Consolidated CDA
3.0.0-ballot - ballot United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0-ballot: CCDA 3.0 Ballot 1) based on FHIR (HL7® FHIR® Standard) v5.0.0. . For a full list of available versions, see the Directory of published versions

Example Binary: Note Activity Entry Relationship Example

This content is an example of the Note Activity Logical Model and is not a FHIR Resource

    
<?xml version="1.0" encoding="UTF-8"?>
<section xmlns="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
  <!-- C-CDA 2.1 Procedures Section -->
  <templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
  <templateId root="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09"/>
  <code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PROCEDURES"/>
  <title>Procedures</title>
  <text>
    <table>
      <thead>
        <tr>
          <th>Description</th>
          <th>Date and Time (Range)</th>
          <th>Status</th>
          <th>Notes</th>
        </tr>
      </thead>
      <tbody>
        <tr ID="Procedure1">
          <td ID="ProcedureDesc1">Laparoscopic appendectomy</td>
          <td>(03 Feb 2014 09:22am- 03 Feb 2014 11:15am)</td>
          <td>Completed</td>
          <td ID="ProcedureNote1">
            <paragraph>Dr. Physician - 03 Feb 2014</paragraph>
            <paragraph>Free-text note about the procedure.</paragraph>
          </td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry typeCode="DRIV">
    <!-- Procedures should be used for care that directly changes the patient's physical state.-->
    <procedure moodCode="EVN" classCode="PROC">
      <templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
      <id root="64af26d5-88ef-4169-ba16-c6ef16a1824f"/>
      <code code="6025007" displayName="Laparoscopic appendectomy" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT">
        <originalText>
          <reference value="#ProcedureDesc1" />
        </originalText>
      </code>
      <text>
        <reference value="#Procedure1" />
      </text>
      <statusCode code="completed" />
      <effectiveTime>
        <low value="20140203092205-0700" />
        <high value="20140203111514-0700" />
      </effectiveTime>
      <!-- Note Activity entry -->
      <entryRelationship typeCode="COMP">
        <act classCode="ACT" moodCode="EVN">
          <templateId root="2.16.840.1.113883.10.20.22.4.202" extension="2016-11-01"/>
          <code code="34109-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Note">
            <translation code="28570-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure note" />
          </code>
          <text>
            <reference value="#ProcedureNote1" />
          </text>
          <statusCode code="completed"/>
          <!-- Clinically-relevant time of the note -->
          <effectiveTime value="20140203" />
          <!-- Author Participation -->
          <author>
            <templateId root="2.16.840.1.113883.10.20.22.4.119" />
            <!-- Time note was actually written -->
            <time value="20140204083215-0500" />
            <assignedAuthor>
              <id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c" />
              <assignedPerson>
                <name>Dr. Physician</name>
              </assignedPerson>
            </assignedAuthor>
          </author>
          <!-- Reference to encounter -->
          <entryRelationship typeCode="COMP" inversionInd="true">
            <encounter classCode="ENC" moodCode="EVN">
              <!-- Encounter ID matches an encounter in the Encounters Section -->
              <id root="1.2.3.4" />
            </encounter>
          </entryRelationship>
        </act>
      </entryRelationship>
    </procedure>
  </entry>
</section>