An electronic health record keeps a digital record of clinical information about a particular individual. With the amount of variability among Health IT systems, it is important to have a consistent set of health information for each patient.
For Blue Button, the recommended standard for representing the patient health record is the HL7 Consolidated Clinical Document Architecture also known as the Consolidated CDA.
The Consolidated CDA is a XML-based standard that specifies the encoding, structure, and semantics of a clinical document.
There are a wide-range of templates that can be represented in the Consolidated CDA standard. For Blue Button we are outlining a subset of sections and fields that should be used.
Tools: NIST Validator Web App and C-CDA Scorecard
Blue Button adopts the requirements for sections and fields from Meaningful Use Stage 2. Meaningful Use specifies the fields and content structure of clinical data that providers will share with patients at care transitions. This same structure and consistency will aid application developers as they design and build consumer tools.
Whenever the C-CDA is generated for patients, it should have the following fields, if they exist in the dataholder’s system:
| Section | Description | Quick Link |
|---|---|---|
| Header | Patient information and demographics | Jump to XML |
| Allergies, Adverse Reactions, and Alerts | Includes status and severity of each. | Jump to XML |
| Encounters | Surgeries, ED visits, etc. | Jump to XML |
| Immunizations | Immunizations and vaccines | Jump to XML |
| Medications | As prescribed by the provider | Jump to XML |
| Care Plan | Planned activities and encounters | Jump to XML |
| Discharge Medications | Part of hospital discharge summary | Jump to XML |
| Reason for Referral | Written reason for referral | Jump to XML |
| Problem List | Concerns, complaints, and observations | Jump to XML |
| Procedures | History of procedures | Jump to XML |
| Functional and Cognitive Status | List of impairments | Jump to XML |
| Results | Includes laboratory tests | Jump to XML |
| Social History | Observations like smoking, drinking, etc. | Jump to XML |
| Vital Signs | Includes height, weight, blood pressure, etc. | Jump to XML |
| Discharge Instructions | Written discharge instructions | Jump to XML |
Link to Companion Guide to Consolidated CDA produced by ONC.
Throughout the C-CDA a variety of codes are used to describe the values within it.
| Code System | Description |
|---|---|
| LOINC | Database and universal standard for identifying medical laboratory observations |
| RxNorm | Normalized names for clinical drugs |
| SNOMED CT | Collection of clinical terms |
| ICD-10 | Codes to classify diseases and a wide variety of signs and symptoms |
| ICD-9 | Codes to classify diseases and a wide variety of signs and symptoms |
If a patient or other person is the main consumer of the health record, it should include a stylesheet.
To make the C-CDA XML human readable, an XSLT stylesheet should be included. This will allow a person to easily view their information on a computer or print it.
Here is a sample stylesheet.
This section dissects a well-formed C-CDA. This is the entire XML file. This is another example.
The XML file references the schema from HL7.
<?xml version="1.0"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 ../../../CDA%20R2/cda-schemas-and-samples/infrastructure/cda/CDA.xsd"
xmlns="urn:hl7-org:v3"
xmlns:cda="urn:hl7-org:v3"
xmlns:sdtc="urn:hl7-org:sdtc">
The CDA Header includes details about the identity of the patient, the creator of the XML document, and the reason the encounter that generated data occured.
<!--
********************************************************
CDA Header
********************************************************
-->
<!-- CONF 16791 -->
<realmCode
code="US"/>
<!-- CONF 5361 -->
<typeId
root="2.16.840.1.113883.1.3"
extension="POCD_HD000040"/>
<!-- US General Header Template -->
<!-- CONF 5252 -->
<templateId
root="2.16.840.1.113883.10.20.22.1.1"/>
<!-- *** Note: The next templateId, code and title will differ depending on what type of document is being sent. *** -->
<!-- conforms to the document specific requirements -->
<templateId
root="2.16.840.1.113883.10.20.22.1.2"/>
<!-- CONF 5363 -->
<id
extension="Test CCDA"
root="1.1.1.1.1.1.1.1.1"/>
<!-- CONF 5253 "CCD document" -->
<code
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
code="34133-9"
displayName="Summarization of Episode Note"/>
<!-- CONF 5254 -->
<title>Community Health and Hospitals: Health Summary</title>
<!-- CONF 5256 -->
<effectiveTime
value="20120912000000-0000"/>
<!-- 5259 -->
<confidentialityCode
code="N"
codeSystem="2.16.840.1.113883.5.25"/>
<!-- 5372 -->
<languageCode
code="en-US"/>
<!-- CONF 5266 -->
<recordTarget>
<!-- CONF 5267 -->
<patientRole>
<!-- CONF 5268-->
<id
extension="1"
root="2.16.840.1.113883.4.6"/>
<!-- Fake ID using HL7 example OID. -->
<!-- Patient SSN recorded as an ID -->
<id
extension="123-101-5230"
root="2.16.840.1.113883.4.1"/>
<!-- CONF 5271 -->
<addr
use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Drive</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>
<!-- CONF 5280 -->
<telecom
value="tel:(816)276-6909"
use="HP"/>
<!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<!-- CONF 5283 -->
<patient>
<!-- CONF 5284 -->
<name
use="L">
<!-- L is "Legal" from HL7 EntityNameUse 2.16.840.1.113883.5.45 -->
<given>Myra</given>
<!-- CL is "Call me" from HL7 EntityNamePartQualifier 2.16.840.1.113883.5.43 -->
<family>Jones</family>
</name>
<administrativeGenderCode
code="F"
codeSystem="2.16.840.1.113883.5.1"
displayName="Female"/>
<birthTime
value="19470501"/>
<maritalStatusCode
code="M"
displayName="Married"
codeSystem="2.16.840.1.113883.5.2"
codeSystemName="MaritalStatusCode"/>
<religiousAffiliationCode
code="1013"
displayName="Christian (non-Catholic, non-specific)"
codeSystemName="HL7 Religious Affiliation "
codeSystem="2.16.840.1.113883.5.1076"/>
<!-- Need to Fix the Race Code to be from the OMB Standards -->
<raceCode
code="2106-3"
displayName="White"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="Race and Ethnicity - CDC"/>
<ethnicGroupCode
code="2186-5"
displayName="Not Hispanic or Latino"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="Race and Ethnicity - CDC"/>
<guardian>
<code
code="GPARNT"
displayName="Grandfather"
codeSystem="2.16.840.1.113883.5.111"
codeSystemName="HL7 Role code"/>
<addr
use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Drive</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:(816)276-6909"
use="HP"/>
<guardianPerson>
<name>
<given>Ralph</given>
<family>Jones</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
</place>
</birthplace>
<!-- FIX the Code System to be 639.2 -->
<languageCommunication>
<languageCode
code="eng"/>
<modeCode
code="ESP"
displayName="Expressed spoken"
codeSystem="2.16.840.1.113883.5.60"
codeSystemName="LanguageAbilityMode"/>
<preferenceInd
value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id
root="1.1.1.1.1.1.1.1.4"/>
<name>Community Health and Hospitals</name>
<telecom
use="WP"
value="tel: 555-555-5000"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time
value="20050813000000+0500"/>
<assignedAuthor>
<id
extension="111111"
root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
use="WP"
value="tel:555-555-1002"/>
<assignedPerson>
<name>
<prefix>Dr</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id
root="2.16.840.1.113883.4.6"
extension="999999943252"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
use="WP"
