<?xml version="1.0"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!--
Title: US_Realm_Header_Template
Revision History:
01/31/2011 bam created
07/29/2011 RWM modified
11/26/2011 RWM modified
08/12/2012 RWM modified
09/12/2012 BNR(Dragon) modified
-->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 ../../../CDA%20R2/cda-schemas-and-samples/infrastructure/cda/CDA.xsd"
xmlns="urn:hl7-org:v3"
xmlns:cda="urn:hl7-org:v3"
xmlns:sdtc="urn:hl7-org:sdtc">
<!--
********************************************************
CDA Header
********************************************************
-->
<!-- CONF 16791 -->
<realmCode
code="US"/>
<!-- CONF 5361 -->
<typeId
root="2.16.840.1.113883.1.3"
extension="POCD_HD000040"/>
<!-- US General Header Template -->
<!-- CONF 5252 -->
<templateId
root="2.16.840.1.113883.10.20.22.1.1"/>
<!-- *** Note: The next templateId, code and title will differ depending on what type of document is being sent. *** -->
<!-- conforms to the document specific requirements -->
<templateId
root="2.16.840.1.113883.10.20.22.1.2"/>
<!-- CONF 5363 -->
<id
extension="Test CCDA"
root="1.1.1.1.1.1.1.1.1"/>
<!-- CONF 5253 "CCD document" -->
<code
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
code="34133-9"
displayName="Summarization of Episode Note"/>
<!-- CONF 5254 -->
<title>Community Health and Hospitals: Health Summary</title>
<!-- CONF 5256 -->
<effectiveTime
value="20120912000000-0000"/>
<!-- 5259 -->
<confidentialityCode
code="N"
codeSystem="2.16.840.1.113883.5.25"/>
<!-- 5372 -->
<languageCode
code="en-US"/>
<!-- CONF 5266 -->
<recordTarget>
<!-- CONF 5267 -->
<patientRole>
<!-- CONF 5268-->
<id
extension="1"
root="2.16.840.1.113883.4.6"/>
<!-- Fake ID using HL7 example OID. -->
<!-- Patient SSN recorded as an ID -->
<id
extension="123-101-5230"
root="2.16.840.1.113883.4.1"/>
<!-- CONF 5271 -->
<addr
use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Drive</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<!-- CONF 5280 -->
<telecom
value="tel:(816)276-6909"
use="HP"/>
<!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<!-- CONF 5283 -->
<patient>
<!-- CONF 5284 -->
<name
use="L">
<!-- L is "Legal" from HL7 EntityNameUse 2.16.840.1.113883.5.45 -->
<given>Myra</given>
<!-- CL is "Call me" from HL7 EntityNamePartQualifier 2.16.840.1.113883.5.43 -->
<family>Jones</family>
</name>
<administrativeGenderCode
code="F"
codeSystem="2.16.840.1.113883.5.1"
displayName="Female"/>
<birthTime
value="19470501"/>
<maritalStatusCode
code="M"
displayName="Married"
codeSystem="2.16.840.1.113883.5.2"
codeSystemName="MaritalStatusCode"/>
<religiousAffiliationCode
code="1013"
displayName="Christian (non-Catholic, non-specific)"
codeSystemName="HL7 Religious Affiliation "
codeSystem="2.16.840.1.113883.5.1076"/>
<!-- Need to Fix the Race Code to be from the OMB Standards -->
<raceCode
code="2106-3"
displayName="White"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="Race and Ethnicity - CDC"/>
<ethnicGroupCode
code="2186-5"
displayName="Not Hispanic or Latino"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="Race and Ethnicity - CDC"/>
<guardian>
<code
code="GPARNT"
displayName="Grandfather"
codeSystem="2.16.840.1.113883.5.111"
codeSystemName="HL7 Role code"/>
<addr
use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Drive</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom
value="tel:(816)276-6909"
use="HP"/>
<guardianPerson>
<name>
<given>Ralph</given>
<family>Jones</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
</place>
</birthplace>
<!-- FIX the Code System to be 639.2 -->
<languageCommunication>
<languageCode
code="eng"/>
<modeCode
code="ESP"
displayName="Expressed spoken"
codeSystem="2.16.840.1.113883.5.60"
codeSystemName="LanguageAbilityMode"/>
<preferenceInd
value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id
root="1.1.1.1.1.1.1.1.4"/>
<name>Community Health and Hospitals</name>
<telecom
use="WP"
value="tel: 555-555-5000"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time
value="20050813000000+0500"/>
<assignedAuthor>
<id
extension="111111"
root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
use="WP"
value="tel:555-555-1002"/>
<assignedPerson>
<name>
<prefix>Dr</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id
root="2.16.840.1.113883.4.6"
extension="999999943252"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
use="WP"
value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Mary</given>
<family>McDonald</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<informant>
<assignedEntity>
<id
extension="KP00017"
root="2.16.840.1.113883.19.5"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
use="WP"
value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</informant>
<informant>
<relatedEntity
classCode="PRS">
<!-- classCode PRS represents a person with personal relationship with the patient. -->
<code
code="SPS"
displayName="SPOUSE"
codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<relatedPerson>
<name>
<given>Frank</given>
<family>Jones</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id
extension="99999999"
root="2.16.840.1.113883.4.6"/>
<name>Community Health and Hospitals</name>
<telecom
value="tel: 555-555-1002"
use="WP"/>
<addr
use="WP">
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</informationRecipient>
<receivedOrganization>
<name>Community Health and Hospitals</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<time
value="20120813"/>
<signatureCode
code="S"/>
<assignedEntity>
<id
extension="999999999"
root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
use="WP"
value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<authenticator>
<time
value="20120813"/>
<signatureCode
code="S"/>
<assignedEntity>
<id
extension="999999999"
root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
use="WP"
value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<participant typeCode="IND">
<associatedEntity classCode="PRS">
<code
code="GPARNT"
displayName="Grand Parent"
codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<addr
use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Drive</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value='tel:(555)555-2006' use='WP'/>
<associatedPerson>
<name>
<prefix>Mr.</prefix>
<given>Ralph</given>
<family>Jones</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<participant typeCode="IND">
<associatedEntity classCode="PRS">
<code
code="SPS"
displayName="SPOUSE"
codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<addr
use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Drive</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value='tel:(555)555-2006' use='WP'/>
<associatedPerson>
<name>
<prefix>Mr.</prefix>
<given>Frank</given>
<family>Jones</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<documentationOf
typeCode="DOC">
<serviceEvent
classCode="PCPR">
<code
code="233604007"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT"
displayName="Pnuemonia"/>
<effectiveTime>
<low
value="20120806"/>
<high
value="20120813"/>
</effectiveTime>
<performer
typeCode="PRF">
<functionCode
code="PP"
displayName="Primary Care Provider"
codeSystem="2.16.840.1.113883.12.443"
codeSystemName="Provider Role">
<originalText>Primary Care Provider</originalText>
</functionCode>
<time>
<low
value="20120806"/>
<high
value="20120813"/>
</time>
<assignedEntity>
<id
extension="PseudoMD-1"
root="2.16.840.1.113883.4.6"/>
<code
code="208D00000X"
displayName="General Practice"
codeSystemName="Provider Codes"
codeSystem="2.16.840.1.113883.6.101"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
value="tel:+1-555-555-5000"
use="WP"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom
value="tel:+1-555-555-5000"
use="WP"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
<performer
typeCode="PRF">
<functionCode
code="PP"
displayName="Primary Care Provider"
codeSystem="2.16.840.1.113883.12.443"
codeSystemName="Provider Role">
<originalText>Primary Care Provider</originalText>
</functionCode>
<time>
<low
value="20120806"/>
<high
