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Patient-124.xml
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<?xml version="1.0" encoding="utf-8"?>
<!-- The following sample document depicts a fictional characters health summary. Any resemblance to a real person is coincidental. -->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 ../../C-CDA%20rules/infrastructure/cda/CDA_SDTC.xsd"
xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc">
<!--
********************************************************
CDA Header
********************************************************
-->
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<!-- US General Header Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
<!-- Continuity of Care Document (CCD) - Patient Health Summary;
Conformant to C-CDA Implementation Guide "CDAR2_IG_IHE_CONSOL_DSTU_R1.1_2012JUL.pdf"
(DSTU) July 2012CCD v1.0 Templates Root -->
<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
<id root="db734647-fc99-424c-a864-7e3cda82e703"/>
<code code="34133-9" codeSystem="2.16.840.1.113883.6.1" displayName="Summarization of episode note"/>
<title>Community Health and Hospitals: Health Summary</title>
<effectiveTime value="20131119014635"/>
<confidentialityCode code="N" displayName="Normal" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality Code"/>
<languageCode code="en-US"/>
<setId extension="sTT988" root="2.16.840.1.113883.19.5.99999.19"/>
<versionNumber value="1"/>
<recordTarget>
<patientRole>
<id extension="998991" root="2.16.840.1.113883.19.5.99999.2"/>
<!-- Fake ID using HL7 example OID. -->
<id extension="111-00-2330" root="2.16.840.1.113883.4.1"/>
<!-- Fake Social Security Number using the actual SSN OID. -->
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Drive</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:(816)276-6909" use="MC"/>
<!-- MC is "mobile contact" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<patient>
<name use="L">
<given qualifier="BR">Jonathan</given>
<family qualifier="AD">Guzman</family>
</name>
<administrativeGenderCode code="M" displayName="Male"
codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender"/>
<birthTime value="19510622120000"/>
<maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatus"/>
<religiousAffiliationCode code="1005" displayName="Anglican"
codeSystem="2.16.840.1.113883.5.1076" codeSystemName="ReligiousAffiliation"/>
<!-- CDC Race and Ethnicity code set contains the minimum race and ethnicity categories defined by OMB Standards for Race and Ethnicity -->
<raceCode code="2106-3" displayName="White" codeSystem="2.16.840.1.113883.6.238"
codeSystemName="Race & Ethnicity - CDC"/>
<ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino"
codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/>
<guardian>
<code code="HPOWATT" displayName="healthcare power of attorney" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 Role code"/>
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>125 Dalmatian Road</streetAddressLine>
<city>Agram</city>
<state>VA</state>
<postalCode>22201</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:(781)555-1212" use="HP"/>
<guardianPerson>
<name>
<given>Daniel</given>
<family>Spalato</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<city>Washington</city>
<state>DC</state>
<postalCode>20009</postalCode>
<country>USA</country>
</addr>
</place>
</birthplace>
<languageCommunication>
<languageCode code="en-US"/>
<modeCode
code="ESP"
displayName="Expressed spoken"
codeSystem="2.16.840.1.113883.5.60"
codeSystemName="LanguageAbilityMode"/>
<preferenceInd value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id root="2.16.840.1.113883.4.6"/>
<name>Community Health and Hospitals</name>
<telecom use="WP" value="tel: 555-555-5000"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time value="20131119014635"/>
<assignedAuthor>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101"
displayName="Allopathic & Osteopathic Physicians"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="999999943252"/>
<code code="207Q00000X" codeSystem="2.16.840.1.113883.6.101"
displayName="Allopathic & Osteopathic Physicians"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<informant>
<assignedEntity>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101"
displayName="Allopathic & Osteopathic Physicians"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</informant>
