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

: Procedure Note Complete Header Example - XML Representation

Raw xml | Download


  <!-- 
 Title:        Procedure Note
 Based on:     C-CDA_R2_Procedure_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 Procedure 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"/>
  <!--  US Realm Header Template  -->
  <templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2024-05-01"/>
  <!--  Procedure Note Template  -->
  <templateId root="2.16.840.1.113883.10.20.22.1.6" extension="2024-05-01"/>
  <id root="2.16.840.1.113883.19.5.99999.1" extension="TT988"/>
  <sdtc:sdtcCategory xmlns:sdtc="urn:hl7-org:sdtc"
                     displayName="Procedure note" codeSystem="2.16.840.1.113883.6.1" code="28570-0"/>
  <code displayName="Procedure Note" codeSystemName="LOINC"
        codeSystem="2.16.840.1.113883.6.1" code="28570-0"/>
  <title>Community Health and Hospitals: Procedure Note</title>
  <effectiveTime value="20120916191100-0400"/>
  <confidentialityCode codeSystem="2.16.840.1.113883.5.25" code="N"/>
  <languageCode code="en-US"/>
  <setId root="2.16.840.1.113883.19.5.99999.19" extension="sTT988"/>
  <versionNumber value="1"/>
  <recordTarget>
    <patientRole>
      <!--  Fake ID using HL7 example OID.  -->
      <id root="2.16.840.1.113883.19.5.99999.2" extension="998991"/>
      <!--  Fake Social Security Number using the actual SSN OID.  -->
      <id root="2.16.840.1.113883.4.1" extension="111-00-2330"/>
      <!--  HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119  -->
      <addr use="HP">
        <streetAddressLine>1357 Amber Drive</streetAddressLine>
        <city>Beaverton</city>
        <state>OR</state>
        <postalCode>97867</postalCode>
        <!--  US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1  -->
        <country>US</country>
      </addr>
      <!--  HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119  -->
      <telecom value="tel:(816)276-6909" use="HP"/>
      <patient>
        <!--  L is "Legal" from HL7 EntityNameUse 2.16.840.1.113883.5.45  -->
        <name use="L">
          <given>Isabella</given>
          <family>Jones</family>
        </name>
        <administrativeGenderCode displayName="Female"
                                  codeSystem="2.16.840.1.113883.5.1" code="F"/>
        <birthTime value="20050501"/>
        <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"/>
        <raceCode displayName="American Indian or Alaska Native"
                  codeSystemName="Race &amp; Ethnicity - CDC" codeSystem="2.16.840.1.113883.6.238" code="1002-5"/>
        <sdtc:sdtcRaceCode xmlns:sdtc="urn:hl7-org:sdtc" displayName="Aleut"
                           codeSystemName="Race &amp; Ethnicity - CDC" codeSystem="2.16.840.1.113883.6.238"
                           code="1966-1"/>
        <ethnicGroupCode displayName="Not Hispanic or Latino"
                         codeSystemName="Race &amp; Ethnicity - CDC" codeSystem="2.16.840.1.113883.6.238" code="2186-5"/>
        <guardian>
          <code displayName="Grandparent" codeSystemName="HL7 Role code"
                codeSystem="2.16.840.1.113883.5.111" code="GRPRN"/>
          <!--  HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119  -->
          <addr use="HP">
            <streetAddressLine>1357 Amber Drive</streetAddressLine>
            <city>Beaverton</city>
            <state>OR</state>
            <postalCode>97867</postalCode>
            <!--  US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1  -->
            <country>US</country>
          </addr>
          <telecom value="tel:(816)276-6909" use="HP"/>
          <guardianPerson>
            <name>
              <given>Ralph</given>
              <family>Jones</family>
            </name>
          </guardianPerson>
        </guardian>
        <birthplace>
          <place>
            <addr>
              <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"/>
          <preferenceInd value="true"/>
        </languageCommunication>
      </patient>
      <providerOrganization>
        <!--  Organizations SHOULD have an NPI; this is a real root; fake extension -->
