Clinical Document Architecture (CDA) is a document markup standard that specifies the structure and semantics of clinical documents for the purpose of exchange between health care providers and patients.
| CDA Entry | Example | Salesforce Object | Field |
|---|---|---|---|
| Name: Given Name | Jane | EhrPatient | GivenName1 |
| Name: Family Name | Appleseed-Monroe | EhrPatient | FamilyName1 |
| Name: Family Name | Appleseed-Monroe | Account | Account Name |
| Name: Family Name | Appleseed-Monroe | Contact | Contact Name |
| SSN | 123-456-7890 | ||
| Birth Time (date) | 19770330 | Account | Date of Birth |
| Birth Time (date) | 19770330 | EhrPatient | BirthDate |
| Gender: Code | F | EhrPatient | GenderCode |
| Gender: Display Name | Female | EhrPatient | GenderLabel |
| Gender: Code System | AdministrativeGender (2.16.840.1.113883.5.1) | EhrPatient | GenderSystem |
| Marital Status: Code | M | EhrPatient | MaritalStatusCode |
| Marital Status: Display Name | Married | EhrPatient | MaritalStatusLabel |
| Language: Code | en | EhrPatient | Communication1Code (1 to 5) |
| Language: Display Name | English | EhrPatient | Communication1Label (1 to 5) |
| Language: Display Name | English | Contact | PrimaryLanguage |
| Language: Display Name | English | Account | PrimaryLanguage |
| Language: Code System | LanguageCode (2.16.840.1.113883.1.11.11526) | EhrPatient | Communication1System (1 to 5) |
| Street Address: Line 1 | 999 Huckleberry Ave, Apt #3 | EhrPatient | Address1Line1 |
| Street Address: Line 1 | 999 Huckleberry Ave, Apt #3 | Contact | Address Information: Mailing Street |
| Street Address: Line 2 | EhrPatient | Address1Line2 | |
| Street Address: City | Springfield | EhrPatient | Address1City |
| Street Address: City | Springfield | Contact | Mailing City |
| Street Address: State | PA | EhrPatient | Address1State |
| Street Address: State | PA | Contact | Mailing State |
| Street Address: Postal Code | 19604 | EhrPatient | Address1PostalCode |
| Street Address: Postal Code | 19604 | Contact | Mailing Zip/ Postal Code |
| Street Address: Country | US | EhrPatient | Address1Country |
| Street Address: Country | US | Contact | Mailing Country |
| Home Telephone | 1(610)555-0000 | EhrPatient | Telecom1Use, Telecom1Value |
| Home Telephone | 1(610)555-0000 | Contact | HomePhone |
| Mobile Telephone | 1(610)555-1111 | EhrPatient | Telecom2Use, Telecom2Value |
| Mobile Telephone | 1(610)555-1111 | Contact | Phone |
| CDA Entry | Example | Salesforce Object | Field |
|---|---|---|---|
| Effective Time: Low Value | 1/22/2011 | EhrCondition | DateAsserted |
| Effective Time: High Value | 1/31/2011 | ||
| Narrative Description | Sleep Apnea; Patient experiencing flu symptoms including chills and fever | EhrCondition | Notes |
| Condition: Code | 6142004 | EhrCondition | CategoryCode |
| Condition: Display Name | Influenza | EhrCondition | CatergoryLabel |
| Condition: Code System | SNOMED CT (2.16.840.1.113883.6.96) | EhrCondition | CategorySystem |
| Symptoms: Code | 43724002 | EhrCondition | EvidenceCode |
| Symptoms: Display Name | Chill | EhrCondition | EvidenceDetail, EvidenceLabel |
| Symptoms: Code System | SNOMED CT (2.16.840.1.113883.6.96) | EhrCondition | EvidenceSystem |
This section can repeat for multiple medications. EHR Dosage Instruction object is a child object to EHR Medication Prescription, which contains Dose, Route and Frequency.
