CDA profile support
CDA content profiles define clinical semantics for generic CDA documents. A profile usually constrains the CDA model in one or more of the following areas:
- defining templateIds to uniquely identify the semantics of a CDA element
- defining codes and code systems
- defining CDA body sections
The aim of IPF's CDA profile support is to abstract from the generic CDA representation of a certain profile towards a syntax that reflects the structure and vocabulary of the profile specification. In particular, all CDA "boilerplate" code shall be hidden, e.g. with respect to templateIds, codes and titles. This helps to achieve profile-compliant CDA documents, although there's no guarantee for it as for some restrictions it is not possible to automatically enforce them.
CDA profile support also adds Schematron validation against rules that are often released as informative addendum to the profile specification.
The CDA profile support is not only limited to creating profile-compliant documents, but also for extracting information from existing documents, and for validating existing documents.
CCD
The CCD specification is a constraint on the HL7 Clinical Document Architecture (CDA) standard. CCD was developed as a collaborative effort between ASTM and HL7, combining the benefits of ASTMs Continuity of Care Record (CCR) and the HL7 Clinical Document Architecture (CDA) specifications. It is intended as an alternate implementation to the one specified in ASTM ADJE2369 for those institutions or organizations committed to implementation of the HL7 Clinical Document Architecture.
The CCD specification contains U.S. specific requirements; its use is therefore limited to the U.S. The U.S. Healthcare Information Technology Standards Panel (HITSP) has selected the CCD as one of its standards.
Configuration
Building a CCD document does not require any additional dependencies in the Maven setup. It requires, however even more Groovy metaclass extensions on top of the underlying CDA Object model to facilitate accessing CCD documents. Note that the CCDModelExtensions contain the CDAR2ModelExtensions.
You can register the extensions manually:
import org.openehealth.ipf.modules.ccd.builder.CCDModelExtension ... ExpandoMetaClass.enableGlobally() new CCDModelExtension().extensions.call()
Usually you would use a Spring ApplicationContext to register the extensions, especially in conjunction with Camel routes:
<beans xmlns="http://www.springframework.org/schema/beans" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:camel="http://activemq.apache.org/camel/schema/spring" xsi:schemaLocation=" http://www.springframework.org/schema/beans http://www.springframework.org/schema/beans/spring-beans-2.5.xsd http://activemq.apache.org/camel/schema/spring http://activemq.apache.org/camel/schema/spring/camel-spring.xsd"> <camel:camelContext id="camelContext"/> ... <bean id="ccdModelExtension" class="org.openehealth.ipf.modules.ccd.builder.CCDModelExtension"> </bean> <bean id="routeModelExtender" class="org.openehealth.ipf.platform.camel.core.extend.DefaultModelExtender"> <property name="routeModelExtensions"> <list> ... <ref bean="coreModelExtension" /> <ref bean="ccdModelExtension" /> </list> </property> </bean>
Usage
The CCDBuilder is a subclass of the org.openehealth.ipf.modules.cda.builder.CDAR2Builder class. The top-level element is now continuityOfCareDocument instead of clinicalDocument:
import org.openehealth.ipf.modules.cda.builder.content.document.CCDBuilder ... def builder = new CCDBuilder() def ccd = builder.build { continuityOfCareDocument { ... } }
Take care to instantiate CCDBuilder only once and reuse the instance! Note that you use the standard CDAR2Renderer to ender a CCD document to XML.
CCD support also conatins a DSL extension that checks a CCD document in its XML representation against the specified constraints by using a Schematron validator.
import org.openehealth.ipf.commons.xml.SchematronProfile; ... from('direct:input1') .... // get XML CCD into message body .validate().ccd() // equivalent with: // .validate().schematron().staticProfile(new SchematronProfile(CDAR2Constants.CCD_SCHEMATRON_RULES)) ...
You can use the CCDBuilder just like the CDAR2Builder. You can also use it to construct non-CCD documents as its provided functrionality is actually a superset.
However, it offers many additional CCD-specific builder elements and cardinality checks that closely correspond with subchapters of the CCD specification. These special elements facilitate the creation of correct CCD documents by automatically setting static elements and attributes and enforcing the CCD-specific constraints as good as possible.
Below you find a detailed list of how the CCD sections have been mapped into builder elements.
- Purpose section
- Payers section
- Advance Directives section
- Support section
- Functional Status section
- Problems section
- Familiy History section
- Social History section
- Alerts section
- Medications section
- Medical Equipment section
- Immunizations section
- Vital Signs section
- Results section
- Procedures section
- Encounters section
- Plan of Care section
Purpose section
Represents the specific reason for which the summarization was generated, such as in response to a request. The general use case does not require a purpose. Purpose should be utilized when the CCD has a specific purpose such as a transfer, referral, or patient request.
Builder Elements
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| purpose | Section | 0..1 | Purpose section |
| purposeActivity | EntryRelationship | 0(1)..* | Reason for creating the document. The target act may be an Observation, Procedure, or some other kind of act, and it may represent an order, an event, etc. |
Example
Purpose section
... // CCD Purpose (Chapter 2.8) purpose { text('Transfer of Care!') purposeActivity { // Example of an Purpose Activity Act act { code(code:'308292007', codeSystem:'2.16.840.1.113883.6.96', displayName:'Transfer of care') statusCode('completed') } } } ...
Resulting CDA document part
...
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.13"/>
<code code="48764-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summary purpose"/>
<title>Summary purpose</title>
<text>Transfer of Care!</text>
<entry contextConductionInd="true" typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.30"/>
<code code="23745001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Documentation procedure"/>
<statusCode code="completed"/>
<entryRelationship contextConductionInd="true" typeCode="RSON">
<act>
<code code="308292007" codeSystem="2.16.840.1.113883.6.96" displayName="Transfer of care"/>
<statusCode code="completed"/>
</act>
</entryRelationship>
</act>
</entry>
</section>
</component>
</structuredBody>
</component>
...
Payers section
Payers contains data on the patient's payers, whether a 'third party' insurance, self-pay, other payer or guarantor, or some combination of payers, and is used to define which entity is the responsible fiduciary for the financial aspects of a patient's care.
Builder Elements
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| payers | Section | 0(1) | Payers section |
| coverageActivity | Act | 0(1)..* | serves to order the payment sources |
| policyActivity | Act | 1..* | the policy or program providing the coverage |
| payer | AssignedEntity | 1 | performer of the policy activity |
| coveredParty | ParticipantRole | 1 | The person for whom payment is being provided |
| subscriber | ParticipantRole | 0..1 | participant that is the holder the coverage |
| authorizationActivity | Act | 0..* | authorizations or pre-authorizations currently active for the patient for the particular payer |
| promise | EntryRelationsship | 0..* |
Example
Payers section
...
// CCD Payers (Chapter 3.1)
payers {
text {
...
}
coverageActivity {
id('1fe2cdd0-7aad-11db-9fe1-0800200c9a66')
policyActivity {
id('3e676a50-7aac-11db-9fe1-0800200c9a66')
code('EHCPOL')
payer {
id('329fcdf0-7ab3-11db-9fe1-0800200c9a66')
representedOrganization {
name('Good Health Insurance')
}
}
coveredParty {
id('14d4a520-7aae-11db-9fe1-0800200c9a66')
code('SELF')
}
authorizationActivity {
id('f4dce790-8328-11db-9fe1-0800200c9a66')
code(nullFlavor:'NA')
promise {
procedure(moodCode:'PRMS') {
code(code:'73761001',
codeSystem:'2.16.840.1.113883.6.96',
displayName:'Colonoscopy')
}
}
}
}
}
}
...
Resulting CDA document part
...
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.9"/>
<code code="48768-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payment sources"/>
<title>Payers</title>
<text>...</text>
<entry>
<act classCode="ACT" moodCode="DEF">
<templateId root="2.16.840.1.113883.10.20.1.20"/>
<id root="1fe2cdd0-7aad-11db-9fe1-0800200c9a66"/>
<code xsi:type="CE" code="48768-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payment sources"/>
<statusCode code="completed"/>
<entryRelationship contextConductionInd="true" typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.26"/>
<id root="3e676a50-7aac-11db-9fe1-0800200c9a66"/>
<code xsi:type="CE" code="EHCPOL" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<performer typeCode="PRF">
<assignedEntity>
<id root="329fcdf0-7ab3-11db-9fe1-0800200c9a66"/>
<representedOrganization>
<name>Good Health Insurance</name>
</representedOrganization>
</assignedEntity>
</performer>
<participant typeCode="COV">
<participantRole>
<id root="14d4a520-7aae-11db-9fe1-0800200c9a66"/>
<code code="SELF" codeSystem="2.16.840.1.113883.5.111"/>
</participantRole>
</participant>
<entryRelationship typeCode="REFR">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.19"/>
<id root="f4dce790-8328-11db-9fe1-0800200c9a66"/>
<code nullFlavor="NA"/>
<entryRelationship contextConductionInd="true" typeCode="SUBJ">
<procedure classCode="PROC" moodCode="PRMS">
<code code="73761001" codeSystem="2.16.840.1.113883.6.96" displayName="Colonoscopy"/>
</procedure>
</entryRelationship>
</act>
</entryRelationship>
</act>
</entryRelationship>
</act>
</entry>
</section>
</component>
</structuredBody>
</component>
...
