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
@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
#
Title: Progress Note
Based on: C-CDA_R2_Progress_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 Progress 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.
********************************************************
a fhir:ClinicalDocument ;
fhir:nodeRole fhir:treeRoot ;
fhir:realmCode ( [
fhir:code [ fhir:v "US" ]
] ) ; # ** CDA Header **
fhir:typeId [
fhir:extension [ fhir:v "POCD_HD000040" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.1.3" ]
] ; #
fhir:templateId ( [
fhir:extension [ fhir:v "2024-05-01" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.10.20.22.1.1" ]
] [
fhir:extension [ fhir:v "2024-05-01" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.10.20.22.1.9" ]
] ) ; # US General Header Template
fhir:id [
fhir:extension [ fhir:v "999022" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.19" ]
] ; #
fhir:sdtcCategory ( [
fhir:code [ fhir:v "11506-3" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.6.1" ] ;
fhir:displayName [ fhir:v "Progress note" ]
] ) ; #
fhir:code [
fhir:code [ fhir:v "11506-3" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.6.1" ] ;
fhir:codeSystemName [ fhir:v "LOINC" ] ;
fhir:displayName [ fhir:v "Progress note" ]
] ; #
fhir:title [
fhir:xmlText [ fhir:v "Progress Note" ]
] ; #
fhir:effectiveTime [
fhir:value [ fhir:v "2005-03-29T17:15:04-05:00"^^xsd:dateTime ]
] ; #
fhir:confidentialityCode [
fhir:code [ fhir:v "N" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.5.25" ]
] ; #
fhir:languageCode [
fhir:code [ fhir:v "en-US" ]
] ; #
fhir:setId [
fhir:extension [ fhir:v "111199021" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.19" ]
] ; #
fhir:versionNumber [
fhir:value [ fhir:v "1"^^xsd:integer ]
] ; #
fhir:recordTarget ( [
fhir:patientRole [
( fhir:id [
fhir:extension [ fhir:v "12345" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.19" ] ] [
fhir:extension [ fhir:v "111-00-1234" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.4.1" ] ] ) ; # Fake ID using HL7 example OID.
( fhir:addr [
( fhir:use [ fhir:v "HP" ] ) ;
( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "17 Daws Rd." ] ] ] [
fhir:city [
fhir:xmlText [ fhir:v "Blue Bell" ] ] ] [
fhir:state [
fhir:xmlText [ fhir:v "MA" ] ] ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "02368" ] ] ] [
fhir:country [
fhir:xmlText [ fhir:v "US" ] ] # US is \"United States\" from ISO 3166-1 Country Codes: 1.0.3166.1 ] ) ] ) ; # HP is \"primary home\" from codeSystem 2.16.840.1.113883.5.1119
( fhir:telecom [
( fhir:use [ fhir:v "HP" ] ) ;
fhir:value [ fhir:v "tel:(781)555-1212"^^xsd:anyURI ] ] ) ;
fhir:patient [
( fhir:name [
( fhir:use [ fhir:v "L" ] ) ;
( fhir:item [
( fhir:prefix [
fhir:xmlText [ fhir:v "Mr." ] ] ) # L is \"Legal\" from HL7 EntityNameUse 2.16.840.1.113883.5.45 ] [
( fhir:given [
fhir:xmlText [ fhir:v "Adam" ] ] ) ] [
( fhir:given [
fhir:xmlText [ fhir:v "Frankie" ] ;
( fhir:qualifier [ fhir:v "CL" ] ) ] ) ] [
( fhir:family [
fhir:xmlText [ fhir:v "Everyman" ] ] ) # CL is \"Call me\" from HL7 EntityNamePartQualifier 2.16.840.1.113883.5.43 ] ) ] ) ;
fhir:administrativeGenderCode [
