Admission Diagnosis Section

This section contains a narrative description of the problems or diagnoses identified by the clinician at the time of the patient’s admission. This section may contain a coded entry which represents the admitting diagnoses.

Referenced in:

• Discharge Summary
• Transfer Summary

Admission Medications Section (entries optional)

The section contains the medications taken by the patient prior to and at the time of admission to the facility.

Referenced in:

• Discharge Summary
• Transfer Summary

Advance Directives Section (entries optional)

This section contains data defining the patient’s advance directives and any reference to supporting documentation, including living wills, healthcare proxies, and CPR and resuscitation status. If the referenced documents are available, they can be included in the exchange package. The most recent directives are required, if known, and should be listed in as much detail as possible. This section differentiates between "advance directives" and "advance directive documents". The former is the directions to be followed whereas the latter refers to a legal document containing those directions.

Referenced in:

• Consultation Note
• Continuity of Care Document (CCD)
• Referral Note

Advance Directives Section (entries required)

This section contains data defining the patient’s advance directives and any reference to supporting documentation, including living wills, healthcare proxies, and CPR and resuscitation status. If the referenced documents are available, they can be included in the exchange package. The most recent directives are required, if known, and should be listed in as much detail as possible. This section differentiates between "advance directives" and "advance directive documents". The former is the directions to be followed whereas the latter refers to a legal document containing those directions.

Referenced in:

• Transfer Summary

Allergies and Intolerances Section (entries optional)

This section lists and describes any medication allergies, adverse reactions, idiosyncratic reactions, anaphylaxis/anaphylactoid reactions to food items, and metabolic variations or adverse reactions/allergies to other substances (such as latex, iodine, tape adhesives). At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.

Referenced in:

• Discharge Summary
• History and Physical
• Progress Note
• Procedure Note

Allergies and Intolerances Section (entries required)

This section lists and describes any medication allergies, adverse reactions, idiosyncratic reactions, anaphylaxis/anaphylactoid reactions to food items, and metabolic variations or adverse reactions/allergies to other substances (such as latex, iodine, tape adhesives). At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.

Referenced in:

• Consultation Note
• Continuity of Care Document (CCD)
• Transfer Summary
• Referral Note

Anesthesia Section

The Anesthesia Section records the type of anesthesia (e.g., general or local) and may state the actual agent used. This may be a subsection of the Procedure Description Section. The full details of anesthesia are usually found in a separate Anesthesia Note.

Referenced in:

• Procedure Note
• Operative Note

Assessment Section

The Assessment Section (also referred to as “impression” or “diagnoses” outside of the context of CDA) represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The assessment may be a list of specific disease entities or a narrative block.

Referenced in:

• Consultation Note
• History and Physical
• Transfer Summary
• Referral Note
• Progress Note
• Procedure Note

Assessment and Plan Section

This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. See also the Assessment Section and Plan of Treatment Section

Referenced in:

• Consultation Note
• History and Physical
• Transfer Summary
• Referral Note
• Progress Note
• Procedure Note

Chief Complaint Section

This section records the patient's chief complaint (the patient’s own description).

Referenced in:

• Consultation Note
• Discharge Summary
• History and Physical
• Progress Note
• Procedure Note

Chief Complaint and Reason for Visit Section

This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.

Referenced in:

• Consultation Note
• Discharge Summary
• History and Physical
• Procedure Note

Complications Section

This section contains problems that occurred during or around the time of a procedure. The complications may be known risks or unanticipated problems.

Referenced in:

• Procedure Note
• Operative Note

Course of Care Section

The Course of Care section describes what happened during the course of an encounter.

Referenced in:

• Transfer Summary

DICOM Object Catalog Section - DCM 121181

DICOM Object Catalog lists all referenced objects and their parent Series and Studies, plus other DICOM attributes required for retrieving the objects. DICOM Object Catalog sections are not intended for viewing and contain empty section text.

Referenced in:

• Diagnostic Imaging Report

Discharge Diagnosis Section

This template represents problems or diagnoses present at the time of discharge which occurred during the hospitalization. This section includes an optional entry to record patient diagnoses specific to this visit. Problems that need ongoing tracking should also be included in the Problem Section.

