| <?xml version="1.0"?> | |
| <?xml-stylesheet type="text/xsl" href="CDA.xsl"?> | |
| <!-- | |
| Readers should be aware of the evolving "Using SNOMED CT in HL7 Version 3" implementation guide, currently in a draft state. The guide, co-developed by HL7 and the College of American Pathologists, will be balloted by HL7 as an Informative Document. Recommendations in the final published guide should usurp patterns of SNOMED CT usage found in this sample instance. | |
| --> | |
| <ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd" classCode="DOCCLIN" moodCode="EVN"> | |
| <!-- | |
| ******************************************************** | |
| CDA Header | |
| ******************************************************** | |
| --> | |
| <!-- | |
| Original value - valid | |
| <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/> | |
| root, extension - invalid if not present. | |
| <typeId /> | |
| extension - Invalid - present but empty | |
| <typeId root="2.16.840.1.113883.1.3" extension=""/> | |
| --> | |
| <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/> | |
| <templateId root="2.16.840.1.113883.3.27.1776"/> | |
| <!-- | |
| root - Valid uid example | |
| <id extension="c266" root="2.16.840.1.113883.19.4"/> | |
| root - invalid uid example - fails all three patterns. | |
| <id extension="c266" root="100"/> | |
| extension, assigningAuthorityName - valid if not present | |
| <id root="2.16.840.1.113883.19.4"/> | |
| extension, assigningAuthorityName - invalid if present but empty | |
| <id root="2.16.840.1.113883.19.4" extension="" assigningAuthorityName="" /> | |
| extension, assigningAuthorityName - valid if present but have 1 or more characters | |
| <id root="2.16.840.1.113883.19.4" extension="c266" assigningAuthorityName="Test" /> | |
| --> | |
| <id root="2.16.840.1.113883.19.4" extension="c266" assigningAuthorityName="Test" /> | |
| <!-- Comment out for a bad value on CodeSystem - verifies the regular expression. | |
| - Original working version. | |
| <code code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Consultation note"/> | |
| - Valid codeSystem-uid (oid), matches first valid pattern. - | |
| <code code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Consultation note"/> | |
| - Invalid codeSystem, uid (oid)- first pattern and third pattern. | |
| <code code="11488-4" codeSystem="100" codeSystemName="LOINC" displayName="Consultation note"/> | |
| - Invalid codeSystem, uid (oid)- first pattern | |
| <code code="11488-4" codeSystem="3.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Consultation note"/> | |
| - Invalid codeSystem, uid (oid)- first pattern | |
| <code code="11488-4" codeSystem="2.01.840.1.113883.6.1" codeSystemName="LOINC" displayName="Consultation note"/> | |
| - Valid codeSystem-uid (uuid), matches second pattern. | |
| <code code="11488-4" codeSystem="0123abCD-1aBc-Z111-0111-0123456789zx" codeSystemName="LOINC" displayName="Consultation note"/> | |
| - Valid codeSystem-uid (uuid), Fails second pattern. | |
| <code code="11488-4" codeSystem="0123abCD-1aBc-Z111-0123456789zx" codeSystemName="LOINC" displayName="Consultation note"/> | |
| - Valid codeSystem-uid (ruid), matches third pattern | |
| <code code="11488-4" codeSystem="Ax-0-a-1-x-p1" codeSystemName="LOINC" displayName="Consultation note"/> | |
| - Valid codeSystem-uid (ruid), matches third pattern | |
| <code code="11488-4" codeSystem="A100" codeSystemName="LOINC" displayName="Consultation note"/> | |
| Checking codeSystemName, codeSystemVersion, displayName - Valid if all missing... | |
| <code code="11488-4" codeSystem="2.16.840.1.113883.6.1"/> | |
| Checking codeSystemName, codeSystemVersion, displayName - inValid if all present but empty... | |
| <code code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="" codeSystemVersion="" displayName=""/> | |
| Checking codeSystemName, codeSystemVersion, displayName - Valid if all present and have 1 or more characters... | |
| <code code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" codeSystemVersion="1" displayName="Consultation Note"/> | |
| --> | |
| <code code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" codeSystemVersion="1" displayName="Consultation Note"/> | |
| <!-- | |
| <title compression="DF" integrityCheckAlgorithm="SHA-1" representation="B64">Good Health Clinic Consultation Note</title> | |
| --> | |
| <!-- | |
| <title representation="TXT">Good Health Clinic Consultation Note</title> | |
| --> | |
| <title>Good Health Clinic Consultation Note</title> | |
| <!-- | |
| value - Valid time pattern.. This one is valid.. | |
| <effectiveTime value="20000407"/> | |
| value - Valid time pattern.. This one is valid.. | |
| <effectiveTime value="20000407010101"/> | |
| value - Valid time pattern.. This one is valid.. | |
| <effectiveTime value="20000407010101+1"/> | |
| value - Valid time pattern.. This one is valid.. | |
| <effectiveTime value="20000407010101-1000"/> | |
| value - Valid time pattern.. This one is valid.. | |
| <effectiveTime value="20000407010101.100-1000"/> | |
| value - invalid time pattern.. This one is invalid - it can only have 4 digits after the -. | |
| <effectiveTime value="20000407010101.100-10001"/> | |
| value - invalid time pattern.. This one is invalid - it has too many numbers for any of the valid patterns. | |
| <effectiveTime value="2000040701010101"/> | |
| value - invalid time pattern.. This one is invalid - it must have at least one digit. | |
| <effectiveTime value=""/> | |
| --> | |
| <effectiveTime value="20000407"/> | |
| <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> | |
| <languageCode code="en-US"/> | |
| <setId extension="BB35" root="2.16.840.1.113883.19.7"/> | |
| <versionNumber value="2"/> | |
| <!-- | |
| <recordTarget> | |
| <recordTarget typeCode="RCT" contextControlCode="OP"> | |
| --> | |
| <recordTarget typeCode="RCT" contextControlCode="OP"> | |
| <!-- | |
| <patientRole classCode="PAT"> | |
| <patientRole> | |
| --> | |
| <patientRole classCode="PAT"> | |
| <id extension="12345" root="2.16.840.1.113883.19.5"/> | |
| <!-- | |
| <patient> | |
| <patient classCode="PSN" determinerCode="INSTANCE"> | |
| --> | |
| <patient classCode="PSN" determinerCode="INSTANCE"> | |
| <name> | |
| <given>Henry</given> | |
| <family>Levin</family> | |
| <suffix>the 7th</suffix> | |
| </name> | |
| <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/> | |
| <birthTime value="19320924"/> | |
| <guardian classCode="GUARD"> | |
| <guardianPerson></guardianPerson> | |
| </guardian> | |
| <birthplace classCode="BIRTHPL"> | |
| <place classCode="PLC" determinerCode="INSTANCE"></place> | |
| </birthplace> | |
| </patient> | |
| <providerOrganization classCode="ORG" determinerCode="INSTANCE"> | |
| <id root="2.16.840.1.113883.19.5"/> | |
