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: SDOH Problem

Approval Status: Approved
Task Force Approval: 2024-06-06
SDWG Approval: 2024-06-06

This example illustrates how to structure an Active SDOH problem with a translation to ICD10. Some systems may document active SDOH issues in the Social History Section or the Health Concerns Section. Gravity and other industry initiatives may provide additional guidance on best practices.

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="ProblemObs1">
          <td ID="Problem1">Nutrition impaired due to limited access to healthful foods</td>
          <td>
            <content>Onset: March 21 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  -->
      <text>
        <reference value="#ProblemObs1"/>
      </text>
      <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="20140302121536-0500"/>
      </effectiveTime>
      <entryRelationship typeCode="SUBJ">
        <!--  SDOH Problem  -->
        <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="2022-06-01"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.4"
                      extension="2024-05-01"/>
          <id root="1.2.840.114350.1.13.6289.1.7.2.768076" extension="68993"/>
          <id root="093A5380-00CE-11E6-B4C5-0050568B000B" extension="1.1"/>
          <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>
          <statusCode code="completed"/>
          <effectiveTime>
            <low value="20140302121536-0500"/>
          </effectiveTime>
          <value xsi:type="CD"
                 displayName="Nutrition impaired due to limited access to healthful foods (finding)" codeSystemName="SNOMED CT"
                 codeSystem="2.16.840.1.113883.6.96" code="445281000124101">
            <originalText>
              <reference value="#Problem1"/>
            </originalText>
            <translation xsi:type="CD"
                         displayName="Other specified lack of adequate food" codeSystemName="ICD-10-CM"
                         codeSystem="2.16.840.1.113883.6.90" code="Z59.48"/>
          </value>
          <!--  Optional Author Element -->
          <author>
            <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
            <time value="20140302124536-0500"/>
            <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>
              <!--  Optional Organization Element -->
              <representedOrganization>
                <id root="2.16.840.1.113883.19.5"/>
                <name>Neighborhood Physicians Practice</name>
              </representedOrganization>
            </assignedAuthor>
          </author>
        </observation>
      </entryRelationship>
    </act>
  </entry>
</section>