Parent Document Replace Relationship

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Example metadata last updated 2017-08-06 10:15:50.456000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 5/4/2017
  • SDWG: 5/18/2017

SITE C-CDA Validator

Certification

Comments:

  • This is an example of how a continuity of care document (or other document) may reference parent documents. This one replaces a previous document.

Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)

Full sample: This is a complete document for validation

Example: download example view on GitHub

<?xml version="1.0" encoding="UTF-8"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!--
	This sample shows a document which replaces a prior clinical document (e.g. CCD)
	The reason for this example is to demonstrate the use of relatedDocument@typeCode="RPLC"
	No clinical data is contained in any of the sections 
	Look to lines 364 for the relevant illustrative example xml
 -->
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" 
	xmlns:voc="urn:hl7-org:v3/voc" xmlns:sdtc="urn:hl7-org:sdtc">
	<realmCode code="US"/>
	<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
	<!-- US Realm Header ID-->
	<templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2015-08-01"/>
	<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
	<!-- CCD template ID-->
	<templateId root="2.16.840.1.113883.10.20.22.1.2" extension="2015-08-01"/>
	<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
	<!-- Globally unique identifier for the document  -->
	<id extension="TT662" root="2.16.840.1.113883.19.5.99999.1"/>
	<code code="34133-9" displayName="Summarization of Episode Note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
	<!-- Title of this document -->
	<title>CCD Demonstrating Replacement of Prior CCD</title>
	<effectiveTime value="20150722180000-0500" />
	<confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality"/>
	<languageCode code="en-US"/>
	<setId root="004bb033-b948-4f4c-b5bf-a8dbd7d8dd40"/>
	<!-- Version of this document -->
	<versionNumber value="2"/>
	<recordTarget>
		<patientRole>
			<id extension="414122222" root="2.16.840.1.113883.4.1"/>
			<!-- Example Social Security Number using the actual SSN OID. -->
			<addr use="HP">
				<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
				<streetAddressLine>1357 Amber Dr</streetAddressLine>
				<city>Beaverton</city>
				<state>OR</state>
				<postalCode>97006</postalCode>
				<country>US</country>
				<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
			</addr>
			<telecom value="tel:+1(555)-777-1234" use="MC"/>
			<telecom value="tel:+1(555)-723-1544" use="HP"/>
			<!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
			<patient>
				<name use="L">
					<given>Richard</given>
					<family>Maur</family>
					<suffix>jr</suffix>
				</name>
				<administrativeGenderCode code="M" displayName="Male" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender"/>
				<!-- Date of birth need only be precise to the day -->
				<birthTime value="19800801"/>
				<maritalStatusCode nullFlavor="NI"/>
				<religiousAffiliationCode code="1013" displayName="Christian (non-Catholic, non-specific)" codeSystem="2.16.840.1.113883.5.1076" codeSystemName="HL7 Religious Affiliation"/>
				<raceCode nullFlavor="UNK"/>
				<sdtc:raceCode nullFlavor="UNK"/>
				<ethnicGroupCode nullFlavor="UNK"/>
				<languageCommunication>
					<languageCode code="en"/>
					<modeCode code="ESP" displayName="Expressed spoken"
						codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/>
					<preferenceInd value="true"/>
				</languageCommunication>
			</patient>
			<providerOrganization>
				<id extension="99999999" root="2.16.840.1.113883.4.6"/>
				<name>Community Health and Hospitals</name>
				<telecom use="WP" value="tel:+1(555)-555-5000"/>
				<addr>
					<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
					<city>Portland</city>
					<state>OR</state>
					<postalCode>97266</postalCode>
					<country>US</country>
				</addr>
			</providerOrganization>
		</patientRole>
	</recordTarget>
	<!-- The author represents the person who provides the content in the document -->
	<author>
		<time value="20150722"/>
		<assignedAuthor>
			<id extension="111111" root="2.16.840.1.113883.4.6"/>
			<code code="281P00000X" codeSystem="2.16.840.1.113883.6.101"
				displayName="Chronic Disease Hospital"/>
			<addr>
				<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
				<city>Portland</city>
				<state>OR</state>
				<postalCode>97266</postalCode>
				<country>US</country>
			</addr>
			<telecom use="WP" value="tel:+1(555)-555-1002"/>
			<assignedPerson>
				<name>
					<prefix>Dr</prefix>
					<given>Henry</given>
					<family>Seven</family>
				</name>
			</assignedPerson>
		</assignedAuthor>
	</author>
	<!-- The dataEnterer transferred the content created by the author into the document -->
	<dataEnterer>
		<assignedEntity>
			<id root="2.16.840.1.113883.4.6" extension="999999943252"/>
			<addr>
				<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
				<city>Portland</city>
				<state>OR</state>
				<postalCode>97266</postalCode>
				<country>US</country>
			</addr>
			<telecom use="WP" value="tel:+1(555)-555-1002"/>
			<assignedPerson>
				<name>
					<given>Mary</given>
					<family>McDonald</family>
				</name>
			</assignedPerson>
		</assignedEntity>
	</dataEnterer>
	<!-- The informant represents any sources of information for document content -->
	<informant>
		<assignedEntity>
			<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
			<addr>
				<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
				<city>Portland</city>
				<state>OR</state>
				<postalCode>97266</postalCode>
				<country>US</country>
			</addr>
			<telecom use="WP" value="tel:+1(555)-555-1002"/>
			<assignedPerson>
				<name>
					<given>Henry</given>
					<family>Seven</family>
				</name>
			</assignedPerson>
		</assignedEntity>
	</informant>
	<informant>
		<relatedEntity classCode="PRS">
			<!-- classCode PRS represents a person with personal relationship with the patient. -->
			<code code="SPS" displayName="SPOUSE" codeSystem="2.16.840.1.113883.1.11.19563"
				codeSystemName="Personal Relationship Role Type Value Set"/>
			<relatedPerson>
				<name>
					<given>Caroline</given>
					<family>Maur</family>
				</name>
			</relatedPerson>
		</relatedEntity>
	</informant>
	<!-- The custodian represents the organization charged with maintaining the original source document -->
	<custodian>
		<assignedCustodian>
			<representedCustodianOrganization>
				<id extension="99998899" root="2.16.840.1.113883.4.6"/>
				<name>Community Health and Hospitals</name>
				<telecom use="WP" value="tel:+1(555)-555-5000"/>
				<addr>
					<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
					<city>Portland</city>
					<state>OR</state>
					<postalCode>97266</postalCode>
					<country>US</country>
				</addr>
			</representedCustodianOrganization>
		</assignedCustodian>
	</custodian>
	<!-- The informationRecipient represents the intended recipient of the document -->
	<informationRecipient>
		<intendedRecipient>
			<informationRecipient>
				<name>
					<prefix>Dr</prefix>
					<given>Henry</given>
					<family>Seven</family>
				</name>
			</informationRecipient>
			<receivedOrganization>
				<name>Community Health and Hospitals</name>
			</receivedOrganization>
		</intendedRecipient>
	</informationRecipient>
	<!-- The legalAuthenticator represents the individual who is responsible for the document -->
	<legalAuthenticator>
		<time value="20150722"/>
		<signatureCode code="S"/>
		<assignedEntity>
			<id extension="999998899" root="2.16.840.1.113883.4.6"/>
			<addr>
				<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
