This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions
Ccd-example.xml

Raw XML (canonical form)
Example CCD (id = "ccd-example")
<Composition xmlns="http://hl7.org/fhir">
    <id value="ccd-example"/>
    <text><status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: ccd-example</p><p><b>identifier</b>: 1</p><p><b>date</b>: 14/02/2016 8:10:14 PM</p><p><b>type</b>: Summary of episode note <span>(Details : {LOINC code '34133-9' = 'Summary of episode note', given as 'Summary of episode
           note'})</span></p><p><b>title</b>: Continuity of Care Document</p><p><b>status</b>: preliminary</p><p><b>confidentiality</b>: N</p><p><b>author</b>: <a>Adam Everyman, MD</a></p><h3>Attesters</h3><table><tr><td>-</td><td><b>Mode</b></td><td><b>Time</b></td><td><b>Party</b></td></tr><tr><td>*</td><td>legal</td><td>04/01/2012 8:10:14 PM</td><td><a>Adam Everyman, MD</a></td></tr></table><p><b>custodian</b>: <a>Community Health and Hospitals</a></p><h3>Events</h3><table><tr><td>-</td><td><b>Code</b></td><td><b>Period</b></td></tr><tr><td>*</td><td>Care Provision <span>(Details : {http://hl7.org/fhir/v3/ActClass code 'PCPR' = 'care provision', given as 'Care
               Provision'})</span></td><td>18/11/2015 --&gt; 12/12/2015</td></tr></table><p><b>encounter</b>: <a>http://hl7.org/fhir/daf-encounter</a></p></div></text><extension url="http://hl7.org/fhir/StructureDefinition/ccda-data-enterer-extension">
        <valueUri value="http://fhir2.healthintersections.com.au/open/Practitioner/00929"/>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/ccda-informant-extension">
        <valueUri value="http://fhir2.healthintersections.com.au/open/Practitioner/00929"/>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/ccda-information-recipient-extension">
        <valueUri value="http://fhir2.healthintersections.com.au/open/Practitioner/00929"/>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/ccda-participant-extension">
        <valueUri value="http://fhir2.healthintersections.com.au/open/Practitioner/00929"/>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/ccda-performer-extension">
        <valueUri value="http://fhir2.healthintersections.com.au/open/Practitioner/00929"/>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/ccda-authorization-extension">
        <valueUri value="http://hl7.org/fhir/StructureDefinition/ccda-consent"/>
    </extension>
    <identifier>
        <system value="http://hl7.org/fhir/StructureDefinition/ccda-ccd-composition"/>
        <value value="1"/>
    </identifier>
    <date value="2016-02-14T09:10:14Z"/>
    <type>
        <coding>
            <system value="http://loinc.org"/>
            <code value="34133-9"/>
            <display value="Summary of episode note"/>
        </coding>
    </type>
    <title value="Continuity of Care Document"/>
    <status value="preliminary"/>
    <confidentiality value="N"/>
    <subject>
        <reference value="http://fhir2.healthintersections.com.au/open/Patient/1234568501"/>
        <display value="Henry Jones"/>
    </subject>
    <author>
        <reference value="http://fhir2.healthintersections.com.au/open/Practitioner/00929"/>
        <display value="Adam Everyman, MD"/>
    </author> 
    <attester>
        <mode value="legal"/>
        <time value="2012-01-04T09:10:14Z"/>
        <party>
            <reference value="http://fhir2.healthintersections.com.au/open/Practitioner/00929"/>
            <display value="Adam Everyman, MD"/>
        </party>
    </attester>
    <custodian>
        <reference value="http://fhir2.healthintersections.com.au/open/Organization/57"/>
        <display value="Community Health and Hospitals"/>
    </custodian>
    <event>
        <code>
            <coding>
                <system value="http://hl7.org/fhir/v3/ActClass"/>
                <code value="PCPR"/>
                <display value="Care Provision"/>
            </coding>
        </code>
        <period>
            <start value="2015-11-18"/>
            <end value="2015-12-12"/>
        </period>
    </event>
    <encounter>
        <reference value="http://hl7.org/fhir/daf-encounter"/>
    </encounter>
    <!--    Included all sections identified in the Trifolia C-CDA on FHIR profile http://hl7.org/fhir/Struct
  ureDefinition/ccda-ccd-composition    -->
    <section>
        <title value="Allergies and Intolerances Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="48765-2"/>
                <display value="Allergies and adverse reactions"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Substance</b>
                        </td>
                        <td>
                            <b>Overall Severity</b>
                        </td>
                        <td>
                            <b>Reaction</b>
                        </td>
                        <td>
                            <b>Reaction Severity</b>
                        </td>
                        <td>
                            <b>Status</b>
                        </td>
                    </tr>
                    <tr>
                        <td>Penicillin</td>
                        <td>Moderate to Severe</td>
                        <td>Nausea</td>
                        <td>Mild</td>
                        <td>Inactive</td>
                    </tr>
                    <tr>
                        <td>Codeine</td>
                        <td>Mild</td>
                        <td>Wheezing</td>
                        <td>Moderate</td>
                        <td>Active</td>
                    </tr>
                    <tr>
                        <td>Aspirin</td>
                        <td>Mild</td>
