bluebutton
Version:
BlueButton.js helps developers navigate complex health data with ease.
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text/xml
<?xml version="1.0" encoding="utf-8"?>
<!-- The following sample document depicts a fictional characters health summary. Any resemblance to a real person is coincidental. -->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 ../../C-CDA%20rules/infrastructure/cda/CDA_SDTC.xsd"
xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc">
<!--
********************************************************
CDA Header
********************************************************
-->
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<!-- US General Header Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
<!-- Continuity of Care Document (CCD) - Patient Health Summary;
Conformant to C-CDA Implementation Guide "CDAR2_IG_IHE_CONSOL_DSTU_R1.1_2012JUL.pdf"
(DSTU) July 2012CCD v1.0 Templates Root -->
<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
<id root="db734647-fc99-424c-a864-7e3cda82e703"/>
<code code="34133-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summarization of Episode Note"/>
<title>Community Health and Hospitals: Health Summary</title>
<effectiveTime value="20140416115455"/>
<confidentialityCode code="N" displayName="Normal" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality Code"/>
<languageCode code="en-US"/>
<setId extension="sTT988" root="2.16.840.1.113883.19.5.99999.19"/>
<versionNumber value="1"/>
<recordTarget>
<patientRole>
<id extension="998991" root="2.16.840.1.113883.19.5.99999.2"/>
<!-- Fake ID using HL7 example OID. -->
<id extension="111-00-2330" root="2.16.840.1.113883.4.1"/>
<!-- Fake Social Security Number using the actual SSN OID. -->
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>2935 Asylum Avenue</streetAddressLine>
<city>New Haven</city>
<state>CT</state>
<postalCode>6510</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:(203)737-7575" use="MC"/>
<!-- MC is "mobile contact" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<patient>
<name use="L">
<given qualifier="BR">Charlene</given>
<family qualifier="AD">Willis</family>
</name>
<administrativeGenderCode code="F" displayName="Female"
codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender"/>
<birthTime value="19520314010000"/>
<maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatus"/>
<religiousAffiliationCode code="1005" displayName="Anglican"
codeSystem="2.16.840.1.113883.5.1076" codeSystemName="ReligiousAffiliation"/>
<!-- CDC Race and Ethnicity code set contains the minimum race and ethnicity categories defined by OMB Standards for Race and Ethnicity -->
<raceCode code="2131-1" displayName="Other Race" codeSystem="2.16.840.1.113883.6.238"
codeSystemName="Race & Ethnicity - CDC"/>
<ethnicGroupCode code="2135-2" displayName="Hispanic or Latino"
codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/>
<guardian>
<code code="FRND" displayName="friend" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 Role code"/>
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>4336 Upton Avenue</streetAddressLine>
<city>Westbrook</city>
<state>ME</state>
<postalCode>4092</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:(207)837-2944" use="HP"/>
<telecom value="email:ElnaJConti@rhyta.com" use="WP"/>
<guardianPerson>
<name>
<prefix>Ms.</prefix>
<given>Elna</given>
<family>Conti</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<city>Wausau</city>
<state>WI</state>
<postalCode>54403</postalCode>
<country>US</country>
</addr>
</place>
</birthplace>
<languageCommunication>
<languageCode code="spa"/>
<modeCode
code="ESP"
displayName="Expressed spoken"
codeSystem="2.16.840.1.113883.5.60"
codeSystemName="LanguageAbilityMode"/>
<preferenceInd value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id root="2.16.840.1.113883.4.6"/>
<name>Community Health and Hospitals</name>
<telecom use="WP" value="tel: 555-555-5000"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time value="20140416115455"/>
<assignedAuthor>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101"
displayName="Allopathic & Osteopathic Physicians"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="999999943252"/>
<code code="207Q00000X" codeSystem="2.16.840.1.113883.6.101"
displayName="Allopathic & Osteopathic Physicians"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<informant>
<assignedEntity>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101"
