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Continuity of Care Document (CCD) (V3) [ClinicalDocument, 2.16.840.1.113883.10.20.22.1.2, release 2015-08-01, open] view pdf view prototype


Description:

This document type 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) 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 ServiceEvent is constrained to "PCPR". This means it does not function to report new ServiceEvents 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 documents in this guide.

Contained By: Contains:
none Advance Directives Section (entries optional) (V3)
Allergies and Intolerances Section (entries required) (V3)
Medications Section (entries required) (V2)
Problem Section (entries required) (V3)
Procedures Section (entries required) (V2)
Results Section (entries required) (V3)
Encounters Section (entries optional) (V3)
Family History Section (V3)
Functional Status Section (V2)
Immunizations Section (entries required) (V3)
Medical Equipment Section (V2)
Payers Section (V3)
Plan of Treatment Section (V2)
Social History Section (V3)
Vital Signs Section (entries required) (V3)
Mental Status Section (V2)
Nutrition Section

Conformance Statements:

HL7 Code Systems are available here. HL7 Value Sets are available here. Links to Value Set Authority Center (VSAC) are shown as hyperlinks and require UMLS login

Guide Examples:




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