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: Narrative Reference - SubstanceAdministration

Approval Status: Approved
Task Force Approval: 2017-06-01
SDWG Approval: 2017-07-06

This example demonstrates how to link the section narrative (section.text) to the coded information (entry) below. The example includes several comments and does not conform to any specific C-CDA/CDA template. The principles agreed to in this sample should be present in all other examples.

This file includes examples of the following templates:


  <!--  The following section is fictitious - it exists solely for the purpose of showing examples of text/reference and originalText/reference from discrete entry children. As such, many elements are omitted and replaced by ... comments. The text and content in the discrete entry elements does not use actual clinical content, but instead relies on filler text commonly used in publishing and graphic design.  -->
<section xmlns="urn:hl7-org:v3">
  <text>
    <!--  The text in this section is created strictly to illustrate how discrete entry child elements make references into the human readable text.   -->
    <!--  this table is used for a simple sunstanceAdministration; the ID values are meant to be unique across the whole document  -->
    <table>
      <tbody>
        <tr ID="simpleSubstanceAdministrationFullTextReference1">
          <td>
            <content>
              <content ID="substanceAdministrationProductCodeTextReference1">Lorem ipsum dolor sit amet, consectetuer adipiscing elit.</content>
              <content ID="substanceAdministrationFreeTextSIGReference1"> Aenean commodo ligula eget dolor. Aenean massa.</content>
              <br/>
              <!--  ...  -->
            </content>
          </td>
          <td>
            <!--  ...  --></td>
          <td>
            <!--  ...  --></td>
        </tr>
      </tbody>
    </table>
  </text>
  <!--  This illustrates a simple substanceAdministration. In C-CDA this is used for both Immunization and Medication Activity  -->
  <entry>
    <!--  ...  -->
    <substanceAdministration moodCode="EVN" classCode="SBADM">
      <!--  ...  -->
      <!--  Could include code element, although rarely used in substanceAdministration  -->
      <!--  the entire text of the substanceAdministration
           Example, of a medication: 0.3 ML Enoxaparin Sodium 100 MG/ML Prefilled Syringe 100 MG injected DAILY AS DIRECTED. Site: Upper abdomen Quantity: 100 Refills: 5001 Administer one syringe daily for 7 days. Call for signs of bleeding. Ordered: 1-Jan-2013 Primari, Phillip Start: 14-Jul-2014 End: 14-Jul-2014 Reaction: Hives (Moderate), Abdominal pain (Severe), Vomiting (Severe) Indication: DVT Generic substitution allowed. Comment: Patient is having difficulty paying co-pays for this medication
            -->
      <text>
        <reference value="#simpleSubstanceAdministrationFullTextReference1"/>
      </text>
      <consumable>
        <manufacturedProduct classCode="MANU">
          <!--  ...  -->
          <manufacturedMaterial>
            <code displayName="lorem ipsum dolor sit amet"
                  codeSystem="1.2.3.4.5.6.7.8.42" code="89012">
              <originalText>
                <!--  notice this reference is just to a piece of the entire substanceAdministration text, and that the reference text is different than the code @displayName  -->
                <reference
                           value="#substanceAdministrationProductCodeTextReference1"/>
              </originalText>
            </code>
            <name>lorem ipsum</name>
          </manufacturedMaterial>
        </manufacturedProduct>
      </consumable>
      <!--  ...  -->
      <!--  because of the importance of the following entryRelationship, we show actual templateId content for the Medication Free Text SIG and recommend viewing this as a SHOULD  -->
      <entryRelationship typeCode="COMP">
        <substanceAdministration moodCode="INT" classCode="SBADM">
          <templateId root="2.16.840.1.113883.10.20.22.4.147"/>
          <code codeSystem="2.16.840.1.113883.6.1" code="76662-6"/>
          <text>
            <reference value="#substanceAdministrationFreeTextSIGReference1"/>
          </text>
          <consumable>
            <manufacturedProduct>
              <manufacturedLabeledDrug nullFlavor="NA"/>
            </manufacturedProduct>
          </consumable>
        </substanceAdministration>
      </entryRelationship>
    </substanceAdministration>
  </entry>
</section>