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  1. <?xml version="1.0" encoding="UTF-8"?>
  2. <ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xsi:schemaLocation="urn:hl7-org:v3 infrastructure/cda/CDA_SDTC.xsd">
  3. <realmCode code="US"/>
  4. <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
  5. <templateId root="2.16.840.1.113883.10.20.22.1.2"/>
  6. <templateId root="2.16.840.1.113883.10.20.22.1.1"/>
  7. <id root="2.16.840.1.113883.3.6492" extension="56497fd3-c9ec-42ef-b5ed-99049eb859e2"/>
  8. <code code="34133-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summarization of Episode Note"/>
  9. <title>Continuity Of Care Document</title>
  10. <effectiveTime xsi:type="IVL_TS" value="20190422075313-0700"/>
  11. <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" codeSystemName="ConfidentialityCode"/>
  12. <languageCode code="en-US"/>
  13. <recordTarget>
  14. <patientRole>
  15. <id root="2.16.840.1.113883.3.6492" extension="15444"/>
  16. <addr><streetAddressLine>820 JORIE BLVD</streetAddressLine><city>CHICAGO</city><state>IL</state><postalCode>60523</postalCode></addr>
  17. <telecom value="414379-1212" use="HP"/>
  18. <telecom value="414271-3434" use="WP"/>
  19. <patient>
  20. <name use="L"><family>Test</family><given>Random3</given></name>
  21. <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>
  22. <birthTime value="19781208"/>
  23. <maritalStatusCode code="S" codeSystem="2.16.840.1.113993.5.2" displayName="Never Married"/>
  24. <religiousAffiliationCode code="1081" codeSystem="2.16.840.1.113883.5.1076" displayName="Unitarian Universalist"/>
  25. <raceCode code="2034-7" codeSystem="2.16.840.1.113883.6.238" displayName="Chinese"/>
  26. <ethnicGroupCode code="1193-2" codeSystem="2.16.840.1.113883.6.238" displayName="Creek"/>
  27. <languageCommunication>
  28. <languageCode code="enm"/>
  29. <preferenceInd value="true"/>
  30. </languageCommunication>
  31. </patient>
  32. </patientRole>
  33. </recordTarget>
  34. <documentationOf>
  35. <serviceEvent classCode="PCPR">
  36. <effectiveTime>
  37. <low nullFlavor="NI"/>
  38. <high nullFlavor="NI"/>
  39. </effectiveTime>
  40. </serviceEvent>
  41. </documentationOf>
  42. <component>
  43. <structuredBody>
  44. <component>
  45. <section>
  46. <templateId root="2.16.840.1.113883.10.20.22.2.21.1"/>
  47. <code code="42348-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Advance Directives"/>
  48. <title>Advance Directives</title>
  49. <text>No known advance directives.</text>
  50. </section>
  51. </component>
  52. <component>
  53. <section>
  54. <templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
  55. <code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts"/>
  56. <title>Allergies and adverse reactions</title>
  57. <text>No known allergies.</text>
  58. <entry>
  59. <act classCode="ACT" moodCode="EVN">
  60. <templateId root="2.16.840.1.113883.10.20.22.4.30"/>
  61. <id nullFlavor="NI"/>
  62. <code xsi:type="CE" code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts"/>
  63. <statusCode nullFlavor="NI"/>
  64. <effectiveTime nullFlavor="NI"/>
  65. <entryRelationship typeCode="SUBJ">
  66. <observation classCode="OBS" moodCode="EVN">
  67. <templateId root="2.16.840.1.113883.10.20.22.4.7"/>
  68. <id nullFlavor="NI"/>
  69. <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
  70. <statusCode code="completed"/>
  71. <effectiveTime nullFlavor="NI"/>
  72. <value xsi:type="CE" nullFlavor="NI"/>
  73. </observation>
  74. </entryRelationship>
  75. </act>
  76. </entry>
  77. </section>
  78. </component>
  79. <component>
  80. <section>
  81. <templateId root="2.16.840.1.113883.10.20.22.2.22"/>
  82. <templateId root="2.16.840.1.113883.10.20.22.2.22.1"/>
