CCD Sample 3

Page 1

<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">

<realmCode code="US"/>

<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>

<templateId root="2.16.840.1.113883.10.20.22.1.1"/>

<templateId root="2.16.840.1.113883.10.20.22.1.2"/>

<id root="183427c2-2021-724a-1a9e-001A64958C30"/>

<code code="34133-9" codeSystem="2.16.840.1.113883.6.1" displayName="Summarization of Episode Note"/>

<title>Ambulatory Summary</title>

<effectiveTime value="20210406071234-0400"/>

<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>

<languageCode code="en-US"/>

<recordTarget>

<patientRole>

<id extension="INT42441" root="2.16.840.1.113883.3.564.28492"/>

<addr use="HP">

<streetAddressLine>INT42441 RATE</streetAddressLine>

<streetAddressLine nullFlavor="NI"/>

<city>NAKAMOTO</city>

<state>MD</state>

<postalCode>21075</postalCode>

<country>US</country>

</addr>

<patient>

<name>

<given>SIXPM</given>

<family>INT42441</family>

</name>

<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>

<birthTime value="19560505"/>

<maritalStatusCode code="M" codeSystem="2.16.840.1.113883.5.2" displayName="Married"/>

<raceCode code="2106-3" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race &amp; Ethnicity - CDC" displayName="White"/>

<ethnicGroupCode code="2186-5" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race &amp; Ethnicity - CDC" displayName="Not Hispanic or Latino"/>