                        <td>Hives</td>
                        <td>Mild to Moderate</td>
                        <td>Active</td>
                    </tr>
                </table>
            </div>
        </text>
        <!--    Composition.section.mode and orderedBy are optional in FHIR DSTU2, and not specified
     in the Trifolia CCD CCoF profile - should it be removed from the sample?     -->  
        <mode value="snapshot"/>
        <orderedBy>
            <coding>
                <system value="http://hl7.org/fhir/list-order"/>
                <code value="event-date"/>
                <display value="Sorted by Event Date"/>
            </coding>
        </orderedBy>
    </section>
    <section>
        <title value="Medication Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="10160-0"/>
                <display value="History of Medication Use"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Medication</b>
                        </td>
                        <td>
                            <b>Directions</b>
                        </td>
                        <td>
                            <b>Start Date</b>
                        </td>
                        <td>
                            <b>Status</b>
                        </td>
                        <td>
                            <b>Indications</b>
                        </td>
                        <td>
                            <b>Fill Instructions</b>
                        </td>
                    </tr>
                    <tr>
                        <td>Proventil HFA</td>
                        <td>Inhalant solution - 2 puffs QID PRN wheezing</td>
                        <td>20151029</td>
                        <td>Active</td>
                        <td>Pneumonia</td>
                        <td>Generic substitution allowed</td>
                    </tr>
                </table>
            </div>
        </text>
    </section>
    <section>
        <title value="Problem Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="11450-4"/>
                <display value="Problem list"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Problem Name</b>
                        </td>
                        <td>
                            <b>Type</b>
                        </td>
                        <td>
                            <b>Onset Date</b>
                        </td>
                        <td>
                            <b>Abatement Date</b>
                        </td>
                        <td>
                            <b>Status</b>
                        </td>
                    </tr>
                    <tr>
                        <td>Pneumonia</td>
                        <td>Diagnosis</td>
                        <td>2015-10-29</td>
                        <td>2016-01-15</td>
                        <td>Complete</td>
                    </tr>
                    <tr>
                        <td>Asthma</td>
                        <td>Condition</td>
                        <td>2000-02-15</td>
                        <td/>
                        <td>Active</td>
                    </tr>
                </table>
            </div>
        </text>
    </section>
    <section>
        <title value="Procedures Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="47519-4"/>
                <display value="History of procedures"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Procedure Name</b>
                        </td>
                        <td>
                            <b>Body Site</b>
                        </td>
                        <td>
                            <b>Performer</b>
                        </td>
                        <td>
                            <b>Date Performed</b>
                        </td>
                    </tr>
                    <tr>
                        <td>Lumbar Spinal Fusion</td>
                        <td>Back Region</td>
                        <td>Dr. S. Steen</td>
                        <td>20150816</td>
                    </tr>
                </table>
            </div>
        </text>
    </section>
    <section>
        <title value="Results Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="30954-2"/>
                <display value="Relevant diagnostic tests and laboratory data"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Result Type</b>
                        </td>
                        <td>
                            <b>Quantity Value</b>
                        </td>
                        <td>
                            <b>Date</b>
                        </td>
                        <td>
                            <b>Status</b>
                        </td>
                    </tr>
                    <tr>
                        <td>Blood Chemistry - Folate in Red Blood Cells</td>
                        <td>13.8 ug</td>
                        <td>2015/02/01</td>
                        <td>Preliminary</td>
                    </tr>
                </table>
            </div>
        </text>
    </section>
    <section>
        <title value="Advance Directives Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="42348-3"/>
                <display value="Advance directives"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Name</b>
                        </td>
                        <td>
                            <b>Applies Period</b>
                        </td>
                    </tr>
                    <tr>
                        <td>Resuscitation</td>
                        <td>2015/01/01 - 2016/12/31</td>
                    </tr>
