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: Sexual Orientation Gender Identity

Approval Status: Approved
Task Force Approval: 2019-07-11
SDWG Approval: 2019-07-25

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>