Darena Solutions - CCDA 2 FHIR
Upload
Sample CCDAs
Sample #1
Sample #2
Ignore Duplicate Ids (Generate Unique Ids)
Convert
<?xml version="1.0" encoding="UTF-8"?> <?xml-stylesheet type="text/xsl" href="CDA.xsl"?> <!-- Title: Continuity of Care Document (CCD) $LastChangedDate: 2015-8-11 11:25:09 -0400 (Wed, 11 Aug 2015) $ 2015-10 AM and DB: -Altered to be error free (not considering MU rules), general updates per recommendations, and added US Realm Header Template ID. 2014-10 DB: -Created 'master doc' MANY modifications, additions, and reorganizations were made to accommodate the requirements. In addition, removed Advance Directives, Family History components, and others as not required by test data. -Updated to match 170.315_b1_toc_amb_sample1.docx test data. ******************************************************** Disclaimer: This sample file contains representative data elements to represent a Continuity of Care Document (CCD). The file depicts a fictional character's health data. Any resemblance to a real person is coincidental. To illustrate as many data elements as possible, the clinical scenario may not be plausible. The data in this sample file is not intended to represent real patients, people or clinical events. This sample is designed to be used in conjunction with the C-CDA Clinical Notes Implementation Guide. ******************************************************** --> <ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:voc="urn:hl7-org:v3/voc" xmlns:sdtc="urn:hl7-org:sdtc"> <realmCode code="US"/> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <!-- US Realm Header ID--> <templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.1.1"/> <!-- CCD template ID--> <templateId root="2.16.840.1.113883.10.20.22.1.2" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.1.2"/> <!-- Globally unique identifier for the document --> <id extension="ToC_2" root="2.16.840.1.113883.19.5.99999.1"/> <code code="34133-9" displayName="Summarization of Episode Note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <!-- Title of this document --> <title>170.315_b1_toc_amb_ccd_r21_sample1 test data</title> <effectiveTime value="20150622"/> <confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality"/> <languageCode code="en-US"/> <setId extension="sTT101" root="2.16.840.1.113883.19.5.99999.19"/> <!-- Version of this document --> <versionNumber value="1"/> <recordTarget> <patientRole> <id extension="111223333" root="2.16.840.1.113883.4.1"/> <!-- Example Social Security Number using the actual SSN OID. --> <addr use="HP"> <!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 --> <streetAddressLine>1001 Amber Dr</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> <!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 --> </addr> <telecom value="tel:+1(555)-111-1234" use="MC"/> <telecom value="tel:+1(555)-111-1234" use="MC"/> <telecom value="tel:+1(555)-112-1544" use="HP"/> <!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 --> <patient> <name use="L"> <given>Katherine</given> <given>Jones</given> <family>Madison</family> </name> <name> <given qualifier="BR">Kathy</given> <given>Jones</given> <family>Madison</family> </name> <administrativeGenderCode code="F" displayName="Female" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender"/> <!-- Date of birth need only be precise to the day --> <birthTime value="19700601"/> <maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatusCode"/> <religiousAffiliationCode code="1013" displayName="Christian (non-Catholic, non-specific)" codeSystem="2.16.840.1.113883.5.1076" codeSystemName="HL7 Religious Affiliation"/> <!-- CDC Race and Ethnicity code set contains the five minimum race and ethnicity categories defined by OMB Standards --> <raceCode code="2106-3" displayName="White" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/> <!-- The raceCode extension is only used if raceCode is valued --> <raceCode code="2108-9" displayName="White European" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC" xmlns="urn:hl7-org:sdtc"/> <ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/> <languageCommunication> <languageCode code="en-US"/> <modeCode code="ESP" displayName="Expressed spoken" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/> <preferenceInd value="true"/> </languageCommunication> </patient> <providerOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom use="WP" value="tel:+1(555)-555-5000"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </providerOrganization> </patientRole> </recordTarget> <!-- The author represents the person who provides the content in the document --> <author> <time value="20150622"/> <assignedAuthor> <id extension="8851602754" root="2.16.840.1.113883.4.6"/> <code code="200000000X" codeSystem="2.16.840.1.113883.6.101" displayName="Allopathic & Osteopathic Physicians"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:+1(555)-555-1002"/> <assignedPerson xmlns:sdtc="urn:hl7-org:sdtc"> <name> <prefix>Dr</prefix> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> <representedOrganization> <id root="2.16.840.1.113883.19.5"/> <name>Neighborhood Physicians Practice</name> </representedOrganization> </assignedAuthor> </author> <!-- The dataEnterer transferred the content created by the author into the document --> <dataEnterer> <assignedEntity> <id root="2.16.840.1.113883.4.6" extension="2149882245"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:+1(555)-555-1002"/> <assignedPerson> <name> <!-- Tracy Davis is a Registered Nurse who is performing some office functions and nurse functions --> <given>Tracy</given> <family>Davis</family> </name> </assignedPerson> </assignedEntity> </dataEnterer> <!-- The informant represents any sources of information for document content --> <informant> <assignedEntity> <id extension="KP00017" root="2.16.840.1.113883.19.5"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:+1(555)-555-1002"/> <assignedPerson> <name> <given>Albert</given> <family>Davis</family> </name> </assignedPerson> </assignedEntity> </informant> <informant> <relatedEntity classCode="PRS"> <!-- classCode PRS represents a person with personal relationship with the patient. --> <code code="SPS" displayName="SPOUSE" codeSystem="2.16.840.1.113883.1.11.19563" codeSystemName="Personal Relationship Role Type Value Set"/> <relatedPerson> <name> <given>James</given> <family>Madison</family> </name> </relatedPerson> </relatedEntity> </informant> <!-- The custodian represents the organization charged with maintaining the original source document --> <custodian> <assignedCustodian> <representedCustodianOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-1002" use="WP"/> <addr use="WP"> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedCustodianOrganization> </assignedCustodian> </custodian> <!-- The informationRecipient represents the intended recipient of the document --> <informationRecipient> <intendedRecipient> <informationRecipient> <name> <prefix>Dr</prefix> <given>Albert</given> <family>Davis</family> </name> </informationRecipient> <receivedOrganization> <name>Neighborhood Physicians Practice</name> </receivedOrganization> </intendedRecipient> </informationRecipient> <!-- The legalAuthenticator represents the individual who is responsible for the document --> <legalAuthenticator> <time value="20150622"/> <signatureCode code="S"/> <assignedEntity> <id extension="2537011886" root="2.16.840.1.113883.4.6"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:+1(555)-555-1002"/> <assignedPerson> <name> <prefix>Dr</prefix> <given>Albert</given> <family>Davis</family> </name> </assignedPerson> </assignedEntity> </legalAuthenticator> <!-- The authenticator represents the individual attesting to the accuracy of information in the document--> <authenticator> <time value="20150622"/> <signatureCode code="S"/> <assignedEntity> <id extension="2537011886" root="2.16.840.1.113883.4.6"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:+1(555)-555-1002"/> <assignedPerson> <name> <prefix>Dr</prefix> <given>Albert</given> <family>Davis</family> </name> </assignedPerson> </assignedEntity> </authenticator> <documentationOf> <serviceEvent classCode="PCPR"> <id extension="5283815" root="1.3.6.1.4.1.22812.4.99930.4.3.8"/> <code code="386661006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Fever"/> <!-- The effectiveTime reflects the provision of care summarized in the document. In this scenario, the provision of care summarized is the lifetime for the patient --> <effectiveTime> <low value="201506221000-0500"/> <!-- The low value represents when the summarized provision of care began. In this scenario, the patient's date of birth --> <high value="201506221030-0500"/> <!-- The high value represents when the summarized provision of care being ended. In this scenario, when chart summary was created --> </effectiveTime> <!-- since there are two Care Team members we need two performer elements. -db --> <!-- Note: example of Care Team here: https://github.com/gecole/HL7-Task-Force-Examples/blob/master/CareTeamToC170.314b2Ambulatory.xml db --> <performer typeCode="PRF"> <functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88" codeSystemName="ParticipationFunction" displayName="Primary Care Provider"> <originalText>Primary Care Provider</originalText> </functionCode> <assignedEntity> <id extension="2458897032" root="2.16.840.1.113883.4.6"/> <code code="207QA0505X" displayName="Adult Medicine" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:+1(555)-555-1002"/> <assignedPerson> <name> <prefix qualifier="TITLE">Dr</prefix> <given>Albert</given> <family>Davis</family> </name> </assignedPerson> <representedOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-5000" use="WP"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedOrganization> </assignedEntity> </performer> <performer typeCode="PRF"> <!-- we do not have a function code for this person since recording as RN for now --> <time> <low nullFlavor="UNK"/> </time> <assignedEntity> <!-- this provider has an id, but it is not an NPI --> <id extension="91138" root="1.3.6.1.4.1.22812.4.99930.4"/> <!-- Tracy Davis is a Registered Nurse who is performing some office functions and nurse functions --> <code codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC Health Care Provider Taxonomy" code="163W00000X" displayName="Registered Nurse"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:+1(555)-555-1002"/> <assignedPerson> <name> <!-- Tracy Davis is a Registered Nurse who is performing some office functions and nurse functions --> <given>Tracy</given> <family>Davis</family> </name> </assignedPerson> </assignedEntity> </performer> </serviceEvent> </documentationOf> <!-- added componentOf to represent encounter and to represent length of stay better as per SME suggestion -db --> <componentOf> <encompassingEncounter> <id extension="9621089603" root="2.16.840.1.113883.4.6"/> <code code="233604007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Pnuemonia"/> <effectiveTime> <low value="20120806"/> <high value="20120813"/> </effectiveTime> <responsibleParty > <assignedEntity> <id root="2.16.840.1.113883.4.6" extension="4293431431"/> <assignedPerson> <name> <prefix>Dr</prefix> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedEntity> </responsibleParty> <encounterParticipant typeCode="ATND"> <assignedEntity> <id root="2.16.840.1.113883.4.6" extension="6931880119"/> <code code="208D00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="General Practice" /> <assignedPerson> <name> <prefix>Dr</prefix> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedEntity> </encounterParticipant> <!--<location> <healthCareFacility> <id root="2.16.840.1.113883.4.6"/> </healthCareFacility> </location>--> </encompassingEncounter> </componentOf> <!-- ******************************************************** CDA Body ******************************************************** --> <component> <structuredBody> <!-- ***************** ALLERGIES *************** --> <!-- edited as per test doc - all data relevant -db --> <component> <section> <!-- *** Allergies and Intolerances Section (entries required) (V3) *** --> <templateId root="2.16.840.1.113883.10.20.22.2.6.1" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.2.6.1"/> <!-- Alerts section template --> <code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>ALLERGIES AND ADVERSE REACTIONS</title> <text> <table border="1" width="100%"> <thead> <tr> <th>Substance</th> <th>Reaction</th> <th>Severity</th> <th>Status</th> </tr> </thead> <tbody> <tr> <td> <content ID="product1">Penicillin G</content> </td> <td> <content ID="reaction1">Hives</content> </td> <td> <content ID="severity1">Moderate</content> </td> <td>Active</td> </tr> <tr> <td> <content ID="product2">Ampicillin</content> </td> <td> <content ID="reaction2">Hives</content> </td> <td> <content ID="severity2">Moderate</content> </td> <td>Active</td> </tr> </tbody> </table> </text> <!-- replaced Allergy Problem Act (R1.1) with Allergy Concern Act (V3) to meet R2.1 validation requirements -DB--> <entry typeCode="DRIV"> <act classCode="ACT" moodCode="EVN"> <!-- ** Allergy Concern Act (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.30" extension="2015-08-01"/> <!--Critical Change--> <templateId root="2.16.840.1.113883.10.20.22.4.30"/> <id root="36e3e930-7b14-11db-9fe1-0800200c9a66" /> <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/> <!-- The statusCode represents the need to continue tracking the allergy --> <!-- This is of ongoing concern to the provider --> <statusCode code="active"/> <effectiveTime> <!-- The low value represents when the allergy was first recorded in the patient's chart --> <low value="19800501"/> </effectiveTime> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN"> <!-- ** Allergy observation (V2) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.7" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.7"/> <id root="4adc1020-7b14-11db-9fe1-0800200c9a66"/> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <!-- Observation statusCode represents the status of the act of observing --> <statusCode code="completed"/> <effectiveTime> <!-- The low value reflects the date of onset of the allergy --> <low value="19800501"/> <!