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: Family History Generic

Approval Status: Approved
Task Force Approval: 2015-02-12
SDWG Approval: 2015-02-19, 2016-12-01

Example shows generic "family history of x" and "no family history of x" with commentary suggesting better options.

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <!--  C-CDAR2 Example Family History Section (Generic Family History) -->
  <templateId root="2.16.840.1.113883.10.20.22.2.15"/>
  <templateId root="2.16.840.1.113883.10.20.22.2.15" extension="2015-08-01"/>
  <code displayName="Family History" codeSystem="2.16.840.1.113883.6.1"
        code="10157-6"/>
  <title>Family History</title>
  <text>
    <!--  Family history is intended to convery information about discrete family members' health conditions.
         The best way to convey "Family history of heart disease" would be to identify which family members
         actually HAD heart disease.
         The best way to convey "No family history of asthma" would be to explicitly state:
         The father did not have asthma.
         The mother did not have asthma.
         The grandfather did not have asthma.
         ...and so on.
         
         An alternative to using this section to convey generic family history would be to add
         codes from the SNOMED 416471007: Family Medical History hierarchy to the patient's problem list.
         
         This example, however, shows how to convey generic family history in the Family History
         section in the absence of any known discrete family relationships.  -->
    <paragraph ID="FH1">Patient has a family history of 
      <content ID="FHGeneric1prob">heart disease</content>.
    </paragraph>
    <paragraph ID="FH2">Patient has no known family history of 
      <content ID="FHGeneric2prob">asthma</content>.
    </paragraph>
  </text>
  <!--  Generic family member's history  -->
  <entry>
    <organizer moodCode="EVN" classCode="CLUSTER">
      <templateId root="2.16.840.1.113883.10.20.22.4.45"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.45"
                  extension="2015-08-01"/>
      <!--  Unique ID for the collection of observations about "generic family member"  -->
      <id root="01faa204-3333-4610-864f-cb50b650d0fa"/>
      <statusCode code="completed"/>
      <subject>
        <!--  No additional subject information is necessary, since we are not talking about an individual person  -->
        <relatedSubject classCode="PRS">
          <!--  Identifies this subject as a generic 'Family Member'  -->
          <code displayName="family member" codeSystemName="HL7 RoleCode"
                codeSystem="2.16.840.1.113883.5.111" code="FAMMEMB"/>
        </relatedSubject>
      </subject>
      <!--  Heart Disease observation  -->
      <component>
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.46"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.46"
                      extension="2015-08-01"/>
          <!--  Unique ID for this individual observation  -->
          <id root="02faa204-3333-4610-864f-cb50b650d0fa"/>
          <code xsi:type="CD" displayName="Disease"
                codeSystem="2.16.840.1.113883.6.96" code="64572001">
            <translation xsi:type="CD" displayName="Condition Family member"
                         codeSystem="2.16.840.1.113883.6.1" code="75315-2"/>
          </code>
          <text xsi:type="ED">
            <reference value="#FH1"/>
          </text>
          <statusCode code="completed"/>
          <!--  Since no date is given, effectiveTime is UNKnown  -->
          <effectiveTime nullFlavor="UNK"/>
          <!--  SNOMED for Heart Disease
               Note: explicitly NOT using 266894000: FH Cardiovascular disease, since we are scoped by the "family member"
               The family member has 'Heart Disease', not a 'Family History of Heart Disease'  -->
          <value xsi:type="CD" displayName="Heart disease (disorder)"
                 codeSystem="2.16.840.1.113883.6.96" code="56265001">
            <originalText>
              <reference value="#FHGeneric1prob"/>
            </originalText>
          </value>
        </observation>
      </component>
      <!--  Asthma negative observation  -->
      <component>
        <!--  Similar to Problem Observation, negationInd here represents Observation.ValueNegation,
             stating the relative does NOT have asthma -->
        <observation negationInd="true" moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.46"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.46"
                      extension="2015-08-01"/>
          <!--  Unique ID for this individual observation  -->
          <id root="04faa204-3333-4610-864f-cb50b650d0fa"/>
          <code xsi:type="CD" displayName="Disease"
                codeSystem="2.16.840.1.113883.6.96" code="64572001">
            <translation xsi:type="CD" displayName="Condition Family member"
                         codeSystem="2.16.840.1.113883.6.1" code="75315-2"/>
          </code>
          <text xsi:type="ED">
            <reference value="#FH2"/>
          </text>
          <statusCode code="completed"/>
          <!--  Since no date is given, effectiveTime is UNKnown  -->
          <effectiveTime nullFlavor="UNK"/>
          <!--  SNOMED for Asthma
               Again, not using 160377001: Family History of Asthma. That code would be
               appropriate for the patient's own problem list.  -->
          <value xsi:type="CD" displayName="Asthma"
                 codeSystem="2.16.840.1.113883.6.96" code="195967001">
            <originalText>
              <reference value="#FHGeneric2prob"/>
            </originalText>
          </value>
        </observation>
      </component>
    </organizer>
  </entry>
</section>