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

Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions

Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Document Templates

Document-level templates describe the purpose and rules for constructing a conforming CDA document. Document templates include constraints on the CDA header and indicate contained section-level templates.

Each document-level template contains the following information:

  • Scope and intended use of the document type
  • Description and explanatory narrative
  • Template metadata (e.g., templateId)
  • Header constraints (e.g., document type, template id, participants)
  • Required and optional section-level templates
Care Plan

A Care Plan is a consensus-driven dynamic plan that represents a patient's and Care Team Member's prioritized concerns, goals, and planned interventions.

Consultation Note

The Consultation Note is generated by a request from a clinician for an opinion or advice from another clinician.

Continuity of Care Document (CCD)

The Continuity of Care Document (CCD) represents a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters.

Discharge Summary

The Discharge Summary is a document which synopsizes a patient's admission to a hospital, LTPAC provider, or other setting.

History and Physical

A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient.

Operative Note

The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies.

Procedure Note

A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields.

Progress Note

This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter.

Referral Note

A Referral Note communicates pertinent information from a provider who is requesting services of another provider of clinical or non-clinical services.

Transfer Summary

The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between health care settings.

Unstructured Document

An Unstructured Document (UD) document type can (1) include unstructured content, such as a graphic, directly in a text element with a mediaType attribute, or (2) reference a single document file, such as a word-processing document using a text/reference element.

US Realm Header

This template defines constraints that represent common administrative and demographic concepts for US Realm CDA documents.

US Realm Header for Patient Generated Document

This template focuses on the patient or related person in the roles of author and other participants and is designed to be used in conjunction with the US Realm Header.

Section Templates

This chapter contains the section-level templates referenced by one or more of the document types of this consolidated guide. These templates describe the purpose of each section and the section-level constraints.

Section-level templates are always included in a document. One and only one of each section type is allowed in a given document instance. Please see the document context tables to determine the sections that are contained in a given document type. Please see the conformance verb in the conformance statements to determine if it is required (SHALL), strongly recommended (SHOULD), or optional (MAY).

Each section-level template contains the following:

  • Template metadata (e.g., templateId, etc.)
  • Description and explanatory narrative
  • LOINC section code
  • Section title
  • Requirements for a text element
  • Entry-level template names and Ids for referenced templates (required and optional)

Narrative Text

The text element within the section stores the narrative to be rendered, as described in the CDA R2 specification, and is referred to as the CDA narrative block.

The content model of the CDA narrative block schema is handcrafted to meet requirements of human readability and rendering. The schema is registered as a MIME type (text/x-hl7-text+xml), which is the fixed media type for the text element.

As noted in the CDA R2 specification, the document originator is responsible for ensuring that the narrative block contains the complete, human readable, attested content of the section. Structured entries support computer processing and computation and are not a replacement for the attestable, human-readable content of the CDA narrative block. The special case of structured entries with an entry relationship of "DRIV" (is derived from) indicates to the receiving application that the source of the narrative block is the structured entries, and that the contents of the two are clinically equivalent.

For all CDA documents—even when a report consisting entirely of structured entries is transformed into CDA—the encoding application must ensure that the authenticated content (narrative plus multimedia) is a faithful and complete rendering of the clinical content of the structured source data. As a general guideline, a generated narrative block should include the same human readable content that would be available to users viewing that content in the originating system. Although content formatting in the narrative block need not be identical to that in the originating system, the narrative block should use elements from the CDA narrative block schema to provide sufficient formatting to support human readability when rendered according to the rules defined in Section Narrative Block (§ 4.3.5 ) of the CDA R2 specification.

By definition, a receiving application cannot assume that all clinical content in a section (i.e., in the narrative block and multimedia) is contained in the structured entries unless the entries in the section have an entry relationship of "DRIV".

Additional specification information for the CDA narrative block can be found in the CDA R2 specification in sections 1.2.1, 1.2.3, 1.3, 1.3.1, 1.3.2, 4.3.4.2, and 6.

Activities Section

This template represents Activities.

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.

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.

Advance Directives Section

This section contains details about the patient’s advance healthcare directives, including references to supporting documents such as Living Wills, Healthcare Power of Attorney, Personal Advance Care Plans, DNR Orders, and Portable Medical Orders.

Allergies and Intolerances Section

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).

Anesthesia Section

The Anesthesia Section records the type of anesthesia (e.g., general or local) and may state the actual agent used.

Assessment and Plan Section

This section represents the clinician's conclusions and working assumptions that will guide treatment of the patient.

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.

Care Teams Section

The Care Teams Section is used to share historical and current Care Team information.

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).

Chief Complaint Section

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

Complications Section

This section contains problems that occurred during or around the time of a procedure.

Course of Care Section

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

Discharge Diagnosis Section

This template represents problems or diagnoses present at the time of discharge which occurred during the hospitalization.

Discharge Medications Section

This section contains the medications the patient is intended to take or stop after discharge.

Encounters Section

This section lists and describes any healthcare encounters pertinent to the patient's current health status or historical health history.

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.

Functional Status Section

The Functional Status Section contains observations and assessments of a patient's physical abilities.

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.

Goals Section

This template represents patient Goals.

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.

Health Status Evaluations and Outcomes Section

This section represents observations regarding the evaluation or assessment of the patient, and the outcome of care from the interventions used to treat the patient.

