CCDA Section Mapping
Each heading contains a list of that section's data elements, the element's location in the system, and additional notes when applicable.
Jump to Section:
Client
| Data Element | eCR Location | Field | Notes |
| NameFamily | Patient Details > Name/Address | Last Name | |
| NameGiven | Patient Details > Name/Address | First Name | |
| NameMiddle | Patient Details > Name/Address | Middle Name | |
| DateOfBirth | Patient Details > Name/Address | DOB | |
| Gender | Patient Details > Name/Address | Sex | |
| GenderDesc | Patient Details > Name/Address | Sex | |
| AddressStreet1 | Patient Details > Name/Address | Physical Address 1 | |
| AddressStreet2 | Patient Details > Name/Address | Physical Address 2 | |
| AddressCity | Patient Details > Name/Address | City | |
| AddressState | Patient Details > Name/Address | State | |
| AddressZip | Patient Details > Name/Address | Zip | |
| AddressCountry | Patient Details > Name/Address | Country | |
| Phone1Type | Patient Details > Name/Address | Mobile, Home, or Work Phone | Mobile Phone = MC Home Phone = HP Work Phone = WP |
| Phone1 | Patient Details > Name/Address | Phone Number | Phone marked as primary |
| LanguageCode | Patient Details > Additional Demographic Info | Preferred Language | |
| Race | Patient Details > Additional Demographic Info | Race 1 | LOINC mapped to value |
| RaceDesc | Patient Details > Additional Demographic Info | Race 1 description from a look up table | Description from a look up table |
| Ethnicity | Patient Details > Additional Demographic Info | Ethnicity 1, LOINC mapped to value | LOINC mapped to value |
| EthnicityDesc | Patient Details > Additional Demographic Info | Ethnicity description from a look up table | Description from a look up table |
| LanguageDesc | Patient Details > Additional Demographic Info | Preferred Language | Description from a look up table |
| OrganizationName | Administration > Facilities | Facility Name | |
| OrganizationTel | Administration > Facilities | Phone | |
| OrgAddrST1 | Administration > Facilities | Address 1 | |
| OrgAddrCity | Administration > Facilities | City | |
| OrgAddrState | Administration > Facilities | St | |
| OrgAddrZip | Administration > Facilities | Zip | |
| EmailAddress | Patient Details > Name/Address | ||
| SecondaryNameFamily | Patient Details > Additional Demographic Info > Additional Name/Alias grid | Previous Last Name | |
| SecondaryNameFamilyQualifier | Previous Last Name | Type, BR = birth | |
| SecondaryNameGiven | Patient Details > Additional Demographic Info > Additional Name/Alias grid | Previous First Name | |
| SecondaryNameGivenQualifier | Previous First Name | Type, BR = birth | |
| NameSuffix | Patient Details > Additional Demographic Info > Additional Name/Alias grid | Previous Name Suffix | |
| NamePrefix | Patient Details > Additional Demographic Info > Additional Name/Alias grid | Previous Name Prefix | |
| Phone2 | Patient Details > Name/Address | Phone Number Not Marked as Primary | |
| SecondaryRaceCode | Patient Details > Additional Demographic Info | Race 2 LOINC mapped to value | |
| SecondaryRaceDesc | Patient Details > Additional Demographic Info | Race 2 description | |
| SecondaryEthnicityCode | Patient Details > Additional Demographic Info | Ethnicity 2 | |
| SecondaryEthnicityDesc | Patient Details > Additional Demographic Info | Secondary Ethinicity description | |
| AddressUseDateLow | Patient Details > Name/Address > Physical Address | Address Start Date | |
| AddressUseDateHigh | Patient Details > Name/Address > Physical Address | Address End Date | |
| PreviousAddressType | Patient Details > Name/Address > Previous Address | Type, H=Home | |
| PreviousAddressStreet1 | Patient Details > Name/Address > Previous Address | Address | |
| PreviousAddressStreet2 | Patient Details > Name/Address > Previous Address | Address 2 | |
| PreviousAddressCity | Patient Details > Name/Address > Previous Address | City | |
| PreviousAddressState | Patient Details > Name/Address > Previous Address | State | |
| PreviousAddressZip | Patient Details > Name/Address > Previous Address | Zip Code | |
| PreviousAddressCountry | Patient Details > Name/Address > Previous Address | Country | |
| PreviousAddressUseDateLow | Patient Details > Name/Address > Previous Address | Start Date | |
| PreviousAddressUseDateHigh | Patient Details > Name/Address > Previous Address | End Date | |
