| 1 | <?xml version="1.0" encoding="utf-8"?>
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| 2 | <?xml-stylesheet type="text/xsl" href="cda.xsl"?>
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| 3 | <!-- Created with Liquid XML Studio 1.0.8.0 (http://www.liquid-technologies.com) -->
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| 4 | <ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
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| 5 | <!--
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| 6 | ********************************************************
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| 7 | CDA Header
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| 8 | ********************************************************
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| 9 | -->
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| 10 | <realmCode code="US" />
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| 11 | <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040" />
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| 12 | <!-- QRDA Category I generic template ID. -->
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| 13 | <templateId root="2.16.840.1.113883.10.20.12" />
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| 14 | <id root="88414c01-715a-45bb-83bb-db7ac860fe9d" />
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| 15 | <!-- QRDA document type code (yet to be created). -->
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| 16 | <code code="55182-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Quality Measure Report" />
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| 17 | <title>QRDA Incidence Report</title>
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| 18 | <effectiveTime value="20080513" />
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| 19 | <confidentialityCode codeSystem="2.16.840.1.113883.5.25" code="N" />
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| 20 | <languageCode code="en-US" />
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| 21 | <!-- This is the patient for which the report is describing. -->
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| 22 | <recordTarget>
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| 23 | <patientRole>
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| 24 | <id extension="123456789" root="2.16.840.1.113883.19.5" />
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| 25 | <patient>
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| 26 | <name>
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| 27 | <given>Henry</given>
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| 28 | <family>Levin</family>
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| 29 | <suffix>the 7th</suffix>
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| 30 | </name>
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| 31 | <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" />
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| 32 | <birthTime value="19320924" />
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| 33 | </patient>
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| 34 | </patientRole>
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| 35 | </recordTarget>
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| 36 | <!-- This example assumes a workflow whereby a quality manager nurse is creating the report. -->
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| 37 | <author>
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| 38 | <time value="2000040714" />
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| 39 | <assignedAuthor>
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| 40 | <id root="bc01a5d1-3a34-4286-82cc-43eb04c972a7" />
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| 41 | <assignedPerson>
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| 42 | <name>
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| 43 | <given>Nancy</given>
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| 44 | <family>Nightingale</family>
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| 45 | <suffix>N</suffix>
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| 46 | </name>
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| 47 | </assignedPerson>
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| 48 | <representedOrganization>
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| 49 | <id root="2.16.840.1.113883.19.5" />
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| 50 | <name>Good Health Clinic</name>
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| 51 | </representedOrganization>
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| 52 | </assignedAuthor>
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| 53 | </author>
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| 54 | <!-- The reporting healthcare facility is represented using the CCD "Source of Information" construct, via the Informant participant. -->
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| 55 | <informant>
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| 56 | <assignedEntity>
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| 57 | <id nullFlavor="NA"/>
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| 58 | <representedOrganization>
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| 59 | <id root="2.16.840.1.113883.19.5"/>
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| 60 | <name>Good Health Clinic</name>
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| 61 | </representedOrganization>
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| 62 | </assignedEntity>
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| 63 | </informant>
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| 64 | <!-- This example assumes that the institution responsible for the data is serving as custodian. -->
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| 65 | <custodian>
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| 66 | <assignedCustodian>
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| 67 | <representedCustodianOrganization>
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| 68 | <id root="2.16.840.1.113883.19.5" />
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| 69 | <name>Good Health Clinic</name>
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| 70 | </representedCustodianOrganization>
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| 71 | </assignedCustodian>
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| 72 | </custodian>
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| 73 | <!-- In this example, the author is also serving as legal authenticator. -->
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| 74 | <legalAuthenticator>
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| 75 | <time value="20000408" />
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| 76 | <signatureCode code="S" />
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| 77 | <assignedEntity>
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| 78 | <id root="bc01a5d1-3a34-4286-82cc-43eb04c972a7" />
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| 79 | <assignedPerson>
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| 80 | <name>
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| 81 | <given>Nancy</given>
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| 82 | <family>Nightingale</family>
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| 83 | <suffix>N</suffix>
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| 84 | </name>
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| 85 | </assignedPerson>
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| 86 | <representedOrganization>
