CCD Sample 2

<?xml-stylesheet type="text/xsl" href="cda.xsl"?><ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:cda="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc" xmlns:voc="urn:hl7-org:v3/voc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" classCode="DOCCLIN" moodCode="EVN" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">

<! *********************************************************************** CCD Header *********************************************************************** >

<! CCD Template Root >

<! Consolidated CCD Template v2.1 >

<! Consolidated CCD Template v1.1 >

<! US Realm Header v2.1 >

<! US Realm Header v1.1 >

<title>Manchester Memorial Hospital Consolidated CDA Continuity of Care Document v2.1</title>

<city>VERNON</city>

</addr>

<given>Barry</given>

</name>

</administrativeGenderCode>

<originalText>SINGLE</originalText>

</maritalStatusCode>

</religiousAffiliationCode>

<originalText>Other Race</originalText>

</raceCode>

<sdtc:raceCode nullFlavor="UNK"/>

<originalText>Unknown</originalText>

</ethnicGroupCode>

<sdtc:ethnicGroupCode nullFlavor="UNK"/>

</languageCommunication>

</patient>

<name>Manchester Memorial Hospital</name>

<streetAddressLine>71 Haynes St</streetAddressLine>

<city>Manchester</city>

</addr>

</providerOrganization>

</patientRole>

</recordTarget>

<streetAddressLine>71 Haynes St</streetAddressLine>

<city>Manchester</city>

</addr>

<manufacturerModelName>Iatric Systems, Inc.</manufacturerModelName>

<softwareName>Clinical Document Exchange (CDE) Certified v1.5</softwareName>

</assignedAuthoringDevice>

<name>Manchester Memorial Hospital</name>

<streetAddressLine>71 Haynes St</streetAddressLine>

<city>Manchester</city>

</addr>

</representedOrganization>

</assignedAuthor>

</author>

<name>Manchester Memorial Hospital</name>

<streetAddressLine>71 Haynes St</streetAddressLine>

<city>Manchester</city>

</addr>

</representedCustodianOrganization>

</assignedCustodian>

</custodian>

<originalText>SISTER</originalText>

</code>

</addr>

<name>

</name>

</associatedPerson>

</associatedEntity>

</participant>

<originalText>OTHER OR FRIEND</originalText>

</code>

</addr>

<name>

<family>Greene</family>

</name>

</associatedPerson>

</associatedEntity>

</participant>

</effectiveTime>

<originalText>Attending Physician</originalText>

</functionCode>

<time>

</time>

</addr>

</assignedPerson>

<name>Manchester Memorial Hospital</name>

<streetAddressLine>71 Haynes St</streetAddressLine>

<city>Manchester</city>

</addr>

</representedOrganization>

</assignedEntity>

</performer>

<originalText>Admitting Physician</originalText>

</functionCode>

<time>

</time>

<streetAddressLine>554 Talcottville Road</streetAddressLine>

<city>Vernon</city>

</addr>

<name>

<family>Schifferdecker</family>

</name>

</assignedPerson>

<name>Manchester Memorial Hospital</name>

<streetAddressLine>71 Haynes St</streetAddressLine>

<city>Manchester</city>

</addr>

</representedOrganization>

</assignedEntity>

</performer>

<originalText>Primary Care Physician</originalText>

</functionCode>

<time>

</time>

<streetAddressLine>554 Talcottville Road</streetAddressLine>

<city>Vernon</city>

</addr>

<name>

<family>Schifferdecker</family>

</name>

</assignedPerson>

<name>Manchester Memorial Hospital</name>

<streetAddressLine>71 Haynes St</streetAddressLine>

<city>Manchester</city>

</addr>

</representedOrganization>

</assignedEntity>

</performer>

</serviceEvent>

</documentationOf>

</effectiveTime>

</encompassingEncounter>

</componentOf>

<! *********************************************************************** CCD Body *********************************************************************** >

<! *********************************************************************** C.CDA Advance Directives *********************************************************************** >

<! Advance Directives section template >

<! Advance Directives Section v2.1 >

<! Advance Directives Section v1.1 >

<title>Advance Directives</title>

<text>

<thead>

<tr>

<th colspan="1">Advance Directives</th>

</tr>

</thead> <tbody>

<tr>

<td>

<content>No Advance Directives Information<br/>

</content>

</td>

</tr>

</tbody>

</table>

</text>

</section>

</component>

<! *********************************************************************** C-CDA Results Data *********************************************************************** >

