This observation represents the sex of the patient at birth. It is the sex that is entered on the person’s birth certificate at time of birth.

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 is an example of a patient using Electronic cigarette liquid containing nicotine. The concept selected aligns with the 2019 guidance https://www.healthit.gov/isa/representing-patient-electronic-cigarette-use-vaping. The examples task force spent significant time discussion the different substances that can be used in an electronic cigarette, more than just nicotine.

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 is an example of a never smoker in smoking status. A best practice to avoid confusion is for each social history section to only include a single smoking status.

This is an example of patient that is not pregnant.

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 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 is an example of unknown pregnancy status.

WE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education) is a clinic-based screening and referral system developed for pediatric settings USCF. This example includes the assessment in the Social History section