Consolidated CDA (C-CDA)
3.0.0 - STU3
Consolidated CDA (C-CDA)
3.0.0 - STU3
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
This content is an example of the Referral Note Logical Model and is not a FHIR Resource
<?xml version="1.0" encoding="UTF-8" standalone="yes"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!--
Title: Referral Note
Based on: C-CDA_R2_Referral_Note.xml
Updated for C-CDA R3.0 with a focus on header elements
- required/suggested sections are populated with nullFlavor="NI"
to demonstrate WHICH sections should be included, but they
all contain "No information" as this is an example of the header
********************************************************
Disclaimer: This sample file contains representative data elements to represent a Referral Note.
The file depicts a fictional character's health data. Any resemblance to a real person is coincidental.
To illustrate as many data elements as possible, the clinical scenario may not be plausible.
The data in this sample file is not intended to represent real patients, people or clinical events.
This sample is designed to be used in conjunction with the C-CDA Clinical Notes Implementation Guide.
********************************************************
-->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xmlns:cda="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc">
<!-- ** CDA Header ** -->
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<!-- Identifies document as conformant to US Realm Header (V2) Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2024-05-01"/>
<!-- Referral Note Document
Conforms to the document specific requirements -->
<templateId root="2.16.840.1.113883.10.20.22.1.14" extension="2024-05-01" />
<!-- DocumentID: unique ID for the document -->
<id root="6f1bd58b-c58f-40b7-b314-caf1294ed98b"/>
<!-- Referral Note -->
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="57133-1" displayName="Referral Note"/>
<!-- Use the name of the code as the title -->
<title>Referral Note</title>
<effectiveTime value="201309210500-0800"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en"/>
<setId extension="sTT988" root="2.16.840.1.113883.19.5.99999.19"/>
<versionNumber value="1"/>
<recordTarget>
<patientRole>
<id extension="444222222" root="2.16.840.1.113883.4.1"/>
<!-- Example Social Security Number using the actual SSN OID. -->
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>2222 Home Street</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:+1(555)555-2003" use="HP"/>
<!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<patient>
<!-- The first name element represents what the patient is known as -->
<name use="L">
<given>Eve</given>
<!-- The "SP" is "Spouse" from HL7 Code System EntityNamePartQualifier 2.16.840.1.113883.5.43 -->
<family qualifier="SP">Betterhalf</family>
</name>
<!-- The second name element represents another name associated with the patient -->
<name use="SRCH">
<given>Eve</given>
<!-- The "BR" is "Birth" from HL7 Code System EntityNamePartQualifier 2.16.840.1.113883.5.43 -->
<family qualifier="BR">Everywoman</family>
</name>
<administrativeGenderCode code="F" displayName="Female" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender"/>
<!-- Date of birth need only be precise to the day -->
<birthTime value="19750501"/>
<maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatusCode"/>
<religiousAffiliationCode code="1013" displayName="Christian (non-Catholic, non-specific)" codeSystem="2.16.840.1.113883.5.1076" codeSystemName="HL7 Religious Affiliation"/>
<!-- CDC Race and Ethnicity code set contains the five minimum race and ethnicity
categories defined by OMB Standards -->
<raceCode code="2106-3" displayName="White" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/>
<!-- The raceCode extension is only used if raceCode is valued -->
<sdtc:raceCode code="2076-8" displayName="Native Hawaiian or Other Pacific Islander" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/>
<ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/>
<guardian>
<code code="POWATT" displayName="Power of Attorney" codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode"/>
<addr use="HP">
<streetAddressLine>2222 Home Street</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(555)555-2008" use="MC"/>
<guardianPerson>
<name>
<given>Boris</given>
<given qualifier="CL">Bo</given>
<family>Betterhalf</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<streetAddressLine>4444 Home Street</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
</addr>
</place>
</birthplace>
<languageCommunication>
<languageCode code="en"/>
<modeCode code="ESP" displayName="Expressed spoken" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/>
<proficiencyLevelCode code="G" displayName="Good" codeSystem="2.16.840.1.113883.5.61" codeSystemName="LanguageAbilityProficiency"/>
<!-- Patient's preferred language -->
<preferenceInd value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id extension="219BX" root="2.16.840.1.113883.4.6"/>
<name>The DoctorsTogether Physician Group</name>
<telecom use="WP" value="tel:+1(555)555-5000"/>
<addr use="WP">
<streetAddressLine>1007 Health Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time value="201303111030-0800"/>
<assignedAuthor>
<id extension="5555555555" root="2.16.840.1.113883.4.6"/>
<code code="207QA0505X" displayName="Adult Medicine" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/>
<addr use="WP">
<streetAddressLine>1004 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-1004"/>
<assignedPerson>
<name>
<given>Patricia</given>
<given qualifier="CL">Patty</given>
<family>Primary</family>
<suffix qualifier="AC">M.D.</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id extension="333777777" root="2.16.840.1.113883.4.6"/>
<addr use="WP">
<streetAddressLine>1007 Healthcare Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-1050"/>
<assignedPerson>
<name>
<given>Ellen</given>
<family>Enter</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<informant>
