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.
********************************************************
{
"resourceType" : "ClinicalDocument",
"realmCode" : [
// ** CDA Header **
{
"code" : "US"
}
],
"typeId" : {
"extension" : "POCD_HD000040",
"root" : "2.16.840.1.113883.1.3"
},
"templateId" : [
// US General Header Template
{
"extension" : "2024-05-01",
"root" : "2.16.840.1.113883.10.20.22.1.1"
},
{
"extension" : "2024-05-01",
"root" : "2.16.840.1.113883.10.20.22.1.7"
}
],
"id" : // Operative Note Template
{
"extension" : "TT988",
"root" : "2.16.840.1.113883.19.5.99999.1"
},
"sdtcCategory" : [
{
"code" : "11504-8",
"codeSystem" : "2.16.840.1.113883.6.1",
"displayName" : "Surgical operation note"
}
],
"code" : {
"code" : "11504-8",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "Surgical Operation Note"
},
"title" : {
"xmlText" : "Community Health and Hospitals: Operative Note"
},
"effectiveTime" : {
"value" : "2012-09-16T19:10:00-04:00"
},
"confidentialityCode" : {
"code" : "N",
"codeSystem" : "2.16.840.1.113883.5.25"
},
"languageCode" : {
"code" : "en-US"
},
"setId" : {
"extension" : "sTT988",
"root" : "2.16.840.1.113883.19.5.99999.19"
},
"versionNumber" : {
"value" : 1
},
"recordTarget" : [
{
"patientRole" : {
"id" : [
{
"extension" : "998991",
"root" : "2.16.840.1.113883.19.5.99999.2"
},
{
"extension" : "111-00-2330",
"root" : "2.16.840.1.113883.4.1"
}
],
"addr" : [
// Fake ID using HL7 example OID.
// Fake 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" : "1357 Amber Drive"
}
},
{
"city" : {
"xmlText" : "Beaverton"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "97867"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"HP"
],
"value" : "tel:(816)276-6909"
}
],
"patient" : // HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119
{
"name" : [
{
"use" : [
"L"
],
"item" : [
{
"given" : [
// L is "Legal" from HL7 EntityNameUse 2.16.840.1.113883.5.45
{
"xmlText" : "Isabella"
}
]
},
{
"given" : [
{
"xmlText" : "Isa"
}
]
},
{
"family" : [
// CL is "Call me" from HL7 EntityNamePartQualifier 2.16.840.1.113883.5.43
{
"xmlText" : "Jones"
}
]
}
]
}
],
"administrativeGenderCode" : {
"code" : "F",
"codeSystem" : "2.16.840.1.113883.5.1",
"displayName" : "Female"
},
"birthTime" : {
"value" : "2005-05-01"
},
"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" : {
"code" : "1002-5",
"codeSystem" : "2.16.840.1.113883.6.238",
"codeSystemName" : "Race & Ethnicity - CDC",
"displayName" : "American Indian or Alaska Native"
},
"sdtcRaceCode" : [
{
"code" : "1966-1",
"codeSystem" : "2.16.840.1.113883.6.238",
"codeSystemName" : "Race & Ethnicity - CDC",
"displayName" : "Aleut"
}
],
"ethnicGroupCode" : {
"code" : "2186-5",
"codeSystem" : "2.16.840.1.113883.6.238",
"codeSystemName" : "Race & Ethnicity - CDC",
"displayName" : "Not Hispanic or Latino"
},
"guardian" : [
{
"code" : {
"code" : "GRPRN",
"codeSystem" : "2.16.840.1.113883.5.111",
"codeSystemName" : "HL7 Role code",
"displayName" : "Grandparent"
},
"addr" : [
// 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" : "1357 Amber Drive"
}
},
{
"city" : {
"xmlText" : "Beaverton"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "97867"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"HP"
],
"value" : "tel:(816)276-6909"
}
],
"guardianPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Ralph"
}
]
},
{
"family" : [
{
"xmlText" : "Jones"
}
]
}
]
}
]
}
}
],
"birthplace" : {
"place" : {
"addr" : {
"item" : [
{
"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" : {
"value" : true
}
}
]
},
"providerOrganization" : {
"id" : [
{
"extension" : "444444444",
"root" : "2.16.840.1.113883.4.6"
}
],
"name" : [
{
"item" : [
{
"xmlText" : "Community Health and Hospitals"
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:555-555-5000"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Village Avenue"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
]
}
}
}
],
"author" : [
{
"time" : {
"value" : "2005-03-29T22:44:11+05:00"
},
"assignedAuthor" : {
"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" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:555-555-1002"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
}
}
}
],
"dataEnterer" : {
"assignedEntity" : {
"id" : [
{
"extension" : "999999943252",
"root" : "2.16.840.1.113883.4.6"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Village Avenue"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:555-555-1002"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
}
}
},
"informant" : [
{
"assignedEntity" : {
"id" : [
{
"extension" : "KP00017",
"root" : "2.16.840.1.113883.19.5"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Village Avenue"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:555-555-1002"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
}
}
},
{
"relatedEntity" : {
"classCode" : "PRS",
"code" : // classCode PRS represents a person with personal relationship with the patient.