value="20120813"/>
</time>
<assignedEntity>
<id
extension="PseudoMD-3"
root="2.16.840.1.113883.4.6"/>
<code
code="208D00000X"
displayName="General Practice"
codeSystemName="Provider Codes"
codeSystem="2.16.840.1.113883.6.101"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
value="tel:+1-555-555-5000"
use="HP"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom
value="tel:+1-555-555-5000"
use="HP"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<componentOf>
<encompassingEncounter>
<id extension="1" root="2.16.840.1.113883.4.6"/>
<code
code="233604007"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT"
displayName="Pnuemonia"/>
<effectiveTime>
<low
value="20120806"/>
<high
value="20120813"/>
</effectiveTime>
<responsibleParty>
<assignedEntity>
<id root="2.16.840.1.113883.4.6"/>
<assignedPerson>
<name>
<prefix>Dr</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</responsibleParty>
<encounterParticipant typeCode="ATND">
<assignedEntity>
<id root="2.16.840.1.113883.4.6"/>
<assignedPerson>
<name>
<prefix>Dr</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</encounterParticipant>
<location>
<healthCareFacility>
<id root="2.16.840.1.113883.4.6"/>
</healthCareFacility>
</location>
</encompassingEncounter>
</componentOf>
<!-- ********************************************************
CDA Body
******************************************************** -->
<component>
<structuredBody>
<!-- *********************** -->
<!--
********************************************************
Allergies, Adverse Reactions, Alerts
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.6.1"/>
<!-- Alerts section template -->
<code
code="48765-2"
codeSystem="2.16.840.1.113883.6.1"/>
<title>ALLERGIES, ADVERSE REACTIONS, ALERTS</title>
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Substance</th>
<th>Reaction</th>
<th>Severity</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Penicillin G benzathine</td>
<td><content
ID="reaction1">Hives</content></td>
<td><content
ID="severity1">Moderate to severe</content></td>
<td>Inactive</td>
</tr>
<tr>
<td>Codeine</td>
<td><content
ID="reaction2">Shortness of Breath</content></td>
<td><content
ID="severity2">Moderate</content></td>
<td>Active</td>
</tr>
<tr>
<td>Aspirin</td>
<td><content
ID="reaction3">Hives</content></td>
<td><content
ID="severity3">Mild to moderate</content></td>
<td>Active</td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<act
classCode="ACT"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.30"/>
<!-- ** Allergy problem act ** -->
<id
root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code
code="48765-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Allergies, adverse reactions, alerts"/>
<statusCode
code="completed"/>
<effectiveTime
value="20070501">
<low
value="20070501"/>
<high
value="20120806"/>
</effectiveTime>
<entryRelationship
typeCode="SUBJ">
<observation
classCode="OBS"
moodCode="EVN">
<!-- allergy observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.7"/>
<id
root="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
<code
code="ASSERTION"
codeSystem="2.16.840.1.113883.5.4"/>
<statusCode
code="completed"/>
<effectiveTime>
<low nullFlavor="UNK"/>
<high value="20120806"/>
</effectiveTime>
<value
xsi:type="CD"
code="419511003"
displayName="Propensity to adverse reaction to drug"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT">
<originalText>
<reference
value="#reaction1"/>
</originalText>
</value>
<participant
typeCode="CSM">
<participantRole
classCode="MANU">
<playingEntity
classCode="MMAT">
<code
code="7982"
displayName="Penicillin G benzathine"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm">
<originalText>
<reference
value="#reaction1"/>
</originalText>
</code>
</playingEntity>
</participantRole>
</participant>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.28"/>
<!-- Allergy status observation template -->
<code
code="33999-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Status"/>
<statusCode
code="completed"/>
<value
xsi:type="CE"
code="73425007"
codeSystem="2.16.840.1.113883.6.96"
displayName="Inactive"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="MFST"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.9"/>
<!-- Reaction observation template -->
<id
root="4adc1020-7b14-11db-9fe1-0800200c9a64"/>
<code
nullFlavor="NA"/>
<text>
<reference
value="#reaction1"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20070501"/>
</effectiveTime>
<value
xsi:type="CD"
code="247472004"
codeSystem="2.16.840.1.113883.6.96"
displayName="Hives"/>
</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 template ** -->
<code xsi:type="CE"
code="SEV"
displayName="Severity Observation"
codeSystem="2.16.840.1.113883.5.4"
codeSystemName="ActCode"/>
<text>
<reference
value="#severity1"/>
</text>
<statusCode
code="completed"/>
<value
xsi:type="CD"
code="371924009"
displayName="Moderate to severe"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
<entry
typeCode="DRIV">
<act
classCode="ACT"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.30"/>
<!-- ** Allergy problem act ** -->
<id
root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code
code="48765-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Allergies, adverse reactions, alerts"/>
<statusCode
code="completed"/>
<effectiveTime
value="20060501">
<low
value="20060501"/>
<high
value="20120806"/>
</effectiveTime>
<entryRelationship
typeCode="SUBJ">
<observation
classCode="OBS"
moodCode="EVN">
<!-- allergy observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.7"/>
<id
root="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
<code
code="ASSERTION"
codeSystem="2.16.840.1.113883.5.4"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20060501"/>
</effectiveTime>
<value
xsi:type="CD"
code="419511003"
displayName="Propensity to adverse reaction to drug"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT">
<originalText>
<reference
value="#reaction2"/>
</originalText>
</value>
<participant
typeCode="CSM">
<participantRole
classCode="MANU">
<playingEntity
classCode="MMAT">
<code
code="2670"
displayName="Codeine"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm">
<originalText>
<reference
value="#reaction2"/>
</originalText>
</code>
</playingEntity>
</participantRole>
</participant>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.28"/>
<!-- Allergy status observation template -->
<code
code="33999-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Status"/>
<statusCode
code="completed"/>
<value
xsi:type="CE"
code="55561003"
codeSystem="2.16.840.1.113883.6.96"
displayName="Active"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="MFST"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.9"/>
<!-- Reaction observation template -->
<id
root="4adc1020-7b14-11db-9fe1-0800200c9a64"/>
<code
nullFlavor="NA"/>
<text>
<reference
value="#reaction2"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20060501"/>
</effectiveTime>
<value
xsi:type="CD"
code="267036007"
codeSystem="2.16.840.1.113883.6.96"
displayName="Shortness of Breath"/>
</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 template ** -->
<code xsi:type="CE"
code="SEV"
displayName="Severity Observation"
codeSystem="2.16.840.1.113883.5.4"
codeSystemName="ActCode"/>
<text>
<reference
value="#severity2"/>
</text>
<statusCode
code="completed"/>
<value
xsi:type="CD"
code="6736007"
displayName="Moderate"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
<entry
typeCode="DRIV">
<act
classCode="ACT"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.30"/>
<!-- ** Allergy problem act ** -->
<id
root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code
code="48765-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Allergies, adverse reactions, alerts"/>
<statusCode
code="completed"/>
<effectiveTime
value="20080501">
<low
value="20080501"/>
<high
value="20120806"/>
</effectiveTime>
<entryRelationship
typeCode="SUBJ">
<observation
classCode="OBS"
moodCode="EVN">
<!-- allergy observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.7"/>
