bluebutton
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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="20140416115507"/>
<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>3612 Khale Street</streetAddressLine>
<city>Hemingway</city>
<state>SC</state>
<postalCode>29554</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:(843)558-6567" use="MC"/>
<!-- MC is "mobile contact" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<patient>
<name use="L">
<given qualifier="BR">Lori</given>
<family qualifier="AD">Lee</family>
</name>
<administrativeGenderCode code="F" displayName="Female"
codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender"/>
<birthTime value="19440508120000"/>
<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="2106-3" displayName="White" codeSystem="2.16.840.1.113883.6.238"
codeSystemName="Race & Ethnicity - CDC"/>
<ethnicGroupCode code="2186-5" displayName="Not 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>3527 Oakmound Road</streetAddressLine>
<city>Chicago</city>
<state>IL</state>
<postalCode>60609</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:(773)254-9019" use="HP"/>
<telecom value="email:AaronMAnaya@rhyta.com" use="WP"/>
<guardianPerson>
<name>
<prefix>Mr.</prefix>
<given>Aaron</given>
<family>Anaya</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<city>Alhambra</city>
<state>CA</state>
<postalCode>91801</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="20140416115507"/>
<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="20140416115507"/>
<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="20091025100000"/>
<high value="20101130100000"/>
</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>Very susceptible</td>
<td>05-09-2010 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>Neomycin</td>
<td>RxNorm</td>
<td>866041</td>
<td><content ID="Allergy2"/>Neomycin Sulfate 500 MG</td>
<td><content ID="Severity2"/>Mild to moderate</td>
<td>Moderately Susceptible</td>
<td>05-09-2010 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"/>Fatal</td>
<td>Moderately Susceptible</td>
<td>05-09-2010 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="20100509100000"/>
</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="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="20100509100000"/>
</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>
Neomycin + Neomycin Sulfate 500 MG
<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="866041"
displayName="Neomycin Sulfate 500 MG"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm">
<originalText>
Neomycin + Neomycin Sulfate 500 MG
<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="371923003" displayName="Mild to 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="20100509100000"/>
</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="399166001" displayName="Fatal" 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>
</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 Office Visit</td>
<td>CPT</td>
<td>99212</td>
<td><content ID="Encounter1"/>Office/outpatient visit, est</td>
<td>05-09-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td>Encounter Outpatient</td>
<td>CPT</td>
<td>99213</td>
<td><content ID="Encounter2"/>Office/outpatient visit, est</td>
<td>09-10-2010 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 Office Visit</td>
<td>CPT</td>
<td>99212</td>
<td><content ID="Encounter3"/>Office/outpatient visit, est</td>
<td>09-11-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td>Encounter Acute Inpt</td>
<td>CPT</td>
<td>99251</td>
<td><content ID="Encounter4"/>Initial inpatient consult</td>
<td>09-14-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td>Encounter Inpatient Discharge</td>
<td>CPT</td>
<td>99238</td>
<td><content ID="Encounter5"/>Hospital discharge day</td>
<td>09-17-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td>Encounter Health and Behavior Assessment</td>
<td>CPT</td>
<td>96150</td>
<td><content ID="Encounter6"/>Assess hlth/behave, init</td>
<td>09-25-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td>Encounter Office Visit</td>
<td>CPT</td>
<td>99212</td>
<td><content ID="Encounter7"/>Office/outpatient visit, est</td>
<td>10-25-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td>Encounter Outpatient</td>
<td>CPT</td>
<td>99213</td>
<td><content ID="Encounter8"/>Office/outpatient visit, est</td>
<td>11-30-2010 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="99212" codeSystem="2.16.840.1.113883.6.12"
displayName="Office/outpatient visit, est"
codeSystemName="CPT">
<originalText>
Encounter Office Visit + Encounter Office Visit
