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 document shows how an ordered referral could have a completed Constulation Note Document fulfill the requirements of Closing the Loop quality measure https://ecqi.healthit.gov/ecqm/measures/cms50v7 Note that the examples task force has approved multiple samples in regards to this quality measure. The Planned Referral Act opens the loop (see example: Referral Request and Close Referral with a Note) and this Consultation Note Document would be eligible to close the loop.
This file includes examples of the following templates:
This content is an example of the Consultation Note Logical Model and is not a FHIR Resource
<!-- This sample shows illustrative information (excluding structuredBody) for a Consultation Note -->
<!-- It was specifically developed to show how a consultation note can complete a referral loop -->
<!-- The inFulfillmentOf element links back to the original requested referral -->
<!-- Original sample adapted from Lantana samples provided with C-CDA 2.0 Guide -->
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:voc="urn:hl7-org:v3/voc" xmlns:sdtc="urn:hl7-org:sdtc">
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<!-- Identifies document as conformant to US Realm Header (V2) Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2024-05-01"/>
<!-- Consultation Note V2 -->
<templateId root="2.16.840.1.113883.10.20.22.1.4" extension="2015-08-01"/>
<!-- Consultation Note C-CDA 3.0 -->
<templateId root="2.16.840.1.113883.10.20.22.1.4" extension="2024-05-01"/>
<id extension="TT988" root="2.16.840.1.113883.19.5.99999.1"/>
<code code="11488-4" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Consult note">
<!-- Additional SNOMED code which is equivalent to the LOINC consultation note code -->
<!-- The quality measure CMS50 v7 requires a concept from 2.16.840.1.113883.3.464.1003.121.12.1006 -->
<!-- There is a potential for the LOINC codes to be added to the prior value set, although it is not currently available -->
<translation code="371530004" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT" displayName="Clinical consultation report (record artifact)" />
</code>
<title>Community Health Consult Note</title>
<effectiveTime value="201806230900-0800"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" displayName="normal" />
<languageCode code="en-US"/>
<setId extension="sTT988" root="2.16.840.1.113883.19.5.99999.19"/>
<versionNumber value="1"/>
<recordTarget>
<patientRole>
<!-- Example Social Security Number using the actual SSN OID. -->
<id extension="000-00-0000" root="2.16.840.1.113883.4.1"/>
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<addr use="HP">
<streetAddressLine>2222 Home Street</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
<country>US</country>
</addr>
<!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<telecom value="tel:+1(555)555-2003" use="HP"/>
<patient>
<!-- The first name element represents what the patient is known as -->
<name use="L">
<given>Eve</given>
<family qualifier="SP">Betterhalf</family>
</name>
<!-- The second name element represents another name associated with the patient -->
<name use="SRCH">
<given>Eve</given>
<family qualifier="BR">Everywoman</family>
</name>
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"
displayName="Female" codeSystemName="AdministrativeGender" />
<!-- Date of birth need only be precise to the day -->
<birthTime value="19750501"/>
<maritalStatusCode code="M" codeSystem="2.16.840.1.113883.5.2"
displayName="Married" codeSystemName="MaritalStatusCode" />
<religiousAffiliationCode code="1013" codeSystem="2.16.840.1.113883.5.1076"
displayName="Christian (non-Catholic, non-specific)" codeSystemName="HL7 Religious Affiliation" />
<!-- CDC Race and Ethnicity code set contains the five minimum race and ethnicity
categories defined by OMB Standards -->
<raceCode code="2106-3" codeSystem="2.16.840.1.113883.6.238"
displayName="White" codeSystemName="Race & Ethnicity - CDC" />
<!-- The raceCode extension is only used if raceCode is valued -->
<sdtc:raceCode code="2076-8" codeSystem="2.16.840.1.113883.6.238"
displayName="Native Hawaiian or Other Pacific Islander" codeSystemName="Race & Ethnicity - CDC" />
<ethnicGroupCode code="2186-5" codeSystem="2.16.840.1.113883.6.238"
displayName="Not Hispanic or Latino" codeSystemName="Race & Ethnicity - CDC" />
<guardian>
<code code="POWATT" codeSystem="2.16.840.1.113883.5.111"
displayName="Power of Attorney" codeSystemName="ResponsibleParty" />
<addr use="HP">
<streetAddressLine>2222 Home Street</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(555)555-2008" use="MC"/>
<guardianPerson>
<name>
<given>Boris</given>
<given qualifier="CL">Bo</given>
<family>Betterhalf</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<streetAddressLine>4444 Home Street</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
