C-CDA Project: Social History Content
1
SECTION LEVEL ............................................................................................................. 2
1.1
2
Updated Social History Section (V2) ........................................................................... 3
ENTRY LEVEL ................................................................................................................ 6
2.1
Social History Observation (V2) .................................................................................. 6
2.1.1
Template XML Sample ........................................................................................ 8
2.1.2
IMPACT Data Element under “Social History Observation V2” ............................. 8
2.2
NEW Cultural and Religious Practices ........................................................................ 9
2.2.1
Template XML Sample ...................................................................................... 11
2.2.2
IMPACT Data Element under “Cultural and Religious Practices” ........................ 11
2.3
NEW Environmental Exposures ............................................................................... 11
2.3.1
Template XML Sample ...................................................................................... 13
2.3.2
IMPACT Data Element under “Environmental Exposures” ................................. 13
2.4
3
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NEW Housing Status Observation ............................................................................ 14
2.4.1
Template XML Sample ...................................................................................... 15
2.4.2
IMPACT Data Element under “Housing Status” ................................................. 15
DOCUMENT SPECIFIC CONFORMANCE AND CARDINALITY ......................................... 16
C-CDA Project: Social History Content
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SOCIAL HISTORY SECTION
Note:
For hierarchical position demonstration purposes, only few Social History Status entry
templates have been included here.






MAY [0...*] – Pregnancy Observation
MAY [0...*] – Smoking Status Observation
MAY [0...*] – Caregiver Characteristics
SHALL [0...*] Cultural and Religious Practices, SHOULD?
SHOULD [0...*] Environmental Exposures, MAY?
SHALL [0...*] – Housing Status Observation, SHOULD?
C-CDA Project: Social History Content
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SECTION LEVEL
2.1
Updated Social History Section (V2)
6/19/2013
[section: templateId 2.16.840.1.113883.10.20.22.2.17.2 (open)]
Table 1: Social History Section (V2) Contexts
Used By:
Contains Entries:
Caregiver Characteristics
Cultural and Religious Practices
Pregnancy Observation
Smoking Status Observation
Social History Observation (V2)
Tobacco Use
This section contains data defining the patient’s occupational, personal (e.g. lifestyle),
social, environmental and health risk factors and history, as well as administrative data
such as marital status, race, ethnicity and religious affiliation. Social history can have
significant influence on a patient’s physical, psychological and emotional health and
wellbeing so should be considered in the development of a complete record.
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Table 2: Social History Section (V2) Constraints Overview
Name
XPath
Card.
Verb
Data
Type
CONF#
Fixed Value
section[templateId/@root = '2.16.840.1.113883.10.20.22.2.17.2']
templateId
1..1
SHALL
28114
1..1
SHALL
28115
1..1
SHALL
28116
1..1
SHALL
28117
title
1..1
SHALL
28118
text
1..1
SHALL
28119
entry
0..*
MAY
28120
1..1
SHALL
28121
0..*
MAY
28122
1..1
SHALL
28123
0..*
SHOULD
28124
1..1
SHALL
28125
0..*
MAY
28126
1..1
SHALL
28127
0..*
MAY
28361
1..1
SHALL
28362
0..*
MAY
1..1
SHALL
@root
code
@code
2.16.840.1.113883.10.20.22.2.17.2
2.16.840.1.113883.6.1 (LOINC) =
29762-2
observation
entry
observation
entry
observation
entry
observation
entry
observation
entry
Entry
28366
28367
observation
1. SHALL contain exactly one [1..1] templateId (CONF:28114) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.2.17.2" (CONF:28115).
2. SHALL contain exactly one [1..1] code (CONF:28116).
a. This code SHALL contain exactly one [1..1] @code="29762-2" Social History
(CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:28117).
3. SHALL contain exactly one [1..1] title (CONF:28118).
4. SHALL contain exactly one [1..1] text (CONF:28119).
5. MAY contain zero or more [0..*] entry (CONF:28120) such that it
a. SHALL contain exactly one [1..1] Social History Observation (V2)
(templateId:2.16.840.1.113883.10.20.22.4.38.2) (CONF:28121).
6. MAY contain zero or more [0..*] entry (CONF:28122) such that it
C-CDA Project: Social History Content
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a. SHALL contain exactly one [1..1] Pregnancy Observation
(templateId:2.16.840.1.113883.10.20.15.3.8) (CONF:28123).
