Consolidated CDA (C-CDA)
3.0.0 - STU3 United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0: CCDA 3.0) generated with FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version in its permanent home (it will always be available at this URL). 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 Average Blood Pressure Organizer
.... 11.90 Basic Industry Observation
.... 11.91 Basic Occupation Observation
.... 11.92 Birth Sex Observation
.... 11.93 Brand Name Observation
.... 11.94 Care Experience Preference
.... 11.95 Care Team Member Act
.... 11.96 Care Team Member Schedule Observation
.... 11.97 Care Team Organizer
.... 11.98 Care Team Type Observation
.... 11.99 Caregiver Characteristics
.... 11.100 Catalog Number Observation
.... 11.101 Characteristics of Home Environment
.... 11.102 Comment Activity
.... 11.103 Company Name Observation
.... 11.104 Coverage Activity
.... 11.105 Criticality Observation
.... 11.106 Cultural and Religious Observation
.... 11.107 Date of Diagnosis Act
.... 11.108 Deceased Observation
.... 11.109 Device Identifier Observation
.... 11.110 Disability Status Observation
.... 11.111 Discharge Medication
.... 11.112 Distinct Identification Code Observation
.... 11.113 Drug Monitoring Act
.... 11.114 Drug Vehicle
.... 11.115 Encounter Activity
.... 11.116 Encounter Diagnosis
.... 11.117 Entry Reference
.... 11.118 Estimated Date of Delivery
.... 11.119 Expiration Date Observation
.... 11.120 External Document Reference
.... 11.121 Family History Death Observation
.... 11.122 Family History Observation
.... 11.123 Family History Organizer
.... 11.124 Functional Status Observation
.... 11.125 Functional Status Organizer
.... 11.126 Gender Identity Observation
.... 11.127 Goal Observation
.... 11.128 Handoff Communication Participants
.... 11.129 Health Concern Act
.... 11.130 Health Status Observation
.... 11.131 Highest Pressure Ulcer Stage
.... 11.132 Hospital Admission Diagnosis
.... 11.133 Hospital Discharge Diagnosis
.... 11.134 Immunization Activity
.... 11.135 Immunization Medication Information
.... 11.136 Immunization Not Given Reason
.... 11.137 Implantable Device Status Observation
.... 11.138 Indication
.... 11.139 Instruction
.... 11.140 Intervention Act
.... 11.141 Latex Safety Observation
.... 11.142 Longitudinal Care Wound Observation
.... 11.143 Lot or Batch Number Observation
.... 11.144 Manufacturing Date Observation
.... 11.145 Medical Equipment Organizer
.... 11.146 Medication Activity
.... 11.147 Medication Adherence
.... 11.148 Medication Dispense
.... 11.149 Medication Free Text Sig
.... 11.150 Medication Information
.... 11.151 Medication Supply Order
.... 11.152 Mental Status Observation
.... 11.153 Mental Status Organizer
.... 11.154 Model Number Observation
.... 11.155 MRI Safety Observation
.... 11.156 Non-Medicinal Supply Activity
.... 11.157 Note Activity
.... 11.158 Number of Pressure Ulcers Observation
.... 11.159 Nutrition Assessment
.... 11.160 Nutrition Recommendation
.... 11.161 Nutritional Status Observation
.... 11.162 Outcome Observation
.... 11.163 Patient Referral 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 Procedure
.... 11.170 Planned Supply
.... 11.171 Policy Activity
.... 11.172 Postprocedure Diagnosis
.... 11.173 Precondition for Substance Administration
.... 11.174 Pregnancy Intention in Next Year
.... 11.175 Pregnancy Observation
.... 11.176 Preoperative Diagnosis
.... 11.177 Priority Preference
.... 11.178 Problem Concern Act
.... 11.179 Problem Observation
.... 11.180 Problem Status
.... 11.181 Procedure Activity Procedure
.... 11.182 Product Instance
.... 11.183 Prognosis Observation
.... 11.184 Progress Toward Goal Observation
.... 11.185 Reaction Observation
.... 11.186 Reason
.... 11.187 Result Observation
.... 11.188 Result Organizer
.... 11.189 Risk Concern Act
.... 11.190 Section Time Range Observation
.... 11.191 Self-Care Activities (ADL and IADL)
.... 11.192 Sensory Status
.... 11.193 Serial Number Observation
.... 11.194 Service Delivery Location
.... 11.195 Severity Observation
.... 11.196 Sex Observation
.... 11.197 Sexual Orientation Observation
.... 11.198 Smoking Status
.... 11.199 Social History Observation
.... 11.200 Specimen Collection Procedure
.... 11.201 Specimen Condition Observation
