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: 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.
********************************************************
-->
<ClinicalDocument xmlns="urn:hl7-org:v3">
<!-- ** CDA Header ** -->
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<!-- Identifies document as conformant to US Realm Header (V2) Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2024-05-01"/>
<!-- Referral Note Document
Conforms to the document specific requirements -->
<templateId root="2.16.840.1.113883.10.20.22.1.14" extension="2024-05-01"/>
<!-- DocumentID: unique ID for the document -->
<id root="6f1bd58b-c58f-40b7-b314-caf1294ed98b"/>
<sdtc:sdtcCategory xmlns:sdtc="urn:hl7-org:sdtc"
displayName="Referral note" codeSystem="2.16.840.1.113883.6.1" code="57133-1"/>
<!-- Referral Note -->
<code displayName="Referral Note" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="57133-1"/>
<!-- Use the name of the code as the title -->
<title>Referral Note</title>
<effectiveTime value="20130921050000-0800"/>
<confidentialityCode codeSystem="2.16.840.1.113883.5.25" code="N"/>
<languageCode code="en"/>
<setId root="2.16.840.1.113883.19.5.99999.19" extension="sTT988"/>
<versionNumber value="1"/>
<recordTarget>
<patientRole>
<id root="2.16.840.1.113883.4.1" extension="444222222"/>
<!-- Example Social Security Number using the actual SSN OID. -->
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>2222 Home Street</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(555)555-2003" use="HP"/>
<!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<patient>
<!-- The first name element represents what the patient is known as -->
<name use="L">
<given>Eve</given>
<!-- The "SP" is "Spouse" from HL7 Code System EntityNamePartQualifier 2.16.840.1.113883.5.43 -->
<family qualifier="SP">Betterhalf</family>
</name>
<!-- The second name element represents another name associated with the patient -->
<name use="SRCH">
<given>Eve</given>
<!-- The "BR" is "Birth" from HL7 Code System EntityNamePartQualifier 2.16.840.1.113883.5.43 -->
<family qualifier="BR">Everywoman</family>
</name>
<administrativeGenderCode displayName="Female"
codeSystemName="AdministrativeGender" codeSystem="2.16.840.1.113883.5.1"
code="F"/>
<!-- Date of birth need only be precise to the day -->
<birthTime value="19750501"/>
<maritalStatusCode displayName="Married"
codeSystemName="MaritalStatusCode" codeSystem="2.16.840.1.113883.5.2" code="M"/>
<religiousAffiliationCode
displayName="Christian (non-Catholic, non-specific)" codeSystemName="HL7 Religious Affiliation"
codeSystem="2.16.840.1.113883.5.1076" code="1013"/>
<!-- CDC Race and Ethnicity code set contains the five minimum race and ethnicity
categories defined by OMB Standards -->
<raceCode displayName="White"
codeSystemName="Race & Ethnicity - CDC" codeSystem="2.16.840.1.113883.6.238" code="2106-3"/>
<!-- The raceCode extension is only used if raceCode is valued -->
<sdtc:sdtcRaceCode xmlns:sdtc="urn:hl7-org:sdtc"
displayName="Native Hawaiian or Other Pacific Islander" codeSystemName="Race & Ethnicity - CDC"
codeSystem="2.16.840.1.113883.6.238" code="2076-8"/>
<ethnicGroupCode displayName="Not Hispanic or Latino"
codeSystemName="Race & Ethnicity - CDC" codeSystem="2.16.840.1.113883.6.238" code="2186-5"/>
<guardian>
<code displayName="Power of Attorney" codeSystemName="RoleCode"
codeSystem="2.16.840.1.113883.5.111" code="POWATT"/>
<addr use="HP">
<streetAddressLine>2222 Home Street</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(555)555-2008" use="MC"/>
<guardianPerson>
<name>
<given>Boris</given>
<given qualifier="CL">Bo</given>
<family>Betterhalf</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<streetAddressLine>4444 Home Street</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
</addr>
</place>
</birthplace>
<languageCommunication>
<languageCode code="en"/>
<modeCode displayName="Expressed spoken"
codeSystemName="LanguageAbilityMode" codeSystem="2.16.840.1.113883.5.60" code="ESP"/>
<proficiencyLevelCode displayName="Good"
codeSystemName="LanguageAbilityProficiency" codeSystem="2.16.840.1.113883.5.61" code="G"/>
<!-- Patient's preferred language -->
<preferenceInd value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id root="2.16.840.1.113883.4.6" extension="219BX"/>
<name>The DoctorsTogether Physician Group</name>
<telecom value="tel:+1(555)555-5000" use="WP"/>
<addr use="WP">
<streetAddressLine>1007 Health Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time value="20130311103000-0800"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="5555555555"/>
<code displayName="Adult Medicine"
codeSystemName="Healthcare Provider Taxonomy (HIPAA)" codeSystem="2.16.840.1.113883.6.101" code="207QA0505X"/>
<addr use="WP">
<streetAddressLine>1004 Healthcare Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(555)-1004" use="WP"/>
<assignedPerson>
<name>
<given>Patricia</given>
<given qualifier="CL">Patty</given>
<family>Primary</family>
<suffix qualifier="AC">M.D.</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="333777777"/>
<addr use="WP">
<streetAddressLine>1007 Healthcare Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(555)-1050" use="WP"/>
<assignedPerson>
<name>
<given>Ellen</given>
<family>Enter</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<informant>
<assignedEntity>
<id root="2.16.840.1.113883.19.5" extension="888888888"/>
<addr use="WP">
<streetAddressLine>1007 Healthcare Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(555)-1003" use="WP"/>
<assignedPerson>
<name>
<given>Harold</given>
<family>Hippocrates</family>
<suffix qualifier="AC">D.O.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</informant>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="2.16.840.1.113883.4.6" extension="321CX"/>
<name>Good Health HIE</name>
<telecom value="tel:+1(555)-1009" use="WP"/>
<addr use="WP">
<streetAddressLine>1009 Healthcare Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<given>Nancy</given>
<family>Nightingale</family>