Advance Directives section
This section contains data defining the patient's advance directives and any reference to supporting documentation. The most recent and up-to-date directives are required, if known, and should be listed in as much detail as possible. This section contains data such as the existence of living wills, healthcare proxies, and CPR and resuscitation status. If referenced documents are available, they can be included in the CCD exchange package.
Builder Elements
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| advanceDirectives | Section | 0(1) | Advance Directives section |
| advanceDirectiveObservation | Observation | 0(1)..* | Advance Directives observation |
| advanceDirectiveStatus | Observation | 1 | Advance Directive observation status |
| verifier | Participant | 0..* | A verification of an advance directive observation |
| advanceDirectiveReference | ExternalDocument | 0..1 | Referenced advance directive document |
Example
Advance Directives section
... // CCD Advance Directives (Chapter 3.2) advanceDirectives{ text{ table(border:'1', width:'100%'){ thead{ tr{ th('Directive') th('Description') th('Verification') th('Supporting Document(s)') } } tbody{ tr{ td('Resuscitation status') td('Do not resuscitate') td('Dr. Robert Dolin, Nov 07, 1999') td{ linkHtml(href:'AdvanceDirective.b50b7910-7ffb-4f4c-bbe4-177ed68cbbf3.pdf','Advance directive') } } } } }//text advanceDirectiveObservation{ id(root:'9b54c3c9-1673-49c7-aef9-b037ed72ed27') code(code:'304251008', codeSystem:'2.16.840.1.113883.6.96', displayName:'Resuscitation') value(make{ cd(code:'304253006', codeSystem:'2.16.840.1.113883.6.96', displayName:'Do not resuscitate'){ originalText{ reference(value:'#AD1') } } }) verifier{ time(value:'19991107') participantRole{ id(root:'20cf14fb-b65c-4c8c-a54d-b0cca834c18c') } } advanceDirectiveStatus{ value(code:'15240007', codeSystem:'2.16.840.1.113883.6.96', displayName:'Current and verified') }//advance directive observation status advanceDirectiveReference{ id(root:'b50b7910-7ffb-4f4c-bbe4-177ed68cbbf3') code(code:'371538006', codeSystem:'2.16.840.1.113883.6.96', displayName:'Advance directive') text(mediaType:'application/pdf'){ reference(value:'AdvanceDirective.b50b7910-7ffb-4f4c-bbe4-177ed68cbbf3.pdf') } } } } ...
Resulting CDA document part
...
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.1"/>
<code code="42348-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Advance directives"/>
<title>Advance Directives</title>
<text><table border="1" width="100%">
<thead>
<tr>
<th colspan="1" rowspan="1">Directive</th>
<th colspan="1" rowspan="1">Description</th>
<th colspan="1" rowspan="1">Verification</th>
<th colspan="1" rowspan="1">Supporting Document(s)</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="1" rowspan="1">Resuscitation status</td>
<td colspan="1" rowspan="1">Do not resuscitate</td>
<td colspan="1" rowspan="1">Dr. Robert Dolin, Nov 07, 1999</td>
<td colspan="1" rowspan="1"><linkHtml href="AdvanceDirective.b50b7910-7ffb-4f4c-bbe4-177ed68cbbf3.pdf">Advance directive</linkHtml></td>
</tr>
</tbody>
</table></text>
<entry contextConductionInd="true" typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.17"/>
<id root="9b54c3c9-1673-49c7-aef9-b037ed72ed27"/>
<code xsi:type="CE" code="304251008" codeSystem="2.16.840.1.113883.6.96" displayName="Resuscitation"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="304253006" codeSystem="2.16.840.1.113883.6.96" displayName="Do not resuscitate">
<originalText><reference value="#AD1"/></originalText>
</value>
<participant typeCode="VRF">
<templateId root="2.16.840.1.113883.10.20.1.58"/>
<time value="19991107"/>
<participantRole>
<id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c"/>
</participantRole>
</participant>
<entryRelationship contextConductionInd="true" typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.37"/>
<code xsi:type="CE" code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="15240007" codeSystem="2.16.840.1.113883.6.96" displayName="Current and verified"/>
</observation>
</entryRelationship>
<reference typeCode="REFR">
<externalDocument classCode="DOC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.36"/>
<id root="b50b7910-7ffb-4f4c-bbe4-177ed68cbbf3"/>
<code code="371538006" codeSystem="2.16.840.1.113883.6.96" displayName="Advance directive"/>
<text mediaType="application/pdf"><reference value="AdvanceDirective.b50b7910-7ffb-4f4c-bbe4-177ed68cbbf3.pdf"/></text>
</externalDocument>
</reference>
</observation>
</entry>
</section>
</component>
</structuredBody>
</component>
...
Support section
This section represents the patient's sources of support such as immediate family, relatives, and guardian at the time the summarization is generated. Support information also includes next of kin, caregivers, and support organizations. At a minimum, key support contacts relative to healthcare decisions, including next of kin, should be included.
Builder Elements
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| gardian | Patient/Guardian | 0(1) | Guardian entry |
| nextOfKin | Participant/associatedEntity | 0..* | Next of kin participant entry |
| emergencyContact | Participant/associatedEntity | 0..* | Emergency contact participant entry |
| caregiver | Participant/associatedEntity | 0..* | Caregiver participant entry |
Example
Support entries
continuityOfCareDocument {
...
nextOfKin{
id(root:'4ac71514-6a10-4164-9715-f8d96af48e6d')
code(code:'65656005', codeSystem:'2.16.840.1.113883.6.96', displayName:'Biiological mother')
telecom(value:'tel:(999)555-1212')
associatedPerson{
name{
given('Henrietta')
family('Levin')
}
}
}//next of kin
emergencyContact{
id(root:'4ac71514-6a10-4164-9715-f8d96af48e6f')
associatedPerson{
name{
given('Baba')
family('John')
}
}
}//emergency contact
caregiver{
scopingOrganization{
name('Very Good Health Clinic')
}
}//patient caregiver
...
}
Resulting CDA document part
.... <participant typeCode="IND"> <associatedEntity classCode="NOK"> <id root="4ac71514-6a10-4164-9715-f8d96af48e6d"/> <code code="65656005" codeSystem="2.16.840.1.113883.6.96" displayName="Biiological mother"/> <telecom value="tel:(999)555-1212"/> <associatedPerson> <name><given>Henrietta</given><family>Levin</family></name> </associatedPerson> </associatedEntity> </participant> <participant typeCode="IND"> <associatedEntity classCode="ECON"> <id root="4ac71514-6a10-4164-9715-f8d96af48e6f"/> <associatedPerson> <name><given>Baba</given><family>John</family></name> </associatedPerson> </associatedEntity> </participant> <participant typeCode="IND"> <associatedEntity classCode="CAREGIVER"> <scopingOrganization> <name>Very Good Health Clinic</name> </scopingOrganization> </associatedEntity> </participant> ...
Functional Status section
Functional Status describes the patient's status of normal functioning at the time the Care Record was created.
Functional Status
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| funcationalStatus | Section | 0(1) | Functional Status section |
| problemAct | Act | 0(1)..* | see Problems section |
| functionalStatusStaus | Act | 0..1 | Problem observation may contain a status observation of functional status |
Example
Functional Status section
...
// CCD Funtional Stats (Chapter 3.4)
functionalStatus{
text{
...
}
problemAct{
id(root:'6z2fa88d-4174-4909-aece-db44b60a3abb')
code(nullFlavor:'NA')
problemObservation{
id(root:'fd07111a-b15b-4dce-8518-1274d07f142a')
code(code:'ASSERTION', codeSystem:'2.16.840.1.113883.5.4')
effectiveTime{low(value:'1998')}
value( make{
cd(code:'105504002',
codeSystem:'2.16.840.1.113883.6.96',
displayName:'Dependence on cane')
}
)
functionalStatusStatus{
value(code:'55561003',
codeSystem:'2.16.840.1.113883.6.96',
displayName:'Active')
}
}
}
problemAct{
id(root:'64606e86-c080-11db-8314-0800200c9a66')
problemObservation{
id(root:'64606e86-c080-11db-8314-0800200c9a66')
code(code:'ASSERTION', codeSystem:'2.16.840.1.113883.5.4')
value( make{
cd(code:'386807006',
codeSystem:'2.16.840.1.113883.6.96',
displayName:'Memory impairment')
}
)
functionalStatusStatus{
value(code:'55561003',
codeSystem:'2.16.840.1.113883.6.96',
displayName:'Active')
}
}
}
}
...
