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: Note directly attached to a Procedure

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

This is an example of how to associate a Procedure Note with a Procedure in the Procedure section.

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <!--  Note directly attached to the associated act  -->
  <!--  C-CDA 2.1 Procedures Section  -->
  <templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
  <templateId root="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09"/>
  <code displayName="HISTORY OF PROCEDURES" codeSystemName="LOINC"
        codeSystem="2.16.840.1.113883.6.1" code="47519-4"/>
  <title>Procedures</title>
  <text>
    <table>
      <thead>
        <tr>
          <th>Description</th>
          <th>Date and Time (Range)</th>
          <th>Notes</th>
        </tr>
      </thead>
      <tbody>
        <tr ID="Procedure1">
          <td ID="ProcedureDesc1">Laparoscopic appendectomy</td>
          <td>(03 Feb 2014 09:22am - 03 Feb 2014 11:15am)</td>
          <td ID="ProcedureNote1">
            <paragraph>Dr. Physician - 03 Feb 2014</paragraph>
            <paragraph>Patient repositioned with arms extended on arm boards...</paragraph>
          </td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry typeCode="DRIV">
    <!--  Procedures should be used for care that directly changes the patient's physical state. -->
    <procedure moodCode="EVN" classCode="PROC">
      <templateId root="2.16.840.1.113883.10.20.22.4.14"/>
      <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"
                  extension="2024-05-01"/>
      <id root="64af26d5-88ef-4169-ba16-c6ef16a1824f"/>
      <code displayName="Laparoscopic appendectomy"
            codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="6025007">
        <originalText>
          <reference value="#ProcedureDesc1"/>
        </originalText>
      </code>
      <text>
        <reference value="#Procedure1"/>
      </text>
      <statusCode code="completed"/>
      <effectiveTime>
        <low value="20140203092205-0700"/>
        <high value="20140203111514-0700"/>
      </effectiveTime>
      <!--  Note Activity entry  -->
      <entryRelationship typeCode="COMP">
        <act moodCode="EVN" classCode="ACT">
          <templateId root="2.16.840.1.113883.10.20.22.4.202"
                      extension="2016-11-01"/>
          <code displayName="Note" codeSystemName="LOINC"
                codeSystem="2.16.840.1.113883.6.1" code="34109-9">
            <translation xsi:type="CD" displayName="Procedure note"
                         codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="28570-0"/>
          </code>
          <text>
            <reference value="#ProcedureNote1"/>
          </text>
          <statusCode code="completed"/>
          <!--  Clinically-relevant time of the note  -->
          <effectiveTime value="20140203"/>
          <!--  Author Participation  -->
          <author>
            <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
            <!--  Time note was actually written  -->
            <time value="20140204083215-0500"/>
            <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  -->
          <entryRelationship typeCode="COMP" inversionInd="true">
            <encounter moodCode="EVN" classCode="ENC">
              <!--  Encounter ID matches an encounter in the Encounters Section  -->
              <id root="1.2.3.4"/>
            </encounter>
          </entryRelationship>
        </act>
      </entryRelationship>
    </procedure>
  </entry>
</section>