<id
root="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
<code
code="ASSERTION"
codeSystem="2.16.840.1.113883.5.4"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20080501"/>
<high value="20120806"/>
</effectiveTime>
<value
xsi:type="CD"
code="419511003"
displayName="Propensity to adverse reaction to drug"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT">
<originalText>
<reference
value="#reaction3"/>
</originalText>
</value>
<participant
typeCode="CSM">
<participantRole
classCode="MANU">
<playingEntity
classCode="MMAT">
<code
code="1191"
displayName="Aspirin"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm">
<originalText>
<reference
value="#reaction3"/>
</originalText>
</code>
</playingEntity>
</participantRole>
</participant>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.28"/>
<!-- Allergy status observation template -->
<code
code="33999-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Status"/>
<statusCode
code="completed"/>
<value
xsi:type="CE"
code="55561003"
codeSystem="2.16.840.1.113883.6.96"
displayName="Active"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="MFST"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.9"/>
<!-- Reaction observation template -->
<id
root="4adc1020-7b14-11db-9fe1-0800200c9a64"/>
<code
nullFlavor="NA"/>
<text>
<reference
value="#reaction3"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20080501"/>
</effectiveTime>
<value
xsi:type="CD"
code="247472004"
codeSystem="2.16.840.1.113883.6.96"
displayName="Hives"/>
</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 template ** -->
<code xsi:type="CE"
code="SEV"
displayName="Severity Observation"
codeSystem="2.16.840.1.113883.5.4"
codeSystemName="ActCode"/>
<text>
<reference
value="#severity3"/>
</text>
<statusCode
code="completed"/>
<value
xsi:type="CD"
code="371923003"
displayName="Mild to moderate"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!--
********************************************************
ENCOUNTERS
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.22.1"/>
<!-- Encounters Section - required entries -->
<code
code="46240-8"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="History of encounters"/>
<title>ENCOUNTERS</title>
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Encounter</th>
<th>Performer</th>
<th>Location</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<content
ID="Encounter1"/> Pnuemonia</td>
<td>Dr Henry Seven</td>
<td>Community Health and Hospitals</td>
<td>20120806</td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<encounter
classCode="ENC"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.49"/>
<!-- Encounter Activities -->
<!-- ******** Encounter activity template ******** -->
<id
root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code
code="99222"
displayName="InPatient Admission"
codeSystemName="CPT"
codeSystem="2.16.840.1.113883.6.12"
codeSystemVersion="4">
<originalText>Mild Fever<reference
value="#Encounter1"/>
</originalText>
</code>
<effectiveTime
value="20120806"/>
<performer>
<assignedEntity>
<id
root="2a620155-9d11-439e-92a3-5d9815ff4de8"/>
<code
code="59058001"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="General Physician"/>
</assignedEntity>
</performer>
<participant
typeCode="LOC">
<participantRole
classCode="SDLOC">
<templateId
root="2.16.840.1.113883.10.20.22.4.32"/>
<!-- Service Delivery Location template -->
<code
code="1160-1"
codeSystem="2.16.840.1.113883.6.259"
codeSystemName="HealthcareServiceLocation"
displayName="Urgent Care Center"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
nullFlavor="UNK"/>
<playingEntity
classCode="PLC">
<name>Community Health and Hospitals</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship
typeCode="RSON">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.19"/>
<id
root="db734647-fc99-424c-a864-7e3cda82e703"
extension="45665"/>
<code
code="404684003"
displayName="Finding"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20120806"/>
</effectiveTime>
<value
xsi:type="CD"
code="233604007"
displayName="Pneumonia"
codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="SUBJ" inversionInd="false">
<act classCode="ACT" moodCode="EVN">
<!--Encounter diagnosis act -->
<templateId root="2.16.840.1.113883.10.20.22.4.80"/>
<id root="5a784260-6856-4f38-9638-80c751aff2fb"/>
<code xsi:type="CE"
code="29308-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="ENCOUNTER DIAGNOSIS"/>
<statusCode code="active"/>
<effectiveTime>
<low value="20120806"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<observation classCode="OBS" moodCode="EVN" negationInd="false">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<!-- Problem Observation -->
<id
root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code
code="409586006"
codeSystem="2.16.840.1.113883.6.96"
displayName="Complaint"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20120806"/>
</effectiveTime>
<value
xsi:type="CD"
code="233604007"
codeSystem="2.16.840.1.113883.6.96"
displayName="Pneumonia"/>
</observation>
</entryRelationship>
</act>
</entryRelationship>
</encounter>
</entry>
</section>
</component>
<!--
********************************************************
IMMUNIZATIONS
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.2.1"/>
<!-- Entries Required -->
<!-- ******** Immunizations section template ******** -->
<code
code="11369-6"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="History of immunizations"/>
<title>IMMUNIZATIONS</title>
<text><content
ID="immunSect"/>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Vaccine</th>
<th>Date</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td><content
ID="immun2"/>Influenza virus vaccine, IM</td>
<td>May 2012</td>
<td>Completed</td>
</tr>
<tr>
<td><content
ID="immun4"/>Tetanus and diphtheria toxoids, IM</td>
<td>Apr 2012</td>
<td>Completed</td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<substanceAdministration
classCode="SBADM"
moodCode="EVN"
negationInd="false">
<templateId
root="2.16.840.1.113883.10.20.22.4.52"/>
<!-- ******** Immunization activity template ******** -->
<id
root="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92"/>
<text>
<reference
value="#immun2"/>
</text>
<statusCode
code="completed"/>
<effectiveTime
xsi:type="IVL_TS"
value="20120510"/>
<routeCode
code="C28161"
codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="National Cancer Institute (NCI) Thesaurus"
displayName="Intramuscular injection"/>
<doseQuantity
value="50"
unit="mcg"/>
<consumable>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.54"/>
<!-- ******** Immunization Medication Information ******** -->
<manufacturedMaterial>
<code
code="88"
codeSystem="2.16.840.1.113883.6.59"
displayName="Influenza virus vaccine"
codeSystemName="CVX">
<originalText>Influenza virus vaccine</originalText>
<translation
code="111"
displayName="influenza, live, intranasal"
codeSystemName="CVX"
codeSystem="2.16.840.1.113883.6.59"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Health LS - Immuno Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<entryRelationship
typeCode="SUBJ" inversionInd="true">
<act
classCode="ACT"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.20"/>
<!-- ** Instructions Template ** -->
<code xsi:type="CE"
code="171044003"
codeSystem="2.16.840.1.113883.6.96"
displayName="immunization education"/>
<text><reference
value="#immunSect"/>Possible flu-like symptoms for three days.</text>
<statusCode
code="completed"/>
</act>
</entryRelationship>
</substanceAdministration>
</entry>
<entry
typeCode="DRIV">
<substanceAdministration
classCode="SBADM"
moodCode="EVN"
negationInd="false">
<templateId
root="2.16.840.1.113883.10.20.22.4.52"/>
<!-- ******** Immunization activity template ******** -->
<id
root="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92"/>
<text>
<reference
value="#immun4"/>
</text>
<statusCode
code="completed"/>
<effectiveTime
xsi:type="IVL_TS"
value="20120401"/>
<routeCode
code="C28161"
codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="National Cancer Institute (NCI) Thesaurus"
