA fields to choose from include:

• Assessment and Plan - Typically a narrative created by the provider that describes the assessment and subsequent plan discussed during the visit.
• Chief Complaint - If noted as part of the form or progress note, this is the chief complaint noted during the visit.
• Consultation Note - A generic note option for organizations that have fields that may not match the named sections available. Multiple form or progress note fields may populate this note.
• Discharge Summary Note - A generic note option for organizations that have fields that may not match the named sections available. Multiple form or progress note fields may populate this note.
• Goals - Visit goals that are not intended to be treatment plan goals.
• Health Concerns - General concerns stated by the client or patient that are not already included in Problems or other parts of the client’s record.
• History and Physical Note - A generic note option for organizations that have fields that may not match the named sections available. Multiple form or progress note fields may populate this note.
• History of Present Illness - A description in the client's or patient’s own words about the history of their illness.
• Hospital Course - Narrative description of the client's or patient’s hospital stay. This option is only available when the CCDA document is a discharge summary.
• Mental Status - Mental status documentation created as part of the visit.
• Physical Exam - Physical exam documentation created as part of the visit.
• Procedure Note - This note type only requires mapping when the progress note being completed is for a specific procedure (for example, colonoscopy). Any procedure notes documented during a med note visit are included automatically.
• Progress Note - Narrative description of the client's or patient’s hospital stay. This option is only available when the CCDA document is a discharge summary.
• Review of Systems - Review of Systems documentation created as part of the visit.