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| 87 | <id root="2.16.840.1.113883.19.5" />
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| 88 | <name>Good Health Clinic</name>
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| 89 | </representedOrganization>
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| 90 | </assignedEntity>
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| 91 | </legalAuthenticator>
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| 92 | <!--
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| 93 | ********************************************************
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| 94 | CDA Body
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| 95 | ********************************************************
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| 96 | -->
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| 97 | <component>
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| 98 | <structuredBody>
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| 99 | <!--
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| 100 | ********************************************************
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| 101 | MeasureSet: NQF Pneumonia, V2.5
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| 102 | ********************************************************
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| 103 | -->
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| 104 | <component>
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| 105 | <section>
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| 106 | <templateId root="2.16.840.1.113883.19.1"/> <!-- templateId uniquely identifies the measure set (Fake ID for illustration) -->
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| 107 | <code code="55185-3" codeSystem="2.16.840.1.113883.6.1" />
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| 108 | <title>Measure Set: NQF Pneumonia Measure Set, V2.5</title>
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| 109 | <text>... (optional) description of measure set ...</text>
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| 110 | <!--
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| 111 | ********************************************************
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| 112 | Measure Section
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| 113 | ********************************************************
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| 114 | -->
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| 115 | <component>
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| 116 | <section>
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| 117 | <!-- QRDA Category I measure-specific template ID for each measure in this section (Fake IDs for illustration). -->
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| 118 | <templateId root="2.16.840.1.113883.19.2" />
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| 119 | <templateId root="2.16.840.1.113883.19.3" />
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| 120 | <templateId root="2.16.840.1.113883.19.4" />
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| 121 | <code code="55186-1" codeSystem="2.16.840.1.113883.6.1" />
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| 122 | <title>Measure Section</title>
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| 123 | <text>
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| 124 | <list>
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| 125 | <item>NQF PN-1: Oxygenation Assessment, V2.5</item>
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| 126 | <item>NQF PN-4: Adult Smoking Cessation Advice/Counseling, V2.5</item>
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| 127 | <item>NQF PN-6a: Initial Antibiotic Selection for CAP in Immunocompetent - ICU Patient, V2.5</item>
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| 128 | </list>
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| 129 | </text>
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| 130 | <entry typeCode="DRIV">
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| 131 | <!--
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| 132 | The measure is represented as an <act> in definition mood.
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| 133 | A narrative description of the measure is in act/text.
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| 134 | A formal computable representation of the measure is not included here, but potentially could be.
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| 135 | -->
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| 136 | <act classCode="ACT" moodCode="DEF">
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| 137 | <id root="4dd3b0b4-a5fc-4bd6-9a87-755da494f6eb" />
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| 138 | <!-- Fake code for illustration -->
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| 139 | <code code="11111-X" codeSystem="2.16.840.1.113883.6.1" displayName="Oxygenation Assessment,V2.5" />
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| 140 | <text>... (optional) description of measure ...</text>
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| 141 | <statusCode code="completed" />
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| 142 | </act>
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| 143 | </entry>
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| 144 | <entry typeCode="DRIV">
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| 145 | <act classCode="ACT" moodCode="DEF">
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| 146 | <id root="4dd3b0b4-a5fc-4bd6-9a87-755da494f6ee" />
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| 147 | <code code="11111-X" codeSystem="2.16.840.1.113883.6.1" displayName="Adult Smoking Cessation Advice/Counseling" />
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| 148 | <text>... (optional) description of measure ...</text>
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| 149 | <statusCode code="completed" />
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| 150 | </act>
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| 151 | </entry>
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| 152 | <entry typeCode="DRIV">
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| 153 | <act classCode="ACT" moodCode="DEF">
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| 154 | <id root="4dd3b0b4-a5fc-4bd6-9a87-755da494f6ea" />
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| 155 | <code code="11111-X" codeSystem="2.16.840.1.113883.6.1" displayName="Initial Antibiotic Selection for CAP in Immunocompetent - ICU Patient" />
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| 156 | <text>... (optional) description of measure ...</text>
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| 157 | <statusCode code="completed" />
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| 158 | </act>
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| 159 | </entry>
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| 160 | <!--
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| 161 | ********************************************************
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| 162 | Reporting Parameters
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| 163 | ********************************************************
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| 164 | -->
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| 165 | <component>
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| 166 | <section>
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| 167 | <code code="55187-9" codeSystem="2.16.840.1.113883.6.1" />