{
"code" : "SPS",
"codeSystem" : "2.16.840.1.113883.1.11.19563",
"codeSystemName" : "Personal Relationship Role Type Value Set",
"displayName" : "SPOUSE"
},
"relatedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Frank"
}
]
},
{
"family" : [
{
"xmlText" : "Jones"
}
]
}
]
}
]
}
}
}
],
"custodian" : {
"assignedCustodian" : {
"representedCustodianOrganization" : {
"id" : [
{
"extension" : "99999999",
"root" : "2.16.840.1.113883.4.6"
}
],
"name" : {
"item" : [
{
"xmlText" : "Community Health and Hospitals"
}
]
},
"telecom" : {
"use" : [
"WP"
],
"value" : "tel:555-555-1002"
},
"addr" : {
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1002 Healthcare Drive"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
}
}
},
"informationRecipient" : [
{
"intendedRecipient" : {
"informationRecipient" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
},
"receivedOrganization" : {
"name" : [
{
"item" : [
{
"xmlText" : "Community Health and Hospitals"
}
]
}
]
}
}
}
],
"legalAuthenticator" : {
"time" : {
"value" : "2009-02-27T13:00:00+05:00"
},
"signatureCode" : {
"code" : "S"
},
"assignedEntity" : {
"id" : [
{
"extension" : "999999999",
"root" : "2.16.840.1.113883.4.6"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Village Avenue"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:555-555-1002"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
}
}
},
"authenticator" : [
{
"time" : {
"value" : "2009-02-27T13:00:00+05:00"
},
"signatureCode" : {
"code" : "S"
},
"assignedEntity" : {
"id" : [
{
"extension" : "999999999",
"root" : "2.16.840.1.113883.4.6"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Village Avenue"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"WP"
],
"value" : "tel:555-555-1002"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
}
}
}
],
"documentationOf" : [
{
"typeCode" : "DOC",
"serviceEvent" : {
"classCode" : "PCPR",
"code" : {
"code" : "73761001",
"codeSystem" : "2.16.840.1.113883.6.96",
"codeSystemName" : "SNOMED CT",
"displayName" : "Colonoscopy"
},
"effectiveTime" : {
"low" : {
"value" : "2012-09-09T19:10:00-04:00"
},
"high" : {
"value" : "2012-09-16T19:10:00-04:00"
}
},
"performer" : [
{
"typeCode" : "PPRF",
"functionCode" : {
"code" : "PCP",
"codeSystem" : "2.16.840.1.113883.5.88",
"codeSystemName" : "ParticipationFunction",
"displayName" : "Primary Care Physician",
"originalText" : {
"xmlText" : "Primary Care Provider"
}
},
"time" : {
"low" : {
"value" : "2012-09-09T19:10:00-04:00"
},
"high" : {
"value" : "2012-09-16T19:10:00-04:00"
}
},
"assignedEntity" : {
"id" : [
{
"extension" : "PseudoMD-3",
"root" : "2.16.840.1.113883.4.6"
}
],
"code" : {
"code" : "207RG0100X",
"codeSystem" : "2.16.840.1.113883.6.101",
"codeSystemName" : "Provider Codes",
"displayName" : "Gastroenterology Physician"
},
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Village Avenue"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
],
"telecom" : [
{
"use" : [
"HP"
],
"value" : "tel:+1-555-555-5000"
}
],
"assignedPerson" : {
"name" : [
{
"item" : [
{
"prefix" : [
{
"xmlText" : "Dr."