				<city>Portland</city>
				<state>OR</state>
				<postalCode>97266</postalCode>
				<country>US</country>
			</addr>
			<telecom use="WP" value="tel:+1(555)-555-1002"/>
			<assignedPerson>
				<name>
					<prefix>Dr</prefix>
					<given>Henry</given>
					<family>Seven</family>
				</name>
			</assignedPerson>
		</assignedEntity>
	</legalAuthenticator>
	<!-- The authenticator represents the individual attesting to the accuracy of information in the document-->
	<authenticator>
		<time value="20150722"/>
		<signatureCode code="S"/>
		<assignedEntity>
			<id extension="999998899" root="2.16.840.1.113883.4.6"/>
			<addr>
				<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
				<city>Portland</city>
				<state>OR</state>
				<postalCode>97266</postalCode>
				<country>US</country>
			</addr>
			<telecom use="WP" value="tel:+1(555)-555-1002"/>
			<assignedPerson>
				<name>
					<prefix>Dr</prefix>
					<given>Henry</given>
					<family>Seven</family>
				</name>
			</assignedPerson>
		</assignedEntity>
	</authenticator>
	<!-- The participant represents supporting entities -->
	<participant typeCode="IND">
		<!-- patient's grandfather -->
		<associatedEntity classCode="PRS">
			<code code="GPARNT" displayName="grandparent" codeSystem="2.16.840.1.113883.1.11.19563"
				codeSystemName="Personal Relationship Role Type Value Set"/>
			<addr use="HP">
				<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
				<streetAddressLine>1357 Amber Dr</streetAddressLine>
				<city>Beaverton</city>
				<state>OR</state>
				<postalCode>97006</postalCode>
				<country>US</country>
				<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
			</addr>
			<telecom value="tel:+1(555)-723-1544" use="HP"/>
			<associatedPerson>
				<name>
					<prefix>Mr.</prefix>
					<given>Issac</given>
					<family>Maur</family>
				</name>
			</associatedPerson>
		</associatedEntity>
	</participant>
	<!-- Note: Entities playing multiple roles are recorded in multiple participants -->
	<participant typeCode="IND">
		<!-- patient's spouse -->
		<associatedEntity classCode="PRS">
			<code code="SPS" displayName="SPOUSE" codeSystem="2.16.840.1.113883.1.11.19563"
				codeSystemName="Personal Relationship Role Type Value Set"/>
			<addr use="HP">
				<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
				<streetAddressLine>1357 Amber Dr</streetAddressLine>
				<city>Beaverton</city>
				<state>OR</state>
				<postalCode>97006</postalCode>
				<country>US</country>
				<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
			</addr>
			<telecom value="tel:+1(555)-723-1544" use="HP"/>
			<associatedPerson>
				<name>
					<prefix>Ms</prefix>
					<given>Caroline</given>
					<family>Maur</family>
				</name>
			</associatedPerson>
		</associatedEntity>
	</participant>	
	<documentationOf>
		<serviceEvent classCode="PCPR">
			<code code="423123007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"
				displayName="Burn by Fire"/>
			<effectiveTime>
				<low value="2015072218-0500"/>
				<high value="2015072223-0500"/>
			</effectiveTime>
			<!-- since there are two Care Team members we need two performer elements. -db -->
			<!-- Note: example of Care Team here:
			https://github.com/gecole/HL7-Task-Force-Examples/blob/master/CareTeamToC170.314b2Ambulatory.xml
			db -->
			<performer typeCode="PRF">
				<functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88" codeSystemName="ParticipationFunction" displayName="Primary Care Provider">
					<originalText>Primary Care Provider</originalText>
				</functionCode>
				<assignedEntity>
					<id extension="5555555555" root="2.16.840.1.113883.4.6"/>
					<code code="207QA0505X" displayName="Adult Medicine" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/>
					<addr>
						<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
						<city>Portland</city>
						<state>OR</state>
						<postalCode>97266</postalCode>
						<country>US</country>
					</addr>
					<telecom use="WP" value="tel:+1(555)-555-1002"/>
					<assignedPerson>
						<name>
							<prefix qualifier="TITLE">Dr</prefix>
							<given>Henry</given>
							<family>Seven</family>
						</name>
					</assignedPerson>
					<representedOrganization>
						<id extension="99998899" root="2.16.840.1.113883.4.6"/>
						<name>Community Health and Hospitals</name>
						<telecom use="WP" value="tel:+1(555)-555-5000"/>
						<addr>
							<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
							<city>Portland</city>
							<state>OR</state>
							<postalCode>97266</postalCode>
							<country>US</country>
						</addr>
					</representedOrganization>
				</assignedEntity>
			</performer>
			<performer typeCode="PRF">
				<!-- we do not have a function code for this person since recording as RN for now -->
				<time>
					<low nullFlavor="UNK"/>
				</time>
				<assignedEntity>
					<!-- this provider has an id, but it is not an NPI  -->
					<id extension="91138" root="1.3.6.1.4.1.22812.4.99930.4"/>
					<!-- the provider is a Registered Nurse - may not be so -->
					<!-- note: we don't know what Mary is from the test data
						 but since not specified, RN should not be an issue -db -->
					<code codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC Health Care Provider Taxonomy" code="163W00000X" displayName="Registered Nurse"/>
					<addr>
						<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
						<city>Portland</city>
						<state>OR</state>
						<postalCode>97266</postalCode>
						<country>US</country>
					</addr>
					<telecom use="WP" value="tel:+1(555)-555-1002"/>
					<assignedPerson>
						<name>
							<given>Mary</given>
							<family>McDonald</family>
						</name>
					</assignedPerson>
				</assignedEntity>
			</performer>			
		</serviceEvent>
	</documentationOf>
	<!-- ******************************************************** START OF RELATED DOCUMENT EXAMPLE ******************************************************** -->
	<!-- This is the illustrative part of this example
	This replaces a previous continuity of care (CCD) document -->
	<relatedDocument typeCode="RPLC">
		<parentDocument>
			<id extension="TT661" root="2.16.840.1.113883.19.5.99999.1"/>
			<code code="34133-9" displayName="Summarization of Episode Note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
			<!-- While not required, there is a benefit of using <setId> and <versionNumber> as a secondary key on documents.   
			If the flow from a document source system or repository to a destination system is infrequent or  not able to guarantee 
			sequential transmission of  document revisions.  The setId and versionNumber pair are actually better for detecting which 
			new document revises a previous older version of that document.  -->
			<!-- If setId and versionNumber are not available or applicable, they may be omitted -->
			<setId root="004bb033-b948-4f4c-b5bf-a8dbd7d8dd40"/>
			<versionNumber value="1"/>
		</parentDocument>
	</relatedDocument>
	<!-- ******************************************************** END OF RELATED DOCUMENT EXAMPLE ******************************************************** -->
	<!-- added componentOf to represent encounter and to represent length of stay better as per SME suggestion -db -->
	<componentOf>
		<encompassingEncounter>
			<id extension="9937012" root="2.16.840.1.113883.19"/>
			<effectiveTime>
				<!-- represents length of time spent in hospital -db -->
				<low value="2015072218-0500"/>
				<high value="2015072223-0500"/>
			</effectiveTime>			
		</encompassingEncounter>
	</componentOf>
	<!-- ******************************************************** CDA Body ******************************************************** -->
	<component>
		<structuredBody>