displayName="Intramuscular injection"/>
<doseQuantity
value="50"
unit="mcg"/>
<consumable>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.54"/>
<!-- ******** Immunization Medication Information ******** -->
<manufacturedMaterial>
<code
code="103"
codeSystem="2.16.840.1.113883.6.59"
displayName="Tetanus and diphtheria toxoids - preservative free"
codeSystemName="CVX">
<originalText>Tetanus and diphtheria toxoids - preservative free</originalText>
<translation
code="09"
displayName="Tetanus and diphtheria toxoids - preservative free"
codeSystemName="CVX"
codeSystem="2.16.840.1.113883.6.59"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Health LS - Immuno Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<act
classCode="ACT"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.20"/>
<!-- ** Instructions Template ** -->
<code xsi:type="CE"
code="171044003"
codeSystem="2.16.840.1.113883.6.96"
displayName="immunization education"/>
<text><reference
value="#immunSect"/>Possible flu-like symptoms for three days.</text>
<statusCode
code="completed"/>
</act>
</entryRelationship>
</substanceAdministration>
</entry>
</section>
</component>
<!--
********************************************************
MEDICATIONS
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.1.1"/>
<code
code="10160-0"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="HISTORY OF MEDICATION USE"/>
<title>Medications</title>
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Medication</th>
<th>Directions</th>
<th>Start Date</th>
<th>Status</th>
<th>Indications</th>
<th>Fill Instructions</th>
</tr>
</thead>
<tbody>
<tr>
<td><content
ID="Med1">Albuterol 0.09 MG/ACTUAT inhalant solution</content></td>
<td>0.09 MG/ACTUAT inhalant solution, 2 puffs once</td>
<td>20120806</td>
<td>Active</td>
<td>Pneumonia (233604007 SNOMED CT)</td>
<td><content ID="FillIns">Generic Substitition Allowed</content></td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<substanceAdministration
classCode="SBADM"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.16"/>
<!-- ** MEDICATION ACTIVITY -->
<id
root="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/>
<text>
<reference
value="#Med1"/>0.09 MG/ACTUAT inhalant solution, 2 puffs </text>
<statusCode
code="completed"/>
<effectiveTime
xsi:type="IVL_TS">
<low
value="20120806"/>
<high
value="20120813"/>
</effectiveTime>
<effectiveTime
xsi:type="PIVL_TS"
institutionSpecified="true"
operator="A">
<period
value="12"
unit="h"/>
</effectiveTime>
<routeCode
code="C38216"
codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="NCI Thesaurus"
displayName="RESPIRATORY (INHALATION)"/>
<doseQuantity
value="0.09"
unit="mg/actuat"/>
<rateQuantity
value="90"
unit="ml/min"/>
<administrationUnitCode
code="C42944"
displayName="INHALANT"
codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="NCI Thesaurus"/>
<consumable>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.23"/>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code
code="573621"
codeSystem="2.16.840.1.113883.6.88"
displayName="Albuterol 0.09 MG/ACTUAT inhalant solution">
<originalText><reference
value="#Med1"/></originalText>
<translation
code="573621"
displayName="Proventil 0.09 MG/ACTUAT inhalant solution"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Medication Factory Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<performer>
<assignedEntity>
<id
nullFlavor="NI"/>
<addr
nullFlavor="UNK"/>
<telecom
nullFlavor="UNK"/>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom
nullFlavor="UNK"/>
<addr
nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
<participant
typeCode="CSM">
<participantRole
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.24"/>
<code
code="412307009"
displayName="drug vehicle"
codeSystem="2.16.840.1.113883.6.96"/>
<playingEntity
classCode="MMAT">
<code
code="324049"
displayName="Aerosol"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
<name>Aerosol</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship
typeCode="RSON">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.19"/>
<id
root="db734647-fc99-424c-a864-7e3cda82e703"
extension="45665"/>
<code
code="404684003"
displayName="Finding"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
<statusCode
code="completed"/>
<effectiveTime>
<low nullFlavor="UNK" />
<high value="20120813"/>
</effectiveTime>
<value
xsi:type="CD"
code="233604007"
displayName="Pneumonia"
codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="REFR">
<supply
classCode="SPLY"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.17"/>
<id
nullFlavor="NI"/>
<statusCode
code="completed"/>
<effectiveTime
xsi:type="IVL_TS">
<low
value="20120806"/>
<high
value="20120813"/>
</effectiveTime>
<repeatNumber
value="1"/>
<quantity
value="75"/>
<product>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.23"/>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code
code="573621"
codeSystem="2.16.840.1.113883.6.88"
displayName="Albuterol 0.09 MG/ACTUAT inhalant solution">
<originalText><reference
value="#Med1"/></originalText>
<translation
code="573621"
displayName="Albuterol 0.09 MG/ACTUAT inhalant solution"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Medication Factory Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</product>
<performer>
<assignedEntity>
<id
extension="2981823"
root="2.16.840.1.113883.19.5.9999.456"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</assignedEntity>
</performer>
<author>
<time
nullFlavor="UNK"/>
<assignedAuthor>
<id
root="2a620155-9d11-439e-92b3-5d9815fe4de8"/>
<addr
nullFlavor="UNK"/>
<telecom
nullFlavor="UNK"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<act
classCode="ACT"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.20"/>
<!-- ** Instructions Template ** -->
<code xsi:type="CE"
code="409073007"
codeSystem="2.16.840.1.113883.6.96"
displayName="instruction"/>
<text><reference
value="#FillIns"/>label in spanish</text>
<statusCode
code="completed"/>
</act>
</entryRelationship>
</supply>
</entryRelationship>
<entryRelationship
typeCode="REFR">
<supply
classCode="SPLY"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.18"/>
<!-- ** Medication Dispense Template ** -->
<id
root="1.2.3.4.56789.1"
extension="cb734647-fc99-424c-a864-7e3cda82e704"/>
<statusCode
code="completed"/>
<effectiveTime
value="20120806"/>
<repeatNumber
value="1"/>
<product>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.23"/>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code
code="573621"
codeSystem="2.16.840.1.113883.6.88"
displayName="Albuterol 0.09 MG/ACTUAT inhalant solution">
<originalText><reference
value="#Med1"/></originalText>
<translation
code="573621"
displayName="Albuterol 0.09 MG/ACTUAT inhalant solution"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Medication Factory Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</product>
<performer>
<time
nullFlavor="UNK"/>
<assignedEntity>
<id
root="2.16.840.1.113883.19.5.9999.456"
extension="2981823"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
nullFlavor="UNK"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom
nullFlavor="UNK"/>
<addr
nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
</supply>
</entryRelationship>
<precondition
typeCode="PRCN">
<templateId
root="2.16.840.1.113883.10.20.22.4.25"/>
<criterion>
<code
code="ASSERTION"
codeSystem="2.16.840.1.113883.5.4"/>
<value
xsi:type="CE"
code="56018004"
codeSystem="2.16.840.1.113883.6.96"
displayName="Wheezing"/>
</criterion>
</precondition>
</substanceAdministration>
</entry>
</section>
</component>
<!--
********************************************************
CARE PLAN
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.10"/>
<!-- **** Plan of Care section template **** -->
<code
code="18776-5"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Treatment plan"/>
<title>CARE PLAN</title>
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Planned Activity</th>
<th>Planned Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>Consultation with Dr George Potomac for Asthma</td>
