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: History and Physical
Based on: C-CDA_R2_History_and_Physical.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
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Disclaimer: This sample file contains representative data elements to represent a History and Physical.
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"/>
<!-- History and Physical Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.3" extension="2024-05-01"/>
<id root="2.16.840.1.113883.19.5.99999.1" extension="TT988"/>
<sdtc:sdtcCategory xmlns:sdtc="urn:hl7-org:sdtc"
displayName="History and physical note" codeSystem="2.16.840.1.113883.6.1" code="34117-2"/>
<code displayName="History and Physical Note" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="34117-2"/>
<title>Community Health and Hospitals: History & Physical</title>
<effectiveTime value="20120916190500-0400"/>
<confidentialityCode 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"/>
<versionNumber value="1"/>
<recordTarget>
<patientRole>
<id root="2.16.840.1.113883.19.5.99999.2" extension="998991"/>
<!-- Fake ID using HL7 example OID. -->
<id root="2.16.840.1.113883.4.1" extension="111-00-2330"/>
<!-- Fake 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>1357 Amber Drive</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
</addr>
<telecom value="tel:(816)276-6909" 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 -->
<given>Isabella</given>
<given>Isa</given>
<!-- CL is "Call me" from HL7 EntityNamePartQualifier 2.16.840.1.113883.5.43 -->
<family>Jones</family>
</name>
<administrativeGenderCode displayName="Female"
codeSystem="2.16.840.1.113883.5.1" code="F"/>
<birthTime value="20050501"/>
<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="American Indian or Alaska Native"
codeSystemName="Race & Ethnicity - CDC" codeSystem="2.16.840.1.113883.6.238" code="1002-5"/>
<sdtc:sdtcRaceCode xmlns:sdtc="urn:hl7-org:sdtc" displayName="Aleut"
codeSystemName="Race & Ethnicity - CDC" codeSystem="2.16.840.1.113883.6.238"
code="1966-1"/>
<ethnicGroupCode displayName="Not Hispanic or Latino"
codeSystemName="Race & Ethnicity - CDC" codeSystem="2.16.840.1.113883.6.238" code="2186-5"/>
<guardian>
<code displayName="Grandparent" codeSystemName="HL7 Role code"
codeSystem="2.16.840.1.113883.5.111" code="GRPRN"/>
<!-- 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>1357 Amber Drive</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
</addr>
<telecom value="tel:(816)276-6909" use="HP"/>
<guardianPerson>
<name>
<given>Ralph</given>
<family>Jones</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
</addr>
</place>
</birthplace>
<languageCommunication>
<languageCode code="en"/>
<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"/>
<preferenceInd value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom value="tel:555-555-5000" use="WP"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time value="20050329224411+0500"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="99999999"/>
<code displayName="Allopathic & Osteopathic Physicians"
codeSystem="2.16.840.1.113883.6.101" code="200000000X"/>
<addr use="WP">
<streetAddressLine>1002 Healthcare Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom value="tel:555-555-1002" 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="999999943252"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom value="tel:555-555-1002" use="WP"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<informant>
<assignedEntity>
<id root="2.16.840.1.113883.19.5" extension="KP00017"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom value="tel:555-555-1002" use="WP"/>
<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>Frank</given>
<family>Jones</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="2.16.840.1.113883.4.6" extension="99999999"/>
<name>Community Health and Hospitals</name>
<telecom value="tel:555-555-1002" use="WP"/>
<addr use="WP">
<streetAddressLine>1002 Healthcare Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</informationRecipient>
<receivedOrganization>
<name>Community Health and Hospitals</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<time value="20090227130000+0500"/>
<signatureCode code="S"/>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="999999999"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom value="tel:555-555-1002" use="WP"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<authenticator>
<time value="20090227130000+0500"/>
<signatureCode code="S"/>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="999999999"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom value="tel:555-555-1002" use="WP"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<participant typeCode="IND">
<time>
<low value="19590101"/>
<high value="20111025"/>
</time>
<associatedEntity classCode="NOK">
<code codeSystem="2.16.840.1.113883.5.111" code="MTH"/>
<addr use="WP">
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
</addr>
<telecom value="tel:(999)555-1212" use="WP"/>
<associatedPerson>
<name>
<prefix>Mrs.</prefix>
<given>Martha</given>
<family>Jones</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>
<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="20090227130000+0500"/>
<high value="20090227130000+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>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"
extension="2015-08-01"/>
<code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
code="48765-2"/>
<title>ALLERGIES AND ADVERSE REACTIONS</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"
extension="2015-08-01"/>
<code displayName="PROBLEM LIST" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="11450-4"/>
<title>PROBLEMS</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"
extension="2014-06-09"/>
<code displayName="HISTORY OF MEDICATION USE"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="10160-0"/>
<title>MEDICATIONS</title>
<text>No information</text>
</section>
</component>
<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 nullFlavor="NI">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.4"/>
<code displayName="History of Present illness Narrative"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="10164-2"/>
<title>History of Present Illness</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.3.1"
extension="2015-08-01"/>
<code displayName="RESULTS" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="30954-2"/>
<title>RESULTS</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.12"/>
<code displayName="Reason for visit Narrative"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="29299-5"/>
<title>Reason for Visit</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.2.10"
extension="2015-08-01"/>
<code displayName="Physical Findings" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="29545-1"/>
<title>Physical Examination</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.4.1"
extension="2015-08-01"/>
<code displayName="VITAL SIGNS" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="8716-3"/>
<title>VITAL SIGNS</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.17"
extension="2015-08-01"/>
<code displayName="Social History" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="29762-2"/>
<title>SOCIAL HISTORY</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.15"
extension="2015-08-01"/>
<code displayName="History of family member diseases Narrative"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="10157-6"/>
<title>Family History</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.20"
extension="2015-08-01"/>
<code displayName="History of Past illness Narrative"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="11348-0"/>
<title>Past Medical History</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.2.5"/>
<code displayName="Physical findings of General status Narrative"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="10210-3"/>
<title>General Status</title>
<text>No information</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.18"/>
<code displayName="Review of systems Narrative - Reported"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="10187-3"/>
<title>Review of Systems</title>
<text>No information</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>