C-CDA on FHIR
1.2.0-ballot - CI Build
C-CDA on FHIR
1.2.0-ballot - CI Build
This page is part of the C-CDA on FHIR Implementation Guide (v1.2.0-ballot: STU 1 Ballot 4) based on FHIR R4. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions 
{
"resourceType" : "Composition",
"id" : "Operative-Note-Example",
"meta" : {
"versionId" : "4",
"lastUpdated" : "2020-08-12T21:30:19.501+00:00",
"source" : "#csn482LCsnDWyxbW",
"profile" : [
"http://hl7.org/fhir/us/ccda/StructureDefinition/Operative-Note"
]
},
"language" : "en-US",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\">\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Document Id</span>\n </td>\n <td class=\"td_header_role_value\">12345</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Document Created:</span>\n </td>\n <td class=\"td_header_role_value\">June 15, 2016, 16:14, PST </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Care Provision</span>\n </td>\n <td class=\"td_header_role_value\">Operation Note for Amy\n Shaw</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Performer </span>\n </td>\n <td class=\"td_header_role_value\">Ronald Boone, MD</td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Author</span>\n </td>\n <td class=\"td_header_role_value\">Ronald Boone, MD</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n\t\t\t\t\t\t\t\t\t\t\n <br/>Amherst MA 01002,\u00a0US \n <br/>Tel: +1(555)555-1003\n\t\t\t\t\t\t\t\t\t\t\n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Encounter Id</span>\n </td>\n <td class=\"td_header_role_value\">9937012\n 2.16.840.1.113883.19</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Event Type</span>\n </td>\n <td class=\"td_header_role_value\">Surgery</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Event Date</span>\n </td>\n <td class=\"td_header_role_value\">\u00a0From\u00a0June 15, 2016, 16:20 to\n June 15, 2016, 18:20 </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Encounter Location</span>\n </td>\n <td class=\"td_header_role_value\">Perioperative Department at\n Community Health and Hospitals</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Responsible party</span>\n </td>\n <td class=\"td_header_role_value\">Ronald Boone, MD</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n\t\t\t\t\t\t\t\t\t\t\n <br/>Amherst MA 01002,\u00a0US \n <br/>Tel: +1(555)555-1003\n\t\t\t\t\t\t\t\t\t\t\n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Assigned entity</span>\n </td>\n <td class=\"td_header_role_value\">Community Health and Hospitals\n\t\t\t\t\t\t\t\t\t\t\n <br/>\n </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Emergency contact</span>\n </td>\n <td class=\"td_header_role_value\">Michael Shaw \n <br/>\n <br/>\n </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">49 Meadow St \n <br/>Amherst MA\n 01003,\u00a0US \n <br/>Tel: (555)555-1212 \n <br/>\n </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Care giver</span>\n </td>\n <td class=\"td_header_role_value\">Mrs. Lillian White \n <br/>\n </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">49 Meadow St \n <br/>Amherst MA\n 01003,\u00a0US \n <br/>Tel: (555)555-1215 \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Entered by</span>\n </td>\n <td class=\"td_header_role_value\">Sally Jones</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n\t\t\t\t\t\t\t\t\t\t\n <br/>Amherst MA 01002,\u00a0US \n <br/>Tel: +1(555)555-1003\n\t\t\t\t\t\t\t\t\t\t\n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Signed </span>\n </td>\n <td class=\"td_header_role_value\">Ronald Boone at June 15, 2016\n\t\t\t\t\t\t\t\t\t</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n\t\t\t\t\t\t\t\t\t\t\n <br/>Amherst MA 01002,\u00a0US \n <br/>Tel: +1(555)555-1003\n\t\t\t\t\t\t\t\t\t\t\n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Informant</span>\n </td>\n <td class=\"td_header_role_value\">Henry Vincent, CPh</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1007 Pharmacy Drive\n\t\t\t\t\t\t\t\t\t\t\n <br/>Portland,\u00a0OR\u00a099123,\u00a0US \n <br/>Tel: +1(555)555-1215\n\t\t\t\t\t\t\t\t\t\t\n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Information recipient:</span>\n </td>\n <td class=\"td_header_role_value\">Primary Physician, MD</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1005 St. Clair Avenue\n\t\t\t\t\t\t\t\t\t\t\n <br/>Amherst MA 01002,\u00a0US \n <br/>Tel: +1(555)555-1666\n\t\t\t\t\t\t\t\t\t\t\n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Legal authenticator</span>\n </td>\n <td class=\"td_header_role_value\">Ronald Boone, MD signed at June\n 15, 2016 </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n\t\t\t\t\t\t\t\t\t\t\n <br/>Amherst MA 01002,\u00a0US \n <br/>Tel: +1(555)555-1003\n\t\t\t\t\t\t\t\t\t\t\n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Document maintained by</span>\n </td>\n <td class=\"td_header_role_value\">Community Health and\n Hospitals</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n\t\t\t\t\t\t\t\t\t\t\n <br/>Amherst MA 01002,\u00a0US \n <br/>Tel: +1(555)555-1003\n\t\t\t\t\t\t\t\t\t\t\n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n </div>"
},
"identifier" : {
"system" : "urn:ietf:rfc:3986",
"value" : "urn:uuid:75a12dcd-f85d-4c7f-b1de-38a1a2b7498f"
},
"status" : "preliminary",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11504-8",
"display" : "Surgical operation note"
}
]
},
"subject" : {
"reference" : "Patient/example",
"display" : "Amy V. Shaw"
},
"date" : "2016-06-15T09:10:14Z",
"author" : [
{
"reference" : "PractitionerRole/ccda-practitionerrole-example",
"display" : "Ronald Bone, MD"
}
],
"title" : "Operative Note",
"attester" : [
{
"mode" : "legal",
"time" : "2016-06-15T09:10:14Z",
"party" : {