Note
| CDA Entry | Example | Salesforce Object | Field |
|---|---|---|---|
| Effective Time: Low Value (Date) | 20070312 | EhrMedicationPrescription | DateWritten |
| Status Code | active | EhrMedicationPrescription | StatusCode, StatusLabel, StatusSystem |
| Narrative Text | Take Acetaminophen 500 MG Oral Tablet every 8 hours for 10 days; Take Fluoxetine 15 MG Oral Tablet once a day at breakfast. | EhrDosageInstruction | Instruction, SupplementalInstruction |
| Medication Information: Code | 198440 | EhrMedicationPrescription | DispenseMedicationCode, MedicationCode |
| Medication Information: Display Name | Acetaminophen 500 MG Oral Tablet | EhrMedicationPrescription | DispenseMedicationLabel, MedicationCodeLabel |
| Medication Information: Code System | RxNorm (2.16.840.1.113883.6.88) | EhrMedicationPrescription | DispenseMedicationCodeSystem, MedicationCodeSystem |
| Route of Administration: Code | C38288 | EhrDosageInstruction | RouteCode |
| Route of Administration: Display Name | Oral | EhrDosageInstruction | RouteLabel |
| Route of Administration: Code System | NCI Thesaurus (2.16.840.1.113883.3.26.1.1) | EhrDosageInstruction | RouteSystem |
| Dose Quantity | EhrDosageInstruction | DoseQuantityUnit, DoseQuantityValue | |
| Product Form: Code | C42998 | EhrMedicationPrescription | DispenseMedicationProductFormCode |
| Product Form: Display Name | Tablet | EhrMedicationPrescription | DispenseMedicationProductFormLabel |
| Product Form: Code System | NCI Thesaurus (2.16.840.1.113883.3.26.1.1) | EhrMedicationPrescription | DispenseMedicationProductFormSystem |
| CDA Entry | Example | Salesforce Object | Field |
|---|---|---|---|
| Effective Time: Low Value (Date) | 20070312 | EhrAllergyIntolerance | RecordedDate |
| Status Code | completed | EhrAllergyIntolerance | StatusCode, StatusLabel, StatusSystem |
| Narrative Text | Patient relays that they experienced erythema of skin after taking sulfa drug and was told to never take it again; Patient has allergy to soybean, Experienced swelling of the tongue as a child and has been instructed to avoid soybean. | EhrAllergyIntolerance | Reaction |
| Type of Allergy: Code | 416098002 | EhrAllergyIntolerance | SensitivityTypeCode |
| Type of Allergy: Display Name | drug allergy | EhrAllergyIntolerance | SensitivityTypeLabel |
| Type of Allergy: Code: Code System | SNOMED CT (2.16.840.1.113883.6.96) | EhrAllergyIntolerance | SensitivityTypeSystem |
| Drug: Code | 10180 | EhrAllergyIntolerance | SubstanceCode |
| Drug: Display Name | Sulfamethoxazole | EhrAllergyIntolerance | Substance255 |
| Drug: Code System | RxNorm (2.16.840.1.113883.6.88) | EhrAllergyIntolerance | SubstanceCodeSystem |
| Reaction: Code | 444827008 | No equivalent in Health Cloud | |
| Reaction: Display Name | Erythema of skin | EhrAllergyIntolerance | Reaction255 |
| Reaction: Code System | SNOMED CT (2.16.840.1.113883.6.96) | No equivalent in Health Cloud | |
| Severity: Code | 6736007 | EhrAllergyIntolerance | CriticalityCode |
| Severity: Display Name | Moderate | EhrAllergyIntolerance | CriticalityLabel |
| Severity: Code System | SNOMED CT (2.16.840.1.113883.6.96) | EhrAllergyIntolerance | CriticalitySystem |
| CDA Entry | Example | Salesforce Object | Field |
|---|---|---|---|
| Effective Time (Vaccine Date) | 20070312 | EhrImmunization | DateAdministered |
| Vaccine Code | 33 | EhrImmunization | VaccineTypeCode |
| Vaccine DisplayName | Pneumococcal (PCV, PPSV) | EhrImmunization | VaccineTypeLabel |
| Vaccine Code System | CVX (2.16.840.1.113883.12.292) | EhrImmunization | VaccineTypeSystem |
| Status Code | Completed | ||
| Dose Quantity: Unit | mL | EhrImmunization | DoseQuantityUnits |
| Dose Quantity: Value | 2 | EhrImmunization | DoseQuantityValue |
| Lot Number | 3422 | EhrImmunization | LotNumber |
| CDA Entry | Example | Salesforce Object | Field |
|---|---|---|---|
| Effective Time: Low Value (Date) | 20070312 | EHR Care Plan | PeriodStart |
| Effective Time: High Value (Date) | EHR Care Plan | PeriodEnd | |
