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MED_Preconditions_in_empty_CCD.xml
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MED_Preconditions_in_empty_CCD.xml
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<?xml version="1.0"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!-- This is an empty C-CDA skeleton which will be used by HL7 CDA Example Task Force -->
<!-- This document was based on prior work by Lisa Nelson and Brian Weiss. contact John D'Amore with questions -->
<!-- See http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force -->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 ../90%20HL7/00%20Standard%20-%20C-CDA/20130409%20C-CDA%20R1dot1_2012JUL/Updated_CDA_Schema_Files_Extension_Support/CDA_Schema_Files/infrastructure/cda/CDA_SDTC.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>Empty CCD Skeleton That Validates on TTT. Note this was based on work by Lisa Nelson and Brian Weiss</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="20130607000000"/>
<assignedAuthor>
<id extension="22222" root="2.16.840.1.113883.4.6"/>
<code code="207QA0505X" codeSystem="2.16.840.1.113883.6.101"
displayName="Adult Medicine" codeSystemName="NUCC"/>
<addr use="HP">
<streetAddressLine>2222 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)222-2222" use="WP"/>
<assignedPerson>
<name>
<given>Doctor</given>
<family>Second</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="20130607000000"/>
<signatureCode code="S"/>
<assignedEntity>
<id root="2.16.840.1.113883.3.3208.101.3" extension="20130607102400-Authenticator1"/>
<addr use="WP">
<streetAddressLine>5555 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)555-5555" use="WP"/>
<assignedPerson>
<name>
<given>Physician</given>
<family>Fifthly</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="19330316"/>
<high value="20130607"/>
</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>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<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>No Information</text>
</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>
<table border="1" width="100%">
<thead>
<tr>
<th>Medication</th>
<th>Instructions</th>
<th>Dosage</th>
<th>Effective Dates (start - stop)</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr ID="Medication_0">
<td>
<content ID="MedicationName_0">Ibuprofen 600mg Oral Tablet</content>
</td>
<td>
<content ID="MedicationSig_0">take 1 tablet QID PRN</content>
</td>
<td>
<content ID="MedicationDosage_0">600 MG</content>
</td>
<td>Mar-10-2013 - </td>
<td>Active</td>
</tr>
<tr ID="Medication_1">
<td>
<content ID="MedicationName_1">Ibuprofen 600mg Oral Tablet</content>
</td>
<td>
<content ID="MedicationSig_1">take 1 tablet QID PRN as Directed</content>
</td>
<td>
<content ID="MedicationDosage_1">600 MG</content>
</td>
<td>Mar-10-2013 - </td>
<td>Active</td>
</tr>
<tr ID="Medication_2">
<td>
<content ID="MedicationName_2">Ibuprofen 600mg Oral Tablet</content>
</td>
<td>
<content ID="MedicationSig_2">take 1 tablet QID PRN for joint pain</content>
</td>
<td>
<content ID="MedicationDosage_2">600 MG</content>
</td>
<td>Mar-10-2013 - </td>
<td>Active</td>
</tr>
<tr ID="Medication_3">
<td>
<content ID="MedicationName_3">Ibuprofen 600mg Oral Tablet</content>
</td>
<td>
<content ID="MedicationSig_3">take 1 tablet QID as needed for joint pain</content>
</td>
<td>
<content ID="MedicationDosage_3">600 MG</content>
</td>
<td>Mar-10-2013 - </td>
<td>Active</td>
</tr>
<tr ID="Medication_4">
<td>
<content ID="MedicationName_4">Ibuprofen 600mg Oral Tablet</content>
</td>
<td>
<content ID="MedicationSig_4">
take 1 tablet QID for <content ID="MedicationIndication_4">joint pain</content>
</content>
</td>
<td>
<content ID="MedicationDosage_4">600 MG</content>
</td>
<td>Mar-10-2013 - </td>
<td>Active</td>
</tr>
</tbody>
</table>
</text>
<!-- Example #1 - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours PRN -->
<entry>
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id extension="100035" root="1.3.6.1.4.1.22812.3.99930.3.4.9"/>
<id extension="100013" root="1.3.6.1.4.1.22812.3.99930.3.4.9"/>
<text>
<reference value="#Medication_0"/>
</text>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20110310000000-0500"/>
<high nullFlavor="NI"/>
</effectiveTime>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="false" operator="A">
<period value="6" unit="h"/>
</effectiveTime>
<doseQuantity value="1"/>
<consumable typeCode="CSM">
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="308182" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Ibuprofen 600mg Oral Tablet">
<originalText>
<reference value="#MedicationName_0"/>
</originalText>
<translation code="67253014050" codeSystem="2.16.840.1.113883.6.69" codeSystemName="NDC" displayName="Ibuprofen 600mg Oral Tablet"/>
</code>
<name>Ibuprofen</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<precondition typeCode="PRCN">
<criterion>
<!-- ** Precondition for substance administration ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.25"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<!-- If a precondition were specified in medication sig, you would include code here. Include nullFlavor="NI" when PRN specified but without precondition-->
<value xsi:type="CD" nullFlavor="NI" />
</criterion>
</precondition>
</substanceAdministration>
</entry>
<!-- Example # 2 - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours PRN as Directed
as basic PRN, but the question now becomes: what is "as Directed"? patient instruction? precondition?
