CCDA Templates Used in athenaOne
Note: For more information about summary of care records in CCDA format, see Summary of Care Record/Continuity of Care Document.
The government has defined structured CCDA document templates to store patient health data, so that the data is readable on all systems. To ensure electronic health record interoperability, athenahealth creates CCDA documents that are compliant with the content and formatting standards set forth by the Office of the National Coordinator (ONC).
athenaOne uses the following standard CCDA templates.
Care plan document template
The care plan document template is used when you create a document from the care plan in athenaClinicals (see athenaClinicals Care Plan).
The CCDA care plan document template includes the following sections:
- Patient Demographics
- Care Team Members
- Health Concerns
- Goals
- Health Status and Evaluations
- Interventions
Continuity of care template
The continuity of care template is used when patients retrieve their health history using the My health / Health Records page on the Patient Portal (or the Patient Information Center). For more information, see To download and transmit health records from the Patient Portal or the Patient Information Center.
The CCD continuity of care template includes the following sections:
- Allergies
- Assessment
- Encounters
- Family History
- Goals
- Health Concerns
- Hospital Instructions
- Immunizations
- Medical Equipment
- Medical History
- Medications
- Patient Demographics
- Plan of Treatment
- Problems
- Procedures
- Reason for Referral
- Reason for Visit
- Results
- Social History
- Vitals
Data portability template
The data portability template is used when a provider generates a patient health record using the CCDA - Manage Data Export Jobs page.
The CCDA data portability template includes the following sections:
- Allergies
- Assessment
- Care Team Members
- Devices (Medical Equipment)
- Encounters
- Family History
- Functional Status
- Goals
- Health Concerns
- Hospital Instructions
- Immunizations
- Medical History
- Medications
- Mental Status
- Patient Demographics
- Payers (Ambulatory Only)
- Plan of Treatment
- Problems
- Procedures
- Reason for Referral
- Results
- Social History
- Vitals
Discharge summary template
Note: The discharge summary template is available only if you use athenaOne for Hospitals & Health Systems.
The discharge summary template is used when a provider completes the discharge of a patient from the hospital and a summary of care record is generated and sent to the receiving provider via Direct Messaging.
The CCDA discharge summary template includes the following sections:
- Allergies
- Assessment
- Encounters
- Family History
- Goals
- Health Concerns
- History of Present Illness
- Hospital Course
- Hospital Diagnosis
- Hospital Discharge Instructions
- Hospital Discharge Medications
- Immunizations
- Medical Equipment
- Medications
- Plan of Treatment
- Problems
- Procedures
- Reason for Visit
- Results
- Social History
- Vitals
Referral note template
The referral note template is used when a provider creates a referral order that includes a transition of care document.
The CCDA referral note template includes the following sections:
- Allergies
- Assessment
- Care Team Members
- Family History
- Functional Status
- Goals
- Health Concerns
- History of Present Illness
- Immunizations
- Medical Equipment
- Medical History
- Medications
- Mental Status
- Past Encounters
- Patient Demographics
- Physical Exam
- Plan of Treatment
- Problems
- Procedures
- Reason for Referral
- Reason for Visit
- Results
- Review of Systems
- Social History
- Vitals