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BlueButton.js helps developers navigate complex health data with ease.

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<?xml version="1.0" encoding="UTF-8"?> <?xml-stylesheet type="text/xsl" href="cda.xsl"?> <ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:sdtc="urn:hl7-org:sdtc" xsi:schemaLocation="urn:hl7-org:v3../../../CDA%20R2/cda-schemas-and-samples/infrastructure/cda/CDA.xsd" classCode="DOCCLIN" moodCode="EVN"> <realmCode code="US"/> <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/> <templateId root="2.16.840.1.113883.10.20.22.1.1"/> <templateId root="2.16.840.1.113883.10.20.22.1.2"/> <id root="2.16.840.1.113883.1.13.99999.999362" extension="280004"/> <code code="34133-9" codeSystem="2.16.840.1.113883.6.1" displayName="Summarization of episode note"/> <title>Transition of Care/Referral Summary</title> <effectiveTime value="20130717114446.302-0500"/> <confidentialityCode code="N" displayName="Normal" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="en-US"/> <recordTarget typeCode="RCT" contextControlCode="OP"> <patientRole 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</author> <custodian typeCode="CST"> <assignedCustodian classCode="ASSIGNED"> <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE"> <id root="2.16.840.1.113883.1.13.99999"/> <name>Local Community Hospital Organization</name> <telecom use="WP" value="tel:(555) 555-1010"/> <addr use="WP"> <streetAddressLine>4000 Hospital Dr.</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>97005- </postalCode> <country>US</country> </addr> </representedCustodianOrganization> </assignedCustodian> </custodian> <documentationOf typeCode="DOC"> <serviceEvent classCode="PCPR" moodCode="EVN"> <effectiveTime> <low value="20130710214400.000-0500"/> <high value="20130717114441.401-0500"/> </effectiveTime> <performer typeCode="PRF"> <functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88" codeSystemName="HL7 ParticipationFunction" displayName="primary care physician"/> <assignedEntity classCode="ASSIGNED"> <id nullFlavor="NI"/> <addr use="WP"> <streetAddressLine>1006 Healthcare Dr</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>97005- </postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:(555) 555-1006"/> <assignedPerson> <name> <given>Aaron</given> <family>Admit</family> <suffix>MD</suffix> </name> </assignedPerson> </assignedEntity> </performer> </serviceEvent> </documentationOf> <componentOf> <encompassingEncounter> <id root="2.16.840.1.113883.1.13.99999.2" extension="162" assigningAuthorityName="LCH Fin #"/> <effectiveTime> <low value="20130710214400.000-0500"/> <high nullFlavor="NI"/> </effectiveTime> <encounterParticipant typeCode="ATND"> <assignedEntity classCode="ASSIGNED"> <id nullFlavor="NI"/> <addr nullFlavor="UNK"/> <telecom nullFlavor="NI"/> <assignedPerson> <name> <given>Dale</given> <family>Owens</family> </name> </assignedPerson> </assignedEntity> </encounterParticipant> <encounterParticipant typeCode="ATND"> <assignedEntity classCode="ASSIGNED"> <id nullFlavor="NI"/> <addr use="WP"> <streetAddressLine>1004 Healthcare Dr.</streetAddressLine> <streetAddressLine>Get Well Clinic</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>97005- </postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:(555) 555-1014"/> <assignedPerson> <name> <given>Nancy</given> <family>Nightengale</family> <suffix>RN</suffix> </name> </assignedPerson> </assignedEntity> </encounterParticipant> <encounterParticipant typeCode="ADM"> <assignedEntity classCode="ASSIGNED"> <id nullFlavor="NI"/> <addr use="WP"> <streetAddressLine>1006 Healthcare Dr</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>97005- </postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:(555) 555-1006"/> <assignedPerson> <name> <given>Aaron</given> <family>Admit</family> <suffix>MD</suffix> </name> </assignedPerson> </assignedEntity> </encounterParticipant> </encompassingEncounter> </componentOf> <component typeCode="COMP"> <structuredBody classCode="DOCBODY" moodCode="EVN"> <component typeCode="COMP" contextConductionInd="true"> <section classCode="DOCSECT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.2.22.1"/> <templateId root="2.16.840.1.113883.10.20.22.2.22"/> <code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of hospitalizations+History of outpatient visits"/> <title>Encounter</title> <text> <table cellspacing="1" cellpadding="0" width="95%"> <colgroup> <col width="10%"/> <col width="35%"/> <col width="20%"/> <col width="35%"/> </colgroup> <thead> <tr> <th>Dates</th> <th>Location</th> <th>Diagnoses</th> <th>Providers</th> </tr> </thead> <tbody> <tr> <td>07/10/2013</td> <td>Local Community Hospital Organization<br/>4000 Hospital Dr.