displayName="Allopathic & Osteopathic Physicians"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</informant>
<informant>
<relatedEntity classCode="PRS">
<!-- classCode PRS represents a person with personal relationship with
the patient. -->
<code code="SPS" displayName="SPOUSE" codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<relatedPerson>
<name>
<given>Frank</given>
<family>Jones</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<name>Community Health and Hospitals</name>
<telecom value="tel: 555-555-1002" use="WP"/>
<addr use="WP">
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</informationRecipient>
<receivedOrganization>
<name>Community Health and Hospitals</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<time value="20130418090000+0500"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="999999999" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<authenticator>
<time value="20140416115455"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="999999999" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<participant typeCode="IND">
<associatedEntity classCode="NOK">
<code code="MTH" codeSystem="2.16.840.1.113883.5.111"/>
<addr>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
</addr>
<telecom value="tel:(999)555-1212" use="WP"/>
<associatedPerson>
<name>
<prefix>Mrs.</prefix>
<given>Martha</given>
<family>Jones</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="20100512100000"/>
<high value="20101231100000"/>
</effectiveTime>
<performer typeCode="PRF">
<functionCode code="PCP" displayName="Primary Care Physician"
codeSystem="2.16.840.1.113883.5.88" codeSystemName="participationFunction">
<originalText>Primary Care Provider</originalText>
</functionCode>
<assignedEntity>
<!-- Provider NPI "PseudoMD-1" -->
<id extension="PseudoMD-1" root="2.16.840.1.113883.4.6"/>
<code code="261QP2300X" displayName="Primary Care [Ambulatory Health Care Facilities\Clinic/Center]"
codeSystemName="NUCC Provider Codes" codeSystem="2.16.840.1.113883.6.101"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-555-555-5000" use="HP"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom value="tel:+1-555-555-5000" use="HP"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<!--
********************************************************
CDA Body
********************************************************
-->
<component>
<structuredBody>
<!--
*********************************
Allergies, Adverse Reactions, Alerts
******************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
<code code="48765-2" displayName="Allergies, adverse reactions, alerts"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Allergies, Adverse Reactions & Alerts</title>
<text>
<table>
<thead>
<tr>
<th>Group Description</th>
<th>Code System</th>
<th>Code</th>
<th>Code Description</th>
<th>Severity</th>
<th>Susceptibility</th>
<th>Date and Time</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Allergy to Eggs</td>
<td>UNII</td>
<td>291P45F896</td>
<td><content ID="Allergy1"/>Eggs</td>
<td><content ID="Severity1"/>Moderate</td>
<td>Moderately Susceptible</td>
<td>05-12-2010 10:00:00</td>
<td>Active</td>
</tr>
<tr>
<td/>
<td>ICD-9-CM</td>
<td>V15.03</td>
<td>Allergy to eggs</td>
<td/>
<td/>
<td/>
<td/>
</tr>
<tr>
<td>Fosfomycin</td>
<td>RxNorm</td>
<td>808917</td>
<td><content ID="Allergy2"/>Fosfomycin 33.3 MG/ML Oral Suspension</td>
<td><content ID="Severity2"/>Moderate to severe</td>
<td>Very susceptible</td>
<td>05-12-2010 10:00:00</td>
<td>Active</td>
</tr>
<tr>
<td>Tetracyclines</td>
<td>RxNorm</td>
<td>406524</td>
<td><content ID="Allergy3"/>Doxycycline 75 MG Enteric Coated Tablet</td>
<td><content ID="Severity3"/>Mild</td>
<td>Susceptible</td>
<td>05-12-2010 10:00:00</td>
<td>Active</td>
</tr>
<tr>
<td/>
<td>NDF-RT</td>
<td>N0000006275</td>
<td>Tetracycline</td>
<td/>
<td/>
<td/>
<td/>
</tr>
</tbody>
</table> </text>
<entry typeCode="DRIV">
<!-- Allergy Problem Act template -->
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code xsi:type="CE" code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Allergies, adverse reactions, alerts"/>
<statusCode code="active"/>
<effectiveTime>
<low value="20100512100000"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<!--Allergy - Intolerance Observation -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="UNK"/>
</effectiveTime>
<!-- The following XML tag, <value>, states whether patient is allergic to DRUG, FOOD or SUBSTANCE.
