This page is part of the electronic Case Reporting (eCR) (v0.1.0: STU 1 Ballot 1) based on FHIR R3. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions 
<?xml version="1.0" encoding="UTF-8"?>
<!--
File: CDAR2_IG_PHCASERPT_R2_STU1.1_SAMPLE_MANUAL.xml
Specification: Public Health Case Report, Release 2, STU Release 1.1 - US Realm
Created: Eric M Haas, Health eData Inc, on behalf of HL7 PHER Working Group
Revision History: 11/09/2015 Eric M Haas Pre-publication
October/November 2016 Sarah Gaunt Additions/Revisions for 1st update to STU Release 1 (Release 1, STU Release 1.1)
-->
<!--
Disclaimer:
This sample file is informative only.
This sample file contains representative data elements from the eICR IG.
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 entirely plausible.
The data in this sample file is not intended to represent a real patients, people or clinical events.
This sample is designed to be used in conjunction with the eICR IG.
Where guidance has been given to the conformance or cardinality of elements or
attributes and there is a discrepancy with the IG, the IG is always the normative
source of truth.
Please note: This sample is valid against the Schema and Schematron for ERRORS (not warnings).
Logical schematron WARNINGS will generate from the sample file.
It is logical to generate a samples file from a system with valid warnings.
-->
<!--
Templates are identified in comments above their template id.
The IG in which the template version was first published is identified in square brackets before the template name.
e.g.: [C-CDA 2.1] Continuity of Care (CCD) (V3) indicates that the Discharge Summary (V3) template was first published in IG C-CDA R2.1
[C-CDA R2.0] Plan of Treatment Section (V2) indicates that the Plan of Treatment Section (V2) template was first published in IG C-CDA R2.0
[C-CDA R1.1] History of Present Illness Section indicates that the Hospital Course Section was first published in IG C-CDA R1.1
Even though all 3 templates above are included in IG C-CDA 2.1, because there have been no new versions of
the History of Present Illness Section template in IGs later than C-CDA R1.1, it is considered to be published in R1.1.
Similarly, there have been no new versions of the Plan of Treatment Section template later than C-CDA R.2 so it
is considered to be published in R2.0.
-->
<!--
While assertion of conformance with both C-CDA R2.1 and C-CDA R1.1 is NOT a requirement of the eICR IG, it is recommended that, if the
originating system includes both the versioned and un-versioned templateId, then both these templateIds SHOULD be preserved in the eICR document.
The examples and sample file included with this IG illustrate the optional use of the C-CDA R1.1 templateId.
-->
<?xml-stylesheet type="text/xsl" href="../../transform/cda.xsl"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:voc="http://www.lantanagroup.com/voc" xmlns="urn:hl7-org:v3"
xmlns:cda="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc" xsi:schemaLocation="urn:hl7-org:v3 ../../schema/infrastructure/cda/CDA_SDTC.xsd">
<!--
********************************************************
CDA Header
********************************************************
-->
<!-- US Realm Header template -->
<realmCode code="US" />
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3" />
<!-- [C-CDA R1.1] US Realm Header -->
<templateId root="2.16.840.1.113883.10.20.22.1.1" />
<!-- [C-CDA R2.1] US Realm Header (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2015-08-01" />
<!-- [eICR R2 STU1.1] Initial Public Health Case Report Document (eICR) (V2) -->
<templateId root="2.16.840.1.113883.10.20.15.2" extension="2016-12-01" />
<!-- Globally unique document ID (extension) is scoped by vendor/software -->
<id root="db734647-fc99-424c-a864-7e3cda82e703" />
<!-- Document Code -->
<code code="55751-2" codeSystem="2.16.840.1.113883.6.1" displayName="Public Health Case Report" />
<title>Initial Public Health Case Report</title>
