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 is panel of the nine common vital signs collected on an adult in metric units, with the additional inclusion of oxygen concentration as a separate observation.
This file includes examples of the following templates:
<section xmlns="urn:hl7-org:v3">
<!--
Vital signs example with oxygen concentration included.
Note that this is almost identical to the Panel of Vital Signs in Metric Units example[1],
with the exception that this example contains a demonstration of the Structured Docs
Workgroup's recommendation for sending oxygen concentration. However, since this
recommendation generates a schematron warning against CONF:1098-32934, it should be
considered a weaker recommendation than the example it's based on, and implementers
who are certain that receivers support some alternate means of structuring O2
concentration (for instance, by nesting it within an entryRelationship linked to
SpO2, akin to the approach in FHIR US Core[2]) may choose to send this differently.
[1]: http://cdasearch.hl7.org/examples/view/713669406c546a843ed2b78cfd99080f87834191
[2]: http://hl7.org/fhir/us/core/StructureDefinition/us-core-pulse-oximetry -->
<!-- Note that C-CDA 3.0 has a different LOINC code requirement for Vital Signs Organizer.
C-CDA 2.1 allows this as long as the 1.1 templateId is not present.
For that reason, the 1.1 templateIds have been omitted in this example.
See more information at organizer/code -->
<!-- <templateId root="2.16.840.1.113883.10.20.22.2.4.1" /> -->
<templateId root="2.16.840.1.113883.10.20.22.2.4.1" extension="2015-08-01"/>
<code displayName="Vital signs" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="8716-3"/>
<title>Vital Signs (Last Filed)</title>
<text>
<table>
<thead>
<tr>
<th>Date</th>
<th>Blood Pressure</th>
<th>Pulse</th>
<th>Temperature</th>
<th>Respiratory Rate</th>
<th>Height</th>
<th>Weight</th>
<th>BMI</th>
<th>SpO2</th>
<th>O2 Concentration</th>
</tr>
</thead>
<tbody>
<tr>
<td>05/20/2014 7:36pm</td>
<!-- You can consolidate Systolic and Diastolic in human view if desired but should retain separate references -->
<td>
<content ID="SystolicBP_1">120</content>/
<content ID="DiastolicBP_1">80</content>mm[Hg]
</td>
<td ID="Pulse_1">80 /min</td>
<td ID="Temp_1">37.2 C</td>
<td ID="RespRate_1">18 /min</td>
<td ID="Height_1">170.2 cm</td>
<td ID="Weight_1">108.8 kg</td>
<td ID="BMI_1">37.58 kg/m2</td>
<td ID="SPO2_1">98%</td>
<td ID="O2Conc_1">36%</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<!-- When a set of vital signs are recorded together, include them in single clustered organizer -->
<!-- Other components like inhaled oxygen flow rate (3151-8) may also be included similarly to the component above... -->
<organizer moodCode="EVN" classCode="CLUSTER">
<!-- <templateId root="2.16.840.1.113883.10.20.22.4.26"/> -->
<templateId root="2.16.840.1.113883.10.20.22.4.26"
extension="2015-08-01"/>
<id root="e6c800c4-4a71-41bf-80e2-e741dd1168e9"/>
<!-- If this were C-CDA 1.1 + 2.1 (with an additional templateId containing no extension),
the code element would have SNOMED code 46680005. Since this is not allowed in C-CDA 3.0,
it has been omitted from this example. -->
<code
displayName="Vital signs, weight, height, head circumference, oximetry, BMI, and BSA panel" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
code="74728-7"/>
<statusCode code="completed"/>
<effectiveTime value="20140520193605-0500"/>
<!-- Each vital sign should be its own component. Note that systolic and diastolic BP must be separate components -->
<component>
<!-- Additional information of interpretation and/or reference range may be included but are optional -->
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
<templateId root="2.16.840.1.113883.10.20.22.4.27"
extension="2014-06-09"/>
<id root="fdbd831b-5919-4f06-9467-76b07022f8e8"/>
<code xsi:type="CD" displayName="Systolic blood pressure"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="8480-6"/>
<text xsi:type="ED">
<!-- This reference identifies content in human readable formatted text -->
<reference value="#SystolicBP_1"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20140520193605-0500"/>
<!-- Example of Value with UCUM unit. Note that metric units used in this example -->
<value xsi:type="PQ" value="120" unit="mm[Hg]"/>
</observation>
</component>
<component>
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
<templateId root="2.16.840.1.113883.10.20.22.4.27"
extension="2014-06-09"/>
<id root="553f3f45-9046-4659-b3e7-5de904003550"/>
<code xsi:type="CD" displayName="Diastolic blood pressure"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="8462-4"/>
<text xsi:type="ED">
