Consolidated CDA (C-CDA)
4.0.0 - STU4 United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v4.0.0: CCDA 4.0) 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

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 Provenance in C-CDA
... 8 How To Read
... 9 Downloads
... 10 Terminology
... 11 Change Log
... 12 Template IDs
... 13 Artifacts Summary
.... 13.1 Care Plan
.... 13.2 Consultation Note
.... 13.3 Continuity of Care Document (CCD)
.... 13.4 Discharge Summary
.... 13.5 History and Physical
.... 13.6 Operative Note
.... 13.7 Procedure Note
.... 13.8 Progress Note
.... 13.9 Referral Note
.... 13.10 Transfer Summary
.... 13.11 Unstructured Document
.... 13.12 US Realm Header
.... 13.13 US Realm Header for Patient Generated Document
.... 13.14 Activities Section
.... 13.15 Admission Diagnosis Section
.... 13.16 Admission Medications Section (entries optional)
.... 13.17 Advance Directives Section
.... 13.18 Allergies and Intolerances Section
.... 13.19 Anesthesia Section
.... 13.20 Assessment and Plan Section
.... 13.21 Assessment Section
.... 13.22 Care Teams Section
.... 13.23 Chief Complaint and Reason for Visit Section
.... 13.24 Chief Complaint Section
.... 13.25 Complications Section
.... 13.26 Course of Care Section
.... 13.27 Discharge Diagnosis Section
.... 13.28 Discharge Medications Section
.... 13.29 Encounters Section
.... 13.30 Family History Section
.... 13.31 Functional Status Section
.... 13.32 General Status Section
.... 13.33 Goals Section
.... 13.34 Health Concerns Section
.... 13.35 History of Present Illness Section
.... 13.36 Hospital Consultations Section
.... 13.37 Hospital Course Section
.... 13.38 Hospital Discharge Instructions Section
.... 13.39 Hospital Discharge Physical Section
.... 13.40 Hospital Discharge Studies Summary Section
.... 13.41 Immunizations Section
.... 13.42 Instructions Section
.... 13.43 Medical (General) History Section
.... 13.44 Medical Equipment Section
.... 13.45 Medications Administered Section
.... 13.46 Medications Section
.... 13.47 Mental Status Section
.... 13.48 Notes Section
.... 13.49 Nutrition Section
.... 13.50 Objective Section
.... 13.51 Operative Note Fluids Section
.... 13.52 Operative Note Surgical Procedure Section
.... 13.53 Outcomes Section
.... 13.54 Past Medical History
.... 13.55 Payers Section
.... 13.56 Physical Exam Section
.... 13.57 Plan of Treatment Section
.... 13.58 Planned Procedure Section
.... 13.59 Postoperative Diagnosis Section
.... 13.60 Postprocedure Diagnosis Section
.... 13.61 Preoperative Diagnosis Section
.... 13.62 Problem Section
.... 13.63 Procedure Description Section
.... 13.64 Procedure Disposition Section
.... 13.65 Procedure Estimated Blood Loss Section
.... 13.66 Procedure Findings Section
.... 13.67 Procedure Implants Section
.... 13.68 Procedure Indications Section
.... 13.69 Procedure Specimens Taken Section
.... 13.70 Procedures Section
.... 13.71 Reason for Referral Section
.... 13.72 Reason for Visit Section
.... 13.73 Results Section
.... 13.74 Review of Systems Section
.... 13.75 Social History Section
.... 13.76 Subjective Section
.... 13.77 Surgical Drains Section
.... 13.78 Vital Signs Section
.... 13.79 Admission Medication
.... 13.80 Advance Directive Observation
.... 13.81 Advance Directive Existence Observation
.... 13.82 Age Observation
.... 13.83 Age Range Observation
.... 13.84 Allergy - Intolerance Observation
.... 13.85 Allergy Concern Act
.... 13.86 Allergy Status Observation
.... 13.87 Assessment Scale Observation
.... 13.88 Assessment Scale Supporting Observation
.... 13.89 Authorization Activity
.... 13.90 Average Blood Pressure Organizer
.... 13.91 Basic Industry Observation
.... 13.92 Basic Occupation Observation
.... 13.93 Birth Sex Observation
.... 13.94 Brand Name Observation
.... 13.95 Care Experience Preference
.... 13.96 Care Team Member Act
.... 13.97 Care Team Member Schedule Observation
.... 13.98 Care Team Organizer
.... 13.99 Care Team Type Observation
.... 13.100 Caregiver Characteristics
.... 13.101 Catalog Number Observation
.... 13.102 Characteristics of Home Environment
.... 13.103 Comment Activity
.... 13.104 Company Name Observation
.... 13.105 Coverage Activity
.... 13.106 Criticality Observation
