Guide Examples Section Examples from C-CDA

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This section has 214 examples

Name Status

Admission Diagnosis Section (V3)_2.16.840.1.113883.10.20.22.2.43

None

Admission Medication (V2)_2.16.840.1.113883.10.20.22.4.36

None

Advance Directive Observation (V3)_2.16.840.1.113883.10.20.22.4.48

None

Advance Directive Organizer (V2)_2.16.840.1.113883.10.20.22.4.108

None

Advance Directives Section (entries required) (V3)_2.16.840.1.113883.10.20.22.2.21.1

None

Age Observation_2.16.840.1.113883.10.20.22.4.31

None

Allergies and Intolerances Section (entries required) (V3)_2.16.840.1.113883.10.20.22.2.6.1

None

Allergy - Intolerance Observation (V2)_2.16.840.1.113883.10.20.22.4.7

None

Allergy Concern Act (V3)_2.16.840.1.113883.10.20.22.4.30

None

Anesthesia Section (V2)_2.16.840.1.113883.10.20.22.2.25

None

Assessment Scale Observation_2.16.840.1.113883.10.20.22.4.69

None

Assessment Scale Supporting Observation_2.16.840.1.113883.10.20.22.4.86

None

Assessment Section_2.16.840.1.113883.10.20.22.2.8

None

Assessment and Plan Section (V2)_2.16.840.1.113883.10.20.22.2.9

None

Author Participation_2.16.840.1.113883.10.20.22.4.119

None

Authorization Activity_2.16.840.1.113883.10.20.1.19

None

Birth Sex Observation_2.16.840.1.113883.10.20.22.4.200

None

Boundary Observation_2.16.840.1.113883.10.20.6.2.11

None

Brand Name Observation_2.16.840.1.113883.10.20.22.4.301

None

Care Plan (V2)_2.16.840.1.113883.10.20.22.1.15

None

Care Team Member Act_2.16.840.1.113883.10.20.22.4.500.1

None

Care Team Organizer_2.16.840.1.113883.10.20.22.4.500

None

Care Team Type Observation_2.16.840.1.113883.10.20.22.4.500.2

None

Care Teams Section_2.16.840.1.113883.10.20.22.2.500

None

Caregiver Characteristics_2.16.840.1.113883.10.20.22.4.72

None

Catalog Number Observation_2.16.840.1.113883.10.20.22.4.302

None

Characteristics of Home Environment_2.16.840.1.113883.10.20.22.4.109

None

Chief Complaint Section_1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1

None

Chief Complaint and Reason for Visit Section_2.16.840.1.113883.10.20.22.2.13

None

Code Observations_2.16.840.1.113883.10.20.6.2.13

None

Comment Activity_2.16.840.1.113883.10.20.22.4.64

None

Company Name Observation_2.16.840.1.113883.10.20.22.4.303

None

Complications Section (V3)_2.16.840.1.113883.10.20.22.2.37

None

Consultation Note (V3)_2.16.840.1.113883.10.20.22.1.4

None

Continuity of Care Document (CCD) (V3)_2.16.840.1.113883.10.20.22.1.2

None

Course of Care Section_2.16.840.1.113883.10.20.22.2.64

None

Coverage Activity (V3)_2.16.840.1.113883.10.20.22.4.60

None

Criticality Observation _2.16.840.1.113883.10.20.22.4.145

None

Cultural and Religious Observation_2.16.840.1.113883.10.20.22.4.111

None

DICOM Object Catalog Section - DCM 121181_2.16.840.1.113883.10.20.6.1.1

None

Deceased Observation (V3)_2.16.840.1.113883.10.20.22.4.79

None

Device Identifier Observation_2.16.840.1.113883.10.20.22.4.304

None

Diagnostic Imaging Report (V3)_2.16.840.1.113883.10.20.22.1.5

None

Discharge Diagnosis Section (V3)_2.16.840.1.113883.10.20.22.2.24

None

Discharge Medication (V3)_2.16.840.1.113883.10.20.22.4.35

None

Discharge Medications Section (entries required) (V3)_2.16.840.1.113883.10.20.22.2.11.1

