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: Memory Impairment

Approval Status: Approved
Task Force Approval: 2017-06-15
SDWG Approval: 2017-07-06

This is an example of mental (cognitive) impairment. It only illustrates one potential templated within the mental 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 a mental 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 a memory (cognitive) impairment  -->
  <!--  Original design influenced by Transitions of Care test scenario, inpatient for MU2 170.314(b)(2) -->
  <!--  Note that in C-CDA 1.1, functional and cognitive status (mental) are within the same section  -->
  <!--  Section not backwards compaitble with prior 2.16.840.1.113883.10.20.22.2.14 since new section  -->
  <templateId root="2.16.840.1.113883.10.20.22.2.56" extension="2015-08-01"/>
  <code displayName="Mental status Narrative" codeSystemName="LOINC"
        codeSystem="2.16.840.1.113883.6.1" code="10190-7"/>
  <title>MENTAL STATUS</title>
  <text>
    <table>
      <thead>
        <tr>
          <th>Assessment</th>
          <th>Date</th>
          <th>Results</th>
          <th>Comments</th>
        </tr>
      </thead>
      <tbody>
        <tr ID="MS_Narrative1">
          <td ID="MS_Type1">Cognitive Status</td>
          <!--  Some systems may just report this to day rather than hour and minute timestamp. Both of which are acceptable.  -->
          <td>August 15 2012, 5:32pm</td>
          <td ID="MS_Finding1">Memory Impairment</td>
          <td/>
        </tr>
      </tbody>
    </table>
  </text>
  <entry>
    <!--  Template for Mental Status Result Observation. Note other templates may apply.  -->
    <observation moodCode="EVN" classCode="OBS">
      <templateId root="2.16.840.1.113883.10.20.22.4.74"
                  extension="2024-05-01"/>
      <!--  C-CDA 3.0  -->
      <id root="faa09c19-fa1f-4a6c-ae79-10a3b711550f"/>
      <code xsi:type="CD" displayName="Mental Status" codeSystemName="LOINC"
            codeSystem="2.16.840.1.113883.6.1" code="8693-4"/>
      <!--  C-CDA 2.1 version of this observation
           <templateId root="2.16.840.1.113883.10.20.22.4.74"/>
           <templateId root="2.16.840.1.113883.10.20.22.4.74" extension="2015-08-01"/>
           <code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="373930000" displayName="Cognitive function finding">
             <originalText>
               <reference value="#MS_Type1" />
             </originalText>
             <translation code="75275-8" codeSystem="2.16.840.1.113883.6.1"
                          displayName="Cognitive function [Interpretation]" codeSystemName="LOINC" />
           </code>  -->
      <text xsi:type="ED">
        <reference value="#MS_Narrative1"/>
      </text>
      <statusCode code="completed"/>
      <effectiveTime>
        <!--  Some systems may just report this to day rather than hour and minute timestamp. Both of which are acceptable.  -->
        <low value="20120815173215-0500"/>
      </effectiveTime>
      <value xsi:type="CD" displayName="Memory impairment"
             codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="386807006">
        <originalText>
          <reference value="#MS_Finding1"/>
        </originalText>
      </value>
    </observation>
  </entry>
</section>