Consolidated CDA (C-CDA)
4.0.0 - 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 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: Vital Signs Section Example


<section xmlns="urn:hl7-org:v3">
  <templateId root="2.16.840.1.113883.10.20.22.2.4.1" extension="2015-08-01"/>
  <code displayName="Vital signs" codeSystemName="LOINC"
        codeSystem="2.16.840.1.113883.6.1" code="8716-3"/>
  <title>Vital Signs (Last Filed)</title>
  <text>
    <table>
      <thead>
        <tr>
          <th>Date</th>
          <th>Blood Pressure</th>
          <th>Average Blood Pressure</th>
          <th>Pulse</th>
          <th>Temperature</th>
          <th>Respiratory Rate</th>
          <th>Height</th>
          <th>Weight</th>
          <th>BMI</th>
          <th>SpO2</th>
        </tr>
      </thead>
      <tbody>
        <tr>
          <td>05/20/2014 7:36pm</td>
          <!--  You can consolidate Systolic and Diastolic in human view if desired but should retain separate references -->
          <td>
            <content ID="SystolicBP_1">120</content>/
            <content ID="DiastolicBP_1">80</content>mm[Hg] 
          </td>
          <!--  You can consolidate Systolic and Diastolic in human view if desired but should retain separate references -->
          <td>
            <content ID="SystolicAVGBP_1">122</content>/
            <content ID="DiastolicAVGBP_1">82</content>mm[Hg] 
          </td>
          <td ID="Pulse_1">80 /min</td>
          <td ID="Temp_1">37.2 C</td>
          <td ID="RespRate_1">18 /min</td>
          <td ID="Height_1">170.2 cm</td>
          <td ID="Weight_1">108.8 kg</td>
          <td ID="BMI_1">37.58 kg/m2</td>
          <td ID="SPO2_1">98%</td>
        </tr>
      </tbody>
    </table>
  </text>
  <!--  Average Blood Pressure Organizer - exists on its own outside Vital Signs Organizer  -->
  <entry typeCode="DRIV">
    <organizer moodCode="EVN" classCode="BATTERY">
      <templateId root="2.16.840.1.113883.10.20.22.4.512"
                  extension="2024-05-01"/>
      <id root="604b2f9e-a3e7-4f4c-a4f8-0022d72dee2b"/>
      <code
            displayName="Blood pressure panel mean systolic and mean diastolic" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
            code="96607-7"/>
      <sdtcText/>
      <statusCode code="completed"/>
      <effectiveTime value="20140519193605-0500"/>
      <component typeCode="COMP">
        <!--  Additional information of interpretation and/or reference range may be included but are optional -->
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.27"
                      extension="2014-06-09"/>
          <id root="a24910a8-2710-4940-908e-b3d805d5130c"/>
          <code xsi:type="CD" displayName="average aystolic blood pressure"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="96608-5"/>
          <text xsi:type="ED">
            <!--  This reference identifies content in human readable formatted text -->
            <reference value="#SystolicAVGBP_1"/>
          </text>
          <statusCode code="completed"/>
          <effectiveTime value="20140519193605-0500"/>
          <!--  Example of Value with UCUM unit. Note that metric units used in this example -->
          <value xsi:type="PQ" value="122" unit="mm[Hg]"/>
        </observation>
      </component>
      <component typeCode="COMP">
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.27"
                      extension="2014-06-09"/>
          <id root="553f3f45-9046-4659-b3e7-5de904003550"/>
          <code xsi:type="CD" displayName="average Diastolic blood pressure"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="96609-3"/>
          <text xsi:type="ED">
            <reference value="#DiastolicBP_1"/>
          </text>
          <statusCode code="completed"/>
          <effectiveTime value="20140520193605-0500"/>
          <value xsi:type="PQ" value="82" unit="mm[Hg]"/>
        </observation>
      </component>
    </organizer>
  </entry>
  <entry typeCode="DRIV">
    <!--  When a set of vital signs are recorded together, include them in single clustered organizer -->
    <organizer moodCode="EVN" classCode="CLUSTER">
      <templateId root="2.16.840.1.113883.10.20.22.4.26"
                  extension="2015-08-01"/>
      <id root="e6c800c4-4a71-41bf-80e2-e741dd1168e9"/>
      <code
            displayName="Vital signs, weight, height, head circumference, oximetry, BMI, and BSA panel" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
            code="74728-7"/>
      <statusCode code="completed"/>
      <effectiveTime value="20140520193605-0500"/>
      <!--  Each vital sign should be its own component. Note that systolic and diastolic BP must be separate components -->
      <component>
        <!--  Additional information of interpretation and/or reference range may be included but are optional -->
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.27"
                      extension="2014-06-09"/>
          <id root="fdbd831b-5919-4f06-9467-76b07022f8e8"/>
          <code xsi:type="CD" displayName="Systolic blood pressure"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="8480-6"/>
          <text xsi:type="ED">