None

Discharge Summary (V3)_2.16.840.1.113883.10.20.22.1.8

None

Distinct Identification Code Observation_2.16.840.1.113883.10.20.22.4.308

None

Drug Monitoring Act_2.16.840.1.113883.10.20.22.4.123

None

Drug Vehicle_2.16.840.1.113883.10.20.22.4.24

None

Encounter Activity (V3)_2.16.840.1.113883.10.20.22.4.49

None

Encounter Diagnosis (V3)_2.16.840.1.113883.10.20.22.4.80

None

Encounters Section (entries required) (V3)_2.16.840.1.113883.10.20.22.2.22.1

None

Entry Reference_2.16.840.1.113883.10.20.22.4.122

None

Estimated Date of Delivery_2.16.840.1.113883.10.20.15.3.1

None

Expiration Date Observation_2.16.840.1.113883.10.20.22.4.309

None

External Document Reference_2.16.840.1.113883.10.20.22.4.115

None

Family History Death Observation_2.16.840.1.113883.10.20.22.4.47

None

Family History Observation (V3)_2.16.840.1.113883.10.20.22.4.46

None

Family History Organizer (V3)_2.16.840.1.113883.10.20.22.4.45

None

Family History Section (V3)_2.16.840.1.113883.10.20.22.2.15

None

Fetus Subject Context_2.16.840.1.113883.10.20.6.2.3

None

Findings Section (DIR)_2.16.840.1.113883.10.20.6.1.2

None

Functional Status Observation (V2)_2.16.840.1.113883.10.20.22.4.67

None

Functional Status Organizer (V2)_2.16.840.1.113883.10.20.22.4.66

None

Functional Status Section (V2)_2.16.840.1.113883.10.20.22.2.14

None

General Status Section_2.16.840.1.113883.10.20.2.5

None

Goal Observation_2.16.840.1.113883.10.20.22.4.121

None

Goals Section_2.16.840.1.113883.10.20.22.2.60

None

Handoff Communication Participants_2.16.840.1.113883.10.20.22.4.141

None

Health Concern Act (V2)_2.16.840.1.113883.10.20.22.4.132

None

Health Concerns Section (V2)_2.16.840.1.113883.10.20.22.2.58

None

Health Status Evaluations and Outcomes Section_2.16.840.1.113883.10.20.22.2.61

None

Health Status Observation (V2)_2.16.840.1.113883.10.20.22.4.5

None

Highest Pressure Ulcer Stage_2.16.840.1.113883.10.20.22.4.77

None

History and Physical (V3)_2.16.840.1.113883.10.20.22.1.3

None

History of Present Illness Section_1.3.6.1.4.1.19376.1.5.3.1.3.4

None

Hospital Admission Diagnosis (V3)_2.16.840.1.113883.10.20.22.4.34

None

Hospital Consultations Section_2.16.840.1.113883.10.20.22.2.42

None

Hospital Course Section_1.3.6.1.4.1.19376.1.5.3.1.3.5

None

Hospital Discharge Diagnosis (V3)_2.16.840.1.113883.10.20.22.4.33

None

Hospital Discharge Instructions Section_2.16.840.1.113883.10.20.22.2.41

None

Hospital Discharge Physical Section_1.3.6.1.4.1.19376.1.5.3.1.3.26

None

Hospital Discharge Studies Summary Section_2.16.840.1.113883.10.20.22.2.16

None

Immunization Activity (V3)_2.16.840.1.113883.10.20.22.4.52

None

Immunization Medication Information (V2)_2.16.840.1.113883.10.20.22.4.54

None

Immunization Refusal Reason_2.16.840.1.113883.10.20.22.4.53

None

Immunizations Section (entries required) (V3)_2.16.840.1.113883.10.20.22.2.2.1

None

Implantable Device Status Observation_2.16.840.1.113883.10.20.22.4.305

None

Indication (V2)_2.16.840.1.113883.10.20.22.4.19

None

Instruction (V2)_2.16.840.1.113883.10.20.22.4.20

None

Instructions Section (V2)_2.16.840.1.113883.10.20.22.2.45

None

Intervention Act (V2)_2.16.840.1.113883.10.20.22.4.131

None

Interventions Section (V3)_2.16.840.1.113883.10.20.21.2.3

None

Latex Safety Observation_2.16.840.1.113883.10.20.22.4.314

None

Longitudinal Care Wound Observation (V2)_2.16.840.1.113883.10.20.22.4.114

None

Lot or Batch Number Observation_2.16.840.1.113883.10.20.22.4.315

None

MRI Safety Observation_2.16.840.1.113883.10.20.22.4.318

None

Manufacturing Date Observation_2.16.840.1.113883.10.20.22.4.316

None

Medical Equipment Organizer_2.16.840.1.113883.10.20.22.4.135

None

Medical Equipment Section (V2)_2.16.840.1.113883.10.20.22.2.23

None