"reference" : "PractitionerRole/ccda-practitionerrole-example",
"display" : "Ronald Boone, MD"
}
}
],
"custodian" : {
"reference" : "Organization/organization-1",
"display" : "Community Health and Hospitals"
},
"event" : [
{
"code" : [
{
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "73761001",
"display" : "Colonoscopy"
}
]
}
],
"period" : {
"start" : "2016-06-15",
"end" : "2016-06-15"
}
}
],
"section" : [
//
<section>
<title value="Allergies and Intolerances Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="48765-2"/>
<display value="Allergies and adverse reactions Document"/>
</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>Cashew Nut</td>
<td>Severe</td>
<td>Anaphylactic reaction</td>
<td>Mild</td>
<td>Active</td>
</tr>
</table>
</div>
</text>
<entry>
<reference value="AllergyIntolerance/allergy-intolerance"/>
</entry>
</section>
//
<entry>
<reference value="Condition/condition-problem"/>
</entry>
{
"title" : "Anesthesia Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "59774-0",
"display" : "Anesthesia"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Conscious sedation with propofol 200 mg IV</p>\n </div>"
}
},
{
"title" : "Complications Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "55109-3",
"display" : "Complications Document"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Asthmatic symptoms while under general anesthesia.</p>\n </div>"
},
"entry" : [
{
"reference" : "Condition/condition-problem"
}
]
},
{
"title" : "Preoperative Diagnosis Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10219-4",
"display" : "Surgical operation note preoperative diagnosis Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Appendicitis</p>\n </div>"
}
},
{
"title" : "Operative Note Surgical Procedure Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10223-6",
"display" : "Surgical operation note surgical procedure Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Laparoscopic Appendectomy</p>\n </div>"
}
},
{
"title" : "Planned Procedure Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "59772-4",
"display" : "Planned procedure"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Colonoscopy</p>\n </div>"
}
},
{
"title" : "Procedure Indications Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "59768-2",
"display" : "Procedure indications [Interpretation] Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>The procedure is performed for screening in a low risk\n individual.</p>\n </div>"
}
},
{
"title" : "Procedure Description Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29554-3",
"display" : "Procedure Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>The patient was brought to the operating room, placed in the supine\n position, and general anesthesia was induced. A detailed technical\n narrative of a laparoscopic appendectomy from initial incision to\n placement of any dressings follows. </p>\n </div>"
}
},
{
"title" : "Procedure Estimated Blood Loss Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "59770-8",
"display" : "Procedure estimated blood loss Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Minimal</p>\n </div>"
}
},
{
"title" : "Procedure Findings Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "59776-5",
"display" : "Procedure findings Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>A 6 mm sessile polyp was found in the ascending colon and removed by\n snare, no cautery. Bleeding was controlled. Moderate diverticulosis\n and hemorrhoids were incidentally noted.</p>\n </div>"
},
"entry" : [
{
"reference" : "Condition/condition-problem"
}
]
},
{
"title" : "Procedure Specimens Taken Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "59773-2",
"display" : "Procedure specimens taken Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Ascending colon polyp</p>\n </div>"
}
},
{
"title" : "Operative Note Fluids Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10216-0",
"display" : "Operative Note Fluids"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>250 ML Ringers Lactate</p>\n </div>"
}
},
{
"title" : "Surgical Drains Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11537-8",
"display" : "Surgical Drains"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Penrose drain placed</p>\n </div>"
}
},
{
"title" : "Procedure Implants Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "59771-6",
"display" : "Procedure implants Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>No implants were placed.</p>\n </div>"
}
},
{
"title" : "Procedure Disposition Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "59775-7",
"display" : "Procedure disposition Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>The patient was taken to the Endoscopy Recovery Unit in stable\n condition.</p>\n </div>"
}
},
{
"title" : "Postoperative Diagnosis Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10218-6",
"display" : "Surgical operation note postoperative diagnosis Narrative"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Appendicitis with periappendiceal abscess</p>\n </div>"
}
},
{
"title" : "Plan of Treatment Section",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "18776-5",
"display" : "Plan of care note"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Planned Activity</b>\n </td>\n <td>\n <b>Period</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Colonoscopy</td>\n <td>2016/09/17 - 2010/09/17</td>\n <td>Planned</td>\n </tr>\n <tr>\n <td>Recommendation to Exercise</td>\n <td>2016/06/25</td>\n <td>Ongoing</td>\n </tr>\n </table>\n </div>"
}
}
]
}
IG © 2020+ HL7 Structured Documents Working Group. Package hl7.fhir.us.ccda#1.2.0-ballot based on FHIR 4.0.1. Generated 2023-03-27
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