CCDA Format Specifications

M-Systems' EHI Export capabilities enable the extraction of the electronic health record (EHR) from the M-Systems MHS system.

The file is in C-CDA xml format.

Formatted in accordance with §170.315(b)(10) - Electronic Health Information export of the ONC 2015 Edition Cures Certification Criteria.

http://www.w3.org/2001/XMLSchema-instance

https://www.healthit.gov/topic/certification-ehrs/2015-edition-cures-update-test-method

Table layout is: C-CDA R2.1: C-CDA Templates for Clinical Notes R2.1 Companion Guide, Release 2

<?xml version="1.0" encoding="UTF-8"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc" xmlns:sdtc="urn:hl7-org:sdtc">
<realmCode code="US"/>
 <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
 <templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2015-08-01"/>
 <templateId root="2.16.840.1.113883.10.20.22.1.1"/>
 <templateId root="2.16.840.1.113883.10.20.22.1.2" extension="2015-08-01"/>
 <templateId root="2.16.840.1.113883.10.20.22.1.2"/>
 <id  root="2.16.840.1.113883.19.5" extension="CCDA-135214" />
  <code code="34133-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summarization of Episode Note" />
  <title>TEST HOSPITAL: Continuity of Care Document (C-CDA)</title>
  <effectiveTime value="20230907205900-0500" />
  <confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality" />
  <languageCode code="en-US" />
  <setId extension="135214" root="2.16.840.1.113883.19.5"/>
  <versionNumber value="1"/>
  <recordTarget>
    <patientRole>
      <id root="2.16.840.1.113883.19.5" extension="41535" />
      <addr use="HP">
         <streetAddressLine>2 TEST STREET</streetAddressLine>
         <city>TEST</city>
         <state>HI</state>
         <postalCode>77777</postalCode>
         <country>US</country>
      </addr>
      <telecom value="tel:+1(123)-456-1212" use="HP" />
      <patient>
        <name use="L">
          <given>DAVE</given>
          <family>TESTPATIENT</family>
        </name>
        <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male" codeSystemName="AdministrativeGender"/>
        <birthTime value="20000101" />
        <maritalStatusCode nullFlavor="NA" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatusCode"/>
        <raceCode code="2028-9" displayName="ASIAN" codeSystem="2.16.840.1.113883.6.238" codeSystemName="CDCREC"/>
        <ethnicGroupCode code="2135-2" displayName="Hispanic or Latino" codeSystem="2.16.840.1.113883.6.238" codeSystemName="CDCREC"/>
        <languageCommunication>
          <languageCode code="en-US" />
          <modeCode code="ESP" displayName="Expressed spoken" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode" />
          <proficiencyLevelCode code="G" codeSystem="2.16.840.1.113883.5.61" displayName="Good" codeSystemName="LanguageAbilityProficiency" />
          <preferenceInd value="true" />
        </languageCommunication>
      </patient>
      <providerOrganization>
        <id extension="1234567890" root="2.16.840.1.113883.4.6" />
        <name>TEST HOSPITAL</name>
        <telecom use="WP" value="tel: +1(777)-777-7777" />
        <addr use="WP">
          <streetAddressLine>111 TEST STREET</streetAddressLine>
          <city>TEST</city>
          <state>TX</state>
          <postalCode>77777</postalCode>
          <country>US</country>
        </addr>
        </providerOrganization>
    </patientRole>
  </recordTarget>