Consolidated CDA (C-CDA)
3.0.0 - STU United States of America flag

Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 3.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions

Example Binary: Entry Reference Example

This content is an example of the Entry Reference Logical Model and is not a FHIR Resource

    
<!-- The Entry Reference template points to another entry elsewhere in the document

  Here, it is present wihin a health concerns section to reference a goal observation elsewhere in the document
-->
<structuredBody xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
  <component>
    <section>
      <!-- Health Concerns section code/text omitted for examlple -->
      <entry>
        <act classCode="ACT" moodCode="EVN">
          <templateId root="2.16.840.1.113883.10.20.22.4.132" extension="2022-06-01"/>
          <id root="4eab0e52-dd7d-4285-99eb-72d32ddb195c" />
          <code code="75310-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Health Concern" />
          <statusCode code="active" />
          <effectiveTime value="20130616" />
          <entryRelationship typeCode="REFR">
            <observation classCode="OBS" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2024-05-01" />
              <id root="8dfacd73-1682-4cc4-9351-e54ccea83612" />
              <code code="29308-4" 
                    codeSystem="2.16.840.1.113883.6.1" 
                    codeSystemName="LOINC" 
                    displayName="Diagnosis"/>
              <statusCode code="completed" />
              <effectiveTime>
                <low value="20130616" />
              </effectiveTime>
              <value xsi:type="CD" code="233604007" 
                    codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED" 
                    displayName="Pneumonia" />

              <!-- Location of EntryReference within the Health Concern Act -->
              <entryRelationship typeCode="SPRT">

                <!-- This is the primary example of the entry reference template -->
                <act classCode="ACT" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.22.4.122" />
                  <!-- This ID equals the ID of the goal of a pulse ox greater than 92% -->
                  <id root="3700b3b0-fbed-11e2-b778-0800200c9a66" />
                  <!-- The code is nulled to "NP" Not Present" -->
                  <code nullFlavor="NP" />
                  <statusCode code="completed" />
                </act>
              </entryRelationship>
            </observation>
          </entryRelationship>
        </act>
      </entry>
    </section>
  </component>

  <!-- Elsewhere in the document -->
  <component>
    <section>
      <entry>
        <!--
          This is an observation about the expected outcome of a pulse ox reading
            of 92 or greater.  The Id is the same as the ID as the ID of the
            entry reference in the pneumonia problem above  -->

        <observation classCode="OBS" moodCode="GOL">
          <id root="3700b3b0-fbed-11e2-b778-0800200c9a66" />
          <code code="59408-5" 
                codeSystem="2.16.840.1.113883.6.1" 
                codeSystemName="LOINC" 
                displayName="Oxygen saturation in Arterial blood by Pulse oximetry"/>
          <statusCode code="active" />
          <value xsi:type="IVL_PQ">
            <low value="92" unit="%" />
          </value>
          <!-- 
          There could be another Entry Reference here referring to the 
                  related health concern, actual outcome, or intervention
          ... -->
        </observation>
      </entry>
    </section>
  </component>  
</structuredBody>