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="20140416115512"/>
<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>2645 Turkey Pen Lane</streetAddressLine>
<city>Columbus</city>
<state>AL</state>
<postalCode>31901</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:(334)560-3266" use="MC"/>
<!-- MC is "mobile contact" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<patient>
<name use="L">
<given qualifier="BR">Casey</given>
<family qualifier="AD">Hansen</family>
</name>
<administrativeGenderCode code="M" displayName="Male"
codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender"/>
<birthTime value="19430722120000"/>
<maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatus"/>
<religiousAffiliationCode code="1059" displayName="Zen Buddhism"
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>2880 Ralph Drive</streetAddressLine>
<city>Warrensville Heights</city>
<state>OH</state>
<postalCode>44128</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:(440)304-0659" use="HP"/>
<telecom value="email:JamesVMedina@rhyta.com" use="WP"/>
<guardianPerson>
<name>
<prefix>Mr.</prefix>
<given>James</given>
<family>Medina</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<city>Philomath</city>
<state>OR</state>
<postalCode>97370</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="20140416115512"/>
<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="20140416115512"/>
<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="20090516100000"/>
<high value="20101215100000"/>
</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 to severe</td>
<td>Very susceptible</td>
<td>02-13-2010 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>Codeine</td>
<td>NDF-RT</td>
<td>N0000006691</td>
<td><content ID="Allergy2"/>Codeine</td>
<td><content ID="Severity2"/>Fatal</td>
<td>Very susceptible</td>
<td>02-13-2010 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="20100213100000"/>
</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="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="20100213100000"/>
</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>
Codeine + Codeine
<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="N0000006691"
displayName="Codeine"
codeSystem="2.16.840.1.113883.3.26.1.5"
codeSystemName="NDF-RT">
<originalText>
Codeine + Codeine
<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="399166001" displayName="Fatal" 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>05-16-2009 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>04-14-2010 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 Prev Med Group Counseling</td>
<td>CPT</td>
<td>99412</td>
<td><content ID="Encounter3"/>Preventive counseling, group</td>
<td>05-16-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td>Encounter Prev Med Group Counseling</td>
<td>CPT</td>
<td>99412</td>
<td><content ID="Encounter4"/>Preventive counseling, group</td>
<td>09-15-2010 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>12-15-2010 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="20090516100000"/>
<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="20090516100000"/>
</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="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="20100414100000"/>
</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="99412" codeSystem="2.16.840.1.113883.6.12"
displayName="Preventive counseling, group"
codeSystemName="CPT">
<originalText>
Encounter Prev Med Group Counseling + Encounter Prev Med Group Counseling
<reference value="#Encounter3"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100516100000"/>
</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="99412" codeSystem="2.16.840.1.113883.6.12"
displayName="Preventive counseling, group"
codeSystemName="CPT">
<originalText>
Encounter Prev Med Group Counseling + Encounter Prev Med Group Counseling
<reference value="#Encounter4"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100915100000"/>
</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="20101215100000"/>
</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>05-16-2009 10:00:00</td>
<td>Active</td>
</tr>
<tr>
<td>Antihypertensive combinations</td>
<td>RxNorm</td>
<td>858828</td>
<td><content ID="Medication2"/>Enalapril Maleate 10 MG / Hydrochlorothiazide 25 MG Oral Tablet</td>
<td>04-14-2010 10:00:00</td>
<td>Active</td>
</tr>
<tr>
<td>Smoking Cessation Agents</td>
<td>RxNorm</td>
<td>1046847</td>
<td><content ID="Medication3"/>24 HR Nicotine 0.313 MG/HR Transdermal Patch</td>
<td>09-15-2010 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="20090516100000"/>
<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="20100414100000"/>
<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="#Medication2"/>
</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="20100915100000"/>
<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="1046847" codeSystem="2.16.840.1.113883.6.88"
displayName="24 HR Nicotine 0.313 MG/HR Transdermal Patch"
