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: Care Team In Transition of Care Documents

Approval Status: Approved
Task Force Approval: 2016-12-22
SDWG Approval: 2017-02-02

This is an example of how to include Care Team information for 170.315_b1 Ambulatory test data


  <!--  Transition of Care snip to show Care Team from test data for 170.315_b1 Ambulatory
     
     B)  Relevant Information regarding the Visit
     Care Team
     •  Dr Albert Davis, 2472 Rocky place, Beaverton, OR 97006
     •  Tracy Davis, 555-555-1002, 2472 Rocky place, Beaverton, OR 97006
     
     This example includes members of the Care Team in the documentationOf/serviceEvent.
     
     From C-CDA R2.1 we have this statement:
     A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent.
     
     and for serviceEvent/performer the guide says:
     The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors
     
     For single encounter events, the guide says:
     If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template. The componentOf/encompassingEncounter may be used to document any subset of the providers on the care team that were active participants in the encounter.
      -->
<documentationOf xmlns="urn:hl7-org:v3">
  <serviceEvent classCode="PCPR">
    <id root="1.3.6.1.4.1.22812.4.99930.4.3.8" extension="5283815"/>
    <!--  The service event being documented is shown as happening from 10 - 10:30am Eastern on 6/22/2015.
         The date is in the Test Data for §170.315(b)(1) Transitions of care the test data.  -->
    <effectiveTime>
      <low value="20150622100000-0600"/>
      <high value="20150622103000-0600"/>
    </effectiveTime>
    <!--  Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
         there are two Care Team members, so two performer elements.  -->
    <performer typeCode="PRF">
      <!--  we infer from the test data description that Dr Davis is the PCP  -->
      <!--  MAY provide functionCode  -->
      <functionCode displayName="primary care physician"
                    codeSystem="2.16.840.1.113883.5.88" code="PCP"/>
      <!--  we do not know how long Dr Davis has been associated with the patient   -->
      <time>
        <low nullFlavor="UNK"/>
      </time>
      <assignedEntity>
        <!--  a fake NPI number  -->
        <id root="2.16.840.1.113883.4.6" extension="1111111111"/>
        <!--  optional, and NOT in Test data: a code from the NUCC Health Care Provider taxonomy showing this is an an internal medicine provider  -->
        <code
              displayName="Allopathic &amp; Osteopathic Physicians; Internal Medicine" codeSystemName="NUCC Health Care Provider Taxonomy"
              codeSystem="2.16.840.1.113883.6.101" code="207R00000X"/>
        <!--  work address  -->
        <addr use="WP">
          <streetAddressLine>Neighborhood Physicians Practice</streetAddressLine>
          <streetAddressLine>2472 Rocky place</streetAddressLine>
          <city>Beaverton</city>
          <state>OR</state>
          <postalCode>97006</postalCode>
          <country>US</country>
        </addr>
        <assignedPerson>
          <name>
            <prefix qualifier="TITLE">Dr</prefix>
            <given>Albert</given>
            <family>Davis</family>
          </name>
        </assignedPerson>
      </assignedEntity>
    </performer>
    <performer typeCode="PRF">
      <time>
        <low nullFlavor="UNK"/>
      </time>
      <assignedEntity>
        <!--  this provider has an id, but it is not an NPI   -->
        <id root="1.3.6.1.4.1.22812.4.99930.4" extension="91138"/>
        <!--  optional, and NOT in test data: the provider is a Registered Nurse  -->
        <code displayName="Nursing Service Providers; Registered Nurse"
              codeSystemName="NUCC Health Care Provider Taxonomy" codeSystem="2.16.840.1.113883.6.101" code="163W00000X"/>
        <addr use="WP">
          <streetAddressLine>Neighborhood Physicians Practice</streetAddressLine>
          <streetAddressLine>2472 Rocky place</streetAddressLine>
          <city>Beaverton</city>
          <state>OR</state>
          <postalCode>97006</postalCode>
          <country>US</country>
        </addr>
        <telecom value="tel:+1-(555)555-1002" use="WP"/>
        <assignedPerson>
          <name>
            <given>Tracy</given>
            <family>Davis</family>
          </name>
        </assignedPerson>
      </assignedEntity>
    </performer>
  </serviceEvent>
</documentationOf>