CDA Document

CDA Document

Name: CCDA 2.1_0724.xml

Creation Date: 7/24/2019

Content
<ClinicalDocument xmlns="urn:hl7-org:v3">
    <realmCode code="US"/>
    <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
    <templateId extension="2015-08-01" root="2.16.840.1.113883.10.20.22.1.1"/>
    <templateId extension="2015-08-01" root="2.16.840.1.113883.10.20.22.1.2"/>
    <id extension="b567132c-ae55-11e9-8261-005056011db9" root="2.16.840.1.113883.4.349"/>
    <code code="34133-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summary of episode note"/>
    <title>Department of Veterans Affairs Health Summary</title>
    <effectiveTime value="20190724155755"/>
    <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" codeSystemName="ConfidentialityCode"/>
    <languageCode code="en-US"/>
    <versionNumber value="2"/>
    <recordTarget>
        <patientRole>
            <id extension="1012638924V546709" root="2.16.840.1.113883.4.349"/>
            <addr use="HP">
            <streetAddressLine>1100 TEST STREET</streetAddressLine>
            <city>HELENA</city>
            <state>AL</state>
            <postalCode>35080</postalCode>
            <country>United States</country>
         </addr>
            <telecom use="HP" value="tel:(989)898-9898"/>
            <telecom use="WP" value="tel:205-111-1111"/>
            <telecom use="MC" value="tel:(205)111-1111"/>
            <telecom value="mailto:myemail78090279@unattended.com"/>
            <patient>
                <name use="L">
               <family>NWHINZZZTESTPATIENT</family>
               <given>NWHINONE</given>
            </name>
                <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGenderCode" displayName="Male">
                    <originalText>M</originalText>
                </administrativeGenderCode>
                <birthTime value="19810101000000"/>
                <maritalStatusCode code="M" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatusCode" displayName="Married">
                    <originalText>Married</originalText>
                </maritalStatusCode>
                <religiousAffiliationCode nullFlavor="UNK">
                    <originalText>BAPTIST</originalText>
                </religiousAffiliationCode>
                <raceCode code="2028-9" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race &amp; Ethnicity - CDC" displayName="Asian">
                    <originalText>Asian</originalText>
                </raceCode>
                <ethnicGroupCode code="2186-5" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race &amp; Ethnicity - CDC" displayName="Not Hispanic or Latino">
                    <originalText>Not Hispanic or Latino</originalText>
                </ethnicGroupCode>
                <languageCommunication>
                    <languageCode code="EN"/>
                    <modeCode code="ESP" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode" displayName="Expressed spoken"/>
                    <proficiencyLevelCode nullFlavor="NA"/>
                    <preferenceInd value="true"/>
                </languageCommunication>
            </patient>
        </patientRole>
    </recordTarget>
    <author>
        <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
        <time value="20190724155755"/>
        <assignedAuthor>
            <id nullFlavor="NA"/>
            <code nullFlavor="UNK"/>
            <telecom nullFlavor="NA"/>
            <assignedPerson>
                <name>Department of Veterans Affairs</name>
            </assignedPerson>
            <representedOrganization>
                <id root="2.16.840.1.113883.4.349"/>
                <name>Department of Veterans Affairs</name>
                <telecom nullFlavor="NA"/>
                <addr use="WP">
               <streetAddressLine>810 Vermont Avenue, NW</streetAddressLine>
               <city>Washington</city>
               <state>DC</state>
               <postalCode>20420</postalCode>
               <country>US</country>
            </addr>
            </representedOrganization>
        </assignedAuthor>
    </author>
    <informant>
        <assignedEntity>
            <id nullFlavor="NI"/>
            <addr nullFlavor="NA"/>
            <telecom nullFlavor="NA"/>
            <assignedPerson>
                <name>Department of Veterans Affairs</name>
            </assignedPerson>
        </assignedEntity>
    </informant>
    <custodian>
        <assignedCustodian>
            <representedCustodianOrganization>
                <id root="2.16.840.1.113883.4.349"/>
                <name>Department of Veterans Affairs</name>
                <telecom nullFlavor="NA"/>
                <addr>
               <streetAddressLine>810 Vermont Avenue NW</streetAddressLine>
               <city>Washington</city>
               <state>DC</state>
               <postalCode>20420</postalCode>
               <country>US</country>
            </addr>
            </representedCustodianOrganization>
        </assignedCustodian>
    </custodian>
    <legalAuthenticator>
        <time value="20190724155755"/>
        <signatureCode code="S"/>
        <assignedEntity>
            <id nullFlavor="NI"/>
            <code nullFlavor="NI"/>
            <addr>
            <streetAddressLine>810 Vermont Avenue NW</streetAddressLine>
            <city>Washington</city>
            <state>DC</state>
            <postalCode>20420</postalCode>
            <country>US</country>
         </addr>
            <telecom nullFlavor="NA"/>
            <assignedPerson>
                <name>Department of Veterans Affairs</name>
            </assignedPerson>
            <representedOrganization>
                <id root="2.16.840.1.113883.4.349"/>
                <name>Department of Veterans Affairs</name>
                <addr>
               <streetAddressLine>810 Vermont Avenue NW</streetAddressLine>
               <city>Washington</city>
               <state>DC</state>
               <postalCode>20420</postalCode>
               <country>US</country>
            </addr>
            </representedOrganization>
        </assignedEntity>
    </legalAuthenticator>
    <participant typeCode="IND">
        <time nullFlavor="UNK"/>
        <associatedEntity classCode="NOK">