History of Present Illness Section

The History of Present Illness section describes the history related to the reason for the encounter.

Hospital Consultations Section

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

Hospital Course Section

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

Hospital Discharge Instructions Section

The Hospital Discharge Instructions Section records instructions at discharge.

Hospital Discharge Physical Section

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

Hospital Discharge Studies Summary Section

This section records the results of observations generated by laboratories, imaging procedures, and other procedures.

Immunizations Section

The Immunizations Section defines a patient's current immunization status and pertinent immunization history.

Instructions Section

The Instructions Section records instructions given to a patient.

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.

Medical Equipment Section

This section defines a patient's implanted and external health and medical devices and equipment.

Medications Administered Section

The Medications Administered Section usually resides inside a Procedure Note describing a procedure.

Medications Section

The Medications Section contains a patient's current medications and pertinent medication history.

Mental Status Section

The Mental Status Section contains observations and evaluations related to a patient's psychological and mental competency and deficits.

Notes Section

The Notes Section allow for inclusion of clinical documentation which does not fit precisely within any other C-CDA section.

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).

Objective Section

The Objective Section contains data about the patient gathered through tests, measures, or observations that produce a quantified or categorized result.

Operative Note Fluids Section

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

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.

Past Medical History

This section contains a record of the patient's past complaints, problems, and diagnoses.

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.

Physical Exam Section

The section includes direct observations made by a clinician.

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.

Planned Procedure Section

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

Postoperative Diagnosis Section

The Postoperative Diagnosis Section records the diagnosis or diagnoses discovered or confirmed during the surgery.

Postprocedure Diagnosis Section

The Postprocedure Diagnosis Section records the diagnosis or diagnoses discovered or confirmed during the procedure.

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.

Problem Section

This section lists and describes all relevant clinical problems at the time the document is generated.

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.

Procedure Disposition Section

The Procedure Disposition Section records the status and condition of the patient at the completion of the procedure or surgery.

Procedure Estimated Blood Loss Section

The Procedure Estimated Blood Loss Section may be a subsection of another section such as the Procedure Description Section.

Procedure Findings Section

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

Procedure Implants Section

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

Procedure Indications Section

This section contains the reason(s) for the procedure or surgery.

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.

Procedures Section

This section describes all historical or current interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient at the time the document is generated.

Reason for Referral Section

This section describes the clinical reason why a provider is sending a patient to another provider for care.

Reason for Visit Section

This section records the patient's reason for the patient's visit (as documented by the provider).

Results Section

The Results Section contains observations of results generated by laboratories, imaging procedures, and other procedures.

Review of Systems Section

The Review of Systems Section contains a relevant collection of symptoms and functions systematically gathered by a clinician.

Social History Section

This section contains social history data that influence a patient's physical, psychological or emotional health (e.g., smoking status, pregnancy).

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.

Surgical Drains Section

The Surgical Drains Section may be used to record drains placed during the surgical procedure.

Vital Signs Section

The Vital Signs Section contains relevant vital signs for the context and use case of the document type, such as blood pressure (including average blood pressure), heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area.

Entry Templates

This chapter describes the clinical statement entry templates used within the sections of the document types of this consolidated guide. Entry templates contain constraints that are required for conformance.

Entry-level templates are always in sections.

Each entry-level template description contains the following information:

  • Key template metadata (e.g., template identifier, etc.)
  • Description and explanatory narrative.
  • Required CDA acts, participants and vocabularies.
  • Optional CDA acts, participants and vocabularies. Several entry-level templates require an effectiveTime:

The effectiveTime of an observation is the time interval over which the observation is known to be true. The low and high values should be as precise as possible, but no more precise than known. While CDA has multiple mechanisms to record this time interval (e.g., by low and high values, low and width, high and width, or center point and width), this guide constrains most to use only the low/high form. The low value is the earliest point for which the condition is known to have existed. The high value, when present, indicates the time at which the observation was no longer known to be true. The full description of effectiveTime and time intervals is contained in the CDA R2 normative edition.

Provenance in entry templates:

In this version of Consolidated CDA (C-CDA), we have added a "SHOULD" Author constraint on several entry-level templates. Authorship and Author timestamps must be explicitly asserted in these cases, unless the values propagated from the document header hold true.

ID in entry templates:

Entry-level templates may also describe an id element, which is an identifier for that entry. This id may be referenced within the document, or by the system receiving the document. The id assigned must be globally unique.

Admission Medication

This template represents the medications taken by the patient prior to and at the time of admission.

Advance Directive Observation

The Advance Directive Observation template is nested within the Advance Directive Existence Observation, which indicates whether the individual has any advance directive documents.

Advance Directive Existence Observation

This observation represents a simple observation indicating whether a person has an advance directive document.

Age Observation

This Age Observation represents the subject's age at onset of an event or observation.

Allergy - Intolerance Observation

This template reflects a discrete observation about a patient's allergy or intolerance.

Allergy Concern Act

This template reflects an ongoing concern on behalf of the provider that placed the allergy on a patient's allergy list.

Allergy Status Observation

This template represents the clinical status attributed to the allergy or intolerance.

Assessment Scale Observation

An assessment scale is a collection of observations that together can yield a calculated or non-calculated summary evaluation of a one or more conditions.

