CDA Example Task Force

Approved samples have been migrated to the following resource:

Official HL7 CDA Example Search

SDWG formed the CDA template example task force to collect and share member submitted samples. The task force developed a process with SDWG to receive approval for samples.

Please join us! Our calls a generally held on Thursdays at 12 PM ET, following the SDWG call. Phone number and webinar registration (free) information can be found at SDWG_Teleconferences.

The approved samples are posted below.

Current Task Force Work

 Current week
        See Trello!    
        
        If time allows:
        ?. Procedures and Care Team Sample development with John
        ?. Administered Medications section
            a) Including medication order information (that would have the start and end dates + frequency for the med) along with entries for the actual administrations. 
            b) Last date medication was documented, ordered, prescribed, refilled, dispensed, or edited

Draft IP Sample - (Functional and Cognitive Impairment, Subcutaneous medication administered with event time)

170.314(b)(2) Transitions of care – create and transmit summary care record sample creation is the current focus of the example task force.

CDA Example Task Force Quality Criteria

Discuss updating samples for C-CDA R2.0/R2.1 to support gold standard

Please contact the SDWG co-chairs (primary Brett Marquard) if you any questions.

Historical reference only: CDA Example Task Force - Previous Review Cycles, CDA Example Task Force Examples - Approved and On Deck

Examples - Organized by Section

ALLERGIES, ADVERSE REACTIONS OR ALERTS

Allergies are now in the new HL7 search tool!

Samples included:

• Allergy to specific substance (cat hair)
• Allergy to Specific Drug
• Allergy to Drug Class
• Propensity to adverse reaction to substance (Latex)
• Food allergy (Egg)
• No Known Allergies with Author Timestamp
• No Known Medication Allergies with Author Timestamp
• Drug intolerance with multiple reactions (epinephrine)
• Drug intolerance with multiple reactions (codeine)

CDA Header

CDA Header Examples are now in the new HL7 search tool!

• Patient demographic information
• Previous Patient Name
• Care Team In Transition of Care Documents

ENCOUNTERS

Encounters are now in the new HL7 search tool!

Samples included:

• Hospital Discharge Encounter with Billable Diagnoses
• Outpatient Encounter with Diagnoses
• Outpatient Encounter Patient Disenrolled
• Inpatient Encounter Discharged to Rehab Location

FUNCTIONAL AND COGNITIVE STATUS (deprecated, not moved)

No Impairment (on trello)

(back to overview table)

• Status: Approved by task force on 6/18/2015. SDWG approved 7/9/2015
• CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
  • TemplateId(s) illustrated: Functional Status Section (2.16.840.1.113883.10.20.22.2.14), Functional Status Problem Observation (2.16.840.1.113883.10.20.22.4.68), Cognitive Status Problem Observation (2.16.840.1.113883.10.20.22.4.73)
  • No Impairment Functional Status Section R1.1 (via GitHub)
• CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
  • Not yet completed
• Known bad example?: Valid example
• Reference to full CDA sample: No Impairment Functional Status section in empty C-CDA
• Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
• Validation location: NIST TTT Validator Ambulatory
• Comments: This is an example of no functional or cognitive impairment. It only illustrates two of multiple potential templated within the functional status section and was prepared for the 170.314(b)(2) Transitions of care - M) Functional and Cognitive Status. Note that there are significant changes to functional and cognitive status in C-CDA 2.0 and 2.1 (including section breakout and deprecation of certain tempaltes). We may re-visit this sample after reconciliation of such changes.

Functional and Cognitive Status with Impairment (on trello)

(back to overview table)

• Status: Not yet approved
• CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
  • TemplateId(s) illustrated: Functional Status Section (2.16.840.1.113883.10.20.22.2.14), Functional Status Problem Observation (2.16.840.1.113883.10.20.22.4.68), Cognitive Status Problem Observation (2.16.840.1.113883.10.20.22.4.73)
  • Functional and Cognitive Status with Impairment
• CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.0
  • Not yet completed
• Known bad example?: Valid example
• Reference to full CDA sample: Functional and Cognitive Status in full C-CDA Sample
• Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
• Validation location: NIST TTT Validator Ambulatory
• Comments: This is an example of functional and cognitive impairment as outlined in MU2 inpatient test data.

