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 provider and practice information.
The Table of Contents is a good way to see the data included in the CCDA file. This information is pulled in 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
The next piece of encounter data is from the clinical note. This will include only the text from the clinical note. Free draw images are NOT included with the CCDA. You can export the clinical notes that contain the images if needed.
The clinical note data contains:
- Text of the clinical note
- Vital signs taken during the visit
- ICD-10, CPT, and HCPCS codes
- Medications Prescribed
- Medications and Allergies
Family History information can be entered in 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. Immunizations
Immunization data can be entered in 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.
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 an prescription through the send eRx feature on the web or EHR app
Plan of Care
The Plan of Care data is populated by
- Some data from the clinical note
- Care plan data entered in the patient's chart by scrolling down to the Care Plan section under the Clinical Dashboard tab.
- 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.
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, procedures 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 through 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.
Vital Signs data can be entered in the appointment window, in the clinical note, or through the iPhone or iPad EHR app.