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: Current Smoking Status

Approval Status: Approved
Task Force Approval: 2014-06-26
SDWG Approval: 2014-07-03, 2016-12-01

This is an example of current smoking status. This example also includes a coordinating social history observation to convey the amount of smoking using a SNOMED code. This SNOMED code in the accompanying observation is not acceptable since smoking status, which is constrained by HL7 and Meaningful Use value set requirements. Each social history section shall only include a single smoking status.

This file includes examples of the following templates: 


<section xmlns="urn:hl7-org:v3">
  <templateId root="2.16.840.1.113883.10.20.22.2.17"/>
  <templateId root="2.16.840.1.113883.10.20.22.2.17" extension="2015-08-01"/>
  <code displayName="Social History" codeSystemName="LOINC"
        codeSystem="2.16.840.1.113883.6.1" code="29762-2"/>
  <title>Social History</title>
  <text>
    <list listType="unordered">
      <caption>Smoking Status</caption>
      <item ID="SmokingStatus">
        <content>Status: Current every day smoker</content>
        <content ID="SmokingDetail1">Detail: Moderate smoker (10-19 cigs/day)</content>
        <content>Started: 1992</content>
        <content>Stopped:</content>
        <content>Recorded June 6, 2014 10:32am</content>
      </item>
    </list>
  </text>
  <!--  Only include one smoking status per patient.  -->
  <entry>
    <observation moodCode="EVN" classCode="OBS">
      <templateId root="2.16.840.1.113883.10.20.22.4.78"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.78"
                  extension="2014-06-09"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.78"
                  extension="2024-05-01"/>
      <!--  C-CDA 3.0  -->
      <id root="2.16.840.1.113883.19" extension="123456789"/>
      <code xsi:type="CD" displayName="Tobacco smoking status NHIS"
            codeSystem="2.16.840.1.113883.6.1" code="72166-2"/>
      <text xsi:type="ED">
        <reference value="#SmokingStatus"/>
      </text>
      <statusCode code="completed"/>
      <effectiveTime value="20140606103200-0500"/>
      <!--  Note: This template represents a "snapshot in time" observation, simply reflecting what the patient's
           current smoking status is at the time of the observation. As a result, the effectiveTime is constrained
           to just a time stamp, and will approximately correspond with the author/time.  -->
      <value xsi:type="CD" displayName="Smokes tobacco daily"
             codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="449868002"/>
      <author>
        <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
        <time value="20140606103200-0500"/>
        <assignedAuthor>
          <id root="2.16.840.1.113883.4.6" extension="99999999"/>
          <!--  Root means NPI number.  -->
          <code displayName="Allopathic and Osteopathic Physicians"
                codeSystem="2.16.840.1.113883.6.101" code="200000000X"/>
          <addr nullFlavor="UNK"/>
          <telecom value="tel:+1(555)555-1002" use="WP"/>
          <assignedPerson>
            <name>
              <given>Henry</given>
              <family>Seven</family>
            </name>
          </assignedPerson>
        </assignedAuthor>
      </author>
    </observation>
  </entry>
  <!-- - You can use a social history observation template entry for additional smoking detail, such as smoking quantity -->
  <entry>
    <observation moodCode="EVN" classCode="OBS">
      <!--  ** Tobacco use **  -->
      <templateId root="2.16.840.1.113883.10.20.22.4.85"/>
      <templateId root="2.16.840.1.113883.10.20.22.4.85"
                  extension="2014-06-09"/>
      <id root="45efb604-7049-4a2e-ad33-d38556c9636c"/>
      <code xsi:type="CD" displayName="History of tobacco use"
            codeSystem="2.16.840.1.113883.6.1" code="11367-0"/>
      <text xsi:type="ED">
        <reference value="#SmokingStatus"/>
      </text>
      <statusCode code="completed"/>
      <effectiveTime>
        <!--  To record a current smoker, the effectiveTime/low will define the time the patient started
             smoking and will have no effectiveTime/high to indicated that the patient is still smoking.  -->
        <low value="1992"/>
      </effectiveTime>
      <value xsi:type="CD" displayName="Moderate cigarette smoker"
             codeSystem="2.16.840.1.113883.6.96" code="160604004"/>
      <author>
        <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
        <time value="20140606103200-0500"/>
        <assignedAuthor>
          <id root="2.16.840.1.113883.4.6" extension="99999999"/>
          <!--  Root means NPI number.  -->
          <code displayName="Allopathic and Osteopathic Physicians"
                codeSystem="2.16.840.1.113883.6.101" code="200000000X"/>
          <addr nullFlavor="UNK"/>
          <telecom value="tel:+1(555)555-1002" use="WP"/>
          <assignedPerson>
            <name>
              <given>Henry</given>
              <family>Seven</family>
            </name>
          </assignedPerson>
        </assignedAuthor>
      </author>
    </observation>
  </entry>
</section>