CCD Sample 4

<title>CCD document using C-CDA</title>

<streetAddressLine>239 Upton Walk</streetAddressLine>

<city>Lowell</city>

</addr>

<family>QTFTEST-003</family>

</name>

</languageCommunication>

</patient>

<name>Johnston Family Medicine</name>

<streetAddressLine>41 Magna Way</streetAddressLine>

<streetAddressLine>Suite 100</streetAddressLine>

<city>WESTMINSTER</city>

</addr>

<name>Johnston Family Medicine</name>

</wholeOrganization>

</asOrganizationPartOf>

</providerOrganization>

</patientRole>

</recordTarget>

<streetAddressLine>41 Magna Way</streetAddressLine>

<city>WESTMINSTER</city>

</addr>

<name>

<given>Dennis</given>

<family>Vinias</family>

</name>

</assignedPerson>

<name>Johnston Family Medicine</name>

</representedOrganization>

</assignedAuthor>

</author>

<name>Johnston Family Medicine. Client ID: 1067686</name>

<streetAddressLine>41 Magna Way</streetAddressLine>

<streetAddressLine>Suite 100</streetAddressLine>

<city>WESTMINSTER</city>

</addr>

</representedCustodianOrganization>

</assignedCustodian>

</custodian>

<streetAddressLine>41 Magna Way</streetAddressLine>

<city>WESTMINSTER</city>

</addr>

<name>

<given>Dennis</given>

<family>Vinias</family>

</name>

</assignedPerson>

</assignedEntity>

</legalAuthenticator>

</effectiveTime>

<originalText>Primary Provider</originalText>

</functionCode>

<time>

</time>

<streetAddressLine>41 Magna Way</streetAddressLine>

<city>WESTMINSTER</city>

</addr>

<name>

<given>Renee</given>

<family>Orlando-Hart</family>

</name>

</assignedPerson>

<name>Johnston Family Medicine</name>

<streetAddressLine>41 Magna Way</streetAddressLine>

<streetAddressLine>Suite 100</streetAddressLine>

<city>WESTMINSTER</city>

</addr>

</representedOrganization>

</assignedEntity>

</performer>

<originalText>Chronic Care Management</originalText>

</functionCode>

<time>

</time>

<name/>

</assignedPerson>

<name>Johnston Family Medicine</name>

<streetAddressLine>41 Magna Way</streetAddressLine>

<streetAddressLine>Suite 100</streetAddressLine>

<city>WESTMINSTER</city>

</addr>

</representedOrganization>

</assignedEntity>

</performer>

</serviceEvent>

</documentationOf>

<title>Summary Purpose</title>

<text>Interface Exchange</text>

</act>

</entryRelationship>

</act>

</entry>

</section>

</component>

<title>Insurance Providers</title>

<text>

<thead>

<tr>

<th>Payer name</th>

<th>Policy type / Coverage type</th>

<th>Covered party ID</th>

<th>Effective Begin Date</th>

<th>Effective End Date</th>

</tr>

</thead>

<tbody>

<tr>

<td>Aetna</td>

<td>Commercial Insurance</td>

<td>Unknown</td>

</tr>

</tbody>

</table>

</text>

<name/>

</assignedPerson>

<name>Aetna</name>

</representedOrganization>

</assignedEntity>

</performer>

<name/>

</assignedPerson>

<name>Aetna</name>

</representedOrganization>

</assignedEntity>

</performer>

<time>

</time>

<given>ELIJAH</given>

<family>BARBE</family>

</name>

</playingEntity>

</participantRole>

</participant>

<streetAddressLine>1485 CARRIAGE HILL DRIVE</streetAddressLine> <city>WESTMINSTER</city>

