ContinuityOfCareDocument

Continuity of Care Document

activeC-CDA on FHIR1.2.0resource102 key elements

This profile 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) profile 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 Composition.event.code is constrained to "PCPR". This means it does not function to report new services 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 profiles.

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/fhir/us/ccda/StructureDefinition/Continuity-of-Care-Document
ID
Continuity-of-Care-Document
Type
Base Definition
US-Realm-Header
Derivation
constraint
Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

PathCard.TypeFlagsDescription
type
S
Summary of episode note
event1..1
S1+
serviceEvent
event.period
1+
period
event.period.start
1+
start
event.period.end
1+
end
:allergies_and_intolerances_section1..1
S1+
Allergies and Intolerances Section
section.title
S1+
title
section.code
S1+
Allergies and adverse reactions
section.text
S1+
text
section.entry
S
entry
:allergy_entry
Reference
S
:medications_section1..1
S1+
Medications Section
section.title
S1+
title
section.code
S1+
History of medication use
section.text
S1+
text
:medication_entry
Reference
S
:problem_section1..1
S1+
Problem Section
section.title
S1+
title
section.code
S1+
Problem list
section.text
S1+
text
:problems_entry
Reference
S
:results_section1..1
S1+
Results Section
section.title
S1+
title
section.code
S1+
Relevant diagnostic tests and laboratory data
section.text
S1+
text
:sliceEntry
Reference
S
:social_history_section1..1
S1+
Social History Section
section.title
S1+
title
section.code
S1+
Social history
section.text
S1+
text
:smoking_status_entry
Reference
S
Smoking status
:vital_signs_section1..1
S1+
Vital Signs Section
section.title
S1+
title
section.code
S1+
Vital signs
section.text
S1+
text
:vital_signs_entry
Reference
S
:plan_of_treatment_section
S
Plan of Treatment Section
section.title
S1+
title
section.code
S1+
Plan of treatment
section.text
S1+
text
:procedures_section
S
Procedures Section
section.title
S1+
title
section.code
S1+
History of procedures
section.text
S1+
text
:procedure_entry
Reference
S
:family_history_section
S
Family History Section
section.title
S1+
title
section.code
S1+
History of family member diseases
section.text
S1+
text
:family_history_entry
Reference
S
This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:advance_directives_section
S
Advance Directives Section
section.title
S1+
title
section.code
S1+
Advance directives
section.text
S1+
text
:advance_directive_entry
Reference
S
:encounters_section
S
Encounters Section
section.title
S1+
title
section.code
S1+
Encounters
section.text
S1+
text
:encounter_entry
Reference
S
This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:functional_status_section
S
Functional Status Section
section.title
S1+
title
section.code
S1+
Functional status assessment
section.text
S1+
text
:functional_status_entry
Reference
S
This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:immunizations_section
S
Immunizations Section
section.title
S1+
title
section.code
S1+
History of immunization
section.text
S1+
text
:immunization_entry
Reference
S
:nutrition_section
S
Nutrition Section
section.title
S1+
title
section.code
S1+
Diet and nutrition
section.text
S1+
text
:nutrition_entry
Reference
S
This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:mental_status_section
S
Mental Status Section
section.title
S1+
title
section.code
S1+
Mental status
section.text
S1+
text
:mental_status_entry
Reference
S
This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:medical_equipment_section
S
Medical Equipment Section
section.title
S1+
title
section.code
S1+
Medical equipment
section.text
S1+
text
section.entry
S
entry
:medical_equipment_entry
Reference
S
This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:payers_section
S
Payers Section
section.title
S1+
title
section.code
S1+
Payers
section.text
S1+
text
section.entry
S
entry
:coverage_entry
Reference
S
This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:goals_section0..1
S
Goals Section
section.title
S1+
title
section.code
S1+
Goals
section.text
S1+
text
:goals_entry
Reference
S
entry
:health_concerns_section0..1
S
Health Concerns Section
section.title
S1+
title
section.code
S1+
Health concerns section code
section.text
S1+
text
:health_concerns_entry
Reference
S
This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.