value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Mary</given>
<family>McDonald</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<informant>
<assignedEntity>
<id
extension="KP00017"
root="2.16.840.1.113883.19.5"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
use="WP"
value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</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>Frank</given>
<family>Jones</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id
extension="99999999"
root="2.16.840.1.113883.4.6"/>
<name>Community Health and Hospitals</name>
<telecom
value="tel: 555-555-1002"
use="WP"/>
<addr
use="WP">
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</informationRecipient>
<receivedOrganization>
<name>Community Health and Hospitals</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<time
value="20120813"/>
<signatureCode
code="S"/>
<assignedEntity>
<id
extension="999999999"
root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
use="WP"
value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<authenticator>
<time
value="20120813"/>
<signatureCode
code="S"/>
<assignedEntity>
<id
extension="999999999"
root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
use="WP"
value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<participant typeCode="IND">
<associatedEntity classCode="PRS">
<code
code="GPARNT"
displayName="Grand Parent"
codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<addr
use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Drive</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:(555)555-2006' use='WP'/>
<associatedPerson>
<name>
<prefix>Mr.</prefix>
<given>Ralph</given>
<family>Jones</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<participant typeCode="IND">
<associatedEntity classCode="PRS">
<code
code="SPS"
displayName="SPOUSE"
codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<addr
use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Drive</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:(555)555-2006' use='WP'/>
<associatedPerson>
<name>
<prefix>Mr.</prefix>
<given>Frank</given>
<family>Jones</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<documentationOf
typeCode="DOC">
<serviceEvent
classCode="PCPR">
<code
code="233604007"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT"
displayName="Pnuemonia"/>
<effectiveTime>
<low
value="20120806"/>
<high
value="20120813"/>
</effectiveTime>
<performer
typeCode="PRF">
<functionCode
code="PP"
displayName="Primary Care Provider"
codeSystem="2.16.840.1.113883.12.443"
codeSystemName="Provider Role">
<originalText>Primary Care Provider</originalText>
</functionCode>
<time>
<low
value="20120806"/>
<high
value="20120813"/>
</time>
<assignedEntity>
<id
extension="PseudoMD-1"
root="2.16.840.1.113883.4.6"/>
<code
code="208D00000X"
displayName="General Practice"
codeSystemName="Provider Codes"
codeSystem="2.16.840.1.113883.6.101"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
value="tel:+1-555-555-5000"
use="WP"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom
value="tel:+1-555-555-5000"
use="WP"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
<performer
typeCode="PRF">
<functionCode
code="PP"
displayName="Primary Care Provider"
codeSystem="2.16.840.1.113883.12.443"
codeSystemName="Provider Role">
<originalText>Primary Care Provider</originalText>
</functionCode>
<time>
<low
value="20120806"/>
<high
value="20120813"/>
</time>
<assignedEntity>
<id
extension="PseudoMD-3"
root="2.16.840.1.113883.4.6"/>
<code
code="208D00000X"
displayName="General Practice"
codeSystemName="Provider Codes"
codeSystem="2.16.840.1.113883.6.101"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
value="tel:+1-555-555-5000"
use="HP"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom
value="tel:+1-555-555-5000"
use="HP"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<componentOf>
<encompassingEncounter>
<id extension="1" 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"/>
<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"/>
<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>
This is the start of the CDA Body which contains all the sections in the health record.
<!-- ********************************************************
CDA Body
******************************************************** -->
<component>
<structuredBody>
<!-- *********************** -->
This Alerts section contains a description of allergies, reactions, and alerts for the particular patient.
<!--
********************************************************
Allergies, Adverse Reactions, Alerts
********************************************************
-->
<component>
<section>
<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"/>
<title>ALLERGIES, ADVERSE REACTIONS, ALERTS</title>
<!-- Unstructured text field -->
<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>Penicillin G benzathine</td>
<td><content
ID="reaction1">Hives</content></td>
<td><content
ID="severity1">Moderate to severe</content></td>
<td>Inactive</td>
</tr>
<tr>
<td>Codeine</td>
<td><content
ID="reaction2">Shortness of Breath</content></td>
<td><content
ID="severity2">Moderate</content></td>
<td>Active</td>
</tr>
<tr>
<td>Aspirin</td>
<td><content
ID="reaction3">Hives</content></td>
<td><content
ID="severity3">Mild to moderate</content></td>
<td>Active</td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<act
classCode="ACT"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.30"/>
<!-- ** Allergy problem act ** -->
<id
root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code
code="48765-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Allergies, adverse reactions, alerts"/>
<statusCode
code="completed"/>
<effectiveTime
value="20070501">
<low
value="20070501"/>
<high
value="20120806"/>
</effectiveTime>
<entryRelationship
typeCode="SUBJ">
<observation
classCode="OBS"
moodCode="EVN">
<!-- allergy observation template -->
<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"/>
<statusCode
code="completed"/>
<effectiveTime>
<low nullFlavor="UNK"/>
<high value="20120806"/>
</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">
<originalText>
<reference
value="#reaction1"/>
</originalText>
</value>
<participant
typeCode="CSM">
<participantRole
classCode="MANU">
<playingEntity
classCode="MMAT">
<code
code="7982"
displayName="Penicillin G benzathine"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm">
<originalText>
<reference
value="#reaction1"/>
</originalText>
</code>
</playingEntity>
</participantRole>
</participant>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.28"/>
<!-- Allergy status observation template -->
<code
code="33999-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Status"/>
<statusCode
code="completed"/>
<value
xsi:type="CE"
code="73425007"
codeSystem="2.16.840.1.113883.6.96"
displayName="Inactive"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="MFST"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.9"/>
<!-- Reaction observation template -->
<id
root="4adc1020-7b14-11db-9fe1-0800200c9a64"/>
<code
nullFlavor="NA"/>
<text>
<reference
value="#reaction1"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20070501"/>
</effectiveTime>
<value
xsi:type="CD"
code="247472004"
codeSystem="2.16.840.1.113883.6.96"
displayName="Hives"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.8"/>
<!-- ** Severity observation template ** -->
<code xsi:type="CE"
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="371924009"
displayName="Moderate to severe"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
<entry
typeCode="DRIV">
<act
