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 Impairment

Approval Status: Approved
Task Force Approval: 2017-06-15
SDWG Approval: 2017-07-06

This is an example of a functional impairment. It only illustrates one potential templated within the functional status section and was originally prepared for the ONC 2014 Transitions of Care test scenario, inpatient for MU2 170.314(b)(2). Note that there are significant changes to functional and cognitive status in C-CDA 2.1 (including section breakout and deprecation of certain templates). This example represents the proper way to send a functional impairment in C-CDA R2.1.

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <!--  This is an example of how to affirmatively assert there is a functional impairment  -->
  <!--  Original design influenced by Transitions of Care test scenario, inpatient for MU2 170.314(b)(2) -->
  <!--  Note that in C-CDA 1.1, functional and cognitive status (mental) are within the same section  -->
  <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>
      <thead>
        <tr>
          <th>Assessment</th>
          <th>Date</th>
          <th>Results</th>
          <th>Comments</th>
        </tr>
      </thead>
      <tbody>
        <tr ID="FS_Narrative1">
          <td ID="FS_Type1">Functional Status</td>
          <td>August 15 2012, 5:32pm</td>
          <td ID="FS_Finding1">Dependence on walking stick</td>
          <td/>
        </tr>
      </tbody>
    </table>
  </text>
  <entry>
    <observation moodCode="EVN" classCode="OBS">
      <!--  Template for Functional Status Observation. Note other templates may apply.  -->
      <templateId root="2.16.840.1.113883.10.20.22.4.67"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.67"
                  extension="2014-06-09"/>
      <id root="e4f9eb37-52ca-4e95-90f3-570dace107e6"/>
      <code xsi:type="CD" displayName="Functional status"
            codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="54522-8">
        <originalText>
          <reference value="#FS_Type1"/>
        </originalText>
      </code>
      <text xsi:type="ED">
        <reference value="#FS_Narrative1"/>
      </text>
      <statusCode code="completed"/>
      <effectiveTime>
        <!--  Some systems may just report this to day rather than hour and minute timestamp. Both of which are acceptable.  -->
        <low value="20120815173215-0500"/>
      </effectiveTime>
      <value xsi:type="CD" displayName="Dependence on walking stick"
             codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="105504002">
        <originalText>
          <reference value="#FS_Finding1"/>
        </originalText>
      </value>
    </observation>
  </entry>
</section>