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: Care Plan Goals and Instructions

Approval Status: Approved
Task Force Approval: 2015-08-20
SDWG Approval: 2015-09-10, 2017-02-02

This example illustrates how to structure a Goals and Instructions for the 170.314(b)(2) Transitions of care - K) Care Plan (Goals and Instructions).

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09"/>
  <templateId root="2.16.840.1.113883.10.20.22.2.10"/>
  <!--  Plan of Care Section  -->
  <code displayName="Plan of care note" codeSystem="2.16.840.1.113883.6.1"
        code="18776-5"/>
  <title>PLAN OF CARE</title>
  <text>
    <table width="100%" border="1">
      <thead>
        <tr>
          <th>Date/time</th>
          <th>Goal</th>
          <th>Instructions</th>
        </tr>
      </thead>
      <tbody>
        <tr ID="Goal1">
          <td>August 15, 2012 10:00am</td>
          <td ID="Goal1_desc">Weight Loss</td>
          <td ID="Action1">
            <content ID="Action1_Type">Patient Education:</content>
            <content ID="Action1_desc">Diet and exercise counseling provided during visit.</content>
          </td>
        </tr>
        <tr ID="Goal2">
          <td>August 15, 2012 10:00am</td>
          <td ID="Goal2_desc">Asthma management</td>
          <td ID="Action2">
            <content ID="Action2_Type">Patient Education:</content>
            <content ID="Action2_desc">Resources and instructions provided during visit.</content>
          </td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry>
    <observation moodCode="GOL" classCode="OBS">
      <!--  Goal Observation C-CDA R2.1 -->
      <templateId root="2.16.840.1.113883.10.20.22.4.121"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.121"
                  extension="2022-06-01"/>
      <!--  Companion Guide  -->
      <!--  Plan of Care Activity Observation C-CDA R1.1 -->
      <templateId root="2.16.840.1.113883.10.20.22.4.44"/>
      <id root="2a620155-9d11-439e-92b3-5d9815ff4dd4"/>
      <code xsi:type="CD" displayName="Exercising to lose weight"
            codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="289169006">
        <originalText>
          <reference value="#Goal1_desc"/>
        </originalText>
      </code>
      <text xsi:type="ED">
        <reference value="#Goal1"/>
      </text>
      <statusCode code="active"/>
      <effectiveTime value="20120815100000-0800"/>
      <entryRelationship typeCode="RSON" inversionInd="true">
        <act moodCode="EVN" classCode="ACT">
          <!--  Procedure Activity Act - selected over instructions template
               since it requries moodCode=INT. This act records education provided
               during the visit. -->
          <templateId root="2.16.840.1.113883.10.20.22.4.12"
                      extension="2014-06-09"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.12"/>
          <id root="2a620155-9d11-439e-92b3-5d9815ff4df2"/>
          <code displayName="Patient education" codeSystemName="SNOMED CT"
                codeSystem="2.16.840.1.113883.6.96" code="311401005">
            <originalText>
              <reference value="#Action1_Type"/>
            </originalText>
          </code>
          <statusCode code="completed"/>
          <!-- 
               <text>
                 <reference value="#Action1" />
               </text>  -->
          <!--  In this example, the instruction was given at the same time that the goal was set.
               effectiveTime is the same in this case.  -->
          <effectiveTime value="20120815100000-0800"/>
        </act>
      </entryRelationship>
    </observation>
  </entry>
  <entry>
    <observation moodCode="INT" classCode="OBS">
      <!--  Plan of Care Activity Observation  -->
      <templateId root="2.16.840.1.113883.10.20.22.4.44"
                  extension="2014-06-09"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.44"/>
      <id root="2a620155-9d11-439e-92b3-5d9815ff4dd3"/>
      <code xsi:type="CD" displayName="Asthma management"
            codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="406162001">
        <originalText>
          <reference value="#Goal2_desc"/>
        </originalText>
      </code>
      <text xsi:type="ED">
        <reference value="#Goal2"/>
      </text>
      <statusCode code="active"/>
      <effectiveTime value="20120815100000-0800"/>
      <entryRelationship typeCode="RSON" inversionInd="true">
        <act moodCode="EVN" classCode="ACT">
          <templateId root="2.16.840.1.113883.10.20.22.4.12"
                      extension="2014-06-09"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.12"/>
          <id root="2a620155-9d11-439e-92b3-5d9815ff4df6"/>
          <code displayName="Patient education" codeSystemName="SNOMED CT"
                codeSystem="2.16.840.1.113883.6.96" code="311401005">
            <originalText>
              <reference value="#Action2_Type"/>
            </originalText>
          </code>
          <statusCode code="completed"/>
          <!-- 
               <text>
                 <reference value="#Action2" />
               </text>  -->
          <!--  In this example, the instruction was given at the same time that the goal was set.
               effectiveTime is the same in this case.  -->
          <effectiveTime value="20120815100000-0800"/>
        </act>
      </entryRelationship>
    </observation>
  </entry>
</section>