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: Planned Encounter - Referral

Approval Status: Approved
Task Force Approval: 2015-09-24
SDWG Approval: 2015-10-15, 2017-02-02

This example illustrates how to structure a Referral for the 170.314(b)(2) Transitions of care - N) Referral

This file includes examples of the following templates: 


  <!--  Transition of Care snips to show Referral from test data for 170.314b2 Ambulatory
     
     N)  Referral
     - Pulmonary function tests, Dr. Penny Puffer, tel:555-555-1049, 1047 Healthcare Drive, Portland, OR 97005, Scheduled date: Test date + 2 days
     
     The minimal content to include for the stated test data is text in the Reason for Referral section, and that is shown below as the first section of this example.
     
     This example also includes details of the referral as text and Planned Encounter discrete entry in the Plan of Treatment section. Depending upon how the test data are interpreted,
     there are systems that might very well represent the data in the Plan of Treatment section, based upon the test data statement about Scheduled date.
      -->
<structuredBody xmlns="urn:hl7-org:v3">
  <!--  here is the minimally necessary Reason for Referral section with the text showing the scheduled referral
       note: depending upon how the test data are interpreted the content of the text may vary as regards the Scheduled date.  -->
  <component>
    <section>
      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.1"
                  extension="2014-06-09"/>
      <code displayName="Reason For Referral" codeSystemName="LOINC"
            codeSystem="2.16.840.1.113883.6.1" code="42349-1"/>
      <title>Reason For Referral</title>
      <text>Pulmonary function tests, Dr. Penny Puffer, tel:555-555-1049, 1047 Healthcare Drive, Portland, OR 97005, Scheduled date: 08/17/2012</text>
    </section>
  </component>
  <!--  here is the optional section for Plan of Care with the Planned Encounter  -->
  <component>
    <section>
      <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 Care</title>
      <text>
        <!--  this section may contain many different Planned items, so we use the table caption to help identify each  -->
        <table>
          <caption>Planned Encounters</caption>
          <thead>
            <tr>
              <th>Name</th>
              <th>Date</th>
              <th>Details</th>
            </tr>
          </thead>
          <tbody>
            <tr>
              <td ID="ID0EFFFFFFCA">
                <content ID="ID0EFAAAAACA">Pulmonary Function Tests; Dr. Penny Puffer, tel:555-555-1049, 1047 Healthcare Drive, Portland OR 97005</content>
              </td>
              <td>17-Aug-2012</td>
              <td ID="ID0EAAAAAAAAACA">Indication: Costal Chondritis</td>
            </tr>
          </tbody>
        </table>
      </text>
      <!--  a planned encounter entry  -->
      <entry>
        <!--  encounter with moodCode indicating Intent  -->
        <encounter moodCode="INT" classCode="ENC">
          <!--  Planned Encounter templateId  -->
          <templateId root="2.16.840.1.113883.10.20.22.4.40"
                      extension="2014-06-09"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.40"/>
          <id root="1.3.6.1.42424242.4.99930.4.3.4" extension="52487"/>
          <!--  templateId and id are all that are required or specified in C-CDA R1.1; with C-CDA R2.0 the documentation changes quite a bit  -->
          <!--  code from the Planned Encounter Type value set; 11429006 is reflective of the example data, but local policy and use may result in selection of a different code  -->
          <code displayName="Consultation" codeSystemName="SNOMED CT"
                codeSystem="2.16.840.1.113883.6.96" code="11429006">
            <!--  referencing back to the text of the type -->
            <originalText>
              <reference value="#ID0EFAAAAACA"/>
            </originalText>
          </code>
          <text>
            <!--  referencing the entire text  -->
            <reference value="#ID0EFFFFFFCA"/>
          </text>
          <statusCode code="active"/>
          <effectiveTime>
            <!--  appointment requested for Test date + 2 days , so 8/17/2012  -->
            <low value="20120817"/>
          </effectiveTime>
          <!--  the requested Penny Puffer provider  -->
          <performer typeCode="PRF">
            <assignedEntity>
              <id root="2.16.840.1.113883.4.6" extension="3333333333"/>
              <addr>
                <streetAddressLine>1047 Healthcare Dr</streetAddressLine>
                <city>Portland</city>
                <state>OR</state>
                <postalCode>97005</postalCode>
                <country>US</country>
              </addr>
              <telecom value="tel:+1-(555)555-1049"/>
              <assignedPerson>
                <name>
                  <prefix>Dr</prefix>
                  <given>Penny</given>
                  <family>Puffer</family>
                </name>
              </assignedPerson>
            </assignedEntity>
          </performer>
          <!--  Penny Puffer office location as a service delivery location  -->
          <participant typeCode="LOC">
            <participantRole classCode="SDLOC">
              <templateId root="2.16.840.1.113883.10.20.22.4.32"/>
              <code displayName="Mixed Age Mixed Acuity Unit"
                    codeSystem="2.16.840.1.113883.6.259" code="1212-0"/>
              <addr nullFlavor="UNK"/>
              <telecom nullFlavor="UNK"/>
              <playingEntity classCode="PLC">
                <name>Dr. Penny Puffer Office</name>
              </playingEntity>
            </participantRole>
          </participant>
          <!--  this references the indication (reason) for the planned encounter; example data suggests the reason was the encounter diagnosis
               L)  Encounter Diagnosis
               - Costal Chondritis, [SNOMED-CT: 64109004], Start: 8/15/2012, Active  -->
          <entryRelationship typeCode="RSON">
            <observation moodCode="EVN" classCode="OBS">
              <templateId root="2.16.840.1.113883.10.20.22.4.19"
                          extension="2023-05-01"/>
              <templateId root="2.16.840.1.113883.10.20.22.4.19"
                          extension="2014-06-09"/>
              <templateId root="2.16.840.1.113883.10.20.22.4.19"/>
              <id root="1.3.6.1.4.1.42424242.4.99930.4.4.1.2.1"
                  extension="45678"/>
              <code xsi:type="CD" displayName="Diagnosis interpretation"
                    codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="282291009"/>
              <text xsi:type="ED">
                <reference value="#ID0EAAAAAAAAACA"/>
              </text>
              <statusCode code="completed"/>
              <effectiveTime>
                <low value="20120815"/>
              </effectiveTime>
              <!--  includes the code for Costal Chondritis  -->
              <value xsi:type="CD" displayName="Costal chondritis"
                     codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="64109004"/>
            </observation>
          </entryRelationship>
        </encounter>
      </entry>
    </section>
  </component>
</structuredBody>