<br/>Portland, OR 97005- , USA</td> <td> <content ID="ENCDIAG121480396">Final: Exercise-induced angina</content> <br/> <br/> <content ID="ENCDIAG121480397">Final: Angina</content> </td> <td>Owens , Dale<br/>Admit MD, Aaron<br/>Nightengale RN, Nancy<br/> </td> </tr> </tbody> </table> </text> <entry> <encounter classCode="ENC" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.49"/> <id root="2.16.840.1.113883.1.13.99999.2" extension="162" assigningAuthorityName="LCH Fin #"/> <code nullFlavor="UNK"> <originalText>Inpatient</originalText> </code> <effectiveTime> <low value="20130710214400.000-0500"/> </effectiveTime> <performer> <assignedEntity classCode="ASSIGNED"> <id nullFlavor="NI"/> <addr nullFlavor="UNK"/> <telecom nullFlavor="NI"/> <assignedPerson> <name> <given>Dale</given> <family>Owens</family> </name> </assignedPerson> </assignedEntity> </performer> <performer> <assignedEntity classCode="ASSIGNED"> <id nullFlavor="NI"/> <addr use="WP"> <streetAddressLine>1004 Healthcare Dr.</streetAddressLine> <streetAddressLine>Get Well Clinic</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>97005- </postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:(555) 555-1014"/> <assignedPerson> <name> <given>Nancy</given> <family>Nightengale</family> <suffix>RN</suffix> </name> </assignedPerson> </assignedEntity> </performer> <performer> <assignedEntity classCode="ASSIGNED"> <id nullFlavor="NI"/> <addr use="WP"> <streetAddressLine>1006 Healthcare Dr</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>97005- </postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:(555) 555-1006"/> <assignedPerson> <name> <given>Aaron</given> <family>Admit</family> <suffix>MD</suffix> </name> </assignedPerson> </assignedEntity> </performer> <participant typeCode="LOC"> <participantRole classCode="SDLOC"> <templateId root="2.16.840.1.113883.10.20.22.4.32"/> <code nullFlavor="NI"/> <addr use="WP"> <streetAddressLine>4000 Hospital Dr.</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>97005- </postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:(555) 555-1010"/> <playingEntity classCode="PLC"> <name>Local Community Hospital Organization</name> </playingEntity> </participantRole> </participant> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.80"/> <code code="29308-4" codeSystem="2.16.840.1.113883.6.1" displayName="Diagnosis" codeSystemName="LOINC"/> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.4"/> <id root="4061A4A6-F8D6-4870-B6D5-05E1F3DAB302"/> <code code="89100005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> <originalText>Final</originalText> </code> <text> <reference value="#ENCDIAG121480396"/> </text> <statusCode code="completed"/> <effectiveTime> <low value="20130711000000.000-0500"/> </effectiveTime> <value xsi:type="CD" nullFlavor="OTH"> <originalText> <reference value="#ENCDIAG121480396"/> </originalText> <translation code="413.9" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD-9CM (diagnosis codes)" displayName="Other and unspecified angina pectoris"/> </value> </observation> </entryRelationship> </act> </entryRelationship> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.80"/> <code code="29308-4" codeSystem="2.16.840.1.113883.6.1" displayName="Diagnosis" codeSystemName="LOINC"/> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.4"/> <id root="F2C50FAB-B95D-4002-B33E-50D6E5B66AE1"/> <code code="89100005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> <originalText>Final</originalText> </code> <text> <reference value="#ENCDIAG121480397"/> </text> <statusCode code="completed"/> <effectiveTime> <low value="20130717000000.000-0500"/> </effectiveTime> <value xsi:type="CD" nullFlavor="OTH"> <originalText> <reference value="#ENCDIAG121480397"/> </originalText> <translation code="194828000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Angina (disorder)"/> </value> </observation> </entryRelationship> </act> </entryRelationship> </encounter> </entry> </section> </component> <component typeCode="COMP" contextConductionInd="true"> <section classCode="DOCSECT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.2.4"/> <templateId