fhir:code [ fhir:v "M" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.5.1" ] ;
fhir:displayName [ fhir:v "Male" ] ] ;
fhir:birthTime [
fhir:value [ fhir:v "1954-11-25"^^xsd:date ] ] ;
fhir:maritalStatusCode [
fhir:code [ fhir:v "M" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.5.2" ] ;
fhir:codeSystemName [ fhir:v "MaritalStatusCode" ] ;
fhir:displayName [ fhir:v "Married" ] ] ;
fhir:religiousAffiliationCode [
fhir:code [ fhir:v "1013" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.5.1076" ] ;
fhir:codeSystemName [ fhir:v "HL7 Religious Affiliation" ] ;
fhir:displayName [ fhir:v "Christian (non-Catholic, non-specific)" ] ] ;
fhir:raceCode [
fhir:code [ fhir:v "2106-3" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.6.238" ] ;
fhir:codeSystemName [ fhir:v "Race & Ethnicity - CDC" ] ;
fhir:displayName [ fhir:v "White" ] ] ;
fhir:ethnicGroupCode [
fhir:code [ fhir:v "2186-5" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.6.238" ] ;
fhir:codeSystemName [ fhir:v "Race & Ethnicity - CDC" ] ;
fhir:displayName [ fhir:v "Not Hispanic or Latino" ] ] ;
( fhir:guardian [
fhir:code [
fhir:code [ fhir:v "GRFTH" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.5.111" ] ;
fhir:codeSystemName [ fhir:v "HL7 Role code" ] ;
fhir:displayName [ fhir:v "Grandfather" ] ] ;
( fhir:addr [
( fhir:use [ fhir:v "HP" ] ) ;
( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "17 Daws Rd." ] ] # HP is \"primary home\" from codeSystem 2.16.840.1.113883.5.1119 ] [
fhir:city [
fhir:xmlText [ fhir:v "Blue Bell" ] ] ] [
fhir:state [
fhir:xmlText [ fhir:v "MA" ] ] ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "02368" ] ] ] [
fhir:country [
fhir:xmlText [ fhir:v "US" ] ] ] ) ] ) ; # US is \"United States\" from ISO 3166-1 Country Codes: 1.0.3166.1
( fhir:telecom [
( fhir:use [ fhir:v "HP" ] ) ;
fhir:value [ fhir:v "tel:(781)555-1212"^^xsd:anyURI ] ] ) ;
fhir:guardianPerson [
( fhir:name [
( fhir:item [
( fhir:given [
fhir:xmlText [ fhir:v "Ralph" ] ] ) ] [
( fhir:family [
fhir:xmlText [ fhir:v "Relative" ] ] ) ] ) ] ) ] ] ) ;
fhir:birthplace [
fhir:place [
fhir:addr [
( fhir:item [
fhir:state [
fhir:xmlText [ fhir:v "MA" ] ] ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "02368" ] ] ] [
fhir:country [
fhir:xmlText [ fhir:v "USA" ] ] ] ) ] ] ] ;
( fhir:languageCommunication [
fhir:languageCode [
fhir:code [ fhir:v "fr-CN" ] ] ;
fhir:modeCode [
fhir:code [ fhir:v "RWR" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.5.60" ] ;
fhir:codeSystemName [ fhir:v "LanguageAbilityMode" ] ;
fhir:displayName [ fhir:v "Received Written" ] ] ;
fhir:preferenceInd [
fhir:value [ fhir:v "true"^^xsd:boolean ] ] ] ) ] ; # HP is \"primary home\" from HL7 AddressUse 2.16.840.1.113883.5.1119
fhir:providerOrganization [
( fhir:id [
fhir:extension [ fhir:v "111122223333" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.4.6" ] ] ) ; # Organizations SHOULD have an NPI; this is a real root; fake extension
( fhir:name [
( fhir:item [
fhir:xmlText [ fhir:v "Good Health Clinic" ] ] ) ] ) ;
( fhir:telecom [
( fhir:use [ fhir:v "WP" ] ) ;
fhir:value [ fhir:v "tel:(781)555-1212"^^xsd:anyURI ] ] ) ;
( fhir:addr [
( fhir:use [ fhir:v "WP" ] ) ;
( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "21 North Ave" ] ] ] [
