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. For a full list of available versions, see the Directory of published versions

Downloads

Full Implementation Guide

The entire implementation guide (including the HTML files, definitions, validation information, etc.) may be downloaded here.

In addition, there are format specific definitions files.

• XML
• JSON
• TTL

Examples: All the examples that are used in this Implementation Guide are available for download:

• XML
• JSON
• TTl

Cross Version Analysis

Dependency Table

Package hl7.fhir.uv.extensions.r5#5.1.0 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Sat, Apr 27, 2024 18:39+1000+10:00)

Package hl7.fhir.uv.extensions.r4#1.0.0 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Sun, Mar 26, 2023 08:46+1100+11:00)

Package hl7.fhir.uv.bulkdata#2.0.0 FHIR based approach for exporting large data sets from a FHIR server to a client application (built Fri, Nov 26, 2021 05:56+1100+11:00)

Package hl7.fhir.r4.examples#4.0.1 Example resources in the R4 version of the FHIR standard

Package hl7.fhir.uv.sdc#3.0.0 The SDC specification provides an infrastructure to standardize the capture and expanded use of patient-level data collected within an EHR. This includes two components: * Support more sophisticated questionnaire/form use-cases such as those needed for research, oncology, pathology and other clinical domains. *Support pre-population and auto-population of EHR data into forms/questionnaires for uses outside direct clinical care (patient safety, adverse event reporting, public health reporting, etc.). (built Tue, Mar 8, 2022 18:32+0000+00:00)

Package ihe.formatcode.fhir#1.1.0 Implementation Guide for IHE defined FormatCode vocabulary. (built Thu, Feb 24, 2022 16:55-0600-06:00)

Package hl7.fhir.uv.extensions#5.1.0-ballot1 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Tue, Dec 19, 2023 08:38+1100+11:00)

Package hl7.fhir.us.core#7.0.0 The US Core Implementation Guide is based on FHIR Version R4 and defines the minimum conformance requirements for accessing patient data. The Argonaut pilot implementations, ONC 2015 Edition Common Clinical Data Set (CCDS), and ONC U.S. Core Data for Interoperability (USCDI) v1 provided the requirements for this guide. The prior Argonaut search and vocabulary requirements, based on FHIR DSTU2, are updated in this guide to support FHIR Version R4. This guide was used as the basis for further testing and guidance by the Argonaut Project Team to provide additional content and guidance specific to Data Query Access for purpose of ONC Certification testing. These profiles are the foundation for future US Realm FHIR implementation guides. In addition to Argonaut, they are used by DAF-Research, QI-Core, and CIMI. Under the guidance of HL7 and the HL7 US Realm Steering Committee, the content will expand in future versions to meet the needs specific to the US Realm. These requirements were originally developed, balloted, and published in FHIR DSTU2 as part of the Office of the National Coordinator for Health Information Technology (ONC) sponsored Data Access Framework (DAF) project. For more information on how DAF became US Core see the US Core change notes. (built Tue, Dec 19, 2023 21:01+0000+00:00)

Global Profiles Table

There are no Global profiles defined

IP Statements

This publication includes IP covered under the following statements.