.... 13.107 Cultural and Religious Observation
.... 13.108 Date of Diagnosis Act
.... 13.109 Deceased Observation
.... 13.110 Device Identifier Observation
.... 13.111 Disability Status Observation
.... 13.112 Discharge Medication
.... 13.113 Distinct Identification Code Observation
.... 13.114 Drug Monitoring Act
.... 13.115 Drug Vehicle
.... 13.116 Encounter Activity
.... 13.117 Encounter Diagnosis
.... 13.118 Entry Reference
.... 13.119 Estimated Date of Delivery
.... 13.120 Expiration Date Observation
.... 13.121 External Document Reference
.... 13.122 Family History Death Observation
.... 13.123 Family History Observation
.... 13.124 Family History Organizer
.... 13.125 Functional Status Observation
.... 13.126 Functional Status Organizer
.... 13.127 Gender Identity Observation
.... 13.128 Goal Observation
.... 13.129 Handoff Communication Participants
.... 13.130 Health Concern Act
.... 13.131 Health Status Observation
.... 13.132 Highest Pressure Ulcer Stage
.... 13.133 Hospital Admission Diagnosis
.... 13.134 Hospital Discharge Diagnosis
.... 13.135 Immunization Activity
.... 13.136 Immunization Medication Information
.... 13.137 Immunization Not Given Reason
.... 13.138 Implantable Device Status Observation
.... 13.139 Indication
.... 13.140 Individual Pronoun Observation
.... 13.141 Instruction Observation
.... 13.142 Interpreter Needed Observation
.... 13.143 Intervention Act
.... 13.144 Latex Safety Observation
.... 13.145 Longitudinal Care Wound Observation
.... 13.146 Lot or Batch Number Observation
.... 13.147 Manufacturing Date Observation
.... 13.148 Medical Equipment Organizer
.... 13.149 Medication Activity
.... 13.150 Medication Adherence
.... 13.151 Medication Dispense
.... 13.152 Medication Free Text Sig
.... 13.153 Medication Information
.... 13.154 Medication Supply Order
.... 13.155 Mental Status Observation
.... 13.156 Mental Status Organizer
.... 13.157 Model Number Observation
.... 13.158 MRI Safety Observation
.... 13.159 Non-Medicinal Supply Activity
.... 13.160 Note Activity
.... 13.161 Number of Pressure Ulcers Observation
.... 13.162 Nutrition Assessment
.... 13.163 Nutrition Recommendation
.... 13.164 Nutritional Status Observation
.... 13.165 Outcome Observation
.... 13.166 Planned Coverage
.... 13.167 Planned Encounter
.... 13.168 Planned Immunization Activity
.... 13.169 Planned Intervention Act
.... 13.170 Planned Medication Activity
.... 13.171 Planned Procedure
.... 13.172 Planned Supply
.... 13.173 Policy Activity
.... 13.174 Postprocedure Diagnosis
.... 13.175 Precondition for Substance Administration
.... 13.176 Pregnancy Intention in Next Year
.... 13.177 Pregnancy Status Observation
.... 13.178 Preoperative Diagnosis
.... 13.179 Priority Preference
.... 13.180 Problem Concern Act
.... 13.181 Problem Observation
.... 13.182 Problem Status
.... 13.183 Procedure Activity Procedure
.... 13.184 Product Instance
.... 13.185 Prognosis Observation
.... 13.186 Progress Toward Goal Observation
.... 13.187 Reaction Observation
.... 13.188 Reason
.... 13.189 Referral Act
.... 13.190 Result Observation
.... 13.191 Result Organizer
.... 13.192 Risk Concern Act
.... 13.193 Section Time Range Observation
.... 13.194 Self-Care Activities (ADL and IADL)
.... 13.195 Sensory Status
.... 13.196 Serial Number Observation
.... 13.197 Service Delivery Location
.... 13.198 Severity Observation
.... 13.199 Sex Observation
.... 13.200 Sex Parameter For Clinical Use Observation
.... 13.201 Sexual Orientation Observation
.... 13.202 Smoking Status
.... 13.203 Social History Observation
.... 13.204 Specimen Collection Procedure
.... 13.205 Specimen Condition Observation
.... 13.206 Substance Administered Act
.... 13.207 Substance or Device Allergy - Intolerance Observation
.... 13.208 Treatment Intervention Preference
.... 13.209 Tribal Affiliation Observation
.... 13.210 UDI Organizer
.... 13.211 Vital Sign Observation
.... 13.212 Vital Signs Organizer
.... 13.213 Wound Characteristic
.... 13.214 Wound Measurement Observation
.... 13.215 Author Participation
.... 13.216 Provenance - Assembler Participation
.... 13.217 Provenance - Author Participation
.... 13.218 Related Person Relationship and Name Participant
