The following content has been modified for better visualization. Validation will be performed on original content
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<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:nphies="urn:oid:2.16.840.1.113883.3.3731.1.2.2.11111111111110" xmlns:pharm="urn:ihe:pharm" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
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<realmCode code="SA"/>
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<code code="18842-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Discharge Summary"/>
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<title>Discharge Summary</title>
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<effectiveTime value="20210602080000+0300"/>
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<recordTarget>
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<patientRole>
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<id extension="30000999999999" root="2.16.840.1.113883.3.3731.1.1.100.1"/>
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<addr>
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<streetAddressLine>2448 Zarga Alyamamah St</streetAddressLine>
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<city>Riyadh</city>
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<postalCode>13337</postalCode>
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<country>Saudi Arabia</country>
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| 24 |
</addr>
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<telecom value="tel:+974.143.47333"/>
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<patient>
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<name use="L ABC">
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<family>ALQAHTANI</family>
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<given>YAHYA</given>
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<given>SAEED A</given>
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<suffix>Jr</suffix>
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</name>
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<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>
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<birthTime value="19761230"/>
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<maritalStatusCode code="S" codeSystem="2.16.840.1.113883.5.2" displayName="Single"/>
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<guardian>
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<addr>
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<streetAddressLine>1234 Guardian St</streetAddressLine>
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<city>Riyadh</city>
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<postalCode>13337</postalCode>
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<country>Saudi Arabia</country>
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</addr>
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<telecom value="tel:+974.143.2345678"/>
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| 45 |
<guardianPerson>
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| 46 |
<name>ALQAHTANI Heba (mother)</name>
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| 47 |
</guardianPerson>
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</guardian>
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<languageCommunication>
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<languageCode code="ara"/>
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</languageCommunication>
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</patient>
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</patientRole>
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</recordTarget>
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<author>
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<functionCode code="100000003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Medicine and Surgery"/>
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<time value="20130829124538+0300"/>
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<assignedAuthor>
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<id extension="05RM14422" root="2.16.840.1.113883.3.3731.1.2.1"/>
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<code code="179D7C6B-62F9-E811-B80F-005056AD2FD8" codeSystem="2.16.840.1.113883.3.3731.1.202.5" codeSystemName="Healthcare Specialty Identifier" displayName="Obstetrics and Gynecology"/>
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<addr>
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| 64 |
<streetAddressLine>3920 Mathar Alshibani St</streetAddressLine>
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| 65 |
<city>Riyadh</city>
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| 66 |
<postalCode>12629</postalCode>
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| 67 |
<country>Saudi Arabia</country>
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| 68 |
</addr>
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<telecom value="tel:+966920011223"/>
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<assignedPerson>
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| 71 |
<name>
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| 72 |
<prefix>Dr</prefix>
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<family>Khan</family>
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<given>Aditya</given>
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</name>
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</assignedPerson>
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<representedOrganization>
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<id extension="11000000002333" root="2.16.840.1.113883.3.3731.1.2.2"/>
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<name>International University Hospital</name>
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<telecom nullFlavor="NI"/>
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<addr nullFlavor="NI"/>
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</representedOrganization>
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</assignedAuthor>
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</author>
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<custodian>
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<assignedCustodian>
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<representedCustodianOrganization>
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<templateId root="2.16.840.1.113883.3.3731.1.203.28.4"/>
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<id extension="11000000002333" root="2.16.840.1.113883.3.3731.1.2.2"/>
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<name>International University Hospital</name>
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<telecom value="tel:+966920011223"/>
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| 95 |
<addr>
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<streetAddressLine>3920 Mathar Alshibani St</streetAddressLine>
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<city>Riyadh</city>
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<postalCode>12629</postalCode>
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<country>Saudi Arabia</country>
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</addr>
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</representedCustodianOrganization>
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</assignedCustodian>
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</custodian>
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<legalAuthenticator>
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<time value="20210602123500+0300"/>
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<signatureCode code="S"/>
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<id extension="13KA0054149" root="2.16.840.1.113883.3.3731.1.2.1"/>
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<addr nullFlavor="NI"/>
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<telecom nullFlavor="NI"/>
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<assignedPerson>
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<name use="L">
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<prefix>Dr.</prefix>
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<family>GOPAL</family>
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<given>Arjun</given>
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</name>
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</assignedPerson>
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</assignedEntity>
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</legalAuthenticator>
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<participant typeCode="SBJ">
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<associatedEntity classCode="CIT">
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<code code="SAU" codeSystem="1.0.3166.1"/>
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</associatedEntity>
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</participant>
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<documentationOf>
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<serviceEvent>
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<performer typeCode="PRF">
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<time value="20210602123500+0300"/>
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<assignedEntity>
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<id extension="17JP0032773" root="2.16.840.1.113883.3.3731.1.2.1"/>
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<addr nullFlavor="NI"/>
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<telecom nullFlavor="NI"/>
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<assignedPerson>
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<name>
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<family>PARAMEDIC</family>
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<given>Osama</given>
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</name>
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</assignedPerson>
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</assignedEntity>
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</performer>
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</serviceEvent>
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</documentationOf>
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<componentOf>
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<encompassingEncounter>
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<code code="D" codeSystem="2.16.840.1.113883.18.5" codeSystemName="HL7 Patient Class" displayName="Inpatient Daycase"/>
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<effectiveTime>
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<low value="20130829060525+0300"/>
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<high value="20130829124538+0300"/>
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</effectiveTime>
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<location>
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<healthCareFacility>
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<id extension="11000000002333" root="2.16.840.1.113883.3.3731.1.2.2"/>
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<serviceProviderOrganization>
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<name>International University Hospital</name>
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</serviceProviderOrganization>
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</healthCareFacility>
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</location>
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</encompassingEncounter>
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</componentOf>
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<component>
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<structuredBody>
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<component>
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<section>
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<templateId root="2.16.840.1.113883.3.3731.1.210.100.1"/>
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<code code="10154-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="CHIEF COMPLAINT"/>
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<title>Chief Complaint</title>
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<text>
|
| 205 |
This is the chief complaint of the patient.
|
| 206 |
</text>
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</section>
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</component>
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<component>
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<section>
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<templateId root="2.16.840.1.113883.3.3731.1.210.100.17"/>
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.3"/>
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<code code="46241-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HOSPITAL ADMISSION DX"/>
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<title>Admitting Diagnosis</title>
|
| 222 |
<text>
|
| 223 |
<table>
|
| 224 |
<thead>
|
| 225 |
<tr>
|
| 226 |
<th>Diagnosis</th>
|
| 227 |
<th>Date from</th>
|
| 228 |
<th>Date to</th>
|
| 229 |
<th>Status</th>
|
| 230 |
</tr>
|
| 231 |
</thead>
|
| 232 |
<tbody>
|
| 233 |
<tr ID="admdiag-1">
|
| 234 |
<td ID="admdiag-1_diagnosis">M25.46, Effusion of joint, lower leg</td>
|
| 235 |
<td>2021.01.23</td>
|
| 236 |
<td>-</td>
|
| 237 |
<td>Active</td>
|
| 238 |
</tr>
|
| 239 |
</tbody>
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</table>
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</text>
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<entry typeCode="DRIV">
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<act classCode="ACT" moodCode="EVN">
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<templateId root="2.16.840.1.113883.3.3731.1.210.100.43"/>
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.1"/>
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.2"/>
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<templateId root="2.16.840.1.113883.10.20.1.27"/>
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<id nullFlavor="NI"/>
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<code nullFlavor="NA"/>
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<statusCode code="active"/>
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<effectiveTime>
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<low value="20210123"/>
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</effectiveTime>
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<entryRelationship inversionInd="false" typeCode="SUBJ">
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<observation classCode="OBS" moodCode="EVN">
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<templateId root="2.16.840.1.113883.3.3731.1.210.100.44"/>
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>
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<templateId root="2.16.840.1.113883.10.20.1.28"/>
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<id root="DBA414DE-6B92-4D74-30D1-46BC36770F79"/>
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<code code="282291009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Diagnosis"/>
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<text>
|
| 262 |
<reference value="#admdiag-1"/>
|
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</text>
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<statusCode code="completed"/>
|
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<effectiveTime>
|
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<low value="20210123"/>
|
| 267 |
</effectiveTime>
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<value code="M25.46" codeSystem="2.16.840.1.113883.6.135" codeSystemName="ICD10-AM" displayName="Effusion of joint, lower leg" xsi:type="CD">
|
| 269 |
<originalText>
|
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<reference value="#admdiag-1_diagnosis"/>
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</originalText>
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</value>
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</observation>
|
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</entryRelationship>
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</act>
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</entry>
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</section>
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</component>
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|
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|
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|
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<component>
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<section>
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<templateId root="2.16.840.1.113883.3.3731.1.210.100.4"/>
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.4"/>
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<code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PRESENT ILLNESS"/>
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| 292 |
<title>History of Present Illness</title>
|
| 293 |
<text>
|
| 294 |
This is the history of the present illness of the patient.
