CDA Examples
1.0.0 - active
CDA Examples
1.0.0 - active
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 example illustrates a planned surgical procedure with multiple proposed alternatives, with the expectation that the surgeon will choose one to perform when the surgery actually occurs.
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"/>
<templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09"/>
<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>
<caption>Scheduled Procedures</caption>
<colgroup>
<col width="40%"/>
<col width="10%"/>
<col width="25%" span="2"/>
</colgroup>
<thead>
<tr>
<th>Name</th>
<th>Priority</th>
<th>Associated Diagnoses</th>
<th>Date/Time</th>
</tr>
</thead>
<tbody>
<tr ID="procedure32">
<td>
<content ID="procedure32name">Appendectomy Open</content>
</td>
<td>Urgent</td>
<td>
<paragraph>Appendicitis</paragraph>
</td>
<td>04/30/2022 9:00 PM CDT</td>
</tr>
</tbody>
</table>
</text>
<entry>
<!-- Planned Procedure (V2) -->
<procedure moodCode="INT" classCode="PROC">
<templateId root="2.16.840.1.113883.10.20.22.4.41"/>
<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"
extension="2022-06-01"/>
<!-- Companion Guide -->
<id root="1.2.840.114350.1.13.861.1.7.1.1988.2" extension="237181-1-1"/>
<code displayName="Appendectomy" codeSystemName="CPT-4"
codeSystem="2.16.840.1.113883.6.12" code="44950">
<originalText>Appendectomy Open
<reference value="#procedure32name"/>
</originalText>
<translation xsi:type="CD" displayName="Excision of appendix"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="80146002"/>
</code>
<text>
<reference value="#procedure32"/>
</text>
<statusCode code="active"/>
<effectiveTime>
<low value="20220430210000-0500"/>
<high value="20220430213200-0500"/>
</effectiveTime>
<!-- Omitted: MAY contain zero or more [0..*] performer (CONF:1098-30449) -->
<!-- Omitted: SHOULD contain zero or one [0..1] Author Participation (CONF:1098-31979) -->
<!-- Priority Preference -->
<entryRelationship typeCode="REFR">
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.143"/>
<id nullFlavor="NI"/>
<code xsi:type="CD" displayName="Preference"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="225773000"/>
<effectiveTime value="20220430201102-0500"/>
<value xsi:type="CD" displayName="High priority"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="394849002"/>
</observation>
</entryRelationship>
<!-- Indication -->
<entryRelationship typeCode="RSON">
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<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"
extension="2023-05-01"/>
<!-- C-CDA 3.0 -->
<id root="1.2.840.114350.1.13.861.1.7.2.696871" extension="86579"/>
<code xsi:type="CD" displayName="Problem"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="55607006"/>
<text xsi:type="ED">Appendicitis</text>
<statusCode code="completed"/>
<value xsi:type="CD" displayName="Appendicitis"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="74400008">
<translation xsi:type="CD" codeSystemName="ICD10"
codeSystem="2.16.840.1.113883.6.90" code="K37"/>
<translation xsi:type="CD" codeSystemName="ICD9"
codeSystem="2.16.840.1.113883.6.103" code="541"/>
</value>
</observation>
</entryRelationship>
<!-- Omitted: MAY contain zero or more [0..*] entryRelationship (CONF:1098-31985) such that it
SHALL contain exactly one [1..1] Instruction (V2) (CONF:1098-31989). -->
<!-- Omitted: MAY contain zero or more [0..*] entryRelationship (CONF:1098-31990) such that it
SHALL contain exactly one [1..1] Planned Coverage (CONF:1098-31992). -->
<!-- This entryRelationship contains an organizer listing alternative planned procedures...
The options below should be read as: CPT 44960 OR 44970 -->
<entryRelationship typeCode="REFR">
<!-- To represent multiple combined procedures as one option, an organizer may be used to group multiple proposed procedures -->
<organizer moodCode="PRP" classCode="CLUSTER">
<!-- "PRP" = proposal
A non-mandated intent to perform an act. Used to record intents that are explicitly not Orders.
Professional responsibility for the 'proposal' may or may not be present. -->
<!-- Implementers may include an organizer/code here with a value "alternative procedure options,"
although we were unable to find an appropriate one. -->
<statusCode code="active"/>
<!-- First alternative -->
<component>
<procedure moodCode="PRP" classCode="SUBST">
<!-- "SUBST" = substitution
Indicates that the subject Act has undergone or should undergo substitution of a type indicated by Act.code. -->
<code
displayName="Appendectomy; for ruptured appendix with abscess or generalized peritonitis" codeSystemName="CPT-4"
codeSystem="2.16.840.1.113883.6.12" code="44960"/>
</procedure>
</component>
<!-- Second alternative -->
<component>
<procedure moodCode="PRP" classCode="SUBST">
<code displayName="Laparoscopy, surgical, appendectomy"
codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12" code="44970"/>
</procedure>
</component>
</organizer>
</entryRelationship>
</procedure>
</entry>
</section>
IG © Health Level Seven. Package hl7.cda.examples#1.0.0 based on FHIR 5.0.0. Generated 2025-08-28
Links: Table of Contents |
QA Report
| Version History 
|
|
Propose a change