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Doc-No Known Problems 20140226.xml
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Doc-No Known Problems 20140226.xml
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<?xml version="1.0" encoding="UTF-8"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 ../../05%20Professional/90%20HL7/00%20Standard%20-%20CDA%20R2/cda%20r2%20normativewebedition2010/infrastructure/cda/CDA.xsd"
xmlns="urn:hl7-org:v3"
xmlns:cda="urn:hl7-org:v3"
xmlns:sdtc="urn:hl7-org:sdtc">
<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"/> <!-- C-CDA -->
<templateId root="2.16.840.1.113883.10.20.22.1.2"/> <!-- CCD -->
<id root="2.16.840.1.113883.3.3208.101.1" extension="20130607100315-CCDA-CCD"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34133-9" displayName="Summarization of Episode Note"/>
<title>CDA PRO C-CDA CCD Skeleton That Validates on TTT</title>
<effectiveTime value="20130607000000-0000"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<recordTarget>
<patientRole>
<id root="2.16.840.1.113883.3.3208.101.2" extension="20130607100800-Patient1"/>
<addr use="HP">
<streetAddressLine>1111 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)111-1111" use="HP"/>
<patient>
<name use="L"><given>Patient</given><family>One</family></name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male" codeSystemName="AdministrativeGender"/>
<birthTime value="19300911"/>
<maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatus"/>
<raceCode code="2106-3" displayName="White"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="OMB Standards for Race and Ethnicity"/>
<ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="OMB Standards for Race and Ethnicity"/>
<languageCommunication>
<languageCode code="eng"/>
<modeCode code="ESP" displayName="Expressed spoken" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/>
<proficiencyLevelCode code="E" displayName="Excellent" codeSystem="2.16.840.1.113883.5.61" codeSystemName="LanguageAbilityProficiency"/>
</languageCommunication>
</patient>
</patientRole>
</recordTarget>
<author>
<time value="20130607161500"/>
<assignedAuthor>
<id extension="66666" root="2.16.840.1.113883.4.6"/>
<code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"
displayName="Cardiovascular Disease"/>
<addr>
<streetAddressLine>6666 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)666-6666" use="WP"/>
<assignedPerson>
<name>
<given>Heartly</given>
<family>Sixer</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id extension="33333" root="2.16.840.1.113883.4.6"/>
<code code="364SA2200X" displayName="Adult Health" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"/>
<addr use="WP">
<streetAddressLine>3333 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)333-3333" use="WP"/>
<assignedPerson>
<name>
<given>Nurse</given>
<family>Tertiary</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="44444" root="2.16.840.1.113883.4.6"/>
<name>CDA PRO Fictional Hospital</name>
<telecom value="tel:+1(301)444-4444" use="WP"/>
<addr use="WP">
<streetAddressLine>4444 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<legalAuthenticator>
<time value="20130607161500"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="66666" root="2.16.840.1.113883.4.6"/>
<code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"
displayName="Cardiovascular Disease"/>
<addr>
<streetAddressLine>6666 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)666-6666" use="WP"/>
<assignedPerson>
<name>
<given>Heartly</given>
<family>Sixer</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="20130607160200"/>
<high value="20130607161500"/>
</effectiveTime>
<performer typeCode="PRF">
<assignedEntity>
<id extension="66666" root="2.16.840.1.113883.4.6"/>
<code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"
displayName="Cardiovascular Disease"/>
<addr>
<streetAddressLine>6666 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)666-6666" use="WP"/>
<assignedPerson>
<name>
<given>Heartly</given>
<family>Sixer</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<!-- CDA Body -->
<component>
<structuredBody>
<!-- Allergies Section -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/> <!-- Allergies (entries required) section -->
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" displayName="Allergies, adverse reactions, alerts" codeSystemName="LOINC"/>
<title>ALLERGIES</title>
<text>
<content ID="Alg_Concern_1">Allergy Concern:
Concern Tracker Start Date: 01/03/2014
Concern Tracker End Date:
Concern Tracker Status: Completed
<content ID="allergy1">No known <content ID="adverseEvent1">allergies.</content></content></content></text>
<entry typeCode="DRIV">
<!-- Allergy Concern Act -->
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<!-- SDWG supports 48765-2 or CONC in the code element -->
<!--<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>-->
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" displayName="Allergies, adverse reactions, alerts" codeSystemName="LOINC"/>
<text><reference value="#Alg_Concern_1"></reference></text>
<statusCode code="completed"/> <!-- The concern is not active, in terms of there being an active condition to be managed.-->
<effectiveTime>
<low value="20100103"/> <!--show time when the concern about allergies was assessed and completed. -->
