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MaryGrant-ClinicalSummary.xml
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MaryGrant-ClinicalSummary.xml
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<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<realmCode code="US"></realmCode>
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<code code="34133-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summarization of episode note"></code>
<title xsi:type="SC">Summary of Care</title>
<effectiveTime xsi:type="IVL_TS" value="20140507013340"></effectiveTime>
<confidentialityCode code="R" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality" displayName="Restricted"></confidentialityCode>
<languageCode code="en-US"></languageCode>
<recordTarget>
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<addr use="H"><streetAddressLine>No Address Indicated</streetAddressLine><city>No City Indicated</city><state>CA</state><postalCode>99999</postalCode><country>United States of America</country></addr>
<telecom nullFlavor="NI"></telecom>
<patient>
<name use="L"><given>Mary</given><family>Grant</family></name>
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female"></administrativeGenderCode>
<birthTime xsi:type="IVL_TS" value="19870321"></birthTime>
<raceCode code="2106-3" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC" displayName="White"></raceCode>
<ethnicGroupCode code="2186-5" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC" displayName="Not Hispanic or Latino"></ethnicGroupCode>
<languageCommunication>
<languageCode code="eng"></languageCode>
<modeCode code="RWR" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode" displayName="Receive Written"></modeCode>
<preferenceInd value="true"></preferenceInd></languageCommunication></patient>
<providerOrganization>
<id root="2.16.840.1.113883.3.3388.1.1.1.310936"></id>
<name>Get Well Clinic</name>
<telecom value="tel:(415)427-2132" use="WP"></telecom>
<addr use="WP"><streetAddressLine>1002 Healthcare Dr.</streetAddressLine><city>Beaverton</city><state>OR</state><postalCode>97005</postalCode><country>United States of America</country></addr></providerOrganization></patientRole></recordTarget>
<author>
<time xsi:type="IVL_TS" value="20140507122640"></time>
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<id root="2.16.840.1.113883.3.3388.1.1.1.310936.1.3" extension="683266"></id>
<code code="208D00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Provider Codes" displayName="General Practice"></code>
<addr use="WP"><streetAddressLine>Get Well Clinic Facility</streetAddressLine><streetAddressLine>1002 Healthcare Dr.</streetAddressLine><city>Portland</city><state>OR</state><postalCode>97005</postalCode><country>United States of America</country></addr>
<telecom value="tel:(555)555-1002" use="WP"></telecom>
<assignedPerson>
<name><given>Martin</given><family>Green</family></name></assignedPerson>
<representedOrganization>
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<name>Get Well Clinic</name>
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<author>
<time xsi:type="IVL_TS" value="20140507122640"></time>
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<dataEnterer>
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<custodian>
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<legalAuthenticator>
<time xsi:type="IVL_TS" value="20140507060210"></time>
<signatureCode code="S"></signatureCode>
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<assignedPerson>
<name><given>Fname</given><family>Lname</family></name></assignedPerson></assignedEntity></legalAuthenticator>
<documentationOf>
<serviceEvent classCode="PCPR" moodCode="EVN">
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<effectiveTime>
<low value="20140101120000"></low>
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<performer typeCode="PRF">
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<componentOf>
<encompassingEncounter>
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<component>
<structuredBody>
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<section>
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<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, Adverse Reactions, Alerts"></code>
<title>Allergies</title>
<text><table width="95%" border="1">
<thead>
<tr>
<th>Allergy</th>
<th>Date</th>
<th>Reaction Status</th>
<th>Severity Status</th></tr></thead>
<tbody>
<tr ID="allergy4560388">
<td>Bicillin L-A</td>
<td>Onset: Not Indicated</td>
<td>Hives</td>
<td>Very Mild</td></tr>
<tr ID="allergy4560391">
<td>Aspirin</td>
<td>Onset: Not Indicated</td>
<td>Nausea</td>
<td>Mild</td></tr></tbody></table></text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
