CDA Examples
1.0.0 - active
CDA Examples
1.0.0 - active
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 administered orally with a PRN coded precondition, instructions (not PRN), and indications (not PRN).
This file includes examples of the following templates:
<!-- These examples illustrate multiple ways that a medication can be prescribed for pain
These examples are meant to illustrate for comparison purposes only!
DO NOT COPY as an example of a Medication Section. These would not appear together in one patient document.
Summary of examples:
1. PRN with a coded precondition
Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours as needed for joint pain
2. Instructions; similar to above but NOT a PRN
Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours. Do not take on an empty stomach.
3. Indication; again, NOT a PRN -
Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours for joint pain -->
<section xmlns="urn:hl7-org:v3">
<!-- Medication Section (entries required) (V2) -->
<templateId root="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
<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_PRN_222222">
<td>
<content ID="MedicationName_PRN_222222">Ibuprofen 600mg Oral Tablet</content>
</td>
<td>
<content ID="MedicationSig_PRN_222222">take 1 tablet Every 6 Hours PRN for joint pain</content>
</td>
<td>600 MG</td>
<td>Mar-10-2013 - </td>
<td>Active</td>
</tr>
<tr ID="Medication_42424242">
<td>
<content ID="MedicationName_42424242">Ibuprofen 600mg Oral Tablet</content>
</td>
<td>
<content ID="MedicationSig_42424242">Take 1 tablet Every 6 Hours.
<content ID="MedicationInstruction_42424242">Do not take on an empty stomach.</content>
</content>
</td>
<td>600 MG</td>
<td>Mar-10-2013 - </td>
<td>Active</td>
</tr>
<tr ID="Medication_84838281">
<td>
<content ID="MedicationName_84838281">Ibuprofen 600mg Oral Tablet</content>
</td>
<td>
<content ID="MedicationSig_84838281">take 1 tablet Every 6 Hours for
<content ID="MedicationIndication_84838281">joint pain</content>
</content>
</td>
<td>600 MG</td>
<td>Mar-10-2013 - </td>
<td>Active</td>
</tr>
</tbody>
</table>
</text>
<!-- 1. PRN with a coded precondition - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours PRN for joint pain
compare to "Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours PRN"
coded here as an precondition with a code
note the following wording would be coded the same way, with a coded precondition:
Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours as needed for joint pain -->
<entry>
<substanceAdministration moodCode="EVN" classCode="SBADM">
<!-- Medication Activity (V2) -->
<templateId root="2.16.840.1.113883.10.20.22.4.16"
extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="1.3.6.1.4.1.22812.3.99930.3.4.9" extension="300035"/>
<id root="1.3.6.1.4.1.22812.3.99930.3.4.9" extension="300013"/>
<text>
<reference value="#Medication_PRN_222222"/>
</text>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20130310"/>
<high nullFlavor="NI"/>
</effectiveTime>
<!--
institutionSpecified="true" for a PRN medication
See http://hl7-c-cda-examples.herokuapp.com/examples/22 or https://docs.google.com/document/d/1Y0Z458o_MrR2aPnpx6EygO6hpI88Bl95esjRWZ0agtY/edit
-->
<effectiveTime xsi:type="PIVL_TS" operator="A"
institutionSpecified="true">
<period value="6" unit="h"/>
</effectiveTime>
<doseQuantity value="1"/>
<consumable typeCode="CSM">
<manufacturedProduct classCode="MANU">
<!-- Medication Information (V2) -->
<templateId root="2.16.840.1.113883.10.20.22.4.23"
extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code displayName="ibuprofen 600 MG Oral Tablet"
codeSystemName="RxNorm" codeSystem="2.16.840.1.113883.6.88" code="197806">
<originalText>
<reference value="#MedicationName_PRN_222222"/>
</originalText>
<translation xsi:type="CD"
displayName="Ibuprofen 600mg Oral Tablet" codeSystemName="NDC"
codeSystem="2.16.840.1.113883.6.69" code="00603402221"/>
</code>
<name>Ibuprofen</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<entryRelationship typeCode="COMP">
<!-- Medication Free Text SIG -->
<substanceAdministration moodCode="INT" classCode="SBADM">
<templateId root="2.16.840.1.113883.10.20.22.4.147"/>
<code codeSystem="2.16.840.1.113883.6.1" code="76662-6"/>
<text>
<reference value="#MedicationSig_PRN_222222"/>
</text>
<consumable>
<manufacturedProduct>
<manufacturedLabeledDrug nullFlavor="NA"/>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entryRelationship>
<precondition typeCode="PRCN">
<criterion>
<!-- ** Precondition for substance administration (V2) -->
<templateId root="2.16.840.1.113883.10.20.22.4.25"
extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.25"/>
<code codeSystem="2.16.840.1.113883.5.4" code="ASSERTION"/>
<!-- joint pain -->
<value xsi:type="CD" displayName="Joint pain"
codeSystem="2.16.840.1.113883.6.96" code="57676002"/>
</criterion>
</precondition>
</substanceAdministration>
</entry>
<!-- Instructions; similar to above but NOT a PRN - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours with food -->
<entry>
<substanceAdministration moodCode="EVN" classCode="SBADM">
<templateId root="2.16.840.1.113883.10.20.22.4.16"
extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="1.3.6.1.4.1.22812.3.99930.3.4.9" extension="200035"/>