|
| 295 |
</text>
|
| 296 |
</section>
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</component>
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| 299 |
|
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| 301 |
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<component>
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<section>
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<templateId root="2.16.840.1.113883.3.3731.1.210.100.8"/>
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.13"/>
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<templateId root="2.16.840.1.113883.10.20.1.2"/>
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<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ALLERGIES, ADVERSE REACTIONS, ALERTS"/>
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| 311 |
<title>Allergies and Adverse Reactions</title>
|
| 312 |
<text>
|
| 313 |
<table>
|
| 314 |
<thead>
|
| 315 |
<tr>
|
| 316 |
<th>Allergy Type</th>
|
| 317 |
<th>Allergy Substance</th>
|
| 318 |
<th>Date from</th>
|
| 319 |
<th>Date to</th>
|
| 320 |
<th>Status</th>
|
| 321 |
</tr>
|
| 322 |
</thead>
|
| 323 |
<tbody>
|
| 324 |
<tr ID="allergy-1">
|
| 325 |
<td ID="allergy-1_type">ALG, Allergy (other than drug or food)</td>
|
| 326 |
<td ID="allergy-1_substance">427618005, Dextroamphetamine</td>
|
| 327 |
<td>Unknown</td>
|
| 328 |
<td>-</td>
|
| 329 |
<td>Active</td>
|
| 330 |
</tr>
|
| 331 |
</tbody>
|
| 332 |
</table>
|
| 333 |
</text>
|
| 334 |
<entry typeCode="DRIV">
|
| 335 |
<act classCode="ACT" moodCode="EVN">
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<templateId root="2.16.840.1.113883.3.3731.1.210.100.51"/>
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.1"/>
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.3"/>
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<templateId root="2.16.840.1.113883.10.20.1.27"/>
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| 340 |
<id nullFlavor="NI"/>
|
| 341 |
<code nullFlavor="NA"/>
|
| 342 |
<statusCode code="active"/>
|
| 343 |
|
| 344 |
<effectiveTime>
|
| 345 |
<low nullFlavor="UNK"/>
|
| 346 |
</effectiveTime>
|
| 347 |
<entryRelationship inversionInd="false" typeCode="SUBJ">
|
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<observation classCode="OBS" moodCode="EVN">
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<templateId root="2.16.840.1.113883.3.3731.1.210.100.52"/>
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.6"/>
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<templateId root="2.16.840.1.113883.10.20.1.18"/>
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<id root="DBA414DE-6B92-4D74-30D1-46BC36770F79"/>
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<code code="ALG" codeSystem="2.16.840.1.113883.5.4" codeSystemName="HL7 ActCodes" displayName="Allergy (other than drug or food)">
|
| 355 |
<originalText>
|
| 356 |
<reference value="#allergy-1_type"/>
|
| 357 |
</originalText>
|
| 358 |
</code>
|
| 359 |
<text>
|
| 360 |
<reference value="#allergy-1"/>
|
| 361 |
</text>
|
| 362 |
<statusCode code="completed"/>
|
| 363 |
<effectiveTime>
|
| 364 |
<low nullFlavor="UNK"/>
|
| 365 |
</effectiveTime>
|
| 366 |
<value nullFlavor="NA" xsi:type="CD"/>
|
| 367 |
<participant typeCode="CSM">
|
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<participantRole classCode="MANU">
|
| 369 |
<playingEntity classCode="MMAT">
|
| 370 |
<code code="427618005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Dextroamphetamine">
|
| 371 |
<originalText>
|
| 372 |
<reference value="#allergy-1_substance"/>
|
| 373 |
</originalText>
|
| 374 |
</code>
|
| 375 |
</playingEntity>
|
| 376 |
</participantRole>
|
| 377 |
</participant>
|
| 378 |
</observation>
|
| 379 |
</entryRelationship>
|
| 380 |
</act>
|
| 381 |
</entry>
|
| 382 |
</section>
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| 383 |
</component>
|
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|
| 385 |
|
| 386 |
|
| 387 |
|
| 388 |
|
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|
| 390 |
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|
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<component>
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<section>
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<templateId root="2.16.840.1.113883.3.3731.1.210.100.3"/>
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.6"/>
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<templateId root="2.16.840.1.113883.10.20.1.11"/>
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| 399 |
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROBLEM LIST"/>
|
| 400 |
<title>Active problems</title>
|
| 401 |
<text>
|
| 402 |
<table>
|
| 403 |
<thead>
|
| 404 |
<tr>
|
| 405 |
<th>Diagnosis</th>
|
| 406 |
<th>Date from</th>
|
| 407 |
<th>Date to</th>
|
| 408 |
<th>Status</th>
|
| 409 |
</tr>
|
| 410 |
</thead>
|
| 411 |
<tbody>
|
| 412 |
<tr ID="actproblem-1">
|
| 413 |
<td ID="actproblem-1_diagnosis">160245001, No current problems or disability</td>
|
| 414 |
<td>-</td>
|
| 415 |
<td>-</td>
|
| 416 |
<td>Completed</td>
|
| 417 |
</tr>
|
| 418 |
</tbody>
|
| 419 |
</table>
|
| 420 |
</text>
|
| 421 |
<entry typeCode="DRIV">
|
| 422 |
<act classCode="ACT" moodCode="EVN">
|
| 423 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.43"/>
|
| 424 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.1"/>
|
| 425 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.2"/>
|
| 426 |
<templateId root="2.16.840.1.113883.10.20.1.27"/>
|
| 427 |
<id nullFlavor="NI"/>
|
| 428 |
<code nullFlavor="NA"/>
|
| 429 |
<statusCode code="completed"/>
|
| 430 |
<effectiveTime nullFlavor="NA">
|
| 431 |
<low nullFlavor="UNK"/>
|
| 432 |
<high nullFlavor="UNK"/>
|
| 433 |
</effectiveTime>
|
| 434 |
<entryRelationship inversionInd="false" typeCode="SUBJ">
|
| 435 |
<observation classCode="OBS" moodCode="EVN">
|
| 436 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.44"/>
|
| 437 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>
|
| 438 |
<templateId root="2.16.840.1.113883.10.20.1.28"/>
|
| 439 |
<id root="DBA414DE-6B92-4D74-30D1-46BC36770F79"/>
|
| 440 |
