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: Procedures Section Observation Entry

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

This example illustrates how an observation 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="Procedure2">
          <td ID="ProcedureDesc2">Electrocardiogram (12-Lead)</td>
          <td>29 Mar 2014 09:15am</td>
          <td>Completed</td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry typeCode="DRIV">
    <!--  Observations should be used for care that result in information about the patient (e.g. a diagnostic test & result) but do not alter physical state  -->
    <!--  As of C-CDA 3.0, the Procedures Section requires that only the procedure template is used.
         To record observations, use the Result Observation template in the Results Section.  -->
    <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="c03e5445-af1b-4911-a419-e2782f21448c"/>
      <code displayName="12 lead electrocardiogram"
            codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="268400002">
        <originalText>
          <reference value="#ProcedureDesc2"/>
        </originalText>
        <translation xsi:type="CD" displayName="Electrocardiogram, complete"
                     codeSystemName="CPT" codeSystem="2.16.840.1.113883.6.12" code="93000"/>
        <translation xsi:type="CD"
                     displayName="12-Lead Electrocardiogram (Ecg) Performed" codeSystemName="HCPCS"
                     codeSystem="2.16.840.1.113883.6.13" code="G8704"/>
        <translation xsi:type="CD" displayName="Electrocardiogram"
                     codeSystemName="ICD-9 Procedure" codeSystem="2.16.840.1.113883.6.104" code="89.52"/>
        <translation xsi:type="CD"
                     displayName="Measurement of Cardiac Electrical Activity, External Approach" codeSystemName="ICD-10 Procedure"
                     codeSystem="2.16.840.1.113883.6.4" code="4A02X4Z"/>
      </code>
      <text>
        <reference value="#Procedure2"/>
      </text>
      <statusCode code="completed"/>
      <effectiveTime value="20140329091522-0500"/>
    </procedure>
  </entry>
</section>