			<!-- ***************** ALLERGIES *************** -->
			<!-- No known allergies -->
			<component>
				<section>
					<!-- *** Allergies and Intolerances Section (entries required) (V3) *** -->
					<templateId root="2.16.840.1.113883.10.20.22.2.6.1" extension="2015-08-01"/>
					<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
					<!-- Alerts section template -->
					<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<title>ALLERGIES AND ADVERSE REACTIONS</title>
					<text>No Known Drug Allergies</text>
					<!-- replaced Allergy Problem Act (R1.1) with 
					Allergy Concern Act (V3) to meet R2.1 validation requirements -DB-->
					<entry typeCode="DRIV">
						<act classCode="ACT" moodCode="EVN">
							<!-- ** Allergy Concern Act (V3) ** -->
							<templateId root="2.16.840.1.113883.10.20.22.4.30" extension="2015-08-01"/>
							<!--Critical Change-->
							<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
							<id root="36e3e930-7b15-11db-9fe1-0831200c9a66"/>
							<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
							<!-- The statusCode represents the need to continue tracking the allergy -->
							<!-- This is of ongoing concern to the provider -->
							<statusCode code="active"/>
							<effectiveTime>
								<!-- The low value represents when the allergy was first recorded in the patient's chart -->
								<low value="20150722"/>
							</effectiveTime>
							<entryRelationship typeCode="SUBJ">
								<!-- using negationInd="true" to signify that there are is NO food allergy (disorder) allergy -db -->
								<observation classCode="OBS" moodCode="EVN" negationInd="true">
									<!-- ** Allergy observation (V2) ** -->
									<templateId root="2.16.840.1.113883.10.20.22.4.7" extension="2014-06-09"/>
									<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
									<id root="4adc1020-7b16-11db-9fe1-0832200c9a66"/>
									<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
									<statusCode code="completed"/>
									<effectiveTime nullFlavor="NA"/>
									<!-- using Drug allergy (disorder) along with negationInd instead -db -->
									<value xsi:type="CD" code="416098002"
										displayName="Drug allergy (disorder)"
										codeSystem="2.16.840.1.113883.6.96"
										codeSystemName="SNOMED CT">
									</value>
									<!-- In C-CDA R2 the participant is required. The SNOMED code ="105590001" displayName="Substance" could be used in the participant-->									
									<participant typeCode="CSM">
										<participantRole classCode="MANU">
											<playingEntity classCode="MMAT">
												<code nullFlavor="NA"/>
											</playingEntity>
										</participantRole>
									</participant>
								</observation>
							</entryRelationship>
						</act>
					</entry>					
				</section>
			</component>

