Section (78)

#NameSourceVerDescription
1Admission Diagnosis Sectionhl7.cda.us.ccdar2dot2#currentR5This section contains a narrative description of the problems or diagnoses identified by the clinician at the time of the patients admission. This section may contain a coded entry which represents the admitting diagnoses.
2Admission Medications Section (entries optional)hl7.cda.us.ccdar2dot2#currentR5The section contains the medications taken by the patient prior to and at the time of admission to the facility.
3Advance Directives Section (entries optional)hl7.cda.us.ccdar2dot2#currentR5This section contains data defining the patients advance directives and any reference to supporting documentation, including living wills, healthcare proxies, and CPR and resuscitation status. If the referenced documents are available, they can be included in the exchange package. The most recent directives are required, if known, and should be listed in as much detail as possible. This section differentiates between "advance directives" and "advance directive documents". The former is the directions to be followed whereas the latter refers to a legal document containing those directions.
4Advance Directives Section (entries required)hl7.cda.us.ccdar2dot2#currentR5This section contains data defining the patients advance directives and any reference to supporting documentation, including living wills, healthcare proxies, and CPR and resuscitation status. If the referenced documents are available, they can be included in the exchange package. The most recent directives are required, if known, and should be listed in as much detail as possible. This section differentiates between "advance directives" and "advance directive documents". The former is the directions to be followed whereas the latter refers to a legal document containing those directions.
5Allergies and Intolerances Section (entries optional)hl7.cda.us.ccdar2dot2#currentR5This section lists and describes any medication allergies, adverse reactions, idiosyncratic reactions, anaphylaxis/anaphylactoid reactions to food items, and metabolic variations or adverse reactions/allergies to other substances (such as latex, iodine, tape adhesives). At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.
6Allergies and Intolerances Section (entries required)hl7.cda.us.ccdar2dot2#currentR5This section lists and describes any medication allergies, adverse reactions, idiosyncratic reactions, anaphylaxis/anaphylactoid reactions to food items, and metabolic variations or adverse reactions/allergies to other substances (such as latex, iodine, tape adhesives). At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.
7Anesthesia Sectionhl7.cda.us.ccdar2dot2#currentR5The Anesthesia Section records the type of anesthesia (e.g., general or local) and may state the actual agent used. This may be a subsection of the Procedure Description Section. The full details of anesthesia are usually found in a separate Anesthesia Note.
8Assessment and Plan Sectionhl7.cda.us.ccdar2dot2#currentR5This section represents the clinicians conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. See also the Assessment Section: templateId 2.16.840.1.113883.10.20.22.2.8 and Plan of Treatment Section (V2): templateId 2.16.840.1.113883.10.20.22.2.10:2014-06-09
9Assessment Sectionhl7.cda.us.ccdar2dot2#currentR5The Assessment Section (also referred to as impression or diagnoses outside of the context of CDA) represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The assessment may be a list of specific disease entities or a narrative block.
10Chief Complaint and Reason for Visit Sectionhl7.cda.us.ccdar2dot2#currentR5This section records the patient's chief complaint (the patients own description) and/or the reason for the patient's visit (the providers description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
11Chief Complaint Sectionhl7.cda.us.ccdar2dot2#currentR5This section records the patient's chief complaint (the patients own description).
12Complications Sectionhl7.cda.us.ccdar2dot2#currentR5This section contains problems that occurred during or around the time of a procedure. The complications may be known risks or unanticipated problems.
13Course of Care Sectionhl7.cda.us.ccdar2dot2#currentR5The Course of Care section describes what happened during the course of an encounter.
14DICOM Object Catalog Section - DCM 121181hl7.cda.us.ccdar2dot2#currentR5DICOM Object Catalog lists all referenced objects and their parent Series and Studies, plus other DICOM attributes required for retrieving the objects. DICOM Object Catalog sections are not intended for viewing and contain empty section text.