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| 168 | <title>Reporting Parameters</title>
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| 169 | <text>
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| 170 | <list>
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| 171 | <item>Reporting period: 01 Jan 2008 - 31 Mar 2008</item>
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| 172 | </list>
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| 173 | </text>
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| 174 | <entry>
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| 175 | <act classCode="ACT" moodCode="EVN">
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| 176 | <code code="252116004" codeSystem="2.16.840.1.113883.6.96" displayName="Observation Parameters" />
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| 177 | <effectiveTime>
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| 178 | <low value="20080101" /> <!-- The first day of the period reported. -->
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| 179 | <high value="20080331" /> <!-- The last day of the period reported. -->
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| 180 | </effectiveTime>
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| 181 | </act>
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| 182 | </entry>
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| 183 | </section>
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| 184 | </component>
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| 185 | <!--
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| 186 | ********************************************************
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| 187 | Patient Data
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| 188 | ********************************************************
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| 189 | -->
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| 190 | <component>
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| 191 | <section>
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| 192 | <code code="55188-7" codeSystem="2.16.840.1.113883.6.1" />
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| 193 | <title>Patient Data</title>
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| 194 | <text>
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| 195 | <list>
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| 196 | <item>Admission Date: 13 Feb 2008</item>
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| 197 | <item>Discharge Date: 20 Feb 2008</item>
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| 198 | <item>ICD Diagnosis Codes: 481 (Pneumococcal pneumonia)</item>
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| 199 | <item>Initial Oxygen Saturation: 85%</item>
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| 200 | <item>Initial Antibiotics: Levofloxacin 500mg IV q24 hours</item>
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| 201 | <item>Smoker: Yes</item>
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| 202 | <item>Smoking Cessation Counseling Provided: Yes</item>
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| 203 | </list>
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| 204 | </text>
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| 205 | <entry typeCode="DRIV">
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| 206 | <encounter classCode="ENC" moodCode="EVN">
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| 207 | <id root="3e547597-ac81-4232-b20f-317dfd1a3595" />
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| 208 | <code code="IMP" displayName="Inpatient" codeSystem="2.16.840.1.113883.5.83" codeSystemName="actEncounterCode" />
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| 209 | <effectiveTime>
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| 210 | <low value="20080213" />
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| 211 | <high value="20080220" />
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| 212 | </effectiveTime>
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| 213 | <entryRelationship typeCode="COMP">
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| 214 | <observation classCode="OBS" moodCode="EVN" negationInd="false">
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| 215 | <templateId root="2.16.840.1.113883.10.20.1.28" />
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| 216 | <!-- Problem observation template -->
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| 217 | <id root="f7a66e8a-f6e5-48fe-93e5-f0f1ed462c80" />
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| 218 | <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" />
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| 219 | <statusCode code="completed" />
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| 220 | <value xsi:type="CD" code="481" codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD9CM" displayName="Pneumococcal pneumonia" />
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| 221 | </observation>
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| 222 | </entryRelationship>
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| 223 | <entryRelationship typeCode="COMP">
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| 224 | <observation classCode="OBS" moodCode="EVN">
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| 225 | <templateId root="2.16.840.1.113883.10.20.1.31" />
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| 226 | <!-- Result observation template -->
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| 227 | <id root="5ac04863-aa06-4254-84a6-ac01fad60723" />
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| 228 | <code code="103228002" codeSystem="2.16.840.1.113883.6.96" displayName="Oxygen saturation" />
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| 229 | <statusCode code="completed" />
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| 230 | <effectiveTime>
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| 231 | <center value="200802131412" />
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| 232 | </effectiveTime>
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| 233 | <value xsi:type="PQ" value="85" unit="%" />
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| 234 | </observation>
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| 235 | </entryRelationship>
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| 236 | <!-- A real Category I would also include entries for:
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| 237 | <item>Initial Antibiotics: Levofloxacin 500mg IV q24 hours</item>
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| 238 | <item>Smoker: Yes</item>
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| 239 | <item>Smoking Cessation Counseling Provided: Yes</item>
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| 240 | -->
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| 241 | </encounter>
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| 242 | </entry>
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| 243 | </section>
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| 244 | </component>
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| 245 | </section>
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| 246 | </component>
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| 247 | </section>
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| 248 | </component>
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| 249 | </structuredBody>
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| 250 | </component>
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| 251 | </ClinicalDocument>
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