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Bates_Jeremy_0_Ambulatory.xml
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<?xml version="1.0" encoding="UTF-8"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!--
Title: Continuity of Care Document (CCD)
$LastChangedDate: 2015-8-11 11:25:09 -0400 (Wed, 11 Aug 2015) $
2015-10 AM and DB: -Altered to be error free (not considering MU rules), general updates per recommendations, and added US Realm Header Template ID.
2015-10 DB: -Created 'master doc'
MANY modifications, additions, and reorganizations were made to accommodate the requirements.
In addition, removed Advance Directives, Family History components, and others as not required by test data.
-Updated to match 170.315_b1_toc_amb_sample2.docx test data
********************************************************
Disclaimer: This sample file contains representative data elements to represent a Continuity of Care Document (CCD).
The file depicts a fictional character's health data. Any resemblance to a real person is coincidental.
To illustrate as many data elements as possible, the clinical scenario may not be plausible.
The data in this sample file is not intended to represent real patients, people or clinical events.
This sample is designed to be used in conjunction with the C-CDA Clinical Notes Implementation Guide.
********************************************************
-->
<!-- This XML document was retrieved from a public repository of certified EHR samples for Meaningful Use
That repository states "The public will be able to view-download the submitted files from this repository."
The original files have been edited to make them human-readable and easier to download. Please refer to source repository for original versions
The copy date of original repository was February 1, 2018. Here is original repository: https://github.com/siteadmin/2015-C-CDA-Certification-Samples
All of these samples were supposed be C-CDA 2.1 clinical documents. The following disclaimer applies to ALL INFORMATION contained herein:
THIS INFORMATION IS PROVIDED "AS IS", WITHOUT WARRANTY OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO THE WARRANTIES OF MERCHANTABILITY,
FITNESS FOR A PARTICULAR PURPOSE AND NONINFRINGEMENT. IN NO EVENT SHALL THE AUTHORS OR COPYRIGHT HOLDERS BE LIABLE FOR ANY CLAIM, DAMAGES OR OTHER LIABILITY,
WHETHER IN AN ACTION OF CONTRACT, TORT OR OTHERWISE, ARISING FROM, OUT OF OR IN CONNECTION WITH THE INFORMATION OR THE USE OR OTHER DEALINGS IN THE INFORMATION.
Beyond that, I hope they are useful and "hooray" for government transparency! John D'Amore, Diameter Health, Inc. -->
<ClinicalDocument
xmlns="urn:hl7-org:v3"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xmlns:voc="urn:hl7-org:v3/voc"
xmlns:sdtc="urn:hl7-org:sdtc">
<realmCode code="US"/>
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<!-- US Realm Header ID-->
<templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
<!-- Referral Note (V2) template ID -->
<templateId root="2.16.840.1.113883.10.20.22.1.14" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.1.14"/>
<!-- Globally unique identifier for the document -->
<id extension="TT104" root="2.16.840.1.113883.19.5.99999.1"/>
<code code="57133-1" displayName="Referral Note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<!-- Title of this document -->
<title>170.315_b1_toc_amb_ccd_r21_sample2 test data</title>
<effectiveTime value="20150722"/>
<confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality"/>
<languageCode code="en-US"/>
<setId extension="sTT104" root="2.16.840.1.113883.19.5.99999.19"/>
<!-- Version of this document -->
<versionNumber value="1"/>
<recordTarget>
<patientRole>
<id extension="115253336" root="2.16.840.1.113883.4.1"/>
<!-- Example 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>1004 Amber Dr</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:+1(555)-117-1234" use="MC"/>
<telecom value="tel:+1(555)-118-1544" use="HP"/>
<!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<patient>
<name use="L">
<given>Jeremy</given>
<family>Bates</family>
<suffix>jr</suffix>
</name>
<administrativeGenderCode code="M" displayName="Male" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender"/>
<!-- Date of birth need only be precise to the day -->
<birthTime value="19800801"/>
<maritalStatusCode nullFlavor="UNK"/>
<religiousAffiliationCode code="1013" displayName="Christian (non-Catholic, non-specific)" codeSystem="2.16.840.1.113883.5.1076" codeSystemName="HL7 Religious Affiliation"/>
<raceCode nullFlavor="UNK"/>
<sdtc:raceCode nullFlavor="UNK"/>
<ethnicGroupCode nullFlavor="UNK"/>
<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 extension="99999999" root="2.16.840.1.113883.4.6"/>