        <id root="2.16.840.1.113883.4.6" extension="111122223333"/>
        <name>Community Health and Hospitals</name>
        <telecom value="tel:555-555-5000" use="WP"/>
        <addr use="WP">
          <streetAddressLine>1001 Village Avenue</streetAddressLine>
          <city>Portland</city>
          <state>OR</state>
          <postalCode>99123</postalCode>
          <country>US</country>
        </addr>
      </providerOrganization>
    </patientRole>
  </recordTarget>
  <author>
    <time value="20050329224411+0500"/>
    <assignedAuthor>
      <id root="2.16.840.1.113883.4.6" extension="99999999"/>
      <code
            displayName="Allopathic &amp; Osteopathic Physicians; Internal Medicine" codeSystem="2.16.840.1.113883.6.101" code="207R00000X"/>
      <addr use="WP">
        <streetAddressLine>1002 Healthcare Drive</streetAddressLine>
        <city>Portland</city>
        <state>OR</state>
        <postalCode>99123</postalCode>
        <country>US</country>
      </addr>
      <telecom value="tel:555-555-1002" use="WP"/>
      <assignedPerson>
        <name>
          <given>Henry</given>
          <family>Seven</family>
        </name>
      </assignedPerson>
    </assignedAuthor>
  </author>
  <dataEnterer>
    <assignedEntity>
      <id root="2.16.840.1.113883.4.6" extension="999999943252"/>
      <addr use="WP">
        <streetAddressLine>1001 Village Avenue</streetAddressLine>
        <city>Portland</city>
        <state>OR</state>
        <postalCode>99123</postalCode>
        <country>US</country>
      </addr>
      <telecom value="tel:555-555-1002" use="WP"/>
      <assignedPerson>
        <name>
          <given>Henry</given>
          <family>Seven</family>
        </name>
      </assignedPerson>
    </assignedEntity>
  </dataEnterer>
  <informant>
    <assignedEntity>
      <id root="2.16.840.1.113883.19.5" extension="KP00017"/>
      <addr use="WP">
        <streetAddressLine>1001 Village Avenue</streetAddressLine>
        <city>Portland</city>
        <state>OR</state>
        <postalCode>99123</postalCode>
        <country>US</country>
      </addr>
      <telecom value="tel:555-555-1002" use="WP"/>
      <assignedPerson>
        <name>
          <given>Henry</given>
          <family>Seven</family>
        </name>
      </assignedPerson>
    </assignedEntity>
  </informant>
  <informant>
    <!--  classCode PRS represents a person with personal relationship with the patient.  -->
    <relatedEntity classCode="PRS">
      <code displayName="SPOUSE"
            codeSystemName="Personal Relationship Role Type Value Set" codeSystem="2.16.840.1.113883.1.11.19563" code="SPS"/>
      <relatedPerson>
        <name>
          <given>Frank</given>
          <family>Jones</family>
        </name>
      </relatedPerson>
    </relatedEntity>
  </informant>
  <custodian>
    <assignedCustodian>
      <representedCustodianOrganization>
        <id root="2.16.840.1.113883.4.6" extension="99999999"/>
        <name>Community Health and Hospitals</name>
        <telecom value="tel:555-555-1002" use="WP"/>
        <addr use="WP">
          <streetAddressLine>1002 Healthcare Drive</streetAddressLine>
          <city>Portland</city>
          <state>OR</state>
          <postalCode>99123</postalCode>
          <country>US</country>
        </addr>
      </representedCustodianOrganization>
    </assignedCustodian>
  </custodian>
  <informationRecipient>
    <intendedRecipient>
      <informationRecipient>
        <name>
          <given>Henry</given>
          <family>Seven</family>
        </name>
      </informationRecipient>
      <receivedOrganization>
        <name>Community Health and Hospitals</name>
      </receivedOrganization>
    </intendedRecipient>
  </informationRecipient>
  <legalAuthenticator>
    <time value="20090227130000+0500"/>
    <signatureCode code="S"/>
    <assignedEntity>
      <id root="2.16.840.1.113883.4.6" extension="999999999"/>
      <addr use="WP">
        <streetAddressLine>1001 Village Avenue</streetAddressLine>
        <city>Portland</city>
        <state>OR</state>
        <postalCode>99123</postalCode>
        <country>US</country>
      </addr>
      <telecom value="tel:555-555-1002" use="WP"/>
