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: Procedure Unsuccessful

Approval Status: Approved
Task Force Approval: 2022-05-05
SDWG Approval: 2023-03-09

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>