C-CDA Sections Overview¶
Introduction to C-CDA Sections¶
Sections are the fundamental building blocks of C-CDA documents. Each section represents a specific category of clinical information and contains:
- Narrative text - Human-readable HTML table or formatted text
- Structured entries - Machine-processable coded data
- Template IDs - Conformance identifiers
- Section metadata - Title, code, and author information
Section Structure¶
Every C-CDA section follows this pattern:
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" displayName="Problem List"/>
<title>Problems</title>
<text>
<!-- Narrative HTML content -->
<table>
<thead><tr><th>Problem</th><th>Status</th><th>Date</th></tr></thead>
<tbody><tr><td>Type 2 Diabetes</td><td>Active</td><td>2020-03-15</td></tr></tbody>
</table>
</text>
<entry>
<!-- Structured clinical data -->
<observation classCode="OBS" moodCode="EVN">...</observation>
</entry>
</section>
All 39 C-CDA Sections¶
ccdakit implements 39 sections from C-CDA Release 2.1. Sections are organized into four categories based on their clinical purpose and usage patterns.
Core Clinical Sections¶
These 9 sections form the backbone of most clinical documents. They contain essential patient information required for care coordination and continuity.
1. Problems Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.5.1 LOINC Code: 11450-4
Active and historical diagnoses, conditions, and health concerns.
Use Cases: Current problem list, chronic conditions, active diagnoses Key Data: Problem name, SNOMED/ICD-10 codes, onset date, status Common In: CCD, Consultation Notes, Discharge Summaries
2. Medications Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.1.1 LOINC Code: 10160-0
Current and historical medication therapy including prescriptions and over-the-counter medications.
Use Cases: Medication list, drug therapy documentation Key Data: Medication name, RxNorm code, dosage, route, frequency, status Common In: CCD, Progress Notes, Discharge Summaries
3. Allergies Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.6.1 LOINC Code: 48765-2
Allergies, adverse reactions, and intolerances to medications, foods, and environmental factors.
Use Cases: Allergy documentation, contraindication tracking Key Data: Allergen, reaction, severity, status, onset date Common In: CCD, Pre-procedure documentation, Medication reconciliation
4. Immunizations Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.2.1 LOINC Code: 11369-6
Vaccination history including administered vaccines and refusals.
Use Cases: Immunization records, vaccine compliance Key Data: Vaccine name, CVX code, administration date, status, lot number Common In: CCD, School health records, Travel medicine
5. Vital Signs Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.4.1 LOINC Code: 8716-3
Clinical measurements including blood pressure, temperature, pulse, respiratory rate, height, weight, and BMI.
Use Cases: Vital signs documentation, trending, monitoring Key Data: Observation type, value, unit, timestamp Common In: Progress Notes, Emergency Department Notes, All encounters
6. Procedures Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.7.1 LOINC Code: 47519-4
Surgical and diagnostic procedures performed or planned.
Use Cases: Procedure history, surgical documentation Key Data: Procedure name, CPT/SNOMED code, date, status, provider Common In: Operative Notes, Procedure Notes, CCD
7. Results Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.3.1 LOINC Code: 30954-2
Laboratory, radiology, and other diagnostic test results organized into panels.
Use Cases: Lab results, diagnostic imaging findings Key Data: Test name, LOINC code, result value, reference range, interpretation Common In: Lab Reports, CCD, Diagnostic Reports
8. Social History Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.17 LOINC Code: 29762-2
Social determinants of health including smoking status, occupation, education, and living situation.
Use Cases: Social history documentation, risk assessment Key Data: Smoking status, alcohol use, occupation, social circumstances Common In: History and Physical, CCD, Comprehensive assessments
9. Encounters Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.22.1 LOINC Code: 46240-8
Healthcare encounters including visits, admissions, and telehealth sessions.
Use Cases: Encounter history, visit documentation Key Data: Encounter type, date, location, providers, diagnoses Common In: CCD, Transfer Summaries, Care summaries
Extended Clinical Sections¶
These 9 sections provide additional clinical detail for comprehensive patient documentation.
10. Past Medical History Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.20 LOINC Code: 11348-0
Historical diagnoses, conditions, and significant past illnesses.