In EMERGE db, patients have records with allergies to:
(a) DRUG (in EMERGE db, encoded in RxNorm or NDF-RT)
(b) FOOD (in EMERGE db 'Eggs', encoded in UNII) and
CCDA impementation guide distinguishes between "allergy" amd "propensity to allergy". In EMERGE, all patients have "allergy".
Depending on allergen, appropriate value must be selected from Table 117: Allergy/Adverse Event Type Value Set (See CCDA Implementation Guide, pg 311)
(1) If EMERGE patient has allergy to DRUG (RxNorm or NDF-RT), then the code is:
<value code="416098002" displayName="Drug allergy (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
(2) If EMERGE patient has allergy to FOOD (e.g. Eggs, UNII), then the code is:
<value code="414285001" displayName="Food allergy (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
-->
<value xsi:type="CD" code="414285001" displayName="Food allergy (disorder)"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT">
<originalText>
Allergy to Eggs + Eggs
<reference value="#Allergy1"/>
</originalText>
</value>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<!--
This section displays the ACTUAL name of drug/ingredient/food to which person is allergic to.
Please note that FOUR (4) different values sets for documenting Allergies: Brand Names, Clinical Drug Names, Medication Drug Class, and Ingredient name,
encoded in RxNorm, RxNorm, NDF-RT and UNII respectively.
-->
<code code="291P45F896"
displayName="Eggs"
codeSystem="2.16.840.1.113883.4.9"
codeSystemName="UNII">
<originalText>
Allergy to Eggs + Eggs
<reference value="#Allergy1"/>
</originalText>
<!-- <translation> XML tag, if it exist should be placed HERE. In EMERGE db,
Only alergy to "eggs" will contain <translation> xml code with ICD-9 codes system:
<translation code="V15.03" codeSystem="2.16.840.1.113883.6.103"
displayName="Allergy to Eggs" codeSystemName="ICD-9-CM"/>
NOTE: <translation> code can also be used for other codes, such as LOCAL (e..g local hospital) codes.
-->
<translation code="V15.03" codeSystem="2.16.840.1.113883.6.103"
displayName="Allergy to eggs" codeSystemName="ICD-9-CM"/>
</code>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<!-- ** Severity observation template ** -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<code code="SEV" displayName="Severity Observation"
codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
<text>
<reference value="#severity1"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="6736007" displayName="Moderate" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
<interpretationCode code="MS" displayName="Moderately Susceptible" codeSystem="2.16.840.1.113883.1.11.78" codeSystemName="Observation Interpretation"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="DRIV">
<!-- Allergy Problem Act template -->
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code xsi:type="CE" code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Allergies, adverse reactions, alerts"/>
<statusCode code="active"/>
<effectiveTime>
<low value="20100512100000"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<!--Allergy - Intolerance Observation -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="UNK"/>
</effectiveTime>
<!-- The following XML tag, <value>, states whether patient is allergic to DRUG, FOOD or SUBSTANCE.
In EMERGE db, patients have records with allergies to:
(a) DRUG (in EMERGE db, encoded in RxNorm or NDF-RT)
(b) FOOD (in EMERGE db 'Eggs', encoded in UNII) and
CCDA impementation guide distinguishes between "allergy" amd "propensity to allergy". In EMERGE, all patients have "allergy".
Depending on allergen, appropriate value must be selected from Table 117: Allergy/Adverse Event Type Value Set (See CCDA Implementation Guide, pg 311)
(1) If EMERGE patient has allergy to DRUG (RxNorm or NDF-RT), then the code is:
<value code="416098002" displayName="Drug allergy (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
(2) If EMERGE patient has allergy to FOOD (e.g. Eggs, UNII), then the code is:
<value code="414285001" displayName="Food allergy (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
-->
<value xsi:type="CD" code="416098002" displayName="Drug allergy (disorder)"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT">
<originalText>
Fosfomycin + Fosfomycin 33.3 MG/ML Oral Suspension
<reference value="#Allergy1"/>
</originalText>
</value>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<!--
This section displays the ACTUAL name of drug/ingredient/food to which person is allergic to.