<name>Neighborhood Physicians Practice</name>
<telecom use="WP" value="tel:+1(555)-555-5000"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<!-- The author represents the person who provides the content in the document -->
<author>
<time value="20150722"/>
<assignedAuthor>
<id extension="111111" 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>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedAuthoringDevice>
<manufacturerModelName>Neighborhood Physicians Practice EMR</manufacturerModelName>
<softwareName>Amb EMR v1.0</softwareName>
</assignedAuthoringDevice>
<!-- added representedOrganization for CCD requirements when we do NOT have an assignedPerson -db -->
<!-- Consol Continuity of Care Document (CCD) (V3) SHALL contain at least one [1..*] author,
where its type is Author (CONF:1198-9442) each SHALL contain exactly one [1..1] assignedAuthor,
where (CONF:1198-9443) assignedAuthor SHALL contain exactly one [1..1] assignedPerson and/or exactly one [1..1]
representedOrganization (CONF:1198-8456) -->
<representedOrganization>
<id root="2.16.840.1.113883.19.5"/>
<name>Neighborhood Physicians Practice</name>
</representedOrganization>
</assignedAuthor>
</author>
<!-- The dataEnterer transferred the content created by the author into the document -->
<dataEnterer>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="999999943252"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<given>Tracy</given>
<family>Davis</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<!-- The informant represents any sources of information for document content -->
<informant>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<given>Albert</given>
<family>Davis</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>Julia</given>
<family>Hammer</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<!-- The custodian represents the organization charged with maintaining the original source document -->
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<name>Neighborhood Physicians Practice</name>
<telecom value="tel:+1(555)-555-1002" use="WP"/>
<addr use="WP">
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<!-- The informationRecipient represents the intended recipient of the document -->
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<prefix>Dr</prefix>
<given>Albert</given>
<family>Davis</family>
</name>
</informationRecipient>
<receivedOrganization>
<name>Neighborhood Physicians Practice</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<!-- The legalAuthenticator represents the individual who is responsible for the document -->
<legalAuthenticator>
<time value="20150722"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="999999999" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<prefix>Dr</prefix>
<given>Albert</given>
<family>Davis</family>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<!-- The authenticator represents the individual attesting to the accuracy of information in the document-->
<authenticator>
<time value="20150722"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="999999999" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<prefix>Dr</prefix>
<given>Albert</given>
<family>Davis</family>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<!-- The participant represents supporting entities -->
<participant typeCode="IND">
<!-- patient's grandfather -->
<associatedEntity classCode="PRS">
<code code="GPARNT" displayName="grandparent" codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1004 Amber Dr</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:+1(555)-118-1544" use="HP"/>
<associatedPerson>
<name>
<prefix>Mr.</prefix>
<given>Mathew</given>
<family>Bates</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<!-- Note: Entities playing multiple roles are recorded in multiple participants -->
<participant typeCode="IND">
<!-- patient's spouse -->
<associatedEntity classCode="PRS">
<code code="SPS" displayName="SPOUSE" codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1004 Amber Dr</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:+1(555)-118-1544" use="HP"/>
<associatedPerson>
<name>
<prefix>Ms</prefix>
<given>Kathy</given>
<family>Bates</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<documentationOf>
<serviceEvent classCode="PCPR">
<code code="78318003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"
displayName="Annual Health Maintenance, History and Physical"/>
<!-- The effectiveTime reflects the provision of care summarized in the document.
In this scenario, the provision of care summarized is the lifetime for the patient -->
<effectiveTime>
<low value="201507221400-0500"/>
<!-- The low value represents when the summarized provision of care began.