| <asOrganizationPartOf classCode="PART"></asOrganizationPartOf> | |
| </providerOrganization> | |
| </patientRole> | |
| </recordTarget> | |
| <author typeCode="AUT" contextControlCode="OP"> | |
| <time value="2000040714"/> | |
| <assignedAuthor classCode="ASSIGNED"> | |
| <realmCode code="1111" /> | |
| <!-- Uncomment this version to test failure condition | |
| <realmCode code="1111" codeSystem="11" codeSystemName="aa" codeSystemVersion="1" displayName="aa"> | |
| <originalText></originalText> | |
| <qualifier></qualifier> | |
| <translation></translation> | |
| </realmCode> | |
| --> | |
| <id extension="KP00017" root="2.16.840.1.113883.19.5"/> | |
| <code> | |
| <!-- Uncomment this to test that qualifier should not be allowed... | |
| <qualifier></qualifier> | |
| --> | |
| </code> | |
| <assignedPerson> | |
| <name> | |
| <given>Robert</given> | |
| <family>Dolin</family> | |
| <suffix>MD</suffix> | |
| </name> | |
| </assignedPerson> | |
| <!-- | |
| <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> | |
| <asMaintainedEntity classCode="MNT"> | |
| <maintainingPerson></maintainingPerson> | |
| </asMaintainedEntity> | |
| </assignedAuthoringDevice> | |
| --> | |
| <representedOrganization> | |
| <id root="2.16.840.1.113883.19.5"/> | |
| </representedOrganization> | |
| </assignedAuthor> | |
| </author> | |
| <dataEnterer typeCode="ENT" contextControlCode="OP"> | |
| <assignedEntity> | |
| <id/> | |
| </assignedEntity> | |
| </dataEnterer> | |
| <custodian typeCode="CST"> | |
| <assignedCustodian classCode="ASSIGNED"> | |
| <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE"> | |
| <id root="2.16.840.1.113883.19.5"/> | |
| <name>Good Health Clinic</name> | |
| </representedCustodianOrganization> | |
| </assignedCustodian> | |
| </custodian> | |
| <legalAuthenticator typeCode="LA" contextControlCode="OP"> | |
| <time value="20000408"/> | |
| <signatureCode code="S"/> | |
| <assignedEntity classCode="ASSIGNED"> | |
| <id extension="KP00017" root="2.16.840.1.113883.19.5"/> | |
| <assignedPerson> | |
| <name> | |
| <given>Robert</given> | |
| <family>Dolin</family> | |
| <suffix>MD</suffix> | |
| </name> | |
| </assignedPerson> | |
| <representedOrganization> | |
| <id root="2.16.840.1.113883.19.5"/> | |
| </representedOrganization> | |
| </assignedEntity> | |
| </legalAuthenticator> | |
| <authenticator typeCode="AUTHEN"> | |
| <time value="20000408"/> | |
| <signatureCode code="S"/> | |
| <assignedEntity classCode="ASSIGNED"> | |
| <id extension="KP00017" root="2.16.840.1.113883.19.5"/> | |
| <assignedPerson> | |
| <name> | |
| <given>Robert</given> | |
| <family>Dolin</family> | |
| <suffix>MD</suffix> | |
| </name> | |
| </assignedPerson> | |
| <representedOrganization> | |
| <id root="2.16.840.1.113883.19.5"/> | |
| </representedOrganization> | |
| </assignedEntity> | |
| </authenticator> | |
| <participant typeCode="ADM" contextControlCode="OP"> | |
| <associatedEntity classCode="ACCESS"></associatedEntity> | |
| </participant> | |
| <inFulfillmentOf typeCode="FLFS"> | |
| <!-- | |
| <order> | |
| <order classCode="ACT" moodCode="RQO"> | |
| --> | |
| <order classCode="ACT" moodCode="RQO"> | |
| <id/> | |
| </order> | |
| </inFulfillmentOf> | |
| <documentationOf typeCode="DOC"> | |
| <serviceEvent classCode="ACT" moodCode="EVN"></serviceEvent> | |
| </documentationOf> | |
| <relatedDocument typeCode="RPLC"> | |
| <parentDocument classCode="DOCCLIN" moodCode="EVN"> | |
| <id extension="a123" root="2.16.840.1.113883.19.4"/> | |
| <setId extension="BB35" root="2.16.840.1.113883.19.7"/> | |
| <versionNumber value="1"/> | |
| </parentDocument> | |
| </relatedDocument> | |
| <authorization typeCode="AUTH"> | |
| <consent classCode="CONS" moodCode="EVN"> | |
| <statusCode/> | |
| </consent> | |
| </authorization> | |
| <componentOf typeCode="COMP"> | |
| <encompassingEncounter classCode="ENC" moodCode="EVN"> | |
| <id extension="KPENC1332" root="2.16.840.1.113883.19.6"/> | |
| <effectiveTime value="20000407"/> | |
| <responsibleParty typeCode="RESP"> | |
| <assignedEntity> | |
| <id/> | |
| </assignedEntity> | |
| </responsibleParty> | |
| <encounterParticipant typeCode="CON"> | |
| <time value="20000407"/> | |
| <assignedEntity> | |
| <id extension="KP00017" root="2.16.840.1.113883.19.5"/> | |
| <assignedPerson> | |
| <name> | |
| <!-- Uncomment to get error for using "LS" | |
| <given qualifier="LS">Robert</given> | |
| <family qualifier="LS">Dolin</family> | |
| <suffix qualifier="LS">MD</suffix> | |
| <prefix qualifier="LS">Dr.</prefix> | |
| <delimiter qualifier="LS">TheDelim</delimiter> | |
| --> | |
| <given>Robert</given> | |
| <family>Dolin</family> | |
| <suffix>MD</suffix> | |
| </name> | |
| </assignedPerson> | |
| <representedOrganization> | |
| <id root="2.16.840.1.113883.19.5"/> | |
| </representedOrganization> | |
| </assignedEntity> | |
| </encounterParticipant> | |
| <location typeCode="LOC"> | |
| <healthCareFacility classCode="DSDLOC"> | |
| <code code="GIM" codeSystem="2.16.840.1.113883.5.10588" displayName="General internal medicine clinic"/> | |
| </healthCareFacility> | |
| </location> | |
| </encompassingEncounter> | |
| </componentOf> | |
| <!-- | |
| ******************************************************** | |
| CDA Body | |
| ******************************************************** | |
| --> | |
| <component typeCode="COMP" contextConductionInd="true"> | |
| <!-- | |
| <nonXMLBody classCode="DOCBODY" moodCode="EVN"> | |
| <text></text> | |
| </nonXMLBody> | |
| --> | |
| <structuredBody classCode="DOCBODY" moodCode="EVN"> | |
| <!-- | |
| ******************************************************** | |
| History of Present Illness section | |
| ******************************************************** | |
| --> | |
| <component typeCode="COMP" contextConductionInd="true"> | |
| <section classCode="DOCSECT" moodCode="EVN"> | |
| <code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |
| <title>History of Present Illness</title> | |
| <text> | |
| <content styleCode="Bold">Henry Levin, the 7<sup>th</sup> | |
| </content> is a 67 year old male referred for further asthma management. Onset of asthma in his <content revised="delete">twenties</content> | |
| <content revised="insert">teens</content>. He was hospitalized twice last year, and already twice this year. He has not been able to be weaned off steroids for the past several months. | |
| </text> | |
| </section> | |
| </component> | |
| <!-- | |
| ******************************************************** | |
| Past Medical History section | |
| ******************************************************** | |
| --> | |
| <component> | |
| <section> | |
| <code code="10153-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |
| <title>Past Medical History</title> | |
| <text> | |
| <list> | |
| <item> | |
