Non-Normative Content The Normative content for these specifications may be found on the HL7, IHE, and HITSP web sites.

Continuity Of Care Document

[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.2]

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.

Continuity Of Care Document Header Constraints

Continuity Of Care Document Body Constraints

  1. SHALL contain exactly one [1..1] templateId ( C32-[CT1-19] ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.2"
  2. SHALL conform to General Header Constraints template (templateId: 2.16.840.1.113883.10.20.22.1.1)
  3. SHALL contain exactly one [1..1] code (CONF:17180)/@code="34133-9" Summarization of Episode Note (CodeSystem: 2.16.840.1.113883.6.1 LOINC) (CONF:17181)
  4. SHALL contain exactly one [1..1] languageCode (CONF-5)
  5. SHALL contain exactly one [1..1] documentationOf (CONF:8452)
    1. This documentationOf SHALL contain exactly one [1..1] serviceEvent (CONF:8480)
      1. This serviceEvent SHALL contain exactly one [1..1] @classCode="PCPR" (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:8453)
      2. This serviceEvent SHALL contain exactly one [1..1] effectiveTime with data type Effective Time (CONF:8481)
      3. This serviceEvent SHOULD contain zero or more [0..*] performer (CONF:8482)
        1. Such performers SHALL contain exactly one [1..1] @typeCode="PRF" (CONF:8458)
        2. Such performers MAY contain zero or one [0..1] assignedEntity (CONF:8459)
          1. This assignedEntity MAY contain zero or one [0..1] code, where the @code MAY be selected from (CodeSystem: 2.16.840.1.113883.6.101 NUCC Health Care Provider Taxonomy) (CONF:8461)
          2. This assignedEntity SHALL contain at least one [1..*] id (CONF:10027)
          3. This assignedEntity SHOULD include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:10027)
  6. SHALL contain at least one [1..*] author (CONF:9442)
    1. Such authors SHALL contain exactly one [1..1] assignedAuthor (CONF:9443)
      1. This assignedAuthor SHALL contain exactly one [1..1] assignedPerson or exactly one one [1..1] representedOrganization. (CONF:8456)
      2. This assignedAuthor 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:8457)
  7. SHALL contain exactly one [1..1] component (CONF:9445)
    1. Contains exactly one [1..1] Allergies Section (templateId: 2.16.840.1.113883.10.20.22.2.6.1)
  8. SHALL contain exactly one [1..1] component (CONF:9447)
    1. Contains exactly one [1..1] Medications Section (templateId: 2.16.840.1.113883.10.20.22.2.1.1)
  9. SHALL contain exactly one [1..1] component (CONF:9449)
    1. Contains exactly one [1..1] Problem Section (templateId: 2.16.840.1.113883.10.20.22.2.5.1)
  10. SHALL contain exactly one [1..1] component (CONF:9451)
    1. Contains exactly one [1..1] Procedures Section (templateId: 2.16.840.1.113883.10.20.22.2.7.1)
  11. SHALL contain exactly one [1..1] component (CONF:9453)
    1. Contains exactly one [1..1] Results Section (templateId: 2.16.840.1.113883.10.20.22.2.3.1)
  12. MAY contain zero or one [0..1] component (CONF:9455)
    1. Contains exactly one [1..1] Advance Directives Section (templateId: 2.16.840.1.113883.10.20.22.2.21.1)
  13. MAY contain zero or one [0..1] component (CONF:9457)
    1. Contains exactly one [1..1] Encounters Section (templateId: 2.16.840.1.113883.10.20.22.2.22.1)
  14. MAY contain zero or one [0..1] component (CONF:9459)
    1. Contains exactly one [1..1] Family History Section (templateId: 2.16.840.1.113883.10.20.22.2.15)
  15. MAY contain zero or one [0..1] component (CONF:9461)
    1. Contains exactly one [1..1] Functional Status Section (templateId: 2.16.840.1.113883.10.20.22.2.14)
  16. MAY contain zero or one [0..1] component (CONF:9463)
    1. Contains exactly one [1..1] Immunizations Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.2)
  17. MAY contain zero or one [0..1] component (CONF:9466)
    1. Contains exactly one [1..1] Medical Equipment Section (templateId: 2.16.840.1.113883.10.20.22.2.23)
  18. MAY contain zero or one [0..1] component (CONF:9468)
    1. Contains exactly one [1..1] Payers Section (templateId: 2.16.840.1.113883.10.20.22.2.18)
  19. MAY contain zero or one [0..1] component (CONF:9470)
    1. Contains exactly one [1..1] Plan Of Care Section (templateId: 2.16.840.1.113883.10.20.22.2.10)
  20. MAY contain zero or one [0..1] component (CONF:9472)
    1. Contains exactly one [1..1] Social History Section (templateId: 2.16.840.1.113883.10.20.22.2.17)
  21. MAY contain zero or one [0..1] component (CONF:9474)
    1. Contains exactly one [1..1] Vital Signs Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.4)

