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: Single administration of medication

Approval Status: Approved
Task Force Approval: 2014-03-13
SDWG Approval: 2014-04-10, 2016-12-01

This is an example of two baby aspirin being administered at a single point in time. At the January 2014 San Antonio meeting of HL7, this approach was decided as appropriate for medication timing of a point in time. Subsequent to that meeting, the TTT validator was adjusted to accept this format for medication times.

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <!--  Medications section with entries required  -->
  <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"/>
  <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</th>
          <th>Status</th>
        </tr>
      </thead>
      <tbody>
        <tr ID="Medication_7">
          <td ID="MedicationName_7">Aspirin 81mg Oral Tablet</td>
          <td>take 2 tablets</td>
          <td>162 MG</td>
          <td>Sep-11-2013</td>
          <td>Completed</td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry typeCode="DRIV">
    <substanceAdministration moodCode="EVN" classCode="SBADM">
      <!--  This medication use case is a medication administered a single time in the past. If it to be administered use moodCode = "INT". 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="1061a257-3b5c-4b09-9dc7-23e59b788b18"/>
      <text>
        <!--  This reference refers to medication information in unstructured portion of section -->
        <reference value="#Medication_7"/>
      </text>
      <statusCode code="completed"/>
      <!--  This is a one-time administration, so low and high times are not used  -->
      <!--  It is xsi:type = "TS", but that cannot be explicitly declared given the base CDA schema  -->
      <!--  This format was determined as appropriate in San Antonio meeting, January 2014  -->
      <!--  See DSTU 423 of C-CDA 1.1 for more information http://www.hl7.org/dstucomments/showdetail_comment.cfm?commentid=423  -->
      <effectiveTime xsi:type="SXCM-TS" value="20130911160300-0700"/>
      <!--  Since this is a one-time administration, there is no inclusion ofa second effectiveTIme to represent dose frequency (PIVL_TS or EIVL_TS) -->
      <routeCode displayName="Oral Route of Administration"
                 codeSystemName="National Cancer Institute Thesaurus" codeSystem="2.16.840.1.113883.3.26.1.1" code="C38288"/>
      <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"/>
          <manufacturedMaterial>
            <!--  Medications should be specified at a level corresponding to prescription when possible (non-branded below) -->
            <code displayName="aspirin 81 MG Oral Tablet"
                  codeSystem="2.16.840.1.113883.6.88" code="243670">
              <originalText>
                <reference value="#MedicationName_7"/>
              </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="20130911160300-0700"/>
        <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>