C-CDA Form at a Glance

Owned by Dylan Nigh
Last updated: Oct 09, 2023
7 min read

This article is for MacPractice 7.3 and earlier.

Example C-CDA Form Pg 1
Example C-CDA Form Pg 2
Example C-CDA Form Pg 3

Patient

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This will pull from the name fields on the Patient tab in the Patient ability.

 

 

 

 

 

Date of Birth

This will pull from the Birth Date field on the Patient tab in the Patient ability.

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Sex

The Sex of the patient as recorded on the Patient tab in the Patient ability.

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Race

The Race of the patient as recorded on the Patient tab in the Patient ability.

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Ethnicity

The Ethnicity of the patient as recorded on the Patient tab in the Patient ability.

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Preferred Language

The Preferred Language of the patient as recorded on the Patient tab in the Patient ability.

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Contact Info

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The Address and Phone Numbers of the patient as recorded on the Patient tab in the Patient ability.

 

 

 

 

 

 

 

Patient IDs

The ID of the patient as displayed at the top of the MacPractice window.

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Document ID

This unique ID is automatically assigned when each C-CDA is created.

Document Created

This date field is automatically filled in with the date and time that the C-CDA was created.

Author

The patient's provider as recorded on the Patient tab in the Patient ability.

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Contact Info

The office's Mailing Address and phone numbers as recorded in the Offices Reference.

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Encounter ID

This unique ID is automatically assigned when each new incident is created.

Encounter DateThis pulls from the Incident Date and Time fields within the Incident tab on the Incident menu, which is in the Ledger.

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Encounter Location

This pulls from the Facility tab on the Incident tab from the Incident menu inside of the Ledger. If the Facility tab is left blank, this pulls from the office's Mailing Address and phone numbers as recorded in the Offices Reference.

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Responsible Party

The patient's provider as recorded on the Patient tab in the Patient ability.

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Encounter Participant

This pulls from the Care Team Members as listed in the Clinical tab in the Patients ability for the selected incident.

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Document Maintained by

This pulls from the Office Name in the Offices Reference.

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Contact Info

This pulls from the Mailing Address and the Phone Numbers in the Offices Reference.

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Table of Contents

The table of contents acts as links to navigate quickly through the C-CDA.

Chief Complaint and Reason for Visit

This pulls Chief Complaint, which can be entered in two places.

The Chief Complaint section in the EHR ability.

The Chief Complaint section in the EMR/EDR ability.

Plan of Care

There are four different types of "Plan of Care"; Treatment Plans, Appointment, Planned Test, and Goal.

Treatment Plans

This pulls any codes that are listed in the Treatment Plans of ledgers for the incident selected to export.

Appointment

This pulls a list of upcoming appointments.

You will see the provider the appointment is associated with, the Office's Phone number, Office Address, and Appointment Date.

Planned Test

This pulls from Orders with the Type of Laboratory and the Status of 'Pending Results'.

You will see the test name and LOINC code for the planned tests, the Scheduled Date of the test, and the Status of the Order.

Goal

This pulls Goals, which can be entered in three places. The Set Date of the Goal will pull to the summary as well. Any text entered as Instructions will also pull into this section.

 

  1. The Goals tab on the Clinical tab in the Patient ability.

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  1. The Goals and Instructions section in the EHR ability. 

 

  1. The Clinical Instructions section in the EMR/EDR ability.

 

Social History

This pulls the Smoking Status, which can be entered in three places.

  1. The Smoking tab on the Clinical tab in the Patient ability.

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  1. The Smoking Status section in the EHR ability.

  2. The Smoking Status section in the EMR/EDR ability.

 

Problems

This pulls the Problem list that contains a patient’s Diagnosis Codes, which can be entered in three places.

  1. The Problem List tab on the Clinical tab in the Patient ability.

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  1. The Problem List section in the EHR ability.

  2. The Problem List section in the EMR/EDR ability.

 

Procedures

This pulls all charges entered on the Ledger for the selected incident. You will see the Procedure Code, Procedure Description, and Procedure Date.

Medications

This pulls Medications data, including the name of the Medications, Instructions (or the Route of Medications), the Start Date, and the Status of the Medications. This can be entered in three places.

  1. The Rx ability in the Active Medication List or via ePrescribe.

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  1. The Medications section in the EHR ability.

  2. The Medications section in the EMR/EDR ability.

Medications Administered

To ensure this box populates, double check to see that the Administered During Visit box is checked on the medication. This will pull the same information about the Medications as the above Medication section.

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Immunization

This information pulls the Immunization information, including the Vaccine name, Status, and Administered Date. This can be entered in three places.

  1. The Immunizations tab on the Clinical tab in the Patient ability.

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  2. The Immunizations section in the EHR ability.

  3. The Immunizations section in the EMR/EDR ability.

Allergies, Adverse Reactions, Alerts

This box pulls Allergy data, including the Allergy name, Reaction, Severity, Onset Date, Resolved Date, and Status. This can be entered in three places.

  1. The Allergy tab on the Clinical tab in the Patient ability.

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  2. The Allergies section in the EHR ability.

  3. The Allergies section in the EMR/EDR ability.

Vital Signs

This box pulls Vitals data, including the Date and Time the vitals were recorded, Height, Weight, BMI, Temperature, Blood Pressure, and Heart Hate. This can be entered in three places.

  1. The Vitals tab on the Clinical tab in the Patient ability.

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  1. The Vitals section in the EHR ability. 

  2. The Vitals section in the EMR/EDR ability.

Results

This pulls Lab test results from Orders of the type Laboratory within the Patients ability. This will pull from the Tests tab if using our Other Labs ability or from the Lab Result tab if using a lab interface that imports your lab results.

NOTE- lab results pulled into MacPractice from a lab interface will only display on the C-CDA if they include structured data in the form of LOINC codes, as this is the standard required format for C-CDAs.) This includes the Test Name, Date, Value, Abnormal Flag, and Normal Range.

Instructions

There are two different types of "Instructions"; free text Clinical Instructions and Patient Decision Aids.

 

The free text Clinical Instructions can be entered in two places.

 

  1. The free text box portion of the Goal and Instructions section in the EHR Ability.

 

  1. The free text box portion of the Clinical Instructions section in the EMR/EDR Ability.

 

Patient Decision Aids

This will pull Patient Educations, which can be entered in these places.

  1. The Patient Education tab on the Clinical tab in the Patient ability.

 

  1. The Patient Education tab in the EHR ability.

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