</addr>

<streetAddressLine>1485 CARRIAGE HILL DRIVE</streetAddressLine>

<city>WESTMINSTER</city>

</addr>

<given>MICHELLE</given>

<family>BARBE</family>

</name>

</playingEntity>

</participantRole>

</participant>

</procedure>

</entryRelationship>

</act>

</entryRelationship>

</act>

</entryRelationship>

</act>

</entry>

</section>

</component>

<title>Family history</title>

<text>

<paragraph>Mother</paragraph>

<thead>

<tr>

<th>Diagnosis</th>

<th>Age At Onset</th>

</tr>

</thead>

<tbody>

<tr>

<td>No Known Diseases</td>

</tr>

</tbody>

</table>

<paragraph>Paternal Grandmother</paragraph>

<thead>

<tr>

<th>Diagnosis</th>

<th>Age At Onset</th>

</tr> </thead>

<tbody>

<tr>

<td>Stroke</td>

<td>Unknown</td>

</tr>

</tbody>

</table>

<paragraph>Sister</paragraph>

<thead>

<tr>

<th>Diagnosis</th>

<th>Age At Onset</th>

</tr>

</thead>

<tbody>

<tr>

<td>No Known Diseases</td>

</tr>

</tbody>

</table>

<paragraph>Father</paragraph>

<thead>

<tr>

<th>Diagnosis</th>

<th>Age At Onset</th>

</tr>

</thead>

<tbody>

<tr>

<td>Asthma</td>

<td>Unknown</td>

</tr>

<tr>

<td>Allergies</td>

<td>Unknown</td>

</tr>

</tbody>

</table>

<paragraph>Paternal Grandfather</paragraph>

<thead>

<tr>

<th>Diagnosis</th>

<th>Age At Onset</th>

</tr>

</thead>

<tbody>

<tr>

<td>Cancer</td>

<td>Unknown</td>

</tr>

</tbody>

</table>

</text>

<name/>

</subject>

</relatedSubject>

</subject>

</organizer>

</entry>

<name/>

</subject>

</relatedSubject>

</subject>

</effectiveTime>

<originalText>Stroke</originalText>

</value>

</observation>

</component>

</organizer>

</entry>

<name/>

</subject>

</relatedSubject>

</subject>

</organizer>

</entry>

<name/>

</subject>

</relatedSubject>

</subject>

</effectiveTime>

<originalText>Asthma</originalText>

</value>

</observation>

</component>

</effectiveTime>

<originalText>Allergies</originalText>

</value>

</observation>

</component>

</organizer>

</entry>

<name/>

</subject>

</relatedSubject>

</subject>

</effectiveTime>

<originalText>Cancer</originalText>

</value>

</observation>

</component>

</organizer>

</entry>

</section>

</component>

<title>Social History</title>

<text>

<thead>

<tr>

<th>Social History Element</th>

<th>Codes</th>

<th>Description</th>

<th>Effective Dates</th>

</tr>

</thead>

<tbody>

<tr>

<td>Marital status</td>

<td>Unknown</td>

<td>Single</td>

</tr>

<tr>

<td>Education level</td>

<td>Unknown</td>

<td>Grade School</td>

</tr>

<tr>

<td>Employment</td>

<td>Unknown</td>

<td>Student</td>

</tr>

<tr>

<td>Tobacco history</td>

<td>SNOMED CT: 266919005</td>

<td>Never smoker</td>

</tr>

<tr>

<td>Alcohol history</td>

<td>SNOMED CT: 105542008</td>

<td>Never drinks alcohol</td>

</tr>

<tr>

<td>Has the patient ever used illegal drugs?</td> <td>Unknown</td>

<td>Has never used illegal drugs</td>

</tr>

</tbody>

</table>

</text>

<originalText>Single</originalText>

</value>

</observation>

</entry>

<originalText>Grade School</originalText>

</value>

</observation>

</entry>

<originalText>Student</originalText>

</value>

</observation>

</entry>

<originalText>Never smoker</originalText>

</value>

</observation>

</entry>

<originalText>Never drinks alcohol</originalText>

</value>

</observation>

</entry>

<originalText>Has never used illegal drugs</originalText>

</value>

</observation>

</entry>

</section>

</component>

<title>Allergies, Adverse Reactions, Alerts</title>

<text>

<thead>

<tr>

<th>Substance</th>

<th>Reaction</th>

<th>Codes</th>

<th>Entered Date</th>

<th>Inactivated Date</th>

<th>Status</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content ID="substance1">* NO KNOWN DRUG ALLERGIES</content>

