Consolidated CDA (C-CDA)
4.0.0-ballot - STU4
Consolidated CDA (C-CDA)
4.0.0-ballot - STU4
Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions
This content is an example of the Discharge Summary Logical Model and is not a FHIR Resource
<?xml version="1.0" encoding="UTF-8" standalone="yes"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!--
Title: Discharge Summary
Based on: C-CDA_R2_Discharge_Summary.xml
Updated for C-CDA R3.0 with a focus on header elements
- required/suggested sections are populated with nullFlavor="NI"
to demonstrate WHICH sections should be included, but they
all contain "No information" as this is an example of the header
********************************************************
Disclaimer: This sample file contains representative data elements to represent a Discharge Summary.
The file depicts a fictional character's health data. Any resemblance to a real person is coincidental.
To illustrate as many data elements as possible, the clinical scenario may not be plausible.
The data in this sample file is not intended to represent real patients, people or clinical events.
This sample is designed to be used in conjunction with the C-CDA Clinical Notes Implementation Guide.
********************************************************
-->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xmlns:cda="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc">
<!-- ** CDA Header ** -->
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<!-- US General Header Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2024-05-01"/>
<!-- *** Note: The next templateId, code and title will differ depending on what type of document is being sent. *** -->
<templateId root="2.16.840.1.113883.10.20.22.1.8" extension="2024-05-01"/>
<id extension="TT988" root="2.16.840.1.113883.19.5.99999.1"/>
<sdtc:category code="18842-5" displayName="Discharge summary" codeSystem="2.16.840.1.113883.6.1"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="18842-5" displayName="Discharge summary"/>
<title>Community Health and Hospitals: Discharge Summary</title>
<effectiveTime value="201409171904+0500"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<setId extension="sTT988" root="2.16.840.1.113883.19.5.99999.19"/>
<versionNumber value="1"/>
<recordTarget>
<patientRole>
<id extension="998991" root="2.16.840.1.113883.19.5.99999.2"/>
<!-- Fake ID using HL7 example OID. -->
<id extension="111-00-2330" root="2.16.840.1.113883.4.1"/>
<!-- Fake Social Security Number using the actual SSN OID. -->
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Drive</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:(816)276-6909" use="HP"/>
<!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<patient>
<name use="L">
<!-- L is "Legal" from HL7 EntityNameUse 2.16.840.1.113883.5.45 -->
<given>Isabella</given>
<family>Jones</family>
</name>
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female"/>
<birthTime value="20050501"/>
<maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatusCode"/>
<religiousAffiliationCode code="1013" displayName="Christian (non-Catholic, non-specific)" codeSystemName="HL7 Religious Affiliation" codeSystem="2.16.840.1.113883.5.1076"/>
<raceCode code="2028-9" displayName="Asian" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/>
<ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/>
<guardian>
<code code="GRPRN" displayName="Grandparent" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 Role code"/>
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Drive</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:(816)276-6909" use="HP"/>
<guardianPerson>
<name>
<given>Ralph</given>
<family>Jones</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
</addr>
</place>
</birthplace>
<languageCommunication>
<languageCode code="en"/>
<modeCode code="ESP" displayName="Expressed spoken" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/>
<proficiencyLevelCode code="G" displayName="Good" codeSystem="2.16.840.1.113883.5.61" codeSystemName="LanguageAbilityProficiency"/>
<preferenceInd value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom use="WP" value="tel:555-555-5000"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time value="201409171904+0500"/>
<assignedAuthor>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101" displayName="Allopathic & Osteopathic Physicians"/>
<addr use="WP">
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<author>
<time value="201409171904+0500"/>
<assignedAuthor>
<id nullFlavor="NI"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)555-1004"/>
<assignedAuthoringDevice>
<manufacturerModelName>Generic EHR Clinical System 2.0.0.0.0.0</manufacturerModelName>
<softwareName>Generic EHR C-CDA Factory 2.0.0.0.0.0 - C-CDA Transform 2.0.0.0.0</softwareName>
</assignedAuthoringDevice>
<representedOrganization>
<id root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom use="WP" value="tel:555-555-5000"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="999999943252"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<informant>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</informant>
<informant>
<relatedEntity classCode="PRS">
<!-- classCode PRS represents a person with personal relationship with
the patient. -->
<code code="SPS" displayName="SPOUSE" codeSystem="2.16.840.1.113883.1.11.19563" codeSystemName="Personal Relationship Role Type Value Set"/>
<relatedPerson>
<name>
<given>Frank</given>
<family>Jones</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<name>Community Health and Hospitals</name>
