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="5adfedd2-3aaf-4a4f-aa35-5f6600b60c99" /> <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="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09" /> <!-- Medication Section (entries required) --> <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>Instructions</th> <th>Dosage</th> <th>Effective Dates (start - stop)</th> <th>Status</th> </tr> </thead> <tbody> <tr ID="Medication_6"> <td> <content ID="MedicationName_6">3 ML Insulin Glargine 100 UNT/ML Pen Injector [Lantus]</content> </td> <td> <content ID="MedicationSig_6">Administer 40 units at bedtime</content> </td> <td> <content>40 units</content> </td> <td>Jan-09-2009 - </td> <td>Active</td> </tr> </tbody> </table> </text> <entry> <substanceAdministration classCode="SBADM" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09" /> <templateId root="2.16.840.1.113883.10.20.22.4.16" /> <id root="1310a2d3-f888-4722-b4c4-a3c5911ac7f9" /> <text> <!-- This reference refers to medication information in unstructured portion of section--> <reference value="#Medication_6" /> </text> <statusCode code="active" /> <!-- This first effectiveTime shows that medication was added on January 9, 2009 (not known to have stopped)--> <effectiveTime xsi:type="IVL_TS"> <low value="20090109" /> </effectiveTime> <!-- The second effectiveTime specifies dose frequency, which can be either a period (PIVL_TS) or event (EIVL_TS). --> <!-- This long-lasting insulin is administered once per day before bedtime (code = "HS", hour of sleep), which is an event--> <!-- <effectiveTime xsi:type="EIVL_TS" operator="A"> <event code="HS" /> </effectiveTime> --> <effectiveTime xsi:type = "PIVL_TS" institutionSpecified = "true" operator = "A"> <period value = "12" unit = "h"/> </effectiveTime> <!-- This route uses the NCI (National Cancer Institute) Thesauraus code system, which is constrained to the value set of 2.16.840.1.113883.3.88.12.3221.8.7 (FDA Medication Route) --> <routeCode code="C38299" codeSystem="2.16.840.1.113883.3.26.1.1" displayName="Subcutaneous Route of Administration" codeSystemName="NCI Thesaurus" /> <!-- Since this dose is not pre-coordinated, specify both the amount with units in UCUM. [IU] is international units --> <!-- Note that this basal insulin is not administered on a sliding scale and a specific dose is administered--> <doseQuantity value="40" unit="[IU]" /> <consumable typeCode="CSM"> <manufacturedProduct classCode="MANU"> <!-- ** Medication information ** --> <templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09" /> <templateId root="2.16.840.1.113883.10.20.22.4.23" /> <manufacturedMaterial> <!-- Medications should be specified at a level corresponding to prescription when possible (branded medication below)--> <!-- Note the medication code specified in the test data is 261551, but that is not used since it's not an administered product (just brand name)--> <code code="847232" codeSystem="2.16.840.1.113883.6.88" displayName="3 ML insulin glargine 100 UNT/ML Pen Injector [Lantus]" codeSystemName="RxNorm"> <originalText> <reference value="#MedicationName_6" /> </originalText> </code> </manufacturedMaterial> <manufacturerOrganization> <name>SANOFI-AVENTIS</name> </manufacturerOrganization> </manufacturedProduct> </consumable> <entryRelationship typeCode="COMP"> <substanceAdministration classCode="SBADM" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.147" /> <code code="76662-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medication Instructions" /> <text> <!-- Reference into the section.text to a tag that ONLY contains free text SIG --> <reference value="#MedicationSig_6" /> </text> <consumable> <manufacturedProduct> <manufacturedLabeledDrug nullFlavor="NA" /> </manufacturedProduct> </consumable> </substanceAdministration> </entryRelationship> </substanceAdministration> </entry> </section> </component> </structuredBody> </component> </ClinicalDocument>