CDA Examples
1.0.0 - active United States of America flag

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: Procedures Section Act Entry

Approval Status: Approved
Task Force Approval: 2014-05-22
SDWG Approval: 2014-05-29, 2016-12-01

This example illustrates an act within a procedure section.

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>Description</th>
          <th>Date and Time (Range)</th>
          <th>Status</th>
        </tr>
      </thead>
      <tbody>
        <tr ID="Procedure3">
          <td ID="ProcedureDesc3">Individual Counseling For Medical Nutrition </td>
          <td>29 Mar 2014 10:45am</td>
          <td>Completed</td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry typeCode="DRIV">
    <!--  Act should be used for care of the patient that cannot be classified as a procedure or observation (e.g. wound dressing change, counseling)  -->
    <!--  As of C-CDA 3.0, the Procedures Section requires that only the procedure template is used.  -->
    <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="9c0f070c-2e9e-4be1-a5b5-ff6d0f68123c"/>
      <code displayName="Nutrition education" codeSystemName="SNOMED-CT"
            codeSystem="2.16.840.1.113883.6.96" code="61310001">
        <originalText>
          <reference value="#ProcedureDesc3"/>
        </originalText>
        <translation xsi:type="CD"
                     displayName="Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes" codeSystemName="CPT"
                     codeSystem="2.16.840.1.113883.6.12" code="97802"/>
        <translation xsi:type="CD"
                     displayName="Nutritional counseling, diet" codeSystemName="HCPCS"
                     codeSystem="2.16.840.1.113883.6.13" code="S9470"/>
        <!--  For some activities, ICD-9 and ICD-10 procedure codes may not apply (e.g. nutritional counseling). ICD-9 and ICD-10 diagnosis codes translate and shown below -->
        <translation xsi:type="CD"
                     displayName="Dietary surveillance and counseling" codeSystemName="ICD-9 Diagnosis"
                     codeSystem="2.16.840.1.113883.6.103" code="V65.3"/>
        <translation xsi:type="CD"
                     displayName="Dietary counseling and surveillance" codeSystemName="ICD-10 Diagnosis"
                     codeSystem="2.16.840.1.113883.6.90" code="Z71.3"/>
      </code>
      <text>
        <reference value="#Procedure3"/>
      </text>
      <statusCode code="completed"/>
      <effectiveTime value="20140329104513-0500"/>
    </procedure>
  </entry>
</section>