Referenced in:

• Discharge Summary
• Transfer Summary

Discharge Medications Section (entries optional)

This section contains the medications the patient is intended to take or stop after discharge. Current, active medications must be listed. The section may also include a patient’s prescription history and indicate the source of the medication list.

Referenced in:

• Discharge Summary

Discharge Medications Section (entries required)

This section contains the medications the patient is intended to take or stop after discharge. Current, active medications must be listed. The section may also include a patient’s prescription history and indicate the source of the medication list.

Referenced in:

• Discharge Summary

Encounters Section (entries optional)

This section lists and describes any healthcare encounters pertinent to the patient’s current health status or historical health history. An encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patient’s condition. It may include visits, appointments, or non-face-to-face interactions. It is also a contact between a patient and a practitioner who has primary responsibility (exercising independent judgment) for assessing and treating the patient at a given contact. This section may contain all encounters for the time period being summarized, but should include notable encounters.

Referenced in:

• Continuity of Care Document (CCD)

Encounters Section (entries required)

This section lists and describes any healthcare encounters pertinent to the patient’s current health status or historical health history. An encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patient’s condition. It may include visits, appointments, as well as non-face-to-face interactions. It is also a contact between a patient and a practitioner who has primary responsibility (exercising independent judgment) for assessing and treating the patient at a given contact. This section may contain all encounters for the time period being summarized, but should include notable encounters.

Referenced in:

• Transfer Summary

Family History Section

This section contains data defining the patient’s genetic relatives in terms of possible or relevant health risk factors that have a potential impact on the patient’s healthcare risk profile.

Referenced in:

• Consultation Note
• Continuity of Care Document (CCD)
• Discharge Summary
• History and Physical
• Transfer Summary
• Referral Note
• Procedure Note

Fetus Subject Context

For reports on mothers and their fetus(es), information on a mother is mapped to recordTarget, PatientRole, and Patient. Information on the fetus is mapped to subject, relatedSubject, and SubjectPerson at the CDA section level. Both context information on the mother and fetus must be included in the document if observations on fetus(es) are contained in the document.

Referenced in:

• Diagnostic Imaging Report

Findings Section (DIR)

The Findings section contains the main narrative body of the report. While not an absolute requirement for transformed DICOM SR reports, it is suggested that Diagnostic Imaging Reports authored in CDA follow Term Info guidelines for the codes in the various observations and procedures recorded in this section.

Referenced in:

• Diagnostic Imaging Report

Functional Status Section

The Functional Status Section contains observations and assessments of a patient's physical abilities. A patient’s functional status may include information regarding the patient’s ability to perform Activities of Daily Living (ADLs) in areas such as Mobility (e.g., ambulation), Self-Care (e.g., bathing, dressing, feeding, grooming) or Instrumental Activities of Daily Living (IADLs) (e.g., shopping, using a telephone, balancing a check book). Problems that impact function (e.g., dyspnea, dysphagia) can be contained in the section.

Referenced in:

• Consultation Note
• Continuity of Care Document (CCD)
• Discharge Summary
• Transfer Summary
• Referral Note

General Status Section

The General Status section describes general observations and readily observable attributes of the patient, including affect and demeanor, apparent age compared to actual age, gender, ethnicity, nutritional status based on appearance, body build and habitus (e.g., muscular, cachectic, obese), developmental or other deformities, gait and mobility, personal hygiene, evidence of distress, and voice quality and speech.

Referenced in:

• Consultation Note
• History and Physical
• Transfer Summary
• Referral Note

Goals Section

This template represents patient Goals. A goal is a defined outcome or condition to be achieved in the process of patient care. Goals include patient-defined over-arching goals (e.g., alleviation of health concerns, desired/intended positive outcomes from interventions, longevity, function, symptom management, comfort) and health concern-specific or intervention-specific goals to achieve desired outcomes.

To satisfy the 2015 Edition Certification Criteria, Transition of Care documents should include the Assessment Section (2.7) and the Plan of Treatment Section31 (2.48), or the Assessment and Plan Section (2.6). They also should include the Goals Section (2.22). Content should be distinguished as described below when the Goals Section, and the Plan of Treatment Section or Assessment and Plan of Treatment Section, are both included within the same Transition of Care document. This guidance does not apply to the Goals Section within a Care Plan document. There is no additional guidance for the Assessment Section beyond what is already in Consolidated CDA.

