Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build

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

## IG Home Page

Official URL: http://hl7.org/cda/us/ccda/ImplementationGuide/hl7.cda.us.ccda | Version: 2.1
Draft as of 2023-09-29 | Computable Name: CCDA

### Purpose

This two-volume implementation guide (IG) contains an overview of Clinical Document Architecture (CDA) markup standards, design, and use (Volume 1) and a consolidated library of CDA templates for clinical notes applicable to the US Realm (Volume 2). These two volumes comprise a Draft Standard for Trial Use (DSTU). It has been adapted from the Release 2.0 version of the Consolidated CDA Templates for Clinical Notes to support backward compatibility “on the wire” with the 1.1 Release of the templates described in this guide. This will enable implementers of systems conforming to this guide to produce documents that can be understood by systems which only support the C-CDA Release 1.1 specification. The consolidated library incorporates previous efforts from Health Level Seven (HL7), Integrating the Healthcare Enterprise (IHE), the Health Information Technology Standards Panel (HITSP), the HL7 Health Story guides, HITSP C32, and related components of IHE Patient Care Coordination (IHE PCC). It has additional or enhanced document types for greater expressivity and decrease ambiguity (see Volume 2 Summary of Changes). Volume 1 adds new general guidance (see Summary of Changes). This guide, in conjunction with the HL7 CDA Release 2 (CDA R2) standard, is to be used for implementing the following CDA documents and header constraints for clinical notes.

- Care Plan including Home Health Plan of Care (HHPoC)
- Consultation Note
- Continuity of Care Document (CCD)
- Discharge Summary
- History and Physical (H&P)
- Operative Note
- Procedure Note
- Progress Note
- Referral Note
- Transfer Summary
- Unstructured Document
- Patient Generated Document (US Realm Header)

### Audience

The audience for this implementation guide includes architects and developers of healthcare information technology (HIT) systems in the US Realm that exchange patient clinical data. Business analysts and policy managers can also benefit from a basic understanding of the use of CDA templates across multiple implementation use cases.

### Organization of the Guide

This implementation guide is organized into two volumes. Volume 1 contains primarily narrative text describing the Consolidated CDA Release 2 (C-CDA R2) guide, whereas Volume 2 contains normative CDA template definitions.

### Acknowledgments

This R2.1 guide was developed and produced through the efforts of Health Level Seven (HL7).

The editors appreciate the support and sponsorship of the HL7 Structured Documents Working Group (SDWG), the HL7 Patient Care Work Group, the HL7 Child Health Work Group, and all volunteers and staff associated with the creation of this document. This guide would not have been possible without the support of the Department of Defense/Department of Veterans Affairs Interagency Program Office (DoD/VA IPO).

This material contains content from SNOMED CT® (http://www.ihtsdo.org/snomed-ct/). SNOMED CT is a registered trademark of the International Health Terminology Standard Development Organisation (IHTSDO).

This material contains content from the Logical Observation Identifiers Names and Codes (LOINC) organization (http://loinc.org). The LOINC table, LOINC codes, and LOINC panels and forms file are copyright © 1995-2014, Regenstrief Institute, Inc. and LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use.

### Authors

Primary Editor / Co-Chair: | Rick Geimer Lantana Consulting Group rick.geimer@lantanagroup.com | Co-Editor: | Benjamin Flessner Epic Benjamin@epic.com
Primary Editor / Co-Chair: | Brett Marquard River Rock Associates brett@riverrockassociates.com | Co-Editor: | Larry Garber, MD Reliant Medical Group Lawrence.Garber@ReliantMedicalGroup.org
Co-Chair: | Calvin Beebe Mayo Clinic cbeebe@mayo.edu | Co-Editor: | Jennie Harvell, M.Ed US Health and Human Services Jennie.harvell@hhs.gov
Co-Chair: | Diana Behling Iatric Systems Diana.Behling@iatric.com | Co-Editor: | Laura Heermann Langford, RN, PhD Intermountain Healthcare Laura.Heermann@imail.org
Co-Chair: | Austin Kreisler SAIC Consultant to CDC/NHSN duz1@cdc.gov | Co-Editor: | Emma Jones RN-BC, MSN Allscripts emma.jones@allscripts.com
Co-Chair: | Patrick Lloyd Icode Solutions patrick.e.loyd@gmail.com | Co-Editor: | Josh Mandel, MD Harvard Medical School / Boston Children’s Hospital Joshua.Mandel@childrens.harvard.edu
Primary Editor / Co-Chair: | Gaye Dolin, MSN, RN Intelligent Medical Objects, Inc. gdolin@imo-online.com | Co-Editor: | Susan Matney, MSN, RN 3M Health Information Systems samatney@mmm.com
Primary Editor: | Sarah Gaunt Lantana Consulting Group sarah.gaunt@lantanagroup.com | Co-Editor: | Sean McIlvenna Lantana Consulting Group sean.mcilvenna@lantanagroup.com
Primary Editor: | Zabrina Gonzaga Lantana Consulting Group zabrina.gonzaga@lantanagroup.com | Co-Editor: | Dale Nelson Lantana Consulting Group dale.nelson@lantanagroup.com
Co-Editor: | Liora Alschuler Lantana Consulting Group liora.alschuler@lantanagroup.com | Co-Editor: | Lisa Nelson Life Over Time Solutions LisaRNelson@cox.net
Co-Editor: | Virinder Batra Intuit Health virinder.batra@gmail.com | Co-Editor: | Terrence A. O’Malley, MD Partners Healthcare tomalley@partners.org
Co-Editor: | Keith W. Boone GE Healthcare keith.boone@ge.com | Co-Editor: | Eric Parapini Lantana Consulting Group eric.parapini@lantanagroup.com
Co-Editor: | Stephen Chu National E-Health Transition, Australia stephen.chu@nehta.gov.au | Co-Editor: | David Tao, D.Sc. ICSA Labs dtao12@gmail.com
Co-Editor: | John D’Amore Lantana Consulting Group john.damore@lantanagroup.com | Technical Editor: | Adrienne Giannone Lantana Consulting Group adrienne.giannone@lantanagroup.com
Co-Editor: | Robert H. Dolin, MD bobdolin@gmail.com | Technical Editor: | Diana Wright Lantana Consulting Group diana.wright@lantanagroup.com
Co-Editor: | Susan Campbell, PhD, RN bostoncampbell@mindspring.com | Technical Editor: | Veronica Kwok Deloitte vkwok@deloitte.com