This is an example of a food allergy with information on both allergic reaction and reaction severity. It was based upon discussion with Russ Leftwich and Lisa Nelson in coordination with Patient Care Committee. See DSTU 219 for update regarding act/code.

This is an example of a propensity to substance allergy with information on both allergic reaction and reaction severity. It was based upon discussion with Russ Leftwich and Lisa Nelson in coordination with Patient Care Committee. See DSTU 219 for update regarding act/code.

This is an example of a propensity to drug adverse event with information on multiple allergic reactions each with reaction severity. It was based upon discussion with Rob Hausam and John D’Amore and Russ Leftwich in coordination with Patient Care Committee. This sample replaces the Epinephrine sample which had less clinical accuracy/relevance. See DSTU 219 for update regarding act/code.

This is an example of an allergy to a specific drug (penicillin) using RxNorm as terminology with information on both allergic reaction and reaction severity. For drug allergies, this example illustrates a good practice of encoding the allergen at the ingredient level (penicillin) not administration level (10 mg tablet). See DSTU 219 for update regarding act/code. Multiple reactions are listed in some examples

This is an example of an allergy to a drug class (penicillins) using SNOMED CT as terminology with information on both allergic reaction and reaction severity. See DSTU 219 for update regarding act/code

This example illustrates an example of allergy to a new drug ingredient which is in a clinical trial phase and not approved by the FDA. As a result, there is no RxNorm, NDF-RT, SNOMED or UNII code. An NCI thesaurus code is in turn used as a translation code since NCI tracks new chemotherapy drugs in clinical trial phases. Additional Notes and Assumptions: The example drug, talazoparib, was in clinical trial phase at the time of this example. It is possible for this drug to be approved at some point in the future after this C-CDA example is approved.

This is an example of how an author can record a patient has no known allergies.

This is an example of how an author can record a patient has no known medication allergies.

This is an example of no information available for allergies. This example is similar to the No Section Information Problems example. This sample is not approriate for asserting ‘No Known Allergies’.

This is an example of how an author can record a patient is not allergic to a specific substance. In this example, the susbtance is Peanuts.

This is an example of how to send a Care Team with narrative only. Updated 3/5/2020 with proper templateId.

This is an example of how to send a Care Team with structured entries.

This is an example of a hospitalization with discharge diagnoses. Meaningful Use requires a place to document encounter diagnoses, and this example attempts to satisfy. This example aligns with QRDA suggestion to use a Rank Observation for Principal diagnosis.

This is an example of a hospitalization with discharge disposition. The Discharge Disposition includes both the standard code and a local code, and a discharge destination

This is an example of how to record multiple CPT Evaluation and Management codes with a single encounter.

This is an example of an outpatient visit discharge disposition. In order to support a local Discharge Disposition code the dischargeDisposition contains the "OTH" nullFlavor.

This example illustrates how to structure Encounter Diagnosis for the 170.314(b)(2) Transitions of care - L) Encounter Diagnosis

Example shows generic "family history of x" and "no family history of x" with commentary suggesting better options.

Example shows two brothers with multiple conditions. Though they have the same relationship to the patient, they can be identified by their separation into two family history organizers as well as by their subject ID’s.

Example shows multiple observations for one family member, identifying the cause of death, and a family member with no known problems.

Represents an American Community Survey (ACS) Disability Status using Assessment Scale Supporting Observations.

This is an example of a Glasgow Coma Scale. It illustrates an assessment in the Functional Status Section.

This is an example of a functional impairment. It only illustrates one potential templated within the functional status section and was originally prepared for the ONC 2014 Transitions of Care test scenario, inpatient for MU2 170.314(b)(2). Note that there are significant changes to functional and cognitive status in C-CDA 2.1 (including section breakout and deprecation of certain templates). This example represents the proper way to send a functional impairment in C-CDA R2.1.

This is an example of no functional impairment. It only illustrates one potential templated within the functional status section and was originally prepared for the ONC 2014 170.314(b)(2) Transitions of care - M) Functional and Cognitive Status. Note that there are significant changes to functional and cognitive status in C-CDA 2.1 (including section breakout and deprecation of certain templates). This example represents the proper way to send no functional impairment in C-CDA R2.1.