| <content ID="a1">Asthma</content> | |
| </item> | |
| <item> | |
| <content ID="a2">Hypertension (see HTN.cda for details)</content> | |
| </item> | |
| <item> | |
| <content ID="a3">Osteoarthritis, | |
| <content ID="a4">right knee</content> | |
| </content> | |
| </item> | |
| </list> | |
| </text> | |
| <entry typeCode="DRIV" contextConductionInd="true"> | |
| <observation classCode="COND" moodCode="EVN"> | |
| <!-- | |
| Original - Valid. | |
| <code code="195967001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Asthma"> | |
| Checking codeSystemName, displayName, codeSystemVersion - all valid. | |
| <code code="195967001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" codeSystemVersion="1" displayName="Asthma"> | |
| Checking codeSystemName, displayName, codeSystemVersion - all invalid - it should give three errors stating that the value '' must be march one of {'.+'} | |
| <code code="195967001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="" codeSystemVersion="" displayName=""> | |
| Checking codeSystemName, displayName, codeSystemVersion - all valid - if not present at all, then it should not check regular expression support. | |
| <code code="195967001" codeSystem="2.16.840.1.113883.6.96"> | |
| code - valid - cannot have any spaces... | |
| <code code="195967001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Asthma"> | |
| code - invalid - code has spaces in it. | |
| <code code="195967001 11" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Asthma"> | |
| --> | |
| <code code="195967001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Asthma"> | |
| <originalText> | |
| <reference value="#a1"/> | |
| </originalText> | |
| </code> | |
| <!-- | |
| languange, mediaType Valid values for both. Text with no spaces. | |
| <text language="english" mediaType="text/xml"/> | |
| languange, mediaType invalid values for both. These are tokens - they cannot have spaces. | |
| <text language="english one" mediaType="text/xml one"/> | |
| --> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="1950"/> | |
| <value xsi:type="EIVL.event" code="AC" codeSystem="2.16.840.1.113883.5.139" codeSystemName="TimingEvent" codeSystemVersion="1" displayName="AC"/> | |
| <informant typeCode="INF" contextControlCode="OP"> | |
| <relatedEntity classCode="AGNT"> | |
| <relatedPerson classCode="PSN" determinerCode="INSTANCE"></relatedPerson> | |
| </relatedEntity> | |
| </informant> | |
| <reference typeCode="XCRPT"> | |
| <!-- | |
| <externalAct classCode="ACCM" moodCode="EVN"> | |
| </externalAct> | |
| --> | |
| <externalObservation classCode="ALRT" moodCode="EVN"> | |
| <id root="2.16.840.1.113883.19.1.2765"/> | |
| </externalObservation> | |
| <!-- | |
| <externalProcedure classCode="PROC" moodCode="EVN"> | |
| </externalProcedure> | |
| --> | |
| <!-- | |
| <externalDocument classCode="DOCCLIN" moodCode="EVN"> | |
| </externalDocument> | |
| --> | |
| </reference> | |
| <referenceRange typeCode="REFV"> | |
| <observationRange classCode="OBS" moodCode="EVN.CRT"></observationRange> | |
| </referenceRange> | |
| </observation> | |
| <!-- | |
| <organizer moodCode="EVN" classCode="BATTERY"> | |
| <statusCode></statusCode> | |
| <component typeCode="COMP" contextConductionInd="true"> | |
| <supply moodCode="EVN" classCode="SPLY"> | |
| <product typeCode="PRD"> | |
| <manufacturedProduct> | |
| <manufacturedLabeledDrug></manufacturedLabeledDrug> | |
| </manufacturedProduct> | |
| </product> | |
| </supply> | |
| </component> | |
| </organizer> | |
| --> | |
| </entry> | |
| <entry> | |
| <observation classCode="COND" moodCode="EVN"> | |
| <code code="59621000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="HTN"> | |
| <originalText> | |
| <reference value="#a2"/> | |
| </originalText> | |
| </code> | |
| <statusCode code="completed"/> | |
| <reference typeCode="SPRT"> | |
| <seperatableInd value="false"/> | |
| <externalDocument> | |
| <id root="2.16.840.1.113883.19.4.789"/> | |
| <text mediaType="multipart/related"> | |
| <reference value="HTN.cda"/> | |
| </text> | |
| <setId root="2.16.840.1.113883.19.7.2465"/> | |
| <versionNumber value="1"/> | |
| </externalDocument> | |
| </reference> | |
| <reference typeCode="XCRPT"> | |
| <externalObservation> | |
| <id root="2.16.840.1.113883.19.1.2005"/> | |
| </externalObservation> | |
| </reference> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="COND" moodCode="EVN"> | |
| <code xsi:type="CD" code="396275006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Osteoarthritis"> | |
| <originalText> | |
| <reference value="#a3"/> | |
| </originalText> | |
| </code> | |
| <statusCode code="completed"/> | |
| <targetSiteCode code="49076000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Knee joint"> | |
| <originalText> | |
| <reference value="#a4"/> | |
| </originalText> | |
| <qualifier> | |
| <name code="78615007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="with laterality"/> | |
| <value code="24028007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="right"/> | |
| </qualifier> | |
| </targetSiteCode> | |
| <reference typeCode="XCRPT"> | |
| <externalObservation> | |
| <id root="2.16.840.1.113883.19.1.1805"/> | |
| </externalObservation> | |
| </reference> | |
| </observation> | |
| </entry> | |
| </section> | |
| </component> | |
| <!-- | |
| ******************************************************** | |
| Medications section | |
| ******************************************************** | |
| --> | |
| <component> | |
| <section> | |
| <code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |
| <title>Medications</title> | |
| <text> | |
| <list> | |
| <item>Theodur 200mg BID</item> | |
| <item>Proventil inhaler 2puffs QID PRN</item> | |
| <item>Prednisone 20mg qd</item> | |
| <item>HCTZ 25mg qd</item> | |
| </list> | |
| </text> | |
| <entry> | |
| <substanceAdministration classCode="SBADM" moodCode="EVN"> | |
| <text>Theodur 200mg BID</text> | |
| <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true"> | |
| <period value="12" unit="h"/> | |
| </effectiveTime> | |
| <routeCode code="PO" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration"/> | |
| <doseQuantity value="200" unit="mg"/> | |
| <maxDoseQuantity> | |
| <numerator value="100"></numerator> | |
| <denominator value="200"></denominator> | |
| </maxDoseQuantity> | |
| <specimen typeCode="SPC"> | |
| <specimenRole classCode="SPEC"> | |
| <specimenPlayingEntity classCode="ANM" determinerCode="INSTANCE"></specimenPlayingEntity> | |
| </specimenRole> | |
| </specimen> | |
| <consumable typeCode="CSM"> | |
| <manufacturedProduct classCode="MANU"> | |
| <manufacturedLabeledDrug classCode="MMAT" determinerCode="KIND"> | |
| <code code="66493003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Theophylline"/> | |
| </manufacturedLabeledDrug> | |
