<?xml version="1.0" encoding="UTF-8"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!--
This sample shows a document which replaces a prior clinical document (e.g. CCD)
The reason for this example is to demonstrate the use of relatedDocument@typeCode="RPLC"
No clinical data is contained in any of the sections
Look to lines 364 for the relevant illustrative example xml
-->
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xmlns:voc="urn:hl7-org:v3/voc" xmlns:sdtc="urn:hl7-org:sdtc">
<realmCode code="US"/>
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<!-- US Realm Header ID-->
<templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
<!-- CCD template ID-->
<templateId root="2.16.840.1.113883.10.20.22.1.2" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
<!-- Globally unique identifier for the document -->
<id extension="TT662" root="2.16.840.1.113883.19.5.99999.1"/>
<code code="34133-9" displayName="Summary of episode note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<!-- Title of this document -->
<title>CCD Demonstrating Replacement of Prior CCD</title>
<effectiveTime value="201507221800-0500" />
<confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality"/>
<languageCode code="en-US"/>
<setId root="004bb033-b948-4f4c-b5bf-a8dbd7d8dd40"/>
<!-- Version of this document -->
<versionNumber value="2"/>
<recordTarget>
<patientRole>
<id extension="414122222" root="2.16.840.1.113883.4.1"/>
<!-- Example 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>1357 Amber Dr</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:+1(555)-777-1234" use="MC"/>
<telecom value="tel:+1(555)-723-1544" use="HP"/>
<!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<patient>
<name use="L">
<given>Richard</given>
<family>Maur</family>
<suffix>jr</suffix>
</name>
<administrativeGenderCode code="M" displayName="Male" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender"/>
<!-- Date of birth need only be precise to the day -->
<birthTime value="19800801"/>
<maritalStatusCode nullFlavor="NI"/>
<religiousAffiliationCode code="1013" displayName="Christian (non-Catholic, non-specific)" codeSystem="2.16.840.1.113883.5.1076" codeSystemName="HL7 Religious Affiliation"/>
<raceCode nullFlavor="UNK"/>
<sdtc:raceCode nullFlavor="UNK"/>
<ethnicGroupCode nullFlavor="UNK"/>
<languageCommunication>
<languageCode code="en"/>
<modeCode code="ESP" displayName="Expressed spoken"
codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/>
<preferenceInd value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<name>Community Health and Hospitals</name>
<telecom use="WP" value="tel:+1(555)-555-5000"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<!-- The author represents the person who provides the content in the document -->
<author>
<time value="20150722"/>
<assignedAuthor>
<id extension="111111" root="2.16.840.1.113883.4.6"/>
<code code="281P00000X" codeSystem="2.16.840.1.113883.6.101"
displayName="Hospitals; Chronic Disease Hospital"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<prefix>Dr</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<!-- The dataEnterer transferred the content created by the author into the document -->
<dataEnterer>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="999999943252"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<given>Mary</given>
<family>McDonald</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<!-- The informant represents any sources of information for document content -->
<informant>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(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>Caroline</given>
<family>Maur</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<!-- The custodian represents the organization charged with maintaining the original source document -->
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="99998899" root="2.16.840.1.113883.4.6"/>
<name>Community Health and Hospitals</name>
<telecom use="WP" value="tel:+1(555)-555-5000"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<!-- The informationRecipient represents the intended recipient of the document -->
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<prefix>Dr</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</informationRecipient>
<receivedOrganization>
<name>Community Health and Hospitals</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<!-- The legalAuthenticator represents the individual who is responsible for the document -->
<legalAuthenticator>
<time value="20150722"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="999998899" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<prefix>Dr</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<!-- The authenticator represents the individual attesting to the accuracy of information in the document-->
<authenticator>
<time value="20150722"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="999998899" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<prefix>Dr</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<!-- The participant represents supporting entities -->
<participant typeCode="IND">
<!-- patient's grandfather -->
<associatedEntity classCode="PRS">