-- The high value reflects when the allergy was known to be resolved (and will generally be absent) --> </effectiveTime> <value xsi:type="CD" code="419511003" displayName="Propensity to adverse reaction to drug" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"> </value> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119"/> <!-- This equates to the date when last updated by the author--> <time value="201903101256-0500"/> <assignedAuthor> <id extension="3158932954" root="2.16.840.1.113883.4.6"/> <code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Cardiovascular Disease"/> <addr> <streetAddressLine>6666 StreetName St.</streetAddressLine> <city>Silver Spring</city> <state>MD</state> <postalCode>20901</postalCode> <country>US</country> </addr> <telecom value="tel:+1(301)666-6666" use="WP"/> <assignedPerson> <name> <given>Heartly</given> <family>Sixer</family> <suffix>MD</suffix> </name> </assignedPerson> <representedOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-5000" use="WP"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> <participant typeCode="CSM"> <participantRole classCode="MANU"> <playingEntity classCode="MMAT"> <code code="7980" displayName="Penicillin G" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"> <originalText> <reference value="#product1"/> </originalText> </code> </playingEntity> </participantRole> </participant> <entryRelationship typeCode="MFST" inversionInd="true"> <observation classCode="OBS" moodCode="EVN"> <!-- ** Reaction Observation (V2) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.9" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.9"/> <id root="4adc1020-7b14-11db-9fe1-0800200c9a67"/> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <text> <reference value="#reaction1"/> </text> <statusCode code="completed"/> <value xsi:type="CD" code="247472004" codeSystem="2.16.840.1.113883.6.96" displayName="Hives"/> <entryRelationship typeCode="SUBJ" inversionInd="true"> <observation classCode="OBS" moodCode="EVN"> <!-- ** Severity Observation (V2)** --> <!-- When the Severity Observation is associated directly with an allergy it characterizes the allergy. When the Severity Observation is associated with a Reaction Observation it characterizes a Reaction. --> <templateId root="2.16.840.1.113883.10.20.22.4.8" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.8"/> <code code="SEV" displayName="Severity Observation" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/> <text> <reference value="#severity1"/> </text> <statusCode code="completed"/> <value xsi:type="CD" code="6736007" displayName="Moderate" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/> </observation> </entryRelationship> </observation> </entryRelationship> </observation> </entryRelationship> </act> </entry> <entry typeCode="DRIV"> <act classCode="ACT" moodCode="EVN"> <!-- ** Allergy Concern Act (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.30" extension="2015-08-01"/> <!--Critical Change--> <templateId root="2.16.840.1.113883.10.20.22.4.30"/> <id root="b03805bd-2eb6-4ab8-a9ff-473c6653971a"/> <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/> <!-- The statusCode represents the need to continue tracking the allergy --> <!-- This is of ongoing concern to the provider --> <statusCode code="active"/> <effectiveTime> <!-- The low value represents when the allergy was first recorded in the patient's chart --> <low value="19800501"/> </effectiveTime> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN"> <!-- ** Allergy observation (V2) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.7" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.7"/> <id root="4adc1020-7b14-11db-9fe1-0800200c9a68"/> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <!-- Observation statusCode represents the status of the act of observing --> <statusCode code="completed"/> <effectiveTime> <!-- The low value reflects the date of onset of the allergy --> <low value="19800501"/> <!-- The high value reflects when the allergy was known to be resolved (and will generally be absent) --> </effectiveTime> <value xsi:type="CD" code="419511003" displayName="Propensity to adverse reaction to drug" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"> </value> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119"/> <!-- This equates to the date when last updated by the author--> <time value="201903101256-0500"/> <assignedAuthor> <id extension="3158932954" root="2.16.840.1.113883.4.6"/> <code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Cardiovascular Disease"/> <addr> <streetAddressLine>6666 StreetName St.</streetAddressLine> <city>Silver Spring</city> <state>MD</state> <postalCode>20901</postalCode> <country>US</country> </addr> <telecom value="tel:+1(301)666-6666" use="WP"/> <assignedPerson> <name> <given>Heartly</given> <family>Sixer</family> <suffix>MD</suffix> </name> </assignedPerson> <representedOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-5000" use="WP"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> <participant typeCode="CSM"> <participantRole classCode="MANU"> <playingEntity classCode="MMAT"> <code code="733" displayName="Ampicillin" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"> <originalText> <reference value="#product2"/> </originalText> </code> </playingEntity> </participantRole> </participant> <entryRelationship typeCode="MFST" inversionInd="true"> <observation classCode="OBS" moodCode="EVN"> <!-- ** Reaction Observation (V2) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.9" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.9"/> <id root="4adc1020-7b14-11db-9fe1-0800200c9a69"/> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <text> <reference value="#reaction2"/> </text> <statusCode code="completed"/> <value xsi:type="CD" code="247472004" codeSystem="2.16.840.1.113883.6.96" displayName="Hives"/> <entryRelationship typeCode="SUBJ" inversionInd="true"> <observation classCode="OBS" moodCode="EVN"> <!-- ** Severity Observation (V2)** --> <!-- When the Severity Observation is associated directly with an allergy it characterizes the allergy. When the Severity Observation is associated with a Reaction Observation it characterizes a Reaction. --> <templateId root="2.16.840.1.113883.10.20.22.4.8" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.8"/> <code code="SEV" displayName="Severity Observation" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/> <text> <reference value="#severity2"/> </text> <statusCode code="completed"/> <value xsi:type="CD" code="6736007" displayName="Moderate" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/> </observation> </entryRelationship> </observation> </entryRelationship> </observation> </entryRelationship> </act> </entry> </section> </component> <!-- ******************************* MEDICATIONS ***************************** --> <!-- edited as per test doc - all data relevant -db --> <component> <section> <!-- *** Medications Section (entries required) (V2) *** --> <templateId root="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.2.1.1"/> <code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF MEDICATION USE"/> <title>MEDICATIONS</title> <text> <table border="1" width="100%"> <thead> <tr> <th>Medication</th> <th>Directions</th> <th>Start Date</th> </tr> </thead> <tbody> <tr> <td>Ceftriaxone 100MG/ML</td> <td>Two Times Daily</td> <td>June 22, 2015</td> </tr> <tr> <td>Tylenol 500mg</td> <td>As needed for 10 days</td> <td>June 22, 2015</td> </tr> <tr> <td>Darbepoetin Alfa 0.5 MG/ML</td> <td>Once a week</td> <td>June 22, 2015</td> </tr> </tbody> </table> </text> <entry typeCode="DRIV"> <substanceAdministration classCode="SBADM" moodCode="EVN"> <!-- ** Medication Activity (V2) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.16"/> <id root="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/> <statusCode code="active"/> <effectiveTime xsi:type="IVL_TS"> <low value="20150622"/> <high value="20150630"/> </effectiveTime> <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A"> <period value="12" unit="h"/> </effectiveTime> <routeCode code="C38276" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="INTRAVENOUS"/> <doseQuantity value="1"/> <!-- we don't need an administrationUnitCode element since we have an exact amount specified for injection nor would any code match if we did: reference: https://art-decor.org/art-decor/decor-valuesets search AdministrableDrugForm -db --> <consumable> <manufacturedProduct classCode="MANU"> <!-- ** Medication information ** --> <templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.23"/> <id root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/> <manufacturedMaterial> <code code="309090" codeSystem="2.16.840.1.113883.6.88" displayName="Ceftriaxone 100MG/ML"/> </manufacturedMaterial> </manufacturedProduct> </consumable> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119"/> <!-- This equates to the date when last updated by the author--> <time value="201903101256-0500"/> <assignedAuthor> <id extension="3158932954" root="2.16.840.1.113883.4.6"/> <code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Cardiovascular Disease"/> <addr> <streetAddressLine>6666 StreetName St.</streetAddressLine> <city>Silver Spring</city> <state>MD</state> <postalCode>20901</postalCode> <country>US</country> </addr> <telecom value="tel:+1(301)666-6666" use="WP"/> <assignedPerson> <name> <given>Heartly</given> <family>Sixer</family> <suffix>MD</suffix> </name> </assignedPerson> <representedOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-5000" use="WP"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> <!-- removed participant, performer, and, removed entryRelationships Indication (V2), Medication supply order (V2), and Medication dispense (v2) as not required -db --> <!-- removed precondition as not required -db --> </substanceAdministration> </entry> <entry typeCode="DRIV"> <substanceAdministration classCode="SBADM" moodCode="EVN"> <!-- ** Medication activity (V2) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.16"/> <id root="6c844c75-aa34-411c-b7bd-5e4a9f206e29"/> <statusCode code="active"/> <effectiveTime xsi:type="IVL_TS"> <low value="20150622"/> <high value="20150701"/> </effectiveTime> <!-- InstituionSpecified = "true" means that interval of time for taking need not be exact In this case it alters every 24 hours to mean PRN / take 'as needed' -db --> <!-- Operator "A" means that this timing information is in addition to previous effectiveTime information provided--> <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A"> <period value="24" unit="h"/> </effectiveTime> <routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="ORAL"/> <doseQuantity value="1"/> <consumable> <manufacturedProduct classCode="MANU"> <!-- ** Medication information ** --> <templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.23"/> <id root="2a620155-9d11-439e-92b3-5d9816ff4ee8"/> <manufacturedMaterial> <code code="209459" displayName="Tylenol 500mg" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"/> </manufacturedMaterial> </manufacturedProduct> </consumable> <!-- removed Indication (V2) entryRelatioship as not required. if included would probably be fever -db --> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119"/> <!-- This equates to the date when last updated by the author--> <time value="201903101256-0500"/> <assignedAuthor> <id extension="3158932954" root="2.16.840.1.113883.4.6"/> <code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Cardiovascular Disease"/> <addr> <streetAddressLine>6666 StreetName St.</streetAddressLine> <city>Silver Spring</city> <state>MD</state> <postalCode>20901</postalCode> <country>US</country> </addr> <telecom value="tel:+1(301)666-6666" use="WP"/> <assignedPerson> <name> <given>Heartly</given> <family>Sixer</family> <suffix>MD</suffix> </name> </assignedPerson> <representedOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-5000" use="WP"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> </substanceAdministration> </entry> <entry typeCode="DRIV"> <substanceAdministration classCode="SBADM" moodCode="EVN"> <!-- ** Medication Activity (V2) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.16"/> <id root="cdbd33f0-6cde-11db-9fe1-0800200c9a67"/> <statusCode code="active"/> <effectiveTime xsi:type="IVL_TS"> <low value="20150622"/> <high nullFlavor="UNK"/> </effectiveTime> <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A"> <period value="7" unit="d"/> </effectiveTime> <routeCode code="C38276" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="INTRAVENOUS"/> <doseQuantity value="1"/> <!-- we don't need an administrationUnitCode element since we have an exact amount specified for injection nor would any code match if we did: reference: https://art-decor.org/art-decor/decor-valuesets search AdministrableDrugForm -db --> <consumable> <manufacturedProduct classCode="MANU"> <!-- ** Medication information ** --> <templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.23"/> <id root="2a620155-9d11-439e-92b3-5d9817ff4ee8"/> <manufacturedMaterial> <code code="731184" codeSystem="2.16.840.1.113883.6.88" displayName="Darbepoetin Alfa 0.5 MG/ML"/> </manufacturedMaterial> </manufacturedProduct> </consumable> <!-- removed participant, performer, and, removed entryRelationships Indication (V2), Medication supply order (V2), and Medication dispense (v2) as not required -db --> <!-- removed precondition as not required -db --> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119"/> <!-- This equates to the date when last updated by the author--> <time value="201903101256-0500"/> <assignedAuthor> <id extension="3158932954" root="2.16.840.1.113883.4.6"/> <code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Cardiovascular Disease"/> <addr> <streetAddressLine>6666 StreetName St.</streetAddressLine> <city>Silver Spring</city> <state>MD</state> <postalCode>20901</postalCode> <country>US</country> </addr> <telecom value="tel:+1(301)666-6666" use="WP"/> <assignedPerson> <name> <given>Heartly</given> <family>Sixer</family> <suffix>MD</suffix> </name> </assignedPerson> <representedOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-5000" use="WP"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> </substanceAdministration> </entry> <entry typeCode="DRIV"> <substanceAdministration classCode="SBADM" moodCode="INT"> <!