<informant>
<relatedEntity classCode="PRS">
<!-- classCode PRS represents a person with personal relationship with
the patient. -->
<code code="SPS" displayName="SPOUSE" codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<relatedPerson>
<name>
<given>Frank</given>
<family>Jones</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<name>Community Health and Hospitals</name>
<telecom value="tel: 555-555-1002" use="WP"/>
<addr use="WP">
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</informationRecipient>
<receivedOrganization>
<name>Community Health and Hospitals</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<time value="20130418090000+0500"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="999999999" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<authenticator>
<time value="20131119014635"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="999999999" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:555-555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<participant typeCode="IND">
<associatedEntity classCode="NOK">
<code code="MTH" codeSystem="2.16.840.1.113883.5.111"/>
<addr>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
</addr>
<telecom value="tel:(999)555-1212" use="WP"/>
<associatedPerson>
<name>
<prefix>Mrs.</prefix>
<given>Martha</given>
<family>Jones</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="20100402100000"/>
<high value="20101207100000"/>
</effectiveTime>
<performer typeCode="PRF">
<functionCode code="PCP" displayName="Primary Care Physician"
codeSystem="2.16.840.1.113883.5.88" codeSystemName="participationFunction">
<originalText>Primary Care Provider</originalText>
</functionCode>
<assignedEntity>
<!-- Provider NPI "PseudoMD-1" -->
<id extension="PseudoMD-1" root="2.16.840.1.113883.4.6"/>
<code code="261QP2300X" displayName="Primary Care [Ambulatory Health Care Facilities\Clinic/Center]"
codeSystemName="NUCC Provider Codes" codeSystem="2.16.840.1.113883.6.101"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-555-555-5000" use="HP"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom value="tel:+1-555-555-5000" use="HP"/>
<addr>
<streetAddressLine>1001 Village Avenue</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<!--
********************************************************
CDA Body
********************************************************
-->
<component>
<structuredBody>
<!--
*********************************
Allergies, Adverse Reactions, Alerts
******************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
<code code="48765-2" displayName="Allergies, adverse reactions, alerts"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Allergies, Adverse Reactions & Alerts</title>
<text>
<table>
<thead>
<tr>
<th>Group Description</th>
<th>Code System</th>
<th>Code</th>
<th>Code Description</th>
<th>Date and Time</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Allergy to Eggs</td>
<td>UNII</td>
<td>291P45F896</td>
<td><content ID="Allergy1"/>Eggs</td>
<td>04-02-2010 10:00:00</td>
<td>Active</td>
</tr>
<tr>
<td/>
<td>ICD-9-CM</td>
<td>V15.03</td>
<td>Allergy to eggs</td>
<td/>
<td/>
</tr>
<tr>
<td>Codeine</td>
<td>NDF-RT</td>
<td>N0000006691</td>
<td><content ID="Allergy2"/>Codeine</td>
<td>04-02-2010 10:00:00</td>
<td>Active</td>
</tr>
<tr>
<td>Fosfomycin</td>
<td>RxNorm</td>
<td>808917</td>
<td><content ID="Allergy3"/>Fosfomycin 33.3 MG/ML Oral Suspension</td>
<td>04-02-2010 10:00:00</td>
<td>Active</td>
</tr>
</tbody>
</table> </text>
<entry typeCode="DRIV">
<!-- Allergy Problem Act template -->
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code xsi:type="CE" code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Allergies, adverse reactions, alerts"/>
<statusCode code="active"/>
<effectiveTime>
<low value="20100402100000"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<!--Allergy - Intolerance Observation -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="UNK"/>
</effectiveTime>
<!-- The following XML tag, <value>, states whether patient is allergic to DRUG, FOOD or SUBSTANCE.
In EMERGE db, patients have records with allergies to:
(a) DRUG (in EMERGE db, encoded in RxNorm or NDF-RT)
(b) FOOD (in EMERGE db 'Eggs', encoded in UNII) and
CCDA impementation guide distinguishes between "allergy" amd "propensity to allergy". In EMERGE, all patients have "allergy".