In this scenario, the patient's date of birth -->
<high value="201507221430-0500"/>
<!-- The high value represents when the summarized provision of care being ended.
In this scenario, when chart summary was created -->
</effectiveTime>
<!-- since there are two Care Team members we need two performer elements. -db -->
<!-- Note: example of Care Team here:
https://github.com/gecole/HL7-Task-Force-Examples/blob/master/CareTeamToC170.314b2Ambulatory.xml
db -->
<performer typeCode="PRF">
<functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88" codeSystemName="ParticipationFunction" displayName="Primary Care Provider">
<originalText>Primary Care Provider</originalText>
</functionCode>
<assignedEntity>
<id extension="5555555555" root="2.16.840.1.113883.4.6"/>
<code code="207QA0505X" displayName="Adult Medicine" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<prefix qualifier="TITLE">Dr</prefix>
<given>Albert</given>
<family>Davis</family>
</name>
</assignedPerson>
<representedOrganization>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<name>Neighborhood Physicians Practice</name>
<telecom value="tel:+1(555)-555-5000" use="WP"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
<performer typeCode="PRF">
<!-- we do not have a function code for this person since recording as RN for now -->
<time>
<low nullFlavor="UNK"/>
</time>
<assignedEntity>
<!-- this provider has an id, but it is not an NPI -->
<id extension="91138" root="1.3.6.1.4.1.22812.4.99930.4"/>
<!-- the provider is a Registered Nurse - may not be so -->
<!-- note: we don't know what Tracy is from the test data
but since not specified, RN should not be an issue -db -->
<code codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC Health Care Provider Taxonomy" code="163W00000X" displayName="Registered Nurse"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<given>Tracy</given>
<family>Davis</family>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<!-- added componentOf to represent encounter and to represent length of stay better as per SME suggestion -db -->
<componentOf>
<encompassingEncounter>
<id extension="9937012" root="2.16.840.1.113883.19"/>
<effectiveTime>
<!-- represents length of time spent in hospital -db -->
<low value="201507221400-0500"/>
<high value="201507221430-0500"/>
</effectiveTime>
</encompassingEncounter>
</componentOf>
<!-- ******************************************************** CDA Body ******************************************************** -->
<component>
<structuredBody>
<!-- ***************** ALLERGIES *************** -->
<!-- edited as per test doc - all data relevant -db -->
<component>
<section>
<!-- *** Allergies and Intolerances Section (entries required) (V3) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.6.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
<!-- Alerts section template -->
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>ALLERGIES AND ADVERSE REACTIONS</title>
<text>No Known Allergies</text>
<!-- replaced Allergy Problem Act (R1.1) with
Allergy Concern Act (V3) to meet R2.1 validation requirements -DB-->
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<!-- ** Allergy Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.30" extension="2015-08-01"/>
<!--Critical Change-->
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id root="36e3e930-7b15-11db-9fe1-0800200c9a66"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
<!-- The statusCode represents the need to continue tracking the allergy -->
<!-- This is of ongoing concern to the provider -->
<statusCode code="active"/>
<effectiveTime>
<!-- The low value represents when the allergy was first recorded in the patient's chart -->
<low value="20150722"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<!-- using negationInd="true" to signify that there are is NO food allergy (disorder) allergy -db -->
<observation classCode="OBS" moodCode="EVN" negationInd="true">
<!-- ** Allergy observation (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.7" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="4adc1020-7b16-11db-9fe1-0800200c9a66"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime nullFlavor="NA"/>
<!-- We cannot use the No known Food Allergy value/@code 429625007
required by the test data as it is not part of the valueSet required
(Allergy/Adverse Event Type 2.16.840.1.113883.3.88.12.3221.6.2 DYNAMIC CONF:1098-7390 -db -->
<!--
<value xsi:type="CD" code="429625007"
displayName="No known Food Allergy"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT"><originalText><reference value="#reaction1"/></originalText></value>