			<!-- ******************************* MEDICATIONS ***************************** -->
			<!-- No known medications -->			
			<component>
				<section>
					<!-- *** Medications Section (entries required) (V2) *** -->
					<templateId root="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09"/>
					<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
					<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF MEDICATION USE"/>
					<title>MEDICATIONS</title>
					<text>No known Medications</text>
					<entry>
						<!-- Act.actionNegationInd -->
						<substanceAdministration moodCode="EVN" classCode="SBADM" negationInd="true">
							<!-- ** Medication Activity (V2) ** -->
							<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
							<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
							<id root="cdbd33f0-6cde-11db-9fe1-0833200c9a66"/>
							<statusCode code="active"/>
							<effectiveTime nullFlavor="NA"/>
							<doseQuantity nullFlavor="NA"/>
							<consumable>
								<manufacturedProduct classCode="MANU">
									<!-- ** Medication information ** -->
									<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
									<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
									<manufacturedMaterial>
										<code nullFlavor="OTH" codeSystem="2.16.840.1.113883.6.88"> 
											<translation code="410942007" displayName="drug or medication"
												codeSystem="2.16.840.1.113883.6.96"            
												codeSystemName="SNOMED CT"/>
										</code>
									</manufacturedMaterial>
								</manufacturedProduct>
							</consumable>
						</substanceAdministration>
					</entry>
				</section>
			</component>

			<!-- ******************************* MEDICATIONS ADMINISTERED			***************************** 
				NO known medications 
			-->
			<component>
				<section>
					<!-- The section contains the medications taken by the patient prior to 
					and 
					at the time of admission to the facility. -->
					<!-- Admission Medications Section (entries optional) (V3) -->
					<templateId root="2.16.840.1.113883.10.20.22.2.44" extension="2015-08-01"/>
					<templateId root="2.16.840.1.113883.10.20.22.2.44"/>
					<code code="42346-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MEDICATIONS ON ADMISSION"/>
					<title>Admission Medications</title>
					<text>No Medications Administered</text>
					<entry>
						<!-- Act.actionNegationInd -->
						<substanceAdministration moodCode="EVN" classCode="SBADM" negationInd="true">
							<!-- ** Medication Activity (V2) ** -->
							<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
							<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
							<id root="cdbd33f0-6cde-11db-9fe1-0834200c9a66"/>
							<statusCode code="active"/>
							<effectiveTime nullFlavor="NA"/>
							<doseQuantity nullFlavor="NA"/>
							<consumable>
								<manufacturedProduct classCode="MANU">
									<!-- ** Medication information ** -->
									<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
									<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
									<manufacturedMaterial>
										<code nullFlavor="OTH" codeSystem="2.16.840.1.113883.6.88"> 
											<translation code="410942007" displayName="drug or medication"
												codeSystem="2.16.840.1.113883.6.96"            
												codeSystemName="SNOMED CT"/>
										</code>
									</manufacturedMaterial>
								</manufacturedProduct>
							</consumable>
						</substanceAdministration>
					</entry>
				</section>
			</component>	
			<!-- Added Discharge Medications Section (entries required) (V3) No known medications -->
			<component>
				<section nullFlavor="NI">
					<!-- Discharge Medications Section (entries required) (V3) -->
					<templateId root="2.16.840.1.113883.10.20.22.2.11.1" extension="2015-08-01" />
					<templateId root="2.16.840.1.113883.10.20.22.2.11.1" />
					<code code="10183-2" displayName="Hospital Discharge Medications"
												codeSystem="2.16.840.1.113883.6.1"
												codeSystemName="LOINC">
						<translation code="75311-1" displayName="Discharge Medications"
													codeSystem="2.16.840.1.113883.6.1"
													codeSystemName="LOINC"/>
					</code>
					<title>Discharge Medications</title>
					<text>No Information</text>
				</section>
			</component>			

