Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 United States of America flag

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

: Care Plan Complete Header Example - XML Representation

Raw xml | Download


  <!-- 
 Title:        Care Plan

 Based on:     C-CDA_R2_Care_Plan.xml
 Created by:   Lantana Consulting Group, LLC
 
 Updated for C-CDA R3.0 with a focus on header elements
  
 ********************************************************
 Disclaimer: This sample file contains representative data elements to represent a Care Plan. 
 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 Realm Header  -->
  <templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2024-05-01"/>
  <!--  Care Plan  -->
  <templateId root="2.16.840.1.113883.10.20.22.1.15" extension="2024-05-01"/>
  <id root="db734647-fc99-424c-a864-7e3cda82e703"/>
  <sdtc:sdtcCategory xmlns:sdtc="urn:hl7-org:sdtc"
                     displayName="Plan of care note" codeSystem="2.16.840.1.113883.6.1" code="18776-5"/>
  <code displayName="Healthcare navigator Plan of care note"
        codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="93902-5"/>
  <title>Good Health Hospital Care Plan</title>
  <effectiveTime value="20130820112000-0800"/>
  <confidentialityCode codeSystem="2.16.840.1.113883.5.25" code="N"/>
  <languageCode code="en-US"/>
  <!--  This document is the second document in the set (see setId for id for the set  -->
  <setId root="004bb033-b948-4f4c-b5bf-a8dbd7d8dd40"/>
  <!--  See relatedDocument for the previous version in the set  -->
  <versionNumber value="2"/>
  <!--  Patient (recordTarget)  -->
  <recordTarget>
    <patientRole>
      <id root="2.16.840.1.113883.4.1" extension="444222222"/>
      <!--  Example 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>2222 Home Street</streetAddressLine>
        <city>Beaverton</city>
        <state>OR</state>
        <postalCode>97867</postalCode>
        <country>US</country>
      </addr>
      <telecom value="tel:+1(555)555-2003" use="HP"/>
      <!--  HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119  -->
      <patient>
        <!--  The first name element represents what the patient is known as  -->
        <name use="L">
          <given>Eve</given>
          <!--  The "SP" is "Spouse" from HL7 Code System EntityNamePartQualifier 2.16.840.1.113883.5.43  -->
          <family qualifier="SP">Betterhalf</family>
        </name>
        <!--  The second name element represents another name associated with the patient  -->
        <name use="SRCH">
          <given>Eve</given>
          <!--  The "BR" is "Birth" from HL7 Code System EntityNamePartQualifier 2.16.840.1.113883.5.43  -->
          <family qualifier="BR">Everywoman</family>
        </name>
        <administrativeGenderCode displayName="Female"
                                  codeSystemName="AdministrativeGender" codeSystem="2.16.840.1.113883.5.1"
                                  code="F"/>
        <!--  Date of birth need only be precise to the day  -->
        <birthTime value="19750501"/>
        <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"/>
        <!--  CDC Race and Ethnicity code set contains the five minimum race and ethnicity categories defined by OMB Standards  -->
        <raceCode displayName="White"
                  codeSystemName="Race &amp; Ethnicity - CDC" codeSystem="2.16.840.1.113883.6.238" code="2106-3"/>
        <!--  The raceCode extension is only used if raceCode is valued  -->
        <sdtc:sdtcRaceCode xmlns:sdtc="urn:hl7-org:sdtc"
                           displayName="Native Hawaiian or Other Pacific Islander" codeSystemName="Race &amp; Ethnicity - CDC"
                           codeSystem="2.16.840.1.113883.6.238" code="2076-8"/>
        <ethnicGroupCode displayName="Not Hispanic or Latino"
