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: Influenza Vaccination - Patient Reported

Approval Status: Approved
Task Force Approval: 2022-07-28
SDWG Approval: 2023-03-09

This example illustrates how to structure Immunizations when it’s reported by a patient

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <!--  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>
    <content ID="immunSect"/>
    <table width="100%" border="1">
      <thead>
        <tr>
          <th>Vaccine</th>
          <th>Lot Number</th>
          <th>Date</th>
          <th>Status</th>
          <th>Source</th>
        </tr>
      </thead>
      <tbody>
        <tr ID="immun1">
          <td ID="ImmunizationProduct_100">Influenza Virus Vaccine</td>
          <td>1</td>
          <td>8/15/2010</td>
          <td>Completed</td>
          <td>Patient Reported</td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry typeCode="DRIV">
    <substanceAdministration negationInd="false" 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="3b3e2533-46aa-4e3f-b675-12ac6749cdcd"/>
      <text>
        <reference value="#immun1"/>
      </text>
      <!--  Indicates the status of the substanceAdministartion  -->
      <statusCode code="completed"/>
      <effectiveTime xsi:type="SXCM-TS" value="20100815"/>
      <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"/>
          <manufacturedMaterial>
            <code
                  displayName="influenza virus vaccine, unspecified formulation" codeSystemName="CVX" codeSystem="2.16.840.1.113883.12.292"
                  code="88">
              <originalText>
                <reference value="#ImmunizationProduct_100"/>
              </originalText>
            </code>
            <lotNumberText>1</lotNumberText>
          </manufacturedMaterial>
        </manufacturedProduct>
      </consumable>
      <!--  Optional Author  -->
      <author>
        <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
        <!--  Provenance - Author Participation  -->
        <templateId root="2.16.840.1.113883.10.20.22.5.6"
                    extension="2019-10-01"/>
        <time value="20100815"/>
        <assignedAuthor>
          <!--  NPI of Author (example)  -->
          <id root="2.16.840.1.113883.4.6" extension="9911223334"/>
          <code displayName="Family Medicine Physician"
                codeSystemName="Health Care Provider Taxonomy" codeSystem="2.16.840.1.113883.6.101" code="207Q00000X"/>
          <addr nullFlavor="UNK"/>
          <telecom value="tel:555-555-1002" use="WP"/>
          <assignedPerson>
            <name>
              <given>Henry</given>
              <family>Seven</family>
            </name>
          </assignedPerson>
          <representedOrganization>
            <id root="2.16.840.1.113883.19.5.9999.1394"/>
            <!--  Tax ID Required Identifier -->
            <id root="2.16.840.1.113883.4.2" nullFlavor="UNK"/>
            <!--  NPI Required Identifier -->
            <id root="2.16.840.1.113883.4.6" nullFlavor="UNK"/>
            <name>Good Health Clinic</name>
            <telecom nullFlavor="UNK"/>
            <addr nullFlavor="UNK"/>
          </representedOrganization>
        </assignedAuthor>
      </author>
      <informant>
        <assignedEntity>
          <!--  This is a fictional OID and identifier for the patient. This should be adapted to local implementation  -->
          <id root="2.16.840.1.113883.3.3208.101.2"
              extension="20130607100800-Patient2"/>
          <addr use="HP">
            <streetAddressLine>1111 StreetName St.</streetAddressLine>
            <city>Silver Spring</city>
            <state>MD</state>
            <postalCode>20901</postalCode>
            <country>US</country>
          </addr>
          <telecom value="tel:+1(301)111-1111" use="HP"/>
          <assignedPerson>
            <name>
              <given>Patient</given>
              <family>One</family>
            </name>
          </assignedPerson>
        </assignedEntity>
      </informant>
    </substanceAdministration>
  </entry>
</section>