-->
<!-- using Food allergy (disorder) along with negationInd instead -db -->
<value xsi:type="CD" code="419199007"
displayName="Allergy to substance (disorder)"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT"></value>
<!-- In C-CDA R2 the participant is required. The SNOMED code ="105590001" displayName="Substance" could be used in the participant-->
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code nullFlavor="NA"/>
</playingEntity>
</participantRole>
</participant>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!-- ******************************* MEDICATIONS ***************************** -->
<!-- edited as per test doc - all data relevant -db -->
<component>
<section>
<!-- *** Medications Section (entries required) (V2) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF MEDICATION USE"/>
<title>MEDICATIONS</title>
<text>No known Medications</text>
<entry>
<!-- Act.actionNegationInd -->
<substanceAdministration moodCode="EVN" classCode="SBADM" negationInd="true">
<!-- ** Medication Activity (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="cdbd33f0-6cde-12db-9fe1-0800200c9a66"/>
<statusCode code="active"/>
<effectiveTime nullFlavor="NA"/>
<doseQuantity nullFlavor="NA"/>
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Medication information ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code nullFlavor="OTH" codeSystem="2.16.840.1.113883.6.88">
<translation code="410942007" displayName="drug or medication"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT"/>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<!-- ***************** PROBLEM LIST *********************** -->
<!-- edited as per test doc - all data relevant -db -->
<component>
<section>
<!-- *** Problem Section (entries required) (V3) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROBLEM LIST"/>
<title>PROBLEMS</title>
<text ID="Concern_1">
<content ID="problems1">No known
<content ID="problemType1">problems</content>
</content>
</text>
<entry typeCode="DRIV">
<!-- Problem Concern Act -->
<act classCode="ACT" moodCode="EVN">
<!-- ** Problem Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<id root="36e3e930-7b14-13db-9fe1-0800200c9a66"/>
<!-- SDWG supports 48765-2 or CONC in the code element -->
<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
<text>
<reference value="#Concern_1"></reference>
</text>
<statusCode code="active"/>
<!-- The concern is not active, in terms of there being an active condition to be managed.-->
<effectiveTime>
<low value="20150722"/>
<!-- Time at which THIS ?concern? began being tracked.-->
</effectiveTime>
<!-- status is active so high is not applicable. If high is present it should have nullFlavor of NA-->
<entryRelationship typeCode="SUBJ">
<!-- Model of Meaning for No Problems -->
<!-- The use of negationInd corresponds with the newer Observation.ValueNegationInd -->
<!-- The negationInd = true negates the value element. -->
<!-- problem observation template -->
<observation classCode="OBS" moodCode="EVN" negationInd="true">
<!-- ** Problem observation (V3)** -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="4adc1021-7b15-14db-9fe1-0800200c9a67"/>
<!-- updated for R2.1 -db -->
<code code="55607006" displayName="Problem" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96">
<!-- This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem"/>
</code>
<text>
<reference value="#problems1"></reference>
</text>
<statusCode code="completed"/>
<!-- The time when this was biologically relevant ie True for the patient. -->
<!-- As a minimum time interval over which this is true, populate the effectiveTime/low with the current time. -->
<!-- It would be equally valid to have a longer range of time over which this statement was represented as being true. -->
<!-- As a maximum, you would never indicate an effectiveTime/high that was greater than the current point in time. -->
<effectiveTime>
<low value="20150722"/>
</effectiveTime>
<!-- This idea assumes that the value element could come from the Problem value set, or-->
<!-- when negationInd was true, is could also come from the ProblemType value set (and code would be ASSERTION). -->
<value xsi:type="CD" code="55607006"
displayName="Problem"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT">
<originalText>
<reference value="#problems1"></reference>
</originalText>
</value>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!-- added Encounters Section data as required by sample2 db -->
<!-- ************************ ENCOUNTERS *********************** -->