| <!-- | |
| <manufacturedMaterial classCode="MMAT" determinerCode="KIND"> | |
| </manufacturedMaterial> | |
| --> | |
| </manufacturedProduct> | |
| </consumable> | |
| <entryRelationship typeCode="CAUS"> | |
| <supply moodCode="EVN" classCode="SPLY"> | |
| <text integrityCheckAlgorithm="SHA-1"> | |
| <thumbnail> | |
| <!-- Uncomment to test for thumbnail_thumbnail constraint... | |
| <thumbnail></thumbnail> | |
| --> | |
| </thumbnail> | |
| </text> | |
| <!-- | |
| unit - Valid Value - Token - value can be set of any characters except white space. | |
| <quantity unit="100"> | |
| unit - invalid Value - Token - value can be set of any characters except white space. | |
| <quantity unit="100 100"> | |
| --> | |
| <quantity unit="1"> | |
| <!-- | |
| codeSystem - Valid uid | |
| <translation code="100" codeSystem="1.1"/> | |
| codeSystem - Invalid uid - all three patterns | |
| <translation code="100" codeSystem="100"/> | |
| codeSystemName, codeSystemVersion, displayName - Valid if all missing. | |
| <translation code="100" codeSystem="1.1"/> | |
| codeSystemName, codeSystemVersion, displayName - invalid if present but empty. | |
| <translation code="100" codeSystem="1.1" codeSystemName="" codeSystemVersion="" displayName="" /> | |
| codeSystemName, codeSystemVersion, displayName - valid if present and have one or more characters. | |
| <translation code="100" codeSystem="1.1" codeSystemName="Test" codeSystemVersion="1" displayName="Test2" /> | |
| --> | |
| <translation code="100" codeSystem="1.1" codeSystemName="Test" codeSystemVersion="1" displayName="Test2" /> | |
| </quantity> | |
| </supply> | |
| </entryRelationship> | |
| <reference typeCode="REFR"> | |
| <externalObservation></externalObservation> | |
| </reference> | |
| </substanceAdministration> | |
| </entry> | |
| <entry> | |
| <substanceAdministration classCode="SBADM" moodCode="EVN"> | |
| <text>Proventil inhaler 2puffs QID PRN</text> | |
| <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true"> | |
| <period value="6" unit="h"/> | |
| </effectiveTime> | |
| <priorityCode code="PRN"/> | |
| <routeCode code="IPINHL" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration" displayName="Inhalation, oral"/> | |
| <doseQuantity value="2"/> | |
| <consumable> | |
| <manufacturedProduct> | |
| <manufacturedLabeledDrug> | |
| <code code="91143003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Albuterol"/> | |
| </manufacturedLabeledDrug> | |
| </manufacturedProduct> | |
| </consumable> | |
| </substanceAdministration> | |
| </entry> | |
| <entry> | |
| <substanceAdministration classCode="SBADM" moodCode="EVN"> | |
| <id root="2.16.840.1.113883.19.8.1"/> | |
| <text>Prednisone 20mg qd</text> | |
| <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true"> | |
| <period value="24" unit="h"/> | |
| </effectiveTime> | |
| <routeCode code="PO" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration"/> | |
| <doseQuantity value="20" unit="mg"/> | |
| <consumable> | |
| <manufacturedProduct> | |
| <manufacturedLabeledDrug> | |
| <code code="10312003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Prednisone preparation"/> | |
| </manufacturedLabeledDrug> | |
| </manufacturedProduct> | |
| </consumable> | |
| </substanceAdministration> | |
| </entry> | |
| <entry> | |
| <substanceAdministration classCode="SBADM" moodCode="EVN"> | |
| <text>HCTZ 25mg qd</text> | |
| <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true"> | |
| <period value="24" unit="h"/> | |
| </effectiveTime> | |
| <routeCode code="PO" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration"/> | |
| <consumable> | |
| <manufacturedProduct> | |
| <manufacturedLabeledDrug> | |
| <code code="376209006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hydrochlorothiazide 25mg tablet"/> | |
| </manufacturedLabeledDrug> | |
| </manufacturedProduct> | |
| </consumable> | |
| </substanceAdministration> | |
| </entry> | |
| </section> | |
| </component> | |
| <!-- | |
| ******************************************************** | |
| Allergies & Adverse Reactions section | |
| ******************************************************** | |
| --> | |
| <component> | |
| <section> | |
| <code code="10155-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |
| <title>Allergies and Adverse Reactions</title> | |
| <text> | |
| <list> | |
| <item>Penicillin - Hives</item> | |
| <item>Aspirin - Wheezing</item> | |
| <item>Codeine - Itching and nausea</item> | |
| </list> | |
| </text> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code xsi:type="CD" code="247472004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hives"/> | |
| <statusCode code="completed"/> | |
| <entryRelationship typeCode="MFST"> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code xsi:type="CD" code="91936005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Allergy to penicillin"/> | |
| <statusCode code="completed"/> | |
| </observation> | |
| </entryRelationship> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="56018004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Wheezing"/> | |
| <statusCode code="completed"/> | |
| <entryRelationship typeCode="MFST"> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="293586001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Allergy to aspirin"/> | |
| <statusCode code="completed"/> | |
| </observation> | |
| </entryRelationship> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="32738000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Pruritis"/> | |
| <statusCode code="completed"/> | |
| <entryRelationship typeCode="MFST"> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <id root="2.16.840.1.113883.19.1.2010"/> | |
| <code code="62014003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Adverse reaction to drug"> | |
| <qualifier> | |
| <name code="246075003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="causative agent"/> | |
| <value code="1476002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="codeine"/> | |
| </qualifier> | |
| </code> | |
| <statusCode code="completed"/> | |
| </observation> | |
| </entryRelationship> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="73879007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Nausea"/> | |
| <statusCode code="completed"/> | |
| <entryRelationship typeCode="MFST"> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <id root="2.16.840.1.113883.19.1.2010"/> | |
| <code code="84100007" codeSystem="2.16.840.1.113883.6.96"/> | |
| </observation> | |
| </entryRelationship> | |
| </observation> | |
| </entry> | |
| </section> | |
| </component> | |
| <!-- | |
| ******************************************************** | |
| Family History section | |
| ******************************************************** | |
