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

Table of Contents

.. 0 Table of Contents
... 1 IG Home Page
... 2 USCDI
... 3 General Guidance
... 4 Screening And Assessments
... 5 Supporting Guidance
... 6 Validation
... 7 How To Read
... 8 Downloads
... 9 Terminology
... 10 Change Log
... 11 Artifacts Summary
.... 11.1 Care Plan
.... 11.2 Consultation Note
.... 11.3 Continuity of Care Document (CCD)
.... 11.4 Discharge Summary
.... 11.5 History and Physical
.... 11.6 Operative Note
.... 11.7 Procedure Note
.... 11.8 Progress Note
.... 11.9 Referral Note
.... 11.10 Transfer Summary
.... 11.11 Unstructured Document
.... 11.12 US Realm Header
.... 11.13 US Realm Header for Patient Generated Document
.... 11.14 Activities Section
.... 11.15 Admission Diagnosis Section
.... 11.16 Admission Medications Section (entries optional)
.... 11.17 Advance Directives Section
.... 11.18 Allergies and Intolerances Section
.... 11.19 Anesthesia Section
.... 11.20 Assessment and Plan Section
.... 11.21 Assessment Section
.... 11.22 Care Teams Section
.... 11.23 Chief Complaint and Reason for Visit Section
.... 11.24 Chief Complaint Section
.... 11.25 Complications Section
.... 11.26 Course of Care Section
.... 11.27 Discharge Diagnosis Section
.... 11.28 Discharge Medications Section
.... 11.29 Encounters Section
.... 11.30 Family History Section
.... 11.31 Functional Status Section
.... 11.32 General Status Section
.... 11.33 Goals Section
.... 11.34 Health Concerns Section
.... 11.35 Health Status Evaluations and Outcomes Section
.... 11.36 History of Present Illness Section
.... 11.37 Hospital Consultations Section
.... 11.38 Hospital Course Section
.... 11.39 Hospital Discharge Instructions Section
.... 11.40 Hospital Discharge Physical Section
.... 11.41 Hospital Discharge Studies Summary Section
.... 11.42 Immunizations Section
.... 11.43 Instructions Section
.... 11.44 Medical (General) History Section
.... 11.45 Medical Equipment Section
.... 11.46 Medications Administered Section
.... 11.47 Medications Section
.... 11.48 Mental Status Section
.... 11.49 Notes Section
.... 11.50 Nutrition Section
.... 11.51 Objective Section
.... 11.52 Operative Note Fluids Section
.... 11.53 Operative Note Surgical Procedure Section
.... 11.54 Past Medical History
.... 11.55 Payers Section
.... 11.56 Physical Exam Section
.... 11.57 Plan of Treatment Section
.... 11.58 Planned Procedure Section
.... 11.59 Postoperative Diagnosis Section
.... 11.60 Postprocedure Diagnosis Section
.... 11.61 Preoperative Diagnosis Section
.... 11.62 Problem Section
.... 11.63 Procedure Description Section
.... 11.64 Procedure Disposition Section
.... 11.65 Procedure Estimated Blood Loss Section
.... 11.66 Procedure Findings Section
.... 11.67 Procedure Implants Section
.... 11.68 Procedure Indications Section
.... 11.69 Procedure Specimens Taken Section
.... 11.70 Procedures Section
.... 11.71 Reason for Referral Section
.... 11.72 Reason for Visit Section
.... 11.73 Results Section
.... 11.74 Review of Systems Section
.... 11.75 Social History Section
.... 11.76 Subjective Section
.... 11.77 Surgical Drains Section
.... 11.78 Vital Signs Section
.... 11.79 Admission Medication
.... 11.80 Advance Directive Observation
.... 11.81 Advance Directive Organizer
.... 11.82 Age Observation
.... 11.83 Allergy - Intolerance Observation
.... 11.84 Allergy Concern Act
.... 11.85 Allergy Status Observation
.... 11.86 Assessment Scale Observation
.... 11.87 Assessment Scale Supporting Observation
.... 11.88 Authorization Activity
.... 11.89 Basic Industry Observation
.... 11.90 Basic Occupation Observation
.... 11.91 Birth Sex Observation
.... 11.92 Brand Name Observation
.... 11.93 Care Experience Preference
.... 11.94 Care Team Member Act
.... 11.95 Care Team Member Schedule Observation
.... 11.96 Care Team Organizer
.... 11.97 Care Team Type Observation
.... 11.98 Caregiver Characteristics
.... 11.99 Catalog Number Observation
