[875] | 1 | <?xml version="1.0" encoding="utf-8"?>
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| 2 | <ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc" xmlns:sdtc="urn:hl7-org:sdtc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 http://xreg2.nist.gov:8080/hitspValidation/schema/cdar2c32/infrastructure/cda/C32_CDA.xsd" classCode="DOCCLIN" moodCode="EVN">
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| 3 | <realmCode code="US"/>
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| 4 | <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
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| 5 | <templateId root="2.16.840.1.113883.10.20.1"/>
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| 6 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.1"/>
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| 7 | <templateId root="2.16.840.1.113883.10.20.3"/>
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| 8 | <templateId root="2.16.840.1.113883.3.88.11.32.1"/>
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| 9 | <id root="0665fe32-df85-40c6-a3db-185fee18efab"/>
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| 10 | <code code="34133-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summarization of episode note"/>
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| 11 | <title>Continuity of Care Document from ZZ ALBANY-PRRTP</title>
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| 12 | <effectiveTime value="20107562725+0000"/>
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| 13 | <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
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| 14 | <languageCode code="en-US"/>
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| 15 | <recordTarget typeCode="RCT" contextControlCode="OP">
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| 16 | <patientRole>
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| 17 | <id extension="002030004" root="SSN"/>
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| 18 | <addr use="H">
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| 19 | <streetAddressLine/>
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| 20 | <city/>
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| 21 | <state/>
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| 22 | <postalCode/>
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| 23 | </addr>
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| 24 | <telecom/>
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| 25 | <patient>
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| 26 | <name>
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| 27 | <given>JODY</given>
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| 28 | <given>JEAN</given>
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| 29 | <family>JONES</family>
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| 30 | </name>
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| 31 | <administrativeGenderCode displayName="FEMALE" code="F" codeSystemName="HL7 AdministrativeGender" codeSystem=""/>
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| 32 | <birthTime value="1945111200"/>
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| 33 | </patient>
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| 34 | </patientRole>
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| 35 | </recordTarget>
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| 36 | <author>
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| 37 | <time value="20107562725"/>
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| 38 | <assignedAuthor>
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| 39 | <id extension="ACTORPROVIDER_10000000020" root="CCRActorID"/>
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| 40 | <addr use="WP">
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| 41 | <streetAddressLine>123 MAIN</streetAddressLine>
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| 42 | <city>ALBANY</city>
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| 43 | <state>NY</state>
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| 44 | <postalCode>12180</postalCode>
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| 45 | </addr>
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| 46 | <telecom use="WP" value="tel:+1-509.989.3732"/>
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| 47 | <assignedPerson>
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| 48 | <name>
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| 49 | <given>SYSTEM</given>
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| 50 | <family>MANAGER</family>
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| 51 | </name>
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| 52 | </assignedPerson>
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| 53 | </assignedAuthor>
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| 54 | </author>
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| 55 | <custodian>
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| 56 | <assignedCustodian>
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| 57 | <representedCustodianOrganization>
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| 58 | <id extension="ACTORORGANIZATION_1" root="CCRActorID"/>
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| 59 | <name>ZZ ALBANY-PRRTP</name>
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| 60 | <telecom/>
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| 61 | <addr use="WP">
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| 62 | <streetAddressLine>123 MAIN</streetAddressLine>
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| 63 | <city>ALBANY</city>
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| 64 | <state>NEW YORK</state>
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| 65 | <postalCode>12180</postalCode>
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| 66 | </addr>
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| 67 | </representedCustodianOrganization>
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| 68 | </assignedCustodian>
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| 69 | </custodian>
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| 70 | <documentationOf>
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| 71 | <serviceEvent classCode="PCPR">
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| 72 | <effectiveTime>
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| 73 | <low value="201073"/>
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| 74 | <high value="201074"/>
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| 75 | </effectiveTime>
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| 76 | </serviceEvent>
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| 77 | </documentationOf>
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| 78 | <component>