.... 11.202 Substance Administered Act
.... 11.203 Substance or Device Allergy - Intolerance Observation
.... 11.204 Treatment Intervention Preference
.... 11.205 Tribal Affiliation Observation
.... 11.206 UDI Organizer
.... 11.207 Vital Sign Observation
.... 11.208 Vital Signs Organizer
.... 11.209 Wound Characteristic
.... 11.210 Wound Measurement Observation
.... 11.211 Author Participation
.... 11.212 Provenance - Assembler Participation
.... 11.213 Provenance - Author Participation
.... 11.214 Related Person Relationship and Name Participant
.... 11.215 US Realm Address
.... 11.216 US Realm Date and Time - Interval
.... 11.217 US Realm Date and Time - Point in Time
.... 11.218 US Realm Patient Name (PTN.US.FIELDED)
.... 11.219 US Realm Person Name (PN.US.FIELDED)
.... 11.220 Smoking Status - Meaningful Use
.... 11.221 Tobacco Use
.... 11.222 Example of Allergy Intolerance to Food Egg
.... 11.223 Admission Diagnosis Section Example
.... 11.224 Admission Medication example
.... 11.225 Advance Directive Observation Example
.... 11.226 Advance Directive Organizer Example
.... 11.227 Advance Directives Section Example
.... 11.228 Age Observation Example
.... 11.229 Allergies and Intolerances Section Example
.... 11.230 Allergy Concern Act Example
.... 11.231 Allergy Intolerance Observation Medication Example
.... 11.232 Allergy Intolerance Observation Drug Class Example
.... 11.233 Allergy Intolerance Observation Non-Medication Example
.... 11.234 Anesthesia Section Example
.... 11.235 Assessment and Plan Section Example
.... 11.236 Assessment Scale Observation Example
.... 11.237 Assessment Scale Supporting Observation Example
.... 11.238 Assessment Section Example
.... 11.239 Author Participation Example
.... 11.240 Authorization Activity Example
.... 11.241 Basic Industry Observation Example
.... 11.242 Basic Occupation Observation Example
.... 11.243 Birth Sex Observation Example
.... 11.244 Brand Name Observation Example
.... 11.245 Care Plan Caregiver participant Example
.... 11.246 Care Plan Patient authenticator Example
.... 11.247 Care Plan performer Example
.... 11.248 Care Plan relatedDocument Example
.... 11.249 Care Plan Review Example
.... 11.250 Care Plan Complete Header Example
.... 11.251 Care Team Member Act Example
.... 11.252 Care Team Member Schedule Observation Example
.... 11.253 Care Team Organizer Example
.... 11.254 Care Teams Section Example
.... 11.255 Care Team Type Observation Example
.... 11.256 Catalog Number Observation Example
.... 11.257 Caregiver Characteristics Example
.... 11.258 Characteristics of Home Environment Example
.... 11.259 Chief Complaint and Reason for Visit Section Example
.... 11.260 Chief Complaint Section Example
.... 11.261 Comment Activity Example
.... 11.262 Company Name Observation Example
.... 11.263 Complications Section Example
.... 11.264 Continuity Of Care Document Complete Header Example
.... 11.265 Continuity Of Care Document Author Example
.... 11.266 Continuity Of Care Document Performer
.... 11.267 Continuity Of Care Document serviceEvent Example
.... 11.268 Consultation Note Complete Header Example
.... 11.269 Consultation Note Callback participant Example
.... 11.270 Consultation Note inFulfillmentOf Example
.... 11.271 Course of Care Section Example
.... 11.272 Coverage Activity Example
.... 11.273 Criticality Observation Example
.... 11.274 Cultural and Religious Observation Example
.... 11.275 Date of Diagnosis Act Example
.... 11.276 Deceased Observation Example
.... 11.277 Device Identifier Observation Example
.... 11.278 Diagnosis Reference Example
.... 11.279 Disability Status Observation Example
.... 11.280 Discharge Diagnosis Example
.... 11.281 Discharge Medication Example
.... 11.282 Discharge Medications Section Example
.... 11.283 Discharge Summary Complete Header Example
.... 11.284 Discharge Summary encompassingEncounter Example
.... 11.285 Distinct Identification Code Observation Example
.... 11.286 Drug Monitoring Act Example
.... 11.287 Drug Vehicle Example
.... 11.288 Encounter Activity Example
.... 11.289 Encounter Diagnosis Example
.... 11.290 Encounters Section Example
.... 11.291 Entry Reference Example
.... 11.292 Estimated Date of Delivery Example
.... 11.293 Expiration Date Observation Example
.... 11.294 External Document Reference Example
