Consolidated CDA
3.0.0-ballot - ballot United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0-ballot: CCDA 3.0 Ballot 1) based on FHIR (HL7® FHIR® Standard) v5.0.0. . For a full list of available versions, see the Directory of published versions

USCDI

The C-CDA templates were designed to meet the 2015 Edition certification criterion for Consolidated CDA Creation 170.315(g)(6). They were created for each item in the 2015 Edition Common Clinical Data Set (CCDS). The C-CDA templates on this page contain requirements up to and including U.S. Core Data for Interoperability (USCDI) v4.

Note that:

  • USCDI Data Classes and Element names may not be the same as the C-CDA template names and element names.
  • Not every USCDI Data Class and Element is mapped to a single template.
  • Many C-CDA elements do not map to a USCDI Data Class or Element because C-CDA usage is broader than certification and because additional C-CDA elements are required to make CDA implementable.

Updates to C-CDA depend upon community input and we encourage our audience to submit questions and feedback to C-CDA specifications by clicking on the Propose a change link in the footer of every page. In addition, we encourage our audience to request any necessary clarifications to USCDI through the USCDI ONDEC process that helps inform future updates to C-CDA.

The table below lists the C-CDA templates used for the corresponding USCDI Data elements.:

USCDI Logo

US Core Data for Interoperability USCDI

Allergies and Intolerances
Allergies and Intolerances Allergies and Intolerances Section
    •Substance (Medication) Allergy - Intolerance Observation
    •Substance (Drug Class) Allergy - Intolerance Observation
    •Substance (Non-Medication) Allergy - Intolerance Observation
    •Reaction Allergy - Intolerance Observation
Care Team Members
Care Team Members Care Teams Section
    •Name Care Team Member Act
    •Identifier Care Team Member Act
    •Location Care Team Member Act
    •Telecom Care Team Member Act
    •Role Care Team Member Act
Clinical Notes
Clinical Notes Notes Section
Results Section
Procedures Section
    •Consultation Note Note Activity
    •Discharge Summary Note Note Activity
    •History & Physical Note Activity
    •Imaging Narrative Note Activity
    •Procedure Note Note Activity
    •Progress Note Note Activity
Clinical Tests
Clinical Tests Results Section
    •Clinical Test Result Organizer
Result Observation
    •Clinical Test Result/Report Result Observation
Diagnostic Imaging
Diagnostic Imaging Results Section
    •Diagnostic Imaging Test Result Organizer
    •Diagnostic Imaging Result/Report Result Observation
Encounter
Encounter Encounters Section
    •Identifier Encounter Activity
    •Type Encounter Activity
    •Diagnosis Encounter Diagnosis
Hospital Discharge Diagnosis
Problem Observation
    •Time Encounter Activity
    •Location Encounter Activity
    •Disposition Encounter Activity
Facility Information
Facility Information Service Delivery Location
    •Identifier Service Delivery Location
    •Type Service Delivery Location
    •Name Service Delivery Location
Goals and Preferences
Goals and Preferences Goals Section
    •Patient Goals Goal Observation
    •SDOH Goals Goal Observation See Screening and Assessments Guidance
    •Treatment Intervention Preference Treatment Intervention Preference
    •Care Experience Preference Care Experience Preference
Health Insurance Information
Health Insurance Information Payers Section
    •Coverage Status Coverage Activity
    •Coverage Type Policy Activity
    •Relationship to Subscriber Policy Activity
    •Member Identifier Policy Activity
    •Subscriber Identifier Policy Activity
    •Group Number Policy Activity
    •Payer Identifier Policy Activity
Health Status Assessments
Health Status Assessments Functional Status Section
Problem Section
Social History Section
    •Health Concerns Health Concern Act
    •Functional Status Assessment Scale Observation
Assessment Scale Supporting Observation
Functional Status Observation 		See Screening and Assessments Guidance
    •Disability Status Disability Status Observation See Screening and Assessments Guidance
    •Mental/Cognitive Status Assessment Scale Observation
Assessment Scale Supporting Observation
Mental Status Observation 		See Screening and Assessments Guidance
    •Pregnancy Status Pregnancy Observation
Pregnancy Intention in Next Year
    •Alcohol Use Assessment Scale Observation