| --> | |
| <component> | |
| <section> | |
| <code code="10157-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |
| <title>Family history</title> | |
| <text> | |
| <list> | |
| <item>Father had fatal MI in his early 50's.</item> | |
| <item>No cancer or diabetes.</item> | |
| </list> | |
| </text> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="22298006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="MI"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="1970"/> | |
| <subject typeCode="SBJ" contextControlCode="OP"> | |
| <relatedSubject classCode="PRS"> | |
| <code code="FTH" codeSystem="2.16.840.1.113883.5.111"/> | |
| <subject classCode="PSN" determinerCode="INSTANCE"></subject> | |
| </relatedSubject> | |
| </subject> | |
| <entryRelationship typeCode="CAUS"> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="399347008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="death"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="1970"/> | |
| </observation> | |
| </entryRelationship> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN" negationInd="true"> | |
| <code code="275937001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Family history of cancer"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime> | |
| <high value="20000407" inclusive="true"/> | |
| </effectiveTime> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="160274005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="No family history of diabetes"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime> | |
| <high value="20000407" inclusive="true"/> | |
| </effectiveTime> | |
| </observation> | |
| </entry> | |
| </section> | |
| </component> | |
| <!-- | |
| ******************************************************** | |
| Social History section | |
| ******************************************************** | |
| --> | |
| <component> | |
| <section> | |
| <code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |
| <title>Social History</title> | |
| <text> | |
| <list> | |
| <item>Smoking :: 1 PPD between the ages of 20 and 55, and then he quit.</item> | |
| <item>Alcohol :: rare</item> | |
| </list> | |
| </text> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="266924008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="ex-heavy cigarette smoker (20-39/day)"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime> | |
| <low value="1955"/> | |
| <high value="1990"/> | |
| </effectiveTime> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="160625004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Date ceased smoking"/> | |
| <statusCode code="completed"/> | |
| <value xsi:type="TS" value="1990"/> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="266917007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Trivial drinker - less than 1/day"/> | |
| <statusCode code="completed"/> | |
| </observation> | |
| </entry> | |
| </section> | |
| </component> | |
| <!-- | |
| ******************************************************** | |
| Physical Exam section | |
| ******************************************************** | |
| --> | |
| <component> | |
| <section> | |
| <code code="11384-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |
| <title>Physical Examination</title> | |
| <!-- | |
| ******************************************************** | |
| Physical Exam - Vital Signs | |
| ******************************************************** | |
| --> | |
| <component> | |
| <section> | |
| <code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |
| <title>Vital Signs</title> | |
| <text> | |
| <table> | |
| <tbody> | |
| <tr> | |
| <th>Date / Time</th> | |
| <th>April 7, 2000 14:30</th> | |
| <th>April 7, 2000 15:30</th> | |
| </tr> | |
| <tr> | |
| <th>Height</th> | |
| <td>177 cm (69.7 in)</td> | |
| </tr> | |
| <tr> | |
| <th>Weight</th> | |
| <td>194.0 lbs (88.0 kg)</td> | |
| </tr> | |
| <tr> | |
| <th>BMI</th> | |
| <td>28.1 kg/m2</td> | |
| </tr> | |
| <tr> | |
| <th>BSA</th> | |
| <td>2.05 m2</td> | |
| </tr> | |
| <tr> | |
| <th>Temperature</th> | |
| <td>36.9 C (98.5 F)</td> | |
| <td>36.9 C (98.5 F)</td> | |
| </tr> | |
| <tr> | |
| <th>Pulse</th> | |
| <td>86 / minute</td> | |
| <td>84 / minute</td> | |
| </tr> | |
| <tr> | |
| <th>Rhythm</th> | |
| <td>Regular</td> | |
| <td>Regular</td> | |
| </tr> | |
| <tr> | |
| <th>Respirations</th> | |
| <td>16 / minute, unlabored</td> | |
| <td>14 / minute</td> | |
| </tr> | |
| <tr> | |
| <th>Systolic</th> | |
| <td>132 mmHg</td> | |
| <td>135 mmHg</td> | |
| </tr> | |
| <tr> | |
| <th>Diastolic</th> | |
| <td>86 mmHg</td> | |
| <td>88 mmHg</td> | |
| </tr> | |
| <tr> | |
| <th>Position / Cuff</th> | |
| <td>Left Arm</td> | |
| <td>Left Arm</td> | |
| </tr> | |
| </tbody> | |
| </table> | |
| </text> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="50373000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Body height measure"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071430"/> | |
| <value xsi:type="PQ" value="1.77" unit="m"> | |
| <translation value="69.7" code="[in_I]" codeSystem="2.16.840.1.113883.6.8" codeSystemName="UCUM"/> | |
| </value> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="363808001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Body weight measure"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071430"/> | |
| <value xsi:type="PQ" value="194.0" unit="[lb_ap]"> | |
| <translation value="88.0" code="kg" codeSystem="2.16.840.1.113883.6.8" codeSystemName="UCUM"/> | |
| </value> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="60621009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Body mass index"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071430"/> | |
| <value xsi:type="RTO_PQ_PQ"> | |
| <numerator value="28.1" unit="kg"/> | |
| <denominator value="1" unit="ar"/> | |
| </value> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="301898006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Body surface area"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071430"/> | |
| <value xsi:type="PQ" value="2.05" unit="ar"/> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="386725007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Body temperature"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071430"/> | |
| <value xsi:type="PQ" value="36.9" unit="Cel"> | |
| <translation value="98.5" code="[degF]" codeSystem="2.16.840.1.113883.6.8" codeSystemName="UCUM"/> | |
| </value> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="364075005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Heart rate"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071430"/> | |
| <value xsi:type="RTO_PQ_PQ"> | |
| <numerator value="86"/> | |
| <denominator value="1" unit="min"/> | |
