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<?xml version="1.0" encoding="UTF-8"?>
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<ClinicalDocument
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xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
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xmlns="urn:hl7-org:v3"
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xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd"
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xmlns:sdtc="urn:hl7-org:sdtc">
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<realmCode code="US"/>
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<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
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<templateId root="2.16.840.1.113883.10.20.22.1.1" assigningAuthorityName="HL7 C-CDA R1.1 General Header" />
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<templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2015-08-01" assigningAuthorityName="HL7 C-CDA R2.1 General Header" />
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<templateId root="2.16.840.1.113883.10.20.22.1.1" assigningAuthorityName="HL7/CCDA General Header"/>
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<templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2015-08-01" assigningAuthorityName="HL7/CCDA General Header"/>
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<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
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<templateId root="2.16.840.1.113883.10.20.22.1.2" extension="2015-08-01"/>
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<id root="2.16.840.1.113883.3.198" extension="1666580073/34133-9/BFDDA623-8C74-D900-2FCD-9335D217D4AB" />
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<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34133-9" displayName="Summarization of Episode Note"/>
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<title>Department of Defense Consolidated CDA Document (C-CDA CCD)</title>
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<effectiveTime value="20180424212300+0000" />
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<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" codeSystemName="ConfidentialityCode"/>
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<languageCode code="en-US"/>
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<recordTarget>
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<patientRole>
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<id extension="1666580073" root="2.16.840.1.113883.3.42.10001.100001.12" assigningAuthorityName="DoD Electronic Data Interchange Person Identifier" />
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<addr nullFlavor="UNK" />
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<telecom nullFlavor="UNK" />
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<patient>
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<name use="L">
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<given>RPATSEVENTY V</given>
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<family>CHDRAMDREG</family>
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<suffix nullFlavor="UNK" />
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</name>
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<administrativeGenderCode codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender" nullFlavor="UNK" />
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<birthTime value="19700303" />
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<maritalStatusCode codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatusCode" nullFlavor="UNK" />
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<religiousAffiliationCode codeSystem="2.16.840.1.113883.5.1076" codeSystemName="ReligiousAffiliation" nullFlavor="UNK" />
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<raceCode codeSystem="2.16.840.1.113883.6.238" codeSystemName="OMB Standards for Race and Ethnicity" nullFlavor="UNK" />
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<ethnicGroupCode codeSystem="2.16.840.1.113883.6.238" codeSystemName="OMB Standards for Race and Ethnicity" nullFlavor="UNK" />
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</patient>
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<providerOrganization xsi:type="POCD_MT000040.Organization">
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<id root="2.16.840.1.113883.3.42" />
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<name>DoD MHS</name>
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<telecom nullFlavor="NI" />
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<addr nullFlavor="NI" />
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</providerOrganization>
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</patientRole>
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</recordTarget>
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<author>
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<time value="20180424212300+0000" />
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<assignedAuthor>
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<id root="2.16.840.1.113883.3.198" />
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<addr nullFlavor="UNK" />
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<telecom nullFlavor="UNK" />
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<assignedAuthoringDevice>
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<manufacturerModelName>DoD DMIX DES</manufacturerModelName>
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<softwareName>Data Exchange Services (DES)</softwareName>
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</assignedAuthoringDevice>
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<representedOrganization>
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<id root="2.16.840.1.113883.3.198" />