classCode="ACT"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.30"/>
<!-- ** Allergy problem act ** -->
<id
root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code
code="48765-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Allergies, adverse reactions, alerts"/>
<statusCode
code="completed"/>
<effectiveTime
value="20060501">
<low
value="20060501"/>
<high
value="20120806"/>
</effectiveTime>
<entryRelationship
typeCode="SUBJ">
<observation
classCode="OBS"
moodCode="EVN">
<!-- allergy observation template -->
<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"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20060501"/>
</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">
<originalText>
<reference
value="#reaction2"/>
</originalText>
</value>
<participant
typeCode="CSM">
<participantRole
classCode="MANU">
<playingEntity
classCode="MMAT">
<code
code="2670"
displayName="Codeine"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm">
<originalText>
<reference
value="#reaction2"/>
</originalText>
</code>
</playingEntity>
</participantRole>
</participant>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.28"/>
<!-- Allergy status observation template -->
<code
code="33999-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Status"/>
<statusCode
code="completed"/>
<value
xsi:type="CE"
code="55561003"
codeSystem="2.16.840.1.113883.6.96"
displayName="Active"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="MFST"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.9"/>
<!-- Reaction observation template -->
<id
root="4adc1020-7b14-11db-9fe1-0800200c9a64"/>
<code
nullFlavor="NA"/>
<text>
<reference
value="#reaction2"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20060501"/>
</effectiveTime>
<value
xsi:type="CD"
code="267036007"
codeSystem="2.16.840.1.113883.6.96"
displayName="Shortness of Breath"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.8"/>
<!-- ** Severity observation template ** -->
<code xsi:type="CE"
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>
</act>
</entry>
<entry
typeCode="DRIV">
<act
classCode="ACT"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.30"/>
<!-- ** Allergy problem act ** -->
<id
root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code
code="48765-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Allergies, adverse reactions, alerts"/>
<statusCode
code="completed"/>
<effectiveTime
value="20080501">
<low
value="20080501"/>
<high
value="20120806"/>
</effectiveTime>
<entryRelationship
typeCode="SUBJ">
<observation
classCode="OBS"
moodCode="EVN">
<!-- allergy observation template -->
<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"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20080501"/>
<high value="20120806"/>
</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">
<originalText>
<reference
value="#reaction3"/>
</originalText>
</value>
<participant
typeCode="CSM">
<participantRole
classCode="MANU">
<playingEntity
classCode="MMAT">
<code
code="1191"
displayName="Aspirin"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm">
<originalText>
<reference
value="#reaction3"/>
</originalText>
</code>
</playingEntity>
</participantRole>
</participant>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.28"/>
<!-- Allergy status observation template -->
<code
code="33999-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Status"/>
<statusCode
code="completed"/>
<value
xsi:type="CE"
code="55561003"
codeSystem="2.16.840.1.113883.6.96"
displayName="Active"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="MFST"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.9"/>
<!-- Reaction observation template -->
<id
root="4adc1020-7b14-11db-9fe1-0800200c9a64"/>
<code
nullFlavor="NA"/>
<text>
<reference
value="#reaction3"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20080501"/>
</effectiveTime>
<value
xsi:type="CD"
code="247472004"
codeSystem="2.16.840.1.113883.6.96"
displayName="Hives"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.8"/>
<!-- ** Severity observation template ** -->
<code xsi:type="CE"
code="SEV"
displayName="Severity Observation"
codeSystem="2.16.840.1.113883.5.4"
codeSystemName="ActCode"/>
<text>
<reference
value="#severity3"/>
</text>
<statusCode
code="completed"/>
<value
xsi:type="CD"
code="371923003"
displayName="Mild to moderate"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
This Encounters section includes all the office visits, emergency room visits, surgeries, etc.
<!--
********************************************************
ENCOUNTERS
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.22.1"/>
<!-- Encounters Section - required entries -->
<code
code="46240-8"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="History of encounters"/>
<title>ENCOUNTERS</title>
<!-- Unstructured text field -->
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Encounter</th>
<th>Performer</th>
<th>Location</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<content
ID="Encounter1"/> Pnuemonia</td>
<td>Dr Henry Seven</td>
<td>Community Health and Hospitals</td>
<td>20120806</td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<encounter
classCode="ENC"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.49"/>
<!-- Encounter Activities -->
<!-- ******** Encounter activity template ******** -->
<id
root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code
code="99222"
displayName="InPatient Admission"
codeSystemName="CPT"
codeSystem="2.16.840.1.113883.6.12"
codeSystemVersion="4">
<originalText>Mild Fever<reference
value="#Encounter1"/>
</originalText>
</code>
<effectiveTime
value="20120806"/>
<performer>
<assignedEntity>
<id
root="2a620155-9d11-439e-92a3-5d9815ff4de8"/>
<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 -->
<code
code="1160-1"
codeSystem="2.16.840.1.113883.6.259"
codeSystemName="HealthcareServiceLocation"
displayName="Urgent Care Center"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
nullFlavor="UNK"/>
<playingEntity
classCode="PLC">
<name>Community Health and Hospitals</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship
typeCode="RSON">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.19"/>
<id
root="db734647-fc99-424c-a864-7e3cda82e703"
extension="45665"/>
<code
code="404684003"
displayName="Finding"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20120806"/>
</effectiveTime>
<value
xsi:type="CD"
code="233604007"
displayName="Pneumonia"
codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="SUBJ" inversionInd="false">
<act classCode="ACT" moodCode="EVN">
<!--Encounter diagnosis act -->
<templateId root="2.16.840.1.113883.10.20.22.4.80"/>
<id root="5a784260-6856-4f38-9638-80c751aff2fb"/>
<code xsi:type="CE"
code="29308-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="ENCOUNTER DIAGNOSIS"/>
<statusCode code="active"/>
<effectiveTime>
<low value="20120806"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<observation classCode="OBS" moodCode="EVN" negationInd="false">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<!-- Problem Observation -->
<id
root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code
code="409586006"
codeSystem="2.16.840.1.113883.6.96"
displayName="Complaint"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20120806"/>
</effectiveTime>
<value
xsi:type="CD"
code="233604007"
codeSystem="2.16.840.1.113883.6.96"
displayName="Pneumonia"/>
</observation>
</entryRelationship>
</act>
</entryRelationship>
</encounter>
</entry>
</section>
</component>
This Immunizations section includes all the vaccines an individual has been administered.
