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 Relative Dose IV Drug

Approval Status: Approved
Task Force Approval: 2018-02-15
SDWG Approval: 2019-06-27

This example illustrates an example of a medication order with the following characteristics: an IV drug with a relative dose quantity that is based on weight, a drug vehicle used for preparation, and indications for the medication. This example was created to address the following Use Case: An oncologist is ordering a drug as part of a chemotherapy regimen. Chemotherapy regimens consist of orders could be administered weeks or months in advance. Moreover their preparation is based on the patient’s weight at the time of administration. Because of these constraints, the C-CDA medications section needs to be represented in a way that reflects this. Additional Notes and Assumptions: the /entry/substanceAdministration/effectiveTime/@value is meant to be set at a future date relative to the date of the encounter. The date of the encounter would have been represented in a separate section outside of this example.

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 Date(s)</th>
          <th>Status</th>
        </tr>
      </thead>
      <tbody>
        <tr ID="Medication_1">
          <td>
            <content ID="MedicationName_1">4 ML bevacizumab 25 MG/ML Injection</content>
          </td>
          <td/>
          <td>
            <content>5 mg/kg</content>
          </td>
          <td>2018-02-15</td>
          <!--  one time administration on Day 1  -->
          <td>Active</td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry typeCode="DRIV">
    <substanceAdministration moodCode="INT" 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="6c844c75-aa34-411c-b7bd-5e4a9f206e29"/>
      <text>
        <!--  This reference refers to medication information in unstructured portion of section -->
        <reference value="#Medication_1"/>
      </text>
      <statusCode code="active"/>
      <!--  the medication order is currently active  -->
      <!--  for this regimen, bevacizumab will only be administered once, on Day 1,
           as an example scheduled for a future date relative to the date of the encounter.   -->
      <effectiveTime xsi:type="SXCM-TS" value="20180215"/>
      <routeCode displayName="Intravenous Route of Administration"
                 codeSystemName="NCI Thesaurus" codeSystem="2.16.840.1.113883.3.26.1.1" code="C38276"/>
      <!--  an absolute dose quantity is unknown at the time the order is placed because
           the drug is prepared based on the weight at the time of administration.  -->
      <!--  unit of measure taken from UCUM: http://download.hl7.de/documents/ucum/ucumdata.html  -->
      <doseQuantity value="5" unit="mg/kg"/>
      <consumable>
        <manufacturedProduct classCode="MANU">
          <!--  ** Medication information **  -->
          <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"/>
          <id root="2a620155-9d11-439e-92b3-5d9815ff3cc2"/>
          <manufacturedMaterial>
            <code displayName="4 ML bevacizumab 25 MG/ML Injection"
                  codeSystemName="RxNorm" codeSystem="2.16.840.1.113883.6.88" code="1657066">
              <originalText>
                <reference value="#MedicationName_1"/>
              </originalText>
            </code>
          </manufacturedMaterial>
        </manufacturedProduct>
      </consumable>
      <participant typeCode="CSM">
        <participantRole classCode="MANU">
          <templateId root="2.16.840.1.113883.10.20.22.4.24"/>
          <code displayName="Drug vehicle"
                codeSystem="2.16.840.1.113883.6.96" code="412307009"/>
          <playingEntity classCode="MMAT">
            <!--  bevacizumab is prepared with a compatible solution for continuous infusion.
                 In this example, we use normal saline for preparation.  -->
            <code displayName="1000 ML sodium chloride 9 MG/ML Injection"
                  codeSystemName="RxNorm" codeSystem="2.16.840.1.113883.6.88" code="1807639"/>
            <name>Sodium Chloride 0.9%</name>
          </playingEntity>
        </participantRole>
      </participant>
      <entryRelationship typeCode="RSON">
        <observation moodCode="EVN" classCode="OBS">
          <!--  ** Indication **  -->
          <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"
                      extension="2023-05-01"/>
          <!--  Companion Guide  -->
          <!--  This ID may link to the problem ID entry in the problem list, if it already exists.  -->
          <id root="e63166c7-6482-4a44-83a1-37ccdbdd532b"/>
          <code xsi:type="CD" displayName="Clinical finding"
                codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="75321-0"/>
          <statusCode code="completed"/>
          <value xsi:type="CD" displayName="Malignant neoplasm of colon"
                 codeSystem="2.16.840.1.113883.6.96" code="363406005"/>
        </observation>
      </entryRelationship>
    </substanceAdministration>
  </entry>
</section>