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<name>DoD</name>
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<telecom nullFlavor="NI"/>
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<addr nullFlavor="NI"/>
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</representedOrganization>
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</assignedAuthor>
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</author>
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<dataEnterer>
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<assignedEntity>
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<id root="2.16.840.1.113883.3.198" />
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<addr nullFlavor="UNK" />
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<telecom nullFlavor="UNK" />
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<assignedPerson>
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<name>DoD NwHIN Adapter</name>
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</assignedPerson>
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<representedOrganization>
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<id root="2.16.840.1.113883.3.198" />
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<name>DoD</name>
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<telecom nullFlavor="NI" />
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<addr nullFlavor="NI" />
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</representedOrganization>
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</assignedEntity>
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</dataEnterer>
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<informant typeCode="INF">
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<assignedEntity>
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<id root="2.16.840.1.113883.3.198" />
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<addr nullFlavor="UNK" />
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<telecom nullFlavor="UNK" />
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<assignedPerson nullFlavor="UNK">
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<name nullFlavor="UNK"/>
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</assignedPerson>
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<representedOrganization>
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<id root="2.16.840.1.113883.3.198" />
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<name>DoD</name>
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<telecom nullFlavor="NI" />
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<addr nullFlavor="NI" />
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</representedOrganization>
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</assignedEntity>
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</informant>
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<custodian>
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<assignedCustodian>
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<representedCustodianOrganization>
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<id extension="2.16.840.1.113883.3.198" root="2.16.840.1.113883.4.6" />
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<name>Department of Defense</name>
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<telecom nullFlavor="NI" />
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<addr nullFlavor="NI" />
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</representedCustodianOrganization>
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</assignedCustodian>
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</custodian>
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<legalAuthenticator>
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<time value="20180424212300+0000" />
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<signatureCode code="S"/>
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<assignedEntity>
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<id root="2.16.840.1.113883.3.198" />
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<addr nullFlavor="UNK" />
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<telecom nullFlavor="UNK" />
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<assignedPerson>
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<name/>
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</assignedPerson>
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<representedOrganization>
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<id root="2.16.840.1.113883.3.198" />
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<name>DoD</name>
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129 |
<telecom nullFlavor="NI" />
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130 |
<addr nullFlavor="NI" />
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</representedOrganization>
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</assignedEntity>
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</legalAuthenticator>
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|
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<participant typeCode="IND">
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<associatedEntity classCode="NOK">
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<code codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode" nullFlavor="UNK" />
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<addr nullFlavor="UNK" />
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<telecom nullFlavor="NI" />
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<associatedPerson>
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<name></name>
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</associatedPerson>
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143 |
</associatedEntity>
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144 |
