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
Example shows multiple observations for one family member, identifying the cause of death, and a family member with no known problems.
This file includes examples of the following templates:
<section xmlns="urn:hl7-org:v3">
<!-- C-CDAR2 Example Family History Section -->
<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>
<!-- Narrative may be structured in any manner, but clear references between the narrative and discrete entries are encouraged -->
<table>
<thead>
<tr>
<th>Family Member</th>
<th>Relation</th>
<th>Problem</th>
<th>Age of Onset</th>
<th>Comments</th>
</tr>
</thead>
<tbody>
<tr>
<td rowspan="2">Lucas Valieri</td>
<td rowspan="2" ID="FH1rel">Dad</td>
<td ID="FH1prob1">Stroke</td>
<td ID="FH1prob1age">72</td>
<td ID="FH1prob1comment">Cause of death, January 2003</td>
</tr>
<tr>
<td ID="FH1prob2">High Blood Pressure</td>
<td/>
<td/>
</tr>
<tr>
<td>Mia Jones</td>
<td ID="FH2rel">Mom</td>
<td ID="FH2prob">No known problems</td>
<td/>
<td/>
</tr>
</tbody>
</table>
</text>
<!-- Father died of a stroke -->
<entry>
<!-- Organizes the Father's medical history -->
<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 identifier for this family member's HISTORY (not the individual) -->
<id root="01faa204-db62-4610-864f-cb50b650d0fa"/>
<statusCode code="completed"/>
<subject typeCode="SBJ">
<relatedSubject classCode="PRS">
<!-- Identifies subject's relationship to recordTarget (i.e. Patient) -->
<code displayName="father" codeSystemName="HL7 RoleCode"
codeSystem="2.16.840.1.113883.5.111" code="FTH">
<originalText>
<reference value="#FH1rel"/>
</originalText>
</code>
<subject>
<!-- Unique ID for the father as an individual -->
<sdtc:sdtcId xmlns:sdtc="urn:hl7-org:sdtc"
root="1.3.6.1.4.1.16517.1" extension="98765432-1"/>
<!-- Father's name; could be sent formatted or as a string like this -->
<name>Lucas Valieri</name>
<administrativeGenderCode displayName="Male"
codeSystem="2.16.840.1.113883.5.1" code="M"/>
<!-- Father's birth date/time, SHOULD be sent. In this example, we did not know the
father's birth date, so we assert that the birthTime is "Unknown" -->
<birthTime nullFlavor="UNK"/>
<!-- Identifies the father's living status as deceased. -->
<sdtc:sdtcDeceasedInd xmlns:sdtc="urn:hl7-org:sdtc" value="true"/>
<!-- Date and optional time of death (only needed if deceasedInd="true") -->
<sdtc:sdtcDeceasedTime xmlns:sdtc="urn:hl7-org:sdtc"
value="200301"/>
</subject>
</relatedSubject>
</subject>
<!-- Stroke 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-db62-4610-864f-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="#FH1prob1"/>
</text>
<statusCode code="completed"/>
<!-- Date of the stroke -->
<effectiveTime value="200301"/>
<!-- The actual finding on the father.
Note: this is deliberately NOT set to 275104002-Family History of Stroke,
since we are saying the father had a "stroke" not a "family history of stroke".
Family History of Stroke would be a valid code to add to the recordTarget's problem list. -->
<value xsi:type="CD" displayName="Cerebrovascular accident"
codeSystem="2.16.840.1.113883.6.96" code="230690007">
<originalText>
<reference value="#FH1prob1"/>
</originalText>
</value>
<!-- Age at the time of the event -->
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.31"/>
<code xsi:type="CD" displayName="Age at Onset"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="445518008"/>
<text xsi:type="ED">
<reference value="#FH1prob1age"/>
</text>
<statusCode code="completed"/>
<!-- 'a' is UCUM for Years -->
<value xsi:type="PQ" value="72" unit="a"/>
</observation>
</entryRelationship>
<!-- This finding was the cause of death -->
<entryRelationship typeCode="CAUS">
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.47"/>
<code xsi:type="CD" codeSystem="2.16.840.1.113883.5.4"
code="ASSERTION"/>
<text xsi:type="ED">
<reference value="#FH1prob1comment"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" displayName="Dead"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="419099009"/>
</observation>
</entryRelationship>
</observation>
</component>
<!-- High Blood Pressure 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="04faa204-db62-4610-864f-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="#FH1prob2"/>
</text>
<statusCode code="completed"/>
<!-- Date of blood pressure (unknown) -->
<effectiveTime nullFlavor="UNK"/>
<!-- The actual finding on the father.
Again, not using 160357008-Family History of Hypertension, since we're stating
the father HAD hypertension, not a family history of hypertension -->
<value xsi:type="CD" displayName="Essential hypertension"
codeSystem="2.16.840.1.113883.6.96" code="59621000">
<originalText>
<reference value="#FH1prob2"/>
</originalText>
</value>
</observation>
</component>
</organizer>
</entry>
<!-- Mother living with no known problems -->
<entry>
<!-- Organizes the Mother's medical history -->
<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 identifier for this family member's HISTORY (not the individual) -->
<id root="03faa204-db62-4610-864f-cb50b650d0fa"/>
<statusCode code="completed"/>
<subject>
<relatedSubject classCode="PRS">
<!-- Identifies subject's relationship to recordTarget (i.e. Patient) -->
<code displayName="mother" codeSystemName="HL7 RoleCode"
codeSystem="2.16.840.1.113883.5.111" code="MTH">
<originalText>
<reference value="#FH2rel"/>
</originalText>
</code>
<subject>
<!-- Unique ID for the mother as an individual
(note - different extension than father) -->
<sdtc:sdtcId xmlns:sdtc="urn:hl7-org:sdtc"
root="1.3.6.1.4.1.16517.1" extension="98765432-2"/>
<!-- Mother's name; could be sent formatted or as a string like this -->
<name>Mia Jones</name>
<administrativeGenderCode displayName="Female"
codeSystem="2.16.840.1.113883.5.1" code="F"/>
<!-- Mother's birth time, SHOULD be sent -->
<birthTime nullFlavor="UNK"/>
<!-- Identifies the mother's living status as living. -->
<sdtc:sdtcDeceasedInd xmlns:sdtc="urn:hl7-org:sdtc"
value="false"/>
</subject>
</relatedSubject>
</subject>
<component>
<observation negationInd="true" moodCode="EVN" classCode="OBS">
<!-- Similar to no known problems or allergies,
the use of negationInd corresponds with the newer Observation.ValueNegationInd
The negationInd = true negates the value element -->
<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="05faa204-db62-4610-864f-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="#FH2prob"/>
</text>
<statusCode code="completed"/>
<effectiveTime nullFlavor="NI"/>
<!-- Generic problem; negationInd identifies the mother has having no active problems -->
<value xsi:type="CD" displayName="Problem"
codeSystem="2.16.840.1.113883.6.96" code="55607006"/>
</observation>
</component>
</organizer>
</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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