Consolidated CDA Release 2.1 StructureDefinition Prototype Publication
2.1.0-draft1 - CI Build United States of America

This page is part of the CCDA: Consolidated CDA Release (v2.1.0-draft1: CCDA 2.1 Draft) generated with FHIR v5.0.0. . For a full list of available versions, see the Directory of published versions

Table of Contents

...0 Table of Contents
...1 IG Home Page
...2 Background
...3 Design Considerations
...4 Using this Implementation Guide
...5 References
...6 Appendix
...7 Validation
...8 Downloads
...9 How To Read
....10 Artifacts Summary
....10.1 US Realm Header
....10.2 Care Plan (V2)
....10.3 Consultation Note (V3)
....10.4 Continuity of Care Document (CCD)
....10.5 Diagnostic Imaging Report (V3)
....10.6 Discharge Summary (V3)
....10.7 History and Physical (V3)
....10.8 Operative Note (V3)
....10.9 Procedure Note
....10.10 Progress Note (V3)
....10.11 Referral Note
....10.12 Transfer Summary
....10.13 Unstructured Document
....10.14 US Realm Header for Patient Generated Document (V2)
....10.15 Admission Diagnosis Section
....10.16 Admission Medications Section - entries optional
....10.17 Advance Directives Section - entries optional
....10.18 Advance Directives Section - entries required
....10.19 Allergies and Intolerances Section - entries optional
....10.20 Allergies and Intolerances Section - entries required
....10.21 Anesthesia Section
....10.22 Assessment and Plan Section
....10.23 Assessment Section
....10.24 Chief Complaint and Reason for Visit Section
....10.25 Chief Complaint Section
....10.26 Complications Section (V3)
....10.27 Course of Care Section
....10.28 DICOM Object Catalog Section - DCM 121181
....10.29 Discharge Diagnosis Section
....10.30 Discharge Diet Section (DEPRECATED)
....10.31 Discharge Medications Section - entries optional (V3)
....10.32 Discharge Medications Section - entries required (V3)
....10.33 Encounters Section - entries optional
....10.34 Encounters Section - entries required
....10.35 Family History Section
....10.36 Fetus Subject Context
....10.37 Findings Section (DIR)
....10.38 Functional Status Section
....10.39 General Status Section
....10.40 Goals Section
....10.41 Health Concerns Section (V2)
....10.42 Health Status Evaluations and Outcomes Section
....10.43 History of Present Illness Section
....10.44 Hospital Consultations Section
....10.45 Hospital Course Section
....10.46 Hospital Discharge Instructions Section
....10.47 Hospital Discharge Physical Section
....10.48 Hospital Discharge Studies Summary Section
....10.49 Immunizations Section - entries optional
....10.50 Immunizations Section - entries required
....10.51 Implants Section (DEPRECATED)
....10.52 Instructions Section (V2)
....10.53 Interventions Section
....10.54 Medical Equipment Section
....10.55 Medical (General) History Section
....10.56 Medications Administered Section (V2)
....10.57 Medications Section - entries optional
....10.58 Medications Section - entries required
....10.59 Mental Status Section
....10.60 Nutrition Section
....10.61 Objective Section
....10.62 Observer Context
....10.63 Operative Note Fluids Section
....10.64 Operative Note Surgical Procedure Section
....10.65 Past Medical History
....10.66 Payers Section
....10.67 Physical Exam Section
....10.68 Plan of Treatment Section
....10.69 Planned Procedure Section (V2)
....10.70 Postoperative Diagnosis Section
....10.71 Postprocedure Diagnosis Section (V3)
....10.72 Preoperative Diagnosis Section (V3)
....10.73 Problem Section - entries optional
....10.74 Problem Section - entries required
....10.75 Procedure Description Section
....10.76 Procedure Disposition Section
....10.77 Procedure Estimated Blood Loss Section
....10.78 Procedure Findings Section (V3)
....10.79 Procedure Implants Section
....10.80 Procedure Indications Section (V2)
....10.81 Procedure Specimens Taken Section
....10.82 Procedures Section - entries optional
....10.83 Procedures Section - entries required
....10.84 Reason for Referral Section
....10.85 Reason for Visit Section
....10.86 Results Section - entries optional
....10.87 Results Section - entries required
....10.88 Review of Systems Section
....10.89 Social History Section
....10.90 Subjective Section
....10.91 Surgery Description Section (DEPRECATED)
....10.92 Surgical Drains Section
....10.93 Vital Signs Section - entries optional
....10.94 Vital Signs Section - entries required
....10.95 Admission Medication
....10.96 Advance Directive Observation
....10.97 Advance Directive Organizer
....10.98 Age Observation
....10.99 Allergy - Intolerance Observation
....10.100 Allergy Concern Act
....10.101 Allergy Status Observation
....10.102 Assessment Scale Observation
....10.103 Assessment Scale Supporting Observation
....10.104 Authorization Activity