<!--
********************************************************
IMMUNIZATIONS
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.2.1"/>
<!-- Entries Required -->
<!-- ******** Immunizations section template ******** -->
<code
code="11369-6"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="History of immunizations"/>
<title>IMMUNIZATIONS</title>
<!-- Unstructured text field -->
<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="immun2"/>Influenza virus vaccine, IM</td>
<td>May 2012</td>
<td>Completed</td>
</tr>
<tr>
<td><content
ID="immun4"/>Tetanus and diphtheria toxoids, IM</td>
<td>Aor 2012</td>
<td>Completed</td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<substanceAdministration
classCode="SBADM"
moodCode="EVN"
negationInd="false">
<templateId
root="2.16.840.1.113883.10.20.22.4.52"/>
<!-- ******** Immunization activity template ******** -->
<id
root="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92"/>
<text>
<reference
value="#immun2"/>
</text>
<statusCode
code="completed"/>
<effectiveTime
xsi:type="IVL_TS"
value="20120510"/>
<routeCode
code="C28161"
codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="National Cancer Institute (NCI) Thesaurus"
displayName="Intramuscular injection"/>
<doseQuantity
value="50"
unit="mcg"/>
<consumable>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.54"/>
<!-- ******** Immunization Medication Information ******** -->
<manufacturedMaterial>
<code
code="88"
codeSystem="2.16.840.1.113883.6.59"
displayName="Influenza virus vaccine"
codeSystemName="CVX">
<originalText>Influenza virus vaccine</originalText>
<translation
code="111"
displayName="influenza, live, intranasal"
codeSystemName="CVX"
codeSystem="2.16.840.1.113883.6.59"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Health LS - Immuno Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<entryRelationship
typeCode="SUBJ" inversionInd="true">
<act
classCode="ACT"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.20"/>
<!-- ** Instructions Template ** -->
<code xsi:type="CE"
code="171044003"
codeSystem="2.16.840.1.113883.6.96"
displayName="immunization education"/>
<text><reference
value="#immunSect"/>Possible flu-like symptoms for three days.</text>
<statusCode
code="completed"/>
</act>
</entryRelationship>
</substanceAdministration>
</entry>
<entry
typeCode="DRIV">
<substanceAdministration
classCode="SBADM"
moodCode="EVN"
negationInd="false">
<templateId
root="2.16.840.1.113883.10.20.22.4.52"/>
<!-- ******** Immunization activity template ******** -->
<id
root="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92"/>
<text>
<reference
value="#immun4"/>
</text>
<statusCode
code="completed"/>
<effectiveTime
xsi:type="IVL_TS"
value="20120401"/>
<routeCode
code="C28161"
codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="National Cancer Institute (NCI) Thesaurus"
displayName="Intramuscular injection"/>
<doseQuantity
value="50"
unit="mcg"/>
<consumable>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.54"/>
<!-- ******** Immunization Medication Information ******** -->
<manufacturedMaterial>
<code
code="103"
codeSystem="2.16.840.1.113883.6.59"
displayName="Tetanus and diphtheria toxoids - preservative free"
codeSystemName="CVX">
<originalText>Tetanus and diphtheria toxoids - preservative free</originalText>
<translation
code="09"
displayName="Tetanus and diphtheria toxoids - preservative free"
codeSystemName="CVX"
codeSystem="2.16.840.1.113883.6.59"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Health LS - Immuno Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<act
classCode="ACT"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.20"/>
<!-- ** Instructions Template ** -->
<code xsi:type="CE"
code="171044003"
codeSystem="2.16.840.1.113883.6.96"
displayName="immunization education"/>
<text><reference
value="#immunSect"/>Possible flu-like symptoms for three days.</text>
<statusCode
code="completed"/>
</act>
</entryRelationship>
</substanceAdministration>
</entry>
</section>
</component>
This section includes all the Medications prescribed to an individual. It includes the type of medication, start date, instructions, and why it was prescribed.
<!--
********************************************************
MEDICATIONS
********************************************************
-->
<component>
<section>
<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>
<!-- Unstructured text field -->
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Medication</th>
<th>Directions</th>
<th>Start Date</th>
<th>Status</th>
<th>Indications</th>
<th>Fill Instructions</th>
</tr>
</thead>
<tbody>
<tr>
<td><content
ID="Med1">Albuterol 0.09 MG/ACTUAT inhalant solution</content></td>
<td>0.09 MG/ACTUAT inhalant solution, 2 puffs once</td>
<td>20120806</td>
<td>Active</td>
<td>Pneumonia (233604007 SNOMED CT)</td>
<td><content ID="FillIns">Generic Substitition Allowed</content></td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<substanceAdministration
classCode="SBADM"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.16"/>
<!-- ** MEDICATION ACTIVITY -->
<id
root="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/>
<text>
<reference
value="#Med1"/>0.09 MG/ACTUAT inhalant solution, 2 puffs </text>
<statusCode
code="completed"/>
<effectiveTime
xsi:type="IVL_TS">
<low
value="20120806"/>
<high
value="20120813"/>
</effectiveTime>
<effectiveTime
xsi:type="PIVL_TS"
institutionSpecified="true"
operator="A">
<period
value="12"
unit="h"/>
</effectiveTime>
<routeCode
code="C38216"
codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="NCI Thesaurus"
displayName="RESPIRATORY (INHALATION)"/>
<doseQuantity
value="0.09"
unit="mg/actuat"/>
<rateQuantity
value="90"
unit="ml/min"/>
<administrationUnitCode
code="C42944"
displayName="INHALANT"
codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="NCI Thesaurus"/>
<consumable>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.23"/>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code
code="573621"
codeSystem="2.16.840.1.113883.6.88"
displayName="Albuterol 0.09 MG/ACTUAT inhalant solution">
<originalText><reference
value="#Med1"/></originalText>
<translation
code="573621"
displayName="Proventil 0.09 MG/ACTUAT inhalant solution"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Medication Factory Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<performer>
<assignedEntity>
<id
nullFlavor="NI"/>
<addr
nullFlavor="UNK"/>
<telecom
nullFlavor="UNK"/>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom
nullFlavor="UNK"/>
<addr
nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
<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">
<code
code="324049"
displayName="Aerosol"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
<name>Aerosol</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship
typeCode="RSON">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.19"/>
<id
root="db734647-fc99-424c-a864-7e3cda82e703"
extension="45665"/>
<code
code="404684003"
displayName="Finding"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
<statusCode
code="completed"/>
<effectiveTime>
<low nullFlavor="UNK" />
<high value="20120813"/>
</effectiveTime>
<value
xsi:type="CD"
code="233604007"
displayName="Pneumonia"
codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="REFR">
<supply
classCode="SPLY"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.17"/>
<id
nullFlavor="NI"/>
<statusCode
code="completed"/>
<effectiveTime
xsi:type="IVL_TS">
<low
value="20120806"/>
<high
value="20120813"/>
</effectiveTime>
<repeatNumber
value="1"/>
<quantity
value="75"/>
<product>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.23"/>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code
code="573621"
codeSystem="2.16.840.1.113883.6.88"
displayName="Albuterol 0.09 MG/ACTUAT inhalant solution">
<originalText><reference
value="#Med1"/></originalText>
<translation
code="573621"
displayName="Albuterol 0.09 MG/ACTUAT inhalant solution"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Medication Factory Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</product>
<performer>
<assignedEntity>
<id
extension="2981823"
root="2.16.840.1.113883.19.5.9999.456"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</assignedEntity>
</performer>
<author>
<time
nullFlavor="UNK"/>
<assignedAuthor>
<id
root="2a620155-9d11-439e-92b3-5d9815fe4de8"/>
<addr
nullFlavor="UNK"/>
<telecom
nullFlavor="UNK"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<act
classCode="ACT"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.20"/>
<!-- ** Instructions Template ** -->
<code xsi:type="CE"
code="409073007"
codeSystem="2.16.840.1.113883.6.96"
displayName="instruction"/>
<text><reference
value="#FillIns"/>label in spanish</text>
<statusCode
code="completed"/>
</act>
</entryRelationship>
</supply>
</entryRelationship>
<entryRelationship
typeCode="REFR">
<supply
classCode="SPLY"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.18"/>
<!-- ** Medication Dispense Template ** -->
<id
root="1.2.3.4.56789.1"
extension="cb734647-fc99-424c-a864-7e3cda82e704"/>
<statusCode
code="completed"/>
<effectiveTime
value="20120806"/>
<repeatNumber
value="1"/>
<product>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.23"/>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code
code="573621"
codeSystem="2.16.840.1.113883.6.88"
displayName="Albuterol 0.09 MG/ACTUAT inhalant solution">
<originalText><reference
value="#Med1"/></originalText>
<translation
code="573621"
displayName="Albuterol 0.09 MG/ACTUAT inhalant solution"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Medication Factory Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</product>
<performer>
<time
nullFlavor="UNK"/>
<assignedEntity>
<id
root="2.16.840.1.113883.19.5.9999.456"
extension="2981823"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
nullFlavor="UNK"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom
nullFlavor="UNK"/>
<addr
nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
</supply>
</entryRelationship>
<precondition
typeCode="PRCN">
<templateId
root="2.16.840.1.113883.10.20.22.4.25"/>
<criterion>
<code
code="ASSERTION"
codeSystem="2.16.840.1.113883.5.4"/>
<value
xsi:type="CE"
code="56018004"
codeSystem="2.16.840.1.113883.6.96"
displayName="Wheezing"/>
</criterion>
</precondition>
</substanceAdministration>
</entry>
</section>
</component>
This Care Plan section lists all the planned activities and encounters recorded in the system.