</td>

<td/>

<td>Unknown</td>

<td>No Inactive Date</td>

<td>Active</td>

</tr>

</tbody>

</table>

</text>

</effectiveTime>

</effectiveTime>

<reference value="#substance1"/>* NO KNOWN DRUG ALLERGIES</originalText>

</code>

<name>* NO KNOWN DRUG ALLERGIES</name>

</playingEntity>

</participantRole>

</participant>

<code code="33999-4" codeSystem="2.16.840.1.113883.6.1"

displayName="Status"/>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</act>

</entry>

</section>

</component>

<title>Problems</title>

<text>

<thead>

<tr>

<th>Condition</th>

<th>Codes</th>

<th>Effective Dates</th>

<th>Condition Status</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content ID="Condition1">Well child examination</content>

</td>

<td>Active</td>

</tr>

<tr>

<td>

<content ID="Condition2">Encounter for screening for other disorder</content>

</td>

<td>Active</td>

</tr>

<tr>

<td>

<content ID="Condition3">Unspecified asthma, uncomplicated</content>

</td>

<td>Active</td>

</tr>

</tbody>

</table>

</text>

</effectiveTime>

<translation code="75323-6" codeSystem="2.16.840.1.113883.6.1"

codeSystemName="LOINC" displayName="Condition"/>

</code>

<text>

<reference value="#Condition1"/>Well child examination</text>

</effectiveTime>

<value code="Z00.129" codeSystem="2.16.840.1.113883.6.90"

codeSystemName="ICD-10" displayName="Well child examination" xsi:type="CD">

<translation code="V20.2" codeSystem="2.16.840.1.113883.6.103"

codeSystemName="ICD-9" displayName="Well child examination"/>

</value>

</observation>

</entryRelationship>

</act>

</entry>

</effectiveTime>

</code>

<text>

<reference value="#Condition2"/>Encounter for screening for other disorder</text>

</effectiveTime>

<value code="Z13.89" codeSystem="2.16.840.1.113883.6.90"

codeSystemName="ICD-10" displayName="Encounter for screening for other disorder" xsi:type="CD">

<translation code="V79.1" codeSystem="2.16.840.1.113883.6.103"

codeSystemName="ICD-9" displayName="Encounter for screening for other disorder"/>

</value>

</observation>

</entryRelationship>

</act>

</entry>

</effectiveTime>

<translation code="75323-6" codeSystem="2.16.840.1.113883.6.1"

codeSystemName="LOINC" displayName="Condition"/>

</code>

<text>

<reference value="#Condition3"/>Unspecified asthma, uncomplicated</text>

</effectiveTime>

<translation code="493.90" codeSystem="2.16.840.1.113883.6.103"