• Copyright HL7. Licensed under creative commons public domain
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  • specimenCondition: SpecimenConditionObservation
• ISO Maintains the copyright on the country codes, and controls it's use carefully. For futher details see the ISO 3166 web page: https://www.iso.org/iso-3166-country-codes.html
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  • ISO 3166-1 Codes for the representation of names of countries and their subdivisions — Part 1: Country code: ActivitiesSection, AdmissionDiagnosisSection... Show 221 more, AdmissionMedication, AdmissionMedicationsSectionEntriesOptional, AdvanceDirectiveObservation, AdvanceDirectiveOrganizer, AdvanceDirectivesSection, AgeObservation, AllergiesAndIntolerancesSection, AllergyConcernAct, AllergyIntoleranceObservation, AllergyStatusObservation, AnesthesiaSection, AssessmentScaleObservation, AssessmentScaleSupportingObservation, AssessmentSection, AssessmentandPlanSection, AuthorParticipation, AuthorizationActivity, AverageBloodPressureOrganizer, BasicIndustryObservation, BasicOccupationObservation, BirthSexObservation, BrandNameObservation, CCDA, CareExperiencePreference, CarePlan, CareTeamMemberAct, CareTeamMemberScheduleObservation, CareTeamOrganizer, CareTeamTypeObservation, CareTeamsSection, CaregiverCharacteristics, CatalogNumberObservation, CharacteristicsofHomeEnvironment, ChiefComplaintSection, ChiefComplaintandReasonforVisitSection, CommentActivity, CompanyNameObservation, ComplicationsSection, ConsultationNote, ContinuityofCareDocumentCCD, CourseofCareSection, CoverageActivity, CriticalityObservation, CulturalandReligiousObservation, DateOfDiagnosisAct, DeceasedObservation, DeviceIdentifierObservation, DisabilityStatusObservation, DischargeDiagnosisSection, DischargeMedication, DischargeMedicationsSection, DischargeSummary, DistinctIdentificationCodeObservation, DrugMonitoringAct, DrugVehicle, EncounterActivity, EncounterDiagnosis, EncountersSection, EntryReference, EstimatedDateofDelivery, ExpirationDateObservation, ExternalDocumentReference, FamilyHistoryDeathObservation, FamilyHistoryObservation, FamilyHistoryOrganizer, FamilyHistorySection, FunctionalStatusObservation, FunctionalStatusOrganizer, FunctionalStatusSection, GenderIdentityObservation, GeneralStatusSection, GoalObservation, GoalsSection, HandoffCommunicationParticipants, HealthConcernAct, HealthConcernsSection, HealthStatusEvaluationsandOutcomesSection, HealthStatusObservation, HighestPressureUlcerStage, HistoryandPhysical, HistoryofPresentIllnessSection, HospitalAdmissionDiagnosis, HospitalConsultationsSection, HospitalCourseSection, HospitalDischargeDiagnosis, HospitalDischargeInstructionsSection, HospitalDischargePhysicalSection, HospitalDischargeStudiesSummarySection, ImmunizationActivity, ImmunizationMedicationInformation, ImmunizationNotGivenReason, ImmunizationsSection, ImplantableDeviceStatusObservation, Indication, Instruction, InstructionsSection, InterventionAct, LatexSafetyObservation, LongitudinalCareWoundObservation, LotOrBatchNumberObservation, MRISafetyObservation, ManufacturingDateObservation, MedicalEquipmentOrganizer, MedicalEquipmentSection, MedicalGeneralHistorySection, MedicationActivity, MedicationAdherence, MedicationDispense, MedicationFreeTextSig, MedicationInformation, MedicationSupplyOrder, MedicationsAdministeredSection, MedicationsSection, MentalStatusObservation, MentalStatusOrganizer, MentalStatusSection, ModelNumberObservation, NonMedicinalSupplyActivity, NoteActivity, NotesSection, NumberofPressureUlcersObservation, NutritionAssessment, NutritionRecommendation, NutritionSection, NutritionalStatusObservation, ObjectiveSection, OperativeNote, OperativeNoteFluidsSection, OperativeNoteSurgicalProcedureSection, OutcomeObservation, PastMedicalHistory, PatientReferralAct, PatientStatus, PayersSection, PhysicalExamSection, PlannedCoverage, PlannedEncounter, PlannedImmunizationActivity, PlannedInterventionAct, PlannedMedicationActivity, PlannedProcedure, PlannedProcedureSection, PlannedSupply, PlanofTreatmentSection, PolicyActivity, PostoperativeDiagnosisSection, PostprocedureDiagnosis, PostprocedureDiagnosisSection, PreconditionforSubstanceAdministration, PregnancyIntentionInNextYear, PregnancyObservation, PreoperativeDiagnosis, PreoperativeDiagnosisSection, PriorityPreference, ProblemConcernAct, ProblemObservation, ProblemSection, ProblemStatus, ProcedureActivityProcedure, ProcedureDescriptionSection, ProcedureDispositionSection