bluebutton
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BlueButton.js helps developers navigate complex health data with ease.
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text/xml
<!--
Title: US_Realm_Header_Template
Original Filename: US_Realm_Header_Template.xml
Version: 1.0
Revision History:
01/31/2011 bam created
07/29/2011 RWM modified
-->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 http://xreg2.nist.gov:8080/hitspValidation/schema/cdar2c32/infrastructure/cda/C32_CDA.xsd"
xmlns="urn:hl7-org:v3"
xmlns:mif="urn:hl7-org:v3/mif">
<!--
********************************************************
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"/>
<!-- *** Note: The next templateId, code and title will differ depending on what type of document is being sent. *** -->
<!-- conforms to the document specific requirements -->
<templateId root="2.16.840.1.113883.10.20.22.1.7"/>
<id extension="999021" root="2.16.840.1.113883.19"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="11504-8" displayName="Surgical Operation Note"/>
<title>Good Health Clinic Operative Note</title>
<effectiveTime value="20050329171504+0500"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<setId extension="111199021" root="2.16.840.1.113883.19"/>
<versionNumber value="1"/>
<recordTarget>
<patientRole>
<id extension="12345" root="2.16.840.1.113883.19"/>
<!-- Fake ID using HL7 example OID. -->
<id extension="111-00-1234" 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>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:(781)555-1212" use="HP"/>
<!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<patient>
<name use="L">
<!-- L is "Legal" from HL7 EntityNameUse 2.16.840.1.113883.5.45 -->
<prefix>Mr.</prefix>
<given>Adam</given>
<given qualifier="CL">Frankie</given>
<!-- CL is "Call me" from HL7 EntityNamePartQualifier 2.16.840.1.113883.5.43 -->
<family>Everyman</family>
</name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>
<birthTime value="19541125"/>
<maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatusCode"/>
<religiousAffiliationCode code="1013" displayName="Christian (non-Catholic, non-specific)" codeSystemName="HL7 Religious Affiliation " codeSystem="2.16.840.1.113883.1.11.19185"/>
<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="GRFTH" displayName="Grandfather" 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>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:(781)555-1212" use="HP"/>
<guardianPerson>
<name>
<given>Ralph</given>
<family>Relative</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
</place>
</birthplace>
<languageCommunication>
<languageCode code="fr-CN"/>
<modeCode code="RWR" displayName="Recieve Written" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/>
<preferenceInd value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id root="2.16.840.1.113883.19"/>
<name>Good Health Clinic</name>
<telecom use="WP" value="tel:(781)555-1212"/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time value="20050329224411+0500"/>
<assignedAuthor>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<addr>
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom use="WP" value="tel:(555)555-1003"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id root="2.16.840.1.113883.19.5" extension="43252"/>
<addr>
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom use="WP" value="tel:(555)555-1003"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<informant>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<addr>
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom value="tel:(555)555-1003"/>
<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>Rose</given>
<family>Everyman</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="2.16.840.1.113883.19.5"/>
<name>Good Health Clinic</name>
<telecom value="tel:(555)555-1212" use="WP"/>
<addr use="WP">
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</informationRecipient>
<receivedOrganization>
<name>Good Health Clinic</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<time value="20050329224411+0500"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19"/>
<addr>
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom use="WP" value="tel:(555)555-1003"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<authenticator>
<time value="20050329224411+0500"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19"/>
<addr>
<streetAddressLine>21 North Ave.</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom use="WP" value="tel:(555)555-1003"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<documentationOf typeCode="DOC">
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="20100601"/>
<high value="20100915"/>
</effectiveTime>
<performer typeCode="PRF">
<functionCode code="PP" displayName="Primary Care Provider" codeSystem="2.16.840.1.113883.12.443" codeSystemName="Provider Role">
<originalText>Primary Care Provider</originalText>
</functionCode>
<time>
<low value="20020716"/>
<high value="20070915"/>
</time>
<assignedEntity>
<id extension="PseudoMD-1" root="2.16.840.1.113883.19"/>
<code code="200000000X" displayName="Allopathic and Osteopathic Physicians" codeSystemName="Provider Codes" codeSystem="2.16.840.1.113883.6.101"/>
<addr/>
<telecom value="tel:+1-301-975-3251" use="HP"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Pseudo</given>