<td>20120820</td>
</tr>
<tr>
<td>Chest X-ray</td>
<td>20120826</td>
</tr>
<tr>
<td>Sputum Culture</td>
<td>20120820</td>
</tr>
</tbody>
</table>
</text>
<entry>
<encounter
moodCode="INT"
classCode="ENC">
<templateId
root="2.16.840.1.113883.10.20.22.4.40"/>
<!-- **** Plan of Care Activity Encounter template **** -->
<id
root="9a6d1bac-17d3-4195-89a4-1121bc809b4d"/>
<code
code="99241"
displayName="Office consultation - 15 minutes"
codeSystemName="CPT"
codeSystem="2.16.840.1.113883.6.12"/>
<effectiveTime>
<center value="20120820"/>
</effectiveTime>
<entryRelationship
typeCode="SUBJ" inversionInd="true">
<act
classCode="ACT"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.20"/>
<!-- ** Instructions Template ** -->
<code xsi:type="CE"
code="409073007"
codeSystem="2.16.840.1.113883.6.96"
displayName="instruction"/>
<text>Follow up with Dr George Potomac for Asthma</text>
<statusCode
code="completed"/>
</act>
</entryRelationship>
</encounter>
</entry>
<entry>
<procedure
moodCode="RQO"
classCode="PROC">
<templateId
root="2.16.840.1.113883.10.20.22.4.41"/>
<!-- ** Plan of Care Activity Procedure template ** -->
<id
root="9a6d1bac-17d3-4195-89c4-1121bc809b5a"/>
<code
code="168731009"
codeSystem="2.16.840.1.113883.6.96"
displayName="Chest X-Ray"
codeSystemName="SNOMED-CT"/>
<statusCode
code="new"/>
<effectiveTime>
<center
value="20120826"/>
</effectiveTime>
</procedure>
</entry>
<entry
typeCode="DRIV">
<observation
classCode="OBS"
moodCode="RQO">
<templateId
root="2.16.840.1.113883.10.20.22.4.44"/>
<!-- Plan of Care Activity Observation template -->
<id
root="9a6d1bac-17d3-4195-89a4-1121bc809b4a"/>
<code
code="624-7"
codeSystem="2.16.840.1.113883.6.1"
displayName="Sputum Culture"/>
<statusCode
code="new"/>
<effectiveTime>
<center
value="20120820"/>
</effectiveTime>
</observation>
</entry>
</section>
</component>
<!--
********************************************************
HOSPITAL DISCHARGE MEDICATIONS
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.11.1"/>
<!-- Entries Required -->
<!-- Hospital Discharge Summary templateId -->
<code
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
code="10183-2"
displayName=" HOSPITAL DISCHARGE MEDICATIONS "/>
<title>HOSPITAL DISCHARGE MEDICATIONS</title>
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Medication</th>
<th>Directions</th>
<th>Start Date</th>
<th>Status</th>
<th>Indications</th>
<th>Fill Instructions</th>
</tr>
</thead>
<tbody>
<tr>
<td><content ID="DM">120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler</content></td>
<td><content ID="DM1">0.11 MG/ACTUAT Metered Dose Once Daily</content></td>
<td>20120813</td>
<td>Active</td>
<td>Bronchitis (32398004 SNOMED CT)</td>
<td><content ID="FillIns_DM">Generic Substitition Allowed</content></td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<act
classCode="ACT"
moodCode="EVN">
<!-- Discharge Medication Entry -->
<templateId
root="2.16.840.1.113883.10.20.22.4.35"/>
<id
root="5a784260-6856-4f38-9638-80c751aff2fb"/>
<code
code="10183-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Discharge medication"/>
<statusCode
code="active"/>
<effectiveTime>
<low value="20120813"/>
<high value="20120813"/>
</effectiveTime>
<entryRelationship
typeCode="SUBJ">
<substanceAdministration
classCode="SBADM"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.16"/>
<!-- ** MEDICATION ACTIVITY -->
<id
root="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/>
<text>
<reference
value="#DM1"/>0.11 MG/ACTUAT Metered Dose Once Daily </text>
<statusCode
code="completed"/>
<effectiveTime
xsi:type="IVL_TS">
<low value="20120813"/>
<high value="20120813"/>
</effectiveTime>
<effectiveTime
xsi:type="PIVL_TS"
institutionSpecified="true"
operator="A">
<period
value="24"
unit="h"/>
</effectiveTime>
<routeCode
code="C38216"
codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="NCI Thesaurus"
displayName="RESPIRATORY (INHALATION)"/>
<doseQuantity
value="1"
unit="mg/actuat"/>
<rateQuantity
value="110"
unit="ml/min"/>
<maxDoseQuantity
nullFlavor="UNK">
<numerator
nullFlavor="UNK"/>
<denominator
nullFlavor="UNK"/>
</maxDoseQuantity>
<administrationUnitCode
code="C42944"
displayName="INHALANT"
codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="NCI Thesaurus"/>
<consumable>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.23"/>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code
code="896001"
codeSystem="2.16.840.1.113883.6.88"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler">
<originalText><reference
value="#DM"/></originalText>
<translation
code="896001"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Medication Factory Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<performer>
<assignedEntity>
<id
nullFlavor="NI"/>
<addr
nullFlavor="UNK"/>
<telecom
nullFlavor="UNK"/>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5.9999.1395"/>
<name>Community Health and Hospitals</name>
<telecom
nullFlavor="UNK"/>
<addr
nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
<participant
typeCode="CSM">
<participantRole
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.24"/>
<code
code="412307009"
displayName="drug vehicle"
codeSystem="2.16.840.1.113883.6.96"/>
<playingEntity
classCode="MMAT">
<code
code="324049"
displayName="Aerosol"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
<name>Aerosol</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship
typeCode="RSON">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.19"/>
<id
root="db734647-fc99-424c-a864-7e3cda82e703"
extension="45665"/>
<code
code="404684003"
displayName="Finding"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20110113"/>
</effectiveTime>
<value
xsi:type="CD"
code="32398004"
displayName="Bronchitis"
codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="REFR">
<supply
classCode="SPLY"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.17"/>
<id
nullFlavor="NI"/>
<statusCode
code="completed"/>
<effectiveTime
xsi:type="IVL_TS">
<low
value="20120813"/>
<high
nullFlavor="UNK"/>
</effectiveTime>
<repeatNumber
value="1"/>
<quantity
value="75"/>
<product>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.23"/>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code
code="896001"
codeSystem="2.16.840.1.113883.6.88"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler">
<originalText><reference
value="#DM"/></originalText>
<translation
code="896001"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Medication Factory Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</product>
<performer>
<assignedEntity>
<id
extension="2981825"
root="2.16.840.1.113883.19.5.9999.456"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</assignedEntity>
</performer>
<author>
<time
nullFlavor="UNK"/>
<assignedAuthor>
<id
root="2a620155-9d11-439e-92b3-5d9815fe4de8"/>
<addr
nullFlavor="UNK"/>
<telecom
nullFlavor="UNK"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<act
classCode="ACT"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.20"/>
<!-- ** Instructions Template ** -->
<code xsi:type="CE"
code="409073007"
codeSystem="2.16.840.1.113883.6.96"
displayName="instruction"/>
<text><reference
value="#FillIns_DM"/>Generic Substitution Allowed</text>
<statusCode
code="completed"/>
</act>
</entryRelationship>
</supply>
</entryRelationship>
<entryRelationship
typeCode="REFR">
<supply
classCode="SPLY"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.18"/>
<!-- ** Medication Dispense Template ** -->
<id
root="1.2.3.4.56789.1"
extension="cb734647-fc99-424c-a864-7e3cda82e704"/>
<statusCode
code="completed"/>
<effectiveTime
value="20120813"/>
<repeatNumber
value="1"/>
<quantity
value="75"/>
<product>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.23"/>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code
code="896001"
codeSystem="2.16.840.1.113883.6.88"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler">
<originalText><reference
value="#DM"/></originalText>
<translation