<!--
********************************************************
CARE PLAN
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.10"/>
<!-- **** Plan of Care section template **** -->
<code
code="18776-5"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Treatment plan"/>
<title>CARE PLAN</title>
<!-- Unstructured text field -->
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Planned Activity</th>
<th>Planned Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>Consultation with Dr George Potomac for Asthma</td>
<td>20120820</td>
</tr>
<tr>
<td>Chest X-ray</td>
<td>20120826</td>
</tr>
<tr>
<td>Sputum Culture</td>
<td>20120820</td>
</tr>
</tbody>
</table>
</text>
<entry>
<encounter
moodCode="INT"
classCode="ENC">
<templateId
root="2.16.840.1.113883.10.20.22.4.40"/>
<!-- **** Plan of Care Activity Encounter template **** -->
<id
root="9a6d1bac-17d3-4195-89a4-1121bc809b4d"/>
<code
code="99241"
displayName="Office consultation - 15 minutes"
codeSystemName="CPT"
codeSystem="2.16.840.1.113883.6.12"/>
<effectiveTime>
<center value="20120820"/>
</effectiveTime>
<entryRelationship
typeCode="SUBJ" inversionInd="true">
<act
classCode="ACT"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.20"/>
<!-- ** Instructions Template ** -->
<code xsi:type="CE"
code="409073007"
codeSystem="2.16.840.1.113883.6.96"
displayName="instruction"/>
<text>Follow up with Dr George Potomac for Asthma</text>
<statusCode
code="completed"/>
</act>
</entryRelationship>
</encounter>
</entry>
<entry>
<procedure
moodCode="RQO"
classCode="PROC">
<templateId
root="2.16.840.1.113883.10.20.22.4.41"/>
<!-- ** Plan of Care Activity Procedure template ** -->
<id
root="9a6d1bac-17d3-4195-89c4-1121bc809b5a"/>
<code
code="168731009"
codeSystem="2.16.840.1.113883.6.96"
displayName="Chest X-Ray"
codeSystemName="SNOMED-CT"/>
<statusCode
code="new"/>
<effectiveTime>
<center
value="20120826"/>
</effectiveTime>
</procedure>
</entry>
<entry
typeCode="DRIV">
<observation
classCode="OBS"
moodCode="RQO">
<templateId
root="2.16.840.1.113883.10.20.22.4.44"/>
<!-- Plan of Care Activity Observation template -->
<id
root="9a6d1bac-17d3-4195-89a4-1121bc809b4a"/>
<code
code="624-7"
codeSystem="2.16.840.1.113883.6.1"
displayName="Sputum Culture"/>
<statusCode
code="new"/>
<effectiveTime>
<center
value="20120820"/>
</effectiveTime>
</observation>
</entry>
</section>
</component>
This Hospital Discharge Summary section captures the medication prescribed at discharge.
<!--
********************************************************
HOSPITAL DISCHARGE MEDICATIONS
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.11.1"/>
<!-- Entries Required -->
<!-- Hospital Discharge Summary templateId -->
<code
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
code="10183-2"
displayName=" HOSPITAL DISCHARGE MEDICATIONS "/>
<title>HOSPITAL DISCHARGE MEDICATIONS</title>
<!-- Unstructured text field -->
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Medication</th>
<th>Directions</th>
<th>Start Date</th>
<th>Status</th>
<th>Indications</th>
<th>Fill Instructions</th>
</tr>
</thead>
<tbody>
<tr>
<td><content ID="DM">120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler</content></td>
<td><content ID="DM1">0.11 MG/ACTUAT Metered Dose Once Daily</content></td>
<td>20120813</td>
<td>Active</td>
<td>Bronchitis (32398004 SNOMED CT)</td>
<td><content ID="FillIns_DM">Generic Substitition Allowed</content></td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<act
classCode="ACT"
moodCode="EVN">
<!-- Discharge Medication Entry -->
<templateId
root="2.16.840.1.113883.10.20.22.4.35"/>
<id
root="5a784260-6856-4f38-9638-80c751aff2fb"/>
<code
code="10183-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Discharge medication"/>
<statusCode
code="active"/>
<effectiveTime>
<low value="20120813"/>
<high value="20120813"/>
</effectiveTime>
<entryRelationship
typeCode="SUBJ">
<substanceAdministration
classCode="SBADM"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.16"/>
<!-- ** MEDICATION ACTIVITY -->
<id
root="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/>
<text>
<reference
value="#DM1"/>0.11 MG/ACTUAT Metered Dose Once Daily </text>
<statusCode
code="completed"/>
<effectiveTime
xsi:type="IVL_TS">
<low value="20120813"/>
<high value="20120813"/>
</effectiveTime>
<effectiveTime
xsi:type="PIVL_TS"
institutionSpecified="true"
operator="A">
<period
value="24"
unit="h"/>
</effectiveTime>
<routeCode
code="C38216"
codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="NCI Thesaurus"
displayName="RESPIRATORY (INHALATION)"/>
<doseQuantity
value="1"
unit="mg/actuat"/>
<rateQuantity
value="110"
unit="ml/min"/>
<maxDoseQuantity
nullFlavor="UNK">
<numerator
nullFlavor="UNK"/>
<denominator
nullFlavor="UNK"/>
</maxDoseQuantity>
<administrationUnitCode
code="C42944"
displayName="INHALANT"
codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="NCI Thesaurus"/>
<consumable>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.23"/>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code
code="896001"
codeSystem="2.16.840.1.113883.6.88"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler">
<originalText><reference
value="#DM"/></originalText>
<translation
code="896001"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Medication Factory Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<performer>
<assignedEntity>
<id
nullFlavor="NI"/>
<addr
nullFlavor="UNK"/>
<telecom
nullFlavor="UNK"/>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5.9999.1395"/>
<name>Community Health and Hospitals</name>
<telecom
nullFlavor="UNK"/>
<addr
nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
<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">
<code
code="324049"
displayName="Aerosol"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
<name>Aerosol</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship
typeCode="RSON">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.19"/>
<id
root="db734647-fc99-424c-a864-7e3cda82e703"
extension="45665"/>
<code
code="404684003"
displayName="Finding"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20110113"/>
</effectiveTime>
<value
xsi:type="CD"
code="32398004"
displayName="Bronchitis"
codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="REFR">
<supply
classCode="SPLY"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.17"/>
<id
nullFlavor="NI"/>
<statusCode
code="completed"/>
<effectiveTime
xsi:type="IVL_TS">
<low
value="20120813"/>
<high
nullFlavor="UNK"/>
</effectiveTime>
<repeatNumber
value="1"/>
<quantity
value="75"/>
<product>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.23"/>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code
code="896001"
codeSystem="2.16.840.1.113883.6.88"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler">
<originalText><reference
value="#DM"/></originalText>
<translation
code="896001"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Medication Factory Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</product>
<performer>
<assignedEntity>
<id
extension="2981825"
root="2.16.840.1.113883.19.5.9999.456"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</assignedEntity>
</performer>
<author>
<time
nullFlavor="UNK"/>
<assignedAuthor>
<id
root="2a620155-9d11-439e-92b3-5d9815fe4de8"/>
