source: ccr2ccd-xslt/trunk/make/PAT_100840_CCD.xml@ 990

Last change on this file since 990 was 875, checked in by George Lilly, 15 years ago

broke the stylesheet into pieces with a script to reassemble
File size: 27.1 KB
RevLine 
[875]1<?xml version="1.0" encoding="utf-8"?>
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">
3<realmCode code="US"/>
4<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
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10<code code="34133-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summarization of episode note"/>
11<title>Continuity of Care Document from ZZ ALBANY-PRRTP</title>
12<effectiveTime value="20107562725+0000"/>
13<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
14<languageCode code="en-US"/>
15<recordTarget typeCode="RCT" contextControlCode="OP">
16<patientRole>
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18<addr use="H">
19<streetAddressLine/>
20<city/>
21<state/>
22<postalCode/>
23</addr>
24<telecom/>
25<patient>
26<name>
27<given>JODY</given>
28<given>JEAN</given>
29<family>JONES</family>
30</name>
31<administrativeGenderCode displayName="FEMALE" code="F" codeSystemName="HL7 AdministrativeGender" codeSystem=""/>
32<birthTime value="1945111200"/>
33</patient>
34</patientRole>
35</recordTarget>
36<author>
37<time value="20107562725"/>
38<assignedAuthor>
39<id extension="ACTORPROVIDER_10000000020" root="CCRActorID"/>
40<addr use="WP">
41<streetAddressLine>123 MAIN</streetAddressLine>
42<city>ALBANY</city>
43<state>NY</state>
44<postalCode>12180</postalCode>
45</addr>
46<telecom use="WP" value="tel:+1-509.989.3732"/>
47<assignedPerson>
48<name>
49<given>SYSTEM</given>
50<family>MANAGER</family>
51</name>
52</assignedPerson>
53</assignedAuthor>
54</author>
55<custodian>
56<assignedCustodian>
57<representedCustodianOrganization>
58<id extension="ACTORORGANIZATION_1" root="CCRActorID"/>
59<name>ZZ ALBANY-PRRTP</name>
60<telecom/>
61<addr use="WP">
62<streetAddressLine>123 MAIN</streetAddressLine>
63<city>ALBANY</city>
64<state>NEW YORK</state>
65<postalCode>12180</postalCode>
66</addr>
67</representedCustodianOrganization>
68</assignedCustodian>
69</custodian>
70<documentationOf>
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82<templateId root="2.16.840.1.113883.10.20.1.13"/>
83<code code="48764-5" codeSystem="2.16.840.1.113883.6.1"/>
84<title>Purpose</title>
85<text>CEND PHR</text>
86</section>
87</component>
88<component>
89<section>
90<templateId root="2.16.840.1.113883.3.88.11.83.103" assigningAuthorityName="HITSP/C83"/>
91<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.6" assigningAuthorityName="IHE PCC"/>
92<templateId root="2.16.840.1.113883.10.20.1.11" assigningAuthorityName="HL7 CCD"/>
93<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem list"/>
94<title>Problems</title>
95<text>
96<table>
97<tbody>
98<tr>
99<th>Type</th>
100<th>Date</th>
101<th>Code</th>
102<th>Description</th>
103<th>Status</th>
104<th>Source</th>
105</tr>
106<tr>
107<td>Problem</td>
108<td>
109<table>
110<tbody>
111<tr xmlns="">
112<td>Jul 3, 2010</td>
113</tr>
114</tbody>
115</table>
116</td>
117<td>250.00 (ICD9CM)
118 </td>
119<td ID="PROBLEM1">Diabetes Mellitus</td>
120<td>Active/Chronic</td>
121<td>SYSTEM MANAGER </td>
122</tr>
123<tr>
124<td>Problem</td>
125<td>
126<table>
127<tbody>
128<tr xmlns="">
129<td>Jul 4, 2010</td>
130</tr>
131</tbody>
132</table>
133</td>
134<td>428.0 (ICD9CM)
135 </td>
136<td ID="PROBLEM2">Congestive Heart Failure</td>
137<td>Active/Chronic</td>
138<td>SYSTEM MANAGER </td>
139</tr>
140<tr>
141<td>Problem</td>
142<td>
143<table>
144<tbody>
145<tr xmlns="">
146<td>Jul 4, 2010</td>
147</tr>
148</tbody>
149</table>
150</td>
151<td>412. (ICD9CM)
152 </td>