  83. <code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
  84. <title>Encounters</title>
  85. <text>No known encounters.</text>
  86. <entry>
  87. <encounter classCode="ENC" moodCode="EVN">
  88. <performer>
  89. <assignedEntity>
  90. <id extension="121008" root="2.16.840.1.113883.19.5"/>
  91. <code code="1154359" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Astemizole Pill"/>
  92. <assignedPerson>
  93. <name>
  94. <prefix>Dr.</prefix>
  95. <given>Pill</given>
  96. <family>Astemizole</family>
  97. </name>
  98. </assignedPerson>
  99. </assignedEntity>
  100. </performer>
  101. <participant typeCode="LOC">
  102. <participantRole classCode="SDLOC">
  103. <templateId root="2.16.840.1.113883.10.20.22.4.32"/>
  104. <code nullFlavor="NI"/>
  105. <playingEntity classCode="PLC">
  106. <name>ABBOTT NORTHWESTERN EMERGENCY DEPARTMENT</name>
  107. <desc>Emergency</desc>
  108. </playingEntity>
  109. </participantRole>
  110. </participant>
  111. <entryRelationship typeCode="RSON">
  112. <observation classCode="OBS" moodCode="EVN">
  113. <templateId root="2.16.840.1.113883.10.20.22.4.19"/>
  114. <id root="2.16.840.1.113883.3.6492" extension="278"/>
  115. <code code="55607006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Problem"/>
  116. <statusCode code="completed"/>
  117. <value xsi:type="CD" code="202794004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Back pain of lumbosacaral region with sciatica"/>
  118. </observation>
  119. </entryRelationship>
  120. <templateId root="2.16.840.1.113883.10.20.22.4.49"/>
  121. <id root="2.16.840.1.113883.3.6492" extension="153"/>
  122. <code code="3" codeSystem="1.2.840.114350.1.13.8.3.7.4.698084.30" codeSystemName="Epic.EncounterType" displayName="Hospital Encounter">
  123. <originalText>Hospital Encounter</originalText>
  124. </code>
  125. <effectiveTime>
  126. <center value="20161222"/>
  127. </effectiveTime>
  128. </encounter>
  129. </entry>
  130. </section>
  131. </component>
  132. <component>
  133. <section>
  134. <templateId root="2.16.840.1.113883.10.20.22.2.15"/>
  135. <code code="10157-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Family History"/>
  136. <title>Family history</title>
  137. <text>No known family history</text>
  138. </section>
  139. </component>
  140. <component/>
  141. <component>
  142. <section>
  143. <templateId root="2.16.840.1.113883.10.20.22.2.2"/>
  144. <code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of immunizations"/>
  145. <title>Immunizations</title>
  146. <text>No known immunizations.</text>
  147. </section>
  148. </component>
  149. <component>
  150. <section>
  151. <templateId root="2.16.840.1.113883.10.20.22.2.23"/>
  152. <code code="46264-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of medical device use"/>
  153. <title>Medical Equipment</title>
  154. <text>No known medical equipment.</text>
  155. </section>
  156. </component>
  157. <component>
  158. <section>
  159. <templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
  160. <code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF MEDICATION USE"/>
  161. <title>Medications</title>
  162. <text>No known medications.</text>
  163. <entry>
  164. <substanceAdministration classCode="SBADM" moodCode="EVN">
  165. <templateId root="2.16.840.1.113883.10.20.22.4.16"/>
  166. <id nullFlavor="NI"/>
  167. <statusCode nullFlavor="NI"/>
  168. <effectiveTime xsi:type="IVL_TS" nullFlavor="NI"/>
  169. <consumable>
  170. <manufacturedProduct classCode="MANU">
  171. <templateId root="2.16.840.1.113883.10.20.22.4.23"/>
  172. <id nullFlavor="NI"/>
  173. <manufacturedMaterial>
  174. <code nullFlavor="NI"/>
  175. </manufacturedMaterial>
  176. </manufacturedProduct>
  177. </consumable>
  178. </substanceAdministration>
  179. </entry>