<addr
nullFlavor="UNK"/>
<telecom
nullFlavor="UNK"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<act
classCode="ACT"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.20"/>
<!-- ** Instructions Template ** -->
<code xsi:type="CE"
code="409073007"
codeSystem="2.16.840.1.113883.6.96"
displayName="instruction"/>
<text><reference
value="#FillIns_DM"/>Generic Substitution Allowed</text>
<statusCode
code="completed"/>
</act>
</entryRelationship>
</supply>
</entryRelationship>
<entryRelationship
typeCode="REFR">
<supply
classCode="SPLY"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.18"/>
<!-- ** Medication Dispense Template ** -->
<id
root="1.2.3.4.56789.1"
extension="cb734647-fc99-424c-a864-7e3cda82e704"/>
<statusCode
code="completed"/>
<effectiveTime
value="20120813"/>
<repeatNumber
value="1"/>
<quantity
value="75"/>
<product>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.23"/>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code
code="896001"
codeSystem="2.16.840.1.113883.6.88"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler">
<originalText><reference
value="#DM"/></originalText>
<translation
code="896001"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Medication Factory Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</product>
<performer>
<time
nullFlavor="UNK"/>
<assignedEntity>
<id
root="2.16.840.1.113883.19.5.9999.456"
extension="2981825"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
nullFlavor="UNK"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5.9999.1395"/>
<name>Community Health and Hospitals</name>
<telecom
nullFlavor="UNK"/>
<addr
nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
</supply>
</entryRelationship>
<precondition
typeCode="PRCN">
<templateId
root="2.16.840.1.113883.10.20.22.4.25"/>
<criterion>
<code
code="ASSERTION"
codeSystem="2.16.840.1.113883.5.4"/>
<value
xsi:type="CE"
code="56018004"
codeSystem="2.16.840.1.113883.6.96"
displayName="Wheezing"/>
</criterion>
</precondition>
</substanceAdministration>
</entryRelationship>
</act>
</entry>
</section>
</component>
This Referral section is a free text field that captures the reason for the referral.
<!--
********************************************************
REASON FOR REFERRAL
********************************************************
-->
<component>
<section>
<templateId
root="1.3.6.1.4.1.19376.1.5.3.1.3.1"/>
<!-- ** Reason for Referral Section Template ** -->
<code
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
code="42349-1"
displayName="REASON FOR REFERRAL"/>
<title>REASON FOR REFERRAL</title>
<!-- Unstructured text field -->
<text>
<paragraph>Follow up with Dr George Potomac for Asthma</paragraph>
</text>
</section>
</component>
The Problem List section includes all concerns, complaints, and observations; with their corresponding status.
<!--
********************************************************
PROBLEM LIST
********************************************************
-->
<component>
<section>
<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>
<!-- Unstructured text field -->
<text><content
ID="problems"/>
<list
listType="ordered">
<item><content
ID="problem1">Pneumonia : Status - Resolved</content></item>
<item><content
ID="problem2">Asthma : Status - Active</content></item>
</list>
</text>
<entry
typeCode="DRIV">
<act
classCode="ACT"
moodCode="EVN">
<!-- Problem act template -->
<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"/>
<statusCode
code="active"/>
<effectiveTime>
<low
value="20120806"/>
<high
value="20120813"/>
</effectiveTime>
<entryRelationship
typeCode="SUBJ">
<observation
classCode="OBS"
moodCode="EVN">
<!-- Problem observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.4"/>
<id
root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code
code="409586006"
codeSystem="2.16.840.1.113883.6.96"
displayName="Complaint"/>
<text>
<reference
value="#problem1"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low value="20120806"/>
<high value="20120813"/>
</effectiveTime>
<value
xsi:type="CD"
code="233604007"
codeSystem="2.16.840.1.113883.6.96"
displayName="Pneumonia"/>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.31"/>
<!-- Age observation template -->
<code
code="445518008"
codeSystem="2.16.840.1.113883.6.96"
displayName="Age At Onset"/>
<statusCode
code="completed"/>
<value
xsi:type="PQ"
value="65"
unit="a"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="REFR">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.5"/>
<!-- Health status observation template -->
<code xsi:type="CE"
code="11323-3"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Health status"/>
<text><reference
value="#problems"/></text>
<statusCode
code="completed"/>
<value
xsi:type="CD"
code="162467007"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="Symptom Free"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<!-- Status observation template -->
<templateId root="2.16.840.1.113883.10.20.22.4.6"/>
<code xsi:type="CE"
code="33999-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Status"/>
<text><reference
value="#problem2"/></text>
<statusCode code="completed"/>
<value xsi:type="CD"
code="413322009"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="Resolved"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
<entry
typeCode="DRIV">
<act
classCode="ACT"
moodCode="EVN">
<!-- Problem act template -->
<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"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20070103"/>
</effectiveTime>
<entryRelationship
typeCode="SUBJ">
<observation
classCode="OBS"
moodCode="EVN">
<!-- Problem observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.4"/>
<id
root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code
code="409586006"
codeSystem="2.16.840.1.113883.6.96"
displayName="Complaint"/>
<text>
<reference
value="#problem2"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20070103"/>
</effectiveTime>
<value
xsi:type="CD"
code="195967001"
codeSystem="2.16.840.1.113883.6.96"
displayName="Asthma"/>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.31"/>
<!-- Age observation template -->
<code
code="445518008"
codeSystem="2.16.840.1.113883.6.96"
displayName="Age At Onset"/>
<statusCode
code="completed"/>
<value
xsi:type="PQ"
value="59"
unit="a"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="REFR">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.5"/>
<!-- Health status observation template -->
<code xsi:type="CE"
code="11323-3"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Health status"/>
<text><reference
value="#problems"/></text>
<statusCode
code="completed"/>
<value
xsi:type="CD"
code="162467007"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="Symptom Free"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<!-- Status observation template -->
<templateId root="2.16.840.1.113883.10.20.22.4.6"/>
<code xsi:type="CE"
code="33999-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Status"/>
<text><reference
value="#problem2"/></text>
<statusCode code="completed"/>
<value xsi:type="CD"
code="55561003"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="Active"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
The Procedures section details a history of procedures like x-rays.