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| 79 | <structuredBody>
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| 80 | <component>
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| 81 | <section>
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| 82 | <templateId root="2.16.840.1.113883.10.20.1.13"/>
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| 83 | <code code="48764-5" codeSystem="2.16.840.1.113883.6.1"/>
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| 84 | <title>Purpose</title>
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| 85 | <text>CEND PHR</text>
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| 86 | </section>
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| 87 | </component>
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| 88 | <component>
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| 89 | <section>
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| 90 | <templateId root="2.16.840.1.113883.3.88.11.83.103" assigningAuthorityName="HITSP/C83"/>
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| 91 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.6" assigningAuthorityName="IHE PCC"/>
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| 92 | <templateId root="2.16.840.1.113883.10.20.1.11" assigningAuthorityName="HL7 CCD"/>
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| 93 | <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem list"/>
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| 94 | <title>Problems</title>
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| 95 | <text>
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| 96 | <table>
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| 97 | <tbody>
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| 98 | <tr>
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| 99 | <th>Type</th>
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| 100 | <th>Date</th>
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| 101 | <th>Code</th>
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| 102 | <th>Description</th>
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| 103 | <th>Status</th>
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| 104 | <th>Source</th>
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| 105 | </tr>
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| 106 | <tr>
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| 107 | <td>Problem</td>
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| 108 | <td>
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| 109 | <table>
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| 110 | <tbody>
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| 111 | <tr xmlns="">
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| 112 | <td>Jul 3, 2010</td>
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| 113 | </tr>
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| 114 | </tbody>
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| 115 | </table>
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| 116 | </td>
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| 117 | <td>250.00 (ICD9CM)
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| 118 | </td>
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| 119 | <td ID="PROBLEM1">Diabetes Mellitus</td>
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| 120 | <td>Active/Chronic</td>
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| 121 | <td>SYSTEM MANAGER </td>
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| 122 | </tr>
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| 123 | <tr>
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| 124 | <td>Problem</td>
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| 125 | <td>
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| 126 | <table>
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| 127 | <tbody>
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| 128 | <tr xmlns="">
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| 129 | <td>Jul 4, 2010</td>
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| 130 | </tr>
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| 131 | </tbody>
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| 132 | </table>
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| 133 | </td>
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| 134 | <td>428.0 (ICD9CM)
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| 135 | </td>
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| 136 | <td ID="PROBLEM2">Congestive Heart Failure</td>
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| 137 | <td>Active/Chronic</td>
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| 138 | <td>SYSTEM MANAGER </td>
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| 139 | </tr>
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| 140 | <tr>
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| 141 | <td>Problem</td>
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| 142 | <td>
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| 143 | <table>
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| 144 | <tbody>
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| 145 | <tr xmlns="">
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| 146 | <td>Jul 4, 2010</td>
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| 147 | </tr>
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| 148 | </tbody>
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| 149 | </table>
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| 150 | </td>
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| 151 | <td>412. (ICD9CM)
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| 152 | </td>
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| 153 | <td ID="PROBLEM3">Old Myocardial Infarction</td>
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| 154 | <td>Inactive/Chronic</td>
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| 155 | <td>SYSTEM MANAGER </td>
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| 156 | </tr>
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| 157 | </tbody>
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| 158 | </table>
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| 159 | </text>
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| 160 | <entry typeCode="DRIV">
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| 161 | <act classCode="ACT" moodCode="EVN">
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| 162 | <templateId root="2.16.840.1.113883.10.20.1.27"/>
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| 163 | <id root="PROBLEM1" extension="CCRObjectID"/>
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| 164 | <code nullFlavor="NA"/>
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| 165 | <performer typeCode="PRF">
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| 166 | <assignedEntity>