      <assignedPerson>
        <name>
          <given>Henry</given>
          <family>Seven</family>
        </name>
      </assignedPerson>
    </assignedEntity>
  </legalAuthenticator>
  <authenticator>
    <time value="20090227130000+0500"/>
    <signatureCode code="S"/>
    <assignedEntity>
      <id root="2.16.840.1.113883.4.6" extension="999999999"/>
      <addr use="WP">
        <streetAddressLine>1001 Village Avenue</streetAddressLine>
        <city>Portland</city>
        <state>OR</state>
        <postalCode>99123</postalCode>
        <country>US</country>
      </addr>
      <telecom value="tel:555-555-1002" use="WP"/>
      <assignedPerson>
        <name>
          <given>Henry</given>
          <family>Seven</family>
        </name>
      </assignedPerson>
    </assignedEntity>
  </authenticator>
  <participant typeCode="IND">
    <functionCode displayName="Primary Care Physician"
                  codeSystemName="participationFunction" codeSystem="2.16.840.1.113883.5.88" code="PCP"/>
    <associatedEntity classCode="PROV">
      <associatedPerson>
        <name>
          <given>Henry</given>
          <family>Seven</family>
        </name>
      </associatedPerson>
    </associatedEntity>
  </participant>
  <documentationOf typeCode="DOC">
    <serviceEvent classCode="PCPR">
      <code displayName="Colonoscopy" codeSystemName="SNOMED CT"
            codeSystem="2.16.840.1.113883.6.96" code="73761001"/>
      <effectiveTime>
        <low value="20120909191100-0400"/>
        <high value="20120916191100-0400"/>
      </effectiveTime>
      <performer typeCode="SPRF">
        <functionCode displayName="Primary Care Provider"
                      codeSystemName="ParticipationFunction" codeSystem="2.16.840.1.113883.5.88" code="PCP">
          <originalText>Primary Care Provider</originalText>
        </functionCode>
        <time>
          <low value="20120909191100-0400"/>
          <high value="20120916191100-0400"/>
        </time>
        <assignedEntity>
          <id root="2.16.840.1.113883.4.6" extension="PseudoMD-1"/>
          <code displayName="Internal Medicine Physician"
                codeSystem="2.16.840.1.113883.6.101" code="207R00000X"/>
          <addr use="WP">
            <streetAddressLine>1001 Village Avenue</streetAddressLine>
            <city>Portland</city>
            <state>OR</state>
            <postalCode>99123</postalCode>
            <country>US</country>
          </addr>
          <telecom value="tel:+1-555-555-5000" use="WP"/>
          <assignedPerson>
            <name>
              <prefix>Dr.</prefix>
              <given>Henry</given>
              <family>Seven</family>
            </name>
          </assignedPerson>
          <representedOrganization>
            <id root="2.16.840.1.113883.19.5.9999.1393"/>
            <name>Community Health and Hospitals</name>
            <telecom value="tel:+1-555-555-5000" use="WP"/>
            <addr use="WP">
              <streetAddressLine>1001 Village Avenue</streetAddressLine>
              <city>Portland</city>
              <state>OR</state>
              <postalCode>99123</postalCode>
              <country>US</country>
            </addr>
          </representedOrganization>
        </assignedEntity>
      </performer>
      <performer typeCode="PPRF">
        <functionCode displayName="Primary Care Provider"
                      codeSystemName="ParticipationFunction" codeSystem="2.16.840.1.113883.5.88" code="PCP">
          <originalText>Primary Care Provider</originalText>
        </functionCode>
        <time>
          <low value="20120909191100-0400"/>
          <high value="20120916191100-0400"/>
        </time>
        <assignedEntity>
          <id root="2.16.840.1.113883.4.6" extension="PseudoMD-3"/>
          <code displayName="Gastroenterology Physician"
                codeSystemName="Provider Codes" codeSystem="2.16.840.1.113883.6.101" code="207RG0100X"/>
          <addr use="WP">
            <streetAddressLine>1001 Village Avenue</streetAddressLine>
            <city>Portland</city>
            <state>OR</state>
            <postalCode>99123</postalCode>
            <country>US</country>