                         codeSystemName="Race &amp; Ethnicity - CDC" codeSystem="2.16.840.1.113883.6.238" code="2186-5"/>
        <guardian>
          <code displayName="Power of Attorney" codeSystemName="RoleCode"
                codeSystem="2.16.840.1.113883.5.111" code="POWATT"/>
          <addr use="HP">
            <streetAddressLine>2222 Home Street</streetAddressLine>
            <city>Beaverton</city>
            <state>OR</state>
            <postalCode>97867</postalCode>
            <country>US</country>
          </addr>
          <telecom value="tel:+1(555)555-2008" use="MC"/>
          <guardianPerson>
            <name>
              <given>Boris</given>
              <given qualifier="CL">Bo</given>
              <family>Betterhalf</family>
            </name>
          </guardianPerson>
        </guardian>
        <birthplace>
          <place>
            <addr>
              <streetAddressLine>4444 Home Street</streetAddressLine>
              <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"/>
          <!--  Patient's preferred language  -->
          <preferenceInd value="true"/>
        </languageCommunication>
      </patient>
      <providerOrganization>
        <id root="2.16.840.1.113883.4.6" extension="219BX"/>
        <name>The DoctorsTogether Physician Group</name>
        <telecom value="tel:+1(555)555-5000" use="WP"/>
        <addr use="WP">
          <streetAddressLine>1007 Health Drive</streetAddressLine>
          <city>Portland</city>
          <state>OR</state>
          <postalCode>99123</postalCode>
          <country>US</country>
        </addr>
      </providerOrganization>
    </patientRole>
  </recordTarget>
  <!--  Author  -->
  <author>
    <time value="20130730123500-0800"/>
    <assignedAuthor>
      <id root="2.16.840.1.113883.4.6" extension="77777777777"/>
      <code displayName="Registered nurse"
            codeSystemName="Healthcare Provider Taxonomy (HIPAA)" codeSystem="2.16.840.1.113883.6.101" code="163W00000X"/>
      <addr use="WP">
        <streetAddressLine>1004 Healthcare Drive</streetAddressLine>
        <city>Portland</city>
        <state>OR</state>
        <postalCode>99123</postalCode>
        <country>US</country>
      </addr>
      <telecom value="tel:+1(555)555-1004" use="WP"/>
      <assignedPerson>
        <name>
          <given>Nurse</given>
          <family>Nightingale</family>
          <suffix>RN</suffix>
        </name>
      </assignedPerson>
      <representedOrganization>
        <id root="2.16.840.1.113883.19.5"/>
        <name>Good Health Hospital</name>
      </representedOrganization>
    </assignedAuthor>
  </author>
  <!--  Data Enterer  -->
  <dataEnterer>
    <assignedEntity>
      <id root="2.16.840.1.113883.4.6" extension="333777777"/>
      <addr use="WP">
        <streetAddressLine>1007 Healthcare Drive</streetAddressLine>
        <city>Portland</city>
        <state>OR</state>
        <postalCode>99123</postalCode>
        <country>US</country>
      </addr>
      <telecom value="tel:+1(555)-1050" use="WP"/>
      <assignedPerson>
        <name>
          <given>Ellen</given>
          <family>Enter</family>
        </name>
      </assignedPerson>
    </assignedEntity>
  </dataEnterer>
  <!--  Informant  -->
  <informant>
    <assignedEntity>
      <id root="2.16.840.1.113883.19.5" extension="888888888"/>
      <addr use="WP">
        <streetAddressLine>1007 Healthcare Drive</streetAddressLine>
        <city>Portland</city>
        <state>OR</state>
        <postalCode>99123</postalCode>
        <country>US</country>
      </addr>
      <telecom value="tel:+1(555)-1003" use="WP"/>
      <assignedPerson>
        <name>
          <given>Harold</given>
          <family>Hippocrates</family>
          <suffix qualifier="AC">D.O.</suffix>
        </name>
      </assignedPerson>
    </assignedEntity>
  </informant>
  <!--  Custodian  -->
  <custodian>