Resulting CDA document part
....
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.5"/>
<code code="47420-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Functional status assessment"/>
<title>Functional Status</title>
<text>...</text>
<entry contextConductionInd="true" typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.27"/>
<id root="6z2fa88d-4174-4909-aece-db44b60a3abb"/>
<code nullFlavor="NA"/>
<entryRelationship contextConductionInd="true" typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28"/>
<id root="fd07111a-b15b-4dce-8518-1274d07f142a"/>
<code xsi:type="CE" code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="1998"/>
</effectiveTime>
<value xsi:type="CD" code="105504002" codeSystem="2.16.840.1.113883.6.96" displayName="Dependence on cane"/>
<entryRelationship contextConductionInd="true" typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.44"/>
<code xsi:type="CE" code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="55561003" codeSystem="2.16.840.1.113883.6.96" displayName="Active"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
<entry contextConductionInd="true" typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.27"/>
<id root="64606e86-c080-11db-8314-0800200c9a66"/>
<code nullFlavor="NA"/>
<entryRelationship contextConductionInd="true" typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28"/>
<id root="64606e86-c080-11db-8314-0800200c9a66"/>
<code xsi:type="CE" code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="386807006" codeSystem="2.16.840.1.113883.6.96" displayName="Memory impairment"/>
<entryRelationship contextConductionInd="true" typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.44"/>
<code xsi:type="CE" code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="55561003" codeSystem="2.16.840.1.113883.6.96" displayName="Active"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
</structuredBody>
</component>
...
Problems section
This section lists and describes all relevant clinical problems at the time the summary is generated. At a minimum, all pertinent current and historical problems should be listed. CDA R2 represents problems as Observations.
Builder Elements
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| problems | Section | 0(1) | Problems section |
| problemAct | Act | 0(1)..* | Problem clinical statement |
| problemObservation | Observation | 1..* | Related problem observations |
| problemStatus | Observation | 0..1 | The status of a given problem observation |
| problemHealthstatus | Observation | 0..1 | Describes overall patient health status as a result of a particular problem |
| episodeObservation | Observation | 0..1 | May be used to indicate that a problem act represents a new episode, distinct from other episodes of a similar concern |
| patientAwareness | Observation | 0..1 | Patient awareness of a problem act or problem observation |
Example
Problems section
... // CCD Problems (Chapter 3.5) component { structuredBody { problems{ text('Patient Problems Acts') problemAct{ id(root:'d11275e9-67ae-11db-bd13-0800200c9a66') problemObservation{ id(root:'9d3d416d-45ab-4da1-912f-4583e0632000') code(code:'ASSERTION', codeSystem:'2.16.840.1.113883.5.4') value(make{ cd(code:'233604007',codeSystem:'2.16.840.1.113883.6.96',displayName:'Pneumonia') } ) problemStatus{ value(code:'413322009', codeSystem:'2.16.840.1.113883.6.96', displayName:'Resolved') } problemHealthstatus{ value(code:'162467007', codeSystem:'2.16.840.1.113883.6.96', displayName:'Symptom Free') } } episodeObservation{ code(code:'ASSERTION', codeSystem:'2.16.840.1.113883.5.4') value(make{ cd(code:'404684003', codeSystem:'2.16.840.1.113883.6.96', displayName:'Clinical finding') } ) entryRelationship(typeCode:'SAS'){ act(classCode:'ACT', moodCode:'EVN'){ id(root:'ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7') code(nullFlavor:'NA') }//act } } patientAwareness{ awarenessCode(code:'TEST', codeSystem:'2.16.840.1.113883.5.4') participantRole{ id(root:'c8a6ff8-ed4b-4f7e-82c3-e98e58b45de8') } } } } } } } ...
Resulting CDA document part
....
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.11"/>
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem list"/>
<title>Problems</title>
<text>Patient Problems Acts</text>
<entry contextConductionInd="true" typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.27"/>
<id root="d11275e9-67ae-11db-bd13-0800200c9a66"/>
<code nullFlavor="NA"/>
<participant typeCode="SBJ">
<templateId root="2.16.840.1.113883.10.20.1.48"/>
<awarenessCode code="TEST" codeSystem="2.16.840.1.113883.5.4"/>
<participantRole>
<id root="c8a6ff8-ed4b-4f7e-82c3-e98e58b45de8"/>
</participantRole>
</participant>
<entryRelationship contextConductionInd="true" typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28"/>
<id root="9d3d416d-45ab-4da1-912f-4583e0632000"/>
<code xsi:type="CE" code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="233604007" codeSystem="2.16.840.1.113883.6.96" displayName="Pneumonia"/>
<entryRelationship contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.50"/>
<code xsi:type="CE" code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="413322009" codeSystem="2.16.840.1.113883.6.96" displayName="Resolved"/>
</observation>
</entryRelationship>
<entryRelationship contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.51"/>
<code xsi:type="CE" code="11323-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Health status"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="162467007" codeSystem="2.16.840.1.113883.6.96" displayName="Symptom Free"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
<entryRelationship contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.41"/>
<code xsi:type="CE" code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="404684003" codeSystem="2.16.840.1.113883.6.96" displayName="Clinical finding"/>
<entryRelationship contextConductionInd="true" typeCode="SAS">
<act classCode="ACT" moodCode="EVN">
<id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7"/>
<code nullFlavor="NA"/>
</act>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
</structuredBody>
</component>
...
Familiy History section
This section contains data defining the patient's genetic relatives in terms of possible or relevant health risk factors that have a potential impact on the patient's healthcare risk profile.
Builder Elements
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| familyHistory | Section | 0(1) | Family history section |
| familyHistoryObservation | Observation | 0(1)..* | Family history observation |
| problemStatus | Observation | 0..1 | The status of a given family history observation (see Problem Observation) |
| causeOfDeath | Observation | 0(1)..* | A special family history observation describing the cause of death |
| cause | Observation | 1 | Family history observation of death |
| familyMember | Organizer | 0(1)..* | Family history organizer in order to group the family history observations related to a family member |
| familyPerson | RelatedSubject | 1 | Subject participant, representing the family member who is the subject of the family history observations |
| age | Observation | 1 | Representation of age |
Example
Family History Section
...
// CCD Family History (Chapter 3.6)
familyHistory {
text('skipped')
familyMember {
familyPerson {
code(code:'9947008', codeSystem:'2.16.840.1.113883.6.96', displayName:'Biological father')
subject {
administrativeGenderCode('M')
birthTime(value:'1912')
}
}
causeOfDeath {
id('d42ebf70-5c89-11db-b0de-0800200c9a66')
code('ASSERTION')
value(make {
ce(code:'22298006',codeSystem:'2.16.840.1.113883.6.96',displayName:'MI')
})
cause {
id('6898fae0-5c8a-11db-b0de-0800200c9a66')
code('ASSERTION', codeSystem:'2.16.840.1.113883.5.4')
statusCode('completed')
value(make {
ce(code:'419099009',codeSystem:'2.16.840.1.113883.6.96',displayName:'Dead')
})
}
age {
value(make { _int(57) })
}
}
familyHistoryObservation{
id('5bfe3ec0-5c8b-11db-b0de-0800200c9a66')
code('ASSERTION', codeSystem:'2.16.840.1.113883.5.4')
value(make {
ce(code:'59621000',codeSystem:'2.16.840.1.113883.6.96',displayName:'HTN')
})
age {
value(make { _int(40) })
}
problemStatus{
value(code:'413322009', displayName:'Resolved')
}
}
}
familyMember {
familyPerson {
code(code:'65656005', codeSystem:'2.16.840.1.113883.6.96', displayName:'Biological mother')
subject {
administrativeGenderCode('F')
birthTime(value:'1912')
}
}
familyHistoryObservation{
id('a13c6160-5c8b-11db-b0de-0800200c9a66')
code('ASSERTION', codeSystem:'2.16.840.1.113883.5.4')
value(make {
ce(code:'195967001',codeSystem:'2.16.840.1.113883.6.96',displayName:'Asthma')
})
age {
value(make { _int(30) })
}
}
}
}
...
Resulting CDA document part
...