Assessment Scale Supporting Observation

An Assessment Scale Supporting Observation represents the components of a scale used in an Assessment Scale Observation.

Authorization Activity

An Authorization Activity represents authorizations or pre-authorizations currently active for the patient for the particular payer.

Average Blood Pressure Organizer

This template represents a single instance of an Average Blood Pressure reading.

Basic Industry Observation

This template represents a simple observation about the type of business that compensates for work or assigns work to an unpaid worker or volunteer (e.g., US Army, cement manufacturing, children and youth services).

Basic Occupation Observation

This template represents a simple observation about the type of work (e.g., infantry, business analyst, social worker) of a person.

Birth Sex Observation

This observation represents the sex of the patient at birth.

Brand Name Observation

This template is intended to be used in addition to the Product Instance template to exchange the Brand Name.

Care Experience Preference

This Care Experience Preference template represents a person's care preferences for their care and treatment.

Care Team Member Act

This template is used to represent a member of the care team.

Care Team Member Schedule Observation

This template represents the schedule of when the care team member participates on the care team.

Care Team Organizer

This organizer template contains information about a single care team.

Care Team Type Observation

This template is used to express the care team type.

Caregiver Characteristics

This clinical statement represents a caregiver's willingness to provide care and the abilities of that caregiver to provide assistance to a patient in relation to a specific need.

Catalog Number Observation

This template is intended to be used in addition to the Product Instance template to exchange the Catalog Number.

Characteristics of Home Environment

This template represents the patient's home environment including, but not limited to, type of residence (trailer, single family home, assisted living), living arrangement (e.g., alone, with parents), and housing status (e.g., evicted, homeless, home owner).

Comment Activity

Comments are free text data that cannot otherwise be recorded using data elements already defined by this specification.

Company Name Observation

This template is intended to be used in addition to the Product Instance template to exchange the Company Name.

Coverage Activity

A Coverage Activity groups the policy and authorization acts within a Payers Section to order the payment sources.

Criticality Observation

This observation represents the gravity of the potential risk for future life-threatening adverse reactions when exposed to a substance known to cause an adverse reaction in that individual.

Cultural and Religious Observation

This template represents a patient's spiritual, religious, and cultural belief practices, such as a kosher diet or fasting ritual.

Date of Diagnosis Act

This template represents the earliest date of diagnosis, which is the date of first determination by a qualified professional of the presence of a problem or condition affecting a patient.

Deceased Observation

This template represents the observation that a patient has died.

Device Identifier Observation

This template is intended to be used in addition to the Product Instance template to exchange the Device Identifier (also known as the "Primary DI Number") for a medical device marketed in the US.

Disability Status Observation

This template represents an assessment of patients perception of their physical, cognitive, intellectual, or psychiatric disabilities.

Discharge Medication

This template represents medications that the patient is intended to take (or stop) after discharge.

Distinct Identification Code Observation

This template is intended to be used in addition to the Product Instance template to exchange the Distinct Identification Code for an HCT/P product regulated as a device as cited in 21 CFR 1271.290(c).

Drug Monitoring Act

This template represents the act of monitoring the patient's medication and includes a participation to record the person responsible for monitoring the medication.

Drug Vehicle

This template represents the vehicle (e.g., saline, dextrose) for administering a medication.

Encounter Activity

This clinical statement describes an interaction between a patient and clinician.

Encounter Diagnosis

This template wraps relevant problems or diagnoses at the close of a visit or that need to be followed after the visit.

Entry Reference

This template represents the act of referencing another entry in the same CDA document instance.

Estimated Date of Delivery

This clinical statement represents the anticipated date when a woman will give birth.

Expiration Date Observation

This template is intended to be used in addition to the Product Instance template to exchange the Expiration Date of the device.

External Document Reference

Where it is necessary to reference an external clinical document, the External Document Reference template can be used to reference this external document.

Family History Death Observation

This clinical statement records whether the family member is deceased.

Family History Observation

Family History Observations related to a particular family member are contained within a Family History Organizer.

Family History Organizer

The Family History Organizer associates a set of observations with a family member.

Functional Status Observation

This template represents the patient's physical function (e.g., mobility status, instrumental activities of daily living, self-care status) and problems that limit function (dyspnea, dysphagia).

Functional Status Organizer

This template groups related functional status observations into categories (e.g., mobility, self-care).

Gender Identity Observation

This observation represents the gender identity of the patient.

Goal Observation

This template represents a patient health goal.

Handoff Communication Participants

This template represents the sender (author) and receivers (participants) of a handoff communication in a plan of treatment.

Health Concern Act

This template represents a health concern.

Health Status Observation

This template represents information about the overall health status of the patient.

Highest Pressure Ulcer Stage

This observation contains a description of the wound tissue of the most severe or highest staged pressure ulcer observed on a patient.

Hospital Admission Diagnosis

This template represents problems or diagnoses identified by the clinician at the time of the patient's admission.

Hospital Discharge Diagnosis

This template represents problems or diagnoses present at the time of discharge which occurred during the hospitalization or need to be monitored after hospitalization.

Immunization Activity

An Immunization Activity describes immunization substance administrations that have actually occurred or are intended to occur.

Immunization Medication Information

The Immunization Medication Information represents product information about the immunization substance.

Immunization Not Given Reason

The Immunization Not Given Reason documents the rationale for the patient declining an immunization.