<effectiveTime value="20161107094421-0500" />
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" displayName="Normal" />
<languageCode code="en-US" />
<!--
********************************************************
recordTarget: The patient
********************************************************
-->
<recordTarget>
<!-- Patient demographic information -->
<patientRole>
<!-- Fake root for sample -->
<id extension="123453" root="2.16.840.1.113883.19.5" />
<!--SSN-->
<id extension="111-00-1234" root="2.16.840.1.113883.4.1" />
<!--Could have multiple addresses-->
<addr use="H">
<streetAddressLine>5101 Peachtree St NE</streetAddressLine>
<city>Atlanta</city>
<state>GA</state>
<postalCode>30302</postalCode>
<!-- Although "county" is not explicitly specified in the US Realm Address,
it is not precluded from use and for the purposes of this IG it is
recommended to be included. -->
<county>Fulton County</county>
<country>US</country>
</addr>
<telecom use="HP" value="tel:+1-(404)555-1212" />
<telecom use="WP" value="tel:+1(555)555-2003" />
<patient>
<name use="L">
<given>Jane</given>
<given qualifier="IN">H</given>
<family>Stinn</family>
</name>
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" />
<birthTime value="19741124" />
<!-- If sdtc:deceasedInd is true then sdtc:deceasedTime must be present -->
<sdtc:deceasedInd value="false" />
<raceCode code="2106-3" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC" displayName="White" />
<ethnicGroupCode code="2186-5" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"
displayName="Not Hispanic or Latino" />
<!-- Parent/Guardian information-->
<guardian>
<!-- Parent/Guardian Address -->
<addr use="H">
<streetAddressLine>1700 Dawes St</streetAddressLine>
<city>Lowell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
<!-- Parent/Guardian phone -->
<telecom use="HP" value="tel:+1(999)555-1212" />
<!-- Parent/Guardian email -->
<telecom value="mailto:mail@guardian.com" />
<guardianPerson>
<!-- Parent/guardian name -->
<name use="L">
<given>Ruth</given>
<given qualifier="IN">L</given>
<family>Stinn</family>
</name>
</guardianPerson>
</guardian>
<languageCommunication>
<languageCode code="en" />
<modeCode code="ESP" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode" displayName="Expressed spoken" />
<proficiencyLevelCode code="G" codeSystem="2.16.840.1.113883.5.61" codeSystemName="LanguageAbilityProficiency" displayName="Good" />
<!-- Preferred Language -->
<preferenceInd value="true" />
</languageCommunication>
</patient>
</patientRole>
</recordTarget>
<!--
********************************************************
author
********************************************************
-->
<author>
<time value="20161107094421-0500" />
<!--Author/authenticator may be software or may be a provider such as "infection control professional".-->
<assignedAuthor>
<!--Id for authoring device - made up application OID-->
<id root="2.16.840.1.113883.3.72.5.20" />
<!--authoring device address - may or may not be same as facility where care provided for case-->
<addr>
<streetAddressLine>4646 Brown Rd</streetAddressLine>
<city>Salem</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1-(555)555-1212;ext=9998" />
<assignedAuthoringDevice>
<manufacturerModelName displayName="Acme" />
<softwareName displayName="Acme EHR" />
</assignedAuthoringDevice>
</assignedAuthor>
</author>
<!--
********************************************************
custodian: The custodian of the CDA document is the generator of the document
********************************************************
-->
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="88888888" root="2.16.840.1.113883.4.6" />
<name>Salem Medical Center</name>
<telecom use="WP" value="tel:+1(555)555-1212" />
<addr>
<streetAddressLine>4646 Brown Rd</streetAddressLine>
<city>Salem</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<!-- When documentationOf/serviceEvent is present, it indicates that
this eICR document was manually initiated/generated by the provider.