  180. </section>
  181. </component>
  182. <component>
  183. <section>
  184. <templateId root="2.16.840.1.113883.10.20.22.2.18"/>
  185. <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payers"/>
  186. <title>Payers</title>
  187. <text>No known payers.</text>
  188. </section>
  189. </component>
  190. <component>
  191. <section>
  192. <templateId root="2.16.840.1.113883.10.20.22.2.10"/>
  193. <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of Care"/>
  194. <title>Plan Of Care</title>
  195. <text>No plan of care.</text>
  196. </section>
  197. </component>
  198. <component>
  199. <section>
  200. <templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
  201. <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem List"/>
  202. <title>Problems</title>
  203. <text>No known problems.</text>
  204. <entry>
  205. <act classCode="ACT" moodCode="EVN">
  206. <templateId root="2.16.840.1.113883.10.20.22.4.3"/>
  207. <id nullFlavor="NI"/>
  208. <code code="CONC" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass" displayName="Concern"/>
  209. <statusCode nullFlavor="NI"/>
  210. <effectiveTime nullFlavor="NI"/>
  211. <entryRelationship typeCode="SUBJ">
  212. <observation classCode="OBS" moodCode="EVN">
  213. <templateId root="2.16.840.1.113883.10.20.22.4.4"/>
  214. <id nullFlavor="NI"/>
  215. <code nullFlavor="NI"/>
  216. <statusCode code="completed"/>
  217. <value xsi:type="CD" nullFlavor="UNK"/>
  218. </observation>
  219. </entryRelationship>
  220. </act>
  221. </entry>
  222. </section>
  223. </component>
  224. <component>
  225. <section>
  226. <templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
  227. <code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Procedures"/>
  228. <title>Procedures</title>
  229. <text>No known procedures.</text>
  230. <entry>
  231. <procedure classCode="PROC" moodCode="EVN">
  232. <templateId root="2.16.840.1.113883.10.20.22.4.14"/>
  233. <id nullFlavor="NI"/>
  234. <code xsi:type="CE" nullFlavor="NI"/>
  235. <statusCode nullFlavor="NI"/>
  236. </procedure>
  237. </entry>
  238. </section>
  239. </component>
  240. <component>
  241. <section>
  242. <templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
  243. <code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="RESULTS"/>
  244. <title>Results</title>
  245. <text>No known results.</text>
  246. <entry>
  247. <organizer classCode="BATTERY" moodCode="EVN">
  248. <templateId root="2.16.840.1.113883.10.20.22.4.1"/>
  249. <id nullFlavor="NI"/>
  250. <code xsi:type="CE" nullFlavor="NI"/>
  251. <statusCode nullFlavor="NI"/>
  252. <component>
  253. <observation classCode="OBS" moodCode="EVN">
  254. <templateId root="2.16.840.1.113883.10.20.22.4.2"/>
  255. <id nullFlavor="NI"/>
  256. <code xsi:type="CE" nullFlavor="NI"/>
  257. <statusCode nullFlavor="NI"/>
  258. <effectiveTime nullFlavor="NI"/>
  259. <value xsi:type="PQ" nullFlavor="NI"/>
  260. </observation>
  261. </component>
  262. </organizer>
  263. </entry>
  264. </section>
  265. </component>
  266. <component>
  267. <section>
  268. <templateId root="2.16.840.1.113883.10.20.22.2.17"/>
  269. <code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social History"/>
  270. <title>Social History</title>
  271. <text>No known Social History.</text>
  272. </section>
  273. </component>
  274. <component>
  275. <section>
  276. <templateId root="2.16.840.1.113883.10.20.22.2.4.1"/>
  277. <code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital Signs"/>
  278. <title>Vital Signs</title>
  279. <text>No known vital signs.</text>
  280. </section>
  281. </component>
  282. </structuredBody>
  283. </component>
  284. </ClinicalDocument>
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