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
//
Title: Progress Note
Based on: C-CDA_R2_Progress_Note.xml
Updated for C-CDA R3.0 with a focus on header elements
- required/suggested sections are populated with nullFlavor="NI"
to demonstrate WHICH sections should be included, but they
all contain "No information" as this is an example of the header
********************************************************
Disclaimer: This sample file contains representative data elements to represent a Progress Note.
The file depicts a fictional character's health data. Any resemblance to a real person is coincidental.
To illustrate as many data elements as possible, the clinical scenario may not be plausible.
The data in this sample file is not intended to represent real patients, people or clinical events.
This sample is designed to be used in conjunction with the C-CDA Clinical Notes Implementation Guide.
********************************************************
{
"resourceType" : "ClinicalDocument",
"realmCode" : [
// ** CDA Header **
{
"code" : "US"
}
],
"typeId" : {
"extension" : "POCD_HD000040",
"root" : "2.16.840.1.113883.1.3"
},
"templateId" : [
// US General Header Template
{
"extension" : "2024-05-01",
"root" : "2.16.840.1.113883.10.20.22.1.1"
},
{
"extension" : "2024-05-01",
"root" : "2.16.840.1.113883.10.20.22.1.9"
}
],
"id" : // Progress Note Template
{
"extension" : "999022",
"root" : "2.16.840.1.113883.19"
},
"sdtcCategory" : [
{
"code" : "11506-3",
"codeSystem" : "2.16.840.1.113883.6.1",
"displayName" : "Progress note"
}
],
"code" : {
"code" : "11506-3",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "Progress note"
},
"title" : {
"xmlText" : "Progress Note"
},
"effectiveTime" : {
"value" : "2005-03-29T17:15:04-05:00"
},
"confidentialityCode" : {
"code" : "N",
"codeSystem" : "2.16.840.1.113883.5.25"
},
"languageCode" : {
"code" : "en-US"
},
"setId" : {
"extension" : "111199021",
"root" : "2.16.840.1.113883.19"
},
"versionNumber" : {
"value" : 1
},
"recordTarget" : [
{
"patientRole" : {
"id" : [
// Fake ID using HL7 example OID.
{
"extension" : "12345",
"root" : "2.16.840.1.113883.19"
},
{
"extension" : "111-00-1234",
"root" : "2.16.840.1.113883.4.1"
}
],
"addr" : [
// Fake Social Security Number using the actual SSN OID.
// HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119
{
"use" : [
"HP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "17 Daws Rd."
}
},
{
"city" : {
"xmlText" : "Blue Bell"
}
},
{
"state" : {
"xmlText" : "MA"
}
},
{
"postalCode" : {
"xmlText" : "02368"
}
},
{
"country" : // US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1
{
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"HP"
],
"value" : "tel:(781)555-1212"
}
],
"patient" : // HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119
{
"name" : [
{
"use" : [
"L"
],
"item" : [
{
"prefix" : [
// L is "Legal" from HL7 EntityNameUse 2.16.840.1.113883.5.45
{
"xmlText" : "Mr."
}
]
},
{
"given" : [
{
"xmlText" : "Adam"
}
]
},
{
"given" : [
{
"xmlText" : "Frankie",
"qualifier" : [
"CL"
]
}
]
},
{
"family" : [
// CL is "Call me" from HL7 EntityNamePartQualifier 2.16.840.1.113883.5.43
{
"xmlText" : "Everyman"
}
]
}
]
}
],
"administrativeGenderCode" : {
"code" : "M",
"codeSystem" : "2.16.840.1.113883.5.1",
"displayName" : "Male"
},
"birthTime" : {
"value" : "1954-11-25"
},
"maritalStatusCode" : {
"code" : "M",
"codeSystem" : "2.16.840.1.113883.5.2",
"codeSystemName" : "MaritalStatusCode",
"displayName" : "Married"
},
"religiousAffiliationCode" : {
"code" : "1013",
"codeSystem" : "2.16.840.1.113883.5.1076",
"codeSystemName" : "HL7 Religious Affiliation",
"displayName" : "Christian (non-Catholic, non-specific)"
},
"raceCode" : {
"code" : "2106-3",
"codeSystem" : "2.16.840.1.113883.6.238",
"codeSystemName" : "Race & Ethnicity - CDC",
"displayName" : "White"
},
"ethnicGroupCode" : {
"code" : "2186-5",
"codeSystem" : "2.16.840.1.113883.6.238",
"codeSystemName" : "Race & Ethnicity - CDC",
"displayName" : "Not Hispanic or Latino"
},
"guardian" : [
{
"code" : {
"code" : "GRFTH",
"codeSystem" : "2.16.840.1.113883.5.111",
"codeSystemName" : "HL7 Role code",
"displayName" : "Grandfather"
},
"addr" : [
// US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1
{
"use" : [
"HP"
],
"item" : [
{
"streetAddressLine" : // HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119
{
"xmlText" : "17 Daws Rd."
