Table 1.

Relevance of Clinical Domains in C-CDA documents Tested as Part of Certification

Domain	C-CDA 2.1 Location	Relevance for Interoperability and Clinical Use
Patient Name	Document header	Patient identification and matching
Sex (administrative and birth sex)	Document header and structured section (social history)	Patient matching and gender related care
Date of Birth	Document header	Patient matching and age calculation. Common eligibility criteria for quality measures
Race and Ethnicity	Document header	Race related medical decisions. Common stratification criteria for quality measures
Preferred Language	Document header	Patient communication
Care Team Members	Document header	Care team coordination
Drug Allergies	Structured section (allergies)	Drug-allergy checking. Common exclusion criteria for quality measures
Heath Concerns	Structured section (health concerns)	Patient risk factors
Immunizations	Structured section (immunizations)	Preventative care. Common quality measure criteria
Implanted Devices	Structured section (equipment)	Prior medical history
Medications	Structured section (medications)	Prior and current therapies. Used in medication reconciliation. Common quality measure criteria
Laboratory Tests & Values	Structured section (results)	Objective assessments of organ systems. Common quality measure criteria
Patient Goals	Structured section (goals)	Desired care outcomes
Plan of Treatment	Structured section (plan of treatment)	Planned care activities
Problems	Structured sections (problems and encounter diagnoses)	Prior and current diagnostic history. Common eligibility criteria for quality measures
Procedures	Structured section (procedures)	Prior and current medical interventions. Common quality measure criteria
Smoking Status	Structured section (social history)	Prior and current social history. Common quality measure criteria
Vital Signs	Structured section (vital signs)	Objective assessments for patient health and dosing. Common quality measure criteria