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: Immunization not given Patient refused

Approval Status: Approved
Task Force Approval: 2015-10-29
SDWG Approval: 2015-11-12, 2016-12-01

This is an example of how an author can record a patient refused an immunization.

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <!--  conforms to Immunizations section with entries optional  -->
  <templateId root="2.16.840.1.113883.10.20.22.2.2"/>
  <templateId root="2.16.840.1.113883.10.20.22.2.2" extension="2015-08-01"/>
  <!--  Immunizations section with entries required  -->
  <templateId root="2.16.840.1.113883.10.20.22.2.2.1"/>
  <templateId root="2.16.840.1.113883.10.20.22.2.2.1" extension="2015-08-01"/>
  <code displayName="History of Immunizations" codeSystemName="LOINC"
        codeSystem="2.16.840.1.113883.6.1" code="11369-6"/>
  <title>Immunizations</title>
  <text>
    <paragraph ID="immun1">Patient objected to 
      <content ID="ImmunizationProduct_1">influenza, intradermal, quadrivalent</content> on 11/15/2015
    </paragraph>
  </text>
  <entry typeCode="COMP">
    <!--  negationInd=true indicates substance was NOT given at this date -->
    <substanceAdministration negationInd="true" moodCode="EVN"
                             classCode="SBADM">
      <!--  ** Immunization activity **  -->
      <templateId root="2.16.840.1.113883.10.20.22.4.52"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.52"
                  extension="2015-08-01"/>
      <id root="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92"/>
      <text>
        <reference value="#immun1"/>
      </text>
      <!--  Indicates the status of the substanceAdministartion  -->
      <statusCode code="completed"/>
      <effectiveTime xsi:type="SXCM-TS" value="20151115"/>
      <consumable>
        <!--  Optional manufacturerOrganization
               <manufacturerOrganization>
                 <name>Health LS - Immuno Inc.</name>
               </manufacturerOrganization> -->
        <manufacturedProduct classCode="MANU">
          <!--  ** Immunization medication information **  -->
          <templateId root="2.16.840.1.113883.10.20.22.4.54"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.54"
                      extension="2014-06-09"/>
          <!--  DSTU comment relaxing lotNumber requirement  -->
          <!--  http://www.hl7.org/dstucomments/showdetail_comment.cfm?commentid=995  -->
          <!--  <lotNumberText>1</lotNumberText>  -->
          <manufacturedMaterial>
            <code
                  displayName="influenza, intradermal, quadrivalent, preservative free, injectable" codeSystemName="CVX" codeSystem="2.16.840.1.113883.12.292"
                  code="166">
              <originalText>
                <reference value="#ImmunizationProduct_1"/>
              </originalText>
            </code>
          </manufacturedMaterial>
        </manufacturedProduct>
      </consumable>
      <entryRelationship typeCode="RSON">
        <observation moodCode="EVN" classCode="OBS">
          <!--  Immunization Refusal Reason   -->
          <!--  Included the reason since it may be relevant to a future clinician or quality measurement  -->
          <templateId root="2.16.840.1.113883.10.20.22.4.53"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.53"
                      extension="2024-05-01"/>
          <!--  C-CDA 3.0  -->
          <id root="c1296315-9a6d-45a2-aac0-ee225d375409"/>
          <code xsi:type="CD" displayName="Immunization Refusal Reason"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="71798-3"/>
          <value xsi:type="CD" displayName="patient objection"
                 codeSystemName="HL7 ActNoImmunizationReason" codeSystem="2.16.840.1.113883.5.8" code="PATOBJ"/>
          <statusCode code="completed"/>
        </observation>
      </entryRelationship>
    </substanceAdministration>
  </entry>
</section>