The Summary of Care screen (Manual & Interfaced), and QuickPay screens generate Clinical Summaries. This relates to data pertinent to a specific appointment/encounter and may contain historical data related to a patient based upon the configured company setting for "Summary of Care Encounter Data Time Period".
The purpose of this document is to describe the data expected to be contained within a Clinical Summary. The XML template specification per the HL7 International standard is available by selecting the template OID hyperlink. This documentation is primarily for technical resources and assumes prior knowledge and expectations of XML and CCDAs.
NOTE: Please note that the data elements outlined below may only be captured in specific cases, based on the proper documentation in relevant screens and accurate coding. While a CCD-A generated from OfficeEMR has the ability to populate the data elements listed below, their presence is not guaranteed in every patient record.
Sample Files
Alice Newman (ONC Test Patient) | AliceNewmanAPIGenerated-12.21.22.xml
XML Content & Source
The below describes the XML standard being used for the top-level components of the CCDA, subsequent components and their templates can be found within the HL7 specification links for each template. The "Contains" section can be used to review the requirements of the embedded sections. The C-CDA is comprised of two main parts, a Header, and a Document (the Continuity of Care Document)
Overview
| Template/Section Name | OfficeEMR Source | Notes |
|---|---|---|
| US Realm Header (V3) 2.16.840.1.113883.10.20.22.1.1 | The header contains various components ranging from details from the Company Profile, User, Provider, and Patient Setup screens. | All SHALL statements described within the specifications will be present within the XML. |
| Continuity of Care Document 2.16.840.1.113883.10.20.22.1.2 | The CCD contains the Clinical Information largely coming from a myriad of chart tabs within the EMR. Some details may come from the appointment on the iScheduler. | The CCD will contain the clinical, demographic, and administrative data for a specific patient. Refer to the SHALL statements within the specifications for expected values. The section templates contained within the CCD are described below. |
Continuity of Care Document (Sections)
| Continuity of Care Document 2.16.840.1.113883.10.20.22.1.2 | OfficeEMR Location | Notes / Example |
|---|---|---|
| Reason for Referral 1.3.6.1.4.1.19376.1.5.3.1.3.1 | Reports > Summary of Care > "Reason" OR Direct Email "Reason" The Reason field is only used on Transition of Care / Referral CCDs. | Will not be present in most CCDs. |
| Allergies and Adverse Reactions 2.16.840.1.113883.10.20.22.2.6.1 | EMR > Allergies chart tab The data contained refers to the Allergen, Reaction, Severity & Status. | All codified Allergens will be included in the CCD. These will conform to either SNOMED or RxNorm depending upon the allergen type. |
| Medications Administered During Visit 2.16.840.1.113883.10.20.22.2.38 | EMR > Medications / Prescriptions chart tab. The data contained refers to the Drug / Directions, Dose, Start Date, and Status. | Contains medications prescribed with a written date equivalent to the encounter date. |
| Medications 2.16.840.1.113883.10.20.22.2.1.1 | EMR > Medications / Prescriptions chart tab. The data contained refers to the Drug / Directions, Dose, Start Date, and Status. | Contains historic medications as part of the patient record. |
| Conditions or Problems 2.16.840.1.113883.10.20.22.2.5.1 | EMR > Problem List chart tab. The data contained refers to the Problem, Onset Date, and Problem Status. | Contains all active problems from the patient Problem List. Codification will be represented in either ICD10 or SNOMED terminology. |
| Chief Compliant 2.16.840.1.113883.10.20.22.2.13 | iScheduler > Appointment > Chief Compliant The entry within the Chief Complaint section will contain the |  |
| Immunizations 2.16.840.1.113883.10.20.22.2.2.1 | EMR > Immunizations The entries within Immunizations contain the codified date and injection, reaction, and/or refusal reasons. | Contains all immunizations present within the patient chart. |
| Vitals 2.16.840.1.113883.10.20.22.2.4.1 | EMR > Vitals Each entry within the Vitals section represents a vital template being completed within the EMR. | Contains all vital records recorded during the patient encounter. Values are codified to LOINC values. |
