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 demonstrates how an individual entry may refer to an external document where information was originally provided (e.g. a problem in this example). In addition, how to also link back to the original observation using externalObservation is also shown. While these elements are optional, they help create a chain of data provenance.
This file includes examples of the following templates:
<!-- This example illustrates how parts of a specific entry may refer to an external document and/or act, observation, procedure
The use case would be where information from a prior document have been imported and
other information may be available in the newly created clinical document.
It uses the QRDA template for external document reference 2.16.840.1.113883.10.20.22.4.115:2014-06-09
It references the approved active problem example http://cdasearch.hl7.org/examples/view/b6f23e38249108eb5bc47905c949e9bb59fc33b4 -->
<section xmlns="urn:hl7-org:v3">
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
<templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
<code displayName="Problem List" codeSystem="2.16.840.1.113883.6.1"
code="11450-4"/>
<title>Problem List</title>
<text>
<table>
<thead>
<tr>
<th>Name</th>
<th>Dates</th>
<th>Status</th>
<th>Author</th>
<th>Author Time</th>
</tr>
</thead>
<tbody>
<tr ID="Problem1">
<td ID="Problem1Value">Community Acquired Pneumonia</td>
<td>Onset: February 27 2014</td>
<td>Active</td>
<td>Heartly Sixer, MD (NPI: 66666)</td>
<td>Mar 2, 2014</td>
<!-- Additional information linking to source document may be appropriate based on use case -->
</tr>
</tbody>
</table>
</text>
<entry>
<act moodCode="EVN" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
<templateId root="2.16.840.1.113883.10.20.22.4.3"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.3"
extension="2024-05-01"/>
<!-- Since this represents an element which has been imported from the original document
but may vary from original act, a different GUID is used to idenitfy -->
<!-- Some systems may also include the original id here. This example did
not since the externalObservation is more appropriate -->
<id root="11526f79-94a3-4682-a969-0f3d039db732"/>
<code codeSystem="2.16.840.1.113883.5.6" code="CONC"/>
<statusCode code="active"/>
<effectiveTime>
<low value="20140302124536-0500"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<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"
extension="2024-05-01"/>
<!-- Since this represents an element which has been imported from the original document
but may vary from original observation, a different GUID is used to idenitfy -->
<!-- Some systems may also include the original id here. This example did
not since the externalObservation is more appropriate -->
<id root="35e97377-b63b-4e6a-a53e-9cfb016bea0b"/>
<code xsi:type="CD" displayName="Problem"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="55607006">
<translation xsi:type="CD" displayName="Problem"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="75326-9"/>
</code>
<text xsi:type="ED">
<reference value="#Problem1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20140227"/>
</effectiveTime>
<value xsi:type="CD" displayName="Community acquired pneumonia"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="385093006">
<originalText>
<reference value="#Problem1Value"/>
</originalText>
</value>
<!-- Since no changes were made to the observation, the orginal author is included here -->
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20140302124536"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="66666"/>
<code
displayName="Allopathic & Osteopathic Physicians; Internal Medicine, Cardiovascular Disease" codeSystemName="NUCC"
codeSystem="2.16.840.1.113883.6.101" code="207RC0000X"/>
<addr>
<streetAddressLine>6666 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)666-6666" use="WP"/>
<assignedPerson>
<name>
<given>Heartly</given>
<family>Sixer</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<!-- This reference refers to the external document where the problem was documented -->
<!-- It uses a template for externalDocument from the QRDA 1 3.1 Implementation Guide -->
<reference typeCode="REFR">
<externalDocument moodCode="EVN" classCode="DOCCLIN">
<templateId root="2.16.840.1.113883.10.20.22.4.115"
extension="2014-06-09"/>
<!-- This refers to the ClinicalDocument/id of the original document -->
<id root="2.16.840.1.113883.19.5.99999.1" extension="TT661"/>
<code displayName="Summary of episode note"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="34133-9"/>
<!-- While not required, there is a benefit of using <setId> and <versionNumber> as a secondary key on documents.
If the flow from a document source system or repository to a destination system is infrequent or not able to guarantee
sequential transmission of document revisions. The setId and versionNumber pair are actually better for detecting which
new document revises a previous older version of that document. -->
<!-- If setId and versionNumber are not available or applicable, they may be omitted -->
<!-- This refers to the ClinicalDocument/setId and versionNumber of the original document -->
<setId root="004bb033-b948-4f4c-b5bf-a8dbd7d8dd40"/>
<versionNumber value="1"/>
</externalDocument>
</reference>
<!-- This reference refers to the observation within external document the where the problem was documented -->
<!-- Other options are the use of reference/externalAct or reference/externalProcedures -->
<reference typeCode="REFR">
<externalObservation moodCode="EVN" classCode="OBS">
<!-- This refers to the observation/id of the original observation -->
<!-- If there are multiple id elements, all should be included -->
<id root="1.3.6.1.4.1.22812.4.111.0.4.1.2.1"
extension="10241104348"/>
<code displayName="Problem" codeSystemName="SNOMED CT"
codeSystem="2.16.840.1.113883.6.96" code="55607006">
<translation xsi:type="CD" displayName="Problem"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
code="75326-9"/>
</code>
</externalObservation>
</reference>
</observation>
</entryRelationship>
</act>
</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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