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

: US Realm Header Example - JSON Representation

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{
  "resourceType" : "ClinicalDocument",
  "realmCode" : [
    {
      "code" : "US"
    }
  ],
  "typeId" : {
    "extension" : "POCD_HD000040",
    "root" : "2.16.840.1.113883.1.3"
  },
  "templateId" : [
    //  US Realm Header Template 
    {
      "extension" : "2024-05-01",
      "root" : "2.16.840.1.113883.10.20.22.1.1"
    }
  ],
  "id" : //  Globally unique identifier for the document  
  {
    "extension" : "TT988",
    "root" : "2.16.840.1.113883.19.5.99999.1"
  },
  "code" : {
    "code" : "34133-9",
    "codeSystem" : "2.16.840.1.113883.6.1",
    "codeSystemName" : "LOINC",
    "displayName" : "Summarization of Episode Note"
  },
  "title" : //  Title of the document 
  {
    "xmlText" : "Patient Chart Summary"
  },
  "effectiveTime" : {
    "value" : "2012-09-15T10:30:00-08:00"
  },
  "confidentialityCode" : {
    "code" : "N",
    "codeSystem" : "2.16.840.1.113883.5.25",
    "codeSystemName" : "Confidentiality",
    "displayName" : "normal"
  },
  "languageCode" : {
    "code" : "en-US"
  },
  "setId" : {
    "extension" : "sTT988",
    "root" : "2.16.840.1.113883.19.5.99999.19"
  },
  "versionNumber" : //  Version of the document 
  {
    "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" : [
            {
              "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"
                      ]
                    }
                  ]
                }
              ]
            }
          ],
          "administrativeGenderCode" : {
            "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" : //  <sdtc:multipleBirthOrderNumber value="2" /> 
          {
            "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" : //  "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" : [
    //  The author represents the person who provides the content in the document 
    {
      "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" : //  The custodian represents the organization charged with maintaining the original source document 
  {
    "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" : [
    {
      "intendedRecipient" : {
        "classCode" : "ASSIGNED",
        "addr" : [
          {
            "item" : [
              {
                "streetAddressLine" : {
                  "xmlText" : "1004 Healthcare Drive"
                }
              },
              {
                "city" : {
                  "xmlText" : "Portland"
                }
              },
              {
                "state" : {
                  "xmlText" : "OR"
                }
              },
              {
                "postalCode" : {
                  "xmlText" : "99123"
                }
              },
              {
                "country" : {
                  "xmlText" : "US"
                }
              }
            ]
          }
        ]
      }
    }
  ],
  "component" : {
    "structuredBody" : {
      "component" : [
        {
          
        }
      ]
    }
  }
}