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: Not Allergic to Peanuts

Approval Status: Approved
Task Force Approval: 2018-04-05
SDWG Approval: 2018-10-01

This is an example of how an author can record a patient is not allergic to a specific substance. In this example, the susbtance is Peanuts.

This file includes examples of the following templates: 


  <!--  ***************** ALLERGIES ***************  -->
<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>
    <content ID="allergyobs1">Not Allergic to Peanuts</content>
  </text>
  <!--  Could include two tables with one recording active allergies and another with Not Allergic - Need to clearly denote -->
  <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="91a4e6a1-e192-438c-a85d-abb210af6d25"/>
      <code codeSystem="2.16.840.1.113883.5.6" code="CONC"/>
      <text>
        <reference value="#allergyobs1"/>
      </text>
      <statusCode code="active"/>
      <!--  This is the time stamp for when the non-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">
        <!--  negationInd is used here as valueNegationInd - the substance allergy -->
        <observation negationInd="true" 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="55ac1612-2d3f-4084-b687-0997446cabad"/>
          <code xsi:type="CD" codeSystem="2.16.840.1.113883.5.4"
                code="ASSERTION"/>
          <text xsi:type="ED">
            <reference value="#allergyobs1"/>
          </text>
          <statusCode code="completed"/>
          <!--  This is the time stamp for when patient believes they were tested.  -->
          <!--  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 substance  -->
          <!--  Considered 'Allergy to peanuts' above but decided to use substance since this is what systems will expect  -->
          <value xsi:type="CD" displayName="Allergy to food"
                 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="99999999214"/>
              <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">
                <!--  SNOMED is used to report specific susbtance  -->
                <!--  Considered 'Allergy to peanuts' above but decided to use substance since this is what systems will expect  -->
                <code displayName="Peanut" codeSystemName="SNOMED CT"
                      codeSystem="2.16.840.1.113883.6.96" code="762952008"/>
              </playingEntity>
            </participantRole>
          </participant>
        </observation>
      </entryRelationship>
    </act>
  </entry>
</section>