<code code="GPARNT" displayName="grandparent" codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Dr</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:+1(555)-723-1544" use="HP"/>
<associatedPerson>
<name>
<prefix>Mr.</prefix>
<given>Issac</given>
<family>Maur</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<!-- Note: Entities playing multiple roles are recorded in multiple participants -->
<participant typeCode="IND">
<!-- patient's spouse -->
<associatedEntity classCode="PRS">
<code code="SPS" displayName="SPOUSE" codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Dr</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:+1(555)-723-1544" use="HP"/>
<associatedPerson>
<name>
<prefix>Ms</prefix>
<given>Caroline</given>
<family>Maur</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<documentationOf>
<serviceEvent classCode="PCPR">
<code code="423123007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"
displayName="Burn caused by fire"/>
<effectiveTime>
<low value="2015072218-0500"/>
<high value="2015072223-0500"/>
</effectiveTime>
<!-- since there are two Care Team members we need two performer elements. -db -->
<!-- Note: example of Care Team here:
https://github.com/gecole/HL7-Task-Force-Examples/blob/master/CareTeamToC170.314b2Ambulatory.xml
db -->
<performer typeCode="PRF">
<functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88" codeSystemName="ParticipationFunction" displayName="primary care physician">
<originalText>Primary Care Provider</originalText>
</functionCode>
<assignedEntity>
<id extension="5555555555" root="2.16.840.1.113883.4.6"/>
<code code="207QA0505X" displayName="Allopathic & Osteopathic Physicians; Family Medicine, Adult Medicine" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<prefix qualifier="TITLE">Dr</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
<representedOrganization>
<id extension="99998899" root="2.16.840.1.113883.4.6"/>
<name>Community Health and Hospitals</name>
<telecom use="WP" value="tel:+1(555)-555-5000"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
<performer typeCode="PRF">
<!-- we do not have a function code for this person since recording as RN for now -->
<time>
<low nullFlavor="UNK"/>
</time>
<assignedEntity>
<!-- this provider has an id, but it is not an NPI -->
<id extension="91138" root="1.3.6.1.4.1.22812.4.99930.4"/>
<!-- the provider is a Registered Nurse - may not be so -->
<!-- note: we don't know what Mary is from the test data
but since not specified, RN should not be an issue -db -->
<code codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC Health Care Provider Taxonomy" code="163W00000X" displayName="Nursing Service Providers; Registered Nurse"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<given>Mary</given>
<family>McDonald</family>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<!-- ******************************************************** START OF RELATED DOCUMENT EXAMPLE ******************************************************** -->
<!-- This is the illustrative part of this example
This replaces a previous continuity of care (CCD) document -->
<relatedDocument typeCode="RPLC">
<parentDocument>
<id extension="TT661" root="2.16.840.1.113883.19.5.99999.1"/>
<code code="34133-9" displayName="Summary of episode note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<!-- While not required, there is a benefit of using <setId> and <versionNumber> as a secondary key on documents.
If the flow from a document source system or repository to a destination system is infrequent or not able to guarantee
sequential transmission of document revisions. The setId and versionNumber pair are actually better for detecting which
new document revises a previous older version of that document. -->
<!-- If setId and versionNumber are not available or applicable, they may be omitted -->
<setId root="004bb033-b948-4f4c-b5bf-a8dbd7d8dd40"/>
<versionNumber value="1"/>
</parentDocument>
</relatedDocument>
<!-- ******************************************************** END OF RELATED DOCUMENT EXAMPLE ******************************************************** -->
<!-- added componentOf to represent encounter and to represent length of stay better as per SME suggestion -db -->
<componentOf>
<encompassingEncounter>
<id extension="9937012" root="2.16.840.1.113883.19"/>
<effectiveTime>
<!-- represents length of time spent in hospital -db -->
<low value="2015072218-0500"/>
<high value="2015072223-0500"/>
</effectiveTime>
</encompassingEncounter>
</componentOf>
<!-- ******************************************************** CDA Body ******************************************************** -->
<component>
<structuredBody>
<!-- ***************** ALLERGIES *************** -->
<!-- No known allergies -->
<component>
<section>
<!-- *** Allergies and Intolerances Section (entries required) (V3) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.6.1" extension="2015-08-01"/>
<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" codeSystemName="LOINC"/>
<title>ALLERGIES AND ADVERSE REACTIONS</title>
<text>No Known Drug Allergies</text>
<!-- replaced Allergy Problem Act (R1.1) with
Allergy Concern Act (V3) to meet R2.1 validation requirements -DB-->
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<!-- ** Allergy Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.30" extension="2015-08-01"/>