Medication Activity (V2)_2.16.840.1.113883.10.20.22.4.16

None

Medication Dispense (V2)_2.16.840.1.113883.10.20.22.4.18

None

Medication Free Text Sig_2.16.840.1.113883.10.20.22.4.147

None

Medication Information (V2)_2.16.840.1.113883.10.20.22.4.23

None

Medication Supply Order (V2)_2.16.840.1.113883.10.20.22.4.17

None

Medications Administered Section (V2)_2.16.840.1.113883.10.20.22.2.38

None

Medications Section (entries required) (V2)_2.16.840.1.113883.10.20.22.2.1.1

None

Mental Status Observation (V3)_2.16.840.1.113883.10.20.22.4.74

None

Mental Status Organizer (V3)_2.16.840.1.113883.10.20.22.4.75

None

Mental Status Section (V2)_2.16.840.1.113883.10.20.22.2.56

None

Model Number Observation_2.16.840.1.113883.10.20.22.4.317

None

Non-Medicinal Supply Activity (V2)_2.16.840.1.113883.10.20.22.4.50

None

Note Activity_2.16.840.1.113883.10.20.22.4.202

None

Notes Section_2.16.840.1.113883.10.20.22.2.65

None

Number of Pressure Ulcers Observation (V3)_2.16.840.1.113883.10.20.22.4.76

None

Nutrition Assessment_2.16.840.1.113883.10.20.22.4.138

None

Nutrition Recommendation_2.16.840.1.113883.10.20.22.4.130

None

Nutrition Section_2.16.840.1.113883.10.20.22.2.57

None

Nutritional Status Observation_2.16.840.1.113883.10.20.22.4.124

None

Objective Section_2.16.840.1.113883.10.20.21.2.1

None

Observer Context_2.16.840.1.113883.10.20.6.2.4

None

Operative Note (V3)_2.16.840.1.113883.10.20.22.1.7

None

Operative Note Fluids Section_2.16.840.1.113883.10.20.7.12

None

Operative Note Surgical Procedure Section_2.16.840.1.113883.10.20.7.14

None

Outcome Observation_2.16.840.1.113883.10.20.22.4.144

None

Past Medical History (V3)_2.16.840.1.113883.10.20.22.2.20

None

Patient Referral Act_2.16.840.1.113883.10.20.22.4.140

None

Payers Section (V3)_2.16.840.1.113883.10.20.22.2.18

None

Physical Exam Section (V3)_2.16.840.1.113883.10.20.2.10

None

Physician Reading Study Performer (V2)_2.16.840.1.113883.10.20.6.2.1

None

Physician of Record Participant (V2)_2.16.840.1.113883.10.20.6.2.2

None

Plan of Treatment Section (V2)_2.16.840.1.113883.10.20.22.2.10

None

Planned Act (V2)_2.16.840.1.113883.10.20.22.4.39

None

Planned Coverage_2.16.840.1.113883.10.20.22.4.129

None

Planned Encounter (V2)_2.16.840.1.113883.10.20.22.4.40

None

Planned Immunization Activity_2.16.840.1.113883.10.20.22.4.120

None

Planned Medication Activity (V2)_2.16.840.1.113883.10.20.22.4.42

None

Planned Observation (V2)_2.16.840.1.113883.10.20.22.4.44

None

Planned Procedure (V2)_2.16.840.1.113883.10.20.22.4.41

None

Planned Procedure Section (V2)_2.16.840.1.113883.10.20.22.2.30

None

Planned Supply (V2)_2.16.840.1.113883.10.20.22.4.43

None

Policy Activity (V3)_2.16.840.1.113883.10.20.22.4.61

None

Postoperative Diagnosis Section_2.16.840.1.113883.10.20.22.2.35

None

Postprocedure Diagnosis (V3)_2.16.840.1.113883.10.20.22.4.51

None

Postprocedure Diagnosis Section (V3)_2.16.840.1.113883.10.20.22.2.36

None

Precondition for Substance Administration (V2)_2.16.840.1.113883.10.20.22.4.25

None

Pregnancy Observation_2.16.840.1.113883.10.20.15.3.8

None

Preoperative Diagnosis (V3)_2.16.840.1.113883.10.20.22.4.65

None

Preoperative Diagnosis Section (V3)_2.16.840.1.113883.10.20.22.2.34

None

Priority Preference_2.16.840.1.113883.10.20.22.4.143

None

Problem Concern Act (V3)_2.16.840.1.113883.10.20.22.4.3

None

Problem Observation (V3)_2.16.840.1.113883.10.20.22.4.4

None

Problem Section (entries required) (V3)_2.16.840.1.113883.10.20.22.2.5.1

None

Procedure Activity Act (V2)_2.16.840.1.113883.10.20.22.4.12

None

Procedure Activity Observation (V2)_2.16.840.1.113883.10.20.22.4.13

None

Procedure Activity Procedure (V2)_2.16.840.1.113883.10.20.22.4.14

None

Procedure Context_2.16.840.1.113883.10.20.6.2.5

None

