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
The C-CDA templates were designed to meet the 2015 Edition certification criterion for Consolidated CDA Creation 170.315(g)(6). They were created for each item in the 2015 Edition Common Clinical Data Set (CCDS). The C-CDA templates on this page contain requirements up to and including U.S. Core Data for Interoperability (USCDI) v5. Consolidated CDA is based on community input and used for USCDI ONC certification.
Note that:
ONC's USCDI and Consolidated CDA are complementary initiatives, with USCDI defining high-level data requirements and Consolidated CDA providing detailed templates for meeting those requirements. Mapping between them is necessary for achieving interoperability and consistency in healthcare data exchange within the United States. Consolidated CDA is broader than USCDI and therefore, to make USCDI implementable in CDA, interpretation of USCDI is necessary. USCDI data classes and element names may not be the same as the Consolidated CDA template and element names.
Updates to C-CDA depend upon community input and we encourage our audience to submit questions and feedback to C-CDA specifications by clicking on the Propose a change link in the footer of every page. In addition, we encourage our audience to request any necessary clarifications to USCDI through the USCDI ONDEC process that helps inform future updates to C-CDA.
USCDI Version | Referenced Specification |
---|---|
v5 | C-CDA STU 4.0 |
v4 | C-CDA STU 3.0 |
v3 | C-CDA Companion Guide Release 4.1 |
v2 | C-CDA Companion Guide Release 3 |
v1 | C-CDA Companion Guide Release 2 |
The table below lists the C-CDA templates used for the corresponding USCDI Data elements. It is a mapping between USCDI data elements and C-CDA Templates and C-CDA elements.
US Core Data for Interoperability USCDI
Allergies and Intolerances | Allergies and Intolerances Section | |
---|---|---|
•Substance (Medication) | Allergy - Intolerance Observation | |
•Substance (Drug Class) | Allergy - Intolerance Observation | |
•Substance (Non-Medication) | Allergy - Intolerance Observation | |
•Reaction | Allergy - Intolerance Observation |
Care Team Members | Care Teams Section | |
---|---|---|
•Name | Care Team Member Act | |
•Identifier | Care Team Member Act | |
•Location | Care Team Member Act | |
•Telecom | Care Team Member Act | |
•Role | Care Team Member Act |
Clinical Notes |
Notes Section
Results Section Procedures Section |
|
---|---|---|
•Consultation Note | Note Activity | |
•Discharge Summary Note | Note Activity | |
•History & Physical | Note Activity | |
•Imaging Narrative | Note Activity | |
•Procedure Note | Note Activity | |
•Progress Note | Note Activity | |
•Operative Note | Note Activity | |
•Emergency Department Note | Note Activity |
Clinical Tests | Results Section | |
---|---|---|
•Clinical Test |
Result Organizer
Result Observation |
|
•Clinical Test Result/Report | Result Observation |
Diagnostic Imaging | Results Section | |
---|---|---|
•Diagnostic Imaging Test | Result Organizer | |
•Diagnostic Imaging Result/Report | Result Observation |
Encounter | Encounters Section | |
---|---|---|
•Identifier | Encounter Activity | |
•Type | Encounter Activity | |
•Diagnosis |
Encounter Diagnosis
Hospital Discharge Diagnosis Problem Observation |
|
•Time | Encounter Activity | |
•Location | Encounter Activity | |
•Disposition | Encounter Activity |
Facility Information | Service Delivery Location | |
---|---|---|
•Identifier | Service Delivery Location | |
•Type | Service Delivery Location | |
•Name | Service Delivery Location |
Goals and Preferences | Goals Section | |
---|---|---|
•Patient Goals | Goal Observation | |
•SDOH Goals | Goal Observation | See Screening and Assessments Guidance |
•Treatment Intervention Preference | Treatment Intervention Preference | |
•Care Experience Preference | Care Experience Preference |
Health Insurance Information | Payers Section | |
---|---|---|
•Coverage Status | Coverage Activity | |