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| 167 | <id extension="ACTORPROVIDER_10000000020" root="CCRActorID"/>
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| 168 | <addr use="WP">
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| 169 | <streetAddressLine>123 MAIN</streetAddressLine>
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| 170 | <city>ALBANY</city>
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| 171 | <state>NY</state>
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| 172 | <postalCode>12180</postalCode>
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| 173 | </addr>
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| 174 | <telecom use="WP" value="tel:+1-509.989.3732"/>
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| 175 | <assignedPerson>
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| 176 | <name>
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| 177 | <given>SYSTEM</given>
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| 178 | <family>MANAGER</family>
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| 179 | </name>
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| 180 | </assignedPerson>
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| 181 | </assignedEntity>
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| 182 | </performer>
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| 183 | <entryRelationship typeCode="SUBJ">
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| 184 | <observation classCode="OBS" moodCode="EVN">
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| 185 | <templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
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| 186 | <id root="PROBLEM1" extension="CCRObjectID"/>
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| 187 | <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
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| 188 | <text>
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| 189 | <reference value="#PROBLEM1"/>
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| 190 | </text>
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| 191 | <statusCode code="completed"/>
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| 192 | <effectiveTime>
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| 193 | <low value="201073"/>
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| 194 | <high nullFlavor="UNK"/>
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| 195 | </effectiveTime>
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| 196 | <value displayName="Diabetes Mellitus" code="250.00" codeSystemName="ICD9CM" codeSystem=""/>
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| 197 | <entryRelationship typeCode="REFR">
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| 198 | <observation classCode="OBS" moodCode="EVN">
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| 199 | <templateId root="2.16.840.1.113883.10.20.1.50"/>
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| 200 | <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
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| 201 | <statusCode code="completed"/>
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| 202 | <value>
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| 203 | <originalText>Active/Chronic</originalText>
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| 204 | </value>
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| 205 | </observation>
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| 206 | </entryRelationship>
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| 207 | </observation>
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| 208 | </entryRelationship>
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| 209 | </act>
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| 210 | </entry>
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| 211 | <entry typeCode="DRIV">
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| 212 | <act classCode="ACT" moodCode="EVN">
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| 213 | <templateId root="2.16.840.1.113883.10.20.1.27"/>
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| 214 | <id root="PROBLEM2" extension="CCRObjectID"/>
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| 215 | <code nullFlavor="NA"/>
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| 216 | <performer typeCode="PRF">
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| 217 | <assignedEntity>
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| 218 | <id extension="ACTORPROVIDER_10000000020" root="CCRActorID"/>
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| 219 | <addr use="WP">
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| 220 | <streetAddressLine>123 MAIN</streetAddressLine>
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| 221 | <city>ALBANY</city>
|
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| 222 | <state>NY</state>
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| 223 | <postalCode>12180</postalCode>
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| 224 | </addr>
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| 225 | <telecom use="WP" value="tel:+1-509.989.3732"/>
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| 226 | <assignedPerson>
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| 227 | <name>
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| 228 | <given>SYSTEM</given>
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| 229 | <family>MANAGER</family>
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| 230 | </name>
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| 231 | </assignedPerson>
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| 232 | </assignedEntity>
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| 233 | </performer>
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| 234 | <entryRelationship typeCode="SUBJ">
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| 235 | <observation classCode="OBS" moodCode="EVN">
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| 236 | <templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
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| 237 | <id root="PROBLEM2" extension="CCRObjectID"/>
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| 238 | <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
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| 239 | <text>
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| 240 | <reference value="#PROBLEM2"/>
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| 241 | </text>
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| 242 | <statusCode code="completed"/>
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| 243 | <effectiveTime>
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| 244 | <low value="201074"/>