15Discharge Diagnosis Sectionhl7.cda.us.ccdar2dot2#currentR5This template represents problems or diagnoses present at the time of discharge which occurred during the hospitalization. This section includes an optional entry to record patient diagnoses specific to this visit. Problems that need ongoing tracking should also be included in the Problem Section.
16Discharge Diet Section (DEPRECATED)hl7.cda.us.ccdar2dot2#currentR5This section records a narrative description of the expectations for diet and nutrition, including nutrition prescription, proposals, goals, and order requests for monitoring, tracking, or improving the nutritional status of the patient, used in a discharge from a facility such as an emergency department, hospital, or nursing home. THIS TEMPLATE HAS BEEN DEPRECATED IN C-CDA R2 AND MAY BE DELETED FROM A FUTURE RELEASE OF THIS IMPLEMENTATION GUIDE. USE OF THIS TEMPLATE IS NOT RECOMMENDED. *Reason for deprecation*: This template has been replaced by the Nutrition Section (2.16.840.1.113883.10.20.22.2.57).
17Discharge Medications Section (entries optional)hl7.cda.us.ccdar2dot2#currentR5This section contains the medications the patient is intended to take or stop after discharge. Current, active medications must be listed. The section may also include a patients prescription history and indicate the source of the medication list.
18Discharge Medications Section (entries required)hl7.cda.us.ccdar2dot2#currentR5This section contains the medications the patient is intended to take or stop after discharge. Current, active medications must be listed. The section may also include a patients prescription history and indicate the source of the medication list.
19Encounters Section (entries optional)hl7.cda.us.ccdar2dot2#currentR5This section lists and describes any healthcare encounters pertinent to the patients current health status or historical health history. An encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patients condition. It may include visits, appointments, or non-face-to-face interactions. It is also a contact between a patient and a practitioner who has primary responsibility (exercising independent judgment) for assessing and treating the patient at a given contact. This section may contain all encounters for the time period being summarized, but should include notable encounters.
20Encounters Section (entries required)hl7.cda.us.ccdar2dot2#currentR5This section lists and describes any healthcare encounters pertinent to the patients current health status or historical health history. An encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patients condition. It may include visits, appointments, as well as non-face-to-face interactions. It is also a contact between a patient and a practitioner who has primary responsibility (exercising independent judgment) for assessing and treating the patient at a given contact. This section may contain all encounters for the time period being summarized, but should include notable encounters.
21Family History Sectionhl7.cda.us.ccdar2dot2#currentR5This section contains data defining the patients genetic relatives in terms of possible or relevant health risk factors that have a potential impact on the patients healthcare risk profile.
22Findings Section (DIR)hl7.cda.us.ccdar2dot2#currentR5The Findings section contains the main narrative body of the report. While not an absolute requirement for transformed DICOM SR reports, it is suggested that Diagnostic Imaging Reports authored in CDA follow Term Info guidelines for the codes in the various observations and procedures recorded in this section.
23Functional Status Sectionhl7.cda.us.ccdar2dot2#currentR5The Functional Status Section contains observations and assessments of a patient's physical abilities. A patients functional status may include information regarding the patients ability to perform Activities of Daily Living (ADLs) in areas such as Mobility (e.g., ambulation), Self-Care (e.g., bathing, dressing, feeding, grooming) or Instrumental Activities of Daily Living (IADLs) (e.g., shopping, using a telephone, balancing a check book). Problems that impact function (e.g., dyspnea, dysphagia) can be contained in the section.
24General Status Sectionhl7.cda.us.ccdar2dot2#currentR5The General Status section describes general observations and readily observable attributes of the patient, including affect and demeanor, apparent age compared to actual age, gender, ethnicity, nutritional status based on appearance, body build and habitus (e.g., muscular, cachectic, obese), developmental or other deformities, gait and mobility, personal hygiene, evidence of distress, and voice quality and speech.
