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: Unknown Smoking Status

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

This is an example of unknown smoking status. There is a major variation in how no information is managed for smoking status. C-CDA explicitly guides to not utilize a nullFlavor for this information. Instead a SNOMED code should be used as demonstrated in the example. 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>Unknown if ever smoked</content>
        <content>Started: </content>
        <content>Stopped:</content>
        <content>Recorded June 6, 2014 10:32am</content>
      </item>
    </list>
  </text>
  <!--  A best practice is to only include one smoking status per patient to avoid confusion.  -->
  <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="Tobacco smoking consumption unknown"
             codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="266927001"/>
      <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>