| (PreviousName (Start Date)) validTime.Low | Patient Details > Additional Demographic Info > Additional Name/Alias grid | Previous Name Start Date | |
| (PreviousName (End Date)) validTime.High | Patient Details > Additional Demographic Info > Additional Name/Alias grid | Previous Name End Date |
Authors
| Data Element | eCR Location | Field | Notes |
| AssignedAuthor | This is the Individual responsible for the data; the one who is locking or modifying data or the Primary Provider. | ||
| NameFamily | Administration > User > User tab | Last Name | |
| NameGiven | Administration > User > User tab | First Name | |
| NameSuffix | Administration > Users > User | Initials | |
| Telecom | Administration > User > Contact/Provider Info | Phone | |
| AddressStreet1 | Administration > Facilities | Address 1 | For Facility associated with Staff |
| AddressStreet2 | Administration > Facilities | Address 2 | For Facility associated with Staff |
| AddressCity | Administration > Facilities | City | For Facility associated with Staff |
| AddressState | Administration > Facilities | St | For Facility associated with Staff |
| AddressZip | Administration > Facilities | Zip | For Facility associated with Staff |
| AddressCountry | Administration > Facilities | Country | For Facility associated with Staff |
| RepresentedOrganizationName | Administration > Facilities | Organization name | For Facility associated with Staff |
| Author ID (NPI number if available) | Administration > User > Contact/Provider Info | NPI | |
| EffDateLow | This is the effective date of the data, document level = current date, OR the date the data was effective/signed. | ||
| TaxonomyCode | Administration > User > Contact/Provider Info | Taxonomy |
CompofEncounter
| Data Element | eCR Location | Field | Notes |
| AdmitDate | Patient Details > Chart | Admit Date | |
| DischargeDate | Patient Details > Discharge Patient | Discharge Date | |
| DispositionCode | Discharge Reason | ||
| DispositionCodeDesc | Discharge Status |
Allergies
| Data Element | eCR Location | Field | Notes |
| AllergyCode | NewCrop | Entered Allergy | |
| AllergyDisplayName | NewCrop | Entered Allergy | |
| ReactionCode | NewCrop | Entered Allergy | One is required, multiples allowed |
| ReactionDesc | NewCrop | Reaction | One is required, multiples allowed |
| SevCode (severity of the allergy) | NewCrop | Severity | Of Entered Allergy |
| SevName (severity of the allergy) | NewCrop | Severity | Of Entered Allergy |
| StartDate | NewCrop | Start Date | Of Entered Allergy |
| StopDate | NewCrop | End Date | Of Entered Allergy |
| StatusCode | NewCrop | Status | Of Entered Allergy |
| StatusName | NewCrop | Status | Of Entered Allergy |
| TypeSNOMEDCode | NewCrop | SNOMED Code | Of Entered Allergy |
| TypeDesc | NewCrop | SNOMED Desc | Of Entered Allergy |
| CriticalityCode | NewCrop | Entered Allergy | |
| CriticalityName | NewCrop | Entered Allergy | |
| Reaction Severity Code | NewCrop | Reaction Code of Entered Allergy | Optional, multiples allowed |
| Reaction Severity Name | NewCrop | Description of Entered Allergy Reaction | Optional, multiples allowed |
Medication
| Data Element | eCR Location | Field |
| ProductCode | NewCrop | RXNORM crosswalk |
| GenericName | NewCrop | Generic name |
| ProductName | NewCrop | Name Brand |
| DoseValue | NewCrop | Dose |
| DoseUnit | NewCrop | Unit |
| AdministrationUnitAmount | NewCrop | Dose |
| AdministrationUnitName | NewCrop | Unit |
| RouteCode | NewCrop | Crosswalk Code |
| RouteCodeDisplayName | NewCrop | Route |
| Frequency | NewCrop | Frequency |
| DateStarted | NewCrop | Date prescribed |
| DateStopped | NewCrop | Stop Date |
| StatusName | NewCrop | Received from NewCrop |
| FillInstructions | NewCrop | Sig |
Problem
| Data Element | eCR Location | Field | Additional Notes |
| ProblemCode | SNOMED mapping | ||
| ProblemDescription | Diagnosis description | ||
| DateLow | Start Date | ||
| DateHigh | End Date | ||
| ProblemType | Defaults to "Complaint" | ||
| ProblemTypeTranslation | Defaults to "Complaint" |
Encounter
| Data Element | eCR Location | Field | Additional Notes |
| EncounterCode | Visit | CPT code | |
| EncounterDescription | Visit | Description | |
| EncounterCodeSystem | Visit | 2.16.840.1.113883.6.13 | |
| EncounterCodeSystemName | Visit | CPT-5 | |
| EncounterDate | Visit | Date | |
| EncounterDiagnosisCode | Visit | SNOMED mapping | |
| EncounterDiagnosisDescription | Visit | Diagnosis listed on visit | |