</participant>
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145 |
|
146 |
<documentationOf>
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<serviceEvent classCode="PCPR">
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<effectiveTime>
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<low nullFlavor="UNK" />
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<high value="20180424212300+0000"/>
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</effectiveTime>
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<performer typeCode="PRF">
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<assignedEntity>
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<id extension="41249547" root="2.16.840.1.113883.4.6" />
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<code codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC Health Care Provider Taxonomy" code="207Q00000X" displayName="Allopathic & Osteopathic Physicians-Family Medicine-" />
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156 |
<addr nullFlavor="NI" />
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157 |
<telecom nullFlavor="NI" />
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158 |
<assignedPerson>
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<name>ABL, USER SIXTYSIX</name>
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160 |
</assignedPerson>
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</assignedEntity>
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</performer>
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</serviceEvent>
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</documentationOf>
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165 |
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166 |
|
167 |
<component>
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<structuredBody>
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169 |
<component>
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<section nullFlavor="NI">
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171 |
<templateId root="2.16.840.1.113883.10.20.22.2.6"/>
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172 |
<templateId root="2.16.840.1.113883.10.20.22.2.6" extension="2015-08-01"/>
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<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
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<templateId root="2.16.840.1.113883.10.20.22.2.6.1" extension="2015-08-01"/>
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175 |
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts" />
|
176 |
<title>Allergies and Adverse Reactions (C-CDA)</title>
|
177 |
<text>
|
178 |
<table>
|
179 |
<thead>
|
180 |
<tr>
|
181 |
<th>Substance</th>
|
182 |
<th>Reaction</th>
|
183 |
<th>Effective Time</th>
|
184 |
<th>Source</th>
|
185 |
</tr>
|
186 |
</thead>
|
187 |
<tbody>
|
188 |
<tr>
|
189 |
<td colspan="3">
|
190 |
<content ID="allergycomment" styleCode="Italics">This section is an empty allergy results section.</content>
|
191 |
</td>
|
192 |
</tr>
|
193 |
</tbody>
|
194 |
</table>
|
195 |
</text>
|
196 |
<entry>
|
197 |
<act classCode="ACT" moodCode="EVN">
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198 |
<templateId root="2.16.840.1.113883.10.20.22.4.64"/>
|
199 |
<code code="48767-8" displayName="comment" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>
|
200 |
<text><reference value="#allergycomment"/></text>
|
201 |
<statusCode code="completed" />
|
202 |
</act>
|
203 |
</entry>
|
204 |
</section>
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205 |
</component>
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206 |
|
207 |
<component>
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208 |
<section nullFlavor="NI">
|
209 |
<templateId root="2.16.840.1.113883.10.20.22.2.2"/>
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210 |
<templateId root="2.16.840.1.113883.10.20.22.2.2" extension="2015-08-01"/>
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211 |
<templateId root="2.16.840.1.113883.10.20.22.2.2.1"/>
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212 |
<templateId root="2.16.840.1.113883.10.20.22.2.2.1" extension="2015-08-01"/>
|
213 |
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of immunizations"/>
|
214 |
<title>History Of Immunizations (C-CDA)</title>
|
215 |
<text>
|
216 |
<table>
|
217 |
<thead>
|
218 |
<tr>
|
219 |
<th>Vaccine</th>
|
220 |
<th>Series #</th>
|
221 |
<th>Dosage</th>
|
222 |
<th>Date</th>
|
223 |
<th>Administered By</th>
|
224 |
<th>Drug Manufacturer</th>
|
225 |
<th>Lot Number</th>
|
226 |
<th>CVX Code</th>
|
227 |
<th>Refusal Reason</th>
|
228 |
</tr>
|
229 |
</thead>
|
230 |
<tbody>
|
231 |
<tr> <th>This section is an empty immunization section.</th></tr>
|
232 |
</tbody>
|
233 |
</table>
|
234 |
<content ID="immunizationscomment" styleCode="Italics">There are multiple immunizations systems within the Military Health System (MHS). All immunizations and exemptions/refusals for this patient that are stored in the MHS's Clinical Data Repository (CDR) are included here, but this list is empty.</content>
|
235 |
</text>
|
236 |
</section>
|
237 |
</component>
|
238 |
|
239 |
<component>
|
240 |
<section>
|
241 |
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
|
242 |
<templateId root="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09"/>
|
243 |
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF MEDICATION USE"/>
|
244 |
<title>Medications</title>
|
245 |
<text>
|
246 |
<table>
|
247 |
<thead>
|
248 |
<tr>
|
249 |
<th>Product Name</th>
|
250 |
<th>RouteOfAdministration</th>
|
251 |
<th>Timing Qty</th>
|
252 |
<th>Order Date</th>
|
253 |
<th>Order Qty</th>
|
254 |
<th>Status</th>
|
255 |
<th>Start Date</th>
|
256 |
<th>Expiration Date</th>
|
257 |
<th>Last Dispensed Date</th>
|
258 |
<th>Discontinued Date</th>
|
259 |
<th>Source</th>
|
260 |
</tr>
|
261 |
</thead>
|
262 |
<tbody>
|
263 |
<tr>
