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<section>
<templateId root="2.16.840.1.113883.10.20.22.2.22" assigningAuthorityName="CCDA Encounters Section" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.2.22" assigningAuthorityName="CCDA Encounters Section" />
<id root="6c628dae-578b-4e3a-b0d9-e82453d29c14" />
<code code="46240-8" displayName="History of encounters" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
<title>Encounters</title>
<text>
<table width="100%">
<thead>
<tr>
<th>Encounter</th>
<th>Provider</th>
<th>Location</th>
<th>Date</th>
<th>Diagnosis</th>
</tr>
</thead>
<tbody>
<tr ID="encounterDescriptionID0">
<td ID="encounterTypeDescriptionID0">Wellness Visit</td>
<td>David E Ford MD</td>
<td>
</td>
<td>09/18/2017</td>
<td><content ID="encounterDiagnosisID0">Jaw Asymmetry Maxillary</content>, <content ID="encounterDiagnosisID1">Anomaly of Dental Arch</content>, <content ID="encounterDiagnosisID2">Malocclusion Mesio-occlusion</content></td>
</tr>
</tbody> <!-- Some systems may include the CPT E&M code descriptions in the narrative -->
</table>
</text>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49" assigningAuthorityName="CCDA Encounter Activity" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.49" assigningAuthorityName="CCDA Encounter Activity" />
<id root="2.16.840.1.113883.3.140.1.1918489287.6.10.16" extension="449" assigningAuthorityName="Intergy Encounter ID" />
<id root="2.16.840.1.113883.3.140.1.1918489287.6.10.16.1" extension="271818" assigningAuthorityName="Intergy Encounter Number" />
<code code="AMB" displayName="ambulatory" codeSystem="2.16.840.1.113883.1.11.13955" codeSystemName="ActEncounterCode">
<originalText>
<reference value="#encounterTypeDescriptionID0"/><!-- This is the text the user saw and was the basis for the AMB coding -->
</originalText>
</code>
<text>
<reference value="#encounterDescriptionID0" />
</text>
<effectiveTime>
<low value="20170918093900-0400" />
<high value="20170918095100-0400" />
</effectiveTime>
<!-- Could include optional performer -->
<entryRelationship typeCode="COMP"> <!-- Encounter Diagnosis Act -->
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.80" assigningAuthorityName="CCDA Encounter Diagnosis" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.80" assigningAuthorityName="CCDA Encounter Diagnosis" />
<id root="2.16.840.1.113883.3.140.1.1918489287.6.10.7" extension="449" />
<code code="29308-4" displayName="ENCOUNTER DIAGNOSIS" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
<entryRelationship typeCode="SUBJ" inversionInd="false">
<observation classCode="OBS" moodCode="EVN" negationInd="false">
<templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" />
<id root="755efd22-a0d1-4504-9e6f-de4e173f91bc" />
<code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<translation code="75326-9" displayName="Problem" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
</code>
<statusCode code="completed" />
<effectiveTime>
<low value="20170918093900-0400" />
<high nullFlavor="NI"/> <!-- Better to omit high if problem is ongoing, but if you always include high use nullFlavor=NI -->
</effectiveTime>
<value code="235083001" displayName="Asymmetry of maxilla (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" xsi:type="CD">
<originalText>
<reference value="#encounterDiagnosisID0" />
</originalText>
<translation code="524.11" displayName="Jaw Asymmetry Maxillary" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD9CM" />
<translation code="M26.11" displayName="Jaw Asymmetry Maxillary" codeSystem="2.16.840.1.113883.6.3" codeSystemName="ICD10" />
<translation code="95980" displayName="Jaw Asymmetry Maxillary" codeSystem="2.16.840.1.113883.6.26" codeSystemName="MEDCIN" />
</value>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<observation classCode="OBS" moodCode="EVN" negationInd="false">
<templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" />
<id root="c351f35e-ad79-4519-aae2-153526171926" />
<code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<translation code="75326-9" displayName="Problem" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
</code>
<statusCode code="completed" />
<effectiveTime>
<low value="20170918093900-0400" />
<high nullFlavor="NI"/> <!-- Better to omit high if problem is ongoing, but if you always include high use nullFlavor=NI -->
</effectiveTime>
<value code="23997001" displayName="Anomaly of dental arch (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" xsi:type="CD">
<originalText>
<reference value="#encounterDiagnosisID1" />
</originalText>
<translation code="524.20" displayName="Anomaly of Dental Arch" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD9CM" />
<translation code="312141" displayName="Anomaly of Dental Arch" codeSystem="2.16.840.1.113883.6.26" codeSystemName="MEDCIN" />
</value>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<observation classCode="OBS" moodCode="EVN" negationInd="false">
<templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.4" assigningAuthorityName="CCDA Problem Observation" />
<id root="1dd3d744-6108-4284-823a-138c2568e446" />
<code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<translation code="75326-9" displayName="Problem" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
</code>
<statusCode code="completed" />
<effectiveTime>
<low value="20170918093900-0400" />
<high nullFlavor="NI"/> <!-- Better to omit high if problem is ongoing, but if you always include high use nullFlavor=NI -->
</effectiveTime>
<value code="12264001" displayName="Mesio-occlusion of teeth (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" xsi:type="CD">
<originalText>
<reference value="#encounterDiagnosisID2" />
</originalText>
<translation code="524.23" displayName="Malocclusion Mesio-occlusion" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD9CM" />
<translation code="M26.213" displayName="Malocclusion Mesio-occlusion" codeSystem="2.16.840.1.113883.6.3" codeSystemName="ICD10" />
<translation code="219237" displayName="Malocclusion Mesio-occlusion" codeSystem="2.16.840.1.113883.6.26" codeSystemName="MEDCIN" />
</value>
</observation>
</entryRelationship>
</act>
</entryRelationship>
<entryRelationship typeCode="REFR" inversionInd="false">
<act classCode="ACT" moodCode="EVN">
<code code="99408" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12" displayName="Alcohol and/or substance abuse structured screening and brief intervention services" />
</act>
</entryRelationship>
<entryRelationship typeCode="REFR" inversionInd="false">
<act classCode="ACT" moodCode="EVN">
<code code="99394" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12" displayName="Well Office Visit Established Patient Ages 12-17"/>
</act>
</entryRelationship>
<entryRelationship typeCode="REFR" inversionInd="false">
<act classCode="ACT" moodCode="EVN">
<code code="99213" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12" displayName="Office Visit, Established Patient Level 3"/>
</act>
</entryRelationship>
</encounter>
</entry>
</section>