| </value> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="364075005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Heart rate"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071530"/> | |
| <value xsi:type="RTO_PQ_PQ"> | |
| <numerator value="84"/> | |
| <denominator value="1" unit="min"/> | |
| </value> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="364074009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Regularity of heart rhythm"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071430"/> | |
| <value xsi:type="CD" code="248649006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Heart regular"/> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="364074009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Regularity of heart rhythm"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071530"/> | |
| <value xsi:type="CD" code="248649006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Heart regular"/> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="86290005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Respiratory rate"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071430"/> | |
| <value xsi:type="RTO_PQ_PQ"> | |
| <numerator value="16"/> | |
| <denominator value="1" unit="min"/> | |
| </value> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="276362002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Breathing easily"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071430"/> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="86290005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Respiratory rate"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071530"/> | |
| <value xsi:type="RTO_PQ_PQ"> | |
| <numerator value="14"/> | |
| <denominator value="1" unit="min"/> | |
| </value> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="251076008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Cuff blood pressure"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071430"/> | |
| <targetSiteCode code="368208006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Left arm"/> | |
| <entryRelationship typeCode="COMP"> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="271649006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Systolic BP"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071530"/> | |
| <value xsi:type="PQ" value="132" unit="mm[Hg]"/> | |
| </observation> | |
| </entryRelationship> | |
| <entryRelationship typeCode="COMP"> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="271650006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Diastolic BP"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071530"/> | |
| <value xsi:type="PQ" value="86" unit="mm[Hg]"/> | |
| </observation> | |
| </entryRelationship> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="251076008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Cuff blood pressure"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071530"/> | |
| <targetSiteCode code="368208006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Left arm"/> | |
| <entryRelationship typeCode="COMP"> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="271649006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Systolic BP"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071530"/> | |
| <value xsi:type="PQ" value="135" unit="mm[Hg]"/> | |
| </observation> | |
| </entryRelationship> | |
| <entryRelationship typeCode="COMP"> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="271650006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Diastolic BP"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071530"/> | |
| <value xsi:type="PQ" value="88" unit="mm[Hg]"/> | |
| </observation> | |
| </entryRelationship> | |
| </observation> | |
| </entry> | |
| </section> | |
| </component> | |
| <!-- | |
| ******************************************************** | |
| Physical Exam - Skin | |
| ******************************************************** | |
| --> | |
| <component> | |
| <section> | |
| <code code="8709-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |
| <title>Skin Exam</title> | |
| <text>Erythematous rash, palmar surface, left index finger. | |
| <renderMultiMedia referencedObject="MM1"/> | |
| </text> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="271807003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Rash"/> | |
| <statusCode code="completed"/> | |
| <methodCode code="32750006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Inspection"/> | |
| <targetSiteCode code="48856004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Skin of palmer surface of index finger"> | |
| <qualifier> | |
| <name code="78615007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="with laterality"/> | |
| <value code="7771000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="left"/> | |
| </qualifier> | |
| </targetSiteCode> | |
| <entryRelationship typeCode="SPRT"> | |
| <regionOfInterest classCode="ROIOVL" moodCode="EVN" ID="MM1"> | |
| <id root="2.16.840.1.113883.19.3.1"/> | |
| <code code="ELLIPSE"/> | |
| <value value="3"/> | |
| <value value="1"/> | |
| <value value="3"/> | |
| <value value="7"/> | |
| <value value="2"/> | |
| <value value="4"/> | |
| <value value="4"/> | |
| <value value="4"/> | |
| <entryRelationship typeCode="SUBJ"> | |
| <observationMedia classCode="OBS" moodCode="EVN"> | |
| <id root="2.16.840.1.113883.19.2.1"/> | |
| <value mediaType="image/gif"> | |
| <reference value="lefthand.gif"/> | |
| </value> | |
| </observationMedia> | |
| </entryRelationship> | |
| </regionOfInterest> | |
| </entryRelationship> | |
| </observation> | |
| </entry> | |
| </section> | |
| </component> | |
| <!-- | |
| ******************************************************** | |
| Physical Exam - Lungs | |
| ******************************************************** | |
| --> | |
| <component> | |
| <section> | |
| <code code="8710-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |
| <title>Lungs</title> | |
| <text>Clear with no wheeze. Good air flow.</text> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="48348007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Chest clear"/> | |
| <statusCode code="completed"/> | |
| <methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN" negationInd="true"> | |
| <code code="56018004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Wheezing"/> | |
| <statusCode code="completed"/> | |
| <methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/> | |
| </observation> | |
| </entry> | |
| </section> | |
| </component> | |
| <!-- | |
| ******************************************************** | |
| Physical Exam - Cardiac | |
| ******************************************************** | |
| --> | |
| <component typeCode="COMP" contextConductionInd="true"> | |
| <section> | |
