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 Planned Tests

Approval Status: Approved
Task Force Approval: 2014-11-20
SDWG Approval: 2015-04-16, 2017-02-02

This is an example of how an author can record no planned tests.

This file includes examples of the following templates:


  <!--  This is an example of where a nullFlavor of OTH is used to represent the negation of any planned procedure  -->
<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"/>
  <code displayName="Plan of care note" codeSystemName="LOINC"
        codeSystem="2.16.840.1.113883.6.1" code="18776-5"/>
  <title>Plan of Treatment</title>
  <text>
    <table>
      <thead>
        <tr>
          <th>Description</th>
          <th>Date and Time (Range)</th>
          <th>Status</th>
        </tr>
      </thead>
      <tbody>
        <tr>
          <td>PLANNED TESTS</td>
        </tr>
        <tr>
          <td ID="PlannedTestDesc1">No Planned Tests</td>
        </tr>
        <tr>
          <td>PLANNED PROCEDURES</td>
        </tr>
        <tr ID="PlannedProcedure1">
          <td ID="PlannedProcedureDesc1">Laparoscopic Appendectomy</td>
          <td>05/02/2015</td>
          <td>Scheduled</td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry typeCode="DRIV">
    <!--  For this example, we are recommended action.negationInd task force recommendation  -->
    <observation negationInd="true" 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="c03e5445-af1b-4911-a419-e2782f21448c"/>
      <!--  If a code is available for the general concept for which there is no information (e.g. Problem), use that
           code in the code attribute, otherwise use a nullFlavor of OTH  -->
      <code xsi:type="CD" nullFlavor="OTH">
        <originalText>
          <reference value="#PlannedTestDesc1"/>
        </originalText>
      </code>
      <text xsi:type="ED">
        <reference value="#PlannedTestDesc1"/>
      </text>
      <statusCode code="active"/>
      <!--  nullFlavor of NA used since no time is applicable in this context. -->
      <effectiveTime nullFlavor="NA"/>
      <!--  nullFlavor of NA used since no value is applicable in this context. -->
      <value xsi:type="CD" nullFlavor="NA"/>
    </observation>
  </entry>
  <entry typeCode="DRIV">
    <procedure moodCode="RQO" classCode="PROC">
      <!--  ** Plan of care procedure**  -->
      <templateId root="2.16.840.1.113883.10.20.22.4.41"
                  extension="2022-06-01"/>
      <!--  Companion Guide  -->
      <templateId root="2.16.840.1.113883.10.20.22.4.41"
                  extension="2014-06-09"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.41"/>
      <id root="9a6d1bac-17d3-4195-89a4-1121bc809b4a"/>
      <code displayName="Laparoscopic appendectomy"
            codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="6025007">
        <originalText>
          <reference value="#PlannedProcedureDesc1"/>
        </originalText>
      </code>
      <text>
        <reference value="#PlannedProcedure1"/>
      </text>
      <statusCode code="active"/>
      <!--  Effective times can be either a value or interval. For procedures with start and stop times, an interval would be more appropriate  -->
      <effectiveTime value="20150502"/>
      <!--  methodCode indicates how the procedure was performed. It cannot conflict with the code used for procedure -->
      <methodCode displayName="Laparoscopic procedure"
                  codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="51316009"/>
      <!--  targetSiteCode indicates the body site addressed by procedure and must be from value set 2.16.840.1.113883.3.88.12.3221.8.9 -->
      <targetSiteCode displayName="Entire appendix"
                      codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="181255000"/>
    </procedure>
  </entry>
</section>