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BlueButton.js helps developers navigate complex health data with ease.

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<?xml version="1.0" encoding="utf-8"?> <!-- The following sample document depicts a fictional characters health summary. Any resemblance to a real person is coincidental. --> <ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 ../../C-CDA%20rules/infrastructure/cda/CDA_SDTC.xsd" xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc"> <!-- ******************************************************** CDA Header ******************************************************** --> <realmCode code="US"/> <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/> <!-- US General Header Template --> <templateId root="2.16.840.1.113883.10.20.22.1.1"/> <!-- Continuity of Care Document (CCD) - Patient Health Summary; Conformant to C-CDA Implementation Guide "CDAR2_IG_IHE_CONSOL_DSTU_R1.1_2012JUL.pdf" (DSTU) July 2012CCD v1.0 Templates Root --> <templateId root="2.16.840.1.113883.10.20.22.1.2"/> <id root="db734647-fc99-424c-a864-7e3cda82e703"/> <code code="34133-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summarization of Episode Note"/> <title>Community Health and Hospitals: Health Summary</title> <effectiveTime value="20140416115524"/> <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>4329 McKinley Avenue</streetAddressLine> <city>Denver</city> <state>CO</state> <postalCode>80218</postalCode> <country>US</country> <!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 --> </addr> <telecom value="tel:(303)831-1316" use="MC"/> <!-- MC is "mobile contact" from HL7 AddressUse 2.16.840.1.113883.5.1119 --> <patient> <name use="L"> <given qualifier="BR">Joseph</given> <family qualifier="AD">Stevens</family> </name> <administrativeGenderCode code="M" displayName="Male" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender"/> <birthTime value="19390628120000"/> <maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatus"/> <religiousAffiliationCode code="1005" displayName="Anglican" codeSystem="2.16.840.1.113883.5.1076" codeSystemName="ReligiousAffiliation"/> <!-- CDC Race and Ethnicity code set contains the minimum race and ethnicity categories defined by OMB Standards for Race and Ethnicity --> <raceCode code="2131-1" displayName="Other Race" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race &amp; Ethnicity - CDC"/> <ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race &amp; Ethnicity - CDC"/> <guardian> <code code="FRND" displayName="friend" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 Role code"/> <addr use="HP"> <!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 --> <streetAddressLine>3771 Westfall Avenue</streetAddressLine> <city>Rochester</city> <state>MN</state> <postalCode>55904</postalCode> <country>US</country> <!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 --> </addr> <telecom value="tel:(507)208-3644" use="HP"/> <telecom value="email:SandraJLiverman@cuvox.de" use="WP"/> <guardianPerson> <name> <prefix>Ms.</prefix> <given>Sandra</given> <family>Liverman</family> </name> </guardianPerson> </guardian> <birthplace> <place> <addr> <city>Nacogdoches</city> <state>TX</state> <postalCode>75961</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="20140416115524"/> <assignedAuthor> <id extension="99999999" root="2.16.840.1.113883.4.6"/> <code code="200000000X" codeSystem="2.16.840.1.113883.6.101" displayName="Allopathic &amp; Osteopathic Physicians"/> <addr> <streetAddressLine>1002 Healthcare Drive </streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:555-555-1002"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> <suffix>MD</suffix> </name> </assignedPerson> </assignedAuthor> </author> <dataEnterer> <assignedEntity> <id root="2.16.840.1.113883.4.6" extension="999999943252"/> <code code="207Q00000X" codeSystem="2.16.840.1.113883.6.101" displayName="Allopathic &amp; Osteopathic Physicians"/> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:555-555-1002"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedEntity> </dataEnterer> <informant> <assignedEntity> <id extension="99999999" root="2.16.840.1.113883.4.6"/> <code code="200000000X" codeSystem="2.16.840.1.113883.6.101" displayName="Allopathic &amp; Osteopathic Physicians"/> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:555-555-1002"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedEntity> </informant> <informant> <relatedEntity classCode="PRS"> <!