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| # 🏥 CCDA (Consolidated Clinical Document Architecture) 📄 | |
| The CCD is a document standard developed by Health Level Seven International (HL7) for the exchange of clinical information. 🔄 It is a universally accepted format for sharing clinical data across different electronic health record (EHR) systems. 🌐 | |
| ## 📚 CCD Standard Templates 📋 | |
| The CCD standard includes templates for different types of clinical documents, like: | |
| - 📤 Discharge summaries | |
| - 🗒️ Progress notes | |
| - 📄 Clinical summaries | |
| These templates are based on existing document standards like the Continuity of Care Record (CCR). ✅ | |
| # FHIR Map to CCD | |
| | CCD Templates | Emoji | FHIR Resources | | |
| |---------------|-------|----------------| | |
| | Patient Demographics | 🏥 | [Patient](https://www.hl7.org/fhir/patient.html) | | |
| | Encounters | 👩⚕️ | [Encounter](https://www.hl7.org/fhir/encounter.html) | | |
| | Procedures | 🚑 | [Procedure](https://www.hl7.org/fhir/procedure.html) | | |
| | Laboratory Results | 🔬 | [Observation](https://www.hl7.org/fhir/observation.html) | | |
| | Vital Signs | 📈 | [Observation](https://www.hl7.org/fhir/observation.html) | | |
| | Clinical Notes | 📝 | [ClinicalImpression](https://www.hl7.org/fhir/clinicalimpression.html), [Composition](https://www.hl7.org/fhir/composition.html) | | |
| | Medications | 💊 | [MedicationStatement](https://www.hl7.org/fhir/medicationstatement.html), [MedicationRequest](https://www.hl7.org/fhir/medicationrequest.html) | | |
| | Immunizations | 📅 | [Immunization](https://www.hl7.org/fhir/immunization.html) | | |
| # CCD Documents - Standard Templates | |
| ## 1. 🏥 Patient Demographics | |
| | Attribute | Description | | |
| |-----------|-------------| | |
| | Patient ID | Unique identifier for the patient | | |
| | Name | Full name of the patient | | |
| | Date of Birth | Birth date of the patient | | |
| | Sex | Gender of the patient | | |
| | Address | Residential address of the patient | | |
| ## 2. 💊 Medications | |
| | Attribute | Description | | |
| |-----------|-------------| | |
| | Medication Name | Name of the medication | | |
| | Dosage | Dosage of the medication | | |
| | Frequency | How often the medication is taken | | |
| | Start Date | When the medication was started | | |
| | End Date | When the medication was stopped | | |
| ## 3. 👩⚕️ Encounters | |
| | Attribute | Description | | |
| |-----------|-------------| | |
| | Encounter ID | Unique identifier for the encounter | | |
| | Encounter Type | Type of encounter (e.g., office visit, hospitalization) | | |
| | Start Date/Time | When the encounter began | | |
| | End Date/Time | When the encounter ended | | |
| | Encounter Provider | Healthcare provider during the encounter | | |
| ## 4. 🔬 Laboratory Results | |
| | Attribute | Description | | |
| |-----------|-------------| | |
| | Test Name | Name of the lab test | | |
| | Date/Time | When the lab test was performed | | |
| | Result | Result of the lab test | | |
| | Normal Range | Normal range for the lab test result | | |
| ## 5. 🚑 Procedures | |
| | Attribute | Description | | |
| |-----------|-------------| | |
| | Procedure Name | Name of the procedure | | |
| | Date/Time | When the procedure was performed | | |
| | Performing Provider | Healthcare provider who performed the procedure | | |
| ## 6. 📅 Immunizations | |
| | Attribute | Description | | |
| |-----------|-------------| | |
| | Vaccine Name | Name of the vaccine | | |
| | Administration Date | When the vaccine was administered | | |
| | Administering Provider | Healthcare provider who administered the vaccine | | |
| ## 7. 📈 Vital Signs | |
| | Attribute | Description | | |
| |-----------|-------------| | |
| | Vital Sign Type | Type of vital sign (e.g., blood pressure, temperature) | | |