25Goals Sectionhl7.cda.us.ccdar2dot2#currentR5This template represents patient Goals. A goal is a defined outcome or condition to be achieved in the process of patient care. Goals include patient-defined over-arching goals (e.g., alleviation of health concerns, desired/intended positive outcomes from interventions, longevity, function, symptom management, comfort) and health concern-specific or intervention-specific goals to achieve desired outcomes.
26Health Concerns Sectionhl7.cda.us.ccdar2dot2#currentR5This section contains data describing an interest or worry about a health state or process that could possibly require attention, intervention, or management. A Health Concern is a health related matter that is of interest, importance or worry to someone, who may be the patient, patient's family or patient's health care provider. Health concerns are derived from a variety of sources within an EHR (such as Problem List, Family History, Social History, Social Worker Note, etc.). Health concerns can be medical, surgical, nursing, allied health or patient-reported concerns. Problem Concerns are a subset of Health Concerns that have risen to the level of importance that they typically would belong on a classic Problem List, such as Diabetes Mellitus or Family History of Melanoma or Tobacco abuse. These are of broad interest to multiple members of the care team. Examples of other Health Concerns that might not typically be considered a Problem Concern include Risk of Hyperkalemia for a patient taking an ACE-inhibitor medication, or Transportation difficulties for someone who doesn't drive and has trouble getting to appointments, or Under-insured for someone who doesn't have sufficient insurance to properly cover their medical needs such as medications. These are typically most important to just a limited number of care team members.
27Health Status Evaluations and Outcomes Sectionhl7.cda.us.ccdar2dot2#currentR5This template represents observations regarding the outcome of care from the interventions used to treat the patient. These observations represent status, at points in time, related to established care plan goals and/or interventions.
28History of Present Illness Sectionhl7.cda.us.ccdar2dot2#currentR5The History of Present Illness section describes the history related to the reason for the encounter. It contains the historical details leading up to and pertaining to the patients current complaint or reason for seeking medical care.
29Hospital Consultations Sectionhl7.cda.us.ccdar2dot2#currentR5The Hospital Consultations Section records consultations that occurred during the admission.
30Hospital Course Sectionhl7.cda.us.ccdar2dot2#currentR5The Hospital Course Section describes the sequence of events from admission to discharge in a hospital facility.
31Hospital Discharge Instructions Sectionhl7.cda.us.ccdar2dot2#currentR5The Hospital Discharge Instructions Section records instructions at discharge.
32Hospital Discharge Physical Sectionhl7.cda.us.ccdar2dot2#currentR5The Hospital Discharge Physical Section records a narrative description of the patients physical findings.
33Hospital Discharge Studies Summary Sectionhl7.cda.us.ccdar2dot2#currentR5This section records the results of observations generated by laboratories, imaging procedures, and other procedures. The scope includes hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. This section often includes notable results such as abnormal values or relevant trends, and could record all results for the period of time being documented. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory. Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as when a cardiologist reports the left ventricular ejection fraction based on the review of an echocardiogram. Procedure results are typically generated by a clinician wanting to provide more granular information about component observations made during the performance of a procedure, such as when a gastroenterologist reports the size of a polyp observed during a colonoscopy. Note that there are discrepancies between CCD and the lab domain model, such as the effectiveTime in specimen collection.
34Immunizations Section (entries optional)hl7.cda.us.ccdar2dot2#currentR5The Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section should include current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.
35Immunizations Section (entries required)hl7.cda.us.ccdar2dot2#currentR5The Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section should include current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.
36Implants Section (DEPRECATED)hl7.cda.us.ccdar2dot2#currentR5THIS TEMPLATE HAS BEEN DEPRECATED IN C-CDA R2 AND MAY BE DELETED FROM A FUTURE RELEASE OF THIS IMPLEMENTATION GUIDE. USE OF THIS TEMPLATE IS NOT RECOMMENDED. *Reason for Deprecation*: Replaced by the Procedure Implants Section (2.16.840.1.113883.10.20.22.2.40)
37Instructions Sectionhl7.cda.us.ccdar2dot2#currentR5The Instructions Section records instructions given to a patient. List patient decision aids here.