<family>Physician-1</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.3.72.5"/>
<name>NIST HL7 Test Laboratory</name>
<telecom/>
<addr/>
</representedOrganization>
</assignedEntity>
</performer>
<performer typeCode="PRF">
<functionCode code="PP" displayName="Primary Care Provider" codeSystem="2.16.840.1.113883.12.443" codeSystemName="Provider Role">
<originalText>Primary Care Provider</originalText>
</functionCode>
<time>
<low value="20020716"/>
<high value="20070915"/>
</time>
<assignedEntity>
<id extension="PseudoMD-3" root="2.16.840.1.113883.19"/>
<code code="200000000X" displayName="Allopathic and Osteopathic Physicians" codeSystemName="Provider Codes" codeSystem="2.16.840.1.113883.6.101"/>
<addr/>
<telecom value="tel:+1-301-975-3251" use="HP"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Pseudo</given>
<family>Physician-3</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.19.123"/>
<name>HL7 Test Laboratory</name>
<telecom/>
<addr/>
</representedOrganization>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<authorization typeCode="AUTH">
<consent classCode="CONS" moodCode="EVN">
<id extension="99370125" root="2.16.840.1.113883.19"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="CONSP-X" displayName="Consent for Surgical Procedure"/>
<statusCode code="completed"/>
</consent>
</authorization>
<!--
***********************************
***********************************
-->
<!-- ********************************************************
CDA Body
******************************************************** -->
<component>
<structuredBody>
<!--
********************************************************
ANESTHESIA
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.25"/>
<code code="59774-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE ANESTHESIA"/>
<title>Procedure Anesthesia</title>
<text>
<content ID="Med1">Conscious sedation with propofol 200 mg IV </content>
</text>
<entry>
<procedure classCode="PROC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<!-- ***** Procedure Activity Procedure Template ***** -->
<id root="d68b7e32-7810-4f5b-9cc2-acd54b0fd85d"/>
<code code="274025005" codeSystem="2.16.840.1.113883.6.96" displayName="Colonic polypectomy">
<originalText>
<reference value="#Proc1"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20110215"/>
<methodCode nullFlavor="UNK"/>
<specimen typeCode="SPC">
<specimenRole classCode="SPEC">
<id root="c2ee9ee9-ae31-4628-a919-fec1cbb58683"/>
<specimenPlayingEntity>
<code code="309226005" codeSystem="2.16.840.1.113883.6.96" displayName="colonic polyp sample"/>
</specimenPlayingEntity>
</specimenRole>
</specimen>
<performer>
<assignedEntity>
<id root="c2ee9ee9-ae31-4628-a919-fec1cbb58687"/>
<addr>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="(555)555-555-1234"/>
<representedOrganization>
<id root="c2ee9ee9-ae31-4628-a919-fec1cbb58686"/>
<name>Good Health Clinic</name>
<telecom use="WP" value="(555)555-555-1234"/>
<addr>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
<participant typeCode="LOC">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.37"/>
<!-- Product instance template -->
<id root="eb936010-7b17-11db-9fe1-0800200c9a68"/>
<playingDevice>
<code code="90412006" codeSystem="2.16.840.1.113883.6.96" displayName="Colonoscope"/>
</playingDevice>
<scopingEntity>
<id root="eb936010-7b17-11db-9fe1-0800200c9b65"/>
</scopingEntity>
</participantRole>
</participant>
</procedure>
</entry>
<entry>
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<!-- ** MEDICATION ACTIVITY -->
<id root="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/>
<text>
<reference value="#Med1"/>Propofol 20mg/mL injection emulsion 50mL vial
</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20110301"/>
<high value="20120301"/>
</effectiveTime>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
<period value="1" unit="h"/>
</effectiveTime>
<routeCode code="C38276" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="INTRAVENOUS"/>
<doseQuantity value="1"/>
<rateQuantity value="2" unit="ml/min"/>
<maxDoseQuantity nullFlavor="UNK">
<numerator nullFlavor="UNK"/>
<denominator nullFlavor="UNK"/>
</maxDoseQuantity>
<administrationUnitCode code="C38276" displayName="INTRAVENOUS" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus"/>
<consumable>
<manufacturedProduct>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<id/>
<manufacturedMaterial>
<code code="153475" codeSystem="2.16.840.1.113883.6.88" displayName="Propofol 20 MG/ML Injectable Suspension">
</code>
</manufacturedMaterial>
<manufacturerOrganization/>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<!--
********************************************************
COMPLICATIONS
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.37"/>
<code code="55109-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Complications"/>
<title>Complications</title>
<text>Asthmatic symptoms while under general anesthesia.</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<!-- Problem observation template -->
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code code="409586006" codeSystem="2.16.840.1.113883.6.96" displayName="Complaint"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="199803"/>
</effectiveTime>