code="896001"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Medication Factory Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</product>
<performer>
<time
nullFlavor="UNK"/>
<assignedEntity>
<id
root="2.16.840.1.113883.19.5.9999.456"
extension="2981825"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
nullFlavor="UNK"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5.9999.1395"/>
<name>Community Health and Hospitals</name>
<telecom
nullFlavor="UNK"/>
<addr
nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
</supply>
</entryRelationship>
<precondition
typeCode="PRCN">
<templateId
root="2.16.840.1.113883.10.20.22.4.25"/>
<criterion>
<code
code="ASSERTION"
codeSystem="2.16.840.1.113883.5.4"/>
<value
xsi:type="CE"
code="56018004"
codeSystem="2.16.840.1.113883.6.96"
displayName="Wheezing"/>
</criterion>
</precondition>
</substanceAdministration>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!--
********************************************************
REASON FOR REFERRAL
********************************************************
-->
<component>
<section>
<templateId
root="1.3.6.1.4.1.19376.1.5.3.1.3.1"/>
<!-- ** Reason for Referral Section Template ** -->
<code
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
code="42349-1"
displayName="REASON FOR REFERRAL"/>
<title>REASON FOR REFERRAL</title>
<text>
<paragraph>Follow up with Dr George Potomac for Asthma</paragraph>
</text>
</section>
</component>
<!--
********************************************************
PROBLEM LIST
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.5.1"/>
<code
code="11450-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="PROBLEM LIST"/>
<title>PROBLEMS</title>
<text><content
ID="problems"/>
<list
listType="ordered">
<item><content
ID="problem1">Pneumonia : Status - Resolved</content></item>
<item><content
ID="problem2">Asthma : Status - Active</content></item>
</list>
</text>
<entry
typeCode="DRIV">
<act
classCode="ACT"
moodCode="EVN">
<!-- Problem act template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.3"/>
<id
root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7"/>
<code
code="CONC"
codeSystem="2.16.840.1.113883.5.6"
displayName="Concern"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20120806"/>
<high
value="20120806"/>
</effectiveTime>
<entryRelationship
typeCode="SUBJ">
<observation
classCode="OBS"
moodCode="EVN">
<!-- Problem observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.4"/>
<id
root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code
code="409586006"
codeSystem="2.16.840.1.113883.6.96"
displayName="Complaint"/>
<text>
<reference
value="#problem1"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20120806"/>
</effectiveTime>
<value
xsi:type="CD"
code="233604007"
codeSystem="2.16.840.1.113883.6.96"
displayName="Pneumonia"/>
<entryRelationship
typeCode="REFR">
<observation
classCode="OBS"
moodCode="EVN">
<!-- Problem observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.68"/>
<id
root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code
code="409586006"
codeSystem="2.16.840.1.113883.6.96"
displayName="Complaint"/>
<text>
<reference
value="#problem1"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20120806"/>
</effectiveTime>
<value
xsi:type="CD"
code="233604007"
codeSystem="2.16.840.1.113883.6.96"
displayName="Pneumonia"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.31"/>
<!-- Age observation template -->
<code
code="445518008"
codeSystem="2.16.840.1.113883.6.96"
displayName="Age At Onset"/>
<statusCode
code="completed"/>
<value
xsi:type="PQ"
value="65"
unit="a"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="REFR">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.5"/>
<!-- Health status observation template -->
<code xsi:type="CE"
code="11323-3"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Health status"/>
<text><reference
value="#problems"/></text>
<statusCode
code="completed"/>
<value
xsi:type="CD"
code="162467007"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="Symptom Free"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<!-- Status observation template -->
<templateId root="2.16.840.1.113883.10.20.22.4.6"/>
<code xsi:type="CE"
code="33999-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Status"/>
<text><reference
value="#problem2"/></text>
<statusCode code="completed"/>
<value xsi:type="CD"
code="413322009"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="Resolved"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
<entry
typeCode="DRIV">
<act
classCode="ACT"
moodCode="EVN">
<!-- Problem act template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.3"/>
<id
root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7"/>
<code
code="CONC"
codeSystem="2.16.840.1.113883.5.6"
displayName="Concern"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20070103"/>
<high
value="20120806"/>
</effectiveTime>
<entryRelationship
typeCode="SUBJ">
<observation
classCode="OBS"
moodCode="EVN">
<!-- Problem observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.4"/>
<id
root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code
code="409586006"
codeSystem="2.16.840.1.113883.6.96"
displayName="Complaint"/>
<text>
<reference
value="#problem2"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20070103"/>
</effectiveTime>
<value
xsi:type="CD"
code="195967001"
codeSystem="2.16.840.1.113883.6.96"
displayName="Asthma"/>
<entryRelationship
typeCode="REFR">
<observation
classCode="OBS"
moodCode="EVN">
<!-- Problem observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.68"/>
<id
root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code
code="409586006"
codeSystem="2.16.840.1.113883.6.96"
displayName="Complaint"/>
<text>
<reference
value="#problem2"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20120806"/>
</effectiveTime>
<value
xsi:type="CD"
code="195967001"
codeSystem="2.16.840.1.113883.6.96"
displayName="Asthma"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.31"/>
<!-- Age observation template -->
<code
code="445518008"
codeSystem="2.16.840.1.113883.6.96"
displayName="Age At Onset"/>
<statusCode
code="completed"/>
<value
xsi:type="PQ"
value="65"
unit="a"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="REFR">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.5"/>
<!-- Health status observation template -->
<code xsi:type="CE"
code="11323-3"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Health status"/>
<text><reference
value="#problems"/></text>
<statusCode
code="completed"/>
<value
xsi:type="CD"
code="162467007"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="Symptom Free"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<!-- Status observation template -->
<templateId root="2.16.840.1.113883.10.20.22.4.6"/>
<code xsi:type="CE"
code="33999-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Status"/>
<text><reference
value="#problem2"/></text>
<statusCode code="completed"/>
<value xsi:type="CD"
code="55561003"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="Active"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!--
********************************************************
PROCEDURES
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.7.1"/>
<!-- Procedures section template -->
<code
code="47519-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="HISTORY OF PROCEDURES"/>
<title>PROCEDURES</title>
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Procedure</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<content ID="Proc2">Chest X-Ray</content>
</td>
<td>8/7/2012</td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<procedure
classCode="PROC"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.14"/>
<!-- Procedure Activity Observation -->
<id
extension="123456789"
root="2.16.840.1.113883.19"/>
<code
code="168731009"
codeSystem="2.16.840.1.113883.6.96"
displayName="Chest X-Ray"
codeSystemName="SNOMED-CT">
<originalText>
<reference
value="#Proc2"/>
</originalText>
</code>
<statusCode
code="completed"/>
<effectiveTime
value="20120807"/>
<priorityCode
code="CR"
