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: Unknown Immunization Status

Approval Status: Approved
Task Force Approval: 2013-11-21
SDWG Approval: 2013-12-05, 2016-12-01

This is an example of how an author can record they do now know whether the patient has received any vaccinations.

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>
    <table width="100%" border="1">
      <thead>
        <tr>
          <th>Vaccine</th>
          <th>Date</th>
          <th>Status</th>
        </tr>
      </thead>
      <tbody>
        <tr ID="immun1">
          <td> Unknown Immunization  Status</td>
          <td>Nov 1999</td>
          <td>Completed</td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry>
    <substanceAdministration nullFlavor="NI" negationInd="false"
                             moodCode="EVN" classCode="SBADM">
      <!--   We selected NI for this example, C-CDA R2 may describe other appropriate nullFlavors  -->
      <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"/>
      <!--   ****   Immunization activity template  ****  -->
      <id root="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f88"/>
      <!--  No information on whether the patient received a vaccination  -->
      <text>
        <reference value="#immun1"/>
      </text>
      <!--  Link to narrative stating no information on whether the patient received a vaccination  -->
      <statusCode code="completed"/>
      <effectiveTime xsi:type="SXCM-TS" value="199911"/>
      <!--  Date which you do not know whether or not patient received a vaccination  -->
      <consumable>
        <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>
            <!--  Needed to use nullFlavor of OTH since templates requires CVX in code element -->
            <code nullFlavor="OTH">
              <!--  Optional original text  -->
              <originalText>Vaccination</originalText>
              <translation xsi:type="CD" displayName="vaccine"
                           codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96"
                           code="787859002"/>
            </code>
          </manufacturedMaterial>
        </manufacturedProduct>
      </consumable>
    </substanceAdministration>
  </entry>
</section>