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: Implant Without Procedure

Approval Status: Approved
Task Force Approval: 2016-05-19
SDWG Approval: 2016-06-03, 2017-02-02

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>