<! Results Section Template >

<! Results Section v2.1 >

<! Results Section v1.1 >

<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"

displayName="Relevant diagnostic tests and/or laboratory data"/>

<title>Relevant diagnostic tests and/or laboratory data</title>

<text>

<thead>

<tr> <th colspan="1">Results</th>

</tr>

</thead>

<tbody>

<tr>

<td>No Diagnostic/Lab Test or Result Information<br/>

</td>

</tr>

</tbody>

</table> <br/> <br/> <br/>

</text>

</section>

</component>

<! ***********************************************************************

Consolidated CDA Allergies and Other Adverse Reactions Section

<! Allergies and Other Adverse Reactions Section template >

<! Allergies Section v2.1 >

<! Allergies Section v1.1 >

<title>Allergies and Adverse Reactions</title>

<text>

<thead>

<tr>

<th colspan="1">Allergies and Adverse Reactions</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content>No Known Allergies<br/>

</content>

</td>

</tr>

</tbody>

</table>

*********************************************************************** >

</text>

</section>

</component>

<! ***********************************************************************

Consolidated CDA Conditions Data

<! Conditions Section Template >

<! C-CDA Problem List v2.1 >

>

<! C-CDA Problem List v1.1 >

<title>Problem List</title>

<text>

<thead>

<tr>

<th colspan="1">Problem List</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content>No known problems<br/>

</content>

</td>

</tr>

***********************************************************************

<tr>

<th colspan="1">Patient Unit Number: Z003905</th>

</tr>

<tr>

<th colspan="5"> No Problems: </th>

</tr>

</tbody>

</table>

</text>

<! Problems Template >

<! Problem Concern Activity v2.1 >

<! Problem Concern Activity v1.1 >

</effectiveTime>

<! Problem observation template >

<! Problem Observation v2.1 >

<! Problem Observation v.1.1 >

<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1"

codeSystemName="LOINC" displayName="Problem HL7.CCDAR2"/>

</code>

</effectiveTime>

</observation>

</entryRelationship>

</act>

</entry>

</section>

</component>

<!

Consolidated CDA Vital Signs

<! Vital Signs section template >

<! Vital Signs Section v2.1 >

<! Vital Signs Section v.1.1 >

***********************************************************************

>

<title>Vital Signs</title>

<text>

<thead>

<tr>

<th colspan="1">Vital Signs</th>

</tr>

</thead> <tbody>

<tr>

<td>

<content>No Vital Signs Information<br/>

</content>

</td>

</tr>

</tbody>

</table>

</text>

</section>

</component>

<! *********************************************************************** C.CDA

Functional and Cognitive Status

*********************************************************************** >

<! Cognitive and Functional Status section template >

<! Functional Status v2.1 >

<! Functional Status v1.1 >

<title>Functional Status</title>

<text>

<thead>

<tr>

<th colspan="1">Functional Status</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content>No Functional Status Information<br/>

</content>

</td>

</tr>

</tbody>

</table>

</text>

</section>

</component>

<! *********************************************************************** C.CDA Admission Medications

v2.1********************************************************************** >

<! Medication Section Template >

<! C.CDA Admission Medications v2.1 >

<! C.CDA Admission Medications v1.1 >

<title>Medications on Admission</title>

<text>

<thead>

<tr>

<th colspan="1">Medications</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content>No Known Admission Medications<br/>

</content>

</td>

</tr>

</tbody>

</table>

</text>

<! C.CDA Admission Medication Activity v2.1 >

<! C.CDA Admission Medication Activity v1.1 >

<! Medication Activity Template >

<! CCDA Medication Activity v2.1 >

<! CCDA Medication Activity v1.1 >

<! Medication Product Template >

<! Manufactured Product v2.1 >

<! Manufactured Product v1.1 >

</originalText>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entryRelationship>

</act>

</entry>

</section>

</component>

<! *********************************************************************** C.CDA Medications v2.1**********************************************************************