codeSystemName="ICD-9" displayName="Unspecified asthma, uncomplicated"/>

</value>

</observation>

</entryRelationship>

</act>

</entry>

</section>

</component>

<title>Medications</title>

<text>

<thead>

<tr>

<th>Medication</th>

<th>Codes</th>

<th>Instructions</th>

<th>Start Date</th>

<th>Status</th>

<th>Fill Instructions</th>

</tr> </thead>

<tbody>

<tr>

<td>

<content ID="med1">Ventolin HFA 90 mcg/actuation aerosol inhaler</content>

</td>

<td>RxNorm: </td>

<td>Active</td>

<td/>

</tr>

<tr>

<td>

<content ID="med2">amoxicillin 500 mg capsule</content>

</td>

<td>RxNorm: </td>

<td>Inactive</td>

<td/>

</tr>

<tr>

<td>

<content ID="med3">penicillin V potassium 250 mg tablet</content>

</td>

<td>RxNorm: </td>

<td>Inactive</td>

<td/>

</tr>

<tr>

<td>

<content ID="med4">Medrol 4 mg tablet</content>

</td>

<td>RxNorm: </td>

<td>Inactive</td>

<td/>

</tr>

<tr>

<td>

<content ID="med5">amoxicillin 250 mg chewable tablet</content>

</td>

<td>RxNorm: </td>

<td>Inactive</td>

<td/>

</tr>

<tr>

<td>

<content ID="med6">penicillin V potassium 250 mg/5 mL oral solution</content>

</td>

<td>RxNorm: </td>

<td>Inactive</td>

<td/>

</tr>

<tr>

<td>

<content ID="med7">Allegra Allergy 180 mg tablet</content>

</td>

<td>RxNorm: 997422</td>

<td/>

<td>Active</td>

<td/>

</tr>

</tbody>

</table>

</text>

<text>

<reference value="#med1"/>Ventolin HFA 90 mcg/actuation aerosol inhaler 0</text>

</effectiveTime>

<name>Ventolin HFA 90 mcg/actuation aerosol inhaler</name>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</observation>

</entryRelationship>

</effectiveTime>

</manufacturedMaterial>

</manufacturedProduct>

</product>

</supply>

</entryRelationship>

</substanceAdministration>

</entry>

<text>

<reference value="#med2"/>amoxicillin 500 mg capsule 0</text>

</effectiveTime>

<name>amoxicillin 500 mg capsule</name>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

<addr>

<streetAddressLine>41 Magna Way</streetAddressLine> <city>WESTMINSTER</city>

</addr>

<name>

<family>Vinias</family>

<given>Dennis</given>

</name>

</assignedPerson>

</assignedAuthor>

</author>

</observation>

</entryRelationship>

</effectiveTime>

</manufacturedMaterial>

</manufacturedProduct>

</product>

</supply>

</entryRelationship>

</substanceAdministration>

</entry>

<text>

<reference value="#med3"/>penicillin V potassium 250 mg tablet 0</text>

</effectiveTime>

<name>penicillin V potassium 250 mg tablet</name>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

<addr>

<streetAddressLine>41 Magna Way</streetAddressLine>

<city>WESTMINSTER</city>

</addr>

<name>

<family>Orlando-Hart</family>

<given>Renee</given>

</name>

</assignedPerson>

</assignedAuthor>

</author>

</observation>

</entryRelationship>

</effectiveTime>

</manufacturedMaterial>

</manufacturedProduct>

</product>

</supply>

</entryRelationship>

</substanceAdministration>

</entry>

<text>

<reference value="#med4"/>Medrol 4 mg tablet 0</text>

</effectiveTime>

<name>Medrol 4 mg tablet</name>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

<addr>

<streetAddressLine>41 Magna Way</streetAddressLine>

<city>WESTMINSTER</city>

</addr>

<name>

<family>Orlando-Hart</family>

<given>Renee</given>

</name>

</assignedPerson>

</assignedAuthor>

</author>

</observation>

</entryRelationship>

</effectiveTime>

</manufacturedMaterial>

</manufacturedProduct>

</product>

</supply>

</entryRelationship>

</substanceAdministration>

</entry>

<text>

<reference value="#med5"/>amoxicillin 250 mg chewable tablet 2 PO 10</text>

</effectiveTime>

<name>amoxicillin 250 mg chewable tablet</name>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

<addr>

<streetAddressLine>41 Magna Way</streetAddressLine>

<city>WESTMINSTER</city>

</addr>

<name>

<family>Orlando-Hart</family>

<given>Renee</given>

</name>

</assignedPerson>

</assignedAuthor>

</author>

</observation>

</entryRelationship>

</effectiveTime>

</manufacturedMaterial>

</manufacturedProduct>

</product>

</supply>

</entryRelationship>

</substanceAdministration>

</entry>

<text>

<reference value="#med6"/>penicillin V potassium 250 mg/5 mL oral solution 10 ml PO 10</text>

</effectiveTime>

<name>penicillin V potassium 250 mg/5 mL oral solution</name>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