| EncounterDiagnosisDate | Visit | Diagnosis Start Date | |
| ServiceLocationCode | Code | For Facility of Visit | |
| ServiceLocationDisplayName | Name | For Facility of Visit | |
| ServiceLocationAddrST1 | Address | For Facility of Visit | |
| ServiceLocationAddrCity | City | For Facility of Visit | |
| ServiceLocationAddrState | St | For Facility of Visit | |
| ServiceLocationAddrZip | Zip | For Facility of Visit | |
| ServiceLocationTel | Phone | For Facility of Visit | |
| ServiceLocationTelType | Phone | For Facility of Visit | |
| ServiceLocationOrganizationName | Organization Name | For Facility of Visit | |
| ProblemTypeCode | Diagnosis Code | Mapped to Snomed | |
| ProblemTypeDesc | Dx Code Description | Of mapped Snomed Value | |
| Performer TaxonomyCode | Taxonomy | Provider of Service | |
| PerformerName.Family | Last Name | Provider of Service | |
| PerformerName.Given | First Name | Provider of Service | |
| PerformerName.Prefix | Prefix | Provider of Service | |
| PerformerTelecom.Value | Phone | Provider of Service |
Immunization
| Data Element | eCR Location | Field | Additional Notes |
| Code | Immunization Super Bill | CXV code for the Procedure | |
| CodeDesc | Immunization Super Bill | Procedure code description | |
| AdministrationDate | Immunization Super Bill | Immunization Date | |
| Status | Immunization Super Bill | Status | |
| RouteCode | Immunization Super Bill | Route Administered | Mapped to Code |
| RouteDescription | Immunization Super Bill | Route Administered | Mapped to description |
| CodeSystemName | Immunization Super Bill | Code system name mapping | |
| LotNumber | Immunization Super Bill | Number immunization super bill | |
| ManufacturerName | Immunization Super Bill | Manufacturer | |
| AdditionalNotes | Immunization Super Bill | Billing Note | |
| RefusalCode | Immunization Super Bill | From the super immunization form | |
| RefusalCodeDescription | Immunization Super Bill | Substance/Treatment Refusal | |
| DoseQuantityAmount | Immunization Super Bill | Dose Amount | |
| DoseQuantityUnit | Immunization Super Bill | Dose Unit |
Vitals
This section will be populated from vitals as visible in the patient details section, and repeats as necessary for each record found.
| Data Element | eCR Location | Field | Additional Notes |
| ProcedureNameH | Vitals Form | Vital Type | Height, Weight, Body Temp, etc |
| ResultValueH | Vitals Form | Value entered by staff | |
| DatePerformedH | Vitals Form | Measurement Date | |
| ObservationStartDateTime | Vitals Form | Measurement Date | |
| ObservationStopDateTime | Vitals Form | Measurement Date |
Social History
| Data Element | eCR Location | Field |
| Current Smoking Status | BH020 Wellness Screening Form > Tobacco tab | Do you use tobacco products? |
| Historical Smoking Status (Tobacco) | BH020 Wellness Screening Form > Tobacco tab | Have you ever used tobacco products? |
| SexAssignedAtBirth | Administration > Patient Details | Sex |
| Value | BH020 Wellness Screening Form > Tobacco tab | Value from entered Element above |
| EndDateTimeHigh | BH020 Wellness Screening Form > Tobacco tab | Date Quit |
Procedure
| Data Element | eCR Location | Field | Additional Notes |
| Code | SNOMED crosswalk to Procedure | ||
| CodeDisplayName | Procedure name | ||
| StartDateTime | Date of Service | Per Progress Note | |
| DeviceCode | Patient Details > Implantable Devices Form | Code | |
| DeviceName | Patient Details > Implantable Devices Form | Name | |
| PerformerName | Staff performing procedure | ||
| DeviceUID | Patient Details > Implantable Devices Form | UID | |
| ClinicalNote.ClinicalNotesText | FormLab form using "Progress Note" Data tag | Text from Billing Note or Clinical Note | <<Note must have the "Procedure Clinical Note" Data Tag to appear here>> |
| ClinicalNote.DateValue | FormLab form using "Progress Note" Data tag | Date of Service |
Medical Equipment
| Data Element | eCR Location | Field |
| DeviceCode | Patient Details > Implantable Devices Form | SNOMED mapping |
| DeviceName | Patient Details > Implantable Devices Form | Name of device |
| DeviceUid | Patient Details > Implantable Devices Form | UID |
| TargetSiteCode | Patient Details > Implantable Devices Form | Crosswalk from Implantable device form |
| TargetSiteDescription | Patient Details > Implantable Devices Form | from Implantable device form |
| Date | Patient Details > Implantable Devices Form | from Implantable device form |