|
264 |
<td colspan="11">
|
265 |
<content ID="medicationcomment" styleCode="Italics">This section is an empty medications section.</content>
|
266 |
</td>
|
267 |
</tr>
|
268 |
</tbody>
|
269 |
</table>
|
270 |
|
271 |
</text>
|
272 |
<entry>
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273 |
<act classCode="ACT" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.20.22.4.64"/>
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<code code="48767-8" displayName="comment" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>
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276 |
<text><reference value="#medicationcomment" /></text>
|
277 |
<statusCode code="completed" />
|
278 |
</act>
|
279 |
</entry>
|
280 |
<entry nullFlavor="NI">
|
281 |
<substanceAdministration classCode="SBADM" moodCode="EVN" nullFlavor="NI">
|
282 |
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
|
283 |
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
|
284 |
<id nullFlavor="NI"/>
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285 |
<statusCode code="active"/>
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286 |
<effectiveTime xsi:type="IVL_TS">
|
287 |
<low nullFlavor="NI" />
|
288 |
<high nullFlavor="NI" />
|
289 |
</effectiveTime>
|
290 |
<consumable>
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291 |
<manufacturedProduct classCode="MANU">
|
292 |
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
|
293 |
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
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294 |
<manufacturedMaterial>
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295 |
<code nullFlavor="UNK">
|
296 |
<originalText><reference value="#medicationcomment" /></originalText>
|
297 |
</code>
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298 |
</manufacturedMaterial>
|
299 |
</manufacturedProduct>
|
300 |
</consumable>
|
301 |
</substanceAdministration>
|
302 |
</entry>
|
303 |
</section>
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304 |
</component>
|
305 |
|
306 |
|
307 |
<component>
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308 |
<section nullFlavor="NI">
|
309 |
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
|
310 |
<templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
|
311 |
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROBLEM LIST"/>
|
312 |
<title>Problem List (C-CDA)</title>
|
313 |
<text>
|
314 |
<table>
|
315 |
<thead>
|
316 |
<tr>
|
317 |
<th>Name</th>
|
318 |
<th>Status</th>
|
319 |
<th>Onset Date</th>
|
320 |
<th>Chronicity</th>
|
321 |
<th>Code</th>
|
322 |
<th>Source</th>
|
323 |
</tr>
|
324 |
</thead>
|
325 |
<tbody>
|
326 |
<tr>
|
327 |
<td colspan="6">
|
328 |
<content ID="problemcomment" styleCode="Italics">This section is an empty problems section.</content>
|
329 |
</td>
|
330 |
</tr>
|
331 |
</tbody>
|
332 |
</table>
|
333 |
</text>
|
334 |
<entry>
|
335 |
<act classCode="ACT" moodCode="EVN">
|
336 |
<templateId root="2.16.840.1.113883.10.20.22.4.64"/>
|
337 |
<code code="48767-8" displayName="comment" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>
|
338 |
<text><reference value="#problemcomment" /></text>
|
339 |
<statusCode code="completed" />
|
340 |
</act>
|
341 |
</entry>
|
342 |
</section>
|
343 |
</component>
|
344 |
|
345 |
<component>
|
346 |
<section>
|
347 |
<templateId root="2.16.840.1.113883.10.20.22.2.7"/>
|
348 |
<templateId root="2.16.840.1.113883.10.20.22.2.7" extension="2014-06-09"/>
|
349 |
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
|
350 |
<templateId root="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09"/>
|
351 |
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PROCEDURES"/>
|
352 |
<title>Procedures (C-CDA)</title>
|
353 |
<text>
|
354 |
<table>
|
355 |
<thead>
|
356 |
<tr>
|
357 |
<th>Date/Time</th>
|
358 |
<th>Procedure Type</th>
|
359 |
<th>Provider</th>
|
360 |
<th>Procedure Comment</th>
|
361 |
</tr>
|
362 |
</thead>
|
363 |
<tbody>
|
364 |
<tr>
|
365 |
<td colspan="4">
|
366 |
<content ID="procedurecomment" styleCode="Italics">This section is an empty procedures section.</content>
|
367 |
</td>
|
368 |
</tr>
|
369 |
</tbody>
|
370 |
</table>
|
371 |
</text>
|
372 |
<entry>
|
373 |
<act classCode="ACT" moodCode="EVN">
|
374 |
<templateId root="2.16.840.1.113883.10.20.22.4.64"/>
|
375 |
<code code="48767-8" displayName="comment" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>
|
376 |
<statusCode code="completed" />
|
377 |
<text><reference value="#procedurecomment"/></text>
|
378 |
</act>
|
379 |
</entry>
|
380 |
<entry nullFlavor="NI">
|
381 |
<procedure classCode="PROC" moodCode="EVN" nullFlavor="NI">
|
382 |
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
|
383 |
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
|
384 |
<id root="defaultProcedure" />
|
385 |
<code nullFlavor="NI">
|
386 |
<originalText><reference value="#procedurecomment"/></originalText>
|
387 |
</code>
|
388 |
<statusCode code="completed"/>
|
389 |
</procedure>
|
390 |
</entry>
|
391 |
</section>
|
392 |
</component>
|
393 |
|
394 |
<component>
|
395 |
<section nullFlavor="NI">
|
396 |
<templateId root="2.16.840.1.113883.10.20.22.2.3.1" />
|
397 |
<templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01" />
|
398 |
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Relevant diagnostic tests and/or laboratory data" />
|
399 |
<title>Diagnostic tests and laboratory results (C-CDA)</title>
|
400 |
<text>
|
401 |
<table>
|
402 |
<thead>
|
403 |
<tr>
|
404 |
<th>Collection Date/Time</th>
|
405 |
<th>Order/Panel</th>
|
406 |
<th>Test</th>
|
407 |
<th>Result</th>
|
408 |
<th>Ref Range</th>
|
409 |
<th>Interpretation</th>
|
410 |
<th>Source</th>
|
411 |
<th>Order Comment</th>
|
412 |
<th>Result Comment</th>
|
413 |
<th>Result Interpretation Comment</th>
|
414 |
<th>Specimen</th>
|
415 |
</tr>
|
416 |
</thead>
|
417 |
<tbody>
|
418 |
<tr><td colspan="10"><content ID="resultcomment" styleCode="Italics">This section is an empty lab results section.