    <assignedCustodian>
      <representedCustodianOrganization>
        <id root="2.16.840.1.113883.4.6" extension="321CX"/>
        <name>Good Health HIE</name>
        <telecom value="tel:+1(555)555-1009" use="WP"/>
        <addr use="WP">
          <streetAddressLine>1009 Healthcare Drive</streetAddressLine>
          <city>Portland</city>
          <state>OR</state>
          <postalCode>99123</postalCode>
          <country>US</country>
        </addr>
      </representedCustodianOrganization>
    </assignedCustodian>
  </custodian>
  <informationRecipient>
    <intendedRecipient>
      <!--  Receiving Person Provider Id  -->
      <id root="a1cd2b74-c6de-44ee-b552-3adacb7983cc"/>
      <!--  Receiving Medicare/Medicaid Provider Id -->
      <id root="c72f64c2-b1db-444b-bbff-4d2e1d6bd659"/>
      <!--  Receiving Person ID -->
      <id root="fa883fee-b255-4465-8fb5-1d8135e39896"/>
      <!--  Receiving Person Address -->
      <addr use="WP">
        <streetAddressLine>100 Better Health Rd.</streetAddressLine>
        <city>Ann Arbor</city>
        <state>MI</state>
        <postalCode>97857</postalCode>
        <country>US</country>
      </addr>
      <telecom value="tel+1(555)555-1010" use="WP"/>
      <informationRecipient>
        <!--  Receiving Person Name -->
        <name>
          <given>Nurse</given>
          <family>Caresalot</family>
          <suffix>RN</suffix>
        </name>
      </informationRecipient>
      <receivedOrganization>
        <!--  Receiving Organization Id -->
        <id root="c4c416a7-aeeb-4dcc-9662-ab836ff4d265"/>
        <!--  Receiving Organization Provider ID (NPI)  -->
        <id root="ab47f3c4-1267-4b9e-9a29-e966b5a861c8"/>
        <!--  Receiving Organization Name  -->
        <name>Better Health Hospital</name>
        <!--  Receiving Organization Address  -->
        <addr use="WP">
          <streetAddressLine>100 Better Health Rd.</streetAddressLine>
          <city>Ann Arbor</city>
          <state>MI</state>
          <postalCode>97857</postalCode>
          <country>US</country>
        </addr>
        <!--  Receiving Care Setting Type Description: displayName.  Receiving Care Setting Type Code: code  -->
        <standardIndustryClassCode displayName="Long Term Care Hospital"
                                   codeSystemName="Healthcare Provider Taxonomy (HIPAA)" codeSystem="2.16.840.1.113883.6.101"
                                   code="282E00000X"/>
      </receivedOrganization>
    </intendedRecipient>
  </informationRecipient>
  <!--  Legal Authenticator  -->
  <legalAuthenticator>
    <time value="20130730123500-0800"/>
    <signatureCode code="S"/>
    <sdtc:sdtcSignatureText xmlns:sdtc="urn:hl7-org:sdtc"
                            representation="B64" mediaType="text/xml">U2lnbmVkIGJ5IE51cnNlIE5pZ2h0aW5nYWxl</sdtc:sdtcSignatureText>
    <assignedEntity>
      <id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c"/>
      <code displayName="Registered nurse"
            codeSystem="2.16.840.1.113883.6.101" code="163W00000X"/>
      <addr use="WP">
        <streetAddressLine>1004 Healthcare Drive</streetAddressLine>
        <city>Portland</city>
        <state>OR</state>
        <postalCode>99123</postalCode>
        <country>US</country>
      </addr>
      <telecom value="tel:+1(555)555-1004" use="WP"/>
      <assignedPerson>
        <name>
          <given>Nurse</given>
          <family>Nightingale</family>
          <suffix>RN</suffix>
        </name>
      </assignedPerson>
      <!--  the orgnaization id and name  -->
      <representedOrganization>
        <id root="2.16.840.1.113883.19.5"/>
        <name>Good Health Hospital</name>
      </representedOrganization>
    </assignedEntity>
  </legalAuthenticator>
  <!--  This authenticator represents patient agreement or sign-off of the Care Plan -->
  <authenticator>
