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
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 & 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>