<high/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<!-- No Known Allergies -->
<!-- The use of negationInd corresponds with the newer Observation.valueNegationInd -->
<!-- The negationInd = true negates the observation/value -->
<observation classCode="OBS" moodCode="EVN" negationInd="true">
<!-- allergy - intolerance observation template -->
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<!-- N/A - author/time records when this assertion was made -->
<effectiveTime>
<low value="20100103"/>
</effectiveTime>
<!-- 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. -->
<value xsi:type="CD" code="419199007"
displayName="Allergy to substance (disorder)"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
<author>
<time value="20100103"/>
<assignedAuthor>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101"
displayName="Allopathic & Osteopathic Physicians"/>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!-- Medication Section -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/> <!-- Medication Section (entries required) -->
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Medication Use"/>
<title>MEDICATIONS</title>
<text><content ID="meds1">No Information About Medications</content></text>
<entry typeCode="DRIV">
<substanceAdministration moodCode="EVN" classCode="SBADM" nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/> <!-- Medication Activity -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607111500-MedicationActivity"/>
<text><reference value="#meds1"/></text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS"><low nullFlavor="NI"/><high nullFlavor="NI"/></effectiveTime>
<effectiveTime xsi:type="PIVL_TS" operator="A" nullFlavor="NI"/> <!-- Added to meet the "SHOULD" and avoid the warning from the validator -->
<doseQuantity nullFlavor="NI"/> <!-- Added to meet the "SHOULD" and avoid the warning from the validator -->
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/> <!-- Medication Information -->
<manufacturedMaterial>
<code nullFlavor="NI">
<originalText><reference value="#meds1"/></originalText> <!-- I don't this this should need to be present unless you are populating a table with NI-->
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<!-- Problem Section -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/> <!-- Problem Section with Coded Entries Required -->
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem List"/>
<title>PROBLEMS</title>
<text>
<content ID="Concern_1">Problem Concern:
Concern Tracker Start Date: 06/07/2013 16:05:06
Concern Tracker End Date:
Concern Status: Active
<content ID="problems1">No known <content ID="problemType1">problems.</content></content>
</content>
</text>
<entry typeCode="DRIV">
<!-- Problem Concern Act -->
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
<id root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<!-- 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"></reference></text>
<statusCode code="active"/> <!-- The concern is not active, in terms of there being an active condition to be managed.-->
<effectiveTime>
<low value="20130607160506"/> <!-- Time at which THIS “concern” began being tracked.-->
<high/>
</effectiveTime>
<author>
<time value="20130607160506"/>
<assignedAuthor>
<id extension="66666" root="2.16.840.1.113883.4.6"/>
<code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"
displayName="Cardiovascular Disease"/>
<addr>
<streetAddressLine>6666 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)666-6666" use="WP"/>
<assignedPerson>
<name>
<given>Heartly</given>
<family>Sixer</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN" negationInd="true">
<!-- Model of Meaning for No Problems -->
<!-- This is more consistent with how we did no known allergies. -->
<!-- The use of negationInd corresponds with the newer Observation.ValueNegationInd -->
<!-- The negationInd = true negates the value element. -->
<!-- problem observation template -->
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="4adc1021-7b14-11db-9fe1-0800200c9a67"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<text><reference value="#problems1"></reference></text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20130607160506"/>
</effectiveTime>
<!-- 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. -->
<!-- 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="#problemType1"></reference></originalText>
</value>
<author>
<time value="20130607160506"/>
<assignedAuthor>
<id extension="66666" root="2.16.840.1.113883.4.6"/>
<code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"
displayName="Cardiovascular Disease"/>
<addr>
<streetAddressLine>6666 StreetName St.</streetAddressLine>
<city>Silver Spring</city><state>MD</state><postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)666-6666" use="WP"/>
<assignedPerson>
<name>
<given>Heartly</given>
<family>Sixer</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!-- Procedures Section -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/> <!-- Procedures Section with Coded Entries Required-->
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Procedures"/>
<title>PROCEDURES</title>
<text><content ID="procedures1">No Information About Procedures</content></text>
<entry typeCode="DRIV">