fhir:city [
fhir:xmlText [ fhir:v "Burlington" ] ] ] [
fhir:state [
fhir:xmlText [ fhir:v "MA" ] ] ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "02368" ] ] ] [
fhir:country [
fhir:xmlText [ fhir:v "USA" ] ] ] ) ] ) ] ]
] ) ; #
fhir:author ( [
fhir:time [
fhir:value [ fhir:v "2005-03-29T22:44:11+05:00"^^xsd:dateTime ] ] ;
fhir:assignedAuthor [
( fhir:id [
fhir:extension [ fhir:v "999999999" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.4.6" ] ] ) ;
fhir:code [
fhir:code [ fhir:v "200000000X" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.6.101" ] ;
fhir:displayName [ fhir:v "Allopathic & Osteopathic Physicians" ] ] ;
( fhir:addr [
( fhir:use [ fhir:v "WP" ] ) ;
( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "21 North Ave." ] ] ] [
fhir:city [
fhir:xmlText [ fhir:v "Burlington" ] ] ] [
fhir:state [
fhir:xmlText [ fhir:v "MA" ] ] ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "02368" ] ] ] [
fhir:country [
fhir:xmlText [ fhir:v "USA" ] ] ] ) ] ) ;
( fhir:telecom [
( fhir:use [ fhir:v "WP" ] ) ;
fhir:value [ fhir:v "tel:(555)555-1003"^^xsd:anyURI ] ] ) ;
fhir:assignedPerson [
( fhir:name [
( fhir:item [
( fhir:given [
fhir:xmlText [ fhir:v "Henry" ] ] ) ] [
( fhir:family [
fhir:xmlText [ fhir:v "Seven" ] ] ) ] ) ] ) ] ]
] ) ; #
fhir:dataEnterer [
fhir:assignedEntity [
( fhir:id [
fhir:extension [ fhir:v "999999999" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.4.6" ] ] ) ;
( fhir:addr [
( fhir:use [ fhir:v "WP" ] ) ;
( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "21 North Ave." ] ] ] [
fhir:city [
fhir:xmlText [ fhir:v "Burlington" ] ] ] [
fhir:state [
fhir:xmlText [ fhir:v "MA" ] ] ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "02368" ] ] ] [
fhir:country [
fhir:xmlText [ fhir:v "USA" ] ] ] ) ] ) ;
( fhir:telecom [
( fhir:use [ fhir:v "WP" ] ) ;
fhir:value [ fhir:v "tel:(555)555-1003"^^xsd:anyURI ] ] ) ;
fhir:assignedPerson [
( fhir:name [
( fhir:item [
( fhir:given [
fhir:xmlText [ fhir:v "Henry" ] ] ) ] [
( fhir:family [
fhir:xmlText [ fhir:v "Seven" ] ] ) ] ) ] ) ] ]
] ; #
fhir:informant ( [
fhir:assignedEntity [
( fhir:id [
fhir:extension [ fhir:v "999999999" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.4.6" ] ] ) ;
( fhir:addr [
( fhir:use [ fhir:v "WP" ] ) ;
( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "21 North Ave." ] ] ] [
fhir:city [
fhir:xmlText [ fhir:v "Burlington" ] ] ] [
fhir:state [
fhir:xmlText [ fhir:v "MA" ] ] ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "02368" ] ] ] [
fhir:country [
fhir:xmlText [ fhir:v "USA" ] ] ] ) ] ) ;
( fhir:telecom [
fhir:value [ fhir:v "tel:(555)555-1003"^^xsd:anyURI ] ] ) ;
fhir:assignedPerson [
( fhir:name [
( fhir:item [
( fhir:given [
fhir:xmlText [ fhir:v "Henry" ] ] ) ] [
( fhir:family [
fhir:xmlText [ fhir:v "Seven" ] ] ) ] ) ] ) ] ]
] [
fhir:relatedEntity [
fhir:classCode [ fhir:v "PRS" ] ;
fhir:code [
fhir:code [ fhir:v "SPS" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.1.11.19563" ] ;
fhir:codeSystemName [ fhir:v "Personal Relationship Role Type Value Set" ] ;
fhir:displayName [ fhir:v "SPOUSE" ] ] ; # classCode PRS represents a person with personal relationship with the patient.
