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.
Alternatively, select Exported patient records from the patient’s Timeline and click Create in the top-right corner.
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.
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.
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.
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.
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 |
|
Provider name & contact information |
|
Social history |
|
Problem list |
|
Medications |
|
Allergies |
|
Immunizations |
|
Results (Labs) |
|
Vital signs |
Only vital signs from signed encounters will be included. |
Assessment & Plan |
|
Referrals |
|
Procedures |
|
Care team |
|
Encounters |
|
Medical equipment |
|
Functional status |
|
Mental (Cognitive) status |
|
Goals |
|
Health concerns |
|