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="20140416115517"/>
<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>1167 Riverside Drive</streetAddressLine>
<city>Augusta</city>
<state>GA</state>
<postalCode>30906</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:(706)790-8197" use="MC"/>
<!-- MC is "mobile contact" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<patient>
<name use="L">
<given qualifier="BR">Katrina</given>
<family qualifier="AD">Morales</family>
</name>
<administrativeGenderCode code="F" displayName="Female"
codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender"/>
<birthTime value="19350605120000"/>
<maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatus"/>
<religiousAffiliationCode code="1077" displayName="Protestant"
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>4772 Yorkshire Circle</streetAddressLine>
<city>Morehead City</city>
<state>NC</state>
<postalCode>28557</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:(252)276-1976" use="HP"/>
<telecom value="email:DorothyDGooch@fleckens.hu" use="WP"/>
<guardianPerson>
<name>
<prefix>Ms.</prefix>
<given>Dorothy</given>
<family>Gooch</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<city>Modeana</city>
<state>TX</state>
<postalCode>78040</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="20140416115517"/>
<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="20140416115517"/>
<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="20100825100000"/>
<high value="20101030100000"/>
</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"/>Severe</td>
<td>Moderately Susceptible</td>
<td>08-25-2010 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 to severe</td>
<td>Moderately Susceptible</td>
<td>08-25-2010 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"/>Severe</td>
<td>Very susceptible</td>
<td>08-25-2010 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="20100825100000"/>
</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="24484000" displayName="Severe" 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="20100825100000"/>
</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'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's yeast allergenic extract 100 MG/ML Injectable Solution"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm">
<originalText>
Bakers Yeast + Baker'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="371924009" displayName="Moderate to severe" 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="20100825100000"/>
</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="24484000" displayName="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>
</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>08-25-2010 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="Encounter2"/>Office/outpatient visit, est</td>
<td>09-06-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td>Encounter Office Visit</td>
<td>CPT</td>
<td>99212</td>
<td><content ID="Encounter3"/>Office/outpatient visit, est</td>
<td>10-30-2010 10:00:00</td>
<td>Performed</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="20100825100000"/>
</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="#Encounter2"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100906100000"/>
</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="20101030100000"/>
</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>Influenza Vaccine</td>
<td>CVX</td>
<td>135</td>
<td><content ID="Immunization1"/>Influenza, high dose seasonal</td>
<td>10-30-2010 10:00:00</td>
<td>Completed</td>
</tr>
<tr>
<td>Pneumococcal Vaccine all ages</td>
<td>CVX</td>
<td>100</td>
<td><content ID="Immunization2"/>pneumococcal conjugate PCV 7</td>
<td>10-30-2010 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="20101030100000"/>
<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" codeSystem="2.16.840.1.113883.12.292"
displayName="Influenza, high dose seasonal"
codeSystemName="CVX">
<originalText>
Influenza Vaccine + Influenza 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="20101030100000"/>
<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="100" codeSystem="2.16.840.1.113883.12.292"
displayName="pneumococcal conjugate PCV 7"
codeSystemName="CVX">
<originalText>
Pneumococcal Vaccine all ages + Pneumococcal Vaccine all ages
<reference value="#Immunization2"/>
</originalText>
<translation code="90669" codeSystem="2.16.840.1.113883.6.12"
displayName="Pneumococcal vacc, ped<5" codeSystemName="CPT"/>
</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>Colon Cancer</td>
<td>SNOMED-CT</td>
<td>126838000</td>
<td><content ID="Problem1"/>Neoplasm of colon</td>
<td>10-02-2010 10:00:00</td>
<td>Active</td>
</tr>
<tr>
<td/>
<td>ICD-10-CM</td>
<td>C18.9</td>
<td>Malignant neoplasm of colon, unspecified</td>
<td/>
<td/>
</tr>
<tr>
<td/>
<td>ICD-9-CM</td>
<td>153.9</td>
<td>Malignant neoplasm of colon, unspecified site</td>
<td/>
<td/>
</tr>
<tr>
<td>Colon Cancer Stage III</td>
<td>SNOMED-CT</td>
<td>369921003</td>
<td><content ID="Problem2"/>T3: Colon/rectum tumor invades through the muscularis propria into the subserosa or the nonperitonealized pericolic or perirectal soft tissues</td>
<td>10-02-2010 10:00:00</td>
<td>Active</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="20101002100000"/>
</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="20101002100000"/>
</effectiveTime>
<value xsi:type="CD" code="126838000" codeSystem="2.16.840.1.113883.6.96"
displayName="Neoplasm of colon"
codeSystemName="SNOMED-CT">
<translation code="C18.9" codeSystem="2.16.840.1.113883.6.90"
displayName="Malignant neoplasm of colon, unspecified" codeSystemName="ICD-10-CM"/>
<translation code="153.9" codeSystem="2.16.840.1.113883.6.103"
displayName="Malignant neoplasm of colon, unspecified site" 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="20101002100000"/>
</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="20101002100000"/>
</effectiveTime>
<value xsi:type="CD" code="369921003" codeSystem="2.16.840.1.113883.6.96"
displayName="T3: Colon/rectum tumor invades through the muscularis propria into the subserosa or the nonperitonealized pericolic or perirectal soft tissues"
codeSystemName="SNOMED-CT">
</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>Colonoscopy</td>
<td>CPT</td>
<td>45378</td>
<td><content ID="Procedure1"/>Diagnostic colonoscopy</td>
<td>09-06-2010 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>