This demonstrates how an individual entry may refer to an external document where information was originally provided (e.g. a problem in this example). In addition, how to also link back to the original observation using externalObservation is also shown. While these elements are optional, they help create a chain of data provenance.

This example demonstrates how to link the section narrative (section.text) to the coded information (entry) below. The example includes several comments and does not conform to any specific C-CDA/CDA template. The principles agreed to in this sample should be present in all other examples.

This example demonstrates how to link the section narrative (section.text) to the coded information (entry) below. The example includes several comments and does not conform to any specific C-CDA/CDA template. The principles agreed to in this sample should be present in all other examples.

This example demonstrates how to link the section narrative (section.text) to the coded information (entry) below. The example includes several comments and does not conform to any specific C-CDA/CDA template. The principles agreed to in this sample should be present in all other examples.

This example demonstrates how to link the section narrative (section.text) to the coded information (entry) below. The example includes several comments and does not conform to any specific C-CDA/CDA template. The principles agreed to in this sample should be present in all other examples.

This example demonstrates how to link the section narrative (section.text) to the coded information (entry) below. The example includes several comments and does not conform to any specific C-CDA/CDA template. The principles agreed to in this sample should be present in all other examples.

This example demonstrates how to link the section narrative (section.text) to the coded information (entry) below. The example includes several comments and does not conform to any specific C-CDA/CDA template. The principles agreed to in this sample should be present in all other examples.

This example demonstrates how to link the section narrative (section.text) to the coded information (entry) below. The example includes several comments and does not conform to any specific C-CDA/CDA template. The principles agreed to in this sample should be present in all other examples.

This is an example of no information available for problems.

This is an example of how a continuity of care document (or other document) may reference parent documents. This one replaces a previous document.

This is an example of how to mark information in an entry as shareable or not shareable with a patient and/or their proxies. This example uses a Note Activity, but the information below could go inside any entry.

This is an example of how to send a goals section with only narrative.

This is an example of how to send a goals section with a coded Goal using ICD10.

This is an example of how to include Care Team information for 170.315_b1 Ambulatory test data

This demonstrates a patient with a Patient DirectTrust Address and a Provider Organization with a Covered Entity DirectTrust Address.

This is an example of how to represent a social security number (SSN) that has been masked to show only the last four digits.

This demonstrates a patient with multiple identifiers from different institutions.

Best practices for sending one or more patient aliases

This example illustrates how to structure Patient’s birth name, which is a special case of previous name.

This is an example of how to use sdtc extension of deceasedInd. See this site for more on CDA extensions: http://wiki.hl7.org/index.php?title=CDA_R2_Extensions

This example illustrates how to structure Patient Demographics for the 170.314(b)(2) Transitions of care - A) Patient Demographics.

This example illustrates how to structure Patient’s previous name.

This example illustrates how to structure multiple past addresses for a patient

This example demonstrates the idea that name pieces should be sent in a logical display order (ie such that a receiver which only extracts the text and ignores the markup around <given>, <family>, etc. would still display the name in a way a human would interpret correctly).

This is an example of how to link a concern to a problem in the problem list section.

This is an example of how to link a concern to a problem in the problem list section with linkHTML.

This is an example of how to send a health concern section with only narrative.

This is an example of how an author can record they have no health concerns for a patient.

This is an example of how an author can record a patient refused an immunization.

This example illustrates how to structure Immunizations for the 170.314(b)(2) Transitions of care - J) Immunizations.

This example illustrates how to structure Immunizations when it’s reported by a patient

This example illustrates how to structure Immunizations for the 170.314(b)(2) Transitions of care - J) Immunizations with a translation for the NDC code.

This is an example of no information available for immunizations. This example is similar to the No Section Information Problems example. This sample is not approriate for asserting ‘No Known Immunizations’.

This is an example of how an author can record they do now know whether the patient has received any vaccinations.

This example illustrates an intervention section, with an intervention act wrapping a procedure activity act. The example task force approved this to provide a parallel example to how QRDA communicates interventions. Some systems may choose to include this in the procedure section.