<languageCommunication>

<languageCode code="eng"/>

</languageCommunication>

</patient>

</patientRole>

</recordTarget>

<author>

<time value="20210406071234-0400"/>

<assignedAuthor>

<id root="2.16.840.1.113883.3.564"/>

<addr use="WP">

<streetAddressLine>311 Arsenal St</streetAddressLine>

<streetAddressLine nullFlavor="NI"/>

<city>Watertown</city>

<state>MA</state>

<postalCode>02472</postalCode>

<country>US</country>

</addr>

<telecom use="WP" value="tel:+1-617-4021000"/>

<assignedAuthoringDevice>

<manufacturerModelName>athenahealth</manufacturerModelName>

<softwareName>athenahealth</softwareName>

</assignedAuthoringDevice>

</assignedAuthor>

</author>

<custodian>

<assignedCustodian>

<representedCustodianOrganization>

<id root="2.16.840.1.113883.3.564"/>

<name>athenahealth</name>

<telecom use="WP" value="tel:+1-617-4021000"/>

<addr use="WP">

<streetAddressLine>311 Arsenal St</streetAddressLine>

<streetAddressLine nullFlavor="NI"/>

<city>Watertown</city>

<state>MA</state>

<postalCode>02472</postalCode>

<country>US</country>

</addr>

</representedCustodianOrganization>

</assignedCustodian>

</custodian>

<documentationOf>

<serviceEvent classCode="PCPR">

<effectiveTime>

<low value="20210406"/>

<high nullFlavor="NI"/>

</effectiveTime>

<performer typeCode="PRF">

<templateId root="2.16.840.1.113883.10.20.6.2.1"/>

<functionCode code="3" displayName="Primary Care Provider"/>

<assignedEntity>

<id extension="1467409169" root="2.16.840.1.113883.4.6"/>

<code nullFlavor="NI"/>

<addr use="WP">

<streetAddressLine>515 FAIRMOUNT AVENUE</streetAddressLine>

<streetAddressLine nullFlavor="NI"/>

<city>TOWSON</city>

<state>MD</state>

<postalCode>21286</postalCode>

<country>US</country>

</addr>

<telecom use="WP" value="tel:+1-410-7696269"/>

<assignedPerson>

<name>DR. LISE SATTERFIELD</name>

</assignedPerson>

<representedOrganization>

<id root="183427c2-2021-0e85-1a9e-001A64958C30"/>

<name nullFlavor="NI"/>

<telecom nullFlavor="NI"/>

<addr nullFlavor="NI"/>

</representedOrganization>

</assignedEntity>

</performer>

</serviceEvent>

</documentationOf>

<component>

<structuredBody>

<component>

<section>

<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>

<id root="183427c2-2021-8117-1a9e-001A64958C30"/>

<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>

<title>Allergies</title>

<text>

<paragraph>

<content ID="allergy1">None recorded.</content>

</paragraph>

</text>

<entry>

<act classCode="ACT" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.30"/>

<id root="183427c2-2021-ce11-1a9e-001A64958C30"/>

<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts"/>

<statusCode code="completed"/>

<effectiveTime>

<high value="20210406"/>

</effectiveTime>

<entryRelationship typeCode="SUBJ">

<observation classCode="OBS" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.7"/>

<id root="183427c2-2021-785e-1a9e-001A64958C30"/>

<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>

<statusCode code="completed"/>

<effectiveTime>

<low nullFlavor="NI"/>

<high value="20210406"/>

</effectiveTime>

<value code="419199007" codeSystem="2.16.840.1.113883.6.96" displayName="Allergy to substance" xsi:type="CD"/>

<participant typeCode="CSM">

<participantRole classCode="MANU">

<playingEntity classCode="MMAT">

<code nullFlavor="NI">

<translation nullFlavor="NI"/>

</code>

</playingEntity>

</participantRole>

</participant>

<entryRelationship inversionInd="true" typeCode="MFST">

<observation classCode="OBS" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.9"/>

<id root="183427c2-2021-f1d5-1a9e-001A64958C30"/>

<code nullFlavor="NI"/>

<statusCode code="completed"/>

<value nullFlavor="NI" xsi:type="CD"/>

</observation>

</entryRelationship>

<entryRelationship inversionInd="true" typeCode="SUBJ">

<observation classCode="OBS" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.8"/>

<code code="SEV" codeSystem="2.16.840.1.113883.5.4" codeSystemName="HL7ActCode" displayName="Severity Observation"/>

<statusCode code="completed"/>

<value nullFlavor="NI" xsi:type="CD"/>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</act>

</entry>

</section>

</component>

<component>

<section>

<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>

<id root="183427c2-2021-fc06-1a9e-001A64958C30"/>

<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"

displayName="History of Medication Use"/>

<title>Medications</title>

<text>

<table>

<thead>

<tr>

<th>Name</th>

<th>Status</th>

<th>Start Date</th>

<th>Stop Date</th>

<th> </th>

<th> </th>

</tr>

</thead>

<tbody>

<tr>

<td styleCode="Botrule">

<content ID="Med1">clindamycin HCl 300 mg capsule<br/> Take 1 capsule twice a day by oral route with meals for 14 days.</content>

</td>

<td styleCode="Botrule">Active</td>

<td styleCode="Botrule"> </td>

<td styleCode="Botrule">Not available</td>

</tr>

<tr>

<td styleCode="Botrule">

<content ID="Med2">nabumetone 500 mg tablet<br/> Take 1 tablet twice a day by oral route with meals for 21 days.</content>

</td>

<td styleCode="Botrule">Active</td>

<td styleCode="Botrule"> </td>

<td styleCode="Botrule">Not available</td>

</tr>

<tr>

<td>

<content ID="Med3">Percocet 5 mg-325 mg tablet<br/> Take 1-2 tablets every 6-8 hours for postop pain that ranks 6/10 or above on the pain scale. For any postop pain that ranks 5/10 or below on the pain scale, use 1-2 tablets of Extra Strength Tylenol every 6-8 hours as needed</content>

</td>

<td>Active</td>

<td> </td>

<td>Not available</td>

</tr>

</tbody>

</table>

</text>

<entry>

<substanceAdministration classCode="SBADM" moodCode="INT">

<templateId root="2.16.840.1.113883.10.20.22.4.16"/>

<id root="183427c2-2021-09ff-1a9e-001A64958C30"/>

<text>

<reference value="#Med1"/>Take 1 capsule twice a day by oral route with meals for 14 days.</text>