			<!-- ***************** PROBLEM LIST *********************** -->
			<!-- No known problems -->		
			<component>
				<section>
					<!--  *** Problem Section (entries required) (V3) *** -->
					<templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
					<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
					<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROBLEM LIST"/>
					<title>PROBLEMS</title>
					<text ID="Concern_1">
						<content ID="problems1">No known <content ID="problemType1">health problems</content>
						</content>
					</text>
					<entry typeCode="DRIV">
						<!-- Problem Concern Act -->	
						<act classCode="ACT" moodCode="EVN">
							<!-- ** Problem Concern Act (V3) ** -->
							<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
							<templateId root="2.16.840.1.113883.10.20.22.4.3" />
							<id root="36e3e930-7b14-11db-9fe1-0835200c9a66"/>
							<!-- SDWG supports 48765-2 or CONC in the code element -->
							<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
							<text>
								<reference value="#Concern_1"/>
							</text>
							<statusCode code="active"/>
							<!-- The concern is not active, in terms of there being an active condition to be managed.-->
							<effectiveTime>
								<low value="20150722"/>
								<!-- Time at which THIS concern began being tracked.-->
							</effectiveTime>
							<!-- status is active so high is not applicable. If high is present it should have nullFlavor of NA-->
							<entryRelationship typeCode="SUBJ">
								<!-- Model of Meaning for No Problems -->
								<!-- The use of negationInd corresponds with the newer Observation.ValueNegationInd -->
								<!-- The negationInd = true negates the value element. --> 
								<!-- problem observation template -->
								<observation classCode="OBS" moodCode="EVN" negationInd="true">
									<!-- ** Problem observation  (V3)** -->
									<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
									<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
									<id root="4adc1021-7b14-11db-9fe1-0836200c9a67"/>
									<!-- updated for R2.1 -db -->
									<code code="55607006" displayName="Problem" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96">
										<!-- This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
										<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem"/>
									</code>									
									<text>
										<reference value="#problems1"/>
									</text>
									<statusCode code="completed"/>
									<!-- The time when this was biologically relevant ie True for the patient. -->
									<!-- As a minimum time interval over which this is true, populate the effectiveTime/low with the current time. -->
									<!-- It would be equally valid to have a longer range of time over which this statement was represented as being true. -->
									<!-- As a maximum, you would never indicate an effectiveTime/high that was greater than the current point in time. -->
									<effectiveTime>
										<low value="20150722"/>
									</effectiveTime>
									<!-- This idea assumes that the value element could come from the Problem value set, or-->
									<!-- when negationInd was true, is could also come from the ProblemType value set (and code would be ASSERTION). -->
									<value xsi:type="CD" code="55607006"
										displayName="Problem"
										codeSystem="2.16.840.1.113883.6.96"
										codeSystemName="SNOMED CT">
										<originalText>
											<reference value="#problems1"/>
										</originalText>
									</value>
								</observation>
							</entryRelationship>
						</act>
					</entry>
				</section>
			</component>

			<!-- ************************ ENCOUNTERS *********************** -->
			<!-- No known encounters -->
			<component>
				<section nullFlavor="NI">
					<!-- *** Encounters section (entries required) (V3) *** -->
					<templateId root="2.16.840.1.113883.10.20.22.2.22.1" extension="2015-08-01"/>
					<templateId root="2.16.840.1.113883.10.20.22.2.22.1"/>
					<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
					<title>ENCOUNTERS</title>
					<text>No Encounters</text>
				</section>
			</component>

			<!-- ************** PROCEDURES ***************** -->
			<!-- edited as per test doc - all of this data is directly relevant -db -->
			<!-- (NO) UDI section based off of 	https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Implanted_Devices.xml 
			-db -->
			<!-- ************** PROCEDURES and UDI ***************** -->
			<component>
				<!-- nullFlavor of NI indicates No Information.-->
				<section nullFlavor="NI">
					<templateId root="2.16.840.1.113883.10.20.22.2.7" extension="2014-06-09" />
					<!-- Procedures section template -->
					<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURES" />
					<title>Procedures</title>
					<text>No Information</text>
				</section>
			</component>