<!-- edited as per test doc - most of the data is directly relevant -db -->
<!-- Although only EO is needed, ER was used due to the Yellow highlight/2015 certification requirements
in CCD for Encounters. This will of course work for all other cases as well so is more universal. -db -->
<component>
<section>
<!-- *** Encounters section (entries required) (V3) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.22.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.22.1"/>
<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
<title>ENCOUNTERS</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Encounter</th>
<th>Location</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td ID="Encounter1">Annual Health Maintenance, History and Physical</td>
<td>Neighborhood Physicians Practice</td>
<td>July 22, 2015 2pm EST</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<!-- ** Encounter Activity (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<id root="2a620155-9d11-449e-92b3-5d9815ff4de8"/>
<code code="78318003" displayName="Annual Health Maintenance, History and Physical"
codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96">
<originalText>
<reference value="#Encounter1"/>
</originalText>
</code>
<effectiveTime value="20150722"/>
<participant typeCode="LOC">
<participantRole classCode="SDLOC">
<!-- this is the only version of this template -db -->
<templateId root="2.16.840.1.113883.10.20.22.4.32"/>
<!-- Service Delivery Location template -->
<!-- the test data does not specify specific data for this code -db -->
<code code="1160-1" codeSystem="2.16.840.1.113883.6.259" codeSystemName="HL7 HealthcareServiceLocation" displayName="Urgent Care Center"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(555)-555-1002" use="WP"/>
<playingEntity classCode="PLC">
<name>Neighborhood Physicians Practice</name>
</playingEntity>
</participantRole>
</participant>
</encounter>
</entry>
</section>
</component>
<!-- ******************** IMMUNIZATIONS ********************* -->
<!-- edited as per test doc - NOT all data is relevant, but all entries themselves are relevant -db -->
<component>
<section>
<!-- *** Immunizations Section (entries required) (V2) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.2.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.2.1"/>
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of immunizations"/>
<title>IMMUNIZATIONS</title>
<text>No known immunization history</text>
<entry typeCode="DRIV">
<!-- using negationInd="true" to signify that there are no known immunizations -->
<substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="true">
<!-- ** Immunization Activity (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.52" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.52"/>
<id root="de10790f-1496-4729-8fe6-f1b87b6219f7"/>
<statusCode code="active"/>
<effectiveTime nullFlavor="NA"/>
<routeCode nullFlavor="NA"/>
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Immunization Medication Information (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.54" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.54"/>
<manufacturedMaterial>
<!-- there is no generic vaccine code and no known recommended way to do this -
leaving generic flu for now just as an example. Not sure if it makes more sense to apply a nullFlavor? -db -->
<code nullFlavor="OTH">
<!-- Optional original text -->
<originalText>Vaccination</originalText>
<translation code="71181003" displayName="vaccine"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT"/>
</code>
<!-- NA since there is no immunization data -db -->
<lotNumberText nullFlavor="NA"/>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<!-- ************* VITAL SIGNS *************** -->
<!-- edited as per test doc - most of this data is directly relevant -db -->
<component>
<section>
<!-- ** Vital Signs Section (entries required) (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.2.4.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.4.1"/>
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="VITAL SIGNS"/>
<title>VITAL SIGNS</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th align="right">Date / Time: </th>
<th>July 22, 2015</th>
</tr>
</thead>
<tbody>
<tr>
<th align="left">Height</th>
<td ID="vit1">177 cm</td>
</tr>
<tr>
<th align="left">Weight</th>
<td ID="vit2">88 kg</td>
</tr>
<tr>
<th align="left">Blood Pressure</th>
<td ID="vit3">145/88</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<organizer classCode="CLUSTER" moodCode="EVN">
