CDA Examples
1.0.0 - active
CDA Examples
1.0.0 - active
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
This is an example of a patient pregnancy in problem list with information about estimateed delivery date. This is an alternative place to document and share pregancy informatoin in addition to social history and detailed pregnancy sections (see HL7 IG for more on pregancy status here: http://www.hl7.org/implement/standards/product_brief.cfm?product_id=494)
This file includes examples of the following templates:
<section xmlns="urn:hl7-org:v3">
<!-- This is an example of patient pregancy documented in problem list -->
<!-- This information may also be recorded in other sections (e.g. Social History or Pregancy Section) -->
<!-- This is meant to represent high level information related to a pregnancy, not detailed OB/GYN information -->
<!-- Other sections may include much more detail, such as dates of prior births, fetal plurality, etc. -->
<!-- For pregnancy section, refer to IG related to Pregancy Status http://www.hl7.org/implement/standards/product_brief.cfm?product_id=494 -->
<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>Description</th>
<th>Dates</th>
<th>Status</th>
<th>Additional Detail</th>
</tr>
</thead>
<tbody>
<tr ID="Problem1">
<td ID="ProblemDescription1">Pregnancy</td>
<td>
<content>Estimated Conception: Jan 3 2020</content>
</td>
<td>Active</td>
<td ID="Problem1Detail">Estimated Due Date: Sep 19 2020</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"/>
<statusCode code="active"/>
<effectiveTime>
<!-- This equates to the date of when first documented (not date of conception) -->
<low value="20200310"/>
</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"/>
<!-- Note a problem cannot be compliant to pregnancy observation template since code@code different SHALL -->
<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, which for pregnancy would be estimated conception date -->
<low value="20200103"/>
</effectiveTime>
<!-- This is a SNOMED code as the primary vocabulary for problem lists -->
<!-- This SNOMED aligns with pregancy observation value set: 2.16.840.1.113762.1.4.1099.24 -->
<value xsi:type="CD" displayName="Pregnancy"
codeSystem="2.16.840.1.113883.6.96" code="77386006">
<originalText>
<reference value="#ProblemDescription1"/>
</originalText>
<!-- These translation codes provide additional specificity, may be useful in tracking time and billing -->
<translation xsi:type="CD"
displayName="Gestation period, 10 weeks" codeSystem="2.16.840.1.113883.6.96" code="38039008"/>
<translation xsi:type="CD"
displayName="10 weeks gestation of pregnancy" codeSystem="2.16.840.1.113883.6.90" code="Z3A.10"/>
</value>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<!-- This equates to the date when last updated by the author -->
<time value="20190310125600-0500"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="66666"/>
<code
displayName="Allopathic & 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>
<!-- This is not required but the estimated time of delivery can be shared through structured entryRelationship -->
<entryRelationship typeCode="REFR">
<observation moodCode="EVN" classCode="OBS">
<!-- Template for Estimated Date of Delivery -->
<templateId root="2.16.840.1.113883.10.20.15.3.1"/>
<code xsi:type="CD" displayName="Delivery date Estimated"
codeSystem="2.16.840.1.113883.6.1" code="11778-8"/>
<text xsi:type="ED">
<reference value="#Problem1Detail"/>
</text>
<statusCode code="completed"/>
<value xsi:type="TS" value="20200919"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
IG © Health Level Seven. Package hl7.cda.examples#1.0.0 based on FHIR 5.0.0. Generated 2025-08-28
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