.... 13.219 US Realm Address
.... 13.220 US Realm Date and Time - Interval
.... 13.221 US Realm Date and Time - Point in Time
.... 13.222 US Realm Patient Name (PTN.US.FIELDED)
.... 13.223 US Realm Person Name (PN.US.FIELDED)
.... 13.224 Advance Directive Organizer
.... 13.225 Instruction Activity
.... 13.226 Smoking Status - Meaningful Use
.... 13.227 Tobacco Use
.... 13.228 Example of Allergy Intolerance to Food Egg
.... 13.229 Admission Diagnosis Section Example
.... 13.230 Admission Medication example
.... 13.231 Advance Directive Existence Observation Example
.... 13.232 Advance Directive Observation Example
.... 13.233 Advance Directives Section Example
.... 13.234 Age Observation Example
.... 13.235 Allergies and Intolerances Section Example
.... 13.236 Allergy Concern Act Example
.... 13.237 Allergy Intolerance Observation Medication Example
.... 13.238 Allergy Intolerance Observation Drug Class Example
.... 13.239 Allergy Intolerance Observation Non-Medication Example
.... 13.240 Anesthesia Section Example
.... 13.241 Assessment and Plan Section Example
.... 13.242 Assessment Scale Observation Example
.... 13.243 Assessment Scale Supporting Observation Example
.... 13.244 Assessment Section Example
.... 13.245 Author Participation Example
.... 13.246 Authorization Activity Example
.... 13.247 Basic Industry Observation Example
.... 13.248 Basic Occupation Observation Example
.... 13.249 Birth Sex Observation Example
.... 13.250 Birth Sex Observation Example with Null Flavor
.... 13.251 Brand Name Observation Example
.... 13.252 Care Plan Caregiver participant Example
.... 13.253 Care Plan Patient authenticator Example
.... 13.254 Care Plan performer Example
.... 13.255 Care Plan relatedDocument Example
.... 13.256 Care Plan Review Example
.... 13.257 Care Plan Complete Header Example
.... 13.258 Care Team Member Act Example
.... 13.259 Care Team Member Schedule Observation Example
.... 13.260 Care Team Organizer Example
.... 13.261 Care Teams Section Example
.... 13.262 Care Team Type Observation Example
.... 13.263 Catalog Number Observation Example
.... 13.264 Caregiver Characteristics Example
.... 13.265 Characteristics of Home Environment Example
.... 13.266 Chief Complaint and Reason for Visit Section Example
.... 13.267 Chief Complaint Section Example
.... 13.268 Comment Activity Example
.... 13.269 Company Name Observation Example
.... 13.270 Complications Section Example
.... 13.271 Continuity Of Care Document Complete Header Example
.... 13.272 Continuity Of Care Document Author Example
.... 13.273 Continuity Of Care Document Performer
.... 13.274 Continuity Of Care Document serviceEvent Example
.... 13.275 Consultation Note Complete Header Example
.... 13.276 Consultation Note Callback participant Example
.... 13.277 Consultation Note inFulfillmentOf Example
.... 13.278 Course of Care Section Example
.... 13.279 Coverage Activity Example
.... 13.280 Criticality Observation Example
.... 13.281 Cultural and Religious Observation Example
.... 13.282 Date of Diagnosis Act Example
.... 13.283 Deceased Observation Example
.... 13.284 Device Identifier Observation Example
.... 13.285 Diagnosis Reference Example
.... 13.286 Disability Status Observation Example
.... 13.287 Discharge Diagnosis Example
.... 13.288 Discharge Medication Example
.... 13.289 Discharge Medications Section Example
.... 13.290 Discharge Summary Complete Header Example
.... 13.291 Discharge Summary encompassingEncounter Example
.... 13.292 Distinct Identification Code Observation Example
.... 13.293 Drug Monitoring Act Example
.... 13.294 Drug Vehicle Example
.... 13.295 Encounter Activity Example
.... 13.296 Encounter Diagnosis Example
.... 13.297 Encounters Section Example
.... 13.298 Entry Reference Example
.... 13.299 Estimated Date of Delivery Example
.... 13.300 Expiration Date Observation Example
.... 13.301 External Document Reference Example
.... 13.302 Family History Death Observation Example
.... 13.303 Family History Observation Example
.... 13.304 Family History Organizer Example
.... 13.305 Family History Section Example
.... 13.306 Functional Status Observation Example
.... 13.307 Functional Status Organizer Example
.... 13.308 Functional Status Section Example
