Single Consultation Note

Approval Status

  • Approval Status: Approved
  • Example Task Force: 11/16/2017
  • SDWG: 11/30/2017

C-CDA 2.1 Example:

  • 2.16.840.1.113883.
  • 2.16.840.1.113883.

Reference to full CDA sample:

  • Encounter in empty CCD

Validation location


  • This is an example of how to record a single Consultation Note.


  • Brett Marquard, (GitHub: brettmarquard)


  • Note, Note Activity, Notes



Example: download example view on GitHub

    <!-- Notes Section -->
    <templateId root="2.16.840.1.113883." extension="2016-11-01"/>
    <!-- This Notes Section is not intended to replace a C-CDA Consultation Note Document -->
    <!-- If your system captures Consultation Note information in Discrete sections it's not recommended to lump all the text together here. -->
    <!-- This Notes Section could be included in a Consultation Note Document with other discrete sections (Results, Vitals etc.)-->
    <!-- This Notes Section is most appropriate for an encounter specific document -->
    <!-- If this Notes section were included in a CCD, each Note Activity entry should be linked to an appropriate Encounter entry in the Encounters section -->
    <code code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
        displayName="Consultation note"/>
    <title>Consultation Notes</title>
            <item ID="ConsultNote1">
                <paragraph>Dr. Specialist - September 8, 2016</paragraph>
                <paragraph> Dear Dr. Henry Leven: Thank you for referring Ms. Everywoman for evaluation. As
                    you know, she is a 40-year-old woman who has had chronic gastrointestinal
                    symptoms. Approximately 18 years ago, she was hospitalized with a bleeding
                    ulcer. She had a CT scan of the abdomen, which revealed findings consistent with
                    focal nodular hyperplasia (FNH). She has had epigastric abdominal pain as well
                    as a significant change in her bowel movements from baseline constipation to
                    frequent diarrhea. The past medical history is otherwise negative. She takes no
                    prescription medications. The remainder of the history is not contributory. </paragraph>
                <paragraph>Physical examination revealed a well-appearing woman. The vital signs
                    were normal. The head and neck were unremarkable. The lung fields were clear.
                    The heart exam was normal. The abdomen was obese with normal bowel sounds. There
                    was no tenderness, mass, or hepatosplenomegaly. </paragraph>
                <paragraph>Endoscopic evaluation revealed a normal colonoscopy. Biopsies taken
                    throughout the colon were essentially unremarkable. Stool tests for pathogenic
                    organisms were negative. Of note, on the upper endoscopy examination, no
                    significant abnormalities were seen; however, upon biopsy, features of celiac
                    disease were noted.</paragraph>
                <paragraph> In summary, this 40-year-old woman has evidence of celiac disease. We
                    discussed the diagnosis in detail in the office. She was advised to undertake a
                    lifelong gluten-free diet. Followup laboratories in my office were notable for a
                    low serum iron with a low-normal ferritin. The bone density was normal. Repeat
                    triple-phase CT scan of the liver revealed no change in the right hepatic lobe
                    lesion, which is consistent with FNH. I advised periodic reevaluation of the
                    liver with imaging, as well as followup for any potential development of
                    nutritional deficiencies. She should take an iron supplement and continue on a
                    lifelong gluten-free diet. </paragraph>
                <paragraph>Thank you for the courtesy of this referral. I would be pleased to see
                    Ms. Everywoman in followup.</paragraph>
    <!-- Note Activity entry -->
        <act classCode="ACT" moodCode="EVN">
            <templateId root="2.16.840.1.113883." extension="2016-11-01"/>
            <code code="34109-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
                <!-- Code must match or be equivalent to section code -->
                <translation code="11488-4" codeSystem="2.16.840.1.113883.6.1"
                    codeSystemName="LOINC" displayName="Consultation note"/>
                <reference value="#ConsultNote1"/>
            <statusCode code="completed"/>
            <!-- Clinically-relevant time of the note -->
            <effectiveTime value="20160908"/>
            <!-- Author Participation -->
                <templateId root="2.16.840.1.113883."/>
                <!-- Time note was actually written -->
                <time value="20160908083215-0500"/>
                    <!-- Full author information is elsewhere in the document . -->
                    <id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c"/>
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