Normal Family History Father deceased-Mother alive

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Example metadata last updated 2017-12-11 19:21:13.111000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 1/15/2015
  • SDWG: 2/19/2015
  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

SITE C-CDA Validator

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, benjamin@epic.com (GitHub: benjaminflessner)

Full sample: Family history in empty CCD

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="Natural Parent">
						<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"/>
						<!-- 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="Condition" >
						<translation code="75315-2" codeSystem="2.16.840.1.113883.6.1" displayName="Condition Family Member" />
					</code>
					<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="Stroke">
						<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="Condition" >
						<translation code="75315-2" codeSystem="2.16.840.1.113883.6.1" displayName="Condition Family Member" />
					</code>
					<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="Natural Parent">
						<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"/>
						<!-- 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="Condition" >
						<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>
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