CDA Examples
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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

Example: Inpatient Encounter Discharged to Rehab Location

Approval Status: Approved
Task Force Approval: 2016-11-17
SDWG Approval: 2016-02-02

This is an example of a hospitalization with discharge disposition. The Discharge Disposition includes both the standard code and a local code, and a discharge destination

This file includes examples of the following templates: 


  <!--  ************************ ENCOUNTERS ***********************  -->
<section xmlns="urn:hl7-org:v3">
  <!--  *** Encounters section (entries required) (V3) ***  -->
  <templateId root="2.16.840.1.113883.10.20.22.2.22.1"
              extension="2015-08-01"/>
  <templateId root="2.16.840.1.113883.10.20.22.2.22.1"/>
  <code displayName="History of encounters" codeSystemName="LOINC"
        codeSystem="2.16.840.1.113883.6.1" code="46240-8"/>
  <title>ENCOUNTERS</title>
  <text>
    <table width="100%" border="1">
      <thead>
        <tr>
          <th>Encounter</th>
          <th>Performer</th>
          <th>Location</th>
          <th>Date</th>
          <th>Discharge Disposition</th>
          <th>Location</th>
        </tr>
      </thead>
      <tbody>
        <tr ID="Encounter1">
          <td ID="Encounter1_Type"> Inpatient Hospital Care - moderate complexity</td>
          <td>Performer Name</td>
          <td>Community Medical Center</td>
          <td>September 27, 2012 at 1:00pm</td>
          <td ID="Encounter1_DischargeDispositionCode">Discharged/transferred to an intermediate-care facility (ICF)</td>
          <td ID="Encounter1_DischargedToLoc">Sunnyview Rehab Hospital</td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry typeCode="DRIV">
    <encounter moodCode="EVN" classCode="ENC">
      <!--  ** Encounter Activity (V3) **  -->
      <templateId root="2.16.840.1.113883.10.20.22.4.49"
                  extension="2015-08-01"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.49"/>
      <id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
      <!--  MAY MAY contain zero or one [0..1] translation (CONF:1198-32323)
             The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) valueset to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) valueset.
             <translation code="AMB" codeSystem="2.16.840.1.113883.5.4" displayName="Ambulatory" codeSystemName="HL7 ActEncounterCode"/>  -->
      <code
            displayName="Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded." codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"
            code="99221">
        <originalText>
          <reference value="#Encounter1_Type"/>
        </originalText>
      </code>
      <text>
        <reference value="#Encounter1"/>
      </text>
      <effectiveTime value="20120927130000-0500"/>
      <!--  This shows use of the discharge disposition extension AND shows using both the suggested encoding from C-CDA R2.1 and local Good Health Hospital codes.  -->
      <sdtc:sdtcDischargeDispositionCode xmlns:sdtc="urn:hl7-org:sdtc"
                                         displayName="Discharged/transferred to an intermediate-care facility (ICF)"
                                         codeSystemName="HL7 Discharge Disposition"
                                         codeSystem="2.16.840.1.113883.12.112" code="04">
        <originalText>
          <reference value="#Encounter1_DischargeDispositionCode"/>
        </originalText>
        <!--  Good Health Hospital (local OID) to represent their local code system.  -->
        <translation xsi:type="CD" displayName="SUNNYVIEW REHAB HOSPITAL"
                     codeSystemName="Community Medical Center Local Discharge Codes" codeSystem="2.16.840.1.113883.19.5" code="HOSSVR"/>
      </sdtc:sdtcDischargeDispositionCode>
      <performer>
        <assignedEntity>
          <!--  Provider NPI "333444555"  -->
          <id root="2.16.840.1.113883.4.6" extension="333444555"/>
          <code displayName="General physician" codeSystemName="SNOMED CT"
                codeSystem="2.16.840.1.113883.6.96" code="59058001"/>
        </assignedEntity>
      </performer>
      <participant typeCode="LOC">
        <participantRole classCode="SDLOC">
          <templateId root="2.16.840.1.113883.10.20.22.4.32"/>
          <!--  Service Delivery Location template  -->
          <code displayName="Medical Ward"
                codeSystemName="HL7 HealthcareServiceLocation" codeSystem="2.16.840.1.113883.6.259" code="1060-3"/>
          <addr>
            <streetAddressLine>1007 Health Drive</streetAddressLine>
            <city>Portland</city>
            <state>OR</state>
            <postalCode>99123</postalCode>
            <country>US</country>
          </addr>
          <telecom value="tel:+1(555)555-1030" use="WP"/>
          <playingEntity classCode="PLC">
            <name>Community Medical Center</name>
          </playingEntity>
        </participantRole>
      </participant>
      <participant typeCode="DST">
        <participantRole classCode="SDLOC">
          <templateId root="2.16.840.1.113883.10.20.22.4.32"/>
          <!--  Discharged To Location template  -->
          <!--  How do we represent this concept of "the 'discharged to' location?  -->
          <code displayName="Chronic Rehabilitation Unit"
                codeSystemName="HL7 HealthcareServiceLocation" codeSystem="2.16.840.1.113883.6.259" code="1105-6"/>
          <addr>
            <streetAddressLine>200 Rehab Road</streetAddressLine>
            <city>Portland</city>
            <state>NY</state>
            <postalCode>19123</postalCode>
            <country>US</country>
          </addr>
          <telecom value="tel:+1(123)555-1030" use="WP"/>
          <playingEntity classCode="PLC">
            <name>Sunnyview Rehab Hospital</name>
          </playingEntity>
        </participantRole>
      </participant>
      <entryRelationship typeCode="RSON">
        <!--  ** Indication (V2) **  -->
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.19"
                      extension="2023-05-01"/>
          <!--  Companion Guide  -->
          <templateId root="2.16.840.1.113883.10.20.22.4.19"
                      extension="2014-06-09"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.19"/>
          <id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/>
          <!--  code is required; MAY be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2014-09-02 (CONF:1098-31229)  -->
          <code xsi:type="CD" displayName="Clinical finding"
                codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="404684003"/>
          <statusCode code="completed"/>
          <effectiveTime>
            <low value="20120925113000-0500"/>
          </effectiveTime>
          <value xsi:type="CD" displayName="Pneumonia"
                 codeSystem="2.16.840.1.113883.6.96" code="233604007"/>
        </observation>
      </entryRelationship>
    </encounter>
  </entry>
</section>