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EHR Continuity of Care Document (CCD)

A Continuity of Care document (CCD) is a health record document standard used to share patient health information electronically. In Open Dental Clinical Summaries and Summaries of Care are sent in the CCD format. 

The following information shows on a CCD.

Patient Information: Name, Birthday, Ethnicity, Language, Sex and Race are set on the Patient Edit window.

Table of Contents:  Click a link to quickly jump to a category.

Allergies and Adverse Reactions:  Medication allergies only show if, in the Allergy Master List, 1) the allergy is associated with a medication that has an RxNorm, and 2) the Allergy Type is AdverseReactionsToDrug, DrugAllergy, or DrugIntolerance. Otherwise, the allergy is treated as an ingredient allergy (e.g. peanuts, latex), and will only show if it has a UNII code.

Encounters:  A list of Encounters.

Functional Status:  A list of patient Problems that have a Problem Type of 'Problem' and a Functional Status of 'CognitiveResult', 'CognitiveProblem', 'FunctionalResult', or 'Functional Problem'.  This is defined on the Edit Problem window (on the Medical window, double click a problem in the patient's list).

Immunizations:  A lists of all vaccines entered on the Vaccines window.

Instructions: Clinical Summaries only.  Shows information entered as Instructions when a clinical summary is generated.

Medications:  A list of all medications in the Patient's Medication List (inactive and active).

Care Plan:  A list of care plans entered on the Care Plan window.

Problems: All problems in the patient's Problem List (inactive and active), that have a Problem Type of 'Problem' and a Functional Status of 'Problem'.

Procedures:  All procedures in the patient account which are not treatment planned and not referred out, including completed and existing procedures.   The code and description that shows on the CCD is the Proc Code and Description as entered on the Procedure Code Edit window. 

  • If the Proc Code is an CDT code, the CDT code and description show.  These cannot be edited.
  • If the Proc Code is a SNOMED CT code, the SNOMED CT code and official description (not necessarily from the Procedure Code List) show.  These codes must be manually added to the Procedure Code List.  See Adding Procedure Codes.
  • If the Proc Code is a five digit number (CPT code), then the CPT code and description show. These codes must be manually added to the Procedure Code List.
  • If no code is specified, then the procedure will export without a code as required.

Any cross coding in the Procedure Code List does not affect the CCD (e.g. medical codes, alternate codes).

If any procedure has a SNOMED CT Body Site entered on the Procedure Edit - Medical tab, an additional Body Site column will show under Procedures on the CCD.  If no body site is entered, this column is hidden. 

Reason for Referral: This content will change based on which document is being generated/sent.  The text cannot be edited.

Diagnostic Results:  A list of Lab Results that specify Test Performed LOINC. 

Social History:  Includes the patient's Smoking Status and pregnancy information.

Vital Signs:  A log of all Vital Signs entered for this patient

Author:  The patient's primary provider (selected on Patient Edit window) and Practice contact information.

Custodian:  The NPI of the Practice's default provider and the practice address and contact information. For practices with a single provider, will be the same as the author.  For Clinics, will probably be the NPI of the organization instead of a person.

Legal Authenticator:  Only shows when the Practice's default provider is a person. Includes the NPI of the default provider and the practice address and contact information.

 

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