            <!--  This reference identifies content in human readable formatted text -->
            <reference value="#SystolicBP_1"/>
          </text>
          <statusCode code="completed"/>
          <effectiveTime value="20140520193605-0500"/>
          <!--  Example of Value with UCUM unit. Note that metric units used in this example -->
          <value xsi:type="PQ" value="120" unit="mm[Hg]"/>
        </observation>
      </component>
      <component>
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.27"
                      extension="2014-06-09"/>
          <id root="553f3f45-9046-4659-b3e7-5de904003550"/>
          <code xsi:type="CD" displayName="Diastolic blood pressure"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="8462-4"/>
          <text xsi:type="ED">
            <reference value="#DiastolicBP_1"/>
          </text>
          <statusCode code="completed"/>
          <effectiveTime value="20140520193605-0500"/>
          <value xsi:type="PQ" value="80" unit="mm[Hg]"/>
        </observation>
      </component>
      <component>
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.27"
                      extension="2014-06-09"/>
          <id root="77bfe276-a1dd-4372-9072-e603905acc07"/>
          <code xsi:type="CD" displayName="Heart rate"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="8867-4"/>
          <text xsi:type="ED">
            <reference value="#Pulse_1"/>
          </text>
          <statusCode code="completed"/>
          <effectiveTime value="20140520193605-0500"/>
          <value xsi:type="PQ" value="80" unit="/min"/>
        </observation>
      </component>
      <component>
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.27"
                      extension="2014-06-09"/>
          <id root="24faa204-db62-4610-864f-cb50b650d0fa"/>
          <code xsi:type="CD" displayName="Body temperature"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="8310-5"/>
          <text xsi:type="ED">
            <reference value="#Temp_1"/>
          </text>
          <statusCode code="completed"/>
          <effectiveTime value="20140520193605-0500"/>
          <value xsi:type="PQ" value="37.2" unit="Cel"/>
        </observation>
      </component>
      <component>
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.27"
                      extension="2014-06-09"/>
          <id root="79f25395-8ec6-488b-8c05-becc97f79995"/>
          <code xsi:type="CD" displayName="Respiratory rate"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="9279-1"/>
          <text xsi:type="ED">
            <reference value="#RespRate_1"/>
          </text>
          <statusCode code="completed"/>
          <effectiveTime value="20140520193605-0500"/>
          <value xsi:type="PQ" value="18" unit="/min"/>
        </observation>
      </component>
      <component>
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.27"
                      extension="2014-06-09"/>
          <id root="6d3fa9f8-6049-41bd-b0c3-b0196bb6bd37"/>
          <code xsi:type="CD" displayName="Body height"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="8302-2"/>
          <text xsi:type="ED">
            <reference value="#Height_1"/>
          </text>
          <statusCode code="completed"/>
          <effectiveTime value="20140520193605-0500"/>
          <value xsi:type="PQ" value="170.2" unit="cm"/>
        </observation>
      </component>
      <component>
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.27"
                      extension="2014-06-09"/>
          <id root="2594e631-2189-4e72-9dd1-d6769ee2a7be"/>
          <code xsi:type="CD" displayName="Body weight"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="29463-7"/>
          <text xsi:type="ED">
            <reference value="#Weight_1"/>
          </text>
          <statusCode code="completed"/>
          <effectiveTime value="20140520193605-0500"/>
          <value xsi:type="PQ" value="108.863" unit="kg"/>
        </observation>
      </component>
      <component>
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.27"
                      extension="2014-06-09"/>
          <id root="5858e765-2ffe-413f-9197-260f2c6e7aa8"/>
          <code xsi:type="CD" displayName="Body mass index (BMI) [Ratio]"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="39156-5"/>
          <text xsi:type="ED">
            <reference value="#BMI_1"/>
          </text>
          <statusCode code="completed"/>
          <effectiveTime value="20140520193605-0500"/>
          <value xsi:type="PQ" value="37.58" unit="kg/m2"/>
        </observation>
      </component>
      <component>
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.27"
                      extension="2014-06-09"/>
          <id root="4ce6046c-f6e3-41b0-91fc-2d5325f2bbc3"/>
          <code xsi:type="CD" displayName="OXYGEN SATURATION"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="2710-2"/>
          <text xsi:type="ED">
            <reference value="#SPO2_1"/>
          </text>
          <statusCode code="completed"/>
          <effectiveTime value="20140520193605-0500"/>
          <value xsi:type="PQ" value="98" unit="%"/>
        </observation>
      </component>
    </organizer>
  </entry>
</section>