<statusCode code="completed"/>

<effectiveTime xsi:type="IVL_TS">

<low nullFlavor="NI"/>

<high nullFlavor="NI"/>

</effectiveTime>

<effectiveTime institutionSpecified="true" operator="A" xsi:type="PIVL_TS">

<period unit="h" value="12"/>

</effectiveTime>

<doseQuantity unit="capsule(s)" value="1"/>

<consumable>

<manufacturedProduct classCode="MANU">

<templateId root="2.16.840.1.113883.10.20.22.4.23"/>

<manufacturedMaterial>

<code code="284215" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="clindamycin 300 MG Oral Capsule">

<originalText>

<reference value="#Med1"/>

</originalText>

<translation code="167106" codeSystemName="FDB MEDID"/>

</code>

<name>clindamycin 300 MG Oral Capsule</name>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

<entryRelationship inversionInd="true" typeCode="SUBJ">

<act classCode="ACT" moodCode="INT">

<templateId root="2.16.840.1.113883.10.20.22.4.20"/>

<code code="311401005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Patient Education"/>

<text>with meals</text>

<statusCode code="completed"/>

</act>

</entryRelationship>

</substanceAdministration>

</entry>

<entry>

<substanceAdministration classCode="SBADM" moodCode="INT">

<templateId root="2.16.840.1.113883.10.20.22.4.16"/>

<id root="183427c2-2021-cb7e-1a9e-001A64958C30"/>

<text>

<reference value="#Med2"/>Take 1 tablet twice a day by oral route with meals for 21 days.</text>

<statusCode code="completed"/>

<effectiveTime xsi:type="IVL_TS">

<low nullFlavor="NI"/>

<high nullFlavor="NI"/>

</effectiveTime>

<effectiveTime institutionSpecified="true" operator="A" xsi:type="PIVL_TS">

<period unit="h" value="12"/>

</effectiveTime>

<doseQuantity value="1"/>

<consumable>

<manufacturedProduct classCode="MANU">

<templateId root="2.16.840.1.113883.10.20.22.4.23"/>

<manufacturedMaterial>

<code code="311892" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="nabumetone 500 MG Oral Tablet">

<originalText>

<reference value="#Med2"/>

</originalText>

<translation code="297151" codeSystemName="FDB MEDID"/>

</code>

<name>nabumetone 500 MG Oral Tablet</name>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

<entryRelationship inversionInd="true" typeCode="SUBJ">

<act classCode="ACT" moodCode="INT">

<templateId root="2.16.840.1.113883.10.20.22.4.20"/>

<code code="311401005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Patient Education"/>

<text>with meals</text>

<statusCode code="completed"/>

</act>

</entryRelationship>

</substanceAdministration>

</entry>

<entry>

<substanceAdministration classCode="SBADM" moodCode="INT">

<templateId root="2.16.840.1.113883.10.20.22.4.16"/>

<id root="183427c2-2021-34c8-1a9e-001A64958C30"/>

<text>

<reference value="#Med3"/>Take 1-2 tablets every 6-8 hours for postop pain that ranks 6/10 or above on the pain scale. For any postop pain that ranks 5/10 or below on the pain scale, use 1-2 tablets of Extra Strength Tylenol every 6-8 hours as needed</text>

<statusCode code="completed"/>

<effectiveTime xsi:type="IVL_TS">

<low nullFlavor="NI"/>

<high nullFlavor="NI"/>

</effectiveTime>

<consumable>

<manufacturedProduct classCode="MANU">

<templateId root="2.16.840.1.113883.10.20.22.4.23"/>

<manufacturedMaterial>

<code code="1049640" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="acetaminophen 325 MG / oxycodone hydrochloride 5 MG Oral Tablet [Percocet]">