codeSystem="2.16.840.1.113883.5.7"
codeSystemName="ActPriority"
displayName="Callback results"/>
<methodCode
nullFlavor="UNK"/>
<targetSiteCode
code="82094008"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="Lower Respiratory Tract Structure"/>
<performer>
<assignedEntity>
<id
root="2.16.840.1.113883.19.5"
extension="1234"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
use="WP"
value="(555)555-555-1234"/>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5"/>
<name>Community Health and Hospitals</name>
<telecom
nullFlavor="UNK"/>
<addr
nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
<participant
typeCode="LOC">
<participantRole
classCode="SDLOC">
<templateId
root="2.16.840.1.113883.10.20.22.4.32"/>
<!-- Service Delivery Location template -->
<code
code="1160-1"
codeSystem="2.16.840.1.113883.6.259"
codeSystemName="HealthcareServiceLocation"
displayName="Urgent Care Center"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
nullFlavor="UNK"/>
<playingEntity
classCode="PLC">
<name>Community Health and Hospitals</name>
</playingEntity>
</participantRole>
</participant>
</procedure>
</entry>
</section>
</component>
<!--
********************************************************
FUNCTIONAL and COGNITIVE STATUS
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.14"/>
<!-- ******** Functional status section template ******** -->
<code
code="47420-5"
codeSystem="2.16.840.1.113883.6.1"/>
<title>FUNCTIONAL STATUS</title>
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Functional Condition</th>
<th>Effective Dates</th>
<th>Condition Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<content ID="fs1">Dependence on cane</content></td>
<td>2008</td>
<td>Active</td>
</tr>
<tr>
<td>
<content ID="fs2">Memory impairment</content>
</td>
<td>2008</td>
<td>Active</td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<observation
classCode="OBS"
moodCode="EVN">
<!-- Problem observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.68"/>
<id
root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code xsi:type="CE"
code="409586006"
codeSystem="2.16.840.1.113883.6.96"
displayName="Complaint"/>
<text>
<reference
value="#fs1"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20081101"/>
<high nullFlavor="UNK"/>
</effectiveTime>
<value
xsi:type="CD"
code="105504002"
codeSystem="2.16.840.1.113883.6.96"
displayName="Dependence on Cane"/>
</observation>
</entry>
<entry
typeCode="DRIV">
<observation
classCode="OBS"
moodCode="EVN">
<!-- Problem observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.68"/>
<id
root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code xsi:type="CE"
code="409586006"
codeSystem="2.16.840.1.113883.6.96"
displayName="Complaint"/>
<text>
<reference
value="#fs2"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20081101"/>
<high nullFlavor="UNK" />
</effectiveTime>
<value
xsi:type="CD"
code="386807006"
codeSystem="2.16.840.1.113883.6.96"
displayName="Memory Impairment"/>
</observation>
</entry>
<entry
typeCode="DRIV">
<observation
classCode="OBS"
moodCode="EVN">
<!-- Cognitive Status Problem observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.73"/>
<id
root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code xsi:type="CE"
code="373930000"
codeSystem="2.16.840.1.113883.6.96"
displayName="Cognitive Function Finding"/>
<text>
<reference
value="#fs2"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20081101"/>
<high nullFlavor="UNK"/>
</effectiveTime>
<value
xsi:type="CD"
code="48167000"
codeSystem="2.16.840.1.113883.6.96"
displayName="Amnesia"/>
</observation>
</entry>
</section>
</component>
<!--
********************************************************
RESULTS
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.3.1"/>
<!-- Entries Required -->
<code
code="30954-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="RESULTS"/>
<title>RESULTS</title>
<text>
<table>
<tbody>
<tr>
<td
colspan="2">LABORATORY INFORMATION</td>
</tr>
<tr>
<td
colspan="2">Chemistries and drug levels</td>
</tr>
<tr>
<td><content
ID="result1">HGB (M 13-18 g/dl; F 12-16 g/dl)</content></td>
<td>13.2</td>
</tr>
<tr>
<td><content
ID="result2">WBC (4.3-10.8 10+3/ul)</content></td>
<td>6.7</td>
</tr>
<tr>
<td><content
ID="result3">PLT (135-145 meq/l)</content></td>
<td>123 (L)</td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<organizer
classCode="BATTERY"
moodCode="EVN">
<!-- Result organizer template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.1"/>
<id
root="7d5a02b0-67a4-11db-bd13-0800200c9a66"/>
<code xsi:type="CE"
code="43789009"
displayName="CBC WO DIFFERENTIAL"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
<statusCode
code="completed"/>
<component>
<observation
classCode="OBS"
moodCode="EVN">
<!-- Result observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.2"/>
<id
root="107c2dc0-67a5-11db-bd13-0800200c9a66"/>
<code xsi:type="CE"
code="30313-1"
displayName="HGB"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"> </code>
<text>
<reference
value="#result1"/>
</text>
<statusCode
code="completed"/>
<effectiveTime
value="20120810"/>
<value
xsi:type="PQ"
value="10.2"
unit="g/dl"/>
<interpretationCode
code="N"
codeSystem="2.16.840.1.113883.5.83"/>
<methodCode/>
<targetSiteCode/>
<author>
<time/>
<assignedAuthor>
<id
root="2a620155-9d11-439e-92b3-5d9816ff4de8"/>
</assignedAuthor>
</author>
<referenceRange>
<observationRange>
<text>M 13-18 g/dl; F 12-16 g/dl</text>
</observationRange>
</referenceRange>
</observation>
</component>
<component>
<observation
classCode="OBS"
moodCode="EVN">
<!-- Result observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.2"/>
<id
root="107c2dc0-67a5-11db-bd13-0800200c9a66"/>
<code xsi:type="CE"
code="33765-9"
displayName="WBC"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"> </code>
<text>
<reference
value="#result2"/>
</text>
<statusCode
code="completed"/>
<effectiveTime
value="20120810"/>
<value
xsi:type="PQ"
value="12.3"
unit="10+3/ul"/>
<interpretationCode
code="N"
codeSystem="2.16.840.1.113883.5.83"/>
<methodCode/>
<targetSiteCode/>
<author>
<time/>
<assignedAuthor>
<id
root="2a620154-9d11-439e-92b3-5d9815ff4de8"/>
</assignedAuthor>
</author>
<referenceRange>
<observationRange>
<value
xsi:type="IVL_PQ">
<low
value="4.3"
unit="10+3/ul"/>
<high
value="10.8"
unit="10+3/ul"/>
</value>
</observationRange>
</referenceRange>
</observation>
</component>
<component>
<observation
classCode="OBS"
moodCode="EVN">
<!-- Result observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.2"/>
<id
root="107c2dc0-67a5-11db-bd13-0800200c9a66"/>
<code xsi:type="CE"
code="26515-7"
displayName="PLT"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"> </code>
<text>
<reference
value="#result3"/>
</text>
<statusCode
code="completed"/>
<effectiveTime
value="20120810"/>
<value
xsi:type="PQ"
value="123"
unit="10+3/ul"/>
<interpretationCode
code="L"
codeSystem="2.16.840.1.113883.5.83"/>
<methodCode/>
<targetSiteCode/>
<author>
<time/>
<assignedAuthor>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
</assignedAuthor>
</author>
<referenceRange>
<observationRange>
<value
xsi:type="IVL_PQ">
<low
value="150"
unit="10+3/ul"/>
<high
value="350"
unit="10+3/ul"/>
</value>
</observationRange>
</referenceRange>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
<!--
********************************************************
SOCIAL HISTORY
********************************************************
-->
<component>
<!-- Social History ******** -->
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.17"/>
<!-- ******** Social history section template ******** -->
<code
code="29762-2"
codeSystem="2.16.840.1.113883.6.1"
displayName="Social History"/>
<title>SOCIAL HISTORY</title>
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Social History Element</th>
<th>Description</th>
<th>Effective Dates</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<content
ID="soc1"/> smoking</td>
<td>Former Smoker (1 pack per day</td>
<td>20050501 to 20110227</td>
</tr>
<tr>
<td>
<content
ID="soc2"/> smoking</td>