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| 245 | <high nullFlavor="UNK"/>
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| 246 | </effectiveTime>
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| 247 | <value displayName="Congestive Heart Failure" code="428.0" codeSystemName="ICD9CM" codeSystem=""/>
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| 248 | <entryRelationship typeCode="REFR">
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| 249 | <observation classCode="OBS" moodCode="EVN">
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| 250 | <templateId root="2.16.840.1.113883.10.20.1.50"/>
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| 251 | <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
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| 252 | <statusCode code="completed"/>
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| 253 | <value>
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| 254 | <originalText>Active/Chronic</originalText>
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| 255 | </value>
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| 256 | </observation>
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| 257 | </entryRelationship>
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| 258 | </observation>
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| 259 | </entryRelationship>
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| 260 | </act>
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| 261 | </entry>
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| 262 | <entry typeCode="DRIV">
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| 263 | <act classCode="ACT" moodCode="EVN">
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| 264 | <templateId root="2.16.840.1.113883.10.20.1.27"/>
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| 265 | <id root="PROBLEM3" extension="CCRObjectID"/>
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| 266 | <code nullFlavor="NA"/>
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| 267 | <performer typeCode="PRF">
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| 268 | <assignedEntity>
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| 269 | <id extension="ACTORPROVIDER_10000000020" root="CCRActorID"/>
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| 270 | <addr use="WP">
|
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| 271 | <streetAddressLine>123 MAIN</streetAddressLine>
|
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| 272 | <city>ALBANY</city>
|
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| 273 | <state>NY</state>
|
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| 274 | <postalCode>12180</postalCode>
|
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| 275 | </addr>
|
---|
| 276 | <telecom use="WP" value="tel:+1-509.989.3732"/>
|
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| 277 | <assignedPerson>
|
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| 278 | <name>
|
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| 279 | <given>SYSTEM</given>
|
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| 280 | <family>MANAGER</family>
|
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| 281 | </name>
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| 282 | </assignedPerson>
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| 283 | </assignedEntity>
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| 284 | </performer>
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| 285 | <entryRelationship typeCode="SUBJ">
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| 286 | <observation classCode="OBS" moodCode="EVN">
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| 287 | <templateId root="2.16.840.1.113883.10.20.1.28" assigningAuthorityName="CCD"/>
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| 288 | <id root="PROBLEM3" extension="CCRObjectID"/>
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| 289 | <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
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| 290 | <text>
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| 291 | <reference value="#PROBLEM3"/>
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| 292 | </text>
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| 293 | <statusCode code="completed"/>
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| 294 | <effectiveTime>
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| 295 | <low value="201074"/>
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| 296 | <high nullFlavor="UNK"/>
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| 297 | </effectiveTime>
|
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| 298 | <value displayName="Old Myocardial Infarction" code="412." codeSystemName="ICD9CM" codeSystem=""/>
|
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| 299 | <entryRelationship typeCode="REFR">
|
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| 300 | <observation classCode="OBS" moodCode="EVN">
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| 301 | <templateId root="2.16.840.1.113883.10.20.1.50"/>
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| 302 | <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status"/>
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| 303 | <statusCode code="completed"/>
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| 304 | <value>
|
---|
| 305 | <originalText>Inactive/Chronic</originalText>
|
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| 306 | </value>
|
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| 307 | </observation>
|
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| 308 | </entryRelationship>
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| 309 | </observation>
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| 310 | </entryRelationship>
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| 311 | </act>
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| 312 | </entry>
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| 313 | </section>
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| 314 | </component>
|
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| 315 | <component>
|
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| 316 | <section>
|
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| 317 | <templateId root="2.16.840.1.113883.3.88.11.83.112" assigningAuthorityName="HITSP/C83"/>
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| 318 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.19" assigningAuthorityName="IHE PCC"/>
|
---|
| 319 | <templateId root="2.16.840.1.113883.10.20.1.8" assigningAuthorityName="HL7 CCD"/>
|
---|
| 320 | <code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of medication use"/>
|
---|
| 321 | <title>Medications</title>
|
---|
| 322 | <text>
|
---|
| 323 | <table>
|
---|
| 324 | <tbody>
|