, ProcedureEstimatedBloodLossSection, ProcedureFindingsSection, ProcedureImplantsSection, ProcedureIndicationsSection, ProcedureNote, ProcedureSpecimensTakenSection, ProceduresSection, ProductInstance, PrognosisObservation, ProgressNote, ProgressTowardGoalObservation, ProvenanceAssemblerParticipation, ProvenanceAuthorParticipation, ReactionObservation, Reason, ReasonforReferralSection, ReasonforVisitSection, ReferralNote, RelatedPersonRelationshipAndNameParticipant, ResultObservation, ResultOrganizer, ResultsSection, ReviewofSystemsSection, RiskConcernAct, SectionTimeRangeObservation, SelfCareActivitiesADLandIADL, SensoryStatus, SerialNumberObservation, ServiceDeliveryLocation, SeverityObservation, SexObservation, SexualOrientationObservation, SmokingStatus, SmokingStatusMeaningfulUse, SocialHistoryObservation, SocialHistorySection, SpecimenCollectionProcedure, SpecimenConditionObservation, SubjectiveSection, SubstanceAdministeredAct, SubstanceOrDeviceAllergyIntoleranceObservation, SurgicalDrainsSection, TobaccoUse, TransferSummary, TreatmentInterventionPreference, TribalAffiliationObservation, UDIOrganizer, USRealmAddress, USRealmDateTime, USRealmDateTimeInterval, USRealmHeader, USRealmHeaderforPatientGeneratedDocument, USRealmPatientNamePTNUSFIELDED, USRealmPersonNamePNUSFIELDED, UnstructuredDocument, VitalSignObservation, VitalSignsOrganizer, VitalSignsSection, WoundCharacteristic and WoundMeasurementObservation
• Licensing information can be found here These codes are listed within the UB-04 Data Specifications Manual. The Official UB-04 Data Specifications Manual, copyrighted by the American Hospital Association, is the only official source of UB-04 billing information adopted by the National Uniform Billing Committee. No other publication—governmental or private/commercial—can be considered authoritative. The AHA wants to make you aware that the use of codes, descriptions, or any other content contained in the manual to be used in a software application, publication, or any other derivative work must be properly licensed by the AHA. If your organization uses or intends to use any of the codes or other related content from the manual in this manner, please contact the AHA’s licensing manager, Tim Carlson, at 312.893.6816 or tcarlson@aha.org
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  • AHA NUBC Patient Discharge Status Codes: DischargeSummary, EncounterActivity and PatientStatus
• Most of the information on the CDC and ATSDR websites is not subject to copyright, is in the public domain, and may be freely used or reproduced without obtaining copyright permission. For information and exceptions regarding use of CDC material please see https://www.cdc.gov/other/agencymaterials.html
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  • Vaccine Administered Code Set (CVX): ImmunizationMedicationInformation
• The UCUM codes, UCUM table (regardless of format), and UCUM Specification are copyright 1999-2009, Regenstrief Institute, Inc. and the Unified Codes for Units of Measures (UCUM) Organization. All rights reserved. https://ucum.org/trac/wiki/TermsOfUse
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  • Unified Code for Units of Measure (UCUM): AgeObservation, ImmunizationActivity... Show 6 more, MedicationActivity, PlannedImmunizationActivity, PlannedMedicationActivity, ResultObservation, SocialHistoryObservation and VitalSignObservation
• This material contains content from LOINC. LOINC is copyright © 1995-2020, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license. LOINC® is a registered United States trademark of Regenstrief Institute, Inc.
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  • LOINC: AdvanceDirectiveObservation, CarePlan... Show 22 more, CareTeamTypeObservation, ConsultationNote, DischargeSummary, FamilyHistoryObservation, HistoryandPhysical, Indication, NoteActivity, NotesSection, OperativeNote, PhysicalExamSection, PlannedProcedure, ProblemObservation, ProcedureActivityProcedure, ProcedureNote, ProgressNote, ReferralNote, SelfCareActivitiesADLandIADL, SmokingStatus, TransferSummary, TreatmentInterventionPreference, VitalSignObservation and WoundMeasurementObservation
• This material contains content that is copyright of SNOMED International. Implementers of these specifications must have the appropriate SNOMED CT Affiliate license - for more information contact https://www.snomed.org/get-snomed or info@snomed.org.