153<td ID="PROBLEM3">Old Myocardial Infarction</td>
154<td>Inactive/Chronic</td>
155<td>SYSTEM MANAGER </td>
156</tr>
157</tbody>
158</table>
159</text>
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171<state>NY</state>
172<postalCode>12180</postalCode>
173</addr>
174<telecom use="WP" value="tel:+1-509.989.3732"/>
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223<postalCode>12180</postalCode>
224</addr>
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273<state>NY</state>
274<postalCode>12180</postalCode>
275</addr>
276<telecom use="WP" value="tel:+1-509.989.3732"/>
277<assignedPerson>
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281</name>
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313</section>
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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>
325<tr>
326<th>Medication</th>
327<th>Date</th>
328<th>Status</th>
329<th>Form</th>
330<th>Strength</th>
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>
339<td>ASPIRIN 81MG EC TAB</td>
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/>
350<td>3 </td>
351<td>SYSTEM MANAGER </td>
352</tr>
353<tr>
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/>
365<td>3 </td>
366<td>SYSTEM MANAGER </td>
367</tr>
368<tr>
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>
377<br/>
378</td>
379<td/>
380<td>3 </td>
381<td>SYSTEM MANAGER </td>
382</tr>
383</tbody>
384</table>
385</text>
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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>
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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&amp;P EXAMINATION REPORTS</td>
669<td/>
670<td/>
671<td/>
672<td/>
673<td>C&amp;P EXAMINATION REPORTS</td>
674<td/>
675<td/>
676</tr>
677<tr id="ENCOUNTER_4072">
678<td>C&amp;P EXAMINATION REPORTS</td>
679<td/>
680<td/>
681<td/>
682<td/>
683<td>C&amp;P EXAMINATION REPORTS</td>
684<td/>
685<td/>
686</tr>
687<tr id="ENCOUNTER_4070">
688<td>C&amp;P EXAMINATION REPORTS</td>
689<td/>
690<td/>
691<td/>
692<td/>
693<td>C&amp;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&amp;P EXAMINATION REPORTS</td>
709<td/>
710<td/>
711<td/>
712<td/>
713<td>C&amp;P EXAMINATION REPORTS</td>
714<td/>
715<td/>
716</tr>
717<tr id="ENCOUNTER_4067">
718<td>C&amp;P EXAMINATION REPORTS</td>
719<td/>
720<td/>
721<td/>
722<td/>
723<td>C&amp;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&amp;P EXAMINATION REPORTS</originalText>
738</code>
739<text>
740<reference value="#ENCOUNTER_4073"/>
741</text>
742<effectiveTime>
743<low value="201074"/>
744<high nullFlavor="UNK"/>
745</effectiveTime>
746</encounter>
747</entry>
748<entry typeCode="DRIV">
749<encounter classCode="ENC" moodCode="EVN">
750<templateId root="2.16.840.1.113883.3.88.11.83.16" assigningAuthorityName="HITSP C83"/>
751<templateId root="2.16.840.1.113883.10.20.1.21" assigningAuthorityName="CCD"/>
752<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.14" assigningAuthorityName="IHE PCC"/>
753<id root="ENCOUNTER_4072" extension="CCRObjectID"/>
754<code>
755<originalText>C&amp;P EXAMINATION REPORTS</originalText>
756</code>
757<text>
758<reference value="#ENCOUNTER_4072"/>
759</text>
760<effectiveTime>
761<low value="201074"/>
762<high nullFlavor="UNK"/>
763</effectiveTime>
764</encounter>
765</entry>
766<entry typeCode="DRIV">
767<encounter classCode="ENC" moodCode="EVN">
768<templateId root="2.16.840.1.113883.3.88.11.83.16" assigningAuthorityName="HITSP C83"/>
769<templateId root="2.16.840.1.113883.10.20.1.21" assigningAuthorityName="CCD"/>
770<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.14" assigningAuthorityName="IHE PCC"/>
771<id root="ENCOUNTER_4070" extension="CCRObjectID"/>
772<code>
