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cda.xml
OID
1.3.6.1.4.1.12559.11.11.4.33131
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11/16/25 9:52:55 PM (CET GMT+0100)
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1 <ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:mif="urn:hl7-org:v3/mif" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
2   <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
3   <id extension="c266" root="2.16.840.1.113883.19.4"/>
4   <code code="34133-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summarization of Episode Note"/>
5   <title>Nota de episodio</title>
6   <effectiveTime value="202511161545"/>
7   <confidentialityCode code="V" codeSystem="2.16.840.1.113883.5.25"/>
8   <recordTarget>
9     <patientRole>
10       <id assigningAuthorityName="C�dula de extranjer�a" extension="30538292" root="2.16.840.1.113883.19.6.1.2"/>
11       <id extension="1" root="2.16.840.1.113883.19.6.2.1"/>
12       <id extension="2" root="2.16.840.1.113883.19.6.3.2"/>
13       <id extension="1111" root="2.16.840.1.113883.19.6.4"/>
14       <addr use="HP">
15         <country>CO</country>
16         <state>18</state>
17         <city>18001</city>
18         <postalCode>18001</postalCode>
19         <streetAddressLine>CALLE 4</streetAddressLine>
20       </addr>
21       <telecom use="HP" value=""/>
22       <patient>
23         <name>
24           <given>LOLA</given>
25           <given/>
26           <family>LOAIZA</family>
27           <family/>
28         </name>
29         <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
30         <birthTime value="19981120"/>
31       </patient>
32     </patientRole>
33   </recordTarget>
34   <author>
35     <time value="202511161545"/>
36     <assignedAuthor>
37       <id extension="KP00017" root="2.16.840.1.113883.19.5"/>
38       <assignedPerson>
39         <name>
40           <given>ALEJANDRO </given>
41           <given/>
42           <family>ROA</family>
43           <family/>
44           <suffix>MD.</suffix>
45         </name>
46       </assignedPerson>
47       <representedOrganization>
48         <id extension="Codigo ministerio" root="2.16.840.1.113883.19.5.4"/>
49       </representedOrganization>
50     </assignedAuthor>
51   </author>
52   <custodian>
53     <assignedCustodian>
54       <representedCustodianOrganization>
55         <id root="2.16.840.1.113883.19.5.5"/>
56         <name>CLINICA VIDA SANA </name>
57         <telecom/>
58         <addr use="WP">
59           <country>CO</country>
60           <state>18</state>
61           <city>18001</city>
62           <postalCode>18001</postalCode>
63           <streetAddressLine>CALLE 4</streetAddressLine>
64         </addr>
65       </representedCustodianOrganization>
66     </assignedCustodian>
67   </custodian>
68   <componentOf>
69     <encompassingEncounter>
70       <id extension="011103" root="2.16.840.1.113883.2.17"/>
71       <code code="R" codeSystem="2.16.840.1.113883.2.17" codeSystemName="CUPS" displayName="BIOPSIA DE CR�NEO"/>
72       <effectiveTime>
73         <low value="20251116"/>
74         <high value="20251116"/>
75       </effectiveTime>
76       <dischargeDispositionCode code="01" codeSystem="2.16.840.1.113883.12.112" codeSystemName="HL7 Discharge Disposition" displayName="Routine Discharge1 Vivo (a)"/>
77       <location>
78         <healthCareFacility>
79           <id root="2.16.540.1.113883.19.2"/>
80           <location>
81             <name>SALIDA </name>
82           </location>
83         </healthCareFacility>
84       </location>
85     </encompassingEncounter>
86   </componentOf>
87   <component>
88     <structuredBody>
89       <component>
90         <section>
91           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
92           <code code="30525-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Age"/>
93           <title>Edad</title>
94           <text>26 A�o</text>
95         </section>
96       </component>
97       <component>
98         <section>
99           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
100           <code code="76437-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Primary insurance"/>
101           <title>EPS</title>
102           <text>COLSUBSIDIO</text>
103         </section>
104       </component>
105       <component>
106         <section>
107           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
108           <code code="45410-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Admitted from"/>
109           <title>SERVICIO DE INGRESO</title>
110           <text>1 Urgencias</text>
111         </section>
112       </component>
113       <component>
114         <section>
115           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
116           <code code="29299-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Reason for visit Narrative"/>
117           <title>MOTIVO DE LA SOLICITUD DEL SERVICIO PERCEPCI�N DEL USUARIO</title>
118           <text>SE SOLICITA CONSULTA POR UN FUERTE DOLOR DE CABEZ</text>
119         </section>
120       </component>
121       <component>
122         <section>
123           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
124           <code code="67800-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="EMS injury incident description Narrative NEMSIS"/>
125           <title>CAUSA EXTERNA</title>
126           <text>01 Accidente de trabajo</text>
127         </section>
128       </component>
129       <component>
130         <section>
131           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
132           <code code="42347-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Admission diagnosis "/>
133           <title>ESTADO GENERAL AL INGRESO</title>
134           <text>PACIENTE QUE INDICA ESTAR EN BUENAS CONDICIONES DE SALUD SIN EMBARGO PRESENTA UN FUERTE DOLOR DE CABEZA</text>
135         </section>
136       </component>
137       <component>
138         <section>
139           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
140           <code code="81267-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Setting of exposure to illness"/>
141           <title>ENFERMEDAD ACTUAL</title>
142           <text>CEFALEA </text>
143         </section>
144       </component>
145       <component>
146         <section>
147           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
148           <code code="10157-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of family member diseases Narrative"/>
149           <title>ANTECEDENTES FAMILIARES</title>
150           <text>NINGUNO</text>
151         </section>
152       </component>
153       <component>
154         <section>
155           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
156           <code code="11348-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Past illness Narrative"/>
157           <title>ANTECEDENTES PERSONALES</title>
158           <text>Por favor llene los espacios de antecedentes que apliquen para el paciente.
