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="2.16.840.1.113883.10.20.22.2.17" /> <templateId root="2.16.840.1.113883.10.20.22.2.17" extension="2015-08-01" /> <code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social History" /> <title>Social History</title> <text> <list> <caption>Smoking Status</caption> <item ID="SmokingStatus"> <content>Status: Current every day smoker</content> <content ID="SmokingDetail1">Detail: Moderate smoker (10-19 cigs/day)</content> <content>Started: 1992</content> <content>Stopped:</content> <content>Recorded June 6, 2014 10:32am</content> </item> </list> </text> <!-- Only include one smoking status per patient. --> <entry> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.78" /> <templateId root="2.16.840.1.113883.10.20.22.4.78" extension="2014-06-09" /> <id root="e65d0b47-974f-431d-8ad0-563fe48a87ec" /> <id extension="123456789" root="2.16.840.1.113883.19" /> <code code="72166-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Tobacco smoking status NHIS" /> <text> <reference value="#SmokingStatus" /> </text> <statusCode code="completed" /> <effectiveTime value="20140606103200-0500" /> <!--Note: This template represents a “snapshot in time” observation, simply reflecting what the patient’s current smoking status is at the time of the observation. As a result, the effectiveTime is constrained to just a time stamp, and will approximately correspond with the author/time. --> <value xsi:type="CD" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="449868002" displayName="Smokes tobacco daily" /> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119" /> <time value="20140606103200-0500" /> <assignedAuthor> <id root="7a349401-850e-4665-99ad-5cbd991eca56" /> <id root="2.16.840.1.113883.4.6" extension="99999999" /> <!-- Root means NPI number. --> <code code="200000000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC Health Care Provider Taxonomy" displayName="Allopathic and Osteopathic Physicians" /> <addr nullFlavor="UNK" /> <telecom value="tel:+1(555)555-1002" /> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedAuthor> </author> </observation> </entry> <!--- You can use a social history observation template entry for additional smoking detail, such as smoking quantity--> <entry> <observation classCode="OBS" moodCode="EVN"> <!-- ** Tobacco use ** --> <templateId root="2.16.840.1.113883.10.20.22.4.85" /> <templateId root="2.16.840.1.113883.10.20.22.4.85" extension="2014-06-09" /> <id root="45efb604-7049-4a2e-ad33-d38556c9636c" /> <code code="11367-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of tobacco use" /> <text> <reference value="#SmokingStatus" /> </text> <statusCode code="completed" /> <effectiveTime value="20140606103200-0500" /> <value xsi:type="CD" code="160604004" displayName="Moderate cigarette smoker" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" /> <author> <templateId root="2.16.840.1.113883.10.20.22.4.119" /> <time value="20140606103200-0500" /> <assignedAuthor> <id root="7a349401-850e-4665-99ad-5cbd991eca56" /> <id root="2.16.840.1.113883.4.6" extension="99999999" /> <!-- Root means NPI number. --> <code code="200000000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC Health Care Provider Taxonomy" displayName="Allopathic and Osteopathic Physicians" /> <addr nullFlavor="UNK" /> <telecom value="tel:+1(555)555-1002" /> <assignedPerson> <name> <given>Henry</given> <family>Seven</family> </name> </assignedPerson> </assignedAuthor> </author> </observation> </entry> </section> </component> </structuredBody> </component> </ClinicalDocument>