-->
<documentationOf>
<serviceEvent>
<code code="PHC1464" displayName="Manually Initiated eICR" codeSystem="2.16.840.1.114222.4.5.274"
codeSystemName="PHIN VS (CDC Local Coding System)" />
<effectiveTime>
<low value="20161106000000-0500" />
</effectiveTime>
</serviceEvent>
</documentationOf>
<!--
********************************************************
componentOf: contains the encompassingEncouter and the
provider and facility infomation for the case
********************************************************
-->
<componentOf>
<encompassingEncounter>
<!--encounter ID-->
<id extension="9937012" root="2.16.840.1.113883.19" />
<!--CPT-4 E/M codes - granular-->
<code code="99213" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4" displayName="Office outpatient visit 15 minutes">
<!--ActClassEncounterCodes - high level -->
<translation code="AMB" codeSystem="2.16.840.1.113883.5.4" codeSystemName="HL7 ActEncounterCode" displayName="Ambulatory" />
</code>
<effectiveTime>
<low value="20161107" />
<high value="20161107" />
</effectiveTime>
<!--provider in charge of care when case reported-->
<responsibleParty>
<assignedEntity>
<id extension="6666666666666" root="2.16.840.1.113883.4.6" />
<addr>
<streetAddressLine>2100 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
<!-- Provider Phone -->
<telecom use="WP" value="tel:+1(555)555-1003" />
<!-- Provider Fax -->
<telecom use="WP" value="fax:+1(555)555-1234" />
<!-- Provider Email -->
<telecom use="WP" value="mailto:mail@provider_domain.com" />
<assignedPerson>
<!-- Provider Name -->
<name>
<given>Michael</given>
<family>Coletta</family>
<suffix qualifier="AC">M.D.</suffix>
</name>
</assignedPerson>
<representedOrganization>
<!-- Provider Facility/Office Name -->
<name>BMass Doctors</name>
<!-- Provider Address -->
<addr>
<streetAddressLine>2100 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</responsibleParty>
<!-- Information about facility where care was provided when case reported-->
<location>
<healthCareFacility>
<id extension="77777777777" root="2.16.840.1.113883.4.6" />
<!-- Facility Type-->
<code code="OF" codeSystem="2.16.840.1.113883.5.111" displayName="Outpatient facility" />
<!-- Facility location within larger healthcare organization
e.g Kaiser Vacaville within Kaiser North-->
<location>
<addr>
<streetAddressLine>4646 Brown Rd</streetAddressLine>
<city>Salem</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
</location>
<!--Facility contact information-->
<serviceProviderOrganization>
<!-- Facility Name -->
<name>Salem Medical Center</name>
<!-- Facility Phone -->
<telecom use="WP" value="tel: 1+(555)-555-1212" />
<!-- Facility Fax -->
<telecom use="WP" value="fax: 1+(555)-555-3333" />
<!-- Facility Addr -->
<addr>
<streetAddressLine>4646 Brown Rd</streetAddressLine>
<city>Salem</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>US</country>
</addr>
</serviceProviderOrganization>
</healthCareFacility>
</location>
</encompassingEncounter>
</componentOf>
<component>
<structuredBody>
<!--
********************************************************
Encounters Section (entries required) (V3)
********************************************************
-->
<component>
<section>
<!-- [C-CDA R1.1] Encounters Section (entries optional) -->
<templateId root="2.16.840.1.113883.10.20.22.2.22" />
<!-- [C-CDA R2.1] Encounters Section (entries optional) (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.2.22" extension="2015-08-01" />
<!-- [C-CDA R1.1] Encounters Section (entries required) -->
<templateId root="2.16.840.1.113883.10.20.22.2.22.1" />
<!-- [C-CDA R2.1] Encounters Section (entries required) (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.2.22.1" extension="2015-08-01" />
<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters" />
<title>Encounters</title>
<text>
<table>
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<thead>
<tr>
<th>Encounter</th>
<th>Date(s)</th>
<th>Location</th>
</tr>
</thead>
<tbody>
<tr ID="id_2a620155-9d11-439e-92b3-5d9815ff4de8_ref">
<td>Office outpatient visit 15 minutes</td>
<td>NOV 7, 2016</td>
<td>
<list styleCode="none">
<item>
<content styleCode="Italics">Urgent Care Center</content>
</item>
</list>
</td>
</tr>
<tr>
<td colspan="20">
<list styleCode="none">
<item>
<table>
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<thead>
<tr>
<th>Manual Initiation Reason Type</th>
<th>Manual Initiation Reason</th>
<th>Date(s)</th>
</tr>
</thead>
<tbody>