|
419 |
</content></td></tr>
|
420 |
</tbody>
|
421 |
</table>
|
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</text>
|
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<component>
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<section>
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|
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<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="VITAL SIGNS"/>
|
441 |
<title>Vitals (C-CDA)</title>
|
442 |
<text>
|
443 |
<table>
|
444 |
<thead>
|
445 |
<tr>
|
446 |
<th>Collection Date/Time</th>
|
447 |
<th>Test</th>
|
448 |
<th>Result</th>
|
449 |
<th>Site</th>
|
450 |
<th>Method</th>
|
451 |
<th>Source</th>
|
452 |
</tr>
|
453 |
</thead>
|
454 |
<tbody>
|
455 |
<tr>
|
456 |
<td>20180424195014+0000</td>
|
457 |
<td><content ID="vitals-1">BMI</content></td>
|
458 |
<td>22.60 kg/m2</td>
|
459 |
<td><content ID="vitalsite-1"></content></td>
|
460 |
<td><content ID="vitalmethod-1"></content></td>
|
461 |
<td>4th Medical Group(Internal Medicine)</td>
|
462 |
</tr><tr>
|
463 |
<td>20180424195014+0000</td>
|
464 |
<td><content ID="vitals-2">Systolic blood pressure</content></td>
|
465 |
<td>110 mmHg</td>
|
466 |
<td><content ID="vitalsite-2"></content></td>
|
467 |
<td><content ID="vitalmethod-2"></content></td>
|
468 |
<td>4th Medical Group(Internal Medicine)</td>
|
469 |
</tr><tr>
|
470 |
<td>20180424195014+0000</td>
|
471 |
<td><content ID="vitals-3">Respiratory rate</content></td>
|
472 |
<td>32 /min</td>
|
473 |
<td><content ID="vitalsite-3"></content></td>
|
474 |
<td><content ID="vitalmethod-3"></content></td>
|
475 |
<td>4th Medical Group(Internal Medicine)</td>
|
476 |
</tr><tr>
|
477 |
<td>20180424195014+0000</td>
|
478 |
<td><content ID="vitals-4">Body height Measured</content></td>
|
479 |
<td>66 in</td>
|
480 |
<td><content ID="vitalsite-4"></content></td>
|
481 |
<td><content ID="vitalmethod-4"></content></td>
|
482 |
<td>4th Medical Group(Internal Medicine)</td>
|
483 |
</tr><tr>
|
484 |
<td>20180424195014+0000</td>
|
485 |
<td><content ID="vitals-5">Diastolic blood pressure</content></td>
|
486 |
<td>108 mmHg</td>
|
487 |
<td><content ID="vitalsite-5"></content></td>
|
488 |
<td><content ID="vitalmethod-5"></content></td>
|
489 |
<td>4th Medical Group(Internal Medicine)</td>
|
490 |
</tr><tr>
|
491 |
<td>20180424195014+0000</td>
|
492 |
<td><content ID="vitals-6">Body weight Measured</content></td>
|
493 |
<td>140 lb</td>
|
494 |
<td><content ID="vitalsite-6"></content></td>
|
495 |
<td><content ID="vitalmethod-6"></content></td>
|
496 |
<td>4th Medical Group(Internal Medicine)</td>
|
497 |
</tr><tr>
|
498 |
<td>20180424195014+0000</td>
|
499 |
<td><content ID="vitals-7">Heart rate</content></td>
|
500 |
<td>69 /min</td>
|
501 |
<td><content ID="vitalsite-7"></content></td>
|
502 |
<td><content ID="vitalmethod-7"></content></td>
|
503 |
<td>4th Medical Group(Internal Medicine)</td>
|
504 |
</tr><tr>
|
505 |
<td>20180424195014+0000</td>
|
506 |
<td><content ID="vitals-8">Oxygen saturation in Arterial blood by Pulse oximetry</content></td>
|
507 |
<td>95 % saturation</td>
|
508 |
<td><content ID="vitalsite-8"></content></td>
|
509 |
<td><content ID="vitalmethod-8"></content></td>
|
510 |
<td>4th Medical Group(Internal Medicine)</td>
|
511 |
</tr><tr>
|
512 |
<td>20180424195014+0000</td>
|
513 |
<td><content ID="vitals-9">Body temperature</content></td>
|
514 |
<td>98 F</td>
|
515 |
<td><content ID="vitalsite-9"></content></td>
|
516 |
<td><content ID="vitalmethod-9"></content></td>
|
517 |
<td>4th Medical Group(Internal Medicine)</td>
|
518 |
</tr>
|
519 |
</tbody>
|
520 |
</table>
|
521 |
<content ID="vitalsigncomment" styleCode="Italics">This section includes information documenting the patient's vital signs for the past 15 months up to a maximum of 10 sets. Height and weight values may have been measured or stated by the patient.</content>
|
522 |
</text>
|
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|
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<entry>
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<text><reference value="#vitalsigncomment"/></text>
|
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<statusCode code="completed" />
|
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</act>
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</entry>
|
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|
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<entry typeCode="DRIV">
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<code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED -CT" displayName="Vital signs">