root="2.16.840.1.113883.10.20.22.2.4.1"/> <code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital Signs"/> <title>Vital Signs</title> <text> <table border="1" width="95%"> <colgroup> <col width="20%"/> <col width="80%"/> </colgroup> <thead> <tr> <th align="right">Most recent to oldest [Reference Range]:</th> <th>1</th> </tr> </thead> <tbody> <tr> <td>Systolic Blood Pressure [90-140 mmHg]</td> <td> <content ID="VSEVN17364880">150 mmHg <br/>*HI*<br/>(07/10/2013 22:00:00 America/Chicago)</content> </td> </tr> <tr> <td>Diastolic Blood Pressure [60-90 mmHg]</td> <td> <content ID="VSEVN17364882">95 mmHg <br/>*HI*<br/>(07/10/2013 22:00:00 America/Chicago)</content> </td> </tr> <tr> <td>Mean Arterial Pressure [70-100 mmHg]</td> <td> <content ID="VSEVN17364884">113 mmHg <br/>*&gt;HHI*<br/>(07/10/2013 22:00:00 America/Chicago)</content> </td> </tr> <tr> <td>Height/Length Measured</td> <td> <content ID="VSEVN17364890">178 cm <br/>(07/10/2013 22:00:00 America/Chicago)</content> </td> </tr> <tr> <td>Weight Measured</td> <td> <content ID="VSEVN17364892">82 kg <br/>(07/10/2013 22:00:00 America/Chicago)</content> </td> </tr> <tr> <td>BSA Measured</td> <td> <content ID="VSEVN17364894">2.01 mm2 <br/>(07/10/2013 22:00:00 America/Chicago)</content> </td> </tr> <tr> <td>Body Mass Index Measured</td> <td> <content ID="VSEVN17364896">25.88 m2 <br/>(07/10/2013 22:00:00 America/Chicago)</content> </td> </tr> </tbody> </table> </text> <entry typeCode="DRIV" contextConductionInd="true"> <organizer classCode="CLUSTER" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.26"/> <id root="F4B4F69B-88F2-4DD1-B1C8-F620FC799D02"/> <code code="46680005" displayName="Vital Signs" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/> <statusCode code="completed"/> <effectiveTime value="20130710220000.000-0500"/> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27"/> <id root="0D14EEC1-4409-44CB-98A3-F434ADD58B97"/> <code nullFlavor="UNK"> <originalText>Body Mass Index Measured</originalText> </code> <text> <reference value="#VSEVN17364896"/> </text> <statusCode code="completed"/> <effectiveTime value="20130710220000.000-0500"/> <value xsi:type="PQ" value="25.88" unit="m2"/> <author> <time value="20130710220147.000-0500"/> <assignedAuthor classCode="ASSIGNED"> <id nullFlavor="NI"/> <addr nullFlavor="UNK"/> <assignedPerson> <name> <given nullFlavor="NA"/> <family nullFlavor="NA"/> </name> </assignedPerson> </assignedAuthor> </author> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27"/> <id root="6C4E3F38-ED99-4480-B680-1FB35A9FA6C1"/> <code code="3139-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"> <originalText>BSA Measured</originalText> </code> <text> <reference value="#VSEVN17364894"/> </text> <statusCode code="completed"/> <effectiveTime value="20130710220000.000-0500"/> <value xsi:type="PQ" value="2.01" unit="mm2"/> <author> <time value="20130710220147.000-0500"/> <assignedAuthor classCode="ASSIGNED"> <id nullFlavor="NI"/> <addr nullFlavor="UNK"/> <assignedPerson> <name> <given nullFlavor="NA"/> <family nullFlavor="NA"/> </name> </assignedPerson> </assignedAuthor> </author> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27"/> <id root="32FE5620-BCED-4B41-88F2-E0D92D6F2C28"/> <code nullFlavor="UNK"> <originalText>Mean Arterial Pressure</originalText> </code> <text> <reference value="#VSEVN17364884"/> </text> <statusCode code="completed"/> <effectiveTime value="20130710220000.000-0500"/> <value xsi:type="PQ" value="113" unit="mm[Hg]"/> <interpretationCode nullFlavor="UNK"> <originalText>Extreme High</originalText> </interpretationCode> <author> <time value="20130710220147.000-0500"/> <assignedAuthor classCode="ASSIGNED"> <id nullFlavor="NI"/> <addr nullFlavor="UNK"/> <assignedPerson> <name> <given nullFlavor="NA"/> <family nullFlavor="NA"/> </name> </assignedPerson> </assignedAuthor> </author> <referenceRange typeCode="REFV"> <observationRange> <text>70-100 mmHg</text> </observationRange> </referenceRange> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27"/> <id root="0157B02E-26DD-4AE7-82A2-C095EF153C9E"/> <code code="8462-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"> <originalText>Diastolic Blood Pressure</originalText> </code> <text> <reference value="#VSEVN17364882"/> </text> <statusCode code="completed"/> <effectiveTime value="20130710220000.000-0500"/> <value xsi:type="PQ" value="95" unit="mm[Hg]"/> <interpretationCode