-- classCode PRS represents a person with personal relationship with the patient. --> <code code="SPS" displayName="SPOUSE" codeSystem="2.16.840.1.113883.1.11.19563" codeSystemName="Personal Relationship Role Type Value Set"/> <relatedPerson> <name> <given>Frank</given> <family>Jones</family> </name> </relatedPerson> </relatedEntity> </informant> <custodian> <assignedCustodian> <representedCustodianOrganization> <id extension="99999999" root="2.16.840.1.113883.4.6"/> <name>Community Health and Hospitals</name> <telecom value="tel: 555-555-1002" use="WP"/> <addr use="WP"> <streetAddressLine>1002 Healthcare Drive </streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> </representedCustodianOrganization> </assignedCustodian> </custodian> <informationRecipient> <intendedRecipient> <informationRecipient> <name> <given>Henry</given> <family>Seven</family> </name> </informationRecipient> <receivedOrganization> <name>Community Health and Hospitals</name> </receivedOrganization> </intendedRecipient> </informationRecipient> <legalAuthenticator> <time value="20130418090000+0500"/> <signatureCode code="S"/> <assignedEntity> <id extension="999999999" root="2.16.840.1.113883.4.6"/> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> <telecom use="WP" value="tel:555-555-1002"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedEntity> </legalAuthenticator> <authenticator> <time value="20140416115524"/> <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="20100305100000"/> <high value="20100615100000"/> </effectiveTime> <performer typeCode="PRF"> <functionCode code="PCP" displayName="Primary Care Physician" codeSystem="2.16.840.1.113883.5.88" codeSystemName="participationFunction"> <originalText>Primary Care Provider</originalText> </functionCode> <assignedEntity> <!-- Provider NPI "PseudoMD-1" --> <id extension="PseudoMD-1" root="2.16.840.1.113883.4.6"/> <code code="261QP2300X" displayName="Primary Care [Ambulatory Health Care Facilities\Clinic/Center]" codeSystemName="NUCC Provider Codes" codeSystem="2.16.840.1.113883.6.101"/> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> <telecom value="tel:+1-555-555-5000" use="HP"/> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> <suffix>MD</suffix> </name> </assignedPerson> <representedOrganization> <id root="2.16.840.1.113883.19.5.9999.1393"/> <name>Community Health and Hospitals</name> <telecom value="tel:+1-555-555-5000" use="HP"/> <addr> <streetAddressLine>1001 Village Avenue</streetAddressLine> <city>Portland</city> <state>OR</state> <postalCode>99123</postalCode> <country>US</country> </addr> </representedOrganization> </assignedEntity> </performer> </serviceEvent> </documentationOf> <!-- ******************************************************** CDA Body ******************************************************** --> <component> <structuredBody> <!-- ********************************* Allergies, Adverse Reactions, Alerts ****************************** --> <component> <section> <templateId root="2.16.840.1.113883.10.20.22.2.6.1"/> <code code="48765-2" displayName="Allergies, adverse reactions, alerts" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Allergies, Adverse Reactions &amp; Alerts</title> <text> <table> <thead> <tr> <th>Group Description</th> <th>Code System</th> <th>Code</th> <th>Code Description</th> <th>Severity</th> <th>Susceptibility</th> <th>Date and Time</th> <th>Status</th> </tr> </thead> <tbody> <tr> <td>Allergy to Eggs</td> <td>UNII</td> <td>291P45F896</td> <td><content ID="Allergy1"/>Eggs</td> <td><content ID="Severity1"/>Fatal</td> <td>Very susceptible</td> <td>05-05-2010 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"/>Severe</td> <td>Very susceptible</td> <td>05-05-2010 10:00:00</td> <td>Active</td> </tr> <tr> <td>Fosfomycin</td> <td>RxNorm</td> <td>808917</td> <td><content ID="Allergy3"/>Fosfomycin 33.3 MG/ML Oral Suspension</td> <td><content ID="Severity3"/>Moderate to severe</td> <td>Very susceptible</td> <td>05-05-2010 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="20100505100000"/> </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="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> <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="20100505100000"/> </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="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> <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="20100505100000"/> </effectiveTime> <entryRelationship typeCode="SUBJ" inversionInd="true"> <!