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"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!--
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="2.16.840.1.113883.10.20.22.1.6"/>
<id extension="999021" root="2.16.840.1.113883.19"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="28570-0" displayName="Procedure Note"/>
<title>Good Health Clinic Procedure 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>
<participant typeCode="IND">
<functionCode code="PCP"/>
<associatedEntity classCode="PROV">
<associatedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<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="PPRF">
<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="207RG0100X" displayName="Gastroenterologist" 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>
<componentOf>
<encompassingEncounter>
<id extension="9937012" root="2.16.840.1.113883.19"/>
<code codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4" code="99213" displayName="Evaluation and Management"/>
<effectiveTime>
<low value="20050329"/>
<high value="20050329"/>
</effectiveTime>
<location>
<healthCareFacility>
<id root="2.16.540.1.113883.19.2"/>
</healthCareFacility>
</location>
</encompassingEncounter>
</componentOf>
<!--
***********************************
***********************************
-->
<!-- ********************************************************
CDA Body
******************************************************** -->
<component>
<structuredBody>
<!--
********************************************************
Allergies, Adverse Reactions, Alerts
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
<!-- Alerts section template -->
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1"/>
<title>Allergies, Adverse Reactions, Alerts</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Substance</th>
<th>Reaction</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Penicillin</td>
<td>
<content ID="reaction1">Hives</content>
</td>
<td>Active</td>
</tr>
<tr>
<td>Aspirin</td>
<td>
<content ID="reaction2">Wheezing</content>
</td>
<td>Active</td>
</tr>
<tr>
<td>Codeine</td>
<td>
<content ID="reaction3">Nausea</content>
</td>
<td>Active</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<!-- ** Allergy problem act ** -->
<id root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts"/>
<statusCode code="active"/>
<effectiveTime value="20090909">
<low value="20090902"/>
<high value="20100103"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- allergy observation template -->
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
<code code="416098002" displayName="drug allergy" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="20110215"/>
</effectiveTime>
<value xsi:type="CD" code="282100009" displayName="Adverse reaction to substance" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<originalText>
<reference value="#reaction1"/>
</originalText>
</value>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code code="314422" displayName="ALLERGENIC EXTRACT, PENICILLIN" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
<originalText>
<reference value="#reaction1"/>
</originalText>
</code>
<name>Penicillin</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.28"/>
<!-- Alert status observation template -->
<code code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="55561003" codeSystem="2.16.840.1.113883.6.96" displayName="Active"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="MFST">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.9"/>
<!-- Reaction observation template -->
<id root="4adc1020-7b14-11db-9fe1-0800200c9a64"/>
<code nullFlavor="NA"/>
<text>
<reference value="#reaction1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20090711"/>
</effectiveTime>
<value xsi:type="CD" code="247472004" codeSystem="2.16.840.1.113883.6.96" displayName="Hives"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<!-- ** Severity observation template ** -->
<code code="SEV" displayName="Severity Observation" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
<text>
<reference value="#severity1"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="371924009" displayName="Moderate to severe" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<!-- ** Allergy problem act ** -->
<id root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts"/>
<statusCode code="active"/>
<effectiveTime value="20090909">
<low value="20090902"/>
<high value="20100103"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- allergy observation template -->
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
<code code="416098002" displayName="drug allergy" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="20110215"/>
</effectiveTime>
<value xsi:type="CD" code="282100009" displayName="Adverse reaction to substance" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<originalText>
