Consolidated CDA (C-CDA)
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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

: Referral Note Complete Header Example - JSON Representation

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// 
 Title:        Referral Note
 Based on:     C-CDA_R2_Referral_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 Referral 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" : [
    //  Identifies document as conformant to US Realm Header (V2) Template 
    {
      "extension" : "2024-05-01",
      "root" : "2.16.840.1.113883.10.20.22.1.1"
    },
    {
      "extension" : "2024-05-01",
      "root" : "2.16.840.1.113883.10.20.22.1.14"
    }
  ],
  "id" : //  Referral Note Document 
		Conforms to the document specific requirements  
  //  DocumentID: unique ID for the document 
  {
    "root" : "6f1bd58b-c58f-40b7-b314-caf1294ed98b"
  },
  "sdtcCategory" : [
    {
      "code" : "57133-1",
      "codeSystem" : "2.16.840.1.113883.6.1",
      "displayName" : "Referral note"
    }
  ],
  "code" : //  Referral Note 
  {
    "code" : "57133-1",
    "codeSystem" : "2.16.840.1.113883.6.1",
    "codeSystemName" : "LOINC",
    "displayName" : "Referral Note"
  },
  "title" : //  Use the name of the code as the title 
  {
    "xmlText" : "Referral Note"
  },
  "effectiveTime" : {
    "value" : "2013-09-21T05:00:00-08:00"
  },
  "confidentialityCode" : {
    "code" : "N",
    "codeSystem" : "2.16.840.1.113883.5.25"
  },
  "languageCode" : {
    "code" : "en"
  },
  "setId" : {
    "extension" : "sTT988",
    "root" : "2.16.840.1.113883.19.5.99999.19"
  },
  "versionNumber" : {
    "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" : [
            //  The first name element represents what the patient is known as 
            {
              "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"
                      ]
                    }
                  ]
                }
              ]
            },
            {
              "use" : [
                "SRCH"
              ],
              "item" : [
                {
                  "given" : [
                    {
                      "xmlText" : "Eve"
                    }
                  ]
                },
                {
                  "family" : [
                    //  The "BR" is "Birth" from HL7 Code System EntityNamePartQualifier 2.16.840.1.113883.5.43 
                    {
                      "xmlText" : "Everywoman",
                      "qualifier" : [
                        "BR"
                      ]
                    }
                  ]
                }
              ]
            }
          ],
          "administrativeGenderCode" : //  The second name element represents another name associated with the patient 
          {
            "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" : {
            "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" : {
                "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
              }
            }
          ]
        },
        "providerOrganization" : {
          "id" : [
            {
              "extension" : "219BX",
              "root" : "2.16.840.1.113883.4.6"
            }
          ],
          "name" : [
            {
              "item" : [
                {
                  "xmlText" : "The DoctorsTogether Physician Group"
                }
              ]
            }
          ],
          "telecom" : [
            {
              "use" : [
                "WP"
              ],
              "value" : "tel:+1(555)555-5000"
            }
          ],
          "addr" : [
            {
              "use" : [
                "WP"
              ],
              "item" : [
                {
                  "streetAddressLine" : {
                    "xmlText" : "1007 Health Drive"
                  }
                },
                {
                  "city" : {
                    "xmlText" : "Portland"
                  }
                },
                {
                  "state" : {
                    "xmlText" : "OR"
                  }
                },
                {
                  "postalCode" : {
                    "xmlText" : "99123"
                  }
                },
                {
                  "country" : {
                    "xmlText" : "US"
                  }
                }
              ]
            }
          ]
        }
      }
    }
  ],
  "author" : [
    {
      "time" : {
        "value" : "2013-03-11T10:30:00-08:00"
      },
      "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"
        },
        "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)-1004"
          }
        ],
        "assignedPerson" : {
          "name" : [
            {
              "item" : [
                {
                  "given" : [
                    {
                      "xmlText" : "Patricia"
                    }
                  ]
                },
                {
                  "given" : [
                    {
