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: Operative Note
Based on: C-CDA_R2_Operative_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 Operative 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"/>
<!-- Operative Note Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.7" 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="Surgical operation note" codeSystem="2.16.840.1.113883.6.1" code="11504-8"/>
<code displayName="Surgical Operation Note" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="11504-8"/>
<title>Community Health and Hospitals: Operative Note</title>
<effectiveTime value="20120916191000-0400"/>
<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="2.16.840.1.113883.4.6" extension="444444444"/>
<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>
<documentationOf typeCode="DOC">
<serviceEvent classCode="PCPR">
<code displayName="Colonoscopy" codeSystemName="SNOMED CT"
codeSystem="2.16.840.1.113883.6.96" code="73761001"/>
<effectiveTime>
<low value="20120909191000-0400"/>
<high value="20120916191000-0400"/>
</effectiveTime>
<performer typeCode="PPRF">
<functionCode displayName="Primary Care Physician"
codeSystemName="ParticipationFunction" codeSystem="2.16.840.1.113883.5.88" code="PCP">
<originalText>Primary Care Provider</originalText>
</functionCode>
<time>
<low value="20120909191000-0400"/>
<high value="20120916191000-0400"/>
</time>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="PseudoMD-3"/>
<code displayName="Gastroenterology Physician"
codeSystemName="Provider Codes" codeSystem="2.16.840.1.113883.6.101" code="207RG0100X"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-555-555-5000" use="HP"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom value="tel:+1-555-555-5000" use="HP"/>
<addr use="WP">
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<authorization typeCode="AUTH">
<consent moodCode="EVN" classCode="CONS">
<id root="629deb70-5306-11df-9879-0800200c9a66"/>
<code displayName="Procedure consent" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="64293-4"/>
<statusCode code="completed"/>
</consent>
</authorization>
<component>
<!-- All sections are set to nullFlavor / text = No information,
as this is a header example, not a complete body example -->
<structuredBody>
<!-- Anesthesia -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.25"
extension="2014-06-09"/>
<code displayName="Anesthesia" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="59774-0"/>
<title>Procedure Anesthesia</title>
<text>No information</text>
</section>
</component>
<!-- Complications -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.37"
extension="2015-08-01"/>
<code displayName="Complications" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="55109-3"/>
<title>Complications</title>
<text>No information</text>
</section>
</component>
<!-- Preop Dx -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.34"
extension="2015-08-01"/>
<code displayName="PREOPERATIVE DIAGNOSIS" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="10219-4"/>
<title>Preoperative Diagnosis</title>
<text>No information</text>
</section>
</component>
<!-- ProcEstBloodLoss -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.18.2.9"/>
<code displayName="PROCEDURE ESTIMATED BLOOD LOSS"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="59770-8"/>
<title>Procedure Estimated Blood Loss</title>
<text>No information</text>
</section>
</component>
<!-- ProcFindings -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.28"
extension="2015-08-01"/>
<code displayName="PROCEDURE FINDINGS" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="59776-5"/>
<title>Procedure Findings</title>
<text>No information</text>
</section>
</component>
<!-- ProcSpecimensTaken -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.31"/>
<code displayName="PROCEDURE SPECIMENS TAKEN"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="59773-2"/>
<title>Procedure Specimens Taken</title>
<text>No information</text>
</section>
</component>
<!-- Proc Description -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.27"/>
<code displayName="PROCEDURE DESCRIPTION" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="29554-3"/>
<title>Procedure Description</title>
<text>No information</text>
</section>
</component>
<!-- Postop Dx -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.35"/>
<code displayName="POSTOPERATIVE DIAGNOSIS" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="10218-6"/>
<title>Postoperative Diagnosis</title>
<text>No information</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>