<reference value="#reaction2"/>
</originalText>
</value>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code code="1191" displayName="ASPIRIN" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
<originalText>
<reference value="#reaction2"/>
</originalText>
</code>
<name>Aspirin</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.28"/>
<!-- Alert status observation template -->
<code code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="55561003" codeSystem="2.16.840.1.113883.6.96" displayName="Active"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="MFST">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.9"/>
<!-- Reaction observation template -->
<id root="4adc1020-7b14-11db-9fe1-0800200c9a64"/>
<code nullFlavor="NA"/>
<text>
<reference value="#reaction2"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20090711"/>
</effectiveTime>
<value xsi:type="CD" code="56018004" codeSystem="2.16.840.1.113883.6.96" displayName="Wheezing"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<!-- ** Severity observation template ** -->
<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"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<!-- ** Allergy problem act ** -->
<id root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts"/>
<statusCode code="active"/>
<effectiveTime value="20090909">
<low value="20090902"/>
<high value="20100103"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- allergy observation template -->
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
<code code="416098002" displayName="drug allergy" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="20110215"/>
</effectiveTime>
<value xsi:type="CD" code="282100009" displayName="Adverse reaction to substance" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<originalText>
<reference value="#reaction2"/>
</originalText>
</value>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code code="2670" displayName="Codeine" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
<originalText>
<reference value="#reaction3"/>
</originalText>
</code>
<name>Aspirin</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.28"/>
<!-- Alert status observation template -->
<code code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="55561003" codeSystem="2.16.840.1.113883.6.96" displayName="Active"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="MFST">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.9"/>
<!-- Reaction observation template -->
<id root="4adc1020-7b14-11db-9fe1-0800200c9a64"/>
<code nullFlavor="NA"/>
<text>
<reference value="#reaction3"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20090711"/>
</effectiveTime>
<value xsi:type="CD" code="73879007" codeSystem="2.16.840.1.113883.6.96" displayName="Nausea"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<!-- ** Severity observation template ** -->
<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"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!--
********************************************************
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="Med4">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="#Med4"/>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>
<!-- ************************************
ASSESSMENT
************************************ -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.8"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="51848-0" displayName="ASSESSMENT"/>
<title>ASSESSMENT</title>
<text>
<list listType="ordered">
<item>Recurrent GI bleed of unknown etiology; hypotension perhaps secondary to this but as likely secondary to polypharmacy.</item>
<item>Acute on chronic anemia secondary to #1.</item>
<item>Azotemia, acute renal failure with volume loss secondary to #1.</item>
<item>Hyperkalemia secondary to #3 and on ACE and K+ supplement.</item>
<item>Other chronic diagnoses as noted above, currently stable.</item>
</list>
</text>
</section>
</component>
<!-- ************************************
CHIEF COMPLAINT / REASON FOR VISIT
************************************ -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.13"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="46239-0" displayName="REASON FOR VISIT + CHIEF COMPLAINT"/>
<title>REASON FOR VISIT/CHIEF COMPLAINT</title>
<text>
<paragraph>Dark stools.</paragraph>
</text>
</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>
<!--
********************************************************
FAMILY HISTORY
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.15"/>
<!-- ******** Family history section template ******** -->
<code code="10157-6" codeSystem="2.16.840.1.113883.6.1"/>
<title>Family history</title>
<text>
<paragraph>Father (deceased)</paragraph>
<table border="1" width="100%">
<thead>
