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: Free Text Medication SIG

Approval Status: Approved
Task Force Approval: 2018-11-01
SDWG Approval: 2019-06-27

This is an example of having a medication with only a free text SIG when you have no other coded information.

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <templateId root="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09"/>
  <!--  Medication Section (entries required)  -->
  <code displayName="History of Medication Use" codeSystemName="LOINC"
        codeSystem="2.16.840.1.113883.6.1" code="10160-0"/>
  <title>MEDICATIONS</title>
  <text>
    <table width="100%" border="1">
      <thead>
        <tr>
          <th>Medication</th>
          <th>Date</th>
          <th>Status</th>
        </tr>
      </thead>
      <tbody>
        <tr ID="Medication_1">
          <td>
            <!--  This shouldn't be used if a medication substance can be coded  -->
            <content ID="MedicationSIG">Experimental '150 cure-all drug', take one tab by mouth every morning</content>
          </td>
          <td>Jan 10 2018</td>
          <td>Active</td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry typeCode="DRIV">
    <substanceAdministration moodCode="EVN" classCode="SBADM">
      <templateId root="2.16.840.1.113883.10.20.22.4.16"
                  extension="2014-06-09"/>
      <id root="1310a2d3-f888-4722-b4c4-a3c5911ac7f9"/>
      <text>
        <!--  This reference refers to medication information in unstructured portion of section -->
        <reference value="#Medication_1"/>
      </text>
      <statusCode code="active"/>
      <!--  This first effectiveTime shows that medication was added on January 10, 2018 (not known to have stopped) -->
      <effectiveTime xsi:type="IVL_TS">
        <low value="20180110"/>
        <high nullFlavor="NI"/>
      </effectiveTime>
      <doseQuantity nullFlavor="UNK"/>
      <consumable typeCode="CSM">
        <manufacturedProduct classCode="MANU">
          <!--  ** Medication information **  -->
          <templateId root="2.16.840.1.113883.10.20.22.4.23"
                      extension="2014-06-09"/>
          <manufacturedMaterial>
            <!--  Medications should be specified at a level corresponding to prescription when possible - coded information isn't available  -->
            <code nullFlavor="UNK"/>
          </manufacturedMaterial>
        </manufacturedProduct>
      </consumable>
      <entryRelationship typeCode="COMP">
        <substanceAdministration moodCode="EVN" classCode="SBADM">
          <templateId root="2.16.840.1.113883.10.20.22.4.147"/>
          <code displayName="Medication Instructions" codeSystemName="LOINC"
                codeSystem="2.16.840.1.113883.6.1" code="76662-6"/>
          <text>
            <!--  Reference into the section.text to a tag that ONLY contains free text SIG  -->
            <reference value="#MedicationSIG"/>
          </text>
          <consumable>
            <manufacturedProduct>
              <manufacturedLabeledDrug nullFlavor="NA"/>
            </manufacturedProduct>
          </consumable>
        </substanceAdministration>
      </entryRelationship>
    </substanceAdministration>
  </entry>
</section>