}
]
},
{
"given" : [
{
"xmlText" : "Henry"
}
]
},
{
"family" : [
{
"xmlText" : "Seven"
}
]
}
]
}
]
},
"representedOrganization" : {
"id" : [
{
"root" : "2.16.840.1.113883.19.5.9999.1393"
}
],
"name" : [
{
"item" : [
{
"xmlText" : "Community Health and Hospitals"
}
]
}
],
"telecom" : [
{
"use" : [
"HP"
],
"value" : "tel:+1-555-555-5000"
}
],
"addr" : [
{
"use" : [
"WP"
],
"item" : [
{
"streetAddressLine" : {
"xmlText" : "1001 Village Avenue"
}
},
{
"city" : {
"xmlText" : "Portland"
}
},
{
"state" : {
"xmlText" : "OR"
}
},
{
"postalCode" : {
"xmlText" : "99123"
}
},
{
"country" : {
"xmlText" : "US"
}
}
]
}
]
}
}
}
]
}
}
],
"authorization" : [
{
"typeCode" : "AUTH",
"consent" : {
"classCode" : "CONS",
"moodCode" : "EVN",
"id" : [
{
"root" : "629deb70-5306-11df-9879-0800200c9a66"
}
],
"code" : {
"code" : "64293-4",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "Procedure consent"
},
"statusCode" : {
"code" : "completed"
}
}
}
],
"component" : {
"structuredBody" : // All sections are set to nullFlavor / text = No information,
as this is a header example, not a complete body example
{
"component" : [
// Anesthesia
{
"section" : {
"nullFlavor" : "NI",
"templateId" : [
{
"extension" : "2014-06-09",
"root" : "2.16.840.1.113883.10.20.22.2.25"
}
],
"code" : {
"code" : "59774-0",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "Anesthesia"
},
"title" : {
"xmlText" : "Procedure Anesthesia"
},
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
}
},
{
"section" : {
"nullFlavor" : "NI",
"templateId" : [
{
"extension" : "2015-08-01",
"root" : "2.16.840.1.113883.10.20.22.2.37"
}
],
"code" : {
"code" : "55109-3",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "Complications"
},
"title" : {
"xmlText" : "Complications"
},
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
}
},
{
"section" : {
"nullFlavor" : "NI",
"templateId" : [
{
"extension" : "2015-08-01",
"root" : "2.16.840.1.113883.10.20.22.2.34"
}
],
"code" : {
"code" : "10219-4",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "PREOPERATIVE DIAGNOSIS"
},
"title" : {
"xmlText" : "Preoperative Diagnosis"
},
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
}
},
{
"section" : {
"nullFlavor" : "NI",
"templateId" : [
{
"root" : "2.16.840.1.113883.10.20.18.2.9"
}
],
"code" : {
"code" : "59770-8",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "PROCEDURE ESTIMATED BLOOD LOSS"
},
"title" : {
"xmlText" : "Procedure Estimated Blood Loss"
},
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
}
},
{
"section" : {
"nullFlavor" : "NI",
"templateId" : [
{
"extension" : "2015-08-01",
"root" : "2.16.840.1.113883.10.20.22.2.28"
}
],
"code" : {
"code" : "59776-5",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "PROCEDURE FINDINGS"
},
"title" : {
"xmlText" : "Procedure Findings"
},
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
}
},
{
"section" : {
"nullFlavor" : "NI",
"templateId" : [
{
"root" : "2.16.840.1.113883.10.20.22.2.31"
}
],
"code" : {
"code" : "59773-2",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "PROCEDURE SPECIMENS TAKEN"
},
"title" : {
"xmlText" : "Procedure Specimens Taken"
},
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
}
},
{
"section" : {
"nullFlavor" : "NI",
"templateId" : [
{
"root" : "2.16.840.1.113883.10.20.22.2.27"
}
],
"code" : {
"code" : "29554-3",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "PROCEDURE DESCRIPTION"
},
"title" : {
"xmlText" : "Procedure Description"
},
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
}
},
{
"section" : {
"nullFlavor" : "NI",
"templateId" : [
{
"root" : "2.16.840.1.113883.10.20.22.2.35"
}
],
"code" : {
"code" : "10218-6",
"codeSystem" : "2.16.840.1.113883.6.1",
"codeSystemName" : "LOINC",
"displayName" : "POSTOPERATIVE DIAGNOSIS"
},
"title" : {
"xmlText" : "Postoperative Diagnosis"
},
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No information</div>"
}
}
]
}
}
}