<id root="1.3.6.1.4.1.22812.3.99930.3.4.9" extension="200013"/>
<text>
<reference value="#Medication_42424242"/>
</text>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20130310"/>
<high nullFlavor="NI"/>
</effectiveTime>
<!-- for the frequency of every 6 hours, we omit the institutionSpecified="false" attribute as false is the default value
the reader is referred to the Frequency examples for more information. -->
<effectiveTime xsi:type="PIVL_TS" operator="A">
<period value="6" unit="h"/>
</effectiveTime>
<doseQuantity value="1"/>
<consumable typeCode="CSM">
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"
extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code displayName="ibuprofen 600 MG Oral Tablet"
codeSystemName="RxNorm" codeSystem="2.16.840.1.113883.6.88" code="197806">
<originalText>
<reference value="#MedicationName_42424242"/>
</originalText>
<translation xsi:type="CD"
displayName="Ibuprofen 600mg Oral Tablet" codeSystemName="NDC"
codeSystem="2.16.840.1.113883.6.69" code="00603402221"/>
</code>
<name>Ibuprofen</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<entryRelationship typeCode="COMP">
<!-- Medication Free Text SIG -->
<substanceAdministration moodCode="INT" classCode="SBADM">
<templateId root="2.16.840.1.113883.10.20.22.4.147"/>
<code codeSystem="2.16.840.1.113883.6.1" code="76662-6"/>
<text>
<reference value="#MedicationSig_42424242"/>
</text>
<consumable>
<manufacturedProduct>
<manufacturedLabeledDrug nullFlavor="NA"/>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entryRelationship>
<!-- Instructions
Additional Note: careful consideration should be given as to whether or not an instruction is actually a precondition. Note also that including both a precondition and an instruction may be appropriate.
-->
<entryRelationship typeCode="SUBJ" inversionInd="true">
<act moodCode="INT" classCode="ACT">
<!-- Instruction (V2) -->
<templateId root="2.16.840.1.113883.10.20.22.4.20"
extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.20"/>
<code
displayName="Provider medication administration instructions" codeSystemName="SNOMED CT"
codeSystem="2.16.840.1.113883.6.96" code="422037009"/>
<text>
<reference value="#MedicationInstruction_42424242"/>
</text>
<statusCode code="completed"/>
</act>
</entryRelationship>
</substanceAdministration>
</entry>
<!-- Indication; again, NOT a PRN - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours for joint pain
as if "for" was written as "because of", so coded with an indication, not precondition -->
<entry>
<substanceAdministration moodCode="EVN" classCode="SBADM">
<templateId root="2.16.840.1.113883.10.20.22.4.16"
extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="1.3.6.1.4.1.22812.3.99930.3.4.9" extension="500035"/>
<id root="1.3.6.1.4.1.22812.3.99930.3.4.9" extension="500013"/>
<text>
<reference value="#Medication_84838281"/>
</text>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20130310"/>
<high nullFlavor="NI"/>
</effectiveTime>
<!-- for the frequency of every 6 hours, we omit the institutionSpecified="false" attribute as false is the default value
the reader is referred to the Frequency examples for more information. -->
<effectiveTime xsi:type="PIVL_TS" operator="A">
<period value="6" unit="h"/>
</effectiveTime>
<doseQuantity value="1"/>
<consumable typeCode="CSM">
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"
extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code displayName="ibuprofen 600 MG Oral Tablet"
codeSystemName="RxNorm" codeSystem="2.16.840.1.113883.6.88" code="197806">
<originalText>
<reference value="#MedicationName_84838281"/>
</originalText>
<translation xsi:type="CD"
displayName="Ibuprofen 600mg Oral Tablet" codeSystemName="NDC"
codeSystem="2.16.840.1.113883.6.69" code="00603402221"/>
</code>
<name>Ibuprofen</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<entryRelationship typeCode="COMP">
<!-- Medication Free Text SIG -->
<substanceAdministration moodCode="INT" classCode="SBADM">
<templateId root="2.16.840.1.113883.10.20.22.4.147"/>
<code codeSystem="2.16.840.1.113883.6.1" code="76662-6"/>
<text>
<reference value="#MedicationSig_84838281"/>
</text>
<consumable>
<manufacturedProduct>
<manufacturedLabeledDrug nullFlavor="NA"/>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entryRelationship>
<!-- a problem indication of joint pain -->
<entryRelationship typeCode="RSON">
<observation moodCode="EVN" classCode="OBS">
<!-- Indication (V2) -->
<templateId root="2.16.840.1.113883.10.20.22.4.19"
extension="2023-05-01"/>
<!-- Companion Guide -->
<templateId root="2.16.840.1.113883.10.20.22.4.19"
extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="1.3.6.1.4.1.22812.3.99930.3.4.1.3" extension="44"/>
<code xsi:type="CD" displayName="Clinical finding"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="404684003"/>
<text xsi:type="ED">
<reference value="#MedicationIndication_84838281"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD" displayName="Joint pain"
codeSystem="2.16.840.1.113883.6.96" code="57676002"/>
</observation>
</entryRelationship>
</substanceAdministration>
</entry>
</section>
IG © Health Level Seven. Package hl7.cda.examples#1.0.0 based on FHIR 5.0.0. Generated 2025-09-17
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