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> <!-- Health Concerns Section (V2)--> <templateId root="2.16.840.1.113883.10.20.22.2.58" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.2.58"/> <code code="75310-3" displayName="Health Concerns Document" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Health Concerns Section</title> <text> <table border="1" width="100%"> <thead> <tr> <th>Health Concern</th> <th>Date</th> <th>Related Problem</th> </tr> </thead> <tbody> <tr ID="Concern1"> <td ID="Concern1Issue1">Patient is concerned about being contagious and infecting roommate.</td> <td>Concern from 03/02/2014</td> <!-- Providing this as a link to the related problem in problem list is an option using base CDA implementation guidance. --> <td>Community Acquired Pneumonia</td> </tr> </tbody> </table> </text> <entry> <!-- Health Concern Act --> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.132" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.132"/> <id root="63c5e137-3024-46cc-951f-885ec69d9030"/> <code code="75310-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Health Concern"/> <!-- This Health Concern has a statusCode of active because it is an active concern --> <statusCode code="active"/> <!-- The effective time is the date that the Health Concern started being followed - this does not necessarily correlate to the onset date of the contained health issues--> <effectiveTime value="20140302"/> <entryRelationship typeCode="REFR"> <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="59c5ca3e-662f-4e33-943f-2777ebc6227e"/> <code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="55607006" displayName="Problem"> <translation codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="75326-9" displayName="Problem"/> </code> <text> <reference value="#Concern1" /> </text> <statusCode code="completed"/> <effectiveTime> <low value="20140302"/> </effectiveTime> <value xsi:type="CD" nullFlavor="OTH"> <originalText> <reference value="#Concern1Issue1" /> </originalText> </value> </observation> </entryRelationship> <!-- Health Concern Problem: Community Acquired Pneumonia --> <!-- This Entry Reference refers to a problem observation present in Problem List that the Health Concern is related to--> <entryRelationship typeCode="REFR"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.122" /> <!-- This ID equals the ID of the Community Acquired Pneumonia problem --> <id root="49c5ca3e-662f-4e33-948f-2777ebc6727e" /> <!-- The code is nulled to "NP" Not Present" --> <code nullFlavor="NP"/> <statusCode code="completed" /> </act> </entryRelationship> </act> </entry> </section> </component> <component> <section> <!-- Located elsewhere in the document --> <!-- Taken directly (changed observation/id) from prior example https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/Problem_List_Active_Problem.xml --> <templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/> <code code="11450-4" codeSystem="2.16.840.1.113883.6.1" displayName="Problem List"/> <title>Problem List</title> <text> <table> <thead> <tr> <th>Name</th> <th>Dates</th> <th>Status</th> </tr> </thead> <tbody> <tr ID="Problem1"> <td>Community Acquired Pneumonia</td> <td> <content>Onset: 02/27/2014</content> </td> <td>Active</td> </tr> </tbody> </table> </text> <entry> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.4.3"/> <id root="102ca2e9-884c-4523-a2b4-1b6c3469c397" /> <code code="CONC" codeSystem="2.16.840.1.113883.5.6" /> <!-- Since this is an active problem, the concern status is active. --> <!-- While clinicians can track resolved problems, generally active problems will have active concern status and resolved concerns will be completed --> <statusCode code="active" /> <effectiveTime> <!-- This equates to the time the concern was authored in the patient's chart. This may frequently be an EHR timestamp--> <low value="20140302124536-0500" /> </effectiveTime> <entryRelationship typeCode="SUBJ"> <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="49c5ca3e-662f-4e33-948f-2777ebc6727e"/> <code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="55607006" displayName="Problem"> <translation codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="75326-9" displayName="Problem"/> </code> <text> <reference value="#Problem1" /> </text> <statusCode code="completed"/> <effectiveTime> <!-- This represents the date of biological onset. --> <low value="20140227"/> </effectiveTime> <!-- This is a SNOMED code as the primary vocabulary for problem lists--> <value xsi:type="CD" code="385093006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Community acquired pneumonia"/> </observation> </entryRelationship> </act> </entry> </section> </component> </structuredBody> </component> </ClinicalDocument>