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: Close Referral with a Document

Approval Status: Approved
Task Force Approval: 2018-10-16
SDWG Approval: 2018-12-06

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 &amp; 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 &amp; Ethnicity - CDC" />
        <ethnicGroupCode code="2186-5" codeSystem="2.16.840.1.113883.6.238"
                         displayName="Not Hispanic or Latino" codeSystemName="Race &amp; 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>