Referenced in:

• Care Plan

Health Concerns Section

This section contains data describing an interest or worry about a health state or process that could possibly require attention, intervention, or management. A Health Concern is a health related matter that is of interest, importance or worry to someone, who may be the patient, patient's family or patient's health care provider. Health concerns are derived from a variety of sources within an EHR (such as Problem List, Family History, Social History, Social Worker Note, etc.). Health concerns can be medical, surgical, nursing, allied health or patient-reported concerns. Problem Concerns are a subset of Health Concerns that have risen to the level of importance that they typically would belong on a classic “Problem List”, such as “Diabetes Mellitus” or “Family History of Melanoma” or “Tobacco abuse”. These are of broad interest to multiple members of the care team. Examples of other Health Concerns that might not typically be considered a Problem Concern include “Risk of Hyperkalemia” for a patient taking an ACE-inhibitor medication, or “Transportation difficulties” for someone who doesn't drive and has trouble getting to appointments, or “Under-insured” for someone who doesn't have sufficient insurance to properly cover their medical needs such as medications. These are typically most important to just a limited number of care team members.

The Health Concerns Section contains, when available, concerns as expressed by the patient and/or the patient's agent(s), and/or by the patient or other care team members. When the Problem Section and Health Concerns Section both appear in a single document, then the Health Concerns section is titled "Additional Health Concerns" to distinguish it from the Problem List (the author's concerns). If it were simply titled Health Concerns, some would think that it contains all concerns, including the Problem List, which could cause confusion. Also, the Health Concerns Section appears after the Problem Section in the documents. The Health Concerns Section does not duplicate the entries from the Problem List. However, it may include some of the same concerns in the Problem List. It may be formatted as a "list" but may also be free form narrative not in any particular format. Whereas the Problems Section must contain both structured entries and narrative, the 2015 Edition Certification Criteria for Health Concerns section is only narrative. C-CDA conformance requires structured entries which may be populated with relevant data or the appropriate nullFlavor. Patient concerns may be specific to an encounter, or overarching concerns not specific to an encounter. Patient concerns are not limited to medical problems. For example, they can include things like barriers (lack of transportation, lack of finances, difficulty communicating with provider) or anything else relevant to the document/care. Also, the Additional Health Concerns section may contain concerns from members of the care team other than the author/attester of the document. The author/owner of each concern or group of concerns within the Additional Health Concerns section should be clearly labeled (e.g. Patient, Nurse, Therapist).

Referenced in:

• Care Plan

Health Status Evaluations and Outcomes Section

This template represents observations regarding the outcome of care from the interventions used to treat the patient. These observations represent status, at points in time, related to established care plan goals and/or interventions.

Referenced in:

• Care Plan

History of Past Illness Section

This section contains a record of the patient’s past complaints, problems, and diagnoses. It contains data from the patient’s past up to the patient’s current complaint or reason for seeking medical care.

Referenced in:

• Consultation Note
• Discharge Summary
• History and Physical
• Transfer Summary
• Referral Note
• Procedure Note

History of Present Illness Section

The History of Present Illness section describes the history related to the reason for the encounter. It contains the historical details leading up to and pertaining to the patient’s current complaint or reason for seeking medical care.

Referenced in:

• Consultation Note
• Discharge Summary
• History and Physical
• Transfer Summary
• Referral Note
• Procedure Note

Hospital Consultations Section

The Hospital Consultations Section records consultations that occurred during the admission.

Referenced in:

• Discharge Summary

Hospital Course Section

The Hospital Course Section describes the sequence of events from admission to discharge in a hospital facility.

Referenced in:

• Discharge Summary

Hospital Discharge Instructions Section

The Hospital Discharge Instructions Section records instructions at discharge.

Referenced in:

• Discharge Summary

Hospital Discharge Physical Section

The Hospital Discharge Physical Section records a narrative description of the patient’s physical findings.

