Consolidated CDA (C-CDA)
5.0.0-ballot - STU5 Ballot 1 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 5.0.0-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

Table of Contents

.. 0 Table of Contents
... 1 IG Home Page
... 2 USCDI
... 3 General Guidance
... 4 Screening And Assessments
... 5 Supporting Guidance
... 6 Validation
... 7 Provenance in C-CDA
... 8 How To Read
... 9 Downloads
... 10 Terminology
... 11 Change Log
... 12 Template IDs
... 13 Artifacts Summary
.... 13.1 Care Plan
.... 13.2 Consultation Note
.... 13.3 Continuity of Care Document (CCD)
.... 13.4 Discharge Summary
.... 13.5 History and Physical
.... 13.6 Operative Note
.... 13.7 Procedure Note
.... 13.8 Progress Note
.... 13.9 Referral Note
.... 13.10 Transfer Summary
.... 13.11 Unstructured Document
.... 13.12 US Realm Header
.... 13.13 US Realm Header for Patient Generated Document
.... 13.14 Activities Section
.... 13.15 Admission Diagnosis Section
.... 13.16 Admission Medications Section (entries optional)
.... 13.17 Advance Directives Section
.... 13.18 Allergies and Intolerances Section
.... 13.19 Anesthesia Section
.... 13.20 Assessment and Plan Section
.... 13.21 Assessment Section
.... 13.22 Care Teams Section
.... 13.23 Chief Complaint and Reason for Visit Section
.... 13.24 Chief Complaint Section
.... 13.25 Complications Section
.... 13.26 Course of Care Section
.... 13.27 Discharge Diagnosis Section
.... 13.28 Discharge Medications Section
.... 13.29 Encounters Section
.... 13.30 Family History Section
.... 13.31 Functional Status Section
.... 13.32 General Status Section
.... 13.33 Goals Section
.... 13.34 Health Concerns Section
.... 13.35 History of Present Illness Section
.... 13.36 Hospital Consultations Section
.... 13.37 Hospital Course Section
.... 13.38 Hospital Discharge Instructions Section
.... 13.39 Hospital Discharge Physical Section
.... 13.40 Hospital Discharge Studies Summary Section
.... 13.41 Immunizations Section
.... 13.42 Instructions Section
.... 13.43 Medical (General) History Section
.... 13.44 Medical Equipment Section
.... 13.45 Medications Administered Section
.... 13.46 Medications Section
.... 13.47 Mental Status Section
.... 13.48 Notes Section
.... 13.49 Nutrition Section
.... 13.50 Objective Section
.... 13.51 Operative Note Fluids Section
.... 13.52 Operative Note Surgical Procedure Section
.... 13.53 Outcomes Section
.... 13.54 Past Medical History
.... 13.55 Payers Section
.... 13.56 Physical Exam Section
.... 13.57 Plan of Treatment Section
.... 13.58 Planned Procedure Section
.... 13.59 Postoperative Diagnosis Section
.... 13.60 Postprocedure Diagnosis Section
.... 13.61 Pregnancy Section
.... 13.62 Preoperative Diagnosis Section
.... 13.63 Problem Section
.... 13.64 Procedure Description Section
.... 13.65 Procedure Disposition Section
.... 13.66 Procedure Estimated Blood Loss Section
.... 13.67 Procedure Findings Section
.... 13.68 Procedure Implants Section
.... 13.69 Procedure Indications Section
.... 13.70 Procedure Specimens Taken Section
.... 13.71 Procedures Section
.... 13.72 Reason for Referral Section
.... 13.73 Reason for Visit Section
.... 13.74 Results Section
.... 13.75 Review of Systems Section
.... 13.76 Social History Section
.... 13.77 Subjective Section
.... 13.78 Surgical Drains Section
.... 13.79 Vital Signs Section
.... 13.80 Admission Medication
.... 13.81 Advance Directive Observation
.... 13.82 Advance Directive Existence Observation
.... 13.83 Age Observation
.... 13.84 Age Range Observation
.... 13.85 Allergy - Intolerance Observation
.... 13.86 Allergy Concern Act
.... 13.87 Allergy Status Observation
.... 13.88 Assessment Scale Observation
.... 13.89 Assessment Scale Supporting Observation
.... 13.90 Authorization Activity
.... 13.91 Average Blood Pressure Organizer
.... 13.92 Basic Industry Observation
.... 13.93 Basic Occupation Observation
.... 13.94 Birth Sex Observation
.... 13.95 Brand Name Observation
.... 13.96 Care Experience Preference
.... 13.97 Care Plan Act
.... 13.98 Care Team Member Act
.... 13.99 Care Team Member Schedule Observation
.... 13.100 Care Team Organizer
.... 13.101 Care Team Type Observation
.... 13.102 Caregiver Characteristics
.... 13.103 Catalog Number Observation
.... 13.104 Characteristics of Home Environment