<telecom value="tel:555-555-1002" use="WP"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</informationRecipient>
<receivedOrganization>
<name>Community Health and Hospitals</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<time value="201409171904+0500"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="999999999" root="2.16.840.1.113883.4.6"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<authenticator>
<time value="201409171904+0500"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="999999999" root="2.16.840.1.113883.4.6"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<participant typeCode="IND">
<time xsi:type="IVL_TS">
<low value="19890101"/>
<high value="20140916"/>
</time>
<associatedEntity classCode="NOK">
<code code="MTH" codeSystem="2.16.840.1.113883.5.111"/>
<addr>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
</addr>
<telecom value="tel:(999)555-1212" use="WP"/>
<associatedPerson>
<name>
<prefix>Mrs.</prefix>
<given>Martha</given>
<family>Jones</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<documentationOf typeCode="DOC">
<serviceEvent classCode="PCPR">
<code code="6025007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Laparoscopic appendectomy"/>
<effectiveTime>
<low value="201409091904+0500"/>
<high value="201409161904+0500"/>
</effectiveTime>
<performer typeCode="PRF">
<functionCode code="PP" displayName="Primary Care Provider" codeSystem="2.16.840.1.113883.12.443" codeSystemName="Provider Role">
<originalText>Primary Care Provider</originalText>
</functionCode>
<time>
<low value="201409091904+0500"/>
<high value="201409161904+0500"/>
</time>
<assignedEntity>
<id extension="PseudoMD-1" root="2.16.840.1.113883.4.6"/>
<code code="207RG0100X" displayName="Gastroenterology Physician" codeSystemName="Provider Codes" codeSystem="2.16.840.1.113883.6.101"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-555-555-5000" use="WP"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom value="tel:+1-555-555-5000" use="WP"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
<performer typeCode="PPRF">
<functionCode code="PP" displayName="Primary Performer" codeSystem="2.16.840.1.113883.12.443" codeSystemName="Provider Role">
<originalText>Primary Care Provider</originalText>
</functionCode>
<time>
<low value="201409091904+0500"/>
<high value="201409161904+0500"/>
</time>
<assignedEntity>
<id extension="PseudoMD-3" root="2.16.840.1.113883.4.6"/>
<code code="207RG0100X" displayName="Gastroenterology Physician" codeSystemName="Provider Codes" codeSystem="2.16.840.1.113883.6.101"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-555-555-5000" use="HP"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Herman</given>
<family>Eight</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom value="tel:+1-555-555-5000" use="HP"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<componentOf>
<encompassingEncounter>
<id extension="9937012" root="2.16.840.1.113883.19"/>
<!--
<code codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4" code="99213" displayName="Evaluation and Management"/>
-->
<effectiveTime>
<!-- This is the admission date of the hospitalization -->
<low value="201409091904+0500"/>
<!-- This is the discharge date of the hospitalization -->
<high value="201409161904+0500"/>
</effectiveTime>
<dischargeDispositionCode code="01" codeSystem="2.16.840.1.113883.12.112" displayName="Routine Discharge" codeSystemName="HL7 Discharge Disposition"/>
<location>
<healthCareFacility>
<id root="2.16.540.1.113883.19.2"/>
</healthCareFacility>
</location>
</encompassingEncounter>
</componentOf>
<component>
<!-- All sections are set to nullFlavor / text = No information,
as this is a header example, not a complete body example -->
<structuredBody>
<component>
<section nullFlavor="NI">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.5"/>
<code code="8648-8" displayName="HOSPITAL COURSE" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Hospital Course</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.24" extension="2015-08-01" />
<code code="11535-2" displayName="Hospital Discharge Diagnosis" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC">
<translation code="78375-3" displayName="Discharge Diagnosis" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"></translation>
</code>
<title>Discharge Diagnosis</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09" />
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Treatment plan" />
<title>TREATMENT PLAN</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.42"/>
<code code="18841-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Hospital Consultations Section"/>
<title>HOSPITAL CONSULTATIONS</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.11.1" extension="2015-08-01" />
<code code="10183-2" displayName="Hospital Discharge Medications" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC">
<translation code="75311-1" displayName="Discharge Medications" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
</code>
<title>Discharge Medications</title>
<text>No information</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" codeSystemName="LOINC"/>
<title>ALLERGIES AND ADVERSE REACTIONS</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01"/>
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="RESULTS"/>
<title>RESULTS</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09" />
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURES" />
<title>Procedures</title>
<text>No information</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#4.0.0-ballot based on FHIR 5.0.0. Generated 2024-11-21
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