38Interventions Sectionhl7.cda.us.ccdar2dot2#currentR5This template represents Interventions. Interventions are actions taken to maximize the prospects of the goals of care for the patient, including the removal of barriers to success. Interventions can be planned, ordered, historical, etc. Interventions include actions that may be ongoing (e.g., maintenance medications that the patient is taking, or monitoring the patients health status or the status of an intervention). Instructions are nested within interventions and may include self-care instructions. Instructions are information or directions to the patient and other providers including how to care for the individuals condition, what to do at home, when to call for help, any additional appointments, testing, and changes to the medication list or medication instructions, clinical guidelines and a summary of best practice. Instructions are information or directions to the patient. Use the Instructions Section when instructions are included as part of a document that is not a Care Plan. Use the Interventions Section, containing the Intervention Act containing the Instruction entry, when instructions are part of a structured care plan.
39Medical (General) History Sectionhl7.cda.us.ccdar2dot2#currentR5The Medical History Section describes all aspects of the medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. The history may be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections including Past Medical History, Social History.
40Medical Equipment Sectionhl7.cda.us.ccdar2dot2#currentR5This section defines a patient's implanted and external health and medical devices and equipment. This section lists any pertinent durable medical equipment (DME) used to help maintain the patients health status. All equipment relevant to the diagnosis, care, or treatment of a patient should be included. Devices applied to, or placed in, the patient are represented with the Procedure Activity Procedure (V2) template. Equipment supplied to the patient (e.g., pumps, inhalers, wheelchairs) is represented by the Non-Medicinal Supply Activity V2 template. These devices may be grouped together within a Medical Equipment Organizer. The organizer would probably not be used with devices applied in or on the patient but rather to organize a group of medical supplies the patient has been supplied with.
41Medications Administered Sectionhl7.cda.us.ccdar2dot2#currentR5The Medications Administered Section usually resides inside a Procedure Note describing a procedure. This section defines medications and fluids administered during the procedure, its related encounter, or other procedure related activity excluding anesthetic medications. Anesthesia medications should be documented as described in the Anesthesia Section templateId 2.16.840.1.113883.10.20.22.2.25.
42Medications Section (entries optional)hl7.cda.us.ccdar2dot2#currentR5The Medications Section contains a patient's current medications and pertinent medication history. At a minimum, the currently active medications are listed. An entire medication history is an option. The section can describe a patient's prescription and dispense history and information about intended drug monitoring.
43Medications Section (entries required)hl7.cda.us.ccdar2dot2#currentR5The Medications Section contains a patient's current medications and pertinent medication history. At a minimum, the currently active medications are listed. An entire medication history is an option. The section can describe a patient's prescription and dispense history and information about intended drug monitoring. This section requires either an entry indicating the subject is not known to be on any medications or entries summarizing the subject's medications.
44Mental Status Sectionhl7.cda.us.ccdar2dot2#currentR5The Mental Status Section contains observations and evaluations related to a patients psychological and mental competency and deficits including, but not limited to any of the following types of information: Appearance (e.g., unusual grooming, clothing or body modifications) Attitude (e.g., cooperative, guarded, hostile) Behavior/psychomotor (e.g., abnormal movements, eye contact, tics) Mood and affect (e.g., anxious, angry, euphoric) Speech and Language (e.g., pressured speech, perseveration) Thought process (e.g., logic, coherence) Thought content (e.g., delusions, phobias) Perception (e.g., voices, hallucinations) Cognition (e.g., memory, alertness/consciousness, attention, orientation) which were included in Cognitive Status Observation in earlier publications of C-CDA. Insight and judgment (e.g., understanding of condition, decision making)
45Nutrition Sectionhl7.cda.us.ccdar2dot2#currentR5The Nutrition Section represents diet and nutrition information including special diet requirements and restrictions (e.g., texture modified diet, liquids only, enteral feeding). It also represents the overall nutritional status of the patient and nutrition assessment findings.