.... 13.105 Comment Activity
.... 13.106 Company Name Observation
.... 13.107 Coverage Activity
.... 13.108 Criticality Observation
.... 13.109 Cultural and Religious Observation
.... 13.110 Date of Diagnosis Act
.... 13.111 Deceased Observation
.... 13.112 Device Identifier Observation
.... 13.113 Disability Status Observation
.... 13.114 Discharge Medication
.... 13.115 Distinct Identification Code Observation
.... 13.116 Drug Monitoring Act
.... 13.117 Drug Vehicle
.... 13.118 Encounter Activity
.... 13.119 Encounter Diagnosis
.... 13.120 Entry Reference
.... 13.121 Estimated Date of Delivery
.... 13.122 Expiration Date Observation
.... 13.123 External Document Reference
.... 13.124 Family History Death Observation
.... 13.125 Family History Observation
.... 13.126 Family History Organizer
.... 13.127 Functional Status Observation
.... 13.128 Functional Status Organizer
.... 13.129 Gender Identity Observation
.... 13.130 Goal Observation
.... 13.131 Handoff Communication Participants
.... 13.132 Health Concern Act
.... 13.133 Health Status Observation
.... 13.134 Highest Pressure Ulcer Stage
.... 13.135 Hospital Admission Diagnosis
.... 13.136 Hospital Discharge Diagnosis
.... 13.137 Immunization Activity
.... 13.138 Immunization Medication Information
.... 13.139 Immunization Not Given Reason
.... 13.140 Implantable Device Status Observation
.... 13.141 Indication
.... 13.142 Individual Pronoun Observation
.... 13.143 Instruction Observation
.... 13.144 Interpreter Needed Observation
.... 13.145 Intervention Act
.... 13.146 Latex Safety Observation
.... 13.147 Longitudinal Care Wound Observation
.... 13.148 Lot or Batch Number Observation
.... 13.149 Manufacturing Date Observation
.... 13.150 Medical Equipment Organizer
.... 13.151 Medication Activity
.... 13.152 Medication Adherence
.... 13.153 Medication Dispense
.... 13.154 Medication Free Text Sig
.... 13.155 Medication Information
.... 13.156 Medication Supply Order
.... 13.157 Mental Status Observation
.... 13.158 Mental Status Organizer
.... 13.159 Model Number Observation
.... 13.160 MRI Safety Observation
.... 13.161 Non-Medicinal Supply Activity
.... 13.162 Note Activity
.... 13.163 Number of Pressure Ulcers Observation
.... 13.164 Nutrition Assessment
.... 13.165 Nutrition Recommendation
.... 13.166 Nutritional Status Observation
.... 13.167 Outcome Observation
.... 13.168 Planned Coverage
.... 13.169 Planned Encounter
.... 13.170 Planned Immunization Activity
.... 13.171 Planned Intervention Act
.... 13.172 Planned Medication Activity
.... 13.173 Planned Procedure
.... 13.174 Planned Supply
.... 13.175 Policy Activity
.... 13.176 Postprocedure Diagnosis
.... 13.177 Precondition for Substance Administration
.... 13.178 Pregnancy Intention in Next Year
.... 13.179 Pregnancy Status Observation
.... 13.180 Preoperative Diagnosis
.... 13.181 Priority Preference
.... 13.182 Problem Concern Act
.... 13.183 Problem Observation
.... 13.184 Problem Status
.... 13.185 Procedure Activity Procedure
.... 13.186 Product Instance
.... 13.187 Prognosis Observation
.... 13.188 Progress Toward Goal Observation
.... 13.189 Reaction Observation
.... 13.190 Reason
.... 13.191 Referral Act
.... 13.192 Result Observation
.... 13.193 Result Organizer
.... 13.194 Risk Concern Act
.... 13.195 Section Time Range Observation
.... 13.196 Self-Care Activities (ADL and IADL)
.... 13.197 Sensory Status
.... 13.198 Serial Number Observation
.... 13.199 Service Delivery Location
.... 13.200 Severity Observation
.... 13.201 Sex Observation
.... 13.202 Sex Parameter For Clinical Use Observation
.... 13.203 Sexual Orientation Observation
.... 13.204 Smoking Status
.... 13.205 Social History Observation
.... 13.206 Specimen Collection Procedure
.... 13.207 Specimen Condition Observation
.... 13.208 Substance Administered Act
.... 13.209 Substance or Device Allergy - Intolerance Observation
.... 13.210 Treatment Intervention Preference
.... 13.211 Tribal Affiliation Observation
.... 13.212 UDI Organizer
.... 13.213 Vital Sign Observation
.... 13.214 Vital Signs Organizer
.... 13.215 Wound Characteristic
.... 13.216 Wound Measurement Observation
.... 13.217 Author Participation
.... 13.218 Provenance - Assembler Participation
