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: Medication Every 4-6 Hours

Approval Status: Approved
Task Force Approval: 2014-01-30
SDWG Approval: 2014-02-06, 2016-12-01

This is an example of a medication (Sudafed) which to be administered every 4-6 hours, a common dosing pattern. Representing the range of potential of hours is done through a low and high child element of the period within effectiveTime of PIVL_TS.

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"/>
  <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_1">
          <td>
            <content ID="MedicationName_1">Sudafed 30mg Oral Tablet</content>
          </td>
          <td>
            <content>take 2 tablets every 4-6 hours</content>
          </td>
          <td>
            <content>30 MG</content>
          </td>
          <td>Jan-18-2014 - </td>
          <td>Active</td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry typeCode="DRIV">
    <substanceAdministration moodCode="INT" classCode="SBADM">
      <!--  This medication use case is a medication to be administered. If it has been already administered use moodCode = "EVN". If an ordered drug then use moodCode = "RQO"  -->
      <!--  Dependencies exist between moodCode, statusCode and effectiveTime   -->
      <templateId root="2.16.840.1.113883.10.20.22.4.16"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.16"
                  extension="2014-06-09"/>
      <id root="36edd5f0-0b15-49f6-a395-7752b4f18b77"/>
      <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 prescribed on January 18, 2014 (not known to have stopped) -->
      <effectiveTime xsi:type="IVL_TS">
        <low value="20140118"/>
        <high nullFlavor="NI"/>
      </effectiveTime>
      <!--  This second effectiveTime represents every 4-6 hours from medication sig.  -->
      <!--  InstituionSpecified = "false" is implied in ths omission of this attribute and means that it must be administered exactly once per day -->
      <!--  InstituionSpecified = "true"which is not default would mean that receiving institution has flexibility in dosing schedule -->
      <!--  Operator "A" means that this timing information is in addition to previous effectiveTime information provided -->
      <effectiveTime xsi:type="PIVL_TS" operator="A">
        <period>
          <low value="4" unit="h"/>
          <high value="6" unit="h"/>
        </period>
      </effectiveTime>
      <routeCode displayName="Oral Route of Administration"
                 codeSystemName="NCI Thesaurus" codeSystem="2.16.840.1.113883.3.26.1.1" code="C38288"/>
      <!--  This relates directly to the code used for medication. Since it's a tablet, then only specified needed in dose is 2x per administration -->
      <doseQuantity value="2"/>
      <consumable>
        <manufacturedProduct classCode="MANU">
          <!--  ** Medication information **  -->
          <templateId root="2.16.840.1.113883.10.20.22.4.23"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.23"
                      extension="2014-06-09"/>
          <id root="0be61984-eaa5-46b3-b75b-1d1ba28b5fff"/>
          <manufacturedMaterial>
            <!--  Medications should be specified at a level corresponding to prescription when possible, such as 30mg oral tablet (branded) -->
            <code
                  displayName="pseudoephedrine hydrochloride 30 MG Oral Tablet [Sudafed]" codeSystemName="RxNorm"
                  codeSystem="2.16.840.1.113883.6.88" code="1049529">
              <originalText>
                <reference value="#MedicationName_1"/>
              </originalText>
            </code>
          </manufacturedMaterial>
        </manufacturedProduct>
      </consumable>
      <author>
        <!--  Time the author noted that patient is on medication  -->
        <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
        <time value="20140118"/>
        <assignedAuthor>
          <id root="2.16.840.1.113883.4.6" extension="66666"/>
          <code
                displayName="Allopathic &amp; Osteopathic Physicians; Internal Medicine, Cardiovascular Disease" codeSystemName="NUCC" codeSystem="2.16.840.1.113883.6.101"
                code="207RC0000X"/>
          <addr>
            <streetAddressLine>6666 StreetName St.</streetAddressLine>
            <city>Silver Spring</city>
            <state>MD</state>
            <postalCode>20901</postalCode>
            <country>US</country>
          </addr>
          <telecom value="tel:+1(301)666-6666" use="WP"/>
          <assignedPerson>
            <name>
              <given>Heartly</given>
              <family>Sixer</family>
              <suffix>MD</suffix>
            </name>
          </assignedPerson>
        </assignedAuthor>
      </author>
    </substanceAdministration>
  </entry>
</section>