46Objective Sectionhl7.cda.us.ccdar2dot2#currentR5The Objective Section contains data about the patient gathered through tests, measures, or observations that produce a quantified or categorized result. It includes important and relevant positive and negative test results, physical findings, review of systems, and other measurements and observations.
47Operative Note Fluids Sectionhl7.cda.us.ccdar2dot2#currentR5The Operative Note Fluids Section may be used to record fluids administered during the surgical procedure.
48Operative Note Surgical Procedure Sectionhl7.cda.us.ccdar2dot2#currentR5The Operative Note Surgical Procedure Section can be used to restate the procedures performed if appropriate for an enterprise workflow. The procedure(s) performed associated with the Operative Note are formally modeled in the header using serviceEvent.
49Past Medical Historyhl7.cda.us.ccdar2dot2#currentR5This section contains a record of the patients past complaints, problems, and diagnoses. It contains data from the patients past up to the patients current complaint or reason for seeking medical care.
50Payers Sectionhl7.cda.us.ccdar2dot2#currentR5The Payers Section contains data on the patients payers, whether "third party" insurance, self-pay, other payer or guarantor, or some combination of payers, and is used to define which entity is the responsible fiduciary for the financial aspects of a patients care. Each unique instance of a payer and all the pertinent data needed to contact, bill to, and collect from that payer should be included. Authorization information that can be used to define pertinent referral, authorization tracking number, procedure, therapy, intervention, device, or similar authorizations for the patient or provider, or both should be included. At a minimum, the patients pertinent current payment sources should be listed. The sources of payment are represented as a Coverage Activity, which identifies all of the insurance policies or government or other programs that cover some or all of the patient's healthcare expenses. The policies or programs are sequenced by preference. The Coverage Activity has a sequence number that represents the preference order. Each policy or program identifies the covered party with respect to the payer, so that the identifiers can be recorded.
51Physical Exam Sectionhl7.cda.us.ccdar2dot2#currentR5The section includes direct observations made by a clinician. The examination may include the use of simple instruments and may also describe simple maneuvers performed directly on the patients body. It also includes observations made by the examining clinician using only inspection, palpation, auscultation, and percussion. It does not include laboratory or imaging findings. The exam may be limited to pertinent body systems based on the patients chief complaint or it may include a comprehensive examination. The examination may be reported as a collection of random clinical statements or it may be reported categorically. The Physical Exam Section may contain multiple nested subsections.
52Plan of Treatment Sectionhl7.cda.us.ccdar2dot2#currentR5This section, formerly known as "Plan of Care", contains data that define pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only. These are indicated by the @moodCode of the entries within this section. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current care of the patient should be listed. Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and healthcare quality improvements, including widely accepted performance measures. The plan may also indicate that patient education will be provided. When used in a document that includes a Goals Section, all the goals (whether narrative only, or structured Goal Observation entries) should be recorded in the Goals Section, rather than in the Plan of Treatment Section, to avoid confusion as to which/whose goals should be in which section? When used in a document that does not include a Goals Section, the Plan of Treatment section may also contain information about care team members goals, including the patients values, beliefs, preferences, care expectations, and overarching care goals. Values may include the importance of quality of life over longevity. These values are taken into account when prioritizing all problems and their treatments. Beliefs may include comfort with dying or the refusal of blood transfusions because of the patients religious convictions. Preferences may include liquid medicines over tablets, or treatment via secure email instead of in person. Care expectations may range from being treated only by female clinicians, to expecting all calls to be returned within 24 hours. Overarching goals described in this section are not tied to a specific condition, problem, health concern, or intervention. Examples of overarching goals could be to minimize pain or dependence on others, or to walk a daughter down the aisle for her marriage.