Depending on allergen, appropriate value must be selected from Table 117: Allergy/Adverse Event Type Value Set (See CCDA Implementation Guide, pg 311)
(1) If EMERGE patient has allergy to DRUG (RxNorm or NDF-RT), then the code is:
<value code="416098002" displayName="Drug allergy (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
(2) If EMERGE patient has allergy to FOOD (e.g. Eggs, UNII), then the code is:
<value code="414285001" displayName="Food allergy (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
-->
<value xsi:type="CD" code="414285001" displayName="Food allergy (disorder)"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT">
<originalText>
Allergy to Eggs + Eggs
<reference value="#Allergy1"/>
</originalText>
</value>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<!--
This section displays the ACTUAL name of drug/ingredient/food to which person is allergic to.
Please note that FOUR (4) different values sets for documenting Allergies: Brand Names, Clinical Drug Names, Medication Drug Class, and Ingredient name,
encoded in RxNorm, RxNorm, NDF-RT and UNII respectively.
-->
<code code="291P45F896"
displayName="Eggs"
codeSystem="2.16.840.1.113883.4.9"
codeSystemName="UNII">
<originalText>
Allergy to Eggs + Eggs
<reference value="#Allergy1"/>
</originalText>
<!-- <translation> XML tag, if it exist should be placed HERE. In EMERGE db,
Only alergy to "eggs" will contain <translation> xml code with ICD-9 codes system:
<translation code="V15.03" codeSystem="2.16.840.1.113883.6.2"
displayName="Allergy to Eggs" codeSystemName="ICD-9-CM"/>
NOTE: <translation> code can also be used for other codes, such as LOCAL (e..g local hospital) codes.
-->
<translation code="V15.03" codeSystem="2.16.840.1.113883.6.2"
displayName="Allergy to eggs" codeSystemName="ICD-9-CM"/>
</code>
</playingEntity>
</participantRole>
</participant>
<!-- In reality, severity should be documented for allergy.
In EMERGE db, severity information for allergy is not documented for any patient. -->
<entryRelationship typeCode="SUBJ" inversionInd="true">
<!-- ** Severity observation template ** -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<code code="SEV" displayName="Severity Observation"
codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
<text>
<reference value="#severity1"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" nullFlavor="NI" />
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="DRIV">
<!-- Allergy Problem Act template -->
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code xsi:type="CE" code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Allergies, adverse reactions, alerts"/>
<statusCode code="active"/>
<effectiveTime>
<low value="20100402100000"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<!--Allergy - Intolerance Observation -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="UNK"/>
</effectiveTime>
<!-- The following XML tag, <value>, states whether patient is allergic to DRUG, FOOD or SUBSTANCE.
In EMERGE db, patients have records with allergies to:
(a) DRUG (in EMERGE db, encoded in RxNorm or NDF-RT)
(b) FOOD (in EMERGE db 'Eggs', encoded in UNII) and
CCDA impementation guide distinguishes between "allergy" amd "propensity to allergy". In EMERGE, all patients have "allergy".
Depending on allergen, appropriate value must be selected from Table 117: Allergy/Adverse Event Type Value Set (See CCDA Implementation Guide, pg 311)
(1) If EMERGE patient has allergy to DRUG (RxNorm or NDF-RT), then the code is:
<value code="416098002" displayName="Drug allergy (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
(2) If EMERGE patient has allergy to FOOD (e.g. Eggs, UNII), then the code is:
<value code="414285001" displayName="Food allergy (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
-->
<value xsi:type="CD" code="416098002" displayName="Drug allergy (disorder)"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT">
<originalText>
Codeine + Codeine
<reference value="#Allergy1"/>
</originalText>
</value>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<!--
This section displays the ACTUAL name of drug/ingredient/food to which person is allergic to.
Please note that FOUR (4) different values sets for documenting Allergies: Brand Names, Clinical Drug Names, Medication Drug Class, and Ingredient name,
encoded in RxNorm, RxNorm, NDF-RT and UNII respectively.
