Consolidated CDA Release 2.2
2.2 - CI Build

Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/cda-ccda-2.2/ and changes regularly. See the Directory of published versions

Table of Contents

..0 Table of Contents
...1 IG Home Page
...2 Background
...3 Design Considerations
...4 Using this Implementation Guide
...5 References
...6 Appendix
...7 Validation
...8 Downloads
...9 Artifacts Summary
....9.1 Continuity of Care Document (CCD)
....9.2 Referral Note
....9.3 Transfer Summary
....9.4 Unstructured Document
....9.5 US Realm Header
....9.6 Care Plan (V2)
....9.7 History and Physical (V3)
....9.8 Consultation Note (V3)
....9.9 Diagnostic Imaging Report (V3)
....9.10 Procedure Note
....9.11 Progress Note (V3)
....9.12 Operative Note (V3)
....9.13 Discharge Summary (V3)
....9.14 Advance Directives Section (entries optional)
....9.15 Allergies and Intolerances Section (entries optional)
....9.16 Allergies and Intolerances Section (entries required)
....9.17 Immunizations Section (entries optional)
....9.18 Immunizations Section (entries required)
....9.19 Medications Section (entries optional)
....9.20 Medications Section (entries required)
....9.21 Plan of Treatment Section
....9.22 Problem Section (entries optional)
....9.23 Problem Section (entries required)
....9.24 Results Section (entries optional)
....9.25 Results Section (entries required)
....9.26 Vital Signs Section (entries optional)
....9.27 Vital Signs Section (entries required)
....9.28 Procedures Section (entries optional)
....9.29 Procedures Section (entries required)
....9.30 Social History Section
....9.31 Encounters Section (entries optional)
....9.32 Encounters Section (entries required)
....9.33 Family History Section
....9.34 Interventions Section
....9.35 Functional Status Section
....9.36 Medical Equipment Section
....9.37 Anesthesia Section
....9.38 Mental Status Section
....9.39 Payers Section
....9.40 Nutrition Section
....9.41 Course of Care Section
....9.42 Admission Diagnosis Section
....9.43 Admission Medications Section (entries optional)
....9.44 Discharge Diagnosis Section
....9.45 History of Present Illness Section
....9.46 Review of Systems Section
....9.47 Physical Exam Section
....9.48 Assessment Section
....9.49 Assessment and Plan Section
....9.50 Past Medical History
....9.51 General Status Section
....9.52 Reason for Referral Section
....9.53 Advance Directives Section (entries required)
....9.54 Chief Complaint Section
....9.55 Hospital Discharge Physical Section
....9.56 Discharge Diet Section (DEPRECATED)
....9.57 Hospital Course Section
....9.58 Authorization Activity
....9.59 Procedure Disposition Section
....9.60 Procedure Estimated Blood Loss Section
....9.61 Objective Section
....9.62 Subjective Section
....9.63 Chief Complaint and Reason for Visit Section
....9.64 Instructions Section (V2)
....9.65 Reason for Visit Section
....9.66 Findings Section (DIR)
....9.67 DICOM Object Catalog Section - DCM 121181
....9.68 Complications Section (V3)
....9.69 Procedure Description Section
....9.70 Procedure Indications Section (V2)
....9.71 Postprocedure Diagnosis Section (V3)
....9.72 Medical (General) History Section
....9.73 Medications Administered Section (V2)
....9.74 Planned Procedure Section (V2)
....9.75 Procedure Findings Section (V3)
....9.76 Procedure Implants Section
....9.77 Procedure Specimens Taken Section
....9.78 Preoperative Diagnosis Section (V3)
....9.79 Postoperative Diagnosis Section
....9.80 Operative Note Fluids Section
....9.81 Operative Note Surgical Procedure Section
....9.82 Surgical Drains Section
....9.83 Health Concerns Section (V2)
....9.84 Goals Section
....9.85 Health Status Evaluations and Outcomes Section
....9.86 Discharge Medications Section (entries optional) (V3)
....9.87 Discharge Medications Section (entries required) (V3)
....9.88 Hospital Consultations Section
....9.89 Hospital Discharge Instructions Section
....9.90 Hospital Discharge Studies Summary Section
....9.91 Implants Section (DEPRECATED)
....9.92 Surgery Description Section (DEPRECATED)
....9.93 Advance Directive Observation
....9.94 Advance Directive Organizer
....9.95 Age Observation
....9.96 Allergy - Intolerance Observation
....9.97 Allergy Concern Act