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| 325 | <tr>
|
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| 326 | <th>Medication</th>
|
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| 327 | <th>Date</th>
|
---|
| 328 | <th>Status</th>
|
---|
| 329 | <th>Form</th>
|
---|
| 330 | <th>Strength</th>
|
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| 331 | <th>Quantity</th>
|
---|
| 332 | <th>SIG</th>
|
---|
| 333 | <th>Indications</th>
|
---|
| 334 | <th>Instruction</th>
|
---|
| 335 | <th>Refills</th>
|
---|
| 336 | <th>Source</th>
|
---|
| 337 | </tr>
|
---|
| 338 | <tr>
|
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| 339 | <td>ASPIRIN 81MG EC TAB</td>
|
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| 340 | <td/>
|
---|
| 341 | <td>ACTIVE</td>
|
---|
| 342 | <td>TAB,EC</td>
|
---|
| 343 | <td>81 MG</td>
|
---|
| 344 | <td>90 TAB</td>
|
---|
| 345 | <td>81 MG ORAL (BY MOUTH) QD</td>
|
---|
| 346 | <td>
|
---|
| 347 | <br/>
|
---|
| 348 | </td>
|
---|
| 349 | <td/>
|
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| 350 | <td>3 </td>
|
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| 351 | <td>SYSTEM MANAGER </td>
|
---|
| 352 | </tr>
|
---|
| 353 | <tr>
|
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| 354 | <td>ATENOLOL 100MG TAB</td>
|
---|
| 355 | <td/>
|
---|
| 356 | <td>ACTIVE</td>
|
---|
| 357 | <td>TAB</td>
|
---|
| 358 | <td>100 MG</td>
|
---|
| 359 | <td>90 TAB</td>
|
---|
| 360 | <td>100 MG ORAL (BY MOUTH) QD</td>
|
---|
| 361 | <td>
|
---|
| 362 | <br/>
|
---|
| 363 | </td>
|
---|
| 364 | <td/>
|
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| 365 | <td>3 </td>
|
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| 366 | <td>SYSTEM MANAGER </td>
|
---|
| 367 | </tr>
|
---|
| 368 | <tr>
|
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| 369 | <td>LISINOPRIL 20MG TAB</td>
|
---|
| 370 | <td/>
|
---|
| 371 | <td>ACTIVE</td>
|
---|
| 372 | <td>TAB</td>
|
---|
| 373 | <td>20 MG</td>
|
---|
| 374 | <td>90 TAB</td>
|
---|
| 375 | <td>20 MG ORAL (BY MOUTH) QAM</td>
|
---|
| 376 | <td>
|
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| 377 | <br/>
|
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| 378 | </td>
|
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| 379 | <td/>
|
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| 380 | <td>3 </td>
|
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| 381 | <td>SYSTEM MANAGER </td>
|
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| 382 | </tr>
|
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| 383 | </tbody>
|
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| 384 | </table>
|
---|
| 385 | </text>
|
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| 386 | <entry typeCode="DRIV">
|
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| 387 | <substanceAdministration classCode="SBADM" moodCode="EVN">
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| 388 | <templateId root="2.16.840.1.113883.10.20.1.24" assigningAuthorityName="CCD"/>
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| 389 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.1" assigningAuthorityName="IHE PCC"/>
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| 390 | <id root="MED1" extension="CCRObjectID"/>
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| 391 | <statusCode code="completed"/>
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| 397 | <doseQuantity>
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| 398 | <low value="81" unit=""/>
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| 399 | <high value="81" unit=""/>
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| 400 | </doseQuantity>
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| 402 | <manufacturedProduct>
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|
---|
| 406 | <manufacturedMaterial>
|
---|
| 407 | <code displayName="ASPIRIN 81MG EC TAB" code="308416" codeSystemName="RXNORM" codeSystem=""/>
|
---|
| 408 | <name/>
|
---|
| 409 | </manufacturedMaterial>
|
---|
| 410 | </manufacturedProduct>
|
---|
| 411 | </consumable>
|
---|
| 412 | </substanceAdministration>
|
---|
| 413 | </entry>
|
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| 414 | <entry typeCode="DRIV">
|
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| 415 | <substanceAdministration classCode="SBADM" moodCode="EVN">
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|
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| 423 | </effectiveTime>
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| 424 | <routeCode displayName="" code="" codeSystemName="2.16.840.1.113883.5.112"/>
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| 425 | <doseQuantity>
|
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| 426 | <low value="100" unit=""/>
|
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| 427 | <high value="100" unit=""/>
|
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| 428 | </doseQuantity>
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| 429 | <consumable>
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| 433 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.2" assigningAuthorityName="IHE PCC"/>
|
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| 434 | <manufacturedMaterial>
|
---|
| 435 | <code displayName="ATENOLOL 100MG TAB" code="197379" codeSystemName="RXNORM" codeSystem=""/>
|
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| 436 | <name/>
|
---|
| 437 | </manufacturedMaterial>
|
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| 438 | </manufacturedProduct>
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| 439 | </consumable>
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| 440 | </substanceAdministration>
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| 441 | </entry>
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| 442 | <entry typeCode="DRIV">
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| 452 | <routeCode displayName="" code="" codeSystemName="2.16.840.1.113883.5.112"/>
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| 453 | <doseQuantity>
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| 454 | <low value="20" unit=""/>
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| 455 | <high value="20" unit=""/>
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| 456 | </doseQuantity>
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| 457 | <consumable>
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| 458 | <manufacturedProduct>
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|
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| 461 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.2" assigningAuthorityName="IHE PCC"/>
|
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| 462 | <manufacturedMaterial>
|
---|
| 463 | <code displayName="LISINOPRIL 20MG TAB" code="314077" codeSystemName="RXNORM" codeSystem=""/>
|
---|
| 464 | <name/>