-->
<code code="N0000006691"
displayName="Codeine"
codeSystem="2.16.840.1.113883.3.26.1.5"
codeSystemName="NDF-RT">
<originalText>
Codeine + Codeine
<reference value="#Allergy2"/>
</originalText>
<!-- <translation> XML tag, if it exist should be placed HERE. In EMERGE db,
Only alergy to "eggs" will contain <translation> xml code with ICD-9 codes system:
<translation code="V15.03" codeSystem="2.16.840.1.113883.6.2"
displayName="Allergy to Eggs" codeSystemName="ICD-9-CM"/>
NOTE: <translation> code can also be used for other codes, such as LOCAL (e..g local hospital) codes.
-->
</code>
</playingEntity>
</participantRole>
</participant>
<!-- In reality, severity should be documented for allergy.
In EMERGE db, severity information for allergy is not documented for any patient. -->
<entryRelationship typeCode="SUBJ" inversionInd="true">
<!-- ** Severity observation template ** -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<code code="SEV" displayName="Severity Observation"
codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
<text>
<reference value="#severity2"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" nullFlavor="NI" />
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="DRIV">
<!-- Allergy Problem Act template -->
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code xsi:type="CE" code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Allergies, adverse reactions, alerts"/>
<statusCode code="active"/>
<effectiveTime>
<low value="20100402100000"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<!--Allergy - Intolerance Observation -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="UNK"/>
</effectiveTime>
<!-- The following XML tag, <value>, states whether patient is allergic to DRUG, FOOD or SUBSTANCE.
In EMERGE db, patients have records with allergies to:
(a) DRUG (in EMERGE db, encoded in RxNorm or NDF-RT)
(b) FOOD (in EMERGE db 'Eggs', encoded in UNII) and
CCDA impementation guide distinguishes between "allergy" amd "propensity to allergy". In EMERGE, all patients have "allergy".
Depending on allergen, appropriate value must be selected from Table 117: Allergy/Adverse Event Type Value Set (See CCDA Implementation Guide, pg 311)
(1) If EMERGE patient has allergy to DRUG (RxNorm or NDF-RT), then the code is:
<value code="416098002" displayName="Drug allergy (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
(2) If EMERGE patient has allergy to FOOD (e.g. Eggs, UNII), then the code is:
<value code="414285001" displayName="Food allergy (disorder)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
-->
<value xsi:type="CD" code="416098002" displayName="Drug allergy (disorder)"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT">
<originalText>
Fosfomycin + Fosfomycin 33.3 MG/ML Oral Suspension
<reference value="#Allergy1"/>
</originalText>
</value>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<!--
This section displays the ACTUAL name of drug/ingredient/food to which person is allergic to.
Please note that FOUR (4) different values sets for documenting Allergies: Brand Names, Clinical Drug Names, Medication Drug Class, and Ingredient name,
encoded in RxNorm, RxNorm, NDF-RT and UNII respectively.
-->
<code code="808917"
displayName="Fosfomycin 33.3 MG/ML Oral Suspension"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm">
<originalText>
Fosfomycin + Fosfomycin 33.3 MG/ML Oral Suspension
<reference value="#Allergy3"/>
</originalText>
<!-- <translation> XML tag, if it exist should be placed HERE. In EMERGE db,
Only alergy to "eggs" will contain <translation> xml code with ICD-9 codes system:
<translation code="V15.03" codeSystem="2.16.840.1.113883.6.2"
displayName="Allergy to Eggs" codeSystemName="ICD-9-CM"/>
NOTE: <translation> code can also be used for other codes, such as LOCAL (e..g local hospital) codes.
-->
</code>
</playingEntity>
</participantRole>
</participant>
<!-- In reality, severity should be documented for allergy.