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<statusCode code="completed"></statusCode>
<effectiveTime>
<low value="20131218035113"></low>
<high nullFlavor="NI"></high></effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
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<statusCode code="completed"></statusCode>
<effectiveTime nullFlavor="NI"></effectiveTime>
<value xsi:type="CE" code="416098002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="drug allergy"></value>
<performer typeCode="PRF">
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<addr use="WP"><streetAddressLine>1002 Healthcare Dr.</streetAddressLine><city>Portland</city><state>OR</state><postalCode>97005</postalCode><country>United States of America</country></addr>
<telecom value="tel:(415)427-2132" use="WP"></telecom>
<assignedPerson>
<name><given>Martin</given><family>Green</family></name></assignedPerson></assignedEntity></performer>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code code="731570" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Bicillin L-A"></code></playingEntity></participantRole></participant>
<entryRelationship typeCode="SUBJ" inversionInd="true">
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<value xsi:type="CE" code="55561003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Active"></value></observation></entryRelationship>
<entryRelationship typeCode="SUBJ" inversionInd="true">
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<text><reference value="#allergy4560388"></reference></text>
<statusCode code="completed"></statusCode>
<value xsi:type="CD" code="126485001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hives"></value></observation></entryRelationship>
<entryRelationship typeCode="MFST" inversionInd="true">
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<statusCode code="completed"></statusCode>
<value xsi:type="CD" code="255604002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Very Mild"></value></observation></entryRelationship></observation></entryRelationship></act></entry>
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<telecom value="tel:(415)427-2132" use="WP"></telecom>
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<name><given>Martin</given><family>Green</family></name></assignedPerson></assignedEntity></performer>
<participant typeCode="CSM">
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<value xsi:type="CD" code="422587007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Nausea"></value></observation></entryRelationship>
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<value xsi:type="CD" code="255604002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Mild"></value></observation></entryRelationship></observation></entryRelationship></act></entry></section></component>
<component>
<section>
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<code code="51847-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Assessment and Plan"></code>
<title>Assessment and Plan</title>
<text><table>
<thead>
<tr>
<th>Assessment and Plan</th></tr></thead>
<tbody>
<tr ID="APPOC103583514">
<td>Goal: weight loss
Instructions: diet and exercise counseling provided during visit</td></tr></tbody></table></text>
<entry>
<act classCode="ACT" moodCode="INT">
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<code code="46239-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Chief Complaint and Reason For Visit"></code>
<title>Chief Complaint and Reason For Visit</title>
<text><table>
<thead>
<tr>
<th>Chief Complaint or Reason for Visit</th></tr></thead>
<tbody>
<tr ID="ChiefComplaint_1">
<td>2014-01-01 : No Chief Complaint or Reason for Visit given </td></tr></tbody></table></text></section></component>
<component>
<section>
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<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Encounters"></code>
<title>Encounters</title>
<text><table width="95%" border="1">
<thead>
<tr>
<th>Encounter Type </th>
<th>Location Name</th>
<th>Performer</th>
<th>Date of Service</th></tr></thead>
<tbody>
<tr ID="Encounter103583514348">
<td>Encounter: Encounter for "check-up" (procedure)</td>
<td>Get Well Clinic, 1002 Healthcare Dr., Beaverton, OR 97005 Phone: (415) 427-2132</td>
<td> Fname Lname </td>
<td>2014-01-01</td></tr></tbody></table></text>
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<high value="20140101120000"></high></effectiveTime>
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<addr use="WP"><streetAddressLine>1002 Healthcare Dr.</streetAddressLine><city>Beaverton</city><state>OR</state><postalCode>97005</postalCode><country>United States of America</country></addr>
<telecom value="tel:(415)427-2132" use="WP"></telecom>