773<originalText>C&amp;P EXAMINATION REPORTS</originalText>
774</code>
775<text>
776<reference value="#ENCOUNTER_4070"/>
777</text>
778<effectiveTime>
779<low value="201074"/>
780<high nullFlavor="UNK"/>
781</effectiveTime>
782</encounter>
783</entry>
784<entry typeCode="DRIV">
785<encounter classCode="ENC" moodCode="EVN">
786<templateId root="2.16.840.1.113883.3.88.11.83.16" assigningAuthorityName="HITSP C83"/>
787<templateId root="2.16.840.1.113883.10.20.1.21" assigningAuthorityName="CCD"/>
788<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.14" assigningAuthorityName="IHE PCC"/>
789<id root="ENCOUNTER_4069" extension="CCRObjectID"/>
790<code>
791<originalText>ADDICTION SEVERITY INDEX</originalText>
792</code>
793<text>
794<reference value="#ENCOUNTER_4069"/>
795</text>
796<effectiveTime>
797<low value="201073"/>
798<high nullFlavor="UNK"/>
799</effectiveTime>
800</encounter>
801</entry>
802<entry typeCode="DRIV">
803<encounter classCode="ENC" moodCode="EVN">
804<templateId root="2.16.840.1.113883.3.88.11.83.16" assigningAuthorityName="HITSP C83"/>
805<templateId root="2.16.840.1.113883.10.20.1.21" assigningAuthorityName="CCD"/>
806<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.14" assigningAuthorityName="IHE PCC"/>
807<id root="ENCOUNTER_4068" extension="CCRObjectID"/>
808<code>
809<originalText>C&amp;P EXAMINATION REPORTS</originalText>
810</code>
811<text>
812<reference value="#ENCOUNTER_4068"/>
813</text>
814<effectiveTime>
815<low value="201073"/>
816<high nullFlavor="UNK"/>
817</effectiveTime>
818</encounter>
819</entry>
820<entry typeCode="DRIV">
821<encounter classCode="ENC" moodCode="EVN">
822<templateId root="2.16.840.1.113883.3.88.11.83.16" assigningAuthorityName="HITSP C83"/>
823<templateId root="2.16.840.1.113883.10.20.1.21" assigningAuthorityName="CCD"/>
824<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.14" assigningAuthorityName="IHE PCC"/>
825<id root="ENCOUNTER_4067" extension="CCRObjectID"/>
826<code>
827<originalText>C&amp;P EXAMINATION REPORTS</originalText>
828</code>
829<text>
830<reference value="#ENCOUNTER_4067"/>
831</text>
832<effectiveTime>
833<low value="201073"/>
834<high nullFlavor="UNK"/>
835</effectiveTime>
836</encounter>
837</entry>
838</section>
839</component>
840<component>
841<section>
842<templateId root="2.16.840.1.113883.10.20.1.14"/>
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>
883</text>
884<entry typeCode="DRIV">
885<component>
886<observation classCode="OBS" moodCode="EVN">
887<templateId root="2.16.840.1.113883.3.88.11.83.15" assigningAuthorityName="HITSP C83"/>
888<templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
889<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>
890<id root="RESULTTEST_1_1" extension="CCRObjectID"/>
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>
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>
910<entry typeCode="DRIV">
911<component>
912<observation classCode="OBS" moodCode="EVN">
913<templateId root="2.16.840.1.113883.3.88.11.83.15" assigningAuthorityName="HITSP C83"/>
914<templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
915<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>
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>
935</entry>
936<entry typeCode="DRIV">
937<component>
938<observation classCode="OBS" moodCode="EVN">
939<templateId root="2.16.840.1.113883.3.88.11.83.15" assigningAuthorityName="HITSP C83"/>
940<templateId root="2.16.840.1.113883.10.20.1.31" assigningAuthorityName="CCD"/>
941<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" assigningAuthorityName="IHE PCC"/>
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>
965</ClinicalDocument>
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