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: Discharge Note in Hospital Course

Approval Status: Approved
Task Force Approval: 2018-06-14
SDWG Approval: 2018-07-12

This is an example of how to record a single Discharge Note in a Hospital Course Section.

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <!--  Note is in an appropriate section  -->
  <!--  C-CDA Hospital Course Section  -->
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.5"/>
  <code displayName="HOSPITAL COURSE" codeSystemName="LOINC"
        codeSystem="2.16.840.1.113883.6.1" code="8648-8"/>
  <title>Hospital Course</title>
  <text>
    <list listType="unordered">
      <item ID="DischargeNote">
        <caption>Dr. Physician - 09/13/2016 2:46 PM EDT</caption>
        <paragraph>The patient was admitted and started on Lovenox and nitroglycerin paste...</paragraph>
      </item>
    </list>
  </text>
  <entry>
    <!--  Note Activity Entry  -->
    <act moodCode="EVN" classCode="ACT">
      <templateId root="2.16.840.1.113883.10.20.22.4.202"
                  extension="2016-11-01"/>
      <code displayName="Note" codeSystem="2.16.840.1.113883.6.1"
            code="34109-9">
        <translation xsi:type="CD" displayName="Hospital course Narrative"
                     codeSystem="2.16.840.1.113883.6.1" code="8648-8"/>
      </code>
      <text>
        <reference value="#DischargeNote"/>
      </text>
      <statusCode code="completed"/>
      <!--  Clinically-relevant time of the note  -->
      <effectiveTime value="20160913144600-0500"/>
      <!--  Author Participation  -->
      <author>
        <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
        <!--  Time note was actually written  -->
        <time value="20160913144600-0500"/>
        <assignedAuthor>
          <id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c"/>
          <addr nullFlavor="UNK"/>
          <telecom nullFlavor="UNK"/>
          <assignedPerson>
            <name>Dr. Physician</name>
          </assignedPerson>
        </assignedAuthor>
      </author>
      <!--  Reference to encounter  -->
      <!--  When a Note is in an Encounter Specific Document this may not be needed  -->
      <entryRelationship typeCode="COMP" inversionInd="true">
        <encounter moodCode="EVN" classCode="ENC">
          <!--  Encounter ID matches an encounter in the Encounters Section or encompassingEncounter  -->
          <id root="1.2.3.4.5.6"/>
        </encounter>
      </entryRelationship>
    </act>
  </entry>
</section>