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: Sensory Status Example

This content is an example of the Sensory Status Logical Model and is not a FHIR Resource

    
<observation classCode="OBS" moodCode="EVN" xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
    <!-- Sensory and Speech Status(NEW)-->
    <templateId root="2.16.840.1.113883.10.20.22.4.127" />
    <id root="c6b5a04b-2bf4-49d1-8336-636a3813df0a" />
    <code code="47078008" displayName="Hearing" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" />
    <text>
      <reference value="#socialhistory" />
    </text>
    <statusCode code="completed" />
    <effectiveTime>
      <low value="20130311" />
    </effectiveTime>
    <value xsi:type="CD" code="260379002" displayName="Impaired" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" />
    <author typeCode="AUT">
      <templateId root="2.16.840.1.113883.10.20.22.4.119" />
      <time value="201209101145-0800" />
      <assignedAuthor>
        <id extension="555555555" root="1.1.1.1.1.1.1.2" />
        <addr use="HP">
          <!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
          <streetAddressLine>2222 Home Street</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:+1(555)555-2003" use="HP"/>
        <assignedPerson>
          <name>
            <given>Nurse</given>
            <family>Nightingale</family>
            <suffix>RN</suffix>
          </name>
        </assignedPerson>
      </assignedAuthor>
    </author>   
    <entryRelationship typeCode="COMP">
      <observation classCode="OBS" moodCode="EVN">
        <!--Assessment Scale Observation -->
        <templateId root="2.16.840.1.113883.10.20.22.4.69" extension="2022-06-01"/>
        <id root="c6b5a04b-2bf4-49d1-8336-636a3813df0b"/>
				<code code="survey" codeSystem="2.16.840.1.113883.4.642.1.1125" displayName="survey">
					<translation code="54614-3" 
			             displayName="Brief Interview for Mental Status - summary score [BIMS]"
			             codeSystem="2.16.840.1.113883.6.1" 
			             codeSystemName="LOINC"/>
				</code>
        <derivationExpr>Text description of the calculation</derivationExpr>
        <text><reference value="#assessmentScale"/></text>
        <statusCode code="completed"/>
        <effectiveTime value="20120214"/>
        <!-- Summed score of the component values -->
        <value xsi:type="INT" value="7"/>
        <!-- Supporting observations -->
        <entryRelationship typeCode="COMP">
          <observation classCode="OBS" moodCode="EVN">
            <templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2022-06-01"/>
              <id root="f4dce790-8328-11db-9fe1-0800200c9a44"/>
              <code code="248240001" displayName="motor response"
                      codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED"/>
              <text><reference value="#assessmentObservation"/></text>
              <statusCode code="completed"/>
              <value xsi:type="INT" value="3"/>
          </observation>
        </entryRelationship>
      </observation>
    </entryRelationship>
</observation>