-- ** Medication Activity (V2) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.16"/> <id root="6c844c75-aa34-411c-b7bd-5e4a9f206e29"/> <text> <!-- This reference refers to medication information in unstructured portion of section--> <reference value="#Medication_1"/> </text> <statusCode code="active" /> <!-- the medication order is currently active --> <!-- for this regimen, bevacizumab will only be administered once, on Day 1, as an example scheduled for a future date relative to the date of the encounter. --> <effectiveTime value = "20180215" /> <routeCode code="C38276" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="INTRAVENOUS"/> <!-- an absolute dose quantity is unknown at the time the order is placed because the drug is prepared based on the weight at the time of administration. --> <!-- unit of measure taken from UCUM: http://download.hl7.de/documents/ucum/ucumdata.html --> <doseQuantity value="5" unit="mg/kg" /> <consumable> <manufacturedProduct classCode="MANU"> <!-- ** Medication information ** --> <templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.23"/> <id root="2a620155-9d11-439e-92b3-5d9815ff3cc2"/> <manufacturedMaterial> <code code="1657066" displayName="4 ML bevacizumab 25 MG/ML Injection" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"> <originalText> <reference value="#MedicationName_1"/> </originalText> </code> </manufacturedMaterial> </manufacturedProduct> </consumable> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119"/> <!-- This equates to the date when last updated by the author--> <time value="201903101256-0500"/> <assignedAuthor> <id extension="3158932954" root="2.16.840.1.113883.4.6"/> <code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Cardiovascular Disease"/> <addr> <streetAddressLine>6666 StreetName St.</streetAddressLine> <city>Silver Spring</city> <state>MD</state> <postalCode>20901</postalCode> <country>US</country> </addr> <telecom value="tel:+1(301)666-6666" use="WP"/> <assignedPerson> <name> <given>Heartly</given> <family>Sixer</family> <suffix>MD</suffix> </name> </assignedPerson> <representedOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-5000" use="WP"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> <participant typeCode="CSM"> <participantRole classCode="MANU"> <templateId root="2.16.840.1.113883.10.20.22.4.24"/> <code code="412307009" displayName="drug vehicle" codeSystem="2.16.840.1.113883.6.96"/> <playingEntity classCode="MMAT"> <!-- bevacizumab is prepared with a compatible solution for continuous infusion. In this example, we use normal saline for preparation. --> <code code="1807639" displayName="1000 ML Sodium Chloride 9 MG/ML Injection" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"/> <name>Sodium Chloride 0.9%</name> </playingEntity> </participantRole> </participant> <entryRelationship typeCode="RSON"> <observation classCode="OBS" moodCode="EVN"> <!-- ** Indication ** --> <templateId root="2.16.840.1.113883.10.20.22.4.19" extension="2014-06-09"/> <!-- This ID may link to the problem ID entry in the problem list, if it already exists. --> <id root="e63166c7-6482-4a44-83a1-37ccdbdd532b"/> <code code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Clinical finding"/> <statusCode code="completed"/> <value xsi:type="CD" code="363406005" displayName="Malignant neoplasm of colon" codeSystem="2.16.840.1.113883.6.96"/> </observation> </entryRelationship> <entryRelationship typeCode="SUBJ" inversionInd="true"> <act classCode="ACT" moodCode="INT"> <templateId root="2.16.840.1.113883.10.20.1.49" /> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.3" /> <templateId root="2.16.840.1.113883.10.20.22.4.20" /> <code code="PINSTRUCT" codeSystem="1.3.6.1.4.1.19376.1.5.3.2" codeSystemName="IHEActCode" /> <text>Once a week (1 unit) </text> <statusCode code="completed" /> </act> </entryRelationship> </substanceAdministration> </entry> </section> </component> <!-- ***************** PROBLEM LIST *********************** --> <!-- edited as per test doc - all data relevant -db --> <component> <section> <!-- *** Problem Section (entries required) (V3) *** --> <templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.2.5.1"/> <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROBLEM LIST"/> <title>PROBLEMS</title> <text> <paragraph>Active Concerns</paragraph> <list> <item> Problem #1 <list> <item>Essential hypertension (Disorder)</item> </list> </item> <item> Problem #2 <list> <item>Severe Hypothyroidism (Disorder)</item> </list> </item> <item> Problem #3 <list> <item>Chronic rejection of renal transplant (disorder)</item> </list> </item> <item> Problem #4 <list> <item>Fever (finding)</item> </list> </item> </list> <paragraph>Resolved Concerns</paragraph> <list> <item> Problem #5 <list> <item>Overweight (finding)</item> </list> </item> </list> </text> <entry typeCode="DRIV"> <act classCode="ACT" moodCode="EVN"> <!-- ** Problem Concern Act (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" /> <templateId root="2.16.840.1.113883.10.20.22.4.3" /> <id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7" /> <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" /> <!-- The statusCode represents the need to continue tracking the problem --> <!-- This is of ongoing concern to the provider --> <statusCode code="active"/> <effectiveTime> <!-- The low value represents when the problem was first recorded in the patient's chart --> <low value="20111005"/> </effectiveTime> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN"> <!-- ** Problem observation (V3)** --> <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.4"/> <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/> <code code="64572001" displayName="Condition" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96"> <!-- This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) --> <!-- Condition seems like the best option: No EXACT requirement was given in the test data -db --> <translation code="75323-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Condition"/> </code> <!-- The statusCode reflects the status of the observation itself --> <statusCode code="completed"/> <effectiveTime> <!-- The low value reflects the date of onset --> <low value="20111005"/> <!-- The high value reflects when the problem was known to be resolved --> <!-- Absence of effectiveTime/high means the condition is not resolved --> </effectiveTime> <value xsi:type="CD" code="59621000" codeSystem="2.16.840.1.113883.6.96" displayName="Essential hypertension" codeSystemName="SNOMED-CT"/> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119"/> <!-- This equates to the date when last updated by the author--> <time value="201903101256-0500"/> <assignedAuthor> <id extension="3158932954" root="2.16.840.1.113883.4.6"/> <code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Cardiovascular Disease"/> <addr> <streetAddressLine>6666 StreetName St.</streetAddressLine> <city>Silver Spring</city> <state>MD</state> <postalCode>20901</postalCode> <country>US</country> </addr> <telecom value="tel:+1(301)666-6666" use="WP"/> <assignedPerson> <name> <given>Heartly</given> <family>Sixer</family> <suffix>MD</suffix> </name> </assignedPerson> <representedOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-5000" use="WP"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> </observation> </entryRelationship> </act> </entry> <entry typeCode="DRIV"> <act classCode="ACT" moodCode="EVN"> <!-- ** Problem Concern Act (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" /> <templateId root="2.16.840.1.113883.10.20.22.4.3" /> <id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de8" /> <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" /> <!-- The statusCode represents the need to continue tracking the problem --> <!-- This is of ongoing concern to the provider --> <statusCode code="active"/> <effectiveTime> <!-- The low value represents when the problem was first recorded in the patient's chart --> <low value="20061231"/> </effectiveTime> <!-- removed author as not required -db --> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN"> <!-- ** Problem observation (V3)** --> <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.4"/> <id root="ab1791b0-5c71-11db-b0de-0800200c9a68"/> <code code="64572001" displayName="Condition" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96"> <!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) --> <!-- Condition seems like the best option: No EXACT requirement was given in the test data -db --> <translation code="75323-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Condition"/> </code> <!-- The statusCode reflects the status of the observation itself --> <statusCode code="completed"/> <effectiveTime> <!-- The low value reflects the date of onset --> <low value="20061231"/> <!-- The high value reflects when the problem was known to be resolved --> <!-- Absence of effectiveTime/high means the condition is not resolved --> </effectiveTime> <value xsi:type="CD" code="83986005" codeSystem="2.16.840.1.113883.6.96" displayName="Severe Hypothyroidism" codeSystemName="SNOMED-CT"/> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119"/> <!-- This equates to the date when last updated by the author--> <time value="201903101256-0500"/> <assignedAuthor> <id extension="3158932954" root="2.16.840.1.113883.4.6"/> <code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Cardiovascular Disease"/> <addr> <streetAddressLine>6666 StreetName St.</streetAddressLine> <city>Silver Spring</city> <state>MD</state> <postalCode>20901</postalCode> <country>US</country> </addr> <telecom value="tel:+1(301)666-6666" use="WP"/> <assignedPerson> <name> <given>Heartly</given> <family>Sixer</family> <suffix>MD</suffix> </name> </assignedPerson> <representedOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-5000" use="WP"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> </observation> </entryRelationship> </act> </entry> <entry typeCode="DRIV"> <act classCode="ACT" moodCode="EVN"> <!-- ** Problem Concern Act (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" /> <templateId root="2.16.840.1.113883.10.20.22.4.3" /> <id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de9" /> <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" /> <!-- The statusCode represents the need to continue tracking the problem --> <!-- This is of ongoing concern to the provider --> <statusCode code="active"/> <effectiveTime> <!-- The low value represents when the problem was first recorded in the patient's chart --> <low value="20111231"/> </effectiveTime> <!-- removed author as not required -db --> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN"> <!-- ** Problem observation (V3)** --> <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.4"/> <id root="ab1791b0-5c71-11db-b0de-0800200c9a69"/> <code code="64572001" displayName="Condition" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96"> <!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) --> <!-- Condition seems like the best option: No EXACT requirement was given in the test data -db --> <translation code="75323-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Condition"/> </code> <!-- The statusCode reflects the status of the observation itself --> <statusCode code="completed"/> <effectiveTime> <!-- The low value reflects the date of onset --> <low value="20111231"/> <!-- The high value reflects when the problem was known to be resolved --> <!-- Absence of effectiveTime/high means the condition is not resolved --> </effectiveTime> <value xsi:type="CD" code="236578006" codeSystem="2.16.840.1.113883.6.96" displayName="Chronic rejection of renal transplant" codeSystemName="SNOMED-CT"/> <!-- removed author as not required -db --> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119"/> <!-- This equates to the date when last updated by the author--> <time value="201903101256-0500"/> <assignedAuthor> <id extension="3158932954" root="2.16.840.1.113883.4.6"/> <code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Cardiovascular Disease"/> <addr> <streetAddressLine>6666 StreetName St.</streetAddressLine> <city>Silver Spring</city> <state>MD</state> <postalCode>20901</postalCode> <country>US</country> </addr> <telecom value="tel:+1(301)666-6666" use="WP"/> <assignedPerson> <name> <given>Heartly</given> <family>Sixer</family> <suffix>MD</suffix> </name> </assignedPerson> <representedOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-5000" use="WP"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> </observation> </entryRelationship> </act> </entry> <entry typeCode="DRIV"> <act classCode="ACT" moodCode="EVN"> <!-- ** Problem Concern Act (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" /> <templateId root="2.16.840.1.113883.10.20.22.4.3" /> <id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45df9" /> <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" /> <!-- The statusCode represents the need to continue tracking the problem --> <!-- This is of ongoing concern to the provider --> <statusCode code="active"/> <effectiveTime> <!-- The low value represents when the problem was first recorded in the patient's chart --> <low value="20150622"/> </effectiveTime> <!-- removed author as not required -db --> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN"> <!-- ** Problem observation (V3)** --> <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.4"/> <id root="ab1791b0-5c71-11db-b0de-0800200c9a79"/> <code code="29308" displayName="Diagnosis" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96"> <!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) --> <!-- Diagnosis seems like the best option: No EXACT requirement was given in the test data -db --> <translation code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis"/> </code> <!-- The statusCode reflects the status of the observation itself --> <statusCode code="completed"/> <effectiveTime> <!-- The low value reflects the date of onset --> <low value="20150622"/> <!-- The high value reflects when the problem was known to be resolved --> <!-- Absence of effectiveTime/high means the condition is not resolved --> </effectiveTime> <value xsi:type="CD" code="386661006" codeSystem="2.16.840.1.113883.6.96" displayName="Fever" codeSystemName="SNOMED-CT"/> <!