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="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01" /> <templateId root="2.16.840.1.113883.10.20.22.2.5.1" /> <code code="11450-4" displayName="Problem List" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"></code> <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: February 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" /> <templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" /> <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" /> <!-- This equates to the time the concern was authored in the patient's chart. This may frequently be an EHR timestamp--> <effectiveTime> <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" /> <templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01" /> <id extension="10241104348" root="1.3.6.1.4.1.22812.4.111.0.4.1.2.1" /> <code code="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> <translation code = "75323-6" codeSystem = "2.16.840.1.113883.6.1" codeSystemName = "LOINC" displayName = "Condition"/> </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" /> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119" /> <time value="20140302124536-0500" /> <assignedAuthor> <id root="3dfd1be3-1806-48e9-86dd-7282b2cae74f" /> <id extension="66666" root="2.16.840.1.113883.4.6" /> <code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC Health Care Provider Taxonomy" displayName="Allopathic &amp; Osteopathic Physicians; Internal Medicine, Cardiovascular Disease" /> <addr> <streetAddressLine>6666 StreetName St.</streetAddressLine> <city>Silver Spring</city> <state>MD</state> <postalCode>20901</postalCode> <country>US</country> </addr> <telecom value="tel:+1(301)666-6666" /> <assignedPerson> <name> <given>Heartly</given> <family>Sixer</family> <suffix>MD</suffix> </name> </assignedPerson> </assignedAuthor> </author> </observation> </entryRelationship> </act> </entry> </section> </component> </structuredBody> </component> </ClinicalDocument>