D.1 Overview The templates defined in this implementation guide, in conjunction with document-level templates from the C-CDA R2, provide a positive attestation as to the presence or absence of all relevant clinical and administrative information from a single encounter between a provider and a patient. When these documents are created by a conformant EHR, the provider is able to communicate all information relative to the encounter with the patient and assert a specific reason why information for each section is not included (see “required” section 3.4 on use of null flavors). If the provider then applies a digital signature to the document, the result is a non- repudiation declaration of the encounter information. D.2 Purpose document templates are designed for use when the provider needs to exchange a more comprehensive set of clinical information than is supported by the C-CDA R2 document-level templates and/or must declare why information for specific section-level or entry-level templates are not included. For example, payers may allow providers to submit any information they feel substantiates that a services is medically necessary and appropriate under the applicable coverage determination rules. The ability to submit any supporting documentation is a provider’s right under these rules and the ability to declare why specific information is not available which allows payers to avoid requesting additional documentation from the provider when such a request cannot be fulfilled. D.3 Document Template Use This table describes the use of one or more document templates to describe the relevant clinical information in a single encounter between a provider and patient. Table 46: Document Template Use Structured Documents Complete Documents Templates C-CDA R2 C-CDA R2 Encounter Type Complete Complete Time Complete Compete Diagnostic Unstructured Encounter Boxed Procedure Op Note Imaging Document Document Document Document Document Document Document Office Visit Base n/a n/a As Needed As Needed As Needed As Needed Consult Base n/a n/a As Needed As Needed As Needed As Needed Home Health Base n/a As Needed As Needed As Needed As Needed As Needed LTC As Needed Base Per period As Needed As Needed As Needed As Needed Hospitalization As Needed Base Per period As Needed As Needed As Needed As Needed Legend: Base primary document for this type of encounter (e.g. Complete Encounter Document) –
D.1 Overview The templates defined in this implementation guide, in conjunction with document-level templates from the C-CDA R2, provide a positive attestation as to the presence or absence of all relevant clinical and administrative information from a single encounter between a provider and a patient. When these documents are created by a conformant EHR, the provider is able to communicate all information relative to the encounter with the patient and assert a specific reason why information for each “required” section is not included (see section 3.4 on use of null flavors). If the provider then applies a digital signature to the document, the result is a non- repudiation declaration of the encounter information. D.2 Purpose document templates are designed for use when the provider needs to exchange a more comprehensive set of clinical information than is supported by the C-CDA R2 document-level templates and/or must declare why information for specific section-level or entry-level templates are not included. For example, payers may allow providers to submit any information they feel substantiates that a services is medically necessary and appropriate under the applicable coverage determination rules. The ability to submit any supporting documentation is a provider’s right under these rules and the ability to declare why specific information is not available which allows payers to avoid requesting additional documentation from the provider when such a request cannot be fulfilled. D.3 Document Template Use This table describes the use of one or more document templates to describe the relevant clinical information in a single encounter between a provider and patient. Table 46: Document Template Use Structured Documents Complete Documents Templates C-CDA R2 C-CDA R2 Encounter Type Complete Encounter Document Complete Document Time Boxed Document Complete Procedure Document Compete Op Note Document Diagnostic Imaging Document Unstructured Document Office Visit Base n/a n/a As Needed As Needed As Needed As Needed Consult Base n/a n/a As Needed As Needed As Needed As Needed Home Health Base n/a As Needed As Needed As Needed As Needed As Needed LTC As Needed Base Per period As Needed As Needed As Needed As Needed Hospitalization As Needed Base Per period As Needed As Needed As Needed As Needed Legend: Base – primary document for this type of encounter (e.g. Complete Encounter Document)
CDAR2_IG_CCDA_CDT_R1_D1_2014MAR%20V8%201.docx