CDA Examples
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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

Example: Allergy to specific drug Penicillin

Approval Status: Approved
Task Force Approval: 2014-04-10
SDWG Approval: 2014-04-24, 2016-12-01

This is an example of an allergy to a specific drug (penicillin) using RxNorm as terminology with information on both allergic reaction and reaction severity. For drug allergies, this example illustrates a good practice of encoding the allergen at the ingredient level (penicillin) not administration level (10 mg tablet). See DSTU 219 for update regarding act/code. Multiple reactions are listed in some examples

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="allergy2">
          <td ID="allergy2allergen">Penicillin</td>
          <td ID="allergy2reaction">Anaphylaxis</td>
          <td ID="allergy2reactionseverity">Severe</td>
          <td>Jan 4 2014</td>
          <td>2006</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="4a2ac5fc-0c85-4223-baee-c2e254803974"/>
      <code codeSystem="2.16.840.1.113883.5.6" code="CONC"/>
      <text>
        <reference value="#allergy2"/>
      </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="4a2ac5fc-0c85-4223-baee-c2e254803974"/>
          <code xsi:type="CD" codeSystem="2.16.840.1.113883.5.4"
                code="ASSERTION"/>
          <text xsi:type="ED">
            <reference value="#allergy2"/>
          </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="2006"/>
          </effectiveTime>
          <!--  This specifies that the allergy is to a medication in contrast to other allergies (substance)  -->
          <value xsi:type="CD" displayName="Allergy to drug"
                 codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="416098002"/>
          <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>
          <participant typeCode="CSM">
            <participantRole classCode="MANU">
              <playingEntity classCode="MMAT">
                <!--  RxNorm is used to report specific drug allergies. Note to use SNOMED CT for drug classes  -->
                <!--  Best practice is to report drug allergies at ingredient level (e.g. penicillin) not at the adminsitration level (e.g. 10mg tablet) -->
                <code displayName="penicillin G" codeSystemName="RxNorm"
                      codeSystem="2.16.840.1.113883.6.88" code="7980">
                  <originalText>
                    <reference value="#allergy2allergen"/>
                  </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="0506c036-adfb-4e6e-b9e1-eea76177ead5"/>
              <code xsi:type="CD" codeSystem="2.16.840.1.113883.5.4"
                    code="ASSERTION"/>
              <text xsi:type="ED">
                <reference value="#allergy2reaction"/>
              </text>
              <statusCode code="completed"/>
              <effectiveTime>
                <low value="2006"/>
                <high nullFlavor="UNK"/>
              </effectiveTime>
              <value xsi:type="CD" displayName="Anaphylaxis"
                     codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="39579001"/>
              <!--  The Severity observation is no longer recommended, use criticality observation in future exchanges  -->
              <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="#allergy2reactionseverity"/>
                  </text>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" displayName="Severe"
                         codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="24484000"/>
                </observation>
              </entryRelationship>
            </observation>
          </entryRelationship>
        </observation>
      </entryRelationship>
    </act>
  </entry>
</section>