<tr ID="id_ab1791b0-5c71-11db-b0de-0800200c9a65_ref">
<td>Complaint</td>
<td>Free text containing the reason for the manual eICR document</td>
<td>NOV 4, 2016</td>
</tr>
</tbody>
</table>
</item>
</list>
</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<!-- [C-CDA R1.1] Encounter Activity -->
<templateId root="2.16.840.1.113883.10.20.22.4.49" />
<!-- [C-CDA R2.1] Encounter Activity (V3)-->
<templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01" />
<id root="2a620155-9d11-439e-92b3-5d9815ff4de8" />
<code code="99213" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4"
displayName="Office outpatient visit 15 minutes" />
<effectiveTime value="20161107" />
<participant typeCode="LOC">
<participantRole classCode="SDLOC">
<!--Service Delivery Location maps to Hospital Unit -->
<code code="1160-1" codeSystem="2.16.840.1.113883.1.11.20275" codeSystemName="HealthcareServiceLocation"
displayName="Urgent Care Center" />
</participantRole>
</participant>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<!-- [C-CDA R2.1] Problem Observation (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01" />
<!-- [eICR R2 STU1.1] Initial Case Report Manual Initiation Reason Observation -->
<templateId root="2.16.840.1.113883.10.20.15.2.3.5" extension="2016-12-01" />
<id root="ab1791b0-5c71-11db-b0de-0800200c9a65" />
<code code="75322-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Complaint">
<translation code="409586006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
displayName="Complaint" />
</code>
<statusCode code="completed" />
<effectiveTime>
<low value="20161106000000-0500" />
</effectiveTime>
<value xsi:type="CD" nullFlavor="OTH">
<originalText>Free text containing the reason for the manual eICR document</originalText>
</value>
</observation>
</entryRelationship>
</encounter>
</entry>
</section>
</component>
<!--
********************************************************
History of Present Illness Section
********************************************************
-->
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.4" />
<code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PRESENT ILLNESS" />
<title>History of Present Illness</title>
<text mediaType="text/x-hl7-text+xml">
<paragraph> Persistent Cough REPORTED starting on 2016/10/05<br /> Whooping Respiration not reported<br /> Paroxysms Of
Coughing REPORTED starting on 2016/11/04<br /> Post-tussive vomiting not reported<br />
</paragraph>
</text>
</section>
</component>
<!--
********************************************************
Medications Administered Section (V2)
********************************************************
-->
<component>
<section>
<!-- [C-CDA R1.1] Medications Administered Section -->
<templateId root="2.16.840.1.113883.10.20.22.2.38" />
<!-- [C-CDA R2.0] Medications Administered Section (V2) -->
<templateId root="2.16.840.1.113883.10.20.22.2.38" extension="2014-06-09" />
<code code="29549-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medications Administered" />
<title>Medications Administered</title>
<text>
<table>
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<thead>
<tr>
<th>Medication</th>
<th>Dose</th>
<th>Duration</th>
<th>Route</th>
</tr>
</thead>
<tbody>
<tr ID="id_6c844c75-aa34-411c-b7bd-5e4a9f206e29_ref">
<td>Azithromycin 500 MG Oral Tablet</td>
<td>1 g</td>
<td>NOV 7, 2016 11:60</td>
<td>ORAL</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<!-- [C-CDA R1.1] Medication Activity -->
<templateId root="2.16.840.1.113883.10.20.22.4.16" />
<!-- [C-CDA R2.0] Medication Activity (V2) -->
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09" />
<id root="6c844c75-aa34-411c-b7bd-5e4a9f206e29" />
<statusCode code="completed" />
<effectiveTime xsi:type="IVL_TS" operator="A" value="201611071160-0700" />
<routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="ORAL" />
<doseQuantity value="1" unit="g" />
<consumable>
<manufacturedProduct classCode="MANU">
<!-- [C-CDA R2.0] Medication Information (V2) -->
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09" />
<id root="2a620155-9d11-439e-92b3-5d9815ff4ee8" />
<manufacturedMaterial>
<code code="248656" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"
displayName="Azithromycin 500 MG Oral Tablet" />
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
<!--
********************************************************
Problem Section (entries required) (V3)
********************************************************
-->
