Section 1: Primary Standards
Section 1a: Clinical Document Architecture (CDA®)
C-CDA (HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes - US Realm)
DESCRIPTION
C-CDA Online: A navigation website for C-CDA 2.1
The Consolidated CDA (C-CDA) implementation guide contains a library of CDA templates, incorporating and harmonizing previous efforts from Health Level Seven (HL7), Integrating the Healthcare Enterprise (IHE), and Health Information Technology Standards Panel (HITSP). It represents harmonization of the HL7 Health Story guides, HITSP C32, related components of IHE Patient Care Coordination (IHE PCC), and Continuity of Care (CCD). C-CDA Release 1 included all required CDA templates in Final Rules for Stage 1 Meaningful Use and 45 CFR Part 170 – Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology; Final Rule. This R2.1 guide was developed and produced by the HL7 Structured Documents Workgroup. It updates the C-CDA R2 (2014) guide to support “on-the-wire” compatibility with R1.1 systems C-CDA Release 2.1 implementation guide, in conjunction with the HL7 CDA Release 2 (CDA R2) standard, is to be used for implementing the following CDA documents and header constraints for clinical notes: Care Plan including Home Health Plan of Care (HHPoC), Consultation Note, Continuity of Care Document (CCD), Diagnostic Imaging Reports (DIR), Discharge Summary, History and Physical (H&P), Operative Note, Procedure Note, Progress Note, Referral Note, Transfer Summary, Unstructured Document, Patient Generated Document (US Realm Header).
C-CDA 2.1 StructureDefinition Prototype Specification
This is implementation guide is a prototype publication of the C-CDA R2.1 June 2019 with errata publication (Errata #5) using FHIR StructureDefinition (SD) tooling to produce a SD replica of the June 2019 errata package.
This publication is for community review prior to the next ballot of C-CDA (January 2024) which is intended to be produced the FHIR StructureDefinition (SD) tooling.
The C-CDA R2.1 June 2019 with errata pdf publication (Errata #5) has been superseded by the current official published version of C-CDA R2.1 September 2022 (errata #7) pdf publication which should be used for new or updated implementations until superseded by a future version of C-CDA.
Publication Date | Version | Description |
---|---|---|
C-CDA_2.1_Sequence
|
||
Current_Version_Sep 2022 | 2.1 |
Current Official Published Version Errata #7: (CDAR2_IG_CCDA_CLINNOTES_R1_DSTU2.1_2015AUG_2022Sepwith_errata) |
Nov 2020 | 2.1 |
Errata #6: (CDAR2_IG_CCDA_CLINNOTES_R1_DSTU2.1_2015AUG_2020JUN_with_errata) Note: the Technical Specifications did not change from the prior version, only the download package changed. Technical correction for CDA Stylesheet to support use of iframe with active sandbox when rendering pdf files and other embedded content such as images. The updated download package now references the CDA stylesheet available from the HL7 github repository for this artifact. |
Jun 2019 | 2.1 | |
Dec 2018 | 2.1 | |
May 2018 | 2.1 | Errata #3: Emergency fix of DSTU #1276 (CDAR2_IG_CCDA_CLINNOTES_R1_DSTU2.1_2015AUG_2018MAYwith_errata) |
Nov 2017 | 2.1 | Errata #2: (CDAR2_IG_CCDA_CLINNOTES_R1_DSTUR2.1_2015AUG_2017NOVerrata) |
March 2016 | 2.1 | Errata #1: (CDAR2_IG_CCDA_CLINNOTES_R1_DSTU2.1_2015AUG) |
August 2015 | 2.1 | First Version of C-CDA 2.1 (CDAR2_IG_CCDA_CLINNOTES_R1_DSTU2.1_2015AUG) |
C-CDA_2.0_Sequence
|
||
August 2015 | 2.0 | Errata #1: Coincided with C-CDA R2.1 release (CDAR2_IG_CCDA_CLINNOTES_R2_D1_2014NOV) |
November 2014 | 2.0 | First Version of C-CDA 2.0 (CDAR2_IG_CCDA_CLINNOTES_R2_D1_2014NOV) |
C-CDA 1.1 Sequence
|
||
August 2015 | 1.1 | Errata #2: Coincided with C-CDA R2.1 release (CDAR2_IG_IHE_CONSOL_DSTU_R1.1_2012JUL) |
December 2012 | 1.1 | Errata #1: (CDAR2_IG_IHE_CONSOL_DSTU_R1.1_2012JUL) |
July 2012 | 1.1 | C-CDA R1.1 (CDAR2_IG_IHE_CONSOL_DSTU_R1.1_2012JUL) |
December 2011 | 1.0 |
First Version of C-CDA, C-CDA 1.0 (CDAR2_IG_IHE_CONSOL_R1_DSTU_2011DEC) |
Applies to: | Supplemental Implementation Guides defining new template versions and templates for additional use cases | Description |
---|---|---|
C-CDA R2.1 | C-CDA R2.1; Advance Directives Templates, Release 1 STU 2 – US Realm | Advance Directives Templates |
C-CDA R2.1 | HL7 CDA® R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Nutrition, Release 1 - US Realm | Nutrition Templates |
C-CDA R2.1 | HL7 CDA® R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Pregnancy Status, Release 1 – US Realm | Pregnancy Status Templates |
C-CDA R2.1 |
HL7 CDA® R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Occupational Data for Health Release 1, STU Release 1.1 – US Realm |
Occupational Data for Health Templates |
C-CDA R2.1 | HL7 CDA® R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Infectious Disease, Release 1 – US Realm | Infectious Disease Templates |
C-CDA Supporting Resources |
Description |
C-CDA Value Set Expansions Release Packages |
The Structured Documents Work Group supports the evolution of C-CDA value sets by doing an annual release and value set errata updates between the annual releases. This Confluence page lists the releases of the Value Set Release Package and all Value Set errata that need to been applied to the annually released package. |
An HL7 Informative Document describing additional rules to improve the quality of C-CDA documents generated from Health Information Technology systems. |
ALTERNATIVE NAMES
C-CDA (HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes - US Realm) may also go by the following names or acronyms:
BENEFITS
- Provides a single source for implementers to find CDA templates for twelve different document types
- Enables Business analysts and policy managers to gain a basic understanding of the use of Clinical Document Architecture (CDA) templates across multiple implementation use cases
- Provides guidance for transfer of care in the Continuity of Care Document (CCD)
Publishing using FHIR StructureDefintion tooling provides:
- The same underlying tech stack across HL7 Same Look and Feel across standards
- Inherent Validation
- A logical versioning style
- SD makes (new) implementation easier in systems because SD are computer processable
BALLOT TYPE
- STU
STATUS DATE
RESPONSIBLE WORK GROUP
FAMILY
- CDA
CURRENT STATE
- Active
REALM
- US Realm