<!-- ** Vital signs organizer (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.26" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.26"/>
<id root="31b73bd0-cffc-4599-903e-dbe54bc56cb4"/>
<code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Vital signs">
<!-- A vitals organizer conformant to both C-CDA 1.1 and C-CDA 2.1 would contain the SNOMED code (46680005) from R1.1 in the root code and a LOINC code in the translation -->
<translation code="74728-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital signs"/>
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20150722"/>
<high value="20150722"/>
</effectiveTime>
<component>
<observation classCode="OBS" moodCode="EVN">
<!-- ** Vital sign observation (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
<id root="ed9589fd-fda0-42f7-a3d0-dc537554f5c2"/>
<code code="8302-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Height"/>
<statusCode code="completed"/>
<effectiveTime value="201507221405-0500"/>
<value xsi:type="PQ" value="177" unit="cm"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<!-- ** Vital sign observation ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
<id root="f4e729e2-a97f-4a7e-8e24-c92f9b6b55cf"/>
<code code="3141-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient Body Weight - Measured"/>
<statusCode code="completed"/>
<effectiveTime value="201507221405-0500"/>
<value xsi:type="PQ" value="88" unit="kg"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<!-- ** Vital sign observation ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
<id root="1c2748b7-e440-42ba-bc02-dde97d84a036"/>
<code code="8462-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="BP Diastolic"/>
<statusCode code="completed"/>
<effectiveTime value="201507221410-0500"/>
<value xsi:type="PQ" value="88" unit="mm[Hg]"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<!-- ** Vital sign observation ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
<id root="a0e39c70-9675-4b2a-9837-cdf74200d8d5"/>
<code code="8480-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Intravascular Systolic"/>
<statusCode code="completed"/>
<effectiveTime value="201507221410-0500"/>
<value xsi:type="PQ" value="145" unit="mm[Hg]"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
<!-- ******************* SOCIAL HISTORY ********************* -->
<!-- edited as per test doc - most of this data is directly relevant -db -->
<component>
<section>
<!-- ** Social History Section (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.2.17" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.17"/>
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social History"/>
<title>SOCIAL HISTORY</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Social History Observation</th>
<th>Description</th>
<th>Dates Observed</th>
</tr>
</thead>
<tbody>
<tr>
<td>Current Smoking Status</td>
<td>Current every day</td>
<td>July 22, 2015</td>
</tr>
</tbody>
</table>
</text>
<!-- Current Smoking Status - July 22, 2015 -db -->
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Smoking Status - Meaningful Use (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.78" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.78"/>
<id extension="123456789" root="2.16.840.1.113883.19"/>
<!-- code SHALL be 72166-2 for Smoking Status - Meaningful Use (V2) -db -->
<code code="72166-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Tobacco smoking status NHIS"/>
<statusCode code="completed"/>
<!-- The effectiveTime reflects when the current smoking status was observed. -->
<effectiveTime value="20150722"/>
<!-- The value represents the patient's smoking status currently observed. -->
<!-- Consol Smoking Status Meaningful Use2 SHALL contain exactly one [1..1] value (CONF:1098-14810), which SHALL be selected from ValueSet Current Smoking Status 2.16.840.1.113883.11.20.9.38 STATIC 2014-09-01 (CONF:1098-14817) -db -->
<value xsi:type="CD" code="449868002" displayName="Current every day smoker" codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entry>
<!-- removed Social history observation (V3) entry for "Alcoholic drinks per day" -db -->
</section>
</component>
<!-- ************** PROCEDURES and UDI ***************** -->
<!-- edited as per test doc - all of this data is directly relevant -db -->
<!-- based off of
https://github.com/brettmarquard/HL7-C-CDA-Task-Force-Examples/blob/master/No_Implanted_Devices.xml
Fixed proc id in text element Proc->Proc1
-db -->
<component>
<section>
<!-- Procedures Section (entries required) (V2) -->