159
160 Antecedentes quir�rgicos
161 Antecedentes Transfusionales
162 Antecedentes T�xicos
163 Antecedentes inmunol�gicos
164 Antecedentes al�rgicos
165 Antecedentes traum�ticos
166 Antecedentes psiqui�tricos
167 Antecedentes ginecobst�trico
168 Antecedentes farmacol�gicos
169 Antecedentes familiares
170 Antecedentes psicol�gicos
171 Antecedentes otros 
172 Antecedentes medicamento_contraindicado</text>
173         </section>
174       </component>
175       <component>
176         <section>
177           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
178           <code code="8687-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Review of systems - Reported"/>
179           <title>REVISI�N POR SISTEMAS</title>
180           <text>Ojos
181 O�dos
182 Nariz, boca y garganta
183 Cardiovascular
184 Respiratorio
185 Gastrointestinal
186 Genitourinarios
187 Musculoesqueletico
188 Linfatico
189 Tegumentario
190 Neurolog�co
191 Endocrino
192 Inmunolog�co
193 Psiquiatrico</text>
194         </section>
195       </component>
196       <component>
197         <section>
198           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
199           <code code="29545-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Physical findings Narrative"/>
200           <title>HALLAZGOS EXAMEN F�SICO</title>
201           <text>SE EVIDENCIA UN FUERTE DOLOR DE CABEZA DURANTE EL EXAMEN REALIZADO </text>
202         </section>
203       </component>
204       <component>
205         <section>
206           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
207           <code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
208           <title>DIAGNOSTICO PRESUNTIVO INGRESO</title>
209           <text>G441 Cefalea vascular, NCOP</text>
210         </section>
211       </component>
212       <component>
213         <section>
214           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
215           <code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
216           <title>DIAGNOSTICO RELACIONADO INGRESO</title>
217           <text>R51X Cefalea</text>
218         </section>
219       </component>
220       <component>
221         <section>
222           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
223           <code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
224           <title>DIAGNOSTICO CONFIRMADO INGRESO</title>
225           <text>G442 Cefalea debida a tension</text>
226         </section>
227       </component>
228       <component>
229         <section>
230           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
231           <code code="86922-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Therapeutic goals panel"/>
232           <title>CONDUCTA: MANEJO TERAP�UTICO</title>
233           <text>SE LE RECOMIENDA ANTIINFLAMATORIOS Y REPOSO</text>
234         </section>
235       </component>
236       <component>
237         <section>
238           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
239           <code code="11506-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Progress note"/>
240           <title>NOTA DE PROGRESO</title>
241           <text>SE EVIDENCIA UNA MEJORA EN LA SALUD DEL USUARIO</text>
242         </section>
243       </component>
244       <component>
245         <section>
246           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
247           <code code="29554-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure Narrative"/>
248           <title>RESULTADO DE PROCEDIMIENTOS</title>
249           <text>LOS PROCEDIMIENTOS MUESTRAN UN NORMAL RESULTADO</text>
250         </section>
251       </component>
252       <component>
253         <section>
254           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
255           <code code="59768-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure indications"/>
256           <title>INDICACIONES TERAP�UTICAS</title>
257           <text>SE PROCEDE A SUPENDER LOS MEDICAMENTOS Y SE RECOMIENDA REPOSO</text>
258         </section>
259       </component>
260       <component>
261         <section>
262           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
263           <code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
264           <title>DIAGNOSTICO PRESUNTIVO EGRESO</title>
265           <text>H104 Conjuntivitis cronica</text>
266         </section>
267       </component>
268       <component>
269         <section>
270           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
271           <code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
272           <title>DIAGNOSTICO RELACIONADO EGRESO</title>
273           <text>G443 Cefalea postraumatica cronica</text>
274         </section>
275       </component>
276       <component>
277         <section>
278           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
279           <code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
280           <title>DIAGNOSTICO CONFIRMADO EGRESO</title>
281           <text>G442 Cefalea debida a tension</text>
282         </section>
283       </component>
284       <component>
285         <section>
286           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
287           <code code="18842-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Discharge summary"/>
288           <title>PLAN DE MANEJO AMBULATORIO</title>
289           <text>SE RECOMIENDA TOTAL REPOSO </text>
290         </section>
291       </component>
292     </structuredBody>
293   </component>
294 </ClinicalDocument>