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 is an example of a food allergy with information on both allergic reaction and reaction severity. It was based upon discussion with Russ Leftwich and Lisa Nelson in coordination with Patient Care Committee. See DSTU 219 for update regarding act/code.
This file includes examples of the following templates:
<section xmlns="urn:hl7-org:v3">
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
<templateId root="2.16.840.1.113883.10.20.22.2.6.1" extension="2015-08-01"/>
<!-- Allergies (entries required) section template -->
<code codeSystem="2.16.840.1.113883.6.1" code="48765-2"/>
<title>Allergies, Adverse Reactions and Alerts</title>
<text>
<table>
<thead>
<tr>
<th>Allergen</th>
<th>Reaction</th>
<th>Reaction Severity</th>
<th>Documentation Date</th>
<th>Start Date</th>
</tr>
</thead>
<tbody>
<tr ID="allergy5">
<td ID="allergy5allergen">Egg</td>
<td ID="allergy5reaction">Hives</td>
<td ID="allergy5reactionseverity">Moderate</td>
<td>Jan 4 2014</td>
<td>1998</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<act moodCode="EVN" classCode="ACT">
<!-- ** Allergy problem act ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<templateId root="2.16.840.1.113883.10.20.22.4.30"
extension="2015-08-01"/>
<id root="0fffb34f-c1e0-47c2-92af-c414a3ff21ec"/>
<code codeSystem="2.16.840.1.113883.5.6" code="CONC"/>
<text>
<reference value="#allergy5"/>
</text>
<statusCode code="active"/>
<!-- This is the time stamp for when the allergy was first documented as a concern -->
<effectiveTime>
<low value="20140104123506-0500"/>
</effectiveTime>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20140104"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="99999999"/>
<code displayName="Family Medicine Physician"
codeSystemName="Health Care Provider Taxonomy" codeSystem="2.16.840.1.113883.6.101" code="207Q00000X"/>
<addr nullFlavor="UNK"/>
<telecom value="tel:555-555-1002" use="WP"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<entryRelationship typeCode="SUBJ">
<observation moodCode="EVN" classCode="OBS">
<!-- allergy observation template -->
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<templateId root="2.16.840.1.113883.10.20.22.4.7"
extension="2014-06-09"/>
<!-- Substance or Device Allergy Intolerance Observation Template -->
<templateId root="2.16.840.1.113883.10.20.24.3.90"
extension="2014-06-09"/>
<id root="0fffb34f-c1e0-47c2-92af-c414a3ff21ec"/>
<code xsi:type="CD" codeSystem="2.16.840.1.113883.5.4"
code="ASSERTION"/>
<text xsi:type="ED">
<reference value="#allergy5"/>
</text>
<statusCode code="completed"/>
<!-- This is the time stamp for the biological onset of the allergy. -->
<!-- Just the year is shown since a specific month and date was not reported -->
<effectiveTime>
<low value="1998"/>
</effectiveTime>
<!-- This specifies that the allergy is to a food in contrast to other allergies (drug) -->
<value xsi:type="CD" displayName="Allergy to food (finding)"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="414285001"/>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20140104"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="99999999"/>
<code displayName="Family Medicine Physician"
codeSystemName="Health Care Provider Taxonomy" codeSystem="2.16.840.1.113883.6.101" code="207Q00000X"/>
<addr nullFlavor="UNK"/>
<telecom value="tel:555-555-1002" use="WP"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<!-- In C-CDA R2.1 the participant is required. -->
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<!-- The agent responsible for an allergy or adverse reaction is not always a manufactured material (for example, food allergies),
nor is it necessarily consumed. The following constraints reflect limitations in the base CDA R2 specification,
and should be used to represent any type of responsible agent, i.e., use playingEntity classCode = "MMAT" for all agents,
manufactured or not. -->
<!--
... the expectation for use is that the chosen concept identifier for a substance should be appropriately specific and
drawn from the available code systems in the following priority order: RXNORM, then SNOMED CT.
This overarching grouping value set is intended to support identification of drug classes, individual medication
ingredients, foods, general substances and environmental entities. Value set intensionally defined as a GROUPING made
up of:
Value Set: Clinical Drug Ingredient (2.16.840.1.113762.1.4.1010.7) (RxNORM ingredient codes);
Value Set: Medication drug class for allergen intolerance SCT (2.16.840.1.113762.1.4.1114.14) (SNOMED CT substance codes);
Value Set: Substance Other Than Clinical Drug (2.16.840.1.113762.1.4.1010.9) (SNOMED CT substance codes). -->
<code displayName="Eggs (edible)" codeSystemName="SNOMED CT"
codeSystem="2.16.840.1.113883.6.96" code="102263004">
<originalText>
<reference value="#allergy5allergen"/>
</originalText>
</code>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="MFST" inversionInd="true">
<observation moodCode="EVN" classCode="OBS">
<!-- Reaction Observation template -->
<templateId root="2.16.840.1.113883.10.20.22.4.9"/>
<templateId root="2.16.840.1.113883.10.20.22.4.9"
extension="2014-06-09"/>
<id root="d89ce431-e0f1-4f8d-a81f-489b6ed91f09"/>
<code xsi:type="CD" codeSystem="2.16.840.1.113883.5.4"
code="ASSERTION"/>
<text xsi:type="ED">
<reference value="#allergy5reaction"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="1998"/>
<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" displayName="Wheal"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="247472004"/>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation moodCode="EVN" classCode="OBS">
<!-- Severity Observation template -->
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<templateId root="2.16.840.1.113883.10.20.22.4.8"
extension="2014-06-09"/>
<code xsi:type="CD" codeSystemName="ActCode"
codeSystem="2.16.840.1.113883.5.4" code="SEV"/>
<text xsi:type="ED">
<reference value="#allergy5reactionseverity"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" displayName="Moderate"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="6736007"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</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
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