Normal Family History Father deceased-Mother alive

back to homepage

Approval Status

  • Approval Status: Approved
  • Example Task Force: 1/15/2015

  • SDWG: 2/19/2015

  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

C-CDA 2.1 Example:

  • Family History Organizer (2.16.840.1.113883.10.20.22.4.45 2015-08-01)
  • Family History Observation (2.16.840.1.113883.10.20.22.4.46 2015-08-01)

Reference to full CDA sample:

  • Family history in empty CCD

Validation location

Comments

  • Example shows multiple observations for one family member, identifying the cause of death, and a family member with no known problems.

    Custodian

  • Benjamin Flessner (GitHub: benjaminflessner)

    Keywords

  • Family History

Permalink

Links

 

Example: download example view on GitHub 

<section>
	<!-- C-CDAR2 Example Family History Section -->
	<templateId root="2.16.840.1.113883.10.20.22.2.15"/>
	<templateId root="2.16.840.1.113883.10.20.22.2.15" extension="2015-08-01"/>
	<code code="10157-6" codeSystem="2.16.840.1.113883.6.1" displayName="Family History"/>
	<title>Family History</title>
	<text>
		<!-- Narrative may be structured in any manner, but clear references between the narrative and discrete entries are encouraged -->
		<table>
			<thead>
				<tr>
					<th>Family Member</th>
					<th>Relation</th>
					<th>Problem</th>
					<th>Age of Onset</th>
					<th>Comments</th>
				</tr>
			</thead>
			<tbody>
				<tr>
					<td rowspan="2">Lucas Valieri</td>
					<td ID="FH1rel" rowspan="2">Dad</td>
					<td ID="FH1prob1">Stroke</td>
					<td ID="FH1prob1age">72</td>
					<td ID="FH1prob1comment">Cause of death, January 2003</td>
				</tr>
				<tr>
					<td ID="FH1prob2">High Blood Pressure</td>
					<td/>
					<td/>
				</tr>
				<tr>
					<td>Mia Jones</td>
					<td ID="FH2rel">Mom</td>
					<td ID="FH2prob">No known problems</td>
					<td/>
					<td/>
				</tr>
			</tbody>
		</table>
	</text>
	<!-- Father died of a stroke -->
	<entry>
		<!-- Organizes the Father's medical history --> 
		<organizer classCode="CLUSTER" moodCode="EVN">
			<templateId root="2.16.840.1.113883.10.20.22.4.45"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.45" extension="2015-08-01"/>
			<!-- Unique identifier for this family member's HISTORY (not the individual) -->
			<id root="01faa204-db62-4610-864f-cb50b650d0fa" />
			<statusCode code="completed"/>
			<subject typeCode="SBJ">
				<relatedSubject classCode="PRS">
					<!-- Identifies subject's relationship to recordTarget (i.e. Patient) -->
					<code code="FTH" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 RoleCode" displayName="father">
						<originalText>
							<reference value="#FH1rel"/>
						</originalText>
					</code>
					<subject>
						<!-- Unique ID for the father as an individual -->
						<sdtc:id extension="98765432-1" root="1.3.6.1.4.1.16517.1" xmlns:sdtc="urn:hl7-org:sdtc" />
						<!-- Father's name; could be sent formatted or as a string like this -->
						<name>Lucas Valieri</name>
						<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male" />
						<!-- Father's birth date/time, SHOULD be sent. In this example, we did not know the 
						     father's birth date, so we assert that the birthTime is "Unknown" -->
						<birthTime nullFlavor="UNK" />
						<!-- Identifies the father's living status as deceased. -->
						<sdtc:deceasedInd value="true" xmlns:sdtc="urn:hl7-org:sdtc" />
						<!-- Date and optional time of death (only needed if deceasedInd="true") -->
						<sdtc:deceasedTime value="200301" />
					</subject>
				</relatedSubject>
			</subject>
			<!-- Stroke observation -->
			<component>
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.46"/>
					<templateId root="2.16.840.1.113883.10.20.22.4.46" extension="2015-08-01"/>
					<!-- Unique ID for this individual observation -->
					<id root="02faa204-db62-4610-864f-cb50b650d0fa" />
					<code code="64572001" codeSystem="2.16.840.1.113883.6.96" displayName="Disease">
						<translation code="75315-2" codeSystem="2.16.840.1.113883.6.1" displayName="Condition Family member" />
					</code>
					<text>
						<reference value="#FH1prob1" />
					</text>
					<statusCode code="completed"/>
					<!-- Date of the stroke -->
					<effectiveTime value="200301" />
					<!-- The actual finding on the father. 
						 Note: this is deliberately NOT set to 275104002-Family History of Stroke, 
					     since we are saying the father had a "stroke" not a "family history of stroke".
					     Family History of Stroke would be a valid code to add to the recordTarget's problem list.-->
					<value xsi:type="CD" code="230690007" codeSystem="2.16.840.1.113883.6.96" displayName="Cerebrovascular accident">
						<originalText>
							<reference value="#FH1prob1"/>
						</originalText>
					</value>
					<!-- Age at the time of the event -->
					<entryRelationship typeCode="SUBJ" inversionInd="true">
						<observation classCode="OBS" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.31"/>
							<code code="445518008" displayName="Age at Onset" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" />
							<text>
								<reference value="#FH1prob1age"/>
							</text>
							<statusCode code="completed"/>
							<!-- 'a' is UCUM for Years -->
							<value xsi:type="PQ" unit="a" value="72"/>
						</observation>
					</entryRelationship>
					<!-- This finding was the cause of death -->
					<entryRelationship typeCode="CAUS">
						<observation classCode="OBS" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.47"/>
							<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" />
							<text>
								<reference value="#FH1prob1comment"/>
							</text>
							<statusCode code="completed"/>
							<value xsi:type="CD" code="419099009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Dead"/>
						</observation>
					</entryRelationship>
				</observation>
			</component>
			<!-- High Blood Pressure observation -->
			<component>
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.46"/>
					<templateId root="2.16.840.1.113883.10.20.22.4.46" extension="2015-08-01"/>
					<!-- Unique ID for this individual observation -->
					<id root="04faa204-db62-4610-864f-cb50b650d0fa" />
					<code code="64572001" codeSystem="2.16.840.1.113883.6.96" displayName="Disease">
						<translation code="75315-2" codeSystem="2.16.840.1.113883.6.1" displayName="Condition Family member" />
					</code>
					<text>
						<reference value="#FH1prob2" />
					</text>
					<statusCode code="completed"/>
					<!-- Date of blood pressure (unknown) -->
					<effectiveTime nullFlavor="UNK" />
					<!-- The actual finding on the father. 
						Again, not using 160357008-Family History of Hypertension, since we're stating
						the father HAD hypertension, not a family history of hypertension -->
					<value xsi:type="CD" code="59621000" codeSystem="2.16.840.1.113883.6.96" displayName="Essential hypertension">
						<originalText>
							<reference value="#FH1prob2"/>
						</originalText>
					</value>
				</observation>
			</component>
		</organizer>
	</entry>
	<!-- Mother living with no known problems -->
	<entry>
		<!-- Organizes the Mother's medical history --> 
		<organizer classCode="CLUSTER" moodCode="EVN">
			<templateId root="2.16.840.1.113883.10.20.22.4.45"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.45" extension="2015-08-01"/>
			<!-- Unique identifier for this family member's HISTORY (not the individual) -->
			<id root="03faa204-db62-4610-864f-cb50b650d0fa" />
			<statusCode code="completed"/>
			<subject>
				<relatedSubject classCode="PRS">
					<!-- Identifies subject's relationship to recordTarget (i.e. Patient) -->
					<code code="MTH" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 RoleCode" displayName="mother">
						<originalText>
							<reference value="#FH2rel"/>
						</originalText>
					</code>
					<subject>
						<!-- Unique ID for the mother as an individual 
						     (note - different extension than father) -->
						<sdtc:id extension="98765432-2" root="1.3.6.1.4.1.16517.1" xmlns:sdtc="urn:hl7-org:sdtc" />
						<!-- Mother's name; could be sent formatted or as a string like this -->
						<name>Mia Jones</name>
						<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female" />
						<!-- Mother's birth time, SHOULD be sent -->
						<birthTime nullFlavor="UNK" />
						<!-- Identifies the mother's living status as living. -->
						<sdtc:deceasedInd value="false" xmlns:sdtc="urn:hl7-org:sdtc" />
					</subject>
				</relatedSubject>
			</subject>
			<component>
				<observation classCode="OBS" moodCode="EVN" negationInd="true">
					<!-- Similar to no known problems or allergies,
					     the use of negationInd corresponds with the newer Observation.ValueNegationInd 
					     The negationInd = true negates the value element -->
					<templateId root="2.16.840.1.113883.10.20.22.4.46"/>
					<templateId root="2.16.840.1.113883.10.20.22.4.46" extension="2015-08-01"/>
					<!-- Unique ID for this individual observation -->
					<id root="05faa204-db62-4610-864f-cb50b650d0fa" />
					<code code="64572001" codeSystem="2.16.840.1.113883.6.96" displayName="Disease">
						<translation code="75315-2" codeSystem="2.16.840.1.113883.6.1" displayName="Condition Family member" />
					</code>
					<text>
						<reference value="#FH2prob"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime nullFlavor="NI" />
					<!-- Generic problem; negationInd identifies the mother has having no active problems-->
					<value xsi:type="CD" code="55607006" codeSystem="2.16.840.1.113883.6.96" displayName="Problem" />
				</observation>
			</component>
		</organizer>
	</entry>
</section>