Implantable Device Status Observation

This template is intended to be used in addition to the Product Instance template to augment the parsed data from the a Unique Device Identifier (UDI).

Indication

This template represents the rationale for an action such as an encounter, a medication administration, or a procedure.

Individual Pronoun Observation

The Individual Personal Pronoun Observation represents words specified by a person to replace their name when referring to them in speech, clinical notes, and written instructions.

Instruction Observation

The Instruction observation template can be used in several ways, such as to record patient instructions within a Medication Activity or to record fill instructions within a supply order.

Interpreter Needed Observation

The interpreter needed observation represents an indication of whether a person needs language interpretation services.

Intervention Act

This template represents an Intervention Act.

Latex Safety Observation

This template is intended to be used in addition to the Product Instance template to exchange the Latex Safety Status of the patient's medical device.

Longitudinal Care Wound Observation

This template represents acquired or surgical wounds and is not intended to encompass all wound types.

Lot or Batch Number Observation

This template is intended to be used in addition to the Product Instance template to exchange the Lot or Batch Number of the device.

Manufacturing Date Observation

This template is intended to be used in addition to the Product Instance template to exchange the Manufacturing Date of the device.

Medical Equipment Organizer

This template represents a set of current or historical medical devices, supplies, aids and equipment used by the patient.

Medication Activity

A Medication Activity describes substance administrations that have actually occurred (e.g., pills ingested or injections given) or are intended to occur (e.g., "take 2 tablets twice a day for the next 10 days").

Medication Adherence

This profile represents whether a medication has been consumed according to instructions.

Medication Dispense

This template records the act of supplying medications (i.e., dispensing).

Medication Free Text Sig

The template is available to explicitly identify the free text Sig within each medication.

Medication Information

A medication should be recorded as a pre-coordinated ingredient + strength + dose form (e.g., "metoprolol 25mg tablet", "amoxicillin 400mg/5mL suspension") where possible.

Medication Supply Order

This template records the intent to supply a patient with medications.

Mental Status Observation

The Mental Status Observation template represents an observation about mental status that can come from a broad range of subjective and objective information (including measured data) to address those categories described in the Mental Status Section.

Mental Status Organizer

The Mental Status Organizer template may be used to group related Mental Status Observations (e.g., results of mental tests) and associated Assessment Scale Observations into subcategories and/or groupings by time.

Model Number Observation

This template is intended to be used in addition to the Product Instance template to exchange the Model Number associated with the device.

MRI Safety Observation

This template is intended to be used in addition to the Product Instance template to exchange the MRI Safety Status of the patient's medical device.

Non-Medicinal Supply Activity

This template represents equipment supplied to the patient (e.g., pumps, inhalers, wheelchairs).

Note Activity

The Note Activity represents a clinical note.

Number of Pressure Ulcers Observation

This template represents the number of pressure ulcers observed at a particular stage.

Nutrition Assessment

This template represents the patient's nutrition abilities and habits including intake, diet requirements or diet followed.

Nutrition Recommendation

This template represents nutrition regimens (e.g., fluid restrictions, calorie minimum), interventions (e.g., NPO, nutritional supplements), and procedures (e.g., G-Tube by bolus, TPN by central line).

Nutritional Status Observation

This template describes the overall nutritional status of the patient including findings related to nutritional status.

Outcome Observation

This template represents the outcome of care resulting from the interventions used to treat the patient.

Patient Referral Act

This template represents the type of referral (e.g., for dental care, to a specialist, for aging problems) and represents whether the referral is for full care or shared care.

Planned Coverage

This template represents the insurance coverage intended to cover an act or procedure.

Planned Encounter

This template represents a planned or ordered encounter.

Planned Immunization Activity

This template represents planned immunizations.

Planned Intervention Act

This template represents a Planned Intervention Act.

Planned Medication Activity

This template represents planned medication activities.

Planned Procedure

This template is used to represent ordered procedures for a patient.

Planned Supply

This template represents both medicinal and non-medicinal supplies ordered, requested, or intended for the patient (e.g., medication prescription, order for wheelchair).

Policy Activity

A policy activity represents the policy or program providing the coverage.

Postprocedure Diagnosis

This template represents the diagnosis or diagnoses discovered or confirmed during the procedure.

Precondition for Substance Administration

A criterion for administration can be used to record that the medication is to be administered only when the associated criteria are met.

Pregnancy Intention in Next Year

This template represents a patient's reported intention or desire in the next year to either become pregnant or prevent a future pregnancy.

Pregnancy Status Observation

This clinical statement meets the requirements of the US Core Data for Interoperability (USCDI) Pregnancy Status Data Element.

Preoperative Diagnosis

This template represents the surgical diagnosis or diagnoses assigned to the patient before the surgical procedure and is the reason for the surgery.

Priority Preference

This template represents priority preferences chosen by a patient or a care provider.

Problem Concern Act

This template reflects an ongoing concern on behalf of the provider that placed the concern on a patient's problem list.

Problem Observation

This template reflects a discrete observation about a patient's problem.

Problem Status

The Problem Status records the clinical status attributed to the problem.

Procedure Activity Procedure

This template is used to represent the details of current and historical procedures performed on or for a patient.

Product Instance

This clinical statement represents a particular device that was placed in a patient or used as part of a procedure or other act.

