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: Med at bedtime

Approval Status: Approved
Task Force Approval: 2017-02-16
SDWG Approval: 2017-05-18

This is an example of having a medication with event timing (take at bedtime or at the "hour of sleep" (HS))

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>Instructions</th>
          <th>Dosage</th>
          <th>Effective Dates (start - stop)</th>
          <th>Status</th>
        </tr>
      </thead>
      <tbody>
        <tr ID="Medication_6">
          <td>
            <content ID="MedicationName_6">3 ML Insulin Glargine 100 UNT/ML Pen Injector [Lantus]</content>
          </td>
          <td>
            <content ID="MedicationSig_6">Administer 40 units at bedtime</content>
          </td>
          <td>
            <content>40 units</content>
          </td>
          <td>Jan-09-2009 - </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_6"/>
      </text>
      <statusCode code="active"/>
      <!--  This first effectiveTime shows that medication was added on January 9, 2009 (not known to have stopped) -->
      <effectiveTime xsi:type="IVL_TS">
        <low value="20090109"/>
        <high nullFlavor="NI"/>
      </effectiveTime>
      <!--  The second effectiveTime specifies dose frequency, which can be either a period (PIVL_TS) or event (EIVL_TS).  -->
      <!--  This long-lasting insulin is administered once per day before bedtime (code = "HS", hour of sleep), which is an event -->
      <effectiveTime xsi:type="EIVL_TS" operator="A">
        <event code="HS"/>
      </effectiveTime>
      <!--  This route uses the NCI (National Cancer Institute) Thesauraus code system, which is constrained to the value set of 2.16.840.1.113883.3.88.12.3221.8.7 (FDA Medication Route)  -->
      <routeCode displayName="Subcutaneous Route of Administration"
                 codeSystemName="NCI Thesaurus" codeSystem="2.16.840.1.113883.3.26.1.1" code="C38299"/>
      <!--  Since this dose is not pre-coordinated, specify both the amount with units in UCUM. [IU] is international units  -->
      <!--  Note that this basal insulin is not administered on a sliding scale and a specific dose is administered -->
      <doseQuantity value="40" unit="[IU]"/>
      <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 (branded medication below) -->
            <!--  Note the medication code specified in the test data is 261551, but that is not used since it's not an administered product (just brand name) -->
            <code
                  displayName="3 ML insulin glargine 100 UNT/ML Pen Injector [Lantus]" codeSystemName="RxNorm"
                  codeSystem="2.16.840.1.113883.6.88" code="847232">
              <originalText>
                <reference value="#MedicationName_6"/>
              </originalText>
            </code>
          </manufacturedMaterial>
          <manufacturerOrganization>
            <name>SANOFI-AVENTIS</name>
          </manufacturerOrganization>
        </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_6"/>
          </text>
          <consumable>
            <manufacturedProduct>
              <manufacturedLabeledDrug nullFlavor="NA"/>
            </manufacturedProduct>
          </consumable>
        </substanceAdministration>
      </entryRelationship>
    </substanceAdministration>
  </entry>
</section>