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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"?> <!-- 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="20140416115459"/> <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>320 Centennial Farm Road</streetAddressLine> <city>Storm Lake</city> <state>IA</state> <postalCode>50588</postalCode> <country>US</country> <!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 --> </addr> <telecom value="tel:(712)732-7751" use="MC"/> <!-- MC is "mobile contact" from HL7 AddressUse 2.16.840.1.113883.5.1119 --> <patient> <name use="L"> <given qualifier="BR">Mae</given> <family qualifier="AD">Smith</family> </name> <administrativeGenderCode code="F" displayName="Female" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender"/> <birthTime value="19890530120000"/> <maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatus"/> <religiousAffiliationCode code="1074" displayName="Native American" 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 &amp; Ethnicity - CDC"/> <ethnicGroupCode code="2135-2" displayName="Hispanic or Latino" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race &amp; 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>1189 Twin Oaks Drive</streetAddressLine> <city>Traverse City</city> <state>MI</state> <postalCode>49684</postalCode> <country>US</country> <!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 --> </addr> <telecom value="tel:(231)429-9008" use="HP"/> <telecom value="email:SarahMJohnson@dayrep.com" use="WP"/> <guardianPerson> <name> <prefix>Mrs.</prefix> <given>Sarah</given> <family>Johnson</family> </name> </guardianPerson> </guardian> <birthplace> <place> <addr> <city>Portland</city> <state>OR</state> <postalCode>97205</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="20140416115459"/> <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 &amp; 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 &amp; 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 &amp; 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="20140416115459"/> <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="20010516100000"/> <high value="20101012100000"/> </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 &amp; 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"/>Mild to moderate</td> <td>Very 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>Bakers Yeast</td> <td>RxNorm</td> <td>892677</td> <td><content ID="Allergy2"/>Baker's yeast allergenic extract 100 MG/ML Injectable Solution</td> <td><content ID="Severity2"/>Moderate</td> <td>Susceptible</td> <td>05-12-2010 10:00:00</td> <td>Active</td> </tr> <tr> <td>Penicillin V</td> <td>NDF-RT</td> <td>N0000011298</td> <td><content ID="Allergy3"/>Penicillin V</td> <td><content ID="Severity3"/>Moderate</td> <td>Very susceptible</td> <td>05-12-2010 10:00:00</td> <td>Active</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="371923003" displayName="Mild to moderate" 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> Bakers Yeast + Baker&apos;s yeast allergenic extract 100 MG/ML Injectable Solution <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="892677" displayName="Baker&apos;s yeast allergenic extract 100 MG/ML Injectable Solution" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"> <originalText> Bakers Yeast + Baker&apos;s yeast allergenic extract 100 MG/ML Injectable Solution <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="6736007" displayName="Moderate" 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> <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> Penicillin V + Penicillin V <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="N0000011298" displayName="Penicillin V" codeSystem="2.16.840.1.113883.3.26.1.5" codeSystemName="NDF-RT"> <originalText> Penicillin V + Penicillin V <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. --> </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="6736007" displayName="Moderate" 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> </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</td> <td>CPT</td> <td>99213</td> <td><content ID="Encounter2"/>Office/outpatient visit, est</td> <td>10-12-2010 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> </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="194727002" displayName="Nonrheumatic Mitral (valve) disease" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"> <translation code="I34.2" codeSystem="2.16.840.1.113883.6.90" displayName="Nonrheumatic mitral (valve) stenosis" codeSystemName="ICD-10-CM"/> <translation code="424.0" codeSystem="2.16.840.1.113883.6.103" displayName="Mitral valve disorders" 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="99213" codeSystem="2.16.840.1.113883.6.12" displayName="Office/outpatient visit, est" codeSystemName="CPT"> <originalText> Encounter Outpatient + Encounter Outpatient <reference value="#Encounter2"/> </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="20101012100000"/> </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>VZV Vaccine</td> <td>CVX</td> <td>121</td> <td><content ID="Immunization1"/>zoster</td> <td>05-12-2010 10:00:00</td> <td>Completed</td> </tr> </tbody> </table> </text> <entry typeCode="DRIV"> <substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="false"> <!