<!--Critical Change-->
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id root="36e3e930-7b15-11db-9fe1-0831200c9a66"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
<!-- The statusCode represents the need to continue tracking the allergy -->
<!-- This is of ongoing concern to the provider -->
<statusCode code="active"/>
<effectiveTime>
<!-- The low value represents when the allergy was first recorded in the patient's chart -->
<low value="20150722"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<!-- using negationInd="true" to signify that there are is NO food allergy (disorder) allergy -db -->
<observation classCode="OBS" moodCode="EVN" negationInd="true">
<!-- ** Allergy observation (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.7" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="4adc1020-7b16-11db-9fe1-0832200c9a66"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime nullFlavor="NA"/>
<!-- using Drug allergy (disorder) along with negationInd instead -db -->
<value xsi:type="CD" code="416098002"
displayName="Allergy to drug (finding)"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT">
</value>
<!-- In C-CDA R2 the participant is required. The SNOMED code ="105590001" displayName="Substance" could be used in the participant-->
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code nullFlavor="NA"/>
</playingEntity>
</participantRole>
</participant>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!-- ******************************* MEDICATIONS ***************************** -->
<!-- No known medications -->
<component>
<section>
<!-- *** Medications Section (entries required) (V2) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09"/>
<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>No known Medications</text>
<entry>
<!-- Act.actionNegationInd -->
<substanceAdministration moodCode="EVN" classCode="SBADM" negationInd="true">
<!-- ** Medication Activity (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="cdbd33f0-6cde-11db-9fe1-0833200c9a66"/>
<statusCode code="active"/>
<effectiveTime nullFlavor="NA"/>
<doseQuantity nullFlavor="NA"/>
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Medication information ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code nullFlavor="OTH" codeSystem="2.16.840.1.113883.6.88">
<translation code="410942007" displayName="drug or medication"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<!-- ******************************* MEDICATIONS ADMINISTERED *****************************
NO known medications
-->
<component>
<section>
<!-- The section contains the medications taken by the patient prior to
and
at the time of admission to the facility. -->
<!-- Admission Medications Section (entries optional) (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.2.44" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.44"/>
<code code="42346-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MEDICATIONS ON ADMISSION"/>
<title>Admission Medications</title>
<text>No Medications Administered</text>
<entry>
<!-- Act.actionNegationInd -->
<substanceAdministration moodCode="EVN" classCode="SBADM" negationInd="true">
<!-- ** Medication Activity (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="cdbd33f0-6cde-11db-9fe1-0834200c9a66"/>
<statusCode code="active"/>
<effectiveTime nullFlavor="NA"/>
<doseQuantity nullFlavor="NA"/>
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Medication information ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code nullFlavor="OTH" codeSystem="2.16.840.1.113883.6.88">
<translation code="410942007" displayName="drug or medication"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<!-- Added Discharge Medications Section (entries required) (V3) No known medications -->
<component>
<section nullFlavor="NI">
<!-- Discharge Medications Section (entries required) (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.2.11.1" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.2.11.1" />
<code code="10183-2" displayName="Hospital Discharge Medications"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC">
<translation code="75311-1" displayName="Discharge Medications"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
</code>
<title>Discharge Medications</title>
<text>No Information</text>
</section>
</component>
<!-- ***************** PROBLEM LIST *********************** -->
<!-- No known problems -->
<component>
<section>
<!-- *** Problem Section (entries required) (V3) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROBLEM LIST"/>
<title>PROBLEMS</title>
<text ID="Concern_1">
<content ID="problems1">No known <content ID="problemType1">health problems</content>
</content>
</text>
<entry typeCode="DRIV">
<!-- Problem Concern Act -->
<act classCode="ACT" moodCode="EVN">
<!-- ** Problem Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<id root="36e3e930-7b14-11db-9fe1-0835200c9a66"/>
<!-- SDWG supports 48765-2 or CONC in the code element -->
<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
<text>
<reference value="#Concern_1"/>
</text>
<statusCode code="active"/>
<!-- The concern is not active, in terms of there being an active condition to be managed.-->
<effectiveTime>
<low value="20150722"/>