<addr>

<streetAddressLine>41 Magna Way</streetAddressLine> <city>WESTMINSTER</city>

</addr>

<name>

<family>Orlando-Hart</family>

<given>Renee</given>

</name>

</assignedPerson>

</assignedAuthor>

</author>

</observation>

</entryRelationship>

</effectiveTime>

</manufacturedMaterial>

</manufacturedProduct>

</product>

</supply>

</entryRelationship>

</substanceAdministration>

</entry>

<text>

<reference value="#med7"/>Allegra Allergy 180 mg tablet oral</text>

</effectiveTime>

<originalText>Allegra Allergy 180 mg tablet<reference value="#med7"/>

</originalText>

</code>

<name>Allegra Allergy 180 mg tablet</name>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</observation>

</entryRelationship>

</effectiveTime>

<originalText>Allegra Allergy 180 mg tablet<reference value="#med7"/>

</originalText>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</product>

</supply>

</entryRelationship>

</substanceAdministration>

</entry>

</section>

</component>

<title>Medication Administered</title>

<text>No Medication Administered data</text>

</effectiveTime>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</observation>

</entryRelationship>

</effectiveTime>

</supply>

</entryRelationship>

</substanceAdministration>

</entry>

</section>

</component>

<title>Immunizations</title>

<text>

<thead>

<tr>

<th>Vaccine</th>

<th>Codes</th>

<th>Status</th>

</tr>

</thead>

<tbody>

<tr>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td>VARICELLA </td>

<td>Unknown</td>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td>PREVNAR </td>

<td>Unknown</td>

<td/>

<td/>

</tr>

<tr>

<td>VARICELLA </td>

<td>Unknown</td>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td>HEPBVACCIN </td>

<td>Unknown</td>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td>PREVNAR </td>

<td>Unknown</td>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td>PREVNAR </td>

<td>Unknown</td>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td/>

<td/>

</tr>

<tr>

<td>PREVNAR </td>

<td>Unknown</td>

<td/>

<td/>

</tr>

<tr>

<td>HEPBVACCIN </td>

<td>Unknown</td>

<td/>

<td/>

</tr>

<tr>

<td>HEPBVACCIN </td>

<td>Unknown</td>

<td/>

<td/>

</tr>

</tbody>

</table>

</text>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

<code code="20" codeSystem="2.16.840.1.113883.12.292"

codeSystemName="CVX" displayName="DTaP">

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

<code code="49" codeSystem="2.16.840.1.113883.12.292"

codeSystemName="CVX" displayName="Hib (PRP-OMP)">

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</effectiveTime>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</section>

</component>

<title>Results</title>

<text>

<thead>

<tr>

<th>Observation</th>

<th>Observation Code</th>

<th>Result</th>

<th>Service Location</th>

</tr> </thead>

<tbody>

<tr>

<td>AUDIT-C</td>

<td/>

<td>How often do you have a drink containing alcohol</td>

<td>Never </td>

<td>Unknown</td>

</tr>

<tr>

<td>AUDIT-C</td>

<td/>

<td>How many standard drinks containing alcohol do you have on a typical day?</td>

<td>Unknown</td>

</tr>

<tr>

<td>AUDIT-C</td>

<td/>

<td>How often do you have 6 or more drinks on 1 occasion</td>

<td>Never </td>

<td>Unknown</td>

</tr>

<tr>

<td>AUDIT-C</td>

<td/>

<td>Total Score</td>

<td/>

<td>Unknown</td>

</tr>

<tr>

<td>Patient Health Questionnaire (PHQ2)</td>

<td/>

<td>Little interest or pleasure in doing things</td>

<td>Unknown</td>

</tr>

<tr>

<td>Patient Health Questionnaire (PHQ2)</td>

<td/>

<td>Feeling down, depressed, or hopeless</td>

<td>Unknown</td>

</tr>

<tr>

<td>Patient Health Questionnaire (PHQ2)</td>

<td/>

<td>Total Score</td>

<td/>

<td>Unknown</td>

</tr> </tbody>

</table>

</text>

</effectiveTime>

<originalText>AUDIT-C</originalText>

</code>

<text>AUDIT-C</text>

</procedure>

</component>

<text>How often do you have a drink containing alcohol</text>

<originalText>Never</originalText>

</value>

</observation>

</component>

<code code="68519-8" codeSystem="2.16.840.1.113883.6.1"

codeSystemName="LOINC" displayName="How many standard drinks containing alcohol do you have on a typical day?"/>