Prognosis Observation

This template represents the patient's prognosis, which must be associated with a problem observation.

Progress Toward Goal Observation

This template represents a patient's progress toward a goal.

Reaction Observation

This clinical statement represents the response to an undesired symptom, finding, etc.

Reason

This template describes the thought process or justification for an action or for not performing an action.

Result Observation

This template represents the results of a laboratory, radiology, or other study performed on a patient.

Result Organizer

This template provides a mechanism for grouping result observations.

Risk Concern Act

This template represents a risk concern.

Section Time Range Observation

This observation represents the date and time range of the information contained in a section.

Self-Care Activities (ADL and IADL)

This template represents a patient's daily self-care ability.

Sensory Status

This template represents a patient's sensory or speech ability.

Serial Number Observation

This template is intended to be used in addition to the Product Instance template to exchange the Serial Number of the device.

Service Delivery Location

This clinical statement represents the physical place of available services or resources.

Severity Observation

This clinical statement represents the gravity of the problem, such as allergy or reaction, in terms of its actual or potential impact on the patient.

Sex Observation

This Sex Observation template is used to reflect the documentation of a person's sex.

Sex Parameter For Clinical Use Observation

The Sex Parameter for Clinical Use (SPCU) observation is a clinical classification indicating which sex-related information is needed to evaluate how a patient's body may respond or has responded to treatments or diagnostic tests.

Sexual Orientation Observation

This observation represents the sexual orientation of the patient.

Smoking Status

This template represents a patient's smoking status.

Social History Observation

This template represents a patient's job (occupation and industry), lifestyle, and environmental health risk factors.

Specimen Collection Procedure

This template represents clinical information about the specimen including when it was collected, the type and source of specimen, as well as related observations regarding the specimen.

Specimen Condition Observation

This template conveys the condition (mode or state of being) that describes the nature of the specimen.

Substance Administered Act

This template represents the administration course in a series.

Substance or Device Allergy - Intolerance Observation

This template reflects a discrete observation about a patient's allergy or intolerance to a substance or device.

Treatment Intervention Preference

This Treatment Intervention Preference template represents personal health goals, preferences, and priorities for medical treatments or interventions in the event of a future health scenario where a person is unable to make medical decisions because of a serious illness or injury.

Tribal Affiliation Observation

This template represents the tribe or band that an individual associates with, within the United States.

UDI Organizer

This template is nested in an entryRelationship/Procedure Activity Procedure to record all the UDI-related templates to exchange the parsed UDI data elements and associated data.

Vital Sign Observation

This template represents measurement of common vital signs.

Vital Signs Organizer

This template provides a mechanism for grouping vital signs (e.g., grouping systolic blood pressure and diastolic blood pressure).

Wound Characteristic

This template represents characteristics of a wound (e.g., integrity of suture line, odor, erythema).

Wound Measurement Observation

This template represents the Wound Measurement Observations of wound width, depth and length.

Participation & Other Templates

The participation and other templates chapter contains templates for CDA participations (e.g., author, performer), and other fielded items (e.g., address, name) that cannot stand on their own without being nested in another template.

Author Participation

This template represents the Author Participation (including the author timestamp).

Provenance - Assembler Participation

This template represents the organization that supported generation of a CDA document.

Provenance - Author Participation

This template represents the key information to record Provenance in an Author Participation.

Related Person Relationship and Name Participant

This template represents a generic participant person that has a relationship to the patient.

US Realm Address

Reusable address template, for use in US Realm documents.

US Realm Date and Time - Interval

The US Realm Clinical Document Date and Time datatype flavor records date and time information.

US Realm Date and Time - Point in Time

The US Realm Clinical Document Date and Time datatype flavor records date and time information.

US Realm Patient Name (PTN.US.FIELDED)

The US Realm Patient Name datatype flavor is a set of reusable constraints that can be used for the patient or any other person.

US Realm Person Name (PN.US.FIELDED)

The US Realm Clinical Document Person Name datatype flavor is a set of reusable constraints that can be used for Persons.

Deprecated Templates

Deprecated templates are not prohibited from use, but their status as deprecated is a signal to implementers that the template may be permanently retired (terminated) in the future.

Advance Directive Organizer

The Advance Directive Organizer includes information about who verified the content available in each advance healthcare directive source document or other verified source documentation.

Instruction Activity

The Instruction template is used to record instructions intended to be given to the patient.

Smoking Status - Meaningful Use

This template represents the current smoking status of the patient as specified in Meaningful Use (MU) Stage 2 requirements.

Tobacco Use

This template represents a patient's tobacco use.

C-CDA Template Examples

These examples show how the C-CDA logical model templates are constructed.