fhir:relatedPerson [
( fhir:name [
( fhir:item [
( fhir:given [
fhir:xmlText [ fhir:v "Rose" ] ] ) ] [
( fhir:family [
fhir:xmlText [ fhir:v "Everyman" ] ] ) ] ) ] ) ] ]
] ) ; #
fhir:custodian [
fhir:assignedCustodian [
fhir:representedCustodianOrganization [
( fhir:id [
fhir:extension [ fhir:v "444444444" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.4.6" ] ] ) ;
fhir:name [
( fhir:item [
fhir:xmlText [ fhir:v "Good Health Clinic" ] ] ) ] ;
fhir:telecom [
( fhir:use [ fhir:v "WP" ] ) ;
fhir:value [ fhir:v "tel:(555)555-1212"^^xsd:anyURI ] ] ;
fhir:addr [
( fhir:use [ fhir:v "WP" ] ) ;
( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "17 Daws Rd." ] ] ] [
fhir:city [
fhir:xmlText [ fhir:v "Blue Bell" ] ] ] [
fhir:state [
fhir:xmlText [ fhir:v "MA" ] ] ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "02368" ] ] ] [
fhir:country [
fhir:xmlText [ fhir:v "USA" ] ] ] ) ] ] ]
] ; #
fhir:informationRecipient ( [
fhir:intendedRecipient [
fhir:informationRecipient [
( fhir:name [
( fhir:item [
( fhir:given [
fhir:xmlText [ fhir:v "Henry" ] ] ) ] [
( fhir:family [
fhir:xmlText [ fhir:v "Seven" ] ] ) ] ) ] ) ] ;
fhir:receivedOrganization [
( fhir:name [
( fhir:item [
fhir:xmlText [ fhir:v "Good Health Clinic" ] ] ) ] ) ] ]
] ) ; #
fhir:legalAuthenticator [
fhir:time [
fhir:value [ fhir:v "2005-03-29T22:44:11+05:00"^^xsd:dateTime ] ] ;
fhir:signatureCode [
fhir:code [ fhir:v "S" ] ] ;
fhir:assignedEntity [
( fhir:id [
fhir:extension [ fhir:v "444444444" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.4.6" ] ] ) ;
( fhir:addr [
( fhir:use [ fhir:v "WP" ] ) ;
( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "21 North Ave." ] ] ] [
fhir:city [
fhir:xmlText [ fhir:v "Burlington" ] ] ] [
fhir:state [
fhir:xmlText [ fhir:v "MA" ] ] ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "02368" ] ] ] [
fhir:country [
fhir:xmlText [ fhir:v "USA" ] ] ] ) ] ) ;
( fhir:telecom [
( fhir:use [ fhir:v "WP" ] ) ;
fhir:value [ fhir:v "tel:(555)555-1003"^^xsd:anyURI ] ] ) ;
fhir:assignedPerson [
( fhir:name [
( fhir:item [
( fhir:given [
fhir:xmlText [ fhir:v "Henry" ] ] ) ] [
( fhir:family [
fhir:xmlText [ fhir:v "Seven" ] ] ) ] ) ] ) ] ]
] ; #
fhir:authenticator ( [
fhir:time [
fhir:value [ fhir:v "2005-03-29T22:44:11+05:00"^^xsd:dateTime ] ] ;
fhir:signatureCode [
fhir:code [ fhir:v "S" ] ] ;
fhir:assignedEntity [
( fhir:id [
fhir:extension [ fhir:v "444444444" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.4.6" ] ] ) ;
( fhir:addr [
( fhir:use [ fhir:v "WP" ] ) ;
( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "21 North Ave." ] ] ] [
fhir:city [
fhir:xmlText [ fhir:v "Burlington" ] ] ] [
fhir:state [
fhir:xmlText [ fhir:v "MA" ] ] ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "02368" ] ] ] [
fhir:country [
fhir:xmlText [ fhir:v "USA" ] ] ] ) ] ) ;
( fhir:telecom [
( fhir:use [ fhir:v "WP" ] ) ;
fhir:value [ fhir:v "tel:(555)555-1003"^^xsd:anyURI ] ] ) ;