<text>How many standard drinks containing alcohol do you have on a typical day?</text>

<value codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"

nullFlavor="OTH" xsi:type="CD">

</value>

</observation>

</component>

<text>How often do you have 6 or more drinks on 1 occasion</text>

<value codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"

nullFlavor="OTH" xsi:type="CD">

<originalText>Never</originalText>

</value>

</observation>

</component>

<text>Total Score</text>

</value>

</observation>

</component>

</organizer>

</entry>

</effectiveTime>

<originalText>Patient Health Questionnaire (PHQ2)</originalText>

</code>

<text>Patient Health Questionnaire (PHQ2)</text>

</procedure>

</component>

<text>Little interest or pleasure in doing things</text>

</value>

</observation>

</component>

<text>Feeling down, depressed, or hopeless</text>

</value>

</observation>

</component>

<text>Total Score</text>

</value>

</observation>

</component>

</organizer>

</entry>

</section>

</component>

<title>Procedures</title>

<text>

<thead>

<tr>

<th>Procedure</th>

<th>Codes</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content ID="Procedure1">Eye Chart- Visual Acuity Screen<br/>Left Eye/20/20 uncorrected, Both Eyes/20/20 uncorrected, Right Eye/20/20 uncorrected</content>

</td>

<td>CPT-4: 99173Unknown</td>

</tr>

<tr>

<td>

<content ID="Procedure2">URINALYSIS AUTO W/O SCOPE</content>

</td>

</tr>

<tr>

<td>

<content ID="Procedure3">Negative Adult Depression Screening Performed</content>

</td>

<td>SNOMED CT: 428171000124102<br/>CPT-4: NegAdult</td>

</tr>

<tr>

<td>

<content ID="Procedure4">Negative Child Depression Screening Performed</content>

</td>

<td>SNOMED CT: 428171000124102<br/>CPT-4: NegChild</td>

</tr>

<tr>

<td>

<content ID="Procedure5">Audiogram<br/>Right Ear/40 db 500/Yes, Left Ear/40 db 2000/Yes, Left Ear/40 db 1000/Yes, Left Ear/20 db 500/Yes, Right Ear/40 db 1000/Yes, Left Ear/20 db 1000/Yes, Left Ear/20 db 4000/Yes, Left Ear/25 db 2000/Yes, Right Ear/25 db 2000/Yes, Right Ear/40 db 2000/Yes, Right Ear/20 db 4000/Yes, Right Ear/20 db 500/Yes, Left Ear/25 db 4000/Yes, Right Ear/25 db 1000/Yes, Right Ear/20 db 1000/Yes, Right Ear/25 db 4000/Yes, Left Ear/25 db 1000/Yes, Right Ear/40 db 4000/Yes, Left Ear/40 db 4000/Yes, Left Ear/40 db 500/Yes, Left Ear/25 db 500/Yes, Right Ear/25 db 500/Yes, Left Ear/20 db 2000/Yes, Right Ear/20 db 2000/Yes</content>

</td>

<td>CPT-4: 92587Unknown</td>

</tr>

</tbody>

</table>

</text>

<originalText>Eye Chart- Visual Acuity Screen</originalText>

</code>

<text>

<reference value="#Procedure1"/>Eye Chart- Visual Acuity Screen Additional Information:Left Eye/20/20 uncorrected, Both Eyes/20/20 uncorrected, Right Eye/20/20 uncorrected</text>

</effectiveTime>

<originalText>Left Eye/20/20 uncorrected, Both Eyes/20/20 uncorrected, Right Eye/20/20 uncorrected</originalText>

</targetSiteCode>

<text>

</text>

</act>

</entryRelationship>

</procedure>

</entry>

<originalText>URINALYSIS AUTO W/O SCOPE</originalText>

</code>

<text>

<reference value="#Procedure2"/>URINALYSIS AUTO W/O SCOPE Additional Information:</text>

