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 Colonoscopy procedure which with biopsy. Even if not biopsy, a colonscopy is recommended to be in a Procedure Activity Procedure.
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="Procedure1">
<td ID="ProcedureDesc1">Colonoscopy, flexible; with biopsy, single or multiple</td>
<td>(03 May 2019 09:22am- 03 May 2019 11:15am)</td>
<td>Completed</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<!-- Procedures should be used for care that directly changes the patient's physical state. -->
<!-- Colonoscopy with/without Biopsy is appropriate here -->
<!-- The Procedures section records all completed Procedures -->
<!-- Biopsies/test/results from the Procedure are expected 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="56a76ee2-c5a9-4c69-be93-0461bd98691c"/>
<code displayName="Fiberoptic colonoscopy with biopsy"
codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="25732003">
<originalText>
<reference value="#ProcedureDesc1"/>
</originalText>
<translation xsi:type="CD"
displayName="Colonoscopy, flexible; with biopsy, single or multiple" codeSystemName="CPT"
codeSystem="2.16.840.1.113883.6.12" code="45380"/>
</code>
<text>
<reference value="#Procedure1"/>
</text>
<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>
<low value="20190503092205-0700"/>
<high value="20190503111514-0700"/>
</effectiveTime>
</procedure>
</entry>
</section>