Outpatient Encounter with Diagnoses

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 5/7/2015
  • SDWG: 5/28/2015
  • SDWG C-CDA R2.1 Upgrade: 2/2/2017

C-CDA 2.1 Example:

  • 2.16.840.1.113883.
  • 2.16.840.1.113883.
  • 2.16.840.1.113883.
  • 2.16.840.1.113883.
  • 2.16.840.1.113883.
  • 2.16.840.1.113883.

Reference to full CDA sample:

  • Encounter in empty CCD

Validation location


  • This example illustrates how to structure Encounter Diagnosis for the 170.314(b)(2) Transitions of care - L) Encounter Diagnosis


  • Lisa Nelson (GitHub: lisarnelson)


  • ONC


  • Outpatient Visit, Encounter Diagnoses, performer, visit location




Example: download example view on GitHub

    <!-- *** Encounters section (entries required) (V3) *** -->
    <templateId root="2.16.840.1.113883." extension="2015-08-01"/>
    <templateId root="2.16.840.1.113883."/>
    <code code="46240-8" codeSystem="2.16.840.1.113883.6.1" displayName="Encounters"/>
        <table border="1" width="100%">
                    <th>Encounter date</th>
                    <th>Diagnosis Status</th>
                <tr ID="Encounter1">
                    <td ID="Encounter1_type">Office outpatient visit</td>
                    <td>Dr. Samir Kahn <content ID="Encounter1_performer_type">Internal Medicine</content> </td>
                    <td>Community Urgent Care (Urgent Care Center)
                        <paragraph>1004 Healthcare Dr.</paragraph>
                        <paragraph>Portland, OR  97005</paragraph>
                    <td>August 15, 2012</td>
                    <td ID="Encounter1_diagnosis">Costal Chondritis</td>
                    <td ID="Encounter1_diagnosis_status">Active</td>
    <entry typeCode="DRIV">
        <encounter classCode="ENC" moodCode="EVN">
            <!-- ** Encounter Activity (V3) ** -->
            <templateId root="2.16.840.1.113883." extension="2015-08-01"/>
            <templateId root="2.16.840.1.113883."/>
            <id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
            <!-- Selected reasonable encounter/code. Not in test data -->
            <code code="99213" displayName="Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter."
                codeSystemName="CPT" codeSystem="2.16.840.1.113883.6.12"
                <originalText><reference value="#Encounter1_type"/>
            <text><reference value="#Encounter1" /></text>
            <!-- August 15, 2012 - added time (pacific time) since but not present in test data -->
            <effectiveTime value="201208151000-0800"/>
            <!-- Not specified in test data, but could infer Dr. Khan from the test scenario narrative-->
                    <!-- Fake Provider NPI "12345678910" -->
                    <id root="2.16.840.1.113883.4.6" extension="12345678910"/>
                    <code code="207R00000X" codeSystem="2.16.840.1.113883.6.101"
                        codeSystemName="Health Care Provider Taxonomy" 
                        displayName="Allopathic &amp; Osteopathic Physicians; Internal Medicine">
                        <originalText><reference value="Encounter1_performer_type" /></originalText>
                            <!--  Could alternately use <suffix>MD</suffix> -->
            <participant typeCode="LOC">
                <!-- Location is inferred from the care team address in test data -->
                <participantRole classCode="SDLOC">
                    <templateId root="2.16.840.1.113883."/>
                    <!-- Service Delivery Location template -->
                    <code code="1160-1" codeSystem="2.16.840.1.113883.6.259"
                        displayName="Urgent Care Center"/>
                        <streetAddressLine>1004 Healthcare Dr.</streetAddressLine>
                    <telecom value="tel:+1(555)555-1004"/>
                    <playingEntity classCode="PLC">
                        <name>Get Well Clinic</name>
            <entryRelationship typeCode="REFR">
                <act classCode="ACT" moodCode="EVN">
                    <!-- Encounter Diagnosis -->
                    <templateId root="2.16.840.1.113883." extension="2015-08-01" />
                    <templateId root="2.16.840.1.113883."/>
                    <code code="29308-4" displayName="Diagnosis"
                    <!-- This example uses the Problem Status Observation to represent status of the diagnosis.
                                     The statusCode of the encounter diagnosis is an alternative approach.-->
                    <entryRelationship typeCode="SUBJ">
                        <observation classCode="OBS" moodCode="EVN">
                            <!-- Problem Observation -->
                            <templateId root="2.16.840.1.113883." extension="2015-08-01" />
                            <templateId root="2.16.840.1.113883."/>
                            <id root="db734647-fc99-424c-a864-7e3cda82e704"/>
                            <code code="282291009" displayName="Diagnosis interpretation" codeSystem="2.16.840.1.113883.6.96"
                                codeSystemName="SNOMED CT">
                                <translation code="29308-4" displayName="Diagnosis" codeSystem="2.16.840.1.113883.6.1"
                            <statusCode code="completed"/>
                            <!-- This same data may be represented in the Problem List -->
                                <low value="20120815"/>
                            <!-- Test data is SNOMED but in practice this is probably an ICD9/10 code -->
                            <value xsi:type="CD" code="64109004" displayName="Costal chondritis"
                                <originalText><reference value="#Encounter1_diagnosis" /></originalText>
                            <entryRelationship typeCode="REFR">
                                <observation classCode="OBS" moodCode="EVN"> 
                                    <!-- Problem Status which is strange on an encounter diagnosis but 
                                                         included due to the test data -->
                                    <!-- C-CDA R2.0 deprecated this template -->
                                    <templateId root="2.16.840.1.113883."/>
                                    <code code="33999-4" displayName="Status"
                                    <statusCode code="completed"/>
                                    <value xsi:type="CD" code="55561003" displayName="Active"
                                        <originalText><reference value="#Encounter1_diagnosis_status" /></originalText>
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