| # | Name | Source | Ver | Description | |
| 1 | Admission Medication | hl7.cda.us.ccdar2dot2#current | R5 | This template represents the medications taken by the patient prior to and at the time of admission. | |
| 2 | Allergy Concern Act | hl7.cda.us.ccdar2dot2#current | R5 | This template reflects an ongoing concern on behalf of the provider that placed the allergy on a patients allergy list. As long as the underlying condition is of concern to the provider (i.e., as long as the allergy, whether active or resolved, is of ongoing concern and interest to the provider), the statusCode is active. Only when the underlying allergy is no longer of concern is the statusCode set to completed. The effectiveTime reflects the time that the underlying allergy was felt to be a concern. The statusCode of the Allergy Concern Act is the definitive indication of the status of the concern, whereas the effectiveTime of the nested Allergy - Intolerance Observation is the definitive indication of whether or not the underlying allergy is resolved. The effectiveTime/low of the Allergy Concern Act asserts when the concern became active. This equates to the time the concern was authored in the patient's chart. The effectiveTime/high asserts when the concern was completed (e.g., when the clinician deemed there is no longer any need to track the underlying condition). | |
| 3 | Authorization Activity | hl7.cda.us.ccdar2dot2#current | R5 | An Authorization Activity represents authorizations or pre-authorizations currently active for the patient for the particular payer. Authorizations are represented using an act subordinate to the policy or program that provided it. The authorization refers to the policy or program. Authorized treatments can be grouped into an organizer class, where common properties, such as the reason for the authorization, can be expressed. Subordinate acts represent what was authorized. | |
| 4 | Comment Activity | hl7.cda.us.ccdar2dot2#current | R5 | Comments are free text data that cannot otherwise be recorded using data elements already defined by this specification. They are not to be used to record information that can be recorded elsewhere. For example, a free text description of the severity of an allergic reaction would not be recorded in a comment. | |
| 5 | Coverage Activity | hl7.cda.us.ccdar2dot2#current | R5 | A Coverage Activity groups the policy and authorization acts within a Payers Section to order the payment sources. A Coverage Activity contains one or more Policy Activities, each of which contains zero or more Authorization Activities. The Coverage Activity id is the ID from the patient's insurance card. The sequenceNumber/@value shows the policy order of preference. | |
| 6 | Discharge Medication | hl7.cda.us.ccdar2dot2#current | R5 | This template represents medications that the patient is intended to take (or stop) after discharge. | |
| 7 | Drug Monitoring Act | hl7.cda.us.ccdar2dot2#current | R5 | This template represents the act of monitoring the patient's medication and includes a participation to record the person responsible for monitoring the medication. The prescriber of the medication is not necessarily the same person or persons monitoring the drug. The effectiveTime indicates the time when the activity is intended to take place. For example, a cardiologist may prescribe a patient Warfarin. The patient's primary care provider may monitor the patient's INR and adjust the dosing of the Warfarin based on these laboratory results. Here the person designated to monitor the drug is the primary care provider. | |
| 8 | Encounter Diagnosis | hl7.cda.us.ccdar2dot2#current | R5 | This template wraps relevant problems or diagnoses at the close of a visit or that need to be followed after the visit. If the encounter is associated with a Hospital Discharge, the Hospital Discharge Diagnosis must be used. This entry requires at least one Problem Observation entry. | |
| 9 | Entry Reference | hl7.cda.us.ccdar2dot2#current | R5 | This template represents the act of referencing another entry in the same CDA document instance. Its purpose is to remove the need to repeat the complete XML representation of the referred entry when relating one entry to another. This template can be used to reference many types of Act class derivations, such as encounters, observations, procedures etc., as it is often necessary when authoring CDA documents to repeatedly reference other Acts of these types. For example, in a Care Plan it is necessary to repeatedly relate Health Concerns, Goals, Interventions and Outcomes. The id is required and must be the same id as the entry/id it is referencing. The id cannot be a null value. Act/Code is set to nullFlavor=NP (Not Present). This means the value is not present in the message (in act/Code). | |
| 10 | Handoff Communication Participants | hl7.cda.us.ccdar2dot2#current | R5 | This template represents the sender (author) and receivers (participants) of a handoff communication in a plan of treatment. It does not convey details about the communication. The "handoff" process involves senders, those transmitting the patient's information and releasing the care of that patient to the next clinician, and receivers, those who accept the patient information and care of that patient. | |
| 11 | Health Concern Act | hl7.cda.us.ccdar2dot2#current | R5 | This template represents a health concern. It is a wrapper for a single health concern which may be derived from a variety of sources within an EHR (such as Problem List, Family History, Social History, Social Worker Note, etc.). A Health Concern Act is used to track non-optimal physical or psychological situations drawing the patient to the healthcare system. These may be from the perspective of the care team or from the perspective of the patient. When the underlying condition is of concern (i.e., as long as the condition, whether active or resolved, is of ongoing concern and interest), the statusCode is active. Only when the underlying condition is no longer of concern is the statusCode set to completed. The effectiveTime reflects the time that the underlying condition was felt to be a concern; it may or may not correspond to the effectiveTime of the condition (e.g., even five years later, a prior heart attack may remain a concern). Health concerns require intervention(s) to increase the likelihood of achieving the goals of care for the patient and they specify the condition oriented reasons for creating the plan. | |
| 12 | Hospital Admission Diagnosis | hl7.cda.us.ccdar2dot2#current | R5 | This template represents problems or diagnoses identified by the clinician at the time of the patients admission. This Hospital Admission Diagnosis act may contain more than one Problem Observation to represent multiple diagnoses for a Hospital Admission. | |
| 13 | Hospital Discharge Diagnosis | hl7.cda.us.ccdar2dot2#current | R5 | This template represents problems or diagnoses present at the time of discharge which occurred during the hospitalization or need to be monitored after hospitalization. It requires at least one Problem Observation entry. | |
| 14 | Instruction | hl7.cda.us.ccdar2dot2#current | R5 | The Instruction template can be used in several ways, such as to record patient instructions within a Medication Activity or to record fill instructions within a supply order. The template's moodCode can only be INT. If an instruction was already given, the Procedure Activity Act template (instead of this template) should be used to represent the already occurred instruction. The act/code defines the type of instruction. Though not defined in this template, a Vaccine Information Statement (VIS) document could be referenced through act/reference/externalDocument, and patient awareness of the instructions can be represented with the generic participant and the participant/awarenessCode. | |
| 15 | Intervention Act | hl7.cda.us.ccdar2dot2#current | R5 | This template represents an Intervention Act. It is a wrapper for intervention-type activities considered to be parts of the same intervention. For example, an activity such as "elevate head of bed" combined with "provide humidified O2 per nasal cannula" may be the interventions performed for a health concern of "respiratory insufficiency" to achieve a goal of "pulse oximetry greater than 92%". These intervention activities may be newly described or derived from a variety of sources within an EHR. Interventions are actions taken to increase the likelihood of achieving the patient's or providers' goals. An Intervention Act should contain a reference to a Goal Observation representing the reason for the intervention. Intervention Acts can be related to each other, or to Planned Intervention Acts. (E.g., a Planned Intervention Act with moodCode of INT could be related to a series of Intervention Acts with moodCode of EVN, each having an effectiveTime containing the time of the intervention.) All interventions referenced in an Intervention Act must have a moodCode of EVN, indicating that they have occurred. | |
| 16 | Nutrition Recommendation | hl7.cda.us.ccdar2dot2#current | R5 | This template represents nutrition regimens (e.g., fluid restrictions, calorie minimum), interventions (e.g., NPO, nutritional supplements), and procedures (e.g., G-Tube by bolus, TPN by central line). It may also depict the need for nutrition education. | |
| 17 | Patient Referral Act | hl7.cda.us.ccdar2dot2#current | R5 | This template represents the type of referral (e.g., for dental care, to a specialist, for aging problems) and represents whether the referral is for full care or shared care. It may contain a reference to another act in the document instance representing the clinical reason for the referral (e.g., problem, concern, procedure). | |
| 18 | Planned Act | hl7.cda.us.ccdar2dot2#current | R5 | This template represents planned acts that are not classified as an observation or a procedure according to the HL7 RIM. Examples of these acts are a dressing change, the teaching or feeding of a patient or the providing of comfort measures. The priority of the activity to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the activity is intended to take place. | |
| 19 | Planned Coverage | hl7.cda.us.ccdar2dot2#current | R5 | This template represents the insurance coverage intended to cover an act or procedure. | |
| 20 | Planned Intervention Act | hl7.cda.us.ccdar2dot2#current | R5 | This template represents a Planned Intervention Act. It is a wrapper for planned intervention-type activities considered to be parts of the same intervention. For example, an activity such as "elevate head of bed" combined with "provide humidified O2 per nasal cannula" may be the interventions planned for a health concern of "respiratory insufficiency" in order to attempt to achieve a goal of "pulse oximetry greater than 92%". These intervention activities may be newly described or derived from a variety of sources within an EHR. Interventions are actions taken to increase the likelihood of achieving the patient's or providers' goals. An Intervention Act should contain a reference to a Goal Observation representing the reason for the intervention. Planned Intervention Acts can be related to each other or to Intervention Acts. (E.g., a Planned Intervention Act with moodCode of INT could be related to a series of Intervention Acts with moodCode of EVN, each having an effectiveTime containing the time of the intervention.) All interventions referenced in a Planned Intervention Act must have moodCodes indicating that that are planned (have not yet occurred). | |
| 21 | Policy Activity | hl7.cda.us.ccdar2dot2#current | R5 | A policy activity represents the policy or program providing the coverage. The person for whom payment is being provided (i.e., the patient) is the covered party. The subscriber of the policy or program is represented as a participant that is the holder of the coverage. The payer is represented as the performer of the policy activity. | |