| ServiceLocationAddrST1 | Patient Details > Implantable Devices Form | Pulls from listed outside organization |
| ServiceLocationAddrCity | Patient Details > Implantable Devices Form | Pulls from listed outside organization |
| ServiceLocationAddrState | Patient Details > Implantable Devices Form | Pulls from listed outside organization |
| ServiceLocationAddrZip | Patient Details > Implantable Devices Form | Pulls from listed outside organization |
| ServiceLocationAddrCountry | Patient Details > Implantable Devices Form | Pulls from listed outside organization |
| ServiceLocationName | Patient Details > Implantable Devices Form | Pulls from listed outside organization |
| ServiceLocationCode | Patient Details > Implantable Devices Form | Pulls from listed outside organization |
| ServiceLocationPhone | Patient Details > Implantable Devices Form | Pulls from listed outside organization |
| ServiceLocationPhoneType | Patient Details > Implantable Devices Form | Pulls from listed outside organization |
| PerformerName | Patient Details > Implantable Devices Form | Pulls from user listed as an outside provider |
| PerformerAddrST1 | Patient Details > Implantable Devices Form | Pulls from user listed as an outside provider |
| PerformerAddrCity | Patient Details > Implantable Devices Form | Pulls from user listed as an outside provider |
| PerformerAddrState | Patient Details > Implantable Devices Form | Pulls from user listed as an outside provider |
| PerformerAddrZip | Patient Details > Implantable Devices Form | Pulls from user listed as an outside provider |
| PerformerAddrCountry | Patient Details > Implantable Devices Form | Pulls from user listed as an outside provider |
| PerformerOrg | Patient Details > Implantable Devices Form | Pulls from user listed as an outside provider |
| PerformerOrgPhone | Patient Details > Implantable Devices Form | Pulls from user listed as an outside provider |
| PerformerOrgPhoneType | Patient Details > Implantable Devices Form | Pulls from user listed as an outside provider |
| PerformerRepresentedOrganizationId.Extension | Patient Details > Implantable Devices Form | Pulls from user listed as an outside provider |
| PerformerRepresentedOrganizationId.Root | Patient Details > Implantable Devices Form | Pulls from user listed as an outside provider |
Plan of Treatment
| Data Element | eCR Location | Field | Notes |
| CodeDisplayName | Care Plan Form | ||
| ScheduledDate | Care Plan Form | Date Entered | |
| NarrativeText | Care Plan Form | Plan Instructions | |
| Type | Care Plan Form | Type | |
| TypeMoodCode | Care Plan Form | Type Code | INT, PRMS, PRP, RQO |
Goal
| Data Element | eCR location | Field | Notes |
| Code | From Treatment Plan | SNOMED Crosswalk | Optional when ValueType is ST |
| Description | From Treatment Plan | Goal | Optional when ValueType is ST |
| Instructions | From Treatment Plan | Objective | |
| DateTime | From Treatment Plan | Service Plan Date |
Health Concern
| Data Element | eCR Location | Field | Notes |
| Code | TGI MU Health Concerns Form | Type | Mapped to SNOMED Code |
| Description | TGI MU Health Concerns Form | Description | |
| DateTime | TGI MU Health Concerns Form | Date |
Reason for Referral
| Data Element | eCR Location | Field |
| ReasonforReferralInfo | TGI MU3 Comprehensive Assessment/Reason for Referral tab | Reason for Referral |
Functional Status
| Data Element | eCR Location | Field |
| ConditionDecription | TGI_HQ, Health Questions form | Cognitive/Functional Status |
| ConditionCode | TGI_HQ, Health Questions form | Type |
| StartDate | TGI_HQ, Health Questions form | Start Date |
| ValueCode | TGI_HQ, Health Questions form | Cognitive/Functional Status |
| ValueDescription | TGI_HQ, Health Questions form | Type |
Mental Status
| Data Element | eCR Location | Field |
| Code | TGI_HQ, Health Questions form | Type |
| Description | TGI_HQ, Health Questions form | Cognitive/Functional Status |
| StartDate | TGI_HQ, Health Questions form | Start Date |
Clinical Notes
| Data Element | eCR Location | Field |
| ClinicalNotesText | NYDS2, Discharge Summary v2 form > Referrals tab | Aftercare and Resource Options <<Note must have the "Progress Clinical Note" Data Tag to appear here>> |
| DateValue | NYDS2, Discharge Summary v2 form > Referrals tab | Date form was entered |
Discharge Instructions
| Data Element | eCR Location |
| DischargeInstructions | Discharge Instructions Form |