<code code="282291009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Diagnosis"/>
|
| 441 |
<text>
|
| 442 |
<reference value="#actproblem-1"/>
|
| 443 |
</text>
|
| 444 |
<statusCode code="completed"/>
|
| 445 |
<effectiveTime nullFlavor="NA">
|
| 446 |
<low nullFlavor="UNK"/>
|
| 447 |
<high nullFlavor="UNK"/>
|
| 448 |
</effectiveTime>
|
| 449 |
<value code="160245001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="No current problems or disability" xsi:type="CD">
|
| 450 |
<originalText>
|
| 451 |
<reference value="#actproblem-1_diagnosis"/>
|
| 452 |
</originalText>
|
| 453 |
</value>
|
| 454 |
</observation>
|
| 455 |
</entryRelationship>
|
| 456 |
</act>
|
| 457 |
</entry>
|
| 458 |
</section>
|
| 459 |
</component>
|
| 460 |
|
| 461 |
|
| 462 |
|
| 463 |
|
| 464 |
|
| 465 |
|
| 466 |
|
| 467 |
<component>
|
| 468 |
<section>
|
| 469 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.16"/>
|
| 470 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.20"/>
|
| 471 |
<code code="42346-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MEDICATIONS ON ADMISSION"/>
|
| 472 |
<title>Medications History on Admission</title>
|
| 473 |
<text>
|
| 474 |
<table ID="medadmission-1">
|
| 475 |
<tbody>
|
| 476 |
<tr>
|
| 477 |
<td>Medication Item</td>
|
| 478 |
<td>1</td>
|
| 479 |
</tr>
|
| 480 |
<tr>
|
| 481 |
<td>Medication ID</td>
|
| 482 |
<td>CE1215CD-69EC-4C7B-805F-569233C5E159</td>
|
| 483 |
</tr>
|
| 484 |
<tr>
|
| 485 |
<td>Medication Name</td>
|
| 486 |
<td>cardex 5 mg tablet</td>
|
| 487 |
</tr>
|
| 488 |
<tr>
|
| 489 |
<td>Medication Code</td>
|
| 490 |
<td>
|
| 491 |
<content ID="medadmission-1_prodcode">240102-0222-6410-02-04</content>
|
| 492 |
</td>
|
| 493 |
</tr>
|
| 494 |
<tr>
|
| 495 |
<td>Pharmaceutical Dose Form</td>
|
| 496 |
<td>
|
| 497 |
<content ID="medadmission-1_doseform">6410 - tablet, film coated</content>
|
| 498 |
</td>
|
| 499 |
</tr>
|
| 500 |
<tr>
|
| 501 |
<td>Start / End / Duration of treatment</td>
|
| 502 |
<td>for 3 weeks</td>
|
| 503 |
</tr>
|
| 504 |
<tr>
|
| 505 |
<td>Dose / Frequency</td>
|
| 506 |
<td>
|
| 507 |
<content ID="medadmission-1_dose">4 tablets</content> / 2 times per day
|
| 508 |
</td>
|
| 509 |
</tr>
|
| 510 |
<tr>
|
| 511 |
<td>Route of Administration</td>
|
| 512 |
<td>
|
| 513 |
<content ID="medadmission-1_route">oral route</content>
|
| 514 |
</td>
|
| 515 |
</tr>
|
| 516 |
<tr>
|
| 517 |
<td>Approach Site</td>
|
| 518 |
<td>-</td>
|
| 519 |
</tr>
|
| 520 |
<tr>
|
| 521 |
<td>Patient Medication Instructions</td>
|
| 522 |
<td>
|
| 523 |
<content ID="medadmission-1_pinstruct">4 tablets, 2 times per day, for 3 weeks, oral route, with plenty of water</content>
|
| 524 |
</td>
|
| 525 |
</tr>
|
| 526 |
</tbody>
|
| 527 |
</table>
|
| 528 |
<table ID="medadmission-2">
|
| 529 |
<tbody>
|
| 530 |
<tr>
|
| 531 |
<td>Medication Item</td>
|
| 532 |
<td>2</td>
|
| 533 |
</tr>
|
| 534 |
<tr>
|
| 535 |
<td>Medication ID</td>
|
| 536 |
<td>CE1215CD-69EC-4C7B-805F-569233C5E158</td>
|
| 537 |
</tr>
|
| 538 |
<tr>
|
| 539 |
<td>Medication Name</td>
|
| 540 |
<td>croma 40 and 0.5 mg/ml solution/ drops</td>
|
| 541 |
</tr>
|
| 542 |
<tr>
|
| 543 |
<td>Medication Code</td>
|
| 544 |
<td>
|
| 545 |
<content ID="medadmission-2_prodcode">800402-0130-5406-01-06</content>
|
| 546 |
</td>
|
| 547 |
</tr>
|
| 548 |
<tr>
|
| 549 |
<td>Pharmaceutical Dose Form</td>
|
| 550 |
<td>
|
| 551 |
<content ID="medadmission-2_doseform">5406 - solution/ drops</content>
|
| 552 |
</td>
|
| 553 |
</tr>
|
| 554 |
<tr>
|
| 555 |
<td>Start / End / Duration of treatment</td>
|
| 556 |
<td>from 2021.01.23 to 2021.01.26</td>
|
| 557 |
</tr>
|
| 558 |
<tr>
|
| 559 |
<td>Dose / Frequency</td>
|
| 560 |
<td>
|
| 561 |
<content ID="medadmission-2_dosecomp-1">Morning (before breakfast):
|
| 562 |
<content ID="medadmission-2_dosequantity-1">1 drop(s)</content>
|
| 563 |
</content>
|
| 564 |
<content ID="medadmission-2_dosecomp-2">Evening (before dinner):
|
| 565 |
<content ID="medadmission-2_dosequantity-2">2 drop(s)</content>
|
| 566 |
</content>
|
| 567 |
</td>
|
| 568 |
</tr>
|
| 569 |
<tr>
|
| 570 |
<td>Route of Administration</td>
|
| 571 |
<td>
|
| 572 |
<content ID="medadmission-2_route">ophthalmic route</content>
|
| 573 |
</td>
|
| 574 |
</tr>
|
| 575 |
<tr>
|
| 576 |
<td>Approach Site</td>
|
| 577 |
<td>
|
| 578 |
<content ID="medadmission-2_approach">both eyes</content>
|
| 579 |
</td>
|
| 580 |
</tr>
|
| 581 |
<tr>
|
| 582 |
<td>Patient Medication Instructions</td>
|
| 583 |
<td>
|
| 584 |
<content ID="medadmission-2_pinstruct">Morning (before breakfast): 1 drop(s) and Evening (before dinner): 2 drop(s), from 2021.01.23 to 2021.01.26, ophthalmic route, both eyes</content>
|
| 585 |
</td>
|
| 586 |
</tr>
|
| 587 |
</tbody>
|
| 588 |
</table>
|
| 589 |
</text>
|
| 590 |
<entry typeCode="DRIV">
|
| 591 |
|
| 592 |
|
| 593 |
|
| 594 |
|
| 595 |
|
| 596 |
|
| 597 |
|
| 598 |
<substanceAdministration classCode="SBADM" moodCode="INT">
|
| 599 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.45"/>
|
| 600 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7"/>
|
| 601 |
<templateId root="2.16.840.1.113883.10.20.1.24"/>
|
| 602 |
|
| 603 |
|
| 604 |
|
| 605 |
|
| 606 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.46"/>
|
| 607 |
<templateId root="1.3.6.1.4.1.19376.1.9.1.3.6"/>
|
| 608 |
|
| 609 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.1"/>
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| 610 |
|
| 611 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.21"/>
|
| 612 |
|
| 613 |
<id root="CE1215CD-69EC-4C7B-805F-569233C5E159"/>
|
| 614 |
<text>
|
| 615 |
<reference value="#medadmission-1"/>
|
| 616 |
</text>
|
| 617 |
<statusCode code="completed"/>
|
| 618 |
|
| 619 |
<effectiveTime xsi:type="IVL_TS">
|
| 620 |
|
| 621 |
<width unit="wk" value="3"/>
|
| 622 |
</effectiveTime>
|
| 623 |
|
| 624 |
<effectiveTime institutionSpecified="true" operator="A" xsi:type="PIVL_TS">
|
| 625 |
|
| 626 |
<period unit="d" value="2"/>
|
| 627 |
</effectiveTime>
|
| 628 |
|
| 629 |
<routeCode code="26643006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="oral route">
|
| 630 |
<originalText>
|
| 631 |
<reference value="#medadmission-1_route"/>
|
| 632 |
</originalText>
|
| 633 |