53Planned Procedure Sectionhl7.cda.us.ccdar2dot2#currentR5This section contains the procedure(s) that a clinician planned based on the preoperative assessment.
54Postoperative Diagnosis Sectionhl7.cda.us.ccdar2dot2#currentR5The Postoperative Diagnosis Section records the diagnosis or diagnoses discovered or confirmed during the surgery. Often it is the same as the preoperative diagnosis.
55Postprocedure Diagnosis Sectionhl7.cda.us.ccdar2dot2#currentR5The Postprocedure Diagnosis Section records the diagnosis or diagnoses discovered or confirmed during the procedure. Often it is the same as the preprocedure diagnosis or indication.
56Preoperative Diagnosis Sectionhl7.cda.us.ccdar2dot2#currentR5The Preoperative Diagnosis Section records the surgical diagnoses assigned to the patient before the surgical procedure which are the reason for the surgery. The preoperative diagnosis is, in the surgeon's opinion, the diagnosis that will be confirmed during surgery.
57Problem Section (entries optional)hl7.cda.us.ccdar2dot2#currentR5This section lists and describes all relevant clinical problems at the time the document is generated. At a minimum, all pertinent current and historical problems should be listed. Overall health status may be represented in this section.
58Problem Section (entries required)hl7.cda.us.ccdar2dot2#currentR5This section lists and describes all relevant clinical problems at the time the document is generated. At a minimum, all pertinent current and historical problems should be listed. Overall health status may be represented in this section.
59Procedure Description Sectionhl7.cda.us.ccdar2dot2#currentR5The Procedure Description section records the particulars of the procedure and may include procedure site preparation, surgical site preparation, pertinent details related to sedation/anesthesia, pertinent details related to measurements and markings, procedure times, medications administered, estimated blood loss, specimens removed, implants, instrumentation, sponge counts, tissue manipulation, wound closure, sutures used, vital signs and other monitoring data. Local practice often identifies the level and type of detail required based on the procedure or specialty.
60Procedure Disposition Sectionhl7.cda.us.ccdar2dot2#currentR5The Procedure Disposition Section records the status and condition of the patient at the completion of the procedure or surgery. It often also states where the patient was transferred to for the next level of care.
61Procedure Estimated Blood Loss Sectionhl7.cda.us.ccdar2dot2#currentR5The Procedure Estimated Blood Loss Section may be a subsection of another section such as the Procedure Description Section. The Procedure Estimated Blood Loss Section records the approximate amount of blood that the patient lost during the procedure or surgery. It may be an accurate quantitative amount, e.g., 250 milliliters, or it may be descriptive, e.g., minimal or none.
62Procedure Findings Sectionhl7.cda.us.ccdar2dot2#currentR5The Procedure Findings Section records clinically significant observations confirmed or discovered during a procedure or surgery.
63Procedure Implants Sectionhl7.cda.us.ccdar2dot2#currentR5The Procedure Implants Section records any materials placed during the procedure including stents, tubes, and drains.
64Procedure Indications Sectionhl7.cda.us.ccdar2dot2#currentR5This section contains the reason(s) for the procedure or surgery. This section may include the preprocedure diagnoses as well as symptoms contributing to the reason for the procedure.
65Procedure Specimens Taken Sectionhl7.cda.us.ccdar2dot2#currentR5The Procedure Specimens Taken Section records the tissues, objects, or samples taken from the patient during the procedure including biopsies, aspiration fluid, or other samples sent for pathological analysis. The narrative may include a description of the specimens.
66Procedures Section (entries optional)hl7.cda.us.ccdar2dot2#currentR5This section describes all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section should include notable procedures, but can contain all procedures for the period of time being summarized. The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM), therefore this section contains procedure templates represented with three RIM classes: Act, Observation, and Procedure. Procedure Activity Procedure (V2) is for procedures that alter the physical condition of a patient (e.g., splenectomy). Procedure Activity Observation (V2) is for procedures that result in new information about a patient but do not cause physical alteration (e.g., EEG). Procedure Activity Act (V2) is for all other types of procedures (e.g., dressing change).