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.4"/>
<code code="10157-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of family member diseases"/>
<title>Family History</title>
<text>skipped</text>
<entry contextConductionInd="true" typeCode="DRIV">
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.23"/>
<statusCode code="completed"/>
<subject>
<relatedSubject classCode="PRS">
<code xsi:type="CE" code="9947008" codeSystem="2.16.840.1.113883.6.96" displayName="Biological father"/>
<subject>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
<birthTime value="1912"/>
</subject>
</relatedSubject>
</subject>
<component contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.42"/>
<id root="d42ebf70-5c89-11db-b0de-0800200c9a66"/>
<code xsi:type="CE" code="ASSERTION"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="22298006" codeSystem="2.16.840.1.113883.6.96" displayName="MI"/>
<entryRelationship contextConductionInd="true" typeCode="CAUS">
<observation classCode="OBS" moodCode="INT">
<id root="6898fae0-5c8a-11db-b0de-0800200c9a66"/>
<code xsi:type="CE" code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="419099009" codeSystem="2.16.840.1.113883.6.96" displayName="Dead"/>
</observation>
</entryRelationship>
<entryRelationship contextConductionInd="true" inversionInd="true" typeCode="SUBJ">
<observation classCode="OBS" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.1.38"/>
<code xsi:type="CE" code="397659008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Age"/>
<statusCode code="completed"/>
<value xsi:type="INT" value="57"/>
</observation>
</entryRelationship>
</observation>
</component>
<component contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.22"/>
<id root="5bfe3ec0-5c8b-11db-b0de-0800200c9a66"/>
<code xsi:type="CE" code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="59621000" codeSystem="2.16.840.1.113883.6.96" displayName="HTN"/>
<entryRelationship contextConductionInd="true" inversionInd="true" typeCode="SUBJ">
<observation classCode="OBS" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.1.38"/>
<code xsi:type="CE" code="397659008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Age"/>
<statusCode code="completed"/>
<value xsi:type="INT" value="40"/>
</observation>
</entryRelationship>
</observation>
</component>
</organizer>
</entry>
<entry contextConductionInd="true" typeCode="DRIV">
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.23"/>
<statusCode code="completed"/>
<subject>
<relatedSubject classCode="PRS">
<code xsi:type="CE" code="65656005" codeSystem="2.16.840.1.113883.6.96" displayName="Biological mother"/>
<subject>
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
<birthTime value="1912"/>
</subject>
</relatedSubject>
</subject>
<component contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.22"/>
<id root="a13c6160-5c8b-11db-b0de-0800200c9a66"/>
<code xsi:type="CE" code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="195967001" codeSystem="2.16.840.1.113883.6.96" displayName="Asthma"/>
<entryRelationship contextConductionInd="true" inversionInd="true" typeCode="SUBJ">
<observation classCode="OBS" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.1.38"/>
<code xsi:type="CE" code="397659008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Age"/>
<statusCode code="completed"/>
<value xsi:type="INT" value="30"/>
</observation>
</entryRelationship>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
</structuredBody>
</component>
...
Social History section
This section contains data defining the patient's occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation. Social history can have significant influence on a patient's physical, psychological and emotional health and wellbeing so should be considered in the development of a complete record.
Builder Elements
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| socialHistory | Section | 0(1) | Social History section |
| socialHistoryObservation | Observation | 0(1)..* | Social history observation (see also Episode Observation) |
| socialHistoryStatus | Observation | 0..1 | Social history observation status |
Example
Social History Section
...
// CCD Social History (Chapter 3.7)
socialHistory{
text{
....
}
socialHistoryObservation{
id(root:'9b56c25d-9104-45ee-9fa4-e0f3afaa01c1')
code(code:'230056004', codeSystem:'2.16.840.1.113883.6.96', displayName:'Cigarette smoking')
effectiveTime{
low(value:'1947')
high(value:'1972')
}
value(make{
st('1 pack per day')
})
}
socialHistoryObservation{
id(root:'45efb604-7049-4a2e-ad33-d38556c9636c')
code( code:'230056004', codeSystem:'2.16.840.1.113883.6.96', displayName:'Cigarette smoking')
effectiveTime{
low(value:'1973')
}
value(make{
st('None')
})
episodeObservation{
code(code:'ASSERTION', codeSystem:'2.16.840.1.113883.5.4')
entryRelationship(typeCode:'SAS'){
observation(classCode:'OBS', moodCode:'EVN'){
id(root:'9b56c25d-9104-45ee-9fa4-e0f3afaa01c1')
code(code:'230056004',
codeSystem:'2.16.840.1.113883.6.96',
displayName:'Cigarette smoking')
}
}
}
}
}
...
Resulting CDA document part
....
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.15"/>
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social history"/>
<title>Social History</title>
<text>...</text>
<entry contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.33"/>
<id root="9b56c25d-9104-45ee-9fa4-e0f3afaa01c1"/>
<code xsi:type="CE" code="230056004" codeSystem="2.16.840.1.113883.6.96" displayName="Cigarette smoking"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="1947"/>
<high value="1972"/>
</effectiveTime>
<value xsi:type="ST">1 pack per day</value>
</observation>
</entry>
<entry contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.33"/>
<id root="45efb604-7049-4a2e-ad33-d38556c9636c"/>
<code xsi:type="CE" code="230056004" codeSystem="2.16.840.1.113883.6.96" displayName="Cigarette smoking"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="1973"/>
</effectiveTime>
<value xsi:type="ST">None</value>
<entryRelationship contextConductionInd="true" typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.41"/>
<code xsi:type="CE" code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="404684003" codeSystem="2.16.840.1.113883.6.96" displayName="Clinical finding">
<qualifier>
<name code="246456000" displayName="Episodicity"/>
<value code="288527008" displayName="New episode"/>
</qualifier>
</value>
<entryRelationship contextConductionInd="true" typeCode="SAS">
<observation classCode="OBS" moodCode="EVN">
<id root="9b56c25d-9104-45ee-9fa4-e0f3afaa01c1"/>
<code xsi:type="CE" code="230056004" codeSystem="2.16.840.1.113883.6.96" displayName="Cigarette smoking"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</observation>
</entry>
</section>
</component>
</structuredBody>
</component>
...
Alerts section
This section is used to list and describe any allergies, adverse reactions, and alerts that are pertinent to the patient's current or past medical history. At a minimum, currently active and any relevant historical allergies and adverse reactions should be listed.
Builder Elements
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| alerts | Section | 0(1) | Problems section |
| problemAct | Act | 0(1)..* | Problem clinical statement |
| alertObservation | Observation | 1..* | Related alert observations |
| alertStatus | Observation | 0..1 | The status of a given alert observation |
| participantAgent | Observation | 1..* | The agent responsible for an allergy or adverse reaction |
| reactionObservation | Observation | 0(1)..* | Reaction representation to an administered or exposed substance |
| reactionIntervention | EntryRelationship | 0(1)..* | Reaction observation may contain reaction interventions. Reaction Intervention may be represented by any clinical statement | medicationActivity | procedureActivityAct | procedureActivityObservation | procedureActivityProcedure |
| severityObservation | Observation | 0..1 | Reaction severity to a given reactions observation |
Example
Alerts Section
...
// CCD Alerts (Chapter 3.8)
alerts{
text('Patient Alerts')
problemAct{
id(root:'d11275e9-67ae-11db-bd13-0800200c9a66')
alertObservation{
id(root:'9d3d416d-45ab-4da1-912f-4583e0632000')
code(code:'ASSERTION', codeSystem:'2.16.840.1.113883.5.4')
effectiveTime('20000328')
alertStatus{
value(code:'55561003',
codeSystem:'2.16.840.1.113883.6.96',
displayName:'Active')
}
participantAgent{
playingEntity{
code(code:'70618',
codeSystem:'2.16.840.1.113883.6.88',
displayName:'Penicillin')
}
}
reactionObservation{
code(code:'ASSERTION', codeSystem:'2.16.840.1.113883.5.4')
value(make{
cd(code:'247472004',
codeSystem:'2.16.840.1.113883.6.96',
displayName:'Hives')
})
severityObservation{
value(make{
cd(code:'247472004',
codeSystem:'2.16.840.1.113883.6.96',
displayName:'Hives')
})
}
}
}
}
}
...
Resulting CDA document part
....