<assignedEntity>
<id extension="888888888" root="2.16.840.1.113883.19.5"/>
<addr use="WP">
<streetAddressLine>1007 Healthcare Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-1003"/>
<assignedPerson>
<name>
<given>Harold</given>
<family>Hippocrates</family>
<suffix qualifier="AC">D.O.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</informant>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="321CX" root="2.16.840.1.113883.4.6"/>
<name>Good Health HIE</name>
<telecom use="WP" value="tel:+1(555)-1009"/>
<addr use="WP">
<streetAddressLine>1009 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<given>Nancy</given>
<family>Nightingale</family>
<suffix qualifier="AC">RN</suffix>
</name>
</informationRecipient>
<receivedOrganization>
<name>Community Health and Hospitals</name>
<telecom value="tel:+1(555)-555-1002" use="WP"/>
<addr use="WP">
<streetAddressLine>Cardiac Stepdown Unit, 4B </streetAddressLine>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>97857</postalCode>
<country>US</country>
</addr>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<time value="20130915223615-0800"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="5555555555" 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="WP">
<streetAddressLine>1004 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-1004"/>
<assignedPerson>
<name>
<given>Patricia</given>
<given qualifier="CL">Patty</given>
<family>Primary</family>
<suffix qualifier="AC">M.D.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<authenticator>
<time value="201209151030-0800"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="5555555555" root="2.16.840.1.113883.4.6"/>
<code code="207QA0505X" displayName="Adult Medicine" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/>
<addr use="WP">
<streetAddressLine>1004 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-1004"/>
<assignedPerson>
<name>
<given>Patricia</given>
<given qualifier="CL">Patty</given>
<family>Primary</family>
<suffix qualifier="AC">M.D.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<participant typeCode="CALLBCK">
<time value="20050329224411+0500"/>
<associatedEntity classCode="ASSIGNED">
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101" displayName="Allopathic & Osteopathic Physicians"/>
<addr use="WP">
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>97857</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<associatedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
<suffix>DO</suffix>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<!-- Patient Support Identification -->
<participant typeCode="IND">
<functionCode code="407543004" displayName="Primary Carer" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
<!-- Caregiver -->
<associatedEntity classCode="CAREGIVER">
<code code="MTH" codeSystem="2.16.840.1.113883.5.111"/>
<addr use="WP">
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>97857</postalCode>
<country>US</country>
</addr>
<telecom value="tel:1+(555)555-1212" use="WP"/>
<associatedPerson>
<name>
<prefix>Mrs.</prefix>
<given>Martha</given>
<family>Jones</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<component>
<!-- All sections are set to nullFlavor / text = No information,
as this is a header example, not a complete body example -->
<structuredBody>
<!-- Reason for Referral -->
<component>
<section nullFlavor="NI">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.1" extension="2014-06-09" />
<code code="42349-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Reason for Referral" />
<title>REASON FOR REFERRAL</title>
<text>No information</text>
</section>
</component>
<!-- ALLERGIES -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.6.1" extension="2015-08-01"/>
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>ALLERGIES AND ADVERSE REACTIONS</title>
<text>No information</text>
</section>
</component>
<!-- PROBLEM LIST -->
<component>
<section nullFlavor="NI">
<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>No information</text>
</section>
</component>
<!-- MEDICATIONS -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09"/>
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF MEDICATION USE"/>
<title>MEDICATIONS</title>
<text>No information</text>
</section>
</component>
<!-- Plan of treatment -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09" />
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Treatment plan" />
<title>TREATMENT PLAN</title>
<text>No information</text>
</section>
</component>
<!-- Assessment (required with Plan of Treatment; otherwise use the Assessment & Plan Section) -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.8"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="51848-0" displayName="ASSESSMENTS"/>
<title>ASSESSMENTS</title>
<text>No information</text>
</section>
</component>
<!-- Results -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01"/>
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="RESULTS"/>
<title>RESULTS</title>
<text>No information</text>
</section>
</component>
<!-- Functional Status -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.14" extension="2014-06-09" />
<code code="47420-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Functional Status" />
<title>FUNCTIONAL STATUS</title>
<text>No information</text>
</section>
</component>
<!-- Mental Status -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.56" extension="2015-08-01" />
<code code="10190-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Mental status Narrative" />
<title>MENTAL STATUS</title>
<text>No information</text>
</section>
</component>
<!-- Nutrition -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.57" />
<code code="61144-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diet and Nutrition" />
<title>NUTRITION SECTION</title>
<text>No information</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#3.0.0 based on FHIR 5.0.0. Generated 2024-05-18
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