-- Immunization activity template --> <templateId root="2.16.840.1.113883.10.20.22.4.52"/> <id root="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92"/> <text> <reference value="#Immunization1"/> </text> <statusCode code="completed"/> <effectiveTime value="20100512100000"/> <routeCode code="C28161" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Intramuscular injection"/> <consumable> <manufacturedProduct classCode="MANU"> <!-- Product template --> <templateId root="2.16.840.1.113883.10.20.22.4.54"/> <manufacturedMaterial> <code code="121" codeSystem="2.16.840.1.113883.12.292" displayName="zoster" codeSystemName="CVX"> <originalText> VZV Vaccine + VZV Vaccine <reference value="#Immunization1"/> </originalText> </code> </manufacturedMaterial> </manufacturedProduct> </consumable> <performer> <assignedEntity> <id root="2.16.840.1.113883.4.6" extension="999999943252"/> <addr> <streetAddressLine>101 Maple Street</streetAddressLine> <city>Washington</city> <state>DC</state> <postalCode>20009</postalCode> <country>United States</country> </addr> <telecom value="888-888-0000"/> <assignedPerson> <name> <given>Jim</given> <family>Smith</family> </name> </assignedPerson> <representedOrganization> <id root="2.16.840.1.113883.19.5" extension="2981824"/> <name>Good Hospital</name> <telecom use="WP" value="888-888-0000"/> <addr> <streetAddressLine>101 Maple Street</streetAddressLine> <city>Washington</city> <state>DC</state> <postalCode>20009</postalCode> <country>United States</country> </addr> </representedOrganization> </assignedEntity> </performer> </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>No Information</td> </tr> </tbody> </table> </text> <informant> <assignedEntity> <id extension="KP00017" root="2.16.840.1.113883.19.5"/> <representedOrganization> <id nullFlavor="NI"/> <name>No data</name> <telecom nullFlavor="NI"/> <addr nullFlavor="NI"/> </representedOrganization> </assignedEntity> </informant> <entry typeCode="DRIV"> <substanceAdministration classCode="SBADM" moodCode="EVN" nullFlavor="NI"> <!-- Medication activity template --> <templateId root="2.16.840.1.113883.10.20.22.4.16"/> <id nullFlavor="NI"/> <text>No data</text> <statusCode code="completed"/> <effectiveTime xsi:type="IVL_TS"> <low nullFlavor="NI"/> <high nullFlavor="NI"/> </effectiveTime> <consumable> <manufacturedProduct classCode="MANU"> <!-- Medication Information --> <templateId root="2.16.840.1.113883.10.20.22.4.23"/> <manufacturedMaterial> <code nullFlavor="NI"> <originalText> No data <reference value="#Medication1"/> </originalText> </code> <name nullFlavor="NI"/> </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>leukemia</td> <td>SNOMED-CT</td> <td>188725004</td> <td><content ID="Problem1"/>Lymphoid leukemia</td> <td>05-16-2001 10:00:00</td> <td>Active</td> </tr> <tr> <td/> <td>ICD-10-CM</td> <td>C91</td> <td>Lymphoid leukemia</td> <td/> <td/> </tr> <tr> <td/> <td>ICD-9-CM</td> <td>204.90</td> <td>Unspecified lymphoid leukemia, without mention of having achieved remission</td> <td/> <td/> </tr> <tr> <td>Nonrheumatic Mitral (valve) disease</td> <td>SNOMED-CT</td> <td>194727002</td> <td><content ID="Problem2"/>Non-rheumatic mitral valve stenosis</td> <td>05-12-2010 10:00:00</td> <td>Active</td> </tr> <tr> <td/> <td>ICD-10-CM</td> <td>I34.2</td> <td>Nonrheumatic mitral (valve) stenosis</td> <td/> <td/> </tr> <tr> <td/> <td>ICD-9-CM</td> <td>424.0</td> <td>Mitral valve disorders</td> <td/> <td/> </tr> </tbody> </table> </text> <entry typeCode="DRIV"> <act classCode="ACT" moodCode="EVN"> <!-- Problem act template --> <templateId root="2.16.840.1.113883.10.20.22.4.3"/> <id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7"/> <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern"/> <statusCode code="active"/> <effectiveTime> <low value="20010516100000"/> </effectiveTime> <entryRelationship typeCode="SUBJ"> <!-- Problem observation template --> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.4"/> <id root="9d3d416d-45ab-4da1-912f-4583e0632000"/> <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/> <statusCode code="completed"/> <effectiveTime> <low value="20010516100000"/> </effectiveTime> <value xsi:type="CD" code="188725004" codeSystem="2.16.840.1.113883.6.96" displayName="Lymphoid leukemia" codeSystemName="SNOMED-CT"> <translation code="C91" codeSystem="2.16.840.1.113883.6.90" displayName="Lymphoid leukemia" codeSystemName="ICD-10-CM"/> <translation code="204.90" codeSystem="2.16.840.1.113883.6.103" displayName="Unspecified lymphoid leukemia, without mention of having achieved remission" codeSystemName="ICD-9-CM"/> </value> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.6"/> <code xsi:type="CE" code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/> <text> <reference value="#Problem1"/> </text> <statusCode code="completed"/> <value xsi:type="CD" code="55561003" displayName="Active" codeSystem="2.16.840.1.113883.6.96" codeSystemName=" SNOMED-CT"/> </observation> </entryRelationship> </observation> </entryRelationship> </act> </entry> <entry typeCode="DRIV"> <act classCode="ACT" moodCode="EVN"> <!