CDA Examples
1.0.0 - active United States of America flag

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: Share With Patient or Proxy

Approval Status: Approved
Task Force Approval: 2023-02-16
SDWG Approval: 2023-03-09

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>