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" : [
{
"extension" : "2024-05-01",
"root" : "2.16.840.1.113883.10.20.22.1.1"
},
{
"extension" : "2024-05-01",
"root" : "2.16.840.1.113883.10.20.29.1"
}
],
"id" : {
"root" : "2c1e0e12-b0ae-4456-a526-c11d5e69e77c"
},
"code" : {
"code" : "68831-7",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "Discharge summary note"
},
"title" : {
"xmlText" : "Patient Discharge Summary"
},
"effectiveTime" : {
"value" : "2013-08-15T10:30:00-08:00"
},
"confidentialityCode" : {
"code" : "N",
"codeSystem" : "2.16.840.1.113883.5.25",
"codeSystemName" : "Confidentiality",
"displayName" : "normal"
},
"languageCode" : {
"code" : "en-US"
},
"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" : "Adam"
}
]
},
{
"family" : [
{
"xmlText" : "Everyman"
}
]
}
]
}
],
"administrativeGenderCode" : {
"code" : "M",
"codeSystem" : "2.16.840.1.113883.5.1",
"codeSystemName" : "AdministrativeGender",
"displayName" : "Male"
},
"birthTime" : {
"value" : "1975-05-01"
},
"religiousAffiliationCode" : {
"code" : "1013",
"codeSystem" : "2.16.840.1.113883.5.1076",
"codeSystemName" : "HL7 Religious Affiliation",
"displayName" : "Christian (non-Catholic, non-specific)"
},
"raceCode" : {
"code" : "2106-3",
"codeSystem" : "2.16.840.1.113883.6.238",
"codeSystemName" : "Race & Ethnicity - CDC",
"displayName" : "White"
},
"ethnicGroupCode" : {
"code" : "2186-5",
"codeSystem" : "2.16.840.1.113883.6.238",
"codeSystemName" : "Race & Ethnicity - CDC",
"displayName" : "Not Hispanic or Latino"
},
"birthplace" : {
"place" : {
"addr" : {
"use" : [
"H"
],
"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" : [
{
"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" : {
"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" : [
// The document is intended for multiple recipients, Adam himself and his PCP physician.
{
"intendedRecipient" : {
"id" : [
// Identifier based on the person's Direct Address which is a secure and trusted mechanism for identifying
a person discretely. The root of the id is the OID of the HISP Assigning Authority for the Direct Address
{
"extension" : "adameveryman@direct.sampleHISP.com",
"root" : "2.16.123.123.12345.1234"
}
],
"informationRecipient" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Adam"
}
]
},
{
"family" : [
{
"xmlText" : "Everyman"
}
]
}
]
}
]
},
"receivedOrganization" : {
"id" : [
// id using HL7 example OID.
{
"extension" : "999.3",
"root" : "2.16.840.1.113883.19"
}
],
"name" : [
{
"item" : [
{
"xmlText" : "MyPersonalHealthRecord.Com"
}
]
}
]
}
}
},
{
"intendedRecipient" : {
"id" : [
// Unique/Trusted id using HL7 example OID.
{
"extension" : "999.4",
"root" : "2.16.840.1.113883.19"
},
{
"extension" : "1122334455",
"root" : "2.16.840.1.113883.4.6"
},
{
"extension" : "DrP@direct.sampleHISP2.com",
"root" : "2.16.123.123.12345.4321"
}
],
"telecom" : [
// The physician's NPI number
// The physician's Direct Address
// Identifier based on the person's Direct Address which is a secure and trusted mechanism for identifying
a person discretely. The root of the id is the OID of the HISP Assigning Authority for the Direct Address
{
"use" : [
"WP"
],
"value" : "tel:(781)555-1212"
},
{
"use" : [
"WP"
],
"value" : "mailto:DrP@direct.sampleHISP2.com"
}
],
"informationRecipient" : {
"name" : [
{
"item" : [
{
"prefix" : [
{
"xmlText" : "Dr."
}
]
},
{
"given" : [
{
"xmlText" : "Patricia"
}
]
},
{
"family" : [
{
"xmlText" : "Primary"
}
]
}
]
}
]
},
"receivedOrganization" : {
"id" : [
// Unique/Trusted id using HL7 example OID.
{
"extension" : "999.2",
"root" : "2.16.840.1.113883.19"
},
{
"extension" : "1234567890",
"root" : "2.16.840.1.113883.4.6"
}
],
"name" : [
// NPI for the organization
{
"item" : [
{
"xmlText" : "Good Health Internal Medicine"
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:(781)555-1212"
}
],
"addr" : [
{
"item" : [
{
"streetAddressLine" : {
"xmlText" : "100 Health Drive"
}
},
{
"city" : {
"xmlText" : "Boston"
}
},
{
"state" : {
"xmlText" : "MA"
}
},
{
"postalCode" : {
"xmlText" : "02368"
}
},
{
"country" : {
"xmlText" : "USA"
}
}
]
}
]
}
}
}
],
"legalAuthenticator" : {
"time" : {
"value" : "2013-08-01T22:36:15-08:00"
},
"signatureCode" : {
"code" : "S"
},
"assignedEntity" : {
"id" : [
{
"extension" : "555555555",
"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" : [
{
"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"
]
}
]
}
]
}
]
}
}
},
"component" : {
"structuredBody" : {
"component" : [
{
}
]
}
}
}