|
---|
| 465 | </manufacturedMaterial>
|
---|
| 466 | </manufacturedProduct>
|
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| 467 | </consumable>
|
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| 468 | </substanceAdministration>
|
---|
| 469 | </entry>
|
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| 470 | </section>
|
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| 471 | </component>
|
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| 472 | <component>
|
---|
| 473 | <section>
|
---|
| 474 | <templateId root="2.16.840.1.113883.10.20.1.16"/>
|
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| 475 | <code code="8716-3" codeSystem="2.16.840.1.113883.6.1"/>
|
---|
| 476 | <title>Vital Signs</title>
|
---|
| 477 | <text>
|
---|
| 478 | <table>
|
---|
| 479 | <tbody>
|
---|
| 480 | <tr>
|
---|
| 481 | <th>Vital Sign</th>
|
---|
| 482 | <th>Date</th>
|
---|
| 483 | <th>Result</th>
|
---|
| 484 | <th>Source</th>
|
---|
| 485 | </tr>
|
---|
| 486 | <tr id="VITAL1">
|
---|
| 487 | <td>BLOOD PRESSURE</td>
|
---|
| 488 | <td/>
|
---|
| 489 | <td>BLOOD PRESSURE 120/70 <br/>
|
---|
| 490 | </td>
|
---|
| 491 | <td>WorldVistA EHR/VOE 1.0 </td>
|
---|
| 492 | </tr>
|
---|
| 493 | <tr id="VITAL2">
|
---|
| 494 | <td>RESPIRATION</td>
|
---|
| 495 | <td/>
|
---|
| 496 | <td>RESPIRATION 29 <br/>
|
---|
| 497 | </td>
|
---|
| 498 | <td>WorldVistA EHR/VOE 1.0 </td>
|
---|
| 499 | </tr>
|
---|
| 500 | <tr id="VITAL3">
|
---|
| 501 | <td>PULSE</td>
|
---|
| 502 | <td/>
|
---|
| 503 | <td>PULSE 78 <br/>
|
---|
| 504 | </td>
|
---|
| 505 | <td>WorldVistA EHR/VOE 1.0 </td>
|
---|
| 506 | </tr>
|
---|
| 507 | <tr id="VITAL4">
|
---|
| 508 | <td>TEMPERATURE</td>
|
---|
| 509 | <td/>
|
---|
| 510 | <td>TEMPERATURE 98.6 F <br/>
|
---|
| 511 | </td>
|
---|
| 512 | <td>WorldVistA EHR/VOE 1.0 </td>
|
---|
| 513 | </tr>
|
---|
| 514 | </tbody>
|
---|
| 515 | </table>
|
---|
| 516 | </text>
|
---|
| 517 | <entry typeCode="DRIV">
|
---|
| 518 | <organizer classCode="CLUSTER" moodCode="EVN">
|
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| 519 | <templateId root="2.16.840.1.113883.10.20.1.32" assigningAuthorityName="CCD"/>
|
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| 520 | <templateId root="2.16.840.1.113883.10.20.1.35" assigningAuthorityName="CCD"/>
|
---|
| 521 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.1" assigningAuthorityName="IHE PCC"/>
|
---|
| 522 | <id root="VITAL1" extension="CCRObjectID"/>
|
---|
| 523 | <code code="46680005" codeSystem="2.16.840.1.113883.6.96" displayName="Vital signs" codeSystemName="SNOMED CT"/>
|
---|
| 524 | <statusCode code="completed"/>
|
---|
| 525 | <effectiveTime>
|
---|
| 526 | <low value="201073"/>
|
---|
| 527 | <high nullFlavor="UNK"/>
|
---|
| 528 | </effectiveTime>
|
---|
| 529 | <component>
|
---|
| 530 | <observation classCode="OBS" moodCode="EVN">
|
---|
| 531 | <templateId root="2.16.840.1.113883.3.88.11.83.15" assigningAuthorityName="HITSP C83"/>
|
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| 532 | <templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
|
---|
| 533 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>
|
---|
| 534 | <id root="VITALTEST1" extension="CCRObjectID"/>
|
---|
| 535 | <code displayName="BLOOD PRESSURE" code="392570002" codeSystemName="SNOMED" codeSystem=""/>
|
---|
| 536 | <text>
|
---|
| 537 | <reference value="#VITALTEST1"/>
|
---|
| 538 | </text>
|
---|
| 539 | <statusCode code="completed"/>
|
---|
| 540 | <effectiveTime>
|
---|
| 541 | <low value="201073"/>
|
---|
| 542 | <high nullFlavor="UNK"/>
|
---|
| 543 | </effectiveTime>
|
---|
| 544 | <value xsi:type="PQ" value="120/70" unit=""/>
|
---|
| 545 | </observation>
|
---|
| 546 | </component>
|
---|
| 547 | </organizer>
|
---|
| 548 | </entry>
|
---|
| 549 | <entry typeCode="DRIV">
|
---|
| 550 | <organizer classCode="CLUSTER" moodCode="EVN">
|
---|
| 551 | <templateId root="2.16.840.1.113883.10.20.1.32" assigningAuthorityName="CCD"/>
|
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| 552 | <templateId root="2.16.840.1.113883.10.20.1.35" assigningAuthorityName="CCD"/>
|
---|
| 553 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.1" assigningAuthorityName="IHE PCC"/>
|
---|
| 554 | <id root="VITAL2" extension="CCRObjectID"/>
|
---|
| 555 | <code code="46680005" codeSystem="2.16.840.1.113883.6.96" displayName="Vital signs" codeSystemName="SNOMED CT"/>
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---|
| 556 | <statusCode code="completed"/>
|
---|
| 557 | <effectiveTime>
|
---|
| 558 | <low value="201073"/>
|
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| 559 | <high nullFlavor="UNK"/>
|
---|
| 560 | </effectiveTime>
|
---|
| 561 | <component>
|
---|
| 562 | <observation classCode="OBS" moodCode="EVN">
|
---|
| 563 | <templateId root="2.16.840.1.113883.3.88.11.83.15" assigningAuthorityName="HITSP C83"/>
|
---|
| 564 | <templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
|
---|
| 565 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>
|
---|
| 566 | <id root="VITALTEST2" extension="CCRObjectID"/>
|
---|
| 567 | <code displayName="RESPIRATION" code="366147009" codeSystemName="SNOMED" codeSystem=""/>
|
---|
| 568 | <text>
|
---|
| 569 | <reference value="#VITALTEST2"/>
|
---|
| 570 | </text>
|
---|
| 571 | <statusCode code="completed"/>
|
---|
| 572 | <effectiveTime>
|
---|
| 573 | <low value="201073"/>
|
---|
| 574 | <high nullFlavor="UNK"/>
|
---|
| 575 | </effectiveTime>
|
---|
| 576 | <value xsi:type="PQ" value="29" unit=""/>
|
---|
| 577 | </observation>
|
---|
| 578 | </component>
|
---|
| 579 | </organizer>
|
---|
| 580 | </entry>
|
---|
| 581 | <entry typeCode="DRIV">
|
---|
| 582 | <organizer classCode="CLUSTER" moodCode="EVN">
|
---|
| 583 | <templateId root="2.16.840.1.113883.10.20.1.32" assigningAuthorityName="CCD"/>
|
---|
| 584 | <templateId root="2.16.840.1.113883.10.20.1.35" assigningAuthorityName="CCD"/>
|
---|
| 585 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.1" assigningAuthorityName="IHE PCC"/>
|
---|
| 586 | <id root="VITAL3" extension="CCRObjectID"/>
|
---|
| 587 | <code code="46680005" codeSystem="2.16.840.1.113883.6.96" displayName="Vital signs" codeSystemName="SNOMED CT"/>
|
---|
| 588 | <statusCode code="completed"/>
|
---|
| 589 | <effectiveTime>
|
---|
| 590 | <low value="201073"/>
|
---|
| 591 | <high nullFlavor="UNK"/>
|
---|
| 592 | </effectiveTime>
|
---|
| 593 | <component>
|
---|
| 594 | <observation classCode="OBS" moodCode="EVN">
|
---|
| 595 | <templateId root="2.16.840.1.113883.3.88.11.83.15" assigningAuthorityName="HITSP C83"/>
|
---|
| 596 | <templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
|
---|
| 597 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>
|
---|
| 598 | <id root="VITALTEST3" extension="CCRObjectID"/>
|
---|
| 599 | <code displayName="PULSE" code="366199006" codeSystemName="SNOMED" codeSystem=""/>
|
---|
| 600 | <text>
|
---|
| 601 | <reference value="#VITALTEST3"/>
|
---|