<component>
<section>
<!-- [C-CDA R1.1] Problem Section (entries optional) -->
<templateId root="2.16.840.1.113883.10.20.22.2.5" />
<!-- [C-CDA R2.1] Problem Section (entries optional) (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.2.5" extension="2015-08-01" />
<!-- [C-CDA R1.1] Problem Section (entries required) -->
<templateId root="2.16.840.1.113883.10.20.22.2.5.1" />
<!-- [C-CDA R2.1] Problem Section (entries required) (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01" />
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem List" />
<title>Problems</title>
<text>
<table>
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<thead>
<tr>
<th>Concern</th>
<th>Concern Status</th>
<th>Date(s)</th>
</tr>
</thead>
<tbody>
<tr ID="id_ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7_ref">
<td>Problem</td>
<td>active</td>
<td>NOV 7, 2016</td>
</tr>
<tr>
<td colspan="20">
<list styleCode="none">
<item>
<table>
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<thead>
<tr>
<th>Problem Type</th>
<th>Problem</th>
<th>Date(s)</th>
</tr>
</thead>
<tbody>
<tr ID="id_ab1791b0-5c71-11db-b0de-0800200c9a66_ref">
<td>Symptom</td>
<td>Dark stools (finding)</td>
<td>NOV 1, 2016</td>
</tr>
<tr ID="id_ab1791b0-5c71-11db-b0de-0800200c9a67_ref">
<td>Complaint</td>
<td>Paroxysmal cough (finding)</td>
<td>NOV 4, 2016</td>
</tr>
</tbody>
</table>
</item>
</list>
</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<!-- [C-CDA 1.1] Problem Concern Act -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<!-- [C-CDA 2.1] Problem Concern Act (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7" />
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" />
<!-- The statusCode represents the need to continue tracking the problem -->
<!-- This is of ongoing concern to the provider -->
<statusCode code="active" />
<effectiveTime>
<!-- The low value represents when the problem was first recorded in the patient's chart -->
<low value="20161107" />
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- [C-CDA R1.1] Problem Observation -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" />
<!-- [C-CDA R2.1] Problem Observation (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01" />
<id root="ab1791b0-5c71-11db-b0de-0800200c9a66" />
<code code="75325-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Symptom">
<translation code="418799008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
displayName="Symptom" />
</code>
<!-- The statusCode reflects the status of the observation itself -->
<statusCode code="completed" />
<effectiveTime>
<!-- The low value reflects the date of onset -->
<low value="20161101" />
</effectiveTime>
<value code="35064005" codeSystem="2.16.840.1.113883.6.96" displayName="Dark stools (finding)" xsi:type="CD" />
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- [C-CDA R1.1] Problem Observation -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" />
<!-- [C-CDA R2.1] Problem Observation (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01" />
<id root="ab1791b0-5c71-11db-b0de-0800200c9a67" />
<code code="75322-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Complaint">
<translation code="409586006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
displayName="Complaint" />
</code>
<!-- The statusCode reflects the status of the observation itself -->
<statusCode code="completed" />
<effectiveTime>
<!-- The low value reflects the date of onset -->
<low value="20161104" />
</effectiveTime>
<value code="43025008" codeSystem="2.16.840.1.113883.6.96" displayName="Paroxysmal cough (finding)" xsi:type="CD"
/>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!--
********************************************************
Reason for Visit Section
********************************************************
-->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.12" />
<code code="29299-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Reason for visit" />
<title>Reason for Visit</title>
<text>
<paragraph>Dark stools</paragraph>
</text>
</section>
</component>
<!--
********************************************************
Results Section (entries required) (V3)
********************************************************
-->
<component>
<section>
<!-- [C-CDA R1.1] Results Section (entries optional) -->
<templateId root="2.16.840.1.113883.10.20.22.2.3" />
<!-- [C-CDA R2.1] Results Section (entries optional) (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.2.3" extension="2015-08-01" />