....10.105 Boundary Observation
....10.106 Caregiver Characteristics
....10.107 Characteristics of Home Environment
....10.108 Code Observations
....10.109 Cognitive Status Problem Observation (DEPRECATED)
....10.110 Comment Activity
....10.111 Coverage Activity
....10.112 Criticality Observation
....10.113 Cultural and Religious Observation
....10.114 Deceased Observation (V3)
....10.115 Discharge Medication (V3)
....10.116 Drug Monitoring Act
....10.117 Drug Vehicle
....10.118 Encounter Activity
....10.119 Encounter Diagnosis
....10.120 Entry Reference
....10.121 Estimated Date of Delivery
....10.122 External Document Reference
....10.123 Family History Death Observation
....10.124 Family History Observation
....10.125 Family History Organizer
....10.126 Functional Status Observation
....10.127 Functional Status Organizer
....10.128 Functional Status Problem Observation (DEPRECATED)
....10.129 Goal Observation
....10.130 Handoff Communication Participants
....10.131 Health Concern Act (V2)
....10.132 Health Status Observation (V2)
....10.133 Highest Pressure Ulcer Stage
....10.134 Hospital Admission Diagnosis
....10.135 Hospital Discharge Diagnosis
....10.136 Immunization Activity
....10.137 Immunization Medication Information
....10.138 Immunization Refusal Reason
....10.139 Indication
....10.140 Instruction
....10.141 Intervention Act
....10.142 Longitudinal Care Wound Observation
....10.143 Medical Equipment Organizer
....10.144 Medication Activity
....10.145 Medication Dispense
....10.146 Medication Free Text Sig
....10.147 Medication Information
....10.148 Medication Supply Order
....10.149 Mental Status Observation
....10.150 Mental Status Organizer
....10.151 Non-Medicinal Supply Activity
....10.152 Number of Pressure Ulcers Observation
....10.153 Nutrition Assessment
....10.154 Nutrition Recommendation
....10.155 Nutritional Status Observation
....10.156 Outcome Observation
....10.157 Patient Referral Act
....10.158 Planned Act
....10.159 Planned Coverage
....10.160 Planned Encounter
....10.161 Planned Immunization Activity
....10.162 Planned Intervention Act
....10.163 Planned Medication Activity
....10.164 Planned Observation
....10.165 Planned Procedure
....10.166 Planned Supply
....10.167 Policy Activity
....10.168 Postprocedure Diagnosis (V3)
....10.169 Precondition for Substance Administration
....10.170 Pregnancy Observation
....10.171 Preoperative Diagnosis (V3)
....10.172 Pressure Ulcer Observation (DEPRECATED)
....10.173 Priority Preference
....10.174 Problem Concern Act
....10.175 Problem Observation
....10.176 Problem Status
....10.177 Procedure Activity Act
....10.178 Procedure Activity Observation
....10.179 Procedure Activity Procedure
....10.180 Procedure Context
....10.181 Product Instance
....10.182 Prognosis Observation
....10.183 Progress Toward Goal Observation
....10.184 Purpose of Reference Observation
....10.185 Quantity Measurement Observation
....10.186 Reaction Observation
....10.187 Referenced Frames Observation
....10.188 Result Observation
....10.189 Result Organizer
....10.190 Risk Concern Act (V2)
....10.191 Self-Care Activities (ADL and IADL)
....10.192 Sensory Status
....10.193 Series Act
....10.194 Service Delivery Location
....10.195 Severity Observation
....10.196 Smoking Status - Meaningful Use
....10.197 Social History Observation
....10.198 SOP Instance Observation
....10.199 Study Act
....10.200 Substance Administered Act
....10.201 Substance or Device Allergy - Intolerance Observation
....10.202 Text Observation
....10.203 Tobacco Use
....10.204 Vital Sign Observation
....10.205 Vital Signs Organizer
....10.206 Wound Characteristic
....10.207 Wound Measurement Observation
....10.208 Author Participation
....10.209 Physician of Record Participant (V2)
....10.210 Physician Reading Study Performer (V2)
....10.211 US Realm Address - AD.US.FIELDED
....10.212 US Realm Date and Time - DT.US.FIELDED
....10.213 US Realm Date and Time - DTM.US.FIELDED
....10.214 US Realm Patient Name - PTN.US.FIELDED
....10.215 US Realm Person Name - PN.US.FIELDED
....10.216 Example of Allergy Intolerance to Food Egg
....10.217 Admission Diagnosis Section Example
....10.218 Admission Medication example
....10.219 Advance Directive Observation Example
....10.220 Advance Directive Organizer Example
....10.221 Advance Directives Section Example
....10.222 Age Observation Example
....10.223 Allergies and Intolerances Section Example - entries required
....10.224 Allergy Concern Act Example
....10.225 Allergy Intolerance Observation Example
....10.226 Anesthesia Section Example
....10.227 Assessment and Plan Section Example
....10.228 Assessment Scale Observation Example
....10.229 Assessment Scale Supporting Observation Example
....10.230 Assessment Section Example