| 602 | </text>
|
---|
| 603 | <statusCode code="completed"/>
|
---|
| 604 | <effectiveTime>
|
---|
| 605 | <low value="201073"/>
|
---|
| 606 | <high nullFlavor="UNK"/>
|
---|
| 607 | </effectiveTime>
|
---|
| 608 | <value xsi:type="PQ" value="78" unit=""/>
|
---|
| 609 | </observation>
|
---|
| 610 | </component>
|
---|
| 611 | </organizer>
|
---|
| 612 | </entry>
|
---|
| 613 | <entry typeCode="DRIV">
|
---|
| 614 | <organizer classCode="CLUSTER" moodCode="EVN">
|
---|
| 615 | <templateId root="2.16.840.1.113883.10.20.1.32" assigningAuthorityName="CCD"/>
|
---|
| 616 | <templateId root="2.16.840.1.113883.10.20.1.35" assigningAuthorityName="CCD"/>
|
---|
| 617 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.1" assigningAuthorityName="IHE PCC"/>
|
---|
| 618 | <id root="VITAL4" extension="CCRObjectID"/>
|
---|
| 619 | <code code="46680005" codeSystem="2.16.840.1.113883.6.96" displayName="Vital signs" codeSystemName="SNOMED CT"/>
|
---|
| 620 | <statusCode code="completed"/>
|
---|
| 621 | <effectiveTime>
|
---|
| 622 | <low value="201073"/>
|
---|
| 623 | <high nullFlavor="UNK"/>
|
---|
| 624 | </effectiveTime>
|
---|
| 625 | <component>
|
---|
| 626 | <observation classCode="OBS" moodCode="EVN">
|
---|
| 627 | <templateId root="2.16.840.1.113883.3.88.11.83.15" assigningAuthorityName="HITSP C83"/>
|
---|
| 628 | <templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
|
---|
| 629 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>
|
---|
| 630 | <id root="VITALTEST4" extension="CCRObjectID"/>
|
---|
| 631 | <code displayName="TEMPERATURE" code="309646008" codeSystemName="SNOMED" codeSystem=""/>
|
---|
| 632 | <text>
|
---|
| 633 | <reference value="#VITALTEST4"/>
|
---|
| 634 | </text>
|
---|
| 635 | <statusCode code="completed"/>
|
---|
| 636 | <effectiveTime>
|
---|
| 637 | <low value="201073"/>
|
---|
| 638 | <high nullFlavor="UNK"/>
|
---|
| 639 | </effectiveTime>
|
---|
| 640 | <value xsi:type="PQ" value="98.6" unit="F"/>
|
---|
| 641 | </observation>
|
---|
| 642 | </component>
|
---|
| 643 | </organizer>
|
---|
| 644 | </entry>
|
---|
| 645 | </section>
|
---|
| 646 | </component>
|
---|
| 647 | <component>
|
---|
| 648 | <section>
|
---|
| 649 | <templateId root="2.16.840.1.113883.3.88.11.83.127" assigningAuthorityName="HITSP/C83"/>
|
---|
| 650 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.3" assigningAuthorityName="IHE PCC"/>
|
---|
| 651 | <templateId root="2.16.840.1.113883.10.20.1.3" assigningAuthorityName="HL7 CCD"/>
|
---|
| 652 | <code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
|
---|
| 653 | <title>Encounters</title>
|
---|
| 654 | <text>
|
---|
| 655 | <table>
|
---|
| 656 | <tbody>
|
---|
| 657 | <tr>
|
---|
| 658 | <th>Type</th>
|
---|
| 659 | <th>Date</th>
|
---|
| 660 | <th>Location</th>
|
---|
| 661 | <th>Status</th>
|
---|
| 662 | <th>Practitioner</th>
|
---|
| 663 | <th>Description</th>
|
---|
| 664 | <th>Indications</th>
|
---|
| 665 | <th>Source</th>
|
---|
| 666 | </tr>
|
---|
| 667 | <tr id="ENCOUNTER_4073">
|
---|
| 668 | <td>C&P EXAMINATION REPORTS</td>
|
---|
| 669 | <td/>
|
---|
| 670 | <td/>
|
---|
| 671 | <td/>
|
---|
| 672 | <td/>
|
---|
| 673 | <td>C&P EXAMINATION REPORTS</td>
|
---|
| 674 | <td/>
|
---|
| 675 | <td/>
|
---|
| 676 | </tr>
|
---|
| 677 | <tr id="ENCOUNTER_4072">
|
---|
| 678 | <td>C&P EXAMINATION REPORTS</td>
|
---|
| 679 | <td/>
|
---|
| 680 | <td/>
|
---|
| 681 | <td/>
|
---|
| 682 | <td/>
|
---|
| 683 | <td>C&P EXAMINATION REPORTS</td>
|
---|
| 684 | <td/>
|
---|
| 685 | <td/>
|
---|
| 686 | </tr>
|
---|
| 687 | <tr id="ENCOUNTER_4070">
|
---|
| 688 | <td>C&P EXAMINATION REPORTS</td>
|
---|
| 689 | <td/>
|
---|
| 690 | <td/>
|
---|
| 691 | <td/>
|
---|
| 692 | <td/>
|
---|
| 693 | <td>C&P EXAMINATION REPORTS</td>
|
---|
| 694 | <td/>
|
---|
| 695 | <td/>
|
---|
| 696 | </tr>
|
---|
| 697 | <tr id="ENCOUNTER_4069">
|
---|
| 698 | <td>ADDICTION SEVERITY INDEX</td>
|
---|
| 699 | <td/>
|
---|
| 700 | <td/>
|
---|
| 701 | <td/>
|
---|
| 702 | <td/>
|
---|
| 703 | <td>ADDICTION SEVERITY INDEX</td>
|
---|
| 704 | <td/>
|
---|
| 705 | <td/>
|
---|
| 706 | </tr>
|
---|
| 707 | <tr id="ENCOUNTER_4068">
|
---|
| 708 | <td>C&P EXAMINATION REPORTS</td>
|
---|
| 709 | <td/>
|
---|
| 710 | <td/>
|
---|
| 711 | <td/>
|
---|
| 712 | <td/>
|
---|
| 713 | <td>C&P EXAMINATION REPORTS</td>
|
---|
| 714 | <td/>
|
---|
| 715 | <td/>
|
---|
| 716 | </tr>
|
---|
| 717 | <tr id="ENCOUNTER_4067">
|
---|
| 718 | <td>C&P EXAMINATION REPORTS</td>
|
---|
| 719 | <td/>
|
---|
| 720 | <td/>
|
---|
| 721 | <td/>
|
---|
| 722 | <td/>
|
---|
| 723 | <td>C&P EXAMINATION REPORTS</td>
|
---|
| 724 | <td/>
|
---|
| 725 | <td/>
|
---|
| 726 | </tr>
|
---|
| 727 | </tbody>
|
---|
| 728 | </table>
|
---|
| 729 | </text>
|
---|
| 730 | <entry typeCode="DRIV">
|
---|
| 731 | <encounter classCode="ENC" moodCode="EVN">
|
---|
| 732 | <templateId root="2.16.840.1.113883.3.88.11.83.16" assigningAuthorityName="HITSP C83"/>
|
---|
| 733 | <templateId root="2.16.840.1.113883.10.20.1.21" assigningAuthorityName="CCD"/>
|
---|
| 734 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.14" assigningAuthorityName="IHE PCC"/>
|
---|
| 735 | <id root="ENCOUNTER_4073" extension="CCRObjectID"/>
|
---|
| 736 | <code>
|
---|
| 737 | <originalText>C&P EXAMINATION REPORTS</originalText>
|
---|
| 738 | </code>
|
---|
| 739 | <text>
|
---|
| 740 | <reference value="#ENCOUNTER_4073"/>
|
---|
| 741 | </text>
|
---|
| 742 | <effectiveTime>
|
---|
| 743 | <low value="201074"/>
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| 744 | <high nullFlavor="UNK"/>
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| 745 | </effectiveTime>
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| 747 | </entry>
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| 748 | <entry typeCode="DRIV">
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| 749 | <encounter classCode="ENC" moodCode="EVN">
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| 779 | <low value="201074"/>
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| 780 | <high nullFlavor="UNK"/>
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| 781 | </effectiveTime>
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| 783 | </entry>
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| 789 | <id root="ENCOUNTER_4069" extension="CCRObjectID"/>
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| 790 | <code>
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| 791 | <originalText>ADDICTION SEVERITY INDEX</originalText>
|
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| 792 | </code>
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| 793 | <text>
|
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| 794 | <reference value="#ENCOUNTER_4069"/>
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| 808 | <code>
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| 809 | <originalText>C&P EXAMINATION REPORTS</originalText>
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| 810 | </code>
