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="2.16.840.1.113883.10.20.22.2.4.1" extension="2015-08-01" /> <code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital signs" /> <title>Vital Signs (Last Filed)</title> <text> <table> <thead> <tr> <th>Date</th> <th>Blood Pressure</th> <th>Pulse</th> <th>Temperature</th> <th>Respiratory Rate</th> <th>Height</th> <th>Weight</th> <th>BMI</th> <th>SpO2</th> </tr> </thead> <tbody> <tr> <td>05/20/2014 7:36pm</td> <!-- You can consolidate Systolic and Diastolic in human view if desired but should retain separate references--> <td> <content ID="SystolicBP_1">120</content>/<content ID="DiastolicBP_1">80</content>mm[Hg] </td> <td ID="Pulse_1">80 /min</td> <td ID="Temp_1">37.2 C</td> <td ID="RespRate_1">18 /min</td> <td ID="Height_1">170.2 cm</td> <td ID="Weight_1">108.8 kg</td> <td ID="BMI_1">37.58 kg/m2</td> <td ID="SPO2_1">98%</td> </tr> </tbody> </table> </text> <entry> <!-- When a set of vital signs are recorded together, include them in single clustered organizer--> <organizer classCode="CLUSTER" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.26" /> <templateId root="2.16.840.1.113883.10.20.22.4.26" extension="2015-08-01" /> <id root="e6c800c4-4a71-41bf-80e2-e741dd1168e9" /> <code code="46680005" displayName="Vital Signs" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> </code> <statusCode code="completed" /> <effectiveTime value="20140520193605-0500" /> <!-- Each vital sign should be its own component. Note that systolic and diastolic BP must be separate components--> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id root="fdbd831b-5919-4f06-9467-76b07022f8e8" /> <code code="8480-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Systolic blood pressure" /> <text> <!-- This reference identifies content in human readable formatted text--> <reference value="#SystolicBP_1" /> </text> <statusCode code="completed" /> <effectiveTime value="20140520193605-0500" /> <!-- Example of Value with UCUM unit. Note that metric units used in this example--> <value xsi:type="PQ" value="120" unit="mm[Hg]" /> <!-- Additional information of interpretation and/or reference range may be included but are optional--> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id root="553f3f45-9046-4659-b3e7-5de904003550" /> <code code="8462-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diastolic blood pressure" /> <text> <reference value="#DiastolicBP_1" /> </text> <statusCode code="completed" /> <effectiveTime value="20140520193605-0500" /> <value xsi:type="PQ" value="80" unit="mm[Hg]" /> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id root="77bfe276-a1dd-4372-9072-e603905acc07" /> <code code="8867-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Heart rate" /> <text> <reference value="#Pulse_1" /> </text> <statusCode code="completed" /> <effectiveTime value="20140520193605-0500" /> <value xsi:type="PQ" value="80" unit="/min" /> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id root="24faa204-db62-4610-864f-cb50b650d0fa" /> <code code="8310-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Body temperature" /> <text> <reference value="#Temp_1" /> </text> <statusCode code="completed" /> <effectiveTime value="20140520193605-0500" /> <value xsi:type="PQ" value="37.2" unit="Cel" /> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id root="79f25395-8ec6-488b-8c05-becc97f79995" /> <code code="9279-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Respiratory rate" /> <text> <reference value="#RespRate_1" /> </text> <statusCode code="completed" /> <effectiveTime value="20140520193605-0500" /> <value xsi:type="PQ" value="18" unit="/min" /> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id root="6d3fa9f8-6049-41bd-b0c3-b0196bb6bd37" /> <code code="8302-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Body height" /> <text> <reference value="#Height_1" /> </text> <statusCode code="completed" /> <effectiveTime value="20140520193605-0500" /> <value xsi:type="PQ" value="170.2" unit="cm" /> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id root="2594e631-2189-4e72-9dd1-d6769ee2a7be" /> <code code="29463-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Body weight" /> <text> <reference value="#Weight_1" /> </text> <statusCode code="completed" /> <effectiveTime value="20140520193605-0500" /> <value xsi:type="PQ" value="108.863" unit="kg" /> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id root="5858e765-2ffe-413f-9197-260f2c6e7aa8" /> <code code="39156-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Body mass index (BMI) [Ratio]" /> <text> <reference value="#BMI_1" /> </text> <statusCode code="completed" /> <effectiveTime value="20140520193605-0500" /> <value xsi:type="PQ" value="37.58" unit="kg/m2" /> </observation> </component> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id root="4ce6046c-f6e3-41b0-91fc-2d5325f2bbc3" /> <code code="2710-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="OXYGEN SATURATION" /> <text> <reference value="#SPO2_1" /> </text> <statusCode code="completed" /> <effectiveTime value="20140520193605-0500" /> <value xsi:type="PQ" value="98" unit="%" /> </observation> </component> </organizer> </entry> </section> </component> </structuredBody> </component> </ClinicalDocument>