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