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<translation code="74728-7" displayName="Vital signs, weight, height, head circumfrence, oximetry, BMI, and BSA panel"
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<name>4th Medical Group(Internal Medicine)</name>
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<value unit="kg/m2" value="22.60" xsi:type="PQ" />
|
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|
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|
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</component><component>
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|
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<value unit="mm[Hg]" value="110" xsi:type="PQ" />
|
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|
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|
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<value unit="/min" value="32" xsi:type="PQ" />
|
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|
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|
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|
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</component><component>
|
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<value unit="[in_us]" value="66" xsi:type="PQ" />
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<methodCode nullFlavor="UNK">
|
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<originalText><reference value="#vitalmethod-4"/></originalText>
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</methodCode>
|
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|
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|
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</observation>
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|
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<originalText><reference value="#vitals-5"/></originalText>
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<effectiveTime value="20180424195014+0000" />
|
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<value unit="mm[Hg]" value="108" xsi:type="PQ" />
|
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|
629 |
|
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</observation>
|
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</component><component>
|
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<templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09"/>
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<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="3141-9" displayName="Body weight Measured">
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<originalText><reference value="#vitals-6"/></originalText>
|
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</code>
|
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<statusCode code="completed" />
|
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<effectiveTime value="20180424195014+0000" />
|
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<value unit="[lb_av]" value="140" xsi:type="PQ" />
|
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<methodCode nullFlavor="UNK">
|
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<originalText><reference value="#vitalmethod-6"/></originalText>
|
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</methodCode>
|
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|
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|
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</observation>
|
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</component><component>
|
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<observation classCode="OBS" moodCode="EVN">
|
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<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
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<templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09"/>
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<originalText><reference value="#vitals-7"/></originalText>
|
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<statusCode code="completed" />
|
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<effectiveTime value="20180424195014+0000" />
|
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<value unit="/min" value="69" xsi:type="PQ" />
|
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|
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|
661 |
</observation>
|
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</component><component>
|
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<observation classCode="OBS" moodCode="EVN">