</addr>
</place>
</birthplace>
</patient>
<providerOrganization>
<!-- Organizations SHOULD have an NPI; this is a real root; fake extension -->
<id extension="219BX" root="2.16.840.1.113883.4.6"/>
<name>The DoctorsTogether Physician Group</name>
<telecom use="WP" value="tel:+1(555)555-5000"/>
<addr use="WP">
<streetAddressLine>1007 Health Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time value="201307310530-0800"/>
<assignedAuthor>
<id extension="555555555" root="2.16.840.1.113883.4.6"/>
<code code="207QA0505X" codeSystem="2.16.840.1.113883.6.101"
displayName="Family Medicine Physician, Adult Medicine" codeSystemName="Healthcare Provider Taxonomy (HIPAA)" />
<addr use="WP">
<streetAddressLine>1004 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-1004"/>
<assignedPerson>
<name>
<given>Patricia</given>
<given qualifier="CL">Patty</given>
<family>Primary</family>
<suffix qualifier="AC">M.D.</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id extension="333777777" root="2.16.840.1.113883.4.6"/>
<addr use="WP">
<streetAddressLine>1007 Healthcare Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-1050"/>
<assignedPerson>
<name>
<given>Ellen</given>
<family>Enter</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<informant>
<assignedEntity>
<id extension="888888888" root="2.16.840.1.113883.19.5"/>
<addr use="WP">
<streetAddressLine>1007 Healthcare Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-1003"/>
<assignedPerson>
<name>
<given>Harold</given>
<family>Hippocrates</family>
<suffix qualifier="AC">D.O.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</informant>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="321CX" root="2.16.840.1.113883.4.6"/>
<name>Good Health HIE</name>
<telecom use="WP" value="tel:+1(555)-1009"/>
<addr use="WP">
<streetAddressLine>1009 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<given>Sara</given>
<family>Specialize</family>
<suffix qualifier="AC">M.D.</suffix>
</name>
</informationRecipient>
<receivedOrganization>
<name>The DoctorsApart Physician Group</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<authenticator>
<time value="201308011030-0800"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="555555555" root="2.16.840.1.113883.4.6"/>
<code code="207QA0505X" codeSystem="2.16.840.1.113883.6.101"
displayName="Family Medicine Physician, Adult Medicine" codeSystemName="Healthcare Provider Taxonomy (HIPAA)" />
<addr use="WP">
<streetAddressLine>1004 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-1004"/>
<assignedPerson>
<name>
<given>Patricia</given>
<given qualifier="CL">Patty</given>
<family>Primary</family>
<suffix qualifier="AC">M.D.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<!-- Describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note -->
<inFulfillmentOf typeCode="FLFS">
<order classCode="ACT" moodCode="RQO">
<!-- Note that the following id corresponds to referral request -->
<!-- The semantics indicate that the referral was closed/completed -->
<id root="9a6d1bac-17d3-4195-89a4-1121bc809b4e"/>
<code code="103697008" codeSystem="2.16.840.1.113883.6.96"
displayName="Patient referral for dental care" codeSystemName="SNOMED CT" />
</order>
</inFulfillmentOf>
<componentOf>
<encompassingEncounter>
<id extension="9937012" root="2.16.840.1.113883.19"/>
<code code="99213" codeSystem="2.16.840.1.113883.6.12"
codeSystemName="CPT-4"
displayName="Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter." />
<effectiveTime value="201806230800-0800"/>
<location>
<healthCareFacility>
<id root="2.16.540.1.113883.19.2"/>
</healthCareFacility>
</location>
</encompassingEncounter>
</componentOf>
<!-- Note that structured body is stubbed in this example, as the focus is on the header -->
<component>
<structuredBody>
<component><section><templateId root="2.16.840.1.113883.10.20.22.2.9" extension="2014-06-09" /><code code="51847-2" codeSystem="2.16.840.1.113883.6.1" /><title>AP</title><text /></section></component>
<component><section><templateId root="2.16.840.1.113883.10.20.22.2.12" /><code code="29299-5" codeSystem="2.16.840.1.113883.6.1" /><title>RFR</title><text /></section></component>
<component><section><templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.4" /><code code="10164-2" codeSystem="2.16.840.1.113883.6.1" /><title>HPI</title><text /></section></component>
<component><section nullFlavor="NI"><templateId root="2.16.840.1.113883.10.20.22.2.6.1" extension="2015-08-01" /><code code="48765-2" codeSystem="2.16.840.1.113883.6.1" /><title>Allergies</title><text /></section></component>
<component><section nullFlavor="NI"><templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01" /><code code="11450-4" codeSystem="2.16.840.1.113883.6.1" /><title>Problems</title><text /></section></component>
</structuredBody>
</component>
</ClinicalDocument>