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.
********************************************************
-->
<ClinicalDocument xmlns="urn:hl7-org:v3">
<!-- ** CDA Header ** -->
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<!-- US General Header Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2024-05-01"/>
<!-- Progress Note Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.9" extension="2024-05-01"/>
<id root="2.16.840.1.113883.19" extension="999022"/>
<sdtc:sdtcCategory xmlns:sdtc="urn:hl7-org:sdtc"
displayName="Progress note" codeSystem="2.16.840.1.113883.6.1" code="11506-3"/>
<code displayName="Progress note" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="11506-3"/>
<title>Progress Note</title>
<effectiveTime value="20050329171504-0500"/>
<confidentialityCode codeSystem="2.16.840.1.113883.5.25" code="N"/>
<languageCode code="en-US"/>
<setId root="2.16.840.1.113883.19" extension="111199021"/>
<versionNumber value="1"/>
<recordTarget>
<patientRole>
<!-- Fake ID using HL7 example OID. -->
<id root="2.16.840.1.113883.19" extension="12345"/>
<!-- Fake Social Security Number using the actual SSN OID. -->
<id root="2.16.840.1.113883.4.1" extension="111-00-1234"/>
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<addr use="HP">
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
<country>US</country>
</addr>
<telecom value="tel:(781)555-1212" use="HP"/>
<!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<patient>
<name use="L">
<!-- L is "Legal" from HL7 EntityNameUse 2.16.840.1.113883.5.45 -->
<prefix>Mr.</prefix>
<given>Adam</given>
<given qualifier="CL">Frankie</given>
<!-- CL is "Call me" from HL7 EntityNamePartQualifier 2.16.840.1.113883.5.43 -->
<family>Everyman</family>
</name>
<administrativeGenderCode displayName="Male"
codeSystem="2.16.840.1.113883.5.1" code="M"/>
<birthTime value="19541125"/>
<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"/>
<raceCode displayName="White"
codeSystemName="Race & Ethnicity - CDC" codeSystem="2.16.840.1.113883.6.238" code="2106-3"/>
<ethnicGroupCode displayName="Not Hispanic or Latino"
codeSystemName="Race & Ethnicity - CDC" codeSystem="2.16.840.1.113883.6.238" code="2186-5"/>
<guardian>
<code displayName="Grandfather" codeSystemName="HL7 Role code"
codeSystem="2.16.840.1.113883.5.111" code="GRFTH"/>
<!-- 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>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
<telecom value="tel:(781)555-1212" use="HP"/>
<guardianPerson>
<name>
<given>Ralph</given>
<family>Relative</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
</place>
</birthplace>
<languageCommunication>
<languageCode code="fr-CN"/>
<modeCode displayName="Received Written"
codeSystemName="LanguageAbilityMode" codeSystem="2.16.840.1.113883.5.60" code="RWR"/>
<preferenceInd value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<!-- Organizations SHOULD have an NPI; this is a real root; fake extension -->
<id root="2.16.840.1.113883.4.6" extension="111122223333"/>
<name>Good Health Clinic</name>
<telecom value="tel:(781)555-1212" use="WP"/>
<addr use="WP">
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time value="20050329224411+0500"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="999999999"/>
<code displayName="Allopathic & Osteopathic Physicians"
codeSystem="2.16.840.1.113883.6.101" code="200000000X"/>
<addr use="WP">
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom value="tel:(555)555-1003" use="WP"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="999999999"/>
<addr use="WP">
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom value="tel:(555)555-1003" use="WP"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<informant>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="999999999"/>
<addr use="WP">
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom value="tel:(555)555-1003"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</informant>
<informant>
<relatedEntity classCode="PRS">
<!-- classCode PRS represents a person with personal relationship with the patient. -->
<code displayName="SPOUSE"
codeSystemName="Personal Relationship Role Type Value Set" codeSystem="2.16.840.1.113883.1.11.19563" code="SPS"/>
<relatedPerson>
<name>
<given>Rose</given>
<family>Everyman</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="2.16.840.1.113883.4.6" extension="444444444"/>
<name>Good Health Clinic</name>
<telecom value="tel:(555)555-1212" use="WP"/>
<addr use="WP">
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</informationRecipient>
<receivedOrganization>
<name>Good Health Clinic</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<time value="20050329224411+0500"/>
<signatureCode code="S"/>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="444444444"/>
<addr use="WP">
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom value="tel:(555)555-1003" use="WP"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<authenticator>
<time value="20050329224411+0500"/>
<signatureCode code="S"/>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="444444444"/>