                      "xmlText" : "Patty",
                      "qualifier" : [
                        "CL"
                      ]
                    }
                  ]
                },
                {
                  "family" : [
                    {
                      "xmlText" : "Primary"
                    }
                  ]
                },
                {
                  "suffix" : [
                    {
                      "xmlText" : "M.D.",
                      "qualifier" : [
                        "AC"
                      ]
                    }
                  ]
                }
              ]
            }
          ]
        }
      }
    }
  ],
  "dataEnterer" : {
    "assignedEntity" : {
      "id" : [
        {
          "extension" : "333777777",
          "root" : "2.16.840.1.113883.4.6"
        }
      ],
      "addr" : [
        {
          "use" : [
            "WP"
          ],
          "item" : [
            {
              "streetAddressLine" : {
                "xmlText" : "1007 Healthcare Drive"
              }
            },
            {
              "city" : {
                "xmlText" : "Portland"
              }
            },
            {
              "state" : {
                "xmlText" : "OR"
              }
            },
            {
              "postalCode" : {
                "xmlText" : "99123"
              }
            },
            {
              "country" : {
                "xmlText" : "US"
              }
            }
          ]
        }
      ],
      "telecom" : [
        {
          "use" : [
            "WP"
          ],
          "value" : "tel:+1(555)-1050"
        }
      ],
      "assignedPerson" : {
        "name" : [
          {
            "item" : [
              {
                "given" : [
                  {
                    "xmlText" : "Ellen"
                  }
                ]
              },
              {
                "family" : [
                  {
                    "xmlText" : "Enter"
                  }
                ]
              }
            ]
          }
        ]
      }
    }
  },
  "informant" : [
    {
      "assignedEntity" : {
        "id" : [
          {
            "extension" : "888888888",
            "root" : "2.16.840.1.113883.19.5"
          }
        ],
        "addr" : [
          {
            "use" : [
              "WP"
            ],
            "item" : [
              {
                "streetAddressLine" : {
                  "xmlText" : "1007 Healthcare Drive"
                }
              },
              {
                "city" : {
                  "xmlText" : "Portland"
                }
              },
              {
                "state" : {
                  "xmlText" : "OR"
                }
              },
              {
                "postalCode" : {
                  "xmlText" : "99123"
                }
              },
              {
                "country" : {
                  "xmlText" : "US"
                }
              }
            ]
          }
        ],
        "telecom" : [
          {
            "use" : [
              "WP"
            ],
            "value" : "tel:+1(555)-1003"
          }
        ],
        "assignedPerson" : {
          "name" : [
            {
              "item" : [
                {
                  "given" : [
                    {
                      "xmlText" : "Harold"
                    }
                  ]
                },
                {
                  "family" : [
                    {
                      "xmlText" : "Hippocrates"
                    }
                  ]
                },
                {
                  "suffix" : [
                    {
                      "xmlText" : "D.O.",
                      "qualifier" : [
                        "AC"
                      ]
                    }
                  ]
                }
              ]
            }
          ]
        }
      }
    }
  ],
  "custodian" : {
    "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)-1009"
        },
        "addr" : {
          "use" : [
            "WP"
          ],
          "item" : [
            {
              "streetAddressLine" : {
                "xmlText" : "1009 Healthcare Drive"
              }
            },
            {
              "city" : {
                "xmlText" : "Portland"
              }
            },
            {
              "state" : {
                "xmlText" : "OR"
              }
            },
            {
              "postalCode" : {
                "xmlText" : "99123"
              }
            },
            {
              "country" : {
                "xmlText" : "US"
              }
            }
          ]
        }
      }
    }
  },
  "informationRecipient" : [
    {
      "intendedRecipient" : {
        "informationRecipient" : {
          "name" : [
            {
              "item" : [
                {
                  "given" : [
                    {