Referenced in:

• Discharge Summary

Hospital Discharge Studies Summary Section

This section records the results of observations generated by laboratories, imaging procedures, and other procedures. The scope includes hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. This section often includes notable results such as abnormal values or relevant trends, and could record all results for the period of time being documented. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory. Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as when a cardiologist reports the left ventricular ejection fraction based on the review of an echocardiogram. Procedure results are typically generated by a clinician wanting to provide more granular information about component observations made during the performance of a procedure, such as when a gastroenterologist reports the size of a polyp observed during a colonoscopy. Note that there are discrepancies between CCD and the lab domain model, such as the effectiveTime in specimen collection.

Referenced in:

• Discharge Summary

Immunizations Section (entries optional)

The Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section should include current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.

Referenced in:

• Consultation Note
• Discharge Summary
• History and Physical
• Transfer Summary

Immunizations Section (entries required)

The Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section should include current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.

Referenced in:

• Continuity of Care Document (CCD)
• Referral Note

Instructions Section

The Instructions Section records instructions given to a patient. List patient decision aids here.

Referenced in:

• History and Physical
• Progress Note

Interventions Section

This template represents Interventions. Interventions are actions taken to maximize the prospects of the goals of care for the patient, including the removal of barriers to success. Interventions can be planned, ordered, historical, etc. Interventions include actions that may be ongoing (e.g., maintenance medications that the patient is taking, or monitoring the patient’s health status or the status of an intervention). Instructions are nested within interventions and may include self-care instructions. Instructions are information or directions to the patient and other providers including how to care for the individual’s condition, what to do at home, when to call for help, any additional appointments, testing, and changes to the medication list or medication instructions, clinical guidelines and a summary of best practice. Instructions are information or directions to the patient. Use the Instructions Section when instructions are included as part of a document that is not a Care Plan. Use the Interventions Section, containing the Intervention Act containing the Instruction entry, when instructions are part of a structured care plan.

Referenced in:

• Care Plan
• Progress Note

Medical (General) History Section

The Medical History Section describes all aspects of the medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. The history may be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections including Past Medical History, Social History.

Referenced in:

• Procedure Note

Medical Equipment Section

This section defines a patient's implanted and external health and medical devices and equipment. This section lists any pertinent durable medical equipment (DME) used to help maintain the patient’s health status. All equipment relevant to the diagnosis, care, or treatment of a patient should be included. Devices applied to, or placed in, the patient are represented with the Procedure Activity Procedure (V2) template. Equipment supplied to the patient (e.g., pumps, inhalers, wheelchairs) is represented by the Non-Medicinal Supply Activity V2 template. These devices may be grouped together within a Medical Equipment Organizer. The organizer would probably not be used with devices applied in or on the patient but rather to organize a group of medical supplies the patient has been supplied with.

Referenced in:

• Consultation Note
• Continuity of Care Document (CCD)
• Transfer Summary
• Referral Note

Medications Administered Section

The Medications Administered Section usually resides inside a Procedure Note describing a procedure. This section defines medications and fluids administered during the procedure, its related encounter, or other procedure related activity excluding anesthetic medications. Anesthesia medications should be documented as described in the Anesthesia Section templateId 2.16.840.1.113883.10.20.22.2.25.

Referenced in:

• Procedure Note

Medications Section (entries optional)

The Medications Section contains a patient's current medications and pertinent medication history. At a minimum, the currently active medications are listed. An entire medication history is an option. The section can describe a patient's prescription and dispense history and information about intended drug monitoring.

Referenced in:

• History and Physical
• Progress Note
• Procedure Note

Medications Section (entries required)

The Medications Section contains a patient's current medications and pertinent medication history. At a minimum, the currently active medications are listed. An entire medication history is an option. The section can describe a patient's prescription and dispense history and information about intended drug monitoring. This section requires either an entry indicating the subject is not known to be on any medications or entries summarizing the subject's medications.

