Clinical Document Architecture
2.0.0-sd-ballot - ballot
Clinical Document Architecture
2.0.0-sd-ballot - ballot
This page is part of the CDA: Clinical Document Architecture (v2.0.0-sd-ballot: CDA 2.0 Ballot 1) based on FHIR v5.0.0. . For a full list of available versions, see the Directory of published versions
This content is an example of the ClinicalDocument (CDA Class) Logical Model and is not a FHIR Resource
<?xml version="1.0"?>
<!-- Sample document provided with original CDA specification -->
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<!--
********************************************************
CDA Header
********************************************************
-->
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.3.27.1776"/>
<id extension="c266" root="2.16.840.1.113883.19.4"/>
<code code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Consultation note"/>
<title>Good Health Clinic Consultation Note</title>
<effectiveTime value="20000407"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<setId extension="BB35" root="2.16.840.1.113883.19.7"/>
<versionNumber value="2"/>
<recordTarget>
<patientRole>
<id extension="12345" root="2.16.840.1.113883.19.5"/>
<patient>
<name>
<given>Henry</given>
<family>Levin</family>
<suffix>the 7th</suffix>
</name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
<birthTime value="19320924"/>
</patient>
<providerOrganization>
<id root="2.16.840.1.113883.19.5"/>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time value="2000040714"/>
<assignedAuthor>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<assignedPerson>
<name>
<given>Robert</given>
<family>Dolin</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.19.5"/>
</representedOrganization>
</assignedAuthor>
</author>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="2.16.840.1.113883.19.5"/>
<name>Good Health Clinic</name>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<legalAuthenticator>
<time value="20000408"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<assignedPerson>
<name>
<given>Robert</given>
<family>Dolin</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.19.5"/>
</representedOrganization>
</assignedEntity>
</legalAuthenticator>
<relatedDocument typeCode="RPLC">
<parentDocument>
<id extension="a123" root="2.16.840.1.113883.19.4"/>
<setId extension="BB35" root="2.16.840.1.113883.19.7"/>
<versionNumber value="1"/>
</parentDocument>
</relatedDocument>
<componentOf>
<encompassingEncounter>
<id extension="KPENC1332" root="2.16.840.1.113883.19.6"/>
<effectiveTime value="20000407"/>
<encounterParticipant typeCode="CON">
<time value="20000407"/>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<assignedPerson>
<name>
<given>Robert</given>
<family>Dolin</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.19.5"/>
</representedOrganization>
</assignedEntity>
</encounterParticipant>
<location>
<healthCareFacility classCode="DSDLOC">
<!-- Note: the original published example had the wrong codeSystem (2.16.840.1.113883.5.10588) here -->
<code code="GIM" codeSystem="2.16.840.1.113883.5.111" displayName="General internal medicine clinic"/>
</healthCareFacility>
</location>
</encompassingEncounter>
</componentOf>
<!--
********************************************************
CDA Body
********************************************************
-->
<component>
<structuredBody>
<!--
********************************************************
History of Present Illness section
********************************************************
-->
<component>
<section>
<code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>History of Present Illness</title>
<text>
<content styleCode="Bold">Henry Levin, the 7<sup>th</sup>
</content> is a 67 year old male referred for further asthma management. Onset of asthma in his <content revised="delete">twenties</content>
<content revised="insert">teens</content>. He was hospitalized twice last year, and already twice this year. He has not been able to be weaned off steroids for the past several months.