| <code code="10223-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |
| <title>Cardiac</title> | |
| <text>RRR with no murmur, no S3, no S4.</text> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="76863003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Normal heart rate"/> | |
| <statusCode code="completed"/> | |
| <methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN" negationInd="true"> | |
| <code code="88610006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="heart murmur"/> | |
| <statusCode code="completed"/> | |
| <methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN" negationInd="true"> | |
| <code code="277455002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Third heart sound"/> | |
| <statusCode code="completed"/> | |
| <methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="60721002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Fourth heart sound inaudible"/> | |
| <statusCode code="completed"/> | |
| <methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/> | |
| </observation> | |
| </entry> | |
| </section> | |
| </component> | |
| </section> | |
| </component> | |
| <!-- | |
| ******************************************************** | |
| Labs section | |
| ******************************************************** | |
| --> | |
| <component> | |
| <section> | |
| <code code="11502-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |
| <title>Labs</title> | |
| <text> | |
| <list> | |
| <item>CXR 02/03/1999: Hyperinflated. Normal cardiac silhouette, clear lungs.</item> | |
| <item>Peak Flow today: 260 l/m</item> | |
| </list> | |
| </text> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <code code="282290005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Imaging interpretation"/> | |
| <statusCode code="completed"/> | |
| <entryRelationship typeCode="COMP"> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <id root="2.16.840.1.113883.19.1.3005"/> | |
| <code code="249674001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Chest hyperinflated"/> | |
| </observation> | |
| </entryRelationship> | |
| <entryRelationship typeCode="COMP"> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <id root="2.16.840.1.113883.19.1.5505"/> | |
| <code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" nullFlavor="OTH"> | |
| <originalText>normal cardiac silhouette</originalText> | |
| </code> | |
| </observation> | |
| </entryRelationship> | |
| <entryRelationship typeCode="COMP"> | |
| <observation classCode="OBS" moodCode="EVN" negationInd="true"> | |
| <id root="2.16.840.1.113883.19.1.6675"/> | |
| <code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" nullFlavor="OTH"> | |
| <originalText>radiopacities</originalText> | |
| </code> | |
| </observation> | |
| </entryRelationship> | |
| <reference typeCode="SPRT"> | |
| <externalObservation classCode="DGIMG"> | |
| <id root="2.16.840.1.113883.19.1.14"/> | |
| <code code="56350004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Chest-X-ray"/> | |
| </externalObservation> | |
| </reference> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="EVN"> | |
| <id root="2.16.840.1.113883.19.1.7005"/> | |
| <code code="313193002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Peak flow"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="20000407"/> | |
| <value xsi:type="RTO_PQ_PQ"> | |
| <numerator value="260" unit="l"/> | |
| <denominator value="1" unit="min"/> | |
| </value> | |
| </observation> | |
| </entry> | |
| </section> | |
| </component> | |
| <!-- | |
| ******************************************************** | |
| In-office Procedure section | |
| ******************************************************** | |
| --> | |
| <component> | |
| <section> | |
| <code code="29554-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |
| <title>In-office Procedures</title> | |
| <text> | |
| <list> | |
| <item>Suture removal, left forearm.</item> | |
| </list> | |
| </text> | |
| <entry> | |
| <procedure classCode="PROC" moodCode="EVN"> | |
| <code code="30549001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Suture removal"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071430"/> | |
| <targetSiteCode code="66480008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Left forearm"/> | |
| <performer typeCode="PRF"> | |
| <assignedEntity> | |
| <id/> | |
| </assignedEntity> | |
| </performer> | |
| <participant typeCode="ADM" contextControlCode="OP"> | |
| <participantRole></participantRole> | |
| </participant> | |
| </procedure> | |
| </entry> | |
| </section> | |
| </component> | |
| <!-- | |
| ******************************************************** | |
| Assessment section | |
| ******************************************************** | |
| --> | |
| <component> | |
| <section> | |
| <code code="11496-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |
| <title>Assessment</title> | |
| <text> | |
| <list> | |
| <item>Asthma, with prior smoking history. Difficulty weaning off steroids. Will try gradual taper.</item> | |
| <item>Hypertension, well-controlled.</item> | |
| <item>Contact dermatitis on finger.</item> | |
| </list> | |
| </text> | |
| <entry> | |
| <observation classCode="COND" moodCode="EVN"> | |
| <code code="14657009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Established diagnosis"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071530"/> | |
| <value xsi:type="CD" code="195967001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Asthma"> | |
| <translation code="49390" codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD9CM" displayName="ASTHMA W/O STATUS ASTHMATICUS"/> | |
| </value> | |
| <reference typeCode="ELNK"> | |
| <externalObservation classCode="COND"> | |
| <id root="2.16.840.1.113883.19.1.35"/> | |
| </externalObservation> | |
| </reference> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="COND" moodCode="EVN"> | |
| <code code="14657009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Established diagnosis"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071530"/> | |
| <value xsi:type="CD" code="59621000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Essential hypertension"> | |
| <translation code="4019" codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD9CM" displayName="HYPERTENSION NOS"/> | |
| </value> | |
| <reference typeCode="ELNK"> | |
| <externalObservation classCode="COND"> | |
| <id root="2.16.840.1.113883.19.1.37"/> | |
| </externalObservation> | |
| </reference> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <observation classCode="COND" moodCode="EVN"> | |
| <code code="14657009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Established diagnosis"/> | |
| <statusCode code="completed"/> | |
| <effectiveTime value="200004071530"/> | |