Referenced in:

• Consultation Note
• Continuity of Care Document (CCD)
• Transfer Summary
• Referral Note

Mental Status Section

The Mental Status Section contains observations and evaluations related to a patient’s psychological and mental competency and deficits including, but not limited to any of the following types of information:

• Appearance (e.g., unusual grooming, clothing or body modifications)
• Attitude (e.g., cooperative, guarded, hostile)
• Behavior/psychomotor (e.g., abnormal movements, eye contact, tics)
• Mood and affect (e.g., anxious, angry, euphoric)
• Speech and Language (e.g., pressured speech, perseveration)
• Thought process (e.g., logic, coherence)
• Thought content (e.g., delusions, phobias)
• Perception (e.g., voices, hallucinations)
• Cognition (e.g., memory, alertness/consciousness, attention, orientation) – which were included in Cognitive Status Observation in earlier publications of C-CDA.
• Insight and judgment (e.g., understanding of condition, decision making)

Referenced in:

• Consultation Note
• Continuity of Care Document (CCD)
• Transfer Summary
• Referral Note

Nutrition Section

The Nutrition Section represents diet and nutrition information including special diet requirements and restrictions (e.g., texture modified diet, liquids only, enteral feeding). It also represents the overall nutritional status of the patient and nutrition assessment findings.

Referenced in:

• Consultation Note
• Continuity of Care Document (CCD)
• Discharge Summary
• Transfer Summary
• Referral Note
• Progress Note

Objective Section

The Objective Section contains data about the patient gathered through tests, measures, or observations that produce a quantified or categorized result. It includes important and relevant positive and negative test results, physical findings, review of systems, and other measurements and observations.

Referenced in:

• Progress Note

Observer Context

The Observer Context is used to override the author specified in the CDA Header. It is valid as a direct child element of a section.

Referenced in:

• Diagnostic Imaging Report

Operative Note Fluids Section

The Operative Note Fluids Section may be used to record fluids administered during the surgical procedure.

Referenced in:

• Operative Note

Operative Note Surgical Procedure Section

The Operative Note Surgical Procedure Section can be used to restate the procedures performed if appropriate for an enterprise workflow. The procedure(s) performed associated with the Operative Note are formally modeled in the header using serviceEvent.

Referenced in:

• Operative Note

Payers Section

The Payers Section contains data on the patient’s payers, whether "third party" insurance, self-pay, other payer or guarantor, or some combination of payers, and is used to define which entity is the responsible fiduciary for the financial aspects of a patient’s care. Each unique instance of a payer and all the pertinent data needed to contact, bill to, and collect from that payer should be included. Authorization information that can be used to define pertinent referral, authorization tracking number, procedure, therapy, intervention, device, or similar authorizations for the patient or provider, or both should be included. At a minimum, the patient’s pertinent current payment sources should be listed. The sources of payment are represented as a Coverage Activity, which identifies all of the insurance policies or government or other programs that cover some or all of the patient's healthcare expenses. The policies or programs are sequenced by preference. The Coverage Activity has a sequence number that represents the preference order. Each policy or program identifies the covered party with respect to the payer, so that the identifiers can be recorded.

Referenced in:

• Continuity of Care Document (CCD)
• Transfer Summary

Physical Exam Section

The section includes direct observations made by a clinician. The examination may include the use of simple instruments and may also describe simple maneuvers performed directly on the patient’s body. It also includes observations made by the examining clinician using only inspection, palpation, auscultation, and percussion. It does not include laboratory or imaging findings. The exam may be limited to pertinent body systems based on the patient’s chief complaint or it may include a comprehensive examination. The examination may be reported as a collection of random clinical statements or it may be reported categorically. The Physical Exam Section may contain multiple nested subsections.

Referenced in:

• Consultation Note
• History and Physical
• Transfer Summary
• Referral Note
• Progress Note
• Procedure Note

Plan of Treatment Section

This section, formerly known as "Plan of Care", contains data that define pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only. These are indicated by the @moodCode of the entries within this section. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current care of the patient should be listed. Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and healthcare quality improvements, including widely accepted performance measures. The plan may also indicate that patient education will be provided. When used in a document that includes a Goals Section, all the goals (whether narrative only, or structured Goal Observation entries) should be recorded in the Goals Section, rather than in the Plan of Treatment Section, to avoid confusion as to “which/whose goals should be in which section?” When used in a document that does not include a Goals Section, the Plan of Treatment section may also contain information about care team members’ goals, including the patient’s values, beliefs, preferences, care expectations, and overarching care goals. Values may include the importance of quality of life over longevity. These values are taken into account when prioritizing all problems and their treatments. Beliefs may include comfort with dying or the refusal of blood transfusions because of the patient’s religious convictions. Preferences may include liquid medicines over tablets, or treatment via secure email instead of in person. Care expectations may range from being treated only by female clinicians, to expecting all calls to be returned within 24 hours. Overarching goals described in this section are not tied to a specific condition, problem, health concern, or intervention. Examples of overarching goals could be to minimize pain or dependence on others, or to walk a daughter down the aisle for her marriage.

