Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 Ballot
Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 Ballot
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 History and Physical 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: History and Physical
Based on: C-CDA_R2_History_and_Physical.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 History and Physical.
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"/>
<!-- History and Physical Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.3" extension="2024-05-01"/>
<id extension="TT988" root="2.16.840.1.113883.19.5.99999.1"/>
<sdtc:category code="34117-2" displayName="History and physical note" codeSystem="2.16.840.1.113883.6.1"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34117-2" displayName="History and Physical Note"/>
<title>Community Health and Hospitals: History & Physical</title>
<effectiveTime value="201209161905-0400"/>
<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>
<given>Isa</given>
<!-- CL is "Call me" from HL7 EntityNamePartQualifier 2.16.840.1.113883.5.43 -->
<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="1002-5" displayName="American Indian or Alaska Native" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/>
<sdtc:raceCode code="1966-1" displayName="Aleut" 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="20050329224411+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>
<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>1002 Healthcare Drive </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="20090227130000+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="20090227130000+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="19590101"/>
<high value="20111025"/>
</time>
<associatedEntity classCode="NOK">
<code code="MTH" codeSystem="2.16.840.1.113883.5.111"/>
<addr use="WP">
<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>
<inFulfillmentOf typeCode="FLFS">
<order classCode="ACT" moodCode="RQO">
<id root="2.16.840.1.113883.19" extension="12345-67890"/>
</order>
</inFulfillmentOf>
<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" />
<effectiveTime>
<low value="20090227130000+0500"/>
<high value="20090227130000+0500"/>
</effectiveTime>
<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="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="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="PROBLEM LIST"/>
<title>PROBLEMS</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09"/>
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="HISTORY OF MEDICATION USE"/>
<title>MEDICATIONS</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.9" extension="2014-06-09"/>
<code code="51847-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Evaluation + Plan note"/>
<title>Assessment and Plan</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.4"/>
<code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="History of Present illness Narrative"/>
<title>History of Present Illness</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="2.16.840.1.113883.10.20.22.2.12" />
<code code="29299-5" displayName="Reason for visit Narrative" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
<title>Reason for Visit</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.2.10" extension="2015-08-01" />
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="29545-1" displayName="Physical Findings" />
<title>Physical Examination</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.4.1" extension="2015-08-01"/>
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="VITAL SIGNS"/>
<title>VITAL SIGNS</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.17" extension="2015-08-01"/>
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social History"/>
<title>SOCIAL HISTORY</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.15" extension="2015-08-01" />
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="10157-6" displayName="History of family member diseases Narrative" />
<title>Family History</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.20" extension="2015-08-01" />
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="11348-0" displayName="History of Past illness Narrative" />
<title>Past Medical History</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.2.5" />
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="10210-3" displayName="Physical findings of General status Narrative" />
<title>General Status</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.18" />
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="10187-3" displayName="Review of systems Narrative - Reported" />
<title>Review of Systems</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 2024-12-19
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