                      "xmlText" : "Nancy"
                    }
                  ]
                },
                {
                  "family" : [
                    {
                      "xmlText" : "Nightingale"
                    }
                  ]
                },
                {
                  "suffix" : [
                    {
                      "xmlText" : "RN",
                      "qualifier" : [
                        "AC"
                      ]
                    }
                  ]
                }
              ]
            }
          ]
        },
        "receivedOrganization" : {
          "name" : [
            {
              "item" : [
                {
                  "xmlText" : "Community Health and Hospitals"
                }
              ]
            }
          ],
          "telecom" : [
            {
              "use" : [
                "WP"
              ],
              "value" : "tel:+1(555)-555-1002"
            }
          ],
          "addr" : [
            {
              "use" : [
                "WP"
              ],
              "item" : [
                {
                  "streetAddressLine" : {
                    "xmlText" : "Cardiac Stepdown Unit, 4B"
                  }
                },
                {
                  "streetAddressLine" : {
                    "xmlText" : "1002 Healthcare Drive"
                  }
                },
                {
                  "city" : {
                    "xmlText" : "Ann Arbor"
                  }
                },
                {
                  "state" : {
                    "xmlText" : "MI"
                  }
                },
                {
                  "postalCode" : {
                    "xmlText" : "97857"
                  }
                },
                {
                  "country" : {
                    "xmlText" : "US"
                  }
                }
              ]
            }
          ]
        }
      }
    }
  ],
  "legalAuthenticator" : {
    "time" : {
      "value" : "2013-09-15T22:36:15-08:00"
    },
    "signatureCode" : {
      "code" : "S"
    },
    "assignedEntity" : {
      "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)-1004"
        }
      ],
      "assignedPerson" : {
        "name" : [
          {
            "item" : [
              {
                "given" : [
                  {
                    "xmlText" : "Patricia"
                  }
                ]
              },
              {
                "given" : [
                  {
                    "xmlText" : "Patty",
                    "qualifier" : [
                      "CL"
                    ]
                  }
                ]
              },
              {
                "family" : [
                  {
                    "xmlText" : "Primary"
                  }
                ]
              },
              {
                "suffix" : [
                  {
                    "xmlText" : "M.D.",
                    "qualifier" : [
                      "AC"
                    ]
                  }
                ]
              }
            ]
          }
        ]
      }
    }
  },
  "authenticator" : [
    {
      "time" : {
        "value" : "2012-09-15T10:30:00-08:00"
      },
      "signatureCode" : {
        "code" : "S"
      },
      "assignedEntity" : {
        "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"
        },
        "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)-1004"
          }
        ],
        "assignedPerson" : {
          "name" : [
            {
              "item" : [
                {
                  "given" : [
                    {
                      "xmlText" : "Patricia"
                    }
                  ]
                },
                {
                  "given" : [
                    {
                      "xmlText" : "Patty",
                      "qualifier" : [
                        "CL"
                      ]
                    }
                  ]
                },
                {
                  "family" : [
                    {
                      "xmlText" : "Primary"
                    }
                  ]
                },
                {
                  "suffix" : [
                    {
                      "xmlText" : "M.D.",
                      "qualifier" : [
                        "AC"
                      ]
                    }
                  ]
                }
              ]
            }
          ]
        }
      }
    }
  ],
  "participant" : [
    {
      "typeCode" : "CALLBCK",
      "time" : {
        "value" : "2005-03-29T22:44:11+05:00"
      },
      "associatedEntity" : {
        "classCode" : "ASSIGNED",
        "id" : [
          {
            "extension" : "99999999",
            "root" : "2.16.840.1.113883.4.6"
          }
        ],
        "code" : {
          "code" : "200000000X",
          "codeSystem" : "2.16.840.1.113883.6.101",
          "displayName" : "Allopathic & Osteopathic Physicians"