Continuity Of Care Document Example

<?xml version="1.0" encoding="UTF-8"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
  <typeId root="2.16.840.1.113883.1.3"/>
  <id root="MDHT" extension="2060825568"/>
  <code code="531505277"/>
  <title>TEXT FOR TITLE</title>
  <effectiveTime/>
  <confidentialityCode code="600450902"/>
  <languageCode code="Code forlanguageCode"/>
  <setId root="MDHT" extension="33220de4-0444-4f5c-b5ba-efe7b7dfd324"/>
  <versionNumber value="1"/>
  <recordTarget>
    <typeId root="2.16.840.1.113883.1.3"/>
    <patientRole/>
  </recordTarget>
  <author>
    <time/>
    <assignedAuthor>
      <id root="MDHT" extension="953405082"/>
    </assignedAuthor>
  </author>
  <custodian/>
  <documentationOf>
    <serviceEvent classCode="PCPR">
      <performer typeCode="PRF"/>
    </serviceEvent>
  </documentationOf>
  <component>
    <structuredBody>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="779391163"/>
          <code code="181238284"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="436199888"/>
          <languageCode code="Code forlanguageCode"/>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="508139598"/>
              <code code="1959524410"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <languageCode code="Code forlanguageCode"/>
              <entryRelationship>
                <observation/>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1808210844"/>
          <code code="1758764005"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="563082534"/>
          <languageCode code="Code forlanguageCode"/>
          <entry>
            <substanceAdministration classCode="SBADM">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="557930306"/>
              <code code="407723250"/>
              <effectiveTime value="20130627"/>
              <consumable/>
              <performer/>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <act/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <precondition/>
            </substanceAdministration>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1845042087"/>
          <code code="293421682"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="350220926"/>
          <languageCode code="Code forlanguageCode"/>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="231639996"/>
              <code code="202008360"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <languageCode code="Code forlanguageCode"/>
              <entryRelationship>
                <observation/>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1066078420"/>
          <code code="825640601"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1945245955"/>
          <languageCode code="Code forlanguageCode"/>
          <entry>
            <procedure>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1700734699"/>
              <code code="826627070"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <languageCode code="Code forlanguageCode"/>
              <specimen/>
              <performer/>
              <entryRelationship typeCode="COMP" inversionInd="true"/>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <substanceAdministration classCode="SBADM"/>
              </entryRelationship>
              <entryRelationship>
                <act/>
              </entryRelationship>
            </procedure>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1650049435"/>
              <code code="1091982018"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <languageCode code="Code forlanguageCode"/>
              <performer/>
              <entryRelationship typeCode="COMP" inversionInd="true"/>
              <entryRelationship>
                <act/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <substanceAdministration classCode="SBADM"/>
              </entryRelationship>
            </observation>
          </entry>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1804444468"/>
              <code code="718545739"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <languageCode code="Code forlanguageCode"/>
              <performer/>
              <entryRelationship typeCode="COMP" inversionInd="true"/>
              <entryRelationship>
                <act/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <substanceAdministration classCode="SBADM"/>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="190707397"/>
          <code code="928041909"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1716749963"/>
          <languageCode code="Code forlanguageCode"/>
          <entry>
            <organizer>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="845417041"/>
              <code code="678622925"/>
              <statusCode code="completed"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <component>
                <observation/>
              </component>
            </organizer>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="514945641"/>
          <code code="690673826"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1705827460"/>
          <languageCode code="Code forlanguageCode"/>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="48245195"/>
              <code code="1066174105"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <languageCode code="Code forlanguageCode"/>
              <participant typeCode="VRF"/>
              <participant typeCode="CST"/>
              <reference typeCode="REFR"/>
            </observation>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="74551192"/>
          <code code="413894486"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="439142546"/>
          <languageCode code="Code forlanguageCode"/>
          <entry>
            <encounter>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="988247752"/>
              <code code="1263188150"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <performer/>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <act/>
              </entryRelationship>
            </encounter>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="52899888"/>
          <code code="566161848"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1024069834"/>