Referenced in:

• Consultation Note
• Continuity of Care Document (CCD)
• Discharge Summary
• History and Physical
• Transfer Summary
• Referral Note
• Progress Note
• Procedure Note
• Operative Note

Planned Procedure Section

This section contains the procedure(s) that a clinician planned based on the preoperative assessment.

Referenced in:

• Procedure Note
• Operative Note

Postoperative Diagnosis Section

The Postoperative Diagnosis Section records the diagnosis or diagnoses discovered or confirmed during the surgery. Often it is the same as the preoperative diagnosis.

Referenced in:

• Operative Note

Postprocedure Diagnosis Section

The Postprocedure Diagnosis Section records the diagnosis or diagnoses discovered or confirmed during the procedure. Often it is the same as the preprocedure diagnosis or indication.

Referenced in:

• Procedure Note

Preoperative Diagnosis Section

The Preoperative Diagnosis Section records the surgical diagnoses assigned to the patient before the surgical procedure which are the reason for the surgery. The preoperative diagnosis is, in the surgeon's opinion, the diagnosis that will be confirmed during surgery.

Referenced in:

• Operative Note

Problem Section (entries optional)

This section lists and describes all relevant clinical problems at the time the document is generated. At a minimum, all pertinent current and historical problems should be listed. Overall health status may be represented in this section.

Referenced in:

• Discharge Summary
• History and Physical
• Progress Note

Problem Section (entries required)

This section lists and describes all relevant clinical problems at the time the document is generated. At a minimum, all pertinent current and historical problems should be listed. Overall health status may be represented in this section.

Referenced in:

• Consultation Note
• Continuity of Care Document (CCD)
• Transfer Summary
• Referral Note

Procedure Description Section

The Procedure Description section records the particulars of the procedure and may include procedure site preparation, surgical site preparation, pertinent details related to sedation/anesthesia, pertinent details related to measurements and markings, procedure times, medications administered, estimated blood loss, specimens removed, implants, instrumentation, sponge counts, tissue manipulation, wound closure, sutures used, vital signs and other monitoring data. Local practice often identifies the level and type of detail required based on the procedure or specialty.

Referenced in:

• Procedure Note
• Operative Note

Procedure Disposition Section

The Procedure Disposition Section records the status and condition of the patient at the completion of the procedure or surgery. It often also states where the patient was transferred to for the next level of care.

Referenced in:

• Procedure Note
• Operative Note

Procedure Estimated Blood Loss Section

The Procedure Estimated Blood Loss Section may be a subsection of another section such as the Procedure Description Section. The Procedure Estimated Blood Loss Section records the approximate amount of blood that the patient lost during the procedure or surgery. It may be an accurate quantitative amount, e.g., 250 milliliters, or it may be descriptive, e.g., “minimal” or “none”.

Referenced in:

• Procedure Note
• Operative Note

Procedure Findings Section

The Procedure Findings Section records clinically significant observations confirmed or discovered during a procedure or surgery.

Referenced in:

• Procedure Note
• Operative Note

Procedure Implants Section

The Procedure Implants Section records any materials placed during the procedure including stents, tubes, and drains.

Referenced in:

• Procedure Note
• Operative Note

Procedure Indications Section

This section contains the reason(s) for the procedure or surgery. This section may include the preprocedure diagnoses as well as symptoms contributing to the reason for the procedure.

Referenced in:

• Procedure Note
• Operative Note

Procedure Specimens Taken Section

The Procedure Specimens Taken Section records the tissues, objects, or samples taken from the patient during the procedure including biopsies, aspiration fluid, or other samples sent for pathological analysis. The narrative may include a description of the specimens.

Referenced in:

• Procedure Note
• Operative Note

Procedures Section (entries optional)

This section describes all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section should include notable procedures, but can contain all procedures for the period of time being summarized. The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM), therefore this section contains procedure templates represented with three RIM classes: Act, Observation, and Procedure. Procedure Activity Procedure (V2) is for procedures that alter the physical condition of a patient (e.g., splenectomy). Procedure Activity Observation (V2) is for procedures that result in new information about a patient but do not cause physical alteration (e.g., EEG). Procedure Activity Act (V2) is for all other types of procedures (e.g., dressing change).

