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="ce862cfe-6559-411e-92e9-e8d005b1c226" /> <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> </patient> </patientRole> </recordTarget> <component> <structuredBody> <component> <section> <templateId root="2.16.840.1.113883.10.20.22.2.22.1" extension="2015-08-01" /> <templateId root="2.16.840.1.113883.10.20.22.2.22.1" /> <code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Hospitalizations+Outpatient visits Narrative" /> <title>ENCOUNTERS</title> <text> <table border="1" width="100%"> <thead> <tr> <th>Encounter Diagnosis</th> <th>Location</th> <th>Date</th> </tr> </thead> <tbody> <tr> <td ID="Encounter1">Fever (finding)</td> <td>Neighborhood Physicians Practice</td> <td>June 22, 2015</td> </tr> </tbody> </table> </text> <entry> <encounter classCode="ENC" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01" /> <templateId root="2.16.840.1.113883.10.20.22.4.49" /> <id root="2a620155-9d12-439e-92b3-5d9815ff4de8" /> <!--Removed CPT code because Scorecard could not find proper display name terminology <code code = "99213" displayName = "Office outpatient visit" codeSystemName = "CPT-4" codeSystem = "2.16.840.1.113883.6.12"> --> <code nullFlavor="OTH" /> <effectiveTime value="201506221000-0500" /> <performer> <assignedEntity> <id root="27aa3679-130e-498b-bfde-3964a2a1605a" /> <id extension="99999999" root="2.16.840.1.113883.4.6" /> <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" /> <code code="1160-1" codeSystem="2.16.840.1.113883.6.259" codeSystemName="HL7 HealthcareServiceLocation" displayName="Urgent Care Center" /> <addr> <streetAddressLine>2472 Rocky place</streetAddressLine> <city>Beaverton</city> <state>OR</state> <postalCode>97006</postalCode> <country>US</country> </addr> <telecom value="tel:+1(555)-555-1002" /> <playingEntity classCode="PLC"> <name>Neighborhood Physicians Practice</name> </playingEntity> </participantRole> </participant> <entryRelationship typeCode="SUBJ"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.80" extension="2015-08-01" /> <templateId root="2.16.840.1.113883.10.20.22.4.80" /> <!--<templateId root = "2.16.840.1.113883.10.20.22.4.19"/> --> <id root="5a784260-6857-4f38-9638-80c751aff2fb" /> <code xsi:type="CE" code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="DIAGNOSIS" /> <effectiveTime> <low value="20150622" /> </effectiveTime> <entryRelationship typeCode="SUBJ" inversionInd="false"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01" /> <templateId root="2.16.840.1.113883.10.20.22.4.4" /> <id root="ab1791b0-5c71-12db-b0de-0800200c9a66" /> <code code="404684003" displayName="Clinical finding" codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96"> <translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Clinical finding" /> </code> <statusCode code="completed" /> <effectiveTime> <low value="20150622" /> </effectiveTime> <value xsi:type="CD" code="386661006" displayName="Fever (finding)" codeSystem="2.16.840.1.113883.6.96" /> </observation> </entryRelationship> </act> </entryRelationship> </encounter> </entry> </section> </component> </structuredBody> </component> </ClinicalDocument>