<!-- [C-CDA R1.1] Results Section (entries required) -->
<templateId root="2.16.840.1.113883.10.20.22.2.3.1" />
<!-- [C-CDA R2.1] Results Section (entries required) (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01" />
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Relevant diagnostic tests and/or laboratory data" />
<title>Results</title>
<text>
<table>
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<thead>
<tr>
<th>Results Panel</th>
<th>Date(s)</th>
</tr>
</thead>
<tbody>
<tr ID="id_7d5a02b0-67a4-11db-bd13-0800200c9a66_ref">
<td>CBC W Auto Differential panel in Blood</td>
<td>NOV 7, 2016 to NOV 7, 2016</td>
</tr>
<tr>
<td colspan="20">
<list styleCode="none">
<item>
<table>
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<thead>
<tr>
<th>Test</th>
<th>Outcome</th>
<th>Interpretation</th>
<th>Date(s)</th>
<th>Reference Range</th>
<th>Reference Range Interpretation</th>
<th>Reference Range Description</th>
</tr>
</thead>
<tbody>
<tr ID="id_7c0704bb-9c40-41b5-9c7d-26b2d59e234f_ref">
<td>Hematocrit</td>
<td>35.3 %</td>
<td>Low</td>
<td>NOV 7, 2016</td>
<td>34.9 % to 44.5 %</td>
<td>Low</td>
<td>Low</td>
</tr>
<tr ID="id_7c0704bb-9c40-41b5-9c7d-26b2d59e234g_ref">
<td>Lymphocytes [#/volume] in Blood by Automated count</td>
<td>5.2 10*3/uL</td>
<td>High</td>
<td>NOV 7, 2016</td>
<td>1.0 10*3/uL to 4.8 10*3/uL</td>
<td>Normal</td>
<td />
</tr>
</tbody>
</table>
</item>
</list>
</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<organizer classCode="BATTERY" moodCode="EVN">
<!-- [C-CDA R1.1] Result Organizer -->
<templateId root="2.16.840.1.113883.10.20.22.4.1" />
<!-- [C-CDA R2.1] Result Organizer (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.4.1" extension="2015-08-01" />
<id root="7d5a02b0-67a4-11db-bd13-0800200c9a66" />
<code code="57021-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="CBC W Auto Differential panel in Blood" />
<statusCode code="completed" />
<effectiveTime>
<low value="20161107" />
<high value="20161107" />
</effectiveTime>
<component>
<!-- This observation is a non-trigger code result observation -->
<observation classCode="OBS" moodCode="EVN">
<!-- [C-CDA R1.1] Result Observation -->
<templateId root="2.16.840.1.113883.10.20.22.4.2" />
<!-- [C-CDA R2.1] Result Observation (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.4.2" extension="2015-08-01" />
<id root="7c0704bb-9c40-41b5-9c7d-26b2d59e234f" />
<code code="20570-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Hematocrit" />
<statusCode code="completed" />
<effectiveTime value="20161107" />
<value unit="%" value="35.3" xsi:type="PQ" />
<interpretationCode code="L" codeSystem="2.16.840.1.113883.1.11.78" displayName="Low" />
<referenceRange>
<observationRange>
<text>Low</text>
<value xsi:type="IVL_PQ">
<low unit="%" value="34.9" />
<high unit="%" value="44.5" />
</value>
<interpretationCode code="L" codeSystem="2.16.840.1.113883.5.83" displayName="Low" />
</observationRange>
</referenceRange>
</observation>
</component>
<component>
<!-- This observation is a non-trigger code result observation -->
<observation classCode="OBS" moodCode="EVN">
<!-- [C-CDA R1.1] Result Observation -->
<templateId root="2.16.840.1.113883.10.20.22.4.2" />
<!-- [C-CDA R2.1] Result Observation (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.4.2" extension="2015-08-01" />
<id root="7c0704bb-9c40-41b5-9c7d-26b2d59e234g" />
<code code="731-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Lymphocytes [#/volume] in Blood by Automated count" />
<statusCode code="completed" />
<effectiveTime value="20161107" />
<value unit="10*3/uL" value="5.2" xsi:type="PQ" />
<interpretationCode code="H" codeSystem="2.16.840.1.113883.1.11.78" displayName="High" />
<referenceRange>
<observationRange>
<value xsi:type="IVL_PQ">
<low unit="10*3/uL" value="1.0" />
<high unit="10*3/uL" value="4.8" />
</value>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" displayName="Normal" />
</observationRange>
</referenceRange>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
<!--
********************************************************
Social History Section (V3)
********************************************************
-->
<component>
<section>
<!-- [C-CDA 1.1] Social History Section -->
<templateId root="2.16.840.1.113883.10.20.22.2.17" />
<!-- [C-CDA 2.1] Social History Section (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.2.17" extension="2015-08-01" />
