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> <raceCode nullFlavor="UNK"/> <ethnicGroupCode nullFlavor="UNK"/> </patient> </patientRole> </recordTarget> <component> <structuredBody> <component> <section> <templateId root="2.16.840.1.113883.10.20.22.2.10" /> <templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09" /> <!-- Plan of Care Section --> <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of care note" /> <title>PLAN OF CARE</title> <text> <table border="1" width="100%"> <thead> <tr> <th>Date/time</th> <th>Goal</th> <th>Instructions</th> </tr> </thead> <tbody> <tr ID="Goal1"> <td>August 15, 2012 10:00am</td> <td ID="Goal1_desc">Weight Loss</td> <td ID="Action1"> <content ID="Action1_Type">Patient Education:</content> <content ID="Action1_desc">Diet and exercise counseling provided during visit.</content> </td> </tr> <tr ID="Goal2"> <td>August 15, 2012 10:00am</td> <td ID="Goal2_desc">Asthma management</td> <td ID="Action2"> <content ID="Action2_Type">Patient Education:</content> <content ID="Action2_desc">Resources and instructions provided during visit.</content> </td> </tr> </tbody> </table> </text> <entry> <observation classCode="OBS" moodCode="GOL"> <!-- Goal Observation C-CDA R2.1--> <!-- Plan of Care Activity Observation C-CDA R1.1--> <templateId root="2.16.840.1.113883.10.20.22.4.44" /> <id root="2a620155-9d11-439e-92b3-5d9815ff4dd4" /> <code code="289169006" displayName="Exercising to lose weight" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> </code> <text> <reference value="#Goal1" /> </text> <value xsi:type="ST">Exercising to lose weight</value> <statusCode code="active" /> <effectiveTime value="20120815" /> <entryRelationship typeCode="RSON" inversionInd="true"> <act classCode="ACT" moodCode="EVN"> <!-- Procedure Activity Act - selected over instructions template since it requries moodCode=INT. This act records education provided during the visit.--> <templateId root="2.16.840.1.113883.10.20.22.4.12" /> <templateId root="2.16.840.1.113883.10.20.22.4.12" extension="2014-06-09" /> <code code="311401005" displayName="Patient education" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> </code> <statusCode code="completed" /> <!-- <text> <reference value="#Action1" /> </text> --> <!-- In this example, the instruction was given at the same time that the goal was set. effectiveTime is the same in this case. --> <effectiveTime value="20120815" /> </act> </entryRelationship> </observation> </entry> <entry> <observation classCode="OBS" moodCode="GOL"> <!-- Plan of Care Activity Observation --> <templateId root="2.16.840.1.113883.10.20.22.4.44" /> <id root="2a620155-9d11-439e-92b3-5d9815ff4dd3" /> <code code="406162001" displayName="Asthma management" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> </code> <text> <reference value="#Goal2" /> </text> <value xsi:type="ST">Asthma management</value> <statusCode code="active" /> <effectiveTime value="20120815" /> <entryRelationship typeCode="RSON" inversionInd="true"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.12" /> <templateId root="2.16.840.1.113883.10.20.22.4.12" extension="2014-06-09" /> <code code="311401005" displayName="Patient education" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> </code> <statusCode code="completed" /> <!-- <text> <reference value="#Action2" /> </text> --> <!-- In this example, the instruction was given at the same time that the goal was set. effectiveTime is the same in this case. --> <effectiveTime value="20120815" /> </act> </entryRelationship> </observation> </entry> </section> </component> </structuredBody> </component> </ClinicalDocument>