-- removed author as not required -db --> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119"/> <!-- This equates to the date when last updated by the author--> <time value="201903101256-0500"/> <assignedAuthor> <id extension="3158932954" root="2.16.840.1.113883.4.6"/> <code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Cardiovascular Disease"/> <addr> <streetAddressLine>6666 StreetName St.</streetAddressLine> <city>Silver Spring</city> <state>MD</state> <postalCode>20901</postalCode> <country>US</country> </addr> <telecom value="tel:+1(301)666-6666" use="WP"/> <assignedPerson> <name> <given>Heartly</given> <family>Sixer</family> <suffix>MD</suffix> </name> </assignedPerson> <representedOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-5000" use="WP"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> </observation> </entryRelationship> </act> </entry> <entry typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> <!-- ** Problem Concern Act (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" /> <templateId root="2.16.840.1.113883.10.20.22.4.3" /> <id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45df8" /> <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" /> <!-- The statusCode represents the need to continue tracking the problem --> <!-- This is of ongoing concern to the provider --> <statusCode code="completed"/> <effectiveTime> <!-- The low value represents when the problem was first recorded in the patient's chart --> <low value="20061231"/> <!-- The high value reflects when there was no longer a need to track the problem --> <high value="20070601"/> </effectiveTime> <!-- removed author as not required -db --> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN"> <!-- ** Problem observation (V3)** --> <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.4"/> <id root="ab1791b0-5c71-11db-b0de-0800200c2b11"/> <code code="29308" displayName="Diagnosis" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96"> <!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) --> <!-- Diagnosis seems like the best option: No EXACT requirement was given in the test data -db --> <translation code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis"/> </code> <!-- The statusCode reflects the status of the observation itself --> <statusCode code="completed"/> <effectiveTime> <!-- The low value reflects the date of onset --> <low value="20061231"/> <!-- The high value reflects when the problem was known to be resolved --> <high value="20070601"/> </effectiveTime> <value xsi:type="CD" code="238131007" codeSystem="2.16.840.1.113883.6.96" displayName="Overweight" codeSystemName="SNOMED-CT"/> <!-- removed author as not required -db --> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119"/> <!-- This equates to the date when last updated by the author--> <time value="201903101256-0500"/> <assignedAuthor> <id extension="3158932954" root="2.16.840.1.113883.4.6"/> <code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Cardiovascular Disease"/> <addr> <streetAddressLine>6666 StreetName St.</streetAddressLine> <city>Silver Spring</city> <state>MD</state> <postalCode>20901</postalCode> <country>US</country> </addr> <telecom value="tel:+1(301)666-6666" use="WP"/> <assignedPerson> <name> <given>Heartly</given> <family>Sixer</family> <suffix>MD</suffix> </name> </assignedPerson> <representedOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-5000" use="WP"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> </observation> </entryRelationship> </act> </entry> </section> </component> <!-- ************************ ENCOUNTERS *********************** --> <!-- edited as per test doc - NOT all data is relevant, but all entries themselves are relevant -db --> <!-- Although only EO is needed, ER was used due to the Yellow highlight/2015 certification requirements in CCD for Encounters. This will of course work for all other cases as well so is more universal. -db --> <component> <section> <!-- *** Encounters section (entries required) (V3) *** --> <templateId root="2.16.840.1.113883.10.20.22.2.22.1" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.2.22.1"/> <code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/> <title>ENCOUNTERS</title> <text> <table border="1" width="100%"> <thead> <tr> <th>Encounter Diagnosis</th> <th>Location</th> <th>Date</th> </tr> </thead> <tbody> <tr> <td ID="Encounter1"> Fever </td> <td>Neighborhood Physicians Practice</td> <td>June 22, 2015 at 10am EST</td> </tr> </tbody> </table> </text> <entry typeCode="DRIV"> <encounter classCode="ENC" moodCode="EVN"> <!-- ** Encounter Activity (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.49"/> <id root="2.16.840.1.113883.3.140.1.1918489287.6.10.16" extension="449" /> <code code="99213" displayName="Office outpatient visit" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12"> <originalText> <reference value="#Encounter1"/> </originalText> <translation code="AMB" codeSystem="2.16.840.1.113883.5.4" displayName="Ambulatory" codeSystemName="HL7 ActEncounterCode" /> <!-- MAY MAY contain zero or one [0..1] translation (CONF:1198-32323) The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) valueset to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) valueset. <translation code="AMB" codeSystem="2.16.840.1.113883.5.4" displayName="Ambulatory" codeSystemName="HL7 ActEncounterCode"/> --> </code> <effectiveTime value="201506221000-0500"/> <performer> <assignedEntity> <!-- Provider NPI "4948714330" -db --> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <code code="59058001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="General Physician"/> </assignedEntity> </performer> <participant typeCode="LOC"> <participantRole classCode="SDLOC"> <templateId root="2.16.840.1.113883.10.20.22.4.32"/> <!-- Service Delivery Location template --> <!-- the test data does not specify specific data for this code -db --> <code code="1160-1" codeSystem="2.16.840.1.113883.6.259" codeSystemName="HL7 HealthcareServiceLocation" displayName="Urgent Care Center"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> <telecom value="tel:+1(555)-555-1002" use="WP"/> <playingEntity classCode="PLC"> <name>Neighborhood Physicians Practice</name> </playingEntity> </participantRole> </participant> <entryRelationship typeCode="SUBJ"> <!-- ** Encounter Diagnosis (V3)** --> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.80" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.80" /> <templateId root="2.16.840.1.113883.10.20.22.4.19"/> <id root="5a784260-6857-4f38-9638-80c751aff2fb"/> <code xsi:type="CE" code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ENCOUNTER DIAGNOSIS"/> <effectiveTime> <low value="20150622"/> </effectiveTime> <entryRelationship typeCode="SUBJ" inversionInd="false"> <!-- Problem Observation (V3) --> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.4"/> <id root="ab1791b0-5c71-12db-b0de-0800200c9a66"/> <code code="404684003" displayName="Finding" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96"> <!-- this SHALL be present --> <translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Clinical finding"/> </code> <!-- SHALL be completed --> <statusCode code="completed"/> <effectiveTime> <low value="20150622"/> </effectiveTime> <value xsi:type="CD" code="386661006" displayName="Fever" codeSystem="2.16.840.1.113883.6.96"/> </observation> </entryRelationship> </act> </entryRelationship> </encounter> </entry> </section> </component> <!-- ******************** IMMUNIZATIONS ********************* --> <!-- edited as per test doc - NOT all data is relevant, but all entries themselves are relevant -db --> <component> <section> <!-- *** Immunizations Section (entries required) (V2) *** --> <templateId root="2.16.840.1.113883.10.20.22.2.2.1" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.2.2.1"/> <code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of immunizations"/> <title>IMMUNIZATIONS</title> <text> <content ID="immunSect"/> <table border="1" width="100%"> <thead> <tr> <th>Vaccine</th> <th>Date</th> <th>Status</th> </tr> </thead> <tbody> <tr> <td> <content ID="immun1"/>Influenza Virus Vaccine </td> <td>May 10, 2014</td> <td>Completed</td> </tr> <tr> <td> <content ID="immun2"/>Tetanus and diphtheria toxoids </td> <td>January 4, 2012</td> <td>Completed</td> </tr> <tr> <td> <content ID="immun3"/>influenza, intradermal, quadrivalent, preservative free </td> <td>June 22, 2015</td> <td>Refused by Patient</td> </tr> </tbody> </table> </text> <!-- Influenza Virus Vaccine --> <entry typeCode="DRIV"> <substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="false"> <!-- ** Immunization Activity (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.52" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.52"/> <id root="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92"/> <text> <reference value="#immun1"/> </text> <statusCode code="completed"/> <effectiveTime value="20140510"/> <routeCode code="C28161" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Intramuscular injection"/> <consumable> <manufacturedProduct classCode="MANU"> <!-- ** Immunization Medication Information (V2) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.54" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.54"/> <id root="2a620155-9d11-439e-92b3-5d9815ff3cc3"/> <manufacturedMaterial> <code code="88" codeSystem="2.16.840.1.113883.12.292" displayName="Influenza virus vaccine" codeSystemName="CVX"/> <lotNumberText>1</lotNumberText> </manufacturedMaterial> <manufacturerOrganization> <name>Immuno Inc.</name> </manufacturerOrganization> </manufacturedProduct> </consumable> </substanceAdministration> </entry> <!-- Tetanus and diphtheria toxoids --> <entry typeCode="DRIV"> <substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="false"> <!-- ** Immunization Activity (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.52" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.52"/> <id root="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f93"/> <text> <reference value="#immun2"/> </text> <statusCode code="completed"/> <effectiveTime value="20120104"/> <routeCode code="C28161" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Intramuscular injection"/> <consumable> <manufacturedProduct classCode="MANU"> <!-- ** Immunization Medication Information (V2) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.54" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.54"/> <id root="2a620155-9d11-439e-92b3-5d9815ff3cc4"/> <manufacturedMaterial> <code code="106" codeSystem="2.16.840.1.113883.12.292" displayName="Tetanus and diphtheria toxoids" codeSystemName="CVX"> <!-- i. This code MAY contain zero or more [0..*] translation, which MAY be selected from ValueSet Vaccine Clinical Drug urn:oid:2.16.840.1.113762.1.4.1010.8 DYNAMIC (CONF:1098-31543). ii. This code MAY contain zero or more [0..*] translation, which MAY be selected from ValueSet Specific Vaccine Clinical Drug urn:oid:2.16.840.1.113762.1.4.1010.10 DYNAMIC (CONF:1098-31881). <translation code="1300310" displayName="Daptacel DTaP (Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed) Injectable Suspension" codeSystemName="RxNORM" codeSystem="2.16.840.1.113883.6.88"/> --> </code> <lotNumberText>2</lotNumberText> </manufacturedMaterial> <manufacturerOrganization> <name>Immuno Inc.</name> </manufacturerOrganization> </manufacturedProduct> </consumable> </substanceAdministration> </entry> <!-- updated as per ETF https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Immunization_Not_Given_Patient_Refusal.xml -db --> <!-- REJECTED influenza, intradermal, quadrivalent, preservative free --> <entry typeCode="COMP"> <!-- negationInd=true indicates substance was NOT given at this date--> <substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="true"> <!-- ** Immunization Activity (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.52" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.52"/> <id root="de10790f-1496-4719-8fe6-f1b87b6219f7"/> <text> <reference value="#immun3"/> </text> <!-- replaced completed with cancelled as per test data requirement but may not be the recommended approach -db --> <statusCode code="completed"/> <effectiveTime value="20150622"/> <routeCode code="C28161" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Intramuscular injection"/> <consumable> <manufacturedProduct classCode="MANU"> <!-- ** Immunization Medication Information (V2) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.54" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.54"/> <id root="2a620155-9d11-439e-92b3-5d9815ff3cc5"/> <manufacturedMaterial> <code code="166" codeSystem="2.16.840.1.113883.12.292" displayName="influenza, intradermal, quadrivalent, preservative free" codeSystemName="CVX"> <originalText> <reference value="#immun3"/> </originalText> </code> <lotNumberText>1</lotNumberText> </manufacturedMaterial> <!-- added manufacturerOrganization + name as per test data -db --> <manufacturerOrganization> <name>Immuno Inc.</name> </manufacturerOrganization> </manufacturedProduct> </consumable> <entryRelationship typeCode="RSON"> <observation classCode="OBS" moodCode="EVN"> <!-- Immunization Refusal Reason --> <!-- there is no versioned version of this template --> <!-- Included the reason since it may be relevant to a future clinician or quality measurement --> <templateId root="2.16.840.1.113883.10.20.22.4.53"/> <id root="c1296315-9a6d-45a2-aac0-ee225d375409"/> <code displayName="Patient Objection" code="PATOBJ" codeSystemName="HL7 ActNoImmunizationReason" codeSystem="2.16.840.1.113883.5.8"/> <statusCode code="completed"/> </observation> </entryRelationship> </substanceAdministration> </entry> </section> </component> <!-- ************* VITAL SIGNS *************** --> <!-- edited as per test doc - most of this data is directly relevant -db --> <component> <section> <!