Entry Reference_2.16.840.1.113883.10.20.22.4.122

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SDWG Supported Sample from Implementation Guide

The initial load of this repository in January 2021 includes all examples (figures) from the June 2019 Errata published PDF of C-CDA 2.1 and 2019 release of C-CDA Companion Guide.

These examples were reviewed through the HL7 ballot process. They have not been formally reviewed/approved by the examples task force.

Keywords:

Entry Reference

2.16.840.1.113883.10.20.22.4.122

 

Example: Diagnosis Reference Example.xml download example view on GitHub

<!-- Show how an encounter can include a discharge diagnosis which references an 
       item on the problem list using the Entry Reference template -->
<ClinicalDocument>
  <!-- This ClinicalDocument's structure is stubbed with the minimum elements necessary
       to demonstrate the locations of the entries across multiple different sections;
       however, required content like the document header and section LOINC codes
       has been omitted. -->
  <component>
    <structuredBody>
      <component>
        <!-- Problem Section -->
        <section>
          <!-- ... -->
          <entry>
            <observation classCode="OBS" moodCode="EVN">
              <id root="1234567" />
              <code code="123" codeSystem="1.2.3" displayName="asthma" />
            </observation>
          </entry>
        </section>
      </component>
      <!-- ... -->
      <component>
        <!-- Encounter Section -->
        <section>
          <entry>
            <encounter classCode="ENC" moodCode="EVN">
              <!-- ... -->
              <entryRelationship typeCode="COMP">
                <act>
                  <code code="145" codeSystem="4.5.6" displayName="discharge diagnosis" />
                  <templateId root="2.16.840.1.113883.10.20.22.4.33" extension="2014-06-09" />
                  <!-- this is for illustrative purposes only. In this particular 
                      case, the template requires a nested Problem 
                      Observation (V2). In the Health Concern template, 
                      we'd need a constraint that says it's allowable to 
                      include the Entry Reference template. -->
                  <entryRelationship typeCode="SUBJ">
                    <act classCode="ACT" moodCode="XXX">
                      <templateId root="2.16.840.1.113883.10.20.22.4.122" />
                      <id root="1234567" />
                      <code nullFlavor="NP" />
                    </act>
                  </entryRelationship>
                </act>
              </entryRelationship>
            </encounter>
          </entry>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>

Example: Entry Reference Example.xml download example view on GitHub

<ClinicalDocument>
  <!-- This ClinicalDocument's structure is stubbed with the minimum elements necessary
       to demonstrate the locations of the entries across multiple different sections;
       however, required content like the document header and section LOINC codes
       has been omitted. -->
  <component>
    <structuredBody>
      <component>
        <!-- 
            ********************************************************
            Health Concern section
            ********************************************************
        -->
        <section>
          <entry>
            <act classCode="ACT" moodCode="EVN">
              <!-- Health Concern Act of a pneumonia diagnosis -->
              <templateId root="2.16.840.1.113883.10.20.22.4.132" />
              <id root="4eab0e52-dd7d-4285-99eb-72d32ddb195c" />
              <code code="75310-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Health Concern" />
              <statusCode code="active" />
              <effectiveTime value="20130616" />
              <entryRelationship typeCode="REFR">
                <!-- Problem Observation (V2) -->
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2014-06-09" />
                  <id root="8dfacd73-1682-4cc4-9351-e54ccea83612" />
                  <code code="29308-4" 
                    codeSystem="2.16.840.1.113883.6.1" 
                    codeSystemName="LOINC" 
                    displayName="Diagnosis"/>
                  <statusCode code="completed" />
                  <effectiveTime>
                    <!-- Date of diagnosis -->
                    <low value="20130616" />
                  </effectiveTime>
                  <value xsi:type="CD" code="233604007" 
                    codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED" 
                    displayName="Pneumonia" />
                  <!-- This Entry Reference refers to a goal, intervention, actual 
                       outcome, or some other entry present in the Care Plan
                       that the Health Concern is related to-->
                  <entryRelationship typeCode="REFR">
                    <act classCode="ACT" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.22.4.122" />
                      <!-- This ID equals the ID of the goal of a pulse 
                        ox greater than 92% -->
                      <id root="3700b3b0-fbed-11e2-b778-0800200c9a66" />
                      <!-- The code is nulled to "NP" Not Present" -->
                      <code nullFlavor="NP" />
                      <statusCode code="completed" />
                    </act>
                  </entryRelationship>
                </observation>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
        <!-- 
            ********************************************************
            Expected Outcomes/Goals section
            ********************************************************
        -->
          <entry>
            <!-- This is an observation about the expected outcome of a pulse ox reading
                 of 92 or greater.  The Id is the same as the ID as the ID of the 
                 pneumonia problem above  -->
            <observation classCode="OBS" moodCode="GOL">
              <id root="3700b3b0-fbed-11e2-b778-0800200c9a66" />
              <code code="59408-5" 
                codeSystem="2.16.840.1.113883.6.1" 
                codeSystemName="LOINC" 
                displayName="Oxygen saturation in Arterial blood by Pulse oximetry"/>
              <statusCode code="active" />
              <value xsi:type="IVL_PQ">
                <low value="92" unit="%" />
              </value>
              <!-- There could be another Entry Reference here referring to the 
                   related health concern, actual outcome, or intervention -->
            </observation>
          </entry>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>
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