CDA Examples
1.0.0 - active
CDA Examples
1.0.0 - active
CDA Examples, published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-Examples/ and changes regularly. See the Directory of published versions
This example illustrates how to structure an active problem with value codes that need translation & qualifiers. Note that no formally vetted post-coordination semantics exist for codesystems besides SNOMED today (eg ICD-10), which is a limitation to this example. Example was updated after the March 2022 C-CDA Implementation-a-thon.
This file includes examples of the following templates:
<section xmlns="urn:hl7-org:v3">
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
<templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
<code displayName="Problem List" codeSystem="2.16.840.1.113883.6.1"
code="11450-4"/>
<title>Problem List</title>
<text>
<table>
<thead>
<tr>
<th>Name</th>
<th>Dates</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr ID="Problem1">
<td ID="Problem1Text">Diabetes mellitus due to underlying condition with chronic kidney disease on chronic dialysis (CMS/HCC)</td>
<td>
<content>Onset: February 27 2014</content>
</td>
<td>Active</td>
</tr>
</tbody>
</table>
</text>
<entry>
<act moodCode="EVN" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
<templateId root="2.16.840.1.113883.10.20.22.4.3"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.3"
extension="2024-05-01"/>
<id root="102ca2e9-884c-4523-a2b4-1b6c3469c397"/>
<code codeSystem="2.16.840.1.113883.5.6" code="CONC"/>
<!-- Since this is an active problem, the concern status is active. -->
<!-- While clinicians can track resolved problems, generally active problems will have active concern status and resolved concerns will be completed -->
<statusCode code="active"/>
<effectiveTime>
<!-- This equates to the time the concern was authored in the patient's chart. This may frequently be an EHR timestamp -->
<low value="20140302124536-0500"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2024-05-01"/>
<id root="1.3.6.1.4.1.22812.4.111.0.4.1.2.1"
extension="10241104348"/>
<code xsi:type="CD" displayName="Problem"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="55607006">
<translation xsi:type="CD" displayName="Problem"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="75326-9"/>
</code>
<text xsi:type="ED">
<reference value="#Problem1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<!-- This represents the date of biological onset. -->
<low value="20140227"/>
</effectiveTime>
<!-- Post-coordination can be used for SNOMED to create a single problem encapsulating multiple
codes. No such semantics have been agreed on yet for other code systems. -->
<!-- Other translations as above... -->
<value xsi:type="CD" displayName="Secondary diabetes mellitus"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="8801005">
<originalText>
<reference value="#Problem1Text"/>
</originalText>
<!-- Additional qualifiers representing the concepts not captured in the first SNOMED code. The qualifier/name
uses the SNOMED code "associated with" or its children ("causative agent", "due to", or "temporarily related to"). -->
<qualifier>
<name displayName="Associated with" codeSystemName="SNOMED CT"
codeSystem="2.16.840.1.113883.6.96" code="47429007"/>
<value displayName="Dependence on renal dialysis"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="105502003"/>
</qualifier>
<qualifier>
<name displayName="Associated with" codeSystemName="SNOMED CT"
codeSystem="2.16.840.1.113883.6.96" code="47429007"/>
<value displayName="Chronic kidney disease"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="709044004"/>
</qualifier>
<!-- ICD-10 translation. Note the lack of specificity due to not having qualifiers! -->
<translation xsi:type="CD"
displayName="Diabetes mellitus due to underlying condition with diabetic chronic kidney disease" codeSystemName="ICD10"
codeSystem="2.16.840.1.113883.6.90" code="E08.22"/>
<!-- 3rd-party vocabulary codes (for example, from terminology vendors) may also allow senders to represent complex problems
without losing specificity... however, this requires both the sender and receiver to understand the same vendor terminology. -->
<translation xsi:type="CD"
displayName="Diabetes mellitus due to underlying condition with diabetic chronic kidney disease" codeSystemName="3rdPartyCodeSystem"
codeSystem="2.16.840.1.113883.3.247.1.1" code="65167828"/>
</value>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20140302124536"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="66666"/>
<code
displayName="Allopathic & Osteopathic Physicians; Internal Medicine, Cardiovascular Disease" codeSystemName="NUCC"
codeSystem="2.16.840.1.113883.6.101" code="207RC0000X"/>
<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>
</assignedAuthor>
</author>
</observation>
</entryRelationship>
</act>
</entry>
</section>
IG © Health Level Seven. Package hl7.cda.examples#1.0.0 based on FHIR 5.0.0. Generated 2025-08-28
Links: Table of Contents |
QA Report
| Version History 
|
|
Propose a change