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.2"/>
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts"/>
<title>Allergies and adverse reactions, alerts</title>
<text>Patient Alerts</text>
<entry contextConductionInd="true" typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.27"/>
<id root="d11275e9-67ae-11db-bd13-0800200c9a66"/>
<code nullFlavor="NA"/>
<entryRelationship contextConductionInd="true" typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.18"/>
<id root="9d3d416d-45ab-4da1-912f-4583e0632000"/>
<code xsi:type="CE" code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime value="20000328"/>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code code="70618" codeSystem="2.16.840.1.113883.6.88" displayName="Penicillin"/>
</playingEntity>
</participantRole>
</participant>
<entryRelationship contextConductionInd="true" typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.39"/>
<code xsi:type="CE" code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="55561003" codeSystem="2.16.840.1.113883.6.96" displayName="Active"/>
</observation>
</entryRelationship>
<entryRelationship contextConductionInd="true" typeCode="MFST">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.54"/>
<code xsi:type="CE" code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="247472004" codeSystem="2.16.840.1.113883.6.96" displayName="Hives"/>
<entryRelationship contextConductionInd="true" typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.55"/>
<code xsi:type="CE" code="SEV" codeSystem="2.16.840.1.113883.5.4" displayName="Severity observation"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="247472004" codeSystem="2.16.840.1.113883.6.96" displayName="Hives"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
</structuredBody>
</component>
...
Medications section
The Medications section defines a patient's current medications and pertinent medication history. At a minimum, the currently active medications should be listed, with an entire medication history as an option, particularly when the summary document is used for comprehensive data export. The section may also include a patient's prescription history, and enables the determination of the source of a medication list (e.g. from a pharmacy system vs. from the patient).
Builder Elements
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| medications | Section | 0(1) | Social History section |
| medicationActivity | SubstanceAdministration | 0(1)..* | Medication activity describes what is administered |
| consumable | Consumable | 1 | Targets a product template |
| seriesNumber | Observation | 0..1 | Medication activity series number observation. As of per definition the structure is strictly defined, seriesNumber accepts only int parameter seriesNumber(Integer) (see the example) |
| indication | EntryRelationship | 0(1)..* | Shows the relation to problem observation or problem act (see Problems) |
| patientInstruction | Act | 0(1)..* | Additional information provided to a patient related to one of their medications |
| supplyActivity | Supply | 0(1)..* | Supply activity describes what has been dispensed |
| fulfillmentInstruction | Act | 0(1)..* | Additional information provided to the dispensing party |
| supplyLocation | Participant | 0(1)..* | Indicates the supply location |
| product | Product | 0..1 | Supply activity product |
| medicationStatus | Observation | 0..1 | Medication status observation can be applied to medication or supply activity |
| productInstance | Act | 0(1)..* | Identify a particular product instance for medication and supply activities (see Procedures) |
| reactionObservation | Observation | 0(1)..* | Reaction representation to an administered or exposed substance (see Alerts ) |
Example
Medications Section
... // CCD Medications (Chapter 3.9) medications{ text { .... } informant { assignedEntity { id('996-756-495@2.16.840.1.113883.19.5') representedOrganization { id('2.16.840.1.113883.19.5') name('Good Health Clinic') } } } medicationActivity { id('cdbd33f0-6cde-11db-9fe1-0800200c9a66') effectiveTime(make { pivlts { period('6 h') } }) routeCode(code:'IPINHL', displayName:"Inhalation, oral") doseQuantity(value:2.0) administrationUnitCode(code:"415215001", codeSystem:"2.16.840.1.113883.6.96", displayName:"Puff") consumable { manufacturedProduct { manufacturedMaterial { code(code:"307782", codeSystem:"2.16.840.1.113883.6.88", displayName:"Albuterol 0.09 MG/ACTUAT inhalant solution") { originalText('Albuterol inhalant') } } } } patientInstruction{ id('cdbd5b08-6cde-11db-9fe1-0800200b8a66') code(code:'ASSERTION', codeSystem:'2.16.840.1.113883.5.4') effectiveTime{ low('20000338') } text('Read the instructions carefully') } seriesNumber(1) precondition { criterion { code(code:"ASSERTION",codeSystem:"2.16.840.1.113883.5.4") value(make { ce(code:'56018004', codeSystem:'2.16.840.1.113883.6.96', displayName:'Wheezing') }) } } reactionObservation{ code(code:'ASSERTION', codeSystem:'2.16.840.1.113883.5.4') value(make{ cd(code:'247472004', codeSystem:'2.16.840.1.113883.6.96', displayName:'Hives') } ) severityObservation{ value(make{ cd(code:'247472004', codeSystem:'2.16.840.1.113883.6.96', displayName:'Hives') }) } }//reaction observation } medicationActivity { id('cdbd5b07-6cde-11db-9fe1-0800200c9a66') effectiveTime(make { ivlts { low('20000328') high('20000404') } }) effectiveTime(make { pivlts(operator:'A') { period('6 h') } }) routeCode(code:'PO') doseQuantity(value:1.0) consumable { manufacturedProduct { manufacturedMaterial { code(code:"197454", codeSystem:"2.16.840.1.113883.6.88", displayName:"Cephalexin 500 MG oral tablet") { originalText('Cephalexin') } } } } indication { problemObservation(classCode:'COND') { id('cdbd5b08-6cde-11db-9fe1-0800200c9a66') code(code:'ASSERTION', codeSystem:'2.16.840.1.113883.5.4') effectiveTime { low('20000328') } value(make { ce(code:'32398004', codeSystem:'2.16.840.1.113883.6.96', displayName:'Bronchitis') }) } } } } ...
Resulting CDA document part
...
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.8"/>
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of medication use"/>
<title>Medication</title>
<text>...</text>
<informant>
<assignedEntity>
<id extension="996-756-495" root="2.16.840.1.113883.19.5"/>
<representedOrganization>
<id root="2.16.840.1.113883.19.5"/>
<name>Good Health Clinic</name>
</representedOrganization>
</assignedEntity>
</informant>
<entry contextConductionInd="true">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<id root="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/>
<statusCode code="active"/>
<effectiveTime/>
<routeCode code="IPINHL" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration" displayName="Inhalation, oral"/>
<doseQuantity unit="1" value="2.0"/>
<administrationUnitCode code="415215001" codeSystem="2.16.840.1.113883.6.96" displayName="Puff"/>
<consumable>
<manufacturedProduct>
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<manufacturedMaterial>
<code code="307782" codeSystem="2.16.840.1.113883.6.88" displayName="Albuterol 0.09 MG/ACTUAT inhalant solution">
<originalText>Albuterol inhalant</originalText>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<entryRelationship contextConductionInd="true" typeCode="SUBJ">
<act moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.1.49"/>
<id root="cdbd5b08-6cde-11db-9fe1-0800200b8a66"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<text>Read the instructions carefully</text>
<effectiveTime>
<low value="20000338"/>
</effectiveTime>
</act>
</entryRelationship>
<entryRelationship contextConductionInd="true" typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.46"/>
<code xsi:type="CE" code="30973-2" codeSystem="2.16.840.1.113883.6.1" displayName="Dose number"/>
<statusCode code="completed"/>
<value xsi:type="INT" value="1"/>
</observation>
</entryRelationship>
<entryRelationship contextConductionInd="true" typeCode="CAUS">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.54"/>
<code xsi:type="CE" code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="247472004" codeSystem="2.16.840.1.113883.6.96" displayName="Hives"/>
<entryRelationship contextConductionInd="true" typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.55"/>
<code xsi:type="CE" code="SEV" codeSystem="2.16.840.1.113883.5.4" displayName="Severity observation"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="247472004" codeSystem="2.16.840.1.113883.6.96" displayName="Hives"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
<precondition>
<criterion>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<value xsi:type="CE" code="56018004" codeSystem="2.16.840.1.113883.6.96" displayName="Wheezing"/>
</criterion>
</precondition>
</substanceAdministration>
</entry>
<entry contextConductionInd="true">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<id root="cdbd5b07-6cde-11db-9fe1-0800200c9a66"/>
<statusCode code="active"/>
<effectiveTime/>
<effectiveTime/>
<routeCode code="PO" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration"/>
<doseQuantity unit="1" value="1.0"/>
<consumable>
<manufacturedProduct>
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<manufacturedMaterial>
<code code="197454" codeSystem="2.16.840.1.113883.6.88" displayName="Cephalexin 500 MG oral tablet">
<originalText>Cephalexin</originalText>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<entryRelationship contextConductionInd="true" typeCode="RSON">
<observation classCode="COND" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28"/>
<id root="cdbd5b08-6cde-11db-9fe1-0800200c9a66"/>
<code xsi:type="CE" code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="20000328"/>
</effectiveTime>
<value xsi:type="CE" code="32398004" codeSystem="2.16.840.1.113883.6.96" displayName="Bronchitis"/>
</observation>
</entryRelationship>
</substanceAdministration>
</entry>
</section>
</component>
</structuredBody>
</component>
...
Medical Equipment section
The Medical Equipment section defines a patient's implanted and external medical devices and equipment that their health status depends on, as well as any pertinent equipment or device history. Medical equipment uses the same data objects and constraints as Medications.
