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pending Template  Continuity of Care Document (CCD)

Template 2.16.840.1.113883.10.20.22.1.2 - ContinuityofCareDocumentCCD
Id 2.16.840.1.113883.10.20.22.1.2
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Document Level Template
Context Pathname //
Open/Closed Open (other than defined elements are allowed)
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.
Used by / Uses
Used by / Uses 15 templates
Uses Template id as Name Version
2.16.840.1.113883.10.20.22.2.6.1 Containment AllergiesSectionentriesrequired DYNAMIC
2.16.840.1.113883.10.20.22.2.1.1 Containment MedicationsSectionentriesrequired DYNAMIC
2.16.840.1.113883.10.20.22.2.5.1 Containment ProblemSectionentriesrequired DYNAMIC
2.16.840.1.113883.10.20.22.2.7.1 Containment ProceduresSectionentriesrequired DYNAMIC
2.16.840.1.113883.10.20.22.2.3.1 Containment ResultsSectionentriesrequired DYNAMIC
2.16.840.1.113883.10.20.22.2.18 Containment PayersSection DYNAMIC
2.16.840.1.113883.10.20.22.2.17 Containment SocialHistorySection DYNAMIC
2.16.840.1.113883.10.20.22.2.23 Containment MedicalEquipmentSection DYNAMIC
2.16.840.1.113883.10.20.22.2.2 Containment ImmunizationsSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.14 Containment FunctionalStatusSection DYNAMIC
2.16.840.1.113883.10.20.22.2.15 Containment FamilyHistorySection DYNAMIC
2.16.840.1.113883.10.20.22.2.22 Containment EncountersSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.21 Containment AdvanceDirectivesSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.10 Containment PlanofCareSection DYNAMIC
2.16.840.1.113883.10.20.22.2.4 Containment VitalSignsSectionentriesoptional DYNAMIC
Item DT Card Conf Description Label
cda:ClinicalDocument
The component/structuredBody SHALL conform to the section constraints below (ContinuityofCareDocumentCCD)
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:8450) such that it conf‑8450
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.1.2
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:17180). conf‑17180
treeblank treetree @code
1 .. 1 F 34133-9
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (LOINC)
treetree cda:author
1 .. * M SHALL contain at least one [1..*] author (CONF:9442). conf‑9442
treeblank treetree cda:assignedAuthor
1 .. 1 M Such authors SHALL contain exactly one [1..1] assignedAuthor (CONF:9443).

SHALL contain exactly one [1..1] assignedPerson or exactly one [1..1] representedOrganization

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.
conf‑9443
  Schematron assert role red error
  test count(cda:author/cda:assignedAuthor/cda:assignedPerson | cda:author/cda:assignedAuthor/cda:representedOrganization)=1
  Message SHALL contain exactly one [1..1] assignedPerson or exactly one [1..1] representedOrganization
  Schematron assert role red error
  test (count(cda:author/cda:assignedAuthor/cda:representedOrganization[cda:assignedPerson | cda:assignedAuthoringDevice])=0 and (//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.
treetree cda:documentationOf
1 .. 1 M SHALL contain exactly one [1..1] documentationOf (CONF:8452). conf‑8452
treeblank treetree cda:serviceEvent
1 .. 1 M This documentationOf SHALL contain exactly one [1..1] serviceEvent (CONF:8480). conf‑8480
treeblank treeblank treetree @classCode
1 .. 1 F PCPR
treeblank treeblank treetree cda:effectiveTime
1 .. 1 M This serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:8481). conf‑8481
treeblank treeblank treeblank treetree cda:low
1 .. 1 M This effectiveTime SHALL contain exactly one [1..1] low (CONF:8454). conf‑8454
treeblank treeblank treeblank treetree cda:high
1 .. 1 M This effectiveTime SHALL contain exactly one [1..1] high (CONF:8455). conf‑8455
treeblank treeblank treetree cda:performer
0 .. * R This serviceEvent SHOULD contain zero or more [0..*] performer (CONF:8482).

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 The performer, if present, MAY contain zero or one [0..1] assignedEntity (CONF:8459). conf‑8459
treeblank treeblank treeblank treeblank treetree cda:id
1 .. * M The assignedEntity, if present, SHALL contain at least one [1..*] id (CONF:8460).

SHOULD include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier
conf‑8460
  Schematron assert role red error
  test not(cda:documentationOf/cda:serviceEvent/cda:performer/cda:assignedEntity) or cda:documentationOf/cda:serviceEvent/cda:performer/cda:assignedEntity/cda:id/@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
0 .. 1 The assignedEntity, if present, MAY contain zero or one [0..1] code (CONF:8461). conf‑8461
treetree cda:component
1 .. 1 M (ContinuityofCareDocumentCCD)
treeblank treetree cda:structuredBody
(ContinuityofCareDocumentCCD)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.6.1']]
1 .. 1 M conf‑9445
  Contains 2.16.840.1.113883.10.20.22.2.6.1 Allergies Section (entries required) (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.1.1']]
1 .. 1 M conf‑9447
  Contains 2.16.840.1.113883.10.20.22.2.1.1 Medications Section (entries required) (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.5.1']]
1 .. 1 M conf‑9449
  Contains 2.16.840.1.113883.10.20.22.2.5.1 Problem Section (entries required) (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.7.1']]
0 .. 1 R conf‑9451
  Contains 2.16.840.1.113883.10.20.22.2.7.1 Procedures Section (entries required) (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.3.1']]
1 .. 1 M conf‑9453
  Contains 2.16.840.1.113883.10.20.22.2.3.1 Results Section (entries required) (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.18']]
0 .. 1 conf‑9455
  Contains 2.16.840.1.113883.10.20.22.2.18 Payers Section (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.17']]
0 .. 1 conf‑9974
  Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.23']]
0 .. 1 conf‑9975
  Contains 2.16.840.1.113883.10.20.22.2.23 Medical Equipment Section (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.2']]
0 .. 1 conf‑9976
  Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.14']]
0 .. 1 conf‑9977
  Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.15']]
0 .. 1 conf‑9978
  Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.22']]
0 .. 1 conf‑9979
  Contains 2.16.840.1.113883.10.20.22.2.22 Encounters Section (entries optional) (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.21']]
0 .. 1 conf‑9980
  Contains 2.16.840.1.113883.10.20.22.2.21 Advance Directives Section (entries optional) (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.10']]
0 .. 1 conf‑9981
  Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (DYNAMIC)
treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.4']]
0 .. 1 conf‑9983
  Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (DYNAMIC)