.... 11.100 Characteristics of Home Environment
.... 11.101 Comment Activity
.... 11.102 Company Name Observation
.... 11.103 Coverage Activity
.... 11.104 Criticality Observation
.... 11.105 Cultural and Religious Observation
.... 11.106 Date of Diagnosis Act
.... 11.107 Deceased Observation
.... 11.108 Device Identifier Observation
.... 11.109 Disability Status Observation
.... 11.110 Discharge Medication
.... 11.111 Distinct Identification Code Observation
.... 11.112 Drug Monitoring Act
.... 11.113 Drug Vehicle
.... 11.114 Encounter Activity
.... 11.115 Encounter Diagnosis
.... 11.116 Entry Reference
.... 11.117 Estimated Date of Delivery
.... 11.118 Expiration Date Observation
.... 11.119 External Document Reference
.... 11.120 Family History Death Observation
.... 11.121 Family History Observation
.... 11.122 Family History Organizer
.... 11.123 Functional Status Observation
.... 11.124 Functional Status Organizer
.... 11.125 Gender Identity Observation
.... 11.126 Goal Observation
.... 11.127 Handoff Communication Participants
.... 11.128 Health Concern Act
.... 11.129 Health Status Observation
.... 11.130 Highest Pressure Ulcer Stage
.... 11.131 Hospital Admission Diagnosis
.... 11.132 Hospital Discharge Diagnosis
.... 11.133 Immunization Activity
.... 11.134 Immunization Medication Information
.... 11.135 Immunization Refusal Reason
.... 11.136 Implantable Device Status Observation
.... 11.137 Indication
.... 11.138 Instruction
.... 11.139 Intervention Act
.... 11.140 Latex Safety Observation
.... 11.141 Longitudinal Care Wound Observation
.... 11.142 Lot or Batch Number Observation
.... 11.143 Manufacturing Date Observation
.... 11.144 Medical Equipment Organizer
.... 11.145 Medication Activity
.... 11.146 Medication Adherence
.... 11.147 Medication Dispense
.... 11.148 Medication Free Text Sig
.... 11.149 Medication Information
.... 11.150 Medication Supply Order
.... 11.151 Mental Status Observation
.... 11.152 Mental Status Organizer
.... 11.153 Model Number Observation
.... 11.154 MRI Safety Observation
.... 11.155 Non-Medicinal Supply Activity
.... 11.156 Note Activity
.... 11.157 Number of Pressure Ulcers Observation
.... 11.158 Nutrition Assessment
.... 11.159 Nutrition Recommendation
.... 11.160 Nutritional Status Observation
.... 11.161 Outcome Observation
.... 11.162 Patient Referral Act
.... 11.163 Planned Act
.... 11.164 Planned Coverage
.... 11.165 Planned Encounter
.... 11.166 Planned Immunization Activity
.... 11.167 Planned Intervention Act
.... 11.168 Planned Medication Activity
.... 11.169 Planned Observation
.... 11.170 Planned Procedure
.... 11.171 Planned Supply
.... 11.172 Policy Activity
.... 11.173 Postprocedure Diagnosis
.... 11.174 Precondition for Substance Administration
.... 11.175 Pregnancy Intention in Next Year
.... 11.176 Pregnancy Observation
.... 11.177 Preoperative Diagnosis
.... 11.178 Priority Preference
.... 11.179 Problem Concern Act
.... 11.180 Problem Observation
.... 11.181 Problem Status
.... 11.182 Procedure Activity Procedure
.... 11.183 Product Instance
.... 11.184 Prognosis Observation
.... 11.185 Progress Toward Goal Observation
.... 11.186 Reaction Observation
.... 11.187 Reason
.... 11.188 Result Observation
.... 11.189 Result Organizer
.... 11.190 Risk Concern Act
.... 11.191 Section Time Range Observation
.... 11.192 Self-Care Activities (ADL and IADL)
.... 11.193 Sensory Status
.... 11.194 Serial Number Observation
.... 11.195 Service Delivery Location
.... 11.196 Severity Observation
.... 11.197 Sex Observation
.... 11.198 Sexual Orientation Observation
.... 11.199 Smoking Status - Meaningful Use
.... 11.200 Social History Observation
.... 11.201 Specimen Collection Procedure
.... 11.202 Specimen Condition Observation
.... 11.203 Specimen Reject Reason Observation
.... 11.204 Substance Administered Act
.... 11.205 Substance or Device Allergy - Intolerance Observation
.... 11.206 Tobacco Use
.... 11.207 Treatment Intervention Preference