|
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<originalText><reference value="#vitals-8"/></originalText>
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|
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<statusCode code="completed" />
|
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<effectiveTime value="20180424195014+0000" />
|
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<value unit="%" value="95" xsi:type="PQ" />
|
673 |
|
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|
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</observation>
|
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</component><component>
|
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<observation classCode="OBS" moodCode="EVN">
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<statusCode code="completed" />
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<effectiveTime value="20180424195014+0000" />
|
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<value unit="[degF]" value="98" xsi:type="PQ" />
|
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|
688 |
|
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</observation>
|
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</component>
|
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</organizer>
|
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|
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|
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|
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<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
|
704 |
<title>History of encounters (C-CDA)</title>
|
705 |
<text>
|
706 |
<table>
|
707 |
<thead>
|
708 |
<tr>
|
709 |
<th>Date/Time</th>
|
710 |
<th>Encounter Type</th>
|
711 |
<th>Reason for Visit</th>
|
712 |
<th>Provider</th>
|
713 |
<th>Disposition</th>
|
714 |
<th>Source</th>
|
715 |
</tr>
|
716 |
</thead>
|
717 |
<tbody>
|
718 |
<tr>
|
719 |
<td>20180424194959</td>
|
720 |
<td><content ID="encounter-1">OFFICE/OUTPATIENT VISIT NEW</content></td>
|
721 |
<td><content ID="encounterreason-1"></content></td>
|
722 |
<td>ABL, USER SIXTYSIX</td>
|
723 |
<td><content ID="encounterDisposition-1">Released w/o Limitations</content></td>
|
724 |
<td>4th Medical Group(Internal Medicine)</td>
|
725 |
</tr>
|
726 |
</tbody>
|
727 |
</table>
|
728 |
<content ID="encountercomment" styleCode="Italics">This section includes appointments/admissions for the past 280 months.</content>
|
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</text>
|
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|
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<entry>
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<act classCode="ACT" moodCode="EVN">
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<text><reference value="#encountercomment"/></text>
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<statusCode code="completed" />
|
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</act>
|
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</entry>
|
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|
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<entry typeCode="DRIV">
|
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<encounter classCode="ENC" moodCode="EVN">
|
742 |
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
|
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<templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01"/>
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<code codeSystem="2.16.840.1.113883.6.12"
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codeSystemName="Current Procedure Terminology 4 (CPT-4) codes."
|
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|
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displayName="OFFICE/OUTPATIENT VISIT NEW">
|
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<originalText><reference value="#encounter-1"/></originalText>
|
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</code>
|
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|
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<effectiveTime value="20180424194959" />
|
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|
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<sdtc:dischargeDispositionCode codeSystem="2.16.840.1.113883.12.112" codeSystemName="NUBC UB-04 FL17-Patient Status" nullFlavor="UNK">
|
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<originalText><reference value="#encounterDisposition-1"></reference></originalText>