<td>Current Everyday Smoker 2 packs per day</td>
<td>20110227 - today</td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<observation
classCode="OBS"
moodCode="EVN">
<!-- Smoking status observation template -->
<templateId
root="2.16.840.1.113883.10.22.4.78"/>
<id
extension="123456789"
root="2.16.840.1.113883.19"/>
<code
code="ASSERTION"
codeSystem="2.16.840.1.113883.5.4"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20050501"/>
<high
value="20110227"/>
</effectiveTime>
<value
xsi:type="CD"
code="8517006"
displayName="Former smoker"
codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entry>
<entry
typeCode="DRIV">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.38"/>
<!-- ******** Social history observation template ******** -->
<id
root="9b56c25d-9104-45ee-9fa4-e0f3afaa01c1"/>
<code
code="230056004"
codeSystem="2.16.840.1.113883.6.96"
displayName="Cigarette smoking">
<originalText>
<reference
value="#soc1"/>
</originalText>
</code>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20050501"/>
<high
value="20110227"/>
</effectiveTime>
<value
xsi:type="ST">1 pack per day</value>
</observation>
</entry>
<entry
typeCode="DRIV">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.38"/>
<!-- ******** Social history observation template ******** -->
<id
root="45efb604-7049-4a2e-ad33-d38556c9636c"/>
<code
code="230056004"
codeSystem="2.16.840.1.113883.6.96"
displayName="Cigarette smoking">
<originalText>
<reference
value="#soc2"/>
</originalText>
</code>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20110227"/>
<high nullFlavor="UNK"/>
</effectiveTime>
<value
xsi:type="CD"
code="449868002"
displayName="Current Everyday Smoker"
codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entry>
</section>
</component>
<!--
********************************************************
VITAL SIGNS
********************************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.4.1"/>
<code
code="8716-3"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="VITAL SIGNS"/>
<title>VITAL SIGNS</title>
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th
align="right">Date / Time: </th>
<th>Nov 1, 2011</th>
<th>August 6, 2012</th>
</tr>
</thead>
<tbody>
<tr>
<th
align="left">Height</th>
<td>
<content
ID="vit1">69 inches</content></td>
<td>
<content
ID="vit2">69 inches</content></td>
</tr>
<tr>
<th
align="left">Weight</th>
<td>
<content
ID="vit3">189 lbs</content></td>
<td>
<content
ID="vit4">194 lbs</content></td>
</tr>
<tr>
<th
align="left">Blood Pressure</th>
<td><content
ID="vit5">132/86 mmHg</content></td>
<td><content
ID="vit6">145/88 mmHg</content></td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<organizer
classCode="CLUSTER"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.26"/>
<!-- Vital signs organizer template -->
<id
root="c6f88320-67ad-11db-bd13-0800200c9a66"/>
<code
code="46680005"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED -CT"
displayName="Vital signs"/>
<statusCode
code="completed"/>
<effectiveTime
value="20111101"/>
<component>
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.27"/>
<!-- Vital Sign Observation template -->
<id
root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
<code
code="8302-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Height"/>
<text><reference
value="#vit1"/></text>
<statusCode
code="completed"/>
<effectiveTime
value="20081101"/>
<value
xsi:type="PQ"
value="69"
unit="in"/>
<interpretationCode
code="N"
codeSystem="2.16.840.1.113883.5.83"/>
</observation>
</component>
<component>
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.27"/>
<!-- Vital Sign Observation template -->
<id
root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
<code
code="3141-9"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Patient Body Weight - Measured"/>
<text><reference
value="#vit4"/></text>
<statusCode
code="completed"/>
<effectiveTime
value="20111101"/>
<value
xsi:type="PQ"
value="189"
unit="lbs"/>
<interpretationCode
code="N"
codeSystem="2.16.840.1.113883.5.83"/>
</observation>
</component>
<component>
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.27"/>
<!-- Vital Sign Observation template -->
<id
root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
<code
code="8480-6"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Intravascular Systolic"/>
<text><reference
value="#vit5"/></text>
<statusCode
code="completed"/>
<effectiveTime
value="20111101"/>
<value
xsi:type="PQ"
value="132"
unit="mm[Hg]"/>
<interpretationCode
code="N"
codeSystem="2.16.840.1.113883.5.83"/>
</observation>
</component>
</organizer>
</entry>
<entry
typeCode="DRIV">
<organizer
classCode="CLUSTER"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.26"/>
<!-- Vital signs organizer template -->
<id
root="c6f88320-67ad-11db-bd13-0800200c9a66"/>
<code
code="46680005"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED -CT"
displayName="Vital signs"/>
<statusCode
code="completed"/>
<effectiveTime
value="20120806"/>
<component>
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.27"/>
<!-- Vital Sign Observation template -->
<id
root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
<code
code="8302-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Height"/>
<text><reference
value="#vit2"/></text>
<statusCode
code="completed"/>
<effectiveTime
value="20120806"/>
<value
xsi:type="PQ"
value="69"
unit="in"/>
<interpretationCode
code="N"
codeSystem="2.16.840.1.113883.5.83"/>
</observation>
</component>
<component>
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.27"/>
<!-- Vital Sign Observation template -->
<id
root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
<code
code="3141-9"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Patient Body Weight - Measured"/>
<text><reference
value="#vit4"/></text>
<statusCode
code="completed"/>
<effectiveTime
value="20120806"/>
<value
xsi:type="PQ"
value="194"
unit="lbs"/>
<interpretationCode
code="N"
codeSystem="2.16.840.1.113883.5.83"/>
</observation>
</component>
<component>
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.27"/>
<!-- Vital Sign Observation template -->
<id
root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
<code
code="8480-6"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Intravascular Systolic"/>
<text><reference
value="#vit6"/></text>
<statusCode
code="completed"/>
<effectiveTime
value="20120806"/>
<value
xsi:type="PQ"
value="145"
unit="mm[Hg]"/>
<interpretationCode
code="N"
codeSystem="2.16.840.1.113883.5.83"/>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
<!--
************************************
HOSPITAL DISCHARGE INSTRUCTIONS
************************************
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.41"/>
<code
code="8653-8"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="HOSPITAL DISCHARGE INSTRUCTIONS"/>
<title>HOSPITAL DISCHARGE INSTRUCTIONS</title>
<text>
<content>
Ms. Jones, you have been seen by Dr. Henry Seven at Local Community Hospital from August 8th until August 13th 2012. You are currently being discharged from Local Community Hospital. Dr. Seven has provided the following instructions to you at this time; should you have any questions please contact a member of your healthcare team prior to discharge. If you have left the hospital and have questions, please contact Dr. Seven at 555-555-1002.
Instructions:
</content>
<list
listType="ordered">
<item>Take all medications as prescribed.</item>
<item>Please monitor your peak flows. If your peak flows drop to 50% of normal, call my office immediately or return to the Emergency Room.</item>
<item>If you experience any of the following symptoms, call my office immediately or return to the Emergency Room:
<list listType="ordered">
<item>Shortness of Breath</item>
<item>Dizziness or Light-headedness</item>
<item>Fever, chills, or diffuse body aches</item>
<item>Pain or redness at the site of any previous intravenous catheter</item>
<item>Any other unusual problem</item>
</list>
</item>
</list>
</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>