</routeCode>
|
| 634 |
|
| 635 |
<doseQuantity unit="{tablet}" value="4">
|
| 636 |
<translation>
|
| 637 |
<originalText>
|
| 638 |
<reference value="#medadmission-1_dose"/>
|
| 639 |
</originalText>
|
| 640 |
</translation>
|
| 641 |
</doseQuantity>
|
| 642 |
|
| 643 |
<consumable>
|
| 644 |
<manufacturedProduct classCode="MANU">
|
| 645 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.2"/>
|
| 646 |
<templateId root="2.16.840.1.113883.10.20.1.53"/>
|
| 647 |
<manufacturedMaterial classCode="MMAT" determinerCode="KIND">
|
| 648 |
<code code="240102-0222-6410-02-04" codeSystem="2.16.840.1.113883.3.3731.1.205.2" codeSystemName="KSA Dispensation Pharmacy Item Name" displayName="cardex 5 mg tablet">
|
| 649 |
<originalText>
|
| 650 |
<reference value="#medadmission-1_prodcode"/>
|
| 651 |
</originalText>
|
| 652 |
</code>
|
| 653 |
<name>cardex 5 mg tablet</name>
|
| 654 |
<pharm:formCode code="6410" codeSystem="2.16.840.1.113883.3.3731.1.205.8" codeSystemName="KSA Medication Pharmaceutical Dose Form" displayName="tablet, film coated">
|
| 655 |
<originalText>
|
| 656 |
<reference value="#medadmission-1_doseform"/>
|
| 657 |
</originalText>
|
| 658 |
</pharm:formCode>
|
| 659 |
<pharm:ingredient classCode="ACTI">
|
| 660 |
<pharm:quantity>
|
| 661 |
<numerator unit="mg" value="5" xsi:type="PQ"/>
|
| 662 |
<denominator value="1" xsi:type="INT"/>
|
| 663 |
</pharm:quantity>
|
| 664 |
</pharm:ingredient>
|
| 665 |
</manufacturedMaterial>
|
| 666 |
</manufacturedProduct>
|
| 667 |
</consumable>
|
| 668 |
|
| 669 |
<entryRelationship inversionInd="true" typeCode="SUBJ">
|
| 670 |
<act classCode="ACT" moodCode="INT">
|
| 671 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.3"/>
|
| 672 |
<templateId root="2.16.840.1.113883.10.20.1.49"/>
|
| 673 |
<code code="PINSTRUCT" codeSystem="1.3.6.1.4.1.19376.1.5.3.2" codeSystemName="IHEActCode"/>
|
| 674 |
<text>
|
| 675 |
<reference value="#medadmission-1_pinstruct"/>
|
| 676 |
</text>
|
| 677 |
<statusCode code="completed"/>
|
| 678 |
</act>
|
| 679 |
</entryRelationship>
|
| 680 |
</substanceAdministration>
|
| 681 |
</entry>
|
| 682 |
<entry typeCode="DRIV">
|
| 683 |
|
| 684 |
|
| 685 |
|
| 686 |
|
| 687 |
|
| 688 |
|
| 689 |
|
| 690 |
<substanceAdministration classCode="SBADM" moodCode="EVN">
|
| 691 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.45"/>
|
| 692 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7"/>
|
| 693 |
<templateId root="2.16.840.1.113883.10.20.1.24"/>
|
| 694 |
|
| 695 |
|
| 696 |
|
| 697 |
|
| 698 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.47"/>
|
| 699 |
<templateId root="1.3.6.1.4.1.19376.1.9.1.3.6"/>
|
| 700 |
|
| 701 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.9"/>
|
| 702 |
|
| 703 |
<id root="CE1215CD-69EC-4C7B-805F-569233C5E158"/>
|
| 704 |
<text>
|
| 705 |
<reference value="#medadmission-2"/>
|
| 706 |
</text>
|
| 707 |
<statusCode code="completed"/>
|
| 708 |
|
| 709 |
<effectiveTime xsi:type="IVL_TS">
|
| 710 |
<low value="20210123"/>
|
| 711 |
<high value="20210126"/>
|
| 712 |
</effectiveTime>
|
| 713 |
|
| 714 |
<routeCode code="54485002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="ophthalmic route">
|
| 715 |
<originalText>
|
| 716 |
<reference value="#medadmission-2_route"/>
|
| 717 |
</originalText>
|
| 718 |
</routeCode>
|
| 719 |
|
| 720 |
<approachSiteCode code="362508001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="both eyes">
|
| 721 |
<originalText>
|
| 722 |
<reference value="#medadmission-2_approach"/>
|
| 723 |
</originalText>
|
| 724 |
</approachSiteCode>
|
| 725 |
|
| 726 |
<consumable>
|
| 727 |
<manufacturedProduct classCode="MANU">
|
| 728 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.2"/>
|
| 729 |
<templateId root="2.16.840.1.113883.10.20.1.53"/>
|
| 730 |
<manufacturedMaterial classCode="MMAT" determinerCode="KIND">
|
| 731 |
<code code="800402-0130-5406-01-06" codeSystem="2.16.840.1.113883.3.3731.1.205.2" codeSystemName="KSA Dispensation Pharmacy Item Name" displayName="croma 40 and 0.5 mg/ml solution/ drops">
|
| 732 |
<originalText>
|
| 733 |
<reference value="#medadmission-2_prodcode"/>
|
| 734 |
</originalText>
|
| 735 |
</code>
|
| 736 |
<name>croma 40 and 0.5 mg/ml solution/ drops</name>
|
| 737 |
<pharm:formCode code="5406" codeSystem="2.16.840.1.113883.3.3731.1.205.8" codeSystemName="KSA Medication Pharmaceutical Dose Form" displayName="solution/ drops">
|
| 738 |
<originalText>
|
| 739 |
<reference value="#medadmission-2_formcode"/>
|
| 740 |
</originalText>
|
| 741 |
</pharm:formCode>
|
| 742 |
|
| 743 |
</manufacturedMaterial>
|
| 744 |
</manufacturedProduct>
|
| 745 |
</consumable>
|
| 746 |
|
| 747 |
<entryRelationship typeCode="COMP">
|
| 748 |
|
| 749 |
<sequenceNumber value="1"/>
|
| 750 |
<substanceAdministration classCode="SBADM" moodCode="INT">
|
| 751 |
<text>
|
| 752 |
<reference value="#medadmission-2_dosecomp-1"/>
|
| 753 |
</text>
|
| 754 |
<effectiveTime xsi:type="EIVL_TS">
|
| 755 |
<event code="ACM"/>
|
| 756 |
<offset unit="s" value="0"/>
|
| 757 |
</effectiveTime>
|
| 758 |
<doseQuantity unit="{drop}" value="1">
|
| 759 |
<translation>
|
| 760 |
<originalText>
|
| 761 |
<reference value="#medadmission-2_dosequantity-1"/>
|
| 762 |
</originalText>
|
| 763 |
</translation>
|
| 764 |
</doseQuantity>
|
| 765 |
<consumable>
|
| 766 |
<manufacturedProduct>
|
| 767 |
<manufacturedMaterial nullFlavor="NA"/>
|
| 768 |
</manufacturedProduct>
|
| 769 |
</consumable>
|
| 770 |
</substanceAdministration>
|
| 771 |
</entryRelationship>
|
| 772 |
<entryRelationship typeCode="COMP">
|
| 773 |
|
| 774 |
<sequenceNumber value="2"/>
|
| 775 |
<substanceAdministration classCode="SBADM" moodCode="INT">
|
| 776 |
<text>
|
| 777 |
<reference value="#medadmission-2_dosecomp-2"/>
|
| 778 |
</text>
|
| 779 |
<effectiveTime xsi:type="EIVL_TS">
|
| 780 |
<event code="ACV"/>
|
| 781 |
<offset unit="s" value="0"/>
|
| 782 |
</effectiveTime>
|
| 783 |
<doseQuantity unit="{drop}" value="2">
|
| 784 |
<translation>
|
| 785 |
<originalText>
|
| 786 |
<reference value="#medadmission-2_dosequantity-2"/>
|
| 787 |
</originalText>
|
| 788 |
</translation>
|
| 789 |
</doseQuantity>
|
| 790 |
<consumable>
|
| 791 |
<manufacturedProduct>
|
| 792 |
