Table A.6-1 contains a sample document encoding. Refer to Section A.5.1 for description.

<?xml version="1.0" encoding="utf-8"?>
<?xml-stylesheet type="text/xsl" href="CDA-DIR.xsl"?>
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
  <realmCode code="UV" />
  <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040" />
  <templateId root="2.16.840.1.113883.10.20.6" />
  <id root="1.2.840.113619.2.62.994044785528.12"
  extension="20060828170821659" />
  <code code="18748-4" codeSystem="2.16.840.1.113883.6.1"
  codeSystemName="LOINC" displayName="Diagnostic Imaging Report" />
  <!-- from DICOM TID 1210 "Equivalent Meaning(s) of Concept Name"
       (Concept Modifier to DICOM SR document report title) -->
  <title>Chest X-Ray, PA and LAT View</title>
  <!-- /from TID 1210  -->
  <effectiveTime value="20060828170821" />
  <!-- CDA DIR effective time usually will be different from SR study date
       and SR content date and time-->
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" />
  <languageCode code="en-US" />
  <recordTarget>
    <patientRole>
      <id root="1.2.840.113619.2.62.994044785528.10" extension="0000680029" />
      <!-- Unique identifier for root: {root}.10 = patient ID list added based on
           organizational policy (not present in SR sample document because root is
           not specified by DICOM. DICOM Patient ID (0010,0020) value inserted into
           extension -->
      <addr nullFlavor="NI" />
      <telecom nullFlavor="NI" />
      <patient>
        <name>
          <given>John</given>
          <family>Doe</family>
        </name>
        <administrativeGenderCode codeSystem="2.16.840.1.113883.5.1"
        code="M" />
        <birthTime value="19641128" />
      </patient>
    </patientRole>
  </recordTarget>
  <author>
    <time value="20060823224352" />
    <assignedAuthor>
      <id extension="121008" root="2.16.840.1.113883.19.5" />
      <addr nullFlavor="NI" />
      <telecom nullFlavor="NI" />
      <assignedPerson>
        <name>
          <given>Richard</given>
          <family>Blitz</family>
          <suffix>MD</suffix>
        </name>
      </assignedPerson>
    </assignedAuthor>
  </author>
  <custodian>
    <!-- custodian values have been added based on organizational policy (in
         this case they are not mapped from the SR sample document)-->
    <assignedCustodian>
      <representedCustodianOrganization>
        <id root="2.16.840.1.113883.19.5" />
        <name>World University Hospital</name>
        <telecom nullFlavor="NI" />
        <addr nullFlavor="NI" />
      </representedCustodianOrganization>
    </assignedCustodian>
  </custodian>
  <!-- legal authenticator present in sample, document is VERIFIED -->
  <legalAuthenticator>
    <time value="20060827141500" />
    <!-- verification date time (0040,A030)-->
    <signatureCode code="S" />
    <assignedEntity>
      <id extension="08150000" root="1.2.840.113619.2.62.994044785528.33" />
      <addr nullFlavor="NI" />
      <telecom nullFlavor="NI" />
      <assignedPerson>
        <name>
          <given>Richard</given>
          <family>Blitz</family>
          <suffix>MD</suffix>
        </name>
      </assignedPerson>
    </assignedEntity>
  </legalAuthenticator>
  <!-- Mapped from Referring physicians name (0008,0090) SR sample document -->
  <participant typeCode="REF">
    <associatedEntity classCode="PROV">
      <id nullFlavor="NI" />
      <addr nullFlavor="NI" />
      <telecom nullFlavor="NI" />
      <associatedPerson>
        <name>
          <given>John</given>
          <family>Smith</family>
          <suffix>MD</suffix>
        </name>
      </associatedPerson>
    </associatedEntity>
  </participant>
  <inFulfillmentOf>
    <order>
      <id extension="10523475" root="1.2.840.113619.2.62.994044785528.27" />
      <!-- {root}.27 of accession number added based on organizational policy (not
           present in SR sample document because root is not specified by DICOM).
           Accession number value used in extension -->
      <id extension="123452" root="1.2.840.113619.2.62.994044785528.28" />
      <!-- {root}.28 of filler order number added based on organizational policy (not
           present in SR sample document because root is not specified by DICOM).
           Filler number value used in extension -->
      <id extension="123451" root="1.2.840.113619.2.62.994044785528.29" />
      <!-- {root}.29 of placer order number added based on organizational policy (not
           present in SR sample document because root is not specified by DICOM).