This is an example of how to record the full details of a UDI. This examples follows the design in Appendix B of the 2019 C-CDA Companion Guide.

This is an example of a medical equipment section containing an implantable device where the full unique device identifier (UDI) is unknown.

This is an example of how an author can record an implant when the procedure is unknown.

This is an example of how a single procedure (angioplasty) can have multiple implants (2 drug eluting stents). There are still two entries since this is being included in medical equipment rather than procedure section.

This is an example of how an author can record a patient has no implanted devices

This example demonstrates how to represent equipment supplied to or used by a patient such as wheelchairs, canes, walkers, hearing aids, eye glasses.

This is an example of a mixture of three or more different drug ingredients, each with a different relative concentration. Note the use of the urn:ihe:pharm:medication namespace, which is required by the UV Medication Information (detail) template. The CDA schema doesn’t recognize content from this namespace and so flags it as invalid by default, although extension content from other namespaces is allowed in CDA even when not recognized by the schema (see 1.4 CDA Extensibility).

This is an example of having a medication with only a free text SIG when you have no other coded information.

This example illustrates an example of a medication order with the following characteristics: an IV drug with a relative dose quantity that is based on weight, a drug vehicle used for preparation, and indications for the medication. This example was created to address the following Use Case: An oncologist is ordering a drug as part of a chemotherapy regimen. Chemotherapy regimens consist of orders could be administered weeks or months in advance. Moreover their preparation is based on the patient’s weight at the time of administration. Because of these constraints, the C-CDA medications section needs to be represented in a way that reflects this. Additional Notes and Assumptions: the /entry/substanceAdministration/effectiveTime/@value is meant to be set at a future date relative to the date of the encounter. The date of the encounter would have been represented in a separate section outside of this example.

This is an example of having a medication with event timing (take at bedtime or at the "hour of sleep" (HS))

This is an example of a medication which is QID and PRN (as needed) but with no precondition specified. It was generated based on SDWG list-serv discussion in December 2013. It also demonstrated a pre-coordinated generic medication coded at the SDC level (generic 600mg Oral Tablet) in RxNorm hierarchy.

This is an example of a medication administered orally with a PRN coded precondition, instructions (not PRN), and indications (not PRN).

This is an example of a patient refusing to take a medication at a point in time due to a reason of patient objection (QRDA template used)

This is an example of a medication (Sudafed) which to be administered every 4-6 hours, a common dosing pattern. Representing the range of potential of hours is done through a low and high child element of the period within effectiveTime of PIVL_TS.

This is an example of no medications

This is an example of two baby aspirin being administered at a single point in time. At the January 2014 San Antonio meeting of HL7, this approach was decided as appropriate for medication timing of a point in time. Subsequent to that meeting, the TTT validator was adjusted to accept this format for medication times.

This is an example of to include a PHQ-9 survey with total score and compoonent questions. While not all questions may be necessary in all uses, the total score has an impact on quality measures related to depression screening.

This is an example of mental (cognitive) impairment. It only illustrates one potential templated within the mental status section and was originally prepared for the ONC 2014 170.314(b)(2) Transitions of care - M) Functional and Cognitive Status. Note that there are significant changes to functional and cognitive status in C-CDA 2.1 (including section breakout and deprecation of certain templates). This example represents the proper way to send a mental impairment in C-CDA R2.1.

This is an example of no cognitive impairment. It only illustrates one potential templated within the mental status section and was originally prepared for the ONC 2014 170.314(b)(2) Transitions of care - M) Functional and Cognitive Status. Note that there are significant changes to functional and cognitive status in C-CDA 2.1 (including section breakout and deprecation of certain templates). This example represents the proper way to send no cognitive impairment in C-CDA R2.1.

This is an example of how to record a single Discharge Note in a Hospital Course Section.

This is an example of how to associate a Procedure Note with a Procedure in the Procedure section.

This is an example of how to include rich text in a C-CDA Note Activity.

This is an example of how to record a single Consultation Note.