Please note that FOUR (4) different values sets for documenting Allergies: Brand Names, Clinical Drug Names, Medication Drug Class, and Ingredient name,
encoded in RxNorm, RxNorm, NDF-RT and UNII respectively.
-->
<code code="808917"
displayName="Fosfomycin 33.3 MG/ML Oral Suspension"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm">
<originalText>
Fosfomycin + Fosfomycin 33.3 MG/ML Oral Suspension
<reference value="#Allergy2"/>
</originalText>
<!-- <translation> XML tag, if it exist should be placed HERE. In EMERGE db,
Only alergy to "eggs" will contain <translation> xml code with ICD-9 codes system:
<translation code="V15.03" codeSystem="2.16.840.1.113883.6.103"
displayName="Allergy to Eggs" codeSystemName="ICD-9-CM"/>
NOTE: <translation> code can also be used for other codes, such as LOCAL (e..g local hospital) codes.
-->
</code>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<!-- ** Severity observation template ** -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<code code="SEV" displayName="Severity Observation"
codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
<text>
<reference value="#severity2"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="371924009" displayName="Moderate to severe" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
<interpretationCode code="VS" displayName="Very susceptible" codeSystem="2.16.840.1.113883.1.11.78" codeSystemName="Observation Interpretation"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="DRIV">
<!-- Allergy Problem Act template -->
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code xsi:type="CE" code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Allergies, adverse reactions, alerts"/>
<statusCode code="active"/>
<effectiveTime>
<low value="20100512100000"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<!--Allergy - Intolerance Observation -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="UNK"/>
</effectiveTime>
<!-- The following XML tag, <value>, states whether patient is allergic to DRUG, FOOD or SUBSTANCE.
In EMERGE db, patients have records with allergies to:
(a) DRUG (in EMERGE db, encoded in RxNorm or NDF-RT)
(b) FOOD (in EMERGE db 'Eggs', encoded in UNII) and
CCDA impementation guide distinguishes between "allergy" amd "propensity to allergy". In EMERGE, all patients have "allergy".
Depending on allergen, appropriate value must be selected from Table 117: Allergy/Adverse Event Type Value Set (See CCDA Implementation Guide, pg 311)
(1) If EMERGE patient has allergy to DRUG (RxNorm or NDF-RT), then the code is:
<value code="416098002" displayName="Drug allergy (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
(2) If EMERGE patient has allergy to FOOD (e.g. Eggs, UNII), then the code is:
<value code="414285001" displayName="Food allergy (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
-->
<value xsi:type="CD" code="416098002" displayName="Drug allergy (disorder)"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT">
<originalText>
Tetracyclines + Doxycycline 75 MG Enteric Coated Tablet
<reference value="#Allergy1"/>
</originalText>
</value>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<!--
This section displays the ACTUAL name of drug/ingredient/food to which person is allergic to.
Please note that FOUR (4) different values sets for documenting Allergies: Brand Names, Clinical Drug Names, Medication Drug Class, and Ingredient name,
encoded in RxNorm, RxNorm, NDF-RT and UNII respectively.
-->
<code code="406524"
displayName="Doxycycline 75 MG Enteric Coated Tablet"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm">
<originalText>
Tetracyclines + Doxycycline 75 MG Enteric Coated Tablet
<reference value="#Allergy3"/>
</originalText>
<!-- <translation> XML tag, if it exist should be placed HERE. In EMERGE db,
Only alergy to "eggs" will contain <translation> xml code with ICD-9 codes system:
<translation code="V15.03" codeSystem="2.16.840.1.113883.6.103"
displayName="Allergy to Eggs" codeSystemName="ICD-9-CM"/>
NOTE: <translation> code can also be used for other codes, such as LOCAL (e..g local hospital) codes.