.... 11.208 Tribal Affiliation Observation
.... 11.209 UDI Organizer
.... 11.210 Vital Sign Observation
.... 11.211 Vital Signs Organizer
.... 11.212 Wound Characteristic
.... 11.213 Wound Measurement Observation
.... 11.214 Author Participation
.... 11.215 Provenance - Assembler Participation
.... 11.216 Provenance - Author Participation
.... 11.217 Related Person Relationship and Name Participant
.... 11.218 US Realm Address
.... 11.219 US Realm Date and Time - Interval
.... 11.220 US Realm Date and Time - Point in Time
.... 11.221 US Realm Patient Name (PTN.US.FIELDED)
.... 11.222 US Realm Person Name (PN.US.FIELDED)
.... 11.223 Example of Allergy Intolerance to Food Egg
.... 11.224 Admission Diagnosis Section Example
.... 11.225 Admission Medication example
.... 11.226 Advance Directive Observation Example
.... 11.227 Advance Directive Organizer Example
.... 11.228 Advance Directives Section Example
.... 11.229 Age Observation Example
.... 11.230 Allergies and Intolerances Section Example
.... 11.231 Allergy Concern Act Example
.... 11.232 Allergy Intolerance Observation Example
.... 11.233 Anesthesia Section Example
.... 11.234 Assessment and PlanSection Example
.... 11.235 Assessment Scale Observation Example
.... 11.236 Assessment Scale Supporting Observation Example
.... 11.237 Assessment Section Example
.... 11.238 Author Participation Example
.... 11.239 Authorization Activity Example
.... 11.240 Basic Industry Observation Example
.... 11.241 Basic Occupation Observation Example
.... 11.242 Birth Sex Observation Example
.... 11.243 Brand Name Observation Example
.... 11.244 Care Plan Caregiver participant Example
.... 11.245 Care Plan Patient authenticator Example
.... 11.246 Care Plan performer Example
.... 11.247 Care Plan relatedDocument Example
.... 11.248 Care Plan Review Example
.... 11.249 Care Plan Complete Example
.... 11.250 Care Team Member Act Example
.... 11.251 Care Team Member Schedule Observation Example
.... 11.252 Care Team Organizer Example
.... 11.253 Care Teams Section Example
.... 11.254 Care Team Type Observation Example
.... 11.255 Catalog Number Observation Example
.... 11.256 Caregiver Characteristics Example
.... 11.257 Characteristics of Home Environment Example
.... 11.258 Chief Complaint and Reason for Visit Section Example
.... 11.259 Chief Complaint Section Example
.... 11.260 Comment Activity Example
.... 11.261 Company Name Observation Example
.... 11.262 Complications Section Example
.... 11.263 Continuity Of Care Document Author Example
.... 11.264 Continuity Of Care Document Performer
.... 11.265 Continuity Of Care Document serviceEvent Example
.... 11.266 Consultation Note Complete Example
.... 11.267 Consultation Note Callback participant Example
.... 11.268 Consultation Note inFulfillmentOf Example
.... 11.269 Course of Care Section Example
.... 11.270 Coverage Activity Example
.... 11.271 Criticality Observation Example
.... 11.272 Cultural and Religious Observation Example
.... 11.273 Date of Diagnosis Act Example
.... 11.274 Deceased Observation Example
.... 11.275 Device Identifier Observation Example
.... 11.276 Diagnosis Reference Example
.... 11.277 Disability Status Observation Example
.... 11.278 Discharge Diagnosis Example
.... 11.279 Discharge Medication Example
.... 11.280 Discharge Medications Section Example
.... 11.281 Discharge Summary encompassingEncounter Example
.... 11.282 Distinct Identification Code Observation Example
.... 11.283 Drug Monitoring Act Example
.... 11.284 Drug Vehicle Example
.... 11.285 Encounter Activity Example
.... 11.286 Encounter Diagnosis Example
.... 11.287 Encounters Section Example
.... 11.288 Entry Reference Example
.... 11.289 Estimated Date of Delivery Example
.... 11.290 Expiration Date Observation Example
.... 11.291 External Document Reference Example
.... 11.292 Family History Death Observation Example
.... 11.293 Family History Observation Example
.... 11.294 Family History Organizer Example