fhir:assignedPerson [
( fhir:name [
( fhir:item [
( fhir:given [
fhir:xmlText [ fhir:v "Henry" ] ] ) ] [
( fhir:family [
fhir:xmlText [ fhir:v "Seven" ] ] ) ] ) ] ) ] ]
] ) ; #
fhir:participant ( [
fhir:typeCode [ fhir:v "IND" ] ;
fhir:associatedEntity [
fhir:classCode [ fhir:v "NOK" ] ;
fhir:code [
fhir:code [ fhir:v "MTH" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.5.111" ] ] ;
( fhir:addr [
( fhir:use [ fhir:v "WP" ] ) ;
( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "17 Daws Rd." ] ] ] [
fhir:city [
fhir:xmlText [ fhir:v "Blue Bell" ] ] ] [
fhir:state [
fhir:xmlText [ fhir:v "MA" ] ] ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "02368" ] ] ] [
fhir:country [
fhir:xmlText [ fhir:v "USA" ] ] ] ) ] ) ;
( fhir:telecom [
( fhir:use [ fhir:v "WP" ] ) ;
fhir:value [ fhir:v "tel:(999)555-1212"^^xsd:anyURI ] ] ) ;
fhir:associatedPerson [
( fhir:name [
( fhir:item [
( fhir:prefix [
fhir:xmlText [ fhir:v "Mrs." ] ] ) ] [
( fhir:given [
fhir:xmlText [ fhir:v "Abigail" ] ] ) ] [
( fhir:family [
fhir:xmlText [ fhir:v "Ruth" ] ] ) ] ) ] ) ] ]
] ) ; #
fhir:inFulfillmentOf ( [
fhir:typeCode [ fhir:v "FLFS" ] ;
fhir:order [
fhir:classCode [ fhir:v "ACT" ] ;
fhir:moodCode [ fhir:v "RQO" ] ;
( fhir:id [
fhir:extension [ fhir:v "12345-67890" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.19" ] ] ) ]
] ) ; #
fhir:documentationOf ( [
fhir:typeCode [ fhir:v "DOC" ] ;
fhir:serviceEvent [
fhir:classCode [ fhir:v "PCPR" ] ;
( fhir:templateId [
fhir:root [ fhir:v "2.16.840.1.113883.10.20.21.3.1" ] ] ) ;
fhir:effectiveTime [
fhir:low [
fhir:value [ fhir:v "2010-06-01T10:35:00-05:00"^^xsd:dateTime ] ] ;
fhir:high [
fhir:value [ fhir:v "2010-09-15T22:00:00-05:00"^^xsd:dateTime ] ] ] ;
( fhir:performer [
fhir:typeCode [ fhir:v "PRF" ] ;
fhir:functionCode [
fhir:code [ fhir:v "PCP" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.5.88" ] ;
fhir:codeSystemName [ fhir:v "ParticipationFunction" ] ;
fhir:displayName [ fhir:v "Primary Care Provider" ] ;
fhir:originalText [
fhir:xmlText [ fhir:v "Primary Care Provider" ] ] ] ;
fhir:time [
fhir:low [
fhir:value [ fhir:v "2002-07-16T10:35:00-05:00"^^xsd:dateTime ] ] ;
fhir:high [
fhir:value [ fhir:v "2007-09-15T22:00:00-05:00"^^xsd:dateTime ] ] ] ;
fhir:assignedEntity [
( fhir:id [
fhir:extension [ fhir:v "555555555" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.4.6" ] ] ) ;
fhir:code [
fhir:code [ fhir:v "207R00000X" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.6.101" ] ;
fhir:displayName [ fhir:v "Internal Medicine Physician" ] ] ;
( fhir:addr [ ] ) ;
( fhir:telecom [
( fhir:use [ fhir:v "HP" ] ) ;
fhir:value [ fhir:v "tel:+1-301-975-3251"^^xsd:anyURI ] ] ) ;
fhir:assignedPerson [
( fhir:name [
( fhir:item [
( fhir:prefix [
fhir:xmlText [ fhir:v "Dr." ] ] ) ] [
( fhir:given [
fhir:xmlText [ fhir:v "Pseudo" ] ] ) ] [
( fhir:family [
fhir:xmlText [ fhir:v "Physician-1" ] ] ) ] ) ] ) ] ;