codeSystemName="RxNorm">
<originalText>
Smoking Cessation Agents + 24 HR Nicotine 0.313 MG/HR Transdermal Patch
<reference value="#Medication3"/>
</originalText>
</code>
<name>Smoking Cessation Agents</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>Hypertension</td>
<td>SNOMED-CT</td>
<td>59621000</td>
<td><content ID="Problem1"/>Essential hypertension</td>
<td>05-16-2009 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>
</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="20090516100000"/>
</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="20090516100000"/>
</effectiveTime>
<value xsi:type="CD" code="59621000" codeSystem="2.16.840.1.113883.6.96"
displayName="Essential hypertension"
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>
<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>
</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>05-16-2010 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>Colonoscopy</td>
<td>CPT</td>
<td>45378</td>
<td><content ID="Procedure2"/>Diagnostic colonoscopy</td>
<td>06-22-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td/>
<td>HCPCS</td>
<td>G0121</td>
<td>Colon ca scrn not hi rsk ind</td>
<td/>
<td/>
</tr>
<tr>
<td/>
<td>ICD-10-CM</td>
<td>Z12.11</td>
<td>Encounter for screening for malignant neoplasm of colon</td>
<td/>
<td/>
</tr>
<tr>
<td/>
<td>ICD-9-CM</td>
<td>45.23</td>
<td>Colonoscopy</td>
<td/>
<td/>
</tr>
<tr>
<td/>
<td>SNOMED-CT</td>
<td>174184006</td>
<td>Diagnostic endoscopic examination on colon</td>
<td/>
<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="20100516100000"/>
<methodCode nullFlavor="UNK"/>
</procedure>
</entry>
<entry typeCode="DRIV">
<procedure classCode="OBS" moodCode="EVN">
<!-- Procedure Activity Observation Template -->
<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
<id root="e401f340-7be2-11db-9fe1-0800200c9a66"/>
<code xsi:type="CE" code="45378" codeSystem="2.16.840.1.113883.6.12"
displayName="Diagnostic colonoscopy"
codeSystemName="CPT">
<originalText>
Colonoscopy + Diagnostic colonoscopy
<reference value="#Procedure2"/>
</originalText>
<translation code="G0121" codeSystem="2.16.840.1.113883.6.13"
displayName="Colon ca scrn not hi rsk ind" codeSystemName="HCPCS"/>
<translation code="Z12.11" codeSystem="2.16.840.1.113883.6.90"
displayName="Encounter for screening for malignant neoplasm of colon" codeSystemName="ICD-10-CM"/>
<translation code="45.23" codeSystem="2.16.840.1.113883.6.103"
displayName="Colonoscopy" codeSystemName="ICD-9-CM"/>
<translation code="174184006" codeSystem="2.16.840.1.113883.6.96"
displayName="Diagnostic endoscopic examination on colon" codeSystemName="SNOMED-CT"/>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100622100000"/>
<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 Laboratory tests available in EMERGE db and how they correspond to Labcategories,
and whether such tests are considered CLUSTER or BATTERY in EMERGE db:
TEST LabCATEGORY classCode
HbA1c test Blood Chemistry CLUSTER
Prostate Specific Antigen Test Blood Chemistry CLUSTER
Pap Test Cytology CLUSTER
FOBT FOBT CLUSTER
High Density Lipoprotein (HDL) Lipid Panel BATTERY
Low Density Lipoprotein (LDL) Lipid Panel BATTERY
Total Cholesterol Lipid Panel BATTERY
Triglycerides Lipid Panel BATTERY
Chlamydia Screening Microbiology CLUSTER
Group A Streptococcus Test Microbiology CLUSTER
Gleason Score Pathology CLUSTER
Gleason Score <=6 Pathology CLUSTER
HIV Screening Serology CLUSTER
Pregnancy Test Serology CLUSTER
Rh Status Baby Serology CLUSTER
Rh Status Mother Serology CLUSTER
Urine Macroalbumin Urinalysis CLUSTER
Note that laboratories may sometimes differ in terms of what they consider BATTERY as opposed to CLUSTER for soem tests;
depending on method that is used to execute such lab tests.
The <entry> tags for Results section (further below after narrative <text> tags) are organized based on the following rule:
(1) All tests belonging to the same Lab Category are grouped as <components> under one <entry> having one <organizer>.
For example, HDL LDL, Total Ch and TG are declared as 4 <components> belonging to one <entry>, having one <organizer>
(2) In cases where patient has two lipid panels performed on two different dates, such case will result in two <entry> tags,
each <entry> tag having one <organizer> and 4 <components>.
Note that C-CDA schema explicitly allows one, and only one, <organizer> per <entry> (CONF:7113, C-CDA IG page 288).
-->
<component>
<section>
<!-- conforms to Results section with entries optional -->
<templateId root="2.16.840.1.113883.10.20.22.2.3"/>
<!-- Results section with entries required -->
<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Results"/>
<title>Results</title>
<text>
<table>
<thead>
<tr>
<th>Group Description</th>
<th>Code System</th>
<th>Code</th>
<th>Code Description</th>
<th>Value</th>
<th>Unit</th>
<th>Reference Range</th>
<th>Date and Time</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>High Density Lipoprotein (HDL)</td>
<td>LOINC</td>
<td>1464