<originalText>

<reference value="#Med3"/>

</originalText>

<translation code="282127" codeSystemName="FDB MEDID"/>

</code>

<name>acetaminophen 325 MG / oxycodone hydrochloride 5 MG Oral Tablet [Percocet]</name>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

<entryRelationship inversionInd="true" typeCode="SUBJ">

<act classCode="ACT" moodCode="INT">

<templateId root="2.16.840.1.113883.10.20.22.4.20"/>

<code code="311401005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Patient Education"/>

<text/>

<statusCode code="completed"/>

</act>

</entryRelationship>

</substanceAdministration>

</entry>

</section>

</component>

<component>

<section>

<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>

<id root="183427c2-2021-5c7a-1a9e-001A64958C30"/>

<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>

<title>Problems</title>

<text>

<paragraph>None recorded.</paragraph>

</text>

<entry>

<act classCode="ACT" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.3"/>

<id root="183427c2-2021-ba1f-1a9e-001A64958C30"/>

<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>

<statusCode code="active"/>

<effectiveTime>

<low nullFlavor="NI"/>

</effectiveTime>

<entryRelationship inversionInd="false" typeCode="SUBJ">

<observation classCode="OBS" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.4"/>

<id root="183427c2-2021-9a1e-1a9e-001A64958C30"/>

<code code="55607006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Problem"/>

<statusCode code="completed"/>

<effectiveTime>

<low nullFlavor="NI"/>

</effectiveTime>

<value nullFlavor="NI" xsi:type="CD"/>

</observation>

</entryRelationship>

</act>

</entry>

</section>

</component>

<component>

<section>

<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>

<id root="183427c2-2021-c153-1a9e-001A64958C30"/>

<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>

<title>Procedures</title>

<text>

<paragraph>

<content ID="Proc1">None recorded.</content>

</paragraph>

</text>

<entry>

<procedure classCode="PROC" moodCode="INT">

<templateId root="2.16.840.1.113883.10.20.22.4.14"/>

<id root="183427c2-2021-6c72-1a9e-001A64958C30"/>

<code nullFlavor="NI"/>

<text>

<reference value="#Proc1"/>

</text>

<statusCode code="active"/>

<effectiveTime nullFlavor="NI"/>

</procedure>

</entry>

</section>

</component>

<component>

<section>

<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>

<id root="183427c2-2021-d0a3-1a9e-001A64958C30"/>

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

<title>Results</title>

<text>

<table>

<thead>

<tr>

<th>Lab Results</th>

</tr> </thead>

<tbody>

<tr>

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

</table>

<paragraph>

<content ID="result1">None recorded.</content>

</paragraph>

</text>

<entry>

<organizer classCode="BATTERY" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.1"/>

<id root="183427c2-2021-0696-1a9e-001A64958C30"/>

<code nullFlavor="NI" xsi:type="CE">

<translation codeSystemName="Lab Result Description" displayName="None recorded."/>

</code>

<statusCode code="completed"/>

<effectiveTime nullFlavor="NI"/>

<component>

<observation classCode="OBS" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.2"/>

<id root="183427c2-2021-47aa-1a9e-001A64958C30"/>

<code nullFlavor="NI"/>

<text>

<reference value="#result1"/>

</text>

<statusCode code="completed"/>

<effectiveTime nullFlavor="NI"/>

<value nullFlavor="NI" xsi:type="CD"/>

<interpretationCode nullFlavor="NI"/>

<referenceRange>

<observationRange>

<text nullFlavor="NI"/>

<value nullFlavor="NI" xsi:type="ST"/>

</observationRange>

</referenceRange>

</observation>

</component>

</organizer>

</entry>

</section>

</component>

<component>

<section>

<templateId root="2.16.840.1.113883.10.20.22.2.22"/>

<id root="183427c2-2021-d2e0-1a9e-001A64958C30"/>

<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of hospitalizations+History of outpatient visits"/>