.... 11.295 Family History Section Example
.... 11.296 Functional Status Observation Example
.... 11.297 Functional Status Organizer Example
.... 11.298 Functional Status Section Example
.... 11.299 Gender Identity Observation Example
.... 11.300 General Status Section Example
.... 11.301 Goal Observation Example
.... 11.302 Goals Section Example
.... 11.303 Handoff Communication Participants Example
.... 11.304 Health Concern Act Example
.... 11.305 Health Concerns Section Example
.... 11.306 Health Status Evalutations and Outcomes Section Example
.... 11.307 Health Status Observation Example
.... 11.308 Highest Pressure Ulcer Stage Example
.... 11.309 History and Physical Encompassing Encounter Example
.... 11.310 History Of Present Illness Example
.... 11.311 Hospital Admission Diagnosis Example
.... 11.312 Hospital Consultations Section Example
.... 11.313 Hospital Course Section Example
.... 11.314 Hospital Discharge Diagnosis Example
.... 11.315 Hospital Discharge Instructions Section Example
.... 11.316 Hospital Discharge Physical Section Example
.... 11.317 Hospital Discharge Studies Summary Section Example
.... 11.318 Immunization Activity Example
.... 11.319 Immunization Medication Information Example
.... 11.320 Immunization Refusal Reason Example
.... 11.321 Immunizations Section Example
.... 11.322 Implantable Device Status Observation Example
.... 11.323 Indication Example
.... 11.324 Instructions Section Example
.... 11.325 Instruction Example
.... 11.326 Intervention Act Example
.... 11.327 Latex Safety Observation Example
.... 11.328 Longitudinal Care Wound Observation Example
.... 11.329 Lot or Batch Number Observation Example
.... 11.330 Manufacturing Date Observation Example
.... 11.331 Medical Equipment Organizer Example
.... 11.332 Medical Equipment Section Example
.... 11.333 Medication Activity Example
.... 11.334 Medication Dispense Example
.... 11.335 Medication Free Text Sig Example
.... 11.336 Medication Information Example
.... 11.337 Medication Supply Order Example
.... 11.338 Medications Administered Section Example
.... 11.339 Medications Section Example
.... 11.340 Mental Status Observation Example
.... 11.341 Mental Status Organizer Example
.... 11.342 Mental Status Section Example
.... 11.343 Model Number Observation Example
.... 11.344 MRI Safety Observation Example
.... 11.345 No Known Medications Example
.... 11.346 No Known Problem Section Example
.... 11.347 Non-Medicinal Supply Activity Example
.... 11.348 Note Activity Entry Relationship Example
.... 11.349 Note Activity Standalone Example
.... 11.350 nonXML Body Example with Compressed Content
.... 11.351 nonXML Body Example with Embedded Content
.... 11.352 nonXML Body Example with Referenced Content
.... 11.353 Number of Pressure Ulcers Observation Example
.... 11.354 Nutrition Assessment Example
.... 11.355 Nutrition Recommendation Example
.... 11.356 Nutrition Section Example
.... 11.357 Nutritional Status Observation Example
.... 11.358 Objective Section Example
.... 11.359 Operative Note performer Example
.... 11.360 Operative Note serviceEvent Example
.... 11.361 Operative Note Fluids Section Example
.... 11.362 Operative Note Surgical Procedure Section Example
.... 11.363 Outcome Observation Example
.... 11.364 Past Medical History Example
.... 11.365 Patient Generated Document authenticator
.... 11.366 Patient Generated Document author device Example
.... 11.367 Patient Generated Document author
.... 11.368 Patient Generated Document custodian Example
.... 11.369 Patient Generated Document dataEnterer
.... 11.370 Patient Generated Document informant Example informant
.... 11.371 Patient Generated Document informant RelEnt Example
.... 11.372 Patient Generated Document informationRecipient Example
.... 11.373 Patient Generated Document inFulfillmentOf Example
.... 11.374 Patient Generated Document legalAuthenticator Example
.... 11.375 Patient Generated Document participant Example
.... 11.376 Patient Generated Document recordTarget