           Placer number value used in extension  -->
    </order>
  </inFulfillmentOf>
  <documentationOf>
    <serviceEvent classCode="ACT">
      <id root="1.2.840.113619.2.62.994044785528.114289542805" />
      <!-- study instance UID -->
      <code nullFlavor="NI" />
      <effectiveTime value="20060823222400" />
    </serviceEvent>
  </documentationOf>
  <!-- transformation of a DICOM SR -->
  <relatedDocument typeCode="XFRM">
    <parentDocument>
      <id root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.9" />
      <!-- SOP Instance UID (0008,0018) of SR sample document-->
    </parentDocument>
  </relatedDocument>
  <component>
    <structuredBody>
      <component>
        <!--
**********************************************************************
                     DICOM Object Catalog Section
**********************************************************************
        -->
        <section classCode="DOCSECT" moodCode="EVN">
          <templateId root="2.16.840.1.113883.10.20.6.1.1" />
          <code code="121181" codeSystem="1.2.840.10008.2.16.4"
          codeSystemName="DCM" displayName="DICOM Object Catalog" />
          <entry>
            <!--    
**********************************************************************
                            Study
**********************************************************************
        -->
            <act classCode="ACT" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.6.2.6" />
              <id root="1.2.840.113619.2.62.994044785528.114289542805" />
              <code code="113014" codeSystem="1.2.840.10008.2.16.4"
              codeSystemName="DCM" displayName="Study" />
              <!--             
*****************************************************************
                 Series (Parent SR Document)
*****************************************************************
        -->
              <entryRelationship typeCode="COMP">
                <act classCode="ACT" moodCode="EVN">
                  <id root="1.2.840.113619.2.62.994044785528.20060823222132232023" />
                  <code code="113015" codeSystem="1.2.840.10008.2.16.4"
                  codeSystemName="DCM" displayName="Series">
                    <qualifier>
                      <name code="121139" codeSystem="1.2.840.10008.2.16.4"
                      codeSystemName="DCM" displayName="Modality"></name>
                      <value code="CR" codeSystem="1.2.840.10008.2.16.4"
                      codeSystemName="DCM" displayName="SR Document"></value>
                    </qualifier>
                  </code>
                  <!--                                                                                                             
*****************************************************************
                      SopInstance UID
*****************************************************************
        -->
                  <!--    Reference to SR Document -->
                  <entryRelationship typeCode="COMP">
                    <observation classCode="DGIMG" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.6.2.8" />
                      <id root="1.2.840.113619.2.62.994044785528.20060823.200608242334312.3" />
                      <code code="1.2.840.10008.5.1.4.1.1.88.22"
                      codeSystem="1.2.840.10008.2.6.1" codeSystemName="DCMUID"
                      displayName="Enhanced SR"></code>
                      <text mediaType="application/dicom">
                        <reference value="http://www.example.org/wado?requestType=WADO
                            &amp;studyUID=1.2.840.113619.2.62.994044785528.114289542805
                            &amp;seriesUID=1.2.840.113619.2.62.994044785528.20060823222132232023
                            &amp;objectUID=1.2.840.113619.2.62.994044785528.20060823.200608232232322.9
                            &amp;contentType=application/dicom" />
                        <!--reference to image 1 (PA) -->
                      </text>
                      <effectiveTime value="20060823223232" />
                    </observation>
                  </entryRelationship>
                </act>
              </entryRelationship>
              <!--             
*****************************************************************
                      Series (CR Images)
*****************************************************************
        -->
              <entryRelationship typeCode="COMP">
                <act classCode="ACT" moodCode="EVN">
                  <id root="1.2.840.113619.2.62.994044785528.20060823223142485051" />
                  <code code="113015" codeSystem="1.2.840.10008.2.16.4"
                  codeSystemName="DCM" displayName="Series">
                    <qualifier>
                      <name code="121139" codeSystem="1.2.840.10008.2.16.4"
                      codeSystemName="DCM" displayName="Modality"></name>
                      <value code="CR" codeSystem="1.2.840.10008.2.16.4"
                      codeSystemName="DCM" displayName="Computed Radiography">
                      </value>
                    </qualifier>
                  </code>
                  <!--                                                                                                             
*****************************************************************
                       SopInstance UID
*****************************************************************
        -->
                  <!--    2 References (chest PA and LAT) -->
                  <entryRelationship typeCode="COMP">
                    <observation classCode="DGIMG" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.6.2.8" />
                      <id root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.3" />
                      <code code="1.2.840.10008.5.1.4.1.1.1"
                      codeSystem="1.2.840.10008.2.6.1" codeSystemName="DCMUID"
                      displayName="Computed Radiography Image Storage"></code>