                </table>
            </div>
        </text>
    </section>
    <section>
        <title value="Encounters Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="46240-8"/>
                <display value="Encounters"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Encounter</b>
                        </td>
                        <td>
                            <b>Performer</b>
                        </td>
                        <td>
                            <b>Location</b>
                        </td>
                        <td>
                            <b>Date</b>
                        </td>
                    </tr>
                    <tr>
                        <td>Checkup Examination</td>
                        <td>Dr. S. Steene</td>
                        <td>Community Urgent Care Center</td>
                        <td>2015/09/26</td>
                    </tr>
                </table>
            </div>
        </text>
    </section>
    <section>
        <title value="Family History Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="10157-6"/>
                <display value="History of family member diseases"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Relationship</b>
                        </td>
                        <td>
                            <b>Diagnosis</b>
                        </td>
                        <td>
                            <b>Age at Onset</b>
                        </td>
                    </tr>
                    <tr>
                        <td>Father</td>
                        <td>Myocardial Infarction(cause of Death)</td>
                        <td>57</td>
                    </tr>
                    <tr>
                        <td>Father</td>
                        <td>Diabetes</td>
                        <td>40</td>
                    </tr>
                </table>
            </div>
        </text>
    </section>
    <section>
        <title value="Functional Status Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="47420-5"/>
                <display value="Functional status assessment"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Functional or Cognitive Finding</b>
                        </td>
                        <td>
                            <b>Observation</b>
                        </td>
                        <td>
                            <b>Observation Date</b>
                        </td>
                        <td>
                            <b>Condition Status</b>
                        </td>
                    </tr>
                    <tr>
                        <td>Ambulation (Dependent to Independent</td>
                        <td>Independently able</td>
                        <td>2010/03/11</td>
                        <td>Active</td>
                    </tr>
                    <tr>
                        <td>Finding of Functional Performance and Activity</td>
                        <td>Dyspnea</td>
                        <td>2008/02/16</td>
                        <td>Active</td>
                    </tr>
                    <tr>
                        <td>Cognitive Function Finding</td>
                        <td>Memory Impairment</td>
                        <td>2014/04/29</td>
                        <td>Active</td>
                    </tr>
                </table>
            </div>
        </text>
    </section>
    <section>
        <title value="Immunizations Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="11369-6"/>
                <display value="History of immunization"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Vaccine</b>
                        </td>
                        <td>
                            <b>Date</b>
                        </td>
                        <td>
                            <b>Status</b>
                        </td>
                    </tr>
                    <tr>
                        <td>Influenza, Seasonal, IM</td>
                        <td>1999/11/25</td>
                        <td>Completed</td>
                    </tr>
                    <tr>
                        <td>Tetanus and diptheria toxoids, IM</td>
                        <td>1997/10/16</td>
                        <td>Refused</td>
                    </tr>
                </table>
            </div>
        </text>
    </section>
    <section>
        <title value=" Nutrition Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="61144-2"/>
                <display value="Diet and nutrition"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Date</b>
                        </td>
                        <td>
                            <b>Nutritional Status</b>
                        </td>
                        <td>
                            <b>Diet</b>
                        </td>
                    </tr>
                    <tr>
                        <td>2005/12/29</td>
                        <td>Well nourished</td>
                        <td>Low sodium diet, excessive carbohydrate</td>
                    </tr>
                    <tr>
                        <td>2010/05/26</td>
                        <td>Slight dehydration</td>
                        <td>High protein, low fibre</td>
                    </tr>
                </table>
            </div>
        </text>
    </section>
    <section>
        <title value="Mental Status Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="10190-7"/>
                <display value="Mental status"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Date</b>
                        </td>
                        <td>
