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
This content is an example of the Note Activity Logical Model and is not a FHIR Resource
<?xml version="1.0" encoding="UTF-8"?>
<!-- Demonstrates a Note Activity as an entryRelationship to a -->
<section xmlns="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<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="2024-05-01"/>
<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>
<!-- Would be <low value="20140203092205-0700" /> but since
we don't have a complete document example, the Validator
cannot compare this to ClinicalDocument/effectiveTime to
satisfy the ts-value-before-document constraint -->
<low nullFlavor="NI" />
<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" />
<addr use="WP" nullFlavor="UNK" />
<telecom use="WP" nullFlavor="UNK" />
<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>