                      <text mediaType="application/dicom">
                        <reference value="http://www.example.org/wado?requestType=WADO
                            &amp;studyUID=1.2.840.113619.2.62.994044785528.114289542805
                            &amp;seriesUID=1.2.840.113619.2.62.994044785528.20060823223142485051
                            &amp;objectUID=1.2.840.113619.2.62.994044785528.20060823.200608232232322.3
                            &amp;contentType=application/dicom" />
                        <!--reference to image 1 (PA) -->
                      </text>
                      <effectiveTime value="20060823223232" />
                    </observation>
                  </entryRelationship>
                  <entryRelationship typeCode="COMP">
                    <observation classCode="DGIMG" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.6.2.8" />
                      <id root="1.2.840.113619.2.62.994044785528.20060823.200608232231422.3" />
                      <code code="1.2.840.10008.5.1.4.1.1.1"
                      codeSystem="1.2.840.10008.2.6.1" codeSystemName="DCMUID"
                      displayName="Computed Radiography Image Storage"></code>
                      <text mediaType="application/dicom">
                        <reference value="http://www.example.org/wado?requestType=WADO
                            &amp;studyUID=1.2.840.113619.2.62.994044785528.114289542805
                            &amp;seriesUID=1.2.840.113619.2.62.994044785528.20060823223142485051
                            &amp;objectUID=1.2.840.113619.2.62.994044785528.20060823.200608232231422.3
                            &amp;contentType=application/dicom" />
                        <!--reference to image 2 (LAT) -->
                      </text>
                      <effectiveTime value="20060823223142" />
                    </observation>
                  </entryRelationship>
                </act>
              </entryRelationship>
            </act>
          </entry>
        </section>
        <!--                                                    
**********************************************************************
          End of DICOM Object Catalog Section
**********************************************************************
        -->
      </component>
      <component>
        <!--
**********************************************************************
                  Reason for study Section 
**********************************************************************
The original DICOM SR document that is mapped does not contain a
"Indications for Procedure" section. The attribute value "Reason
for the Requested Procedure"  (0040,1002) within the Referenced
Request Sequence (0040,A370) of the SR header has been mapped under
the assumption that the header attribute value has been displayed to
and included by the legal authenticator.
        -->
        <section>
          <code code="121109" codeSystem="1.2.840.10008.2.16.4"
          codeSystemName="DCM" displayName="Indications for Procedure" />
          <title>Indications for Procedure</title>
          <text>Suspected lung tumor</text>
        </section>
        <!--                                                    
**********************************************************************
                    Reason for study Section
**********************************************************************
        -->
      </component>
      <component>
        <!--
**********************************************************************
                   History Section 
**********************************************************************
        -->
        <section>
          <code code="121060" codeSystem="1.2.840.10008.2.16.4"
          codeSystemName="DCM" displayName="History" />
          <title>History</title>
          <text>
            <paragraph>
              <caption>History</caption>
              <content ID="Fndng1">Sore throat.</content>
            </paragraph>
          </text>
          <entry>
            <!-- History report element (TEXT) -->
            <observation classCode="OBS" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.6.2.12" />
              <code code="121060" codeSystem="1.2.840.10008.2.16.4"
              codeSystemName="DCM" displayName="History" />
              <value xsi:type="ED">
                <reference value="#Fndng1" />
              </value>
            </observation>
          </entry>
        </section>
        <!--                                                    
**********************************************************************
                    End of History Section
**********************************************************************
        -->
      </component>
      <component>
        <!--
**********************************************************************
                     Findings Section
**********************************************************************
        -->
        <section>
          <templateId root="2.16.840.1.113883.10.20.6.1.2" />
          <code code="121070" codeSystem="1.2.840.10008.2.16.4"
          codeSystemName="DCM" displayName="Findings" />
          <title>Findings</title>
          <text>
            <paragraph>
              <caption>Finding</caption>
              <content ID="Fndng2">The cardiomediastinum is within normal
              limits. The trachea is midline. The previously described opacity
              at the medial right lung base has cleared. There are no new
              infiltrates. There is a new round density at the left hilus,
              superiorly (diameter about 45mm). A CT scan is recommended for
              further evaluation. The pleural spaces are clear. The visualized
              musculoskeletal structures and the upper abdomen are stable and
              unremarkable.</content>
            </paragraph>
            <paragraph>
              <caption>Diameter</caption>
              <content ID="Diam2">45mm</content>
