Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build United States of America flag

Consolidated CDA Release 2.1 StructureDefinition Publication, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.1). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.1-sd/ and changes regularly. See the Directory of published versions

Table of Contents

.. 0 Table of Contents
... 1 IG Home Page
... 2 Background
... 3 Design Considerations
... 4 Using this Implementation Guide
... 5 References
... 6 Appendix
... 7 Validation
... 8 How To Read
... 9 Downloads
... 10 Introduction
... 11 Understanding C-CDA and the C-CDA Companion Guide
... 12 Document Level Guidance
... 13 Section Level Guidance
... 14 Representation of Discrete Data
... 15 USCDI Guidance
... 16 Resources
... 17 Change Log
... 18 Artifacts Summary
.... 18.1 Care Plan
.... 18.2 Consultation Note
.... 18.3 Continuity of Care Document (CCD)
.... 18.4 Discharge Summary
.... 18.5 History and Physical
.... 18.6 Operative Note
.... 18.7 Procedure Note
.... 18.8 Progress Note
.... 18.9 Referral Note
.... 18.10 Transfer Summary
.... 18.11 Unstructured Document
.... 18.12 US Realm Header
.... 18.13 US Realm Header for Patient Generated Document
.... 18.14 Activities Section
.... 18.15 Admission Diagnosis Section
.... 18.16 Admission Medications Section (entries optional)
.... 18.17 Advance Directives Section
.... 18.18 Allergies and Intolerances Section
.... 18.19 Anesthesia Section
.... 18.20 Assessment and Plan Section
.... 18.21 Assessment Section
.... 18.22 Care Teams Section
.... 18.23 Chief Complaint and Reason for Visit Section
.... 18.24 Chief Complaint Section
.... 18.25 Complications Section
.... 18.26 Course of Care Section
.... 18.27 Discharge Diagnosis Section
.... 18.28 Discharge Medications Section
.... 18.29 Encounters Section
.... 18.30 Family History Section
.... 18.31 Functional Status Section
.... 18.32 General Status Section
.... 18.33 Goals Section
.... 18.34 Health Concerns Section
.... 18.35 Health Status Evaluations and Outcomes Section
.... 18.36 History of Present Illness Section
.... 18.37 Hospital Consultations Section
.... 18.38 Hospital Course Section
.... 18.39 Hospital Discharge Instructions Section
.... 18.40 Hospital Discharge Physical Section
.... 18.41 Hospital Discharge Studies Summary Section
.... 18.42 Immunizations Section
.... 18.43 Instructions Section
.... 18.44 Medical (General) History Section
.... 18.45 Medical Equipment Section
.... 18.46 Medications Administered Section
.... 18.47 Medications Section
.... 18.48 Mental Status Section
.... 18.49 Notes Section
.... 18.50 Nutrition Section
.... 18.51 Objective Section
.... 18.52 Operative Note Fluids Section
.... 18.53 Operative Note Surgical Procedure Section
.... 18.54 Past Medical History
.... 18.55 Payers Section
.... 18.56 Physical Exam Section
.... 18.57 Plan of Treatment Section
.... 18.58 Planned Procedure Section
.... 18.59 Postoperative Diagnosis Section
.... 18.60 Postprocedure Diagnosis Section
.... 18.61 Preoperative Diagnosis Section
.... 18.62 Problem Section
.... 18.63 Procedure Description Section
.... 18.64 Procedure Disposition Section
.... 18.65 Procedure Estimated Blood Loss Section
.... 18.66 Procedure Findings Section
.... 18.67 Procedure Implants Section
.... 18.68 Procedure Indications Section
.... 18.69 Procedure Specimens Taken Section
.... 18.70 Procedures Section
.... 18.71 Reason for Referral Section
.... 18.72 Reason for Visit Section
.... 18.73 Results Section
.... 18.74 Review of Systems Section
.... 18.75 Social History Section
.... 18.76 Subjective Section
.... 18.77 Surgical Drains Section
.... 18.78 Vital Signs Section