<title>Past Encounters</title>

<text>

<table>

<tbody>

<tr>

<td>04/02/2021<br/>Bone Spur of Right Foot<br/>

<content ID="Encounter1">Patrick Felton, DPM: 9105 Franklin Square Drive, Suite 206, NAKAMOTO, MD 21237-3903, Ph. (410) 803-0788</content>

</td>

</tr>

</tbody>

</table>

</text>

<entry>

<encounter classCode="ENC" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.49"/>

<id root="183427c2-2021-ccaf-1a9e-001A64958C30"/>

<code nullFlavor="NI">

<originalText>

<reference value="#Encounter1"/>

</originalText>

</code>

<effectiveTime value="20210402"/>

<performer>

<assignedEntity>

<id extension="1679519672" root="2.16.840.1.113883.4.6"/>

<code code="213E00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Podiatrist"/>

<addr use="WP">

<streetAddressLine>9105 Franklin Square Drive</streetAddressLine>

<streetAddressLine>Suite 206</streetAddressLine>

<city>NAKAMOTO</city>

<state>MD</state>

<postalCode>21237-3903</postalCode>

<country>US</country>

</addr>

<telecom use="WP" value="tel:+1-410-8030788"/>

<assignedPerson>

<name>

<given>Patrick</given>

<family>Felton</family>

</name>

</assignedPerson>

</assignedEntity>

</performer>

<participant typeCode="LOC">

<participantRole classCode="SDLOC">

<templateId root="2.16.840.1.113883.10.20.22.4.32"/>

<code nullFlavor="NI"/>

<addr>

<streetAddressLine>9105 Franklin Square Drive</streetAddressLine>

<streetAddressLine>Suite 206</streetAddressLine>

<city>NAKAMOTO</city>

<state>MD</state>

<postalCode>21237-3903</postalCode>

<country>US</country>

</addr>

<telecom use="WP" value="tel:+1-410-8030788"/>

<playingEntity classCode="PLC">

<name>MD - Podiatry Associates, P.A. - Franklin Square ASC</name>

</playingEntity>

</participantRole>

</participant>

<entryRelationship typeCode="SUBJ">

<act classCode="ACT" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.80"/>

<code code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ENCOUNTER DIAGNOSIS" xsi:type="CE"/>

<entryRelationship typeCode="SUBJ">

<observation classCode="OBS" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.4"/>

<id root="183427c2-2021-f926-1a9e-001A64958C30"/>

<code code="282291009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Diagnosis"/>

<statusCode code="completed"/>

<effectiveTime>

<low value="20210402124944-0400"/>

</effectiveTime>

<value code="316651000119103" codeSystem="2.16.840.1.113883.6.96" displayName="Bone spur of right foot" xsi:type="CD"/>

</observation>

</entryRelationship>

</act>

</entryRelationship>

</encounter>

</entry>

</section>

</component>

<component>

<section>

<templateId root="2.16.840.1.113883.10.20.22.2.17"/>

<id root="183427c2-2021-ea54-1a9e-001A64958C30"/>

<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>

<title>Social History</title>

<text>

<paragraph>None recorded.</paragraph>

</text>

<entry>

<observation classCode="OBS" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.78"/>

<id root="183427c2-2021-8340-1a9e-001A64958C30"/>

<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>

<statusCode code="completed"/>

<effectiveTime>

<low nullFlavor="NI"/>

</effectiveTime>

<value code="266927001" codeSystem="2.16.840.1.113883.6.96" displayName="Unknown If Ever Smoked" xsi:type="CD"/>