            </paragraph>
            <paragraph>
              <caption>Source of Measurement</caption>
              <content ID="SrceOfMeas2">
                <linkHtml href="http://www.example.org/wado?requestType=WADO
                    &amp;studyUID=1.2.840.113619.2.62.994044785528.114289542805
                    &amp;seriesUID=1.2.840.113619.2.62.994044785528.20060823223142485051
                    &amp;objectUID=1.2.840.113619.2.62.994044785528.20060823.200608232232322.3
                    &amp;contentType=application/dicom">
                Chest_PA</linkHtml>
              </content>
            </paragraph>
          </text>
          <entry>
            <observation classCode="OBS" moodCode="EVN">
              <!-- Text Observation -->
              <templateId root="2.16.840.1.113883.10.20.6.2.12" />
              <code code="121071" codeSystem="1.2.840.10008.2.16.4"
              codeSystemName="DCM" displayName="Finding" />
              <value xsi:type="ED">
                <reference value="#Fndng2" />
              </value>
              <!-- inferred from measurement -->
              <entryRelationship typeCode="SPRT">
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.6.2.14" />
                  <code code="246120007" codeSystem="2.16.840.1.113883.6.96"
                  codeSystemName="SNOMED" displayName="Nodule size">
                    <originalText>
                      <reference value="#Diam2" />
                    </originalText>
                  </code>
                  <!-- no DICOM attribute  <statusCode code="completed"/> -->
                  <effectiveTime value="20060823223912" />
                  <value xsi:type="PQ" value="45" unit="mm" />
                  <!-- inferred from image -->
                  <entryRelationship typeCode="SUBJ">
                    <observation classCode="DGIMG" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.6.2.8" />
                      <!-- (0008,1155) Referenced SOP Instance UID-->
                      <id root="1.2.840.113619.2.62.994044785528.20060823.200608232232322.3" />
                      <!-- (0008,1150) Referenced SOP Class UID -->
                      <code code="1.2.840.10008.5.1.4.1.1.1"
                      codeSystem="1.2.840.10008.2.6.1" codeSystemName="DCMUID"
                      displayName="Computed Radiography Image Storage"></code>
                      <text mediaType="application/dicom">
                        <!--reference to CR DICOM image (PA view) -->
                        <reference value="http://www.example.org/wado?requestType=WADO
                            &amp;studyUID=1.2.840.113619.2.62.994044785528.114289542805
                            &amp;seriesUID=1.2.840.113619.2.62.994044785528.20060823223142485051
                            &amp;objectUID=1.2.840.113619.2.62.994044785528.20060823.200608232232322.3
                            &amp;contentType=application/dicom" />
                      </text>
                      <effectiveTime value="20060823223232" />
                      <!-- Purpose of Reference -->
                      <entryRelationship typeCode="RSON">
                        <observation classCode="OBS" moodCode="EVN">
                          <templateId root="2.16.840.1.113883.10.20.6.2.9" />
                          <code code="ASSERTION"
                          codeSystem="2.16.840.1.113883.5.4" />
                          <value xsi:type="CD" code="121112"
                          codeSystem="1.2.840.10008.2.16.4"
                          codeSystemName="DCM"
                          displayName="Source of Measurement">
                            <originalText>
                              <reference value="#SrceOfMeas2" />
                            </originalText>
                          </value>
                        </observation>
                      </entryRelationship>
                    </observation>
                  </entryRelationship>
                </observation>
              </entryRelationship>
            </observation>
          </entry>
        </section>
        <!--                                                    
**********************************************************************
                    End of Findings Section
**********************************************************************
        -->
      </component>
      <component>
        <!--
**********************************************************************
                    Impressions Section 
**********************************************************************
        -->
        <section>
          <code code="121072" codeSystem="1.2.840.10008.2.16.4"
          codeSystemName="DCM" displayName="Impressions" />
          <title>Impressions</title>
          <text>
            <paragraph>
              <caption>Impression</caption>
              <content ID="Fndng3">No acute cardiopulmonary process. Round
              density in left superior hilus, further evaluation with CT is
              recommended as underlying malignancy is not excluded.</content>
            </paragraph>
          </text>
          <entry>
            <!-- Impression report element (TEXT) -->
            <observation classCode="OBS" moodCode="EVN">
              <!-- Text Observation -->
              <templateId root="2.16.840.1.113883.10.20.6.2.12" />
              <code code="121073" codeSystem="1.2.840.10008.2.16.4"
              codeSystemName="DCM" displayName="Impression" />
              <value xsi:type="ED">
                <reference value="#Fndng3" />
              </value>
            </observation>
          </entry>
        </section>
        <!--                                                    
**********************************************************************
                    End of Impressions Section
**********************************************************************
        -->
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>