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 example illustrates how to structure Encounter Diagnosis for the 170.314(b)(2) Transitions of care - L) Encounter Diagnosis
This file includes examples of the following templates:
<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="Encounters" 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>Encounter date</th>
<th>Diagnosis</th>
<th>Diagnosis Status</th>
</tr>
</thead>
<tbody>
<tr ID="Encounter1">
<td ID="Encounter1_type">Office outpatient visit</td>
<td>Dr. Samir Kahn
<content ID="Encounter1_performer_type">Internal Medicine</content>
</td>
<td>Community Urgent Care (Urgent Care Center)
<paragraph>1004 Healthcare Dr.</paragraph>
<paragraph>Portland, OR 97005</paragraph>
</td>
<td>August 15, 2012</td>
<td ID="Encounter1_diagnosis">Costal Chondritis</td>
<td ID="Encounter1_diagnosis_status">Active</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"/>
<!-- Selected reasonable encounter/code. Not in test data -->
<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." codeSystemVersion="4" codeSystemName="CPT"
codeSystem="2.16.840.1.113883.6.12" code="99213">
<originalText>
<reference value="#Encounter1_type"/>
</originalText>
</code>
<text>
<reference value="#Encounter1"/>
</text>
<!-- August 15, 2012 - added time (pacific time) since but not present in test data -->
<effectiveTime value="20120815100000-0800"/>
<!-- Not specified in test data, but could infer Dr. Khan from the test scenario narrative -->
<performer>
<assignedEntity>
<!-- Fake Provider NPI "12345678910" -->
<id root="2.16.840.1.113883.4.6" extension="12345678910"/>
<code
displayName="Allopathic & Osteopathic Physicians; Internal Medicine" codeSystemName="Health Care Provider Taxonomy"
codeSystem="2.16.840.1.113883.6.101" code="207R00000X">
<originalText>
<reference value="Encounter1_performer_type"/>
</originalText>
</code>
<assignedPerson>
<!-- Could alternately use <suffix>MD</suffix> -->
<name>
<prefix>Dr.</prefix>
<given>Samir</given>
<family>Khan</family>
</name>
</assignedPerson>
</assignedEntity>
</performer>
<participant typeCode="LOC">
<!-- Location is inferred from the care team address in test data -->
<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="HealthcareServiceLocation" codeSystem="2.16.840.1.113883.6.259" code="1160-1"/>
<addr>
<streetAddressLine>1004 Healthcare Dr.</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97005</postalCode>
</addr>
<telecom value="tel:+1(555)555-1004"/>
<playingEntity classCode="PLC">
<name>Get Well Clinic</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="REFR">
<act moodCode="EVN" classCode="ACT">
<!-- Encounter Diagnosis -->
<templateId root="2.16.840.1.113883.10.20.22.4.80"
extension="2024-05-01"/>
<!-- C-CDA 3.0 -->
<templateId root="2.16.840.1.113883.10.20.22.4.80"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.80"/>
<code displayName="Diagnosis" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="29308-4"/>
<statusCode code="completed"/>
<!-- This example uses the Problem Status Observation to represent status of the diagnosis.
The statusCode of the encounter diagnosis is an alternative approach. -->
<entryRelationship typeCode="SUBJ">
<observation moodCode="EVN" classCode="OBS">
<!-- Problem Observation -->
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2024-05-01"/>
<!-- C-CDA 3.0 -->
<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"/>
<id root="db734647-fc99-424c-a864-7e3cda82e704"/>
<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>
<statusCode code="completed"/>
<!-- This same data may be represented in the Problem List -->
<effectiveTime>
<low value="20120815"/>
</effectiveTime>
<!-- Test data is SNOMED but in practice this is probably an ICD9/10 code -->
<value xsi:type="CD" displayName="Costal chondritis"
codeSystem="2.16.840.1.113883.6.96" code="64109004">
<originalText>
<reference value="#Encounter1_diagnosis"/>
</originalText>
</value>
<entryRelationship typeCode="REFR">
<observation moodCode="EVN" classCode="OBS">
<!-- Problem Status which is strange on an encounter diagnosis but
included due to the test data -->
<!-- C-CDA R2.0 deprecated this template, but it was revised in the Companion Guide -->
<templateId root="2.16.840.1.113883.10.20.22.4.6"/>
<templateId root="2.16.840.1.113883.10.20.22.4.6"
extension="2019-06-20"/>
<code xsi:type="CD" displayName="Status"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="33999-4"/>
<statusCode code="completed"/>
<value xsi:type="CD" displayName="Active"
codeSystem="2.16.840.1.113883.6.96" code="55561003">
<originalText>
<reference value="#Encounter1_diagnosis_status"/>
</originalText>
</value>
</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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