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Template Continuity of Care Document (CCD) 2013‑01‑31

Id2.16.840.1.113883.10.20.22.1.2Effective Date2013‑01‑31
Statusdraft DraftVersion Label1.1
NameContinuityofCareDocumentCCDDisplay NameContinuity of Care Document (CCD)
Description
This section—Continuity of Care Document (CCD) Release 1.1—describes CDA constraints in accordance with Stage 1 Meaningful Use. The CCD requirements in this guide supersede CCD Release 1; in the near future, this guide could supersede HITSP C32. The CCD is 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. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care. The primary use case for the CCD is to provide a snapshot in time containing the pertinent clinical, demographic, and administrative data for a specific patient . More specific use cases, such as a Discharge Summary or Progress Note, are available as alternative documents in this guide.
ContextPathname //
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 15 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.1Transactionfinal Continuity of Care Document (CCD) (Release 1.1)2013‑01‑31
Uses as NameVersion
2.16.840.1.113883.10.20.22.2.1.1Containmentdraft Medications Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.2Containmentdraft Immunizations Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.3.1Containmentdraft Results Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.4Containmentdraft Vital Signs Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.5.1Containmentdraft Problem Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6.1Containmentdraft Allergies Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.7.1Containmentdraft Procedures Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.10Containmentdraft Plan of Care Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.14Containmentdraft Functional Status Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.15Containmentdraft Family History Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.17Containmentdraft Social History Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.18Containmentdraft Payers Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.21Containmentdraft Advance Directives Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.22Containmentdraft Encounters Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.23Containmentdraft Medical Equipment Section (1.1)2013‑01‑31
ItemDTCardConfDescriptionLabel
cda:ClinicalDocument
The component/structuredBody SHALL conform to the section constraints belowContdotstCCD
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:8450) such that itconf‑8450
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.2confdots0038
cda:code
1 … 1MSHALL contain exactly one [1..1] code (CONF:17180).confdots7180
@code
CONF1 … 1F34133-9
@codeSystem
1 … 1F2.16.840.1.113883.6.1
cda:author
1 … *MSHALL contain at least one [1..*] author (CONF:9442).conf‑9442
cda:assignedAuthor
1 … 1MSuch authors SHALL contain exactly one [1..1] assignedAuthor (CONF:9443).

SHALL contain exactly one [1..1] assignedPerson or exactly one [1..1] representedOrganization

If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for “ClinicalDocument/author/assignedAuthor/id/@nullFlavor” SHALL be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC.		conf‑9443
cda:assignedPerson
conf‑9443
cda:representedOrganization
conf‑9443
 Schematron assertrolered error 
 testnot(cda:representedOrganization) or cda:assignedPerson or cda:assignedAuthoringDevice or cda:id/@nullFlavor='NA' 
 MessageIf assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for “ClinicalDocument/author/assignedAuthor/id/@nullFlavor” SHALL be “NA” “Not applicable” 2.16.840.1.113883.5.1008 NullFlavor STATIC. 
cda:documentationOf
1 … 1MSHALL contain exactly one [1..1] documentationOf (CONF:8452).conf‑8452
cda:serviceEvent
1 … 1MThis documentationOf SHALL contain exactly one [1..1] serviceEvent (CONF:8480).conf‑8480
@classCode
cs1 … 1FPCPRconf‑8453
cda:effectiveTime
1 … 1MThis serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:8481).conf‑8481
cda:low
1 … 1RThis effectiveTime SHALL contain exactly one [1..1] low (CONF:8454).conf‑8454
cda:high
1 … 1RThis effectiveTime SHALL contain exactly one [1..1] high (CONF:8455).conf‑8455
cda:performer
0 … *RThis serviceEvent SHOULD contain zero or more [0..*] performer (CONF:8482).

serviceEvent/performer represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient’s key healthcare providers would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors		conf‑8482
@typeCode
cs1 … 1FPRFconf‑8458
cda:assignedEntity
0 … 1The performer, if present, MAY contain zero or one [0..1] assignedEntity (CONF:8459).conf‑8459
cda:id
II1 … *The assignedEntity, if present, SHALL contain at least one [1..*] id (CONF:8460).

SHOULD include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier		conf‑8460
@root
uid1 … 1R
cda:code
CE0 … 1The assignedEntity, if present, MAY contain zero or one [0..1] code (CONF:8461).conf‑8461
cda:component
1 … 1MContdotstCCD
cda:structuredBody
ContdotstCCD
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.6.1 Allergies Section (entries required) (2013‑01‑31)conf‑9445
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.1.1 Medications Section (entries required) (2013‑01‑31)conf‑9447
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.5.1 Problem Section (entries required) (2013‑01‑31)conf‑9449
cda:component
0 … 1RContains 2.16.840.1.113883.10.20.22.2.7.1 Procedures Section (entries required) (2013‑01‑31)conf‑9451
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.3.1 Results Section (entries required) (2013‑01‑31)conf‑9453
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.18 Payers Section (2013‑01‑31)conf‑9455
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (2013‑01‑31)conf‑9974
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.23 Medical Equipment Section (2013‑01‑31)conf‑9975
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (2013‑01‑31)conf‑9976
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (2013‑01‑31)conf‑9977
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (2013‑01‑31)conf‑9978
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.22 Encounters Section (entries optional) (2013‑01‑31)conf‑9979
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.21 Advance Directives Section (entries optional) (2013‑01‑31)conf‑9980
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (2013‑01‑31)conf‑9981
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (2013‑01‑31)conf‑9983