-- ** Vital Signs Section (entries required) (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.2.4.1" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.2.4.1"/> <code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="VITAL SIGNS"/> <title>VITAL SIGNS</title> <text> <table border="1" width="100%"> <thead> <tr> <th align="right">Date / Time: </th> <th>June 22, 2015</th> </tr> </thead> <tbody> <tr> <th align="left">Height</th> <td ID="vit1">177 cm</td> </tr> <tr> <th align="left">Weight</th> <td ID="vit2">88 kg</td> </tr> <tr> <th align="left">Blood Pressure</th> <td ID="vit3">145/88 mm[Hg]</td> </tr> <tr> <th align="left">Heart Rate</th> <td ID="vit4">80 beats per minute</td> </tr> <tr> <th align="left">O2 Percentage BldC Oximetry</th> <td ID="vit5">95 percent</td> </tr> <tr> <th align="left">Body Temperature</th> <td ID="vit6">38 degree celsius</td> </tr> <tr> <th align="left">Respiratory Rate</th> <td ID="vit7">18 breaths per minute</td> </tr> </tbody> </table> </text> <entry typeCode="DRIV"> <organizer classCode="CLUSTER" moodCode="EVN"> <!-- ** Vital signs organizer (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.26" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.26"/> <id root="31b73bd0-cffc-4599-902e-dbe54bc56cb4"/> <code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Vital signs"> <!-- A vitals organizer conformant to both C-CDA 1.1 and C-CDA 2.1 would contain the SNOMED code (46680005) from R1.1 in the root code and a LOINC code in the translation --> <translation code="74728-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital signs"/> </code> <statusCode code="completed"/> <effectiveTime> <low value="20150622"/> <high value="20150622"/> </effectiveTime> <component> <observation classCode="OBS" moodCode="EVN"> <!-- ** Vital sign observation (V2) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.27"/> <id root="ed9589fd-fda0-41f7-a3d0-dc537554f5c2"/> <code code="8302-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Height"/> <statusCode code="completed"/> <effectiveTime value="201506221005-0500"/> <value xsi:type="PQ" value="177" unit="cm"/> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <!-- ** Vital sign observation ** --> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.27"/> <id root="f4e729e2-a97f-4a7e-8e23-c92f9b6b55cf"/> <code code="29463-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient Body Weight"/> <statusCode code="completed"/> <effectiveTime value="201506221005-0500"/> <value xsi:type="PQ" value="88" unit="kg"/> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <!-- ** Vital sign observation ** --> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.27"/> <id root="1c2748b7-e440-41ba-bc01-dde97d84a036"/> <code code="8462-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="BP Diastolic"/> <statusCode code="completed"/> <effectiveTime value="201506221008-0500"/> <value xsi:type="PQ" value="88" unit="mm[Hg]"/> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <!-- ** Vital sign observation ** --> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.27"/> <id root="a0e39c70-9674-4b2a-9837-cdf74200d8d5"/> <code code="8480-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Intravascular Systolic"/> <statusCode code="completed"/> <effectiveTime value="201506221008-0500"/> <value xsi:type="PQ" value="145" unit="mm[Hg]"/> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <!-- ** Vital sign observation ** --> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.27"/> <id root="a0e39c70-9675-4b2a-9838-cdf74200d8d5"/> <code code="8867-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Heart Rate"/> <statusCode code="completed"/> <effectiveTime value="201506221010-0500"/> <value xsi:type="PQ" value="80" unit="/min"/> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <!-- ** Vital sign observation ** --> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.27"/> <id root="a0e39c70-9675-4b2a-9839-cdf74200d8d5"/> <code code="59408-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="O2 % BldC Oximetry"/> <statusCode code="completed"/> <effectiveTime value="201506221012-0500"/> <value xsi:type="PQ" value="95" unit="%"/> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <!-- ** Vital sign observation ** --> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.27"/> <id root="a0e39c70-9675-4b2a-9841-cdf74200d8d5"/> <code code="8310-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Body Temperature"/> <statusCode code="completed"/> <effectiveTime value="201506221015-0500"/> <value xsi:type="PQ" value="38" unit="Cel"/> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <!-- ** Vital sign observation ** --> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.27"/> <id root="a0e39c70-9675-4b2a-9842-cdf74200d8d5"/> <code code="9279-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Respiratory Rate"/> <statusCode code="completed"/> <effectiveTime value="201506221015-0500"/> <value xsi:type="PQ" value="18" unit="/min"/> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <id root="ff955903-97eb-47fd-863e-664b1f4878ea" /> <code code="3150-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Inhaled oxygen concentration" /> <statusCode code="completed" /> <effectiveTime> <low value="20150622" /> </effectiveTime> <value xsi:type="PQ" value="36" unit="%" /> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" /> </observation> </component> <!--pediatric measures--> <!-- The components are all based on the Vital Sign Observation template defined in the C-CDA Implementation Guide, just with different LOINC Codes --> <!-- BMI Percentile --> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id extension="5710719405-BMIPerc-Z197199" root="1.2.840.114350.1.13.861.1.7.1.2109.1" /> <code code="59576-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Body mass index (BMI) [Percentile] Per age and sex"> <originalText> <reference value="#bmiPerc_2Name"/> </originalText> </code> <!-- This reference identifies content in human readable formatted text--> <text> <reference value="#bmiPerc_2" /> </text> <statusCode code="completed" /> <effectiveTime value="20151120193605-0600" /> <value xsi:type="PQ" unit="%" value="49" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"/> <referenceRange> <observationRange> <!-- Since BMI Percentile is dependent on which Growth Chart is used to determine percentile, that is important to include. This indicates that the patient was in the 49th percentile of BMIs using the Males, 2-20 Years CDC BMI Percentile Growth Chart. --> <text> <reference value="#bmiPerc_2GC" /> </text> <value xsi:type="ED"> <reference value="#bmiPerc_2GC"/> </value> </observationRange> </referenceRange> </observation> </component> <!-- Weight-for-length Percentile --> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id extension="5710719405-WfLPerc-Z197199" root="1.2.840.114350.1.13.861.1.7.1.2109.1" /> <code code="77606-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Weight-for-length Per age and sex"> <originalText> <reference value="#WfLPerc_2Name"/> </originalText> </code> <!-- This reference identifies content in human readable formatted text--> <text> <reference value="#WfLPerc_2" /> </text> <statusCode code="completed" /> <effectiveTime value="20151120193605-0600" /> <value xsi:type="PQ" unit="%" value="48" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"/> <referenceRange> <observationRange> <!-- Since Weight-for-length Percentile is dependent on which Growth Chart is used to determine percentile, that is important to include. This indicates that the patient was in the 48th percentile of weight-for-lengths using the Males, 2-20 Years CDC Weight-for-length Growth Chart. --> <text> <reference value="#WfLPerc_2GC" /> </text> <value xsi:type="ED"> <reference value="#WfLPerc_2GC"/> </value> </observationRange> </referenceRange> </observation> </component> <!-- Head Circumference Percentile --> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id extension="5710719405-headCirPerc-Z197199" root="1.2.840.114350.1.13.861.1.7.1.2109.1" /> <code code="8289-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Head Occipital-frontal circumference Percentile"> <originalText> <reference value="#headCircPerc_2Name"/> </originalText> </code> <!-- This reference identifies content in human readable formatted text--> <text> <reference value="#headCircPerc_2" /> </text> <statusCode code="completed" /> <effectiveTime value="20151120193605-0600" /> <value xsi:type="PQ" unit="%" value="50" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"/> <referenceRange> <observationRange> <!-- Since Head Circumference Percentile is dependent on which Growth Chart is used to determine percentile, that is important to include. This indicates that the patient was in the 50th percentile of head circumferences using the CDC Males, 0-36 months Chart Head Circumference Growth Chart. --> <text> <reference value="#headCircPerc_2GC" /> </text> <value xsi:type="ED"> <reference value="#headCircPerc_2GC"/> </value> </observationRange> </referenceRange> </observation> </component> </organizer> </entry> </section> </component> <!-- ******************* SOCIAL HISTORY ********************* --> <!-- edited as per test doc - most of this data is directly relevant -db --> <component> <section> <!-- ** Social History Section (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.2.17" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.2.17"/> <code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social History"/> <title>SOCIAL HISTORY</title> <text> <table border="1" width="100%"> <thead> <tr> <th>Social History Observation</th> <th>Description</th> <th>Dates Observed</th> </tr> </thead> <tbody> <tr> <td>Smoking Status</td> <td>Heavy tobacco smoker</td> <td>May 1, 2005 - February 27, 2011</td> </tr> <tr> <td>Current Smoking Status</td> <td>Current every day</td> <td>June 22, 2015</td> </tr> <tr> <td ID="BirthSexInfo">Birth Sex</td> <td>Female</td> <td>June 22, 2015</td> </tr> </tbody> </table> </text> <!-- Smoking Status - May 1, 2005 - February 27, 2011 -db --> <entry typeCode="DRIV"> <observation classCode="OBS" moodCode="EVN"> <!-- ** Tobacco use (V2) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.85" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.85"/> <id root="45efb604-7049-4a2e-ad33-d38556c9636c"/> <!-- code SHALL be 11367-0 for Tobacco use (V2) -db --> <code code="11367-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of tobacco use"/> <statusCode code="completed"/> <effectiveTime> <!-- The low value reflects the start date of the observation/value --> <low value="20050501"/> <!-- The high value reflects the end date of the observation/value --> <high value="20110227"/> </effectiveTime> <!-- Consol Tobacco Use SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:16562, R2.0=CONF:1098-16562), which SHALL be selected from ValueSet Tobacco Use 2.16.840.1.113883.11.20.9.41 DYNAMIC (CONF:16563, R2.0=CONF:1098-16563) -db --> <value xsi:type="CD" code="428071000124103" displayName="Heavy tobacco smoker" codeSystem="2.16.840.1.113883.6.96"/> </observation> </entry> <!-- Current Smoking Status - June 22, 2015 -db --> <entry typeCode="DRIV"> <observation classCode="OBS" moodCode="EVN"> <!-- ** Smoking Status - Meaningful Use (V2) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.78" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.78"/> <id extension="123456789" root="2.16.840.1.113883.19"/> <!-- code SHALL be 72166-2 for Smoking Status - Meaningful Use (V2) -db --> <code code="72166-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Tobacco smoking status NHIS"/> <statusCode code="completed"/> <!-- The effectiveTime reflects when the current smoking status was observed. --> <effectiveTime value="20150622"/> <!-- The value represents the patient's smoking status currently observed. --> <!-- Consol Smoking Status Meaningful Use2 SHALL contain exactly one [1..1] value (CONF:1098-14810), which SHALL be selected from ValueSet Current Smoking Status 2.16.840.1.113883.11.20.9.38 STATIC 2014-09-01 (CONF:1098-14817) -db --> <value xsi:type="CD" code="449868002" displayName="Current every day smoker" codeSystem="2.16.840.1.113883.6.96"/> </observation> </entry> <!-- Add Birth Sex entry --> <entry> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.200" extension="2016-06-01"/> <code code="76689-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Sex Assigned At Birth"/> <text> <reference value="#BirthSexInfo"/> </text> <statusCode code="completed"/> <effectiveTime value="20150622"/> <value code="F" codeSystem="2.16.840.1.113883.5.1" xsi:type="CD" displayName="Female"/> </observation> </entry> </section> </component> <!-- ************** PROCEDURES and UDI ***************** --> <!-- edited as per test doc - all of this data is directly relevant -db --> <component> <section> <!-- Procedures Section (entries required) (V2) --> <templateId root="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.2.7.1"/> <code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PROCEDURES"/> <title>PROCEDURES</title> <text> <table border="1" width="100%"> <thead> <tr> <th>Procedure</th> <th>Date</th> </tr> </thead> <tbody> <tr> <td ID="Proc1">Nebulizer Therapy</td> <td>June 22, 2015</td> </tr> <tr> <td ID="Proc2">Introduction of cardiac pacemaker system via vein</td> <td>October 5, 2011</td> </tr> </tbody> </table> </text> <entry typeCode="DRIV"> <procedure classCode="PROC" moodCode="EVN"> <!-- ** Procedure activity procedure (V2) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.14"/> <id root="d68b7e32-7810-4f5b-9cc2-acd54b0fd85d"/> <code code="56251003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Nebulizer Therapy"> </code> <statusCode code="completed"/> <effectiveTime value="20150622"/> <methodCode nullFlavor="UNK"/> <targetSiteCode code="82094008" displayName="Lower Respiratory Tract Structure" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/> <!-- removed specimen as not required by test data -db --> <!-- removed participant as not required by test data -db --> </procedure> </entry> <entry typeCode="DRIV"> <procedure classCode="PROC" moodCode="EVN"> <!-- ** Procedure activity procedure (V2) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.14"/> <id root="d68b7e32-7810-4f5b-9cc2-acd54b0fd85e"/> <code code="175135009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Introduction of cardiac pacemaker system via vein"> </code> <statusCode code="completed"/> <effectiveTime value="20111005"/> <methodCode nullFlavor="UNK"/> <targetSiteCode code="9454009" displayName="Structure of subclavian vein" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/> <!-- removed specimen as not required by test data -db --> <!