Consolidated Clinical Document Architecture
{{short description|XML standard for clinical documents}}
{{Infobox technology standard
| title = Consolidated Clinical Document Architecture (C-CDA)
| long_name =
| image =
| caption =
| status = Published
| year_started =
| first_published = {{Start date|2011|12|df=y}}
| version = 2.1
| version_date = 2015
| preview =
| preview_date =
| organization = Health Level Seven International
| committee = Structured Documents Group
| editors =
| authors =
| base_standards = {{Unbulleted list |XML |CDA |{{abbr|HL7|Health Level Seven}} {{abbr|RIM|Reference Information Model}} }}
| related_standards = {{Unbulleted list |CCD }}
| abbreviation = C-CDA
| domain = Electronic health records
| license =
| website = {{URL|1=http://www.hl7.org/implement/standards/product_brief.cfm?product_id=492|2=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.{{cite web |title=Clinical Interoperability is Happening|website=Change Healthcare |url=https://www.changehealthcare.com/insights/clinical-interoperability-is-happening|access-date=23 August 2020 }}{{cite web |title=Carequality Hits Over 1 Billion Clinical Document Exchanges| website=EHR Intelligence|url=https://ehrintelligence.com/news/carequality-hits-over-1-billion-clinical-document-exchanges}}{{cite web|title=First Survey of the SHIEC Shows HIES provide Critical National Infrastructure|website=Strategic Health Information Exchange Collaborative(SHIEC)|url=https://strategichie.com/2019/08/19/first-survey-of-the-strategic-health-information-exchange-collaborative-shiec-shows-health-information-exchanges-hies-provide-critical-national-infrastructure/}} All certified Electronic health records in the United States are required to export medical data using the C-CDA standard.{{cite web |title=Consolidated CDA Overview|website=Office of the National Coordinator for Health IT|url=https://www.healthit.gov/topic/standards-technology/consolidated-cda-overview/}} 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{{cite web |title=C-CDA (HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes – US Realm)|website=HL7|url=http://www.hl7.org/implement/standards/product_brief.cfm?product_id=492}}
- 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.{{cite web |title=Care Plan (V2)|website=HL7|url=http://www.hl7.org/ccdasearch/templates/2.16.840.1.113883.10.20.22.1.15.html}}
- Consultation Note - The Consultation Note is generated by a request from a clinician for an opinion or advice from another clinician.{{cite web |title=Consultation Note (V3)|website=HL7|url=http://www.hl7.org/ccdasearch/templates/2.16.840.1.113883.10.20.22.1.4.html}}
- 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. {{cite web |title=CCD (V23)|website=HL7|url=http://www.hl7.org/ccdasearch/templates/2.16.840.1.113883.10.20.22.1.2.html}}
- Diagnostic Imaging Report - A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialist's interpretation of image data. {{cite web |title=Diagnostic Imaging Report (V3)|website=HL7|url=http://www.hl7.org/ccdasearch/templates/2.16.840.1.113883.10.20.22.1.5.html}}
- 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.{{cite web |title=Discharge Summary (V3)|website=HL7|url=http://www.hl7.org/ccdasearch/templates/2.16.840.1.113883.10.20.22.1.8.html}}
- History and Physical - A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. {{cite web |title=H&P (V3)|website=HL7|url=http://www.hl7.org/ccdasearch/templates/2.16.840.1.113883.10.20.22.1.3.html}}
- 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. {{cite web |title=Operative Note (V3)|website=HL7|url=http://www.hl7.org/ccdasearch/templates/2.16.840.1.113883.10.20.22.1.7.htmll}}
- 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. {{cite web |title=Procedure Note (V3)|website=HL7|url=http://www.hl7.org/ccdasearch/templates/2.16.840.1.113883.10.20.22.1.6.html}}
- Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter.{{cite web |title=Progress Note (V3)|website=HL7|url=http://www.hl7.org/ccdasearch/templates/2.16.840.1.113883.10.20.22.1.9.html}}
- Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between health care settings. {{cite web |title=Transfer Summary (V3)|website=HL7|url=http://www.hl7.org/ccdasearch/templates/2.16.840.1.113883.10.20.22.1.13.html}}
- 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.{{cite web |title=Unstructured Document (V3)|website=HL7|url=http://www.hl7.org/ccdasearch/templates/2.16.840.1.113883.10.20.22.1.10.html}}
References
{{Reflist}}
Further reading
{{refbegin}}
- {{cite book |last=Boone |first=Keith W. |date=2011 |title=The CDA Book |publisher=Springer Science & Business Media |isbn=978-0-85729-336-7 |url={{google books|rwa6DDB4jY8C|plainurl=yes}} }}
{{refend}}
External links
- {{cite web |title=C-CDA (HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes - US Realm)|website=HL7|url=http://www.hl7.org/implement/standards/product_brief.cfm?product_id=492}}
Category:Standards for electronic health records