</text>
</section>
</component>
<!--
********************************************************
Past Medical History section
********************************************************
-->
<component>
<section>
<code code="10153-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Past Medical History</title>
<text>
<list>
<item>
<content ID="a1">Asthma</content>
</item>
<item>
<content ID="a2">Hypertension (see HTN.cda for details)</content>
</item>
<item>
<content ID="a3">Osteoarthritis,
<content ID="a4">right knee</content>
</content>
</item>
</list>
</text>
<entry>
<observation classCode="COND" moodCode="EVN">
<code code="195967001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Asthma">
<originalText>
<reference value="#a1"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="1950"/>
<reference typeCode="XCRPT">
<externalObservation>
<id root="2.16.840.1.113883.19.1.2765"/>
</externalObservation>
</reference>
</observation>
</entry>
<entry>
<observation classCode="COND" moodCode="EVN">
<code code="59621000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="HTN">
<originalText>
<reference value="#a2"/>
</originalText>
</code>
<statusCode code="completed"/>
<reference typeCode="SPRT">
<seperatableInd value="false"/>
<externalDocument>
<id root="2.16.840.1.113883.19.4.789"/>
<text mediaType="multipart/related">
<reference value="HTN.cda"/>
</text>
<setId root="2.16.840.1.113883.19.7.2465"/>
<versionNumber value="1"/>
</externalDocument>
</reference>
<reference typeCode="XCRPT">
<externalObservation>
<id root="2.16.840.1.113883.19.1.2005"/>
</externalObservation>
</reference>
</observation>
</entry>
<entry>
<observation classCode="COND" moodCode="EVN">
<code xsi:type="CD" code="396275006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Osteoarthritis">
<originalText>
<reference value="#a3"/>
</originalText>
</code>
<statusCode code="completed"/>
<targetSiteCode code="49076000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Knee joint">
<originalText>
<reference value="#a4"/>
</originalText>
<qualifier>
<name code="78615007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="with laterality"/>
<value code="24028007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="right"/>
</qualifier>
</targetSiteCode>
<reference typeCode="XCRPT">
<externalObservation>
<id root="2.16.840.1.113883.19.1.1805"/>
</externalObservation>
</reference>
</observation>
</entry>
</section>
</component>
<!--
********************************************************
Medications section
********************************************************
-->
<component>
<section>
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Medications</title>
<text>
<list>
<item>Theodur 200mg BID</item>
<item>Proventil inhaler 2puffs QID PRN</item>
<item>Prednisone 20mg qd</item>
<item>HCTZ 25mg qd</item>
</list>
</text>
<entry>
<substanceAdministration classCode="SBADM" moodCode="EVN">
<text>Theodur 200mg BID</text>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
<period value="12" unit="h"/>
</effectiveTime>
<routeCode code="PO" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration"/>
<doseQuantity value="200" unit="mg"/>
<consumable>
<manufacturedProduct>
<manufacturedLabeledDrug>
<code code="66493003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Theophylline"/>
</manufacturedLabeledDrug>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<entry>
<substanceAdministration classCode="SBADM" moodCode="EVN">
<text>Proventil inhaler 2puffs QID PRN</text>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
<period value="6" unit="h"/>
</effectiveTime>
<priorityCode code="PRN"/>
<routeCode code="IPINHL" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration" displayName="Inhalation, oral"/>
<doseQuantity value="2"/>
<consumable>
<manufacturedProduct>
<manufacturedLabeledDrug>
<code code="91143003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Albuterol"/>
</manufacturedLabeledDrug>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<entry>
<substanceAdministration classCode="SBADM" moodCode="EVN">
<id root="2.16.840.1.113883.19.8.1"/>
<text>Prednisone 20mg qd</text>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
<period value="24" unit="h"/>
</effectiveTime>
<routeCode code="PO" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration"/>
<doseQuantity value="20" unit="mg"/>
<consumable>
<manufacturedProduct>
<manufacturedLabeledDrug>
<code code="10312003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Prednisone preparation"/>
</manufacturedLabeledDrug>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<entry>
<substanceAdministration classCode="SBADM" moodCode="EVN">
<text>HCTZ 25mg qd</text>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
<period value="24" unit="h"/>
</effectiveTime>
<routeCode code="PO" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration"/>
<consumable>
<manufacturedProduct>
<manufacturedLabeledDrug>
<code code="376209006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hydrochlorothiazide 25mg tablet"/>
</manufacturedLabeledDrug>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<!--
********************************************************
Allergies & Adverse Reactions section
********************************************************
-->
<component>
<section>
<code code="10155-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Allergies and Adverse Reactions</title>
<text>
<list>
<item>Penicillin - Hives</item>
<item>Aspirin - Wheezing</item>
<item>Codeine - Itching and nausea</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code xsi:type="CD" code="247472004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hives"/>
<statusCode code="completed"/>