-- removed participant as not required by test data -db --> <participant typeCode="DEV"> <participantRole classCode="MANU"> <!-- ** Product instance ** --> <templateId root="2.16.840.1.113883.10.20.22.4.37"/> <!-- UDI -db --> <!-- this UDI provided by the test data is not valid as per CDA schema -db --> <!-- <id root="00643169007222"/> --> <!-- <id root="d68b7e32-7810-4f5b-9cc2-acd54b0fd85e" extension="00643169007222"/> --> <!-- root is FDA OID, extension is the UDI id --> <id root="2.16.840.1.113883.3.3719" extension="(01)00643169007222(17)160128(21)BLC200461H"/> <playingDevice> <!-- the actual UDI device -db --> <code code="704708004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Cardiac resynchronization therapy implantable pacemaker"> </code> </playingDevice> <!-- FDA Scoping Entity OID for UDI-db --> <scopingEntity> <id root="2.16.840.1.113883.3.3719"/> </scopingEntity> </participantRole> </participant> </procedure> </entry> </section> </component> <!-- ************ Medical Device Equipment *********************** --> <component> <section> <templateId root="2.16.840.1.113883.10.20.22.2.23"/> <templateId root="2.16.840.1.113883.10.20.22.2.23" extension="2014-06-09"/> <code code="46264-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medical Equipment"/> <title>Implants</title> <text> <table> <thead> <tr> <th>Implanted</th> <th>Area</th> <th>UDI</th> </tr> </thead> <tbody> <tr> <td ID="implant1">Cardiac Pacemaker</td> <td>Subclavian Vein</td> <td>(01)00643169007222(17)160128(21)BLC200461H</td> </tr> </tbody> </table> </text> <entry> <procedure classCode="PROC" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.14" /> <id extension="2744" root="1.2.840.114350.1.13.5552.1.7.2.737780"/> <code nullFlavor="UNK"/> <!-- Procedure is completed, even though the implant is still active --> <statusCode code="completed"/> <effectiveTime> <!-- Placed Date --> <low value="20111005"/> </effectiveTime> <targetSiteCode code="9454009" displayName="Structure of subclavian vein" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/> <participant typeCode="DEV"> <participantRole classCode="MANU"> <!-- ** Product instance ** --> <templateId root="2.16.840.1.113883.10.20.22.4.37"/> <!-- UDI -db --> <!-- this UDI provided by the test data is not valid as per CDA schema -db --> <!-- <id root="00643169007222"/> --> <!-- <id root="d68b7e32-7810-4f5b-9cc2-acd54b0fd85e" extension="00643169007222"/> --> <!-- root is FDA OID, extension is the UDI id --> <id root="2.16.840.1.113883.3.3719" extension="(01)00643169007222(17)160128(21)BLC200461H"/> <playingDevice> <!-- the actual UDI device -db --> <code code="00643169007222" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Cardiac resynchronization therapy implantable pacemaker"> </code> </playingDevice> <!-- FDA Scoping Entity OID for UDI-db --> <scopingEntity> <id root="2.16.840.1.113883.3.3719"/> </scopingEntity> </participantRole> </participant> <entryRelationship typeCode="COMP"> <!-- UDI Organizer --> <organizer classCode="CLUSTER" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.311" extension="2019-06-21"/> <id root="2.16.840.1.113883.3.3719" extension="(01)00643169007222(17)160128(21)BLC200461H" assigningAuthorityName="FDA"/> <code code="74711-3" codeSystem="2.16.840.1.113883.6.1"/> <sdtc:text> <reference value="#_2350e0a1-5ffb-4b6d-ba9f-be489d9dfc2f"/> </sdtc:text> <statusCode code="completed"/> <!-- Device Identifier --> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.304" extension="2019-06-21"/> <code code="C101722" codeSystem="2.16.840.1.113883.3.26.1.1"/> <value xsi:type="II" root="1.3.160" extension="00643169007222" assigningAuthorityName="GSI" displayable="true"/> </observation> </component> <!-- Lot or Batch Number --> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.315" extension="2019-06-21"/> <code code="C101672" codeSystem="2.16.840.1.113883.3.26.1.1"/> <value xsi:type="ST"></value> </observation> </component> <!-- Serial Number --> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.319" extension="2019-06-21"/> <code code="C101671" codeSystem="2.16.840.1.113883.3.26.1.1"/> <value xsi:type="ST">BLC200461H</value> </observation> </component> <!-- Manufacturing Date --> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.316" extension="2019-06-21"/> <code code="C101669" codeSystem="2.16.840.1.113883.3.26.1.1"/> <value xsi:type="TS" value="20181015"/> </observation> </component> <!-- Expiration Date --> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.309" extension="2019-06-21"/> <code code="C101670" codeSystem="2.16.840.1.113883.3.26.1.1"/> <value xsi:type="TS" value="20221015"/> </observation> </component> <!-- Distinct Identification --> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.308" extension="2019-06-21"/> <code code="C113843" codeSystem="2.16.840.1.113883.3.26.1.1"/> <value xsi:type="ST"></value> </observation> </component> </organizer> </entryRelationship> </procedure> </entry> </section> </component> <!-- ******************** RESULTS ************************ --> <!-- edited as per test doc - all of this data is directly relevant -db --> <component> <section> <!-- Results Section (entries required) (V3) --> <templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.2.3.1"/> <code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="RESULTS"/> <title>RESULTS</title> <text> <table> <thead> <tr> <th>Result Type</th> <th>Result Value</th> <th>Relevant Reference Range</th> <th>Interpretation</th> <th>Date</th> </tr> </thead> <tbody> <!-- this 1st item is from 'I) Laboratory Tests' and has no result yet as it is just a test -db --> <tr> <td ID="result2">Color of Urine</td> <td ID="resultvalue2">YELLOW</td> <td ID="referencerange2">YELLOW</td> <td>Normal</td> <td>06/22/2015</td> </tr> <tr> <td ID="result3">Appearance of Urine</td> <td ID="resultvalue3">CLEAR</td> <td ID="referencerange3">CLEAR</td> <td>Normal</td> <td>06/22/2015</td> </tr> <tr> <td ID="result4">Specific gravity of Urine by Test strip</td> <td ID="resultvalue4">1.015</td> <td ID="referencerange4">1.005 - 1.030</td> <td>Normal</td> <td>06/22/2015</td> </tr> <tr> <td ID="result5">pH of Urine by Test strip</td> <td ID="resultvalue5">5.0 [pH]</td> <td ID="referencerange5">5.0 - 8.0</td> <td>Normal</td> <td>06/22/2015</td> </tr> <tr> <td ID="result6">Glucose [Mass/volume] in urine by test strip</td> <td ID="resultvalue6">50 mg/dL</td> <td ID="referencerange6">Neg</td> <td></td> <td>06/22/2015</td> </tr> <tr> <td ID="result7">Ketones [Mass/Volume] in urine by test strip</td> <td ID="resultvalue7">Negative</td> <td ID="referencerange7">Negative</td> <td></td> <td>06/22/2015</td> </tr> <tr> <td ID="result8">Protein[Mass/Volume] in urine by test strip</td> <td ID="resultvalue8">100 mg/dL</td> <td ID="referencerange8">negative</td> <td></td> <td>06/22/2015</td> </tr> </tbody> </table> </text> <entry typeCode="DRIV"> <organizer classCode="BATTERY" moodCode="EVN"> <!-- ** Result organizer (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.1" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.1"/> <id root="7d5a02b0-67a4-11db-bd13-0800200c9a66"/> <code code="24357-6" displayName="Urinalysis" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <statusCode code="completed"/> <effectiveTime> <low value="20150622"/> <high value="20150622"/> </effectiveTime> <component> <observation classCode="OBS" moodCode="EVN"> <!-- ** Result Observation (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.2" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.2"/> <id root="f1aa44dd-6f39-4f5c-b267-897c3824b563"/> <code code="5778-6" displayName="Color of Urine" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <text> <reference value="#result2"/> </text> <statusCode code="completed"/> <effectiveTime value="20150622"/> <!-- value usage and comment for this scenario sourced from https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Use_of_String_Value.xml -db --> <!-- Representing a result returned as unstructured string--> <!-- There may be a code for this and other colors, but this would be practice when the code is not provided or unknown--> <!-- C-CDA R1.1 does not include a vocabulary binding on the value element --> <value xsi:type="ST">YELLOW</value> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/> <referenceRange> <observationRange> <value xsi:type="ST">YELLOW</value> </observationRange> </referenceRange> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <!-- ** Result Observation (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.2" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.2"/> <id root="f1aa44dd-6f39-4f5c-b267-897c3824b574"/> <code code="5767-9" displayName="Appearance of Urine" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <text> <reference value="#result3"/> </text> <statusCode code="completed"/> <effectiveTime value="20150622"/> <value xsi:type="ST">CLEAR</value> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/> <referenceRange> <observationRange> <value xsi:type="ST">CLEAR</value> </observationRange> </referenceRange> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119" /> <time value="20161020194152+0000" /> <assignedAuthor> <id root="2.16.840.1.113883.19.5" /> <assignedPerson> <name> <prefix nullFlavor="UNK" /> <given nullFlavor="UNK" /> <family nullFlavor="UNK" /> <suffix nullFlavor="UNK" /> </name> </assignedPerson> <representedOrganization> <id root="2.16.840.1.113883.19.5" /> <name>Value Labs</name> <addr use="WP"> <streetAddressLine>2472, Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97007</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <!-- ** Result Observation (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.2" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.2"/> <id root="f1aa44dd-6f39-4f5c-b267-896c3825c678"/> <code code="5811-5" displayName="Specific gravity of Urine by Test strip" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <text> <reference value="#result4"/> </text> <statusCode code="completed"/> <effectiveTime value="20150622"/> <value xsi:type="ST">1.015</value> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/> <referenceRange> <observationRange> <value xsi:type="IVL_PQ"> <low value="1.005"/> <high value="1.030"/> </value> </observationRange> </referenceRange> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119" /> <time value="20161020194152+0000" /> <assignedAuthor> <id root="2.16.840.1.113883.19.5" /> <assignedPerson> <name> <prefix nullFlavor="UNK" /> <given nullFlavor="UNK" /> <family nullFlavor="UNK" /> <suffix nullFlavor="UNK" /> </name> </assignedPerson> <representedOrganization> <id root="2.16.840.1.113883.19.5" /> <name>Value Labs</name> <addr use="WP"> <streetAddressLine>2472, Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97007</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <!-- ** Result Observation (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.2" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.2"/> <id root="f1aa44dd-6f39-4f5c-b267-297c3825cd7x"/> <code code="5803-2" displayName="pH of Urine by Test strip" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <text> <reference value="#result5"/> </text> <statusCode code="completed"/> <effectiveTime value="20150622"/> <value xsi:type="PQ" value="5.0" unit="[pH]"/> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/> <referenceRange> <observationRange> <value xsi:type="IVL_PQ"> <low value="5.0" unit="[pH]"/> <high value="8.0" unit="[pH]"/> </value> </observationRange> </referenceRange> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119" /> <time value="20161020194152+0000" /> <assignedAuthor> <id root="2.16.840.1.113883.19.5" /> <assignedPerson> <name> <prefix nullFlavor="UNK" /> <given nullFlavor="UNK" /> <family nullFlavor="UNK" /> <suffix nullFlavor="UNK" /> </name> </assignedPerson> <representedOrganization> <id root="2.16.840.1.113883.19.5" /> <name>Value Labs</name> <addr use="WP"> <streetAddressLine>2472, Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97007</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <!-- ** Result Observation (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.2" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.2"/> <id root="f1aa44xd-6f39-4f5c-b267-897c3825cd7x"/> <code code="5792-7" displayName="Glucose [Mass/volume] in urine by test strip" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <text> <reference value="#result6"/> </text> <statusCode code="completed"/> <effectiveTime value="20150622"/> <value xsi:type="PQ" value="50" unit="mg/dL"/> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/> <referenceRange> <observationRange> <value xsi:type="CO" code="260385009" codeSystemName="SNOMED-CT" displayName="Negative" codeSystem="2.16.840.1.113883.6.96"/> </observationRange> </referenceRange> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119" /> <time value="20161020194152+0000" /> <assignedAuthor> <id root="2.16.840.1.113883.19.5" /> <assignedPerson> <name> <prefix nullFlavor="UNK" /> <given nullFlavor="UNK" /> <family nullFlavor="UNK" /> <suffix nullFlavor="UNK" /> </name> </assignedPerson> <representedOrganization> <id root="2.16.840.1.113883.19.5" /> <name>Value Labs</name> <addr use="WP"> <streetAddressLine>2472, Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97007</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <!-- ** Result Observation (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.2" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.2"/> <id root="f1aa44dd-6f39-4f5c-b267-123c3824b571"/> <code code="5797-6" displayName="Ketones [Mass/Volume] in urine by test strip" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <text> <reference value="#result7"/> </text> <statusCode code="completed"/> <effectiveTime value="20150622"/> <!-- reference for best practice of using value with negative here: https://github.com/jddamore/HL7-Task-Force-Examples/blob/master/RESULT_Panel_with_Two_Ordinal_Values.xml -db --> <!-- Representing a result of an ordinal test (See LOINC axes) as negative in SNOMED--> <value xsi:type="CO" code="260385009" codeSystemName="SNOMED-CT" displayName="Negative" codeSystem="2.16.840.1.113883.6.96"/> <!