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 Procedure Entry

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

This example illustrates how a procedure which "alters the physical state" of the patient and should be classified as a 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">Laparoscopic appendectomy</td>
          <td>(03 Feb 2014 09:22am- 03 Feb 2014 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. -->
    <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="64af26d5-88ef-4169-ba16-c6ef16a1824f"/>
      <code displayName="Laparoscopic appendectomy"
            codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="6025007">
        <originalText>
          <reference value="#ProcedureDesc1"/>
        </originalText>
        <translation xsi:type="CD" displayName="Laparoscopic Appendectomy"
                     codeSystemName="CPT" codeSystem="2.16.840.1.113883.6.12" code="44970"/>
        <translation xsi:type="CD"
                     displayName="Resection of Appendix, Percutaneous Endoscopic Approach" codeSystemName="ICD-10-PCS"
                     codeSystem="2.16.840.1.113883.6.4" code="0DTJ4ZZ"/>
        <translation xsi:type="CD" displayName="Laparoscopic appendectomy"
                     codeSystemName="ICD-9-CM" codeSystem="2.16.840.1.113883.6.104" code="47.01"/>
      </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="20140203092205-0700"/>
        <high value="20140203111514-0700"/>
      </effectiveTime>
      <!--  methodCode indicates how the procedure was performed. It cannot conflict with the code used for procedure -->
      <methodCode displayName="Laparoscopic procedure"
                  codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="51316009"/>
      <!--  targetSiteCode indicates the body site addressed by procedure and must be from value set 2.16.840.1.113883.3.88.12.3221.8.9 -->
      <targetSiteCode displayName="Entire appendix"
                      codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="181255000"/>
    </procedure>
  </entry>
</section>