<entryRelationship typeCode="MFST">
<observation classCode="OBS" moodCode="EVN">
<code xsi:type="CD" code="91936005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Allergy to penicillin"/>
<statusCode code="completed"/>
</observation>
</entryRelationship>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="56018004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Wheezing"/>
<statusCode code="completed"/>
<entryRelationship typeCode="MFST">
<observation classCode="OBS" moodCode="EVN">
<code code="293586001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Allergy to aspirin"/>
<statusCode code="completed"/>
</observation>
</entryRelationship>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="32738000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Pruritis"/>
<statusCode code="completed"/>
<entryRelationship typeCode="MFST">
<observation classCode="OBS" moodCode="EVN">
<id root="2.16.840.1.113883.19.1.2010"/>
<code code="62014003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Adverse reaction to drug">
<qualifier>
<name code="246075003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="causative agent"/>
<value code="1476002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="codeine"/>
</qualifier>
</code>
<statusCode code="completed"/>
</observation>
</entryRelationship>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="73879007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Nausea"/>
<statusCode code="completed"/>
<entryRelationship typeCode="MFST">
<observation classCode="OBS" moodCode="EVN">
<id root="2.16.840.1.113883.19.1.2010"/>
<code code="84100007" codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entryRelationship>
</observation>
</entry>
</section>
</component>
<!--
********************************************************
Family History section
********************************************************
-->
<component>
<section>
<code code="10157-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Family history</title>
<text>
<list>
<item>Father had fatal MI in his early 50's.</item>
<item>No cancer or diabetes.</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="22298006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="MI"/>
<statusCode code="completed"/>
<effectiveTime value="1970"/>
<subject>
<relatedSubject classCode="PRS">
<code code="FTH" codeSystem="2.16.840.1.113883.5.111"/>
</relatedSubject>
</subject>
<entryRelationship typeCode="CAUS">
<observation classCode="OBS" moodCode="EVN">
<code code="399347008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="death"/>
<statusCode code="completed"/>
<effectiveTime value="1970"/>
</observation>
</entryRelationship>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN" negationInd="true">
<code code="275937001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Family history of cancer"/>
<statusCode code="completed"/>
<effectiveTime>
<high value="20000407" inclusive="true"/>
</effectiveTime>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="160274005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="No family history of diabetes"/>
<statusCode code="completed"/>
<effectiveTime>
<high value="20000407" inclusive="true"/>
</effectiveTime>
</observation>
</entry>
</section>
</component>
<!--
********************************************************
Social History section
********************************************************
-->
<component>
<section>
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Social History</title>
<text>
<list>
<item>Smoking :: 1 PPD between the ages of 20 and 55, and then he quit.</item>
<item>Alcohol :: rare</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="266924008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="ex-heavy cigarette smoker (20-39/day)"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="1955"/>
<high value="1990"/>
</effectiveTime>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="160625004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Date ceased smoking"/>
<statusCode code="completed"/>
<value xsi:type="TS" value="1990"/>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="266917007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Trivial drinker - less than 1/day"/>
<statusCode code="completed"/>
</observation>
</entry>
</section>
</component>
<!--
********************************************************
Physical Exam section
********************************************************
-->
<component>
<section>
<code code="11384-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Physical Examination</title>
<!--
********************************************************
Physical Exam - Vital Signs
********************************************************
-->
<component>
<section>
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Vital Signs</title>
<text>
<table>
<tbody>
<tr>
<th>Date / Time</th>
<th>April 7, 2000 14:30</th>
<th>April 7, 2000 15:30</th>
</tr>
<tr>
<th>Height</th>
<td>177 cm (69.7 in)</td>
</tr>
<tr>
<th>Weight</th>
<td>194.0 lbs (88.0 kg)</td>
</tr>
<tr>
<th>BMI</th>
<td>28.1 kg/m2</td>
</tr>
<tr>
<th>BSA</th>
<td>2.05 m2</td>
</tr>
<tr>
<th>Temperature</th>
<td>36.9 C (98.5 F)</td>
<td>36.9 C (98.5 F)</td>
</tr>
<tr>
<th>Pulse</th>
<td>86 / minute</td>
<td>84 / minute</td>
</tr>
<tr>
<th>Rhythm</th>
<td>Regular</td>
<td>Regular</td>
</tr>
<tr>
<th>Respirations</th>
<td>16 / minute, unlabored</td>
<td>14 / minute</td>
</tr>
<tr>
<th>Systolic</th>
<td>132 mmHg</td>
<td>135 mmHg</td>
</tr>
<tr>
<th>Diastolic</th>
<td>86 mmHg</td>
<td>88 mmHg</td>
</tr>
<tr>
<th>Position / Cuff</th>
<td>Left Arm</td>
<td>Left Arm</td>
</tr>
</tbody>