			<!-- ************** No UDI ***************** -->
			<component>
				<section>
					<!-- Medical equipment section -->
					<templateId root="2.16.840.1.113883.10.20.22.2.23" extension="2014-06-09"/>
					<code code="46264-8" codeSystem="2.16.840.1.113883.6.1" />
					<title>MEDICAL EQUIPMENT</title>
					<!-- Alternative text: Patient has no history of procedures with implantable devices'-->
					<!-- Alternative text: Patient has no implanted devices'-->
					<text>
						<paragraph ID="Proc2">Patient has no history of implantable devices</paragraph>
					</text>				
					<entry>
						<procedure classCode="PROC" moodCode="EVN" negationInd="true">
							<!-- Procedure Activity Procedure V2-->
							<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
							<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
							<id root="d5b614bd-01ce-410d-8728-e1fd01dcc72a" />
							<code code="71388002" codeSystem="2.16.840.1.113883.6.96"   
								displayName="Procedure"/>
							<text>
								<reference value="#Proc2"/>
							</text>
							<statusCode code="completed" />
							<effectiveTime nullFlavor="NA" />
							<participant typeCode="DEV">
								<participantRole classCode="MANU">
									<templateId root="2.16.840.1.113883.10.20.22.4.37"/>
									<!-- UDI is 'not applicable' since no procedure -->
									<id nullFlavor="NA" root="2.16.840.1.113883.3.3719"/>  
									<playingDevice>
										<code code="40388003" codeSystem="2.16.840.1.113883.6.96"   
											displayName="Implant"/>
									</playingDevice>
									<scopingEntity>
										<id root="2.16.840.1.113883.3.3719"/>
									</scopingEntity>
								</participantRole>
							</participant>	
						</procedure>
					</entry>
				</section>
			</component>


			<!-- ******************** IMMUNIZATIONS ********************* -->
			<!-- No immunizations -->
			<component>
				<section>
					<!-- *** Immunizations Section (entries required) (V2) *** -->
					<templateId root="2.16.840.1.113883.10.20.22.2.2.1" extension="2014-06-09"/>
					<templateId root="2.16.840.1.113883.10.20.22.2.2.1"/>
					<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of immunizations"/>
					<title>IMMUNIZATIONS</title>
					<text>No immunization history</text>
					<entry typeCode="DRIV">
						<!-- using negationInd="true" to signify that there are no known immunizations -->
						<substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="true">
							<!-- ** Immunization Activity (V3) ** -->
							<templateId root="2.16.840.1.113883.10.20.22.4.52" extension="2015-08-01"/>
							<templateId root="2.16.840.1.113883.10.20.22.4.52"/>
							<id root="de10790f-1496-4729-8fe6-f1b87b6219f7"/>
							<statusCode code="active"/>
							<effectiveTime nullFlavor="NA"/>
							<routeCode nullFlavor="NA"/>
							<consumable>
								<manufacturedProduct classCode="MANU">
									<!-- ** Immunization Medication Information (V2) ** -->
									<templateId root="2.16.840.1.113883.10.20.22.4.54" extension="2014-06-09"/>
									<templateId root="2.16.840.1.113883.10.20.22.4.54"/>
									<manufacturedMaterial>
										<!-- there is no generic vaccine code and no known recommended way to do this - 
										leaving generic flu for now just as an example. Not sure if it makes more sense to apply a nullFlavor? -db -->
										<code nullFlavor="OTH">
											<!-- Optional original text -->
											<originalText>Vaccination</originalText>
											<translation code="71181003" displayName="vaccine"
												codeSystem="2.16.840.1.113883.6.96"
												codeSystemName="SNOMED CT"/>
										</code>
										<!-- NA since there is no immunization data -db -->
										<lotNumberText nullFlavor="NA"/>
									</manufacturedMaterial>
								</manufacturedProduct>
							</consumable>
						</substanceAdministration>
					</entry>
				</section>
			</component>

			<!-- ************* VITAL SIGNS *************** -->
			<!-- No vital signs  -db -->
			<component>
				<section nullFlavor="NI">
					<templateId root="2.16.840.1.113883.10.20.22.2.4.1" extension="2015-08-01" />
					<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="VITAL SIGNS" />
					<title>VITAL SIGNS</title>
					<text>No Recorded Vital Signs</text>
				</section>
			</component>

