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: Result panel with coded values of negative-positive

Approval Status: Approved
Task Force Approval: 2013-11-21, 2015-03-05, 2020-02-13
SDWG Approval: 2015-03-12, 2020-02-27, 2016-12-01

This is an example of how to encode positive and negative, which are common data types returned form lab equipment. While some technologies may represent this as a type of ST (string), it is logical and easily possible to encode this information using SNOMED-CT. This would allow structured examination of this information downstream as well as comparison to a structured reference range, as shown in the example. Previously the examples task force approved this sample with the data type Coded Ordinal (CO) with the example name: Result panel with two ordinal values of negative-positive. The examples task force received feedback during implementation that CO is not commonly used, and CD is preferred. Updated the sample name to Result panel with coded values of negative-positive

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
  <templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01"/>
  <!--  Results Section with Coded Entries Required -->
  <code displayName="Relevant diagnostic tests and/or laboratory data"
        codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="30954-2"/>
  <title>Results</title>
  <text>
    <table border="1">
      <thead>
        <tr>
          <th>Description</th>
          <th>Value / Unit</th>
          <th>Interpretation</th>
          <th>Reference Range</th>
        </tr>
      </thead>
      <tbody>
        <tr>
          <th colspan="4">Chlamydia trachomatis and Neisseria gonorrhoeae rRNA panel -
            Urine by Probe and target amplification method at 10-22-2013 2:26p</th>
        </tr>
        <tr ID="LabResult3">
          <td>Chlamydia trachomatis rRNA [Presence] in Urine by Probe and target amplification method R</td>
          <td>Negative</td>
          <td>Normal</td>
          <td>Negative</td>
        </tr>
        <tr ID="LabResult4">
          <td>Neisseria gonorrhoeae rRNA [Presence] in Urine by Probe and target amplification method R</td>
          <td>Positive</td>
          <td>Abnormal</td>
          <td>Negative</td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry>
    <organizer moodCode="EVN" classCode="BATTERY">
      <templateId root="2.16.840.1.113883.10.20.22.4.1"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.1"
                  extension="2015-08-01"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.1"
                  extension="2023-05-01"/>
      <id root="b5684bf0-eb6f-46dd-9f2e-b6cbcc4196fd"/>
      <code
            displayName="Chlamydia trachomatis and Neisseria gonorrhoeae rRNA panel - Urine by NAA with probe detection" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
            code="70161-5"/>
      <statusCode code="completed"/>
      <effectiveTime>
        <low value="20131022142600-0500"/>
        <high value="20131022142600-0500"/>
      </effectiveTime>
      <component>
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.2"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.2"
                      extension="2015-08-01"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.2"
                      extension="2023-05-01"/>
          <id root="5a6be91a-32d5-4d24-a8bd-07d10a3ef14d"/>
          <code xsi:type="CD"
                displayName="Chlamydia trachomatis rRNA [Presence] in Urine by NAA with probe detection" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
                code="42931-6"/>
          <text xsi:type="ED">
            <reference value="#LabResult3"/>
          </text>
          <statusCode code="completed"/>
          <effectiveTime value="20131022142600-0500"/>
          <!--  Representing a result of an ordinal test (See LOINC axes) as negative in SNOMED -->
          <!--  Note, this example had type="CO" but feedback from implementation is this is not deployed, and CD is better  -->
          <value xsi:type="CD" displayName="Negative"
                 codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="260385009"/>
          <interpretationCode displayName="Normal"
                              codeSystem="2.16.840.1.113883.5.83" code="N"/>
          <referenceRange>
            <observationRange>
              <text>A negative value is a normal result</text>
              <value xsi:type="CD" displayName="Negative"
                     codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="260385009"/>
              <!--  This interpretation code denotes that this reference range is for normal results. This is not the interpretation a specific patient value -->
              <interpretationCode displayName="Normal"
                                  codeSystem="2.16.840.1.113883.5.83" code="N"/>
            </observationRange>
          </referenceRange>
        </observation>
      </component>
      <component>
        <observation moodCode="EVN" classCode="OBS">
          <templateId root="2.16.840.1.113883.10.20.22.4.2"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.2"
                      extension="2015-08-01"/>
          <templateId root="2.16.840.1.113883.10.20.22.4.2"
                      extension="2023-05-01"/>
          <id root="404bba0e-1c76-4265-afb5-1a57b55e128b"/>
          <code xsi:type="CD"
                displayName="Neisseria gonorrhoeae rRNA [Presence] in Urine by NAA with probe detection" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
                code="60256-5"/>
          <text xsi:type="ED">
            <reference value="#LabResult4"/>
          </text>
          <statusCode code="completed"/>
          <effectiveTime value="20131022142600-0500"/>
          <!--  Representing a result of an ordinal test (See LOINC axes) as positive in SNOMED -->
          <value xsi:type="CD" displayName="Positive"
                 codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="10828004"/>
          <interpretationCode displayName="Abnormal"
                              codeSystem="2.16.840.1.113883.5.83" code="A"/>
          <referenceRange>
            <observationRange>
              <text>A negative value is a normal result</text>
              <value xsi:type="CD" displayName="Negative"
                     codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="260385009"/>
              <!--  This interpretation code denotes that this reference range is for normal results. This is not the interpretation a specific patient value -->
              <interpretationCode displayName="Normal"
                                  codeSystem="2.16.840.1.113883.5.83" code="N"/>
            </observationRange>
          </referenceRange>
          <!--  Here is how additional reference ranges may be included -->
          <referenceRange>
            <observationRange>
              <text>A positive value is an abnormal result</text>
              <value xsi:type="CD" displayName="Positive"
                     codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="10828004"/>
              <!--  This optional second interpretation code denotes that this reference range is for abnormal results. This is not the interpretation a specific patient value -->
              <interpretationCode displayName="Abnormal"
                                  codeSystem="2.16.840.1.113883.5.83" code="A"/>
            </observationRange>
          </referenceRange>
        </observation>
      </component>
    </organizer>
  </entry>
</section>