  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 |
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