Package | hl7.fhir.us.ccda |
Type | StructureDefinition |
Id | Id |
FHIR Version | R4 |
Source | http://hl7.org/fhir/us/ccda/https://build.fhir.org/ig/HL7/ccda-on-fhir/StructureDefinition-Continuity-of-Care-Document.html |
Url | http://hl7.org/fhir/us/ccda/StructureDefinition/Continuity-of-Care-Document |
Version | 2.0.0-ballot |
Status | active |
Date | 2024-12-12T19:41:54+00:00 |
Name | ContinuityOfCareDocument |
Title | Continuity of Care Document |
Experimental | False |
Realm | us |
Authority | hl7 |
Description | This profile was originally based on the Continuity of Care Document (CCD) Release 1.1 which itself was derived from HITSP C32 and CCD Release 1.0. The Continuity of Care Document (CCD) profile 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. 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 to support the continuity of care. 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. The key characteristic of a CCD is that the Composition.event.code is constrained to "PCPR". This means it does not function to report new services associated with performing care. It reports on care that has already been provided. The CCD provides a historical tally of the care over a range of time and is not a record of new services delivered. More specific use cases, such as a Discharge Summary, Transfer Summary, Referral Note, Consultation Note, or Progress Note, are available as alternative profiles. |
Type | Composition |
Kind | resource |
CapabilityStatement | |
CcdaOnFhirClient | CCDA on FHIR Client |
CcdaOnFhirServer | CCDA on FHIR Server |
StructureDefinition | |
US-Realm-Header | US Realm Header |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance | US Core AllergyIntolerance Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter | US Core Encounter Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal | US Core Goal Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization | US Core Immunization Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication | US Core Medication Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest | US Core MedicationRequest Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab | US Core Laboratory Result Observation Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure | US Core Procedure Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus | US Core Smoking Status Observation Profile |
Note: links and images are rebased to the (stated) source
Generated Narrative: StructureDefinition Continuity-of-Care-Document
version: 14; Last updated: 2020-08-12 21:30:20+0000;
Information Source: #csn482LCsnDWyxbW
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
type | S | 1..1 | CodeableConcept | Summary of episode note Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 34133-9 | |
event | S | 1..1 | BackboneElement | serviceEvent |
code | 0..* | CodeableConcept | code | |
period | 1..1 | Period | period | |
start | 1..1 | dateTime | start | |
end | 1..1 | dateTime | end | |
Slices for section | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
section:allergies_and_intolerances_section | S | 1..1 | BackboneElement | Allergies and Intolerances Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | Allergies and adverse reactions Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
text | S | 1..1 | Narrative | text |
Slices for entry | S | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() |
entry:allergy_entry | S | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
section:medications_section | S | 1..1 | BackboneElement | Medications Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | History of medication use Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
text | S | 1..1 | Narrative | text |
Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
entry:medication_entry | S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section |
section:problem_section | S | 1..1 | BackboneElement | Problem Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | Problem list Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
text | S | 1..1 | Narrative | text |
Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
entry:problems_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
section:results_section | S | 1..1 | BackboneElement | Results Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | Relevant diagnostic tests and laboratory data Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
text | S | 1..1 | Narrative | text |
Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
entry:sliceEntry | S | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section |
section:social_history_section | S | 1..1 | BackboneElement | Social History Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | Social history Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
text | S | 1..1 | Narrative | text |
Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
entry:smoking_status_entry | S | 0..* | Reference(US Core Smoking Status Observation Profile) | Smoking status |
section:vital_signs_section | S | 1..1 | BackboneElement | Vital Signs Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | Vital signs Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
text | S | 1..1 | Narrative | text |
Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
entry:vital_signs_entry | S | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this section |
section:plan_of_treatment_section | S | 0..1 | BackboneElement | Plan of Treatment Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | Plan of treatment Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
text | S | 1..1 | Narrative | text |
Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
entry:sliceEntry | 0..* | Reference(US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
section:procedures_section | S | 0..1 | BackboneElement | Procedures Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | History of procedures Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
text | S | 1..1 | Narrative | text |
Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
entry:procedure_entry | S | 0..* | Reference(US Core Procedure Profile) | A reference to data that supports this section |
section:family_history_section | S | 0..1 | BackboneElement | Family History Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | History of family member diseases Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |
text | S | 1..1 | Narrative | text |
Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
entry:family_history_entry | S | 0..* | Reference(FamilyMemberHistory) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
section:advance_directives_section | S | 0..1 | BackboneElement | Advance Directives Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | Advance directives Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |