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description
This page contains the list of supported C-CDA documents and sections level templates.

List of supported templates

The C-CDA to FHIR Converter comes with pre-built scripts for converting C-CDA documents to FHIR Bundles.

These scripts can be extended or modified to suit specific conversion needs. The flexibility of the conversion script enables the inclusion of extra entry or section level templates (e.g., open templates) to adhere to any changes in C-CDA specifications or to accommodate other specifications based on the HL7 CDA domain.

Below is a list of the most commonly used C-CDA document templates and their corresponding section templates.

Note that sections can be reused in multiple document templates, making it easier to cover documents not listed in the table.

If you have specific document or section-level requirements, feel free to contact us for more details.

C-CDA document templates Supported sections

Continuity of Care

The Continuity of Care Document (CCD) is a core set of important administrative, demographic, and clinical information about a patient's healthcare. It allows healthcare providers or systems to gather and share patient data to support continuous care.

Allergies and Intolerances , Advance Directives , Immunizations , Encounters , Medications , Vital Signs , Procedures , Medical Equipment , Functional Status , Plan of Treatment , Results , Problem , Social History , Family History , Mental Status , Nutrition , Payers

Progress Note

A Progress Note is a record of a patient's current status and progress during a particular episode of care. It includes information about the patient's symptoms, vital signs, treatments administered, and response to treatment.

Allergies and Intolerances , Medications , Vital Signs , Plan of Treatment , Review of Systems , Results , Problem , Chief Complaint , Assessment , Nutrition , Objective , Assessment and Plan , Physical Exam , Interventions , Instructions , Subjective

Transfer Summary

A Transfer Summary is a document that provides a summary of a patient's medical history, current condition, and treatment received when transferring care from one healthcare provider or facility to another.

Allergies and Intolerances , History of Present Illness , Advance Directives , Immunizations , Admission Diagnosis , Discharge Diagnosis , Medications , Encounters , Vital Signs , Procedures , Medical Equipment , Functional Status , Plan of Treatment , Past Medical History , Review of Systems , Results , Problem , Social History , Family History , General Status , Mental Status , Course of Care , Assessment , Nutrition , Payers , Admission Medications , Assessment and Plan , Reason for Referral , Physical Exam

Referral Note

A Referral Note is a document generated by a healthcare provider to refer a patient to another healthcare professional or specialist for further evaluation, diagnosis, or treatment.

Allergies and Intolerances , History of Present Illness , Advance Directives , Immunizations , Medications , Procedures , Vital Signs , Medical Equipment , Functional Status , Plan of Treatment , Past Medical History , Review of Systems , Results , Problem , Social History , Family History , General Status , Mental Status , Assessment , Nutrition , Reason for Referral , Assessment and Plan , Physical Exam

Care Plan

A Care Plan is a personalized plan developed by healthcare providers to outline the goals, interventions, and treatments for managing a patient's health condition or multiple health issues.

Health Concerns , Goals , Health Status Evaluations and Outcome , Interventions

History and Physical

A History and Physical is a comprehensive documentation of a patient's medical history, including past illnesses, surgeries, medications, allergies, and a physical examination. It serves as a baseline for further medical assessments and treatment planning.

Chief Complaint and Reason for Visit , Allergies and Intolerances , History of Present Illness , Immunizations , Procedures , Medications , Vital Signs , Plan of Treatment , Past Medical History , Review of Systems , Results , Problem , Reason for Visit , Social History , Family History , Chief Complaint , General Status , Assessment , Assessment and Plan , Physical Exam , Instructions

Consultation Note

A Consultation Note is a document generated by a healthcare provider who seeks the expertise or opinion of another healthcare professional regarding the diagnosis or management of a patient's condition.

Chief Complaint and Reason for Visit , Allergies and Intolerances , History of Present Illness , Advance Directives , Immunizations , Procedures , Medications , Vital Signs , Medical Equipment , Functional Status , Plan of Treatment , Past Medical History , Review of Systems , Results , Problem , Reason for Visit , Social History , Family History , Chief Complaint , Mental Status , General Status , Assessment , Nutrition , Assessment and Plan , Physical Exam

Diagnostic Imaging Report

A Diagnostic Imaging Report is a document generated by a radiologist or other healthcare provider interpreting the findings of diagnostic imaging tests, such as X-rays, CT scans, MRIs, or ultrasounds. It includes descriptions of abnormalities or findings relevant to the patient's health.

DICOM Object Catalog , Findings

Procedure Note

A Procedure Note is a detailed documentation of a medical procedure performed on a patient. It outlines the steps of the procedure, any complications encountered, and post-procedure care instructions.

Chief Complaint and Reason for Visit , Procedure Estimated Blood Loss , Allergies and Intolerances , Medications Administered , History of Present Illness , Procedure Specimens Taken , Postprocedure Diagnosis , Medical General History , Procedure Disposition , Procedure Description , Procedures , Medications , Procedure Implants , Plan of Treatment , Past Medical History , Review of Systems , Reason for Visit , Social History , Family History , Chief Complaint , Complications , Assessment , Procedure Indications , Assessment and Plan , Procedure Findings , Planned Procedure , Physical Exam , Anesthesia

Operative Note

An Operative Note is a documentation of the details regarding a surgical procedure performed on a patient. It includes information about the procedure, findings, complications, and post-operative care instructions.

Operative Note Surgical Procedure , Procedure Estimated Blood Loss , Procedure Specimens Taken , Preoperative Diagnosis , Procedure Disposition , Procedure Description , Operative Note Fluids , Procedure Implants , Plan of Treatment , Complications , Postoperative Diagnosis , Procedure Indications , Procedure Findings , Planned Procedure , Surgical Drains , Anesthesia

Discharge Summary

A Discharge Summary is a document prepared when a patient is discharged from a healthcare facility, summarizing the patient's hospital stay, diagnoses, treatments, and discharge instructions.

Hospital Discharge Studies Summary , Chief Complaint and Reason for Visit , Hospital Discharge Instructions , Hospital Discharge Physical , Allergies and Intolerances , History of Present Illness , Hospital Consultations , Immunizations , Admission Diagnosis , Discharge Diagnosis , Procedures , Vital Signs , Functional Status , Plan of Treatment , Past Medical History , Review of Systems , Problem , Reason for Visit , Social History , Family History , Chief Complaint , Hospital Course , Nutrition , Admission Medications , Discharge Meds , Discharge Meds

Unstructured Document

An Unstructured Document refers to any document or report that does not follow a specific format or template. It could include free-text notes, letters, or other forms of narrative documentation.

Section Name LOINCs Alias Narrative
Admission Diagnosis Section (V3) 46241-6 admission-diagnosis
Advance Directives Section (entries optional) (V3) 42348-3 advance-directives
Advance Directives Section (entries required) (V3) 42348-3 advance-directives
Allergies and Intolerances Section (entries optional) (V3) 48765-2 allergies
Allergies and Intolerances Section (entries required) (V3) 48765-2 allergies
Assessment Section 51848-0 N/A
Chief Complaint Section 10154-3 chief-complaint
Chief Complaint and Reason for Visit Section 46239-0 chief-complaint-and-reason-for-visit
Complications Section (V3) 55109-3 complications
Course of Care Section 8648-8 course-of-care
DICOM Object Catalog Section - DCM 121181 121181 diagnostic-imaging-report
Default Section Rules default
Discharge Diagnosis Section (V3) 11535-2 discharge-diagnosis
Document Header header
Encounters Section (entries optional) (V3) 46240-8 encounters
Encounters Section (entries required) (V3) 46240-8 encounters
Family History Section (V3) 10157-6 family-history
Functional Status Section (V2) 47420-5 funcstatus
General Status Section 10210-3 general-status
Goals Section 61146-7 goals
Health Concerns Section (V2) 75310-3 health-concerns
History of Present Illness Section 10164-2 history-of-present-illness
Hospital Consultations Section 18841-7 hospital-consultations
Hospital Course Section 8648-8 N/A
Hospital Discharge Instructions Section 8653-8 N/A
Hospital Discharge Physical Section 10184-0 hospital-discharge-physical
Hospital Discharge Studies Summary Section 11493-4 hospital-discharge-studies-summary
Immunizations Section (entries optional) (V3) 11369-6 immunizations
Immunizations Section (entries required) (V3) 11369-6 immunizations
Medical (General) History Section 11329-0 medical-general-history
Medical Equipment Section (V2) 46264-8 medical-equipment
Medications Administered Section (V2) 29549-3 medications
Medications Section (entries optional) (V2) 10160-0 medications
Medications Section (entries required) (V2) 10160-0 medications
Mental Status Section (V2) 10190-7 mental-status
Notes 18748-4, 11488-4, 28570-0, 11502-2, 34117-2, 18842-5, 11506-3 N/A
Nutrition Section 61144-2 nutrition
Objective Section 61149-1 objective
Operative Note Fluids Section 10216-0 operative-note-fluids
Operative Note Surgical Procedure Section 10223-6 operative-note-surgical-procedure
Past Medical History (V3) 11348-0 past-medical-history
Payers Section (V3) 48768-6 payers
Plan of Treatment Section (V2) 18776-5 plan-of-treatment
Postprocedure Diagnosis Section (V3) 59769-0 postprocedure-diagnosis
Preoperative Diagnosis Section (V3) 10219-4 preoperative-diagnosis
Problem Section (entries optional) (V3) 11450-4 problems
Problem Section (entries required) (V3) 11450-4 problems
Procedure Description Section 29554-3 procedure-description
Procedure Disposition Section 59775-7 procedure-disposition
Procedure Estimated Blood Loss Section 59770-8 procedure-estimated-blood-loss
Procedure Implants Section 59771-6 procedure-implants
Procedure Specimens Taken Section 59773-2 procedure-specimens-taken
Procedures Section (entries optional) (V2) 47519-4 procedures
Procedures Section (entries required) (V2) 47519-4 procedures
Reason for Visit Section 29299-5 reason-for-visit
Results Section (entries optional) (V3) 30954-2 results
Results Section (entries required) (V3) 30954-2 results
Review of Systems Section 10187-3 review-of-systems
Social History Section (V3) 29762-2 social-history
Vital Signs Section (entries optional) (V3) 8716-3 vital-signs
Vital Signs Section (entries required) (V3) 8716-3 vital-signs