....10.231 Author Participation Example
....10.232 Authorization Activity Example
....10.233 Boundary Observation Example
....10.234 Care Plan Caregiver participant Example
....10.235 Care Plan Patient authenticator Example
....10.236 Care Plan performer Example
....10.237 Care Plan relatedDocument Example
....10.238 Care Plan Review Example
....10.239 Caregiver Characteristics Example
....10.240 Characteristics of Home Environment Example
....10.241 Chief Complaint and Reason for Visit Section Example
....10.242 Chief Complaint Section Example
....10.243 Code Observations Example
....10.244 Comment Activity Example
....10.245 Complications Section Example
....10.246 Continuity Of Care Document Author Example
....10.247 Continuity Of Care Document Performer
....10.248 Continuity Of Care Document serviceEvent Example
....10.249 Consultation Note Callback participant Example
....10.250 Consultation Note structuredBody
....10.251 Consultation Note inFulfillmentOf Example
....10.252 Course of Care Section Example
....10.253 Coverage Activity Example
....10.254 Criticality Observation Example
....10.255 Cultural and Religious Observation Example
....10.256 Deceased Observation Example
....10.257 Diagnosis Reference Example
....10.258 DICOM Object Catalog Section DCM 121181 Example
....10.259 Diagnostic Imaging Report Example
....10.260 Discharge Diagnosis Example
....10.261 Discharge Medications Section Example - entries required
....10.262 Discharge Medication Example
....10.263 Discharge Summary encompassingEncounter Example
....10.264 Drug Monitoring Act Example
....10.265 Drug Vehicle Example
....10.266 Encounter Activity Example
....10.267 Encounter Diagnosis Example
....10.268 Encounters Section Example - entries required
....10.269 Entry Reference Example
....10.270 Estimated Date of Delivery Example
....10.271 External Document Reference Example
....10.272 Family History Death Observation Example
....10.273 Family History Observation Example
....10.274 Family History Organizer Example
....10.275 Family History Section Example
....10.276 Fetus Subject Context Example
....10.277 Findings Section Example (DIR)
....10.278 Functional Status Observation Example
....10.279 Functional Status Organizer Example
....10.280 Functional Status Section Example
....10.281 General Status Section Example
....10.282 Goal Observation Example
....10.283 Goals Section Example
....10.284 Handoff Communication Participants Example
....10.285 Health Concern Act Example
....10.286 Health Concerns Section Example
....10.287 Health Status Evaluations and Outcomes Section Example
....10.288 Health Status Observation Example
....10.289 Highest Pressure Ulcer Stage Example
....10.290 History and Physical Encompassing Encounter Example
....10.291 History Of Present Illness Example
....10.292 Hospital Admission Diagnosis Example
....10.293 Hospital Consultations Section Example
....10.294 Hospital Course Section Example
....10.295 Hospital Discharge Diagnosis Example
....10.296 Hospital Discharge Instructions Section Example
....10.297 Hospital Discharge Physical Section Example
....10.298 Hospital Discharge Studies Summary Section Example
....10.299 Immunization Activity Example
....10.300 Immunization Medication Information Example
....10.301 Immunization Refusal Reason Example
....10.302 Immunizations Section Example - entries required
....10.303 Indication Example
....10.304 Instructions Section Example
....10.305 Instruction Example
....10.306 Intervention Act Example
....10.307 Interventions Section Example
....10.308 Longitudinal Care Wound Observation Example
....10.309 Medical Equipment Organizer Example
....10.310 Medical Equipment Section Example
....10.311 Medication Activity Example
....10.312 Medication Dispense Example
....10.313 Medication Free Text Sig Example
....10.314 Medication Information Example
....10.315 Medication Supply Order Example
....10.316 Medications Administered Section Example
....10.317 Medications Section Example - entries required
....10.318 Mental Status Organizer Example
....10.319 Mental Status Organizer Example - V3
....10.320 Mental Status Section Example
....10.321 No Known Medications Example
....10.322 No Known Problem Section Example - entries optional
....10.323 Non-Medicinal Supply Activity Example
....10.324 nonXML Body Example with Compressed Content
....10.325 nonXML Body Example with Embedded Content
....10.326 nonXML Body Example with Referenced Content
....10.327 Number of Pressure Ulcers Observation Example
....10.328 Nutrition Assessment Example
....10.329 Nutrition Recommendation Example
....10.330 Nutrition Section Example
....10.331 Nutritional Status Observation Example
....10.332 Objective Section Example
....10.333 Observer Context Example
....10.334 Operative Note performer Example
