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FUNCTIONAL_Example_in_empty_CCD.xml
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FUNCTIONAL_Example_in_empty_CCD.xml
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<?xml version="1.0"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!-- This is an empty C-CDA skeleton which will be used by HL7 CDA Example Task Force -->
<!-- This document was based on prior work by Lisa Nelson and Brian Weiss. contact John D'Amore with questions -->
<!-- See http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force -->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 ../90%20HL7/00%20Standard%20-%20C-CDA/20130409%20C-CDA%20R1dot1_2012JUL/Updated_CDA_Schema_Files_Extension_Support/CDA_Schema_Files/infrastructure/cda/CDA_SDTC.xsd"
xmlns="urn:hl7-org:v3"
xmlns:cda="urn:hl7-org:v3"
xmlns:sdtc="urn:hl7-org:sdtc">
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1"/> <!-- C-CDA -->
<templateId root="2.16.840.1.113883.10.20.22.1.2"/> <!-- CCD -->
<id root="2.16.840.1.113883.3.3208.101.1" extension="20130607100315-CCDA-CCD"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34133-9" displayName="Summarization of Episode Note"/>
<title>Empty CCD Skeleton That Validates on TTT. Note this was based on work by Lisa Nelson and Brian Weiss</title>
<effectiveTime value="20130607000000-0000"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<recordTarget>
<patientRole>
<id root="2.16.840.1.113883.3.3208.101.2" extension="20130607100800-Patient1"/>
<addr use="HP">
<streetAddressLine>1111 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)111-1111" use="HP"/>
<patient>
<name use="L"><given>Patient</given><family>One</family></name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male" codeSystemName="AdministrativeGender"/>
<birthTime value="19300911"/>
<maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatus"/>
<raceCode code="2106-3" displayName="White"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="OMB Standards for Race and Ethnicity"/>
<ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="OMB Standards for Race and Ethnicity"/>
<languageCommunication>
<languageCode code="eng"/>
<modeCode code="ESP" displayName="Expressed spoken" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/>
<proficiencyLevelCode code="E" displayName="Excellent" codeSystem="2.16.840.1.113883.5.61" codeSystemName="LanguageAbilityProficiency"/>
</languageCommunication>
</patient>
</patientRole>
</recordTarget>
<author>
<time value="20130607000000"/>
<assignedAuthor>
<id extension="22222" root="2.16.840.1.113883.4.6"/>
<code code="207QA0505X" codeSystem="2.16.840.1.113883.6.101"
displayName="Adult Medicine" codeSystemName="NUCC"/>
<addr use="HP">
<streetAddressLine>2222 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)222-2222" use="WP"/>
<assignedPerson>
<name>
<given>Doctor</given>
<family>Second</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id extension="33333" root="2.16.840.1.113883.4.6"/>
<code code="364SA2200X" displayName="Adult Health" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"/>
<addr use="WP">
<streetAddressLine>3333 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)333-3333" use="WP"/>
<assignedPerson>
<name>
<given>Nurse</given>
<family>Tertiary</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="44444" root="2.16.840.1.113883.4.6"/>
<name>CDA PRO Fictional Hospital</name>
<telecom value="tel:+1(301)444-4444" use="WP"/>
<addr use="WP">
<streetAddressLine>4444 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<legalAuthenticator>
<time value="20130607000000"/>
<signatureCode code="S"/>
<assignedEntity>
<id root="2.16.840.1.113883.3.3208.101.3" extension="20130607102400-Authenticator1"/>
<addr use="WP">
<streetAddressLine>5555 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)555-5555" use="WP"/>
<assignedPerson>
<name>
<given>Physician</given>
<family>Fifthly</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="19330316"/>
<high value="20130607"/>
</effectiveTime>
<performer typeCode="PRF">
<assignedEntity>
<id extension="66666" root="2.16.840.1.113883.4.6"/>
<code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"
displayName="Cardiovascular Disease"/>
<addr>
<streetAddressLine>6666 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)666-6666" use="WP"/>
<assignedPerson>
<name>
<given>Heartly</given>
<family>Sixer</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<!-- CDA Body -->
<component>
<structuredBody>
<!-- Allergies Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
<!-- Allergies (entries required) section -->
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" displayName="Allergies, adverse reactions, alerts" codeSystemName="LOINC"/>
<title>ALLERGIES</title>
<text>No Information</text>
</section>
</component>
<!-- Medication Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
<!-- Medication Section (entries required) -->
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Medication Use"/>
<title>MEDICATIONS</title>
<text>No Information</text>
</section>
</component>
<!-- Problem Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<!-- conforms to Problems section with entries required -->
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="PROBLEM LIST"/>
<title>PROBLEMS</title>
<text>No Information</text>
</section>
</component>
<!-- Procedures Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
<!-- Procedures Section with Coded Entries Required-->
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Procedures"/>
<title>PROCEDURES</title>
<text>No Information</text>
</section>
</component>
<!-- Results Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
<!-- Results Section with Coded Entries Required-->
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Relevant diagnostic tests and/or laboratory data"/>
<title>RESULTS</title>
<text>No Information</text>
</section>
</component>
<!-- Plan of Care Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.10"/>
<!-- Plan of Care Section-->
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of Care"/>
<title>PLAN OF CARE</title>
<text>No Information</text>
</section>
</component>
<!-- Social History (with Smoking Status Observation) -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.17"/>
<!-- Social History Section -->
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" displayName="Social History"/>
<title>SOCIAL HISTORY</title>
<text>No Information</text>
</section>
</component>
<!-- Vital Signs Section (entries required) -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.4.1"/>
<!-- Vital Signs (entries required) -->
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital Signs"/>
<title>VITAL SIGNS</title>
<text>No Information</text>
</section>
</component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.14"/>
<code code="47420-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Functional Status"/>
<title>Functional and Cognitive Status</title>
<text>
<table>
<thead>
<tr>
<th colspan="3">Functional and Cognitive Status</th>
</tr>
<tr>
<th>Assessment</th>
<th>Date</th>
<th>Results</th>
<th>Comments</th>
</tr>
</thead>
<tbody>
<tr ID="FS_Narrative1">
<td>Functional Status</td>
<td>Apr 3 2015, 5:32pm</td>
<td ID="FS_Finding1">No impairment</td>
<td></td>
</tr>
<tr ID="FS_Narrative2">
<td>Cognitive Status</td>
<td>Apr 3 2015, 5:32pm</td>
<td ID="FS_Finding2">No impairment</td>
<td></td>
</tr>
</tbody>
</table>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.68"/>
<id root="e4f9eb37-52ca-4e95-90f3-570dace107e6"/>
<code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="248536006" displayName="Functional limitation"/>
<text>
<reference value="#FS_Narrative1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20150403173215+0500"/>
</effectiveTime>
<value xsi:type="CD" code="66557003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="No Impairment">
<originalText>
<reference value="#FS_Finding1"/>
</originalText>
</value>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.73"/>
<id root="faa09c19-fa1f-4a6c-ae79-10a3b711550f"/>
<code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="373930000" displayName="Cognitive function finding"/>
<text>
<reference value="#FS_Narrative2"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20150403173215+0500"/>
</effectiveTime>
<value xsi:type="CD" code="66557003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="No Impairment">
<originalText>
<reference value="#FS_Finding2"/>
</originalText>
</value>
</observation>
</entry>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>