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JEREMY BATES_20170924184858_CCD.xml
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JEREMY BATES_20170924184858_CCD.xml
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<?xml version="1.0" encoding="UTF-8"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!-- 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. -->
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<code code="55607006" displayName="Problem" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96">
<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"/>
<effectiveTime>
<low value="20170924"/>
</effectiveTime>
<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>
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</entryRelationship>
</act>
</entry>
</section>
</component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.22.1" extension="2014-06-09"/>
<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>Performer</th>
<th>Location</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td ID="Encounter1">Established Professional Service - Level 4</td>
<td>Robert Alexander</td>
<td>MedConnect MU3 Clinic</td>
<td>Jul 22, 2015</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
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<id root="1560A8EC-26BF-4B9D-AA55-8FBEF73EB45B"/>
<code code="99214" displayName="Established Professional Service - Level 4" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12">
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<reference value="Encounter1"/>
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<translation code="AMB" codeSystem="2.16.840.1.113883.5.4" displayName="Ambulatory" codeSystemName="HL7 ActEncounterCode"/>
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<effectiveTime value="20150722"/>
<performer>
<assignedEntity>
<id extension="1234567890" root="2.16.840.1.113883.4.6"/>
<code code="59058001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="General Physician"/>
</assignedEntity>
</performer>
<participant typeCode="LOC">
<participantRole classCode="SDLOC">
<templateId root="2.16.840.1.113883.10.20.22.4.32"/>
<code code="1160-1" codeSystem="2.16.840.1.113883.6.259" codeSystemName="HL7 HealthcareServiceLocation" displayName="MedConnect MU3 Clinic"/>
<addr>
<streetAddressLine>2012 Berry Chase Place</streetAddressLine>
<city>Montgomery</city>
<state>AL</state>
<postalCode>36117</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel: +13342153568"/>
<playingEntity classCode="PLC">
<name>MedConnect MU3 Clinic</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.19" extension="2014-06-09"/>
<id root="3DBFE2E0-BB78-4364-BD42-B09507F97E7E" extension="9735889"/>
<code code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Clinical finding"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="20150722"/>
</effectiveTime>
<value xsi:type="CD" code="Z00.00" displayName="ENCNTR FOR GEN ADULT MEDICAL EXAM W/O AB FIND" codeSystem="2.16.840.1.113883.6.3"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.80"/>
<id root="3431AB0E-6E24-44F4-AE13-3C824190ED1C"/>
<code xsi:type="CE" code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ENCOUNTER DIAGNOSIS"/>
<statusCode code="active"/>
<effectiveTime>
<low value="20150722"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<observation classCode="OBS" moodCode="EVN" negationInd="false">
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<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="0137FC41-D90C-449D-9062-0732AEB0A6CF"/>
<code code="409586006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Complaint">
<translation code="75322-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Complaint"/>
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20150722"/>
</effectiveTime>
<value xsi:type="CD" code="699134002" codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entryRelationship>
</act>
</entryRelationship>
</encounter>
</entry>
</section>
</component>
<component>
<section nullFlavor="NI">
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<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>No Known Procedures</text>
</section>
</component>
<component>
<section nullFlavor="NI">
<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>
<text>Patient has no history of implantable devices</text>
</section>
</component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.2.1" extension="2014-06-09"/>
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1"/>
<title>IMMUNIZATIONS</title>
<text>No immunization history</text>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="true">
<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="5fe052cb-2632-4e96-80ff-38d6af7c9bb8"/>
<statusCode code="active"/>
<effectiveTime nullFlavor="NA"/>
<routeCode nullFlavor="NA"/>
<consumable>
<manufacturedProduct classCode = "MANU">
<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>
<code nullFlavor="OTH">
<originalText>Vaccination</originalText>
<translation code="71181003" displayName="vaccine" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</code>
<lotNumberText nullFlavor="NA"/>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<component>
<section>
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<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>Date</th>
<th>Height</th>
<th>Weight</th>
<th>BMI</th>
<th>Blood Pressure</th>
<th>Temperature</th>
<th>Pulse</th>
<th>Pulse Oximetry</th>
<th>Respiratory Rate</th>
<th>Inhaled Oxygen Concentration </th>
</tr>
</thead>
<tbody>
<tr>
<td ID = "vital_1">06/18/2017</td>
<td ID = "vital_1_height">177 cm</td>
<td ID = "vital_1_weight">88 kg</td>
<td ID = "vital_1_bmi">28.09</td>
<td ID = "vital_1_bp">145/88 mm[Hg]</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<organizer classCode="CLUSTER" moodCode="EVN">
<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="C9B8227D-835F-4902-95F6-C010628FFFC6"/>
<code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Vital signs">
<translation code="74728-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital signs"/>
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20170618"/>
<high value="20170618"/>
</effectiveTime>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20170924174900-0600"/>
<assignedAuthor>
<id extension="1234567890" 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)"/>
</assignedAuthor>
</author>
<component>
<observation classCode="OBS" moodCode="EVN">
<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="77997C68-8D81-4AF5-96A3-77CE95D16EF8"/>
<code code="8302-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Height"/>
<text>
<reference value="#vital_1_height"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20170618"/>
<value xsi:type="PQ" value="177" unit="cm"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20170924174900-0600"/>
<assignedAuthor>
<id extension="1234567890" 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)"/>