}
},
{
"city" : {
"xmlText" : "Blue Bell"
}
},
{
"state" : {
"xmlText" : "MA"
}
},
{
"postalCode" : {
"xmlText" : "02368"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"HP"
],
"value" : "tel:(781)555-1212"
}
],
"guardianPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Ralph"
}
]
},
{
"family" : [
{
"xmlText" : "Relative"
}
]
}
]
}
]
}
}
],
"birthplace" : {
"place" : {
"addr" : {
"item" : [
{
"state" : {
"xmlText" : "MA"
}
},
{
"postalCode" : {
"xmlText" : "02368"
}
},
{
"country" : {
"xmlText" : "USA"
}
}
]
}
}
},
"languageCommunication" : [
{
"languageCode" : {
"code" : "fr-CN"
},
"modeCode" : {
"code" : "RWR",
"codeSystem" : "2.16.840.1.113883.5.60",
"codeSystemName" : "LanguageAbilityMode",
"displayName" : "Received Written"
},
"preferenceInd" : {
"value" : true
}
}
]
},
"providerOrganization" : {
"id" : [
// Organizations SHOULD have an NPI; this is a real root; fake extension
{
"extension" : "111122223333",
"root" : "2.16.840.1.113883.4.6"
}
],
"name" : [
{
"item" : [
{
"xmlText" : "Good Health Clinic"
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:(781)555-1212"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "21 North Ave"
}
},
{
"city" : {
"xmlText" : "Burlington"
}
},
{
"state" : {
"xmlText" : "MA"
}
},
{
"postalCode" : {
"xmlText" : "02368"
}
},
{
"country" : {
"xmlText" : "USA"
}
}
]
}
]
}
}
}
],
"author" : [
{
"time" : {
"value" : "2005-03-29T22:44:11+05:00"
},
"assignedAuthor" : {
"id" : [
{
"extension" : "999999999",
"root" : "2.16.840.1.113883.4.6"
}
],
"code" : {
"code" : "200000000X",
"codeSystem" : "2.16.840.1.113883.6.101",
"displayName" : "Allopathic & Osteopathic Physicians"
},
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "21 North Ave."
}
},
{
"city" : {
"xmlText" : "Burlington"
}
},
{
"state" : {
"xmlText" : "MA"
}
},
{
"postalCode" : {
"xmlText" : "02368"
}
},
{
"country" : {
"xmlText" : "USA"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:(555)555-1003"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
}
}
}
],
"dataEnterer" : {
"assignedEntity" : {
"id" : [
{
"extension" : "999999999",
"root" : "2.16.840.1.113883.4.6"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "21 North Ave."
}
},
{
"city" : {
"xmlText" : "Burlington"
}
},
{
"state" : {
"xmlText" : "MA"
}
},
{
"postalCode" : {
"xmlText" : "02368"
}
},
{
"country" : {
"xmlText" : "USA"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:(555)555-1003"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
}
}
},
"informant" : [
{
"assignedEntity" : {
"id" : [
{
"extension" : "999999999",
"root" : "2.16.840.1.113883.4.6"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "21 North Ave."
}
},
{
"city" : {
"xmlText" : "Burlington"
}
},
{
"state" : {
"xmlText" : "MA"
}
},
{
"postalCode" : {
"xmlText" : "02368"
}
},
{
"country" : {
"xmlText" : "USA"
}
}
]
}
],
"telecom" : [
{
"value" : "tel:(555)555-1003"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
}
}
},
{
"relatedEntity" : {
"classCode" : "PRS",
"code" : // classCode PRS represents a person with personal relationship with the patient.
{
"code" : "SPS",
"codeSystem" : "2.16.840.1.113883.1.11.19563",
"codeSystemName" : "Personal Relationship Role Type Value Set",
"displayName" : "SPOUSE"
},
"relatedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Rose"
}
]
},
{
"family" : [
{
"xmlText" : "Everyman"
}
]
}
]
}
]
}
}
}
],
"custodian" : {
"assignedCustodian" : {
"representedCustodianOrganization" : {
"id" : [
{
"extension" : "444444444",
"root" : "2.16.840.1.113883.4.6"
}
],
"name" : {
"item" : [
{
"xmlText" : "Good Health Clinic"
}
]
},
"telecom" : {
"use" : [
"WP"
],
"value" : "tel:(555)555-1212"
},
"addr" : {
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "17 Daws Rd."