<!-- Time at which THIS “concern” began being tracked.-->
</effectiveTime>
<!-- status is active so high is not applicable. If high is present it should have nullFlavor of NA-->
<entryRelationship typeCode="SUBJ">
<!-- Model of Meaning for No Problems -->
<!-- The use of negationInd corresponds with the newer Observation.ValueNegationInd -->
<!-- The negationInd = true negates the value element. -->
<!-- problem observation template -->
<observation classCode="OBS" moodCode="EVN" negationInd="true">
<!-- ** Problem observation (V3)** -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="4adc1021-7b14-11db-9fe1-0836200c9a67"/>
<!-- updated for R2.1 -db -->
<code code="55607006" displayName="Problem" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96">
<!-- This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem"/>
</code>
<text>
<reference value="#problems1"/>
</text>
<statusCode code="completed"/>
<!-- The time when this was biologically relevant ie True for the patient. -->
<!-- As a minimum time interval over which this is true, populate the effectiveTime/low with the current time. -->
<!-- It would be equally valid to have a longer range of time over which this statement was represented as being true. -->
<!-- As a maximum, you would never indicate an effectiveTime/high that was greater than the current point in time. -->
<effectiveTime>
<low value="20150722"/>
</effectiveTime>
<!-- This idea assumes that the value element could come from the Problem value set, or-->
<!-- when negationInd was true, is could also come from the ProblemType value set (and code would be ASSERTION). -->
<value xsi:type="CD" code="55607006"
displayName="Problem"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT">
<originalText>
<reference value="#problems1"/>
</originalText>
</value>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!-- ************************ ENCOUNTERS *********************** -->
<!-- No known encounters -->
<component>
<section nullFlavor="NI">
<!-- *** Encounters section (entries required) (V3) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.22.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.22.1"/>
<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
<title>ENCOUNTERS</title>
<text>No Encounters</text>
</section>
</component>
<!-- ************** PROCEDURES ***************** -->
<!-- edited as per test doc - all of this data is directly relevant -db -->
<!-- (NO) UDI section based off of https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Implanted_Devices.xml
-db -->
<!-- ************** PROCEDURES and UDI ***************** -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.7" extension="2014-06-09" />
<!-- Procedures section template -->
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURES" />
<title>Procedures</title>
<text>No Information</text>
</section>
</component>
<!-- ************** No UDI ***************** -->
<component>
<section>
<!-- Medical equipment section -->
<templateId root="2.16.840.1.113883.10.20.22.2.23" extension="2014-06-09"/>
<code code="46264-8" codeSystem="2.16.840.1.113883.6.1" />
<title>MEDICAL EQUIPMENT</title>
<!-- Alternative text: Patient has no history of procedures with implantable devices'-->
<!-- Alternative text: Patient has no implanted devices'-->
<text>
<paragraph ID="Proc2">Patient has no history of implantable devices</paragraph>
</text>
<entry>
<procedure classCode="PROC" moodCode="EVN" negationInd="true">
<!-- Procedure Activity Procedure V2-->
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="d5b614bd-01ce-410d-8728-e1fd01dcc72a" />
<code code="71388002" codeSystem="2.16.840.1.113883.6.96"
displayName="Procedure"/>
<text>
<reference value="#Proc2"/>
</text>
<statusCode code="completed" />
<effectiveTime nullFlavor="NA" />
<participant typeCode="DEV">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.37"/>
<!-- UDI is 'not applicable' since no procedure -->
<id nullFlavor="NA" root="2.16.840.1.113883.3.3719"/>
<playingDevice>
<code code="40388003" codeSystem="2.16.840.1.113883.6.96"
displayName="Implant"/>
</playingDevice>
<scopingEntity>
<id root="2.16.840.1.113883.3.3719"/>
</scopingEntity>
</participantRole>
</participant>
</procedure>
</entry>
</section>
</component>
<!-- ******************** IMMUNIZATIONS ********************* -->
<!-- No immunizations -->
<component>
<section>
<!-- *** Immunizations Section (entries required) (V2) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.2.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.2.1"/>
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of immunizations"/>
<title>IMMUNIZATIONS</title>
<text>No immunization history</text>
<entry typeCode="DRIV">
<!-- using negationInd="true" to signify that there are no known immunizations -->
<substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="true">
<!-- ** Immunization Activity (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.52" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.52"/>
<id root="de10790f-1496-4729-8fe6-f1b87b6219f7"/>
<statusCode code="active"/>
<effectiveTime nullFlavor="NA"/>
<routeCode nullFlavor="NA"/>
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Immunization Medication Information (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.54" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.54"/>
