Consolidated CDA (C-CDA)
5.0.0-ballot - STU5 - Ballot 1 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 5.0.0-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: US Realm Header Race Translation Example

This content is an example of the US Realm Header Logical Model and is not a FHIR Resource

    
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc">
  <realmCode code="US" />
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3" />
  <!-- US Realm Header Template -->
  <templateId extension="2024-05-01" root="2.16.840.1.113883.10.20.22.1.1"/>
  <!-- Globally unique identifier for the document  -->
  <id extension="TT988" root="2.16.840.1.113883.19.5.99999.1" />
  <code code="34133-9" displayName="Summarization of Episode Note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
  <!-- Title of the document -->
  <title>Patient Chart Summary</title>
  <effectiveTime value="201209151030-0800" />
  <confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality" />
  <languageCode code="en-US" />
  <recordTarget>
    <patientRole>
      <!-- Example Social Security Number using the actual SSN OID. -->
      <id extension="444222222" root="2.16.840.1.113883.4.1"/>
      <addr nullFlavor="UNK" />
      <telecom nullFlavor="UNK" />
      <patient>
        <name use="L">
          <given>Eve</given>
          <family>Betterhalf</family>
        </name>
        <administrativeGenderCode code="F" displayName="Female" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender"/>
        <!-- Date of birth need only be precise to the day -->
        <birthTime value="19750501"/>
        <maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatusCode"/>

        <!-- One root element for each race; use translations to associate detailed race with categories in the root -->

        <!-- CDC Race and Ethnicity code set contains the five minimum race and ethnicity categories defined by OMB Standards -->
        <raceCode code="2106-3" displayName="White" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race &amp; Ethnicity - CDC">
          <!-- To specify a detailed race and associated it with a category, use the translation element -->
           <translation code="2113-9" displayName="Irish" codeSystem="2.16.840.1.113883.6.238" />
        </raceCode>
        <!-- The raceCode extension is only used if raceCode is valued. It can be used to convey additional races or details.
              But when conveying details using translation elements, send only categories in the root node, and place the detail in a translation -->
        <sdtc:raceCode code="2076-8" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race &amp; Ethnicity - CDC" displayName="Native Hawaiian or Other Pacific Islander">
          <translation code="2079-2" displayName="Native Hawaiian" codeSystem="2.16.840.1.113883.6.238" />
        </sdtc:raceCode>


        <ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race &amp; Ethnicity - CDC"/>
        <languageCommunication>
          <languageCode code="en"/>
          <!-- "en" is ISO 639-1 alpha-2 code for "English" -->
          <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"/>
          <!-- Patient's preferred language -->
          <preferenceInd value="true"/>
        </languageCommunication>
      </patient>
    </patientRole>
  </recordTarget>
  <author>
    <time value="201308151030-0800"/>
    <assignedAuthor>
      <id extension="5555555555" 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 nullFlavor="UNK"/>
      <telecom nullFlavor="UNK"/>
      <assignedPerson>
        <name>
          <given>Patricia</given>
          <given qualifier="CL">Patty</given>
          <family>Primary</family>
          <suffix qualifier="AC">M.D.</suffix>
        </name>
      </assignedPerson>
    </assignedAuthor>
  </author>
  <custodian>
    <assignedCustodian>
      <representedCustodianOrganization>
        <id extension="321CX" root="2.16.840.1.113883.4.6"/>
        <name>Good Health HIE</name>
        <telecom nullFlavor="UNK"/>
        <addr use="WP">
          <streetAddressLine>1009 Healthcare Drive </streetAddressLine>
          <city>Portland</city>
          <state>OR</state>
          <postalCode>99123</postalCode>
          <country>US</country>
        </addr>
      </representedCustodianOrganization>
    </assignedCustodian>
  </custodian>
  <legalAuthenticator>
    <time value="201308151030-0800"/>
    <signatureCode code="S" />
    <assignedEntity>
      <id nullFlavor="UNK" />
      <addr nullFlavor="UNK" />
      <telecom nullFlavor="UNK" />
      <assignedPerson>
        <name nullFlavor="UNK" />
      </assignedPerson>
    </assignedEntity>
  </legalAuthenticator>
  <component>
    <structuredBody>
      <component>
        <section>
          <!-- Individual Body Section Contents --> 
        </section>
      </component>
    </structuredBody>
  </component>

</ClinicalDocument>