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: Procedure Note
Based on: C-CDA_R2_Procedure_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 Procedure 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 Realm Header Template
{
"extension" : "2024-05-01",
"root" : "2.16.840.1.113883.10.20.22.1.1"
},
{
"extension" : "2024-05-01",
"root" : "2.16.840.1.113883.10.20.22.1.6"
}
],
"id" : // Procedure Note Template
{
"extension" : "TT988",
"root" : "2.16.840.1.113883.19.5.99999.1"
},
"sdtcCategory" : [
{
"code" : "28570-0",
"codeSystem" : "2.16.840.1.113883.6.1",
"displayName" : "Procedure note"
}
],
"code" : {
"code" : "28570-0",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "Procedure Note"
},
"title" : {
"xmlText" : "Community Health and Hospitals: Procedure Note"
},
"effectiveTime" : {
"value" : "2012-09-16T19:11:00-04:00"
},
"confidentialityCode" : {
"code" : "N",
"codeSystem" : "2.16.840.1.113883.5.25"
},
"languageCode" : {
"code" : "en-US"
},
"setId" : {
"extension" : "sTT988",
"root" : "2.16.840.1.113883.19.5.99999.19"
},
"versionNumber" : {
"value" : 1
},
"recordTarget" : [
{
"patientRole" : {
"id" : [
// Fake ID using HL7 example OID.
{
"extension" : "998991",
"root" : "2.16.840.1.113883.19.5.99999.2"
},
{
"extension" : "111-00-2330",
"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" : "1357 Amber Drive"
}
},
{
"city" : {
"xmlText" : "Beaverton"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "97867"
}
},
{
"country" : // US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1
{
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
// HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119
{
"use" : [
"HP"
],
"value" : "tel:(816)276-6909"
}
],
"patient" : {
"name" : [
// L is "Legal" from HL7 EntityNameUse 2.16.840.1.113883.5.45
{
"use" : [
"L"
],
"item" : [
{
"given" : [
{
"xmlText" : "Isabella"
}
]
},
{
"family" : [
{
"xmlText" : "Jones"
}
]
}
]
}
],
"administrativeGenderCode" : {
"code" : "F",
"codeSystem" : "2.16.840.1.113883.5.1",
"displayName" : "Female"
},
"birthTime" : {
"value" : "2005-05-01"
},
"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" : "1002-5",
"codeSystem" : "2.16.840.1.113883.6.238",
"codeSystemName" : "Race & Ethnicity - CDC",
"displayName" : "American Indian or Alaska Native"
},
"sdtcRaceCode" : [
{
"code" : "1966-1",
"codeSystem" : "2.16.840.1.113883.6.238",
"codeSystemName" : "Race & Ethnicity - CDC",
"displayName" : "Aleut"
}
],
"ethnicGroupCode" : {
"code" : "2186-5",
"codeSystem" : "2.16.840.1.113883.6.238",
"codeSystemName" : "Race & Ethnicity - CDC",
"displayName" : "Not Hispanic or Latino"
},
"guardian" : [
{
"code" : {
"code" : "GRPRN",
"codeSystem" : "2.16.840.1.113883.5.111",
"codeSystemName" : "HL7 Role code",
"displayName" : "Grandparent"
},
"addr" : [
// HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119
{
"use" : [
"HP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1357 Amber Drive"
}
},
{
"city" : {
"xmlText" : "Beaverton"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "97867"
}
},
{
"country" : // US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1
{
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"HP"
],
"value" : "tel:(816)276-6909"
}
],
"guardianPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Ralph"
}
]
},
{
"family" : [
{
"xmlText" : "Jones"
}
]
}
]
}
]
}
}
],
"birthplace" : {
"place" : {
"addr" : {
"item" : [
{
"city" : {
"xmlText" : "Beaverton"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "97867"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
}
},
"languageCommunication" : [
{
"languageCode" : {
"code" : "en"
},
"modeCode" : {
"code" : "ESP",
"codeSystem" : "2.16.840.1.113883.5.60",
"codeSystemName" : "LanguageAbilityMode",
"displayName" : "Expressed spoken"
},
"proficiencyLevelCode" : {
"code" : "G",
"codeSystem" : "2.16.840.1.113883.5.61",
"codeSystemName" : "LanguageAbilityProficiency",
"displayName" : "Good"
},
"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" : "Community Health and Hospitals"
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:555-555-5000"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Village Avenue"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