--Allergy - Intolerance Observation --> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.7"/> <id root="4adc1020-7b14-11db-9fe1-0800200c9a66"/> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/> <statusCode code="completed"/> <effectiveTime> <low nullFlavor="UNK"/> </effectiveTime> <!-- The following XML tag, <value>, states whether patient is allergic to DRUG, FOOD or SUBSTANCE. In EMERGE db, patients have records with allergies to: (a) DRUG (in EMERGE db, encoded in RxNorm or NDF-RT) (b) FOOD (in EMERGE db 'Eggs', encoded in UNII) and CCDA impementation guide distinguishes between "allergy" amd "propensity to allergy". In EMERGE, all patients have "allergy". Depending on allergen, appropriate value must be selected from Table 117: Allergy/Adverse Event Type Value Set (See CCDA Implementation Guide, pg 311) (1) If EMERGE patient has allergy to DRUG (RxNorm or NDF-RT), then the code is: <value code="416098002" displayName="Drug allergy (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/> (2) If EMERGE patient has allergy to FOOD (e.g. Eggs, UNII), then the code is: <value code="414285001" displayName="Food allergy (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/> --> <value xsi:type="CD" code="416098002" displayName="Drug allergy (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"> <originalText> Fosfomycin + Fosfomycin 33.3 MG/ML Oral Suspension <reference value="#Allergy1"/> </originalText> </value> <participant typeCode="CSM"> <participantRole classCode="MANU"> <playingEntity classCode="MMAT"> <!-- This section displays the ACTUAL name of drug/ingredient/food to which person is allergic to. Please note that FOUR (4) different values sets for documenting Allergies: Brand Names, Clinical Drug Names, Medication Drug Class, and Ingredient name, encoded in RxNorm, RxNorm, NDF-RT and UNII respectively. --> <code code="808917" displayName="Fosfomycin 33.3 MG/ML Oral Suspension" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"> <originalText> Fosfomycin + Fosfomycin 33.3 MG/ML Oral Suspension <reference value="#Allergy3"/> </originalText> <!-- <translation> XML tag, if it exist should be placed HERE. In EMERGE db, Only alergy to "eggs" will contain <translation> xml code with ICD-9 codes system: <translation code="V15.03" codeSystem="2.16.840.1.113883.6.103" displayName="Allergy to Eggs" codeSystemName="ICD-9-CM"/> NOTE: <translation> code can also be used for other codes, such as LOCAL (e..g local hospital) codes. --> </code> </playingEntity> </participantRole> </participant> <entryRelationship typeCode="SUBJ" inversionInd="true"> <!-- ** Severity observation template ** --> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.8"/> <code code="SEV" displayName="Severity Observation" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/> <text> <reference value="#severity3"/> </text> <statusCode code="completed"/> <value xsi:type="CD" code="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> </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>05-05-2010 10:00:00</td> <td>Performed</td> </tr> <tr> <td/> <td>ICD-9-CM</td> <td>V70.0</td> <td>Routine general medical examination at a health care facility</td> <td/> <td/> </tr> <tr> <td>Encounter Outpatient</td> <td>CPT</td> <td>99213</td> <td><content ID="Encounter2"/>Office/outpatient visit, est</td> <td>06-15-2010 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="20100505100000"/> <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="20100505100000"/> </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="20100615100000"/> </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>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>Hypertension</td> <td>SNOMED-CT</td> <td>59621000</td> <td><content ID="Problem1"/>Essential hypertension</td> <td>05-05-2010 