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<!-- This is meant to represent multiple implants during the same procedure and where one of the procedures has an unknown UDI. -->
<!-- This is not necessarily an ideal modeling and other changes to transition away from procedure act may be in future -->
<!-- That said, this is designed for compliance with current C-CDA 1.1 & 2.1 (and MU rules) -->
<!-- Note: This is current state and only representative of the UDI unknown. An example of multiple implants which includes UDI unknown will be release. -->
<templateId root="2.16.840.1.113883."/>
<templateId root="2.16.840.1.113883." extension="2014-06-09"/>
<code code="46264-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medical Equipment"/>
<th>Device Type</th> <!-- This is the generic name of the device. -->
<th>Procedure Site</th>
<th>Implant Date</th> <!-- separated out implant date -->
<th>Provider Name and Organization</th>
<td ID="implantDevice1">Cardiac pacemaker</td>
<td ID="procedureCodeTextReference1">Insertion of intracardiac pacemaker</td>
<td ID="procedureSiteCodeReference1">Structure of upper chest wall</td>
<td/> <!-- Laterality not appropriate for this device. -->
<td>Winston, Harry</td>
<!-- An example where the UDI is unknown or unavailable. In this scenario,
the patient asserts that a pacemaker was inserted 5 years ago. -->
<procedure classCode="PROC" moodCode="EVN">
<templateId root="2.16.840.1.113883."/>
<templateId root="2.16.840.1.113883." extension="2014-06-09"/>
<!-- This a different procedure at the same facility, so the extension is different while the root is the same -->
<id extension="1122334455" root="1.2.840.114350.1.13.5552."/>
<code code="25267002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED" displayName="Insertion of intracardiac pacemaker">
<reference value="#procedureCodeTextReference1"/>
<!-- Procedure is completed, even though the implant is still active -->
<statusCode code="completed"/>
<!-- Placed Date -->
<low value="2012"/>
<targetSiteCode code="699646004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Structure of upper chest wall">
<reference value="#procedureSiteCodeReference1"/>
<performer typeCode="PRF">
<id extension="2222222222" root="2.16.840.1.113883.4.6" />
<streetAddressLine>123 Any Street</streetAddressLine>
<streetAddressLine>Suite 101</streetAddressLine>
<telecom value="tel:+1-(555)555-1234" />
<!-- The informant is identified as the patient. -->
<id extension="12345" root="1.2.840.114350.1.13.5552." />
<!-- the informant is the patient -->
<code code="ONESELF" displayName="Self" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 Role code" />
<addr use="HP">
<streetAddressLine>222 Home Street</streetAddressLine>
<telecom value="tel:(555)555-2004" use="HP" />
<participant typeCode="DEV">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883."/>
<id root="2.16.840.1.113883.3.3719" nullFlavor="NI" /> <!-- There is no UDI information available -->
<code nullFlavor="OTH"> <!-- Vendor doesn't code specific device. -->
<reference value="#implantDevice1"/>
<id root="2.16.840.1.113883.3.3719"/> <!-- The FDA is the issuing agency as a default. -->