<manufacturedMaterial nullFlavor="NA"/>
|
| 793 |
</manufacturedProduct>
|
| 794 |
</consumable>
|
| 795 |
</substanceAdministration>
|
| 796 |
</entryRelationship>
|
| 797 |
|
| 798 |
<entryRelationship inversionInd="true" typeCode="SUBJ">
|
| 799 |
<act classCode="ACT" moodCode="INT">
|
| 800 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.3"/>
|
| 801 |
<templateId root="2.16.840.1.113883.10.20.1.49"/>
|
| 802 |
<code code="PINSTRUCT" codeSystem="1.3.6.1.4.1.19376.1.5.3.2" codeSystemName="IHEActCode"/>
|
| 803 |
<text>
|
| 804 |
<reference value="#medadmission-2_pinstruct"/>
|
| 805 |
</text>
|
| 806 |
<statusCode code="completed"/>
|
| 807 |
</act>
|
| 808 |
</entryRelationship>
|
| 809 |
</substanceAdministration>
|
| 810 |
</entry>
|
| 811 |
</section>
|
| 812 |
</component>
|
| 813 |
|
| 814 |
|
| 815 |
|
| 816 |
|
| 817 |
|
| 818 |
|
| 819 |
|
| 820 |
<component>
|
| 821 |
<section>
|
| 822 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.14"/>
|
| 823 |
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="STUDIES SUMMARY"/>
|
| 824 |
<title>Blood Group Test Results</title>
|
| 825 |
<text>
|
| 826 |
<table>
|
| 827 |
<tbody>
|
| 828 |
<tr>
|
| 829 |
<td>Code</td>
|
| 830 |
<td>Blood group</td>
|
| 831 |
</tr>
|
| 832 |
<tr ID="bloodgroup">
|
| 833 |
<td ID="bloodgroup_code">278147001</td>
|
| 834 |
<td>Blood group O Rh(D) positive</td>
|
| 835 |
</tr>
|
| 836 |
</tbody>
|
| 837 |
</table>
|
| 838 |
</text>
|
| 839 |
<entry typeCode="DRIV">
|
| 840 |
<observation classCode="OBS" moodCode="DEF">
|
| 841 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.56"/>
|
| 842 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
|
| 843 |
<id root="CE1215CD-69EC-4C7B-805F-569233C5E1510"/>
|
| 844 |
<code code="882-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ABO and Rh group [Type] in Blood"/>
|
| 845 |
<text>
|
| 846 |
<reference value="#bloodgroup"/>
|
| 847 |
</text>
|
| 848 |
<statusCode code="completed"/>
|
| 849 |
<effectiveTime value="20210730083000+0300"/>
|
| 850 |
<value code="278147001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Blood group O Rh(D) positive" xsi:type="CD">
|
| 851 |
<originalText>
|
| 852 |
<reference value="#bloodgroup_code"/>
|
| 853 |
</originalText>
|
| 854 |
</value>
|
| 855 |
</observation>
|
| 856 |
</entry>
|
| 857 |
</section>
|
| 858 |
</component>
|
| 859 |
|
| 860 |
|
| 861 |
|
| 862 |
|
| 863 |
|
| 864 |
|
| 865 |
|
| 866 |
<component>
|
| 867 |
<section>
|
| 868 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.21"/>
|
| 869 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.5"/>
|
| 870 |
<code code="8648-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HOSPITAL COURSE"/>
|
| 871 |
<title>Hospital Course</title>
|
| 872 |
<text>
|
| 873 |
This is the narrative description of the hospital course
|
| 874 |
</text>
|
| 875 |
</section>
|
| 876 |
</component>
|
| 877 |
|
| 878 |
|
| 879 |
|
| 880 |
|
| 881 |
|
| 882 |
|
| 883 |
|
| 884 |
<component>
|
| 885 |
<section>
|
| 886 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.7"/>
|
| 887 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.12"/>
|
| 888 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.11"/>
|
| 889 |
<templateId root="2.16.840.1.113883.10.20.1.12"/>
|
| 890 |
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PROCEDURES"/>
|
| 891 |
<title>List of Surgeries</title>
|
| 892 |
<text>
|
| 893 |
<table>
|
| 894 |
<thead>
|
| 895 |
<tr>
|
| 896 |
<th>Procedure</th>
|
| 897 |
<th>Date from</th>
|
| 898 |
<th>Date to</th>
|
| 899 |
<th>Status</th>
|
| 900 |
</tr>
|
| 901 |
</thead>
|
| 902 |
<tbody>
|
| 903 |
<tr ID="listofsurgery-1">
|
| 904 |
<td ID="listofsurgery-1_procedure">32123-00, Anoplasty</td>
|
| 905 |
<td>2019.01.23, 10:00:00</td>
|
| 906 |
<td>2019.01.23, 12:30:00</td>
|
| 907 |
<td>Completed</td>
|
| 908 |
</tr>
|
| 909 |
</tbody>
|
| 910 |
</table>
|
| 911 |
</text>
|
| 912 |
<entry typeCode="DRIV">
|
| 913 |
<procedure classCode="PROC" moodCode="EVN">
|
| 914 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.53"/>
|
| 915 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19"/>
|
| 916 |
<templateId root="2.16.840.1.113883.10.20.1.29"/>
|
| 917 |
<id root="DBA414DE-6B92-4D74-30D1-46BC36770F79"/>
|
| 918 |
<code code="32123-00" codeSystem="2.16.840.1.113883.3.3731.50.2" codeSystemName="ACHI" displayName="Anoplasty">
|
| 919 |
<originalText>
|
| 920 |
<reference value="#listofsurgery-1_procedure"/>
|
| 921 |
</originalText>
|
| 922 |
</code>
|
| 923 |
<text>
|
| 924 |
<reference value="#listofsurgery-1"/>
|
| 925 |
</text>
|
| 926 |
<statusCode code="completed"/>
|
| 927 |
<effectiveTime>
|
| 928 |
<low value="20190123100000+0300"/>
|
| 929 |
<high value="20190123123000+0300"/>
|
| 930 |
</effectiveTime>
|
| 931 |
</procedure>
|
| 932 |
</entry>
|
| 933 |
</section>
|
| 934 |
</component>
|
| 935 |
|
| 936 |
|
| 937 |
|
| 938 |
|
| 939 |
|
| 940 |
|
| 941 |
|
| 942 |
<component>
|
| 943 |
<section>
|
| 944 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.12"/>
|
| 945 |
<templateId root="2.16.840.1.113883.10.20.7.13"/>
|
| 946 |
<code code="11537-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="SURGICAL DRAINS"/>
|
| 947 |
<title>Surgical Drains</title>
|
| 948 |
<text>
|
| 949 |
This is the narrative description of surgical drains
|
| 950 |
</text>
|
| 951 |
</section>
|
| 952 |
</component>
|
| 953 |
|
| 954 |
|
| 955 |
|
| 956 |
|
| 957 |
|
| 958 |
|
| 959 |
|
| 960 |
<component>
|
| 961 |
<section>
|
| 962 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.18"/>
|
| 963 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.21"/>
|
| 964 |
<code code="18610-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MEDICATION ADMINISTERED"/>
|
| 965 |
<title>Medications Administered</title>
|
| 966 |
<text>
|
| 967 |
<table ID="medadministered-1">
|
| 968 |
<tbody>
|
| 969 |
<tr>
|
| 970 |
<td>Medication Item</td>
|
| 971 |
<td>1</td>
|
| 972 |
</tr>
|
| 973 |
<tr>
|
| 974 |
<td>Medication ID</td>
|
| 975 |
<td>CE1215CD-69EC-4C7B-805F-569233C5E159</td>
|
| 976 |
</tr>
|
| 977 |
<tr>
|
| 978 |
<td>Medication Name</td>
|
| 979 |
<td>butafyl 1% cream</td>
|
| 980 |
</tr>
|
| 981 |
<tr>
|
| 982 |
<td>Medication Code</td>