<manufacturedMaterial>
<!-- there is no generic vaccine code and no known recommended way to do this -
leaving generic flu for now just as an example. Not sure if it makes more sense to apply a nullFlavor? -db -->
<code nullFlavor="OTH">
<!-- Optional original text -->
<originalText>Vaccination</originalText>
<translation code="71181003" displayName="vaccine"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
</code>
<!-- NA since there is no immunization data -db -->
<lotNumberText nullFlavor="NA"/>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<!-- ************* VITAL SIGNS *************** -->
<!-- No vital signs -db -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.4.1" extension="2015-08-01" />
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital signs" />
<title>VITAL SIGNS</title>
<text>No Recorded Vital Signs</text>
</section>
</component>
<!-- ******************* SOCIAL HISTORY ********************* -->
<!-- edited as per test doc - most of this data is directly relevant -db -->
<component>
<section>
<!-- ** Social History Section (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.2.17" extension="2015-08-01"/>
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social History"/>
<title>SOCIAL HISTORY</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Social History Observation</th>
<th>Description</th>
<th>Dates Observed</th>
</tr>
</thead>
<tbody>
<tr>
<td>Current Smoking Status</td>
<td>Current every day</td>
<td>July 22, 2015</td>
</tr>
<tr>
<td ID="BirthSexInfo">Birth Sex</td>
<td>Male</td>
<td>July 22, 2015</td>
</tr>
</tbody>
</table>
</text>
<!-- Current Smoking Status - July 22, 2015 -db -->
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Smoking Status - Meaningful Use (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.78" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.78"/>
<id extension="123456789" root="2.16.840.1.113883.19"/>
<!-- code SHALL be 72166-2 for Smoking Status - Meaningful Use (V2) -db -->
<code code="72166-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Tobacco smoking status NHIS"/>
<statusCode code="completed"/>
<!-- The effectiveTime reflects when the current smoking status was observed. -->
<effectiveTime value="20150722"/>
<!-- The value represents the patient's smoking status currently observed. -->
<!-- Consol Smoking Status Meaningful Use2 SHALL contain exactly one [1..1] value (CONF:1098-14810), which SHALL be selected from ValueSet Current Smoking Status 2.16.840.1.113883.11.20.9.38 STATIC 2014-09-01 (CONF:1098-14817) -db -->
<value xsi:type="CD" code="449868002" displayName="Smokes tobacco daily" codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entry>
<!-- removed Social history observation (V3) entry for "Alcoholic drinks per day" -db -->
<!-- Add Birth Sex entry -->
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.200" extension="2016-06-01"/>
<code code="76689-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Sex Assigned At Birth"/>
<text>
<reference value="#BirthSexInfo"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20150722"/>
<value code="M" codeSystem="2.16.840.1.113883.5.1" xsi:type="CD" displayName="Male"/>
</observation>
</entry>
</section>
</component>
<!-- ******************** RESULTS ************************ -->
<!-- edited as per test doc - all of this data is directly relevant -db -->
<component>
<section nullFlavor="NI">
<!-- Results Section (entries required) (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01"/>
<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>Laboratory Test: None needed. Laboratory Values/Results: No Lab Result data</text>
</section>
</component>
<!-- removed component Advance Directives as not required by test data -db -->
<!-- removed component Family History as not required by test data -db -->
<!-- removed component Functional Status as not required by test data (specific to 170.315(b)(1), (b)(2)) -db -->
<!-- removed component Medical Equipment as not required by test data -db -->
<!-- removed component Payers as not required by test data -db -->
<!-- added Assessment -db -->
<!--
********************************************************
Assessment
********************************************************
-->
<!-- edited as per test doc - all of this data is directly relevant -db -->
<component>
<section nullFlavor="NI">
<!-- Assessment Section -db -->
<!-- There is no R2.1 (or 2.0) version of Assessment Section, using R1.1 templateId only -db -->
<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="Evaluation note"/>
<title>ASSESSMENTS</title>
<text>No assessment information</text>
</section>
</component>
<!-- ******************* PLAN OF TREATMENT ********************** -->
<!-- edited as per test doc - all of this data is directly relevant -db -->
<component>
<section>
<!-- **** Plan of Treatment Section (V2) **** -->
<templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.10"/>
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of care note"/>
<title>TREATMENT PLAN</title>
<text>
No Plan of treatment
</text>
</section>
</component>
<!-- Added Goals - original version from C-CDA_R2_Care_Plan.xml from R2.0 IG package.