.... 13.309 Gender Identity Observation Example
.... 13.310 Gender Identity Observation NullFlavor Example
.... 13.311 General Status Section Example
.... 13.312 Goal Observation Example
.... 13.313 Goals Section Example
.... 13.314 Handoff Communication Participants Example
.... 13.315 Health Concern Act Example
.... 13.316 Health Concerns Section Example
.... 13.317 Outcomes Section Example
.... 13.318 Health Status Observation Example
.... 13.319 Highest Pressure Ulcer Stage Example
.... 13.320 History and Physical Encompassing Encounter Example
.... 13.321 History and Physical Complete Header Example
.... 13.322 History Of Present Illness Example
.... 13.323 Hospital Admission Diagnosis Example
.... 13.324 Hospital Consultations Section Example
.... 13.325 Hospital Course Section Example
.... 13.326 Hospital Discharge Diagnosis Example
.... 13.327 Hospital Discharge Instructions Section Example
.... 13.328 Hospital Discharge Physical Section Example
.... 13.329 Hospital Discharge Studies Summary Section Example
.... 13.330 Immunization Activity Example
.... 13.331 Immunization Medication Information Example
.... 13.332 Immunization Not Given Reason Example
.... 13.333 Immunizations Section Example
.... 13.334 Implantable Device Status Observation Example
.... 13.335 Indication Example
.... 13.336 Instructions Section Example
.... 13.337 Instruction Example
.... 13.338 Intervention Act Example
.... 13.339 Latex Safety Observation Example
.... 13.340 Longitudinal Care Wound Observation Example
.... 13.341 Lot or Batch Number Observation Example
.... 13.342 Manufacturing Date Observation Example
.... 13.343 Medical Equipment Organizer Example
.... 13.344 Medical Equipment Section Example
.... 13.345 Medication Activity Example
.... 13.346 Medication Adherence Example
.... 13.347 Medication Adherence NullFlavor Example
.... 13.348 Medication Dispense Example
.... 13.349 Medication Free Text Sig Example
.... 13.350 Medication Information Example
.... 13.351 Medication Supply Order Example
.... 13.352 Medications Administered Section Example
.... 13.353 Medications Section Example
.... 13.354 Mental Status Observation Example
.... 13.355 Mental Status Organizer Example
.... 13.356 Mental Status Section Example
.... 13.357 Model Number Observation Example
.... 13.358 MRI Safety Observation Example
.... 13.359 No Known Medications Example
.... 13.360 No Known Problem Section Example
.... 13.361 Non-Medicinal Supply Activity Example
.... 13.362 Note Activity Entry Relationship Example
.... 13.363 Note Activity Standalone Example
.... 13.364 nonXML Body Example with Compressed Content
.... 13.365 nonXML Body Example with Embedded Content
.... 13.366 nonXML Body Example with Referenced Content
.... 13.367 Number of Pressure Ulcers Observation Example
.... 13.368 Nutrition Assessment Example
.... 13.369 Nutrition Recommendation Example
.... 13.370 Nutrition Section Example
.... 13.371 Nutritional Status Observation Example
.... 13.372 Objective Section Example
.... 13.373 Operative Note Complete Header Example
.... 13.374 Operative Note performer Example
.... 13.375 Operative Note serviceEvent Example
.... 13.376 Operative Note Fluids Section Example
.... 13.377 Operative Note Surgical Procedure Section Example
.... 13.378 Outcome Observation Example
.... 13.379 Past Medical History Example
.... 13.380 Patient Generated Document authenticator
.... 13.381 Patient Generated Document author device Example
.... 13.382 Patient Generated Document author
.... 13.383 Patient Generated Document custodian Example
.... 13.384 Patient Generated Document dataEnterer
.... 13.385 Patient Generated Document informant Example informant
.... 13.386 Patient Generated Document informant RelEnt Example
.... 13.387 Patient Generated Document informationRecipient Example
.... 13.388 Patient Generated Document inFulfillmentOf Example
.... 13.389 Patient Generated Document legalAuthenticator Example
.... 13.390 Patient Generated Document participant Example
.... 13.391 Patient Generated Document recordTarget
.... 13.392 Referral Act Example
.... 13.393 Payers Section Example
.... 13.394 Physical Exam Section Example
.... 13.395 Plan of Treatment Section Example
