Module 13 : Interoperability CCDs and
CDA
Clinical Document (CD) - correct answer ✔✔any type of report or document
CD Examples - correct answer ✔✔1. Surgeon's report 2. anesthesiologists consults 3. pathologists report
4. radiologist report 5. cardiologists report 5. continuity of care document
Continuity of Care Document Sections (CCD) - correct answer ✔✔1. payers 2. AD 3. support 4. functional
status 5. problems 6. family history 7. social history 8. alerts, allergies, AE 9. medications 10. medical
equipment 11. immunizations 12. vital signs 13 results 14 procedures 15. encounters 16. plan of care
CCD - correct answer ✔✔a summary of a patient's status and can be sent from one EHR system to
another
Clinical Document Architecture (CDA) - correct answer ✔✔document markup base standard that
specifies the structure and semantics of electronic clinical documents for the purpose of exchange.
building block template
CDA features - correct answer ✔✔defined information objects that can include text, image, sounds, and
other multimedia content. the architecture specifies the schemas required for exchange
Characteristics of CDA - correct answer ✔✔1. Persistence 2. stewardship 3. potential for authentication
4. wholeness 5. human readability
Persistence - correct answer ✔✔continues to exist in an unaltered state, for a time period defined by
local and regulatory requirements; it may or not be important, depending on what happens on the
receiving end. It can be stored as a persistent document, or its contents can be extracted and included in
an EHR.
stewardship - correct answer ✔✔is maintained by an organization entrusted with its care
