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 an outpatient visit discharge disposition. In order to support a local Discharge Disposition code the dischargeDisposition contains the "OTH" nullFlavor.
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"> Checkup Examination </td>
<td>Performer Name</td>
<td>Community Urgent Care 1007 Health Drive, Portland OR</td>
<td>September 27, 2012 at 1:00pm</td>
<td ID="Encounter1_DischargeDispositionCode">Disenrolled</td>
<td ID="Encounter1_DischargedToLoc">N/A</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="Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter." codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"
code="99213">
<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 some local Good Health Hospital codes. -->
<sdtc:sdtcDischargeDispositionCode xmlns:sdtc="urn:hl7-org:sdtc"
nullFlavor="OTH">
<originalText>
<reference value="#Encounter1_DischargeDispositionCode"/>
</originalText>
<!-- Good Health Hospital (local OID) to represent their local code system. -->
<translation xsi:type="CD" displayName="Disenrolled"
codeSystemName="Community Urgent Care Local Discharge Code" codeSystem="2.16.840.1.113883.19.5" code="DE"/>
</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="Urgent Care Center"
codeSystemName="HL7 HealthcareServiceLocation" codeSystem="2.16.840.1.113883.6.259" code="1160-1"/>
<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 Urgent Care</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>