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

: US Realm Header Example - XML Representation

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<ClinicalDocument xmlns="urn:hl7-org:v3">
  <realmCode code="US"/>
  <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
  <!--  US Realm Header Template  -->
  <templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2024-05-01"/>
  <!--  Globally unique identifier for the document   -->
  <id root="2.16.840.1.113883.19.5.99999.1" extension="TT988"/>
  <code displayName="Summarization of Episode Note" codeSystemName="LOINC"
        codeSystem="2.16.840.1.113883.6.1" code="34133-9"/>
  <!--  Title of the document  -->
  <title>Patient Chart Summary</title>
  <effectiveTime value="20120915103000-0800"/>
  <confidentialityCode displayName="normal" codeSystemName="Confidentiality"
                       codeSystem="2.16.840.1.113883.5.25" code="N"/>
  <languageCode code="en-US"/>
  <setId root="2.16.840.1.113883.19.5.99999.19" extension="sTT988"/>
  <!--  Version of the document  -->
  <versionNumber value="1"/>
  <recordTarget>
    <patientRole>
      <id root="2.16.840.1.113883.4.1" extension="444222222"/>
      <!--  Example Social Security Number using the actual SSN OID.  -->
      <!--  US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1  -->
      <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>
      </addr>
      <telecom value="tel:+1(555)555-2003" use="HP"/>
      <!--  HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119  -->
      <patient>
        <name use="L">
          <given>Eve</given>
          <!--  The "SP" is "Spouse" from HL7 Code System EntityNamePartQualifier 2.16.840.1.113883.5.43  -->
          <family qualifier="SP">Betterhalf</family>
        </name>
        <administrativeGenderCode displayName="Female"
                                  codeSystemName="AdministrativeGender" codeSystem="2.16.840.1.113883.5.1"
                                  code="F"/>
        <!--  Date of birth need only be precise to the day  -->
        <birthTime value="19750501"/>
        <!--  <sdtc:multipleBirthOrderNumber value="2" />  -->
        <maritalStatusCode displayName="Married"
                           codeSystemName="MaritalStatusCode" codeSystem="2.16.840.1.113883.5.2" code="M"/>
        <religiousAffiliationCode
                                  displayName="Christian (non-Catholic, non-specific)" codeSystemName="HL7 Religious Affiliation"
                                  codeSystem="2.16.840.1.113883.5.1076" code="1013"/>
        <!--  CDC Race and Ethnicity code set contains the five minimum race and ethnicity 
					categories defined by OMB Standards  -->
        <raceCode displayName="White"
                  codeSystemName="Race &amp; Ethnicity - CDC" codeSystem="2.16.840.1.113883.6.238" code="2106-3"/>
        <!--  The raceCode extension is only used if raceCode is valued  -->
        <sdtc:sdtcRaceCode xmlns:sdtc="urn:hl7-org:sdtc"
                           displayName="Native Hawaiian or Other Pacific Islander" codeSystemName="Race &amp; Ethnicity - CDC"
                           codeSystem="2.16.840.1.113883.6.238" code="2076-8"/>
        <ethnicGroupCode displayName="Not Hispanic or Latino"
                         codeSystemName="Race &amp; Ethnicity - CDC" codeSystem="2.16.840.1.113883.6.238" code="2186-5"/>
        <guardian>
          <code displayName="Power of Attorney" codeSystemName="RoleCode"
                codeSystem="2.16.840.1.113883.5.111" code="POWATT"/>
          <addr use="HP">
            <streetAddressLine>2222 Home Street</streetAddressLine>
            <city>Beaverton</city>
            <state>OR</state>
            <postalCode>97867</postalCode>
            <country>US</country>
          </addr>
          <telecom value="tel:+1(555)555-2008" use="MC"/>
          <guardianPerson>
            <name>
              <given>Boris</given>
              <given qualifier="CL">Bo</given>
              <family>Betterhalf</family>
            </name>
          </guardianPerson>
        </guardian>
        <birthplace>
          <place>
            <addr>
              <streetAddressLine>4444 Home Street</streetAddressLine>
              <city>Beaverton</city>
              <state>OR</state>
              <postalCode>97867</postalCode>
              <country>US</country>
            </addr>
          </place>
        </birthplace>
        <languageCommunication>
          <languageCode code="en"/>
          <!--  "en" is ISO 639-1 alpha-2 code for "English"  -->
          <modeCode displayName="Expressed spoken"
                    codeSystemName="LanguageAbilityMode" codeSystem="2.16.840.1.113883.5.60" code="ESP"/>
          <proficiencyLevelCode displayName="Good"
                                codeSystemName="LanguageAbilityProficiency" codeSystem="2.16.840.1.113883.5.61" code="G"/>
          <!--  Patient's preferred language  -->
          <preferenceInd value="true"/>
        </languageCommunication>
      </patient>
    </patientRole>
  </recordTarget>
  <!--  The author represents the person who provides the content in the document  -->
  <author>
    <time value="20130815103000-0800"/>
    <assignedAuthor>
      <id root="2.16.840.1.113883.4.6" extension="5555555555"/>
      <code displayName="Adult Medicine Physician"
            codeSystemName="Healthcare Provider Taxonomy (HIPAA)" codeSystem="2.16.840.1.113883.6.101" code="207QA0505X"/>
      <addr use="WP">
        <streetAddressLine>1004 Healthcare Drive</streetAddressLine>
        <city>Portland</city>
        <state>OR</state>
        <postalCode>99123</postalCode>
        <country>US</country>
      </addr>
      <telecom value="tel:+1(555)555-1004" use="WP"/>
      <assignedPerson>
        <name>
          <given>Patricia</given>
          <given qualifier="CL">Patty</given>
          <family>Primary</family>
          <suffix qualifier="AC">M.D.</suffix>
        </name>
      </assignedPerson>
    </assignedAuthor>
  </author>
  <!--  The custodian represents the organization charged with maintaining the original source document  -->
  <custodian>
    <assignedCustodian>
      <representedCustodianOrganization>
        <id root="2.16.840.1.113883.4.6" extension="321CX"/>
        <name>Good Health HIE</name>
        <telecom value="tel:+1(555)555-1009" use="WP"/>
        <addr use="WP">
          <streetAddressLine>1009 Healthcare Drive</streetAddressLine>
          <city>Portland</city>
          <state>OR</state>
          <postalCode>99123</postalCode>
          <country>US</country>
        </addr>
      </representedCustodianOrganization>
    </assignedCustodian>
  </custodian>
  <informationRecipient>
    <intendedRecipient classCode="ASSIGNED">
      <addr>
        <streetAddressLine>1004 Healthcare Drive</streetAddressLine>
        <city>Portland</city>
        <state>OR</state>
        <postalCode>99123</postalCode>
        <country>US</country>
      </addr>
    </intendedRecipient>
  </informationRecipient>
  <component>
    <structuredBody>
      <component>
        <section/>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>