<templateId root="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PROCEDURES"/>
<title>PROCEDURES</title>
<text>
<paragraph ID="Proc1">No Procedure information</paragraph>
</text>
<entry>
<procedure classCode="PROC" moodCode="EVN" negationInd="true">
<!-- Procedure Activity Procedure (V2)-->
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<id root="d5b614bd-01ce-410d-8727-e1fd01dcc72a" />
<code code="71388002" codeSystem="2.16.840.1.113883.6.96"
displayName="Procedure">
<originalText>
<reference value="#Proc1" />
</originalText>
</code>
<statusCode code="completed" />
<effectiveTime nullFlavor="NA" />
<participant typeCode="DEV">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.37"/>
<id nullFlavor="NA" root="2.16.840.1.113883.3.3719"/>
<playingDevice>
<code code="40388003" codeSystem="2.16.840.1.113883.6.96"
displayName="Implant"/>
</playingDevice>
<scopingEntity>
<id root="2.16.840.1.113883.3.3719"/>
</scopingEntity>
</participantRole>
</participant>
</procedure>
</entry>
</section>
</component>
<!-- ************** No UDI ***************** -->
<component>
<section>
<!-- Medical equipment section -->
<templateId root="2.16.840.1.113883.10.20.22.2.23" extension="2014-06-09"/>
<code code="46264-8" codeSystem="2.16.840.1.113883.6.1" />
<title>MEDICAL EQUIPMENT</title>
<!-- Alternative text: Patient has no history of procedures with implantable devices'-->
<!-- Alternative text: Patient has no implanted devices'-->
<text>
<paragraph ID="Proc2">Patient has no history of implantable devices</paragraph>
</text>
<entry>
<procedure classCode="PROC" moodCode="EVN" negationInd="true">
<!-- Procedure Activity Procedure V2-->
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="d5b614bd-01ce-410d-8728-e1fd01dcc72a" />
<code code="71388002" codeSystem="2.16.840.1.113883.6.96"
displayName="Procedure"/>
<text>
<reference value="#Proc2"/>
</text>
<statusCode code="completed" />
<effectiveTime nullFlavor="NA" />
<participant typeCode="DEV">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.37"/>
<!-- UDI is 'not applicable' since no procedure -->
<id nullFlavor="NA" root="2.16.840.1.113883.3.3719"/>
<playingDevice>
<code code="40388003" codeSystem="2.16.840.1.113883.6.96"
displayName="Implant"/>
</playingDevice>
<scopingEntity>
<id root="2.16.840.1.113883.3.3719"/>
</scopingEntity>
</participantRole>
</participant>
</procedure>
</entry>
</section>
</component>
<!-- ******************** RESULTS ************************ -->
<!-- edited as per test doc - all of this data is directly relevant -db -->
<component>
<section nullFlavor="NI">
<!-- Results Section (entries required) (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="RESULTS"/>
<title>RESULTS</title>
<text>No Lab Test required. No Lab results.</text>
</section>
</component>
<!-- removed component Advance Directives as not required by test data -db -->
<!-- removed component Family History as not required by test data -db -->
<!-- added component Functional Status as required by test data -db -->
<!--
********************************************************
FUNCTIONAL STATUS
********************************************************
-->
<component>
<section nullFlavor="NI">
<!-- Functional Status Section (V2)-->
<templateId root="2.16.840.1.113883.10.20.22.2.14" extension="2014-06-09"/>
<!-- Functional Status Section -->
<templateId root="2.16.840.1.113883.10.20.22.2.14"/>
<code code="47420-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Functional Status"/>
<title>FUNCTIONAL STATUS</title>
<text>No information</text>
</section>
</component>
<!-- removed component Medical Equipment as not required by test data -db -->
<!-- removed component Payers as not required by test data -db -->
<!-- added Assessment -db -->
<!--
********************************************************
Assessment
********************************************************
-->
<!-- edited as per test doc - all of this data is directly relevant -db -->
<component>
<section>
<!-- Assessment Section -db -->
<!-- There is no R2.1 (or 2.0) version of Assessment Section, using R1.1 templateId only -db -->
<templateId root="2.16.840.1.113883.10.20.22.2.8"/>
<code codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" code="51848-0"
displayName="ASSESSMENTS"/>
<title>ASSESSMENTS</title>
<text>The patient was found to be healthy and advised to follow his current routine of exercise, work, sleep and quality of life.</text>
</section>
</component>
<!-- ******************* PLAN OF TREATMENT ********************** -->
<!-- edited as per test doc - all of this data is directly relevant -db -->
<component>