as directed is coded here as a precondition using a SNOMED code-->
<entry>
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id extension="200035" root="1.3.6.1.4.1.22812.3.99930.3.4.9"/>
<id extension="200013" root="1.3.6.1.4.1.22812.3.99930.3.4.9"/>
<text>
<reference value="#Medication_1"/>
</text>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20110310000000-0500"/>
<high nullFlavor="NI"/>
</effectiveTime>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="false" operator="A">
<period value="6" unit="h"/>
</effectiveTime>
<doseQuantity value="1"/>
<consumable typeCode="CSM">
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="308182" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Ibuprofen 600mg Oral Tablet">
<originalText>
<reference value="#MedicationName_1"/>
</originalText>
<translation code="67253014050" codeSystem="2.16.840.1.113883.6.69" codeSystemName="NDC" displayName="Ibuprofen 600mg Oral Tablet"/>
</code>
<name>Ibuprofen</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<precondition typeCode="PRCN">
<criterion>
<!-- ** Precondition for substance administration ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.25"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<!-- as directed as the precondition -->
<value xsi:type="CD" code="422135004" codeSystem="2.16.840.1.113883.6.96" displayName="As directed for" />
</criterion>
</precondition>
</substanceAdministration>
</entry>
<!-- Example # 3 - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours PRN for joint pain
adding for joint pain raises the question: is this a precondition or an indication?
coded here as an precondition-->
<entry>
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id extension="300035" root="1.3.6.1.4.1.22812.3.99930.3.4.9"/>
<id extension="300013" root="1.3.6.1.4.1.22812.3.99930.3.4.9"/>
<text>
<reference value="#Medication_2"/>
</text>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20110310000000-0500"/>
<high nullFlavor="NI"/>
</effectiveTime>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="false" operator="A">
<period value="6" unit="h"/>
</effectiveTime>
<doseQuantity value="1"/>
<consumable typeCode="CSM">
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="308182" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Ibuprofen 600mg Oral Tablet">
<originalText>
<reference value="#MedicationName_2"/>
</originalText>
<translation code="67253014050" codeSystem="2.16.840.1.113883.6.69" codeSystemName="NDC" displayName="Ibuprofen 600mg Oral Tablet"/>
</code>
<name>Ibuprofen</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<precondition typeCode="PRCN">
<criterion>
<!-- ** Precondition for substance administration ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.25"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<!-- joint pain -->
<value xsi:type="CD" code="57676002" codeSystem="2.16.840.1.113883.6.96" displayName="Joint pain" />
</criterion>
</precondition>
</substanceAdministration>
</entry>
<!-- Example # 4 - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours as needed for joint pain
maybe this is not a realistic example, but the question this raises is: does the phrase "as needed" constitute
a PRCN as if PRN had been used instead of "as needed" ? propose that Yes, they are the same -->
<entry>
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id extension="400035" root="1.3.6.1.4.1.22812.3.99930.3.4.9"/>
<id extension="400013" root="1.3.6.1.4.1.22812.3.99930.3.4.9"/>
<text>
<reference value="#Medication_3"/>
</text>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20110310000000-0500"/>
<high nullFlavor="NI"/>
</effectiveTime>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="false" operator="A">
<period value="6" unit="h"/>
</effectiveTime>
<doseQuantity value="1"/>
<consumable typeCode="CSM">
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="308182" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Ibuprofen 600mg Oral Tablet">
<originalText>
<reference value="#MedicationName_3"/>
</originalText>
<translation code="67253014050" codeSystem="2.16.840.1.113883.6.69" codeSystemName="NDC" displayName="Ibuprofen 600mg Oral Tablet"/>
</code>
<name>Ibuprofen</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<precondition typeCode="PRCN">
<criterion>
<!-- ** Precondition for substance administration ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.25"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<!-- joint pain -->
<value xsi:type="CD" code="57676002" codeSystem="2.16.840.1.113883.6.96" displayName="Joint pain" />
</criterion>
</precondition>
</substanceAdministration>
</entry>
<!-- Example # 5 - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours for joint pain
as if "for" was worded as "because of" coded with an indication, no precondition -->
<entry>
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id extension="500035" root="1.3.6.1.4.1.22812.3.99930.3.4.9"/>
<id extension="500013" root="1.3.6.1.4.1.22812.3.99930.3.4.9"/>
<text>
<reference value="#Medication_4"/>
</text>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20110310000000-0500"/>
<high nullFlavor="NI"/>
</effectiveTime>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="false" operator="A">
<period value="6" unit="h"/>
</effectiveTime>
<doseQuantity value="1"/>
<consumable typeCode="CSM">
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="308182" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Ibuprofen 600mg Oral Tablet">
<originalText>
<reference value="#MedicationName_4"/>
</originalText>
<translation code="67253014050" codeSystem="2.16.840.1.113883.6.69" codeSystemName="NDC" displayName="Ibuprofen 600mg Oral Tablet"/>
</code>
<name>Ibuprofen</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<!-- a problem indication of joint pain -->
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id extension="44" root="1.3.6.1.4.1.22812.3.99930.3.4.1.3"/>
<code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="404684003"/>
<text>
<reference value="#MedicationIndication_4"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD" code="57676002" codeSystem="2.16.840.1.113883.6.96" displayName="Joint pain" />
</observation>
</entryRelationship>
</substanceAdministration>
</entry>
</section>
</component>
<!-- Problem Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<!-- conforms to Problems section with entries required -->