</table>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="50373000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Body height measure"/>
<statusCode code="completed"/>
<effectiveTime value="200004071430"/>
<value xsi:type="PQ" value="1.77" unit="m">
<translation value="69.7" code="[in_I]" codeSystem="2.16.840.1.113883.6.8" codeSystemName="UCUM"/>
</value>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="363808001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Body weight measure"/>
<statusCode code="completed"/>
<effectiveTime value="200004071430"/>
<value xsi:type="PQ" value="194.0" unit="[lb_ap]">
<translation value="88.0" code="kg" codeSystem="2.16.840.1.113883.6.8" codeSystemName="UCUM"/>
</value>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="60621009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Body mass index"/>
<statusCode code="completed"/>
<effectiveTime value="200004071430"/>
<value xsi:type="RTO_PQ_PQ">
<numerator value="28.1" unit="kg"/>
<denominator value="1" unit="ar"/>
</value>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="301898006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Body surface area"/>
<statusCode code="completed"/>
<effectiveTime value="200004071430"/>
<value xsi:type="PQ" value="2.05" unit="ar"/>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="386725007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Body temperature"/>
<statusCode code="completed"/>
<effectiveTime value="200004071430"/>
<value xsi:type="PQ" value="36.9" unit="Cel">
<translation value="98.5" code="[degF]" codeSystem="2.16.840.1.113883.6.8" codeSystemName="UCUM"/>
</value>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="364075005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Heart rate"/>
<statusCode code="completed"/>
<effectiveTime value="200004071430"/>
<value xsi:type="RTO_PQ_PQ">
<numerator value="86"/>
<denominator value="1" unit="min"/>
</value>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="364075005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Heart rate"/>
<statusCode code="completed"/>
<effectiveTime value="200004071530"/>
<value xsi:type="RTO_PQ_PQ">
<numerator value="84"/>
<denominator value="1" unit="min"/>
</value>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="364074009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Regularity of heart rhythm"/>
<statusCode code="completed"/>
<effectiveTime value="200004071430"/>
<value xsi:type="CD" code="248649006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Heart regular"/>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="364074009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Regularity of heart rhythm"/>
<statusCode code="completed"/>
<effectiveTime value="200004071530"/>
<value xsi:type="CD" code="248649006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Heart regular"/>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="86290005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Respiratory rate"/>
<statusCode code="completed"/>
<effectiveTime value="200004071430"/>
<value xsi:type="RTO_PQ_PQ">
<numerator value="16"/>
<denominator value="1" unit="min"/>
</value>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="276362002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Breathing easily"/>
<statusCode code="completed"/>
<effectiveTime value="200004071430"/>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="86290005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Respiratory rate"/>
<statusCode code="completed"/>
<effectiveTime value="200004071530"/>
<value xsi:type="RTO_PQ_PQ">
<numerator value="14"/>
<denominator value="1" unit="min"/>
</value>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="251076008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Cuff blood pressure"/>
<statusCode code="completed"/>
<effectiveTime value="200004071430"/>
<targetSiteCode code="368208006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Left arm"/>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<code code="271649006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Systolic BP"/>
<statusCode code="completed"/>
<effectiveTime value="200004071530"/>
<value xsi:type="PQ" value="132" unit="mm[Hg]"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<code code="271650006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Diastolic BP"/>
<statusCode code="completed"/>
<effectiveTime value="200004071530"/>
<value xsi:type="PQ" value="86" unit="mm[Hg]"/>
</observation>
</entryRelationship>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="251076008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Cuff blood pressure"/>
<statusCode code="completed"/>
<effectiveTime value="200004071530"/>
<targetSiteCode code="368208006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Left arm"/>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<code code="271649006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Systolic BP"/>
<statusCode code="completed"/>
<effectiveTime value="200004071530"/>
<value xsi:type="PQ" value="135" unit="mm[Hg]"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<code code="271650006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Diastolic BP"/>
<statusCode code="completed"/>
<effectiveTime value="200004071530"/>
<value xsi:type="PQ" value="88" unit="mm[Hg]"/>
</observation>
</entryRelationship>
</observation>
</entry>
</section>
</component>
<!--
********************************************************
Physical Exam - Skin
********************************************************
-->
<component>
<section>
<code code="8709-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Skin Exam</title>
<text>Erythematous rash, palmar surface, left index finger.