•Coverage Type | Policy Activity | |
•Relationship to Subscriber | Policy Activity | |
•Member Identifier | Policy Activity | |
•Subscriber Identifier | Policy Activity | |
•Group Number | Policy Activity | |
•Payer Identifier | Policy Activity |
Immunizations | Immunizations Section | |
---|---|---|
•Immunizations | Immunization Activity | |
•Lot Number | Immunization Medication Information |
Laboratory | Results Section | |
---|---|---|
•Tests |
Result Organizer
Result Observation |
|
•Values/Results | Result Observation | |
•Specimen Type | Result Organizer | |
•Result Status | Result Observation | |
•Result Unit of Measure | Result Observation | |
•Result Reference Range | Result Observation | |
•Result Interpretation | Result Observation | |
•Specimen Identifier | Result Organizer | |
•Specimen Source Site | Specimen Collection Procedure | |
•Specimen Condition Acceptability | Specimen Condition Observation |
Medical Devices | UDI Organizer | |
---|---|---|
•Unique Device Identifier(s) for a Patient's Implantable Device(s) | UDI Organizer |
Medications | Medications Section | |
---|---|---|
•Medications | Medication Activity | |
•Dose | Medication Activity | |
•Dose Unit of Measure | Medication Activity | |
•Route of Administration | Medication Activity | |
•Indication |
Medication Activity
Indication |
|
•Route of Administration | Medication Activity | |
•Medication Instructions | Medication Free Text Sig | |
•Medication Adherence | Medication Adherence | |
•Fill Status | Medication Dispense |
Observation |
Advance Directives Section
US Realm Header |
|
---|---|---|
•Advance Directive Observation | Advance Directive Existence Observation | |
•Sex Parameter for Clinical Use | Sex Parameter For Clinical Use Observation |
Orders |
Planned Procedure Section
Plan of Treatment Section |
|
---|---|---|
•Medication Order | Planned Medication Activity | |
•Laboratory Order | Planned Procedure | |
•Diagnostic Imaging Order | Planned Procedure | |
•Clinical Test Order | Planned Procedure | |
•Procedure Order | Planned Procedure |
Patient Summary and Plan | Assessment Section | |
---|---|---|
•Assessment and Plan of Treatment | Assessment Section |
Problems |
Problem Section
Problem Observation |
|
---|---|---|
•Date of Resolution | Problem Observation | |
•Date of Diagnosis |
Problem Observation
Date of Diagnosis Act |
|
•SDOH Problems/Health Concerns |
Health Concern Act
Problem Observation Social History Observation |
See Screening and Assessments Guidance |
Procedures |
Procedures Section
Procedure Activity Procedure Reason for Referral Section |
|
---|---|---|
•Procedure | Procedure Activity Procedure | |
•Performance Time | Procedure Activity Procedure | |
•Reason for Referral | Reason for Referral Section | |
•SDOH Interventions |
Procedure Activity Procedure
Planned Procedure |
See Screening and Assessments Guidance |
Provenance |
Provenance - Assembler Participation
Provenance - Author Participation |
|
---|---|---|
•Author Time Stamp | Provenance - Author Participation | |
•Author Organization | Provenance - Author Participation | |
•Author | Provenance - Author Participation | |
•Author Role | Provenance - Author Participation |
Vital Signs |
Vital Signs Section
Vital Sign Organizer |
|
---|---|---|
•Average Blood Pressure | Average Blood Pressure Organizer | |
•Diastolic blood pressure | Vital Sign Observation | |
•Systolic blood pressure | Vital Sign Observation | |
•Body height | Vital Sign Observation | |
•Body weight | Vital Sign Observation | |
•Heart rate | Vital Sign Observation | |
•Respiratory rate | Vital Sign Observation | |
•Body temperature | Vital Sign Observation | |
•Pulse oximetry | Vital Sign Observation | |
•Inhaled oxygen concentration | Vital Sign Observation | |
•BMI Percentile (2-20 years old) | Vital Sign Observation | |
•Weight-for-length Percentile (Birth - 36 months) | Vital Sign Observation | |
•Occipital Frontal Head Circumference Percentile (Birth - 36 months) | Vital Sign Observation |