          <languageCode code="Code forlanguageCode"/>
          <entry>
            <organizer>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1342581490"/>
              <code code="867134330"/>
              <statusCode code="completed"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <subject/>
              <component>
                <observation/>
              </component>
            </organizer>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1333422583"/>
          <code code="751025617"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="813825364"/>
          <languageCode code="Code forlanguageCode"/>
          <entry>
            <organizer>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="2064156521"/>
              <code code="513889624"/>
              <statusCode code="completed"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <component>
                <observation/>
              </component>
            </organizer>
          </entry>
          <entry>
            <organizer>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1631443300"/>
              <code code="1545241747"/>
              <statusCode code="completed"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <component>
                <observation/>
              </component>
            </organizer>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1888236175"/>
              <code code="1229030683"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <languageCode code="Code forlanguageCode"/>
              <author/>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <referenceRange/>
            </observation>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="2121769580"/>
              <code code="843695568"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <languageCode code="Code forlanguageCode"/>
              <author/>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <referenceRange/>
            </observation>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="797194911"/>
              <code code="484173008"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <languageCode code="Code forlanguageCode"/>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
            </observation>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1042761662"/>
              <code code="1611172757"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <languageCode code="Code forlanguageCode"/>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
            </observation>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1497835888"/>
              <code code="1312451600"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <languageCode code="Code forlanguageCode"/>
              <participant/>
            </observation>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1351822582"/>
              <code code="1590808186"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <languageCode code="Code forlanguageCode"/>
              <author/>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <referenceRange/>
            </observation>
          </entry>
          <entry>
            <supply classCode="SPLY">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1636993204"/>
              <code code="1651853688"/>
              <effectiveTime value="20130627"/>
            </supply>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="698629434"/>
              <code code="744956433"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <languageCode code="Code forlanguageCode"/>
              <entryRelationship typeCode="COMP"/>
              <entryRelationship typeCode="COMP"/>
              <entryRelationship typeCode="COMP"/>
            </observation>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="855348864"/>
              <code code="754985075"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <languageCode code="Code forlanguageCode"/>
              <author/>
              <entryRelationship typeCode="SUBJ"/>
            </observation>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="2089792361"/>
              <code code="377847640"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <languageCode code="Code forlanguageCode"/>
            </observation>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="372601051"/>
          <code code="1721412042"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="2010312406"/>
          <languageCode code="Code forlanguageCode"/>
          <entry>
            <substanceAdministration classCode="SBADM">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="173498691"/>
              <code code="511054092"/>
              <effectiveTime value="20130627"/>
              <consumable/>
              <performer/>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <act/>
              </entryRelationship>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <precondition/>
            </substanceAdministration>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1018820879"/>
          <code code="350676717"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="2054894600"/>
          <languageCode code="Code forlanguageCode"/>
          <entry>
            <supply classCode="SPLY">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1540373918"/>
              <code code="1354027576"/>
              <effectiveTime value="20130627"/>
            </supply>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1786441277"/>
          <code code="662627102"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="514972436"/>
          <languageCode code="Code forlanguageCode"/>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="496126162"/>
              <code code="1841024717"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <languageCode code="Code forlanguageCode"/>
              <entryRelationship>
                <act/>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1543648217"/>
          <code code="1628446336"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="590607235"/>
          <languageCode code="Code forlanguageCode"/>
          <entry>
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