Use Cases: Historical problem documentation, baseline health status Key Data: Past conditions, resolution dates, historical context Common In: History and Physical, Consultation Notes
11. Family History Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.15 LOINC Code: 10157-6
Family member health conditions and genetic risk factors.
Use Cases: Hereditary risk assessment, genetic counseling Key Data: Relationship, age, conditions, age at onset Common In: History and Physical, Genetic counseling notes
12. Functional Status Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.14 LOINC Code: 47420-5
Physical abilities, activities of daily living (ADLs), and functional assessments.
Use Cases: Disability assessment, rehabilitation planning Key Data: ADL status, IADL status, mobility, self-care abilities Common In: Rehabilitation notes, Long-term care documentation
13. Mental Status Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.56 LOINC Code: 10190-7
Cognitive function, psychological state, and mental competency observations.
Use Cases: Cognitive assessment, mental health documentation Key Data: Cognitive status, affect, orientation, memory Common In: Psychiatric evaluations, Geriatric assessments
14. Goals Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.60 LOINC Code: 61146-7
Patient health goals and treatment objectives.
Use Cases: Care planning, patient engagement, outcome tracking Key Data: Goal description, target date, priority, status Common In: Care plans, Chronic disease management
15. Health Concerns Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.58 LOINC Code: 75310-3
Clinical concerns requiring attention and ongoing management.
Use Cases: Problem tracking, care coordination Key Data: Concern description, status, related observations Common In: Care plans, Consultation notes
16. Medical Equipment Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.23 LOINC Code: 46264-8
Implanted devices and durable medical equipment.
Use Cases: Device tracking, equipment documentation Key Data: Device name, UDI, implant date, status Common In: CCD, Operative notes, Device registries
17. Advance Directives Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.21.1 LOINC Code: 42348-3
Living wills, healthcare proxies, and resuscitation preferences.
Use Cases: End-of-life planning, legal directives Key Data: Directive type, custodian, effective dates Common In: CCD, Admission documentation, Care plans
18. Plan of Treatment Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.10 LOINC Code: 18776-5
Planned procedures, medications, observations, and interventions.
Use Cases: Treatment planning, pending orders Key Data: Planned activities, intent, scheduling Common In: Care plans, Consultation notes, Progress notes
Specialized/Administrative Sections¶
These 11 sections support specific clinical scenarios and administrative requirements.
19. Assessment and Plan Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.9 LOINC Code: 51847-2
Clinical assessment and treatment plan combined.
Use Cases: SOAP note documentation, clinical reasoning Key Data: Assessment findings, plan items, clinical reasoning Common In: Progress Notes, SOAP notes, Outpatient visits
20. Chief Complaint and Reason for Visit Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.13 LOINC Code: 46239-0
Patient's presenting complaint and provider's reason for visit.
Use Cases: Visit documentation, chief complaint capture Key Data: Complaint text, reason for visit Common In: Emergency Department notes, Urgent care visits
21. Reason for Visit Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.12 LOINC Code: 29299-5
Provider's documentation of visit purpose.
Use Cases: Visit justification, billing support Key Data: Reason text (narrative only) Common In: Consultation notes, Specialty visits
22. Physical Exam Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.27 LOINC Code: 29545-1
Physical examination findings organized by body system.
Use Cases: Exam documentation, clinical assessment Key Data: System findings, wound observations, exam results Common In: History and Physical, Progress notes
23. Nutrition Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.57 LOINC Code: 61144-2
Dietary requirements, nutritional status, and diet orders.
Use Cases: Diet planning, nutritional assessment Key Data: Nutritional status, diet orders, restrictions Common In: Nutrition assessments, Hospital orders
24. Interventions Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.60 LOINC Code: 62387-6
Actions taken to address health concerns and achieve goals.
Use Cases: Care coordination, barrier removal Key Data: Intervention type, status, effective time Common In: Care plans, Social work notes
25. Health Status Evaluations and Outcomes Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.61 LOINC Code: 11383-7
Patient health status and outcomes of interventions.
Use Cases: Outcome tracking, quality measurement Key Data: Status codes, outcome values, effectiveness Common In: Quality reports, Outcome assessments
26. Payers Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.18 LOINC Code: 48768-6
Insurance coverage and payer information.