.... 13.219 Provenance - Author Participation
.... 13.220 Related Person Relationship and Name Participant
.... 13.221 US Realm Address
.... 13.222 US Realm Date and Time - Interval
.... 13.223 US Realm Date and Time - Point in Time
.... 13.224 US Realm Patient Name (PTN.US.FIELDED)
.... 13.225 US Realm Person Name (PN.US.FIELDED)
.... 13.226 Advance Directive Organizer
.... 13.227 Instruction Activity
.... 13.228 Smoking Status - Meaningful Use
.... 13.229 Tobacco Use
.... 13.230 Example of Allergy Intolerance to Food Egg
.... 13.231 Admission Diagnosis Section Example
.... 13.232 Admission Medication example
.... 13.233 Advance Directive Existence Observation Example
.... 13.234 Advance Directive Observation Example
.... 13.235 Advance Directives Section Example
.... 13.236 Age Observation Example
.... 13.237 Allergies and Intolerances Section Example
.... 13.238 Allergy Concern Act Example
.... 13.239 Allergy Intolerance Observation Medication Example
.... 13.240 Allergy Intolerance Observation Drug Class Example
.... 13.241 Allergy Intolerance Observation Non-Medication Example
.... 13.242 Anesthesia Section Example
.... 13.243 Assessment and Plan Section Example
.... 13.244 Assessment Scale Observation Example
.... 13.245 Assessment Scale Supporting Observation Example
.... 13.246 Assessment Section Example
.... 13.247 Author Participation Example
.... 13.248 Authorization Activity Example
.... 13.249 Basic Industry Observation Example
.... 13.250 Basic Occupation Observation Example
.... 13.251 Birth Sex Observation Example
.... 13.252 Birth Sex Observation Example with Null Flavor
.... 13.253 Brand Name Observation Example
.... 13.254 Care Plan Caregiver participant Example
.... 13.255 Care Plan Patient authenticator Example
.... 13.256 Care Plan performer Example
.... 13.257 Care Plan relatedDocument Example
.... 13.258 Care Plan Review Example
.... 13.259 Care Plan Complete Header Example
.... 13.260 Care Team Member Act Example
.... 13.261 Care Team Member Schedule Observation Example
.... 13.262 Care Team Organizer Example
.... 13.263 Care Teams Section Example
.... 13.264 Care Team Type Observation Example
.... 13.265 Catalog Number Observation Example
.... 13.266 Caregiver Characteristics Example
.... 13.267 Characteristics of Home Environment Example
.... 13.268 Chief Complaint and Reason for Visit Section Example
.... 13.269 Chief Complaint Section Example
.... 13.270 Comment Activity Example
.... 13.271 Company Name Observation Example
.... 13.272 Complications Section Example
.... 13.273 Continuity Of Care Document Complete Header Example
.... 13.274 Continuity Of Care Document Author Example
.... 13.275 Continuity Of Care Document Performer
.... 13.276 Continuity Of Care Document serviceEvent Example
.... 13.277 Consultation Note Complete Header Example
.... 13.278 Consultation Note Callback participant Example
.... 13.279 Consultation Note inFulfillmentOf Example
.... 13.280 Course of Care Section Example
.... 13.281 Coverage Activity Example
.... 13.282 Criticality Observation Example
.... 13.283 Cultural and Religious Observation Example
.... 13.284 Date of Diagnosis Act Example
.... 13.285 Deceased Observation Example
.... 13.286 Device Identifier Observation Example
.... 13.287 Diagnosis Reference Example
.... 13.288 Disability Status Observation Example
.... 13.289 Discharge Diagnosis Example
.... 13.290 Discharge Medication Example
.... 13.291 Discharge Medications Section Example
.... 13.292 Discharge Summary Complete Header Example
.... 13.293 Discharge Summary encompassingEncounter Example
.... 13.294 Distinct Identification Code Observation Example
.... 13.295 Drug Monitoring Act Example
.... 13.296 Drug Vehicle Example
.... 13.297 Encounter Activity Example
.... 13.298 Encounter Diagnosis Example
.... 13.299 Encounters Section Example
.... 13.300 Entry Reference Example
.... 13.301 Estimated Date of Delivery Example
.... 13.302 Expiration Date Observation Example
.... 13.303 External Document Reference Example
.... 13.304 Family History Death Observation Example
.... 13.305 Family History Observation Example
.... 13.306 Family History Organizer Example
.... 13.307 Family History Section Example
.... 13.308 Functional Status Observation Example
.... 13.309 Functional Status Organizer Example