fhir:representedOrganization [
( fhir:id [
fhir:root [ fhir:v "2.16.840.1.113883.3.72.5" ] ] ) ;
( fhir:name [
( fhir:item [
fhir:xmlText [ fhir:v "NIST HL7 Test Laboratory" ] ] ) ] ) ;
( fhir:telecom [
fhir:nullFlavor [ fhir:v "UNK" ] ] ) ;
( fhir:addr [
fhir:nullFlavor [ fhir:v "UNK" ] ] ) ] ] ] [
fhir:typeCode [ fhir:v "PRF" ] ;
fhir:functionCode [
fhir:code [ fhir:v "PP" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.12.443" ] ;
fhir:codeSystemName [ fhir:v "Provider Role" ] ;
fhir:displayName [ fhir:v "Primary Care Provider" ] ;
fhir:originalText [
fhir:xmlText [ fhir:v "Primary Care Provider" ] ] ] ;
fhir:time [
fhir:low [
fhir:value [ fhir:v "2002-07-16T10:35:00-05:00"^^xsd:dateTime ] ] ;
fhir:high [
fhir:value [ fhir:v "2007-09-15T22:00:00-05:00"^^xsd:dateTime ] ] ] ;
fhir:assignedEntity [
( fhir:id [
fhir:extension [ fhir:v "666666666" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.4.6" ] ] [
fhir:extension [ fhir:v "PseudoMD-3" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.19" ] ] ) ;
fhir:code [
fhir:code [ fhir:v "207R00000X" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.6.101" ] ;
fhir:displayName [ fhir:v "Internal Medicine Physician" ] ] ;
( fhir:addr [ ] ) ;
( fhir:telecom [
( fhir:use [ fhir:v "HP" ] ) ;
fhir:value [ fhir:v "tel:+1-301-975-3251"^^xsd:anyURI ] ] ) ;
fhir:assignedPerson [
( fhir:name [
( fhir:item [
( fhir:prefix [
fhir:xmlText [ fhir:v "Dr." ] ] ) ] [
( fhir:given [
fhir:xmlText [ fhir:v "Pseudo" ] ] ) ] [
( fhir:family [
fhir:xmlText [ fhir:v "Physician-3" ] ] ) ] ) ] ) ] ;
fhir:representedOrganization [
( fhir:id [
fhir:root [ fhir:v "2.16.840.1.113883.19.123" ] ] ) ;
( fhir:name [
( fhir:item [
fhir:xmlText [ fhir:v "HL7 Test Laboratory" ] ] ) ] ) ;
( fhir:telecom [
fhir:nullFlavor [ fhir:v "UNK" ] ] ) ;
( fhir:addr [
fhir:nullFlavor [ fhir:v "UNK" ] ] ) ] ] ] ) ]
] ) ; #
fhir:componentOf [
fhir:encompassingEncounter [
( fhir:id [
fhir:extension [ fhir:v "9937012" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.19" ] ] ) ;
fhir:code [
fhir:code [ fhir:v "99213" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.6.12" ] ;
fhir:codeSystemName [ fhir:v "CPT-4" ] ] ;
fhir:effectiveTime [
fhir:low [
fhir:value [ fhir:v "2005-03-29T10:35:00-05:00"^^xsd:dateTime ] ] ;
fhir:high [
fhir:value [ fhir:v "2005-03-29T22:00:00-05:00"^^xsd:dateTime ] ] ] ;
fhir:location [
fhir:healthCareFacility [
( fhir:id [
fhir:root [ fhir:v "2.16.540.1.113883.19.2" ] ] ) ] ] ]
] ; #
fhir:component [
fhir:structuredBody [
( fhir:component [
fhir:section [
fhir:nullFlavor [ fhir:v "NI" ] ;
( fhir:templateId [
fhir:extension [ fhir:v "2014-06-09" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.10.20.22.2.9" ] ] ) ;
fhir:code [
fhir:code [ fhir:v "51847-2" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.6.1" ] ;
fhir:codeSystemName [ fhir:v "LOINC" ] ;