                            <b>Mental Status</b>
                        </td>
                        <td>
                            <b>Support System</b>
                        </td>
                    </tr>
                    <tr>
                        <td>2005/06/21</td>
                        <td>Good</td>
                        <td>Not required</td>
                    </tr>
                    <tr>
                        <td>2015/12/29</td>
                        <td>Dimentia</td>
                        <td>Daily Home Care</td>
                    </tr>
                </table>
            </div>
        </text>
    </section>
    <section>
        <title value="Social History Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="29762-2"/>
                <display value="Social history"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Social History Element</b>
                        </td>
                        <td>
                            <b>Description</b>
                        </td>
                        <td>
                            <b>Effective Dates</b>
                        </td>
                    </tr>
                    <tr>
                        <td>Smoking</td>
                        <td>1 pack per day</td>
                        <td>2005/05/01 - 2010/02/28</td>
                    </tr>
                    <tr>
                        <td>Alcohol Consumption</td>
                        <td>2 Bottles of Wine per week</td>
                        <td>2001/01/01</td>
                    </tr>
                </table>
            </div>
        </text>
    </section>
    <section>
        <title value="Plan of Treatment Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="18776-5"/>
                <display value="Plan of treatment"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Planned Activity</b>
                        </td>
                        <td>
                            <b>Period</b>
                        </td>
                        <td>
                            <b>Status</b>
                        </td>
                    </tr>
                    <tr>
                        <td>Colonoscopy</td>
                        <td>2010/08/16 - 2010/08/16</td>
                        <td>Completed</td>
                    </tr>
                    <tr>
                        <td>Recommendation to Exercise</td>
                        <td>2015/10/29</td>
                        <td>Ongoing</td>
                    </tr>
                </table>
            </div>
        </text>
    </section>
    <section>
        <title value="Payers Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="48768-6"/>
                <display value="Payers"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Payer Name</b>
                        </td>
                        <td>
                            <b>Policy ID</b>
                        </td>
                        <td>
                            <b>Policy Holder</b>
                        </td>
                    </tr>
                    <tr>
                        <td>United Healthcare</td>
                        <td>12341</td>
                        <td>Self</td>
                    </tr>
                    <tr>
                        <td>Cigna</td>
                        <td>53123</td>
                        <td>Spouse</td>
                    </tr>
                </table>
            </div>
        </text>
    </section>
    <section>
        <title value="Medical Equipment Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="46264-8"/>
                <display value="Medical equipment"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Supply/Device</b>
                        </td>
                        <td>
                            <b>Date Supplied</b>
                        </td>
                    </tr>
                    <tr>
                        <td>Automatic Implantable cardioverter/defbrillator</td>
                        <td>2008/11/16</td>
                    </tr>
                    <tr>
                        <td>Wheelchair</td>
                        <td>1999/12/01</td>
                    </tr>
                </table>
            </div>
        </text>
    </section>
    <section>
        <title value="Vital Signs Section"/>
        <code>
            <coding>
                <system value="http://loinc.org"/>
                <code value="8716-3"/>
                <display value="Vital signs"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div xmlns="http://www.w3.org/1999/xhtml">
                <table>
                    <tr>
                        <td>
                            <b>Vital Sign</b>
                        </td>
                        <td>
                            <b>Date</b>
                        </td>
                        <td>
                            <b>Value</b>
                        </td>
                    </tr>
                    <tr>
                        <td>Height</td>
                        <td>2011/01/13</td>
                        <td>177 cm</td>
                    </tr>
                    <tr>
                        <td>Weight</td>
                        <td>2011/01/13</td>
                        <td>86 kg</td>
                    </tr>
                    <tr>
                        <td>Blood Pressure</td>
                        <td>2011/01/13</td>
                        <td>132/86 mmHg</td>
                    </tr>
                </table>
            </div>
        </text>
    </section>
</Composition>
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.