Template 2.16.840.1.113883.10.20.22.1.2 Continuity of Care Document (CCD)

2012‑01‑12

Template 2.16.840.1.113883.10.20.22.1.2 - ContinuityofCareDocumentCCD
Id 2.16.840.1.113883.10.20.22.1.2
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑737
Version valid from 2012‑01‑12 status draft
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.
Item DT Card Conf Desc Label
cda:ClinicalDocument
The component/structuredBody SHALL conform to the section constraints below conf-737
treetree cda:templateId
II 1..1 M conf‑9441
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:templateId
II 1..1 M conf‑8450
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.2
treetree cda:code
CD 1..1 M conf‑8451
treeblank treetree @code
1..1 F 34133-9
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Summarization of Episode Note
treetree cda:documentationOf
1..1 M conf‑8452
treeblank treetree cda:serviceEvent
1..1 M conf‑8480
treeblank treeblank treetree @classCode
1..1 F PCPR
treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 M conf‑8481
treeblank treeblank treeblank treetree cda:low
TS 1..1 M conf‑8454
treeblank treeblank treeblank treetree cda:high
TS 1..1 M conf‑8455
treeblank treeblank treetree cda:performer
0..* R 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
treeblank treeblank treeblank treetree @typeCode
1..1 F PRF
treeblank treeblank treeblank treetree cda:assignedEntity
0..1 O conf‑8459
treeblank treeblank treeblank treeblank treetree cda:id
II 1..* M conf‑8460
Schematron assert Role red error
Test @root='2.16.840.1.113883.4.6'
Message
SHOULD include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier
treeblank treeblank treeblank treeblank treetree cda:code
CE 0..1 O conf‑8461
Schematron assert Role red error
Test true()
Message
i. The code MAY be the NUCC Health Care Provider Taxonomy (CodeSystem: 2.16.840.1.113883.6.101). (See http://www.nucc.org)
treetree cda:author
1..* M conf‑9442
treeblank treetree cda:assignedAuthor
1..1 M conf‑9443
Schematron assert Role red error
Test count(cda:assignedPerson | cda:representedOrganization)=1
Message
SHALL contain exactly one [1..1] assignedPerson exactly one [1..1] representedOrganization
Schematron assert Role red error
Test (count(cda:representedOrganization[cda:assignedPerson | cda:assignedAuthoringDevice])=0 and (//cda:ClinicalDocument/cda:author/cda:assignedAuthor/cda:id/@nullFlavor='NA')) or (count(cda:representedOrganization[cda:assignedPerson | cda:assignedAuthoringDevice])>0) or (count(cda:representedOrganization)=0)
Message
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.