.... 11.295 Family History Death Observation Example
.... 11.296 Family History Observation Example
.... 11.297 Family History Organizer Example
.... 11.298 Family History Section Example
.... 11.299 Functional Status Observation Example
.... 11.300 Functional Status Organizer Example
.... 11.301 Functional Status Section Example
.... 11.302 Gender Identity Observation Example
.... 11.303 General Status Section Example
.... 11.304 Goal Observation Example
.... 11.305 Goals Section Example
.... 11.306 Handoff Communication Participants Example
.... 11.307 Health Concern Act Example
.... 11.308 Health Concerns Section Example
.... 11.309 Health Status Evalutations and Outcomes Section Example
.... 11.310 Health Status Observation Example
.... 11.311 Highest Pressure Ulcer Stage Example
.... 11.312 History and Physical Encompassing Encounter Example
.... 11.313 History and Physical Complete Header Example
.... 11.314 History Of Present Illness Example
.... 11.315 Hospital Admission Diagnosis Example
.... 11.316 Hospital Consultations Section Example
.... 11.317 Hospital Course Section Example
.... 11.318 Hospital Discharge Diagnosis Example
.... 11.319 Hospital Discharge Instructions Section Example
.... 11.320 Hospital Discharge Physical Section Example
.... 11.321 Hospital Discharge Studies Summary Section Example
.... 11.322 Immunization Activity Example
.... 11.323 Immunization Medication Information Example
.... 11.324 Immunization Not Given Reason Example
.... 11.325 Immunizations Section Example
.... 11.326 Implantable Device Status Observation Example
.... 11.327 Indication Example
.... 11.328 Instructions Section Example
.... 11.329 Instruction Example
.... 11.330 Intervention Act Example
.... 11.331 Latex Safety Observation Example
.... 11.332 Longitudinal Care Wound Observation Example
.... 11.333 Lot or Batch Number Observation Example
.... 11.334 Manufacturing Date Observation Example
.... 11.335 Medical Equipment Organizer Example
.... 11.336 Medical Equipment Section Example
.... 11.337 Medication Activity Example
.... 11.338 Medication Adherence Example
.... 11.339 Medication Dispense Example
.... 11.340 Medication Free Text Sig Example
.... 11.341 Medication Information Example
.... 11.342 Medication Supply Order Example
.... 11.343 Medications Administered Section Example
.... 11.344 Medications Section Example
.... 11.345 Mental Status Observation Example
.... 11.346 Mental Status Organizer Example
.... 11.347 Mental Status Section Example
.... 11.348 Model Number Observation Example
.... 11.349 MRI Safety Observation Example
.... 11.350 No Known Medications Example
.... 11.351 No Known Problem Section Example
.... 11.352 Non-Medicinal Supply Activity Example
.... 11.353 Note Activity Entry Relationship Example
.... 11.354 Note Activity Standalone Example
.... 11.355 nonXML Body Example with Compressed Content
.... 11.356 nonXML Body Example with Embedded Content
.... 11.357 nonXML Body Example with Referenced Content
.... 11.358 Number of Pressure Ulcers Observation Example
.... 11.359 Nutrition Assessment Example
.... 11.360 Nutrition Recommendation Example
.... 11.361 Nutrition Section Example
.... 11.362 Nutritional Status Observation Example
.... 11.363 Objective Section Example
.... 11.364 Operative Note Complete Header Example
.... 11.365 Operative Note performer Example
.... 11.366 Operative Note serviceEvent Example
.... 11.367 Operative Note Fluids Section Example
.... 11.368 Operative Note Surgical Procedure Section Example
.... 11.369 Outcome Observation Example
.... 11.370 Past Medical History Example
.... 11.371 Patient Generated Document authenticator
.... 11.372 Patient Generated Document author device Example
.... 11.373 Patient Generated Document author
.... 11.374 Patient Generated Document custodian Example
.... 11.375 Patient Generated Document dataEnterer
.... 11.376 Patient Generated Document informant Example informant
.... 11.377 Patient Generated Document informant RelEnt Example
.... 11.378 Patient Generated Document informationRecipient Example
.... 11.379 Patient Generated Document inFulfillmentOf Example
.... 11.380 Patient Generated Document legalAuthenticator Example
.... 11.381 Patient Generated Document participant Example
.... 11.382 Patient Generated Document recordTarget