>

<! Medication Section Template >

<! C-CDA Medications Section v2.1 >

<! C-CDA Medications Section v1.1 >

<title>History of medication use</title>

<text>

<thead>

<tr>

<th colspan="1">Medications</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content>No Known Medications<br/>

</content>

</td>

</tr>

</tbody>

</table>

<br/>

</text>

<! Medication Activity Template >

<! CCDA Medication Activity v2.1 >

<! CCDA Medication Activity v1.1 >

<! Medication Product Template >

<! Manufactured Product v2.1 >

<! Manufactured Product v1.1 >

</originalText>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</section>

</component>

<! *********************************************************************** C.CDA Discharge Medications v2.1********************************************************************** >

<! Medication Section Template >

<! C.CDA Discharge Medications v2.1 >

<! C.CDA Discharge Medications v1.1 >

</code>

<title>Hospital Discharge medications</title>

<text>

<thead>

<tr>

<th colspan="1">Medications</th>

</tr>

</thead>

<tbody>

<tr> <td> <content>No Known Discharge Medications<br/>

</content>

</td>

</tr>

</tbody>

</table>

</text>

<! C.CDA Discharge Medication Activity v2.1 >

<! C.CDA Discharge Medication Activity v1.1 >

</code>

<! Medication Activity Template >

<! CCDA Medication Activity v2.1 >

<! CCDA Medication Activity v1.1 >

<! Medication Product Template >

<! Manufactured Product v2.1 >

<! Manufactured Product v1.1 >

</originalText>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entryRelationship>

</act>

</entry>

</section>

</component>

<! ***********************************************************************

Consolidated CDA Encounters Data

<! Encounter Section Template >

<! Encounters Section v2.1 >

>

<! Encounters Section v1.1 >

<title>History Of Encounters</title>

<text>

<thead>

<tr>

<th colspan="6">Encounters</th>

</tr>

</thead>

<tbody>

***********************************************************************

<tr>

<content ID="encounter-1">Visit/Account #D00008389 (May 17, 2023 1:39pmMay 18, 2023 12:00pm)</content>

</th>

</tr>

<tr>

<th colspan="1">Account Status</th>

<th colspan="1">Physician Of Record</th>

<th colspan="1">Reason For Visit</th>

<th colspan="1">Visit Diagnosis</th>

<th colspan="1">Start Date/Time</th>

</tr>

<tr>

<td>

</content>

</td>

<td>DR. MEDITECH<br/>

</td>

<td>

<content ID="mrn-Z003905-acct-D00008389-status-1-SDC-reason">SURGERY<br/>

</content>

</td>

<td>

<content ID="mrn-Z003905-acct-D00008389-status-1-SDC-visit-dx-1">Not Available<br/>

</content>

</td>

</td>

</td>

</tr>

<tr>

<td>

</content>

</td>

<td>DR. MEDITECH<br/>

</td>

<td>

<content ID="mrn-Z003905-acct-D00008389-status-2-IN-reason">SURGERY<br/>

</content>

</td>

<td>

<content ID="mrn-Z003905-acct-D00008389-status-2-IN-visit-dx-2">Not Available<br/>

</content>

</td>

</td>

</td>

</tr>

</tbody>

</table>

</text>

<! Encounter templates >

<! Encounter Activity v2.1 >

<! Encounter Activity v1.1 >

</originalText>

</code>

</effectiveTime>

<time>

</time>

</assignedPerson>

<name>Manchester Memorial Hospital</name>

<streetAddressLine>71 Haynes St</streetAddressLine>

<city>Manchester</city>

</addr>

</representedOrganization>

</assignedEntity>

</performer>

<! Service Delivery Location v2.1 >

<originalText>MMH-MEDICAL</originalText>

</code>

<streetAddressLine>71 Haynes St</streetAddressLine>

<city>Manchester</city>

</addr>

<name>Manchester Memorial Hospital</name>

</playingEntity>

</participantRole>

</participant>

<! Indication v2.1 >

<! Indication v1.1 >

<text>SURGERY<reference value="#mrn-Z003905-acct-D00008389-status-1-SDCreason"/>

</text>

</effectiveTime>

</observation>

</entryRelationship>

<! Encounter Diagnosis Activity v2.1 >

<! Encounter Diagnosis Activity v1.1 >

<! Problem Observation v2.1 >

<! Problem Observation v1.1 >

</code>

</effectiveTime>

</originalText>

</value>

</observation>

</entryRelationship>

</act>

</entryRelationship>

</encounter>

</entry>

<! Encounter templates >

<! Encounter Activity v2.1 >

<! Encounter Activity v1.1 >

</originalText>

<translation code="IMP" codeSystem="2.16.840.1.113883.5.4"

