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
{
"resourceType" : "ClinicalDocument",
"realmCode" : [
{
"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"
}
],
"id" : // Globally unique identifier for the document
{
"extension" : "TT988",
"root" : "2.16.840.1.113883.19.5.99999.1"
},
"code" : {
"code" : "34133-9",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "Summarization of Episode Note"
},
"title" : // Title of the document
{
"xmlText" : "Patient Chart Summary"
},
"effectiveTime" : {
"value" : "2012-09-15T10:30:00-08:00"
},
"confidentialityCode" : {
"code" : "N",
"codeSystem" : "2.16.840.1.113883.5.25",
"codeSystemName" : "Confidentiality",
"displayName" : "normal"
},
"languageCode" : {
"code" : "en-US"
},
"setId" : {
"extension" : "sTT988",
"root" : "2.16.840.1.113883.19.5.99999.19"
},
"versionNumber" : // Version of the document
{
"value" : 1
},
"recordTarget" : [
{
"patientRole" : {
"id" : [
{
"extension" : "444222222",
"root" : "2.16.840.1.113883.4.1"
}
],
"addr" : [
// Example Social Security Number using the actual SSN OID.
// 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" : "2222 Home Street"
}
},
{
"city" : {
"xmlText" : "Beaverton"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "97867"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"HP"
],
"value" : "tel:+1(555)555-2003"
}
],
"patient" : // HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119
{
"name" : [
{
"use" : [
"L"
],
"item" : [
{
"given" : [
{
"xmlText" : "Eve"
}
]
},
{
"family" : [
// The "SP" is "Spouse" from HL7 Code System EntityNamePartQualifier 2.16.840.1.113883.5.43
{
"xmlText" : "Betterhalf",
"qualifier" : [
"SP"
]
}
]
}
]
}
],
"administrativeGenderCode" : {
"code" : "F",
"codeSystem" : "2.16.840.1.113883.5.1",
"codeSystemName" : "AdministrativeGender",
"displayName" : "Female"
},
"birthTime" : // Date of birth need only be precise to the day
{
"value" : "1975-05-01"
},
"maritalStatusCode" : // <sdtc:multipleBirthOrderNumber value="2" />
{
"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" : // CDC Race and Ethnicity code set contains the five minimum race and ethnicity
categories defined by OMB Standards
{
"code" : "2106-3",
"codeSystem" : "2.16.840.1.113883.6.238",
"codeSystemName" : "Race & Ethnicity - CDC",
"displayName" : "White"
},
"sdtcRaceCode" : [
// The raceCode extension is only used if raceCode is valued
{
"code" : "2076-8",
"codeSystem" : "2.16.840.1.113883.6.238",
"codeSystemName" : "Race & Ethnicity - CDC",
"displayName" : "Native Hawaiian or Other Pacific Islander"
}
],
"ethnicGroupCode" : {
"code" : "2186-5",
"codeSystem" : "2.16.840.1.113883.6.238",
"codeSystemName" : "Race & Ethnicity - CDC",
"displayName" : "Not Hispanic or Latino"
},
"guardian" : [
{
"code" : {
"code" : "POWATT",
"codeSystem" : "2.16.840.1.113883.5.111",
"codeSystemName" : "RoleCode",
"displayName" : "Power of Attorney"
},
"addr" : [
{
"use" : [
"HP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "2222 Home Street"
}
},
{
"city" : {
"xmlText" : "Beaverton"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "97867"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"MC"
],
"value" : "tel:+1(555)555-2008"
}
],
"guardianPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Boris"
}
]
},
{
"given" : [
{
"xmlText" : "Bo",
"qualifier" : [
"CL"
]
}
]
},
{
"family" : [
{
"xmlText" : "Betterhalf"
}
]
}
]
}
]
}
}
],
"birthplace" : {
"place" : {
"addr" : {
"item" : [
{
"streetAddressLine" : {
"xmlText" : "4444 Home Street"
}
},
{
"city" : {
"xmlText" : "Beaverton"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "97867"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
}
},
"languageCommunication" : [
{
"languageCode" : {
"code" : "en"
},
"modeCode" : // "en" is ISO 639-1 alpha-2 code for "English"
{
"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" : // Patient's preferred language
{
"value" : true
}
}
]
}
}
}
],
"author" : [
// The author represents the person who provides the content in the document
{
"time" : {
"value" : "2013-08-15T10:30:00-08:00"
},
"assignedAuthor" : {
"id" : [
{
"extension" : "5555555555",
"root" : "2.16.840.1.113883.4.6"
}
],
"code" : {
"code" : "207QA0505X",
"codeSystem" : "2.16.840.1.113883.6.101",
"codeSystemName" : "Healthcare Provider Taxonomy (HIPAA)",
"displayName" : "Adult Medicine Physician"
},
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1004 Healthcare Drive"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:+1(555)555-1004"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Patricia"
}
]
},
{
"given" : [
{
"xmlText" : "Patty",
"qualifier" : [
"CL"
]
}
]
},
{
"family" : [
{
"xmlText" : "Primary"
}
]
},
{
"suffix" : [
{
"xmlText" : "M.D.",
"qualifier" : [
"AC"
]
}
]
}
]
}
]
}
}
}
],
"custodian" : // The custodian represents the organization charged with maintaining the original source document
{
"assignedCustodian" : {
"representedCustodianOrganization" : {
"id" : [
{
"extension" : "321CX",
"root" : "2.16.840.1.113883.4.6"
}
],
"name" : {
"item" : [
{
"xmlText" : "Good Health HIE"
}
]
},
"telecom" : {
"use" : [
"WP"
],
"value" : "tel:+1(555)555-1009"
},
"addr" : {
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1009 Healthcare Drive"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
}
}
},
"informationRecipient" : [
{
"intendedRecipient" : {
"classCode" : "ASSIGNED",
"addr" : [
{
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1004 Healthcare Drive"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
]
}
}
],
"component" : {
"structuredBody" : {
"component" : [
{
}
]
}
}
}