        },
        "addr" : [
          {
            "use" : [
              "WP"
            ],
            "item" : [
              {
                "streetAddressLine" : {
                  "xmlText" : "1002 Healthcare Drive"
                }
              },
              {
                "city" : {
                  "xmlText" : "Ann Arbor"
                }
              },
              {
                "state" : {
                  "xmlText" : "MI"
                }
              },
              {
                "postalCode" : {
                  "xmlText" : "97857"
                }
              },
              {
                "country" : {
                  "xmlText" : "US"
                }
              }
            ]
          }
        ],
        "telecom" : [
          {
            "use" : [
              "WP"
            ],
            "value" : "tel:555-555-1002"
          }
        ],
        "associatedPerson" : {
          "name" : [
            {
              "item" : [
                {
                  "given" : [
                    {
                      "xmlText" : "Henry"
                    }
                  ]
                },
                {
                  "family" : [
                    {
                      "xmlText" : "Seven"
                    }
                  ]
                },
                {
                  "suffix" : [
                    {
                      "xmlText" : "DO"
                    }
                  ]
                }
              ]
            }
          ]
        }
      }
    },
    {
      "typeCode" : "IND",
      "functionCode" : {
        "code" : "407543004",
        "codeSystem" : "2.16.840.1.113883.6.96",
        "codeSystemName" : "SNOMED-CT",
        "displayName" : "Primary Carer"
      },
      "associatedEntity" : //  Caregiver 
      {
        "classCode" : "CAREGIVER",
        "code" : {
          "code" : "MTH",
          "codeSystem" : "2.16.840.1.113883.5.111"
        },
        "addr" : [
          {
            "use" : [
              "WP"
            ],
            "item" : [
              {
                "streetAddressLine" : {
                  "xmlText" : "17 Daws Rd."
                }
              },
              {
                "city" : {
                  "xmlText" : "Ann Arbor"
                }
              },
              {
                "state" : {
                  "xmlText" : "MI"
                }
              },
              {
                "postalCode" : {
                  "xmlText" : "97857"
                }
              },
              {
                "country" : {
                  "xmlText" : "US"
                }
              }
            ]
          }
        ],
        "telecom" : [
          {
            "use" : [
              "WP"
            ],
            "value" : "tel:1+(555)555-1212"
          }
        ],
        "associatedPerson" : {
          "name" : [
            {
              "item" : [
                {
                  "prefix" : [
                    {
                      "xmlText" : "Mrs."
                    }
                  ]
                },
                {
                  "given" : [
                    {
                      "xmlText" : "Martha"
                    }
                  ]
                },
                {
                  "family" : [
                    {
                      "xmlText" : "Jones"
                    }
                  ]
                }
              ]
            }
          ]
        }
      }
    }
  ],
  "component" : //  Patient Support Identification 
  {
    "structuredBody" : //  All sections are set to nullFlavor / text = No information, 
        as this is a header example, not a complete body example 
    {
      "component" : [
        //  Reason for Referral 
        {
          "section" : {
            "nullFlavor" : "NI",
            "templateId" : [
              {
                "extension" : "2014-06-09",
                "root" : "1.3.6.1.4.1.19376.1.5.3.1.3.1"
              }
            ],
            "code" : {
              "code" : "42349-1",
              "codeSystem" : "2.16.840.1.113883.6.1",
              "codeSystemName" : "LOINC",
              "displayName" : "Reason for Referral"
            },
            "title" : {
              "xmlText" : "REASON FOR REFERRAL"
            },
            "text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
          }
        },
        {
          "section" : {
            "nullFlavor" : "NI",
            "templateId" : [
              {
                "extension" : "2015-08-01",
                "root" : "2.16.840.1.113883.10.20.22.2.6.1"
              }
            ],
            "code" : {
              "code" : "48765-2",
              "codeSystem" : "2.16.840.1.113883.6.1",
              "codeSystemName" : "LOINC"
            },
            "title" : {
              "xmlText" : "ALLERGIES AND ADVERSE REACTIONS"
            },
