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. For a full list of available versions, see the Directory of published versions

Example Binary: Encounter Diagnosis Example

This content is an example of the Encounter Diagnosis Logical Model and is not a FHIR Resource

    
<act classCode="ACT" moodCode="EVN" xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
  <templateId root="2.16.840.1.113883.10.20.22.4.80" extension="2024-05-01" />
  <code code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="DIAGNOSIS" />
  <text>
    <reference value="#encounterdiagnosis" />
  </text>
  <statusCode code="completed" />
  <effectiveTime>
    <low value="20090303" />
  </effectiveTime>
  <entryRelationship typeCode="SUBJ">
    <observation classCode="OBS" moodCode="EVN">
      <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>