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 - TTL Representation

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@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 -------------------------------------------------------------------

 a fhir:ClinicalDocument ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:realmCode ( [
fhir:code [ fhir:v "US" ]
  ] ) ; # 
  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" ]
  ] ) ; #  US Realm Header Template 
  fhir:id [
fhir:extension [ fhir:v "TT988" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.19.5.99999.1" ]
  ] ; #  Globally unique identifier for the document  
  fhir:code [
fhir:code [ fhir:v "34133-9" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.6.1" ] ;
fhir:codeSystemName [ fhir:v "LOINC" ] ;
fhir:displayName [ fhir:v "Summarization of Episode Note" ]
  ] ; # 
  fhir:title [
fhir:xmlText [ fhir:v "Patient Chart Summary" ]
  ] ; #  Title of the document 
  fhir:effectiveTime [
fhir:value [ fhir:v "2012-09-15T10:30:00-08:00"^^xsd:dateTime ]
  ] ; # 
  fhir:confidentialityCode [
fhir:code [ fhir:v "N" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.5.25" ] ;
fhir:codeSystemName [ fhir:v "Confidentiality" ] ;
fhir:displayName [ fhir:v "normal" ]
  ] ; # 
  fhir:languageCode [
fhir:code [ fhir:v "en-US" ]
  ] ; # 
  fhir:setId [
fhir:extension [ fhir:v "sTT988" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.19.5.99999.19" ]
  ] ; # 
  fhir:versionNumber [
fhir:value [ fhir:v "1"^^xsd:integer ]
  ] ; #  Version of the document 
  fhir:recordTarget ( [
fhir:patientRole [
      ( fhir:id [
fhir:extension [ fhir:v "444222222" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.4.1" ]       ] ) ;
      ( fhir:addr [
        ( fhir:use [ fhir:v "HP" ] ) ;
        ( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "2222 Home Street" ]           ] #  HP is \"primary home\" from codeSystem 2.16.840.1.113883.5.1119          ] [
fhir:city [
fhir:xmlText [ fhir:v "Beaverton" ]           ]         ] [
fhir:state [
fhir:xmlText [ fhir:v "OR" ]           ]         ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "97867" ]           ]         ] [
fhir:country [
fhir:xmlText [ fhir:v "US" ]           ]         ] )       ] ) ; #  Example Social Security Number using the actual SSN OID. ,  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:+1(555)555-2003"^^xsd:anyURI ]       ] ) ;
fhir:patient [
        ( fhir:name [
          ( fhir:use [ fhir:v "L" ] ) ;
          ( fhir:item [
            ( fhir:given [
fhir:xmlText [ fhir:v "Eve" ]             ] )           ] [
            ( fhir:family [
fhir:xmlText [ fhir:v "Betterhalf" ] ;
              ( fhir:qualifier [ fhir:v "SP" ] )             ] ) #  The \"SP\" is \"Spouse\" from HL7 Code System EntityNamePartQualifier 2.16.840.1.113883.5.43            ] )         ] ) ;
fhir:administrativeGenderCode [
fhir:code [ fhir:v "F" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.5.1" ] ;
fhir:codeSystemName [ fhir:v "AdministrativeGender" ] ;
fhir:displayName [ fhir:v "Female" ]         ] ;
fhir:birthTime [
fhir:value [ fhir:v "1975-05-01"^^xsd:date ]         ] ; #  Date of birth need only be precise to the day 
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" ]         ] ; #  <sdtc:multipleBirthOrderNumber value=\"2\" \/> 
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" ]         ] ; #  CDC Race and Ethnicity code set contains the five minimum race and ethnicity \n					categories defined by OMB Standards 
        ( fhir:sdtcRaceCode [
fhir:code [ fhir:v "2076-8" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.6.238" ] ;
fhir:codeSystemName [ fhir:v "Race & Ethnicity - CDC" ] ;
fhir:displayName [ fhir:v "Native Hawaiian or Other Pacific Islander" ]         ] ) ; #  The raceCode extension is only used if raceCode is valued 
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 "POWATT" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.5.111" ] ;
fhir:codeSystemName [ fhir:v "RoleCode" ] ;
fhir:displayName [ fhir:v "Power of Attorney" ]           ] ;
          ( fhir:addr [
            ( fhir:use [ fhir:v "HP" ] ) ;
            ( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "2222 Home Street" ]               ]             ] [
fhir:city [
fhir:xmlText [ fhir:v "Beaverton" ]               ]             ] [
fhir:state [
fhir:xmlText [ fhir:v "OR" ]               ]             ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "97867" ]               ]             ] [
fhir:country [
fhir:xmlText [ fhir:v "US" ]               ]             ] )           ] ) ;
          ( fhir:telecom [
            ( fhir:use [ fhir:v "MC" ] ) ;
fhir:value [ fhir:v "tel:+1(555)555-2008"^^xsd:anyURI ]           ] ) ;
fhir:guardianPerson [
            ( fhir:name [
              ( fhir:item [
                ( fhir:given [
fhir:xmlText [ fhir:v "Boris" ]                 ] )               ] [
                ( fhir:given [
fhir:xmlText [ fhir:v "Bo" ] ;
