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: Functional Assessment - Glasgow Coma

Approval Status: Approved
Task Force Approval: 2022-08-25
SDWG Approval: 2023-03-09

This is an example of a Glasgow Coma Scale. It illustrates an assessment in the Functional Status Section.

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <templateId root="2.16.840.1.113883.10.20.22.2.14"/>
  <templateId root="2.16.840.1.113883.10.20.22.2.14" extension="2014-06-09"/>
  <code displayName="Functional status assessment note"
        codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="47420-5"/>
  <title>FUNCTIONAL STATUS</title>
  <text>
    <table width="100%" border="1">
      <thead>
        <tr>
          <th>Assessment</th>
          <th>Effective Dates</th>
          <th>Results of Evaluation</th>
        </tr>
      </thead>
      <tbody>
        <tr>
          <!--  If desired you can include individual questions/answer here - see PHQ9 Example  -->
          <td ID="assessmentTotal">Glasgow coma scale</td>
          <td>February 14,2012</td>
          <td>9</td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry>
    <observation moodCode="EVN" classCode="OBS">
      <templateId root="2.16.840.1.113883.10.20.22.4.69"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.69"
                  extension="2022-06-01"/>
      <id root="4f6d8f2d-2efd-41c4-8ef1-465e00706948"/>
      <code xsi:type="CD" displayName="Glasgow coma scale"
            codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="35088-4"/>
      <statusCode code="completed"/>
      <effectiveTime value="20120214"/>
      <!--  Summed score is also in an observation below  -->
      <value xsi:type="INT" value="9"/>
      <entryRelationship typeCode="COMP">
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.86"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.86"
                      extension="2022-06-01"/>
          <id root="f4dce790-8328-11db-9fe1-0800200c9a44"/>
          <code xsi:type="CD" displayName="Glasgow coma score eye opening"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="9267-6"/>
          <statusCode code="completed"/>
          <value xsi:type="INT" value="3"/>
          <!--  Systems may send a second value with LOINC answer concept   -->
          <!--  xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list  -->
          <value xsi:type="CO" displayName="Eye opening to verbal command"
                 codeSystem="2.16.840.1.113883.6.1" code="LA6555-2"/>
        </observation>
      </entryRelationship>
      <entryRelationship typeCode="COMP">
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.86"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.86"
                      extension="2022-06-01"/>
          <id root="f4dce790-8328-11db-9fe1-0800200c9a44"/>
          <code xsi:type="CD" displayName="Glasgow coma score motor"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="9268-4"/>
          <statusCode code="completed"/>
          <value xsi:type="INT" value="3"/>
          <!--  Systems may send a second value with LOINC answer concept   -->
          <!--  xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list  -->
          <value xsi:type="CO" displayName="Flexion to pain"
                 codeSystem="2.16.840.1.113883.6.1" code="LA6564-4"/>
        </observation>
      </entryRelationship>
      <entryRelationship typeCode="COMP">
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.86"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.86"
                      extension="2022-06-01"/>
          <id root="f4dce790-8328-11db-9fe1-0800200c9a44"/>
          <code xsi:type="CD" displayName="Glasgow coma score verbal"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="9270-0"/>
          <statusCode code="completed"/>
          <value xsi:type="INT" value="3"/>
          <!--  Systems may send a second value with LOINC answer concept   -->
          <!--  xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list  -->
          <value xsi:type="CO" displayName="Inappropriate words"
                 codeSystem="2.16.840.1.113883.6.1" code="LA6559-4"/>
        </observation>
      </entryRelationship>
      <entryRelationship typeCode="COMP">
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.86"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.86"
                      extension="2022-06-01"/>
          <id root="9daa31dd-2a72-40b8-a8e9-34c266935a15"/>
          <code xsi:type="CD" displayName="Glasgow coma score total"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="9269-2"/>
          <text xsi:type="ED">
            <reference value="#assessmentTotal"/>
          </text>
          <statusCode code="completed"/>
          <value xsi:type="INT" value="9"/>
        </observation>
      </entryRelationship>
    </observation>
  </entry>
</section>