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 Note Activity Logical Model and is not a FHIR Resource
<section xmlns="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<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="HISTORY OF PROCEDURES"/>
<title>Procedures</title>
<text>
<list>
<item ID="ProcedureNote1">
<paragraph>Dr. Physician - 03 Feb 2014</paragraph>
<paragraph>Free-text note about procedures which have occurred during this visit.</paragraph>
</item>
</list>
</text>
<entry>
<procedure classCode="PROC" moodCode="EVN" xmlns="urn:hl7-org:v3">
<!-- Procedure Activity Procedure -->
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2024-05-01" />
<id root="d5b614bd-01ce-410d-8726-e1fd01dcc72a" />
<code code="103716009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Stent Placement">
<originalText>
<reference value="#Proc1" />
</originalText>
</code>
<statusCode code="completed" />
<effectiveTime xsi:type="IVL_TS">
<low nullFlavor="UNK"/>
<high value="20130512120000-0700" />
</effectiveTime>
<targetSiteCode code="28273000" displayName="bile duct" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" />
<specimen typeCode="SPC">
<specimenRole classCode="SPEC">
<id root="a6d7b927-2b70-43c7-bdf3-0e7c4133062c" />
<specimenPlayingEntity>
<code code="57259009" codeSystem="2.16.840.1.113883.6.96" displayName="gallbladder bile" />
</specimenPlayingEntity>
</specimenRole>
</specimen>
<performer typeCode="PRF" xmlns="urn:hl7-org:v3">
<assignedEntity>
<id extension="IO00017" root="2.16.840.1.113883.19.5" />
<code code="207RG0100X" codeSystem="2.16.840.1.113883.6.96" codeSystemName="NUCC" displayName="Gastroenterologist" />
<addr use="WP">
<streetAddressLine>1001 Hospital Lane</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>99999</postalCode>
<country>US</country>
</addr>
<telecom value="tel:(999)555-1212" />
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Tony</given>
<family>Tum</family>
</name>
</assignedPerson>
<representedOrganization classCode="ORG">
<id root="2.16.840.1.113883.19.5" />
<name>Good Health Hospital</name>
<telecom value="tel:(999)555-1212" />
<addr use="WP">
<streetAddressLine>1001 Hospital Lane</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>99999</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
</procedure>
</entry>
<entry>
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.202" extension="2016-11-01"/>
<code code="34109-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Note">
<translation code="28570-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure note" />
</code>
<text>
<reference value="#ProcedureNote1" />
</text>
<statusCode code="completed"/>
<!-- Clinically-relevant time of the note -->
<effectiveTime value="20140203" />
<!-- Author Participation -->
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119" />
<!-- Time note was actually written -->
<time value="20140204083215-0500" />
<assignedAuthor>
<id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c" />
<addr use="WP">
<streetAddressLine>1001 Hospital Lane</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>99999</postalCode>
<country>US</country>
</addr>
<telecom value="tel:(999)555-1212" />
<assignedPerson>
<name>Dr. Physician</name>
</assignedPerson>
</assignedAuthor>
</author>
<!-- Reference to encounter -->
<entryRelationship typeCode="COMP" inversionInd="true">
<encounter classCode="ENC" moodCode="EVN">
<!-- Encounter ID matches an encounter in the Encounters Section -->
<id root="1.2.3.4" />
</encounter>
</entryRelationship>
</act>
</entry>
</section>