|
| 983 |
<td>
|
| 984 |
<content ID="medadministered-1_prodcode">280102-0101-0901-01-18</content>
|
| 985 |
</td>
|
| 986 |
</tr>
|
| 987 |
<tr>
|
| 988 |
<td>Pharmaceutical Dose Form</td>
|
| 989 |
<td>
|
| 990 |
<content ID="medadministered-1_doseform">0901 - cream</content>
|
| 991 |
</td>
|
| 992 |
</tr>
|
| 993 |
<tr>
|
| 994 |
<td>Start / End / Duration of treatment</td>
|
| 995 |
<td>-</td>
|
| 996 |
</tr>
|
| 997 |
<tr>
|
| 998 |
<td>Dose / Frequency</td>
|
| 999 |
<td>-</td>
|
| 1000 |
</tr>
|
| 1001 |
<tr>
|
| 1002 |
<td>Route of Administration</td>
|
| 1003 |
<td>-</td>
|
| 1004 |
</tr>
|
| 1005 |
<tr>
|
| 1006 |
<td>Approach Site</td>
|
| 1007 |
<td>-</td>
|
| 1008 |
</tr>
|
| 1009 |
<tr>
|
| 1010 |
<td>Patient Medication Instructions</td>
|
| 1011 |
<td>
|
| 1012 |
<content ID="medadministered-1_pinstruct">cream was applied as required</content>
|
| 1013 |
</td>
|
| 1014 |
</tr>
|
| 1015 |
</tbody>
|
| 1016 |
</table>
|
| 1017 |
</text>
|
| 1018 |
<entry typeCode="DRIV">
|
| 1019 |
|
| 1020 |
|
| 1021 |
|
| 1022 |
|
| 1023 |
|
| 1024 |
|
| 1025 |
|
| 1026 |
<substanceAdministration classCode="SBADM" moodCode="EVN">
|
| 1027 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.45"/>
|
| 1028 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7"/>
|
| 1029 |
<templateId root="2.16.840.1.113883.10.20.1.24"/>
|
| 1030 |
|
| 1031 |
<id root="CE1215CD-69EC-4C7B-805F-569233C5E151"/>
|
| 1032 |
<text>
|
| 1033 |
<reference value="#medadministered-1"/>
|
| 1034 |
</text>
|
| 1035 |
<statusCode code="completed"/>
|
| 1036 |
|
| 1037 |
<consumable>
|
| 1038 |
<manufacturedProduct classCode="MANU">
|
| 1039 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.2"/>
|
| 1040 |
<templateId root="2.16.840.1.113883.10.20.1.53"/>
|
| 1041 |
<manufacturedMaterial classCode="MMAT" determinerCode="KIND">
|
| 1042 |
<code code="280102-0101-0901-01-18" codeSystem="2.16.840.1.113883.3.3731.1.205.2" codeSystemName="KSA Dispensation Pharmacy Item Name" displayName="butafyl 1% cream">
|
| 1043 |
<originalText>
|
| 1044 |
<reference value="#medadministered-1_prodcode"/>
|
| 1045 |
</originalText>
|
| 1046 |
</code>
|
| 1047 |
<name>butafyl 1% cream</name>
|
| 1048 |
<pharm:formCode code="0901" codeSystem="2.16.840.1.113883.3.3731.1.205.8" codeSystemName="KSA Medication Pharmaceutical Dose Form" displayName="cream">
|
| 1049 |
<originalText>
|
| 1050 |
<reference value="#medadministered-1_doseform"/>
|
| 1051 |
</originalText>
|
| 1052 |
</pharm:formCode>
|
| 1053 |
<pharm:ingredient classCode="ACTI">
|
| 1054 |
<pharm:quantity>
|
| 1055 |
<numerator unit="%" value="1" xsi:type="PQ"/>
|
| 1056 |
<denominator value="1" xsi:type="INT"/>
|
| 1057 |
</pharm:quantity>
|
| 1058 |
</pharm:ingredient>
|
| 1059 |
</manufacturedMaterial>
|
| 1060 |
</manufacturedProduct>
|
| 1061 |
</consumable>
|
| 1062 |
|
| 1063 |
<entryRelationship inversionInd="true" typeCode="SUBJ">
|
| 1064 |
<act classCode="ACT" moodCode="INT">
|
| 1065 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.3"/>
|
| 1066 |
<templateId root="2.16.840.1.113883.10.20.1.49"/>
|
| 1067 |
<code code="PINSTRUCT" codeSystem="1.3.6.1.4.1.19376.1.5.3.2" codeSystemName="IHEActCode"/>
|
| 1068 |
<text>
|
| 1069 |
<reference value="#medadministered-1_pinstruct"/>
|
| 1070 |
</text>
|
| 1071 |
<statusCode code="completed"/>
|
| 1072 |
</act>
|
| 1073 |
</entryRelationship>
|
| 1074 |
</substanceAdministration>
|
| 1075 |
</entry>
|
| 1076 |
</section>
|
| 1077 |
</component>
|
| 1078 |
|
| 1079 |
|
| 1080 |
|
| 1081 |
|
| 1082 |
|
| 1083 |
|
| 1084 |
|
| 1085 |
<component>
|
| 1086 |
<section>
|
| 1087 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.6"/>
|
| 1088 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.23"/>
|
| 1089 |
<templateId root="2.16.840.1.113883.10.20.1.6"/>
|
| 1090 |
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF IMMUNIZATIONS"/>
|
| 1091 |
<title>Immunizations</title>
|
| 1092 |
<text>
|
| 1093 |
<table ID="immu-1">
|
| 1094 |
<tbody>
|
| 1095 |
<tr>
|
| 1096 |
<td>Immunization Item</td>
|
| 1097 |
<td>1</td>
|
| 1098 |
</tr>
|
| 1099 |
<tr>
|
| 1100 |
<td>Immunization ID</td>
|
| 1101 |
<td>CE1215CD-69EC-4C7B-805F-569233C5E159</td>
|
| 1102 |
</tr>
|
| 1103 |
<tr>
|
| 1104 |
<td>Immunization Name</td>
|
| 1105 |
<td>hepatitis a vaccine</td>
|
| 1106 |
</tr>
|
| 1107 |
<tr>
|
| 1108 |
<td>Immunization Code</td>
|
| 1109 |
<td>
|
| 1110 |
<content ID="immu-1_vaccnamecode">530702-0115-2713</content>
|
| 1111 |
</td>
|
| 1112 |
</tr>
|
| 1113 |
<tr>
|
| 1114 |
<td>Date of administration</td>
|
| 1115 |
<td>2018.01.03</td>
|
| 1116 |
</tr>
|
| 1117 |
<tr>
|
| 1118 |
<td>Dose</td>
|
| 1119 |
<td ID="immu-1_dose">1 ml</td>
|
| 1120 |
</tr>
|
| 1121 |
<tr>
|
| 1122 |
<td>Route of Administration</td>
|
| 1123 |
<td>
|
| 1124 |
<content ID="immu-1_route">Intramuscular route</content>
|
| 1125 |
</td>
|
| 1126 |
</tr>
|
| 1127 |
<tr>
|
| 1128 |
<td>Approach Site</td>
|
| 1129 |
<td>
|
| 1130 |
<content ID="immu-1_approach">Left Upper Arm</content>
|
| 1131 |
</td>
|
| 1132 |
</tr>
|
| 1133 |
<tr>
|
| 1134 |
<td>Reason</td>
|
| 1135 |
<td>
|
| 1136 |
<content ID="immu-1_reason">Routine</content>
|
| 1137 |
</td>
|
| 1138 |
</tr>
|
| 1139 |
<tr>
|
| 1140 |
<td>Vaccination Product Code and Name</td>
|
| 1141 |
<td>
|
| 1142 |
<content ID="immu-1_vaccprodcode">530702-0115-2713-01-19, vaqta hepatitis a vaccine 50 iu/ml solution</content>
|
| 1143 |
</td>
|
| 1144 |
</tr>
|
| 1145 |
<tr>
|
| 1146 |
<td>Pharmaceutical Dose Form</td>
|
| 1147 |
<td>
|
| 1148 |
<content ID="immu-1_doseform">2713 - solution, injection</content>
|
| 1149 |
</td>
|
| 1150 |
</tr>
|
| 1151 |
<tr>
|
| 1152 |
<td>Lot Number</td>
|
| 1153 |
<td>1abc-34aad</td>
|
| 1154 |
</tr>
|
| 1155 |
<tr>
|
| 1156 |
<td>Manufacturer</td>
|
| 1157 |
<td>
|
| 1158 |
<content ID="immu-1_manufacturer">Abbott Laboratories</content>
|
| 1159 |
</td>
|
| 1160 |
</tr>
|
| 1161 |
<tr>
|
| 1162 |
<td>Provider Administering the Vaccine</td>
|
| 1163 |
<td>Vaccine Administration Doc, Osama</td>
|
| 1164 |
</tr>
|
| 1165 |
<tr>
|
| 1166 |
<td>Responsible Provider</td>
|
| 1167 |
<td>Responsible Doc, Osama</td>
|
| 1168 |
</tr>
|
| 1169 |
<tr>
|
| 1170 |
<td>Informant</td>
|
