The Continuity of Care Document (CCD) defines a detailed set of constraints, or templates, for CDA elements. Each template may have further supporting templates as required. The data contained in each of the templates is set by CCR.
Below is an overview of the templates (excludes supporting templates) and how they are used.
Header
Defines the type of document being created, who the document is regarding (patient, physician, author) and how the document relates to other existing documents (if applicable).
Purpose
States the reason the document was generated, but only if a specific purpose is known (i.e., a referral, transfer, or by request of the patient).
Problems
Provides a list of relevant clinical problems, both current and historical, that are present for the patient at the time the document was created.
Procedures
Provides a list of all relevant and notable procedures or treatments, both current and historical, for the patient.
Family history
Gives relevant family health information that may have an impact on the patient’s healthcare risk profile.
Social history
Describes the patient’s lifestyle, occupation, and environmental health risks plus patient demographics such as marital status, ethnicity and religion.
Payers
Provides payment and insurance data pertinent to billing and collection, plus any authorization information that might be required.
Advance directives
Includes information about wills, healthcare proxies and resuscitation wishes, including both patient instructions and references to external documents.
Alerts
Provides a list of allergies and adverse reactions that are relevant for current medical treatment.
Medications
Provides a list of current medications and relevant historical medication usage.
Immunizations
Gives information the patient’s current immunization status plus pertinent historical information about past immunizations.
Medical equipment
Provides a list of medical equipment and any implanted or external devices relevant to patient treatment.
Vital signs
Details information about vital signs for the time period including at a minimum the most recent vital signs, trends over time, and a baseline.
Functional stats
Details information about what is normal for the patient, deviations from the norm (both positive and negative) and extensive examples.
Results
Lists lab and procedure results, and at a minimum lists abnormal results or trends for the time period.
Encounters
Details relevant past healthcare encounters including the activity and location.
Plan of care
Lists active, incomplete or pending activities for the patient that are relevant for ongoing care – including orders, appointments, procedures, referrals and services.
For additional information on getting started with CCD, please read the post on the quick start guide provided by EHRVA.
