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PROCEDURE_Examples_in_empty_CCD.xml
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PROCEDURE_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>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PROCEDURES"/>
<title>Procedures</title>
<text>
<table>
<thead>
<tr>
<th>Description</th>
<th>Date and Time (Range)</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr ID="Procedure1">
<td ID="ProcedureDesc1">Laparoscopic appendectomy</td>
<td>(03 Feb 2014 09:22am- 03 Feb 2014 11:15am</td>
<td>Completed</td>
</tr>
<tr ID="Procedure2">
<td ID="ProcedureDesc2">Electrocardiogram (12-Lead)</td>
<td>29 Mar 2014 09:15am</td>
<td>Completed</td>
</tr>
<tr ID="Procedure3">
<td ID="ProcedureDesc3">Individual Counseling For Medical Nutrition </td>
<td>29 Mar 2014 10:45am</td>
<td>Completed</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<!-- Procedures should be used for care that directly changes the patient's physical state.-->
<procedure moodCode="EVN" classCode="PROC">
<templateId root="2.16.840.1.113883.10.20.22.4.14" />
<id root="64af26d5-88ef-4169-ba16-c6ef16a1824f"/>
<code xsi:type="CE" code="6025007" displayName="Laparoscopic appendectomy" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT">
<originalText>
Laparoscopic appendectomy
<reference value="#ProcedureDesc1" />
</originalText>
<translation xsi:type="CE" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT" code="44970" displayName="Laparoscopic Appendectomy" />
<translation xsi:type="CE" codeSystem="2.16.840.1.113883.6.4" codeSystemName="ICD-10-PCS" code="0DTJ4ZZ" displayName="Resection of Appendix, Percutaneous Endoscopic Approach" />
<translation xsi:type="CE" codeSystem="2.16.840.1.113883.6.104" codeSystemName="ICD-9-CM" code="47.01" displayName="Laparoscopic appendectomy" />
</code>
<text>
<reference value="#Procedure1" />
</text>
<statusCode code="completed" />
<!-- Effective times can be either a value or interval. For procedures with start and stop times, an interval would be more appropriate -->
<effectiveTime xsi:type="IVL_TS">
<low value="20140203092205-0700" />
<high value="20140203111514-0700" />
</effectiveTime>
<!-- methodCode indicates how the procedure was performed. It cannot conflict with the code used for procedure-->
<methodCode code="51316009" codeSystem="2.16.840.1.113883.6.96" displayName="Laparoscopic procedure" codeSystemName="SNOMED-CT" />
<!-- targetSiteCode indicates the body site addressed by procedure and must be from value set 2.16.840.1.113883.3.88.12.3221.8.9-->
<targetSiteCode code="181255000" codeSystem="2.16.840.1.113883.6.96" displayName="Entire Appendix" codeSystemName="SNOMED-CT" />
</procedure>
</entry>
<entry typeCode="DRIV">
<!-- Observations should be used for care that result in information about the patient (e.g. a diagnostic test & result) but do not alter physical state-->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
<id root="c03e5445-af1b-4911-a419-e2782f21448c"/>
<code xsi:type="CE" code="268400002" codeSystem="2.16.840.1.113883.6.96" displayName="12 lead ECG" codeSystemName="SNOMED-CT">
<originalText>
Electrocardiogram (12-Lead)<reference value="#ProcedureDesc2"/>
</originalText>
<translation xsi:type="CE" code="93000" codeSystem="2.16.840.1.113883.6.12" displayName="Electrocardiogram, complete" codeSystemName="CPT" />
<translation xsi:type="CE" code="G8704" codeSystem="2.16.840.1.113883.6.13" displayName="12-Lead Electrocardiogram (Ecg) Performed" codeSystemName="HCPCS"/>
<translation xsi:type="CE" code="89.52" codeSystem="2.16.840.1.113883.6.104" displayName="Electrocardiogram" codeSystemName="ICD-9 Procedure"/>
<translation xsi:type="CE" code="4A02X4Z" codeSystem="2.16.840.1.113883.6.4" displayName="Measurement of Cardiac Electrical Activity, External Approach" codeSystemName="ICD-10 Procedure"/>
</code>
<text>
<reference value="#Procedure2" />
</text>
<statusCode code="completed"/>
<effectiveTime value="20140329091522+0500" />
<!-- When choosing an observation, value records relevant findings-->
<value xsi:type="CD" code="251135002" codeSystem="2.16.840.1.113883.6.96" displayName="Borderline normal ECG" codeSystemName="SNOMED-CT" />
<!-- targetSiteCode indicates the body site addressed by observation and must be from value set 2.16.840.1.113883.3.88.12.3221.8.9-->
<targetSiteCode code="302509004" codeSystem="2.16.840.1.113883.6.96" displayName="Entire Heart" codeSystemName="SNOMED-CT" />
</observation>
</entry>
<entry typeCode="DRIV">
<!-- Act should be used for care of the patient that cannot be classified as a procedure or observation (e.g. wound dressing change, counseling) -->
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
<id root="9c0f070c-2e9e-4be1-a5b5-ff6d0f68123c"/>
<code xsi:type="CE" code="61310001" codeSystem="2.16.840.1.113883.6.96" displayName="Nutrition education" codeSystemName="SNOMED-CT">
<originalText>
Individual Counseling For Medical Nutrition
<reference value="#ProcedureDesc3"/>
</originalText>
<translation xsi:type="CE" code="97802" codeSystem="2.16.840.1.113883.6.12" displayName="Medical nutrition therapy; initial" codeSystemName="CPT" />
<translation xsi:type="CE" code="S9470" codeSystem="2.16.840.1.113883.6.13" displayName="Nutritional counseling, diet" codeSystemName="HCPCS"/>
<!-- For some activities, ICD-9 and ICD-10 procedure codes may not apply (e.g. nutritional counseling). ICD-9 and ICD-10 diagnosis codes translate and shown below-->
<translation xsi:type="CE" code="V65.3" codeSystem="2.16.840.1.113883.6.103" displayName="Dietary surveillance and counseling" codeSystemName="ICD-9 Diagnosis"/>
<translation xsi:type="CE" code="Z71.3" codeSystem="2.16.840.1.113883.6.90" displayName="Dietary counseling and surveillance" codeSystemName="ICD-10 Diagnosis"/>
</code>
<text>
<reference value="#Procedure3" />
</text>
<statusCode code="completed"/>
<effectiveTime value="20140329104513+0500"/>
</act>
</entry>
</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>
</structuredBody>
</component>
</ClinicalDocument>