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 two individuals same relationship to the patient

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

Example shows two brothers with multiple conditions. Though they have the same relationship to the patient, they can be identified by their separation into two family history organizers as well as by their subject ID’s.

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <!--  C-CDAR2 Example Family History Section for two siblings  -->
  <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>
    <paragraph>James, 
      <content ID="FamHist1rel">brother</content>, born 1982
    </paragraph>
    <list listType="unordered">
      <item ID="FamHist1prob1">High blood pressure</item>
      <item ID="FamHist1prob2">Diabetes</item>
    </list>
    <paragraph>Gerald, 
      <content ID="FamHist2rel">brother</content>, born 1985
    </paragraph>
    <list listType="unordered">
      <item ID="FamHist2prob1">Asthma</item>
    </list>
  </text>
  <!--  James' 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 identifier for this family member's HISTORY (not the individual)  -->
      <id root="01faa204-0000-4610-864f-cb50b650d0fa"/>
      <statusCode code="completed"/>
      <subject>
        <relatedSubject classCode="PRS">
          <!--  Identifies relationship; though there are two brothers, the separation into
               two different organizers with their own subject identifies these as two
               distinct individuals. The subject/@sdtc:id can also futher identify the individuals. -->
          <code displayName="brother" codeSystemName="HL7 RoleCode"
                codeSystem="2.16.840.1.113883.5.111" code="BRO">
            <originalText>
              <reference value="#FamHist1rel"/>
            </originalText>
          </code>
          <subject>
            <!--  Unique ID for the brother as an individual  -->
            <sdtc:sdtcId xmlns:sdtc="urn:hl7-org:sdtc"
                         root="1.3.6.1.4.1.16517.1" extension="98765432-1"/>
            <name>James</name>
            <administrativeGenderCode displayName="Male"
                                      codeSystem="2.16.840.1.113883.5.1" code="M"/>
            <birthTime value="1982"/>
          </subject>
        </relatedSubject>
      </subject>
      <!--  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="02faa204-0000-4610-864f-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="#FamHist1prob1"/>
          </text>
          <statusCode code="completed"/>
          <!--  Since we do not know when the brother was diagnosed with High Blood pressure, the effective time is UNKown  -->
          <effectiveTime nullFlavor="UNK"/>
          <!--  SNOMED code for High Blood Pressure  -->
          <value xsi:type="CD" displayName="Essential hypertension"
                 codeSystem="2.16.840.1.113883.6.96" code="59621000">
            <originalText>
              <reference value="#FamHist1prob1"/>
            </originalText>
          </value>
        </observation>
      </component>
      <!--  Diabetes 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="03faa204-0000-4610-864f-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="#FamHist1prob2"/>
          </text>
          <statusCode code="completed"/>
          <!--  Since we do not know when the brother was diagnosed with Diabetes, the effective time is UNKown  -->
          <effectiveTime nullFlavor="UNK"/>
          <!--  SNOMED code for Diabetes  -->
          <value xsi:type="CD" displayName="Diabetes mellitus"
                 codeSystem="2.16.840.1.113883.6.96" code="73211009">
            <originalText>
              <reference value="#FamHist1prob2"/>
            </originalText>
          </value>
        </observation>
      </component>
    </organizer>
  </entry>
  <!--  Gerald'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 identifier for this family member's HISTORY (not the individual)  -->
      <id root="01faa204-1111-4610-864f-cb50b650d0fa"/>
      <statusCode code="completed"/>
      <subject>
        <relatedSubject classCode="PRS">
          <!--  Identifies relationship; though there are two brothers, the separation into
               two different organizers with their own subject identifies these as two
               distinct individuals. The subject/@sdtc:id can also futher identify the individuals. -->
          <code displayName="brother" codeSystemName="HL7 RoleCode"
                codeSystem="2.16.840.1.113883.5.111" code="BRO">
            <originalText>
              <reference value="#FamHist2rel"/>
            </originalText>
          </code>
          <subject>
            <!--  Unique ID for the brother as an individual; note the extension is different from James's id  -->
            <sdtc:sdtcId xmlns:sdtc="urn:hl7-org:sdtc"
                         root="1.3.6.1.4.1.16517.1" extension="98765432-2"/>
            <name>Gerald</name>
            <administrativeGenderCode displayName="Male"
                                      codeSystem="2.16.840.1.113883.5.1" code="M"/>
            <birthTime value="1985"/>
          </subject>
        </relatedSubject>
      </subject>
      <!--  Asthma 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="03faa204-1111-4610-864f-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>
          <statusCode code="completed"/>
          <!--  Since we do not know when the brother was diagnosed with asthma, the effective time is UNKown  -->
          <effectiveTime nullFlavor="UNK"/>
          <!--  SNOMED code for Asthma  -->
          <value xsi:type="CD" displayName="Asthma (disorder)"
                 codeSystem="2.16.840.1.113883.6.96" code="195967001">
            <originalText>
              <reference value="#FamHist2prob1"/>
            </originalText>
          </value>
        </observation>
      </component>
    </organizer>
  </entry>
</section>