</effectiveTime>

<text>

</text>

</act>

</entryRelationship>

</procedure>

</entry>

<originalText>Negative Adult Depression Screening Performed</originalText>

</code>

<text>

<reference value="#Procedure3"/>Negative Adult Depression Screening Performed Additional Information:</text>

</effectiveTime>

<code code="48767-8" codeSystem="2.16.840.1.113883.6.1"

codeSystemName="LOINC" displayName="Annotation comment"/>

<text>

</text>

</act>

</entryRelationship>

</procedure>

</entry>

<code code="428171000124102" codeSystem="2.16.840.1.113883.6.96"

codeSystemName="SNOMED CT" displayName="Negative Child Depression Screening Performed">

<originalText>Negative Child Depression Screening Performed</originalText>

<translation code="NegChild" codeSystem="2.16.840.1.113883.6.12"

codeSystemName="CPT-4" displayName="Negative Child Depression Screening Performed"/>

</code>

<text>

<reference value="#Procedure4"/>Negative Child Depression Screening Performed Additional Information:</text>

</effectiveTime>

<text>

</text>

</act>

</entryRelationship>

</procedure>

</entry>

<originalText>Audiogram</originalText>

</code>

<text>

<reference value="#Procedure5"/>Audiogram Additional Information:Right Ear/40 db 500/Yes, Left Ear/40 db 2000/Yes, Left Ear/40 db 1000/Yes, Left Ear/20 db 500/Yes, Right Ear/40 db 1000/Yes, Left Ear/20 db 1000/Yes, Left Ear/20 db 4000/Yes, Left Ear/25 db 2000/Yes, Right Ear/25 db 2000/Yes, Right Ear/40 db 2000/Yes, Right Ear/20 db 4000/Yes, Right Ear/20 db 500/Yes, Left Ear/25 db 4000/Yes, Right Ear/25 db 1000/Yes, Right Ear/20 db 1000/Yes, Right Ear/25 db 4000/Yes, Left Ear/25 db 1000/Yes, Right Ear/40 db 4000/Yes, Left Ear/40 db 4000/Yes, Left Ear/40 db 500/Yes, Left Ear/25 db 500/Yes, Right Ear/25 db 500/Yes, Left Ear/20 db 2000/Yes, Right Ear/20 db 2000/Yes</text>

</effectiveTime>

<originalText>Right Ear/40 db 500/Yes, Left Ear/40 db 2000/Yes, Left Ear/40 db

1000/Yes, Left Ear/20 db 500/Yes, Right Ear/40 db 1000/Yes, Left Ear/20 db 1000/Yes, Left Ear/20 db 4000/Yes, Left Ear/25 db 2000/Yes, Right Ear/25 db 2000/Yes, Right Ear/40 db 2000/Yes, Right Ear/20 db 4000/Yes, Right Ear/20 db 500/Yes, Left Ear/25 db 4000/Yes, Right Ear/25 db 1000/Yes, Right Ear/20 db 1000/Yes, Right Ear/25 db 4000/Yes, Left Ear/25 db 1000/Yes, Right Ear/40 db 4000/Yes, Left Ear/40 db 4000/Yes, Left Ear/40 db 500/Yes, Left Ear/25 db 500/Yes, Right Ear/25 db 500/Yes, Left Ear/20 db 2000/Yes, Right Ear/20 db 2000/Yes</originalText>

</targetSiteCode>

<text>

</text>

</act>

</entryRelationship>

</procedure>

</entry>

</section>

</component>

<title>Vital Signs</title>

<text>

<thead>

<tr>

<th>Vital</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content>Blood Pressure 1: 104/80 Code: 8480-6</content>