<!--
********************************************************
PROCEDURES
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.7.1"/>
<!-- Procedures section template -->
<code
code="47519-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="HISTORY OF PROCEDURES"/>
<title>PROCEDURES</title>
<!-- Unstructured text field -->
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Procedure</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<content ID="Proc2">Chest X-Ray</content>
</td>
<td>8/7/2012</td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<procedure
classCode="PROC"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.14"/>
<!-- Procedure Activity Observation -->
<id
extension="123456789"
root="2.16.840.1.113883.19"/>
<code
code="168731009"
codeSystem="2.16.840.1.113883.6.96"
displayName="Chest X-Ray"
codeSystemName="SNOMED-CT">
<originalText>
<reference
value="#Proc2"/>
</originalText>
</code>
<statusCode
code="completed"/>
<effectiveTime
value="20120807"/>
<priorityCode
code="CR"
codeSystem="2.16.840.1.113883.5.7"
codeSystemName="ActPriority"
displayName="Callback results"/>
<methodCode
nullFlavor="UNK"/>
<targetSiteCode
code="82094008"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="Lower Respiratory Tract Structure"/>
<performer>
<assignedEntity>
<id
root="2.16.840.1.113883.19.5"
extension="1234"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
use="WP"
value="(555)555-555-1234"/>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5"/>
<name>Community Health and Hospitals</name>
<telecom
nullFlavor="UNK"/>
<addr
nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
<participant
typeCode="LOC">
<participantRole
classCode="SDLOC">
<templateId
root="2.16.840.1.113883.10.20.22.4.32"/>
<!-- Service Delivery Location template -->
<code
code="1160-1"
codeSystem="2.16.840.1.113883.6.259"
codeSystemName="HealthcareServiceLocation"
displayName="Urgent Care Center"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
nullFlavor="UNK"/>
<playingEntity
classCode="PLC">
<name>Community Health and Hospitals</name>
</playingEntity>
</participantRole>
</participant>
</procedure>
</entry>
</section>
</component>
This Functional Status section details the different functional and cognitive impairments.
<!--
********************************************************
FUNCTIONAL and COGNITIVE STATUS
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.14"/>
<!-- ******** Functional status section template ******** -->
<code
code="47420-5"
codeSystem="2.16.840.1.113883.6.1"/>
<title>FUNCTIONAL STATUS</title>
<!-- Unstructured text field -->
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Functional Condition</th>
<th>Effective Dates</th>
<th>Condition Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<content ID="fs1">Dependence on cane</content></td>
<td>2008</td>
<td>Active</td>
</tr>
<tr>
<td>
<content ID="fs2">Memory impairment</content>
</td>
<td>2008</td>
<td>Active</td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<observation
classCode="OBS"
moodCode="EVN">
<!-- Problem observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.68"/>
<id
root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code xsi:type="CE"
code="409586006"
codeSystem="2.16.840.1.113883.6.96"
displayName="Complaint"/>
<text>
<reference
value="#fs1"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20081101"/>
<high nullFlavor="UNK"/>
</effectiveTime>
<value
xsi:type="CD"
code="105504002"
codeSystem="2.16.840.1.113883.6.96"
displayName="Dependence on Cane"/>
</observation>
</entry>
<entry
typeCode="DRIV">
<observation
classCode="OBS"
moodCode="EVN">
<!-- Problem observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.68"/>
<id
root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code xsi:type="CE"
code="409586006"
codeSystem="2.16.840.1.113883.6.96"
displayName="Complaint"/>
<text>
<reference
value="#fs2"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20081101"/>
<high nullFlavor="UNK" />
</effectiveTime>
<value
xsi:type="CD"
code="386807006"
codeSystem="2.16.840.1.113883.6.96"
displayName="Memory Impairment"/>
</observation>
</entry>
<entry
typeCode="DRIV">
<observation
classCode="OBS"
moodCode="EVN">
<!-- Cognitive Status Problem observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.73"/>
<id
root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code xsi:type="CE"
code="373930000"
codeSystem="2.16.840.1.113883.6.96"
displayName="Cognitive Function Finding"/>
<text>
<reference
value="#fs2"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20081101"/>
<high nullFlavor="UNK"/>
</effectiveTime>
<value
xsi:type="CD"
code="48167000"
codeSystem="2.16.840.1.113883.6.96"
displayName="Amnesia"/>
</observation>
</entry>
</section>
</component>
This Results section includes all laboratory results.
<!--
********************************************************
RESULTS
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.3.1"/>
<!-- Entries Required -->
<code
code="30954-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="RESULTS"/>
<title>RESULTS</title>
<!-- Unstructured text field -->
<text>
<table>
<tbody>
<tr>
<td
colspan="2">LABORATORY INFORMATION</td>
</tr>
<tr>
<td
colspan="2">Chemistries and drug levels</td>
</tr>
<tr>
<td><content
ID="result1">HGB (M 13-18 g/dl; F 12-16 g/dl)</content></td>
<td>13.2</td>
</tr>
<tr>
<td><content
ID="result2">WBC (4.3-10.8 10+3/ul)</content></td>
<td>6.7</td>
</tr>
<tr>
<td><content
ID="result3">PLT (135-145 meq/l)</content></td>
<td>123 (L)</td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<organizer
classCode="BATTERY"
moodCode="EVN">
<!-- Result organizer template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.1"/>
<id
root="7d5a02b0-67a4-11db-bd13-0800200c9a66"/>
<code xsi:type="CE"
code="43789009"
displayName="CBC WO DIFFERENTIAL"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
<statusCode
code="completed"/>
<component>
<observation
classCode="OBS"
moodCode="EVN">
<!-- Result observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.2"/>
<id
root="107c2dc0-67a5-11db-bd13-0800200c9a66"/>
<code xsi:type="CE"
code="30313-1"
displayName="HGB"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"> </code>
<text>
<reference
value="#result1"/>
</text>
<statusCode
code="completed"/>
<effectiveTime
value="20120810"/>
<value
xsi:type="PQ"
value="10.2"
unit="g/dl"/>
<interpretationCode
code="N"
codeSystem="2.16.840.1.113883.5.83"/>
<methodCode/>
<targetSiteCode/>
<author>
<time/>
<assignedAuthor>
<id
root="2a620155-9d11-439e-92b3-5d9816ff4de8"/>
</assignedAuthor>
</author>
<referenceRange>
<observationRange>
<text>M 13-18 g/dl; F 12-16 g/dl</text>
</observationRange>
</referenceRange>
</observation>
</component>
<component>
<observation
classCode="OBS"
moodCode="EVN">
<!-- Result observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.2"/>
<id
root="107c2dc0-67a5-11db-bd13-0800200c9a66"/>
<code xsi:type="CE"
code="33765-9"
displayName="WBC"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"> </code>
<text>
<reference
value="#result2"/>
</text>
<statusCode
code="completed"/>
<effectiveTime
value="20120810"/>
<value
xsi:type="PQ"
value="12.3"
unit="10+3/ul"/>
<interpretationCode
code="N"
codeSystem="2.16.840.1.113883.5.83"/>
<methodCode/>
<targetSiteCode/>
<author>
<time/>
<assignedAuthor>
<id
root="2a620154-9d11-439e-92b3-5d9815ff4de8"/>
</assignedAuthor>
</author>
<referenceRange>
<observationRange>
<value
xsi:type="IVL_PQ">
<low
value="4.3"
unit="10+3/ul"/>
<high
value="10.8"
unit="10+3/ul"/>
</value>
</observationRange>
</referenceRange>
</observation>
</component>
<component>
<observation
classCode="OBS"
moodCode="EVN">
<!-- Result observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.2"/>
<id
root="107c2dc0-67a5-11db-bd13-0800200c9a66"/>
<code xsi:type="CE"
code="26515-7"
displayName="PLT"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"> </code>
<text>
<reference
value="#result3"/>
</text>
<statusCode
code="completed"/>
<effectiveTime
value="20120810"/>
<value
xsi:type="PQ"
value="123"
unit="10+3/ul"/>
<interpretationCode
code="L"
codeSystem="2.16.840.1.113883.5.83"/>
<methodCode/>
<targetSiteCode/>
<author>
<time/>
<assignedAuthor>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
</assignedAuthor>
</author>
<referenceRange>
<observationRange>
<value
xsi:type="IVL_PQ">
<low
value="150"
unit="10+3/ul"/>
<high
value="350"
unit="10+3/ul"/>
</value>
</observationRange>
</referenceRange>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
This Social History section includes observations like smoking and drinking habits.
