CDA Examples
1.0.0 - active United States of America flag

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: Active Problem

Approval Status: Approved
Task Force Approval: 2014-10-02
SDWG Approval: 2014-11-06, 2016-12-01

This example illustrates how to structure an active problem.

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
  <templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
  <code displayName="Problem List" codeSystem="2.16.840.1.113883.6.1"
        code="11450-4"/>
  <title>Problem List</title>
  <text>
    <table>
      <thead>
        <tr>
          <th>Name</th>
          <th>Dates</th>
          <th>Status</th>
        </tr>
      </thead>
      <tbody>
        <tr ID="Problem1">
          <td>Community Acquired Pneumonia</td>
          <td>
            <content>Onset: February 27 2014</content>
          </td>
          <td>Active</td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry>
    <act moodCode="EVN" classCode="ACT">
      <templateId root="2.16.840.1.113883.10.20.22.4.3"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.3"
                  extension="2015-08-01"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.3"
                  extension="2024-05-01"/>
      <id root="102ca2e9-884c-4523-a2b4-1b6c3469c397"/>
      <code codeSystem="2.16.840.1.113883.5.6" code="CONC"/>
      <!--  Since this is an active problem, the concern status is active.  -->
      <!--  While clinicians can track resolved problems, generally active problems will have active concern status and resolved concerns will be completed  -->
      <statusCode code="active"/>
      <effectiveTime>
        <!--  This equates to the time the concern was authored in the patient's chart. This may frequently be an EHR timestamp -->
        <low value="20140302124536-0500"/>
      </effectiveTime>
      <entryRelationship typeCode="SUBJ">
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.4"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.4"
                      extension="2015-08-01"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.4"
                      extension="2024-05-01"/>
          <id root="1.3.6.1.4.1.22812.4.111.0.4.1.2.1"
              extension="10241104348"/>
          <code xsi:type="CD" displayName="Problem"
                codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="55607006">
            <translation xsi:type="CD" displayName="Problem"
                         codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="75326-9"/>
          </code>
          <text xsi:type="ED">
            <reference value="#Problem1"/>
          </text>
          <statusCode code="completed"/>
          <effectiveTime>
            <!--  This represents the date of biological onset.  -->
            <low value="20140227"/>
          </effectiveTime>
          <!--  This is a SNOMED code as the primary vocabulary for problem lists -->
          <value xsi:type="CD" displayName="Community acquired pneumonia"
                 codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="385093006"/>
          <author>
            <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
            <time value="20140302124536"/>
            <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>
        </observation>
      </entryRelationship>
    </act>
  </entry>
</section>