Builder Elements
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| medicalEquipment | Section | 0(1) | Medical equipment section (see Medications) |
Example
Medical Equipment Section
...
medicalEquipment{
text{...}
supplyActivity{
id(root:'2413773c-2372-4299-bbe6-5b0f60664446')
effectiveTime(make{
ivlts{
center(value:'199911')
}
})
productInstance{
playingDevice{
code(code:'72506001',
codeSystem:'2.16.840.1.113883.6.96',
displayName:'Automatic implantable cardioverter/defibrillator')
}
}
}
supplyActivity{
id(root:'230b0ab7-206d-42d8-a947-ab4f63aad795')
effectiveTime(make{
ivlts{
center(value:'1998')
}
})
productInstance{
id(root:'03ca01b0-7be1-11db-9fe1-0800200c9a66')
playingDevice{
code(code:'304120007',
codeSystem:'2.16.840.1.113883.6.96',
displayName:'Total hip replacement prosthesis')
}
scopingEntity{
id(root:'0abea950-5b40-4b7e-b8d9-2a5ea3ac5500')
desc('Good Health Prostheses Company')
}
}
}
supplyActivity{
id(root:'c4ffe98e-3cd3-4c54-b5bd-08ecb80379e0')
effectiveTime(make{
ivlts{
center(value:'1999')
}
})
productInstance{
playingDevice{
code(code:'58938008',
codeSystem:'2.16.840.1.113883.6.96',
displayName:'Wheelchair')
}
}
}
}
...
Resulting CDA document part
....
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.7"/>
<code code="46264-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of medical device use"/>
<title>Equipment</title>
<text>...</text>
<entry>
<supply classCode="SPLY">
<templateId root="2.16.840.1.113883.10.20.1.34"/>
<id root="2413773c-2372-4299-bbe6-5b0f60664446"/>
<statusCode code="active"/>
<effectiveTime/>
<participant typeCode="DEV">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.1.52"/>
<playingDevice>
<code code="72506001" codeSystem="2.16.840.1.113883.6.96" displayName="Automatic implantable cardioverter/defibrillator"/>
</playingDevice>
</participantRole>
</participant>
</supply>
</entry>
<entry>
<supply classCode="SPLY">
<templateId root="2.16.840.1.113883.10.20.1.34"/>
<id root="230b0ab7-206d-42d8-a947-ab4f63aad795"/>
<statusCode code="active"/>
<effectiveTime/>
<participant typeCode="DEV">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.1.52"/>
<id root="03ca01b0-7be1-11db-9fe1-0800200c9a66"/>
<playingDevice>
<code code="304120007" codeSystem="2.16.840.1.113883.6.96" displayName="Total hip replacement prosthesis"/>
</playingDevice>
<scopingEntity>
<id root="0abea950-5b40-4b7e-b8d9-2a5ea3ac5500"/>
<desc>Good Health Prostheses Company</desc>
</scopingEntity>
</participantRole>
</participant>
</supply>
</entry>
<entry>
<supply classCode="SPLY">
<templateId root="2.16.840.1.113883.10.20.1.34"/>
<id root="c4ffe98e-3cd3-4c54-b5bd-08ecb80379e0"/>
<statusCode code="active"/>
<effectiveTime/>
<participant typeCode="DEV">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.1.52"/>
<playingDevice>
<code code="58938008" codeSystem="2.16.840.1.113883.6.96" displayName="Wheelchair"/>
</playingDevice>
</participantRole>
</participant>
</supply>
</entry>
</section>
</component>
</structuredBody>
</component>
...
Immunizations section
The Immunizations section defines a patient's current immunization status and pertinent immunization history. Immunizations section uses the same data objects and constraints as Medications.
Builder Elements
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| immunizations | Section | 0(1) | Immunizations section (see Medications) |
Example
Immunizations Section
... // CCD Immunizations (Chapter 3.11) immunizations{ text{...} medicationActivity{ id(root:'e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92') effectiveTime(make{ ivlts{ center(value:'199911') } }) routeCode(code:'IM', displayName:"Intramuscular injection") consumable { manufacturedProduct { manufacturedMaterial { code(code:'88', codeSystem:'2.16.840.1.113883.6.59', displayName:'Influenza virus vaccine') { originalText('Influenza virus vaccine') } } } } } medicationActivity{ id(root:'115f0f70-1343-4938-b62f-631de9749a0a') effectiveTime(make{ ivlts{ center(value:'199812') } }) routeCode(code:'IM', displayName:"Intramuscular injection") consumable { manufacturedProduct { manufacturedMaterial { code(code:'88', codeSystem:'2.16.840.1.113883.6.59', displayName:'Influenza virus vaccine') { originalText('Influenza virus vaccine') } } } } } medicationActivity{ id(root:'78598407-9f16-42d5-8ffd-09281a60fe33') effectiveTime(make{ ivlts{ center(value:'199812') } }) routeCode(code:'IM', displayName:"Intramuscular injection") consumable { manufacturedProduct { manufacturedMaterial { code(code:'33', codeSystem:'2.16.840.1.113883.6.59', displayName:'Pneumococcal polysaccharide vaccine') { originalText('Pneumococcal polysaccharide vaccine') } } } } } medicationActivity{ id(root:'261e94a0-95fb-4975-b5a5-c8e12c01c1bc') effectiveTime(make{ ivlts{ center(value:'1997') } }) routeCode(code:'IM', displayName:"Intramuscular injection") consumable { manufacturedProduct { manufacturedMaterial { code(code:'09', codeSystem:'2.16.840.1.113883.6.59', displayName:'Tetanus and diphtheria toxoids') { originalText('Tetanus and diphtheria toxoids') } } } } } } ...
Resulting CDA document part
...
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.6"/>
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of immunizations"/>
<title>Immunization</title>
<text></text>
<entry contextConductionInd="true">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<id root="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92"/>
<statusCode code="active"/>
<effectiveTime/>
<routeCode code="IM" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration" displayName="Intramuscular injection"/>
<consumable>
<manufacturedProduct>
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<manufacturedMaterial>
<code code="88" codeSystem="2.16.840.1.113883.6.59" displayName="Influenza virus vaccine">
<originalText>Influenza virus vaccine</originalText>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<entry contextConductionInd="true">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<id root="115f0f70-1343-4938-b62f-631de9749a0a"/>
<statusCode code="active"/>
<effectiveTime/>
<routeCode code="IM" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration" displayName="Intramuscular injection"/>
<consumable>
<manufacturedProduct>
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<manufacturedMaterial>
<code code="88" codeSystem="2.16.840.1.113883.6.59" displayName="Influenza virus vaccine">
<originalText>Influenza virus vaccine</originalText>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<entry contextConductionInd="true">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<id root="78598407-9f16-42d5-8ffd-09281a60fe33"/>
<statusCode code="active"/>
<effectiveTime/>
<routeCode code="IM" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration" displayName="Intramuscular injection"/>
<consumable>
<manufacturedProduct>
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<manufacturedMaterial>
<code code="33" codeSystem="2.16.840.1.113883.6.59" displayName="Pneumococcal polysaccharide vaccine">
<originalText>Pneumococcal polysaccharide vaccine</originalText>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<entry contextConductionInd="true">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<id root="261e94a0-95fb-4975-b5a5-c8e12c01c1bc"/>
<statusCode code="active"/>
<effectiveTime/>
<routeCode code="IM" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration" displayName="Intramuscular injection"/>
<consumable>
<manufacturedProduct>
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<manufacturedMaterial>
<code code="09" codeSystem="2.16.840.1.113883.6.59" displayName="Tetanus and diphtheria toxoids">
<originalText>Tetanus and diphtheria toxoids</originalText>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
</structuredBody>
</component>
...
Vital Signs section
This section contains current and historically relevant vital signs, such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, crown-to-rump length, and pulse oximetry. The section may contain all vital signs for the period of time being summarized, but at a minimum should include notable vital signs such as the most recent, maximum and/or minimum, or both, baseline, or relevant trends.
Builder Elements
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| vitalSigns | Section | 0(1) | Vital Signs section |
| vitalSignsOrganizer | Organizer | 0(1)..* | Container for observations |
| resultObservation | Observation | 1..* | Related vital signs observation result |
Example
Vital Signs Section
...