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<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Immunizations"></code>
<title>Immunizations</title>
<text><table width="95%" border="1">
<thead>
<tr>
<th>Vaccine</th>
<th>Date</th>
<th>Delivery Status</th></tr></thead>
<tbody>
<tr ID="immun1">
<td>No immunizations administered during visit</td>
<td>Not Applicable</td>
<td>Not Applicable</td></tr></tbody></table></text>
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<substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="true">
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<component>
<section>
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<code code="69730-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Instructions"></code>
<title>Instructions</title>
<text><table>
<thead>
<tr>
<th>Instructions</th></tr></thead>
<tbody>
<tr ID="Section103583514">
<td>Education resources were given to the patient during the visit</td></tr></tbody></table></text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="INT">
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<text><reference value="#Section103583514"></reference></text>
<statusCode code="completed"></statusCode></act></entry></section></component>
<component>
<section>
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<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Medication Use"></code>
<title>Medications</title>
<text><table width="95%" border="1">
<thead>
<tr>
<th>Material</th>
<th>RXnormCode</th>
<th>GenericName</th>
<th>ProductStrength</th>
<th>StartDate</th>
<th>StopDate</th>
<th>SIG</th></tr></thead>
<tbody>
<tr ID="Med70007979">
<td>Keflex (cephalexin) oral capsule</td>
<td>RxNorm: 212339</td>
<td>cephalexin</td>
<td>500 mg</td>
<td>2012-09-20</td>
<td>Not Indicated</td>
<td>4 times daily for 10 days</td></tr>
<tr ID="Med70008053">
<td>PROzac (FLUoxetine) oral capsule</td>
<td>RxNorm: 261287</td>
<td>FLUoxetine</td>
<td>40 mg</td>
<td>2011-11-10</td>
<td>Not Indicated</td>
<td>once daily</td></tr>
<tr ID="Med70008133">
<td>Synthroid (levothyroxine) oral tablet</td>
<td>RxNorm: 966247</td>
<td>levothyroxine</td>
<td>50 mcg (0.05 mg)</td>
<td>2010-04-15</td>
<td>Not Indicated</td>
<td>once daily</td></tr></tbody></table></text>
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<low value="20111110080000"></low>
<high nullFlavor="NI"></high></effectiveTime>
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<manufacturedMaterial>
<code code="261287" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="FLUoxetine 40 mg"></code></manufacturedMaterial></manufacturedProduct></consumable>
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<manufacturedMaterial>
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<entryRelationship typeCode="SUBJ" inversionInd="true">
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<component>
<section>
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<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem List"></code>
<title>Problem List</title>
<text><table width="95%" border="1">
<thead>
<tr>
<th>Problem Description</th>
<th>Problem StartDate</th>
<th>Status</th></tr></thead>
<tbody>
<tr ID="problem1">
<td>No Problems indicated</td>
<td> </td>
<td> </td></tr></tbody></table></text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.3"></templateId>
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<low nullFlavor="NI"></low>
<high nullFlavor="NI"></high></effectiveTime>
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<id root="2.16.840.1.113883.3.3388.1.1.1.310936.3.83900262.2.1"></id>
<code nullFlavor="NI"></code>
<text><reference value="#problem1"></reference></text>
<statusCode nullFlavor="NA"></statusCode>
<value xsi:type="CD" nullFlavor="NI"></value></observation></entryRelationship></act></entry></section></component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"></templateId>
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedures"></code>
<title>Procedures</title>
<text><table width="95%" border="1">
<thead>
<tr>
<th>Procedure</th>
<th>Date</th></tr></thead>
<tbody>
<tr ID="procedure349">
<td>Standard chest X-ray (procedure)</td>
<td>Performed: 2013-12-18</td></tr></tbody></table></text>
<entry typeCode="DRIV">
<procedure classCode="PROC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.14"></templateId>
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<code xsi:type="CE" code="168731009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Standard chest X-ray (procedure)"></code>
<text><reference value="#procedure349"></reference></text>
<statusCode code="completed"></statusCode>
<priorityCode nullFlavor="NI"></priorityCode>
<methodCode nullFlavor="NI"></methodCode>
<targetSiteCode nullFlavor="NI"></targetSiteCode>
<performer typeCode="PRF">
<assignedEntity>
