Medplum

<?xml version="1.0" encoding="UTF-8"?> <?xml-stylesheet type="text/xsl" href="CDA.xsl"?> <ClinicalDocument xmlns = "urn:hl7-org:v3" xmlns:xsi = "http://www.w3.org/2001/XMLSchema-instance" xmlns:voc = "urn:hl7-org:v3/voc" xmlns:sdtc = "urn:hl7-org:sdtc"> <realmCode code = "US"/> <typeId extension = "POCD_HD000040" root = "2.16.840.1.113883.1.3"/> <templateId root = "2.16.840.1.113883.10.20.22.1.1" extension = "2015-08-01"/> <templateId root = "2.16.840.1.113883.10.20.22.1.1"/> <templateId root = "2.16.840.1.113883.10.20.22.1.2" extension = "2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.1.2" /> <id root="3db70aff-83f5-4caf-91dc-d23fcc5e03bb" /> <code code="34133-9" displayName="Summarization of Episode Note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" /> <title>Medical Summary</title> <effectiveTime value="20250101000000-0500" /> <languageCode code="en-US" /> <recordTarget> <patientRole> <id root="d7830f15-e2c8-4cee-aa2d-a24b36080d53" /> <id extension="111223333" root="2.16.840.1.113883.4.1" /> <telecom nullFlavor="UNK" /> <addr nullFlavor="UNK" /> <patient> <name use="L"> <given>Katherine</given> <family>Madison</family> </name> <raceCode nullFlavor="UNK"/> <ethnicGroupCode nullFlavor="UNK"/> </patient> </patientRole> </recordTarget> <component> <structuredBody> <component> <section> <templateId root="2.16.840.1.113883.10.20.22.2.6.1" extension="2015-08-01" /> <templateId root="2.16.840.1.113883.10.20.22.2.6.1" /> <code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" /> <title>Allergies, Adverse Reactions and Alerts</title> <text> <table> <thead> <tr> <th>Allergen</th> <th>Reaction</th> <th>Reaction Severity</th> <th>Documentation Date</th> <th>Start Date</th> </tr> </thead> <tbody> <tr ID="allergy5"> <td ID="allergy5allergen">Egg</td> <td ID="allergy5reaction">Hives</td> <td ID="allergy5reactionseverity">Moderate</td> <td>Jan 4 2014</td> <td>1998</td> </tr> </tbody> </table> </text> <entry> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.30" /> <templateId root="2.16.840.1.113883.10.20.22.4.30" extension="2015-08-01" /> <id root="0fffb34f-c1e0-47c2-92af-c414a3ff21ec" /> <code code="CONC" codeSystem="2.16.840.1.113883.5.6" /> <text> <reference value="#allergy5" /> </text> <statusCode code="active" /> <!-- This is the time stamp for when the allergy was first documented as a concern--> <effectiveTime> <low value="20140104123506-0500"/> </effectiveTime> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119" /> <time value="20140104123506-0500" /> <assignedAuthor> <id root="b0ff47f4-ff49-43ee-8e46-43db7b57d986" /> <id extension="99999999" root="2.16.840.1.113883.4.6" /> <code code="207Q00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC Health Care Provider Taxonomy" displayName="Allopathic &amp; Osteopathic Physicians; Family Medicine" /> <telecom value="tel:555-555-1002" /> <addr nullFlavor="UNK" /> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedAuthor> </author> <entryRelationship typeCode="SUBJ"> <observation classCode="OBS" moodCode="EVN"> <!-- allergy observation template --> <templateId root="2.16.840.1.113883.10.20.22.4.7" /> <templateId root="2.16.840.1.113883.10.20.22.4.7" extension="2014-06-09" /> <id root="0fffb34f-c1e0-47c2-92af-c414a3ff21ec" /> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" /> <text> <reference value="#allergy5" /> </text> <statusCode code="completed" /> <!-- This is the time stamp for the biological onset of the allergy. --> <!-- Just the year is shown since a specific month and date was not reported --> <effectiveTime> <low value="19980101000000+0000" /> <high nullFlavor="NI" /> </effectiveTime> <!-- This specifies that the allergy is to a food in contrast to other allergies (drug) --> <value xsi:type="CD" code="414285001" displayName="Allergy to food (finding)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" /> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119" /> <time value="20140104123506-0500" /> <assignedAuthor> <id root="b0ff47f4-ff49-43ee-8e46-43db7b57d986" /> <id extension="99999999" root="2.16.840.1.113883.4.6" /> <code code="207Q00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC Health Care Provider Taxonomy" displayName="Allopathic &amp; Osteopathic Physicians; Family Medicine" /> <telecom value="tel:555-555-1002" /> <addr nullFlavor="UNK" /> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedAuthor> </author> <!-- In C-CDA R2.1 the participant is required. --> <participant typeCode="CSM"> <participantRole classCode="MANU"> <playingEntity classCode="MMAT"> <code code="102263004" displayName="Eggs (edible)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> <originalText> <reference value="#allergy5allergen" /> </originalText> </code> </playingEntity> </participantRole> </participant> <entryRelationship typeCode="MFST" inversionInd="true"> <observation classCode="OBS" moodCode="EVN"> <!-- Reaction Observation template --> <templateId root="2.16.840.1.113883.10.20.22.4.9" /> <templateId root="2.16.840.1.113883.10.20.22.4.9" extension="2014-06-09" /> <id root="d89ce431-e0f1-4f8d-a81f-489b6ed91f09" /> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" /> <text> <reference value="#allergy5reaction" /> </text> <statusCode code="completed" /> <effectiveTime value="19980101" /> <value xsi:type="CD" code="247472004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Wheal" /> <entryRelationship typeCode="SUBJ" inversionInd="true"> <observation classCode="OBS" moodCode="EVN"> <!-- Severity Observation template --> <templateId root="2.16.840.1.113883.10.20.22.4.8" /> <templateId root="2.16.840.1.113883.10.20.22.4.8" extension="2014-06-09" /> <code code="SEV" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode" /> <text> <reference value="#allergy5reactionseverity" /> </text> <statusCode code="completed" /> <value xsi:type="CD" code="6736007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Moderate" /> </observation> </entryRelationship> </observation> </entryRelationship> </observation> </entryRelationship> </act> </entry> </section> </component> </structuredBody> </component> </ClinicalDocument>