In EMERGE db, severity information for allergy is not documented for any patient. -->
<entryRelationship typeCode="SUBJ" inversionInd="true">
<!-- ** Severity observation template ** -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<code code="SEV" displayName="Severity Observation"
codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
<text>
<reference value="#severity3"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" nullFlavor="NI" />
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!--
********************************************************
Encounters section
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.22"/>
<!-- Encounters section template -->
<code
code="46240-8"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="History of encounters"/>
<title>Encounters</title>
<text>
<table>
<thead>
<tr>
<th>Group Description</th>
<th>Code System</th>
<th>Code</th>
<th>Code Description</th>
<th>Date and Time</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Encounter Outpatient</td>
<td>CPT</td>
<td>99213</td>
<td><content ID="Encounter1"/>Office/outpatient visit, est</td>
<td>04-02-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td/>
<td>ICD-9-CM</td>
<td>V70.0</td>
<td>Routine general medical examination at a health care facility</td>
<td/>
<td/>
</tr>
<tr>
<td>Encounter Office Visit</td>
<td>CPT</td>
<td>99212</td>
<td><content ID="Encounter2"/>Office/outpatient visit, est</td>
<td>06-06-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td>Encounter Non-Acute Inpatient</td>
<td>CPT</td>
<td>99324</td>
<td><content ID="Encounter3"/>Domicil/r-home visit new pat</td>
<td>06-10-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td>Encounter Inpatient Discharge</td>
<td>CPT</td>
<td>99238</td>
<td><content ID="Encounter4"/>Hospital discharge day</td>
<td>07-15-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td>Encounter Office Visit</td>
<td>CPT</td>
<td>99212</td>
<td><content ID="Encounter5"/>Office/outpatient visit, est</td>
<td>07-28-2010 10:00:00</td>
<td>Performed</td>
</tr>
<tr>
<td>Encounter Ophthalmological Services</td>
<td>CPT</td>
<td>92012</td>
<td><content ID="Encounter6"/>Eye exam established pat</td>
<td>08-06-2010 10:00:00</td>
<td>Performed</td>
</tr>
</tbody>
</table> </text>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<!-- Encounter activity template -->
<id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code code="99213" codeSystem="2.16.840.1.113883.6.12"
displayName="Office/outpatient visit, est"
codeSystemName="CPT">
<originalText>
Encounter Outpatient + Encounter Outpatient
<reference value="#Encounter1"/>
</originalText>
<translation code="V70.0" codeSystem="2.16.840.1.113883.6.2"
displayName="Routine general medical examination at a health care facility" codeSystemName="ICD-9-CM"/>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100402100000"/>
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/>
<code code="404684003" displayName="Finding" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#Problem1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20100402100000"/>
</effectiveTime>
<value xsi:type="CD" code="44054006"
displayName="Diabetes"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT">
<translation code="E11.9" codeSystem="2.16.840.1.113883.6.90"
displayName="Type 2 diabetes mellitus without complications" codeSystemName="ICD-10-CM"/>
<translation code="250.00" codeSystem="2.16.840.1.113883.6.2"
displayName="Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled" codeSystemName="ICD-9-CM"/>
</value>
</observation>
</entryRelationship>
</encounter>
</entry>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<!-- Encounter activity template -->
<id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code code="99212" codeSystem="2.16.840.1.113883.6.12"
displayName="Office/outpatient visit, est"
codeSystemName="CPT">
<originalText>
Encounter Office Visit + Encounter Office Visit
<reference value="#Encounter2"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100606100000"/>
</encounter>
</entry>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<!-- Encounter activity template -->
<id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code code="99324" codeSystem="2.16.840.1.113883.6.12"
displayName="Domicil/r-home visit new pat"
codeSystemName="CPT">
<originalText>
Encounter Non-Acute Inpatient + Encounter Non-Acute Inpatient
<reference value="#Encounter3"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100610100000"/>
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/>