    <time value="20130730123500-0800"/>
    <signatureCode code="S"/>
    <sdtc:sdtcSignatureText xmlns:sdtc="urn:hl7-org:sdtc"
                            representation="B64" mediaType="text/xml">U2lnbmVkIGJ5IEV2ZSBFdmVyeXdvbWFu</sdtc:sdtcSignatureText>
    <assignedEntity>
      <id root="2.16.840.1.113883.4.1" extension="444222222"/>
      <code displayName="Self" codeSystemName="RoleCode"
            codeSystem="2.16.840.1.113883.5.111" code="ONESELF"/>
      <!--  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>2222 Home Street</streetAddressLine>
        <city>Beaverton</city>
        <state>OR</state>
        <postalCode>97867</postalCode>
        <country>US</country>
      </addr>
      <telecom value="tel:+1(555)555-2003" use="HP"/>
      <assignedPerson>
        <name use="L">
          <given>Eve</given>
          <family qualifier="SP">Everywoman</family>
        </name>
      </assignedPerson>
    </assignedEntity>
  </authenticator>
  <!--  This participant represents the person who reviewed the Care Plan. If the date in the time element is in the past, then this review has already taken place. 
         If the date in the time element is in the future, then this is the date of the next scheduled review.  -->
  <!--  This example shows a Care Plan Review that has already taken place  -->
  <participant typeCode="VRF">
    <functionCode displayName="Review of Care Plan"
                  codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="425268008"/>
    <time value="20130801102400-0800"/>
    <associatedEntity classCode="ASSIGNED">
      <id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c"/>
      <code displayName="Registered nurse"
            codeSystem="2.16.840.1.113883.6.101" code="163W00000X"/>
      <associatedPerson nullFlavor="NA"/>
    </associatedEntity>
  </participant>
  <!--  This participant represents the person who reviewed the Care Plan.   If the date in the time element is in the past, then this review has already taken place. 
  If the date in the time element is in the future,  then this is the date of the next scheduled review.  -->
  <!--  This example shows a Scheduled Care Plan Review that is in the future  -->
  <participant typeCode="VRF">
    <functionCode displayName="Review of Care Plan"
                  codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="425268008"/>
    <time value="20131001123000-0800"/>
    <associatedEntity classCode="ASSIGNED">
      <id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c"/>
      <code displayName="self" codeSystem="2.16.840.1.113883.5.111"
            code="SELF"/>
      <associatedPerson nullFlavor="NA"/>
    </associatedEntity>
  </participant>
  <!--  This participant identifies individuals who support the patient such as a relative or caregiver  -->
  <participant typeCode="IND">
    <!--  Emergency Contact   -->
    <associatedEntity classCode="ECON">
      <addr use="HP">
        <streetAddressLine>17 Daws Rd.</streetAddressLine>
        <city>Ann Arbor</city>
        <state>MI</state>
        <postalCode>97857</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>
  <!--  This participant identifies individuals who support the patient such as a relative or caregiver  -->
  <participant typeCode="IND">
    <!--  Caregiver  -->
    <associatedEntity classCode="CAREGIVER">
      <addr use="HP">
        <streetAddressLine>17 Daws Rd.</streetAddressLine>
        <city>Ann Arbor</city>
        <state>MI</state>
        <postalCode>97857</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>
  <documentationOf>
    <serviceEvent classCode="PCPR">
      <effectiveTime>
        <low value="20130720103000-0800"/>
        <high value="20130815130000-0800"/>
      </effectiveTime>
      <!--  The performer(s) represents the healthcare providers involved in the current or historical care of the patient.
