Ccda\ccda - FHIR v1.4.0

STU 3 Candidate

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

M.0 C-CDA on FHIR Implementation Guide (IG)

This is the IG Overview.

M.0.1 Scope

To represent Consolidated CDA Templates for Clinical Notes (C-CDA) 2.1 templates using FHIR profiles.
This first stage of the project defines all the C-CDA document-level profiles and their contained sections.

The C-CDA on FHIR Continuity of Care Document (CCD) profile also defines several entry-level profiles by referencing relevant U.S. Data Access Framework (DAF) FHIR profiles.

M.0.2 Resource Profiles

This guide defines the following profiles.

Profile Name	Description
C-CDA on FHIR US Realm Header	This profile defines constraints that represent common administrative and demographic concepts for US Realm clinical documents. Further specification, such as type, are provided in document profiles that conform to this profile.
C-CDA on FHIR Care Plan	A Care Plan (including Home Health Plan of Care (HHPoC)) is a consensus-driven dynamic plan that represents a patient's and Care Team Members' prioritized concerns, goals, and planned interventions. It serves as a blueprint shared by all Care Team Members (including the patient, their caregivers and providers), to guide the patient's care. A Care Plan integrates multiple interventions proposed by multiple providers and disciplines for multiple conditions.
C-CDA on FHIR Continuity of Care Document (CCD)	The Continuity of Care (CCD) profile represents a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another to support the continuity of care.
C-CDA on FHIR Consultation Note	The Consultation Note is generated by a request from a clinician for an opinion or advice from another clinician. Consultations may involve face-to-face time with the patient or may fall under the auspices of telemedicine visits. Consultations may occur while the patient is inpatient or ambulatory. The Consultation Note should also be used to summarize an Emergency Room or Urgent Care encounter.
C-CDA on FHIR Diagnostic Imaging Report	A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialist’s interpretation of image data. It conveys the interpretation to the referring (ordering) physician and becomes part of the patient’s medical record. It is for use in Radiology, Endoscopy, Cardiology, and other imaging specialties.
C-CDA on FHIR Discharge Summary	The Discharge Summary is a document which synopsizes a patient's admission to a hospital, LTPAC provider, or other setting. It provides information for the continuation of care following discharge.
C-CDA on FHIR History and Physical	A History and Physical note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status.
C-CDA on FHIR Procedure Note	A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patient’s tolerance for the procedure. It should be detailed enough to justify the procedure, describe the course of the procedure, and provide continuity of care.
C-CDA on FHIR Progress Note	This profile represents a patient’s clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter.
C-CDA on FHIR Referral Note	A Referral Note communicates pertinent information from a provider who is requesting services of another provider of clinical or non-clinical services. The information in this document includes the reason for the referral and additional information that would augment decision making and care delivery.
C-CDA on FHIR Operative Note	The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies. The Operative Note is created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.
C-CDA on FHIR Transfer Summary	The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between health care settings. Standardization of information used in this form will promote interoperability; create information suitable for reuse in quality measurement, public health, research, and for reimbursement.

This guide references the following DAF profiles.

Profile Name

U.S. DAF AllergyIntolerance Profile

U.S. DAF Condition Profile

U.S. DAF DiagnosticOrder Profile

U.S. DAF DiagnosticReport Profile

U.S. DAF MedicationStatement Profile

U.S. DAF Results Profile

U.S. DAF Vital Signs Profile

U.S. DAF Organization Profile

U.S. DAF Patient Profile

U.S. DAF Practitioner Profile

U.S. DAF Procedure Profile

U.S. DAF Related Person Profile

M.0.3 Extensions

This guide defines the following extensions.

Name	Definition
C-CDA on FHIR Authorization	An extension to represent CDA header authorization element.
C-CDA on FHIR Data Enterer	An extension to represent CDA header dataEnterer element.
C-CDA on FHIR Data Enterer	An extension to represent CDA inFulfillmentOf/order header element.
C-CDA on FHIR Informant	An extension to represent CDA informant header element.
C-CDA on FHIR Participant	An extension to represent CDA participant header element.
C-CDA on FHIR Performer	An extension to represent CDA performer header element.

M.0.4 Value Sets

This guide references the following value sets.

Name	Definition
HL7 BasicConfidentialityKind	A value set of HL7 Codes indicating the level of confidentiality an act.
LOINC Imaging Document Codes	A value set of LOINC codes indicating the type of imaging document.
HPDocumentType	A value set of LOINC codes indicating the type of history and physical.
ProcedureNoteDocumentTypeCodes	A value set of LOINC codes indicating the type of procedure note.
ProgressNoteDocumentTypeCode	A value set of LOINC codes indicating the type of progress note
ReferralDocumentType	A value set of LOINC codes indicating the type of referral.

M.0.5 Code Systems

This guide references the following code systems.

Name	Definition
ConfidentialityCode	A set of codes specifying the security classification of acts and roles in accordance with the definition for concept domain "Confidentiality".
DCM	DICOM Controlled Terminology
FHIR CompositionAttestationMode	FHIR defined inline code system.
HL7ActClass	Codes indicating the class of an act.
LOINC	Logical Observation Identifiers Names and Codes (LOINC).

M.0.6 References

Name	Definition
HL7 Implementation Guide for CDA Release 2: Consolidated CDA Templates for Clinical Notes	The Consolidated CDA (C-CDA) implementation guide contains a library of CDA templates, incorporating and harmonizing previous efforts from Health Level Seven (HL7), Integrating the Healthcare Enterprise (IHE), and Health Information Technology Standards Panel (HITSP). It represents harmonization of the HL7 Health Story guides, HITSP C32, related components of IHE Patient Care Coordination (IHE PCC), and Continuity of Care (CCD). C-CDA Release 1 included all required CDA templates in Final Rules for Stage 1 Meaningful Use and 45 CFR Part 170 – Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology; Final Rule.
U.S. Data Access Framework (DAF) FHIR Implementation Guide (IG)	A U.S. Realm guide for making use of FHIR resources to support queries between systems within an enterprise and across enterprises

M.0 CDA Logical Model

This defines a Logical Model for CDA itself (the HL7 V3 RIM-based standard). Uses to be evaluated. This is not intended to be part of C-CDA on FHIR but is currently published here until we find a good home for it.