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ENC_Examples_in_Empty_CCD.xml
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ENC_Examples_in_Empty_CCD.xml
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<?xml version="1.0"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!-- This is an empty C-CDA skeleton which will be used by HL7 CDA Example Task Force -->
<!-- This document was based on prior work by Lisa Nelson and Brian Weiss. contact John D'Amore with questions -->
<!-- See http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force -->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 ../90%20HL7/00%20Standard%20-%20C-CDA/20130409%20C-CDA%20R1dot1_2012JUL/Updated_CDA_Schema_Files_Extension_Support/CDA_Schema_Files/infrastructure/cda/CDA_SDTC.xsd"
xmlns="urn:hl7-org:v3"
xmlns:cda="urn:hl7-org:v3"
xmlns:sdtc="urn:hl7-org:sdtc">
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1"/> <!-- C-CDA -->
<templateId root="2.16.840.1.113883.10.20.22.1.2"/> <!-- CCD -->
<id root="2.16.840.1.113883.3.3208.101.1" extension="20130607100315-CCDA-CCD"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34133-9" displayName="Summarization of Episode Note"/>
<title>Empty CCD Skeleton That Validates on TTT. Note this was based on work by Lisa Nelson and Brian Weiss</title>
<effectiveTime value="20130607000000-0000"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<recordTarget>
<patientRole>
<id root="2.16.840.1.113883.3.3208.101.2" extension="20130607100800-Patient1"/>
<addr use="HP">
<streetAddressLine>1111 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)111-1111" use="HP"/>
<patient>
<name use="L"><given>Patient</given><family>One</family></name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male" codeSystemName="AdministrativeGender"/>
<birthTime value="19300911"/>
<maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatus"/>
<raceCode code="2106-3" displayName="White"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="OMB Standards for Race and Ethnicity"/>
<ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="OMB Standards for Race and Ethnicity"/>
<languageCommunication>
<languageCode code="eng"/>
<modeCode code="ESP" displayName="Expressed spoken" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/>
<proficiencyLevelCode code="E" displayName="Excellent" codeSystem="2.16.840.1.113883.5.61" codeSystemName="LanguageAbilityProficiency"/>
</languageCommunication>
</patient>
</patientRole>
</recordTarget>
<author>
<time value="20130607000000"/>
<assignedAuthor>
<id extension="22222" root="2.16.840.1.113883.4.6"/>
<code code="207QA0505X" codeSystem="2.16.840.1.113883.6.101"
displayName="Adult Medicine" codeSystemName="NUCC"/>
<addr use="HP">
<streetAddressLine>2222 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)222-2222" use="WP"/>
<assignedPerson>
<name>
<given>Doctor</given>
<family>Second</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id extension="33333" root="2.16.840.1.113883.4.6"/>
<code code="364SA2200X" displayName="Adult Health" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"/>
<addr use="WP">
<streetAddressLine>3333 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)333-3333" use="WP"/>
<assignedPerson>
<name>
<given>Nurse</given>
<family>Tertiary</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="44444" root="2.16.840.1.113883.4.6"/>
<name>CDA PRO Fictional Hospital</name>
<telecom value="tel:+1(301)444-4444" use="WP"/>
<addr use="WP">
<streetAddressLine>4444 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<legalAuthenticator>
<time value="20130607000000"/>
<signatureCode code="S"/>
<assignedEntity>
<id root="2.16.840.1.113883.3.3208.101.3" extension="20130607102400-Authenticator1"/>
<addr use="WP">
<streetAddressLine>5555 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)555-5555" use="WP"/>
<assignedPerson>
<name>
<given>Physician</given>
<family>Fifthly</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="19330316"/>
<high value="20130607"/>
</effectiveTime>
<performer typeCode="PRF">
<assignedEntity>
<id extension="66666" root="2.16.840.1.113883.4.6"/>
<code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"
displayName="Cardiovascular Disease"/>
<addr>
<streetAddressLine>6666 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)666-6666" use="WP"/>
<assignedPerson>
<name>
<given>Heartly</given>
<family>Sixer</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<!-- CDA Body -->
<component>
<structuredBody>
<!-- Allergies Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
<!-- Allergies (entries required) section -->
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" displayName="Allergies, adverse reactions, alerts" codeSystemName="LOINC"/>
<title>ALLERGIES</title>
<text>No Information</text>
</section>
</component>
<!-- Medication Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
<!-- Medication Section (entries required) -->
<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>
<!-- Problem Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<!-- conforms to Problems section with entries required -->
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
<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>
<!-- Procedures Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
<!-- Procedures Section with Coded Entries Required-->
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Procedures"/>
<title>PROCEDURES</title>
<text>No Information</text>
</section>
</component>
<!-- Results Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
<!-- Results Section with Coded Entries Required-->
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Relevant diagnostic tests and/or laboratory data"/>
<title>RESULTS</title>
<text>No Information</text>
</section>
</component>
<!-- Plan of Care Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.10"/>
<!-- Plan of Care Section-->
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of Care"/>
<title>PLAN OF CARE</title>
<text>No Information</text>
</section>
</component>
<!-- Social History (with Smoking Status Observation) -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.17"/>
<!-- Social History Section -->
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" displayName="Social History"/>
<title>SOCIAL HISTORY</title>
<text>No Information</text>
</section>
</component>
<!-- Vital Signs Section (entries required) -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.4.1"/>
<!-- Vital Signs (entries required) -->
<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>
<component>
<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"/>
<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>
<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"/>
<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 nullFlavor="OTH">
<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>
<!-- 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 & 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">
<templateId root="2.16.840.1.113883.10.20.22.4.32"/>
<participantRole classCode="SDLOC">
<code code="1060-3" codeSystem="2.16.840.1.113883.5.4" 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"/>
<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" />
<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" />
<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.-->
<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>
</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"/>
<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" />
<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" />
<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.-->
<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>
</observation>
</entryRelationship>
</act>
</entryRelationship>
</encounter>
</entry>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>