.... 13.396 Planned Coverage Example
.... 13.397 Planned Encounter Example
.... 13.398 Planned Immunization Activity Example
.... 13.399 Planned Intervention Activity Example
.... 13.400 Planned Medication Activity Example
.... 13.401 Planned Procedure Section Example
.... 13.402 Planned Procedure Example
.... 13.403 Planned Supply Example
.... 13.404 Policy Activity Example
.... 13.405 Postoperative Diagnosis Section Example
.... 13.406 Postprocedure Diagnosis Example
.... 13.407 Postprocedure Diagnosis Section Example
.... 13.408 Precondition for Substance Administration Example
.... 13.409 Pregnancy Intention in Next Year Example
.... 13.410 Pregnancy Status Observation Example
.... 13.411 Preoperative Diagnosis Section Example
.... 13.412 Preoperative Diagnosis Example
.... 13.413 Priority Preference Example
.... 13.414 Problem Concern Act Example
.... 13.415 Problem Observation Example
.... 13.416 Problem Observation with Post-Coordinated SNOMED Example
.... 13.417 Problem Section Example
.... 13.418 Procedure Note Complete Header Example
.... 13.419 Procedure Note performer Example
.... 13.420 Procedure Note serviceEvent Example
.... 13.421 Procedure Activity Procedure Example
.... 13.422 Procedure Description Section Example
.... 13.423 Procedure Disposition Section Example
.... 13.424 Procedure Estimated Blood Loss Section Example
.... 13.425 Procedure Findings Section Example
.... 13.426 Procedure Implants Section Example
.... 13.427 Procedure Indications Section Example
.... 13.428 Procedure Specimens Taken Section Example
.... 13.429 Procedures Section Example
.... 13.430 Product Instance Example
.... 13.431 Prognosis Coded Example
.... 13.432 Prognosis Free Text Example
.... 13.433 Progress Note Complete Header Example
.... 13.434 Progress Note encompassingEncounter Example
.... 13.435 Progress Note serviceEvent Example
.... 13.436 Progress Toward Goal Observation Example
.... 13.437 Provenance - Assembler Participation Example
.... 13.438 Provenance - Author Participation Example
.... 13.439 Reaction Observation Example
.... 13.440 Reason Example
.... 13.441 Reason For Referral
.... 13.442 Reason for Visit Section Example
.... 13.443 Referral Note Complete Header Example
.... 13.444 Referral Note Callback Contact Example
.... 13.445 Referral Note Caregiver
.... 13.446 Referral Note informationRecipient Example
.... 13.447 Related Person Relationship and Name Participant Example
.... 13.448 Result Observation Example
.... 13.449 Result Organizer Example
.... 13.450 Results Section Example
.... 13.451 Review Of Systems Section Example
.... 13.452 Risk Concern Act Example
.... 13.453 Self-Care Activities ADL and IADL Example
.... 13.454 Sensory Status Example
.... 13.455 Serial Number Observation Example
.... 13.456 Service Delivery Location Example
.... 13.457 Severity Observation Example
.... 13.458 Sex Observation Example
.... 13.459 Sex Observation Null Flavor Example
.... 13.460 Sexual Orientation Observation Example
.... 13.461 Sexual Orientation Observation Null Flavor Example
.... 13.462 Smoking Status Coded Example
.... 13.463 Smoking Status Quantity Example
.... 13.464 Smoking Status Meaningful Use Example
.... 13.465 Specimen Collection Procedure Example
.... 13.466 Specimen Condition Observation Example
.... 13.467 Social History Section Example
.... 13.468 Subjective Section Example
.... 13.469 Substance Administered Act Example
.... 13.470 Surgical Drains Section Example
.... 13.471 Tobacco Use Example
.... 13.472 Transfer Summary Complete Header Example
.... 13.473 Transfer Summary Callback Contact Example
.... 13.474 Transfer Summary participant (Support) Example
.... 13.475 Tribal Affiliation Observation Example
.... 13.476 UDI Organizer Example
.... 13.477 US Realm Address Example
.... 13.478 US Realm Date and Time Example
.... 13.479 US Realm Date and Time Interval Example
.... 13.480 US Realm Header Example
.... 13.481 US Realm Person Name Example
.... 13.482 Vital Sign Observation Example
.... 13.483 Average Blood Pressure Organizer Example
.... 13.484 Vital Signs Organizer Example
.... 13.485 Vital Signs Section Example
.... 13.486 Wound Characteristic Example
.... 13.487 Wound Measurement Observation Example