]
}
}
}
],
"author" : [
{
"time" : {
"value" : "2005-03-29T22:44:11+05:00"
},
"assignedAuthor" : {
"id" : [
{
"extension" : "99999999",
"root" : "2.16.840.1.113883.4.6"
}
],
"code" : {
"code" : "207R00000X",
"codeSystem" : "2.16.840.1.113883.6.101",
"displayName" : "Allopathic & Osteopathic Physicians; Internal Medicine"
},
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1002 Healthcare Drive"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:555-555-1002"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
}
}
}
],
"dataEnterer" : {
"assignedEntity" : {
"id" : [
{
"extension" : "999999943252",
"root" : "2.16.840.1.113883.4.6"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Village Avenue"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:555-555-1002"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
}
}
},
"informant" : [
{
"assignedEntity" : {
"id" : [
{
"extension" : "KP00017",
"root" : "2.16.840.1.113883.19.5"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Village Avenue"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:555-555-1002"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
}
}
},
{
"relatedEntity" : // classCode PRS represents a person with personal relationship with the patient.
{
"classCode" : "PRS",
"code" : {
"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" : "Frank"
}
]
},
{
"family" : [
{
"xmlText" : "Jones"
}
]
}
]
}
]
}
}
}
],
"custodian" : {
"assignedCustodian" : {
"representedCustodianOrganization" : {
"id" : [
{
"extension" : "99999999",
"root" : "2.16.840.1.113883.4.6"
}
],
"name" : {
"item" : [
{
"xmlText" : "Community Health and Hospitals"
}
]
},
"telecom" : {
"use" : [
"WP"
],
"value" : "tel:555-555-1002"
},
"addr" : {
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1002 Healthcare Drive"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
}
}
},
"informationRecipient" : [
{
"intendedRecipient" : {
"informationRecipient" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
},
"receivedOrganization" : {
"name" : [
{
"item" : [
{
"xmlText" : "Community Health and Hospitals"
}
]
}
]
}
}
}
],
"legalAuthenticator" : {
"time" : {
"value" : "2009-02-27T13:00:00+05:00"
},
"signatureCode" : {
"code" : "S"
},
"assignedEntity" : {
"id" : [
{
"extension" : "999999999",
"root" : "2.16.840.1.113883.4.6"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Village Avenue"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:555-555-1002"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
}
}
},
"authenticator" : [
{
"time" : {
"value" : "2009-02-27T13:00:00+05:00"
},
"signatureCode" : {
"code" : "S"
},
"assignedEntity" : {
"id" : [
{
"extension" : "999999999",
"root" : "2.16.840.1.113883.4.6"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Village Avenue"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:555-555-1002"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
}
}
}
],
"participant" : [
{
"typeCode" : "IND",
"functionCode" : {
"code" : "PCP",
"codeSystem" : "2.16.840.1.113883.5.88",
"codeSystemName" : "participationFunction",
"displayName" : "Primary Care Physician"
},
"associatedEntity" : {
"classCode" : "PROV",
"associatedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
}
}
}
],
"documentationOf" : [
{
"typeCode" : "DOC",
"serviceEvent" : {
"classCode" : "PCPR",
"code" : {
"code" : "73761001",
"codeSystem" : "2.16.840.1.113883.6.96",
"codeSystemName" : "SNOMED CT",
"displayName" : "Colonoscopy"
},
"effectiveTime" : {
"low" : {
"value" : "2012-09-09T19:11:00-04:00"
},
"high" : {
"value" : "2012-09-16T19:11:00-04:00"
}
},
"performer" : [
{
"typeCode" : "SPRF",
"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" : "2012-09-09T19:11:00-04:00"
},
"high" : {
"value" : "2012-09-16T19:11:00-04:00"
}
},
"assignedEntity" : {
"id" : [
{
"extension" : "PseudoMD-1",
"root" : "2.16.840.1.113883.4.6"
}
],
"code" : {
"code" : "207R00000X",
"codeSystem" : "2.16.840.1.113883.6.101",
"displayName" : "Internal Medicine Physician"
},
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Village Avenue"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:+1-555-555-5000"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"prefix" : [
{
"xmlText" : "Dr."