</assignedAuthor>
</author>
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</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<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="11A9C6A2-E08B-49CB-9D73-085F7DBE2A54"/>
<code code="29463-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Weight"/>
<text>
<reference value="#vital_1_weight"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20170618"/>
<value xsi:type="PQ" value="88" unit="kg"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20170924174900-0600"/>
<assignedAuthor>
<id extension="1234567890" 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)"/>
</assignedAuthor>
</author>
</observation>
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<component>
<observation classCode="OBS" moodCode="EVN">
<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="5CB6971C-0958-497A-94C5-E577EAE32E70"/>
<code code="39156-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="BMI"/>
<text>
<reference value="#vital_1_bmi"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20170618"/>
<value xsi:type="PQ" value="28.09"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20170924174900-0600"/>
<assignedAuthor>
<id extension="1234567890" 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)"/>
</assignedAuthor>
</author>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<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="B329C332-990B-4F1C-AD4C-D038A6066E70"/>
<code code="8480-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="BP Systolic"/>
<text>
<reference value="#vital_1_bp"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20170618"/>
<value xsi:type="PQ" value="145" unit="mm[Hg]"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20170924174900-0600"/>
<assignedAuthor>
<id extension="1234567890" 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)"/>
</assignedAuthor>
</author>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<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="89CD524C-7AA0-4577-9F49-1CBECB6CE937"/>
<code code="8462-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="BP Diastolic"/>
<text>
<reference value="#vital_1_bp"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20170618"/>
<value xsi:type="PQ" value="88" unit="mm[Hg]"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20170924174900-0600"/>
<assignedAuthor>
<id extension="1234567890" 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)"/>
</assignedAuthor>
</author>
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</organizer>
</entry>
</section>
</component>
<component>
<section nullFlavor="NI">
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<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>Laboratory Test: None needed. Laboratory Values/Results: No Lab Result data</text>
</section>
</component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.10"/>
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Treatment plan"/>
<title>TREATMENT PLAN</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Name</th>
<th>Type</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td ID="care_plan_1">Follow-Up</td>
<td>Schedule a visit for next year</td>
<td align="center">July 22, 2015</td>
</tr>
</tbody>
</table>
</text>
<entry>
<observation classCode="OBS" moodCode="RQO">
<templateId root="2.16.840.1.113883.10.20.22.4.39"/>
<id root="C7B1FBE0-7E12-4167-8085-372DB1EC61D4"/>
<code code="61436" displayName="Follow-Up" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>Schedule a visit for next year</text>
<statusCode code="completed"/>
</observation>
</entry>
</section>
</component>
<component>
<section>
<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>
<component>
<section nullFlavor="NI">
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<code code="61146-7" displayName="Goals" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Goals Section</title>
<text>No goal information</text>
</section>
</component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.58" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.58" />
<code code="75310-3" displayName="Health Concerns Document" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Health Concerns Section</title>
<text>No Known Health Concerns on July 22, 2015</text>
<entry typeCode="COMP">
<act classCode="ACT" moodCode="EVN" negationInd="true">
<templateId root="2.16.840.1.113883.10.20.22.4.132" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.132"/>
<id root="4eab0e52-dd7d-4285-99eb-72d32ddb195d"/>
<code code="75310-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Health Concern"/>
<statusCode code="active"/>
<effectiveTime value="20150722"/>
</act>
</entry>
</section>
</component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.45"/>
<code code = "69730-0" codeSystem = "2.16.840.1.113883.6.1"/>
<title>INSTRUCTIONS</title>
<text>No Known Instructions/Patient Education</text>
<entry>
<act classCode="ACT" moodCode="INT" negationInd="true">
<templateId root="2.16.840.1.113883.10.20.22.4.20"/>
<code code = "311401005" codeSystem = "2.16.840.1.113883.6.96"/>
<statusCode code = "completed"/>
</act>
</entry>
</section>
</component>
<component>
<section>
<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 Element</th>
<th>Description</th>
<th>Effective Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>Smoking Status</td>
<td>Current Every Day Smoker, [SNOMED-CT: 449868002], 0 packs per day</td>
<td>20170618</td>
</tr>
<tr>
<td ID="BirthSexInfo">Birth Sex</td>
<td>"Male"</td>
<td>"20150622"</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<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 root="98CEF953-053F-4541-8A4D-5A82C50908CB"/>
<code code="72166-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Tobacco smoking status NHIS"/>
<statusCode code="completed"/>
<effectiveTime value="20170618"/>
<value xsi:type="CD" code="449868002" displayName="Current Every Day Smoker" codeSystem="2.16.840.1.113883.6.96"/>
<author>
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<time value="20170924174900-0600"/>
<assignedAuthor>
<id extension="1234567890" 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)"/>
</assignedAuthor>
</author>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.200" extension="2016-06-01"/>
<code code="76689-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Sex Assigned At Birth"/>
<text>
<reference value="#BirthSexInfo"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20150622"/>
<value code="M" codeSystem="2.16.840.1.113883.5.1" xsi:type="CD" displayName="Male"/>
</observation>
</entry>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.14" extension="2014-06-09"/>
<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>
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<title>MENTAL STATUS</title>
<text>No information</text>
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