            <code codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode" nullFlavor="UNK">
                <originalText>aunt</originalText>
            </code>
            <addr use="HP">
            <streetAddressLine>1100 TEST STREET</streetAddressLine>
            <city>HELENA</city>
            <state>AL</state>
            <postalCode>35080</postalCode>
         </addr>
            <telecom use="HP" value="tel:(205)111-1111"/>
            <telecom use="WP" value="tel:(555)222-9696"/>
            <associatedPerson>
                <name>
               <family>CHEYSHRNOKLAST</family>
               <given>CHEYSHRNOKFIRST</given>
            </name>
            </associatedPerson>
        </associatedEntity>
    </participant>
    <participant typeCode="IND">
        <time nullFlavor="UNK"/>
        <associatedEntity classCode="ECON">
            <code codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode" nullFlavor="UNK">
                <originalText>brother</originalText>
            </code>
            <addr use="HP">
            <streetAddressLine>4444 ANYWHERE STREET</streetAddressLine>
            <city>HELENA</city>
            <state>AL</state>
            <postalCode>35080</postalCode>
         </addr>
            <telecom use="HP" value="tel:(555)555-1010"/>
            <associatedPerson>
                <name>
               <family>CHEYSHRECONLAST</family>
               <given>CHEYSHRECONFIRST</given>
            </name>
            </associatedPerson>
        </associatedEntity>
    </participant>
    <documentationOf>
        <serviceEvent classCode="PCPR">
            <effectiveTime>
                <low value="19810101000000"/>
                <high value="20190724155755"/>
            </effectiveTime>
            <performer typeCode="PRF">
                <templateId extension="2014-06-09" root="2.16.840.1.113883.10.20.6.2.1"/>
                <functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88" codeSystemName="ParticipationFunction" displayName="PRIMARY CARE PROVIDER">
                    <originalText>Primary Care Provider</originalText>
                </functionCode>
                <assignedEntity>
                    <id nullFlavor="NI"/>
                    <code code="203B00000N" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Physicians (M.D. and D.O.)"/>
                    <addr use="WP">
                  <streetAddressLine>2360 E PERSHING BLVD</streetAddressLine>
                  <city>CHEYENNE</city>
                  <postalCode>82001-5356</postalCode>
               </addr>
                    <telecom nullFlavor="NA"/>
                    <assignedPerson>
                        <name>SEITZ, DAVID</name>
                    </assignedPerson>
                    <representedOrganization>
                        <id extension="983" root="2.16.840.1.113883.4.349"/>
                        <name>CHYSHR TEST LAB</name>
                        <telecom nullFlavor="UNK"/>
                        <addr nullFlavor="UNK"/>
                    </representedOrganization>
                </assignedEntity>
            </performer>
            <performer typeCode="PRF">
                <templateId extension="2014-06-09" root="2.16.840.1.113883.10.20.6.2.1"/>
                <functionCode nullFlavor="NI">
                    <originalText>Care Team:  BLUE TEAM</originalText>
                </functionCode>
                <assignedEntity>
                    <id nullFlavor="NI"/>
                    <code nullFlavor="NI"/>
                    <addr nullFlavor="NI"/>
                    <telecom nullFlavor="NA"/>
                    <assignedPerson>
                        <name>CHESNEY, CHRISTINE</name>
                    </assignedPerson>
                    <representedOrganization>
                        <id extension="983" root="2.16.840.1.113883.4.349"/>
                        <name>CHYSHR TEST LAB</name>
                        <telecom nullFlavor="UNK"/>
                        <addr nullFlavor="UNK"/>
                    </representedOrganization>
                </assignedEntity>
            </performer>
            <performer typeCode="PRF">
                <templateId extension="2014-06-09" root="2.16.840.1.113883.10.20.6.2.1"/>
                <functionCode nullFlavor="NI">
                    <originalText>Care Team:  BLUE TEAM</originalText>
                </functionCode>
                <assignedEntity>
                    <id nullFlavor="NI"/>
                    <code code="203BT0002Y" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Physicians (M.D. and D.O.)"/>
                    <addr nullFlavor="NI"/>
                    <telecom nullFlavor="NA"/>
                    <assignedPerson>
                        <name>REED, DANNY</name>
                    </assignedPerson>
                    <representedOrganization>
                        <id extension="983" root="2.16.840.1.113883.4.349"/>
                        <name>CHYSHR TEST LAB</name>
                        <telecom nullFlavor="UNK"/>
                        <addr nullFlavor="UNK"/>
                    </representedOrganization>
                </assignedEntity>
            </performer>
            <performer typeCode="PRF">
                <templateId extension="2014-06-09" root="2.16.840.1.113883.10.20.6.2.1"/>
                <functionCode nullFlavor="NI">
                    <originalText>Care Team:  BLUE TEAM</originalText>
                </functionCode>
                <assignedEntity>
                    <id nullFlavor="NI"/>
                    <code nullFlavor="NI"/>
                    <addr nullFlavor="NI"/>
                    <telecom nullFlavor="NA"/>
                    <assignedPerson>
                        <name>GRANT DAVYES, ANGELITA</name>
                    </assignedPerson>
                    <representedOrganization>
                        <id extension="983" root="2.16.840.1.113883.4.349"/>
                        <name>CHYSHR TEST LAB</name>
                        <telecom nullFlavor="UNK"/>
                        <addr nullFlavor="UNK"/>
                    </representedOrganization>
                </assignedEntity>
            </performer>
        </serviceEvent>
    </documentationOf>
    <component/>
</ClinicalDocument>