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: No Cognitive Impairment

Approval Status: Approved
Task Force Approval: 2015-06-18, 2017-06-15
SDWG Approval: 2015-07-09, 2017-07-06

This is an example of no 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 no cognitive 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 no mental status impairment  -->
  <!--  Note that in C-CDA 1.1, functional and cognitive status (mental) are within the same section  -->
  <!--  If no information is known (i.e. assessment not performed), then a pattern of null entries would be more appropriate  -->
  <!--  This example uses terminology to assert 'No Impairment' rather than 'Impairment' and negationInd='true' (as value.negationInd) since template design didn't include guidance on negation.  -->
  <!--  The test data also included the No Impairment code.  -->
  <!--  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>
          <td>August 15 2012, 5:32pm</td>
          <td ID="MS_Finding1">No impairment</td>
          <td/>
        </tr>
      </tbody>
    </table>
  </text>
  <entry>
    <!--  Template for Mental Status Observation. Note other templates may apply.  -->
    <!--  We chose to use terminology to state 'no impairment' over negation since the C-CDA Mental Status template design didn't include guidance on negation -->
    <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>
        <low value="20120815173215-0500"/>
      </effectiveTime>
      <value xsi:type="CD"
             displayName="Disability evaluation, normal, no disability, no impairment" codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96"
             code="66557003">
        <originalText>
          <reference value="#MS_Finding1"/>
        </originalText>
      </value>
    </observation>
  </entry>
</section>