Example of Allergy Intolerance to Food Egg

Example of an allergy to egg

Admission Diagnosis Section Example

Admission Diagnosis Section example

Admission Medication example

Admission Medication example

Advance Directive Existance Observation Example

Advance Directive Existence Observation example

Advance Directive Observation Example

Advance Directive Observation example

Advance Directives Section Example

Advance Directives Section example

Age Observation Example

Age Observation example

Allergies and Intolerances Section Example

Allergies and Intolerances Section example

Allergy Concern Act Example

Allergy Concern Act example

Allergy Intolerance Observation Medication Example

Allergy Intolerance Observation Medication example

Allergy Intolerance Observation Drug Class Example

Allergy Intolerance Observation Drug Class example

Allergy Intolerance Observation Non-Medication Example

Allergy Intolerance Observation Non-Medication example

Anesthesia Section Example

Anesthesia Section example

Assessment and Plan Section Example

Assessment and Plan Section example

Assessment Scale Observation Example

Assessment Scale Observation example

Assessment Scale Supporting Observation Example

Assessment Scale Supporting Observation example

Assessment Section Example

Assessment Section example

Author Participation Example

Author Participation example

Authorization Activity Example

Authorization Activity example

Basic Industry Observation Example

Basic Industry Observation example

Basic Occupation Observation Example

Basic Occupation example

Birth Sex Observation Example

Birth Sex Observation example

Birth Sex Observation Example with Null Flavor

Birth Sex Observation example with Null Flavor

Brand Name Observation Example

Brand Name Observation example

Care Plan Caregiver participant Example

Care Plan Caregiver participant example

Care Plan Patient authenticator Example

Care Plan Patient authenticator example

Care Plan performer Example

Care Plan performer example

Care Plan relatedDocument Example

Care Plan relatedDocument example

Care Plan Review Example

Care Plan Review example

Care Plan Complete Header Example

Demonstrates most of the Care Plan header requirements. Body sections are empty with nullFlavors.

Care Team Member Act Example

Care Team Member Act example

Care Team Member Schedule Observation Example

Care Team Member Schedule Observation example

Care Team Organizer Example

Care Team Organizer example

Care Teams Section Example

Care Teams Section example

Care Team Type Observation Example

Care Team Type Observation example

Catalog Number Observation Example

Catalog Number Observation example

Caregiver Characteristics Example

Caregiver Characteristics example

Characteristics of Home Environment Example

Characteristics of Home Environment example

Chief Complaint and Reason for Visit Section Example

Chief Complaint and Reason for Visit Section example

Chief Complaint Section Example

Chief Complaint Section example

Comment Activity Example

Comment Activity example

Company Name Observation Example

Company Name Observation example

Complications Section Example

Complications Section example

Continuity Of Care Document Complete Header Example

Demonstrates a fully-valid (but empty) CCD. Nullflavors have been added to all required sections.

Continuity Of Care Document Author Example

Continuity Of Care Document Author example

Continuity Of Care Document Performer

Continuity Of Care Document Performer example

Continuity Of Care Document serviceEvent Example

Continuity Of Care Document serviceEvent example

Consultation Note Complete Header Example

Demonstrates most of the Consultation Note header requirements. Body sections are empty with nullFlavors.

Consultation Note Callback participant Example

Consultation Note Callback participant example

Consultation Note inFulfillmentOf Example

Consultation Note inFulfillmentOf example

Course of Care Section Example

Course of Care Section example

Coverage Activity Example

Coverage Activity example

Criticality Observation Example

Criticality Observation example

Cultural and Religious Observation Example

Cultural and Religious Observation example

Date of Diagnosis Act Example

Date of Diagnosis Act example

Deceased Observation Example

Deceased Observation example

Device Identifier Observation Example

Device Identifier Observation example

Diagnosis Reference Example

Diagnosis Reference example

Disability Status Observation Example

Disability Status Observation Example

Discharge Diagnosis Example

Discharge Diagnosis example

Discharge Medication Example

Discharge Medication example

Discharge Medications Section Example

Discharge Medications Section example

Discharge Summary Complete Header Example

Demonstrates a fully-valid Discharge Summary. Nullflavors have been added to all required sections.

Discharge Summary encompassingEncounter Example

Discharge Summary (encompassingEncounter) example

Distinct Identification Code Observation Example

Distinct Identification Code Observation example

Drug Monitoring Act Example

Drug Monitoring Act example

Drug Vehicle Example

Drug Vehicle example

Encounter Activity Example

Encounter Activity example

Encounter Diagnosis Example

Encounter Diagnosis example

Encounters Section Example

Encounters Section example

Entry Reference Example

Entry Reference example

Estimated Date of Delivery Example

Estimated Date of Delivery example

Expiration Date Observation Example

example

External Document Reference Example

External Document Reference example

Family History Death Observation Example

Family History Death Observation example

Family History Observation Example

Family History Observation example

Family History Organizer Example

Family History Organizer example

Family History Section Example

Family History Section example

Functional Status Observation Example

Functional Status Observation example

Functional Status Organizer Example

Functional Status Organizer example

Functional Status Section Example

Functional Status Section example

Gender Identity Observation Example

Gender Identity Observation example

Gender Identity Observation NullFlavor Example

Gender Identity Observation example with null flavor

General Status Section Example

General Status Section example

Goal Observation Example

Goal Observation example

Goals Section Example

Goals Section example

Handoff Communication Participants Example

Handoff Communication Participants example

Health Concern Act Example

Health Concern Act example

Health Concerns Section Example

Health Concerns Section example

Health Status Evalutations and Outcomes Section Example

Health Status Evaluations and Outcomes Section example

Health Status Observation Example

Health Status Observation example

Highest Pressure Ulcer Stage Example

Highest Pressure Ulcer Stage example

History and Physical Encompassing Encounter Example

History and Physical Encompassing Encounter example

History and Physical Complete Header Example

Demonstrates most of the History and Physical header requirements. Body sections are empty with nullFlavors.