}
},
{
"city" : {
"xmlText" : "Blue Bell"
}
},
{
"state" : {
"xmlText" : "MA"
}
},
{
"postalCode" : {
"xmlText" : "02368"
}
},
{
"country" : {
"xmlText" : "USA"
}
}
]
}
}
}
},
"informationRecipient" : [
{
"intendedRecipient" : {
"informationRecipient" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
},
"receivedOrganization" : {
"name" : [
{
"item" : [
{
"xmlText" : "Good Health Clinic"
}
]
}
]
}
}
}
],
"legalAuthenticator" : {
"time" : {
"value" : "2005-03-29T22:44:11+05:00"
},
"signatureCode" : {
"code" : "S"
},
"assignedEntity" : {
"id" : [
{
"extension" : "444444444",
"root" : "2.16.840.1.113883.4.6"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "21 North Ave."
}
},
{
"city" : {
"xmlText" : "Burlington"
}
},
{
"state" : {
"xmlText" : "MA"
}
},
{
"postalCode" : {
"xmlText" : "02368"
}
},
{
"country" : {
"xmlText" : "USA"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:(555)555-1003"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
}
}
},
"authenticator" : [
{
"time" : {
"value" : "2005-03-29T22:44:11+05:00"
},
"signatureCode" : {
"code" : "S"
},
"assignedEntity" : {
"id" : [
{
"extension" : "444444444",
"root" : "2.16.840.1.113883.4.6"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "21 North Ave."
}
},
{
"city" : {
"xmlText" : "Burlington"
}
},
{
"state" : {
"xmlText" : "MA"
}
},
{
"postalCode" : {
"xmlText" : "02368"
}
},
{
"country" : {
"xmlText" : "USA"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:(555)555-1003"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
}
}
}
],
"participant" : [
{
"typeCode" : "IND",
"associatedEntity" : {
"classCode" : "NOK",
"code" : {
"code" : "MTH",
"codeSystem" : "2.16.840.1.113883.5.111"
},
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "17 Daws Rd."
}
},
{
"city" : {
"xmlText" : "Blue Bell"
}
},
{
"state" : {
"xmlText" : "MA"
}
},
{
"postalCode" : {
"xmlText" : "02368"
}
},
{
"country" : {
"xmlText" : "USA"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:(999)555-1212"
}
],
"associatedPerson" : {
"name" : [
{
"item" : [
{
"prefix" : [
{
"xmlText" : "Mrs."
}
]
},
{
"given" : [
{
"xmlText" : "Abigail"
}
]
},
{
"family" : [
{
"xmlText" : "Ruth"
}
]
}
]
}
]
}
}
}
],
"inFulfillmentOf" : [
{
"typeCode" : "FLFS",
"order" : {
"classCode" : "ACT",
"moodCode" : "RQO",
"id" : [
{
"extension" : "12345-67890",
"root" : "2.16.840.1.113883.19"
}
]
}
}
],
"documentationOf" : [
{
"typeCode" : "DOC",
"serviceEvent" : {
"classCode" : "PCPR",
"templateId" : [
{
"root" : "2.16.840.1.113883.10.20.21.3.1"
}
],
"effectiveTime" : {
"low" : {
"value" : "2010-06-01T10:35:00-05:00"
},
"high" : {
"value" : "2010-09-15T22:00:00-05:00"
}
},
"performer" : [
{
"typeCode" : "PRF",
"functionCode" : {
"code" : "PCP",
"codeSystem" : "2.16.840.1.113883.5.88",
"codeSystemName" : "ParticipationFunction",
"displayName" : "Primary Care Provider",
"originalText" : {
"xmlText" : "Primary Care Provider"
}
},
"time" : {
"low" : {
"value" : "2002-07-16T10:35:00-05:00"
},
"high" : {
"value" : "2007-09-15T22:00:00-05:00"
}
},
"assignedEntity" : {
"id" : [
{
"extension" : "555555555",
"root" : "2.16.840.1.113883.4.6"
}
],
"code" : {
"code" : "207R00000X",
"codeSystem" : "2.16.840.1.113883.6.101",
"displayName" : "Internal Medicine Physician"
},
"addr" : [
null
],
"telecom" : [
{
"use" : [
"HP"
],
"value" : "tel:+1-301-975-3251"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"prefix" : [
{
"xmlText" : "Dr."