<id root="2.16.840.1.113883.3.3388.1.1.1.310936.1.1.3" extension="605196"></id>
<addr use="WP"><streetAddressLine>Get Well Clinic Facility</streetAddressLine><streetAddressLine>1002 Healthcare Dr.</streetAddressLine><city>Portland</city><state>OR</state><postalCode>97005</postalCode><country>United States of America</country></addr>
<telecom value="tel:(555)555-1002" use="WP"></telecom>
<assignedPerson>
<name><given>Fname</given><family>Lname</family></name></assignedPerson></assignedEntity></performer>
<participant typeCode="LOC">
<participantRole classCode="SDLOC">
<templateId root="2.16.840.1.113883.10.20.22.4.32"></templateId>
<code nullFlavor="NI"></code>
<addr use="WP"><streetAddressLine>Get Well Clinic Facility</streetAddressLine><streetAddressLine>1002 Healthcare Dr.</streetAddressLine><city>Portland</city><state>OR</state><postalCode>97005</postalCode><country>United States of America</country></addr>
<telecom value="tel:(555)555-1002" use="WP"></telecom>
<playingEntity classCode="PLC"></playingEntity></participantRole></participant></procedure></entry></section></component>
<component>
<section>
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<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Results"></code>
<title>Results</title>
<text>Not indicated</text>
<entry typeCode="DRIV">
<organizer classCode="BATTERY" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.1"></templateId>
<id nullFlavor="UNK"></id>
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<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.2"></templateId>
<id nullFlavor="NI"></id>
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<component>
<section>
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<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" displayName="Social History"></code>
<title>Social History</title>
<text><table width="95%" border="1">
<thead>
<tr>
<th>Social History</th>
<th>Effective Date</th></tr></thead>
<tbody>
<tr ID="SmokingStatus_1">
<td>Never smoker</td>
<td>2013-12-17</td></tr></tbody></table></text>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.78"></templateId>
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<text><reference value="#SmokingStatus_1"></reference></text>
<statusCode code="completed"></statusCode>
<effectiveTime>
<low value="20131217080000"></low></effectiveTime>
<value xsi:type="CD" code="266919005" codeSystem="2.16.840.1.113883.6.96" displayName="Never smoker"></value></observation></entry></section></component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.4"></templateId>
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital Signs"></code>
<title>Vital Signs</title>
<text><table width="95%" border="1">
<thead>
<tr>
<th>Date:Time</th>
<th>RespiratoryRate /min</th>
<th>HeartRate /min</th>
<th>SystolicBP mm[Hg]</th>
<th>DiastolicBP mm[Hg]</th>
<th>BodyTemperature [degF]</th>
<th>Height [in_us]</th>
<th>Head Circumference [in_us]</th>
<th>Weight [lb_av]</th>
<th>BMI kg/m2</th></tr></thead>
<tbody>
<tr>
<td ID="VitalSigns_DateTime_1">2014-01-01</td>
<td ID="VitalSigns_RespRate_1">0</td>
<td ID="VitalSigns_HeartRate_1">0</td>
<td ID="VitalSigns_BPSystolic_1">116</td>
<td ID="VitalSigns_BPDiastolic_1">72</td>
<td ID="VitalSigns_Temp_1">0</td>
<td ID="VitalSigns_Height_1">64</td>
<td ID="VitalSigns_HeadCircumference_1">0</td>
<td ID="VitalSigns_Weight_1">160</td>
<td ID="VitalSigns_BMI_1">27.4609</td></tr></tbody></table></text>
<entry typeCode="DRIV">
<organizer classCode="CLUSTER" moodCode="EVN">
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<effectiveTime value="20140101120000"></effectiveTime>
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<text><reference value="#VitalSigns_RespRate_1"></reference></text>
<statusCode code="completed"></statusCode>
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<statusCode code="completed"></statusCode>
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<component>
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<statusCode code="completed"></statusCode>
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<component>
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<text><reference value="#VitalSigns_BPDiastolic_1"></reference></text>
<statusCode code="completed"></statusCode>
<effectiveTime value="20140101120000"></effectiveTime>
<value xsi:type="PQ" value="72" unit="mm[Hg]"></value></observation></component>
<component>
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<text><reference value="#VitalSigns_Temp_1"></reference></text>
<statusCode code="completed"></statusCode>
<effectiveTime value="20140101120000"></effectiveTime>
<value xsi:type="PQ" value="0" unit="[degF]"></value></observation></component>
<component>
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