-->
<translation code="N0000006275" codeSystem="2.16.840.1.113883.3.26.1.5"
displayName="Tetracycline" codeSystemName="NDF-RT"/>
</code>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<!-- ** Severity observation template ** -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<code code="SEV" displayName="Severity Observation"
codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
<text>
<reference value="#severity3"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="255604002" displayName="Mild" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
<interpretationCode code="S" displayName="Susceptible" codeSystem="2.16.840.1.113883.1.11.78" codeSystemName="Observation Interpretation"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!--
********************************************************
Encounters section
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.22"/>
<!-- Encounters section template -->
<code
code="46240-8"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="History of encounters"/>
<title>Encounters</title>
<text>
<table>
<thead>
<tr>
<th>Group Description</th>
<th>Code System</th>
<th>Code</th>
<th>Code Description</th>
<th>Date and Time</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Encounter Outpatient</td>
<td>CPT</td>
<td>99213</td>
<td><content ID="Encounter1"/>Office/outpatient visit, est</td>
<td>05-12-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td/>
<td>ICD-9-CM</td>
<td>V70.0</td>
<td>Routine general medical examination at a health care facility</td>
<td/>
<td/>
</tr>
<tr>
<td>Encounter Outpatient Including Orthopedics an</td>
<td>CPT</td>
<td>98940</td>
<td><content ID="Encounter2"/>Chiropractic manipulation</td>
<td>08-13-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td>Encounter Office & Outpatient Consult</td>
<td>CPT</td>
<td>99241</td>
<td><content ID="Encounter3"/>Office consultation</td>
<td>09-25-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td>Encounter Office & Outpatient Consult</td>
<td>CPT</td>
<td>99241</td>
<td><content ID="Encounter4"/>Office consultation</td>
<td>10-27-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td>Encounter Outpatient</td>
<td>CPT</td>
<td>99213</td>
<td><content ID="Encounter5"/>Office/outpatient visit, est</td>
<td>12-07-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td/>
<td>ICD-9-CM</td>
<td>V70.0</td>
<td>Routine general medical examination at a health care facility</td>
<td/>
<td/>
</tr>
</tbody>
</table> </text>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<!-- Encounter activity template -->
<id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code code="99213" codeSystem="2.16.840.1.113883.6.12"
displayName="Office/outpatient visit, est"
codeSystemName="CPT">
<originalText>
Encounter Outpatient + Encounter Outpatient
<reference value="#Encounter1"/>
</originalText>
<translation code="V70.0" codeSystem="2.16.840.1.113883.6.103"
displayName="Routine general medical examination at a health care facility" codeSystemName="ICD-9-CM"/>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100512100000"/>
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/>
<code code="404684003" displayName="Finding" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#Problem1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20100512100000"/>
</effectiveTime>
<value xsi:type="CD" code="195979001"
displayName="Asthma"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT">
<translation code="J45" codeSystem="2.16.840.1.113883.6.90"
displayName="Asthma" codeSystemName="ICD-10-CM"/>
<translation code="493.92" codeSystem="2.16.840.1.113883.6.103"
displayName="Asthma, unspecified type, with (acute) exacerbation" codeSystemName="ICD-9-CM"/>
</value>
</observation>
</entryRelationship>
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/>
<code code="404684003" displayName="Finding" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#Problem2"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20100512100000"/>
</effectiveTime>
<value xsi:type="CD" code="59621000"
displayName="Hypertension"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT">
<translation code="I10" codeSystem="2.16.840.1.113883.6.90"
displayName="Essential (primary) hypertension" codeSystemName="ICD-10-CM"/>
<translation code="401.9" codeSystem="2.16.840.1.113883.6.103"
displayName="Unspecified essential hypertension" codeSystemName="ICD-9-CM"/>
</value>
</observation>
</entryRelationship>
</encounter>