<reference value="#Encounter1"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100509100000"/>
<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="20100509100000"/>
</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>
</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="20100910100000"/>
</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="99212" codeSystem="2.16.840.1.113883.6.12"
displayName="Office/outpatient visit, est"
codeSystemName="CPT">
<originalText>
Encounter Office Visit + Encounter Office Visit
<reference value="#Encounter3"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100911100000"/>
</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="99251" codeSystem="2.16.840.1.113883.6.12"
displayName="Initial inpatient consult"
codeSystemName="CPT">
<originalText>
Encounter Acute Inpt + Encounter Acute Inpt
<reference value="#Encounter4"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100914100000"/>
<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="20100914100000"/>
</effectiveTime>
<value xsi:type="CD" code="188161004"
displayName="Breast Cancer"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT">
<translation code="C50" codeSystem="2.16.840.1.113883.6.90"
displayName="Malignant neoplasm of breast" codeSystemName="ICD-10-CM"/>
<translation code="174.9" codeSystem="2.16.840.1.113883.6.103"
displayName="Malignant neoplasm of breast (female), unspecified" 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="20100914100000"/>
</effectiveTime>
<value xsi:type="CD" code="417742002"
displayName="Breast Cancer ER or PR Positive"
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="#Problem3"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20100914100000"/>
</effectiveTime>
<value xsi:type="CD" code="261653007"
displayName="Breast Cancer Stage IC-IIIC"
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="99238" codeSystem="2.16.840.1.113883.6.12"
displayName="Hospital discharge day"
codeSystemName="CPT">
<originalText>
Encounter Inpatient Discharge + Encounter Inpatient Discharge
<reference value="#Encounter5"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100917100000"/>
</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="96150" codeSystem="2.16.840.1.113883.6.12"
displayName="Assess hlth/behave, init"
codeSystemName="CPT">
<originalText>
Encounter Health and Behavior Assessment + Encounter Health and Behavior Assessment
<reference value="#Encounter6"/>
</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="191615005"
displayName="Depression"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT">
<translation code="F33.3" codeSystem="2.16.840.1.113883.6.90"
displayName="Major depressive disorder, recurrent, severe with psychotic symptoms" codeSystemName="ICD-10-CM"/>
<translation code="296.36" codeSystem="2.16.840.1.113883.6.103"
displayName="Major depressive affective disorder, recurrent episode, in full remission" 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="99212" codeSystem="2.16.840.1.113883.6.12"
displayName="Office/outpatient visit, est"
codeSystemName="CPT">
<originalText>
Encounter Office Visit + Encounter Office Visit
<reference value="#Encounter7"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20101025100000"/>
</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="#Encounter8"/>
</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="20101130100000"/>
</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>Hepatitis A Vaccine</td>
<td>CVX</td>
<td>83</td>
<td><content ID="Immunization1"/>Hep A, ped/adol, 2 dose</td>
<td>11-30-2010 10:00:00</td>
<td>Completed</td>
</tr>
<tr>
<td>Influenza Vaccine</td>
<td>CVX</td>
<td>135</td>
<td><content ID="Immunization2"/>Influenza, high dose seasonal</td>
<td>11-30-2010 10:00:00</td>
<td>Completed</td>
</tr>
<tr>
<td>Pneumococcal Vaccine all ages</td>
<td>CVX</td>
<td>100</td>
<td><content ID="Immunization3"/>pneumococcal conjugate PCV 7</td>
<td>11-30-2010 10:00:00</td>
<td>Completed</td>
</tr>
<tr>
<td/>
<td>CPT</td>
<td>90669</td>
<td>Pneumococcal vacc, ped<5</td>
<td/>
<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="20101130100000"/>
<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="83" codeSystem="2.16.840.1.113883.12.292"
displayName="Hep A, ped/adol, 2 dose"
codeSystemName="CVX">
<originalText>
Hepatitis A Vaccine + Hepatitis A 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>
<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="#Immunization2"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20101130100000"/>
<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="135" co