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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).

 

 

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: Companion Guides defining new template versions and additional templates for regulatory requirements Description
C-CDA R2.1 C-CDA Templates for Clinical Notes R2.1 Companion Guide, Release 3 Includes design for ONC’s USCDI v2
C-CDA R2.1 C-CDA Templates for Clinical Notes R2.1 Companion Guide, Release 2

2015 Certified EHR Technology
(Learn more at the C-CDA Companion Guide Product Brief)

C-CDA R1.1 HL7 Implementation Guide: S&I Framework Transitions of Care Companion Guide to Consolidated-CDA for Meaningful Use Stage 2, Release 1 – US Realm 2015 Certified EHR Technology (Meaningful Use Stage 3)
C-CDA R1 C-CDA Templates for Clinical Notes R1 Companion Guide, Release 1 2014 Certified EHR Technology (Meaningful Use Stage 2)

 

 

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 – 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.

C-CDA Scorecard Rubric, Release 1- US Realm

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:

C-CDA R2.1, Consolidated CDA Release 2.1, "HL7 IG for CDA R2: Consolidated CDA Templates for Clinical Notes, R1", "HL7 IG for CDAR2: IHE Health Story Consolidation, R1", Consolidated CDA, C-CDA, C-CDA R2, Consolidated CDA Release 2, CCDA

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)

BALLOT TYPE

  • STU

STATUS DATE

RESPONSIBLE WORK GROUP

Structured Documents

FAMILY

  • CDA

CURRENT STATE

  • Active

REALM

  • US Realm