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  • SNOMED Clinical Terms® (SNOMED CT®): AdvanceDirectiveObservation, AllergyIntoleranceObservation... Show 48 more, AllergyStatusObservation, CareTeamMemberAct, CareTeamOrganizer, CharacteristicsofHomeEnvironment, EncounterActivity, FamilyHistoryObservation, GenderIdentityObservation, HealthStatusObservation, ImmunizationActivity, Indication, Instruction, LongitudinalCareWoundObservation, MedicationActivity, MedicationAdherence, MedicationInformation, MentalStatusObservation, NumberofPressureUlcersObservation, NutritionRecommendation, NutritionalStatusObservation, OperativeNote, PatientReferralAct, PlannedEncounter, PlannedImmunizationActivity, PlannedMedicationActivity, PlannedProcedure, PreconditionforSubstanceAdministration, PregnancyIntentionInNextYear, PregnancyObservation, PriorityPreference, ProblemObservation, ProblemStatus, ProcedureActivityProcedure, ProgressTowardGoalObservation, ReactionObservation, ResultOrganizer, SelfCareActivitiesADLandIADL, SensoryStatus, SeverityObservation, SexObservation, SexualOrientationObservation, SmokingStatus, SmokingStatusMeaningfulUse, SocialHistoryObservation, SpecimenCollectionProcedure, SubstanceOrDeviceAllergyIntoleranceObservation, TobaccoUse, USRealmHeader and WoundCharacteristic
• This material derives from the HL7 Terminology (THO). THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license
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  • DataAbsentReason: BirthSexObservation, GenderIdentityObservation, MedicationAdherence, SexObservation and SexualOrientationObservation
• This material derives from the HL7 Terminology THO. THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license
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  • ActCode: AssessmentScaleObservation and USRealmHeader
  • ActMood: ImmunizationActivity, MedicationActivity... Show 10 more, MedicationFreeTextSig, NonMedicinalSupplyActivity, NutritionRecommendation, PatientReferralAct, PlannedEncounter, PlannedImmunizationActivity, PlannedInterventionAct, PlannedMedicationActivity, PlannedProcedure and PlannedSupply
  • ActPriority: PatientReferralAct and ProcedureActivityProcedure
  • ActReason: ImmunizationNotGivenReason
  • ActRelationshipType: CarePlan
  • ActStatus: AllergyConcernAct, CareTeamMemberAct... Show 16 more, CareTeamOrganizer, DrugMonitoringAct, GoalObservation, HealthConcernAct, ImmunizationActivity, MedicalEquipmentOrganizer, MedicationActivity, MedicationSupplyOrder, NonMedicinalSupplyActivity, PatientReferralAct, ProblemConcernAct, ProcedureActivityProcedure, ResultObservation, ResultOrganizer, RiskConcernAct and SmokingStatusMeaningfulUse
  • AddressUse: USRealmHeader
  • AdministrativeGender: BirthSexObservation, FamilyHistoryOrganizer and USRealmHeader
  • Confidentiality: USRealmHeader
  • EntityNamePartQualifier: USRealmPatientNamePTNUSFIELDED
  • LanguageAbilityMode: USRealmHeader
  • LanguageAbilityProficiency: USRealmHeader
  • MaritalStatus: USRealmHeader
  • NullFlavor: BirthSexObservation, GenderIdentityObservation and SexualOrientationObservation
  • ObservationInterpretation: VitalSignObservation
  • ObservationValue: CriticalityObservation
  • ParticipationFunction: CareTeamMemberAct, CareTeamOrganizer... Show 4 more, MedicationAdherence, OperativeNote, USRealmHeader and USRealmHeaderforPatientGeneratedDocument
  • ParticipationType: USRealmHeader
  • Religious Affiliation: USRealmHeader
  • RoleClass: CarePlan, DischargeSummary, PolicyActivity, ReferralNote and TransferSummary
  • RoleCode: AdvanceDirectiveObservation, CarePlan... Show 7 more, FamilyHistoryOrganizer, MedicationAdherence, PolicyActivity, ProvenanceAuthorParticipation, RelatedPersonRelationshipAndNameParticipant, USRealmHeader and USRealmHeaderforPatientGeneratedDocument
  • TribalEntityUS: TribalAffiliationObservation
• Using RxNorm codes of type SAB=RXNORM as this specification describes does not require a UMLS license. Access to the full set of RxNorm definitions, and/or additional use of other RxNorm structures and information requires a UMLS license. The use of RxNorm in this specification is pursuant to HL7's status as a licensee of the NLM UMLS. HL7's license does not convey the right to use RxNorm to any users of this specification; implementers must acquire a license to use RxNorm in their own right.
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  • RxNorm: AllergyIntoleranceObservation, MedicationInformation and SubstanceOrDeviceAllergyIntoleranceObservation