CDA Examples
1.0.0 - active
CDA Examples
1.0.0 - active
CDA Examples, published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-Examples/ and changes regularly. See the Directory of published versions
This is an example of a hospitalization with discharge diagnoses. Meaningful Use requires a place to document encounter diagnoses, and this example attempts to satisfy. This example aligns with QRDA suggestion to use a Rank Observation for Principal diagnosis.
This file includes examples of the following templates:
<section xmlns="urn:hl7-org:v3">
<!-- Created for discussion on SDWG CDA Example Task Force. -->
<!-- This is an example of a hospitalization as may be shown in encounters section. -->
<!-- This example demonstrates how billable diagnoses could be included, if they are available -->
<templateId root="2.16.840.1.113883.10.20.22.2.22.1"/>
<templateId root="2.16.840.1.113883.10.20.22.2.22.1"
extension="2015-08-01"/>
<id root="6bc0419f-0398-4a56-8642-7054cbef448c"/>
<code displayName="Encounters" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="46240-8"/>
<title>Encounters</title>
<text>
<table>
<thead>
<tr>
<th>Encounter Type</th>
<th>Provider</th>
<th>Primary Diagnosis</th>
<th>Other Diagnoses</th>
<th>Start Date</th>
<th>End Date</th>
<th>Location</th>
<th>Discharge Disposition</th>
</tr>
</thead>
<tbody>
<tr ID="Encounter1">
<td ID="Enc1_Type">Inpatient</td>
<td>James Getwell, DO</td>
<td ID="Enc1_Dx1">Congestive Heart Failure</td>
<td>
<content ID="Enc1_Dx2">Diabetes</content>
</td>
<td>10/28/2014 12:22pm</td>
<td>10/31/2014 3:04pm</td>
<td>Good Day Hospital (878)378-0909 1002 Healthcare Dr., Portland, OR, 97005</td>
<td>Nursing Home</td>
</tr>
</tbody>
</table>
</text>
<entry>
<encounter moodCode="EVN" classCode="ENC">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<templateId root="2.16.840.1.113883.10.20.22.4.49"
extension="2015-08-01"/>
<id root="248b2c03-2013-e138-07d1-001A64958C30"/>
<!-- CPT code should be used for ambulatory visits, but for a hosptialization, another codeSystem is more appropriate -->
<code
displayName="Hospital inpatient or observation discharge day management; 30 minutes or less on the date of the encounter" codeSystem="2.16.840.1.113883.6.12" code="99238">
<originalText>
<reference value="#Enc1_Type"/>
</originalText>
<translation xsi:type="CD" displayName="Inpatient"
codeSystemName="Act Encounter Code - Act Code" codeSystem="2.16.840.1.113883.5.4" code="IMP"/>
</code>
<text>
<reference value="#Encounter1"/>
</text>
<!-- for a hospitalization, the low and high effectiveTimes would logically be admission and discharge date/time. -->
<effectiveTime>
<low value="20141028122200-0500"/>
<high value="20141031150400-0500"/>
</effectiveTime>
<!-- Note that sdtc extension is used to document dischargeDisposition in encounters -->
<sdtc:sdtcDischargeDispositionCode xmlns:sdtc="urn:hl7-org:sdtc"
displayName="Discharged/Transferred to a Facility that Provides Custodial or Supportive Care" codeSystemName="NUBC UB-04 FL17"
codeSystem="2.16.840.1.113883.6.301.5" code="04"/>
<performer typeCode="PRF">
<time>
<low value="20141028122200-0500"/>
<high value="20141031150400-0500"/>
</time>
<assignedEntity classCode="ASSIGNED">
<id root="2.16.840.1.113883.4.6" extension="12345679"/>
<code displayName="Allopathic & Osteopathic Physicians"
codeSystemName="ProviderCodes" codeSystem="2.16.840.1.113883.6.101" code="200000000X"/>
<addr use="WP">
<streetAddressLine>763 Horseshoe Rd</streetAddressLine>
<city>Gotham</city>
<state>OR</state>
<postalCode>98764</postalCode>
</addr>
<telecom value="tel:+1(814)788-8000" use="WP"/>
<assignedPerson determinerCode="INSTANCE" classCode="PSN">
<name>
<given>James</given>
<family>Getwell</family>
<suffix>DO</suffix>
</name>
</assignedPerson>
</assignedEntity>
</performer>
<participant typeCode="LOC">
<!-- Service Delivery Location Template -->
<participantRole classCode="SDLOC">
<templateId root="2.16.840.1.113883.10.20.22.4.32"/>
<code displayName="Medical-Surgical Ward"
codeSystemName="Healthcare Service Location" codeSystem="2.16.840.1.113883.6.259" code="1061-1"/>
<addr use="WP">
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97005</postalCode>
</addr>
<telecom value="tel:+1(878)378-0909" use="WP"/>
<playingEntity determinerCode="INSTANCE" classCode="PLC">
<name>Good Day Hospital</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ">
<!-- This is the primary diagnosis on the bill -->
<!-- Hospital discharge diagnosis act -->
<act moodCode="EVN" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.33"/>
<templateId root="2.16.840.1.113883.10.20.22.4.33"
extension="2015-08-01"/>
<id root="1d7ff347-9dce-44db-8f66-fc17d8dc4aca"/>
<code displayName="Hospital Discharge Diagnosis"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="11535-2"/>
<statusCode code="active"/>
<!-- This represents the time that the concern was authored. Since this is a hospital discharge diagnosis, this is when it was coded -->
<effectiveTime>
<low value="20141102145806-0500"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<!-- Problem Observation -->
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2024-05-01"/>
<id root="20cdd1a0-6136-4939-802f-edfebe9320bc"/>
<!-- We'll use the type of diagnosis, since this is a coded diagnosis, not from problem list -->
<code xsi:type="CD" displayName="Diagnosis interpretation"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="282291009">