Assessment Scale Supporting Observation
Social History Observation 		See Screening and Assessments Guidance
    •Substance Use Assessment Scale Observation
Assessment Scale Supporting Observation
Social History Observation 		See Screening and Assessments Guidance
    •Physical Activity Assessment Scale Observation See Screening and Assessments Guidance
    •SDOH Assessment Assessment Scale Observation See Screening and Assessments Guidance
    •Smoking Status Smoking Status - Meaningful Use
Tobacco Use
Immunizations
Immunizations Immunizations Section
    •Immunizations Immunization Activity
Laboratory
Laboratory Results Section
    •Tests Result Organizer
Result Observation
    •Values/Results Result Observation
    •Specimen Type Result Organizer
    •Result Status Result Observation
    •Result Unit of Measure Result Observation
    •Result Reference Range Result Observation
    •Result Interpretation Result Observation
    •Specimen Identifier Result Organizer
    •Specimen Source Site Specimen Collection Procedure
    •Specimen Condition Acceptability Specimen Reject Reason Observation
Medical Devices
Medical Devices UDI Organizer
    •Unique Device Identifier(s) for a Patient's Implantable Device(s) UDI Organizer
Medications
Medications Medications Section
    •Medications Medication Activity
    •Dose Medication Activity
    •Dose Unit of Measure Medication Activity
    •Indication Medication Activity
Indication
    •Medication Instructions Medication Free Text Sig
    •Medication Adherence Medication Adherence
    •Fill Status Medication Dispense
Patient Demographics
Patient Demographics US Realm Header
Basic Industry Observation
Basic Occupation Observation
Gender Identity Observation
Sexual Orientation Obervation
Sex Observation
Tribal Affiliation Observation
    •First Name US Realm Header
    •Last Name US Realm Header
    •Previous Name US Realm Header
    •Middle Name (including middle initial) US Realm Header
    •Suffix US Realm Header
    •Sex US Realm Header
Sex Observation
    •Date of Birth US Realm Header
    •Date of Death US Realm Header
    •Race US Realm Header
    •Ethnicity US Realm Header
    •Tribal Affiliation Tribal Affiliation Observation
    •Gender Identity Gender Identity Observation
    •Sexual Orientation Sexual Orientation Observation
    •Preferred Language US Realm Header
    •Address US Realm Header
    •Previous Address US Realm Header
    •Email US Realm Header
    •Phone Number US Realm Header
    •Related Person's Name Related Person Relationship and Name Participant
    •Related Person's Relationship Related Person Relationship and Name Participant
    •Occupation Basic Occupation Observation
    •Occupation Industry Basic Industry Observation
Patient Summary and Plan
Patient Summary and Plan Assessment Section
    •Assessment and Plan of Treatment Assessment Section
Problems
Problems Problem Section
Problem Observation
    •Date of Resolution Problem Observation
    •Date of Diagnosis Problem Observation
Date of Diagnosis Act
    •SDOH Problems/Health Concerns Health Concern Act
Problem Observation
Social History Observation 		See Screening and Assessments Guidance
Procedures
Procedures Procedures Section
Procedure Activity Procedure
Reason for Referral Section
    •Procedure Procedure Activity Procedure
    •Time of Procedure Procedure Activity Procedure
    •Reason for Referral Reason for Referral Section
    •SDOH Interventions Procedure Activity Procedure
Planned Procedure 		See Screening and Assessments Guidance
Provenance
Provenance Provenance - Assembler Participation
Provenance - Author Participation
    •Author Time Stamp Provenance - Author Participation
    •Author Organization Provenance - Author Participation
Vital Signs
Vital Signs Vital Signs Section
Vital Sign Organizer
    •Average Blood Pressure Vital Sign Observation
    •Diastolic blood pressure Vital Sign Observation
    •Systolic blood pressure Vital Sign Observation
    •Body height Vital Sign Observation
    •Body weight Vital Sign Observation
    •Heart rate Vital Sign Observation
    •Respiratory rate Vital Sign Observation
    •Body temperature Vital Sign Observation
    •Pulse oximetry Vital Sign Observation
    •Inhaled oxygen concentration Vital Sign Observation
    •BMI Percentile (2-20 years old) Vital Sign Observation
    •Weight-for-length Percentile (Birth - 36 months) Vital Sign Observation
    •Occipital Frontal Head Circumference Percentile (Birth - 36 months) Vital Sign Observation