....10.335 Operative Note serviceEvent Example
....10.336 Operative Note Fluids Section Example
....10.337 Operative Note Surgical Procedure Section Example
....10.338 Outcome Observation Example
....10.339 Past Medical History Example
....10.340 Patient Generated Document authenticator
....10.341 Patient Generated Document author device Example
....10.342 Patient Generated Document author
....10.343 Patient Generated Document custodian Example
....10.344 Patient Generated Document dataEnterer
....10.345 Patient Generated Document informant Example informant
....10.346 Patient Generated Document informant RelEnt Example
....10.347 Patient Generated Document informationRecipient Example
....10.348 Patient Generated Document inFulfillmentOf Example
....10.349 Patient Generated Document legalAuthenticator Example
....10.350 Patient Generated Document participant Example
....10.351 Patient Generated Document recordTarget
....10.352 Patient Referral Act Example
....10.353 Payers Section Example
....10.354 Physical Exam Section Example
....10.355 Physician Of Record Participant Example
....10.356 Physician Reading Study Performer Example
....10.357 Plan of Treatment Section Example
....10.358 Planned Act Example
....10.359 Planned Coverage Example
....10.360 Planned Encounter Example
....10.361 Planned Immunization Activity Example
....10.362 Planned Medication Activity Example
....10.363 Planned Observation Example
....10.364 Planned Procedure Section Example
....10.365 Planned Procedure Example
....10.366 Planned Supply Example
....10.367 Policy Activity Example
....10.368 Postoperative Diagnosis Section Example
....10.369 Postprocedure Diagnosis Example
....10.370 Postprocedure Diagnosis Section Example
....10.371 Precondition for Substance Administration Example
....10.372 Pregnancy Observation Example
....10.373 Preoperative Diagnosis Section Example
....10.374 Preoperative Diagnosis Example
....10.375 Priority Preference Example
....10.376 Problem Concern Act Example
....10.377 Problem Observation Example
....10.378 Problem Section Example - entries required
....10.379 Procedure Note performer Example
....10.380 Procedure Note serviceEvent Example
....10.381 Procedure Activity Act Example
....10.382 Procedure Activity Observation Example
....10.383 Procedure Activity Procedure Example
....10.384 Procedure Content
....10.385 Procedure Description Section Example
....10.386 Procedure Disposition Section Example
....10.387 Procedure Estimated Blood Loss Section Example
....10.388 Procedure Findings Section Example
....10.389 Procedure Implants Section Example
....10.390 Procedure Indications Section Example
....10.391 Procedure Specimens Taken Section Example
....10.392 Procedures Section Entries Required Example
....10.393 Product Instance Example
....10.394 Prognosis Coded Example
....10.395 Prognosis Free Text Example
....10.396 Progress Note encompassingEncounter Example
....10.397 Progress Note serviceEvent Example
....10.398 Progress Toward Goal Observation Example
....10.399 Purpose of Reference Observation Example
....10.400 Quantity Measurement Observation Example
....10.401 Reaction Observation Example
....10.402 Reason For Referral
....10.403 Reason for Visit Section Example
....10.404 Referenced Frames Observation Example
....10.405 Referral Note Callback Contact Example
....10.406 Referral Note Caregiver
....10.407 Referral Note informationRecipient Example
....10.408 Result Observation Example
....10.409 Result Organizer Example
....10.410 Results Section Example - entries required
....10.411 Review Of Systems Section Example
....10.412 Risk Concern Act Example
....10.413 Self-Care Activities ADL and IADL Example
....10.414 Sensory Status Example
....10.415 Series Act Example
....10.416 Service Delivery Location Example
....10.417 Severity Observation Example
....10.418 Smoking Status Meaningful Use Example
....10.419 Social History Observation Example
....10.420 Social History Section Example
....10.421 SOP Instance Observation Example
....10.422 Study Act Example
....10.423 Subjective Section Example
....10.424 Substance Administered Act Example
....10.425 Surgical Drains Section Example
....10.426 Text Observation Example
....10.427 Tobacco Use Example
....10.428 Transfer Summary Callback Contact Example
....10.429 Transfer Summary participant (Support) Example
....10.430 US Realm Address Example
....10.431 US Realm Date and Time Example
....10.432 US Realm Header Example
....10.433 US Realm Patient Name Example
....10.434 US Realm Person Name Example
....10.435 Vital Sign Observation Example
....10.436 Vital Signs Organizer Example
....10.437 Vital Signs Section Example - entries required
....10.438 Wound Characteristic Example
....10.439 Wound Measurement Observation Example