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</sdtc:dischargeDispositionCode>
|
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|
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<performer typeCode="PRF">
|
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<assignedEntity classCode="ASSIGNED">
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<code codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC Provider Taxonomy" code="207Q00000X" displayName="Allopathic & Osteopathic Physicians-Family Medicine-"/>
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<assignedPerson>
|
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<name>ABL, USER SIXTYSIX</name>
|
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</assignedPerson>
|
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</assignedEntity>
|
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</performer>
|
767 |
|
768 |
<participant typeCode="LOC">
|
769 |
<time xsi:type="IVL_TS">
|
770 |
<low value="20180424194959"/>
|
771 |
|
772 |
</time>
|
773 |
<participantRole classCode="SDLOC">
|
774 |
<templateId root="2.16.840.1.113883.10.20.22.4.32"/>
|
775 |
<id extension="1048021" root="2.16.840.1.113883.3.42.126.100001.16" />
|
776 |
<code nullFlavor="UNK" codeSystem="2.16.840.1.113883.6.259" codeSystemName="HealthcareServiceLocation">
|
777 |
</code>
|
778 |
<addr nullFlavor="UNK" />
|
779 |
<telecom nullFlavor="UNK"/>
|
780 |
<playingEntity classCode="PLC">
|
781 |
<name>4th Medical Group(Internal Medicine)</name>
|
782 |
</playingEntity>
|
783 |
</participantRole>
|
784 |
</participant>
|
785 |
|
786 |
</encounter>
|
787 |
</entry>
|
788 |
|
789 |
</section>
|
790 |
</component>
|
791 |
|
792 |
<component>
|
793 |
<section nullFlavor="NI">
|
794 |
<templateId root="2.16.840.1.113883.10.20.22.2.18"/>
|
795 |
<templateId root="2.16.840.1.113883.10.20.22.2.18" extension="2015-08-01"/>
|
796 |
<templateId root="2.16.840.1.113883.10.20.22.2.18.1"/>
|
797 |
<code code="48768-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payment sources" />
|
798 |
<title>Insurance providers (C-CDA)</title>
|
799 |
<text>
|
800 |
<table>
|
801 |
<thead>
|
802 |
<tr>
|
803 |
<th>Plan Type</th>
|
804 |
<th>Plan Name</th>
|
805 |
<th>Group No</th>
|
806 |
<th>Source</th>
|
807 |
<th>Relation to Subscriber</th>
|
808 |
</tr>
|
809 |
</thead>
|
810 |
<tbody>
|
811 |
<tr> <th>This section is an empty insurance section.</th></tr>
|
812 |
</tbody>
|
813 |
</table>
|
814 |
<content ID="payerssourcescomment" styleCode="Italics">This section contains current third-party (non-TRICARE) insurance information as known by the Department of Defense. This information is empty.</content>
|
815 |
</text>
|
816 |
</section>
|
817 |
</component>
|
818 |
|
819 |
|
820 |
<component>
|
821 |
<section nullFlavor="NI">
|
822 |
<templateId root="2.16.840.1.113883.10.20.22.2.17"/>
|
823 |
<templateId root="2.16.840.1.113883.10.20.22.2.17" extension="2015-08-01"/>
|
824 |
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social History"/>
|
825 |
<title>Social History (C-CDA)</title>
|
826 |
<text><paragraph styleCode="Italics">No Information</paragraph></text>
|
827 |
</section>
|
828 |
</component>
|
829 |
|
830 |
<component>
|
831 |
<section nullFlavor="NI">
|
832 |
<templateId root="2.16.840.1.113883.10.20.22.2.10"/>
|
833 |
<templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09"/>
|
834 |
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of Care"/>
|
835 |
<title>Plan of Care (C-CDA)</title>
|
836 |
<text><paragraph styleCode="Italics">No Information</paragraph></text>
|
837 |
</section>
|
838 |
</component>
|
839 |
|
840 |
<component>
|
841 |
<section nullFlavor="NI">
|
842 |
<templateId root="2.16.840.1.113883.10.20.22.2.45"/>
|
843 |
<templateId root="2.16.840.1.113883.10.20.22.2.45" extension="2014-06-09"/>
|
844 |
<code code="69730-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Instructions"/>
|
845 |
<title>Instructions (C-CDA)</title>
|
846 |
<text><paragraph styleCode="Italics">No Information</paragraph></text>
|
847 |
</section>
|
848 |
</component>
|
849 |
|
850 |
<component>
|
851 |
<section nullFlavor="NI">
|
852 |
<templateId root="2.16.840.1.113883.10.20.22.2.14"/>
|
853 |
<templateId root="2.16.840.1.113883.10.20.22.2.14" extension="2014-06-09"/>
|
854 |
<code code="47420-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Functional Status"/>
|
855 |
<title>Functional Status (C-CDA)</title>
|
856 |
<text><paragraph styleCode="Italics">No Information</paragraph></text>
|
857 |
</section>
|
858 |
</component>
|
859 |
</structuredBody>
|
860 |
</component>
|
861 |
</ClinicalDocument>
|