<value xsi:type="CD" code="233604007" codeSystem="2.16.840.1.113883.6.96" displayName="Pneumonia"/>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<!-- Problem status observation template -->
<templateId root="2.16.840.1.113883.10.20.22.4.6"/>
<code code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="55561003" codeSystem="2.16.840.1.113883.6.96" displayName="Active" codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.31"/>
<!-- Age observation template -->
<code code="397659008" codeSystem="2.16.840.1.113883.6.96" displayName="Age"/>
<statusCode code="completed"/>
<value xsi:type="PQ" value="57" unit="a"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.5"/>
<!-- Health status observation template -->
<code code="11323-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Health status"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="413322009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Resolved"/>
</observation>
</entryRelationship>
</observation>
</entry>
</section>
</component>
<!--
********************************************************
OPERATIVE NOTE FLUIDS
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.7.12"/>
<code code="10216-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="SURGICAL OPERATION NOTE FLUIDS"/>
<title>Operative Note Fluids</title>
<text>250 ML Ringers Lactate</text>
</section>
</component>
<!--
********************************************************
OPERATIVE NOTE SURGICAL PROCEDURE
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.7.14"/>
<code code="10223-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="SURGICAL OPERATION NOTE SURGICAL PROCEDURE"/>
<title>Surgical Procedure</title>
<text>Laparoscopic Appendectomy</text>
</section>
</component>
<!--
********************************************************
PLAN OF CARE
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.10"/>
<!-- **** Plan of Care section template **** -->
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Treatment plan"/>
<title>Plan of Care</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Planned Activity</th>
<th>Planned Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>Colonoscopy</td>
<td>April 21, 2000</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="RQO">
<templateId root="2.16.840.1.113883.10.20.22.4.44"/>
<!-- Plan of Care Activity Observation template -->
<id root="9a6d1bac-17d3-4195-89a4-1121bc809b4a"/>
<code code="310634005" codeSystem="2.16.840.1.113883.6.96" displayName="Colonoscopy"/>
<statusCode code="new"/>
<effectiveTime>
<center value="20000421"/>
</effectiveTime>
</observation>
</entry>
<entry>
<act moodCode="RQO" classCode="ACT">
<templateId root="2.16.840.1.113883.10.20.22.4.39"/>
<!-- **** Plan of Care Activity Act template **** -->
<id root="9a6d1bac-17d3-4195-89a4-1121bc809a5c"/>
<code code="310634005" codeSystem="2.16.840.1.113883.6.96" displayName="Colonoscopy"/>
<statusCode code="new"/>
<effectiveTime>
<center value="20000421"/>
</effectiveTime>
</act>
</entry>
<entry>
<encounter moodCode="INT" classCode="ENC">
<templateId root="2.16.840.1.113883.10.20.22.4.40"/>
<!-- **** Plan of Care Activity Encounter template **** -->
<id root="9a6d1bac-17d3-4195-89a4-1121bc809b4d"/>
</encounter>
</entry>
<entry>
<procedure moodCode="RQO" classCode="PROC">
<templateId root="2.16.840.1.113883.10.20.22.4.41"/>
<!-- ** Plan of Care Activity Procedure template ** -->
<id root="9a6d1bac-17d3-4195-89c4-1121bc809b5a"/>
<code code="310634005" codeSystem="2.16.840.1.113883.6.96" displayName="Colonoscopy"/>
<statusCode code="new"/>
<effectiveTime>
<center value="20000421"/>
</effectiveTime>
</procedure>
</entry>
</section>
</component>
<!--
********************************************************
PLANNED PROCEDURE
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.30"/>
<!-- ******** Planned Procedure Section template ******** -->
<code code="59772-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Planned Procedure"/>
<title>Planned Procedure</title>
<text>Colonoscopy</text>
<entry>
<procedure moodCode="RQO" classCode="PROC">
<templateId root="2.16.840.1.113883.10.20.22.4.41"/>
<!-- ** Plan of Care Activity Procedure template ** -->
<id root="9a6d1bac-17d3-4195-89c4-1121bc809b5a"/>
<code code="274025005" codeSystem="2.16.840.1.113883.6.96" displayName="Colonic polypectomy"/>
<statusCode code="new"/>
<effectiveTime>
<center value="20000421"/>
</effectiveTime>
</procedure>
</entry>
</section>
</component>
<!--
********************************************************
POSTOPERATIVE DIAGNOSIS
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.35"/>
<code code="10218-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="POSTOPERATIVE DIAGNOSIS"/>
<title>Postoperative Diagnosis</title>
<text>Appendicitis with periappendiceal abscess</text>
</section>
</component>
<!--
********************************************************
PREOPERATIVE DIAGNOSIS
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.34"/>
<code code="10219-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="SURGICAL OPERATION NOTE PREOPERATIVE DX"/>
<title>Preoperative Diagnosis</title>
<text>Appendicitis</text>
</section>
</component>
<!--
********************************************************
PROCEDURE DESCRIPTION
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.27"/>