          </addr>
          <telecom value="tel:+1-555-555-5000" use="HP"/>
          <assignedPerson>
            <name>
              <prefix>Dr.</prefix>
              <given>Henry</given>
              <family>Seven</family>
            </name>
          </assignedPerson>
          <representedOrganization>
            <id root="2.16.840.1.113883.19.5.9999.1393"/>
            <name>Community Health and Hospitals</name>
            <telecom value="tel:+1-555-555-5000" use="HP"/>
            <addr use="WP">
              <streetAddressLine>1001 Village Avenue</streetAddressLine>
              <city>Portland</city>
              <state>OR</state>
              <postalCode>99123</postalCode>
              <country>US</country>
            </addr>
          </representedOrganization>
        </assignedEntity>
      </performer>
    </serviceEvent>
  </documentationOf>
  <authorization>
    <consent moodCode="EVN" classCode="CONS">
      <id root="629deb70-5306-11df-9879-0800200c9a66"/>
      <code displayName="Procedure consent" codeSystemName="LOINC"
            codeSystem="2.16.840.1.113883.6.1" code="64293-4"/>
      <statusCode code="completed"/>
    </consent>
  </authorization>
  <componentOf>
    <encompassingEncounter>
      <id root="2.16.840.1.113883.19" extension="9937012"/>
      <code codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"
            code="99213"/>
      <effectiveTime>
        <low value="20090227130000+0500"/>
        <high value="20090227130000+0500"/>
      </effectiveTime>
      <location>
        <healthCareFacility>
          <id root="2.16.540.1.113883.19.2"/>
        </healthCareFacility>
      </location>
    </encompassingEncounter>
  </componentOf>
  <component>
    <!--  All sections are set to nullFlavor / text = No information, 
        as this is a header example, not a complete body example  -->
    <structuredBody>
      <!--  Complications  -->
      <component>
        <section nullFlavor="NI">
          <templateId root="2.16.840.1.113883.10.20.22.2.37"
                      extension="2015-08-01"/>
          <code displayName="Complications" codeSystemName="LOINC"
                codeSystem="2.16.840.1.113883.6.1" code="55109-3"/>
          <title>Complications</title>
          <text>No information</text>
        </section>
      </component>
      <!--  Proc Description  -->
      <component>
        <section nullFlavor="NI">
          <templateId root="2.16.840.1.113883.10.20.22.2.27"/>
          <code displayName="PROCEDURE DESCRIPTION" codeSystemName="LOINC"
                codeSystem="2.16.840.1.113883.6.1" code="29554-3"/>
          <title>Procedure Description</title>
          <text>No information</text>
        </section>
      </component>
      <!--  Proc Indications  -->
      <component>
        <section nullFlavor="NI">
          <templateId root="2.16.840.1.113883.10.20.22.2.29"
                      extension="2014-06-09"/>
          <code displayName="PROCEDURE INDICATIONS" codeSystemName="LOINC"
                codeSystem="2.16.840.1.113883.6.1" code="59768-2"/>
          <title>Procedure Indications</title>
          <text>No information</text>
        </section>
      </component>
      <!--  Post-proc DX  -->
      <component>
        <section nullFlavor="NI">
          <templateId root="2.16.840.1.113883.10.20.22.2.36"
                      extension="2015-08-01"/>
          <code displayName="POSTPROCEDURE DIAGNOSIS" codeSystemName="LOINC"
                codeSystem="2.16.840.1.113883.6.1" code="59769-0"/>
          <title>Postprocedure Diagnosis</title>
          <text>No information</text>
        </section>
      </component>
      <!--  Assessment & Plan (or Assessment Section + Plan Section  -->
      <component>
        <section nullFlavor="NI">
          <templateId root="2.16.840.1.113883.10.20.22.2.9"
                      extension="2014-06-09"/>
          <code displayName="Evaluation + Plan note" codeSystemName="LOINC"
                codeSystem="2.16.840.1.113883.6.1" code="51847-2"/>
          <title>ASSESSMENT AND PLAN</title>
          <text>No information</text>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>