.... 18.79 Admission Medication
.... 18.80 Advance Directive Observation
.... 18.81 Advance Directive Organizer
.... 18.82 Age Observation
.... 18.83 Allergy - Intolerance Observation
.... 18.84 Allergy Concern Act
.... 18.85 Allergy Status Observation
.... 18.86 Assessment Scale Observation
.... 18.87 Assessment Scale Supporting Observation
.... 18.88 Authorization Activity
.... 18.89 Basic Industry Observation
.... 18.90 Basic Occupation Observation
.... 18.91 Birth Sex Observation
.... 18.92 Brand Name Observation
.... 18.93 Care Team Member Act
.... 18.94 Care Team Member Schedule Observation
.... 18.95 Care Team Organizer
.... 18.96 Care Team Type Observation
.... 18.97 Caregiver Characteristics
.... 18.98 Catalog Number Observation
.... 18.99 Characteristics of Home Environment
.... 18.100 Comment Activity
.... 18.101 Company Name Observation
.... 18.102 Coverage Activity
.... 18.103 Criticality Observation
.... 18.104 Cultural and Religious Observation
.... 18.105 Date of Diagnosis Act
.... 18.106 Deceased Observation
.... 18.107 Device Identifier Observation
.... 18.108 Disability Status Observation
.... 18.109 Discharge Medication
.... 18.110 Distinct Identification Code Observation
.... 18.111 Drug Monitoring Act
.... 18.112 Drug Vehicle
.... 18.113 Encounter Activity
.... 18.114 Encounter Diagnosis
.... 18.115 Entry Reference
.... 18.116 Estimated Date of Delivery
.... 18.117 Expiration Date Observation
.... 18.118 External Document Reference
.... 18.119 Family History Death Observation
.... 18.120 Family History Observation
.... 18.121 Family History Organizer
.... 18.122 Functional Status Observation
.... 18.123 Functional Status Organizer
.... 18.124 Gender Identity Observation
.... 18.125 Goal Observation
.... 18.126 Health Concern Act
.... 18.127 Health Status Observation
.... 18.128 Highest Pressure Ulcer Stage
.... 18.129 Hospital Admission Diagnosis
.... 18.130 Hospital Discharge Diagnosis
.... 18.131 Immunization Activity
.... 18.132 Immunization Medication Information
.... 18.133 Immunization Refusal Reason
.... 18.134 Implantable Device Status Observation
.... 18.135 Indication
.... 18.136 Instruction
.... 18.137 Intervention Act
.... 18.138 Latex Safety Observation
.... 18.139 Longitudinal Care Wound Observation
.... 18.140 Lot or Batch Number Observation
.... 18.141 Manufacturing Date Observation
.... 18.142 Medical Equipment Organizer
.... 18.143 Medication Activity
.... 18.144 Medication Adherence
.... 18.145 Medication Dispense
.... 18.146 Medication Free Text Sig
.... 18.147 Medication Information
.... 18.148 Medication Supply Order
.... 18.149 Mental Status Observation
.... 18.150 Mental Status Organizer
.... 18.151 Model Number Observation
.... 18.152 MRI Safety Observation
.... 18.153 Non-Medicinal Supply Activity
.... 18.154 Note Activity
.... 18.155 Number of Pressure Ulcers Observation
.... 18.156 Nutrition Assessment
.... 18.157 Nutrition Recommendation
.... 18.158 Nutritional Status Observation
.... 18.159 Outcome Observation
.... 18.160 Patient Referral Act
.... 18.161 Planned Act
.... 18.162 Planned Coverage
.... 18.163 Planned Encounter
.... 18.164 Planned Immunization Activity
.... 18.165 Planned Intervention Act
.... 18.166 Planned Medication Activity
.... 18.167 Planned Observation
.... 18.168 Planned Procedure
.... 18.169 Planned Supply
.... 18.170 Policy Activity
.... 18.171 Postprocedure Diagnosis
.... 18.172 Precondition for Substance Administration
.... 18.173 Pregnancy Intention in Next Year
.... 18.174 Pregnancy Observation
.... 18.175 Preoperative Diagnosis
.... 18.176 Priority Preference
.... 18.177 Problem Concern Act
.... 18.178 Problem Observation