<tr>
<th>Diagnosis</th>
<th>Age At Onset</th>
</tr>
</thead>
<tbody>
<tr>
<td>Myocardial Infarction (cause of death)</td>
<td>57</td>
</tr>
<tr>
<td>Diabetes</td>
<td>40</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<organizer moodCode="EVN" classCode="CLUSTER">
<templateId root="2.16.840.1.113883.10.20.22.4.45"/>
<!-- ******** Family history organizer template ******** -->
<statusCode code="completed"/>
<subject>
<relatedSubject classCode="PRS">
<code code="FTH" displayName="Father" codeSystemName="HL7 FamilyMember" codeSystem="2.16.840.1.113883.5.111">
<translation code="9947008" displayName="Biological father" codeSystemName="SNOMED" codeSystem="2.16.840.1.113883.6.96"/>
</code>
<subject>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>
<birthTime value="1912"/>
</subject>
</relatedSubject>
</subject>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.46"/>
<!-- Family History Observation template -->
<id root="d42ebf70-5c89-11db-b0de-0800200c9a66"/>
<code code="55561003" displayName="Active" codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96"/>
<statusCode code="completed"/>
<effectiveTime nullFlavor="UNK"/>
<value xsi:type="CD" code="22298006" codeSystem="2.16.840.1.113883.6.96" displayName="Myocardial infarction"/>
<entryRelationship typeCode="CAUS">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.47"/>
<!-- ******** Family history death observation template ******** -->
<id root="6898fae0-5c8a-11db-b0de-0800200c9a66"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="419099009" codeSystem="2.16.840.1.113883.6.96" displayName="Dead"/>
</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>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.46"/>
<!-- ******** Family history observation template ******** -->
<id root="5bfe3ec0-5c8b-11db-b0de-0800200c9a66"/>
<code code="7087005" displayName="Intermittent" codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96"/>
<statusCode code="completed"/>
<effectiveTime value="1994"/>
<value xsi:type="CD" code="46635009" codeSystem="2.16.840.1.113883.6.96" displayName="Diabetes mellitus type 1"/>
<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="40" unit="a"/>
</observation>
</entryRelationship>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
<!-- ************************************
HISTORY OF PAST ILLNESS
************************************ -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.20"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="11348-0" displayName="HISTORY OF PAST ILLNESS"/>
<title>PAST MEDICAL HISTORY</title>
<text>
<paragraph>See History of Present Illness.</paragraph>
</text>
</section>
</component>
<!--
********************************************************
HISTORY OF PRESENT ILLNESS
********************************************************
-->
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.4"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="10164-2" displayName="HISTORY OF PRESENT ILLNESS"/>
<title>HISTORY OF PRESENT ILLNESS</title>
<text>
<paragraph>This patient was only recently discharged for a recurrent GI bleed as described below.</paragraph>
<paragraph>He presented to the ER today c/o a dark stool yesterday but a normal brown stool today. On exam he was hypotensive in the 80?s resolved after .... .... .... </paragraph>
<paragraph>Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes normal. H. pylori antibody pending. Admission hematocrit 16%, discharge hematocrit 29%. WBC 7300, platelet count 256,000. Urinalysis normal. Urine culture: No growth. INR 1.1, PTT 40.</paragraph>
<paragraph>He was transfused with 6 units of packed red blood cells with .... .... ....</paragraph>
<paragraph>GI evaluation 12 September: Colonoscopy showed single red clot in .... .... ....</paragraph>
</text>
</section>
</component>
<!-- ************************************
MEDICAL (GENERAL) HISTORY
************************************ -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.39"/>
<code code="11329-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MEDICAL (GENERAL) HISTORY"/>
<title>MEDICAL (GENERAL) HISTORY</title>
<text>
<list listType="ordered">
<item>Patient has had recent issue with acne that does not seem to be related to any particular cause.</item>
<item>Previous concerns of oral cancer was actually irritated gums as a result of mild food allergy.</item>
<item>Patient had recent weight gain due to sedentary lifestyle and new job.</item>
</list>
</text>
</section>
</component>
<!--
********************************************************
MEDICATIONS
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF MEDICATION USE"/>
<title>MEDICATIONS</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Medication</th>
<th>Directions</th>
<th>Start Date</th>
<th>Status</th>
<th>Indications</th>