  1. C-CDA Example Search Help

    C-CDA Example Search Results
    This screen displays the results of executing the example search criteria against the existing examples recorded in the example database.

  2. Search Criteria Panel

    This panel allow you to further refine your queries and narrow the results

  3. Text Search Words

    Use this field to enter words related to your search. These words can appear in the title, the comments or as part of a special list of keywords associated with the example. The search words should be entered with spaces separating the items.

  4. Filter by example status

    By selecting the various statuses, the search results can be limited to only the example that are set to the selected status(es). By removing all status selections, the filtering is removed and examples from all statuses will be returned (based on any other filtering).

  5. Select only ONC Certified examples

    These are samples referenced in a government rule or certification companion guide.

  6. Execute the search based on the criteria entered (or retrieve all examples if no criteria specified).

  7. The number of results that match the query parameters can be found here.

  8. Use this link to jump back to the initial page of the application (that lists the sections).

  9. This columns list the names of the examples that match the criteria (and the comment for each example).

  10. This columns lists the area in the C-CDA specification (the specification is broken into distinct topics for the various exchangeable documents, the common header, and the sections that occur within the exchangeable documents) that the example demonstrates.

  11. This columns lists the state of the example in the example verification and approval process.

  12. You can select to download the examples directly or navigate to page with the full detailed description of the example.

  13. Tour Complete

    Return to the C-CDA Example Search Results page.