History Of Present Illness Example

History of Present Illness example

Hospital Admission Diagnosis Example

Hospital Admission Diagnosis example

Hospital Consultations Section Example

Hospital Consultations Section example

Hospital Course Section Example

Hospital Course Section example

Hospital Discharge Diagnosis Example

Hospital Discharge Diagnosis example

Hospital Discharge Instructions Section Example

Hospital Discharge Instructions Section example

Hospital Discharge Physical Section Example

Hospital Discharge Physical Section example

Hospital Discharge Studies Summary Section Example

Hospital Discharge Studies Summary Section example

Immunization Activity Example

Immunization Activity example

Immunization Medication Information Example

Immunization Medication Information example

Immunization Not Given Reason Example

Immunization Not Given Reason example

Immunizations Section Example

Immunizations Section example

Implantable Device Status Observation Example

Implantable Device Status Observation example

Indication Example

Indication example

Instructions Section Example

Instructions Section example

Instruction Example

Instruction example

Intervention Act Example

Intervention Act example

Latex Safety Observation Example

Latex Safety Observation example

Longitudinal Care Wound Observation Example

Longitudinal Care Wound Observation example

Lot or Batch Number Observation Example

Lot or Batch Number Observation example

Manufacturing Date Observation Example

Manufacturing Date Observation example

Medical Equipment Organizer Example

Medical Equipment Organizer example

Medical Equipment Section Example

Medical Equipment Section example

Medication Activity Example

Medication Activity example

Medication Adherence Example

Medication Adherence example

Medication Adherence NullFlavor Example

Medication Adherence example with null flavor

Medication Dispense Example

Medication Dispense example

Medication Free Text Sig Example

Medication Free Text Sig example

Medication Information Example

Medication Information example

Medication Supply Order Example

Medication Supply Order example

Medications Administered Section Example

Medications Administered Section example

Medications Section Example

Medications Section example

Mental Status Observation Example

Mental Status Observation example

Mental Status Organizer Example

Mental Status Organizer example

Mental Status Section Example

Mental Status Section example

Model Number Observation Example

Model Number Observation example

MRI Safety Observation Example

MRI Safety Observation example

No Known Medications Example

No Known Medications example

No Known Problem Section Example

No Known Problem Section example

Non-Medicinal Supply Activity Example

Non-Medicinal Supply Activity example

Note Activity Entry Relationship Example

Note Activity example

Note Activity Standalone Example

Note Activity example

nonXML Body Example with Compressed Content

nonXMLBody Example with Compressed Content

nonXML Body Example with Embedded Content

nonXMLBody Example with Embedded Content

nonXML Body Example with Referenced Content

nonXMLBody Example with Referenced Content

Number of Pressure Ulcers Observation Example

Number of Pressure Ulcers Observation example

Nutrition Assessment Example

Nutrition Assessment example

Nutrition Recommendation Example

Nutrition Recommendation example

Nutrition Section Example

Nutrition Section example

Nutritional Status Observation Example

Nutritional Status Observation example

Objective Section Example

Objective Section example

Operative Note Complete Header Example

Demonstrates most of the Operative Note header requirements. Body sections are empty with nullFlavors.

