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 an unsuccessful procedure attempt.
This file includes examples of the following templates:
<section xmlns="urn:hl7-org:v3">
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
<templateId root="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09"/>
<code displayName="HISTORY OF PROCEDURES" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="47519-4"/>
<title>Procedures</title>
<text>
<table>
<thead>
<tr>
<th>Procedure</th>
<th>Date and Time (Range)</th>
<th>Comment</th>
<th>Reason</th>
</tr>
</thead>
<tbody>
<tr ID="Procedure1">
<td ID="ProcedureDesc1">Chest X-ray</td>
<td>03/31/2022 04:49 PM CST</td>
<td ID="Procedure_0_comment">Unsuccessful</td>
<td ID="Procedure_0_reason">Image unreadable</td>
</tr>
</tbody>
</table>
</text>
<entry>
<procedure moodCode="EVN" classCode="PROC">
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14"
extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14"
extension="2024-05-01"/>
<id root="9037af8a-b28f-4bb5-8a02-ff6ea1f24cb0"/>
<code displayName="Standard chest X-ray" codeSystemName="SNOMED-CT"
codeSystem="2.16.840.1.113883.6.96" code="168731009">
<originalText>
<reference value="#ProcedureDesc1"/>
</originalText>
</code>
<text>
<reference value="#Procedure1"/>
</text>
<!-- statusCode is completed because the procedure is complete, even though it was unsuccessful -->
<statusCode code="completed"/>
<!-- Effective times can be either a value or interval. For procedures with start and stop times, an interval would be more appropriate -->
<effectiveTime value="20220331164901-0500"/>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<act moodCode="EVN" classCode="ACT">
<!-- No templateId currently exists for this...
One may be created in a future version of the C-CDA Companion Guide. -->
<!-- REQUIRED: This code is the most important part of the act... it's really the
only core requirement for marking the procedure as unsuccessful. -->
<code displayName="Failed attempted procedure"
codeSystem="2.16.840.1.113883.6.96" code="103709008"/>
<!-- OPTIONAL: May contain info about why the procedure was unsuccessful -->
<text>
<reference value="#Procedure_0_reason"/>
</text>
<!-- This statusCode is always "completed" since it refers to the action of having
documented that the procedure was unsuccessful. -->
<statusCode code="completed"/>
<!-- OPTIONAL: Instant the procedure was marked as unsuccessful -->
<effectiveTime value="20220331165432-0500"/>
<!-- OPTIONAL: Author who marked the procedure as unsuccessful -->
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20220331165432-0500"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="99999999"/>
<code displayName="Family Medicine Physician"
codeSystemName="Health Care Provider Taxonomy" codeSystem="2.16.840.1.113883.6.101" code="207Q00000X"/>
<addr nullFlavor="UNK"/>
<telecom value="tel:555-555-1002" use="WP"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
</act>
</entryRelationship>
</procedure>
</entry>
</section>