</td>

<td>

</td>

<td>

<content>Heart Rate 1: 74 bpm</content>

</td>

<td>

<content>Height: 5'9" Code: 8302-2</content>

</td>

<td>

<content>Temperature: 36.7 (C) / 98.0 (F)</content>

</td>

<td>

<content>Weight: 131 lbs 5 oz Code: 29463-7</content>

</td>

</tr>

</tbody>

</table>

</text>

</code>

</observation>

</component>

</observation>

</component>

</value>

</observationRange>

</referenceRange>

</observation>

</component>

<code code="8462-4" codeSystem="2.16.840.1.113883.6.1"

displayName="DIASTOLIC BLOOD PRESSURE"/>

</value>

</observationRange>

</referenceRange>

</observation>

</component>

</value>

</observationRange>

</referenceRange>

</observation>

</component>

</value>

</observationRange>

</referenceRange>

</observation>

</component>

</value>

</observationRange>

</referenceRange>

</observation>

</component>

</organizer>

</entry>

</section>

</component>

<title>Functional Status</title>

<text>No Functional Status data</text>

</section>

</component>

<title>Reason For Visit</title>

<text>

<thead>

<tr>

<th>Reason For Visit</th>

<th>Effective Dates</th>

<th>Notes</th>

</tr>

</thead>

<tbody>

<tr>

<td>well man exam (12-17 years)</td>

<td/>

</tr>

</tbody>

</table>

</text>

</section>

</component>

<title>Encounters</title>

<text>

<thead>

<tr>

<th>Encounter</th>

<th>Performer</th>

<th>Location</th>

<th>Location Address</th>

<th>Codes</th>

</tr> </thead> <tbody>

<tr>

<td>

<content ID="Encounter1">(99394) PREV VISIT EST AGE 12-17<br/>Diagnosis: Well child examination[ICD10: Z00.129]</content>

</td>

<td>Dennis Vinias</td>

<td>Johnston Family Medicine</td>

<td>41 Magna Way Suite 100 WESTMINSTER, MD 21157</td>

</tr> </tbody>

</table>

</text>

<originalText>(99394) PREV VISIT EST AGE 12-17<reference value="#Encounter1"/>

</originalText>

</code>

<name>

<given>Dennis</given>

<family>Vinias</family>

</name>

</assignedPerson>

</assignedEntity>

</performer>

<addr>

<streetAddressLine>41 Magna Way</streetAddressLine>

<city>WESTMINSTER</city>

</addr>

</participantRole>

</participant>

</effectiveTime>

</code>

<text>Well child examination</text>

</effectiveTime>

</value>

</observation>

</entryRelationship>

</act>

</entryRelationship>

</encounter>

</entry>

</section>

</component>

<text>

<thead>

<tr>

<th>Planned Activity</th>

<th>Notes</th>

<th>Codes</th>

<th>Status</th>

</tr>

</thead>

<tbody>

<tr>

<td>Visit Plan: </td>

<td>Z00.129-V20.2 Well child examination<br/>

</td>

<td/>

</tr>

<tr>

<td>Patient Education: Patient Medication Summary</td>

<td/>

<td>Completed</td>

</tr> </tbody>

</table>

</text>

<entry>

<text>Z00.129-V20.2 Well child examination

</text>

</act>

</entry>

<entry>

<text>

</text>

</encounter>

</entry>

</section>

</component>

<title>Instructions</title>

<text>

<thead>

<tr>

<th>Comment</th>

</tr>

</thead>

<tbody>

<tr>

<td>

<content ID="sect1">. Z00.129-V20.2 Well child examination<br/>

</content>

</td>

</tr>

</tbody>

</table>

</text>

<entry>

<text>

<reference value="#sect1"/>. Z00.129-V20.2 Well child examination

</text>

</act>

</entry>

</section>

</component>

<title>Medical Equipment</title>

<text>No Medical Equipment data</text>

</section>

</component>

<title>Health Concerns Section</title>

<text>Health Concerns data not found</text>

</section>

</component>

<title>Goals Section</title>

<text>Goals data not found</text>

</section>

</component>

<code code="62387-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"

displayName="Interventions Provided"/>

<title>Interventions Section</title>

<text>Interventions data not found</text>

</section>

</component>

<title>Health Status Evaluations/Outcomes Section</title>

<text>Health Status Evaluations/Outcomes data not found</text>

</section>

</component>

<title>Advance Directives</title>

<text>No Advance Directive data</text>

</section>

</component>

</structuredBody>

</component>

</ClinicalDocument>

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