.... 18.179 Problem Status
.... 18.180 Procedure Activity Procedure
.... 18.181 Product Instance
.... 18.182 Prognosis Observation
.... 18.183 Progress Toward Goal Observation
.... 18.184 Reaction Observation
.... 18.185 Reason
.... 18.186 Result Observation
.... 18.187 Result Organizer
.... 18.188 Risk Concern Act
.... 18.189 Section Time Range Observation
.... 18.190 Self-Care Activities (ADL and IADL)
.... 18.191 Sensory Status
.... 18.192 Serial Number Observation
.... 18.193 Service Delivery Location
.... 18.194 Severity Observation
.... 18.195 Sex Observation
.... 18.196 Sexual Orientation Observation
.... 18.197 Smoking Status - Meaningful Use
.... 18.198 Social History Observation
.... 18.199 Substance Administered Act
.... 18.200 Substance or Device Allergy - Intolerance Observation
.... 18.201 Tobacco Use
.... 18.202 Tribal Affiliation Observation
.... 18.203 UDI Organizer
.... 18.204 Vital Sign Observation
.... 18.205 Vital Signs Organizer
.... 18.206 Wound Characteristic
.... 18.207 Wound Measurement Observation
.... 18.208 Author Participation
.... 18.209 Handoff Communication Participants
.... 18.210 Provenance - Assembler Participation
.... 18.211 Provenance - Author Participation
.... 18.212 Related Person Relationship and Name Participant
.... 18.213 US Realm Address (AD.US.FIELDED)
.... 18.214 US Realm Date and Time (DT.US.FIELDED)
.... 18.215 US Realm Date and Time (DTM.US.FIELDED)
.... 18.216 US Realm Patient Name (PTN.US.FIELDED)
.... 18.217 US Realm Person Name (PN.US.FIELDED)
.... 18.218 Example of Allergy Intolerance to Food Egg
.... 18.219 Admission Diagnosis Section Example
.... 18.220 Admission Medication example
.... 18.221 Advance Directive Observation Example
.... 18.222 Advance Directive Organizer Example
.... 18.223 Advance Directives Section Example
.... 18.224 Age Observation Example
.... 18.225 Allergies and Intolerances Section Example
.... 18.226 Allergy Concern Act Example
.... 18.227 Allergy Intolerance Observation Example
.... 18.228 Anesthesia Section Example
.... 18.229 Assessment and Plan Section Example
.... 18.230 Assessment Scale Observation Example
.... 18.231 Assessment Scale Supporting Observation Example
.... 18.232 Assessment Section Example
.... 18.233 Author Participation Example
.... 18.234 Authorization Activity Example
.... 18.235 Care Plan Caregiver participant Example
.... 18.236 Care Plan Patient authenticator Example
.... 18.237 Care Plan performer Example
.... 18.238 Care Plan relatedDocument Example
.... 18.239 Care Plan Review Example
.... 18.240 Caregiver Characteristics Example
.... 18.241 Characteristics of Home Environment Example
.... 18.242 Chief Complaint and Reason for Visit Section Example
.... 18.243 Chief Complaint Section Example
.... 18.244 Comment Activity Example
.... 18.245 Complications Section Example
.... 18.246 Continuity Of Care Document Author Example
.... 18.247 Continuity Of Care Document Performer
.... 18.248 Continuity Of Care Document serviceEvent Example
.... 18.249 Consultation Note Callback participant Example
.... 18.250 Consultation Note structuredBody
.... 18.251 Consultation Note inFulfillmentOf Example
.... 18.252 Course of Care Section Example
.... 18.253 Coverage Activity Example
.... 18.254 Criticality Observation Example
.... 18.255 Cultural and Religious Observation Example
.... 18.256 Deceased Observation Example
.... 18.257 Diagnosis Reference Example
.... 18.258 Discharge Diagnosis Example
.... 18.259 Discharge Medications Section Example
.... 18.260 Discharge Medication Example
.... 18.261 Discharge Summary encompassingEncounter Example
.... 18.262 Drug Monitoring Act Example
.... 18.263 Drug Vehicle Example
