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: Results Radiology with Image Narrative

Approval Status: Approved
Task Force Approval: 2016-03-10
SDWG Approval: 2016-03-31, 2017-02-02

This is an example of how to show a radiology result with narrative report in the results section. For the value, xsi-type equals ED (with reference) for encapsulated data.

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
  <templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01"/>
  <!--  Results Section with Coded Entries Required -->
  <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">Chest X-RAY 2 views</th>
        </tr>
        <tr>
          <th colspan="4">Performed on 02-25-2015 9:10a</th>
        </tr>
        <tr ID="Result1">
          <td>Chest X-Ray 2 Views</td>
          <td ID="Result1OriginalText">The lungs are clear. The heart is enlarged with evidence of cardiomegaly.
            Pulmonary vasculature is normal. The aorta is mildly ectatic and tortuous. IMPRESSION: Cardiomegaly. No other acute abnormality.
          </td>
          <td/>
          <td/>
        </tr>
        <tr>
          <th colspan="4">Electronically signed: Hermione Seaven, MD 02-25-2015 10:32a</th>
        </tr>
      </tbody>
    </table>
  </text>
  <entry>
    <organizer moodCode="EVN" classCode="CLUSTER">
      <!--  Selected CLUSTER since not a set of tests  -->
      <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"/>
      <!--  Results Organizer  -->
      <id root="e1aa44dd-6f39-4f5c-b267-897c3821b563"/>
      <code displayName="Chest X-Ray 2 Views" codeSystemName="CPT"
            codeSystem="2.16.840.1.113883.6.12" code="71020"/>
      <statusCode code="completed"/>
      <!--  an organizer/effectiveTime value="20150225091059-0500" could be used but is not required  -->
      <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"/>
          <!--  Results Observation  -->
          <id root="e1aa44dd-6f39-2f5c-b267-897c3824b563"/>
          <code xsi:type="CD" displayName="XR Chest 2 Views"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="36643-5"/>
          <text xsi:type="ED">
            <reference value="#Result1"/>
          </text>
          <statusCode code="completed"/>
          <!--  This is the timestamp of biologically relevance (i.e. when chest x-ray was performed), aligning with HL7 v3 modeling.  -->
          <effectiveTime value="20150225091059-0500"/>
          <value xsi:type="ED">
            <reference value="#Result1OriginalText"/>
          </value>
          <author>
            <!--  This is the timestamp of when the author (i.e. the radiologist) interepreted the chest x-ray -->
            <time value="20150225103206-0500"/>
            <assignedAuthor>
              <id root="2.16.840.1.113883.4.6" extension="66666"/>
              <code
                    displayName="Chiropractic Providers; Chiropractor, Radiology" codeSystemName="NUCC"
                    codeSystem="2.16.840.1.113883.6.101" code="111NR0200X"/>
              <addr>
                <streetAddressLine>6666 StreetName St.</streetAddressLine>
                <city>Silver Spring</city>
                <state>MD</state>
                <postalCode>20901</postalCode>
                <country>US</country>
              </addr>
              <telecom value="tel:+1(301)666-6666" use="WP"/>
              <assignedPerson>
                <name>
                  <given>Hermione</given>
                  <family>Seaven</family>
                  <suffix>MD</suffix>
                </name>
              </assignedPerson>
            </assignedAuthor>
          </author>
        </observation>
      </component>
    </organizer>
  </entry>
</section>