How do I create and export a Continuity of Care (CCD) clinical document?

Clinical documents formatted to the HL7 Consolidated Clinical Data Architecture (CCDA) standard are XML files that
contain structured and unstructured patient data and can be used to support health information exchange with other
EHR systems. CCDA documents can be formatted according to various document templates, such as the Continuity
of Care (CCD) document template or the Referral Note document template. The Practice Fusion EHR allows you to
easily export a CCD clinical document from within the patient’s chart. Account administrators can also export all
patient records simultaneously within the
Reports section of the EHR using the Exported batch CCD files report.
For more information, see
How do I batch export patient data from the EHR?

Follow the steps below to learn how to create and export individual CCD clinical documents:

1. Click the Actions button in the top-right corner of the patient chart and select Create clinical document.

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Alternatively, select Exported patient records from the patient’s Timeline and click Create in the top-right corner.

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2. Review the sections of the patient chart that will be included in the clinical document, and if applicable, un-check
the boxes next to sections you do not wish to include in the document. For more details on the data that will be
included in the clinical document for each section, see FAQ #2 at the bottom of this article.

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3. To view and download CCD documents that have been created for a specific patient, navigate to the patient’s Timeline
and select
Exported patient records from the drop-down menu.

Alternatively, click the Actions menu and select View exported patient records.

View_exported_patient_recordspng

4. Select Preview to review the exported record. You may also download the record to your computer in XML format, which can be read by other EHRs
and health systems, or in HTML format, which can be read as a web page.

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FAQs

1. What kind of clinical document can I create and export using Practice Fusion? 
Practice Fusion currently offers the ability to create and export Continuity of Care documents that utilize the CCDA clinical document framework. CCDA documents can be formatted according to various document templates, such as the Continuity of Care document (CCD) template or the Referral Note document template.

2. What data is included in each section of a Continuity of Care document (CCD)?
The table below outlines the different sections contained in each exported CCD, including information on the data elements contained in each section. Providers who want to customize the type of data included in exported records can use the checkboxes available within the clinical document generator to include or remove certain sections of data.

CCD section name

Data elements included in section

Patient details & demographics

  • Patient name
  • Sex
  • Date of birth
  • Race
  • Ethnicity
  • Preferred language
  • Contact information (patient address & phone number)

Provider name & contact information

  • Referring provider’s name
  • Referring provider’s office contact information

Social history

  • Current smoking status
  • Birth sex

Problem list

  • All diagnoses

Medications

  • Medications with a start date assigned

Allergies

  • Drug allergies (food and environmental allergies not included)

Immunizations

  • Administered and historical immunizations

Results (Labs)

  • Signed lab tests that have been entered in the patient chart

Vital signs

  • Height
  • Weight
  • Blood pressure
  • BMI

Only vital signs from signed encounters will be included.

Assessment & Plan

  • Text recorded in the Plan section of a SOAP note, for all signed encounters
  • Text recorded in the Care plan section of all signed encounters
  • Medications attached to signed encounters
  • Addendums for all signed encounters
  • Future scheduled lab & imaging orders attached to signed encounters
  • Future appointments scheduled for after the date of CCD generation

Referrals

  • All referrals sent using the Practice Fusion referral workflow, including recipient name, contact information and reason for referral

Procedures

  • Coded procedures, assessments and screenings entered in the Screenings/Interventions/Assessments section of any encounter

Care team

  • Care team members as entered in the Profile section of the patient chart (name only)

Encounters

  • List of all encounters for the patient, including date of service, facility location, and any diagnoses recorded and attached to the encounter note

Medical equipment

  • All Unique Device Identifiers (UDIs) for patient’s implantable devices (if any)

Functional status

  • Functional status as entered in the Observations section of any signed encounter

Mental (Cognitive) status

  • Cognitive status as entered in the Observations section of any signed encounter

Goals

  • All active goals

Health concerns

  • All free-text health concerns
  • Health concerns associated with an allergy or diagnosis 



Charting

  1. How do I search for patients in the EHR?
  2. How do I customize my patient chart view?
  3. How do I complete a chart note?
  4. How do I use rich text editing when charting my encounters?
  5. How do I add diagnoses to a patient chart?
  6. How do I add a medication?
  7. How do I use flowsheets?
  8. How can I preview previous encounters and results while completing an encounter?
  9. How do I print a patient's chart or certain sections of the patient's chart?
  10. How do I print a chart note?
  11. How do I add past medical history (PMH), allergies, medications and diagnoses to an encounter?
  12. How to record and print patient demographics and profile
  13. What information is available in a patient's Timeline?
  14. How do I use the growth charts?
  15. How do I merge duplicate charts?
  16. How do I print the care plan?
  17. How do I open an existing patient chart?
  18. Can vitals be added in Metric Units or US Customary Units?
  19. How do I add advanced directives?
  20. How do I add allergies?
  21. How can I edit my signed chart note?
  22. How do I add Family Health History?
  23. What is the difference between a SOAP and Simple note?
  24. What are the Character Limits when Charting?
  25. What are the limits of simultaneous editing?
  26. What are Screenings/Interventions/Assessments?
  27. Where can I learn more about the different components of an encounter?
  28. How do I delete or deactivate a patient?
  29. How do I edit information on the Patient Summary?
  30. How can I view Diagnosis comments?
  31. How do I search for inactive patients?
  32. What are Clinical Decision Support (CDS) advisories?
  33. How do I change the date in an encounter?
  34. How do I populate the list of Frequently prescribed medications?
  35. How do I view more information for medications?
  36. Why am I receiving the error "Unable to sign" when trying to sign a chart note?
  37. How do I delete an unsigned encounter?
  38. Who can sign a chart note?
  39. How do you change the 'Seen by' provider in the new encounter?
  40. How do I add a patient?
  41. What information is required to save a patient's chart?
  42. How do I create a patient record number?
  43. How do I edit an existing SOAP or Simple Note?
  44. How do I record "Unknown Family History?"
  45. How do I pull history from one patient visit to the next?
  46. How do I refresh a patient's chart?
  47. How do I start a new note/encounter in Practice Fusion?
  48. How do I create and export a Continuity of Care (CCD) clinical document?
  49. What is the file size of a patient image?
  50. Can I move a Patient Record Number from one chart to another?
  51. How do I view or update a patient's appointment within their chart?
  52. How do I add a custom medication?
  53. How many charts can be open and how do I close them simultaneously?
  54. How do I assign a Care Team?
  55. How do I add vitals to flowsheets?
  56. How do I customize my template line settings?
  57. How do I set my patient list and Timeline default?
  58. How do I attach a document to an encounter?
  59. How do I create and update "My Dx List"?
  60. How do I add custom allergies?
  61. How do I participate in the Prolia® Safety Program?
  62. How do I document patient risk score?
  63. How do I document an implantable device?
  64. How do I document social history?
  65. How do I add Goals and Health Concerns to the patient Summary?
  66. Why am I seeing CCDA display errors?
  67. How do I manage display settings for inbound CCDAs?
  68. How do I add new Encounter Types?

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