.... 11.383 Patient Referral Act Example
.... 11.384 Payers Section Example
.... 11.385 Physical Exam Section Example
.... 11.386 Plan of Treatment Section Example
.... 11.387 Planned Coverage Example
.... 11.388 Planned Encounter Example
.... 11.389 Planned Immunization Activity Example
.... 11.390 Planned Intervention Activity Example
.... 11.391 Planned Medication Activity Example
.... 11.392 Planned Procedure Section Example
.... 11.393 Planned Procedure Example
.... 11.394 Planned Supply Example
.... 11.395 Policy Activity Example
.... 11.396 Postoperative Diagnosis Section Example
.... 11.397 Postprocedure Diagnosis Example
.... 11.398 Postprocedure Diagnosis Section Example
.... 11.399 Precondition for Substance Administration Example
.... 11.400 Pregnancy Intention in Next Year Example
.... 11.401 Pregnancy Observation Example
.... 11.402 Preoperative Diagnosis Section Example
.... 11.403 Preoperative Diagnosis Example
.... 11.404 Priority Preference Example
.... 11.405 Problem Concern Act Example
.... 11.406 Problem Observation Example
.... 11.407 Problem Observation with Post-Coordinated SNOMED Example
.... 11.408 Problem Section Example
.... 11.409 Procedure Note Complete Header Example
.... 11.410 Procedure Note performer Example
.... 11.411 Procedure Note serviceEvent Example
.... 11.412 Procedure Activity Procedure Example
.... 11.413 Procedure Description Section Example
.... 11.414 Procedure Disposition Section Example
.... 11.415 Procedure Estimated Blood Loss Section Example
.... 11.416 Procedure Findings Section Example
.... 11.417 Procedure Implants Section Example
.... 11.418 Procedure Indications Section Example
.... 11.419 Procedure Specimens Taken Section Example
.... 11.420 Procedures Section Example
.... 11.421 Product Instance Example
.... 11.422 Prognosis Coded Example
.... 11.423 Prognosis Free Text Example
.... 11.424 Progress Note Complete Header Example
.... 11.425 Progress Note encompassingEncounter Example
.... 11.426 Progress Note serviceEvent Example
.... 11.427 Progress Toward Goal Observation Example
.... 11.428 Provenance - Assembler Participation Example
.... 11.429 Provenance - Author Participation Example
.... 11.430 Reaction Observation Example
.... 11.431 Reason Example
.... 11.432 Reason For Referral
.... 11.433 Reason for Visit Section Example
.... 11.434 Referral Note Complete Header Example
.... 11.435 Referral Note Callback Contact Example
.... 11.436 Referral Note Caregiver
.... 11.437 Referral Note informationRecipient Example
.... 11.438 Related Person Relationship and Name Participant Example
.... 11.439 Result Observation Example
.... 11.440 Result Organizer Example
.... 11.441 Results Section Example
.... 11.442 Review Of Systems Section Example
.... 11.443 Risk Concern Act Example
.... 11.444 Self-Care Activities ADL and IADL Example
.... 11.445 Sensory Status Example
.... 11.446 Serial Number Observation Example
.... 11.447 Service Delivery Location Example
.... 11.448 Severity Observation Example
.... 11.449 Sexual Orientation Observation Example
.... 11.450 Smoking Status Coded Example
.... 11.451 Smoking Status Quantity Example
.... 11.452 Smoking Status Meaningful Use Example
.... 11.453 Specimen Collection Procedure Example
.... 11.454 Specimen Condition Observation Example
.... 11.455 Social History Section Example
.... 11.456 Subjective Section Example
.... 11.457 Substance Administered Act Example
.... 11.458 Surgical Drains Section Example
.... 11.459 Tobacco Use Example
.... 11.460 Transfer Summary Complete Header Example
.... 11.461 Transfer Summary Callback Contact Example
.... 11.462 Transfer Summary participant (Support) Example
.... 11.463 Tribal Affiliation Observation Example
.... 11.464 UDI Organizer Example
.... 11.465 US Realm Address Example
.... 11.466 US Realm Date and Time Example
.... 11.467 US Realm Date and Time Interval Example
.... 11.468 US Realm Header Example
.... 11.469 US Realm Person Name Example
.... 11.470 Vital Sign Observation Example
.... 11.471 Average Blood Pressure Organizer Example
.... 11.472 Vital Signs Organizer Example
.... 11.473 Vital Signs Section Example
.... 11.474 Wound Characteristic Example
.... 11.475 Wound Measurement Observation Example
.... 11.476 NUBC UB-04 FL17 Patient Status