GENERAL PATTERNS

General Patterns are now in the new HL7 search tool!

Samples included:

• No Information Problems Section

To Be Discussed

Allergy and Problem Status observation Review - This is a summary of the work done by the example task force to review[ the extra 'status observations' in C-CDA R1.1 and whether the deprecation in C-CDA R2.0 adequately covers key clinical statuses.

Goals

Goals are now in the new HL7 search tool!

• Goals Section Narrative-only

Health Concerns

Health Concerns are now in the new HL7 search tool!

• Health Concerns Section Narrative-only
• Health Concern Linking Example
• No Known Health Concerns

IMMUNIZATIONS

Immunizations are now in the new HL7 search tool!

Samples included:

• Immunization Not Given - Patient Refused
• Influenza Vaccination
• Unknown Patient Immunization Status

Medical Equipment

Medical Equipment now in the new HL7 search tool!

Samples included:

• Implanted Device - Procedure Unknown
• No Implanted Devices

Multiple Implants Same Procedure (on trello)

(back to overview table)

• Approved by: 7/14/2016

• CDA Implementation Guide where template(s) is(are) defined: C-CDA 2.1
  • TemplateId(s) illustrated: Medical Equipment Section (V2) (2.16.840.1.113883.10.20.22.2.23:2014-06-09) and Procedure Activity Procedure (V2) (2.16.840.1.113883.10.20.22.4.14:2014-06-09 )
  • Multiple Implants same Procedure (via GitHub)
• Known bad example?: Valid example
• Reference to full CDA sample: Not available
• Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
• Validation location: SITE Validator TOC Ambulatory
• Comments: This is an example of how a single procedure (angioplasty) can have multiple implants (2 drug eluting stents). There are still two entries since this is being included in medical equipment rather than procedure section.

MEDICATIONS

Medications are now in new HL7 search tool!

Samples included:

• Medication Frequencies
• Medication statusCodes
• Patient prescribed oral medication QID PRN without precondition specified
• Patient Prescribed Medication Every 4-6 Hours
• Single Administration of Medication (at Single Point in Time)
• No Medications
• Patient Reported Medication without Reported Brand/Dose
• Patient Prescribed Oral Antibiotic with Dosing Regimen that Varies Over Prescription Course (Loading or Tapered)

Patient prescribed basal insulin administered at bedtime (on trello)

(back to overview table)

• Approved by: Not yet approved
• C-CDA 1.1 Example
  • TemplateId(s) illustrated: Medication Activity Medication Information
  • Patient prescribed basal insulin administered at bedtime
• C-CDA 2.0 Example: none yet posted
• Known bad example?: Valid example
• Reference in full CDA Sample: Results Packaged in C-CDA Skeleton
• Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
• Validation location: NIST TTT Message Validator for VDT Ambulatory validated February 27, 2014
• Keywords: Pre-coordinated medication code, dose frequency
• Comments: This is an example of a subcutaneous dose of a common basal insulin. Please note that this insulin dosage does not vary. This dose is administered at bedtime so the dosing frequency utilizes EIVL_TS type to denote this.

Plan of Treatment

Plan of Treatment Examples are now in new HL7 search tool!

Samples included:

• Care Plan Goals and Instructions
• No Planned Tests
• Planned EKG
• Planned Encounter - Referral

PROBLEMS

Problems are now in new HL7 search tool!

Samples included:

• Patient with No Known Problems
• Active Problem'
• Problem which has been resolved/completed
• Patient with No Known Diabetes

PROCEDURES

Procedures are now in new HL7 search tool!

Samples included:

• Procedure Activity Procedure Example in Procedures Section
• Procedures Activity Observation Example in Procedures Section
• Procedure Activity Act Example in Procedures Section

RESULTS

Results are now in new HL7 search tool!