.... 18.264 Encounter Activity Example
.... 18.265 Encounter Diagnosis Example
.... 18.266 Encounters Section Example
.... 18.267 Entry Reference Example
.... 18.268 Estimated Date of Delivery Example
.... 18.269 External Document Reference Example
.... 18.270 Family History Death Observation Example
.... 18.271 Family History Observation Example
.... 18.272 Family History Organizer Example
.... 18.273 Family History Section Example
.... 18.274 Functional Status Observation Example
.... 18.275 Functional Status Organizer Example
.... 18.276 Functional Status Section Example
.... 18.277 General Status Section Example
.... 18.278 Goal Observation Example
.... 18.279 Goals Section Example
.... 18.280 Handoff Communication Participants Example
.... 18.281 Health Concern Act Example
.... 18.282 Health Concerns Section Example
.... 18.283 Health Status Evaluations and Outcomes Section Example
.... 18.284 Health Status Observation Example
.... 18.285 Highest Pressure Ulcer Stage Example
.... 18.286 History and Physical Encompassing Encounter Example
.... 18.287 History Of Present Illness Example
.... 18.288 Hospital Admission Diagnosis Example
.... 18.289 Hospital Consultations Section Example
.... 18.290 Hospital Course Section Example
.... 18.291 Hospital Discharge Diagnosis Example
.... 18.292 Hospital Discharge Instructions Section Example
.... 18.293 Hospital Discharge Physical Section Example
.... 18.294 Hospital Discharge Studies Summary Section Example
.... 18.295 Immunization Activity Example
.... 18.296 Immunization Medication Information Example
.... 18.297 Immunization Refusal Reason Example
.... 18.298 Immunizations Section Example
.... 18.299 Indication Example
.... 18.300 Instructions Section Example
.... 18.301 Instruction Example
.... 18.302 Intervention Act Example
.... 18.303 Interventions Section Example
.... 18.304 Longitudinal Care Wound Observation Example
.... 18.305 Medical Equipment Organizer Example
.... 18.306 Medical Equipment Section Example
.... 18.307 Medication Activity Example
.... 18.308 Medication Dispense Example
.... 18.309 Medication Free Text Sig Example
.... 18.310 Medication Information Example
.... 18.311 Medication Supply Order Example
.... 18.312 Medications Administered Section Example
.... 18.313 Medications Section Example
.... 18.314 Mental Status Organizer Example
.... 18.315 Mental Status Organizer Example
.... 18.316 Mental Status Section Example
.... 18.317 No Known Medications Example
.... 18.318 No Known Problem Section Example
.... 18.319 Non-Medicinal Supply Activity Example
.... 18.320 nonXML Body Example with Compressed Content
.... 18.321 nonXML Body Example with Embedded Content
.... 18.322 nonXML Body Example with Referenced Content
.... 18.323 Number of Pressure Ulcers Observation Example
.... 18.324 Nutrition Assessment Example
.... 18.325 Nutrition Recommendation Example
.... 18.326 Nutrition Section Example
.... 18.327 Nutritional Status Observation Example
.... 18.328 Objective Section Example
.... 18.329 Operative Note performer Example
.... 18.330 Operative Note serviceEvent Example
.... 18.331 Operative Note Fluids Section Example
.... 18.332 Operative Note Surgical Procedure Section Example
.... 18.333 Outcome Observation Example
.... 18.334 Past Medical History Example
.... 18.335 Patient Generated Document authenticator
.... 18.336 Patient Generated Document author device Example
.... 18.337 Patient Generated Document author
.... 18.338 Patient Generated Document custodian Example
.... 18.339 Patient Generated Document dataEnterer
.... 18.340 Patient Generated Document informant Example informant
.... 18.341 Patient Generated Document informant RelEnt Example