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social History" />
<title>Social History</title>
<text>
<table>
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<thead>
<tr>
<th>Birth Sex</th>
<th>Value</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>Sex Assigned At Birth</td>
<td>Female</td>
<td>NOV 24, 1974</td>
</tr>
</tbody>
</table>
<table>
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<thead>
<tr>
<th>Social History Observation Type</th>
<th>Value</th>
<th>Date(s)</th>
</tr>
</thead>
<tbody>
<tr ID="id_6049baec-80df-4dea-82b2-345f6546cda3_ref">
<td>Employment detail</td>
<td>Centers for Disease Control 1, Peachtree St South Atlanta, GA, 404-564-7865</td>
<td>JAN 1, 1993</td>
</tr>
</tbody>
</table>
<table>
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<thead>
<tr>
<th>Travel History: Date(s)</th>
<th>Notes</th>
<th>Location</th>
</tr>
</thead>
<tbody>
<tr ID="id_79565142-eae0-4213-a3b3-b73cdf474682_ref">
<td>1999 to 2007</td>
<td>Spent 8 years in the UK during the BSE outbreak</td>
<td />
</tr>
<tr ID="id_030df1dc-1d31-4e5d-abdd-5edd0b74c5c3_ref">
<td>In the 3 weeks before NOV 9, 2016</td>
<td />
<td>
<list styleCode="none">
<item>Brazil</item>
</list>
</td>
</tr>
<tr ID="id_b98e410c-d29a-46d8-8fc8-f55a9d3022b9_ref">
<td>APR 29, 2016 to OCT 30, 2016</td>
<td />
<td>
<list styleCode="none">
<item>Nadi, FJ</item>
</list>
</td>
</tr>
<tr ID="id_b97346f7-8f9e-4c5b-97bb-df4f6e057fd4_ref">
<td>MAY 6, 2016 to MAY 15, 2016</td>
<td />
<td>
<list styleCode="none">
<item>Montreal, QC, CA</item>
</list>
</td>
</tr>
<tr ID="id_1d957c2a-6133-427d-a6cc-26f132773b86_ref">
<td>JUL 13, 2016 to JUL 15, 2016</td>
<td />
<td>
<list styleCode="none">
<item>Sydney, NSW, AU</item>
</list>
</td>
</tr>
<tr ID="id_45397b5c-e974-4cf1-8b19-e1555bd55701_ref">
<td>OCT 22, 2016 to OCT 30, 2016</td>
<td />
<td>
<list styleCode="none">
<item>1170 N Rancho Robles Rd Oracle, AZ8562, US</item>
</list>
</td>
</tr>
</tbody>
</table>
<table>
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<col width="10%" />
<thead>
<tr>
<th>Pregnancy Status</th>
<th>Date(s)</th>
</tr>
</thead>
<tbody>
<tr ID="id_2.16.840.1.113883.19_ref">
<td>
<content styleCode="Italics Bold">Not </content>Pregnant</td>
<td>JAN 1, 2016 to NOV 7, 2016</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<!-- [C-CDA R2.1 Companion Guide] Birth Sex Observation -->
<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" displayName="Sex Assigned At Birth" />
<statusCode code="completed" />
<!-- effectiveTime if present should match birthTime -->
<effectiveTime value="19741124" />
<value xsi:type="CD" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender" code="F"
displayName="Female"> </value>
</observation>
</entry>
<entry typeCode="DRIV">
<!-- Occupation -->
<observation classCode="OBS" moodCode="EVN">
<!-- [C-CDA R1.1] Social History Observation -->
<templateId root="2.16.840.1.113883.10.20.22.4.38" />
<!-- [C-CDA R2.1] Social History Observation (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.4.38" extension="2015-08-01" />
<id root="6049baec-80df-4dea-82b2-345f6546cda3" />
<code code="364703007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Employment detail">
<translation code="11295-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Current employment - Reported" />
</code>
<statusCode code="completed" />
<effectiveTime>
<low value="19930101" />
</effectiveTime>
<value xsi:type="ST">Centers for Disease Control 1, Peachtree St South Atlanta, GA, 404-564-7865</value>
</observation>
</entry>
<entry typeCode="DRIV">
<!-- Travel History - text example - no specific location -->
<act classCode="ACT" moodCode="EVN">
<!-- [eICR R2 STU1.1] Travel History -->
<templateId root="2.16.840.1.113883.10.20.15.2.3.1" extension="2016-12-01" />
<id root="79565142-eae0-4213-a3b3-b73cdf474682" />
<code code="420008001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Travel" />
<text>Spent 8 years in the UK during the BSE outbreak</text>
<statusCode code="completed" />
<!-- Duration (from 1999 to 2007) -->
<effectiveTime>
<low value="1999" />
<high value="2007" />
</effectiveTime>
</act>
</entry>
<entry typeCode="DRIV">
<!-- Travel History - participant with coded location -->
<act classCode="ACT" moodCode="EVN">
<!-- [eICR R2 STU1.1] Travel History -->
<templateId root="2.16.840.1.113883.10.20.15.2.3.1" extension="2016-12-01" />
<id root="030df1dc-1d31-4e5d-abdd-5edd0b74c5c3" />