.... 11.377 Patient Referral Act Example
.... 11.378 Payers Section Example
.... 11.379 Physical Exam Section Example
.... 11.380 Plan of Treatment Section Example
.... 11.381 Planned Act Example
.... 11.382 Planned Coverage Example
.... 11.383 Planned Encounter Example
.... 11.384 Planned Immunization Activity Example
.... 11.385 Planned Intervention Activity Example
.... 11.386 Planned Medication Activity Example
.... 11.387 Planned Observation Example
.... 11.388 Planned Procedure Section Example
.... 11.389 Planned Procedure Example
.... 11.390 Planned Supply Example
.... 11.391 Policy Activity Example
.... 11.392 Postoperative Diagnosis Section Example
.... 11.393 Postprocedure Diagnosis Section Example
.... 11.394 Precondition for Substance Administration Example
.... 11.395 Pregnancy Intention in Next Year Example
.... 11.396 Pregnancy Observation Example
.... 11.397 Preoperative Diagnosis Section Example
.... 11.398 Preoperative Diagnosis Example
.... 11.399 Priority Preference Example
.... 11.400 Problem Concern Act Example
.... 11.401 Problem Observation Example
.... 11.402 Problem Observation with Post-Coordinated SNOMED Example
.... 11.403 Problem Section Example
.... 11.404 Procedure Note performer Example
.... 11.405 Procedure Note serviceEvent Example
.... 11.406 Procedure Activity Procedure Example
.... 11.407 Procedure Description Section Example
.... 11.408 Procedure Disposition Section Example
.... 11.409 Procedure Estimated Blood Loss Section Example
.... 11.410 Procedure Findings Section Example
.... 11.411 Procedure Implants Section Example
.... 11.412 Procedure Indications Section Example
.... 11.413 Procedure Specimens Taken Section Example
.... 11.414 Procedures Section Example
.... 11.415 Product Instance Example
.... 11.416 Prognosis Coded Example
.... 11.417 Prognosis Free Text Example
.... 11.418 Progress Note encompassingEncounter Example
.... 11.419 Progress Note serviceEvent Example
.... 11.420 Progress Toward Goal Observation Example
.... 11.421 Provenance - Assembler Participation Example
.... 11.422 Provenance - Author Participation Example
.... 11.423 Reaction Observation Example
.... 11.424 Reason Example
.... 11.425 Reason For Referral
.... 11.426 Reason for Visit Section Example
.... 11.427 Referral Note Callback Contact Example
.... 11.428 Referral Note Caregiver
.... 11.429 Referral Note informationRecipient Example
.... 11.430 Related Person Relationship and Name Participant Example
.... 11.431 Result Observation Example
.... 11.432 Result Organizer Example
.... 11.433 Results Section Example
.... 11.434 Review Of Systems Section Example
.... 11.435 Risk Concern Act Example
.... 11.436 Self-Care Activities ADL and IADL Example
.... 11.437 Sensory Status Example
.... 11.438 Serial Number Observation Example
.... 11.439 Service Delivery Location Example
.... 11.440 Severity Observation Example
.... 11.441 Sexual Orientation Observation Example
.... 11.442 Smoking Status Meaningful Use Example
.... 11.443 Social History Observation Example
.... 11.444 Social History Section Example
.... 11.445 Subjective Section Example
.... 11.446 Substance Administered Act Example
.... 11.447 Surgical Drains Section Example
.... 11.448 Tobacco Use Example
.... 11.449 Transfer Summary Callback Contact Example
.... 11.450 Transfer Summary participant (Support) Example
.... 11.451 Tribal Affiliation Observation Example
.... 11.452 UDI Organizer Example
.... 11.453 US Realm Address Example
.... 11.454 US Realm Date and Time Example
.... 11.455 US Realm Date and Time Interval Example
.... 11.456 US Realm Header Example
.... 11.457 US Realm Person Name Example
.... 11.458 Vital Sign Observation Example
.... 11.459 Vital Sign Average Blood Pressure Example
.... 11.460 Vital Signs Organizer Example
.... 11.461 Vital Signs Section Example
.... 11.462 Wound Characteristic Example
.... 11.463 Wound Measurement Observation Example
.... 11.464 NUBC UB-04 FL17 Patient Status