-- Problem act template --> <templateId root="2.16.840.1.113883.10.20.22.4.3"/> <id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7"/> <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern"/> <statusCode code="active"/> <effectiveTime> <low value="20100512100000"/> </effectiveTime> <entryRelationship typeCode="SUBJ"> <!-- Problem observation template --> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.4"/> <id root="9d3d416d-45ab-4da1-912f-4583e0632000"/> <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/> <statusCode code="completed"/> <effectiveTime> <low value="20100512100000"/> </effectiveTime> <value xsi:type="CD" code="194727002" codeSystem="2.16.840.1.113883.6.96" displayName="Non-rheumatic mitral valve stenosis" codeSystemName="SNOMED-CT"> <translation code="I34.2" codeSystem="2.16.840.1.113883.6.90" displayName="Nonrheumatic mitral (valve) stenosis" codeSystemName="ICD-10-CM"/> <translation code="424.0" codeSystem="2.16.840.1.113883.6.103" displayName="Mitral valve disorders" codeSystemName="ICD-9-CM"/> </value> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.6"/> <code xsi:type="CE" code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/> <text> <reference value="#Problem2"/> </text> <statusCode code="completed"/> <value xsi:type="CD" code="55561003" displayName="Active" codeSystem="2.16.840.1.113883.6.96" codeSystemName=" SNOMED-CT"/> </observation> </entryRelationship> </observation> </entryRelationship> </act> </entry> </section> </component> <!-- ******************************************************** Procedures section ******************************************************** --> <component> <section> <!-- conforms to Procedures section with entries optional --> <templateId root="2.16.840.1.113883.10.20.22.2.7"/> <!-- Procedures section with entries required --> <templateId root="2.16.840.1.113883.10.20.22.2.7.1"/> <code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PROCEDURES"/> <title>Procedures</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>Tobacco Use Cessation Counseling</td> <td>CPT</td> <td>99406</td> <td><content ID="Procedure1"/>Behav chng smoking 3-10 min</td> <td>05-12-2010 10:00:00</td> <td>Performed</td> </tr> <tr> <td/> <td>SNOMED-CT</td> <td>384742004</td> <td>Smoking cessation assistance</td> <td/> <td/> </tr> <tr> <td>contraceptive use education</td> <td>SNOMED-CT</td> <td>44651004</td> <td><content ID="Procedure2"/>Contraceptive use education</td> <td>05-12-2010 10:00:00</td> <td>Performed</td> </tr> </tbody> </table> </text> <entry typeCode="DRIV"> <procedure classCode="ACT" moodCode="EVN"> <!-- Procedure Activity Act Template --> <templateId root="2.16.840.1.113883.10.20.22.4.12"/> <id root="e401f340-7be2-11db-9fe1-0800200c9a66"/> <code xsi:type="CE" code="99406" codeSystem="2.16.840.1.113883.6.12" displayName="Behav chng smoking 3-10 min" codeSystemName="CPT"> <originalText> Tobacco Use Cessation Counseling + Behav chng smoking 3-10 min <reference value="#Procedure1"/> </originalText> <translation code="384742004" codeSystem="2.16.840.1.113883.6.96" displayName="Smoking cessation assistance" codeSystemName="SNOMED-CT"/> </code> <statusCode code="completed"/> <effectiveTime value="20100512100000"/> <methodCode nullFlavor="UNK"/> </procedure> </entry> <entry typeCode="DRIV"> <procedure classCode="ACT" moodCode="EVN"> <!-- Procedure Activity Act Template --> <templateId root="2.16.840.1.113883.10.20.22.4.12"/> <id root="e401f340-7be2-11db-9fe1-0800200c9a66"/> <code xsi:type="CE" code="44651004" codeSystem="2.16.840.1.113883.6.96" displayName="Contraceptive use education" codeSystemName="SNOMED-CT"> <originalText> contraceptive use education + Contraceptive use education <reference value="#Procedure2"/> </originalText> </code> <statusCode code="completed"/> <effectiveTime value="20100512100000"/> <methodCode nullFlavor="UNK"/> </procedure> </entry> </section> </component> <!-- ******************************************************** Results section ******************************************************** Note: In EMERGE DB, all results are laboratory test results that are assigned to a specific Lab Category. For example, HDL, LDL, Total Ch and Triglycerides are all grouped under Lipid Panel. Each lab test is associated with one, and only one, LabCategory. Lab tests can further be organized as "BATTERY" or "CLUSTERS" aka. classCode (CONF:7121, C-CDA IG page 503). For example, HDL, LDL, Total Ch and Triglycerides are BATTERY of Lab Category "Lipid Panels" because these tests are executed together, whereas HIV and Chlamydia tests are CLUSTERS since these tests need not be executed together but are categorized under same lab category ("Microbiology") and may be reported on same Lab Report. The following list shows ALL La