			<!-- ******************* SOCIAL HISTORY ********************* -->
			<!-- edited as per test doc - most of this data is directly relevant -db -->
			<component>
				<section>
					<!--  ** Social History Section (V3) ** -->
					<templateId root="2.16.840.1.113883.10.20.22.2.17" extension="2015-08-01"/>
					<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social History"/>
					<title>SOCIAL HISTORY</title>
					<text>
						<table border="1" width="100%">
							<thead>
								<tr>
									<th>Social History Observation</th>
									<th>Description</th>
									<th>Dates Observed</th>
								</tr>
							</thead>
							<tbody>								
								<tr>
									<td>Current Smoking Status</td>
									<td>Current every day</td>
									<td>July 22, 2015</td>
								</tr>
								<tr>
									<td ID="BirthSexInfo">Birth Sex</td>
									<td>Male</td>
									<td>July 22, 2015</td>
								</tr>
							</tbody>
						</table>
					</text>					
					<!-- Current Smoking Status - July 22, 2015 -db -->
					<entry typeCode="DRIV">
						<observation classCode="OBS" moodCode="EVN">
							<!-- ** Smoking Status - Meaningful Use (V2) ** -->
							<templateId root="2.16.840.1.113883.10.20.22.4.78" extension="2014-06-09"/>
							<templateId root="2.16.840.1.113883.10.20.22.4.78"/>
							<id extension="123456789" root="2.16.840.1.113883.19"/>
							<!-- code SHALL be 72166-2 for Smoking Status - Meaningful Use (V2) -db -->
							<code code="72166-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Tobacco smoking status NHIS"/>
							<statusCode code="completed"/>
							<!-- The effectiveTime reflects when the current smoking status was observed. -->
							<effectiveTime value="20150722"/>
							<!-- The value represents the patient's smoking status currently observed. -->
							<!-- Consol Smoking Status Meaningful Use2 SHALL contain exactly one [1..1] value (CONF:1098-14810), which SHALL be selected from ValueSet Current Smoking Status 2.16.840.1.113883.11.20.9.38 STATIC 2014-09-01 (CONF:1098-14817) -db -->
							<value xsi:type="CD" code="449868002" displayName="Current every day smoker" codeSystem="2.16.840.1.113883.6.96"/>
						</observation>
					</entry>					
					<!-- removed Social history observation (V3) entry for "Alcoholic drinks per day" -db -->
					<!-- Add Birth Sex entry -->
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.200" extension="2016-06-01"/>
							<code code="76689-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Sex Assigned At Birth"/>
							<text>
								<reference value="#BirthSexInfo"/>
							</text>
							<statusCode code="completed"/>
							<effectiveTime value="20150722"/>
							<value code="M" codeSystem="2.16.840.1.113883.5.1" xsi:type="CD" displayName="Male"/>
						</observation>
					</entry>


				</section>
			</component>	

			<!-- ******************** RESULTS ************************ -->
			<!-- edited as per test doc - all of this data is directly relevant -db -->
			<component>
				<section nullFlavor="NI">
					<!-- Results Section (entries required) (V3) -->
					<templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01"/>
					<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
					<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="RESULTS"/>
					<title>RESULTS</title>
					<text>Laboratory Test: None needed. Laboratory Values/Results: No Lab Result data</text>
				</section>
			</component>			

			<!-- removed component Advance Directives as not required by test data -db -->

			<!-- removed component Family History as not required by test data -db -->

			<!-- removed component Functional Status as not required by test data (specific to 170.315(b)(1), (b)(2)) -db -->

			<!-- removed component Medical Equipment as not required by test data -db -->

			<!-- removed component Payers as not required by test data -db -->

			<!-- added Assessment -db -->			
			<!-- 
			********************************************************
			Assessment
			********************************************************
			-->
			<!-- edited as per test doc - all of this data is directly relevant -db -->
			<component>
				<section nullFlavor="NI">
					<!-- Assessment Section -db -->
					<!-- There is no R2.1 (or 2.0) version of Assessment Section, using R1.1 templateId only -db -->
					<templateId root="2.16.840.1.113883.10.20.22.2.8"/>
					<code codeSystem="2.16.840.1.113883.6.1" 
						 codeSystemName="LOINC" code="51848-0" 
						 displayName="ASSESSMENTS"/>
					<title>ASSESSMENTS</title>
					<text>No assessment information</text>
				</section>
			</component>

			<!-- ******************* PLAN OF TREATMENT ********************** -->
			<!-- edited as per test doc - all of this data is directly relevant -db -->
			<component>
				<section>
					<!--  **** Plan of Treatment Section (V2) **** -->
					<templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09"/>
					<templateId root="2.16.840.1.113883.10.20.22.2.10"/>
					<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Treatment plan"/>
					<title>TREATMENT PLAN</title>
					<text>
						No Plan of treatment
					</text>
				</section>
			</component>

			<!-- Added Goals - original version from C-CDA_R2_Care_Plan.xml from R2.0 IG package.
			     There are no duplicated template Ids with extensions -
				 as there is only one version in existence for each section and entry listed -db -->
			<!-- 
                ********************************************************
                Goals
                ********************************************************
            -->
			<!-- edited as per test doc -db -->			
			<component>
				<section nullFlavor="NI">
					<!-- Goals Section -->
					<templateId root="2.16.840.1.113883.10.20.22.2.60"/>
					<code code="61146-7" displayName="Goals" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<title>Goals Section</title>
					<text>No goal information</text>
				</section>
			</component>