.... 13.310 Functional Status Section Example
.... 13.311 Gender Identity Observation Example
.... 13.312 Gender Identity Observation NullFlavor Example
.... 13.313 General Status Section Example
.... 13.314 Goal Observation Example
.... 13.315 Goals Section Example
.... 13.316 Handoff Communication Participants Example
.... 13.317 Health Concern Act Example
.... 13.318 Health Concerns Section Example
.... 13.319 Outcomes Section Example
.... 13.320 Health Status Observation Example
.... 13.321 Highest Pressure Ulcer Stage Example
.... 13.322 History and Physical Encompassing Encounter Example
.... 13.323 History and Physical Complete Header Example
.... 13.324 History Of Present Illness Example
.... 13.325 Hospital Admission Diagnosis Example
.... 13.326 Hospital Consultations Section Example
.... 13.327 Hospital Course Section Example
.... 13.328 Hospital Discharge Diagnosis Example
.... 13.329 Hospital Discharge Instructions Section Example
.... 13.330 Hospital Discharge Physical Section Example
.... 13.331 Hospital Discharge Studies Summary Section Example
.... 13.332 Immunization Activity Example
.... 13.333 Immunization Medication Information Example
.... 13.334 Immunization Not Given Reason Example
.... 13.335 Immunizations Section Example
.... 13.336 Implantable Device Status Observation Example
.... 13.337 Indication Example
.... 13.338 Instructions Section Example
.... 13.339 Instruction Example
.... 13.340 Intervention Act Example
.... 13.341 Latex Safety Observation Example
.... 13.342 Longitudinal Care Wound Observation Example
.... 13.343 Lot or Batch Number Observation Example
.... 13.344 Manufacturing Date Observation Example
.... 13.345 Medical Equipment Organizer Example
.... 13.346 Medical Equipment Section Example
.... 13.347 Medication Activity Example
.... 13.348 Medication Adherence Example
.... 13.349 Medication Adherence NullFlavor Example
.... 13.350 Medication Dispense Example
.... 13.351 Medication Free Text Sig Example
.... 13.352 Medication Information Example
.... 13.353 Medication Supply Order Example
.... 13.354 Medications Administered Section Example
.... 13.355 Medications Section Example
.... 13.356 Mental Status Observation Example
.... 13.357 Mental Status Organizer Example
.... 13.358 Mental Status Section Example
.... 13.359 Model Number Observation Example
.... 13.360 MRI Safety Observation Example
.... 13.361 No Known Medications Example
.... 13.362 No Known Problem Section Example
.... 13.363 Non-Medicinal Supply Activity Example
.... 13.364 Note Activity Entry Relationship Example
.... 13.365 Note Activity Standalone Example
.... 13.366 nonXML Body Example with Compressed Content
.... 13.367 nonXML Body Example with Embedded Content
.... 13.368 nonXML Body Example with Referenced Content
.... 13.369 Number of Pressure Ulcers Observation Example
.... 13.370 Nutrition Assessment Example
.... 13.371 Nutrition Recommendation Example
.... 13.372 Nutrition Section Example
.... 13.373 Nutritional Status Observation Example
.... 13.374 Objective Section Example
.... 13.375 Operative Note Complete Header Example
.... 13.376 Operative Note performer Example
.... 13.377 Operative Note serviceEvent Example
.... 13.378 Operative Note Fluids Section Example
.... 13.379 Operative Note Surgical Procedure Section Example
.... 13.380 Outcome Observation Example
.... 13.381 Past Medical History Example
.... 13.382 Patient Generated Document authenticator
.... 13.383 Patient Generated Document author device Example
.... 13.384 Patient Generated Document author
.... 13.385 Patient Generated Document custodian Example
.... 13.386 Patient Generated Document dataEnterer
.... 13.387 Patient Generated Document informant Example informant
.... 13.388 Patient Generated Document informant RelEnt Example
.... 13.389 Patient Generated Document informationRecipient Example
.... 13.390 Patient Generated Document inFulfillmentOf Example
.... 13.391 Patient Generated Document legalAuthenticator Example
.... 13.392 Patient Generated Document participant Example
.... 13.393 Patient Generated Document recordTarget
.... 13.394 Referral Act Example
.... 13.395 Payers Section Example
.... 13.396 Physical Exam Section Example
.... 13.397 Plan of Treatment Section Example