<code code="404684003" displayName="Finding" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#Problem1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20100610100000"/>
</effectiveTime>
<value xsi:type="CD" code="261650005"
displayName="AJCC Cancer Stage Low Risk Recurrence Prostat"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT">
</value>
</observation>
</entryRelationship>
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/>
<code code="404684003" displayName="Finding" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#Problem2"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20100610100000"/>
</effectiveTime>
<value xsi:type="CD" code="399068003"
displayName="Prostate Cancer"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT">
<translation code="C61" codeSystem="2.16.840.1.113883.6.90"
displayName="Malignant neoplasm of prostate" codeSystemName="ICD-10-CM"/>
<translation code="185" codeSystem="2.16.840.1.113883.6.2"
displayName="Malignant neoplasm of prostate" codeSystemName="ICD-9-CM"/>
</value>
</observation>
</entryRelationship>
</encounter>
</entry>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<!-- Encounter activity template -->
<id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code code="99238" codeSystem="2.16.840.1.113883.6.12"
displayName="Hospital discharge day"
codeSystemName="CPT">
<originalText>
Encounter Inpatient Discharge + Encounter Inpatient Discharge
<reference value="#Encounter4"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100715100000"/>
</encounter>
</entry>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<!-- Encounter activity template -->
<id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code code="99212" codeSystem="2.16.840.1.113883.6.12"
displayName="Office/outpatient visit, est"
codeSystemName="CPT">
<originalText>
Encounter Office Visit + Encounter Office Visit
<reference value="#Encounter5"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100728100000"/>
</encounter>
</entry>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<!-- Encounter activity template -->
<id root="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code code="92012" codeSystem="2.16.840.1.113883.6.12"
displayName="Eye exam established pat"
codeSystemName="CPT">
<originalText>
Encounter Ophthalmological Services + Encounter Ophthalmological Services
<reference value="#Encounter6"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20100806100000"/>
</encounter>
</entry>
</section>
</component>
<!--
********************************************************
Immunizations section
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.2"/>
<!-- Immunizations section template -->
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1"/>
<title>Immunizations</title>
<text>
<table>
<thead>
<tr>
<th>Group Description</th>
<th>Code System</th>
<th>Code</th>
<th>Code Description</th>
<th>Date and Time</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Influenza Vaccine</td>
<td>CVX</td>
<td>135</td>
<td><content ID="Immunization1"/>Influenza, high dose seasonal</td>
<td>12-06-2010 10:00:00</td>
<td>Completed</td>
</tr>
<tr>
<td>Pneumococcal Vaccine ages 2 and older</td>
<td>CVX</td>
<td>33</td>
<td><content ID="Immunization2"/>pneumococcal polysaccharide PPV23</td>
<td>12-06-2010 10:00:00</td>
<td>Completed</td>
</tr>
</tbody>
</table> </text>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="false">
<!-- Immunization activity template -->
<templateId root="2.16.840.1.113883.10.20.22.4.52"/>
<id root="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92"/>
<text>
<reference value="#Immunization1"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20101206100000"/>
<routeCode code="C28161" codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="NCI Thesaurus"
displayName="Intramuscular injection"/>
<consumable>
<manufacturedProduct classCode="MANU">
<!-- Product template -->
<templateId root="2.16.840.1.113883.10.20.22.4.54"/>
<manufacturedMaterial>
<code code="135" codeSystem="2.16.840.1.113883.12.292"
displayName="Influenza, high dose seasonal"
codeSystemName="CVX">
<originalText>
Influenza Vaccine + Influenza Vaccine
<reference value="#Immunization1"/>
</originalText>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<performer>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="999999943252"/>
<addr>
<streetAddressLine>101 Maple Street</streetAddressLine>
<city>Washington</city>
<state>DC</state>
<postalCode>20009</postalCode>
<country>United States</country>
</addr>
<telecom value="888-888-0000"/>
<assignedPerson>
<name>
<given>Jim</given>
<family>Smith</family>
</name>
</assignedPerson>