<procedure classCode="PROC" moodCode="EVN"> <!-- I think it makes more sense for this to be an Procedure than an Act -->
<!--<templateId root="2.16.840.1.113883.10.20.22.4.12"/>--> <!-- Procedure Activity Act-->
<templateId root="2.16.840.1.113883.10.20.22.4.14"/> <!-- Procedure Activity Procedure-->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607114600-ProcedureActivity"/>
<code xsi:type="CE" nullFlavor="NI">
<originalText><reference value="#procedures1"/></originalText>
</code>
<statusCode code="completed" />
<effectiveTime><low nullFlavor="NI"/><high value="20130607000000-0000"/></effectiveTime> <!-- Up until now. -->
<targetSiteCode nullFlavor="NI" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"></targetSiteCode>
<performer> <!-- Added to meet "SHOULD" requirment and avoid validator warning -->
<assignedEntity>
<id root="2.16.840.1.113883.3.3208.101.3" extension="20130607154800-UnknownPersonnel"/>
<addr nullFlavor="NI"/>
<telecom nullFlavor="NI"/>
<representedOrganization nullFlavor="NI">
<id root="2.16.840.1.113883.3.3208.101.5" extension="20130607155400-UnknownOrg" />
<telecom nullFlavor="NI" />
<addr nullFlavor="NI" />
</representedOrganization>
</assignedEntity>
</performer>
</procedure>
</entry>
</section>
</component>
<!-- Results Section -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/> <!-- Results Section with Coded Entries Required-->
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Relevant diagnostic tests and/or laboratory data"/>
<title>RESULTS</title>
<text><content ID="results1">No Information About Results</content></text>
<entry typeCode="DRIV">
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.1"/> <!-- Result Organizer -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607113300-ResultOrganizer"/>
<code xsi:type="CE" nullFlavor="NI"/>
<statusCode code="completed"/>
<effectiveTime><low nullFlavor="NI"/><high value="20130607000000-0000"/></effectiveTime> <!-- Up until now. --> <!-- Brian's sample had a weird date in here. -->
<component>
<observation classCode="OBS" moodCode="EVN" > <!-- removed this: nullFlavor="NI"-->
<templateId root="2.16.840.1.113883.10.20.22.4.2"/> <!-- Results Observation -->
<id nullFlavor="NI"/>
<code nullFlavor="NI" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <!-- No code here -->
<text><reference value="#results1"/></text>
<statusCode code="completed"/>
<effectiveTime><low nullFlavor="NI"/><high value="20130607000000-0000"/></effectiveTime> <!-- Up until now. -->
<value xsi:type="CD" nullFlavor="NI"/>
<interpretationCode nullFlavor="NI"/>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
<!-- Plan of Care Section -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.10"/> <!-- Plan of Care Section-->
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of Care"/>
<title>PLAN OF CARE</title>
<text>No Information About Plan of Care</text>
</section>
</component>
<!-- Social History (with Smoking Status Observation) -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.17"/> <!-- Social History Section -->
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" displayName="Social History"/>
<title>SOCIAL HISTORY</title>
<text><content ID="socialhist1">No Information About Social History</content></text>
<entry>
<observation classCode="OBS" moodCode="EVN"> <!-- Removed nullFlavor="NI" -->
<templateId root="2.16.840.1.113883.10.20.22.4.85"/> <!-- Conforms to Tobacco Use template-->
<templateId root="2.16.840.1.113883.10.20.22.4.78"/> <!-- Smoking Status Observation 2.16.840.1.113883.10.20.22.4.78-->
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<text><reference value="#socialhist1"></reference></text>
<statusCode code="completed"/>
<effectiveTime><low nullFlavor="NI"/><high value="20130607000000-0000"/></effectiveTime> <!-- I disagree with the template - The status can at best be observed up until now. I think it documents
the smoking status up until this point in time.-->
<value xsi:type="CD" nullFlavor="NI" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
</entry>
</section>
</component>
<!-- Vital Signs Section (entries required) -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.4.1"/> <!-- Vital Signs (entries required) -->
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital Signs"/>
<title>VITAL SIGNS</title>
<text><content ID="vitalsigns1">No Information About Vital Signs</content></text>
<entry typeCode="DRIV">
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.26" /> <!-- Vital Signs Organizer -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607125100-VitalSignsOrganizer"/>
<code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Vital signs"/>
<statusCode code="completed"/>
<effectiveTime><low nullFlavor="NI"/><high value="20130607000000-0000"/></effectiveTime>
<component>
<observation classCode="OBS" moodCode="EVN" nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.4.27"/> <!-- Vital Signs Observation -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607125100-VitalSignsObservation"/>
<code nullFlavor="NI">
<originalText><reference value="#vitalsigns1"></reference></originalText>
</code>
<text><reference value="#vitalsigns1"/></text>
<statusCode code="completed"/>
<effectiveTime><low nullFlavor="NI"/><high value="20130607000000-0000"/></effectiveTime>
<value xsi:type="PQ" nullFlavor="NI"/>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>