                  ( fhir:qualifier [ fhir:v "CL" ] )                 ] )               ] [
                ( fhir:family [
fhir:xmlText [ fhir:v "Betterhalf" ]                 ] )               ] )             ] )           ]         ] ) ;
fhir:birthplace [
fhir:place [
fhir:addr [
              ( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "4444 Home Street" ]                 ]               ] [
fhir:city [
fhir:xmlText [ fhir:v "Beaverton" ]                 ]               ] [
fhir:state [
fhir:xmlText [ fhir:v "OR" ]                 ]               ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "97867" ]                 ]               ] [
fhir:country [
fhir:xmlText [ fhir:v "US" ]                 ]               ] )             ]           ]         ] ;
        ( fhir:languageCommunication [
fhir:languageCode [
fhir:code [ fhir:v "en" ]           ] ;
fhir:modeCode [
fhir:code [ fhir:v "ESP" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.5.60" ] ;
fhir:codeSystemName [ fhir:v "LanguageAbilityMode" ] ;
fhir:displayName [ fhir:v "Expressed spoken" ]           ] ; #  \"en\" is ISO 639-1 alpha-2 code for \"English\" 
fhir:proficiencyLevelCode [
fhir:code [ fhir:v "G" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.5.61" ] ;
fhir:codeSystemName [ fhir:v "LanguageAbilityProficiency" ] ;
fhir:displayName [ fhir:v "Good" ]           ] ;
fhir:preferenceInd [
fhir:value [ fhir:v "true"^^xsd:boolean ]           ] #  Patient's preferred language          ] )       ] #  HP is \"primary home\" from HL7 AddressUse 2.16.840.1.113883.5.1119      ]
  ] ) ; # 
  fhir:author ( [
fhir:time [
fhir:value [ fhir:v "2013-08-15T10:30:00-08:00"^^xsd:dateTime ]     ] ;
fhir:assignedAuthor [
      ( fhir:id [
fhir:extension [ fhir:v "5555555555" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.4.6" ]       ] ) ;
fhir:code [
fhir:code [ fhir:v "207QA0505X" ] ;
fhir:codeSystem [ fhir:v "2.16.840.1.113883.6.101" ] ;
fhir:codeSystemName [ fhir:v "Healthcare Provider Taxonomy (HIPAA)" ] ;
fhir:displayName [ fhir:v "Adult Medicine Physician" ]       ] ;
      ( fhir:addr [
        ( fhir:use [ fhir:v "WP" ] ) ;
        ( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "1004 Healthcare Drive" ]           ]         ] [
fhir:city [
fhir:xmlText [ fhir:v "Portland" ]           ]         ] [
fhir:state [
fhir:xmlText [ fhir:v "OR" ]           ]         ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "99123" ]           ]         ] [
fhir:country [
fhir:xmlText [ fhir:v "US" ]           ]         ] )       ] ) ;
      ( fhir:telecom [
        ( fhir:use [ fhir:v "WP" ] ) ;
fhir:value [ fhir:v "tel:+1(555)555-1004"^^xsd:anyURI ]       ] ) ;
fhir:assignedPerson [
        ( fhir:name [
          ( fhir:item [
            ( fhir:given [
fhir:xmlText [ fhir:v "Patricia" ]             ] )           ] [
            ( fhir:given [
fhir:xmlText [ fhir:v "Patty" ] ;
              ( fhir:qualifier [ fhir:v "CL" ] )             ] )           ] [
            ( fhir:family [
fhir:xmlText [ fhir:v "Primary" ]             ] )           ] [
            ( fhir:suffix [
fhir:xmlText [ fhir:v "M.D." ] ;
              ( fhir:qualifier [ fhir:v "AC" ] )             ] )           ] )         ] )       ]     ]
  ] ) ; #  The author represents the person who provides the content in the document 
  fhir:custodian [
fhir:assignedCustodian [
fhir:representedCustodianOrganization [
        ( fhir:id [
fhir:extension [ fhir:v "321CX" ] ;
fhir:root [ fhir:v "2.16.840.1.113883.4.6" ]         ] ) ;
fhir:name [
          ( fhir:item [
fhir:xmlText [ fhir:v "Good Health HIE" ]           ] )         ] ;
fhir:telecom [
          ( fhir:use [ fhir:v "WP" ] ) ;
fhir:value [ fhir:v "tel:+1(555)555-1009"^^xsd:anyURI ]         ] ;
fhir:addr [
          ( fhir:use [ fhir:v "WP" ] ) ;
          ( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "1009 Healthcare Drive" ]             ]           ] [
fhir:city [
fhir:xmlText [ fhir:v "Portland" ]             ]           ] [
fhir:state [
fhir:xmlText [ fhir:v "OR" ]             ]           ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "99123" ]             ]           ] [
fhir:country [
fhir:xmlText [ fhir:v "US" ]             ]           ] )         ]       ]     ]
  ] ; #  The custodian represents the organization charged with maintaining the original source document 
  fhir:informationRecipient ( [
fhir:intendedRecipient [
fhir:classCode [ fhir:v "ASSIGNED" ] ;
      ( fhir:addr [
        ( fhir:item [
fhir:streetAddressLine [
fhir:xmlText [ fhir:v "1004 Healthcare Drive" ]           ]         ] [
fhir:city [
fhir:xmlText [ fhir:v "Portland" ]           ]         ] [
fhir:state [
fhir:xmlText [ fhir:v "OR" ]           ]         ] [
fhir:postalCode [
fhir:xmlText [ fhir:v "99123" ]           ]         ] [
fhir:country [
fhir:xmlText [ fhir:v "US" ]           ]         ] )       ] )     ]
  ] ) ; # 
  fhir:component [
fhir:structuredBody [
      ( fhir:component [
fhir:section [ ]       ] )     ]
  ] . #