7. SHOULD contain zero or more [0..*] entry (CONF:28124) such that it
a. SHALL contain exactly one [1..1] Smoking Status Observation
(templateId:2.16.840.1.113883.10.20.22.4.78) (CONF:28125).
8. MAY contain zero or more [0..*] entry (CONF:28126) such that it
a. SHALL contain exactly one [1..1] Tobacco Use
(templateId:2.16.840.1.113883.10.20.22.4.85) (CONF:28127).
9. MAY contain zero or more [0..*] entry (CONF:28361) such that it
a. SHALL contain exactly one [1..1] Caregiver Characteristics
(templateId:2.16.840.1.113883.10.20.22.4.72) (CONF:28362).
10. MAY contain zero or more [0..*] entry (CONF:28366) such that it
a. SHALL contain exactly one [1..1] Cultural and Religious Practices
(templateId:2.16.840.1.113883.10.20.22.4.111) (CONF:28367).
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3
ENTRY LEVEL
3.1
Social History Observation (V2)
[observation: templateId 2.16.840.1.113883.10.20.22.4.38.2 (open)]
Table 3: Social History Observation (V2) Contexts
Used By:
Contains Entries:
Social History Section (V2) (optional)
This Social History Observation defines the patient’s occupational, personal (e.g.,
lifestyle), social, and environmental history and health risk factors, as well as
administrative data such as marital status, race, ethnicity, and religious affiliation.
Table 4: Social History Observation (V2) Constraints Overview
Name
XPath
Card.
Verb
Data
Type
CONF#
Fixed Value
observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.38.2']
@classCode
1..1
SHALL
28128
2.16.840.1.113883.5.6
(HL7ActClass) = OBS
@moodCode
1..1
SHALL
28129
2.16.840.1.113883.5.1001
(ActMood) = EVN
templateId
1..1
SHALL
28130
1..1
SHALL
28131
id
1..*
SHALL
28132
code
1..1
SHALL
28133
0..1
SHOULD
28134
0..1
SHOULD
28135
0..1
SHOULD
28136
0..1
SHOULD
28137
1..1
SHALL
28139
1..1
SHALL
28140
0..1
SHOULD
28141
@root
@code
2.16.840.1.113883.10.20.22.4.38.2
2.16.840.1.113883.3.88.12.80.60.2
(Social History Type Set Definition
(V2))
originalText
reference
@value
statusCode
@code
value
2.16.840.1.113883.5.14
(ActStatus) = completed
11. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:28128).
12. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
2.16.840.1.113883.5.1001 STATIC) (CONF:28129).
C-CDA Project: Social History Content
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13. SHALL contain exactly one [1..1] templateId (CONF:28130) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.38.2" (CONF:28131).
14. SHALL contain at least one [1..*] id (CONF:28132).
15. SHALL contain exactly one [1..1] code (CONF:28133).
a. This code SHOULD contain zero or one [0..1] @code, which SHOULD be selected
from ValueSet Social History Type Set Definition (V2)
2.16.840.1.113883.3.88.12.80.60.2 DYNAMIC (CONF:28134).
b. This code SHOULD contain zero or one [0..1] originalText (CONF:28135).
i.
The originalText, if present, SHOULD contain zero or one [0..1]
reference (CONF:28136).
1. The reference, if present, SHOULD contain zero or one [0..1]
@value (CONF:28137).
