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 oral QID with PRN

Approval Status: Approved
Task Force Approval: 2014-01-09
SDWG Approval: 2014-01-16, 2016-12-01

This is an example of a medication which is QID and PRN (as needed) but with no precondition specified. It was generated based on SDWG list-serv discussion in December 2013. It also demonstrated a pre-coordinated generic medication coded at the SDC level (generic 600mg Oral Tablet) in RxNorm hierarchy.

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_0">
          <td>
            <content ID="MedicationName_0">Ibuprofen 600mg Oral Tablet</content>
          </td>
          <td>
            <content>take 1 tablet QID PRN</content>
          </td>
          <td>
            <content>600 MG</content>
          </td>
          <td>Dec-18-2013 - </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="47d3e719-f688-459d-bcdc-47c6de0767a9"/>
      <text>
        <!--  This reference refers to medication information in unstructured portion of section -->
        <reference value="#Medication_0"/>
      </text>
      <statusCode code="active"/>
      <!--  This first effectiveTime shows that medication was added on December 18, 2013 (not known to have stopped) -->
      <effectiveTime xsi:type="IVL_TS">
        <low value="20131218"/>
        <high nullFlavor="NI"/>
      </effectiveTime>
      <!--  This second effectiveTime represents QID from medication sig.  -->
      <!--  InstituionSpecified = "true" means that it can be given 4 times per day but need not be exactly timed to every 6 hours -->
      <!--  InstituionSpecified = "false" would mean that timing needs to be administered exactly as structured -->
      <!--  Operator "A" means that this timing information is in addition to previous effectiveTime information provided -->
      <effectiveTime xsi:type="PIVL_TS" operator="A"
                     institutionSpecified="true">
        <period value="6" unit="h"/>
      </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 1x per administration -->
      <doseQuantity value="1"/>
      <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="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
          <manufacturedMaterial>
            <!--  Medications should be specified at a level corresponding to prescription when possible, such as 600mg oral tablet (non-branded) -->
            <code displayName="ibuprofen 600 MG Oral Tablet"
                  codeSystemName="RxNorm" codeSystem="2.16.840.1.113883.6.88" code="197806">
              <originalText>
                <reference value="#MedicationName_0"/>
              </originalText>
              <translation xsi:type="CD"
                           displayName="Ibuprofen 600mg Oral Tablet" codeSystemName="NDC"
                           codeSystem="2.16.840.1.113883.6.69" code="00603402221"/>
            </code>
          </manufacturedMaterial>
        </manufacturedProduct>
      </consumable>
      <author>
        <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
        <!--  Time the author noted that patient is on no medications  -->
        <time value="20131218"/>
        <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>
      <precondition typeCode="PRCN">
        <criterion>
          <!--  ** Precondition for substance administration **  -->
          <templateId root="2.16.840.1.113883.10.20.22.4.25"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.25"
                      extension="2014-06-09"/>
          <code codeSystem="2.16.840.1.113883.5.4" code="ASSERTION"/>
          <!--  If a precondition were specified in medication sig, you would include code here. Include nullFlavor="NI" when PRN specified but without precondition -->
          <value xsi:type="CD" nullFlavor="NI"/>
        </criterion>
      </precondition>
    </substanceAdministration>
  </entry>
</section>