codeSystemName="HL7 ActEncounterCode" displayName="Inpatient"/>

</code>

</effectiveTime>

<time>

</time>

</assignedPerson>

<name>Manchester Memorial Hospital</name>

<streetAddressLine>71 Haynes St</streetAddressLine>

<city>Manchester</city>

</addr>

</representedOrganization>

</assignedEntity>

</performer>

<! Service Delivery Location v2.1 >

<originalText>MMH-MEDICAL</originalText>

</code>

<streetAddressLine>71 Haynes St</streetAddressLine>

<city>Manchester</city>

</addr>

<name>Manchester Memorial Hospital</name>

</playingEntity>

</participantRole>

</participant>

<! Indication v2.1 >

<! Indication v1.1 >

<text>SURGERY<reference value="#mrn-Z003905-acct-D00008389-status-2-INreason"/>

</text>

</effectiveTime>

</observation>

</entryRelationship>

<! Encounter Diagnosis Activity v2.1 >

<! Encounter Diagnosis Activity v1.1 >

<! Problem Observation v2.1 >

<! Problem Observation v1.1 >

</code>

</effectiveTime>

</originalText>

</value>

</observation>

</entryRelationship>

</act>

</entryRelationship>

</encounter>

</entry>

</section>

</component>

<! ***********************************************************************

Consolidated CDA Procedures Data *********************************************************************** >

<! Procedure Section Template >

<! Procedures Section v2.1 >

<! Procedures Section v1.1 >

<title>History of Procedures</title>

<text>

<thead>

<tr>

<th colspan="1">Procedure List</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content>No Procedures Information<br/>

</content>

</td>

</tr>

</tbody>

</table>

</text>

</section>

</component>

<! *********************************************************************** C.CDA

Discharge Instructions

<! Discharge Instructions Section Template >

<! Hospital Discharge Instructions >

>

<title>Hospital Discharge Instructions</title>

<text>

<thead>

<tr>

<th colspan="1">Discharge Instructions</th>

</tr>

</thead>

***********************************************************************

<tbody>

<tr>

<th colspan="1">Visit/Account #D00008389 (May 17, 2023 1:39pm - May 18, 2023 12:00pm)</th>

</tr>

<tr>

<th colspan="1">Discharge Information: </th>

</tr>

<tr>

<td>No Discharge Instructions Information<br/> <content/>

</td> </tr> </tbody>

</table>

</text>

</section>

</component>

<! *********************************************************************** C.CDA Social History

>

<! Social History section template >

<! Social History Section Template v2.1 >

<! Social History Section Template v1.1 >

***********************************************************************

<title>Social History</title>

<text>

<thead>

<tr>

<th colspan="1">Social History</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content>No Social History Information<br/>

</content>

</td>

</tr>

</tbody>

</table>

</text>

</section>

</component>

<! *********************************************************************** C.CDA Immunizations Section v2.1********************************************************************** >

<! Immunization Section Template >

<! Immunizations Section v2.1 >

<! Immunizations Section v1.1 >

<title>Immunizations</title>

<text>

<thead>

<tr>

<th colspan="1">Immunizations</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content>No Immunizations History<br/>

</content>

</td>

</tr>

</tbody>

</table>

</text>

</section>

</component>

<! *********************************************************************** C.CDA Family History Data

>

<! Family History Section Template >

<! Family History Section v2.1 >

***********************************************************************

<! Family History Section v1.1 >

<title>Family History</title>

<text>

<thead>

<tr>

<th colspan="1">Family History</th>

</tr>

</thead>

<tbody>

<tr>

<td>No Family History Information<br/>

</td>

</tr>

</tbody>

</table>

</text>

</section>

</component>

<! *********************************************************************** C.CDA Health Concerns

v2.1********************************************************************** >

<! Health Concerns Section Template >

<! Health Concerns Section Template v2.1 >

<title>Health Concerns</title>

<text>

<thead>

<tr>

<th colspan="1">Health Concerns</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content>No Health Concerns Information<br/>