|
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| 811 | <text>
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| 815 | <low value="201073"/>
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| 816 | <high nullFlavor="UNK"/>
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| 817 | </effectiveTime>
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| 819 | </entry>
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| 820 | <entry typeCode="DRIV">
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| 827 | <originalText>C&P EXAMINATION REPORTS</originalText>
|
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| 828 | </code>
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| 834 | <high nullFlavor="UNK"/>
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| 838 | </section>
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| 840 | <component>
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| 841 | <section>
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| 842 | <templateId root="2.16.840.1.113883.10.20.1.14"/>
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| 843 | <code code="30954-2" codeSystem="2.16.840.1.113883.6.1"/>
|
---|
| 844 | <title>Results</title>
|
---|
| 845 | <text>
|
---|
| 846 | <table>
|
---|
| 847 | <tbody>
|
---|
| 848 | <tr>
|
---|
| 849 | <th>Test</th>
|
---|
| 850 | <th>Date</th>
|
---|
| 851 | <th>Result</th>
|
---|
| 852 | <th>Source</th>
|
---|
| 853 | </tr>
|
---|
| 854 | <tr id="RESULT_1">
|
---|
| 855 | <td>Glucose Quant</td>
|
---|
| 856 | <td/>
|
---|
| 857 | <td>
|
---|
| 858 | <div id="RESULTTEST_1_1">GLUCOSE:MCNC:PT:FLU:QN 120 mg/dL H<br/>
|
---|
| 859 | </div>
|
---|
| 860 | </td>
|
---|
| 861 | <td>SYSTEM MANAGER </td>
|
---|
| 862 | </tr>
|
---|
| 863 | <tr id="RESULT_2">
|
---|
| 864 | <td>Gen Chem Specimen</td>
|
---|
| 865 | <td/>
|
---|
| 866 | <td>
|
---|
| 867 | <div id="RESULTTEST_2_1">HEMOGLOBIN A1C 7 % H<br/>
|
---|
| 868 | </div>
|
---|
| 869 | </td>
|
---|
| 870 | <td>EIGHT PROVIDER Scholar Extraordinaire </td>
|
---|
| 871 | </tr>
|
---|
| 872 | <tr id="RESULT_3">
|
---|
| 873 | <td>Calculation</td>
|
---|
| 874 | <td/>
|
---|
| 875 | <td>
|
---|
| 876 | <div id="RESULTTEST_3_1">LDL CHOLESTEROL 90 MG/DL <br/>
|
---|
| 877 | </div>
|
---|
| 878 | </td>
|
---|
| 879 | <td>EIGHT PROVIDER Scholar Extraordinaire </td>
|
---|
| 880 | </tr>
|
---|
| 881 | </tbody>
|
---|
| 882 | </table>
|
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| 883 | </text>
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|
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| 885 | <component>
|
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| 886 | <observation classCode="OBS" moodCode="EVN">
|
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|
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| 888 | <templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
|
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| 889 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>
|
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| 890 | <id root="RESULTTEST_1_1" extension="CCRObjectID"/>
|
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| 891 | <code displayName="GLUCOSE:MCNC:PT:FLU:QN" code="2344-0" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>
|
---|
| 892 | <text>
|
---|
| 893 | <reference value="#RESULTTEST_1_1"/>
|
---|
| 894 | </text>
|
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| 895 | <statusCode code="completed"/>
|
---|
| 896 | <effectiveTime>
|
---|
| 897 | <low value="201073"/>
|
---|
| 898 | <high nullFlavor="UNK"/>
|
---|
| 899 | </effectiveTime>
|
---|
| 900 | <value xsi:type="PQ" value="120" unit="mg/dL"/>
|
---|
| 901 | <interpretationCode displayName="Abnormal High" code="H" codeSystemName="2.16.840.1.113883.5.83"/>
|
---|
| 902 | <referenceRange>
|
---|
| 903 | <observationRange>
|
---|
| 904 | <text>60-110</text>
|
---|
| 905 | </observationRange>
|
---|
| 906 | </referenceRange>
|
---|
| 907 | </observation>
|
---|
| 908 | </component>
|
---|
| 909 | </entry>
|
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| 910 | <entry typeCode="DRIV">
|
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| 911 | <component>
|
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| 912 | <observation classCode="OBS" moodCode="EVN">
|
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|
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|
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| 915 | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>
|
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| 916 | <id root="RESULTTEST_2_1" extension="CCRObjectID"/>
|
---|
| 917 | <code displayName="HEMOGLOBIN A1C" code="CH462" codeSystemName="99VA63" codeSystem=""/>
|
---|
| 918 | <text>
|
---|
| 919 | <reference value="#RESULTTEST_2_1"/>
|
---|
| 920 | </text>
|
---|
| 921 | <statusCode code="completed"/>
|
---|
| 922 | <effectiveTime>
|
---|
| 923 | <low value="201073"/>
|
---|
| 924 | <high nullFlavor="UNK"/>
|
---|
| 925 | </effectiveTime>
|
---|
| 926 | <value xsi:type="PQ" value="7" unit="%"/>
|
---|
| 927 | <interpretationCode displayName="Abnormal High" code="H" codeSystemName="2.16.840.1.113883.5.83"/>
|
---|
| 928 | <referenceRange>
|
---|
| 929 | <observationRange>
|
---|
| 930 | <text>3.5-6</text>
|
---|
| 931 | </observationRange>
|
---|
| 932 | </referenceRange>
|
---|
| 933 | </observation>
|
---|
| 934 | </component>
|
---|
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|
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| 936 | <entry typeCode="DRIV">
|
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| 937 | <component>
|
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| 938 | <observation classCode="OBS" moodCode="EVN">
|
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|
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|
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| 942 | <id root="RESULTTEST_3_1" extension="CCRObjectID"/>
|
---|
| 943 | <code displayName="LDL CHOLESTEROL" code="CH291" codeSystemName="99VA63" codeSystem=""/>
|
---|
| 944 | <text>
|
---|
| 945 | <reference value="#RESULTTEST_3_1"/>
|
---|
| 946 | </text>
|
---|
| 947 | <statusCode code="completed"/>
|
---|
| 948 | <effectiveTime>
|
---|
| 949 | <low value="201073"/>
|
---|
| 950 | <high nullFlavor="UNK"/>
|
---|
| 951 | </effectiveTime>
|
---|
| 952 | <value xsi:type="PQ" value="90" unit="MG/DL"/>
|
---|
| 953 | <referenceRange>
|
---|
| 954 | <observationRange>
|
---|
| 955 | <text>0-130</text>
|
---|
| 956 | </observationRange>
|
---|
| 957 | </referenceRange>
|
---|
| 958 | </observation>
|
---|
| 959 | </component>
|
---|
| 960 | </entry>
|
---|
| 961 | </section>
|
---|
| 962 | </component>
|
---|
| 963 | </structuredBody>
|
---|
| 964 | </component>
|
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| 965 | </ClinicalDocument>
|
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