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: SDOH Goal

Approval Status: Approved
Task Force Approval: 2024-04-04
SDWG Approval: 2024-04-04

This is an example of how to send a goals section with a coded Goal using ICD10.

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <!--  Goals Section  -->
  <templateId root="2.16.840.1.113883.10.20.22.2.60"/>
  <code displayName="Goals" codeSystemName="LOINC"
        codeSystem="2.16.840.1.113883.6.1" code="61146-7"/>
  <title>Goals Section</title>
  <text>
    <paragraph ID="goal1">Goal set to establish stable housing.</paragraph>
  </text>
  <entry>
    <observation moodCode="GOL" classCode="OBS">
      <!--   <templateId root="2.16.840.1.113883.10.20.22.4.121"/> Validator complains when I include both -->
      <templateId root="2.16.840.1.113883.10.20.22.4.121"
                  extension="2022-06-01"/>
      <id root="1.2.840.114350.1.13.6289.1.7.2.737179" extension="3241"/>
      <code xsi:type="CD" displayName="History of Social function"
            codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="8689-2"/>
      <text xsi:type="ED">
        <reference value="#goal1"/>
      </text>
      <statusCode code="active"/>
      <effectiveTime>
        <!--  The effectiveTime/low indicates starting line for the goal  -->
        <low value="20220813"/>
        <!--  The effectiveTime/high indicates "Achieve by" date or "expiration date"  -->
        <high nullFlavor="NI"/>
      </effectiveTime>
      <value xsi:type="CD" displayName="Housing adequate"
             codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="161036002"/>
      <!--  To link to an ICD concept, it's recommended to include an entryRelationship RSON to the Problem or Health concern -->
      <!--  Alternatively the Reason template can be used  -->
      <!--  If the author is the recordTarget (patient), this is a patient goal. If the author is a provider,
           this is a provider goal. If both patient and provider are authors, this is a negotiated goal.
           If no author is present, it is assumed the document or section author(s) is the author of this goal.  -->
      <author>
        <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
        <time value="20220813124536-0500"/>
        <assignedAuthor>
          <id root="2.16.840.1.113883.4.6" extension="66666"/>
          <code
                displayName="Allopathic &amp; Osteopathic Physicians; Internal Medicine, Cardiovascular Disease" codeSystemName="NUCC" codeSystem="2.16.840.1.113883.6.101"
                code="207RC0000X"/>
          <addr>
            <streetAddressLine>6666 StreetName St.</streetAddressLine>
            <city>Silver Spring</city>
            <state>MD</state>
            <postalCode>20901</postalCode>
            <country>US</country>
          </addr>
          <telecom value="tel:+1(301)666-6666" use="WP"/>
          <assignedPerson>
            <name>
              <given>Heartly</given>
              <family>Sixer</family>
              <suffix>MD</suffix>
            </name>
          </assignedPerson>
        </assignedAuthor>
      </author>
      <!--  Embedded Reason template with ICD  -->
      <entryRelationship typeCode="RSON">
        <observation moodCode="EVN" classCode="OBS">
          <!--  Reason (V2)  -->
          <templateId root="2.16.840.1.113883.10.20.24.3.88"
                      extension="2023-05-01"/>
          <id root="3fbadea2-c481-4784-b972-3a571aae31c7"/>
          <code xsi:type="CD"
                displayName="Reason care action performed or not" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
                code="77301-0"/>
          <statusCode code="completed"/>
          <effectiveTime>
            <low value="20220813"/>
          </effectiveTime>
          <value xsi:type="CD" displayName="Inadequate Housing"
                 codeSystemName="ICD-10-CM" codeSystem="2.16.840.1.113883.6.90" code="Z59.1"/>
        </observation>
      </entryRelationship>
    </observation>
  </entry>
</section>