.... 18.342 Patient Generated Document informationRecipient Example
.... 18.343 Patient Generated Document inFulfillmentOf Example
.... 18.344 Patient Generated Document legalAuthenticator Example
.... 18.345 Patient Generated Document participant Example
.... 18.346 Patient Generated Document recordTarget
.... 18.347 Patient Referral Act Example
.... 18.348 Payers Section Example
.... 18.349 Physical Exam Section Example
.... 18.350 Plan of Treatment Section Example
.... 18.351 Planned Act Example
.... 18.352 Planned Coverage Example
.... 18.353 Planned Encounter Example
.... 18.354 Planned Immunization Activity Example
.... 18.355 Planned Medication Activity Example
.... 18.356 Planned Observation Example
.... 18.357 Planned Procedure Section Example
.... 18.358 Planned Procedure Example
.... 18.359 Planned Supply Example
.... 18.360 Policy Activity Example
.... 18.361 Postoperative Diagnosis Section Example
.... 18.362 Postprocedure Diagnosis Example
.... 18.363 Postprocedure Diagnosis Section Example
.... 18.364 Precondition for Substance Administration Example
.... 18.365 Pregnancy Observation Example
.... 18.366 Preoperative Diagnosis Section Example
.... 18.367 Preoperative Diagnosis Example
.... 18.368 Priority Preference Example
.... 18.369 Problem Concern Act Example
.... 18.370 Problem Observation Example
.... 18.371 Problem Section Example
.... 18.372 Procedure Note performer Example
.... 18.373 Procedure Note serviceEvent Example
.... 18.374 Procedure Activity Procedure Example
.... 18.375 Procedure Description Section Example
.... 18.376 Procedure Disposition Section Example
.... 18.377 Procedure Estimated Blood Loss Section Example
.... 18.378 Procedure Findings Section Example
.... 18.379 Procedure Implants Section Example
.... 18.380 Procedure Indications Section Example
.... 18.381 Procedure Specimens Taken Section Example
.... 18.382 Procedures Section Example
.... 18.383 Product Instance Example
.... 18.384 Prognosis Coded Example
.... 18.385 Prognosis Free Text Example
.... 18.386 Progress Note encompassingEncounter Example
.... 18.387 Progress Note serviceEvent Example
.... 18.388 Progress Toward Goal Observation Example
.... 18.389 Reaction Observation Example
.... 18.390 Reason For Referral
.... 18.391 Reason for Visit Section Example
.... 18.392 Referral Note Callback Contact Example
.... 18.393 Referral Note Caregiver
.... 18.394 Referral Note informationRecipient Example
.... 18.395 Result Observation Example
.... 18.396 Result Organizer Example
.... 18.397 Results Section Example
.... 18.398 Review Of Systems Section Example
.... 18.399 Risk Concern Act Example
.... 18.400 Self-Care Activities ADL and IADL Example
.... 18.401 Sensory Status Example
.... 18.402 Service Delivery Location Example
.... 18.403 Severity Observation Example
.... 18.404 Smoking Status Meaningful Use Example
.... 18.405 Social History Observation Example
.... 18.406 Social History Section Example
.... 18.407 Subjective Section Example
.... 18.408 Substance Administered Act Example
.... 18.409 Surgical Drains Section Example
.... 18.410 Tobacco Use Example
.... 18.411 Transfer Summary Callback Contact Example
.... 18.412 Transfer Summary participant (Support) Example
.... 18.413 US Realm Address Example
.... 18.414 US Realm Date and Time Example
.... 18.415 US Realm Header Example
.... 18.416 US Realm Patient Name Example
.... 18.417 US Realm Person Name Example
.... 18.418 Vital Sign Observation Example
.... 18.419 Vital Signs Organizer Example
.... 18.420 Vital Signs Section Example
.... 18.421 Wound Characteristic Example
.... 18.422 Wound Measurement Observation Example