}
]
},
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
},
"representedOrganization" : {
"id" : [
{
"root" : "2.16.840.1.113883.19.5.9999.1393"
}
],
"name" : [
{
"item" : [
{
"xmlText" : "Community Health and Hospitals"
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:+1-555-555-5000"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Village Avenue"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
]
}
}
},
{
"typeCode" : "PPRF",
"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" : "2012-09-09T19:11:00-04:00"
},
"high" : {
"value" : "2012-09-16T19:11:00-04:00"
}
},
"assignedEntity" : {
"id" : [
{
"extension" : "PseudoMD-3",
"root" : "2.16.840.1.113883.4.6"
}
],
"code" : {
"code" : "207RG0100X",
"codeSystem" : "2.16.840.1.113883.6.101",
"codeSystemName" : "Provider Codes",
"displayName" : "Gastroenterology Physician"
},
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Village Avenue"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"HP"
],
"value" : "tel:+1-555-555-5000"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"prefix" : [
{
"xmlText" : "Dr."
}
]
},
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
},
"representedOrganization" : {
"id" : [
{
"root" : "2.16.840.1.113883.19.5.9999.1393"
}
],
"name" : [
{
"item" : [
{
"xmlText" : "Community Health and Hospitals"
}
]
}
],
"telecom" : [
{
"use" : [
"HP"
],
"value" : "tel:+1-555-555-5000"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Village Avenue"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
]
}
}
}
]
}
}
],
"authorization" : [
{
"consent" : {
"classCode" : "CONS",
"moodCode" : "EVN",
"id" : [
{
"root" : "629deb70-5306-11df-9879-0800200c9a66"
}
],
"code" : {
"code" : "64293-4",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "Procedure consent"
},
"statusCode" : {
"code" : "completed"
}
}
}
],
"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" : "2009-02-27T13:00:00+05:00"
},
"high" : {
"value" : "2009-02-27T13:00:00+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" : [
// Complications
{
"section" : {
"nullFlavor" : "NI",
"templateId" : [
{
"extension" : "2015-08-01",
"root" : "2.16.840.1.113883.10.20.22.2.37"
}
],
"code" : {
"code" : "55109-3",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "Complications"
},
"title" : {
"xmlText" : "Complications"
},
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
}
},
{
"section" : {
"nullFlavor" : "NI",
"templateId" : [
{
"root" : "2.16.840.1.113883.10.20.22.2.27"
}
],
"code" : {
"code" : "29554-3",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "PROCEDURE DESCRIPTION"
},
"title" : {
"xmlText" : "Procedure Description"
},
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
}
},
{
"section" : {
"nullFlavor" : "NI",
"templateId" : [
{
"extension" : "2014-06-09",
"root" : "2.16.840.1.113883.10.20.22.2.29"
}
],
"code" : {
"code" : "59768-2",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "PROCEDURE INDICATIONS"
},
"title" : {
"xmlText" : "Procedure Indications"
},
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
}
},
{
"section" : {
"nullFlavor" : "NI",
"templateId" : [
{
"extension" : "2015-08-01",
"root" : "2.16.840.1.113883.10.20.22.2.36"
}
],
"code" : {
"code" : "59769-0",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "POSTPROCEDURE DIAGNOSIS"
},
"title" : {
"xmlText" : "Postprocedure Diagnosis"
},
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
}
},
{
"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>"
}
}
]
}
}
}