<renderMultiMedia referencedObject="MM1"/>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="271807003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Rash"/>
<statusCode code="completed"/>
<methodCode code="32750006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Inspection"/>
<targetSiteCode code="48856004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Skin of palmer surface of index finger">
<qualifier>
<name code="78615007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="with laterality"/>
<value code="7771000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="left"/>
</qualifier>
</targetSiteCode>
<entryRelationship typeCode="SPRT">
<regionOfInterest classCode="ROIOVL" moodCode="EVN" ID="MM1">
<id root="2.16.840.1.113883.19.3.1"/>
<code code="ELLIPSE"/>
<value value="3"/>
<value value="1"/>
<value value="3"/>
<value value="7"/>
<value value="2"/>
<value value="4"/>
<value value="4"/>
<value value="4"/>
<entryRelationship typeCode="SUBJ">
<observationMedia classCode="OBS" moodCode="EVN">
<id root="2.16.840.1.113883.19.2.1"/>
<value mediaType="image/gif">
<reference value="lefthand.gif"/>
</value>
</observationMedia>
</entryRelationship>
</regionOfInterest>
</entryRelationship>
</observation>
</entry>
</section>
</component>
<!--
********************************************************
Physical Exam - Lungs
********************************************************
-->
<component>
<section>
<code code="8710-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Lungs</title>
<text>Clear with no wheeze. Good air flow.</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="48348007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Chest clear"/>
<statusCode code="completed"/>
<methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN" negationInd="true">
<code code="56018004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Wheezing"/>
<statusCode code="completed"/>
<methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/>
</observation>
</entry>
</section>
</component>
<!--
********************************************************
Physical Exam - Cardiac
********************************************************
-->
<component>
<section>
<code code="10223-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Cardiac</title>
<text>RRR with no murmur, no S3, no S4.</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="76863003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Normal heart rate"/>
<statusCode code="completed"/>
<methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN" negationInd="true">
<code code="88610006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="heart murmur"/>
<statusCode code="completed"/>
<methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN" negationInd="true">
<code code="277455002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Third heart sound"/>
<statusCode code="completed"/>
<methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="60721002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Fourth heart sound inaudible"/>
<statusCode code="completed"/>
<methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/>
</observation>
</entry>
</section>
</component>
</section>
</component>
<!--
********************************************************
Labs section
********************************************************
-->
<component>
<section>
<code code="11502-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Labs</title>
<text>
<list>
<item>CXR 02/03/1999: Hyperinflated. Normal cardiac silhouette, clear lungs.</item>
<item>Peak Flow today: 260 l/m</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="282290005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Imaging interpretation"/>
<statusCode code="completed"/>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<id root="2.16.840.1.113883.19.1.3005"/>
<code code="249674001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Chest hyperinflated"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<id root="2.16.840.1.113883.19.1.5505"/>
<code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" nullFlavor="OTH">
<originalText>normal cardiac silhouette</originalText>
</code>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN" negationInd="true">
<id root="2.16.840.1.113883.19.1.6675"/>
<code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" nullFlavor="OTH">
<originalText>radiopacities</originalText>
</code>
</observation>
</entryRelationship>
<reference typeCode="SPRT">
<externalObservation classCode="DGIMG">
<id root="2.16.840.1.113883.19.1.14"/>
<code code="56350004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Chest-X-ray"/>
</externalObservation>
</reference>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<id root="2.16.840.1.113883.19.1.7005"/>
<code code="313193002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Peak flow"/>
<statusCode code="completed"/>
<effectiveTime value="20000407"/>
<value xsi:type="RTO_PQ_PQ">
<numerator value="260" unit="l"/>
<denominator value="1" unit="min"/>
</value>
</observation>
</entry>
</section>
</component>
<!--
********************************************************
In-office Procedure section
********************************************************
-->
<component>
<section>
<code code="29554-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>In-office Procedures</title>
<text>
<list>
<item>Suture removal, left forearm.</item>
</list>
</text>
<entry>
<procedure classCode="PROC" moodCode="EVN">
<code code="30549001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Suture removal"/>
<statusCode code="completed"/>
<effectiveTime value="200004071430"/>
<targetSiteCode code="66480008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Left forearm"/>
</procedure>
</entry>
</section>
</component>
<!--
********************************************************
Assessment section
********************************************************
-->