</observation>

</entry>

</section>

</component>

<component>

<section>

<templateId root="2.16.840.1.113883.10.20.22.2.2.1"/>

<id root="183427c2-2021-f21d-1a9e-001A64958C30"/>

<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>

<title>Vaccine List</title>

<text>

<paragraph>

<content ID="immun1">None recorded.</content>

</paragraph>

</text>

<entry>

<substanceAdministration classCode="SBADM" moodCode="INT" negationInd="false">

<templateId root="2.16.840.1.113883.10.20.22.4.52"/>

<id root="183427c2-2021-9c72-1a9e-001A64958C30"/>

<text>

<reference value="#immun1"/>

</text>

<statusCode code="active"/>

<effectiveTime nullFlavor="NI"/>

<doseQuantity nullFlavor="NI"/>

<consumable>

<manufacturedProduct classCode="MANU">

<templateId root="2.16.840.1.113883.10.20.22.4.54"/>

<manufacturedMaterial>

<code codeSystem="2.16.840.1.113883.12.292" codeSystemName="CVX" nullFlavor="NI"/>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</section>

</component>

<component>

<section>

<templateId root="2.16.840.1.113883.10.20.22.2.10"/>

<id root="183427c2-2021-71d3-1a9e-001A64958C30"/>

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

<title>Plan of Care</title>

<text>

<table>

<thead>

<tr>

<th>Reminders</th>

<th/>

<th/>

<th>Provider</th>

</tr>

</thead>

<tbody>

<tr>

<td styleCode="Botrule">

<content styleCode="Bold">Appointments</content>

</td>

<td styleCode="Botrule">

None recorded.

</td>

<td styleCode="Botrule">

</td>

<td styleCode="Botrule">

</td>

</tr>

<tr>

<td styleCode="Botrule">

<content styleCode="Bold">Lab</content>

</td>

<td styleCode="Botrule">

None recorded.

</td>

<td styleCode="Botrule">

</td>

<td styleCode="Botrule">

</td>

</tr>

<tr>

<td styleCode="Botrule">

<content styleCode="Bold">Referral</content>

</td>

<td styleCode="Botrule">

None recorded.

</td>

<td styleCode="Botrule">

</td>

<td styleCode="Botrule">

</td>

</tr>

<tr>

<td styleCode="Botrule">

<content styleCode="Bold">Procedures</content>

</td>

<td styleCode="Botrule">

None recorded.

</td>

<td styleCode="Botrule">

</td>

<td styleCode="Botrule">

</td>

</tr>

<tr>

<td styleCode="Botrule">

<content styleCode="Bold">Surgeries</content>

</td>

<td styleCode="Botrule">

None recorded.

</td>

<td styleCode="Botrule">

</td>

<td styleCode="Botrule">

</td>

</tr>

<tr>

<td>

<content styleCode="Bold">Imaging</content>

</td>

<td>

None recorded.

</td>

<td>

</td>

<td> </td>

</tr>

</tbody>

</table>

</text>

</section>

</component>

<component>

<section>

<templateId root="2.16.840.1.113883.10.20.22.2.4.1"/>

<id root="183427c2-2021-13b0-1a9e-001A64958C30"/>

<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"

displayName="VITAL SIGNS"/>

<title>Vitals</title>

<text>

<paragraph>

<content ID="vit1">None recorded.</content>

</paragraph>

</text>

<entry typeCode="DRIV">

<organizer classCode="CLUSTER" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.26"/>

<id root="183427c2-2021-87d3-1a9e-001A64958C30"/>

<code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Vital signs"/>

<statusCode code="completed"/>

<effectiveTime nullFlavor="NI"/>

<component>

<observation classCode="OBS" moodCode="EVN">

<templateId root="2.16.840.1.113883.10.20.22.4.27"/>

<id root="183427c2-2021-db95-1a9e-001A64958C30"/>

<code nullFlavor="NI"/>

<text>

<reference value="#vit1"/>

</text>

<statusCode code="completed"/>

<effectiveTime nullFlavor="NI"/>

<value nullFlavor="NI" xsi:type="PQ"/>

</observation>

</component>

</organizer>

</entry>

</section>

</component>

</structuredBody>

</component>

</ClinicalDocument>

Turn static files into dynamic content formats.

Create a flipbook
Issuu converts static files into: digital portfolios, online yearbooks, online catalogs, digital photo albums and more. Sign up and create your flipbook.