-- <value xsi:type="ST">Negative</value> --> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/> <referenceRange> <observationRange> <value xsi:type="CO" code="260385009" codeSystemName="SNOMED-CT" displayName="Negative" codeSystem="2.16.840.1.113883.6.96"/> </observationRange> </referenceRange> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119" /> <time value="20161020194152+0000" /> <assignedAuthor> <id root="2.16.840.1.113883.19.5" /> <assignedPerson> <name> <prefix nullFlavor="UNK" /> <given nullFlavor="UNK" /> <family nullFlavor="UNK" /> <suffix nullFlavor="UNK" /> </name> </assignedPerson> <representedOrganization> <id root="2.16.840.1.113883.19.5" /> <name>Value Labs</name> <addr use="WP"> <streetAddressLine>2472, Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97007</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <!-- ** Result Observation (V3) ** --> <templateId root="2.16.840.1.113883.10.20.22.4.2" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.2"/> <id root="f1aa44Xd-6f39-4f5c-b457-897c3825cd9z"/> <code code="5804-0" displayName="Protein[Mass/Volume] in urine by test strip" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <text> <reference value="#result8"/> </text> <statusCode code="completed"/> <effectiveTime value="20150622"/> <value xsi:type="PQ" value="100" unit="mg/dL"/> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/> <referenceRange> <observationRange> <value xsi:type="CO" code="260385009" codeSystemName="SNOMED-CT" displayName="Negative" codeSystem="2.16.840.1.113883.6.96"/> </observationRange> </referenceRange> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119" /> <time value="20161020194152+0000" /> <assignedAuthor> <id root="2.16.840.1.113883.19.5" /> <assignedPerson> <name> <prefix nullFlavor="UNK" /> <given nullFlavor="UNK" /> <family nullFlavor="UNK" /> <suffix nullFlavor="UNK" /> </name> </assignedPerson> <representedOrganization> <id root="2.16.840.1.113883.19.5" /> <name>Value Labs</name> <addr use="WP"> <streetAddressLine>2472, Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97007</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> </observation> </component> </organizer> </entry> </section> </component> <!-- removed component Advance Directives as not required by test data -db --> <!-- removed component Family History as not required by test data -db --> <!-- added component Functional Status as required by latest version of ToC test data -db --> <!-- ******************************************************** FUNCTIONAL STATUS ******************************************************** --> <component> <section> <!-- Functional Status Section (V2)--> <templateId root="2.16.840.1.113883.10.20.22.2.14" extension="2014-06-09"/> <!-- Functional Status Section --> <templateId root="2.16.840.1.113883.10.20.22.2.14"/> <code code="47420-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Functional Status"/> <title>FUNCTIONAL STATUS</title> <text> <table border="1" width="100%"> <thead> <tr> <th>Functional Category</th> <th>Effective Dates</th> </tr> </thead> <tbody> <tr> <td ID="FUNC1">Dependence on Cane</td> <td>May 01, 2005</td> </tr> </tbody> </table> </text> <entry> <organizer classCode="CLUSTER" moodCode="EVN"> <!-- Functional Status Organizer (V2) --> <templateId root="2.16.840.1.113883.10.20.22.4.66" extension="2014-06-09"/> <!-- Functional Status Result Organizer --> <templateId root="2.16.840.1.113883.10.20.22.4.66"/> <id root="a7bc1062-8649-42a0-833d-eed65bd017c9"/> <code code="d5" displayName="Self-Care" codeSystem="2.16.840.1.113883.6.254" codeSystemName="ICF"/> <statusCode code="completed"/> <component> <!-- cane --> <observation classCode="OBS" moodCode="EVN"> <!-- Functional Status Observation (V2)--> <templateId root="2.16.840.1.113883.10.20.22.4.67" extension="2014-06-09"/> <!-- Functional Status Result Observation --> <templateId root="2.16.840.1.113883.10.20.22.4.67"/> <id root="b63a8636-cfff-4461-b018-40ba58ba8b32"/> <code code="54522-8" displayName="Functional status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <text> <reference value="#FUNC1"/> </text> <statusCode code="completed"/> <effectiveTime value="20050501"/> <value xsi:type="CD" code="105504002" displayName="Dependence on Cane" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/> </observation> </component> <!-- required as per Functional Status Organizer2 - not relevant to test data --> <component> <observation classCode="OBS" moodCode="EVN"> <!-- Self-Care Activities (ADL and IADL) --> <templateId root="2.16.840.1.113883.10.20.22.4.128"/> <id root="c6b5a04b-2bf4-49d1-8336-636a3813df0a"/> <code nullFlavor="NA" /> <statusCode code="completed"/> <effectiveTime value="20050501"/> <value xsi:type="CD" code="371153006" displayName="Independent" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/> </observation> </component> </organizer> </entry> </section> </component> <!-- removed component Medical Equipment as not required by test data -db --> <!-- removed component Payers as not required by test data -db --> <!-- added Assessment -db --> <!-- ******************************************************** Assessment ******************************************************** --> <!-- edited as per test doc - all of this data is directly relevant -db --> <component> <section> <!-- Assessment Section -db --> <!-- There is no R2.1 (or 2.0) version of Assessment Section, using R1.1 templateId only -db --> <templateId root="2.16.840.1.113883.10.20.22.2.8"/> <code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="51848-0" displayName="ASSESSMENTS"/> <title>ASSESSMENTS</title> <text>The patient was found to have fever and Dr Davis is suspecting Anemia based on the patient history. So Dr Davis asked the patient to closely monitor the temperature and blood pressure and get admitted to Community Health Hospitals if the fever does not subside within a day.</text> </section> </component> <!-- ******************* PLAN OF TREATMENT ********************** --> <!-- edited as per test doc - all of this data (except one author) is directly relevant -db --> <component> <section> <!-- **** Plan of Treatment Section (V2) **** --> <templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.2.10"/> <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Treatment plan"/> <title>TREATMENT PLAN</title> <text> <content styleCode="Bold"> Hand-off Communication:</content> <br/> <br/> <table border="1" width="100%"> <thead> <tr> <th>Planned Care</th> <th>Start Date</th> </tr> </thead> <tbody> <!-- Laboratory Tests -db --> <tr> <td>Urinanalysis macro (dipstick) panel</td> <td>June 29, 2015</td> </tr> <!-- Other Observations -db --> <tr ID="ID0EFFFFFFCAB2"> <td ID="ID0EFAAAAACAB2">Get an EKG done on 6/23/2015.</td> <td>June 23, 2015</td> </tr> <tr ID="ID0EFFFFFFCAB3"> <td ID="ID0EFAAAAACAB3">Get a Chest X-ray done on 6/23/2015 showing the Lower Respiratory Tract Structure.</td> <td>June 23, 2015</td> </tr> <!-- Medications -db --> <tr> <td>Take Clindamycin 300mg three times a day as needed if pain does not subside.</td> <td>June 23, 2015 three times a day as needed</td> </tr> <!-- Encounters -db --> <tr> <td>Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2015.</td> <td>July 1, 2015</td> </tr> </tbody> </table> </text> <entry> <observation classCode="OBS" moodCode="RQO"> <templateId root="2.16.840.1.113883.10.20.22.4.44" extension="2014-06-09" /> <templateId root="2.16.840.1.113883.10.20.22.4.44" /> <id root="b52bee94-c34b-4e2c-8c15-5ad9d6def513" /> <code code="24357-6" codeSystem="2.16.840.1.113883.6.1" displayName="Urinanalysis macro (dipstick) panel" /> <text>Urinanalysis macro (dipstick) panel</text> <statusCode code="active" /> <effectiveTime value="20150629" /> </observation> </entry> <entry> <observation classCode="OBS" moodCode="RQO"> <templateId root="2.16.840.1.113883.10.20.22.4.44" extension="2014-06-09" /> <templateId root="2.16.840.1.113883.10.20.22.4.44" /> <id root="b52bee94-c34b-4e2c-8c15-5ad9d6def514" /> <code code="24357-6" codeSystem="2.16.840.1.113883.6.1" displayName="Urinanalysis macro (dipstick) panel" /> <text>Urinanalysis macro (dipstick) panel</text> <statusCode code="active" /> <effectiveTime value="20150622" /> </observation> </entry> <entry> <observation classCode="OBS" moodCode="RQO"> <templateId root="2.16.840.1.113883.10.20.22.4.44" extension="2014-06-09" /> <templateId root="2.16.840.1.113883.10.20.22.4.44" /> <id root="b52bee94-c34b-4e2c-8c15-5ad9d6def515" /> <code code="36643-5" codeSystem="2.16.840.1.113883.6.1" displayName="Chest X-ray 2 Views" /> <text>Chest X-ray 2 Views</text> <statusCode code="active" /> <effectiveTime value="20150622" /> </observation> </entry> <entry typeCode="DRIV"> <act classCode="ACT" moodCode="INT"> <templateId root="2.16.840.1.113883.10.20.22.4.20" /> <id root="b52bee94-c34b-4e2c-8c15-5ad9d6def516" /> <code xsi:type="CE" displayName="Goal" nullFlavor="UNK" codeSystem="2.16.840.1.113883.6.96" /> <text> Get an EKG done on 6/23/2015. Get a Chest X-ray done on 6/23/2015 showing the Lower Respiratory Tract Structure. Take Clindamycin 300mg three times a day as needed if pain does not subside/10. Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2015. </text> <statusCode code="completed" /> <effectiveTime value="20150622" /> </act> </entry> <entry typeCode="DRIV"> <act classCode="ACT" moodCode="INT"> <templateId root="2.16.840.1.113883.10.20.22.4.20" /> <id root="b52bee94-c34b-4e2c-8c15-5ad9d6def517" /> <code xsi:type="CE" displayName="Referral" nullFlavor="OTH" codeSystem="2.16.840.1.113883.6.96" /> <text>Ms Alice Newman is being referred to Community Health Hospitals Inpatient facility because of the high fever noticed and suspected Anemia</text> <statusCode code="completed" /> <effectiveTime nullFlavor="UNK" /> </act> </entry> <!-- Medications -db --> <!-- <entry> --> <!-- Planned Medication Activity (V2)- --> <!-- <substanceAdministration moodCode="INT" classCode="SBADM"> <templateId root="2.16.840.1.113883.10.20.22.4.42" extension="2014-06-09" /> --> <!-- added r1.1 templateId -db --> <!-- <templateId root="2.16.840.1.113883.10.20.22.4.42" /> <id root="cdbd33f0-6cde-11db-9fe1-0800201c9a66" /> <text>Take Clindamycin 300mg three times a day as needed if pain does not subside.</text> <statusCode code="active" /> --> <!-- The effectiveTime in a planned medication activity represents the time that the medication activity should occur. --> <!-- <effectiveTime value="20150623" /> <consumable> <manufacturedProduct classCode="MANU"> --> <!-- Medication Information (V2) --> <!-- <templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09" /> <templateId root="2.16.840.1.113883.10.20.22.4.23" /> <id root="2a620155-9d11-439e-92b3-5d9815ff3cc6"/> <manufacturedMaterial> <code code="284215" codeSystem="2.16.840.1.113883.6.88" displayName="Clindamycin 300mg" codeSystemName="RxNorm"/> </manufacturedMaterial> </manufacturedProduct> </consumable> </substanceAdministration> </entry> --> <!-- Encounters -db --> <!-- --> <!-- added the following planned encounter loosely based off of example here: https://github.com/gecole/HL7-Task-Force-Examples/blob/master/ReferralToC170.314b2Ambulatory.xml -db --> <!-- <entry> --> <!-- encounter with moodCode indicating Intent --> <!-- <encounter classCode="ENC" moodCode="INT"> --> <!-- Planned Encounter (V2) templateId --> <!-- <templateId root="2.16.840.1.113883.10.20.22.4.40" extension="2014-06-09" /> <templateId root="2.16.840.1.113883.10.20.22.4.40"/> <id root="2.3.7.1.42424242.5.11111.1.1.1"/> <code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" code="11429006" displayName="consultation"/> --> <!-- statusCode added as per C-CDA R2.1 -db --> <!-- <statusCode code="active"/> <effectiveTime> <low value="20150701"/> </effectiveTime> --> <!-- required for test data -db --> <!-- <performer> <assignedEntity> <id root="2.16.840.1.113883.19.5.9999.456" extension="2981823"/> <addr use="WP"> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> <telecom value="tel:+1(555)-555-1002" use="WP"/> <representedOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-1002" use="WP"/> <addr use="WP"> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedOrganization> </assignedEntity> </performer> --> <!-- this references the indication (reason) for the planned encounter --> <!-- <entryRelationship typeCode="RSON"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.19" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.19"/> <id root="1.3.6.1.4.1.42424242.4.12354.4.4.4.5.4"/> <code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" code="282291009" displayName="Diagnosis"/> <text>Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2015.</text> <statusCode code="completed"/> <effectiveTime> <low value="20150701"/> </effectiveTime> <value xsi:type="CD" code="386661006" codeSystem="2.16.840.1.113883.6.96" displayName="Fever" codeSystemName="SNOMED-CT"/> </observation> </entryRelationship> </encounter> </entry>--> </section> </component> <!-- Added Goals - original version from C-CDA_R2_Care_Plan.xml from R2.0 IG package. There are no duplicated template Ids with extensions - as there is only one version in existence for each section and entry listed -db --> <!-- ******************************************************** Goals ******************************************************** --> <!-- edited as per test doc - most of this data (except author) is directly relevant - needs work -db --> <component> <section> <!-- Goals Section --> <!-- --> <templateId root="2.16.840.1.113883.10.20.22.2.60"/> <code code="61146-7" displayName="Goals" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Goals Section</title> <text> <table border="1" width="100%"> <thead> <tr> <th>Goal</th> <th>Value</th> <th>Date</th> </tr> </thead> <tbody> <!-- the following two do not need to be coded in entries --> <tr> <td>Get rid of intermittent fever that is occurring every few weeks (Visual Inspection)</td> <td>N/A</td> <td>June 22, 2015</td> </tr> <tr> <td>Need to gain more energy to do regular activities (Visual Inspection)</td> <td>N/A</td> <td>June 22, 2015</td> </tr> </tbody> </table> </text> <entry> <!-- Goal Observation --> <observation classCode="OBS" moodCode="GOL"> <!-- Goal Observation --> <templateId root="2.16.840.1.113883.10.20.22.4.121"/> <id root="3700b3b0-fbed-11e2-b778-0800200c9a66"/> <!