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 former smoker in smoking status. There is a variation in how effectiveTime/high is used since this represents when the patient stopped smoking, not when they stopped being a former smoker. C-CDA explicitly guides to this usage of effectiveTime. A best practice to avoid confusion is for each social history section to 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>Former Smoker</content>
<content>Started: 1994</content>
<content>Stopped: March 2011</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. -->
<!-- The use of a specfic SNOMED code for unknown smoker is an encouraged variation from C-CDA practices in other sections -->
<value xsi:type="CD" displayName="Ex-smoker"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="8517006"/>
<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>
<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>
<!-- The low value reflects the start date of the observation/value (moderate smoker) -->
<low value="1994"/>
<!-- The high value reflects the end date of the observation/value (moderate smoker) -->
<high value="201103"/>
</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>