| 1171 |
<td>Informant for patient supplied information person, Heba</td>
|
| 1172 |
</tr>
|
| 1173 |
<tr>
|
| 1174 |
<td>Immunization Campaign</td>
|
| 1175 |
<td>
|
| 1176 |
<content ID="immu-1_campaign">National Vaccination Campaign for Hepatitis A (2.16.840.1.113883.3.3731.1.2.2.200.100000000000000.100.1)</content>
|
| 1177 |
</td>
|
| 1178 |
</tr>
|
| 1179 |
<tr>
|
| 1180 |
<td>Adverse Immunization(s)</td>
|
| 1181 |
<td>
|
| 1182 |
<content ID="immu-1_adverseimmuevent1">Patient experienced dizziness short after application of the vaccine</content>
|
| 1183 |
</td>
|
| 1184 |
</tr>
|
| 1185 |
<tr>
|
| 1186 |
<td>Dose Number</td>
|
| 1187 |
<td>
|
| 1188 |
<content ID="immu-1_dosenumber">1</content>
|
| 1189 |
</td>
|
| 1190 |
</tr>
|
| 1191 |
<tr>
|
| 1192 |
<td>Comment</td>
|
| 1193 |
<td>
|
| 1194 |
<content ID="immu-1_comment">This is a comment to this vaccine administration</content>
|
| 1195 |
</td>
|
| 1196 |
</tr>
|
| 1197 |
</tbody>
|
| 1198 |
</table>
|
| 1199 |
</text>
|
| 1200 |
<entry typeCode="DRIV">
|
| 1201 |
|
| 1202 |
|
| 1203 |
|
| 1204 |
|
| 1205 |
|
| 1206 |
|
| 1207 |
|
| 1208 |
<substanceAdministration classCode="SBADM" moodCode="EVN">
|
| 1209 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.48"/>
|
| 1210 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.12"/>
|
| 1211 |
<templateId root="2.16.840.1.113883.10.20.1.24"/>
|
| 1212 |
<id root="CE1215CD-69EC-4C7B-805F-569233C5E159"/>
|
| 1213 |
<code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4"/>
|
| 1214 |
<text>
|
| 1215 |
<reference value="#immu-1"/>
|
| 1216 |
</text>
|
| 1217 |
<statusCode code="completed"/>
|
| 1218 |
|
| 1219 |
<effectiveTime value="20180103"/>
|
| 1220 |
|
| 1221 |
<routeCode code="78421000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Intramuscular route">
|
| 1222 |
<originalText>
|
| 1223 |
<reference value="#immu-1_route"/>
|
| 1224 |
</originalText>
|
| 1225 |
</routeCode>
|
| 1226 |
|
| 1227 |
<approachSiteCode code="LUA" codeSystem="2.16.840.1.113883.12.163" codeSystemName="HL7 Body Site" displayName="Left Upper Arm">
|
| 1228 |
<originalText>
|
| 1229 |
<reference value="#immu-1_approach"/>
|
| 1230 |
</originalText>
|
| 1231 |
</approachSiteCode>
|
| 1232 |
|
| 1233 |
<doseQuantity unit="ml" value="1">
|
| 1234 |
<translation>
|
| 1235 |
<originalText>
|
| 1236 |
<reference value="#immu-1_dose"/>
|
| 1237 |
</originalText>
|
| 1238 |
</translation>
|
| 1239 |
</doseQuantity>
|
| 1240 |
<nphies:reasonCode code="50811001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Routine">
|
| 1241 |
<originalText>
|
| 1242 |
<reference value="#immu-1_reason"/>
|
| 1243 |
</originalText>
|
| 1244 |
</nphies:reasonCode>
|
| 1245 |
|
| 1246 |
<consumable>
|
| 1247 |
<manufacturedProduct classCode="MANU">
|
| 1248 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.2"/>
|
| 1249 |
<templateId root="2.16.840.1.113883.10.20.1.53"/>
|
| 1250 |
<manufacturedMaterial classCode="MMAT" determinerCode="KIND">
|
| 1251 |
|
| 1252 |
<code code="530702-0115-2713" codeSystem="2.16.840.1.113883.3.3731.1.205.1" codeSystemName="KSA Prescription Pharmacy Item Name" displayName="hepatitis a vaccine - 50 iu/ml - injection, solution">
|
| 1253 |
<originalText>
|
| 1254 |
<reference value="#immu-1_prodcode"/>
|
| 1255 |
</originalText>
|
| 1256 |
</code>
|
| 1257 |
<name>hepatitis a vaccine</name>
|
| 1258 |
<pharm:formCode code="2713" codeSystem="2.16.840.1.113883.3.3731.1.205.8" codeSystemName="KSA Medication Pharmaceutical Dose Form" displayName="solution, injection">
|
| 1259 |
<originalText>
|
| 1260 |
<reference value="#immu-1_doseform"/>
|
| 1261 |
</originalText>
|
| 1262 |
</pharm:formCode>
|
| 1263 |
<lotNumberText>1abc-34aad</lotNumberText>
|
| 1264 |
<pharm:expirationTime value="20241231"/>
|
| 1265 |
<pharm:asContent classCode="CONT">
|
| 1266 |
<pharm:containerPackagedMedicine classCode="CONT" determinerCode="INSTANCE">
|
| 1267 |
|
| 1268 |
<pharm:code code="530702-0115-2713-01-19" codeSystem="2.16.840.1.113883.3.3731.1.205.2" codeSystemName="KSA Dispensation Pharmacy Item Name" displayName="vaqta vaccine 50 u vial">
|
| 1269 |
<originalText>
|
| 1270 |
<reference value="#immu-1_vaccprodcode"/>
|
| 1271 |
</originalText>
|
| 1272 |
</pharm:code>
|
| 1273 |
</pharm:containerPackagedMedicine>
|
| 1274 |
</pharm:asContent>
|
| 1275 |
<pharm:ingredient classCode="ACTI">
|
| 1276 |
<pharm:quantity>
|
| 1277 |
<numerator unit="iu/ml" value="50" xsi:type="PQ"/>
|
| 1278 |
<denominator value="1" xsi:type="INT"/>
|
| 1279 |
</pharm:quantity>
|
| 1280 |
</pharm:ingredient>
|
| 1281 |
</manufacturedMaterial>
|
| 1282 |
<manufacturerOrganization>
|
| 1283 |
<asOrganizationPartOf>
|
| 1284 |
<code code="AB" codeSystem="2.16.840.1.114222.4.11.826" displayName="Abbott Laboratories">
|
| 1285 |
<originalText>
|
| 1286 |
<reference value="#immu-1_manufacturer"/>
|
| 1287 |
</originalText>
|
| 1288 |
</code>
|
| 1289 |
</asOrganizationPartOf>
|
| 1290 |
</manufacturerOrganization>
|
| 1291 |
</manufacturedProduct>
|
| 1292 |
</consumable>
|
| 1293 |
<performer>
|
| 1294 |
<templateId root="2.16.840.1.113883.3.3731.1.203.28.7"/>
|
| 1295 |
<assignedEntity>
|
| 1296 |
<id extension="17JP0032773" root="2.16.840.1.113883.3.3731.1.2.1"/>
|
| 1297 |
|
| 1298 |
<addr nullFlavor="NI"/>
|
| 1299 |
|
| 1300 |
<telecom nullFlavor="NI"/>
|
| 1301 |
<assignedPerson>
|
| 1302 |
<name>
|
| 1303 |
<family>Vaccine Administration Doc</family>
|
| 1304 |
<given>Osama</given>
|
| 1305 |
</name>
|
| 1306 |
</assignedPerson>
|
| 1307 |
</assignedEntity>
|
| 1308 |
</performer>
|
| 1309 |
<author>
|
| 1310 |
<templateId root="2.16.840.1.113883.3.3731.1.203.28.3"/>
|
| 1311 |
<time value="20180103"/>
|
| 1312 |
<assignedAuthor>
|
| 1313 |
<id extension="17TM0056783" root="2.16.840.1.113883.3.3731.1.2.1"/>
|
| 1314 |
|
| 1315 |
<addr nullFlavor="NI"/>
|
| 1316 |
|
| 1317 |
<telecom nullFlavor="NI"/>
|
| 1318 |
<assignedPerson>
|
| 1319 |
<name>
|
| 1320 |
<family>Responsible Doc</family>
|
| 1321 |
<given>Osama</given>
|
| 1322 |
</name>
|
| 1323 |
</assignedPerson>
|
| 1324 |
</assignedAuthor>
|
| 1325 |
</author>
|
| 1326 |
<informant>
|
| 1327 |
<templateId root="2.16.840.1.113883.3.3731.1.203.28.10"/>
|
| 1328 |