<!--
********************************************************
SOCIAL HISTORY
********************************************************
-->
<component>
<!-- Social History ******** -->
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.17"/>
<!-- ******** Social history section template ******** -->
<code
code="29762-2"
codeSystem="2.16.840.1.113883.6.1"
displayName="Social History"/>
<title>SOCIAL HISTORY</title>
<!-- Unstructured text field -->
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Social History Element</th>
<th>Description</th>
<th>Effective Dates</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<content
ID="smok1"/> Former smoker (smoked from 2005-2011)
</td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<observation
classCode="OBS"
moodCode="EVN">
<!-- Smoking status observation template -->
<templateId
root="2.16.840.1.113883.10.22.4.78"/>
<id
extension="123456789"
root="2.16.840.1.113883.19"/>
<code
code="ASSERTION"
codeSystem="2.16.840.1.113883.5.4"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20050501"/>
<high
value="20110227"/>
</effectiveTime>
<value
xsi:type="CD"
code="8517006"
displayName="Former smoker"
codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entry>
</section>
</component>
The Vital Signs section captures vitals that change over time like height, weight, and blood pressure.
<!--
********************************************************
VITAL SIGNS
********************************************************
-->
<component>
<section>
<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>
<!-- Unstructured text field -->
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th
align="right">Date / Time: </th>
<th>Nov 1, 2011</th>
<th>August 6, 2012</th>
</tr>
</thead>
<tbody>
<tr>
<th
align="left">Height</th>
<td>
<content
ID="vit1">69 inches</content></td>
<td>
<content
ID="vit2">69 inches</content></td>
</tr>
<tr>
<th
align="left">Weight</th>
<td>
<content
ID="vit3">189 lbs</content></td>
<td>
<content
ID="vit4">194 lbs</content></td>
</tr>
<tr>
<th
align="left">Blood Pressure</th>
<td><content
ID="vit5">132/86 mmHg</content></td>
<td><content
ID="vit6">145/88 mmHg</content></td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<organizer
classCode="CLUSTER"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.26"/>
<!-- Vital signs organizer template -->
<id
root="c6f88320-67ad-11db-bd13-0800200c9a66"/>
<code
code="46680005"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED -CT"
displayName="Vital signs"/>
<statusCode
code="completed"/>
<effectiveTime
value="20111101"/>
<component>
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.27"/>
<!-- Vital Sign Observation template -->
<id
root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
<code
code="8302-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Height"/>
<text><reference
value="#vit1"/></text>
<statusCode
code="completed"/>
<effectiveTime
value="20081101"/>
<value
xsi:type="PQ"
value="69"
unit="in"/>
<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"/>
<!-- Vital Sign Observation template -->
<id
root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
<code
code="3141-9"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Patient Body Weight - Measured"/>
<text><reference
value="#vit4"/></text>
<statusCode
code="completed"/>
<effectiveTime
value="20111101"/>
<value
xsi:type="PQ"
value="189"
unit="lbs"/>
<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"/>
<!-- Vital Sign Observation template -->
<id
root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
<code
code="8480-6"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Intravascular Systolic"/>
<text><reference
value="#vit5"/></text>
<statusCode
code="completed"/>
<effectiveTime
value="20111101"/>
<value
xsi:type="PQ"
value="132"
unit="mm[Hg]"/>
<interpretationCode
code="N"
codeSystem="2.16.840.1.113883.5.83"/>
</observation>
</component>
</organizer>
</entry>
<entry
typeCode="DRIV">
<organizer
classCode="CLUSTER"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.26"/>
<!-- Vital signs organizer template -->
<id
root="c6f88320-67ad-11db-bd13-0800200c9a66"/>
<code
code="46680005"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED -CT"
displayName="Vital signs"/>
<statusCode
code="completed"/>
<effectiveTime
value="20120806"/>
<component>
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.27"/>
<!-- Vital Sign Observation template -->
<id
root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
<code
code="8302-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Height"/>
<text><reference
value="#vit2"/></text>
<statusCode
code="completed"/>
<effectiveTime
value="20120806"/>
<value
xsi:type="PQ"
value="69"
unit="in"/>
<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"/>
<!-- Vital Sign Observation template -->
<id
root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
<code
code="3141-9"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Patient Body Weight - Measured"/>
<text><reference
value="#vit4"/></text>
<statusCode
code="completed"/>
<effectiveTime
value="20120806"/>
<value
xsi:type="PQ"
value="194"
unit="lbs"/>
<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"/>
<!-- Vital Sign Observation template -->
<id
root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
<code
code="8480-6"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Intravascular Systolic"/>
<text><reference
value="#vit6"/></text>
<statusCode
code="completed"/>
<effectiveTime
value="20120806"/>
<value
xsi:type="PQ"
value="145"
unit="mm[Hg]"/>
<interpretationCode
code="N"
codeSystem="2.16.840.1.113883.5.83"/>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
The Hospital Discharge Instructions section is a free text field that captures the discharge instructions as written by the provider.
<!--
************************************
HOSPITAL DISCHARGE INSTRUCTIONS
************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.41"/>
<code
code="8653-8"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="HOSPITAL DISCHARGE INSTRUCTIONS"/>
<title>HOSPITAL DISCHARGE INSTRUCTIONS</title>
<!-- Unstructured text field -->
<text>
<content>
Ms. Jones, you have been seen by Dr. Henry Seven at Local Community Hospital from August 8th until August 13th 2012. You are currently being discharged from Local Community Hospital. Dr. Seven has provided the following instructions to you at this time; should you have any questions please contact a member of your healthcare team prior to discharge. If you have left the hospital and have questions, please contact Dr. Seven at 555-555-1002.
Instructions:
</content>
<list
listType="ordered">
<item>Take all medications as prescribed.</item>
<item>Please monitor your peak flows. If your peak flows drop to 50% of normal, call my office immediately or return to the Emergency Room.</item>
<item>If you experience any of the following symptoms, call my office immediately or return to the Emergency Room:
<list listType="ordered">
<item>Shortness of Breath</item>
<item>Dizziness or Light-headedness</item>
<item>Fever, chills, or diffuse body aches</item>
<item>Pain or redness at the site of any previous intravenous catheter</item>
<item>Any other unusual problem</item>
</list>
</item>
</list>
</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>