Table 5: Social History Type Set Definition (V2)
Value Set: Social History Type Set Definition (V2) 2.16.840.1.113883.3.88.12.80.60.2
Code
Code System
Print Name
229819007
SNOMEDCT
Tobacco use and exposure (observable entity)
256235009
SNOMEDCT
Exercise (observable entity)
160573003
SNOMEDCT
Alcohol intake (observable entity)
364393001
SNOMEDCT
Nutritional observable (observable entity)
364703007
SNOMEDCT
Employment detail (observable entity)
425400000
SNOMEDCT
Toxic exposure status (observable entity)
363908000
SNOMEDCT
Details of drug misuse behavior (observable entity)
228272008
SNOMEDCT
Health-related behavior (observable entity)
105421008
SNOMEDCT
Educational Achievement(observable entity)
423514004
SNOMEDCT
Community resource details (observable entity)
302160007
SNOMEDCT
Household, family and support network detail
(observable entity)
102487004
SNOMEDCT
environmental risk factor (observable entity)
424483007
SNOMEDCT
transportation details (observable entity)
442133001
SNOMED-
housing history (observable entity)
C-CDA Project: Social History Content
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CT
224209007
SNOMEDCT
Residence and accommodation circumstances
(observable entity)
446996006
SNOMEDCT
Dosage of radiation exposure (observable entity)
3.1.1 Template XML Sample
For demonstration purposes, sample XML for Tobacco Use is provided below
Figure 1: Social History Observation Example (Updated)
<entry>
<observation classCode="OBS" moodCode="EVN">
<!-- ** Social history observation V2 ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.38.2"/>
<id root="37f76c51-6411-4e1d-8a37-957fd49d2cef"/>
<code code="442133001" codeSystem="2.16.840.1.113883.6.96"
displayName="Housing history"> </code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20130312"/>
</effectiveTime>
<value xsi:type="CD" code="32911000"
displayName="homeless"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"> </value>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<!-- ** Social history observation V2 ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.38.2"/>
<id root="ff8a8af0-d73e-11e2-8b8b-0800200c9a66"/>
<code code="102487004" codeSystem="2.16.840.1.113883.6.96"
displayName="Environmental Risk Factor"> </code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20130312"/>
</effectiveTime>
<value xsi:type="CD" code="422555009"
displayName="environment with high pollution level"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"> </value>
</observation>
</entry>
3.1.2 IMPACT Data Element under “Social History Observation V2”
10.3.1.8 Housing Status
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10.3.1.7 Environmental Factors
10.18.4.7 Lives alone
10.18.4.9 Lives with family
10.18.4.8 Inadequate community support
10.18.5
Exposures
10.18.5.1 Lifetime Radiation Exposure
10.18.5.2 Risky Sexual Behavior
10.18.5.3 Workplace exposures
10.18.5.4 Other exposures
10.18.6.1 Environmental Factors
10.18.6.2 Housing Status
10.18.6.4 Environmental Risks and Decision Modifiers: Home supports
3.1.2.5 Transportation
3.2
NEW Cultural and Religious Practices
[observation: templateId 2.16.840.1.113883.10.20.22.4.111 (open)]
Table 6: Cultural and Religious Practices Contexts
Used By:
Contains Entries:
Social History Section (V2) (optional)
This clinical statement describes an individual practices based on spiritual, religious,
and cultural beliefs. The details in this statement may describe a special diet (vegan or
vegetarian) as a result of a spiritual, cultural or religious practice. The religion code
captured in the document header only identifies the patient religious affiliation.
C-CDA Project: Social History Content
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Table 7: Cultural and Religious Practices Constraints Overview
Name
XPath
Card.
Verb
Data
Type
CONF#
Fixed Value
observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.111']
@classCode
1..1
SHALL
27924
2.16.840.1.113883.5.6
(HL7ActClass) = OBS
@moodCode
1..1
SHALL
27925
2.16.840.1.113883.5.1001
(ActMood) = EVN
templateId
1..1
SHALL
27926
1..1
SHALL
27927
id
1..*
SHALL
27928
code
1..1
SHALL
27929
1..1
SHALL
27930
406198009
1..1
SHALL
27931
2.16.840.1.113883.6.96
(SNOMED-CT) =
2.16.840.1.113883.6.96
1..1
SHALL
27936
1..1
SHALL
27937
0..1
SHALL
28442
0..1
MAY
28443
@root
@code
@codeSystem
statusCode
@code
value
@nullFlavor
2.16.840.1.113883.10.20.22.4.111
2.16.840.1.113883.5.14
(ActStatus) = completed
16. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:27924).
17. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
2.16.840.1.113883.5.1001 STATIC) (CONF:27925).
18. SHALL contain exactly one [1..1] templateId (CONF:27926) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.111" (CONF:27927).
19. SHALL contain at least one [1..*] id (CONF:27928).
20. SHALL contain exactly one [1..1] code (CONF:27929).
a. This code SHALL contain exactly one [1..1] @code="406198009" personal
belief pattern (observable entity) (CONF:27930).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED-CT
2.16.840.1.113883.6.96) (CONF:27931).
21. SHALL contain exactly one [1..1] statusCode (CONF:27936).
a. This statusCode SHALL contain exactly one [1..1] @code="completed"
Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC)
(CONF:27937).