</entry>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<!-- Encounter activity template -->
<id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code code="98940" codeSystem="2.16.840.1.113883.6.12"
displayName="Chiropractic manipulation"
codeSystemName="CPT">
<originalText>
Encounter Outpatient Including Orthopedics an + Encounter Outpatient Including Orthopedics an
<reference value="#Encounter2"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100813100000"/>
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/>
<code code="404684003" displayName="Finding" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#Problem1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20100813100000"/>
</effectiveTime>
<value xsi:type="CD" code="279039007"
displayName="low back pain"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT">
<translation code="M54.9" codeSystem="2.16.840.1.113883.6.90"
displayName="Dorsalgia, unspecified" codeSystemName="ICD-10-CM"/>
<translation code="724.2" codeSystem="2.16.840.1.113883.6.103"
displayName="Lumbago" codeSystemName="ICD-9-CM"/>
</value>
</observation>
</entryRelationship>
</encounter>
</entry>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<!-- Encounter activity template -->
<id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code code="99241" codeSystem="2.16.840.1.113883.6.12"
displayName="Office consultation"
codeSystemName="CPT">
<originalText>
Encounter Office & Outpatient Consult + Encounter Office & Outpatient Consult
<reference value="#Encounter3"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100925100000"/>
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/>
<code code="404684003" displayName="Finding" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#Problem1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20100925100000"/>
</effectiveTime>
<value xsi:type="CD" code="370202007"
displayName="Asthma Daytime Symptoms Quantified"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT">
</value>
</observation>
</entryRelationship>
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/>
<code code="404684003" displayName="Finding" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#Problem2"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20100925100000"/>
</effectiveTime>
<value xsi:type="CD" code="370205009"
displayName="Asthma Nighttime Symptoms Quantified"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT">
</value>
</observation>
</entryRelationship>
</encounter>
</entry>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<!-- Encounter activity template -->
<id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code code="99241" codeSystem="2.16.840.1.113883.6.12"
displayName="Office consultation"
codeSystemName="CPT">
<originalText>
Encounter Office & Outpatient Consult + Encounter Office & Outpatient Consult
<reference value="#Encounter4"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20101027100000"/>
</encounter>
</entry>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<!-- Encounter activity template -->
<id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code code="99213" codeSystem="2.16.840.1.113883.6.12"
displayName="Office/outpatient visit, est"
codeSystemName="CPT">
<originalText>
Encounter Outpatient + Encounter Outpatient
<reference value="#Encounter5"/>
</originalText>
<translation code="V70.0" codeSystem="2.16.840.1.113883.6.103"
displayName="Routine general medical examination at a health care facility" codeSystemName="ICD-9-CM"/>
</code>
<statusCode code="completed"/>
<effectiveTime value="20101207100000"/>
</encounter>
</entry>
</section>
</component>
<!--
********************************************************
Immunizations section
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.2"/>
<!-- Immunizations section template -->
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1"/>
<title>Immunizations</title>
<text>
<table>
<thead>
<tr>
<th>Group Description</th>
<th>Code System</th>
<th>Code</th>
<th>Code Description</th>
<th>Date and Time</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>No data</td>
</tr>
</tbody>
</table>
</text>
<entry>
<substanceAdministration moodCode="EVN" classCode="SBADM" negationInd="true">
<!-- Immunization Activity entry template -->
<templateId root="2.16.840.1.113883.10.20.22.4.52"/>
<id nullFlavor="NI"/>
<statusCode code="completed"/>
<effectiveTime nullFlavor="NI"/>
<consumable>
<manufacturedProduct classCode="MANU">
<!-- Immunization Medication Information template -->