</content>

</td>

</tr>

</tbody>

</table>

</text>

</section>

</component>

<! ***********************************************************************

Consolidated CDA Medical Equipment Data

<! Medical Equipment Section Template >

***********************************************************************

>

<! Medical Equipment Section Template v2.1 >

<! Medical Equipment Section Template v1.1 >

<title>Medical Equipment</title>

<text>

<thead>

<tr>

<th colspan="1">Medical Equipment</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content>No implanted devices or medical equipment information<br/>

</content>

</td>

</tr>

</tbody>

</table>

</text>

</section>

</component>

<! *********************************************************************** C.CDA Assessments Section

***********************************************************************

>

<! Assessments Section template >

<! Assessments Section Template v2.1 >

<title>Assessments</title>

<text>

<thead>

<tr>

<th colspan="1">Assessments</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content>No Assessments Information<br/>

</content>

</td>

</tr>

</tbody>

</table>

</text>

</section>

</component>

<!

C.CDA Plan of Treatment v2.1**********************************************************************

***********************************************************************

>

<! Plan of Treatment Section Template v2.1 >

<! Plan of Treatment Section Template v1.1 >

<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"

displayName="Plan of Treatment"/>

<title>Plan of Treatment</title>

<text>

<thead>

<tr>

<th colspan="1">Plan of Treatment</th>

</tr> </thead>

<tbody>

<tr>

<td>

<content>No Plan Of Treatment Information<br/>

</content>

</td>

</tr> </tbody>

</table>

</text>

</section>

</component>

<! *********************************************************************** C.CDA Goals v2.1********************************************************************** >

<! Goals Section Template v2.1 >

<title>Goals</title>

<text>

<thead>

<tr> <th colspan="1">Goals</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content>No Goals Information<br/>

</content>

</td>

</tr> </tbody>

</table>

</text>

</section>

</component>

<! *********************************************************************** C.CDA Instructions

>

***********************************************************************

<! Instructions Section Template >

<! Instructions Section Template v2.1 >

<! Instructions Section Template v1.1 >

<title>Instructions</title>

<text>

<thead>

<tr>

<th colspan="1">Instructions</th>

</tr>

</thead>

<tbody>

<tr>

<th colspan="1">Visit/Account #D00008389 (May 17, 2023 1:39pm - May 18, 2023 12:00pm)</th>

</tr>

<tr>

<th colspan="1">Discharge Information: </th>

</tr>

<tr>

<td>

<content styleCode="Bold">General Visit Information</content> <br/>

<br/>Reason for Visit/Admission Diagnosis: SURGERY<br/>

<br/>

</content>

</td>

</tr>

</tbody>

</table>

</text>

<entry>

<! Instructions v2.1 >

<! Instructions v1.1 >

<text>

</text>

</act>

</entry>

</section>

</component>

<! *********************************************************************** C.CDA Mental Status

>

<! Mental Status section template >

***********************************************************************

<! Mental Status Section Template v2.1 >

<! Mental Status Section Template v1.1 >

<title>Mental Status</title>

<text>

<thead>

<tr>

<th colspan="1">Mental Status</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content>No Mental Status Information<br/>

</content>

</td>

</tr> </tbody>

</table>

</text>

</section>

</component>

<! *********************************************************************** C.CDA Reason for Visit

***********************************************************************

>

<! Reason For Visit Section Template v2.1 >

<title>Reason For Visit</title>

<text>

<thead>

<tr>

<th colspan="1">Reason for Visit</th>

</tr> </thead>

<tbody>

<tr>

<th colspan="1">Visit/Account #D00008389 (May 17, 2023 1:39pm - May 18, 2023 12:00pm)</th>

</tr>

<tr>

<th colspan="1">Reason</th>

</tr>

<tr>

<td>

<content>SURGERY<br/>

</content>

</td>

</tr>

</tbody>

</table>

</text>

</section>

</component>

</structuredBody>

</component>

</ClinicalDocument>

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