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: No Functional Impairment

Approval Status: Approved
Task Force Approval: 2015-06-18, 2017-06-15
SDWG Approval: 2015-07-09, 2017-07-06

This is an example of no functional impairment. It only illustrates one potential templated within the functional status section and was originally prepared for the ONC 2014 170.314(b)(2) Transitions of care - M) Functional and Cognitive Status. 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 no 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 no functional impairment  -->
  <!--  Note that in C-CDA 1.1, functional and cognitive status (mental) are within the same section  -->
  <!--  If no information is known (i.e. assessment not performed), then a pattern of null entries would be more appropriate  -->
  <!--  This example uses terminology to assert 'No Impairment' rather than 'Impairment' and negationInd='true' (as value.negationInd) since template design didn't include guidance on negation.  -->
  <!--  The test data also included the No Impairment code.  -->
  <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">No impairment</td>
          <td/>
        </tr>
      </tbody>
    </table>
  </text>
  <entry>
    <observation moodCode="EVN" classCode="OBS">
      <!--  Template for Functional Status Result Observation. Note other templates may apply.  -->
      <!--  We chose to use terminology to state 'no impairment' over negation since the C-CDA Functional Status template design didn't include guidance on negation -->
      <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>
        <low value="20120815173215-0500"/>
      </effectiveTime>
      <value xsi:type="CD"
             displayName="Disability evaluation, normal, no disability, no impairment" codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96"
             code="66557003">
        <originalText>
          <reference value="#FS_Finding1"/>
        </originalText>
      </value>
    </observation>
  </entry>
</section>