Operative Note performer Example

Operative Note performer example

Operative Note serviceEvent Example

Operative Note serviceEvent example

Operative Note Fluids Section Example

Operative Note Fluids Section example

Operative Note Surgical Procedure Section Example

Operative Note Surgical Procedure Section example

Outcome Observation Example

Outcome Observation example

Past Medical History Example

Past Medical History example

Patient Generated Document authenticator

Patient Generated Document authenticator example

Patient Generated Document author device Example

Patient Generated Document author device example

Patient Generated Document author

Patient Generated Document author example

Patient Generated Document custodian Example

PPatient Generated Document custodian example

Patient Generated Document dataEnterer

Patient Generated Document dataEnterer example

Patient Generated Document informant Example informant

Patient Generated Document informant Example informant

Patient Generated Document informant RelEnt Example

Patient Generated Document informant RelEnt example

Patient Generated Document informationRecipient Example

Patient Generated Document informationRecipient example

Patient Generated Document inFulfillmentOf Example

Patient Generated Document inFulfillmentOf example

Patient Generated Document legalAuthenticator Example

PPatient Generated Document legalAuthenticator example

Patient Generated Document participant Example

Patient Generated Document participant example

Patient Generated Document recordTarget

Patient Generated Document recordTarget example

Patient Referral Act Example

Patient Referral Act example

Payers Section Example

Payers Section example

Physical Exam Section Example

Physical Exam Section example

Plan of Treatment Section Example

Plan of Treatment Section example

Planned Coverage Example

Planned Coverage example

Planned Encounter Example

Planned Encounter example

Planned Immunization Activity Example

Planned Immunization Activity example

Planned Intervention Activity Example

Planned Intervention Activity example

Planned Medication Activity Example

Planned Medication Activity example

Planned Procedure Section Example

Planned Procedure Section example

Planned Procedure Example

Planned Procedure example

Planned Supply Example

Planned Supply example

Policy Activity Example

Policy Activity example

Postoperative Diagnosis Section Example

Postoperative Diagnosis Section example

Postprocedure Diagnosis Example

Postprocedure Diagnosis example

Postprocedure Diagnosis Section Example

Postprocedure Diagnosis Section example

Precondition for Substance Administration Example

Precondition for Substance Administration example

Pregnancy Intention in Next Year Example

Pregnancy Intention in Next Year example

Pregnancy Status Observation Example

Pregnancy Status Observation example

Preoperative Diagnosis Section Example

Preoperative Diagnosis Section example

Preoperative Diagnosis Example

Preoperative Diagnosis example

Priority Preference Example

Priority Preference example

Problem Concern Act Example

Problem Concern Act example

Problem Observation Example

Problem Observation example

Problem Observation with Post-Coordinated SNOMED Example

Problem Observation with Post-Coordinated SNOMED example

Problem Section Example

Problem Section example

Procedure Note Complete Header Example

Demonstrates most of the Procedure Note header requirements. Body sections are empty with nullFlavors.

Procedure Note performer Example

Procedure Note performer example

Procedure Note serviceEvent Example

Procedure Note serviceEvent example

Procedure Activity Procedure Example

Procedure Activity Procedure example

Procedure Description Section Example

Procedure Description Section example

Procedure Disposition Section Example

Procedure Disposition Section example

Procedure Estimated Blood Loss Section Example

Procedure Estimated Blood Loss Section example

Procedure Findings Section Example

Procedure Findings Section dexample

Procedure Implants Section Example

Procedure Implants Section example

Procedure Indications Section Example

Procedure Indications Section example

Procedure Specimens Taken Section Example

Procedure Specimens Taken Section example

Procedures Section Example

Procedures Section example

Product Instance Example

Product Instance example

Prognosis Coded Example

Prognosis Coded example

Prognosis Free Text Example

Prognosis Free Text example

Progress Note Complete Header Example

Demonstrates most of the Progress Note header requirements. Body sections are empty with nullFlavors.

Progress Note encompassingEncounter Example

Progress Note encompassingEncounter example

Progress Note serviceEvent Example

Progress Note serviceEvent example

Progress Toward Goal Observation Example

Progress Toward Goal Observation example

Provenance - Assembler Participation Example

Provenance - Assembler Participation example

Provenance - Author Participation Example

Provenance - Author Participation example

Reaction Observation Example

Reaction Observation example

Reason Example

Reason example

Reason For Referral

Reason For Referral example

Reason for Visit Section Example

Reason for Visit Section example

Referral Note Complete Header Example

Demonstrates most of the Referral Note header requirements. Body sections are empty with nullFlavors.

Referral Note Callback Contact Example

Referral Note Callback Contact example

Referral Note Caregiver

Referral Note Caregiver example

Referral Note informationRecipient Example

Referral Note informationRecipient example

Related Person Relationship and Name Participant Example

Related Person Relationship and Name Participant example

Result Observation Example

Result Observation example

Result Organizer Example

Result Organizer example

Results Section Example

Results Section example

Review Of Systems Section Example

Review of Systems Section example

Risk Concern Act Example

Risk Concern Act example

Self-Care Activities ADL and IADL Example

Self-Care Activities (ADL and IADL) example

Sensory Status Example

Sensory Status example

Serial Number Observation Example

Serial Number Observation example

Service Delivery Location Example

Service Delivery Location example

Severity Observation Example

Severity Observation example

Sex Observation Example

Sex Observation example

Sex Observation Null Flavor Example

Sexu Observation example with nullflavor code

Sexual Orientation Observation Example

Sexual Orientation Observation example

Sexual Orientation Observation Null Flavor Example

Sexual Orientation Observation example with nullflavor code

Smoking Status Coded Example

Smoking Status Coded example

Smoking Status Quantity Example

Smoking Status Quantity example

Smoking Status Meaningful Use Example

Smoking Status - Meaningful Use example

Specimen Collection Procedure Example

Specimen Collection Procedure example

Specimen Condition Observation Example

Specimen Condition Observation example

Social History Section Example

Social History Section example

Subjective Section Example

Subjective Section example

Substance Administered Act Example

Substance Administered Act example

Surgical Drains Section Example

Surgical Drains Section example

Tobacco Use Example

Tobacco Use example

Transfer Summary Complete Header Example

Demonstrates most of the Transfer Summary header requirements. Body sections are empty with nullFlavors.

Transfer Summary Callback Contact Example

Transfer Summary Callback Contact example

Transfer Summary participant (Support) Example

Transfer Summary participant (Support) example

Tribal Affiliation Observation Example

Tribal Affiliation Observation example

UDI Organizer Example

UDI Organizer example

US Realm Address Example

US Realm Address example

US Realm Date and Time Example

US Realm Date and Time example

US Realm Date and Time Interval Example

US Realm Date and Time Interval example

US Realm Header Example

US Realm Header example

US Realm Person Name Example

US Realm Person Name example

Vital Sign Observation Example

Vital Sign Observation example

Average Blood Pressure Organizer Example

Example of average blood pressure

Vital Signs Organizer Example

Vital Signs Organizer example

Vital Signs Section Example

Vital Signs Section example - including Average Blood Pressure

Wound Characteristic Example

Wound Characteristic example

Wound Measurement Observation Example

Wound Measurement Observation example

C-CDA Internal Terminology

Code Systems and Value Sets that are defined in this guide.

NUBC UB-04 FL17 Patient Status

These codes are used to convey the patient discharge status.