C-CDA on FHIR
1.2.0 - STU 1 United States of America flag

This page is part of the C-CDA on FHIR Implementation Guide (v1.2.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. 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

: Diagnostic Imaging Report - Composition - XML Representation

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  <!-- 
    <section>
        <title value="Indications for Procedure Section"/>
        <code>
            <coding>
                <system value="http://dicom.nema.org/resources/ontology/DCM"/>
                <code value="121109"/>
                <display value="Indications for Procedure"/>
            </coding>
        </code>
        <text>
            <status value="generated"/>
            <div
                xmlns="http://www.w3.org/1999/xhtml">
                <p>Suspected lung tumor</p>
            </div>
        </text>
    </section>
	 -->
<Composition xmlns="http://hl7.org/fhir">
  <id value="Diagnostic-Imaging-Report-Example"/>
  <meta>
    <versionId value="4"/>
    <lastUpdated value="2020-08-12T21:30:12.638+00:00"/>
    <source value="#csn482LCsnDWyxbW"/>
    <profile
             value="http://hl7.org/fhir/us/ccda/StructureDefinition/Diagnostic-Imaging-Report"/>
  </meta>
  <language value="en-US"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US">
            <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
                <tbody>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Document Id</span>
                        </td>
                        <td class="td_header_role_value">12345</td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Document Created:</span>
                        </td>
                        <td class="td_header_role_value">June 15, 2016, 16:14, PST </td>
                    </tr>
                </tbody>
            </table>
            <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
                <tbody>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Evaluation</span>
                        </td>
                        <td class="td_header_role_value">Diagnostic Imaging Study for
                                        Amy Shaw</td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Performer</span>
                        </td>
                        <td class="td_header_role_value">Ronald Boone, MD</td>
                    </tr>
                </tbody>
            </table>
            <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
                <tbody>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Author</span>
                        </td>
                        <td class="td_header_role_value">Ronald Boone, MD</td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Contact info</span>
                        </td>
                        <td class="td_header_role_value">1003 Healthcare Drive
										
                            <br/>Amherst MA 01002, US 
                            <br/>Tel: +1(555)555-1003
										
                            <br/>
                        </td>
                    </tr>
                </tbody>
            </table>
            <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
                <tbody>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Encounter Id</span>
                        </td>
                        <td class="td_header_role_value">9937012
                                        2.16.840.1.113883.19</td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Event Type</span>
                        </td>
                        <td class="td_header_role_value">Diagnotic Imaging Study</td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Event Date</span>
                        </td>
                        <td class="td_header_role_value"> From June 15, 2016, 16:20 to
                                        June 15, 2016, 18:20 </td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Encounter Location</span>
                        </td>
                        <td class="td_header_role_value">Diagnostic Imaging Department
                                        at Acme Laboratories</td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Responsible party</span>
                        </td>
                        <td class="td_header_role_value">Ronald Boone, MD</td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Contact info</span>
                        </td>
                        <td class="td_header_role_value">1003 Healthcare Drive
										
                            <br/>Amherst MA 01002, US 
                            <br/>Tel: +1(555)555-1003
										
                            <br/>
                        </td>
                    </tr>
                </tbody>
            </table>
            <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
                <tbody>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Assigned entity</span>
                        </td>
                        <td class="td_header_role_value">Diagnostic Imaging Department
                                        at Acme Laboratories 
                            <br/>
                        </td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Emergency contact</span>
                        </td>
                        <td class="td_header_role_value">Michael Shaw 
                            <br/>
                            <br/>
                        </td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Contact info</span>
                        </td>
                        <td class="td_header_role_value">49 Meadow St 
                            <br/>Amherst MA
                                        01003, US 
                            <br/>Tel: (555)555-1212 
                            <br/>
                        </td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Care giver</span>
                        </td>
                        <td class="td_header_role_value">Mrs. Lillian White 
                            <br/>
                        </td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Contact info</span>
                        </td>
                        <td class="td_header_role_value">49 Meadow St 
                            <br/>Amherst MA
                                        01003, US 
                            <br/>Tel: (555)555-1215 
                            <br/>
                        </td>
                    </tr>
                </tbody>
            </table>
            <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
                <tbody>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Entered by</span>
                        </td>
                        <td class="td_header_role_value">Sally Jones</td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Contact info</span>
                        </td>
                        <td class="td_header_role_value">1003 Healthcare Drive
										