<addr use="WP">
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom value="tel:(555)555-1003" use="WP"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<participant typeCode="IND">
<associatedEntity classCode="NOK">
<code codeSystem="2.16.840.1.113883.5.111" code="MTH"/>
<addr use="WP">
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom value="tel:(999)555-1212" use="WP"/>
<associatedPerson>
<name>
<prefix>Mrs.</prefix>
<given>Abigail</given>
<family>Ruth</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<inFulfillmentOf typeCode="FLFS">
<order moodCode="RQO" classCode="ACT">
<id root="2.16.840.1.113883.19" extension="12345-67890"/>
</order>
</inFulfillmentOf>
<documentationOf typeCode="DOC">
<serviceEvent classCode="PCPR">
<templateId root="2.16.840.1.113883.10.20.21.3.1"/>
<effectiveTime>
<low value="20100601103500-0500"/>
<high value="20100915220000-0500"/>
</effectiveTime>
<performer typeCode="PRF">
<functionCode displayName="Primary Care Provider"
codeSystemName="ParticipationFunction" codeSystem="2.16.840.1.113883.5.88" code="PCP">
<originalText>Primary Care Provider</originalText>
</functionCode>
<time>
<low value="20020716103500-0500"/>
<high value="20070915220000-0500"/>
</time>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="555555555"/>
<code displayName="Internal Medicine Physician"
codeSystem="2.16.840.1.113883.6.101" code="207R00000X"/>
<addr/>
<telecom value="tel:+1-301-975-3251" use="HP"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Pseudo</given>
<family>Physician-1</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.3.72.5"/>
<name>NIST HL7 Test Laboratory</name>
<telecom nullFlavor="UNK"/>
<addr nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
<performer typeCode="PRF">
<functionCode displayName="Primary Care Provider"
codeSystemName="Provider Role" codeSystem="2.16.840.1.113883.12.443" code="PP">
<originalText>Primary Care Provider</originalText>
</functionCode>
<time>
<low value="20020716103500-0500"/>
<high value="20070915220000-0500"/>
</time>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="666666666"/>
<id root="2.16.840.1.113883.19" extension="PseudoMD-3"/>
<code displayName="Internal Medicine Physician"
codeSystem="2.16.840.1.113883.6.101" code="207R00000X"/>
<addr/>
<telecom value="tel:+1-301-975-3251" use="HP"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Pseudo</given>
<family>Physician-3</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.19.123"/>
<name>HL7 Test Laboratory</name>
<telecom nullFlavor="UNK"/>
<addr nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<componentOf>
<encompassingEncounter>
<id root="2.16.840.1.113883.19" extension="9937012"/>
<code codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"
code="99213"/>
<effectiveTime>
<low value="20050329103500-0500"/>
<high value="20050329220000-0500"/>
</effectiveTime>
<location>
<healthCareFacility>
<id root="2.16.540.1.113883.19.2"/>
</healthCareFacility>
</location>
</encompassingEncounter>
</componentOf>
<component>
<!-- All sections are set to nullFlavor / text = No information,
as this is a header example, not a complete body example -->
<structuredBody>
<!-- Assessment & Plan (or Assessment Section + Plan Section -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.9"
extension="2014-06-09"/>
<code displayName="Evaluation + Plan note" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="51847-2"/>
<title>ASSESSMENT AND PLAN</title>
<text>No information</text>
</section>
</component>
<component>
<section>
<!-- Notes Section -->
<templateId root="2.16.840.1.113883.10.20.22.2.65"
extension="2016-11-01"/>
<code displayName="Consult note" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="11488-4"/>
<title>Consultation Notes</title>
<text>
<list listType="unordered">
<item ID="ConsultNote1">
<paragraph>Dr. Specialist - September 8, 2016</paragraph>
<paragraph>Evaluated patient due to symptoms of...</paragraph>
</item>
</list>
</text>
<!-- Note Activity entry -->
<entry>
<act moodCode="EVN" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.202"
extension="2016-11-01"/>
<code displayName="Note" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="34109-9">
<translation xsi:type="CD" displayName="Procedure note"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
code="28570-0"/>
</code>
<text>
<reference value="#ProcedureNote1"/>
</text>
<statusCode code="completed"/>
<!-- Clinically-relevant time of the note -->
<effectiveTime value="20140203"/>
<!-- Author Participation -->
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<!-- Time note was actually written -->
<time value="20140204083215-0500"/>
<assignedAuthor>
<id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c"/>
<addr use="WP">
<streetAddressLine>1001 Hospital Lane</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>99999</postalCode>
<country>US</country>
</addr>
<telecom value="tel:(999)555-1212"/>
<assignedPerson>
<name>Dr. Physician</name>
</assignedPerson>
</assignedAuthor>
</author>
</act>
</entry>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>