Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 United States of America flag

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

Example Binary: Preoperative Diagnosis Example

This content is an example of the Preoperative Diagnosis Logical Model and is not a FHIR Resource

    
<act moodCode="EVN" classCode="ACT" xmlns="urn:hl7-org:v3">
  <templateId root="2.16.840.1.113883.10.20.22.4.65" extension="2015-08-01" />
  <code code="10219-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Preoperative Diagnosis" />
  <entryRelationship typeCode="SUBJ">
		<observation classCode="OBS" moodCode="EVN" xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
		  <!-- ** Problem Observation ** -->
		  <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2024-05-01" />
		  <id root="AB1791B0-5C71-11DB-B0DE-0800200C9A66" />
		  <code code="64572001" displayName="Disease" 
		                                    codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
		    <translation code="75323-6" 
		           codeSystem="2.16.840.1.113883.6.1" 
		           codeSystemName="LOINC" 
		           displayName="Condition"/>
		  </code>
		  <text><reference value="#problem"/></text>
		  <!-- The statusCode reflects the status of the observation itself -->
		  <statusCode code="completed" />
		  <effectiveTime>
		    <!-- The low value reflects the date of onset -->
		    <!-- Based on patient symptoms, presumed onset is July 3, 2013 -->
		    <low value="20130703" />
		    <!-- The high value reflects when the problem was known to be resolved -->
		    <!-- Based on signs and symptoms, appears to be resolved on Aug 14, 2013 -->
		    <high value="20130814" />
		  </effectiveTime>
		  <value xsi:type="CD"
		    code="233604007" 
		    codeSystem="2.16.840.1.113883.6.96"  
		    displayName="Pneumonia" />
		  <author typeCode="AUT">
		    <templateId root="2.16.840.1.113883.10.20.22.4.119" />
		    <time value="200808141030-0800" />
		    <assignedAuthor>
		      <id extension="555555555" root="2.16.840.1.113883.4.6" />
		      <code code="207QA0505X" 
		        displayName="Adult Medicine Physician" 
		        codeSystem="2.16.840.1.113883.6.101"
		        codeSystemName="Healthcare Provider Taxonomy (HIPAA)" />
		      <addr use="H">
		        <streetAddressLine>23 Anywhere Street</streetAddressLine>
		        <city>El Paso</city>
		        <state>TX</state>
		        <postalCode>90210</postalCode>
		        <country>US</country>
		      </addr>
		      <telecom value="tel:(999)555-1212" use="WP" />
		      <assignedPerson>
		        <name>Joe Anywhere</name>
		      </assignedPerson>
		    </assignedAuthor>
		  </author>
		</observation>
  </entryRelationship>
</act>