<suffix qualifier="AC">RN</suffix>
</name>
</informationRecipient>
<receivedOrganization>
<name>Community Health and Hospitals</name>
<telecom value="tel:+1(555)-555-1002" use="WP"/>
<addr use="WP">
<streetAddressLine>Cardiac Stepdown Unit, 4B</streetAddressLine>
<streetAddressLine>1002 Healthcare Drive</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>97857</postalCode>
<country>US</country>
</addr>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<time value="20130915223615-0800"/>
<signatureCode code="S"/>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="5555555555"/>
<code displayName="Adult Medicine Physician"
codeSystemName="Healthcare Provider Taxonomy (HIPAA)" codeSystem="2.16.840.1.113883.6.101" code="207QA0505X"/>
<addr use="WP">
<streetAddressLine>1004 Healthcare Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(555)-1004" use="WP"/>
<assignedPerson>
<name>
<given>Patricia</given>
<given qualifier="CL">Patty</given>
<family>Primary</family>
<suffix qualifier="AC">M.D.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<authenticator>
<time value="20120915103000-0800"/>
<signatureCode code="S"/>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="5555555555"/>
<code displayName="Adult Medicine"
codeSystemName="Healthcare Provider Taxonomy (HIPAA)" codeSystem="2.16.840.1.113883.6.101" code="207QA0505X"/>
<addr use="WP">
<streetAddressLine>1004 Healthcare Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(555)-1004" use="WP"/>
<assignedPerson>
<name>
<given>Patricia</given>
<given qualifier="CL">Patty</given>
<family>Primary</family>
<suffix qualifier="AC">M.D.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<participant typeCode="CALLBCK">
<time value="20050329224411+0500"/>
<associatedEntity classCode="ASSIGNED">
<id root="2.16.840.1.113883.4.6" extension="99999999"/>
<code displayName="Allopathic & Osteopathic Physicians"
codeSystem="2.16.840.1.113883.6.101" code="200000000X"/>
<addr use="WP">
<streetAddressLine>1002 Healthcare Drive</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>97857</postalCode>
<country>US</country>
</addr>
<telecom value="tel:555-555-1002" use="WP"/>
<associatedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
<suffix>DO</suffix>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<!-- Patient Support Identification -->
<participant typeCode="IND">
<functionCode displayName="Primary Carer" codeSystemName="SNOMED-CT"
codeSystem="2.16.840.1.113883.6.96" code="407543004"/>
<!-- Caregiver -->
<associatedEntity classCode="CAREGIVER">
<code codeSystem="2.16.840.1.113883.5.111" code="MTH"/>
<addr use="WP">
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>97857</postalCode>
<country>US</country>
</addr>
<telecom value="tel:1+(555)555-1212" use="WP"/>
<associatedPerson>
<name>
<prefix>Mrs.</prefix>
<given>Martha</given>
<family>Jones</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<component>
<!-- All sections are set to nullFlavor / text = No information,
as this is a header example, not a complete body example -->
<structuredBody>
<!-- Reason for Referral -->
<component>
<section nullFlavor="NI">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.1"
extension="2014-06-09"/>
<code displayName="Reason for Referral" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="42349-1"/>
<title>REASON FOR REFERRAL</title>
<text>No information</text>
</section>
</component>
<!-- ALLERGIES -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"
extension="2015-08-01"/>
<code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
code="48765-2"/>
<title>ALLERGIES AND ADVERSE REACTIONS</title>
<text>No information</text>
</section>
</component>
<!-- PROBLEM LIST -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"
extension="2015-08-01"/>
<code displayName="PROBLEM LIST" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="11450-4"/>
<title>PROBLEMS</title>
<text>No information</text>
</section>
</component>
<!-- MEDICATIONS -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"
extension="2014-06-09"/>
<code displayName="HISTORY OF MEDICATION USE"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="10160-0"/>
<title>MEDICATIONS</title>
<text>No information</text>
</section>
</component>
<!-- Plan of treatment -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.10"
extension="2014-06-09"/>
<code displayName="Treatment plan" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="18776-5"/>
<title>TREATMENT PLAN</title>
<text>No information</text>
</section>
</component>
<!-- Assessment (required with Plan of Treatment; otherwise use the Assessment & Plan Section) -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.8"/>
<code displayName="ASSESSMENTS" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="51848-0"/>
<title>ASSESSMENTS</title>
<text>No information</text>
</section>
</component>
<!-- Results -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.3.1"
extension="2015-08-01"/>
<code displayName="RESULTS" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="30954-2"/>
<title>RESULTS</title>
<text>No information</text>
</section>
</component>
<!-- Functional Status -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.14"
extension="2014-06-09"/>
<code displayName="Functional Status" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="47420-5"/>
<title>FUNCTIONAL STATUS</title>
<text>No information</text>
</section>
</component>
<!-- Mental Status -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.56"
extension="2015-08-01"/>
<code displayName="Mental status Narrative" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="10190-7"/>
<title>MENTAL STATUS</title>
<text>No information</text>
</section>
</component>
<!-- Nutrition -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.57"/>
<code displayName="Diet and Nutrition" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="61144-2"/>
<title>NUTRITION SECTION</title>
<text>No information</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>