This example illustrates how to structure a Goals and Instructions for the 170.314(b)(2) Transitions of care - K) Care Plan (Goals and Instructions).

This is an example of how an author can record no planned tests.

This example illustrates how to structure a planned observation.

This example illustrates how to structure a Referral for the 170.314(b)(2) Transitions of care - N) Referral

This example illustrates how to structure an active problem.

This example illustrates how to structure a resolved problem, both by having a biological resolution date and a completed status of the concern.

This is an example of no known problems.

This is an example of an author asserting a patient does not have diabetes.

This is an example of a patient pregnancy in problem list with information about estimateed delivery date. This is an alternative place to document and share pregancy informatoin in addition to social history and detailed pregnancy sections (see HL7 IG for more on pregancy status here: http://www.hl7.org/implement/standards/product_brief.cfm?product_id=494)

This is an example of adding a SNOMED qualifier to an ambiguous ICD-9 which could be used in qualifying patients related to QRDA/eCQM measure

This example illustrates how to structure an active problem with value codes that need translation & qualifiers. Note that no formally vetted post-coordination semantics exist for codesystems besides SNOMED today (eg ICD-10), which is a limitation to this example. Example was updated after the March 2022 C-CDA Implementation-a-thon.

This example illustrates how to structure an Active SDOH problem with a translation to ICD10. Some systems may document active SDOH issues in the Social History Section or the Health Concerns Section. Gravity and other industry initiatives may provide additional guidance on best practices.

This example illustrates a planned surgical procedure with multiple proposed alternatives, with the expectation that the surgeon will choose one to perform when the surgery actually occurs.

This is an example of a patient refusing a procedure.

This is an example of an unsuccessful procedure attempt.

This example illustrates an act within a procedure section.

This example illustrates how an observation within a procedure section.

This example illustrates how a procedure which "alters the physical state" of the patient and should be classified as a procedure.

This example illustrates a Colonoscopy procedure which with biopsy. Even if not biopsy, a colonscopy is recommended to be in a Procedure Activity Procedure.

This is an example of how one could report quality measures in a C-CDA document. It is not a C-CDA template, but could be included as a section (since open template) and is conformant to QRDA1 Measure Section constraints. It would not be appropriate for US QRDA submission.

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 example shows how an ordered referral could have a completed note documented in to 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 examples in regards to this quality measure. The Planned Referral Act opens the loop and the Note would be eligible to close the loop. This examples combines into one for ease of reader. In a ‘real-world’ exchange these would be in separate documents. The example titled Close Referral with a Document is another approach where a full document completes the referral. Other additional appaoaches may be appropriate.

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 is an example of how to encode positive and negative, which are common data types returned form lab equipment. While some technologies may represent this as a type of ST (string), it is logical and easily possible to encode this information using SNOMED-CT. This would allow structured examination of this information downstream as well as comparison to a structured reference range, as shown in the example. Previously the examples task force approved this sample with the data type Coded Ordinal (CO) with the example name: Result panel with two ordinal values of negative-positive. The examples task force received feedback during implementation that CO is not commonly used, and CD is preferred. Updated the sample name to Result panel with coded values of negative-positive

This is an example of a value from a lab result with multiple reference ranges: Negative (less than), Bordeline (equal), and Positive (greater than).

This is an example of a value from a lab result that may not be structured.

This is an example of how to encode "greater than" (but not equal to) a specific range when returned from lab equipment. The example is for a point-of-care glucometer, which measures blood sugar for diabetics. Often these devices may have an upper bound, 500 mg/dL is shown in this example. An inclusive tag of false is shown to demonstrate a non-inclusive range. The upper bound of the interval is positive infinity in this example. This example also includes two structured reference ranges for normal and high.

This is an example of a results panel with Laboratory Location details as required by 2015 Certification Sender test 170.315(e1), in compliance with 42 CFR 493.1291(c)(1) through (7).

This is an example of a value from a lab with a discrete unit, but whose value is not a number, so the PQ datatype, the only type with a unit attribute, cannot be used.

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 is an example of a value from a lab which didn’t include a UCUM unit.