                            <br/>Amherst MA 01002, US 
                            <br/>Tel: +1(555)555-1003
										
                            <br/>
                        </td>
                    </tr>
                </tbody>
            </table>
            <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
                <tbody>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Signed </span>
                        </td>
                        <td class="td_header_role_value">Ronald Boone at June 15, 2016
									</td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Contact info</span>
                        </td>
                        <td class="td_header_role_value">1003 Healthcare Drive
										
                            <br/>Amherst MA 01002, US 
                            <br/>Tel: +1(555)555-1003
										
                            <br/>
                        </td>
                    </tr>
                </tbody>
            </table>
            <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
                <tbody>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Informant</span>
                        </td>
                        <td class="td_header_role_value">Henry Vincent, CPh</td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Contact info</span>
                        </td>
                        <td class="td_header_role_value">1007 Pharmacy Drive
										
                            <br/>Portland, OR 99123, US 
                            <br/>Tel: +1(555)555-1215
										
                            <br/>
                        </td>
                    </tr>
                </tbody>
            </table>
            <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
                <tbody>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Information recipient:</span>
                        </td>
                        <td class="td_header_role_value">Primary Physician, MD</td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Contact info</span>
                        </td>
                        <td class="td_header_role_value">1005 St. Clair Avenue
										
                            <br/>Amherst MA 01002, US 
                            <br/>Tel: +1(555)555-1666
										
                            <br/>
                        </td>
                    </tr>
                </tbody>
            </table>
            <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
                <tbody>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Legal authenticator</span>
                        </td>
                        <td class="td_header_role_value">Ronald Boone, MD signed at June
                                        15, 2016 </td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Contact info</span>
                        </td>
                        <td class="td_header_role_value">1003 Healthcare Drive
										
                            <br/>Amherst MA 01002, US 
                            <br/>Tel: +1(555)555-1003
										
                            <br/>
                        </td>
                    </tr>
                </tbody>
            </table>
            <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
                <tbody>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Document maintained by</span>
                        </td>
                        <td class="td_header_role_value">Acme Laboratories</td>
                    </tr>
                    <tr>
                        <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
                            <span class="td_label">Contact info</span>
                        </td>
                        <td class="td_header_role_value">1003 Healthcare Drive
										
                            <br/>Amherst MA 01002, US 
                            <br/>Tel: +1(555)555-1003
										
                            <br/>
                        </td>
                    </tr>
                </tbody>
            </table>
        </div>
  </text>
  <identifier>
    <system value="urn:ietf:rfc:3986"/>
    <value value="urn:uuid:895f6f22-f7d6-4feb-90d4-dbfd49b5471e"/>
  </identifier>
  <status value="preliminary"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="18748-4"/>
      <display value="Diagnostic imaging study"/>
    </coding>
  </type>
  <subject>🔗 
    <reference value="Patient/example"/>
    <display value="Amy V. Shaw"/>
  </subject>
  <date value="2016-05-16T09:10:14Z"/>
  <author>🔗 
    <reference value="PractitionerRole/ccda-practitionerrole-example"/>
    <display value="Ronald Bone, MD"/>
  </author>
  <title value="Diagnostic Imaging Report"/>
  <attester>
    <mode value="legal"/>
    <time value="2016-06-15T09:10:14Z"/>
    <party>🔗 
      <reference value="PractitionerRole/ccda-practitionerrole-example"/>
      <display value="Ronald Boone, MD"/>
    </party>
  </attester>
  <custodian>🔗 
    <reference value="Organization/acme-lab"/>
    <display value="Acme Labs"/>
  </custodian>
  <event>
    <code>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="168731009"/>
        <display value="Standard Chest X-Ray"/>
      </coding>
    </code>
    <period>
      <start value="2016-06-15"/>
      <end value="2016-06-15"/>
    </period>
  </event>
  <section>
    <title value="Findings Section"/>
    <code>
      <coding>
        <system value="http://dicom.nema.org/resources/ontology/DCM"/>
        <code value="121070"/>
        <display value="Findings"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
                <p>The cardiomediastinum is within normal limits. The trachea is
                                midline. The previously described opacity at the medial right lung
                                base has cleared. There are no new infiltrates. There is a new round
                                density at the left hilus, superiorly (diameter about 45mm). A CT
                                scan is recommended for further evaluation. The pleural spaces are
                                clear. The visualized musculoskeletal structures and the upper
                                abdomen are stable and unremarkable.</p>
            </div>
    </text>
  </section>
  <section>
    <title value="DICOM Object Catalog Section"/>
    <code>
      <coding>
        <system value="http://dicom.nema.org/resources/ontology/DCM"/>
        <code value="121181"/>
        <display value="DICOM Object Catalog"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
                <p>Computed Radiography Image Storage</p>
            </div>
    </text>
  </section>
</Composition>