....9.98 Allergy Status Observation
....9.99 Criticality Observation
....9.100 Drug Monitoring Act
....9.101 Drug Vehicle
....9.102 Entry Reference
....9.103 External Document Reference
....9.104 Goal Observation
....9.105 Health Status Observation (V2)
....9.106 Immunization Activity
....9.107 Immunization Medication Information
....9.108 Immunization Refusal Reason
....9.109 Medication Activity
....9.110 Medication Dispense
....9.111 Medication Free Text Sig
....9.112 Medication Information
....9.113 Medication Supply Order
....9.114 Planned Observation
....9.115 Precondition for Substance Administration
....9.116 Problem Concern Act
....9.117 Problem Observation
....9.118 Problem Status
....9.119 Procedure Activity Procedure
....9.120 Product Instance
....9.121 Prognosis Observation
....9.122 Reaction Observation
....9.123 Result Observation
....9.124 Result Organizer
....9.125 Service Delivery Location
....9.126 Severity Observation
....9.127 Substance Administered Act
....9.128 Substance or Device Allergy - Intolerance Observation
....9.129 Vital Sign Observation
....9.130 Vital Signs Organizer
....9.131 Procedure Activity Act
....9.132 Procedure Activity Observation
....9.133 Social History Observation
....9.134 Pregnancy Observation
....9.135 Estimated Date of Delivery
....9.136 Smoking Status - Meaningful Use
....9.137 Tobacco Use
....9.138 Caregiver Characteristics
....9.139 Cultural and Religious Observation
....9.140 Characteristics of Home Environment
....9.141 Encounter Activity
....9.142 Encounter Diagnosis
....9.143 Family History Organizer
....9.144 Family History Observation
....9.145 Family History Death Observation
....9.146 Mental Status Organizer
....9.147 Mental Status Observation
....9.148 Assessment Scale Observation
....9.149 Assessment Scale Supporting Observation
....9.150 Planned Encounter
....9.151 Planned Act
....9.152 Planned Procedure
....9.153 Planned Medication Activity
....9.154 Planned Supply
....9.155 Handoff Communication Participants
....9.156 Nutrition Recommendation
....9.157 Planned Immunization Activity
....9.158 Coverage Activity
....9.159 Nutritional Status Observation
....9.160 Non-Medicinal Supply Activity
....9.161 Medical Equipment Organizer
....9.162 Nutrition Assessment
....9.163 Policy Activity
....9.164 Outcome Observation
....9.165 Intervention Act
....9.166 Planned Intervention Act
....9.167 Functional Status Organizer
....9.168 Functional Status Observation
....9.169 Progress Toward Goal Observation
....9.170 Pressure Ulcer Observation (DEPRECATED)
....9.171 Functional Status Problem Observation (DEPRECATED)
....9.172 Series Act
....9.173 Cognitive Status Problem Observation (DEPRECATED)
....9.174 Sensory Status
....9.175 Self-Care Activities (ADL and IADL)
....9.176 Comment Activity
....9.177 SOP Instance Observation
....9.178 Purpose of Reference Observation
....9.179 Referenced Frames Observation
....9.180 Hospital Admission Diagnosis
....9.181 Admission Medication
....9.182 Hospital Discharge Diagnosis
....9.183 Longitudinal Care Wound Observation
....9.184 Patient Referral Act
....9.185 Boundary Observation
....9.186 Wound Measurement Observation
....9.187 Wound Characteristic
....9.188 Number of Pressure Ulcers Observation
....9.189 Highest Pressure Ulcer Stage
....9.190 US Realm Date and Time (DT.US.FIELDED)
....9.191 Physician Reading Study Performer (V2)
....9.192 Physician of Record Participant (V2)
....9.193 Fetus Subject Context
....9.194 Text Observation
....9.195 Code Observations
....9.196 Quantity Measurement Observation
....9.197 Study Act
....9.198 Observer Context
....9.199 Procedure Context
....9.200 Postprocedure Diagnosis (V3)
....9.201 Preoperative Diagnosis (V3)
....9.202 Health Concern Act (V2)
....9.203 Risk Concern Act (V2)
....9.204 Discharge Medication (V3)
....9.205 Deceased Observation (V3)
....9.206 US Realm Header for Patient Generated Document (V2)
....9.207 Author Participation
....9.208 Indication
....9.209 Instruction
....9.210 Planned Coverage
....9.211 Priority Preference
....9.212 US Realm Address (AD.US.FIELDED)
....9.213 US Realm Date and Time (DTM.US.FIELDED)
....9.214 US Realm Patient Name (PTN.US.FIELDED)
....9.215 US Realm Person Name (PN.US.FIELDED)