Consolidated-Clinical Document Architecture or C-CDA is a standardized format for providing a patient's medical summary and is used by SOAPware to meet the 2014 Edition Certification Criteria for Meaningful Use. The following lesson describes how different sections of the C-CDA are populated from the patient chart in SOAPware.
Problem List - Reported
The Problem List will be populated with all of the SMARText Dx items located in Active Problems and Inactive Problems fields of the Summary. It also includes the primary diagnosis from the Assessment field of the most recent SOAP Note encounter. If the Onset date is recorded it will show in the C-CDA as the Date Diagnosed.
History of Medication Use
The History of Medication Use will be populated with all of the SMARText Rx items located in the Medication field of the Summary. It also includes any medications that were previously in the Summary but removed by being discontinued.
The Medications Administered will be populated with the SMARText Rx items that are prescribed using the Rx Manager.
Allergies, Adverse Reactions, Alerts
Allergies, Adverse Reactions, Alerts will be populated with all of the Rx items and Allergy items located in the Allergies field of the Summary. If an Onset date is recorded it will show in the C-CDA as Adverse Event Date.
History of Immunizations
History of Immunizations will be populated with all of the Immunization items located in the Immunizations section. For instructions on recording immunization data please see Entering Performed Immunizations and Entering Historical, Refused, or Not Performed Immunizations.
History of Encounters
History of Encounters will be populated with a list of all encounters found in the SOAP Notes section of the patient's chart. For every encounter the CCD-A will only display the date, type, and reason. The type of encounter is based on the office visit CPT code in the Plan field, and the Reason is based on the first diagnosis item in the Assessment field.
Procedures will be populated with all SMARText CPT codes from the Plan field of every SOAP note. The C-CDA will display the date, name, and code related to each item in the Plan field.
Social History will be populated with all SMARText and free text found in the Tobacco, Alcohol, and Social History fields of the Summary section.
Relevant Diagnostic Tests
Relevant Diagnostic Tests will be populated with all structured test results in the Labs section. Test results will be displayed in alphabetical order according to the test name.
*Note: Lab results that are scanned into the chart are images that do not contain structured results. Scanned items will not be included on the C-CDA.
Vital Signs will be populated with every vital sign reading from the patient chart. These will be displayed in alphabetical order according to reading type.
Care Plan will be only appear on the C-CDA if the careplanmu item is inserted in the Plan field of the SOAPnote. The Care Plan portion will be populated with Item Comments added to these SMARText items. For further instruction on finding SMARText and adding Item Comments please see SMARText Data Entry Methods.
Reason for Referral
The Reason for Referral portion will simply give the most recent date when a referral was made for the patient. A more detailed reason for referral can be added as an item comment to the Care Plan described above.