Samples included:

• Result panel with the display of two ordinal values of negative/positive
• Result with an unstructured string as the value (e.g. urine color)
• Result with greater than a specified value
• Result with lab location
• Result with discrete units and non-numeric value
• Results Unit Non-UCUM
• Result with a pending component
• Results with less than specific value
• Results with translation unit
• Result of CO2 Test
• Results Radiology with Image Narrative
• Results of Basic Metabolic Panel and Troponin

PAYER

Coverage Activity referencing the holder's employer (on trello)

(back to overview table)

• Approved by: Sample not yet reviewed
• C-CDA 1.1 Implementation Guide Example
  • TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.4.61 (Trifolia Log-in Required) 2.16.840.1.113883.10.20.22.4.61 (Trifolia Log-in Required)
  • Coverage Activity referencing the holder's employer(via GitHub)
• C-CDA 2.0 Example: none yet posted
• Known bad example?: Sample not yet reviewed
• Reference to full CDA sample:
• Custodian: Lisa R. Nelson, lisarnelson@cox.net (GitHub: lisarnelson)
• Validation location: NIST TTT Message Validator for VDT Ambulatory validated December 18, 2013
• Comments: This is an example of how to encode the policy holder's employer through which the insurance is provided - Finding major issues with the Coverage Activity and Policy Activity Templates. See C-CDA R1.1 DSTU Comment #994.

SOCIAL HISTORY (SMOKING)

Social History are now in new HL7 search tool!

Samples included:

• Unknown Smoking Status
• Former Smoker in Smoking Status
• Never Smoker in Smoking Status
• Current Smoker in Smoking Status

VITAL SIGNS

Vital Signs are now in new HL7 search tool!

Samples included:

• Panel of Vital Signs in Metric Units
• Panel of Vital Signs in Mixed Metric/Imperial Units

Family History

Family History examples are now in new HL7 search tool!

Samples included:

• Family History; generic history (not scoped to individuals)
• Normal Family History; Father deceased with conditions; Mother alive with no conditions
• Family History; two individuals with the same relationship to the patient

Formatting of CDA Template Samples

PROTOTYPIC TEMPLATE

Meaningful template example name

• Approved by: (list all approving bodies, including approval date)
• C-CDA 1.1 (link to CDA Implementation Guide) Implementation Guide Example
  • TemplateId(s) illustrated: TemplateId Name(s) (OID Number(s), e.g. 2.16.840.1.113883.10.20.22.1.2)
  • Link to C-CDA 1.1 Example in hosted repository, e.g. GitHub
• C-CDA 2.0 (link to CDA Implementation Guide, when available) Implementation Guide Example
  • TemplateId(s) illustrated: TemplateId Name(s) (OID Number(s), e.g. 2.16.840.1.113883.10.20.22.1.2.2)
  • Link to C-CDA 1.1 Example in hosted repository, e.g. GitHub
• Known bad example?: Explain if this is a deliberately created bad example.
• Reference to full CDA sample: Full example of validated document (hyperlinked)
• Custodian: Name, email address and repository username of the steward for the referenced sample
• Validation location: list of all validators tested against
• Comments: free text comments about the example

Resources and Draft materials

Link to C-CDA 1.1 testing script

• Test Data (as referred in multiple samples above)

C-CDA Empty shell that will validate without errors using NIST TTT.

• Note this example is used to help with testing examples and is not intended as a best practice, since information is suppressed in all sections
• Empty C-CDA CCD (No Information in required sections)

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KNOWN BAD EXAMPLES

• Future bad examples will go here.