67Procedures Section (entries required)hl7.cda.us.ccdar2dot2#currentR5This section describes all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section should include notable procedures, but can contain all procedures for the period of time being summarized. The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM), therefore this section contains procedure templates represented with three RIM classes: Act. Observation, and Procedure. Procedure act is for procedures that alter the physical condition of a patient (e.g., splenectomy). Observation act is for procedures that result in new information about a patient but do not cause physical alteration (e.g., EEG). Act is for all other types of procedures (e.g., dressing change).
68Reason for Referral Sectionhl7.cda.us.ccdar2dot2#currentR5This section describes the clinical reason why a provider is sending a patient to another provider for care. The reason for referral may become the reason for visit documented by the receiving provider.
69Reason for Visit Sectionhl7.cda.us.ccdar2dot2#currentR5This section records the patients reason for the patient's visit (as documented by the provider). Local policy determines whether Reason for Visit and Chief Complaint are in separate or combined sections.
70Results Section (entries optional)hl7.cda.us.ccdar2dot2#currentR5This section contains the results of observations generated by laboratories, imaging and other procedures. The scope includes observations of hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. This section often includes notable results such as abnormal values or relevant trends. It can contain all results for the period of time being documented. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory. Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram. Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy.
71Results Section (entries required)hl7.cda.us.ccdar2dot2#currentR5The Results Section contains observations of results generated by laboratories, imaging procedures, and other procedures. These coded result observations are contained within a Results Organizer in the Results Section. The scope includes observations such as hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. The section often includes notable results such as abnormal values or relevant trends, and could contain all results for the period of time being documented. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory. Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram. Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy.
72Review of Systems Sectionhl7.cda.us.ccdar2dot2#currentR5The Review of Systems Section contains a relevant collection of symptoms and functions systematically gathered by a clinician. It includes symptoms the patient is currently experiencing, some of which were not elicited during the history of present illness, as well as a potentially large number of pertinent negatives, for example, symptoms that the patient denied experiencing.
73Social History Sectionhl7.cda.us.ccdar2dot2#currentR5This section contains social history data that influence a patients physical, psychological or emotional health (e.g., smoking status, pregnancy). Demographic data, such as marital status, race, ethnicity, and religious affiliation, is captured in the header.
74Subjective Sectionhl7.cda.us.ccdar2dot2#currentR5The Subjective Section describes in a narrative format the patients current condition and/or interval changes as reported by the patient or by the patients guardian or another informant.
75Surgery Description Section (DEPRECATED)hl7.cda.us.ccdar2dot2#currentR5THIS TEMPLATE HAS BEEN DEPRECATED IN C-CDA R2 AND MAY BE DELETED FROM A FUTURE RELEASE OF THIS IMPLEMENTATION GUIDE. USE OF THIS TEMPLATE IS NOT RECOMMENDED. *Reason for deprecation*: This template has been replaced by the Procedure Description Section (2.16.840.1.113883.10.20.22.2.27).
76Surgical Drains Sectionhl7.cda.us.ccdar2dot2#currentR5The Surgical Drains Section may be used to record drains placed during the surgical procedure. Optionally, surgical drain placement may be represented with a text element in the Procedure Description Section.
77Vital Signs Section (entries optional)hl7.cda.us.ccdar2dot2#currentR5The Vital Signs Section contains relevant vital signs for the context and use case of the document type, such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area. The section should include notable vital signs such as the most recent, maximum and/or minimum, baseline, or relevant trends. Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions.
78Vital Signs Section (entries required)hl7.cda.us.ccdar2dot2#currentR5The Vital Signs Section contains relevant vital signs for the context and use case of the document type, such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area. The section should include notable vital signs such as the most recent, maximum and/or minimum, baseline, or relevant trends. Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions.

Produced 08 Sep 2023