22. SHALL contain zero or one [0..1] value (CONF:28442).
a. The value, if present, MAY contain zero or one [0..1] @nullFlavor
(CONF:28443).
C-CDA Project: Social History Content
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3.2.1 Template XML Sample
For demonstration purposes, sample XML for Environmental Risk Factors is provided
below.
<entry>
<observation classCode="OBS" moodCode="EVN">
<!-- **Cultural and Religious Practices (NEW)**-->
<templateId root="2.16.840.1.113883.10.20.22.4.111"/>
<id root="37f76c51-6411-4e1d-8a37-957fd49d2cef"/>
<code code="406198009" codeSystem="2.16.840.1.113883.6.96"
displayName="personal belief pattern"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="20130312"/>
</effectiveTime>
<value xsi:type="ST">Does not accept blood tranfusions,
or donates,or stores blood for transfusion.</value>
</observation>
</entry>
3.2.2 IMPACT Data Element under “Cultural and Religious Practices”
8.9.3
3.3
Religious/cultural issues in care
NEW Environmental Exposures
[observation: templateId 2.16.840.1.113883.10.20.22.4.110 (open)]
Table 8: Environmental Exposures Contexts
This clinical statement describes the patient environmental exposures and risks. This
includes but is not limited to airborne illnesses, toxic waste exposures, and workplace
exposures.
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Table 9: Environmental Exposures Constraints Overview
Name
XPath
Card.
Verb
Data
Type
CONF#
Fixed Value
observation[templateId/@root = '2.16.840.1.113883.10.20.22.4.110']
@classCode
1..1
SHALL
27908
2.16.840.1.113883.5.6
(HL7ActClass) = OBS
@moodCode
1..1
SHALL
27909
2.16.840.1.113883.5.1001
(ActMood) = EVN
templateId
1..1
SHALL
27910
1..1
SHALL
27911
id
1..*
SHALL
27912
code
1..1
SHALL
27913
1..1
SHALL
27914
102487004
1..1
SHALL
27915
2.16.840.1.113883.6.96
(SNOMED-CT) =
2.16.840.1.113883.6.96
1..1
SHALL
27920
1..1
SHALL
27921
@root
@code
@codeSystem
statusCode
@code
value
1..1
SHALL
@nullFlavor
0..1
MAY
CD
28341
@code
0..1
SHOULD
28343
2.16.840.1.113883.10.20.22.4.110
2.16.840.1.113883.5.14
(ActStatus) = completed
28332
2.16.840.1.113883.6.96
(SNOMED-CT)
23. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:27908).
24. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
2.16.840.1.113883.5.1001 STATIC) (CONF:27909).
25. SHALL contain exactly one [1..1] templateId (CONF:27910) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.110" (CONF:27911).
26. SHALL contain at least one [1..*] id (CONF:27912).
27. SHALL contain exactly one [1..1] code (CONF:27913).
a. This code SHALL contain exactly one [1..1] @code="102487004"
environmental risk factor (observable entity) (CONF:27914).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED-CT
2.16.840.1.113883.6.96) (CONF:27915).
28. SHALL contain exactly one [1..1] statusCode (CONF:27920).
a. This statusCode SHALL contain exactly one [1..1] @code="completed"
Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC)
(CONF:27921).
29. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:28332).
a. This value MAY contain zero or one [0..1] @nullFlavor (CONF:28341).
C-CDA Project: Social History Content
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6/19/2013
If the code is unknown, @nullFlavor SHALL be “UNK”. If the code is
something other than SNOMED CT, @nullFlavor SHALL be “OTH” and
the other code SHOULD be placed in a translation element
(CONF:28342).
b. This value SHOULD contain zero or one [0..1] @code, which SHOULD be
selected from CodeSystem SNOMED-CT (2.16.840.1.113883.6.96)
(CONF:28343).
3.3.1 Template XML Sample
For demonstration purposes, sample XML for Environmental Risk Factors is provided
below.