| <value xsi:type="CD" code="40275004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Contact dermatitis"> | |
| <translation code="692.9" codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD9CM" displayName="Contact Dermatitis, NOS"/> | |
| </value> | |
| <targetSiteCode code="48856004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Skin of palmer surface of index finger"> | |
| <qualifier> | |
| <name code="78615007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="with laterality"/> | |
| <value code="7771000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="left"/> | |
| </qualifier> | |
| </targetSiteCode> | |
| </observation> | |
| </entry> | |
| </section> | |
| </component> | |
| <!-- | |
| ******************************************************** | |
| Plan section | |
| ******************************************************** | |
| --> | |
| <component> | |
| <section> | |
| <templateId root="2.16.840.1.113883.3.27.354"/> | |
| <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |
| <title>Plan</title> | |
| <text> | |
| <list> | |
| <item>Complete PFTs with lung volumes.</item> | |
| <item>Chem-7 tomorrow.</item> | |
| <item>Teach peak flow rate measurement.</item> | |
| <item>Decrease prednisone to 20qOD alternating with 18qOD.</item> | |
| <item>Hydrocortisone cream to finger BID.</item> | |
| <item>RTC 1 week.</item> | |
| </list> | |
| </text> | |
| <entry> | |
| <act classCode="ACT" moodCode="INT"> | |
| <id/> | |
| <code code="23426006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Pulmonary function test"/> | |
| <text>Complete PFTs with lung volumes.</text> | |
| <entryRelationship typeCode="COMP"> | |
| <act classCode="ACT" moodCode="INT"> | |
| <code code="252472004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Lung volume test"/> | |
| </act> | |
| </entryRelationship> | |
| </act> | |
| </entry> | |
| <entry> | |
| <observation classCode="OBS" moodCode="INT"> | |
| <code code="24320-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"> | |
| <originalText>Chem-7</originalText> | |
| <translation code="aYU7t6" codeSystem="2.16.840.1.113883.19.278.47" codeSystemName="MyLocalCodeSystem" displayName="Chem7"/> | |
| </code> | |
| <text>Chem-7 tomorrow</text> | |
| <effectiveTime value="20000408"/> | |
| </observation> | |
| </entry> | |
| <entry> | |
| <act classCode="ACT" moodCode="INT"> | |
| <id/> | |
| <code code="223468009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Teaching of skills"> | |
| <qualifier> | |
| <name code="363702006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="has focus"/> | |
| <value code="29893006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Peak flow rate measurement"/> | |
| </qualifier> | |
| </code> | |
| </act> | |
| </entry> | |
| <entry> | |
| <substanceAdministration classCode="SBADM" moodCode="RQO"> | |
| <text>prednisone 20qOD alternating with 18qOD.</text> | |
| <routeCode code="PO" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration"/> | |
| <consumable> | |
| <manufacturedProduct> | |
| <manufacturedLabeledDrug> | |
| <code code="10312003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Prednisone preparation"/> | |
| </manufacturedLabeledDrug> | |
| </manufacturedProduct> | |
| </consumable> | |
| </substanceAdministration> | |
| </entry> | |
| <entry> | |
| <substanceAdministration classCode="SBADM" moodCode="RQO"> | |
| <text>Hydrocortisone cream to finger BID.</text> | |
| <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true"> | |
| <period value="12" unit="h"/> | |
| </effectiveTime> | |
| <routeCode code="SKIN" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration" displayName="Topical application, skin"/> | |
| <approachSiteCode code="48856004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Skin of palmer surface of index finger"> | |
| <qualifier> | |
| <name code="78615007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="with laterality"/> | |
| <value code="7771000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="left"/> | |
| </qualifier> | |
| </approachSiteCode> | |
| <consumable> | |
| <manufacturedProduct> | |
| <manufacturedLabeledDrug> | |
| <code code="331646005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hydrocortisone cream"/> | |
| </manufacturedLabeledDrug> | |
| </manufacturedProduct> | |
| </consumable> | |
| </substanceAdministration> | |
| </entry> | |
| <entry> | |
| <encounter classCode="ENC" moodCode="RQO"> | |
| <!-- | |
| codeSystem: valid value | |
| <code code="185389009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Follow-up visit"/> | |
| codeSystem: invalid value - Fails all three patterns. | |
| <code code="185389009" codeSystem="100" codeSystemName="SNOMED CT" displayName="Follow-up visit"/> | |
| --> | |
| <code code="185389009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Follow-up visit"/> | |
| <effectiveTime> | |
| <low value="20000412"/> | |
| <high value="20000417"/> | |
| </effectiveTime> | |
| <participant typeCode="ADM"> | |
| <participantRole> | |
| <playingDevice classCode="CER" determinerCode="INSTANCE"> | |
| <!-- | |
| codeSystem - valid | |
| <manufacturerModelName code="100" codeSystem="1.1"></manufacturerModelName> | |
| codeSystem - inValid | |
| <manufacturerModelName code="100" codeSystem="100"></manufacturerModelName> | |
| codeSystemName, codeSystemVersion, displayName - valid if none present | |
| <manufacturerModelName code="100" codeSystem="1.1"></manufacturerModelName> | |
| codeSystemName, codeSystemVersion, displayName - invalid if present but empty | |
| <manufacturerModelName code="100" codeSystem="1.1" codeSystemName="" codeSystemVersion="" displayName=""/> | |
| codeSystemName, codeSystemVersion, displayName - valid if present and have one or more characters | |
| <manufacturerModelName code="100" codeSystem="1.1" codeSystemName="Test" codeSystemVersion="1" displayName="TestName"/> | |
| code - valid if value has no white space. | |
| <manufacturerModelName code="100" codeSystem="1.1" codeSystemName="Test" codeSystemVersion="1" displayName="TestName"/> | |
| code - invalid if value has white space. | |
| <manufacturerModelName code="100 11" codeSystem="1.1" codeSystemName="Test" codeSystemVersion="1" displayName="TestName"/> | |
| --> | |
| <manufacturerModelName code="100" codeSystem="1.1" codeSystemName="Test" codeSystemVersion="1" displayName="TestName"/> | |
| </playingDevice> | |
| <scopingEntity classCode="ANM" determinerCode="INSTANCE"> | |
| </scopingEntity> | |
| </participantRole> | |
| </participant> | |
| <precondition typeCode="PRCN"> | |
| <criterion classCode="ALRT" moodCode="EVN.CRT"></criterion> | |
| </precondition> | |
| </encounter> | |
| </entry> | |
| </section> | |
| </component> | |
| </structuredBody> | |
| </component> | |
| </ClinicalDocument> |