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<?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>
<!-- conforms to Immunizations section with entries optional -->
<templateId root="2.16.840.1.113883.10.20.22.2.2" />
<templateId root="2.16.840.1.113883.10.20.22.2.2" extension="2015-08-01" />
<!-- Immunizations section with entries required -->
<templateId root="2.16.840.1.113883.10.20.22.2.2.1" />
<templateId root="2.16.840.1.113883.10.20.22.2.2.1" extension="2015-08-01" />
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="History of immunizations" />
<title>IMMUNIZATIONS</title>
<text>
<content ID="immunSect" />
<table border="1" width="100%">
<thead>
<tr>
<th>Vaccine</th>
<th>Lot Number</th>
<th>Date</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr ID="immun1">
<td ID="ImmunizationProduct_100">Influenza Virus Vaccine</td>
<td>1</td>
<td>8/15/2010</td>
<td>Completed</td>
</tr>
</tbody>
</table>
</text>
<entry>
<substanceAdministration classCode="SBADM" moodCode="EVN"
negationInd="false">
<!-- ** Immunization activity ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.52" />
<templateId root="2.16.840.1.113883.10.20.22.4.52"
extension="2015-08-01" />
<id root="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92" />
<text>
<reference value="#immun1" />
</text>
<!-- Indicates the status of the substanceAdministartion -->
<statusCode code="completed" />
<effectiveTime value="20100815" />
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Immunization medication information ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.54" />
<templateId root="2.16.840.1.113883.10.20.22.4.54"
extension="2014-06-09" />
<manufacturedMaterial>
<code code="88" codeSystem="2.16.840.1.113883.12.292"
displayName="influenza virus vaccine, unspecified formulation"
codeSystemName="CVX">
</code>
<lotNumberText>1</lotNumberText>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Health LS - Immuno Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<!-- Optional Performer -->
<performer>
<assignedEntity>
<id root="7ae96c77-6b8f-4e5a-9938-2f6392857789" />
<addr>
<streetAddressLine>1021 Health Drive</streetAddressLine>
<city>Ann Arbor</city>
<state>MI</state>
<postalCode>99099</postalCode>
<country>US</country>
</addr>
<telecom nullFlavor="UNK" />
<assignedPerson>
<id root="7ae96c77-6b8f-4e5a-9938-2f6392857789" />
<name>
<given>Amanda</given>
<family>Assigned</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="7ae96c77-6b8f-4e5a-9938-2f6392857789" />
<name>Good Health Clinic</name>
<telecom nullFlavor="UNK" />
<addr nullFlavor="UNK" />
</representedOrganization>
</assignedEntity>
</performer>
<!-- Optional Author -->
<!--
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119" />
<time value="20100815" />
<assignedAuthor>
<id extension="99999999" root="2.16.840.1.113883.4.6" />
<code code="207Q00000X" codeSystem="2.16.840.1.113883.6.101"
codeSystemName="Health Care Provider Taxonomy"
displayName="Allopathic & Osteopathic Physicians; Family Medicine" />
<telecom value="tel:555-555-1002" />
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
-->
</substanceAdministration>
</entry>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>