Use Cases: Billing, insurance verification Key Data: Payer name, member ID, coverage dates Common In: CCD, Registration documents
27. Hospital Discharge Instructions Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.41 LOINC Code: 8653-8
Instructions provided to patient at hospital discharge.
Use Cases: Discharge planning, patient education Key Data: Instruction text, categories, follow-up Common In: Discharge Summaries, Hospital discharge documentation
28. Discharge Medications Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.11.1 LOINC Code: 10183-2
Medications prescribed or discontinued at discharge.
Use Cases: Medication reconciliation, discharge orders Key Data: Same as Medications Section Common In: Discharge Summaries, Transfer documentation
29. Admission Medications Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.44 LOINC Code: 42346-7
Medications patient was taking at admission.
Use Cases: Medication reconciliation, admission documentation Key Data: Same as Medications Section Common In: History and Physical, Admission notes
Hospital and Surgical Sections¶
These 10 sections are specifically designed for hospital workflows, surgical documentation, and discharge summaries.
30. Admission Diagnosis Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.43 LOINC Code: 46241-6
Diagnoses identified at hospital admission.
Use Cases: Hospital admission documentation, diagnosis reconciliation Key Data: Diagnosis name, SNOMED/ICD-10 codes, admission date, diagnosis date Common In: Discharge Summaries, Hospital admission notes
31. Discharge Diagnosis Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.24 LOINC Code: 11535-2
Final diagnoses at hospital discharge.
Use Cases: Discharge documentation, billing, diagnosis reconciliation Key Data: Diagnosis name, SNOMED/ICD-10 codes, status, discharge disposition, priority Common In: Discharge Summaries, Hospital discharge notes
32. Hospital Course Section¶
Template ID: 1.3.6.1.4.1.19376.1.5.3.1.3.5 LOINC Code: 8648-8
Narrative description of patient's hospital stay from admission to discharge.
Use Cases: Hospital stay documentation, handoff communication Key Data: Narrative text describing daily hospital course, events, interventions Common In: Discharge Summaries, Transfer summaries
33. Instructions Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.45 LOINC Code: 69730-0
General patient instructions and education materials.
Use Cases: Patient education, instruction documentation Key Data: Instruction text, instruction type codes, patient education materials Common In: Discharge Summaries, Procedure notes, Patient education documents
34. Anesthesia Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.25 LOINC Code: 59774-0
Anesthesia procedures and medications administered during surgery.
Use Cases: Operative documentation, anesthesia records Key Data: Anesthesia type, agents used, route, start/end times, performer Common In: Operative Notes, Procedure Notes
35. Postoperative Diagnosis Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.35 LOINC Code: 10218-6
Diagnoses identified or confirmed during surgery.
Use Cases: Surgical documentation, operative findings Key Data: Postoperative diagnosis narrative text Common In: Operative Notes, Surgical procedure notes
36. Preoperative Diagnosis Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.34 LOINC Code: 10219-4
Diagnoses assigned before surgery.
Use Cases: Surgical planning, operative documentation Key Data: Diagnosis name, SNOMED/ICD-10 codes, status, diagnosis date Common In: Operative Notes, Pre-procedure documentation
37. Complications Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.37 LOINC Code: 55109-3
Complications that occurred during or after procedures.
Use Cases: Complication tracking, quality monitoring Key Data: Complication name, severity, onset date, status, related procedure Common In: Operative Notes, Procedure Notes, Discharge Summaries
38. Hospital Discharge Studies Summary Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.16 LOINC Code: 11493-4
Summary of diagnostic studies performed during hospitalization.
Use Cases: Discharge documentation, test result summary Key Data: Study panels, individual studies, results, interpretations, reference ranges Common In: Discharge Summaries, Hospital documentation
39. Medications Administered Section¶
Template ID: 2.16.840.1.113883.10.20.22.2.38 LOINC Code: 29549-3
Medications actually administered during an encounter or procedure.
Use Cases: Medication administration records, procedure documentation Key Data: Medication name, dose, route, administration time, rate, site, performer Common In: Operative Notes, Procedure Notes, Medication administration records
Section Categories Explained¶
Core Clinical Sections¶
The essential information needed for continuity of care. These sections appear in most document types and form the foundation of the CCD (Continuity of Care Document).
