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
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>