| 22 | Postprocedure Diagnosis | hl7.cda.us.ccdar2dot2#current | R5 | This template represents the diagnosis or diagnoses discovered or confirmed during the procedure. They may be the same as preprocedure diagnoses or indications. | |
| 23 | Preoperative Diagnosis | hl7.cda.us.ccdar2dot2#current | R5 | This template represents the surgical diagnosis or diagnoses assigned to the patient before the surgical procedure and is the reason for the surgery. The preoperative diagnosis is, in the opinion of the surgeon, the diagnosis that will be confirmed during surgery. | |
| 24 | Problem Concern Act | hl7.cda.us.ccdar2dot2#current | R5 | This template reflects an ongoing concern on behalf of the provider that placed the concern on a patients problem list. So long as the underlying condition is of concern to the provider (i.e., as long as the condition, whether active or resolved, is of ongoing concern and interest to the provider), the statusCode is active. Only when the underlying condition is no longer of concern is the statusCode set to completed. The effectiveTime reflects the time that the underlying condition was felt to be a concern; it may or may not correspond to the effectiveTime of the condition (e.g., even five years later, the clinician may remain concerned about a prior heart attack). The statusCode of the Problem Concern Act is the definitive indication of the status of the concern, whereas the effectiveTime of the nested Problem Observation is the definitive indication of whether or not the underlying condition is resolved. The effectiveTime/low of the Problem Concern Act asserts when the concern became active. The effectiveTime/high asserts when the concern was completed (e.g., when the clinician deemed there is no longer any need to track the underlying condition). A Problem Concern Act can contain many Problem Observations (templateId 2.16.840.1.113883.10.20.22.4.4). Each Problem Observation is a discrete observation of a condition, and therefore will have a statusCode of completed. The many Problem Observations nested under a Problem Concern Act reflect the change in the clinical understanding of a condition over time. For instance, a Concern may initially contain a Problem Observation of chest pain: - Problem Concern 1 --- Problem Observation: Chest Pain Later, a new Problem Observation of esophagitis will be added, reflecting a better understanding of the nature of the chest pain. The later problem observation will have a more recent author time stamp. - Problem Concern 1 --- Problem Observation (author/time Jan 3, 2012): Chest Pain --- Problem Observation (author/time Jan 6, 2012): Esophagitis Many systems display the nested Problem Observation with the most recent author time stamp, and provide a mechanism for viewing prior observations. | |
| 25 | Procedure Activity Act | hl7.cda.us.ccdar2dot2#current | R5 | This template represents any act that cannot be classified as an observation or procedure according to the HL7 RIM. Examples of these acts are a dressing change, teaching or feeding a patient, or providing comfort measures. The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g., splenectomy). | |
| 26 | Procedure Context | hl7.cda.us.ccdar2dot2#current | R5 | The ServiceEvent Procedure Context of the document header may be overridden in the CDA structured body if there is a need to refer to multiple imaging procedures or acts. The selection of the Procedure or Act entry from the clinical statement choice box depends on the nature of the imaging service that has been performed. The Procedure entry shall be used for image-guided interventions and minimally invasive imaging services, whereas the Act entry shall be used for diagnostic imaging services. | |
| 27 | Risk Concern Act | hl7.cda.us.ccdar2dot2#current | R5 | This template represents a risk concern. It is a wrapper for a single risk concern which may be derived from a variety of sources within an EHR (such as Problem List, Family History, Social History, Social Worker Note, etc.). A Risk Concern Act represents a health concern that is a risk. A risk is a clinical or socioeconomic condition that the patient does not currently have, but the probability of developing that condition rises to the level of concern such that an intervention and/or monitoring is needed. | |
| 28 | Series Act | hl7.cda.us.ccdar2dot2#current | R5 | A Series Act contains the DICOM series information for referenced DICOM composite objects. The series information defines the attributes that are used to group composite instances into distinct logical sets. Each series is associated with exactly one study. Series Act clinical statements are only instantiated in the DICOM Object Catalog section inside a Study Act, and thus do not require a separate templateId; in other sections, the SOP Instance Observation is included directly. | |
| 29 | Study Act | hl7.cda.us.ccdar2dot2#current | R5 | A Study Act contains the DICOM study information that defines the characteristics of a referenced medical study performed on a patient. A study is a collection of one or more series of medical images, presentation states, SR documents, overlays, and/or curves that are logically related for the purpose of diagnosing a patient. Each study is associated with exactly one patient. A study may include composite instances that are created by a single modality, multiple modalities, or by multiple devices of the same modality. The study information is modality-independent. Study Act clinical statements are only instantiated in the DICOM Object Catalog section; in other sections, the SOP Instance Observation is included directly. | |
| 30 | Substance Administered Act | hl7.cda.us.ccdar2dot2#current | R5 | This template represents the administration course in a series. The entryRelationship/sequenceNumber in the containing template shows the order of this particular administration in that medication series. |
Produced 08 Sep 2023