                The patient’s key healthcare providers would be listed here which would include the primary physician and any 
                active consulting physicians, therapists, counselors, and care team members.   -->
      <performer typeCode="PRF">
        <time value="20130715223615-0800"/>
        <assignedEntity>
          <id root="2.16.840.1.113883.4.6" extension="5555555555"/>
          <code displayName="Adult Medicine Physician"
                codeSystemName="Healthcare Provider Taxonomy (HIPAA)" codeSystem="2.16.840.1.113883.6.101" code="207QA0505X"/>
          <addr use="WP">
            <streetAddressLine>1004 Healthcare Drive</streetAddressLine>
            <city>Portland</city>
            <state>OR</state>
            <postalCode>99123</postalCode>
            <country>US</country>
          </addr>
          <telecom value="tel:+1(555)-1004" use="WP"/>
          <assignedPerson>
            <name>
              <given>Patricia</given>
              <given qualifier="CL">Patty</given>
              <family>Primary</family>
              <suffix qualifier="AC">M.D.</suffix>
            </name>
          </assignedPerson>
        </assignedEntity>
      </performer>
    </serviceEvent>
  </documentationOf>
  <!--  The Care Plan is continually evolving and dynamic. The Care Plan CDA instance 
     is NOT dynamic. Each time a Care Plan CDA is generated it represents a snapshot 
     in time of the Care Plan at that moment. Whenever a care provider or patient 
     generates a Care Plan, it should be noted through relatedDocument 
     whether the current Care Plan replaces or appends another Care Plan. 
     The relatedDocumentTypeCode indicates whether the current document is 
     an addendum to the ParentDocument (APND (append)) or the current document 
     is a replacement of the ParentDocument (RPLC (replace)).  -->
  <!--  This document is the second in a set - relatedDocument
      describes the parent document -->
  <relatedDocument typeCode="RPLC">
    <parentDocument>
      <id root="223769be-f6ee-4b04-a0ce-b56ae998c880"/>
      <code displayName="Care Plan" codeSystemName="LOINC"
            codeSystem="2.16.840.1.113883.6.1" code="CarePlan-x"/>
      <setId root="004bb033-b948-4f4c-b5bf-a8dbd7d8dd40"/>
      <versionNumber value="1"/>
    </parentDocument>
  </relatedDocument>
  <componentOf>
    <encompassingEncounter>
      <id root="2.16.840.1.113883.19" extension="9937012"/>
      <code displayName="Inpatient encounter"
            codeSystem="2.16.840.1.113883.5.4" code="IMP"/>
      <!--  captures that this is an inpatient encounter  -->
      <!--  No high value - this patient is still in hospital  -->
      <effectiveTime>
        <low value="20130615093000-0800"/>
      </effectiveTime>
    </encompassingEncounter>
  </componentOf>
  <!--  
********************************************************
CDA Body
********************************************************
 -->
  <component>
    <structuredBody>
      <component>
        <section nullFlavor="NI">
          <templateId root="2.16.840.1.113883.10.20.22.2.58"
                      extension="2015-08-01"/>
          <code displayName="Health Concerns Document"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="75310-3"/>
          <title>Health Concerns Section</title>
          <text>...</text>
        </section>
      </component>
      <component>
        <section nullFlavor="NI">
          <templateId root="2.16.840.1.113883.10.20.22.2.60"/>
          <code displayName="Goals" codeSystemName="LOINC"
                codeSystem="2.16.840.1.113883.6.1" code="61146-7"/>
          <title>Goals Section</title>
          <text>...</text>
        </section>
      </component>
      <component>
        <section nullFlavor="NI">
          <templateId root="2.16.840.1.113883.10.20.22.2.61"/>
          <code displayName="Patient Problem Outcome" codeSystemName="LOINC"
                codeSystem="2.16.840.1.113883.6.1" code="11383-7"/>
          <title>Health Status Evaluations/Outcomes Section</title>
          <text>...</text>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>