<th>Fill Instructions</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<content ID="Med1">Proventil 0.09 MG/ACTUAT inhalant solution</content>
</td>
<td>2 puffs QID PRN wheezing</td>
<td>2011-03-01</td>
<td>Active</td>
<td>Bronchitis (32398004 SNOMED CT)</td>
<td>Generic Substitition Allowed</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<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"/> 0.09 MG/ACTUAT inhalant solution, 2 puffs QID PRN wheezing
</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="6" unit="h"/>
</effectiveTime>
<routeCode code="C38216" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="RESPIRATORY (INHALATION)"/>
<doseQuantity value="1"/>
<rateQuantity value="90" unit="ml/min"/>
<maxDoseQuantity nullFlavor="UNK">
<numerator nullFlavor="UNK"/>
<denominator nullFlavor="UNK"/>
</maxDoseQuantity>
<administrationUnitCode code="C42944" displayName="INHALANT" 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="329498" codeSystem="2.16.840.1.113883.6.88" displayName="Albuterol 0.09 MG/ACTUAT inhalant solution">
<translation code="573621" displayName="Proventil 0.09 MG/ACTUAT inhalant solution" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization/>
</manufacturedProduct>
</consumable>
<performer>
<assignedEntity>
<id nullFlavor="NI"/>
<addr nullFlavor="UNK"/>
<telecom nullFlavor="UNK"/>
<representedOrganization>
<id root="2.16.840.1.113883.19.5"/>
<name>Good Health Clinic</name>
<telecom nullFlavor="UNK"/>
<addr nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.24"/>
<code code="412307009" displayName="drug vehicle" codeSystem="2.16.840.1.113883.6.96"/>
<playingEntity classCode="MMAT">
<code code="5955009" displayName="Diethylene Glycol" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<name>Diethylene Glycol</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="RSON">
<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="32398004" displayName="Bronchitis" codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<supply classCode="SPLY" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.22.4.17"/>
<id nullFlavor="NI"/>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20020101"/>
<high nullFlavor="UNK"/>
</effectiveTime>
<repeatNumber value="1"/>
<quantity value="75"/>
<author>
<time nullFlavor="UNK"/>
<assignedAuthor>
<id/>
<addr nullFlavor="UNK"/>
<telecom nullFlavor="UNK"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Robert</given>
<family>Michaels</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<act classCode="ACT" moodCode="INT">
<templateId root="2.16.840.1.113883.10.20.22.4.20"/>
<!-- ** Instructions Template ** -->
<code code="409073007" codeSystem="2.16.840.1.113883.6.96" displayName="instruction"/>
<text>label in spanish</text>
<statusCode code="completed"/>
</act>
</entryRelationship>
</supply>
</entryRelationship>
<entryRelationship typeCode="REFR">
<supply classCode="SPLY" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.18"/>
<!-- ** Medication Dispense Template ** -->
<id root="1.2.3.4.56789.1" extension="cb734647-fc99-424c-a864-7e3cda82e704"/>
<statusCode code="completed"/>
<effectiveTime value="20020101"/>
<repeatNumber value="1"/>
<quantity value="75"/>
<performer>
<time nullFlavor="UNK"/>
<assignedEntity>
<id/>
<addr>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
<telecom nullFlavor="UNK"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Robert</given>
<family>Michaels</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.19.5"/>
<name>Good Health Clinic</name>
<telecom nullFlavor="UNK"/>
<addr nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
</supply>
</entryRelationship>
<precondition typeCode="PRCN">
<templateId root="2.16.840.1.113883.10.20.22.4.25"/>
<criterion>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<value xsi:type="CE" code="56018004" codeSystem="2.16.840.1.113883.6.96" displayName="Wheezing"/>
</criterion>
</precondition>
</substanceAdministration>
</entry>
</section>
</component>
<!-- ************************************
PHYSICAL EXAMINATION
************************************ -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.2.10"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="29545-1" displayName="PHYSICAL FINDINGS"/>
<title>PHYSICAL EXAMINATION</title>
<text>
<list listType="ordered">
<item>HEENT: All normal to examination.</item>
<item>Heart: RRR, no murmur.</item>
<item>THORAX & LUNGS: Clear without rhonchi or wheeze.</item>
<item>ABDOMEN: No distension, tenderness, or guarding, obese, pos bowel sounds.</item>
<item>BACK: Normal to inspection and palpation, without tenderness; no presacral edema.</item>
<item>EXTREMITIES: Doughy edema bilaterally, chronic stasis changes, no asymmetrical swelling.</item>
</list>
</text>
</section>
</component>
<!--
********************************************************
PLAN