<entry>
<observation classCode="OBS" moodCode="EVN">
<!-- **Environmental Exposures ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.110"/>
<id root="ff8a8af0-d73e-11e2-8b8b-0800200c9a66"/>
<code code="102487004" codeSystem="2.16.840.1.113883.6.96"
displayName="Environmental Risk Factor"> </code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20050501"/>
</effectiveTime>
<!-- The -->
<value xsi:type="CD" code="422555009"
displayName="environment with high pollution level (finding)"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"> </value>
</observation>
</entry>
3.3.2 IMPACT Data Element under “Environmental Exposures”
10.3.1.7 Environmental Factors
10.18.6.1 Environmental Factors
10.18.5
Exposures
10.18.5.1 Lifetime Radiation Exposure
10.18.5.3 Workplace exposures
10.18.5.4 Other exposures
10.18.6.4 Environmental Risks and Decision Modifiers: Home supports
C-CDA Project: Social History Content
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NEW Housing Status Observation
[observation: templateId 2.16.840.1.113883.10.20.22.4.109 (open)]
This clinical statement defines a patient's residence circumstance and accommodation
status. This statement includes but is not limited to physical the type of residence
(trailer, single family home, assisted living), living arrangement (e.g. lives alone, lives
with mother), and housing status (evicted, homeless, awaiting housing).
30. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem:
HL7ActClass 2.16.840.1.113883.5.6 STATIC) (CONF:27890).
31. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood
2.16.840.1.113883.5.1001 STATIC) (CONF:27891).
32. SHALL contain exactly one [1..1] templateId (CONF:27892) such that it
a. SHALL contain exactly one [1..1]
@root="2.16.840.1.113883.10.20.22.4.109" (CONF:27893).
33. SHALL contain at least one [1..*] id (CONF:27894).
34. SHALL contain exactly one [1..1] code (CONF:27895).
a. This code SHALL contain exactly one [1..1] @code="224209007" residence
and accomodation circumstance (CONF:27905).
b. This code SHALL contain exactly one [1..1]
@codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED-CT
2.16.840.1.113883.6.96) (CONF:27906).
35. SHALL contain exactly one [1..1] statusCode (CONF:27901).
a. This statusCode SHALL contain exactly one [1..1] @code="completed"
Completed (CodeSystem: ActStatus 2.16.840.1.113883.5.14 STATIC)
(CONF:27902).
36. SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:28339).
a. This value SHALL contain exactly one [1..1] @code, which SHOULD be selected
from ValueSet Residence and Accomodation Value Set
2.16.840.1.113883.11.20.9.49 (CONF:28340).
Table 10: Residence and Accomodation Value Set
Value Set: Residence and Accomodation Value Set 2.16.840.1.113883.11.20.9.49
Code
Code System
Print Name
105529008
SNOMED-CT
Lives alone
105531004
SNOMED-CT
Housing unsatisfactory
309682003
SNOMED-CT
Poor housing
105531004
SNOMED-CT
Housing unsatisfactory
267129008
SNOMED-CT
Inadequate housing
310207003
SNOMED-CT
Sheltered housing
224133007
SNOMED-CT
Lives with family
32911000
SNOMED-CT
Homeless
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3.4.1 Template XML Sample
For demonstration purposes, sample XML for Residence Circumstances (Copy) is
provided below.
<entry>
<observation classCode="OBS" moodCode="EVN">
<!-- **Housing Status Observation ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.109"/>
<id root="37f76c51-6411-4e1d-8a37-957fd49d2cef"/>
<code code="224209007" codeSystem="2.16.840.1.113883.6.96"
displayName="residence and accomodation circumstance"> </code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20050501"/>
</effectiveTime>
<value xsi:type="CD" code="32911000"
displayName="homeless"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"> </value>
</observation>
</entry>
3.4.2 IMPACT Data Element under “Housing Status”
10.3.1.8 Housing Status
10.18.6.2 Housing Status
10.18.4.7 Lives alone
10.18.4.9 Lives with family
10.18.4.8 Inadequate community support
C-CDA Project: Social History Content
4
6/19/2013
DOCUMENT SPECIFIC CONFORMANCE AND
CARDINALITY
Table 10: Mental Status Section Contexts
Contains Entries:
Transfer Summary
Referral Note
Consult Note
Social History Section
(optional)
(optional)
(optional)
Patient Values Section
SHALL (1..*)
SHALL (1..*)
SHALL (1..*)
Environmental Exposures
SHOULD (1..*)
SHOULD (1..*)
SHOULD (1..*)
Housing Status Observation
SHALL (1..*)
SHALL (1..*)
SHOULD (1..*)
Cultural and Religious
Practices
SHALL (1..*)
SHALL (1..*)
SHALL (1..*)