Two easy ways of viewing what is included in a CCDA export are in the patient's chart under the Clinical Dashboard section. You can select Download PDF or Display C-CDA XML.
The Patient Health Summary contains the demographic information of the patient as well as the provider, care team members (performer), and practice information. For more information on adding care team members, see our article here.
The Table of Contents is a good way to see the data included in the CCDA file. This information is pulled from the patient chart and clinical documentation. While in the PDF and Display C-CDA XML views, you can click on any section in the Table of Contents to jump to that section.
Allergies, Adverse Reactions
Allergy data can be entered on the web: in the patient's chart, in the clinical note, or through the iPad or iPhone EHR app.
The encounter data includes:
- Date of service and appointment time
- Care team members (see our article on adding care team members here)
- Reason for visit
- Encounter type
Family History information can be entered into the patient's chart on the web. Navigate to Family History on the left-side menu. Select +Add Family Member. Once the family member is added, select +Add Observation to enter the data.
Functional status assessments can be entered in the patient's chart by scrolling down to the Functional Status section under the Clinical Dashboard tab.
Mental status assessments can be entered in the patient's chart by scrolling down to the Mental Status section under the Clinical Dashboard tab.
Immunization data can be entered into the patient's chart by navigating to the Immunizations tab on the left-side menu. For information on entering immunizations see our article here.
Instructions information can be entered in the Clinical Dashboard of the patient chart. Scroll down to Care Plan under the Additional Options section. When entering the instruction details, select Patient Clinical Instructions from the Plan Type menu.
Medical Equipment information can be entered into the patient's chart on the web under the Implantable Devices section. Click Add Implantable Device, enter the device information, and Save.
Medications Administered data can be entered on the web or EHR app by selecting Administered During Visit from the Order Status dropdown menu when entering or editing medication info.
Medication data can be entered in multiple areas and ways:
- Entered medication manually in the patient's chart or clinical note on the web or EHR app
- Data sync with SureScripts or
- Reconciliation data with a CCDA import
- Sending a prescription through the send eRx feature on the web or EHR app
The Insurance Providers section is populated by the primary and secondary insurance information in the patient's chart.
The Assessments section contains any information that is entered into the assessment section of the H&P or SOAP forms. This information can be entered on the web version or through the EHR app for iPad or iPhone.
Plan of Care
Plan of care is populated by care plan data entered in the patient's chart by scrolling down to the Care Plan section under the Clinical Dashboard tab.
The Plan of Care includes:
- Patient Education
- Patient Instructions
- Pending lab tests
- Diagnostic Imaging Report (See below for further information)
- Future Appointments
Diagnostic Imaging Report data can be entered in the patient's chart by selecting the Imaging Orders tab and + Add New Order and entering the details.
Health Concerns data can be entered into the patient's chart by scrolling down to the Care Plan section under the Clinical Dashboard tab.
Goals data can be entered into the patient's chart by scrolling down to the Care Plan section under the Clinical Dashboard tab.
Problem (ICD-10) data can be entered through various paths on both the web and EHR app versions of DrChrono. Some examples are:
- Patient's chart > Problem List
- Appointment window > Billing > ICD-10 Codes
- iPhone > Patient Menu > Problems
- iPad > Visit > Assessment or Billing Information
Similar to problems, procedure data (CPT and HCPCS codes) have various points of entry in DrChrono. Some examples include
- Appointment window > Billing > CPT and/or HCPCS Codes
- Billing > Live Claims Feed > Date of Service > Line Item Transactions
- View Clinical Note > Billing
- iPad/iPhone EHR App > Visit > Billing > CPT and/or HCPCS
Lab test data is entered by sending lab orders or entering the data manually. The data can be found in the patient's chart under Lab Orders.
Lab results can be found in the patient chart under Lab Orders. Data can be entered manually or through an integration with our lab partners.
Social History data can be entered in the patient chart under Demographics > Smoking Status. Select + Add Record select the Smoking Status from the drop-down and Create. Only the most recent smoking status will be included.
Social History also includes the birth sex of the patient based on the Sex entered under the Demographics tab.
Vital Signs data can be entered in the appointment window, in the clinical note, or through the iPhone or iPad EHR app.
If pediatric vital percentiles are used, they will be included in the CCDA.