C-CDA (HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes, Edition 5 - US Realm

DESCRIPTION

Edition 5.0: C-CDA Edition 5.0 StructureDefinition Specification

This is implementation guide is the latest release of this publication using FHIR StructureDefinition (SD) tooling.
 

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 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, Edition 5 - 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:

1. The same underlying tech stack across HL7 Same Look and Feel across standards
2. Inherent Validation
3. A logical versioning style
4. SD makes (new) implementation easier in systems because SD are computer processable

 

TOPICS

• Care Provision
• Clinical Statement
• Community-Based Health
• Emergency Management
• Laboratory
• Medical Records
• Nutrition
• Patient Administration
• Patient Care
• Scheduling

BALLOT TYPE

• STU

STATUS DATE

2026-06-12

RESPONSIBLE WORK GROUP

STAKEHOLDERS

• Clinical and Public Health Laboratories
• Clinical Decision Support Systems Vendors
• EHR, PHR Vendors
• Emergency Services Providers
• Health Care IT Vendors
• Healthcare Institutions
• Immunization Registries
• Lab Vendors
• Local and State Departments of Health
• Medical Imaging Service Providers
• Payors
• Pharmaceutical Vendors
• Quality Reporting Agencies
• Regulatory Agency
• Standards Development Organizations (SDOs)

FAMILY

• CDA

CURRENT STATE

• Active

REALM

• US Realm