// Chapter 3.12 Vital Signs
vitalSigns{
text('Patient Vital Signs')
vitalSignsOrganizer(classCode:'CLUSTER'){
id(root:'c6f88320-67ad-11db-bd13-0800200c9a66')
code(code:'46680005', codeSystem:'2.16.840.1.113883.6.96', displayName:'Vital signs')
statusCode(code:'completed')
resultObservation{
id(root:'c6f88321-67ad-11db-bd13-0800200c9a66')
code(code:'50373000', codeSystem:'2.16.840.1.113883.6.96', displayName:'Body height')
statusCode(code:'completed')
value( make {
pq(value:177.0, unit:'cm')
})
}
resultObservation{
id(root:'c6f88322-67ad-11db-bd13-0800200c9a66')
code(code:'27113001', codeSystem:'2.16.840.1.113883.6.96', displayName:'Body weight')
statusCode(code:'completed')
effectiveTime(value:'19991114')
value( make {
pq('86 kg')
})
}
resultObservation{
id(root:'c6f88323-67ad-11db-bd13-0800200c9a66')
code(code:'271649006', codeSystem:'2.16.840.1.113883.6.96', displayName:'Systolic BP')
statusCode(code:'completed')
effectiveTime(value:'19991114')
value( make{
pq(value:132.0, unit:'mm[Hg]')
})
}
resultObservation{
id(root:'c6f88324-67ad-11db-bd13-0800200c9a66')
code(code:'271650006', codeSystem:'2.16.840.1.113883.6.96', displayName:'Diastolic BP')
statusCode(code:'completed')
effectiveTime(value:'19991114')
value( make{
pq(value:86.0, unit:'mm[Hg]')
})
}
}
}
...
Resulting CDA document part
...
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.16"/>
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital signs"/>
<title>Vital signs</title>
<text>Patient Vital Signs</text>
<entry contextConductionInd="true" typeCode="DRIV">
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.35"/>
<id root="c6f88320-67ad-11db-bd13-0800200c9a66"/>
<code code="46680005" codeSystem="2.16.840.1.113883.6.96" displayName="Vital signs"/>
<statusCode code="completed"/>
<component contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.31"/>
<id root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
<code xsi:type="CE" code="50373000" codeSystem="2.16.840.1.113883.6.96" displayName="Body height"/>
<statusCode code="completed"/>
<value xsi:type="PQ" unit="cm" value="177.0"/>
</observation>
</component>
<component contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.31"/>
<id root="c6f88322-67ad-11db-bd13-0800200c9a66"/>
<code xsi:type="CE" code="27113001" codeSystem="2.16.840.1.113883.6.96" displayName="Body weight"/>
<statusCode code="completed"/>
<effectiveTime value="19991114"/>
<value xsi:type="PQ" unit="kg" value="86.0"/>
</observation>
</component>
<component contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.31"/>
<id root="c6f88323-67ad-11db-bd13-0800200c9a66"/>
<code xsi:type="CE" code="271649006" codeSystem="2.16.840.1.113883.6.96" displayName="Systolic BP"/>
<statusCode code="completed"/>
<effectiveTime value="19991114"/>
<value xsi:type="PQ" unit="mm[Hg]" value="132.0"/>
</observation>
</component>
<component contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.31"/>
<id root="c6f88324-67ad-11db-bd13-0800200c9a66"/>
<code xsi:type="CE" code="271650006" codeSystem="2.16.840.1.113883.6.96" displayName="Diastolic BP"/>
<statusCode code="completed"/>
<effectiveTime value="19991114"/>
<value xsi:type="PQ" unit="mm[Hg]" value="86.0"/>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
</structuredBody>
</component>
...
Results section
This section contains the results of observations generated by laboratories, imaging procedures, and other procedures. The scope includes hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, cardiac echo, nuclear medicine, pathology, and procedure observations. The section may contain all results for the period of time being summarized, but should include notable results such as abnormal values or relevant trends.
Builder Elements
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| results | Section | 0(1) | Results section |
| resultOrganizer | Organizer | 0(1)..* | Container for result observations |
| resultObservation | Observation | 1..* | Related observation result |
Example
Results Section
...
// CCD Results (Chapter 3.13)
results{
text('Patient Observation Results')
title('Other results')
resultOrganizer(classCode:'BATTERY'){
id(root:'7d5a02b0-67a4-11db-bd13-0800200c9a66')
code(code:'43789009',
codeSystem:'2.16.840.1.113883.6.96',
displayName:'CBC WO DIFFERENTIAL')
statusCode(code:'completed')
effectiveTime(value:'200003231430')
resultObservation{
id(root:'107c2dc0-67a5-11db-bd13-0800200c9a66')
code(code:'30313-1', codeSystem:'2.16.840.1.113883.6.1', displayName:'HGB')
statusCode(code:'completed')
effectiveTime(value:'200003231430')
value(make {
pq(value:13.2, unit:'g/dl')
})
interpretationCode(code:'N', codeSystem:'2.16.840.1.113883.5.83')
referenceRange{
observationRange{
text('M 13-18 g/dl; F 12-16 g/dl')
}
}
}
resultObservation{
id(root:'8b3fa370-67a5-11db-bd13-0800200c9a66')
code(code:'33765-9', codeSystem:'2.16.840.1.113883.6.1', displayName:'WBC')
statusCode(code:'completed')
value(make{
pq(value:6.7, unit:'10+3/ul')
})
interpretationCode(code:'N', codeSystem:'2.16.840.1.113883.5.83')
referenceRange{
observationRange{
value( make {
ivlpq{
low(value:4.3, unit:'10+3/ul')
high(value:10.8, unit:'10+3/ul')
}
})
}
}
}
}
}
...
Resulting CDA document part
...
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.14"/>
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Relevant diagnostic tests and/or laboratory data"/>
<title>Other results</title>
<text>Patient Observation Results</text>
<entry contextConductionInd="true" typeCode="DRIV">
<organizer classCode="BATTERY" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.32"/>
<id root="7d5a02b0-67a4-11db-bd13-0800200c9a66"/>
<code code="43789009" codeSystem="2.16.840.1.113883.6.96" displayName="CBC WO DIFFERENTIAL"/>
<statusCode code="completed"/>
<effectiveTime value="200003231430"/>
<component contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.31"/>
<id root="107c2dc0-67a5-11db-bd13-0800200c9a66"/>
<code xsi:type="CE" code="30313-1" codeSystem="2.16.840.1.113883.6.1" displayName="HGB"/>
<statusCode code="completed"/>
<effectiveTime value="200003231430"/>
<value xsi:type="PQ" unit="g/dl" value="13.2"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
<referenceRange>
<observationRange>
<text>M 13-18 g/dl; F 12-16 g/dl</text>
</observationRange>
</referenceRange>
</observation>
</component>
<component contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.31"/>
<id root="8b3fa370-67a5-11db-bd13-0800200c9a66"/>
<code xsi:type="CE" code="33765-9" codeSystem="2.16.840.1.113883.6.1" displayName="WBC"/>
<statusCode code="completed"/>
<value xsi:type="PQ" unit="10+3/ul" value="6.7"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
<referenceRange>
<observationRange>
<value xsi:type="IVL_PQ" unit="1">
<low unit="10+3/ul" value="4.3" inclusive="true"/>
<high unit="10+3/ul" value="10.8" inclusive="true"/>
</value>
</observationRange>
</referenceRange>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
</structuredBody>
</component>
...
Procedures section
This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated.
Builder Elements
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| procedures | Section | 0(1) | Procedures section |
| procedureActivity | entry | 1..* | Procedures entry: procedureActivityAct | procedureActivityProcedure | procedureActivityObservation |
| procedureActivityAct | procedureActivityObservation | procedureActivityProcedure | Act | Observation | Procedure | 0(1)..* | Procedure activity instance may contain: Problem activities(see problemActReason), Problem observations(see ProblemObservationReason), Medication acticities, Age observation, result observations, patient instructions, product representations, encounter location. Refer to the CCD specification for details. |
| problemActReason | Act | 0(1)..* | Indication or reason for the procedure targeting problem act |
| problemObservationReason | Observation | 0(1)..* | Indication or reason for the procedure targeting problem observation |
Example
Procedures Section
... // CCD Procedures (Chapter 3.14) procedures{ text('Patient Procedures') templateId(root:'2.16.840.1.113883.10.20.1.12') templateId(root:'1.3.6.1.4.1.19376.1.5.3.1.3.11', assigningAuthorityName:'IHE PCC') text{...} procedureActivity{ procedureActivityProcedure{ id(root:'e401f340-7be2-11db-9fe1-0800200c9a66') code(code:'52734007', codeSystem:'2.16.840.1.113883.6.96', displayName:'Total hip replacement'){ originalText{ reference(value:'#Proc1') } qualifier{ name(code:'272741003', displayName:'Laterality') value(code:'7771000', displayName:'Left') } } text('IHE Requires reference to go here instead of originalText of code.<reference') statusCode('completed') effectiveTime('1998') performer{ assignedEntity{ assignedPerson{ name('Procedure Performers Name') }//assignedPerson } } age { value(make { _int(57) } ) } encounterLocation{ id(root:'2.16.840.1.113883.19.5') playingEntity{ name('Very Good Health Clinic') }//playingEntity } problemObservationReason{ id(root:'9d3d416d-45ab-4da1-912f-4583e0632000') code(code:'ASSERTION', codeSystem:'2.16.840.1.113883.5.4') value(make{ cd(code:'233604007', codeSystem:'2.16.840.1.113883.6.96', displayName:'Pneumonia') }) patientAwareness{ awarenessCode(code:'TEST', codeSystem:'2.16.840.1.113883.5.4') participantRole{ id('996-756-495@2.16.840.1.113883.19.5') } } }//problem observation productInstance{ id(root:'03ca01b0-7be1-11db-9fe1-0800200c9a66') playingDevice{ code(code:'304120007', codeSystem:'2.16.840.1.113883.6.96', displayName:'Total hip replacement prosthesis') } scopingEntity{ id(root:'0abea950-5b40-4b7e-b8d9-2a5ea3ac5500') desc('Good Health Prostheses Company') } } entryRelationship(typeCode:'REFR'){ act(classCode:'ACT', moodCode:'EVN'){ templateId(root:'1.3.6.1.4.1.19376.1.5.3.1.4.4', assigningAuthorityName:'IHE PCC') code(nullFlavor:'NA') text{ reference(value:'PtrToSectionText') }//text reference(typeCode:'REFR'){ externalDocument(classCode:'DOC', moodCode:'EVN'){ text('Location of Documentation - URL or other') } } } } informationSource{ value(make{ st('Unknown') }) } } } } ...