Sample from Meaningful Use test data (inpatient data)

This example illustrates how to structure Laboratory Tests and Values/Results for the 170.314(b)(2) Transitions of care - I) Laboratory Tests and Values/Results.

This is an example of a results panel with pending component.

This is an example of how to encode "less than or equal to" a specific range when returned from lab equipment. The example is for BNP, an immunoassay where the lower threshold for detection is often 5 pg/mL. The lower bound of the interval is zero in this example, even though this is none may be specified, since zero is the lower bound for measures of physical quantity. This example also includes a structured reference range.

This is an example of a value from a lab which requires a translation for its unit. All units for physical quantities should be represent in UCUM.

This observation represents the sex of the patient at birth. It is the sex that is entered on the person’s birth certificate at time of birth.

This is an example of current smoking status. This example also includes a coordinating social history observation to convey the amount of smoking using a SNOMED code. This SNOMED code in the accompanying observation is not acceptable since smoking status, which is constrained by HL7 and Meaningful Use value set requirements. Each social history section shall only include a single smoking status.

This is an example of a patient using Electronic cigarette liquid containing nicotine. The concept selected aligns with the 2019 guidance https://www.healthit.gov/isa/representing-patient-electronic-cigarette-use-vaping. The examples task force spent significant time discussion the different substances that can be used in an electronic cigarette, more than just nicotine.

This is an example of a former smoker in smoking status. There is a variation in how effectiveTime/high is used since this represents when the patient stopped smoking, not when they stopped being a former smoker. C-CDA explicitly guides to this usage of effectiveTime. A best practice to avoid confusion is for each social history section to only include a single smoking status.

This is an example of a never smoker in smoking status. A best practice to avoid confusion is for each social history section to only include a single smoking status.

This is an example of patient that is not pregnant.

This is an example of sexual orientation and gender identity represented in a C-CDA under the social history section. It has codes which align with the ISA recommendations for this information (see: https://www.healthit.gov/isa/representing-patient-identified-sexual-orientation)

This is an example of unknown smoking status. There is a major variation in how no information is managed for smoking status. C-CDA explicitly guides to not utilize a nullFlavor for this information. Instead a SNOMED code should be used as demonstrated in the example. A best practice to avoid confusion is for each social history section to only include a single smoking status.

This is an example of unknown pregnancy status.

WE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education) is a clinic-based screening and referral system developed for pediatric settings USCF. This example includes the assessment in the Social History section

This sample originates from the 2014-11-12 publication. This example shows a CDA document that conforms to the C-CDA Unstructured Document specification using a referenced pdf.

This sample originates from the 2014 C-CDA R2.0 publication but has been altered for C-CDA 2.1 conformance. This example shows a CDA document that conforms to the C-CDA Unstructured Document specification using an embedded 64-bit encoded pdf. The PDF is a discharge summary.

This example shows a CDA document that conforms to the C-CDA Unstructured Document specification using an embedded 64-bit encoded pdf. It also conforms to the HL7 Personal Advance Care Plan specification and the C-CDA Patient Generated Document header.

This example shows a CDA document that conforms to the C-CDA Unstructured Document specification using an embedded text plain document (base 64 encoded). When decoded it will show a surgical consult note. Note that the HL7 standard stylesheet will show this natively

This example illustrates three vital sign observations with LOINC codes and reference growth chart names for BMI percentile, weight-for-length percentile, and head circumference percentile. or example, this illustrates how to send that a child’s BMI percentile is 45 %, and that the CDC (Boys 2-20 years) growth chart was used to determine the value. Pediatric Vital Signs chart to help developers include the appropriate reference range.

This is panel of the 2 vitals signs - pulse, and a Heart Rate Rhythm Observation. Other common vital signs could be included.

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 is panel of the nine common vital signs collected on an adult in metric units. Note that body surface area (BSA), head circumference and height (lying) are not included.

This is panel of the nine common vital signs collected on an adult in mixed metric/imperial units. Note that body surface area (BSA), head circumference and height (lying) are not included.

Extension to indicate the approval status of an example

Identifies the approval status of an example

Identifies the approval status of an example