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 link a concern to a problem in the problem list section with linkHTML.
This file includes examples of the following templates:
<structuredBody xmlns="urn:hl7-org:v3">
<component>
<section>
<!-- Health Concerns Section (V2) -->
<templateId root="2.16.840.1.113883.10.20.22.2.58"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.58"/>
<code displayName="Health Concerns Document" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="75310-3"/>
<title>Health Concerns Section</title>
<text>
<table width="100%" border="1">
<thead>
<tr>
<th>Health Concern</th>
<th>Date</th>
<th>Related Problem</th>
</tr>
</thead>
<tbody>
<tr ID="Concern1">
<td ID="Concern1Issue1">Patient is concerned about being contagious and infecting roommate.</td>
<td>Concern from 03/02/2014</td>
<!-- Providing this as a link to the related problem in problem list is an option using base CDA implementation guidance. -->
<td>
<!-- Temp removal until IG Publisher fixed <linkHtml href="#Problem1">Community Acquired Pneumonia</linkHtml> --></td>
</tr>
</tbody>
</table>
</text>
<entry>
<!-- Health Concern Act -->
<act moodCode="EVN" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.132"
extension="2022-06-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.132"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.132"/>
<id root="63c5e137-3024-46cc-951f-885ec69d9030"/>
<code displayName="Health Concern" codeSystemName="LOINC"
codeSystem="2.16.840.1.113883.6.1" code="75310-3"/>
<text>
<reference value="#Concern1"/>
</text>
<!-- This Health Concern has a statusCode of active because it is an active concern -->
<statusCode code="active"/>
<!-- The effective time is the date that the Health Concern started being followed -
this does not necessarily correlate to the onset date of the contained health issues -->
<effectiveTime value="20140302"/>
<entryRelationship typeCode="REFR">
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2024-05-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="59c5ca3e-662f-4e33-943f-2777ebc6227e"/>
<code xsi:type="CD" displayName="Problem"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="55607006">
<translation xsi:type="CD" displayName="Problem"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
code="75326-9"/>
</code>
<text xsi:type="ED">
<reference value="#Concern1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20140302"/>
</effectiveTime>
<value xsi:type="CD" nullFlavor="OTH">
<originalText>
<reference value="#Concern1Issue1"/>
</originalText>
</value>
</observation>
</entryRelationship>
<!-- Health Concern Problem: Community Acquired Pneumonia -->
<!-- This Entry Reference refers to a problem observation present in Problem List that the Health Concern is related to -->
<entryRelationship typeCode="REFR">
<act moodCode="EVN" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.122"/>
<!-- This ID equals the ID of the Community Acquired Pneumonia problem -->
<id root="49c5ca3e-662f-4e33-948f-2777ebc6727e"/>
<!-- The code is nulled to "NP" Not Present" -->
<code nullFlavor="NP"/>
<statusCode code="completed"/>
</act>
</entryRelationship>
</act>
</entry>
</section>
</component>
<component>
<section>
<!-- Located elsewhere in the document -->
<!-- Taken directly (changed observation/id) from prior example https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Problem_List_Active_Problem.xml -->
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
<code displayName="Problem List" codeSystem="2.16.840.1.113883.6.1"
code="11450-4"/>
<title>Problem List</title>
<text>
<table>
<thead>
<tr>
<th>Name</th>
<th>Dates</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr ID="Problem1">
<td>Community Acquired Pneumonia</td>
<td>
<content>Onset: 02/27/2014</content>
</td>
<td>Active</td>
</tr>
</tbody>
</table>
</text>
<entry>
<act moodCode="EVN" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.3"
extension="2024-05-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.3"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
<id root="102ca2e9-884c-4523-a2b4-1b6c3469c397"/>
<code codeSystem="2.16.840.1.113883.5.6" code="CONC"/>
<text>
<reference value="#Problem1"/>
</text>
<!-- Since this is an active problem, the concern status is active. -->
<!-- While clinicians can track resolved problems, generally active problems will have active concern status and resolved concerns will be completed -->
<statusCode code="active"/>
<effectiveTime>
<!-- This equates to the time the concern was authored in the patient's chart. This may frequently be an EHR timestamp -->
<low value="20140302124536-0500"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2024-05-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="49c5ca3e-662f-4e33-948f-2777ebc6727e"/>
<code xsi:type="CD" displayName="Problem"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="55607006">
<translation xsi:type="CD" displayName="Problem"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
code="75326-9"/>
</code>
<text xsi:type="ED">
<reference value="#Problem1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<!-- This represents the date of biological onset. -->
<low value="20140227"/>
</effectiveTime>
<!-- This is a SNOMED code as the primary vocabulary for problem lists -->
<value xsi:type="CD"
displayName="Community acquired pneumonia" codeSystemName="SNOMED CT"
codeSystem="2.16.840.1.113883.6.96" code="385093006"/>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
</structuredBody>