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: No Known Problems

Approval Status: Approved
Task Force Approval: 2015-02-27
SDWG Approval: 2015-03-06, 2016-12-01

This is an example of no known problems.

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"/>
  <!--  Problem Section with Coded Entries Required  -->
  <templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
  <!--  Problem Section with Coded Entries Required  -->
  <code displayName="Problem List" codeSystemName="LOINC"
        codeSystem="2.16.840.1.113883.6.1" code="11450-4"/>
  <title>PROBLEMS</title>
  <text> Problem Concern:
    <br/> Concern Tracker Start Date: 06/07/2013 16:05:06
    <br/>
Concern Tracker End Date: 
    <br/> Concern Status: Active
    <br/>
    <content ID="problems1">No known 
      <content ID="problemType1">problems.</content>
    </content>
  </text>
  <entry typeCode="DRIV">
    <!--  Problem Concern Act  -->
    <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="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
      <!--  SDWG supports 48765-2 or CONC in the code element  -->
      <code codeSystem="2.16.840.1.113883.5.6" code="CONC"/>
      <text>
        <reference value="#Concern_1"/>
      </text>
      <statusCode code="active"/>
      <!--  So long as the underlying condition is of concern to the provider (i.e., as long as the condition,
         whether active or resolved, is of ongoing concern and interest to the provider), the statusCode is "active".
         Only when the underlying condition is no longer of concern is the statusCode set to "completed".  -->
      <!--  The effectiveTime reflects the time that the underlying condition was felt to be a concern;
           it may or may not correspond to the effectiveTime of the condition (e.g., even five years later, the clinician may remain concerned about a prior heart attack). -->
      <effectiveTime>
        <low value="20130607160506-0400"/>
      </effectiveTime>
      <!--  status is active so high is not applicable. If high is present it should have nullFlavor of NA -->
      <author>
        <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
        <time value="20130607160506-0400"/>
        <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>
      <entryRelationship typeCode="SUBJ">
        <observation negationInd="true" moodCode="EVN" classCode="OBS">
          <!--  The negationInd is used to indicate the absence of the condition in observation/value (Observation.ValueNegationInd).
             A negationInd of "true" coupled with an observation/value of SNOMED code 55607006 "Problem"
             indicates that the patient has no known conditions.  -->
          <!--  problem observation template  -->
          <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="4adc1021-7b14-11db-9fe1-0800200c9a67"/>
          <code xsi:type="CD" displayName="Disease"
                codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="64572001">
            <translation xsi:type="CD" displayName="Condition"
                         codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="75323-6"/>
          </code>
          <text xsi:type="ED">
            <reference value="#problems1"/>
          </text>
          <statusCode code="completed"/>
          <!--  The time when this was biologically relevant ie True for the patient.  -->
          <!--  For "no known problems," this will typically be null unless information
             is available about how long the patient has been problem-free for.  -->
          <!--  As a maximum, you would never indicate an effectiveTime/high that was greater than the current point in time.  -->
          <effectiveTime>
            <low nullFlavor="NI"/>
          </effectiveTime>
          <!--  This idea assumes that the value element could come from the Problem value set, or -->
          <!--  when negationInd was true, is could also come from the ProblemType value set (and code would be ASSERTION).  -->
          <value xsi:type="CD" displayName="Problem"
                 codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="55607006">
            <originalText>
              <reference value="#problemType1"/>
            </originalText>
          </value>
        </observation>
      </entryRelationship>
    </act>
  </entry>
</section>