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FEEDBACK AND AWAITING RESPONSE

• Result with less than a specified value (via GitHub)- Awaiting review from Patrick Lloyd with OO

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COMMUNITY REQUESTS FOR EXAMPLES (include name, email)

• I would like an example of a preliminary lab result (John Doe, JohnDoe@email.com)
• The SMART C-CDA Collaborative generated a list of approximately 50 requested samples here. See the section noted as "Annotated Examples." For more information on the SMART C-CDA Collaborative please visit here. (Ashley Swain, ashley.swain@lantanagroup.com, John D'Amore, jdamore@diameterhealth.com, Josh Mandel, jmandel@gmail.com)

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DRAFT MATERIAL - PLEASE DON'T DELETE

How to Setup an XML example from GitHub

• Sign up for GitHub account. It's free and quick
• Once you've got an account, you will be able to fork repositories and comment on examples through the website
• To post and manage examples, you will likely want to install a graphical user interface for GitHub. Here's where you can download: For Windows or For Mac
• Once you've got the application installed, there are a few steps:
  • Click the "create" button to make a repository where you would like to upload/update to GitHub
  • Once you've created, the repository will exist online and on your local machine
  • On your local machine, place in new or revised files in the local folder (this will generally be under Documents/GitHub). It's good practice to include a text file named README.md, which appears online when people browse your repository. This is a good place to explain what you're working on.
  • Once you've made the edits (or new files) you want to post to GitHub, "commit" the sample entering a description and then hit the "sync" button to upload
  • At this point the changes and new files are posted online publicly
• For an example GitHub repository with C-CDA samples, check out this one from Children's Hospital Boston

• Add instructions for how to upload examples (to github, to other sites)
  • Add examples (to site of your choosing)
  • Add link and metadata too

• enumerated lists
  • validators
  • approving bodies
    • SDWG
    • Infoway
    • NHS

HOW TO PREPARE A SAMPLE FOR APPROVAL BY SDWG

Observing these guidelines will streamline the process for all involved.

• Include XML comments that will:
  • Make assumptions explicit
  • Annotate each lines
  • Highlight choices and key decisions that were made
• Confirm statusCode/moodCode/effectiveTime are in agreement
• Snippet should be in the context of a section
• Confirm narrative to match entries - and content is linked
• Does final sample name accurately reflect the final sample
• Add disclaimer at the top of every sample: SAMPLE DEVELOPED BY HL7 SDWG SAMPLES TASK FORCE - PLEASE SEE http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force FOR ADDITIONAL DETAILS

• Patient with allergies to different substances (via GitHub)
  • Approved by: Not yet approved

• Patient taking pre-coordinated medication (via GitHub)
  • Approved by: Not yet approved

• Copy and paste the template below, and complete for your sample
• Allergy to Substance X
  • Approved by: SDWG (Oct 31, 2013); NHS (Oct 31, 2013)
  • TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.4.30; 2.16.840.1.113883.10.20.22.4.7
  • CDA Implementation Guide where template(s) is(are) defined: C-CDA R2
  • Reference to full CDA sample: N/A
  • Custodian: John Doe (John.Doe@email.com)
  • Validation location: validator.com
  • Comments: This is the best example EVER!

Under Development -

Complaint of no foot pain - Problem Section

(back to overview table)

• • Status: Not Yet Reviewed
• C-CDA 1.1 Implementation Guide Example
  • TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
• (Complaint of No foot pain - Problem Section 2.16.840.1.113883.10.20.22.2.5.1 (via GitHub)
• C-CDA 2.0 Example: None yet posted
• Reference to full CDA sample: https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Doc-No%20Known%20Problems%2020140203.xml
• Custodian: Lisa R. Nelson LisaRNelson@cox.net
• Validation location: TTT
• Comments: This one shows use of Observation.ValueNegationInd

Under Development -

No Complaint of foot pain - Problem Section

(back to overview table)

• • Status: Not Yet Reviewed
• C-CDA 1.1 Implementation Guide Example
  • TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
  • No Complaint of foot pain - Problem Section 2.16.840.1.113883.10.20.22.2.5.1 (via GitHub)
• C-CDA 2.0 Example: None yet posted
• Reference to full CDA sample: https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Doc-No%20Known%20Problems%2020140203.xml
• Custodian: Lisa R. Nelson LisaRNelson@cox.net
• Validation location: TTT
• Comments: This one shows use of Act.NegationInd