<reference value="#DiastolicBP_1"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20140520193605-0500"/>
<value xsi:type="PQ" value="80" unit="mm[Hg]"/>
</observation>
</component>
<component>
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
<templateId root="2.16.840.1.113883.10.20.22.4.27"
extension="2014-06-09"/>
<id root="77bfe276-a1dd-4372-9072-e603905acc07"/>
<code xsi:type="CD" displayName="Heart rate"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="8867-4"/>
<text xsi:type="ED">
<reference value="#Pulse_1"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20140520193605-0500"/>
<value xsi:type="PQ" value="80" unit="/min"/>
</observation>
</component>
<component>
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
<templateId root="2.16.840.1.113883.10.20.22.4.27"
extension="2014-06-09"/>
<id root="24faa204-db62-4610-864f-cb50b650d0fa"/>
<code xsi:type="CD" displayName="Body temperature"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="8310-5"/>
<text xsi:type="ED">
<reference value="#Temp_1"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20140520193605-0500"/>
<value xsi:type="PQ" value="37.2" unit="Cel"/>
</observation>
</component>
<component>
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
<templateId root="2.16.840.1.113883.10.20.22.4.27"
extension="2014-06-09"/>
<id root="79f25395-8ec6-488b-8c05-becc97f79995"/>
<code xsi:type="CD" displayName="Respiratory rate"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="9279-1"/>
<text xsi:type="ED">
<reference value="#RespRate_1"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20140520193605-0500"/>
<value xsi:type="PQ" value="18" unit="/min"/>
</observation>
</component>
<component>
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
<templateId root="2.16.840.1.113883.10.20.22.4.27"
extension="2014-06-09"/>
<id root="6d3fa9f8-6049-41bd-b0c3-b0196bb6bd37"/>
<code xsi:type="CD" displayName="Body height"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="8302-2"/>
<text xsi:type="ED">
<reference value="#Height_1"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20140520193605-0500"/>
<value xsi:type="PQ" value="170.2" unit="cm"/>
</observation>
</component>
<component>
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
<templateId root="2.16.840.1.113883.10.20.22.4.27"
extension="2014-06-09"/>
<id root="2594e631-2189-4e72-9dd1-d6769ee2a7be"/>
<code xsi:type="CD" displayName="Body weight"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="29463-7"/>
<text xsi:type="ED">
<reference value="#Weight_1"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20140520193605-0500"/>
<value xsi:type="PQ" value="108.863" unit="kg"/>
</observation>
</component>
<component>
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
<templateId root="2.16.840.1.113883.10.20.22.4.27"
extension="2014-06-09"/>
<id root="5858e765-2ffe-413f-9197-260f2c6e7aa8"/>
<code xsi:type="CD" displayName="Body mass index (BMI) [Ratio]"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="39156-5"/>
<text xsi:type="ED">
<reference value="#BMI_1"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20140520193605-0500"/>
<value xsi:type="PQ" value="37.58" unit="kg/m2"/>
</observation>
</component>
<component>
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
<templateId root="2.16.840.1.113883.10.20.22.4.27"
extension="2014-06-09"/>
<id root="4ce6046c-f6e3-41b0-91fc-2d5325f2bbc3"/>
<code xsi:type="CD" displayName="OXYGEN SATURATION"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="2710-2"/>
<text xsi:type="ED">
<reference value="#SPO2_1"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20140520193605-0500"/>
<value xsi:type="PQ" value="98" unit="%"/>
</observation>
</component>
<!-- O2 concentration may be included as a Vital Sign Observation within a separate component. -->
<component>
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
<templateId root="2.16.840.1.113883.10.20.22.4.27"
extension="2014-06-09"/>
<id root="07b1fa74-eb88-4331-944f-880704ca7467"/>
<!-- Per CONF:1098-32934, the code for a Vital Sign Observation SHOULD be selected
from ValueSet Vital Sign Result Type (urn:oid:2.16.840.1.113883.3.88.12.80.62),
which does NOT contain the LOINC code 3150-0 (Inhaled oxygen concentration).
However, because this template is the most widely supported way to send and
receive vitals observations, senders may still choose to send O2 concentration
in this way. -->
<code xsi:type="CD" displayName="Inhaled oxygen concentration"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="3150-0"/>
<text xsi:type="ED">
<reference value="#O2Conc_1"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20140520193605-0500"/>
<value xsi:type="PQ" value="36" unit="%"/>
</observation>
</component>
</organizer>
</entry>
</section>