<code code="420008001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Travel" />
<statusCode code="completed" />
<!-- Denotes "past 3 weeks" with the high value being the date the statement was made -->
<effectiveTime>
<width value="3" unit="weeks" />
<high value="20161109" />
</effectiveTime>
<participant typeCode="LOC">
<participantRole classCode="TERR">
<!-- Code specifiying the location traveled -->
<code code="BRA" displayName="Brazil" codeSystem="1.0.3166.1" codeSystemName="Country (ISO 3166-1)" />
</participantRole>
</participant>
</act>
</entry>
<entry typeCode="DRIV">
<!-- Travel History - participant location with address specific to city -->
<act classCode="ACT" moodCode="EVN">
<!-- [eICR R2 STU1.1] Travel History -->
<templateId root="2.16.840.1.113883.10.20.15.2.3.1" extension="2016-12-01" />
<id root="b98e410c-d29a-46d8-8fc8-f55a9d3022b9" />
<code code="420008001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Travel" />
<statusCode code="completed" />
<!-- Duration -->
<effectiveTime>
<low value="20160429" />
<high value="20161030" />
</effectiveTime>
<participant typeCode="LOC">
<participantRole classCode="TERR">
<!-- Address specific to city -->
<addr>
<country>FJ</country>
<city>Nadi</city>
</addr>
</participantRole>
</participant>
</act>
</entry>
<entry typeCode="DRIV">
<!-- Travel History - participant location with addr
specific to city and state (province) -->
<act classCode="ACT" moodCode="EVN">
<!-- [eICR R2 STU1.1] Travel History -->
<templateId root="2.16.840.1.113883.10.20.15.2.3.1" extension="2016-12-01" />
<id root="b97346f7-8f9e-4c5b-97bb-df4f6e057fd4" />
<code code="420008001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Travel" />
<statusCode code="completed" />
<!-- Duration -->
<effectiveTime>
<low value="20160506" />
<high value="20160515" />
</effectiveTime>
<participant typeCode="LOC">
<participantRole classCode="TERR">
<addr>
<country>CA</country>
<city>Montreal</city>
<state>QC</state>
</addr>
</participantRole>
</participant>
</act>
</entry>
<entry typeCode="DRIV">
<!-- Travel History - participant location with addr
specific to city and state -->
<act classCode="ACT" moodCode="EVN">
<!-- [eICR R2 STU1.1] Travel History -->
<templateId root="2.16.840.1.113883.10.20.15.2.3.1" extension="2016-12-01" />
<id root="1d957c2a-6133-427d-a6cc-26f132773b86" />
<code code="420008001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Travel" />
<statusCode code="completed" />
<effectiveTime>
<low value="20160713" />
<high value="20160715" />
</effectiveTime>
<participant typeCode="LOC">
<participantRole classCode="TERR">
<addr>
<country>AU</country>
<city>Sydney</city>
<state>NSW</state>
</addr>
</participantRole>
</participant>
</act>
</entry>
<entry typeCode="DRIV">
<!-- Travel History - participant location with addr
specific to street address-->
<act classCode="ACT" moodCode="EVN">
<!-- [eICR R2 STU1.1] Travel History -->
<templateId root="2.16.840.1.113883.10.20.15.2.3.1" extension="2016-12-01" />
<id root="45397b5c-e974-4cf1-8b19-e1555bd55701" />
<code code="420008001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Travel" />
<statusCode code="completed" />
<effectiveTime>
<low value="20161022" />
<high value="20161030" />
</effectiveTime>
<participant typeCode="LOC">
<participantRole classCode="TERR">
<addr>
<streetAddressLine>1170 N Rancho Robles Rd</streetAddressLine>
<city>Oracle</city>
<state>AZ</state>
<postalCode>8562</postalCode>
<country>US</country>
</addr>
</participantRole>
</participant>
</act>
</entry>
<entry typeCode="DRIV">
<!-- Pregnancy indication -->
<!-- To assert a patient was not pregnant during a specified date range (contained in effectiveTime), set @negationInd="true"
To indicate that a patient's pregnancy status was unknown, set @nullFlavor="UNK" and an effectiveTime element can be
included to assert the period over which it was unknown -->
<observation classCode="OBS" moodCode="EVN" negationInd="true">
<!-- [C-CDA R1.1] Pregnancy Observation -->
<templateId root="2.16.840.1.113883.10.20.15.3.8" />
<id extension="123456789" root="2.16.840.1.113883.19" />
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" />
<statusCode code="completed" />
<effectiveTime>
<low value="20160101" />
<high value="20161107" />
</effectiveTime>
<value xsi:type="CD" code="77386006" displayName="Pregnant" codeSystem="2.16.840.1.113883.6.96" />
</observation>
</entry>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>