			<!-- added Health Concerns -db -->
			<!-- Note: There is no R1.1 version of Health Concerns Section or Health Concern Act -
				 so there is only one templateId per section (they're NEW) -db -->
			<!-- updated as per ETF	https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Known_Health_Concerns.xml 
			-db -->
			<!-- 
			********************************************************
			Health Concerns
			********************************************************
			-->
			<!-- edited as per test doc -db -->					
			<component>
				<!-- This example records assertion of no concerns -->
				<section>
					<!-- Health Concerns Section (V2) (V1 was added as a NEW template in R2.0, V2 was updated in R2.1) -db -->
					<templateId root="2.16.840.1.113883.10.20.22.2.58" extension="2015-08-01"/>
					<code code="75310-3" displayName="Health Concerns Document"
						codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<title>Health Concerns</title>
					<!--Including ID at text element is allowed -->
					<text ID="HealthConcern_1">No Known Health Concerns on 07/22/2015</text>
					<entry typeCode="COMP">
						<!-- negationInd=true indicates no known health concerns at the stated time-->
						<act classCode="ACT" moodCode="EVN" negationInd="true">
							<!-- There is no V1 version of this template -db -->
							<templateId root="2.16.840.1.113883.10.20.22.4.132" extension="2015-08-01"/>
							<id root="4eab0e52-dd7d-4285-99eb-72d32ddb195d"/>
							<code code="75310-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
								displayName="Health Concern"/>
							<text>
								<reference value="#HealthConcern_1"/>
							</text>
							<!-- This Health Concern has a statusCode of concern because assertion is ongoing -->
							<statusCode code="active"/>
							<!-- The effective time is the date that the Health Concern started being followed - 
								this does not necessarily correlate to the onset date of the contained health issues-->
							<effectiveTime value="20150722"/>
							<!-- Time at which THIS concern began being tracked.-->
						</act>
					</entry>
				</section>
			</component>		

			<!-- 
			************************************
			HOSPITAL DISCHARGE INSTRUCTIONS
			************************************ 
			-->
			<component>
				<section>
					<!-- Hospital Discharge Instructions Section - no R2.1 version for this template -db -->
					<templateId
					  root="2.16.840.1.113883.10.20.22.2.41"/>
					<code
					  code="8653-8"
					  codeSystem="2.16.840.1.113883.6.1"
					  codeSystemName="LOINC"
					  displayName="HOSPITAL DISCHARGE INSTRUCTIONS"/>
					<title>HOSPITAL DISCHARGE INSTRUCTIONS</title>
					<!-- Unstructured text field -->
					<text>
						<list
						  listType="ordered">
							<item>Appointments: Schedule an appointment with Dr Seven after 1 week. Follow up with Outpatient facility.</item>
							<item>In case of fever, take Tylenol as advised in plan of treatment.</item>
						</list>
					</text>
				</section>
			</component>				

			<!-- removed Reason for Referral -db -->	

			<!-- added Mental Status Section (V2) (used to be NEW in R2.0) 2.16.840.1.113883.10.20.22.2.56 as required by VDT inp test data -db -->
			<!-- 
			********************************************************
			Mental Status Section
			********************************************************
			-->		
			<component>
				<section nullFlavor="NI">
					<!-- note: the IG lists the wrong templateId in its example of this section, lists ...2,14 instead of 2.56 -db -->
					<!-- There is no R1.1 version of this template -db -->
					<templateId root="2.16.840.1.113883.10.20.22.2.56" extension="2015-08-01" />
					<!-- Mental Status Section -->
					<code code="10190-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MENTAL STATUS" />
					<title>MENTAL STATUS</title>
					<text>No information</text>
				</section>	
			</component>

			<!-- added component Functional Status as required by test data -db -->
			<!-- 
			********************************************************
			FUNCTIONAL STATUS
			********************************************************
			-->			
			<component>				
				<section nullFlavor="NI">
					<!-- Functional Status Section (V2)-->
					<templateId root="2.16.840.1.113883.10.20.22.2.14" extension="2014-06-09"/>
					<!-- Functional Status Section -->
					<templateId root="2.16.840.1.113883.10.20.22.2.14"/>
					<code code="47420-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Functional Status"/>
					<title>FUNCTIONAL STATUS</title>
					<text>No information</text>
				</section>
			</component>

			<!-- added Interventions -->
			<!-- 
			********************************************************
			INTERVENTIONS
			********************************************************
			-->

			<component>
				<section nullFlavor="NI">
					<templateId root="2.16.840.1.113883.10.20.21.2.3" extension="2015-08-01" />
					<code code="62387-6" displayName="Interventions Provided" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
					<title>Interventions Section</title>
					<text>No intervention information</text>
				</section>
			</component>

		</structuredBody>
	</component>
</ClinicalDocument>
  1. C-CDA Example Search Help

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    This panel allow you to further refine your queries and narrow the results

  3. Text Search Words

    Use this field to enter words related to your search. These words can appear in the title, the comments or as part of a special list of keywords associated with the example. The search words should be entered with spaces separating the items.

  4. Filter by example status

    By selecting the various statuses, the search results can be limited to only the example that are set to the selected status(es). By removing all status selections, the filtering is removed and examples from all statuses will be returned (based on any other filtering).

  5. Select only ONC Certified examples

    These are samples referenced in a government rule or certification companion guide.

  6. Execute the search based on the criteria entered (or retrieve all examples if no criteria specified).

  7. The number of results that match the query parameters can be found here.

  8. Use this link to jump back to the initial page of the application (that lists the sections).

  9. This columns list the names of the examples that match the criteria (and the comment for each example).

  10. This columns lists the area in the C-CDA specification (the specification is broken into distinct topics for the various exchangeable documents, the common header, and the sections that occur within the exchangeable documents) that the example demonstrates.

  11. This columns lists the state of the example in the example verification and approval process.

  12. You can select to download the examples directly or navigate to page with the full detailed description of the example.

  13. Tour Complete

    Return to the C-CDA Example Search Results page.