Procedure Description Section_2.16.840.1.113883.10.20.22.2.27

None

Procedure Disposition Section_2.16.840.1.113883.10.20.18.2.12

None

Procedure Estimated Blood Loss Section_2.16.840.1.113883.10.20.18.2.9

None

Procedure Findings Section (V3)_2.16.840.1.113883.10.20.22.2.28

None

Procedure Implants Section_2.16.840.1.113883.10.20.22.2.40

None

Procedure Indications Section (V2)_2.16.840.1.113883.10.20.22.2.29

None

Procedure Note (V3)_2.16.840.1.113883.10.20.22.1.6

None

Procedure Specimens Taken Section_2.16.840.1.113883.10.20.22.2.31

None

Procedures Section (entries required) (V2)_2.16.840.1.113883.10.20.22.2.7.1

None

Product Instance_2.16.840.1.113883.10.20.22.4.37

None

Prognosis Observation_2.16.840.1.113883.10.20.22.4.113

None

Progress Note (V3)_2.16.840.1.113883.10.20.22.1.9

None

Progress Toward Goal Observation_2.16.840.1.113883.10.20.22.4.110

None

Provenance - Author Participation_2.16.840.1.113883.10.20.22.5.6

None

Purpose of Reference Observation_2.16.840.1.113883.10.20.6.2.9

None

Quantity Measurement Observation_2.16.840.1.113883.10.20.6.2.14

None

Reaction Observation (V2)_2.16.840.1.113883.10.20.22.4.9

None

Reason for Referral Section (V2)_1.3.6.1.4.1.19376.1.5.3.1.3.1

None

Reason for Visit Section_2.16.840.1.113883.10.20.22.2.12

None

Referenced Frames Observation_2.16.840.1.113883.10.20.6.2.10

None

Referral Note (V2)_2.16.840.1.113883.10.20.22.1.14

None

Result Observation (V3)_2.16.840.1.113883.10.20.22.4.2

None

Result Organizer (V3)_2.16.840.1.113883.10.20.22.4.1

None

Results Section (entries required) (V3)_2.16.840.1.113883.10.20.22.2.3.1

None

Review of Systems Section_1.3.6.1.4.1.19376.1.5.3.1.3.18

None

Risk Concern Act (V2)_2.16.840.1.113883.10.20.22.4.136

None

SOP Instance Observation_2.16.840.1.113883.10.20.6.2.8

None

Section Time Range Observation_2.16.840.1.113883.10.20.22.4.201

None

Self-Care Activities (ADL and IADL)_2.16.840.1.113883.10.20.22.4.128

None

Sensory Status_2.16.840.1.113883.10.20.22.4.127

None

Serial Number Observation_2.16.840.1.113883.10.20.22.4.319

None

Series Act_2.16.840.1.113883.10.20.22.4.63

None

Service Delivery Location_2.16.840.1.113883.10.20.22.4.32

None

Severity Observation (V2)_2.16.840.1.113883.10.20.22.4.8

None

Smoking Status - Meaningful Use (V2)_2.16.840.1.113883.10.20.22.4.78

None

Social History Observation (V3)_2.16.840.1.113883.10.20.22.4.38

None

Social History Section (V3)_2.16.840.1.113883.10.20.22.2.17

None

Study Act_2.16.840.1.113883.10.20.6.2.6

None

Subjective Section_2.16.840.1.113883.10.20.21.2.2

None

Substance Administered Act_2.16.840.1.113883.10.20.22.4.118

None

Surgical Drains Section_2.16.840.1.113883.10.20.7.13

None

Text Observation_2.16.840.1.113883.10.20.6.2.12

None

Tobacco Use (V2)_2.16.840.1.113883.10.20.22.4.85

None

Transfer Summary (V2)_2.16.840.1.113883.10.20.22.1.13

None

UDI Organizer_2.16.840.1.113883.10.20.22.4.311

None

US Realm Address (AD.US.FIELDED)_2.16.840.1.113883.10.20.22.5.2

None

US Realm Date and Time (DTM.US.FIELDED)_2.16.840.1.113883.10.20.22.5.4

None

US Realm Header (V3)_2.16.840.1.113883.10.20.22.1.1

None

US Realm Header for Patient Generated Document (V2)_2.16.840.1.113883.10.20.29.1

None

US Realm Patient Name (PTN.US.FIELDED)_2.16.840.1.113883.10.20.22.5.1

None

Unstructured Document (V3)_2.16.840.1.113883.10.20.22.1.10

None

Vital Sign Observation (V2)_2.16.840.1.113883.10.20.22.4.27

None

Vital Signs Organizer (V3)_2.16.840.1.113883.10.20.22.4.26

None

Vital Signs Section (entries required) (V3)_2.16.840.1.113883.10.20.22.2.4.1

None

Wound Characteristic_2.16.840.1.113883.10.20.22.4.134

None

Wound Measurement Observation_2.16.840.1.113883.10.20.22.4.133

None
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