<code code="29554-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE DESCRIPTION"/>
<title>Procedure Description</title>
<text>The patient was brought to the operating room, placed in the supine position, and general anesthesia was induced. A detailed technical narrative of a laparoscopic appendectomy from initial incision to placement of any dressings follows.</text>
</section>
</component>
<!-- ***********************************
PROCEDURE DISPOSITION
*********************************** -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.18.2.12"/>
<code code="59775-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE DISPOSITION"/>
<title>Procedure Disposition</title>
<text>The patient was taken to the Endoscopy Recovery Unit in stable
condition.</text>
</section>
</component>
<!--
********************************************************
PROCEDURE ESTIMATED BLOOD LOSS
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.18.2.9"/>
<code code="59770-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE ESTIMATED BLOOD LOSS"/>
<title>Procedure Estimated Blood Loss</title>
<text>Minimal</text>
</section>
</component>
<!--
********************************************************
PROCEDURE FINDINGS
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.28"/>
<code code="59776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE FINDINGS"/>
<title>Procedure Findings</title>
<text>A 6 mm sessile polyp was found in the ascending colon and removed by
snare, no cautery. Bleeding was controlled. Moderate diverticulosis
and hemorrhoids were incidentally noted.</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<!-- Problem observation template -->
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code code="409586006" codeSystem="2.16.840.1.113883.6.96" displayName="Complaint"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="199803"/>
</effectiveTime>
<value xsi:type="CD" code="233604007" codeSystem="2.16.840.1.113883.6.96" displayName="Pneumonia"/>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<!-- Problem status observation template -->
<templateId root="2.16.840.1.113883.10.20.22.4.6"/>
<code code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="55561003" codeSystem="2.16.840.1.113883.6.96" displayName="Active" codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.31"/>
<!-- Age observation template -->
<code code="397659008" codeSystem="2.16.840.1.113883.6.96" displayName="Age"/>
<statusCode code="completed"/>
<value xsi:type="PQ" value="57" unit="a"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.5"/>
<!-- Health status observation template -->
<code code="11323-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Health status"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="413322009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Resolved"/>
</observation>
</entryRelationship>
</observation>
</entry>
</section>
</component>
<!--
********************************************************
PROCEDURE IMPLANTS
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.40"/>
<code code="59771-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE IMPLANTS"/>
<title>Procedure Implants</title>
<text>No implants were placed.</text>
</section>
</component>
<!--
********************************************************
PROCEDURE INDICATIONS
***********************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.29"/>
<code code="59768-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE INDICATIONS"/>
<title>Procedure Indications</title>
<text>The procedure is performed for screening in a low risk individual.
</text>
<entry>
<observation classCode="COND" 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"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="414992000" displayName="Painless rectal bleeding" codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entry>
</section>
</component>
<!--
********************************************************
PROCEDURE SPECIMENS TAKEN
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.31"/>
<code code="59773-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE SPECIMENS TAKEN"/>
<title>Procedure Specimens Taken</title>
<text>Ascending colon polyp</text>
</section>
</component>
<!--
********************************************************
SURGICAL DRAINS
***********************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.7.13"/>
<code code="11537-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="SURGICAL DRAINS"/>
<title>Surgical Drains</title>
<text>Penrose drain placed</text>
</section>
</component>
<!--
**Required Sections
Anesthesia
Complications
Post Operative Diagnosis
Pre Operative Diagnosis
Procedure Estimated Blood Loss
Procedure Findings
Procedure Specimens Taken
Procedure Description
**Optional Sections
Procedure Implants
Operative Note Fluids
Operative Note Surgical Procedure
Plan of Care
Planned Procedure
Procedure Disposition
Procedure Indications
Surgical Drains
* wherever referenced, intent is that either
"Assessment and Plan" is present or both "Assessment" and "Plan of Care".
Only these combinations should be used.
*** wherever referenced, intent is that either "Chief Complaint/Reason for Visit" is present
or "Chief Complaint", and/or "Reason for Visit".
Only these combinations should be used.
-->
</structuredBody>
</component>
</ClinicalDocument>