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: Result COVID Positive

Approval Status: Approved
Task Force Approval: 2020-04-16
SDWG Approval:

This is an example of a positive COVID result using one potential LOINC code. Please note that LOINC information may change as this was an urgent release. Other possible LOINC codes are noted in comments of the example

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <!--  Results Section with Coded Entries Required -->
  <templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
  <templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01"/>
  <code displayName="Relevant diagnostic tests and/or laboratory data"
        codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="30954-2"/>
  <title>Results</title>
  <text>
    <table border="1">
      <thead>
        <tr>
          <th>Description</th>
          <th>Value / Unit</th>
          <th>Interpretation</th>
          <th>Reference Range</th>
        </tr>
      </thead>
      <tbody>
        <tr>
          <th colspan="4">SARS coronavirus 2 RNA panel</th>
        </tr>
        <tr ID="LabResult3">
          <td>SARS coronavirus 2 RNA</td>
          <td>Detected</td>
          <td>Abnormal</td>
          <td>Reference (Normal) for this test is not detected</td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry>
    <organizer moodCode="EVN" classCode="BATTERY">
      <templateId root="2.16.840.1.113883.10.20.22.4.1"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.1"
                  extension="2015-08-01"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.1"
                  extension="2023-05-01"/>
      <id root="b5684bf0-eb6f-46dd-9f2e-b6cbcc4155fd"/>
      <!--  There are LOINC panel codes for a COVID as well as a CPT code -->
      <!--  Panel codes include: 94306-8, 94503-0, 94504-8, 94531-1  -->
      <!--  Please note that these are pre-release LOINC codes and codes may change over time  -->
      <code
            displayName="SARS-CoV-2 (COVID-19) RNA panel - Respiratory specimen by NAA with probe detection" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
            code="94531-1"/>
      <!--  Alternatively CPT codes may be used in the panel as what was ordered  -->
      <!--  <code code="87635" displayName="Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT"/>  -->
      <statusCode code="completed"/>
      <effectiveTime>
        <low value="20200322142600-0500"/>
        <high value="20200322142600-0500"/>
      </effectiveTime>
      <component>
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.2"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.2"
                      extension="2015-08-01"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.2"
                      extension="2023-05-01"/>
          <id root="5a6be91a-32d5-4d24-a8bd-07d10a33414d"/>
          <!--  This is a LOINC code uses respiratory sample which would include nasal pharynx swab. Other codes that could be used in different circumstances include  -->
          <!--  All potential codes for different sample sites or methods include: 94306-8, 94307-6, 94308-4, 94309-2, 94310-0, 94311-8, 94312-6, 94313-4, 94314-2, 94315-9, 94316-7,
               94499-1, 94500-6, 94501-4, 94502-2, 94503-0, 94504-8, 94505-5, 94506-3, 94507-1, 94508-9, 94509-7, 94510-5, 94511-3, 94531-1, 94532-9, 94533-7, 94534-5, 94547-7  -->
          <!--  You can check LOINC code detail by using their open API, such as https://loinc.org/94500-6/  -->
          <!--  Please note that these are pre-release LOINC codes and codes may change over time  -->
          <code xsi:type="CD"
                displayName="SARS-CoV-2 (COVID-19) RNA [Presence] in Respiratory specimen by NAA with probe detection" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
                code="94500-6"/>
          <text xsi:type="ED">
            <reference value="#LabResult3"/>
          </text>
          <statusCode code="completed"/>
          <effectiveTime value="20200322142600-0500"/>
          <!--  Since this is a pre-release code there is not an established answer list and this may vary  -->
          <value xsi:type="CD" displayName="Detected"
                 codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="260373001"/>
          <interpretationCode displayName="Abnormal"
                              codeSystem="2.16.840.1.113883.5.83" code="A"/>
          <referenceRange>
            <observationRange>
              <text>Reference (Normal) for this test is not detected</text>
              <value xsi:type="CD" displayName="Not Detected"
                     codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="260415000"/>
              <!--  This interpretation code denotes that this reference range is for normal results. This is not the interpretation a specific patient value -->
              <interpretationCode displayName="Normal"
                                  codeSystem="2.16.840.1.113883.5.83" code="N"/>
            </observationRange>
          </referenceRange>
        </observation>
      </component>
    </organizer>
  </entry>
</section>