| Narrative Text | ”Patient is to schedule CT scan to examine knee; Follow-up appointment in 2 weeks; Patient was supplied with Malarone 250/100 Oral Tablet and should take one every 24 hours during their visit to Africa to prevent Malaria; Patient instructed to take this medication by mouth with food or a milky drink (such as whole milk, milkshake) that contains fat. “ | EHR Care Plan | Notes |
| Procedure Code | 73700 | EHR Procedure Request | Code |
| Procedure Display Name | CT lower Extremity (Leg) w/o contrast | EHR Procedure Request | CodeLabel |
| Requested Date (Same as Effective Time: Low Value) | EHR Procedure Request | OrderedOn |
| CDA Entry | Example | Salesforce Object | Field |
|---|---|---|---|
| Effective Time: Low Value (Date) | 201209011200 | EhrProcedure | PerformedDateTime |
| Narrative Text | Cath showed significant CAD, best treated medically. | EhrProcedure | Notes |
| Procedure: Code | 93452 | EhrProcedure | Code |
| Procedure: Display Name | L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S+I | EhrProcedure | CodeLabel |
| Practitioner: Prefix | Dr | EhrPractitioner | PrefixName1 (EHR Procedure and EHR Practitioner objects are connected via the EHR Procedure Performer Object) |
| Practitioner: Given | Jefferey | EhrPractitioner | GivenName1 |
| Practitioner: Given | Q | EhrPractitioner | GivenName1 |
| Practitioner: Family | Smith | EhrPractitioner | FamilyName1 |
| Practitioner: Suffix | MD | EhrPractitioner | SuffixName1 |
| Practitioner: Street Address Line 1 | 877 E St NW | EhrPractitioner | Address1Line1 |
| Practitioner: Street Address Line2 | EhrPractitioner | Address1Line2 | |
| Practitioner: City | Springfield | EhrPractitioner | Address1City |
| Practitioner: State | OH | EhrPractitioner | Address1State |
| Practitioner: Postal Code | 45503 | EhrPractitioner | Address1PostalCode |
| Practitioner: Country | US | EhrPractitioner | Address1Country |
| Practitioner: Telephone Number | 1(937)555-0122 | EhrPractitioner | Telecom1System, Telecom1Use, Telecom1Value |
| Practioner Organization:Name | Happy Heart Associates | EhrPractitioner | Location1Name |
| Practioner Organization: Telephone Number | 1(937)555-0199 | EhrPractitioner | Location1TelecomSystem, Location1TelecomUse, Location1TelecomValue |
| Practioner Organization: Street Address Line 1 | 100 Cardio Lane | EhrPractitioner | Location1Line1 |
| Practioner Organization: Street Address Line 2 | EhrPractitioner | Location1Line2 | |
| Practioner Organization: City | Springfield | EhrPractitioner | Location1City |
| Practioner Organization: State | OH | EhrPractitioner | Location1State |
| Practioner Organization: Postal Code | 45503 | EhrPractitioner | Location1PostalCode |
| Practioner Organization: Country | US | EhrPractitioner | Location1Country |
| Facility: Code | 1005-8 | ||
| Facility: Display Name | Cardiac Catheterization Lab | EhrProcedure | Location |
| CDA Entry | Example | Salesforce Object | Field |
|---|---|---|---|
| Effective Time (Date) | 20110914 | EhrObservation | AppliesDateTime |
| Status Code | Completed | EhrObservation | StatusCode |
| Narrative Text | ”Cholesterol - 176 mg/dL (normal) Triglyceride - 100 mg/dL (normal) HDL - 60 mg/dL (normal) LDL - 116 mg/dL (normal)“ | EhrObservation | ValueLabel |
| Observation Code | 2093-3 | EhrObservation | MethodCode |
| Observation Display Name | Cholesterol [Mass/volume] in Serum or Plasma | EhrObservation | MethodLabel |
| Observation Code System | LOINC (2.16.840.1.113883.6.1) | EhrObservation | MethodSystem |
| Observed Value (Result): Value | 176 | EhrObservation | ValueQuantity |
| Observed Value (Result): Unit | mg/DL | EhrObservation | ValueQuantityUnit |
| Interpretation Code: Code | N | EhrObservation | InterpretationCode |
| Interpretation Code: Display Name | Normal | EhrObservation | InterpretationLabel |
| Interpretation Code: Code System | ObservationInterpretation (2.16.840.1.113883.5.83) | EhrObservation | InterpretationSystem |
| Reference Range | Recommended: 0-199; Moderate Risk: 200-239; High Risk: 240+ | EhrObservation | ReferenceRangeHighValue, ReferenceRangeHighUnit, ReferenceRangeLowValue, ReferenceRangeLowUnit |
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