fhir:displayName [ fhir:v "Evaluation + Plan note" ] ] ;
fhir:title [
fhir:xmlText [ fhir:v "ASSESSMENT AND PLAN" ] ] ;
fhir:text "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>" ] ] [
fhir:section [
( fhir:templateId [
fhir:extension [ fhir:v "2016-11-01" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.10.20.22.2.65" ] ] ) ; # Notes Section
fhir:code [
fhir:code [ fhir:v "11488-4" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.6.1" ] ;
fhir:codeSystemName [ fhir:v "LOINC" ] ;
fhir:displayName [ fhir:v "Consult note" ] ] ;
fhir:title [
fhir:xmlText [ fhir:v "Consultation Notes" ] ] ;
fhir:text "<div xmlns=\"http://www.w3.org/1999/xhtml\"><ul><li id=\"ConsultNote1\"><p>Dr. Specialist - September 8, 2016</p><p>Evaluated patient due to symptoms of...</p></li></ul></div>" ;
( fhir:entry [
fhir:act [
fhir:classCode [ fhir:v "ACT" ] ;
fhir:moodCode [ fhir:v "EVN" ] ;
( fhir:templateId [
fhir:extension [ fhir:v "2016-11-01" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.10.20.22.4.202" ] ] ) ;
fhir:code [
fhir:code [ fhir:v "34109-9" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.6.1" ] ;
fhir:codeSystemName [ fhir:v "LOINC" ] ;
fhir:displayName [ fhir:v "Note" ] ;
( fhir:translation [
fhir:code [ fhir:v "28570-0" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.6.1" ] ;
fhir:codeSystemName [ fhir:v "LOINC" ] ;
fhir:displayName [ fhir:v "Procedure note" ] ] ) ] ;
fhir:text [
fhir:reference [
fhir:value [ fhir:v "#ProcedureNote1"^^xsd:anyURI ] ] ] ;
fhir:statusCode [
fhir:code [ fhir:v "completed" ] ] ;
fhir:effectiveTime [
fhir:value [ fhir:v "2014-02-03"^^xsd:date ] ] ; # Clinically-relevant time of the note
( fhir:author [
( fhir:templateId [
fhir:root [ fhir:v "2.16.840.1.113883.10.20.22.4.119" ] ] ) ;
fhir:time [
fhir:value [ fhir:v "2014-02-04T08:32:15-05:00"^^xsd:dateTime ] ] ; # Time note was actually written
fhir:assignedAuthor [
( fhir:id [
fhir:root [ fhir:v "20cf14fb-b65c-4c8c-a54d-b0cca834c18c" ] ] ) ;
( fhir:addr [
( fhir:use [ fhir:v "WP" ] ) ;
( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "1001 Hospital Lane" ] ] ] [
fhir:city [
fhir:xmlText [ fhir:v "Ann Arbor" ] ] ] [
fhir:state [
fhir:xmlText [ fhir:v "MI" ] ] ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "99999" ] ] ] [
fhir:country [
fhir:xmlText [ fhir:v "US" ] ] ] ) ] ) ;
( fhir:telecom [
fhir:value [ fhir:v "tel:(999)555-1212"^^xsd:anyURI ] ] ) ;
fhir:assignedPerson [
( fhir:name [
( fhir:item [
fhir:xmlText [ fhir:v "Dr. Physician" ] ] ) ] ) ] ] ] ) # Author Participation ] ] ) # Note Activity entry ] ] ) # Assessment & Plan (or Assessment Section + Plan Section ] # All sections are set to nullFlavor \/ text = No information, \n as this is a header example, not a complete body example
] . #
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#4.0.0-ballot based on FHIR 5.0.0. Generated 2024-11-21
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change