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
This is an example of how to mark information in an entry as shareable or not shareable with a patient and/or their proxies. This example uses a Note Activity, but the information below could go inside any entry.
<section xmlns="urn:hl7-org:v3">
<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
<templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01"/>
<code displayName="Relevant diagnostic tests and/or laboratory data"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="30954-2"/>
<title>Results</title>
<text>
<list listType="unordered">
<item>
<caption>HIV 1 and 2 Ab panel - Serum, Plasma or Blood by Rapid immunoassay</caption>
<table>
<thead>
<tr>
<th>Description</th>
<th>Value / Unit</th>
<th>Interpretation</th>
<th>Reference Range</th>
</tr>
</thead>
<tbody>
<tr ID="LabResult1">
<td>HIV 1 Ab [Presence] in Serum, Plasma or Blood by Rapid immunoassay</td>
<td>Reactive</td>
<td>Abnormal</td>
<td>Reference (Normal) for this test is not detected</td>
</tr>
</tbody>
</table>
<br/>
<table>
<caption>Disclosure Details</caption>
<thead>
<tr>
<th>Subject</th>
<th>Information safe to disclose?</th>
<th>Effective Until</th>
</tr>
</thead>
<tbody>
<tr ID="DisclosureDetails1">
<td>Patient</td>
<td>No</td>
<td>01/29/2023 12:00 PM CST</td>
</tr>
<tr ID="DisclosureDetails2">
<td>Proxies</td>
<td>Not without patient authorization</td>
<td>Indefinite</td>
</tr>
</tbody>
</table>
</item>
</list>
</text>
<entry>
<organizer moodCode="EVN" classCode="BATTERY">
<templateId root="2.16.840.1.113883.10.20.22.4.1"/>
<templateId root="2.16.840.1.113883.10.20.22.4.1"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.1"
extension="2023-05-01"/>
<id root="b4a47651-8375-44f8-89fd-0261a72a0698"/>
<code
displayName="HIV 1 and 2 Ab panel - Serum, Plasma or Blood by Rapid immunoassay" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
code="89365-1"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="20200322142600-0500"/>
<high value="20200322142600-0500"/>
</effectiveTime>
<component>
<observation moodCode="EVN" classCode="OBS">
<!-- Positive HIV result... -->
<templateId root="2.16.840.1.113883.10.20.22.4.2"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.2"
extension="2023-05-01"/>
<id root="c1a2b3c4-d5e6-7890-abcd-ef1234567890"/>
<code xsi:type="CD"
displayName="HIV 1+2 Ab+HIV1 p24 Ag [Presence] in Serum or Plasma by Immunoassay" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
code="56888-1"/>
<statusCode code="completed"/>
<effectiveTime value="20200322142600-0500"/>
<value xsi:type="CE" displayName="Positive"
codeSystem="2.16.840.1.113883.6.1" code="LA6576-8"/>
<interpretationCode displayName="Abnormal"
codeSystem="2.16.840.1.113883.5.83" code="A"/>
</observation>
</component>
<component>
<!-- Don't share with patient until 12:00 PM on 2023-01-29 -->
<observation moodCode="EVN" classCode="OBS">
<!-- Security Observation -->
<templateId root="2.16.840.1.113883.3.445.21"/>
<!-- Refrain Policy Code template -->
<templateId root="2.16.840.1.113883.3.445.23"/>
<code xsi:type="CD" displayName="Security Classification"
codeSystemName="HL7 SecurityObservationTypeCodeSystem" codeSystem="2.16.840.1.113883.1.11.20457" code="SECCONOBS"/>
<text xsi:type="ED">
<reference value="#DisclosureDetails1"/>
</text>
<effectiveTime>
<!-- Instant result was finalized -->
<low value="20230125120924-0600"/>
<!-- Instant result can be shared -->
<high value="20230129120000-0600"/>
</effectiveTime>
<value xsi:type="CE"
displayName="no disclosure to patient, family or caregivers without attending provider's authorization" codeSystemName="SecurityObservationValueCodeSystem"
codeSystem="2.16.840.1.113883.5.1063" code="NOPAT"/>
</observation>
</component>
<component>
<!-- Share with patient, but hide from their proxies indefinitely -->
<observation moodCode="EVN" classCode="OBS">
<!-- Security Observation -->
<templateId root="2.16.840.1.113883.3.445.21"/>
<!-- Refrain Policy Code template -->
<templateId root="2.16.840.1.113883.3.445.23"/>
<code xsi:type="CD" displayName="Security Classification"
codeSystemName="HL7 SecurityObservationTypeCodeSystem" codeSystem="2.16.840.1.113883.1.11.20457" code="SECCONOBS"/>
<text xsi:type="ED">
<reference value="#DisclosureDetails2"/>
</text>
<!-- This one applies indefinitely -->
<effectiveTime>
<low value="20230125120924-0600"/>
</effectiveTime>
<!-- Don't share it with anyone but the patient -->
<value xsi:type="CE"
displayName="no disclosure without subject authorization" codeSystemName="SecurityObservationValueCodeSystem"
codeSystem="2.16.840.1.113883.5.1063" code="NOAUTH"/>
</observation>
</component>
</organizer>
</entry>
</section>