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<section>
<!-- Created for discussion on SDWG CDA Example Task Force. -->
<!-- This is an example of a hospitalization as may be shown in encounters section. -->
<!-- This example demonstrates how billable diagnoses could be included, if they are available -->
<templateId root="2.16.840.1.113883.10.20.22.2.22.1"/>
<templateId root="2.16.840.1.113883.10.20.22.2.22.1" extension="2015-08-01"/>
<id root="6bc0419f-0398-4a56-8642-7054cbef448c"/>
<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" displayName="Encounters" codeSystemName="LOINC"/>
<title>Encounters</title>
<text>
<table>
<thead>
<tr>
<th>Encounter Type</th>
<th>Provider</th>
<th>Primary Diagnosis</th>
<th>Other Diagnoses</th>
<th>Start Date</th>
<th>End Date</th>
<th>Location</th>
<th>Discharge Disposition</th>
</tr>
</thead>
<tbody>
<tr ID="Encounter1">
<td ID="Enc1_Type">Inpatient</td>
<td>James Getwell, DO</td>
<td ID="Enc1_Dx1">Congestive Heart Failure</td>
<td>
<content ID="Enc1_Dx2">Diabetes</content>
</td>
<td>10/28/2014 12:22pm</td>
<td>10/31/2014 3:04pm</td>
<td>Good Day Hospital (878)378-0909 1002 Healthcare Dr., Portland, OR, 97005</td>
<td>Nursing Home</td>
</tr>
</tbody>
</table>
</text>
<entry>
<encounter moodCode="EVN" classCode="ENC">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01"/>
<id root="248b2c03-2013-e138-07d1-001A64958C30"/>
<!-- CPT code should be used for ambulatory visits, but for a hosptialization, another codeSystem is more appropriate-->
<code code="99238" displayName="Discharge day management services" codeSystem="2.16.840.1.113883.6.12">
<originalText>
<reference value="#Enc1_Type"/>
</originalText>
<translation code="IMP" codeSystem="2.16.840.1.113883.5.4" displayName="Inpatient" codeSystemName="Act Encounter Code - Act Code"/>
</code>
<text>
<reference value="#Encounter1" />
</text>
<!-- for a hospitalization, the low and high effectiveTimes would logically be admission and discharge date/time. -->
<effectiveTime xsi:type="IVL_TS">
<low value ="201410281222+0500" />
<high value="201410311504+0500" />
</effectiveTime>
<!-- Note that sdtc extension is used to document dischargeDisposition in encounters -->
<sdtc:dischargeDispositionCode code="04" displayName="Discharged/Transferred to a Facility that Provides Custodial or Supportive Care"
codeSystem="2.16.840.1.113883.6.301.5" codeSystemName="NUBC UB-04 FL17">
</sdtc:dischargeDispositionCode>
<performer typeCode="PRF">
<time>
<low value="201410281222+0500" />
<high value="201410311504+0500" />
</time>
<assignedEntity classCode="ASSIGNED">
<id root="2.16.840.1.113883.4.6" extension="12345679"/>
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="ProviderCodes" displayName="Allopathic &amp; Osteopathic Physicians" />
<addr use="WP">
<streetAddressLine>763 Horseshoe Rd</streetAddressLine>
<city>Gotham</city>
<state>OR</state>
<postalCode>98764</postalCode>
</addr>
<telecom use="WP" value="tel:+1(814)788-8000"/>
<assignedPerson classCode="PSN" determinerCode="INSTANCE">
<name>
<given>James</given>
<family>Getwell</family>
<suffix>DO</suffix>
</name>
</assignedPerson>
</assignedEntity>
</performer>
<participant typeCode="LOC">
<!-- Service Delivery Location Template -->
<participantRole classCode="SDLOC">
<templateId root="2.16.840.1.113883.10.20.22.4.32"/>
<code code="1061-1" codeSystem="2.16.840.1.113883.6.259" codeSystemName="Healthcare Service Location" displayName="Inpatient medical ward" />
<addr use="WP">
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97005</postalCode>
</addr>
<telecom use="WP" value="tel:+1(878)378-0909"/>
<playingEntity classCode="PLC" determinerCode="INSTANCE">
<name>Good Day Hospital</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ">
<!-- This is the primary diagnosis on the bill -->
<!-- Hospital discharge diagnosis act -->
<act moodCode="EVN" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.33"/>
<templateId root="2.16.840.1.113883.10.20.22.4.33" extension="2015-08-01"/>
<id root="1d7ff347-9dce-44db-8f66-fc17d8dc4aca"/>
<code code="11535-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Hospital Discharge Diagnosis"/>
<statusCode code="active"/>
<!-- This represents the time that the concern was authored. Since this is a hospital discharge diagnosis, this is when it was coded-->
<effectiveTime xsi:type="IVL_TS">
<low value="20141102145806+0500" />
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<!-- Problem Observation -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<id root="20cdd1a0-6136-4939-802f-edfebe9320bc"/>
<!-- We'll use the type of diagnosis, since this is a coded diagnosis, not from problem list-->