Resulting CDA document part
...
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.12"/>
<templateId assigningAuthorityName="IHE PCC" root="1.3.6.1.4.1.19376.1.5.3.1.3.11"/>
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of procedures"/>
<title>Procedures</title>
<text><table border="1" width="100%">
<thead>
<tr>
<th colspan="1" rowspan="1">Procedure</th>
<th colspan="1" rowspan="1">Date</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="1" rowspan="1"><content ID="Proc1">Total hip replacement, left</content></td>
<td colspan="1" rowspan="1"><content>1998</content></td>
</tr>
</tbody>
</table></text>
<entry contextConductionInd="true" typeCode="DRIV">
<procedure classCode="PROC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.29"/>
<id root="e401f340-7be2-11db-9fe1-0800200c9a66"/>
<code code="52734007" codeSystem="2.16.840.1.113883.6.96" displayName="Total hip replacement">
<originalText><reference value="#Proc1"/></originalText>
<qualifier>
<name code="272741003" displayName="Laterality"/>
<value code="7771000" displayName="Left"/>
</qualifier>
</code>
<text>IHE Requires reference to go here instead of originalText of code.<reference</text>
<statusCode code="completed"/>
<effectiveTime value="1998"/>
<performer>
<assignedEntity>
<assignedPerson>
<name>Procedure Performers Name</name>
</assignedPerson>
</assignedEntity>
</performer>
<participant typeCode="LOC">
<templateId root="2.16.840.1.113883.10.20.1.45"/>
<participantRole classCode="SDLOC">
<id root="2.16.840.1.113883.19.5"/>
<playingEntity classCode="PLC">
<name>Very Good Health Clinic</name>
</playingEntity>
</participantRole>
</participant>
<participant typeCode="DEV">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.1.52"/>
<id root="03ca01b0-7be1-11db-9fe1-0800200c9a66"/>
<playingDevice>
<code code="304120007" codeSystem="2.16.840.1.113883.6.96" displayName="Total hip replacement prosthesis"/>
</playingDevice>
<scopingEntity>
<id root="0abea950-5b40-4b7e-b8d9-2a5ea3ac5500"/>
<desc>Good Health Prostheses Company</desc>
</scopingEntity>
</participantRole>
</participant>
<entryRelationship contextConductionInd="true" inversionInd="true" typeCode="SUBJ">
<observation classCode="OBS" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.1.38"/>
<code xsi:type="CE" code="397659008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Age"/>
<statusCode code="completed"/>
<value xsi:type="INT" value="57"/>
</observation>
</entryRelationship>
<entryRelationship contextConductionInd="true" typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28"/>
<id root="9d3d416d-45ab-4da1-912f-4583e0632000"/>
<code xsi:type="CE" code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="233604007" codeSystem="2.16.840.1.113883.6.96" displayName="Pneumonia"/>
<participant typeCode="SBJ">
<templateId root="2.16.840.1.113883.10.20.1.48"/>
<awarenessCode code="TEST" codeSystem="2.16.840.1.113883.5.4"/>
<participantRole>
<id extension="996-756-495" root="2.16.840.1.113883.19.5"/>
</participantRole>
</participant>
</observation>
</entryRelationship>
<entryRelationship contextConductionInd="true" typeCode="REFR">
<act classCode="ACT" moodCode="EVN">
<templateId assigningAuthorityName="IHE PCC" root="1.3.6.1.4.1.19376.1.5.3.1.4.4"/>
<code nullFlavor="NA"/>
<text><reference value="PtrToSectionText"/></text>
<reference typeCode="REFR">
<externalDocument classCode="DOC" moodCode="EVN">
<text>Location of Documentation - URL or other</text>
</externalDocument>
</reference>
</act>
</entryRelationship>
<entryRelationship contextConductionInd="true" typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<code xsi:type="CE" code="48766-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Information source"/>
<statusCode code="completed"/>
<value xsi:type="ST">Unknown</value>
</observation>
</entryRelationship>
</procedure>
</entry>
</section>
</component>
</structuredBody>
</component>
...
Encounters section
This section is used to list and describe any healthcare encounters pertinent to the patient's current health status or historical health history.
Builder Elements
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| encounters | Section | 0(1) | Encounters section |
| encounterActivity | Encounter | 1..* | Encounter activity |
| encounterLocation | ParticipantRole | 0(1)..* | Location participation |
Example
Encounters Section
... //CCD Encounters (Chpater 3.15) encounters { text('Encounter Location: Very Good Health Clinic') title('Encounters') encounterActivity{ id(root:'2a620155-9d11-439e-92b3-5d9815ff4de8') code(code:'GENRL', codeSystem:'2.16.840.1.113883.5.4', displayName:'General'){ originalText('Checkup Examination') }//code encounterLocation{ id(root:'2.16.840.1.113883.19.5') playingEntity{ name('Very Good Health Clinic') }//playingEntity } }//encounter } ...
Resulting CDA document part
...
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.3"/>
<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
<title>Encounters</title>
<text>Encounter Location: Very Good Health Clinic</text>
<entry contextConductionInd="true" typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.21"/>
<id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code xsi:type="CE" code="GENRL" codeSystem="2.16.840.1.113883.5.4" displayName="General">
<originalText>Checkup Examination</originalText>
</code>
<participant typeCode="LOC">
<templateId root="2.16.840.1.113883.10.20.1.45"/>
<participantRole classCode="SDLOC">
<id root="2.16.840.1.113883.19.5"/>
<playingEntity classCode="PLC">
<name>Very Good Health Clinic</name>
</playingEntity>
</participantRole>
</participant>
</encounter>
</entry>
</section>
</component>
</structuredBody>
</component>
...
Plan of Care section
This section is used to list and describe any healthcare encounters pertinent to the patient's current health status or historical health history.
Builder Elements
| Element | CDA Type | Cardinality | Description |
|---|---|---|---|
| planOfCare | Section | 0(1) | Plan of Care section |
| planOfCareActivity | Entry | 1..* | Container for pending clinical events: Act, Encounter, Observation, Procedure, SubstanceAdministration, or Supply. |
Example
Plan of Care Section
... // CCD Plan Of Care (Chapter 3.16) planOfCare { text('Plan') text{ ... } planOfCareActivity { observation(moodCode:'RQO') { id('9a6d1bac-17d3-4195-89a4-1121bc809b4a') code(code:'23426006', codeSystem:'2.16.840.1.113883.6.96', displayName:'Pulmonary function test') statusCode('new') effectiveTime { center('20000421') } } } } ...
Resulting CDA document part
...
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.10"/>
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Treatment Plan"/>
<title>Plan</title>
<text>...</text>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="RQO">
<templateId root="2.16.840.1.113883.10.20.1.25"/>
<id root="9a6d1bac-17d3-4195-89a4-1121bc809b4a"/>
<code xsi:type="CE" code="23426006" codeSystem="2.16.840.1.113883.6.96" displayName="Pulmonary function test"/>
<statusCode code="new"/>
<effectiveTime>
<center value="20000421"/>
</effectiveTime>
</observation>
</entry>
</section>
</component>
</structuredBody>
</component>
...