-- TODO (min - not required for test data): find a more suitable LOINC code for generic fever or for Visual Inspection -db --> <code code="58144-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Resident's overall goal established during assessment process"/> <statusCode code="active"/> <effectiveTime value="20150622"/> <!-- this may not be the recommended way to record a visual inspection -db --> <value xsi:type="ST">Get rid of intermittent fever that is occurring every few weeks. (Visual Inspection)</value> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119"/> <time value="20150622"/> <assignedAuthor> <id root="d839038b-7171-4165-a760-467925b43857"/> <code code="163W00000X" displayName="Registered nurse" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/> <assignedPerson> <name> <!-- Tracy Davis is a Registered Nurse who is performing some office functions and nurse functions --> <given>Tracy</given> <family>Davis</family> <suffix>RN</suffix> </name> </assignedPerson> <representedOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-5000" use="WP"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> <!-- Patient Author --> <author typeCode="AUT"> <templateId root="2.16.840.1.113883.10.20.22.4.119"/> <time/> <assignedAuthor> <id extension="996-756-495" root="2.16.840.1.113883.19.5"/> </assignedAuthor> </author> </observation> </entry> <entry> <!-- Goal Observation --> <observation classCode="OBS" moodCode="GOL"> <!-- Goal Observation --> <templateId root="2.16.840.1.113883.10.20.22.4.121"/> <id root="3700b3b0-fbed-12e2-b778-0800200c9a66"/> <!-- TODO (min - not required for test data): find a more suitable LOINC code for generic fever or for Visual Inspection -db --> <code code="58144-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Resident's overall goal established during assessment process"/> <statusCode code="active"/> <effectiveTime value="20150622"/> <!-- this may not be the recommended way to record a visual inspection -db --> <value xsi:type="ST">Need to gain more energy to do regular activities. (Visual Inspection)</value> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119"/> <time value="20150622"/> <assignedAuthor> <id root="d839038b-7172-4165-a760-467925b43857"/> <code code="163W00000X" displayName="Registered nurse" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/> <assignedPerson> <name> <!-- Tracy Davis is a Registered Nurse who is performing some office functions and nurse functions --> <given>Tracy</given> <family>Davis</family> <suffix>RN</suffix> </name> </assignedPerson> <representedOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-5000" use="WP"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> <!-- Patient Author --> <author typeCode="AUT"> <templateId root="2.16.840.1.113883.10.20.22.4.119"/> <time/> <assignedAuthor> <!-- This id can point back to the record target already described in the CDA header (or someone else can be described here) --> <!-- This particular example points back to the record target --> <id extension="3158932954" root="2.16.840.1.113883.4.6"/> </assignedAuthor> </author> </observation> </entry> <!-- removed Negotiated Goal for Body Temperature entry as no longer in test data -db --> </section> </component> <!-- added Health Concerns -db --> <!-- Note: There is no R1.1 version of Health Concerns Section or Health Concern Act - so there is only one templateId per section (they're NEW) -db --> <!-- ******************************************************** Health Concerns ******************************************************** --> <!-- edited as per test doc - most of this data is directly relevant (this is basically entirely original content) -db --> <component> <section> <!-- Health Concerns Section (V2) (V1 was added as a NEW template in R2.0, V2 was updated in R2.1) -db --> <templateId root="2.16.840.1.113883.10.20.22.2.58" extension="2015-08-01"/> <code code="75310-3" displayName="Health Concerns Document" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Health Concerns Section</title> <text> <table border="1" width="100%"> <thead> <tr> <th>Observations</th> <th>Status</th> <th>Date</th> </tr> </thead> <tbody> <tr> <td>Chronic Sickness exhibited by patient</td> <td>Active</td> <td>June 22, 2015</td> </tr> </tbody> </table> <br/> <table border="1" width="100%"> <thead> <tr> <th>Concern</th> <th>Status</th> <th>Date</th> </tr> </thead> <tbody> <tr> <td>Documented HyperTension problem</td> <td>Active</td> <td>June 22, 2015</td> </tr> <tr> <td>Documented HypoThyroidism problem</td> <td>Active</td> <td>June 22, 2015</td> </tr> <!-- changed from problem to concern in VDT -db --> <tr> <td>Watch Weight of patient</td> <td>Active</td> <td>June 22, 2015</td> </tr> </tbody> </table> <br/> </text> <entry> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.5" extension="2014-06-09"/> <templateId root="2.16.840.1.113883.10.20.22.4.5"/> <id root="1eeb1e51-ee1d-1234-11xy-11z11ddb111z"/> <code code="11323-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Health status"/> <statusCode code="completed"/> <value xsi:type="CD" code="161901003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Chronically ill"/> </observation> </entry> <entry> <!-- Health Concerns Act (V2) (V1 was added as a NEW template in R2.0, V2 was updated in R2.1) -db --> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.132" extension="2015-08-01"/> <id root="4eab0e52-dd7d-4285-99eb-72d32ddb195c"/> <code code="75310-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Health Concern"/> <statusCode code="completed"/> <!-- Concerns -db --> <entryRelationship typeCode="REFR"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.122"/> <!-- This ID equals the problem, HyperTension in this case -db --> <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/> <!-- The code is nulled to "NP" Not Present" (as specified in reference -db) --> <code nullFlavor="NP"/> <statusCode code="completed"/> </act> </entryRelationship> <entryRelationship typeCode="REFR"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.122"/> <!-- This ID equals the problem, HypoThyroidism in this case -db --> <id root="ab1791b0-5c71-11db-b0de-0800200c9a68"/> <!-- The code is nulled to "NP" Not Present" (as specified in reference -db) --> <code nullFlavor="NP"/> <statusCode code="completed"/> </act> </entryRelationship> <entryRelationship typeCode="REFR"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.122"/> <!-- This ID equals the problem, (over) Weight in this case -db --> <id root="ab1791b0-5c71-11db-b0de-0800200c2b11"/> <!-- The code is nulled to "NP" Not Present" (as specified in reference -db) --> <code nullFlavor="NP"/> <statusCode code="completed"/> </act> </entryRelationship> <!-- Problems -db --> <!-- removed in VDT -db --> </act> </entry> <!-- removed (MAY) Risk Concern Act as not required by test data -db --> </section> </component> <!-- added Reason for Referral -db --> <!-- ******************************************************** Reason for Referral ******************************************************** --> <!-- edited as per test doc - all of this data is directly relevant -db --> <component> <section> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.1" extension="2014-06-09" /> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.1" /> <code code="42349-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="REFERRALS" /> <title>REFERRALS</title> <text> Details: Ms Alice Newman is being referred to Community Health Hospitals Inpatient facility because of the high fever noticed and suspected Anemia<br /><br /> </text> <entry> <observation classCode="OBS" moodCode="INT"> <templateId root="2.16.840.1.113883.10.20.22.4.140" /> <id root="9a6d1bac-17d3-4195-89a4-1121bc809b4e" /> <code code="103697008" displayName="Patient referral to specialist" codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" > <originalText> <reference value="#ID0EFAAAAACAB3"/> </originalText> </code> <text> Details: Ms Alice Newman is being referred to Community Health Hospitals Inpatient facility because of the high fever noticed and suspected Anemia<br /><br /> </text> <statusCode code="active" /> <effectiveTime value="20180623" /> </observation> </entry> </section> </component> <!-- added Mental Status Section (V2) (used to be NEW in R2.0) 2.16.840.1.113883.10.20.22.2.56 as required by latest ToC test data -db --> <!-- ******************************************************** Mental Status Section ******************************************************** --> <component> <section> <!-- note: the IG lists the wrong templateId in its example of this section, lists ...2,14 instead of 2.56 -db --> <!-- There is no R1.1 version of this template -db --> <templateId root="2.16.840.1.113883.10.20.22.2.56" extension="2015-08-01" /> <!-- Mental Status Section --> <code code="10190-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MENTAL STATUS" /> <title>MENTAL STATUS</title> <text> <table border="1" width="100%"> <thead> <tr> <th>Status</th> <th>Date</th> </tr> </thead> <tbody> <tr> <td>Amnesia</td> <td>May 05, 2005</td> </tr> </tbody> </table> </text> <entry> <observation classCode="OBS" moodCode="EVN"> <!-- Mental Status Observation (V3) --> <templateId root="2.16.840.1.113883.10.20.22.4.74" extension="2015-08-01" /> <!-- Cognitive Status Result Observation --> <templateId root="2.16.840.1.113883.10.20.22.4.74"/> <id root="a7bc1062-8649-42a0-833d-ekd65bd013d1" /> <code code="373930000" displayName="Cognitive function" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"> <translation code="75275-8" displayName="Cognitive function" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"></translation> </code> <statusCode code="completed"/> <effectiveTime> <low value="20050501"/> <high nullFlavor="UNK"/> </effectiveTime> <!-- Value element holds the Cognitive Function assessment --> <value xsi:type="CD" code="48167000" displayName="Amnesia" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"> </value> </observation> </entry> </section> </component> <component> <section> <!-- Notes Section --> <templateId root="2.16.840.1.113883.10.20.22.2.65" extension="2016-11-01"/> <!-- This Notes Section is not intended to replace a C-CDA Consultation Note Document --> <!-- If your system captures Consultation Note information in Discrete sections it's not recommended to lump all the text together here. --> <!-- This Notes Section could be included in a Consultation Note Document with other discrete sections (Results, Vitals etc.)--> <!-- This Notes Section is most appropriate for an encounter specific document --> <!-- If this Notes section were included in a CCD, each Note Activity entry should be linked to an appropriate Encounter entry in the Encounters section --> <code code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Consultation note"/> <title>Consultation Notes</title> <text> <list> <item ID="ConsultNote1"> <paragraph>Dr. Specialist - September 8, 2016</paragraph> <paragraph> Dear Dr. Henry Leven: Thank you for referring Ms. Everywoman for evaluation. As you know, she is a 40-year-old woman who has had chronic gastrointestinal symptoms. Approximately 18 years ago, she was hospitalized with a bleeding ulcer. She had a CT scan of the abdomen, which revealed findings consistent with focal nodular hyperplasia (FNH). She has had epigastric abdominal pain as well as a significant change in her bowel movements from baseline constipation to frequent diarrhea. The past medical history is otherwise negative. She takes no prescription medications. The remainder of the history is not contributory. </paragraph> <paragraph> Physical examination revealed a well-appearing woman. The vital signs were normal. The head and neck were unremarkable. The lung fields were clear. The heart exam was normal. The abdomen was obese with normal bowel sounds. There was no tenderness, mass, or hepatosplenomegaly. </paragraph> <paragraph> Endoscopic evaluation revealed a normal colonoscopy. Biopsies taken throughout the colon were essentially unremarkable. Stool tests for pathogenic organisms were negative. Of note, on the upper endoscopy examination, no significant abnormalities were seen; however, upon biopsy, features of celiac disease were noted. </paragraph> <paragraph> In summary, this 40-year-old woman has evidence of celiac disease. We discussed the diagnosis in detail in the office. She was advised to undertake a lifelong gluten-free diet. Followup laboratories in my office were notable for a low serum iron with a low-normal ferritin. The bone density was normal. Repeat triple-phase CT scan of the liver revealed no change in the right hepatic lobe lesion, which is consistent with FNH. I advised periodic reevaluation of the liver with imaging, as well as followup for any potential development of nutritional deficiencies. She should take an iron supplement and continue on a lifelong gluten-free diet. </paragraph> <paragraph> Thank you for the courtesy of this referral. I would be pleased to see Ms. Everywoman in followup. </paragraph> </item> </list> </text> <!-- Note Activity entry --> <entry> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.202" extension="2016-11-01"/> <id root="36e3e930-7b14-11db-9fe1-0800200c9a67" /> <code code="34109-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Note"> <!-- Code must match or be equivalent to section code --> <translation code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Consultation note"/> </code> <text> <!--Please check reference to text--> <reference value="#ConsultNote1"/> </text> <statusCode code="completed"/> <!-- Clinically-relevant time of the note --> <effectiveTime value="20160908"/> <!-- Author Participation --> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119"/> <!-- Time note was actually written --> <time value="20160908083215-0500"/> <assignedAuthor> <!-- Full author information is elsewhere in the document . --> <id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c"/> <assignedPerson> <name> <prefix>Dr.</prefix> <family>Specialist</family> </name> </assignedPerson> <representedOrganization> <id extension="4948714330" root="2.16.840.1.113883.4.6"/> <name>Neighborhood Physicians Practice</name> <telecom value="tel:+1(555)-555-5000" use="WP"/> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> </representedOrganization> </assignedAuthor> </author> </act> </entry> </section> </component> </structuredBody> </component> </ClinicalDocument>
Download