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Template Continuity of Care Document (CCD) (V3) 2015‑08‑01

Id2.16.840.1.113883.10.20.22.1.2Effective Date2015‑08‑01
Statusdraft DraftVersion Label2.1
NameContinuityofCareDocumentCCDV3Display NameContinuity of Care Document (CCD) (V3)
Description
This document type was originally based on the Continuity of Care Document (CCD) Release 1.1 which itself was derived from HITSP C32 and CCD Release 1.0. The Continuity of Care Document (CCD) represents 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 to support the continuity of care. The primary use case for the CCD is to provide a snapshot in time containing the germane clinical, demographic, and administrative data for a specific patient. The key characteristic of a CCD is that the ServiceEvent is constrained to "PCPR". This means it does not function to report new ServiceEvents associated with performing care. It reports on care that has already been provided. The CCD provides a historical tally of the care over a range of time and is not a record of new services delivered. More specific use cases, such as a Discharge Summary, Transfer Summary, Referral Note, Consultation Note, 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 17 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.23Transactionfinal Continuity of Care Document (CCD) (V3)2015‑08‑01
Uses as NameVersion
2.16.840.1.113883.10.20.22.2.1.1Containmentdraft Medications Section (entries required) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.2.1Containmentdraft Immunizations Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.3.1Containmentdraft Results Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.4.1Containmentdraft Vital Signs Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.5.1Containmentdraft Problem Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.6.1Containmentdraft Allergies and Intolerances Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.7.1Containmentdraft Procedures Section (entries required) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.10Containmentdraft Plan of Treatment Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.14Containmentdraft Functional Status Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.15Containmentdraft Family History Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.17Containmentdraft Social History Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.18Containmentdraft Payers Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.21Containmentdraft Advance Directives Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.22Containmentdraft Encounters Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.23Containmentdraft Medical Equipment Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.56Containmentdraft Mental Status Section (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.57Containmentdraft Nutrition Section (2.1)2015‑08‑13
RelationshipSpecialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-

Specialization: template 2.16.840.1.113883.10.20.22.1.1 US Realm Header (V3) (2015‑08‑01)
Version: template 2.16.840.1.113883.10.20.22.1.2 Continuity of Care Document (CCD) (2013‑01‑31)
ItemDTCardConfDescriptionLabel
cda:ClinicalDocument
RWhen asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 SHALLinclude both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32934).
ContdotsCDV3
cda:templateId
II1 … 1MC-CDA R1.1 templateId root without an extensionCONFdots2936
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.2
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1198-8450) such that itCONFdots8450
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.2CONFdots0038
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.2" (CONF:1198-10038).
@extension
st1 … 1F2015-08-01CONFdots2516
 SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32516).
cda:code
1 … 1MSHALL contain exactly one [1..1] code (CONF:1198-17180).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:1198-9442).CONFdots9442
cda:assignedAuthor
1 … 1MSuch authors SHALL contain exactly one [1..1] assignedAuthor (CONF:1198-9443).CONFdots9443
 Schematron assertrolered error 
 testcda:assignedPerson | (cda:assignedAuthoringDevice and cda:representedOrganization) 
 Message SHALL contain (exactly one [1..1] assignedPerson) or (exactly one [1..1] assignedAuthoringDevice and exactly one [1..1] representedOrganization) 
 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:1198-8452).

The documentationOf relationship in a Continuity Care Document contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care.
CONFdots8452
cda:serviceEvent
1 … 1MThis documentationOf SHALL contain exactly one [1..1] serviceEvent (CONF:1198-8480).

The main activity being described by a CCD is the provision of healthcare over a period of time. This is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). NOTE: Implementations originating a CCD should take care to discover what the episode of care being summarized is. For example, when a patient fills out a form providing relevant health history, the episode of care being documented might be from birth to the present.
CONFdots8480
@classCode
cs1 … 1FPCPRCONFdots8453
 This serviceEvent SHALL contain exactly one [1..1] @classCode="PCPR" Care Provision (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-8453).
cda:effectiveTime
1 … 1MThis serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:1198-8481).CONFdots8481
cda:low
1 … 1RThis effectiveTime SHALL contain exactly one [1..1] low (CONF:1198-8454).CONFdots8454
cda:high
1 … 1RThis effectiveTime SHALL contain exactly one [1..1] high (CONF:1198-8455).CONFdots8455
cda:performer
0 … *RThis serviceEvent SHOULD contain zero or more [0..*] performer (CONF:1198-8482).

The 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.
CONFdots8482
@typeCode
cs1 … 1FPRFCONFdots8458
 The performer, if present, SHALL contain exactly one [1..1] @typeCode="PRF" Participation physical performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1198-8458).
cda:assignedEntity
0 … 1The performer, if present, MAY contain zero or one [0..1] assignedEntity (CONF:1198-8459).CONFdots8459
cda:id
II1 … *The assignedEntity, if present, SHALL contain at least one [1..*] id (CONF:1198-30882) such that itCONFdots0882
 Schematron assertroleorange warning 
 testnot(cda:assignedPerson) or cda:id/@root='2.16.840.1.113883.4.6' 
 MessageIf this assignedEntity is an assignedPerson, the assignedEntity/id SHOULD contain zero or one [0..1] @root="2.16.840.1.113883.4.6" National Provider Identifier (CONF:1198-32466).  
cda:assignedPerson
0 … 1The assignedEntity, if present, MAY contain zero or one [0..1] assignedPerson (CONF:1198-32467).CONFdots2467
cda:component
1 … 1MSHALL contain exactly one [1..1] component (CONF:1198-30659).CONFdots0659
cda:structuredBody
1 … 1MThis component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30660).CONFdots0660
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.6.1 Allergies and Intolerances Section (entries required) (V3) (2015‑08‑01)CONFdots0661
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.1.1 Medications Section (entries required) (V2) (2014‑06‑09)CONFdots0663
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.5.1 Problem Section (entries required) (V3) (2015‑08‑01)CONFdots0665
cda:component
0 … 1RContains 2.16.840.1.113883.10.20.22.2.7.1 Procedures Section (entries required) (V2) (2014‑06‑09)CONFdots0667
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.3.1 Results Section (entries required) (V3) (2015‑08‑01)CONFdots0669
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.21 Advance Directives Section (entries optional) (V3) (2015‑08‑01)CONFdots0671
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.22 Encounters Section (entries optional) (V3) (2015‑08‑01)CONFdots0673
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (2015‑08‑01)CONFdots0675
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (V2) (2014‑06‑09)CONFdots0677
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.2.1 Immunizations Section (entries required) (V3) (2015‑08‑01)CONFdots0679
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.23 Medical Equipment Section (V2) (2014‑06‑09)CONFdots0681
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.18 Payers Section (V3) (2015‑08‑01)CONFdots0683
cda:component
0 … 1RContains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09)CONFdots0685
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (2015‑08‑01)CONFdots0687
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.4.1 Vital Signs Section (entries required) (V3) (2015‑08‑01)CONFdots0689
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.56 Mental Status Section (V2) (2015‑08‑01)CONFdots2143
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.57 Nutrition Section (2015‑08‑13)CONFdots2624