Consolidated CDA (C-CDA)
3.0.0 - STU3 United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0: CCDA 3.0) generated with FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Example Binary: Problem Section Example

This content is an example of the Problem Section Logical Model and is not a FHIR Resource

    
<section xmlns="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
  <!-- [C-CDA R2.1] Problem Section (entries required) -->
  <templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01" />
  <code code="11450-4" 
        codeSystem="2.16.840.1.113883.6.1" 
        codeSystemName="LOINC" 
        displayName="PROBLEM LIST" />
  <title>PROBLEMS</title>
  <text>
    <list listType="ordered">
      <item>Pneumonia: Resolved in March 1998</item>
      <item>...</item>
    </list>
  </text>
  <entry typeCode="DRIV">
		<act classCode="ACT" moodCode="EVN" xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
		  <!-- ** Problem Concern Act ** -->
		  <templateId root="2.16.840.1.113883.10.20.22.4.3" 
		          extension="2024-05-01" />
		  <id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7" />
		  <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" />
		  <!-- The statusCode represents the need to continue tracking the problem -->
		  <!-- This is of ongoing concern to the provider -->
		  <statusCode code="active" />
		  <effectiveTime>
		    <!-- The low value represents when the problem was first recorded in the patient's chart -->
		    <!-- Concern was documented on July 6, 2013 -->
		    <low value="201307061145-0800" />
		  </effectiveTime>
		  <author typeCode="AUT">
		    <templateId root="2.16.840.1.113883.10.20.22.4.119" />
		    <!-- Same as Concern effectiveTime/low -->
		    <time value="201307061145-0800" />
		    <assignedAuthor>
		      <id extension="555555555" root="2.16.840.1.113883.4.6" />
		      <code code="207QA0505X" displayName="Adult Medicine Physician" codeSystem="2.16.840.1.113883.6.101"
		        codeSystemName="Healthcare Provider Taxonomy (HIPAA)" />
		      <addr nullFlavor="UNK" />
		      <telecom nullFlavor="UNK" />
		      <assignedPerson>
		        <name>Doctor Adult</name>
		      </assignedPerson>
		    </assignedAuthor>
		  </author>
		  <entryRelationship typeCode="SUBJ">
				<observation classCode="OBS" moodCode="EVN" xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
				  <!-- ** Problem Observation ** -->
				  <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2024-05-01" />
				  <id root="AB1791B0-5C71-11DB-B0DE-0800200C9A66" />
				  <code code="64572001" displayName="Disease" 
				                                    codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
				    <translation code="75323-6" 
				           codeSystem="2.16.840.1.113883.6.1" 
				           codeSystemName="LOINC" 
				           displayName="Condition"/>
				  </code>
				  <text><reference value="#problem"/></text>
				  <!-- The statusCode reflects the status of the observation itself -->
				  <statusCode code="completed" />
				  <effectiveTime>
				    <!-- The low value reflects the date of onset -->
				    <!-- Based on patient symptoms, presumed onset is July 3, 2013 -->
				    <low value="20130703" />
				    <!-- The high value reflects when the problem was known to be resolved -->
				    <!-- Based on signs and symptoms, appears to be resolved on Aug 14, 2013 -->
				    <high value="20130814" />
				  </effectiveTime>
				  <value xsi:type="CD"
				    code="233604007" 
				    codeSystem="2.16.840.1.113883.6.96"  
				    displayName="Pneumonia" />
				  <author typeCode="AUT">
				    <templateId root="2.16.840.1.113883.10.20.22.4.119" />
				    <time value="200808141030-0800" />
				    <assignedAuthor>
				      <id extension="555555555" root="2.16.840.1.113883.4.6" />
				      <code code="207QA0505X" 
				        displayName="Adult Medicine Physician" 
				        codeSystem="2.16.840.1.113883.6.101"
				        codeSystemName="Healthcare Provider Taxonomy (HIPAA)" />
				      <addr use="H">
				        <streetAddressLine>23 Anywhere Street</streetAddressLine>
				        <city>El Paso</city>
				        <state>TX</state>
				        <postalCode>90210</postalCode>
				        <country>US</country>
				      </addr>
				      <telecom value="tel:(999)555-1212" use="WP" />
				      <assignedPerson>
				        <name>Joe Anywhere</name>
				      </assignedPerson>
				    </assignedAuthor>
				  </author>
				</observation>
		  </entryRelationship>
		</act>
  </entry>
</section>