Typical documents: CCD, Consultation Notes, Transfer Summaries
Extended Clinical Sections¶
Additional clinical detail that provides comprehensive patient context. Used when more complete documentation is required.
Typical documents: History and Physical, Comprehensive assessments, Care plans
Specialized/Administrative Sections¶
Context-specific sections for particular clinical scenarios or administrative requirements. Not all documents need these sections.
Typical documents: Discharge Summaries, SOAP notes, Specific note types
Hospital and Surgical Sections¶
Sections specifically designed for hospital workflows, surgical procedures, and discharge documentation. Essential for operative notes and discharge summaries.
Typical documents: Discharge Summaries, Operative Notes, Procedure Notes, Hospital documentation
How Sections Fit Into Documents¶
Document Structure Hierarchy¶
ClinicalDocument (root)
├── Header (patient, providers, metadata)
└── Body
└── structuredBody
├── Section (e.g., Problems)
│ ├── Narrative text
│ └── Entries (structured data)
├── Section (e.g., Medications)
│ ├── Narrative text
│ └── Entries
└── [Additional sections...]
Document Type Requirements¶
Different C-CDA document types require different section combinations:
Continuity of Care Document (CCD): - REQUIRED: Allergies, Medications, Problems, Results (if available) - RECOMMENDED: Immunizations, Vital Signs, Procedures, Social History
Discharge Summary: - REQUIRED: Hospital Discharge Diagnosis, Discharge Medications - RECOMMENDED: Chief Complaint, Hospital Course, Discharge Instructions
History and Physical: - REQUIRED: Chief Complaint, History of Present Illness, Physical Exam - RECOMMENDED: Past Medical History, Family History, Social History
Consult the Document Type Matrix (see Document Types guide for details) for complete requirements.
Common Section Patterns¶
Narrative + Entries Pattern¶
Most sections follow this pattern: - Human-readable narrative (HTML) - Machine-processable entries (XML) - Both must represent the same information
from ccdakit import ProblemsSection
section = ProblemsSection(
problems=problem_list, # Generates both narrative and entries
version=CDAVersion.R2_1
)
Narrative-Only Sections¶
Some sections contain only narrative text: - Reason for Visit - Chief Complaint and Reason for Visit (when simple)
Organizer-Based Sections¶
Some sections use organizers to group related observations: - Results (lab panels) - Vital Signs (vital sign sets) - Functional Status (ADL assessments)
Timeline Sections¶
Sections documenting events over time: - Encounters - Procedures - Immunizations
Implementation Guide¶
Getting Started¶
- Identify required sections for your document type
- Prepare your data according to protocol requirements
- Create section instances using ccdakit builders
- Add sections to document in recommended order
- Validate output against C-CDA specifications
Best Practices¶
Section Ordering: - Follow conventional ordering (Problems, Medications, Allergies first) - Group related sections together - Place administrative sections last
Data Quality: - Use proper code systems (SNOMED, LOINC, RxNorm) - Include dates and times with appropriate precision - Provide narrative that matches structured data
Validation: - Test with NIST validator - Verify template IDs match specification version - Check narrative/entry consistency
Common Pitfalls¶
- Missing required data elements - Each section has specific requirements
- Incorrect code systems - Use specified terminologies (LOINC for sections, SNOMED for problems)
- Narrative/entry mismatches - Narrative must reflect structured entries
- Wrong template versions - Use 2.1 template IDs for C-CDA 2.1 documents
- Empty sections - Include only sections with actual data
Next Steps¶
Explore Individual Sections: - Browse sections by category above - Each section page includes implementation details and examples
Learn Common Patterns: - Code Systems - Terminologies reference - Template IDs - Complete template directory
See Complete Examples: - All Sections Example - Working code for all 39 sections - Complete Document - Full CCD implementation
Back to Guide Home: - HL7/C-CDA Guide - Return to main guide page
Need help? Each section page includes detailed implementation guidance, code examples, and common patterns. Start with the sections most relevant to your use case.