| Diagnostic Results 2.16.840.1.113883.10.20.22.2.3.1 | EMR > Orders - History > Results The child templates within the section can be seen as full requisitions as seen within the UI in the system. The entries within each template represent individual result components ex.Template = CMP, Entry = WBC | Based upon the Time Period company setting described at the top of the document. |
| Procedures 2.16.840.1.113883.10.20.22.2.7.1 | EMR > Superbill - Procedure Codes. The claim for the encompassed encounter contains the CPT codes from the superbill. | This will only contain the procedure information related to the specific encounter, not historical procedures. |
| Medical Device Equipment 2.16.840.1.113883.10.20.22.2.23 | EMR > Implantable Devices chart tab. | Requires the practice to document the device ID of the equipment within the Implantable Devices section of the EMR (uncommon) |
| Assessment 2.16.840.1.113883.10.20.22.2.8 | EMR > Assessments chart tab (specific controls*) | Unlikely to be populated in most databases, but if set up. Specific template controls may be configured to populate this section. |
| Future Appointments 2.16.840.1.113883.10.20.22.4.40 | EMR/iScheduler > Patient Setup > Patient Appointments screen. | Dependent upon practice workflow, this section could be blank if the SOAP Note for the encounter is signed off prior to any follow-up appointments being added to the iScheduler. |
| Instructions (V2) 2.16.840.1.113883.10.20.22.4.20 | EMR > {Encounter Based Template} Chart Tab | These are patient instructions specifically set up to populate this template OID from Template Setup. This is unlikely to be populated in most existing databases (legacy section) |
| Patient Education (Planned Supply V2) 2.16.840.1.113883.10.20.22.4.43 | EMR > {Encounter Based Template} Chart Tab | Similar to the above section, each individual control on a template can be set up to populate specific sections of the CCD. However, this is very uncommon amongst existing databases and should not be expected to contain data. |
| Planned Procedure (V3) 2.16.840.1.113883.10.20.22.4.41 | EMR > Orders - History > Order Processing | This section will contain orders with an "Appointment Date" in the future (compared to the encounter date). Specific to Order Types of Procedures |
| Planned Observation (V2) 2.16.840.1.113883.10.20.22.4.44 | EMR > Orders - History > Order Processing | This section will contain orders with an "Appointment Date" in the future (compared to the encounter date). Specific to Order Types of Lab, Radiology, Pathology |
| Goals Section 2.16.840.1.113883.10.20.22.2.60 | EMR > Goals chart tab | Goals specific to the encounter will be present within the CCD. Historical goals or those addressed outside of the encounter will not be included in the Clinical Summary CCD. |
| Health Concerns Section 2.16.840.1.113883.10.20.22.2.58 | EMR > {Encounter Based Template} Chart Tab | This is another section similar to Patient Education and Instructions (above), there are specific configurations at the template level required for this section to be populated. |
| Instructions Section 2.16.840.1.113883.10.20.22.2.45 | EMR > Patient Instructions chart tab | This section notates the more commonly used Patient Instructions chart tab within the EMR. This will notate items such as a PDF document regarding "Health Eating Habits" provided. |
| Social History 2.16.840.1.113883.10.20.22.2.17 | EMR > History > Social History - Smoking Status Patient Setup > Demographics - Sex as Birth Sex | These two values are the only ones listed within the social history section of the template. This typically will consist of a value from the History template > Social History blue bar but is not guaranteed to be present or filled out depending on the practice use case. |
| Encounters 2.16.840.1.113883.10.20.22.2.22.1 | EMR > Superbill | The encounters section describes the patient visit completed at the practice. This contains the ICD-10 code(s) and relevant encounter CPT codes (ex. 99203 - New Patient Office Visit) |
| Functional Status Observation (V2) 2.16.840.1.113883.10.20.22.4.67 | EMR > Problem List - Type = Functional | Functional problems that are active within the Problem List will be included here. ICD-10 or SNOMED |
| Cognitive Status Observation 2.16.840.1.113883.10.20.22.2.56 | EMR > Problem List - Type =Cognitive | Cognitive problems that are active within the Problem List will be included here. ICD-10 or SNOMED |
| Notes Section - Order Result Findings - SOAP/Progress Notes 2.16.840.1.113883.10.20.22.2.65 | EMR > Progress/SOAP Notes (label may vary) EMR > Orders - History > Results w/ Findings | "Signed-off" notes and/or Order Results w/ findings and a designation to be included within the CCD will be included in the 2.65 template OID. Note types are codified to LOINC codes. |
