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: No Known Allergies

Approval Status: Approved
Task Force Approval: 2014-01-09
SDWG Approval: 2014-01-16, 2016-12-01

This is an example of how an author can record a patient has no known allergies.

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <!--  *** Allergies and Intolerances Section (entries required) (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"/>
  <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
        code="48765-2"/>
  <title>ALLERGIES AND ADVERSE REACTIONS</title>
  <text>No Known Allergies</text>
  <entry typeCode="DRIV">
    <!--  Allergy Concern Act  -->
    <act moodCode="EVN" classCode="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="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
      <!--  SDWG supports 48765-2 or CONC in the code element  -->
      <code codeSystem="2.16.840.1.113883.5.6" code="CONC"/>
      <text>
        <reference value="#allergiesNoKnown"/>
      </text>
      <statusCode code="active"/>
      <!-- currently tracked concerns are active concerns -->
      <!-- show time when the concern first began being tracked -->
      <effectiveTime>
        <low value="20100103"/>
      </effectiveTime>
      <author>
        <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
        <time value="20100103"/>
        <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">
        <!--  No Known Allergies  -->
        <!--  The negationInd = true negates the observation/value  -->
        <!--  The use of negationInd corresponds with the newer Observation.valueNegationInd  -->
        <observation negationInd="true" moodCode="EVN" classCode="OBS">
          <!--  allergy - intolerance 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="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
          <code xsi:type="CD" codeSystem="2.16.840.1.113883.5.4"
                code="ASSERTION"/>
          <text xsi:type="ED">
            <reference value="#allergiesNoKnown"/>
          </text>
          <statusCode code="completed"/>
          <!--  The time when this was biologically relevant ie True for the patient.  -->
          <!--  For "no known allergies," this will typically be null unless information
               is available about how long the patient has been allergy-free for.  -->
          <!--  As a maximum, you would never indicate an effectiveTime/high that was greater than the current point in time.  -->
          <effectiveTime>
            <low nullFlavor="NI"/>
          </effectiveTime>
          <!--  Note 419199007 - Allergy to substance has been retired; 609328004 is the recommended replacement  -->
          <value xsi:type="CD" displayName="Allergic disposition (finding)"
                 codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="609328004"/>
          <author>
            <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
            <time value="20100103090800-0500"/>
            <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">
                <code nullFlavor="NA"/>
              </playingEntity>
            </participantRole>
          </participant>
        </observation>
      </entryRelationship>
    </act>
  </entry>
</section>