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 Transfer Summary 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: Transfer Summary
Based on: C-CDA_R2_Transfer_Summary.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 Transfer Summary.
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" />
<!-- Transfer Summary Document -->
<templateId root="2.16.840.1.113883.10.20.22.1.13" extension="2024-05-01" />
<id root="04fc2b90-10e0-11e2-892e-0800200c9a66" />
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="18761-7"
displayName="Transfer summary note" />
<title>Transfer Summary</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="19450501" />
<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>
<!-- The author represents the person who provides the content in the document -->
<author typeCode="AUT">
<templateId root="2.16.840.1.113883.10.20.22.4.119" />
<time value="20130730" />
<assignedAuthor>
<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)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>
<!-- The dataEnterer transferred the content created by the author into the document -->
<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)555-1050" />
<assignedPerson>
<name>
<given>Ellen</given>
<family>Enter</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<!-- The informant represents any sources of information for document content -->
<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)555-1003" />
<assignedPerson>
<name>
<given>Harold</given>
<family>Hippocrates</family>
<suffix qualifier="AC">D.O.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</informant>
<informant>
<relatedEntity classCode="PRS">
<!-- classCode PRS represents a person with personal relationship with the patient. -->
<code code="SPS" displayName="SPOUSE" codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set" />
<relatedPerson>
<name>
<given>Rose</given>
<family>Everyman</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<!-- The custodian represents the organization charged with maintaining the original source document -->
<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)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>
<!-- The informationRecipient represents the intended recipient of the document -->
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<given>Sara</given>
<family>Specialize</family>
<suffix qualifier="AC">M.D.</suffix>
</name>
</informationRecipient>
<receivedOrganization>
<name>The DoctorsApart Physician Group</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<!-- The legalAuthenticator represents the individual who is responsible for the document -->
<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)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>
<!-- The authenticator represents the individual attesting to the accuracy of information in the document-->
<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)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>
<!-- Contact Person -->
<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>
<documentationOf typeCode="DOC">
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="201306011030-0800" />
<high value="201308152200-0800" />
</effectiveTime>
<performer typeCode="PRF">
<functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88" codeSystemName="ParticipationFunction"
displayName="primary care physician">
<originalText>Primary Care Provider</originalText>
</functionCode>
<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)555-1004" />
<assignedPerson>
<name>
<given>Patricia</given>
<given qualifier="CL">Patty</given>
<family>Primary</family>
<suffix qualifier="AC">M.D.</suffix>
</name>
</assignedPerson>
<representedOrganization>
<id extension="219BX" root="1.1.1.1.1.1.1.1.2" />
<name>Good Health Hospital</name>
<telecom use="WP" value="tel:+1(555)555-5000" />
<addr use="WP">
<streetAddressLine>1004 Health Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
<performer typeCode="PRF">
<assignedEntity>
<id extension="5555555555" root="2.16.840.1.113883.4.6" />
<code code="207RN0300X" displayName="Nephrology Physician" codeSystem="2.16.840.1.113883.6.101"
codeSystemName="Healthcare Provider Taxonomy (HIPAA)" />
<addr use="WP">
<streetAddressLine>1004 Healthcare Drive</streetAddressLine>
<city>Ann Arbor</city>
<state>MA</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)555-1038" />
<assignedPerson>
<name>
<given>Rory</given>
<given qualifier="CL">Renal</given>
<family>Primary</family>
<suffix qualifier="AC">M.D.</suffix>
</name>
</assignedPerson>
<representedOrganization>
<id extension="219BX" root="1.1.1.1.1.1.1.1.2" />
<name>Good Health Hospital</name>
<telecom use="WP" value="tel:+1(555)555-1039" />
<addr use="WP">
<streetAddressLine>1036 Health Drive</streetAddressLine>
<city>>Ann Arbor</city>
<state>MA</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<component>
<!-- All sections are set to nullFlavor / text = No information,
as this is a header example, not a complete body example -->
<structuredBody>
<!-- ******************** ENCOUNTERS ************************ -->
<component>
<section nullFlavor="NI">
<!-- *** Encounters section (entries required) (V3) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.22.1" extension="2015-08-01"/>
<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="History of encounters"/>
<title>ENCOUNTERS</title>
<text>No information</text>
</section>
</component>
<!-- ******************* SOCIAL HISTORY ********************* -->
<component>
<section nullFlavor="NI">
<!-- ** Social History Section (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.2.17" extension="2015-08-01"/>
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Social History"/>
<title>SOCIAL HISTORY</title>
<text>No information</text>
</section>
</component>
<!-- ******************** ALLERGIES ************************ -->
<component>
<section nullFlavor="NI">
<!-- *** Allergies and Intolerances Section (entries required) (V3) *** -->
<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">
<!-- *** Problem Section (entries required) (V3) *** -->
<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">
<!-- *** Medications Section (entries required) (V2) *** -->
<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>
<!-- ******************** RESULTS ************************ -->
<component>
<section nullFlavor="NI">
<!-- Results Section (entries required) (V3) -->
<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>
<!-- ************* VITAL SIGNS *************** -->
<component>
<section nullFlavor="NI">
<!-- ** Vital Signs Section (entries required) (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.2.4.1" extension="2015-08-01"/>
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="VITAL SIGNS"/>
<title>VITAL SIGNS</title>
<text>No information</text>
</section>
</component>
<!-- Assessment & Plan (or Assessment Section + Plan Section -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.9" extension="2014-06-09" />
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="51847-2" displayName="Evaluation + Plan note" />
<title>ASSESSMENT AND PLAN</title>
<text>No information</text>
</section>
</component>
<!-- 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>
</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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