There are no duplicated template Ids with extensions -
as there is only one version in existence for each section and entry listed -db -->
<!--
********************************************************
Goals
********************************************************
-->
<!-- edited as per test doc -db -->
<component>
<section nullFlavor="NI">
<!-- Goals Section -->
<templateId root="2.16.840.1.113883.10.20.22.2.60"/>
<code code="61146-7" displayName="Goals" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Goals Section</title>
<text>No goal information</text>
</section>
</component>
<!-- added Health Concerns -db -->
<!-- Note: There is no R1.1 version of Health Concerns Section or Health Concern Act -
so there is only one templateId per section (they're NEW) -db -->
<!-- updated as per ETF https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Known_Health_Concerns.xml
-db -->
<!--
********************************************************
Health Concerns
********************************************************
-->
<!-- edited as per test doc -db -->
<component>
<!-- This example records assertion of no concerns -->
<section>
<!-- Health Concerns Section (V2) (V1 was added as a NEW template in R2.0, V2 was updated in R2.1) -db -->
<templateId root="2.16.840.1.113883.10.20.22.2.58" extension="2015-08-01"/>
<code code="75310-3" displayName="Health Concerns Document"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Health Concerns</title>
<!--Including ID at text element is allowed -->
<text ID="HealthConcern_1">No Known Health Concerns on 07/22/2015</text>
<entry typeCode="COMP">
<!-- negationInd=true indicates no known health concerns at the stated time-->
<act classCode="ACT" moodCode="EVN" negationInd="true">
<!-- There is no V1 version of this template -db -->
<templateId root="2.16.840.1.113883.10.20.22.4.132" extension="2015-08-01"/>
<id root="4eab0e52-dd7d-4285-99eb-72d32ddb195d"/>
<code code="75310-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Health Concern"/>
<text>
<reference value="#HealthConcern_1"/>
</text>
<!-- This Health Concern has a statusCode of concern because assertion is ongoing -->
<statusCode code="active"/>
<!-- The effective time is the date that the Health Concern started being followed -
this does not necessarily correlate to the onset date of the contained health issues-->
<effectiveTime value="20150722"/>
<!-- Time at which THIS “concern” began being tracked.-->
</act>
</entry>
</section>
</component>
<!--
************************************
HOSPITAL DISCHARGE INSTRUCTIONS
************************************
-->
<component>
<section>
<!-- Hospital Discharge Instructions Section - no R2.1 version for this template -db -->
<templateId
root="2.16.840.1.113883.10.20.22.2.41"/>
<code
code="8653-8"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Hospital Discharge instructions"/>
<title>HOSPITAL DISCHARGE INSTRUCTIONS</title>
<!-- Unstructured text field -->
<text>
<list
listType="ordered">
<item>Appointments: Schedule an appointment with Dr Seven after 1 week. Follow up with Outpatient facility.</item>
<item>In case of fever, take Tylenol as advised in plan of treatment.</item>
</list>
</text>
</section>
</component>
<!-- removed Reason for Referral -db -->
<!-- added Mental Status Section (V2) (used to be NEW in R2.0) 2.16.840.1.113883.10.20.22.2.56 as required by VDT inp test data -db -->
<!--
********************************************************
Mental Status Section
********************************************************
-->
<component>
<section nullFlavor="NI">
<!-- note: the IG lists the wrong templateId in its example of this section, lists ...2,14 instead of 2.56 -db -->
<!-- There is no R1.1 version of this template -db -->
<templateId root="2.16.840.1.113883.10.20.22.2.56" extension="2015-08-01" />
<!-- Mental Status Section -->
<code code="10190-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Mental status Narrative" />
<title>MENTAL STATUS</title>
<text>No information</text>
</section>
</component>
<!-- added component Functional Status as required by test data -db -->
<!--
********************************************************
FUNCTIONAL STATUS
********************************************************
-->
<component>
<section nullFlavor="NI">
<!-- Functional Status Section (V2)-->
<templateId root="2.16.840.1.113883.10.20.22.2.14" extension="2014-06-09"/>
<!-- Functional Status Section -->
<templateId root="2.16.840.1.113883.10.20.22.2.14"/>
<code code="47420-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Functional status assessment note"/>
<title>FUNCTIONAL STATUS</title>
<text>No information</text>
</section>
</component>
<!-- added Interventions -->
<!--
********************************************************
INTERVENTIONS
********************************************************
-->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.21.2.3" extension="2015-08-01" />
<code code="62387-6" displayName="Interventions Provided" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
<title>Interventions Section</title>
<text>No intervention information</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>