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 is an example of how an author can record an implant when the procedure is unknown.
This file includes examples of the following templates:
<section xmlns="urn:hl7-org:v3">
<templateId root="2.16.840.1.113883.10.20.22.2.23" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.23"/>
<code displayName="Medical Equipment" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="46264-8"/>
<title>Implants</title>
<text>
<table>
<thead>
<tr>
<th>Implanted</th>
<th>Area</th>
<th>Manufacturer</th>
<th>Device Identifier</th>
<th>Details</th>
<th>Model</th>
<th>Serial</th>
<th>Lot</th>
</tr>
</thead>
<tbody>
<tr>
<td ID="implant1">Patellofemoral Component</td>
<td>Left: Knee</td>
<td>MCK</td>
<td>00848486000400</td>
<td>Implanted: Qty: 1 on 04/13/2016 by Fleming, Barry</td>
<td/>
<td>123777</td>
<td>ABC634</td>
</tr>
<tr>
<td ID="implant2">Inlay Tibial Component</td>
<td>Left: Knee</td>
<td>MCK</td>
<td>00848486001032</td>
<td>Implanted: Qty: 1 on 04/13/2016 by Fleming, Barry</td>
<td>MCK7712</td>
<td/>
<td>ABC124</td>
</tr>
<tr>
<td ID="implant3">Patella Component</td>
<td ID="implant3site">Left: Knee</td>
<td>MCK</td>
<td>00848486000349</td>
<td>Implanted: Qty: 1 on 04/13/2016 by Fleming, Barry</td>
<td>MCK912</td>
<td/>
<td>ABC721</td>
</tr>
</tbody>
</table>
</text>
<entry>
<procedure moodCode="EVN" classCode="PROC">
<templateId root="2.16.840.1.113883.10.20.22.4.14"
extension="2024-05-01"/>
<!-- C-CDA 3.0 -->
<templateId root="2.16.840.1.113883.10.20.22.4.14"
extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<id root="1.2.840.114350.1.13.5552.1.7.2.737780" extension="2744"/>
<code nullFlavor="UNK"/>
<!-- Procedure is completed, even though the implant is still active -->
<statusCode code="completed"/>
<effectiveTime>
<!-- Placed Date -->
<low value="20160413"/>
</effectiveTime>
<!-- Example with qualifier to explicitly convey laterality
See example #2 for an alternative which does not use qualifier
See example #3 for an alternative which does not include any code at all, but still conveys the original site text -->
<targetSiteCode displayName="Knee region structure"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="72696002">
<qualifier>
<name displayName="laterality" codeSystemName="SNOMED CT"
codeSystem="2.16.840.1.113883.6.96" code="272741003"/>
<value displayName="left" codeSystemName="SNOMED CT"
codeSystem="2.16.840.1.113883.9.96" code="7771000"/>
</qualifier>
</targetSiteCode>
<participant typeCode="DEV">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.37"/>
<id root="2.16.840.1.113883.3.3719"
extension="(01)00848486000400(11)160330(10)ABC634(21)123777" assigningAuthorityName="FDA"/>
<playingDevice>
<code nullFlavor="UNK">
<originalText>
<reference value="#implant1"/>
</originalText>
</code>
</playingDevice>
<!-- From Product Instance template:
The scopingEntity/id should correspond to FDA or the appropriate issuing agency. -->
<scopingEntity>
<id root="2.16.840.1.113883.3.3719"/>
</scopingEntity>
</participantRole>
</participant>
</procedure>
</entry>
<entry>
<procedure moodCode="EVN" classCode="PROC">
<templateId root="2.16.840.1.113883.10.20.22.4.14"
extension="2024-05-01"/>
<!-- C-CDA 3.0 -->
<templateId root="2.16.840.1.113883.10.20.22.4.14"
extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<id root="1.2.840.114350.1.13.5552.1.7.2.737780" extension="2745"/>
<code nullFlavor="UNK"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="20160413"/>
</effectiveTime>
<!-- Example without qualifier -->
<targetSiteCode displayName="Structure of left knee region"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="82169009"/>
<participant typeCode="DEV">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.37"/>
<!-- Including assigningAuthorityName is a best practice but not required -->
<id root="2.16.840.1.113883.3.3719"
extension="(01)00848486001032(11)160330(10)ABC124" assigningAuthorityName="FDA"/>
<playingDevice>
<code nullFlavor="UNK">
<originalText>
<reference value="#implant2"/>
</originalText>
</code>
</playingDevice>
<!-- From Product Instance template:
The scopingEntity/id should correspond to FDA or the appropriate issuing agency. -->
<scopingEntity>
<id root="2.16.840.1.113883.3.3719"/>
</scopingEntity>
</participantRole>
</participant>
</procedure>
</entry>
<entry>
<procedure moodCode="EVN" classCode="PROC">
<templateId root="2.16.840.1.113883.10.20.22.4.14"
extension="2024-05-01"/>
<!-- C-CDA 3.0 -->
<templateId root="2.16.840.1.113883.10.20.22.4.14"
extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<id root="1.2.840.114350.1.13.5552.1.7.2.737780" extension="2746"/>
<code nullFlavor="UNK"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="20160413"/>
</effectiveTime>
<!-- Example where targetSiteCode is not mapped -->
<targetSiteCode nullFlavor="UNK">
<originalText>
<reference value="#implant3site"/>
</originalText>
</targetSiteCode>
<participant typeCode="DEV">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.37"/>
<id root="2.16.840.1.113883.3.3719"
extension="(01)00848486000349(11)160330(10)ABC721" assigningAuthorityName="FDA"/>
<playingDevice>
<code nullFlavor="UNK">
<originalText>
<reference value="#implant3"/>
</originalText>
</code>
</playingDevice>
<!-- From Product Instance template:
The scopingEntity/id should correspond to FDA or the appropriate issuing agency. -->
<scopingEntity>
<id root="2.16.840.1.113883.3.3719"/>
</scopingEntity>
</participantRole>
</participant>
</procedure>
</entry>
</section>