<translation xsi:type="CD" displayName="Diagnosis"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
code="29308-4"/>
</code>
<text xsi:type="ED">
<reference value="#Enc1_Dx1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<!-- This represents the date of biological onset. Since this is a coded diagnosis, this may not be documented. -->
<low nullFlavor="UNK"/>
</effectiveTime>
<!-- QRDA R5.2: Updated to use Rank Observation to indicate Principal Diagnosis. There is generally only a single diagnosis for coded bill. -->
<!-- priorityCode is No longer recommended to indicate principal diagnosis -->
<!-- <priorityCode code="63161005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Principal"/> -->
<!-- This is a hospital discharge diagnosis, so the ICD-9 (or ICD-10) diagnosis is in translation. -->
<!-- If a SNOMED is available for this, it could be included, but mapping back from ICD-9 may not always be possible. -->
<value xsi:type="CD" nullFlavor="OTH">
<originalText>
<reference value="#Enc1_Dx1"/>
</originalText>
<translation xsi:type="CD"
displayName="Congestive heart failure, unspecified" codeSystemName="ICD-9"
codeSystem="2.16.840.1.113883.6.103" code="428.0"/>
</value>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20141031"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="99999999"/>
<code
displayName="Allopathic & Osteopathic Physicians; "Neuromusculoskeletal Medicine, Sports Medicine"" codeSystemName="Health Care Provider Taxonomy"
codeSystem="2.16.840.1.113883.6.101" code="204C00000X"/>
<addr nullFlavor="UNK"/>
<telecom value="tel:555-555-1002" use="WP"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<!-- QDM Attribute: Diagnosis - Rank (Principal diagnosis is indicated with a rank of 1 -->
<entryRelationship typeCode="REFR">
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.24.3.166"
extension="2019-12-01"/>
<code xsi:type="CD" displayName="Rank"
codeSystem="2.16.840.1.113883.6.96" code="263486008"/>
<value xsi:type="INT" value="1"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entryRelationship>
<entryRelationship typeCode="SUBJ">
<!-- Hospital discharge diagnosis act -->
<act moodCode="EVN" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.33"/>
<templateId root="2.16.840.1.113883.10.20.22.4.33"
extension="2015-08-01"/>
<id root="f07886ea-7879-478e-8155-5c2cce5cba6a"/>
<code displayName="Hospital Discharge Diagnosis"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="11535-2"/>
<statusCode code="active"/>
<!-- This represents the time that the concern was authored. Since this is a hospital discharge diagnosis, this is when it was coded -->
<effectiveTime>
<low value="20141102145806-0500"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<!-- Problem Observation -->
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2024-05-01"/>
<id root="5f9b714d-a6ec-4f8f-95ae-ea75e5a54bac"/>
<!-- We'll use the type of diagnosis, since this is a coded diagnosis, not from problem list -->
<code xsi:type="CD" displayName="Diagnosis interpretation"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="282291009">
<translation xsi:type="CD" displayName="Diagnosis"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
code="29308-4"/>
</code>
<text xsi:type="ED">
<reference value="#Enc1_Dx2"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<!-- This represents the date of biological onset. Since this is a coded diagnosis, this may not be documented. -->
<low nullFlavor="UNK"/>
</effectiveTime>
<!-- QRDA R5.2: Updated to use Rank Observation to indicate Secondary Diagnosis. priorityCode is No longer recommended. -->
<!-- <priorityCode code="2603003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Secondary"/> -->
<!-- This is a hospital discharge diagnosis, so the ICD-9 (or ICD-10) diagnosis is in translation. -->
<!-- If a SNOMED is available for this, it could be included, but mapping back from ICD-9 may not always be possible. -->
<value xsi:type="CD" nullFlavor="OTH">
<originalText>
<reference value="#Enc1_Dx2"/>
</originalText>
<translation xsi:type="CD"
displayName="Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled" codeSystemName="ICD-9"
codeSystem="2.16.840.1.113883.6.103" code="250.00"/>
</value>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20141031"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="99999999"/>
<code
displayName="Allopathic & Osteopathic Physicians; "Neuromusculoskeletal Medicine, Sports Medicine"" codeSystemName="Health Care Provider Taxonomy"
codeSystem="2.16.840.1.113883.6.101" code="204C00000X"/>
<addr nullFlavor="UNK"/>
<telecom value="tel:555-555-1002" use="WP"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<!-- Diagnosis - Rank (Secondary diagnosis is indicated with a rank of 2) -->
<!-- This denotes that the diagnosis is a secondary diagnosis. There may be multiple secondary diagnoses on coded bills. -->
<entryRelationship typeCode="REFR">
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.24.3.166"
extension="2019-12-01"/>
<code xsi:type="CD" displayName="Rank"
codeSystem="2.16.840.1.113883.6.96" code="263486008"/>
<value xsi:type="INT" value="2"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entryRelationship>
</encounter>
</entry>
</section>
IG © Health Level Seven. Package hl7.cda.examples#1.0.0 based on FHIR 5.0.0. Generated 2025-08-28
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