}
]
},
{
"given" : [
{
"xmlText" : "Pseudo"
}
]
},
{
"family" : [
{
"xmlText" : "Physician-1"
}
]
}
]
}
]
},
"representedOrganization" : {
"id" : [
{
"root" : "2.16.840.1.113883.3.72.5"
}
],
"name" : [
{
"item" : [
{
"xmlText" : "NIST HL7 Test Laboratory"
}
]
}
],
"telecom" : [
{
"nullFlavor" : "UNK"
}
],
"addr" : [
{
"nullFlavor" : "UNK"
}
]
}
}
},
{
"typeCode" : "PRF",
"functionCode" : {
"code" : "PP",
"codeSystem" : "2.16.840.1.113883.12.443",
"codeSystemName" : "Provider Role",
"displayName" : "Primary Care Provider",
"originalText" : {
"xmlText" : "Primary Care Provider"
}
},
"time" : {
"low" : {
"value" : "2002-07-16T10:35:00-05:00"
},
"high" : {
"value" : "2007-09-15T22:00:00-05:00"
}
},
"assignedEntity" : {
"id" : [
{
"extension" : "666666666",
"root" : "2.16.840.1.113883.4.6"
},
{
"extension" : "PseudoMD-3",
"root" : "2.16.840.1.113883.19"
}
],
"code" : {
"code" : "207R00000X",
"codeSystem" : "2.16.840.1.113883.6.101",
"displayName" : "Internal Medicine Physician"
},
"addr" : [
null
],
"telecom" : [
{
"use" : [
"HP"
],
"value" : "tel:+1-301-975-3251"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"prefix" : [
{
"xmlText" : "Dr."
}
]
},
{
"given" : [
{
"xmlText" : "Pseudo"
}
]
},
{
"family" : [
{
"xmlText" : "Physician-3"
}
]
}
]
}
]
},
"representedOrganization" : {
"id" : [
{
"root" : "2.16.840.1.113883.19.123"
}
],
"name" : [
{
"item" : [
{
"xmlText" : "HL7 Test Laboratory"
}
]
}
],
"telecom" : [
{
"nullFlavor" : "UNK"
}
],
"addr" : [
{
"nullFlavor" : "UNK"
}
]
}
}
}
]
}
}
],
"componentOf" : {
"encompassingEncounter" : {
"id" : [
{
"extension" : "9937012",
"root" : "2.16.840.1.113883.19"
}
],
"code" : {
"code" : "99213",
"codeSystem" : "2.16.840.1.113883.6.12",
"codeSystemName" : "CPT-4"
},
"effectiveTime" : {
"low" : {
"value" : "2005-03-29T10:35:00-05:00"
},
"high" : {
"value" : "2005-03-29T22:00:00-05:00"
}
},
"location" : {
"healthCareFacility" : {
"id" : [
{
"root" : "2.16.540.1.113883.19.2"
}
]
}
}
}
},
"component" : {
"structuredBody" : // All sections are set to nullFlavor / text = No information,
as this is a header example, not a complete body example
{
"component" : [
// Assessment & Plan (or Assessment Section + Plan Section
{
"section" : {
"nullFlavor" : "NI",
"templateId" : [
{
"extension" : "2014-06-09",
"root" : "2.16.840.1.113883.10.20.22.2.9"
}
],
"code" : {
"code" : "51847-2",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "Evaluation + Plan note"
},
"title" : {
"xmlText" : "ASSESSMENT AND PLAN"
},
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
}
},
{
"section" : {
"templateId" : [
// Notes Section
{
"extension" : "2016-11-01",
"root" : "2.16.840.1.113883.10.20.22.2.65"
}
],
"code" : {
"code" : "11488-4",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "Consult note"
},
"title" : {
"xmlText" : "Consultation Notes"
},
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><ul><li id=\"ConsultNote1\"><p>Dr. Specialist - September 8, 2016</p><p>Evaluated patient due to symptoms of...</p></li></ul></div>",
"entry" : [
// Note Activity entry
{
"act" : {
"classCode" : "ACT",
"moodCode" : "EVN",
"templateId" : [
{
"extension" : "2016-11-01",
"root" : "2.16.840.1.113883.10.20.22.4.202"
}
],
"code" : {
"code" : "34109-9",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "Note",
"translation" : [
{
"code" : "28570-0",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "Procedure note"
}
]
},
"text" : {
"reference" : {
"value" : "#ProcedureNote1"
}
},
"statusCode" : {
"code" : "completed"
},
"effectiveTime" : // Clinically-relevant time of the note
{
"value" : "2014-02-03"
},
"author" : [
// Author Participation
{
"templateId" : [
{
"root" : "2.16.840.1.113883.10.20.22.4.119"
}
],
"time" : // Time note was actually written
{
"value" : "2014-02-04T08:32:15-05:00"
},
"assignedAuthor" : {
"id" : [
{
"root" : "20cf14fb-b65c-4c8c-a54d-b0cca834c18c"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Hospital Lane"
}
},
{
"city" : {
"xmlText" : "Ann Arbor"
}
},
{
"state" : {
"xmlText" : "MI"
}
},
{
"postalCode" : {
"xmlText" : "99999"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"value" : "tel:(999)555-1212"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"xmlText" : "Dr. Physician"
}
]
}
]
}
}
}
]
}
}
]
}
}
]
}
}
}