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: Patient Does Not Have Diabetes

Approval Status: Approved
Task Force Approval: 2015-11-05
SDWG Approval: 2015-11-12, 2017-02-02

This is an example of an author asserting a patient does not have diabetes.

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>
    <table>
      <thead>
        <tr>
          <td>Start Time:</td>
          <td>End Time:</td>
          <td>Status:</td>
          <td>Problem:</td>
        </tr>
      </thead>
      <tbody>
        <tr ID="problems1">
          <td>12/01/2015 16:05:06</td>
          <td/>
          <td>Active</td>
          <td ID="problem1">No Diabetes (ruled out)</td>
        </tr>
      </tbody>
    </table>
    <!--  The statement above and the associated problem observation could be placed in the History of Past Illness Section  -->
  </text>
  <entry typeCode="COMP">
    <!--  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"/>
      <code codeSystem="2.16.840.1.113883.5.6" code="CONC"/>
      <text>
        <reference value="#Concern_1"/>
      </text>
      <statusCode code="completed"/>
      <!--  The concern is not active, in terms of there being an active condition to be managed. -->
      <!--  Time at which THIS "concern" began being tracked. -->
      <effectiveTime>
        <low value="20151201071605"/>
      </effectiveTime>
      <!--  Optional Author Element -->
      <author>
        <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
        <time value="20151202171605"/>
        <assignedAuthor>
          <id root="2.16.840.1.113883.4.6" extension="666545666"/>
          <code
                displayName="Physician Assistants &amp; Advanced Practice Nursing Providers; Nurse Practitioner, Acute Care" codeSystemName="NUCC" codeSystem="2.16.840.1.113883.6.101"
                code="363LA2100X"/>
          <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>Jenheartly</given>
              <family>Sixer</family>
              <suffix>NP</suffix>
            </name>
          </assignedPerson>
        </assignedAuthor>
      </author>
      <entryRelationship typeCode="SUBJ">
        <!--  This problem observation could be placed in the History of Past Illness Section  -->
        <!--  Or, in future, in the Health Concerns Section  -->
        <observation negationInd="true" moodCode="EVN" classCode="OBS">
          <!--  Model of Meaning for No Diabetes  -->
          <!--  The use of negationInd corresponds with the newer Observation.ValueNegationInd  -->
          <!--  The negationInd = true negates the value element.  -->
          <!--  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-9fe1-0800200c9a69"/>
          <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="#problems1"/>
          </text>
          <statusCode code="completed"/>
          <effectiveTime>
            <low value="20151201160506"/>
          </effectiveTime>
          <!--  The time when this was biologically relevant ie True for the patient.  -->
          <!--  As a minimum time interval over which this is true, populate the effectiveTime/low with the current time.  -->
          <!--  It would be equally valid to have a longer range of time over which this statement was represented as being true.  -->
          <!--  As a maximum, you would never indicate an effectiveTime/high that was greater than the current point in time.  -->
          <value xsi:type="CD"
                 displayName="Diabetes mellitus type 2 (disorder)" codeSystemName="SNOMED CT"
                 codeSystem="2.16.840.1.113883.6.96" code="44054006">
            <originalText>
              <reference value="#problem1"/>
            </originalText>
          </value>
        </observation>
      </entryRelationship>
    </act>
  </entry>
</section>