<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>No Information</text>
</section>
</component>
<!-- Procedures Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<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>No Information</text>
</section>
</component>
<!-- Results Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<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>No Information</text>
</section>
</component>
<!-- Plan of Care Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<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</text>
</section>
</component>
<!-- Social History (with Smoking Status Observation) -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<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>No Information</text>
</section>
</component>
<!-- Vital Signs Section (entries required) -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<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>No Information</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>
<?xml version="1.0"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xmlns:cda="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc">
<!-- This CCD was validated with no warnings/errors with NIST Validator for Ambulatory VDT on December 18, 2013. Note immunizations and procedures would need to be added for "Transition of Care" validation-->
<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>This is a CCD skeleton with some sample medication results created for HL7 Example Task Force - Based on C-CDA Skeleton developed by Lisa Nelson</title>
<effectiveTime value="20131031110101+0500"/>
<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="20130607000000"/>
<assignedAuthor>
<id extension="22222" root="2.16.840.1.113883.4.6"/>
<code code="207QA0505X" codeSystem="2.16.840.1.113883.6.101"
displayName="Adult Medicine" codeSystemName="NUCC"/>
<addr use="HP">
<streetAddressLine>2222 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)222-2222" use="WP"/>
<assignedPerson>
<name>
<given>Doctor</given>
<family>Second</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="20130607000000"/>
<signatureCode code="S"/>
<assignedEntity>
<id root="2.16.840.1.113883.3.3208.101.3" extension="20130607102400-Authenticator1"/>
<addr use="WP">
<streetAddressLine>5555 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)555-5555" use="WP"/>
<assignedPerson>
<name>
<given>Physician</given>
<family>Fifthly</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="19330316"/>
<high value="20130607"/>
</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="allergy1">No Information About Allergies</content>
</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<!-- Allergy Problem Act entry -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607104400-AllergyProblem"/>
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts"/>
<statusCode code="active"/>
<effectiveTime>
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN" nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<!-- Allergy - Intolerance Observation -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607105900-AllergyObservation"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD" nullFlavor="NI">
<originalText>
<reference value="#allergy1"/>
</originalText>
</value>
<participant typeCode="CSM">
<!-- Participant added to meet "SHOULD" and avoid validator warning -->
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code nullFlavor="NI">
<originalText>
<reference value="#allergy1"/>
</originalText>
</code>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="MFST" inversionInd="true">
<observation classCode="OBS" moodCode="EVN" nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.4.9"/>
<!-- Reaction Observation - added to meet "SHOULD" and avoid validator warning -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607151500-ReactionObservation"/>
<code nullFlavor="NI"/>
<text>
<reference value="#allergy1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD" code="183964008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Treatment not indicated"/>
<!-- using this SNOMED code to meet SHALL requirement for code -->
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN" nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<!-- Severity Observation -->
<code code="SEV" xsi:type="CE" nullFlavor="NI"/>
<text>
<reference value="#allergy1"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="255604002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Mild"/>
<!-- using this SNOMED code to meet SHALL requirement for code -->
</observation>
</entryRelationship>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<!-- Severity Observation - added to meet "SHOULD" and avoid validator warning -->
<code code="SEV" xsi:type="CE" nullFlavor="NI"/>
<text>
<reference value="#allergy1"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="255604002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Mild"/>
<!-- using this SNOMED code to meet SHALL requirement for code -->
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!-- Medication Section -->
<!-- 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="problems1">No Information About Problems</content>
</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
<!-- Problem Concern Act (Condition) -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607113300-ProblemConcern"/>
<code code="CONC" displayName="Concern" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass"/>
<statusCode code="active"/>
<effectiveTime>
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN" nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<!-- Problem Observation -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607113430-ProblemObservation"/>
<code nullFlavor="NI"/>
<text>
<reference value="#problems1"/>
</text>
<statusCode code="completed" />
<effectiveTime>
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD" nullFlavor="NI" />
</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">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
<!-- Procedure Activity Act-->
<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 nullFlavor="NI"/>
<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>
</act>
</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" nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.4.78"/>