code="H" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation"> <originalText>High</originalText> </interpretationCode> <author> <time value="20130710220147.000-0500"/> <assignedAuthor classCode="ASSIGNED"> <id nullFlavor="NI"/> <addr nullFlavor="UNK"/> <assignedPerson> <name> <given nullFlavor="NA"/> <family nullFlavor="NA"/> </name> </assignedPerson> </assignedAuthor> </author> <referenceRange typeCode="REFV"> <observationRange> <text>60-90 mmHg</text> </observationRange> </referenceRange> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27"/> <id root="36C153FB-2F34-4E09-A960-693112CBCF35"/> <code code="3141-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"> <originalText>Weight Measured</originalText> </code> <text> <reference value="#VSEVN17364892"/> </text> <statusCode code="completed"/> <effectiveTime value="20130710220000.000-0500"/> <value xsi:type="PQ" value="82" unit="kg"/> <author> <time value="20130710220147.000-0500"/> <assignedAuthor classCode="ASSIGNED"> <id nullFlavor="NI"/> <addr nullFlavor="UNK"/> <assignedPerson> <name> <given nullFlavor="NA"/> <family nullFlavor="NA"/> </name> </assignedPerson> </assignedAuthor> </author> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27"/> <id root="96F24947-A62E-4E26-86F4-9D42B27021FF"/> <code code="8302-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"> <originalText>Height/Length Measured</originalText> </code> <text> <reference value="#VSEVN17364890"/> </text> <statusCode code="completed"/> <effectiveTime value="20130710220000.000-0500"/> <value xsi:type="PQ" value="178" unit="cm"/> <author> <time value="20130710220147.000-0500"/> <assignedAuthor classCode="ASSIGNED"> <id nullFlavor="NI"/> <addr nullFlavor="UNK"/> <assignedPerson> <name> <given nullFlavor="NA"/> <family nullFlavor="NA"/> </name> </assignedPerson> </assignedAuthor> </author> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27"/> <id root="95D23B1C-3115-475D-86BF-F57BDC0E3970"/> <code code="8480-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"> <originalText>Systolic Blood Pressure</originalText> </code> <text> <reference value="#VSEVN17364880"/> </text> <statusCode code="completed"/> <effectiveTime value="20130710220000.000-0500"/> <value xsi:type="PQ" value="150" unit="mm[Hg]"/> <interpretationCode code="H" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation"> <originalText>High</originalText> </interpretationCode> <author> <time value="20130710220147.000-0500"/> <assignedAuthor classCode="ASSIGNED"> <id nullFlavor="NI"/> <addr nullFlavor="UNK"/> <assignedPerson> <name> <given nullFlavor="NA"/> <family nullFlavor="NA"/> </name> </assignedPerson> </assignedAuthor> </author> <referenceRange typeCode="REFV"> <observationRange> <text>90-140 mmHg</text> </observationRange> </referenceRange> </observation> </component> </organizer> </entry> </section> </component> <component typeCode="COMP" contextConductionInd="true"> <section classCode="DOCSECT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.2.5"/> <templateId root="2.16.840.1.113883.10.20.22.2.5.1"/> <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" displayName="Problem List" codeSystemName="LOINC"/> <title>Problem List</title> <text> <table border="1" width="95%"> <colgroup> <col width="20%"/> <col width="20%"/> <col width="20%"/> <col width="20%"/> <col width="20%"/> </colgroup> <thead> <tr> <th>Condition</th> <th>Effective Dates</th> <th>Status</th> <th>Health Status</th> <th>Informant</th> </tr> </thead> <tbody> <tr> <td> <content ID="PROB5850517">Angina(<content ID="CON5850517">Confirmed</content>)</content> </td> <td>07/10/2013</td> <td> <content ID="PROBST5850517">Active</content> </td> <td> <content ID="PROBHST5850517"> </content> </td> <td> </td> </tr> <tr> <td> <content ID="PROB5850509">Diabetes mellitus type 2(<content ID="CON5850509">Confirmed</content>)</content> </td> <td>01/09/2009</td> <td> <content ID="PROBST5850509">Active</content> </td> <td> <content ID="PROBHST5850509"> </content> </td> <td> </td> </tr> <tr> <td> <content ID="PROB5850513">Hypercholesterolemia(<content ID="CON5850513">Confirmed</content>)</content> </td> <td>08/08/2008</td> <td> <content ID="PROBST5850513">Active</content> </td> <td> <content ID="PROBHST5850513"> </content> </td> <td> </td> </tr> </tbody> </table> <br/> <table border="1" width="95%"> <colgroup> <col width="18%"/> <col width="18%"/> <col width="16%"/> <col 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