| | Date/Time | When the vital sign was measured | | |
| | Value | Value of the vital sign | | |
| | Unit | Unit of the vital sign value | | |
| ## 8. 📝 Clinical Notes | |
| | Attribute | Description | | |
| |-----------|-------------| | |
| | Note Type | Type of clinical note (e.g., progress note, discharge summary) | | |
| | Note Date | When the note was written | | |
| | Note Author | Healthcare provider who wrote the note | | |
| | Note Content | Content of the note | | |
| # Messages for ADT, ORM, SIU, EDI, Procedures, Observations | |
| ## ADT (Admit/Discharge/Transfer) messages | |
| | Patient ID | Name | Admission Date/Time | Discharge Date/Time | Clinical Encounter | | |
| |------------|------|---------------------|---------------------|--------------------| | |
| | 001 | John Doe | 2023-05-01 10:00 | 2023-05-10 10:00 | Heart Surgery | | |
| ## ORM (Order Entry) messages | |
| | Order ID | Order Date/Time | Order Status | Relevant Clinical Data | | |
| |----------|-----------------|--------------|------------------------| | |
| | 1001 | 2023-05-01 11:00 | Completed | Lab Test: Blood Sugar Level | | |
| ## SIU (Scheduling Information Update) messages | |
| | Patient Name | Appointment Date/Time | Provider Name | Relevant Clinical Information | | |
| |--------------|-----------------------|---------------|-------------------------------| | |
| | John Doe | 2023-05-15 10:00 | Dr. Smith | Follow-up: Heart Surgery | | |
| ## EDI (Electronic Data Interchange) | |
| | Patient Information | Clinical Data | Billing Information | | |
| |---------------------|---------------|---------------------| | |
| | John Doe, Male, 55 | Heart Surgery | $5000 | | |
| ## Procedures | |
| | Procedure Type | Date/Time of Procedure | Relevant Clinical Data or Reports | | |
| |----------------|------------------------|-----------------------------------| | |
| | Heart Surgery | 2023-05-01 12:00 | Surgery Successful | | |
| ## Observations | |
| | Observation Type | Date/Time of Observation | Relevant Clinical Data or Reports | | |
| |------------------|--------------------------|-----------------------------------| | |
| | Blood Pressure | 2023-05-10 09:00 | 120/80 mmHg | | |
| ## 🔄 Translation to CCD Format 🗂️ | |
| To translate different healthcare documents to the CCD format, follow these guidelines: | |
| 1. **ADT (Admit/Discharge/Transfer) messages** 🏥 | |
| - Patient registration, admission, transfer, and discharge | |
| - Include patient demographic information, admission and discharge date/time, and clinical encounter information | |
| 2. **ORM (Order Entry) messages** 💊 | |
| - Contains requests for labs, procedures, or medication | |
| - Include the order request, order date/time, order status, and any relevant clinical data | |
| 3. **SIU (Scheduling Information Update) messages** 📆 | |
| - Used for scheduling appointments and updating appointment status | |
| - Include the patient name, appointment date/time, provider name, and any relevant clinical information | |
| 4. **EDI (Electronic Data Interchange)** 💻 | |
| - A standardized format for transmitting healthcare data | |
| - Include patient information, clinical data, and billing information | |
| 5. **Procedures** 🚑 | |
| - Any procedures or surgeries performed on a patient | |
| - Include the procedure type, date/time of the procedure, and any relevant clinical data or reports | |
| 6. **Observations** 🔬 | |
| - Any relevant clinical observations or measurements | |
| - Include the observation type, date/time of the observation, and any relevant clinical data or reports | |
| In summary, the CCD is a standardized format for exchanging clinical information. To translate different healthcare documents to the CCD format, follow the guidelines above. ✨ | |
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