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 sexual orientation and gender identity represented in a C-CDA under the social history section. It has codes which align with the ISA recommendations for this information (see: https://www.healthit.gov/isa/representing-patient-identified-sexual-orientation)
This file includes examples of the following templates:
<!-- This sample is undergoing significant review. Please be aware that there may be signficant changes -->
<!-- Developed by Emma Jones -->
<section xmlns="urn:hl7-org:v3">
<templateId root="2.16.840.1.113883.10.20.22.2.17" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.17"/>
<code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"
code="29762-2"/>
<title>Social History</title>
<text>
<table>
<thead>
<tr>
<th>Social History</th>
<th>Observation</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr ID="_a1305452-cddd-4654-980f-bba6745588c8">
<td>
<content ID="_3b8a5051-3968-4cfe-ab70-8b69f84bd378">Sexual orientation</content>
</td>
<td>
<content ID="_12d30bb3-f589-4d3b-a011-4b463aafa093">bisexual</content>
</td>
<td>
<content>2001 - </content>
</td>
</tr>
</tbody>
<tbody>
<tr ID="_6e185602-f807-40c6-8003-41c589ae62af">
<td>
<content ID="_4503c511-8e06-41a0-8f6b-3f5d23b131e2">Gender identity</content>
</td>
<td>
<content ID="_71d1b8e1-b3dd-483f-80f3-49656e518994">Female-to-male transsexual</content>
</td>
<td>
<content>2001 - </content>
</td>
</tr>
</tbody>
</table>
</text>
<entry>
<observation moodCode="EVN" classCode="OBS">
<templateId root="2.16.840.1.113883.10.20.22.4.38"
extension="2022-06-01"/>
<!-- Companion Guide -->
<templateId root="2.16.840.1.113883.10.20.22.4.38"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.38"/>
<id root="2.16.840.1.113883.19" extension="123456789"/>
<!-- Per the C-CDA 2.1 IG - (CONF:1198-8558) - social history type value set is a SHOULD - therefore this value is not in the value set however, it is allowed -->
<code xsi:type="CD" displayName="Sexual orientation"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="76690-7">
<originalText>
<reference value="#_3b8a5051-3968-4cfe-ab70-8b69f84bd378"/>
</originalText>
</code>
<text xsi:type="ED">
<reference value="#_a1305452-cddd-4654-980f-bba6745588c8"/>
</text>
<statusCode code="completed"/>
<!-- interval start with no end to indicate from 2001 -->
<effectiveTime>
<low value="2001"/>
</effectiveTime>
<value xsi:type="CD" displayName="Bisexual" codeSystemName="SNOMED CT"
codeSystem="2.16.840.1.113883.6.96" code="42035005">
<originalText>
<reference value="#_12d30bb3-f589-4d3b-a011-4b463aafa093"/>
</originalText>
</value>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20140606"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="99999999"/>
<code displayName="Allopathic and Osteopathic Physicians"
codeSystemName="Healthcare Provider Taxonomy (HIPAA)" 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">
<templateId root="2.16.840.1.113883.10.20.22.4.38"
extension="2022-06-01"/>
<!-- Companion Guide -->
<templateId root="2.16.840.1.113883.10.20.22.4.38"
extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.38"/>
<id root="2.16.840.1.113883.19" extension="123456789"/>
<!-- Per the C-CDA 2.1 IG - (CONF:1198-8558) - social history type value set is a SHOULD - therefore this value is not in the value set however, it is allowed -->
<code xsi:type="CD" displayName="Gender identity"
codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="76691-5">
<originalText>
<reference value="#_4503c511-8e06-41a0-8f6b-3f5d23b131e2"/>
</originalText>
</code>
<text xsi:type="ED">
<reference value="#_6e185602-f807-40c6-8003-41c589ae62af"/>
</text>
<statusCode code="completed"/>
<!-- interval start with no end to indicate from 2001 -->
<effectiveTime>
<low value="2001"/>
</effectiveTime>
<!-- Selected from this value set - https://phinvads.cdc.gov/vads/ViewValueSet.action?id=B0155EA6-45BB-E711-ACE2-0017A477041A -->
<value xsi:type="CD" displayName="Female-to-male transsexual"
codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="407377005">
<originalText>
<reference value="#_71d1b8e1-b3dd-483f-80f3-49656e518994"/>
</originalText>
</value>
<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"/>
<code displayName="Allopathic and Osteopathic Physicians"
codeSystemName="Healthcare Provider Taxonomy (HIPAA)" 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>