<code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="282291009" displayName="Diagnosis">
<translation code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis"/>
</code>
<text>
<reference value="#Enc1_Dx1" />
</text>
<statusCode code="completed" />
<effectiveTime>
<!-- This represents the date of biological onset. Since this is a coded diagnosis, this may not be documented.-->
<low nullFlavor="UNK" />
</effectiveTime>
<!-- This denotes that the diagnosis is the principal diagnosis. There is generally only a single diagnosis for coded bill.-->
<!-- This current modeling aligns with QRDA. Substantial discussion occurred on the task force regarding this method. -->
<!-- Additional comments on this approach should be included in comments on the QRDA Implementation Guide. We will revisit if QRDA changes their standard approach. -->
<priorityCode code="63161005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Principal"/>
<!-- This is a hospital discharge diagnosis, so the ICD-9 (or ICD-10) diagnosis is in translation. -->
<!-- If a SNOMED is available for this, it could be included, but mapping back from ICD-9 may not always be possible. -->
<value xsi:type="CD" nullFlavor="OTH">
<originalText>
<reference value="#Enc1_Dx1" />
</originalText>
<translation xsi:type="CD" code="428.0" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD-9" displayName="Congestive heart failure, unspecified" />
</value>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20141031"/>
<assignedAuthor>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<code code="204C00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Health Care Provider Taxonomy" displayName="Neuromusculoskeletal Medicine, Sports Medicine" />
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
</observation>
</entryRelationship>
</act>
</entryRelationship>
<entryRelationship typeCode="SUBJ">
<!-- Hospital discharge diagnosis act -->
<act moodCode="EVN" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.33"/>
<templateId root="2.16.840.1.113883.10.20.22.4.33" extension="2015-08-01"/>
<id root="f07886ea-7879-478e-8155-5c2cce5cba6a"/>
<code code="11535-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Hospital Discharge Diagnosis"/>
<statusCode code="active"/>
<!-- This represents the time that the concern was authored. Since this is a hospital discharge diagnosis, this is when it was coded-->
<effectiveTime xsi:type="IVL_TS">
<low value="20141102145806+0500" />
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<!-- Problem Observation -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<id root="5f9b714d-a6ec-4f8f-95ae-ea75e5a54bac"/>
<!-- We'll use the type of diagnosis, since this is a coded diagnosis, not from problem list-->
<code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="282291009" displayName="Diagnosis">
<translation code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis"/>
</code>
<text>
<reference value="#Enc1_Dx2" />
</text>
<statusCode code="completed" />
<effectiveTime>
<!-- This represents the date of biological onset. Since this is a coded diagnosis, this may not be documented.-->
<low nullFlavor="UNK" />
</effectiveTime>
<!-- This denotes that the diagnosis is a secondary diagnosis. There may be multiple secondary diagnoses on coded bills.-->
<!-- This current modeling aligns with QRDA. Substantial discussion occurred on the task force regarding this method. -->
<!-- Additional comments on this approach should be included in comments on the QRDA Implementation Guide. We will revisit if QRDA changes their standard approach. -->
<priorityCode code="2603003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Secondary"/>
<!-- This is a hospital discharge diagnosis, so the ICD-9 (or ICD-10) diagnosis is in translation. -->
<!-- If a SNOMED is available for this, it could be included, but mapping back from ICD-9 may not always be possible. -->
<value xsi:type="CD" nullFlavor="OTH">
<originalText>
<reference value="#Enc1_Dx2" />
</originalText>
<translation xsi:type="CD" code="250.00" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD-9" displayName="Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled" />
</value>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20141031"/>
<assignedAuthor>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<code code="204C00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Health Care Provider Taxonomy" displayName="Neuromusculoskeletal Medicine, Sports Medicine" />
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
</observation>
</entryRelationship>
</act>
</entryRelationship>
</encounter>
</entry>
</section>