.... 13.398 Planned Coverage Example
.... 13.399 Planned Encounter Example
.... 13.400 Planned Immunization Activity Example
.... 13.401 Planned Intervention Activity Example
.... 13.402 Planned Medication Activity Example
.... 13.403 Planned Procedure Section Example
.... 13.404 Planned Procedure Example
.... 13.405 Planned Supply Example
.... 13.406 Policy Activity Example
.... 13.407 Postoperative Diagnosis Section Example
.... 13.408 Postprocedure Diagnosis Example
.... 13.409 Postprocedure Diagnosis Section Example
.... 13.410 Precondition for Substance Administration Example
.... 13.411 Pregnancy Intention in Next Year Example
.... 13.412 Pregnancy Status Observation Example
.... 13.413 Preoperative Diagnosis Section Example
.... 13.414 Preoperative Diagnosis Example
.... 13.415 Priority Preference Example
.... 13.416 Problem Concern Act Example
.... 13.417 Problem Observation Example
.... 13.418 Problem Observation with Post-Coordinated SNOMED Example
.... 13.419 Problem Section Example
.... 13.420 Procedure Note Complete Header Example
.... 13.421 Procedure Note performer Example
.... 13.422 Procedure Note serviceEvent Example
.... 13.423 Procedure Activity Procedure Example
.... 13.424 Procedure Description Section Example
.... 13.425 Procedure Disposition Section Example
.... 13.426 Procedure Estimated Blood Loss Section Example
.... 13.427 Procedure Findings Section Example
.... 13.428 Procedure Implants Section Example
.... 13.429 Procedure Indications Section Example
.... 13.430 Procedure Specimens Taken Section Example
.... 13.431 Procedures Section Example
.... 13.432 Product Instance Example
.... 13.433 Prognosis Coded Example
.... 13.434 Prognosis Free Text Example
.... 13.435 Progress Note Complete Header Example
.... 13.436 Progress Note encompassingEncounter Example
.... 13.437 Progress Note serviceEvent Example
.... 13.438 Progress Toward Goal Observation Example
.... 13.439 Provenance - Assembler Participation Example
.... 13.440 Provenance - Author Participation Example
.... 13.441 Reaction Observation Example
.... 13.442 Reason Example
.... 13.443 Reason For Referral
.... 13.444 Reason for Visit Section Example
.... 13.445 Referral Note Complete Header Example
.... 13.446 Referral Note Callback Contact Example
.... 13.447 Referral Note Caregiver
.... 13.448 Referral Note informationRecipient Example
.... 13.449 Related Person Relationship and Name Participant Example
.... 13.450 Result Observation Example
.... 13.451 Result Organizer Example
.... 13.452 Results Section Example
.... 13.453 Review Of Systems Section Example
.... 13.454 Risk Concern Act Example
.... 13.455 Self-Care Activities ADL and IADL Example
.... 13.456 Sensory Status Example
.... 13.457 Serial Number Observation Example
.... 13.458 Service Delivery Location Example
.... 13.459 Severity Observation Example
.... 13.460 Sex Observation Example
.... 13.461 Sex Observation Null Flavor Example
.... 13.462 Sexual Orientation Observation Example
.... 13.463 Sexual Orientation Observation Null Flavor Example
.... 13.464 Smoking Status Coded Example
.... 13.465 Smoking Status Quantity Example
.... 13.466 Smoking Status Meaningful Use Example
.... 13.467 Specimen Collection Procedure Example
.... 13.468 Specimen Condition Observation Example
.... 13.469 Social History Section Example
.... 13.470 Subjective Section Example
.... 13.471 Substance Administered Act Example
.... 13.472 Surgical Drains Section Example
.... 13.473 Tobacco Use Example
.... 13.474 Transfer Summary Complete Header Example
.... 13.475 Transfer Summary Callback Contact Example
.... 13.476 Transfer Summary participant (Support) Example
.... 13.477 Tribal Affiliation Observation Example
.... 13.478 UDI Organizer Example
.... 13.479 US Realm Address Example
.... 13.480 US Realm Date and Time Example
.... 13.481 US Realm Date and Time Interval Example
.... 13.482 US Realm Header Race Translation Example
.... 13.483 US Realm Header Example
.... 13.484 US Realm Person Name Example
.... 13.485 Vital Sign Observation Example
.... 13.486 Average Blood Pressure Organizer Example
.... 13.487 Vital Signs Organizer Example
.... 13.488 Vital Signs Section Example
.... 13.489 Wound Characteristic Example
.... 13.490 Wound Measurement Observation Example