Referenced in:

• Consultation Note
• Discharge Summary
• History and Physical
• Referral Note
• Procedure Note

Procedures Section (entries required)

This section describes all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section should include notable procedures, but can contain all procedures for the period of time being summarized. The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM), therefore this section contains procedure templates represented with three RIM classes: Act. Observation, and Procedure. Procedure act is for procedures that alter the physical condition of a patient (e.g., splenectomy). Observation act is for procedures that result in new information about a patient but do not cause physical alteration (e.g., EEG). Act is for all other types of procedures (e.g., dressing change).

Referenced in:

• Continuity of Care Document (CCD)
• Transfer Summary

Reason for Referral Section

This section describes the clinical reason why a provider is sending a patient to another provider for care. The reason for referral may become the reason for visit documented by the receiving provider.

Referenced in:

• Transfer Summary
• Referral Note

Reason for Visit Section

This section records the patient’s reason for the patient's visit (as documented by the provider). Local policy determines whether Reason for Visit and Chief Complaint are in separate or combined sections.

Referenced in:

• Consultation Note
• Discharge Summary
• History and Physical
• Procedure Note

Results Section (entries optional)

This section contains the results of observations generated by laboratories, imaging and other procedures. The scope includes observations of hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. This section often includes notable results such as abnormal values or relevant trends. It can contain all results for the period of time being documented. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory. Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram. Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy.

Referenced in:

• History and Physical
• Progress Note

Results Section (entries required)

The Results Section contains observations of results generated by laboratories, imaging procedures, and other procedures. These coded result observations are contained within a Results Organizer in the Results Section. The scope includes observations such as hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. The section often includes notable results such as abnormal values or relevant trends, and could contain all results for the period of time being documented. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory. Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram. Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy.

Referenced in:

• Consultation Note
• Continuity of Care Document (CCD)
• Transfer Summary
• Referral Note

Review of Systems Section

The Review of Systems Section contains a relevant collection of symptoms and functions systematically gathered by a clinician. It includes symptoms the patient is currently experiencing, some of which were not elicited during the history of present illness, as well as a potentially large number of pertinent negatives, for example, symptoms that the patient denied experiencing.

Referenced in:

• Consultation Note
• Discharge Summary
• History and Physical
• Transfer Summary
• Referral Note
• Progress Note
• Procedure Note

Social History Section

This section contains social history data that influence a patient’s physical, psychological or emotional health (e.g., smoking status, pregnancy). Demographic data, such as marital status, race, ethnicity, and religious affiliation, is captured in the header.

Note: in C-CDA birth sex is recorded in the social history section, but C-CDA on FHIR uses the US Core Patient profile for patient data, which itself contains a birth sex extension, so birth sex will be found on the Patient resource, not in this section.

Referenced in:

• Consultation Note
• Continuity of Care Document (CCD)
• Discharge Summary
• History and Physical
• Transfer Summary
• Referral Note
• Procedure Note

Subjective Section

The Subjective Section describes in a narrative format the patient’s current condition and/or interval changes as reported by the patient or by the patient’s guardian or another informant.

Referenced in:

• Progress Note

Surgical Drains Section

The Surgical Drains Section may be used to record drains placed during the surgical procedure. Optionally, surgical drain placement may be represented with a text element in the Procedure Description Section.

Referenced in:

• Operative Note

Vital Signs Section (entries optional)

The Vital Signs Section contains relevant vital signs for the context and use case of the document type, such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area. The section should include notable vital signs such as the most recent, maximum and/or minimum, baseline, or relevant trends. Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions.

Referenced in:

• Discharge Summary
• History and Physical
• Progress Note

Vital Signs Section (entries required)

The Vital Signs Section contains relevant vital signs for the context and use case of the document type, such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area. The section should include notable vital signs such as the most recent, maximum and/or minimum, baseline, or relevant trends. Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions.

Referenced in:

• Consultation Note
• Continuity of Care Document (CCD)
• Transfer Summary
• Referral Note