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Marla_CCD.xml
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Marla_CCD.xml
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<?xml version="1.0" encoding="UTF-8"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
<id root="1.1.1.1.1.1.1.1.1" extension="Test CCDA"/>
<code code="34133-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summarization of Episode Note"/>
<title>Community Health and Hospitals: Health Summary(Example)</title>
<effectiveTime value="20140701000000-0000"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<recordTarget>
<patientRole>
<id root="2.16.840.1.113883.4.1" extension="123-456-7890"/>
<addr use="HP"><streetAddressLine>1221 Middle Street</streetAddressLine><city>Atlanta</city><state>GA</state><postalCode>30308</postalCode></addr>
<telecom value="tel:404-341-5645" use="HP"/>
<patient>
<name><given>Marla</given><family>Dixon</family><suffix>M</suffix></name>
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
<birthTime value="19680304"/>
</patient>
</patientRole>
</recordTarget>
<author>
<time value="20140101000000+0500"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="111111"/>
<addr><streetAddressLine>1054 Atlantic dr</streetAddressLine><city>Atlanta</city><state>GA</state><postalCode>30318</postalCode><country>US</country></addr>
<telecom value="tel:555-555-1002" use="WP"/>
<assignedPerson>
<name><prefix>Dr</prefix><given>Henry</given><family>Seven</family></name>
</assignedPerson>
</assignedAuthor>
</author>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="2.16.840.1.113883.4.6" extension="99999999"/>
<name>Good Health Clinic</name>
<telecom value="tel:123-456-1023" use="WP"/>
<addr><streetAddressLine>1234 Atlantic dr</streetAddressLine><city>Atlanta</city><state>GA</state><postalCode>30318</postalCode><country>US</country></addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.6"/>
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1"/>
<title>ALLERGIES, ADVERSE REACTIONS, ALERTS</title>
<text>null</text>
</section>
</component>
<component>
<section>
<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>
<table border="1" width="100%">
<thead>
<tr>
<th>Visit Date</th>
<th>Chief Complaint</th>
<th>Diagnosis</th>
<th>ICD-9</th>
<th>Height</th>
<th>Weight</th>
<th>Pulse</th>
<th>Respiration</th>
<th>Blood Pressure</th>
<th>Notes</th>
</tr>
</thead>
<tbody>
<tr>
<td><content ID="Encounter1"/>20110423</td>
<td>Annual Physical Exam</td>
<td>Essential Hypertension</td>
<td>401.9</td>
<td>68 inches</td>
<td>185</td>
<td>78</td>
<td>32</td>
<td>160/95</td>
<td>This is an example of Note containing. Use this space for a note.</td>
</tr>
<tr>
<td><content ID="Encounter2"/>20110424</td>
<td>bbbbbbbbb</td>
<td>Essential Hypertension</td>
<td>401.9</td>
<td>68 inches</td>
<td>185</td>
<td>78</td>
<td>32</td>
<td>160/96</td>
<td>This is an example of Note containing,. Use this space for a note.</td>
</tr>
<tr>
<td><content ID="Encounter3"/>20110425</td>
<td>cccccccccc</td>
<td>Essential Hypertension</td>
<td>401.9</td>
<td>69 inches</td>
<td>185</td>
<td>78</td>
<td>32</td>
<td>160/97</td>
<td>This is an, exampl,e of Note containing,. Use t,is, space for a note.</td>
</tr>
</tbody>
</table></text>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<id root="a535d642-5053-483c-80f9-548681117eff"/>
<code code="99241" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT" codeSystemVersion="4" displayName="Annual Physical Exam">
<originalText>Checkup Examination<reference value="#Encounter1"/></originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20110423"/>
</encounter>
</entry>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<id root="2636c8cf-a7a7-4f56-b476-12656fb47596"/>
<code code="99241" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT" codeSystemVersion="4" displayName="Annual Physical Exam">
<originalText>Checkup Examination<reference value="#Encounter2"/></originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20110424"/>
</encounter>
</entry>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<id root="f332bac9-bead-4d9f-933e-c0f6018d2e70"/>
<code code="99241" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT" codeSystemVersion="4" displayName="Annual Physical Exam">
<originalText>Checkup Examination<reference value="#Encounter3"/></originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20110425"/>
</encounter>
</entry>
</section>
</component>
<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>Visit Date</th>
<th>Drug</th>
<th>NDC</th>
<th>Type</th>
<th>Quantity</th>
<th>Refills</th>
<th>Sig</th>
</tr>
</thead>
<tbody>
<tr>
<td><content ID="Medication1"/>20110423</td>
<td>Lasix 40 mg</td>
<td>0039-0060-13 </td>
<td>Tablet</td>
<td>90</td>
<td>4</td>
<td>1 tablet at bedtime</td>
</tr>
<tr>
<td><content ID="Medication2"/>20110423</td>
<td>Propranolol Extended Release 60 mg</td>
<td>0378-6160-05 </td>
<td>Tablet</td>
<td>90</td>
<td>4</td>
<td>1 tablet each morning</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"/>
<id root="f7290fc4-e6c0-4e38-88c3-ba22b79085cd"/>
<text><reference value="#Medication1"/>Lasix 40 mg, 1 tablet at bedtime</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20050501"/>
<high value="20140701"/>
</effectiveTime>
<routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="oral"/>
<doseQuantity value="1"/>
<administrationUnitCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="0039-0060-13 "/>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="Tablet" codeSystem="2.16.840.1.113883.6.88" codeSystemName="NDC" displayName="Lasix 40 mg">
<originalText><reference value="#medication1"/></originalText>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="51da2996-5126-4fbb-b7f6-2b685f612c5c"/>