            "text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
          }
        },
        {
          "section" : {
            "nullFlavor" : "NI",
            "templateId" : [
              {
                "extension" : "2015-08-01",
                "root" : "2.16.840.1.113883.10.20.22.2.5.1"
              }
            ],
            "code" : {
              "code" : "11450-4",
              "codeSystem" : "2.16.840.1.113883.6.1",
              "codeSystemName" : "LOINC",
              "displayName" : "PROBLEM LIST"
            },
            "title" : {
              "xmlText" : "PROBLEMS"
            },
            "text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
          }
        },
        {
          "section" : {
            "nullFlavor" : "NI",
            "templateId" : [
              {
                "extension" : "2014-06-09",
                "root" : "2.16.840.1.113883.10.20.22.2.1.1"
              }
            ],
            "code" : {
              "code" : "10160-0",
              "codeSystem" : "2.16.840.1.113883.6.1",
              "codeSystemName" : "LOINC",
              "displayName" : "HISTORY OF MEDICATION USE"
            },
            "title" : {
              "xmlText" : "MEDICATIONS"
            },
            "text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
          }
        },
        {
          "section" : {
            "nullFlavor" : "NI",
            "templateId" : [
              {
                "extension" : "2014-06-09",
                "root" : "2.16.840.1.113883.10.20.22.2.10"
              }
            ],
            "code" : {
              "code" : "18776-5",
              "codeSystem" : "2.16.840.1.113883.6.1",
              "codeSystemName" : "LOINC",
              "displayName" : "Treatment plan"
            },
            "title" : {
              "xmlText" : "TREATMENT PLAN"
            },
            "text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
          }
        },
        {
          "section" : {
            "nullFlavor" : "NI",
            "templateId" : [
              {
                "root" : "2.16.840.1.113883.10.20.22.2.8"
              }
            ],
            "code" : {
              "code" : "51848-0",
              "codeSystem" : "2.16.840.1.113883.6.1",
              "codeSystemName" : "LOINC",
              "displayName" : "ASSESSMENTS"
            },
            "title" : {
              "xmlText" : "ASSESSMENTS"
            },
            "text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
          }
        },
        {
          "section" : {
            "nullFlavor" : "NI",
            "templateId" : [
              {
                "extension" : "2015-08-01",
                "root" : "2.16.840.1.113883.10.20.22.2.3.1"
              }
            ],
            "code" : {
              "code" : "30954-2",
              "codeSystem" : "2.16.840.1.113883.6.1",
              "codeSystemName" : "LOINC",
              "displayName" : "RESULTS"
            },
            "title" : {
              "xmlText" : "RESULTS"
            },
            "text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
          }
        },
        {
          "section" : {
            "nullFlavor" : "NI",
            "templateId" : [
              {
                "extension" : "2014-06-09",
                "root" : "2.16.840.1.113883.10.20.22.2.14"
              }
            ],
            "code" : {
              "code" : "47420-5",
              "codeSystem" : "2.16.840.1.113883.6.1",
              "codeSystemName" : "LOINC",
              "displayName" : "Functional Status"
            },
            "title" : {
              "xmlText" : "FUNCTIONAL STATUS"
            },
            "text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
          }
        },
        {
          "section" : {
            "nullFlavor" : "NI",
            "templateId" : [
              {
                "extension" : "2015-08-01",
                "root" : "2.16.840.1.113883.10.20.22.2.56"
              }
            ],
            "code" : {
              "code" : "10190-7",
              "codeSystem" : "2.16.840.1.113883.6.1",
              "codeSystemName" : "LOINC",
              "displayName" : "Mental status Narrative"
            },
            "title" : {
              "xmlText" : "MENTAL STATUS"
            },
            "text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
          }
        },
        {
          "section" : {
            "nullFlavor" : "NI",
            "templateId" : [
              {
                "root" : "2.16.840.1.113883.10.20.22.2.57"
              }
            ],
            "code" : {
              "code" : "61144-2",
              "codeSystem" : "2.16.840.1.113883.6.1",
              "codeSystemName" : "LOINC",
              "displayName" : "Diet and Nutrition"
            },
            "title" : {
              "xmlText" : "NUTRITION SECTION"
            },
            "text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
          }
        }
      ]
    }
  }
}