Consolidated Clinical Document Architecture

Consolidated Clinical Document Architecture (C-CDA)
Abbreviation	C-CDA
Status	Published
First published	December 2011 (2011-12)
Latest version	2.1 2015
Organization	Health Level Seven International
Committee	Structured Documents Group
Base standards	XML CDA HL7RIM
Related standards	CCD
Domain	Electronic health records
Website	C-CDA® Release 2.1

The HL7 Consolidated Clinical Document Architecture (C-CDA) is an XML-based markup standard which provides a library of CDA formatted documents. Clinical documents using the C-CDA standards are exchanged billions of times annually in the United States. ^{[1] [2] [3]} All certified Electronic health records in the United States are required to export medical data using the C-CDA standard. ^[4] While the standard was developed primarily for the United States as the C-CDA incorporates references to terminologies and value set required by US regulation, it has also been used internationally.

Content

There are 11 document types in the C-CDA standard ^[5]

• Care Plan - A Care Plan (including Home Health Plan of Care (HHPoC)) is a consensus-driven dynamic plan that represents a patient's and Care Team Members' prioritized concerns, goals, and planned interventions. It represents an instance of this dynamic Care Plan at a point in time. ^[6]
• Consultation Note - The Consultation Note is generated by a request from a clinician for an opinion or advice from another clinician. ^[7]
• Continuity of Care Document - 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. 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. ^[8]
• Diagnostic Imaging Report - A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialist's interpretation of image data. ^[9]
• Discharge Summary - The Discharge Summary is a document which synopsizes a patient's admission to a hospital, LTPAC provider, or other setting. It provides information for the continuation of care following discharge. ^[10]
• History and Physical - A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. ^[11]
• Operative Note - The Operative Note is created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. ^[12]
• Procedure Note - Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act.The Procedure Note is created immediately following a non-operative procedure. ^[13]
• Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. ^[14]
• Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between health care settings. ^[15]
• Unstructured Document - An Unstructured Document (UD) document type can include unstructured content, such as a graphic, directly in a text element with a mediaType attribute, or reference a single document file, such as a word-processing document using a text/reference element. ^[16]

References

1. "Clinical Interoperability is Happening". Change Healthcare. Retrieved 23 August 2020.
2. "Carequality Hits Over 1 Billion Clinical Document Exchanges". EHR Intelligence.
3. "First Survey of the SHIEC Shows HIES provide Critical National Infrastructure". Strategic Health Information Exchange Collaborative(SHIEC).
4. "Consolidated CDA Overview". Office of the National Coordinator for Health IT.
5. "C-CDA (HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes – US Realm)". HL7.
6. "Care Plan (V2)". HL7.
7. "Consultation Note (V3)". HL7.
8. "CCD (V23)". HL7.
9. "Diagnostic Imaging Report (V3)". HL7.
10. "Discharge Summary (V3)". HL7.
11. "H&P (V3)". HL7.
12. "Operative Note (V3)". HL7.
13. "Procedure Note (V3)". HL7.
14. "Progress Note (V3)". HL7.
15. "Transfer Summary (V3)". HL7.
16. "Unstructured Document (V3)". HL7.

Further reading

• Boone, Keith W. (2011). The CDA Book. Springer Science & Business Media. ISBN   978-0-85729-336-7.

External links

• "C-CDA (HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes - US Realm)". HL7.