10:00:00</td> <td>Active</td> </tr> <tr> <td/> <td>ICD-10-CM</td> <td>I10</td> <td>Essential (primary) hypertension</td> <td/> <td/> </tr> <tr> <td/> <td>ICD-9-CM</td> <td>401.9</td> <td>Unspecified essential hypertension</td> <td/> <td/> </tr> <tr> <td>Heart Failure</td> <td>SNOMED-CT</td> <td>84114007</td> <td><content ID="Problem2"/>Heart failure</td> <td>06-13-2010 10:00:00</td> <td>Active</td> </tr> <tr> <td/> <td>ICD-10-CM</td> <td>I50.9</td> <td>Heart failure, unspecified</td> <td/> <td/> </tr> <tr> <td/> <td>ICD-9-CM</td> <td>428.9</td> <td>Heart failure, unspecified</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="20100505100000"/> </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="20100505100000"/> </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> <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="20100613100000"/> </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="20100613100000"/> </effectiveTime> <value xsi:type="CD" code="84114007" codeSystem="2.16.840.1.113883.6.96" displayName="Heart failure" codeSystemName="SNOMED-CT"> <translation code="I50.9" codeSystem="2.16.840.1.113883.6.90" displayName="Heart failure, unspecified" codeSystemName="ICD-10-CM"/> <translation code="428.9" codeSystem="2.16.840.1.113883.6.103" displayName="Heart failure, unspecified" codeSystemName="ICD-9-CM"/> </value> <entryRelationship typeCode="REFR"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.6"/> <code xsi:type="CE" code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/> <text> <reference value="#Problem2"/> </text> <statusCode code="completed"/> <value xsi:type="CD" code="55561003" displayName="Active" codeSystem="2.16.840.1.113883.6.96" codeSystemName=" SNOMED-CT"/> </observation> </entryRelationship> </observation> </entryRelationship> </act> </entry> </section> </component> <!-- ******************************************************** Procedures section ******************************************************** --> <component> <section> <!-- conforms to Procedures section with entries optional --> <templateId root="2.16.840.1.113883.10.20.22.2.7"/> <!-- Procedures section with entries required --> <templateId root="2.16.840.1.113883.10.20.22.2.7.1"/> <code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PROCEDURES"/> <title>Procedures</title> <text> <table> <thead> <tr> <th>Group Description</th> <th>Code System</th> <th>Code</th> <th>Code Description</th> <th>Date and Time</th> <th>Status</th> </tr> </thead> <tbody> <tr> <td>Ejection Fraction</td> <td>SNOMED-CT</td> <td>70822001</td> <td><content ID="Procedure1"/>Cardiac ejection fraction, function</td> <td>06-13-2010 10:00:00</td> <td>Performed</td> </tr> </tbody> </table> </text> <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="70822001" codeSystem="2.16.840.1.113883.6.96" displayName="Cardiac ejection fraction, function" codeSystemName="SNOMED-CT"> <originalText> Ejection Fraction + Cardiac ejection fraction, function <reference value="#Procedure1"/> </originalText> </code> <statusCode code="completed"/> <effectiveTime value="20100613100000"/> <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>14646-4</td> <td><content ID="Result1"/>HDLc SerPl-sCnc</td> <td>48</td> <td>mg/dL</td> <td>&gt;=40 mg/dL</td> <td>06-13-2010 10:00:00</td> <td>Completed</td> </tr> <tr> <td/> <td>CPT</td> <td>83701</td> <td>Lipoprotein bld, hr fraction</td> <td/> <td/> <td/> <td/> <td/> </tr> <tr> <td/> <td>SNOMED-CT</td> <td>28036006</td> <td>High density lipoprotein cholesterol measurement</td> <td/> <td/> <td/> <td/> <td/> </tr> <tr> <td>Low Density Lipoprotein (LDL)</td> <td>LOINC</td> <td>2089-1</td> <td><content ID="Result2"/>LDLc SerPl-mCnc</td> <td>105.6</td> <td>mg/dL</td> <td>&lt;130 mg/dL (calc)</td> <td>06-13-2010 10:00:00</td> <td>Completed</td> </tr> <tr> <td/> <td>CPT</td> <td>83721</td> <td>Assay of blood lipoprotein</td> <td/> <td/> <td/> <td/> <td/> </tr> <tr> <td/> <td>SNOMED-CT</td> <td>113079009</td> <td>Low density lipoprotein cholesterol measurement</td> <td/> <td/> <td/> <td/> <td/> </tr> <tr> <td>Total Cholesterol</td> <td>LOINC</td> <td>2093-3</td> <td><content ID="Result3"/>Cholest SerPl-mCnc</td> <td>179</td> <td>mg/dL</td> <td>125-200 mg/dL</td> <td>06-13-2010 10:00:00</td> <td>Completed</td> </tr>