<text><reference value="#Medication2"/>Propranolol Extended Release 60 mg, 1 tablet each morning</text>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20050501"/>
</effectiveTime>
<routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="oral"/>
<doseQuantity value="2"/>
<administrationUnitCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="0378-6160-05 "/>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="Tablet" codeSystem="2.16.840.1.113883.6.88" codeSystemName="NDC" displayName="Propranolol Extended Release 60 mg">
<originalText><reference value="#medication2"/></originalText>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<component>
<section>
<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><content ID="problems"/>
<list listType="ordered">
<item><content ID="problem1">Diabetes Mellitus</content></item>
<item><content ID="problem2">Essential Hyptertension</content></item>
<item><content ID="problem3">Simple chronic bronchitis</content></item>
<item><content ID="problem4">Coronary artery disease</content></item>
</list>
</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
<id root="af3018a3-86e4-468a-8c9c-574de94dcf98"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
<statusCode code="active"/>
<effectiveTime>
<low value="20050501"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="4941d206-4381-4592-a216-85c3124330c3"/>
<code code="409586006" codeSystem="2.16.840.1.113883.6.96" displayName="Complaint"/>
<text><reference value="#problem1"/></text>
<statusCode code="completed"/>
<value xsi:type="CD" code="987654321" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Diabetes Mellitus"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
<id root="e5f58f87-242b-4e6c-a7f6-06a86ccdbc25"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
<statusCode code="active"/>
<effectiveTime>
<low value="20050501"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="45dbd69e-6938-44c5-869b-9b80965f555b"/>
<code code="409586006" codeSystem="2.16.840.1.113883.6.96" displayName="Complaint"/>
<text><reference value="#problem2"/></text>
<statusCode code="completed"/>
<value xsi:type="CD" code="987654321" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Essential Hyptertension"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
<id root="e63b51a6-e037-4ded-912f-82d56e75005b"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="20050501"/>
<high value="20140701"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="9010e74b-8f52-466c-bc14-d5be9f19fdbc"/>
<code code="409586006" codeSystem="2.16.840.1.113883.6.96" displayName="Complaint"/>
<text><reference value="#problem3"/></text>
<statusCode code="completed"/>
<value xsi:type="CD" code="987654321" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Simple chronic bronchitis"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
<id root="24bb73fd-2cd3-49ba-b6f2-571e85e99590"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="20050501"/>
<high value="20140701"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="973bc0c3-afba-4566-a5e9-3da29682b344"/>
<code code="409586006" codeSystem="2.16.840.1.113883.6.96" displayName="Complaint"/>
<text><reference value="#problem4"/></text>
<statusCode code="completed"/>
<value xsi:type="CD" code="987654321" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Coronary artery disease"/>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PROCEDURES"/>
<title>PROCEDURES</title>
<text>null</text>
</section>
</component>
<component>
<section>
<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>
<table border="1" width="100%">
<thead>
<tr>
<th>Visit Date</th>
<th>Test</th>
<th>LOINC</th>
<th>Value</th>
<th>Unit</th>
<th>Short Name</th>
</tr>
</thead>
<tbody>
<tr>
<td><content ID="result1"/>20110423</td>
<td>Free Hemoglobin [Mass/?volume] in Serum</td>
<td>4635-9 </td>
<td>12.5</td>
<td>g/dl</td>
<td>Serum Hemoglobin</td>
</tr>
<tr>
<td><content ID="result2"/>20110423</td>
<td>Hematocrit [Volume Fraction] of Blood</td>
<td>20570-8 </td>
<td>40</td>
<td>%</td>
<td>Hematocrit</td>
</tr>
<tr>
<td><content ID="result3"/>20110423</td>
<td>Erythrocytes [#/?volume] in Blood by Automated count</td>
<td>789-8</td>
<td>4.2</td>
<td>mcL</td>
<td>Red Blood Count</td>
</tr>
<tr>
<td><content ID="result4"/>20110423</td>
<td>Sodium [Moles/?volume] in Serum or Plasma</td>
<td>2951-2</td>
<td>137</td>
<td>mmol/L</td>
<td>Serum Sodium</td>
</tr>
<tr>
<td><content ID="result5"/>20110423</td>
<td>Potassium [Moles/?volume] in Serum or Plasma</td>
<td>2823-3</td>
<td>3.4</td>
<td>mmol/L</td>
<td>Serum Potassium</td>
</tr>
<tr>
<td><content ID="result6"/>20110423</td>
<td>Chloride [Moles/?volume] in Serum or Plasma</td>
<td>2075-0</td>
<td>98</td>
<td>mmol/L</td>
<td>Serum Chloride</td>
</tr>
<tr>
<td><content ID="result7"/>20110423</td>
<td>Chest and Abdomen X-ray AP and PA chest</td>
<td>42011-7</td>
<td>Mild LV enlargement</td>
<td>text</td>
<td>AP and PA Chest X-ray</td>
</tr>
<tr>
<td><content ID="result8"/>20110423</td>
<td>EKG impression</td>
<td>8601-7</td>
<td>Possible early LVH</td>
<td>text</td>
<td>EKG</td>
</tr>
<tr>
<td><content ID="result9"/>20110423</td>
<td>Oxygen saturation in Arterial blood by Pulse oximetry</td>
<td>59408-5</td>
<td>92</td>
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<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social History"/>
<title>Soical History</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>History</th>
<th>From</th>
<th>To</th>
</tr>
</thead>
<tbody>
<tr>
<td><content ID="soc1"/>Former Smoker</td>
<td>19840101</td>
<td>20140101</td>
</tr>
</tbody>
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