<component>
<section>
<code code="11496-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Assessment</title>
<text>
<list>
<item>Asthma, with prior smoking history. Difficulty weaning off steroids. Will try gradual taper.</item>
<item>Hypertension, well-controlled.</item>
<item>Contact dermatitis on finger.</item>
</list>
</text>
<entry>
<observation classCode="COND" moodCode="EVN">
<code code="14657009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Established diagnosis"/>
<statusCode code="completed"/>
<effectiveTime value="200004071530"/>
<value xsi:type="CD" code="195967001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Asthma">
<translation code="49390" codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD9CM" displayName="ASTHMA W/O STATUS ASTHMATICUS"/>
</value>
<reference typeCode="ELNK">
<externalObservation classCode="COND">
<id root="2.16.840.1.113883.19.1.35"/>
</externalObservation>
</reference>
</observation>
</entry>
<entry>
<observation classCode="COND" moodCode="EVN">
<code code="14657009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Established diagnosis"/>
<statusCode code="completed"/>
<effectiveTime value="200004071530"/>
<value xsi:type="CD" code="59621000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Essential hypertension">
<translation code="4019" codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD9CM" displayName="HYPERTENSION NOS"/>
</value>
<reference typeCode="ELNK">
<externalObservation classCode="COND">
<id root="2.16.840.1.113883.19.1.37"/>
</externalObservation>
</reference>
</observation>
</entry>
<entry>
<observation classCode="COND" moodCode="EVN">
<code code="14657009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Established diagnosis"/>
<statusCode code="completed"/>
<effectiveTime value="200004071530"/>
<value xsi:type="CD" code="40275004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Contact dermatitis">
<translation code="692.9" codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD9CM" displayName="Contact Dermatitis, NOS"/>
</value>
<targetSiteCode code="48856004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Skin of palmer surface of index finger">
<qualifier>
<name code="78615007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="with laterality"/>
<value code="7771000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="left"/>
</qualifier>
</targetSiteCode>
</observation>
</entry>
</section>
</component>
<!--
********************************************************
Plan section
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.3.27.354"/>
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Plan</title>
<text>
<list>
<item>Complete PFTs with lung volumes.</item>
<item>Chem-7 tomorrow.</item>
<item>Teach peak flow rate measurement.</item>
<item>Decrease prednisone to 20qOD alternating with 18qOD.</item>
<item>Hydrocortisone cream to finger BID.</item>
<item>RTC 1 week.</item>
</list>
</text>
<entry>
<act classCode="ACT" moodCode="INT">
<id/>
<code code="23426006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Pulmonary function test"/>
<text>Complete PFTs with lung volumes.</text>
<entryRelationship typeCode="COMP">
<act classCode="ACT" moodCode="INT">
<code code="252472004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Lung volume test"/>
</act>
</entryRelationship>
</act>
</entry>
<entry>
<observation classCode="OBS" moodCode="INT">
<code code="24320-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC">
<originalText>Chem-7</originalText>
<translation code="aYU7t6" codeSystem="2.16.840.1.113883.19.278.47" codeSystemName="MyLocalCodeSystem" displayName="Chem7"/>
</code>
<text>Chem-7 tomorrow</text>
<effectiveTime value="20000408"/>
</observation>
</entry>
<entry>
<act classCode="ACT" moodCode="INT">
<id/>
<code code="223468009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Teaching of skills">
<qualifier>
<name code="363702006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="has focus"/>
<value code="29893006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Peak flow rate measurement"/>
</qualifier>
</code>
</act>
</entry>
<entry>
<substanceAdministration classCode="SBADM" moodCode="RQO">
<text>prednisone 20qOD alternating with 18qOD.</text>
<routeCode code="PO" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration"/>
<consumable>
<manufacturedProduct>
<manufacturedLabeledDrug>
<code code="10312003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Prednisone preparation"/>
</manufacturedLabeledDrug>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<entry>
<substanceAdministration classCode="SBADM" moodCode="RQO">
<text>Hydrocortisone cream to finger BID.</text>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
<period value="12" unit="h"/>
</effectiveTime>
<routeCode code="SKIN" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration" displayName="Topical application, skin"/>
<approachSiteCode code="48856004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Skin of palmer surface of index finger">
<qualifier>
<name code="78615007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="with laterality"/>
<value code="7771000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="left"/>
</qualifier>
</approachSiteCode>
<consumable>
<manufacturedProduct>
<manufacturedLabeledDrug>
<code code="331646005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hydrocortisone cream"/>
</manufacturedLabeledDrug>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<entry>
<encounter classCode="ENC" moodCode="RQO">
<code code="185389009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Follow-up visit"/>
<effectiveTime>
<low value="20000412"/>
<high value="20000417"/>
</effectiveTime>
</encounter>
</entry>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>
IG © 2019+ Health Level 7. Package hl7.cda.uv.core#2.0.0-sd-ballot based on FHIR 5.0.0. Generated 2023-10-27
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