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="d7830f15-e2c8-4cee-aa2d-a24b36080d53" /> <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="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09" /> <code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PROCEDURES" /> <title>Procedures</title> <text> <table> <thead> <tr> <th>Description</th> <th>Date and Time (Range)</th> <th>Status</th> </tr> </thead> <tbody> <tr ID="Procedure1"> <td ID="ProcedureDesc1">Laparoscopic appendectomy</td> <td>(03 Feb 2014 09:22am- 03 Feb 2014 11:15am)</td> <td>Completed</td> </tr> </tbody> </table> </text> <entry> <!-- Procedures should be used for care that directly changes the patient's physical state.--> <procedure moodCode="EVN" classCode="PROC"> <templateId root="2.16.840.1.113883.10.20.22.4.14" /> <templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09" /> <id root="64af26d5-88ef-4169-ba16-c6ef16a1824f" /> <code code="6025007" displayName="Laparoscopic appendectomy" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> </code> <text> <reference value="#Procedure1" /> </text> <statusCode code="completed" /> <!-- Effective times can be either a value or interval. For procedures with start and stop times, an interval would be more appropriate --> <effectiveTime> <low value="20140203092205-0700" /> <high value="20140203111514-0700" /> </effectiveTime> <!-- methodCode indicates how the procedure was performed. It cannot conflict with the code used for procedure--> <!-- <methodCode code="51316009" codeSystem="2.16.840.1.113883.6.96" displayName="Laparoscopic procedure" codeSystemName="SNOMED CT" /> --> <!-- targetSiteCode indicates the body site addressed by procedure and must be from value set 2.16.840.1.113883.3.88.12.3221.8.9--> <targetSiteCode code="181255000" codeSystem="2.16.840.1.113883.6.96" displayName="Entire appendix" codeSystemName="SNOMED CT" /> </procedure> </entry> </section> </component> </structuredBody> </component> </ClinicalDocument>