1.1 The Continuity of Care Record (CCR) is a core data set of the most relevant administrative, demographic, and clinical information facts about a patient’s healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care.
1.1.1 The CCR data set includes a summary of the patient’s health status (for example, problems, medications, allergies) and basic information about insurance, advance directives, care documentation, and the patient’s care plan. It also includes identifying information and the purpose of the CCR. (See 5.1 for a description of the CCR’s components and sections, and Annex A1 for the detailed data fields of the CCR.)
1.1.2 The CCR may be prepared, displayed, and transmitted on paper or electronically, provided the information required by this specification is included. When prepared in a structured electronic format, strict adherence to an XML schema and an accompanying implementation guide is required to support standards-compliant interoperability. The Adjunct to this specification contains a W3C XML schema and Annex A2 contains an Implementation Guide for such representation.
1.2 The primary use case for the CCR is to provide a snapshot in time containing the pertinent clinical, demographic, and administrative data for a specific patient.
1.2.1 This specification does not speak to other use cases or to workflows, but is intended to facilitate the implementation of use cases and workflows. Any examples offered in this specification are not to be considered normative.
1.3 To ensure interchangeability of electronic CCRs, this specification specifies XML codingnbsp;nbsp;nbsp;that is required when the CCR is created in a structured electronic format. This specified XML coding provides flexibility that will allow users to prepare, transmit, and view the CCR in multiple ways, for example, in a browser, as an element in a Health Level 7 (HL7) message or CDA compliant document, in a secure email, as a PDF file, as an HTML file, or as a word processing document. It will further permit users to display the fields of the CCR in multiple formats.
1.3.1 The CCR XML schema or .xsd (see the Adjunct to this specification) is defined as a data object that represents a snapshot of a patient’s relevant administrative, demographic, and clinical information at a specific moment in time. The CCR XML is not a persistent document, and it is not a messaging standard.
Note 18212;The CCR XML schema can also be used to define an XML representation for the CCR data elements, subject to the constraints specified in the accompanying Implementation Guide (see Annex A2).
1.3.2 Using the required XML schema in the Adjunct to this specification or other XML schemas that may be authorized through joints efforts of ASTM and other standards development organizations, properly designed electronic healthcare record (EHR) systems will be able to import and export all CCR data to enable automated healthcare information transmission with minimal workflow disruption for practitioners. Equally important, it will allow the interchange of the CCR data between otherwise incompatible EHR systems.
1.4 Security8212;The data contained within the CCR are patient data and, if those data arenbsp;nbsp;nbsp;identifiable, then end-to-end CCR document integrity......
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