<templateId root="2.16.840.1.113883.10.20.22.4.54"/>
<manufacturedMaterial>
<code nullFlavor="NI">
<originalText>
<reference value="#immunization1"/>
</originalText>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<!--
********************************************************
Medications section
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
<!-- Medications section template -->
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="History of Medication Use"/>
<title>Medications</title>
<text>
<table>
<thead>
<tr>
<th>Group Description</th>
<th>Code System</th>
<th>Code</th>
<th>Code Description</th>
<th>Date and Time</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Antihypertensive combinations</td>
<td>RxNorm</td>
<td>858828</td>
<td><content ID="Medication1"/>Enalapril Maleate 10 MG / Hydrochlorothiazide 25 MG Oral Tablet</td>
<td>05-12-2010 10:00:00</td>
<td>Active</td>
</tr>
<tr>
<td>Short acting beta 2 agonist</td>
<td>RxNorm</td>
<td>630208</td>
<td><content ID="Medication2"/>Albuterol 0.83 MG/ML Inhalant Solution</td>
<td>05-12-2010 10:00:00</td>
<td>Active</td>
</tr>
</tbody>
</table> </text>
<informant>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<representedOrganization>
<id root="2.16.840.1.113883.4.6"/>
<name>Community Health and Hospitals</name>
<telecom use="WP" value="tel: 555-555-5000"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</informant>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<!-- Medication activity template -->
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/>
<text/>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20100512100000"/>
<high nullFlavor="UNK"/>
</effectiveTime>
<consumable>
<manufacturedProduct classCode="MANU">
<!-- Medication Information -->
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="858828" codeSystem="2.16.840.1.113883.6.88"
displayName="Enalapril Maleate 10 MG / Hydrochlorothiazide 25 MG Oral Tablet"
codeSystemName="RxNorm">
<originalText>
Antihypertensive combinations + Enalapril Maleate 10 MG / Hydrochlorothiazide 25 MG Oral Tablet
<reference value="#Medication1"/>
</originalText>
</code>
<name>Antihypertensive combinations</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<!-- Medication activity template -->
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/>
<text/>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20100512100000"/>
<high nullFlavor="UNK"/>
</effectiveTime>
<consumable>
<manufacturedProduct classCode="MANU">
<!-- Medication Information -->
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="630208" codeSystem="2.16.840.1.113883.6.88"
displayName="Albuterol 0.83 MG/ML Inhalant Solution"
codeSystemName="RxNorm">
<originalText>
Short acting beta 2 agonist + Albuterol 0.83 MG/ML Inhalant Solution
<reference value="#Medication2"/>
</originalText>
</code>
<name>Short acting beta 2 agonist</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<!--
********************************************************
Problems section
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
<!-- Problem section template -->
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="PROBLEM LIST"/>
<title>Problems</title>
<text>
<table>
<thead>
<tr>
<th>Group Description</th>
<th>Code System</th>
<th>Code</th>
<th>Code Description</th>
<th>Date and Time</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Asthma</td>
<td>SNOMED-CT</td>
<td>195979001</td>
<td><content ID="Problem1"/>Asthma unspecified</td>
<td>05-12-2010 10:00:00</td>
<td>Active</td>
</tr>
<tr>
<td/>
<td>ICD-10-CM</td>
<td>J45</td>
<td>Asthma</td>
<td/>
<td/>
</tr>
<tr>
<td/>
<td>ICD-9-CM</td>
<td>493.92</td>
<td>Asthma, unspecified type, with (acute) exacerbation</td>
<td/>
<td/>
</tr>
<tr>
<td>Hypertension</td>
<td>SNOMED-CT</td>
<td>59621000</td>
<td><content ID="Problem2"/>Essential hypertension</td>
<td>05-12-2010 10:00:00</td>
<td>Active</td>
</tr>
<tr>
<td/>
<td>ICD-10-CM</td>
<td>I10</td>
<td>Essential (primary) hypertension</td>
<td/>
<td/>
</tr>
<tr>
<td/>
<td>ICD-9-CM</td>
<td>401.9</td>
<td>Unspecified essential hypertension</td>
<td/>
<td/>
</tr>
<tr>
<td>low back pain</td>
<td>SNOMED-CT</td>
<td>279039007</td>
<td><content ID="Problem3"/>Low back pain</td>
<td>08-13-2010 10:00:00</td>
<td>Active</td>
</tr>
<tr>
<td/>
<td>ICD-10-CM</td>
<td>M54.9</td>
<td>Dorsalgia, unspecified</td>
<td/>
<td/>
</tr>
<tr>
<td/>
<td>ICD-9-CM</td>
<td>724.2</td>
<td>Lumbago</td>
<td/>
<td/>
</tr>
<tr>
<td>Asthma Daytime Symptoms Quantified</td>
<td>SNOMED-CT<