<assignedEntity>
|
| 1329 |
<id nullFlavor="UNK"/>
|
| 1330 |
<addr nullFlavor="UNK"/>
|
| 1331 |
<telecom nullFlavor="UNK"/>
|
| 1332 |
<assignedPerson>
|
| 1333 |
<name>
|
| 1334 |
<family>Informant for patient supplied information person</family>
|
| 1335 |
<given>Heba</given>
|
| 1336 |
</name>
|
| 1337 |
</assignedPerson>
|
| 1338 |
</assignedEntity>
|
| 1339 |
</informant>
|
| 1340 |
|
| 1341 |
<entryRelationship typeCode="REFR">
|
| 1342 |
<act classCode="ACT" moodCode="DEF">
|
| 1343 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.49"/>
|
| 1344 |
<id root="2.16.840.1.113883.3.3731.1.2.2.200.100000000000000.100.1"/>
|
| 1345 |
<code nullFlavor="NI"/>
|
| 1346 |
<text>
|
| 1347 |
<reference value="'#immu-1_campaign"/>
|
| 1348 |
</text>
|
| 1349 |
</act>
|
| 1350 |
</entryRelationship>
|
| 1351 |
|
| 1352 |
<entryRelationship inversionInd="false" typeCode="CAUS">
|
| 1353 |
<observation classCode="OBS" moodCode="EVN">
|
| 1354 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.50"/>
|
| 1355 |
<code nullFlavor="NI"/>
|
| 1356 |
<text>
|
| 1357 |
<reference value="#immu-1_adverseimmuevent1"/>
|
| 1358 |
</text>
|
| 1359 |
</observation>
|
| 1360 |
</entryRelationship>
|
| 1361 |
|
| 1362 |
<entryRelationship typeCode="SUBJ">
|
| 1363 |
<observation classCode="OBS" moodCode="EVN">
|
| 1364 |
<templateId root="2.16.840.1.113883.10.20.1.46"/>
|
| 1365 |
<code code="30973-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Dose Number"/>
|
| 1366 |
<text>
|
| 1367 |
<reference value="#immu-1_dosenumber"/>
|
| 1368 |
</text>
|
| 1369 |
<statusCode code="completed"/>
|
| 1370 |
<value value="1" xsi:type="INT"/>
|
| 1371 |
</observation>
|
| 1372 |
</entryRelationship>
|
| 1373 |
<entryRelationship inversionInd="true" typeCode="SUBJ">
|
| 1374 |
<act classCode="ACT" moodCode="EVN">
|
| 1375 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.91"/>
|
| 1376 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.2"/>
|
| 1377 |
<templateId root="2.16.840.1.113883.10.20.1.40"/>
|
| 1378 |
<id root="DBA414DE-6B92-4D74-30D1-46BC36770F79"/>
|
| 1379 |
<code code="48767" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation Comment"/>
|
| 1380 |
<text>
|
| 1381 |
<reference value="#immu-1_comment"/>
|
| 1382 |
</text>
|
| 1383 |
<statusCode code="completed"/>
|
| 1384 |
</act>
|
| 1385 |
</entryRelationship>
|
| 1386 |
</substanceAdministration>
|
| 1387 |
</entry>
|
| 1388 |
</section>
|
| 1389 |
</component>
|
| 1390 |
|
| 1391 |
|
| 1392 |
|
| 1393 |
|
| 1394 |
|
| 1395 |
|
| 1396 |
|
| 1397 |
<component>
|
| 1398 |
<section>
|
| 1399 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.10"/>
|
| 1400 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2"/>
|
| 1401 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.25"/>
|
| 1402 |
<templateId root="2.16.840.1.113883.10.20.1.16"/>
|
| 1403 |
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="VITAL SIGNS"/>
|
| 1404 |
<title>Vital Signs</title>
|
| 1405 |
<text>
|
| 1406 |
<paragraph>Time of measurement: 30.07.2021, 08:30</paragraph>
|
| 1407 |
<table>
|
| 1408 |
<thead>
|
| 1409 |
<tr>
|
| 1410 |
<th>Name</th>
|
| 1411 |
<th>Value</th>
|
| 1412 |
<th>Unit</th>
|
| 1413 |
</tr>
|
| 1414 |
</thead>
|
| 1415 |
<tbody>
|
| 1416 |
<tr ID="vitsig-1">
|
| 1417 |
<td ID="vitsig-1_type">Heart beat</td>
|
| 1418 |
<td>60</td>
|
| 1419 |
<td>/min</td>
|
| 1420 |
</tr>
|
| 1421 |
<tr ID="vitsig-2">
|
| 1422 |
<td ID="vitsig-2_type">Blood Pressure Systolic</td>
|
| 1423 |
<td>110</td>
|
| 1424 |
<td>mm[Hg]</td>
|
| 1425 |
</tr>
|
| 1426 |
<tr ID="vitsig-3">
|
| 1427 |
<td ID="vitsig-3_type">Blood Pressure Diastolic</td>
|
| 1428 |
<td>70</td>
|
| 1429 |
<td>mm[Hg]</td>
|
| 1430 |
</tr>
|
| 1431 |
</tbody>
|
| 1432 |
</table>
|
| 1433 |
<paragraph>Time of measurement: 31.07.2021, 10:00</paragraph>
|
| 1434 |
<table>
|
| 1435 |
<thead>
|
| 1436 |
<tr>
|
| 1437 |
<th>Name</th>
|
| 1438 |
<th>Value</th>
|
| 1439 |
<th>Unit</th>
|
| 1440 |
</tr>
|
| 1441 |
</thead>
|
| 1442 |
<tbody>
|
| 1443 |
<tr ID="vitsig-4">
|
| 1444 |
<td ID="vitsig-4_type">Body Weight (Measured)</td>
|
| 1445 |
<td>85</td>
|
| 1446 |
<td>kg</td>
|
| 1447 |
</tr>
|
| 1448 |
<tr ID="vitsig-5">
|
| 1449 |
<td ID="vitsig-5_type">Body Height (Measured)</td>
|
| 1450 |
<td>190</td>
|
| 1451 |
<td>cm</td>
|
| 1452 |
</tr>
|
| 1453 |
</tbody>
|
| 1454 |
</table>
|
| 1455 |
</text>
|
| 1456 |
<entry typeCode="DRIV">
|
| 1457 |
<organizer classCode="CLUSTER" moodCode="EVN">
|
| 1458 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.54"/>
|
| 1459 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.1"/>
|
| 1460 |
<templateId root="2.16.840.1.113883.10.20.1.32"/>
|
| 1461 |
<templateId root="2.16.840.1.113883.10.20.1.35"/>
|
| 1462 |
<id nullFlavor="NI"/>
|
| 1463 |
<code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Vital signs"/>
|
| 1464 |
<statusCode code="completed"/>
|
| 1465 |
<effectiveTime value="20210730083000+0300"/>
|
| 1466 |
<component>
|
| 1467 |
<observation classCode="OBS" moodCode="EVN">
|
| 1468 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.55"/>
|
| 1469 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
|
| 1470 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.2"/>
|
| 1471 |
<templateId root="2.16.840.1.113883.10.20.1.31"/>
|
| 1472 |
<id root="E6F45742-BA20-7224-15A0-6D8836E96123"/>
|
| 1473 |
<code code="8867-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Heart Beat">
|
| 1474 |
<originalText>
|
| 1475 |
<reference value="#vitsig-1_type"/>
|
| 1476 |
</originalText>
|
| 1477 |
</code>
|
| 1478 |
<text>
|
| 1479 |
<reference value="#vitsig-1"/>
|
| 1480 |
</text>
|
| 1481 |
<statusCode code="completed"/>
|
| 1482 |
<value unit="/min" value="60" xsi:type="PQ"/>
|
| 1483 |
</observation>
|
| 1484 |
</component>
|
| 1485 |
<component>
|
| 1486 |
<observation classCode="OBS" moodCode="EVN">
|
| 1487 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.55"/>
|
| 1488 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
|
| 1489 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.2"/>
|
| 1490 |
<templateId root="2.16.840.1.113883.10.20.1.31"/>
|
| 1491 |
<id root="E6F45742-BA20-7224-15A0-6D8836E96456"/>
|
| 1492 |
<code code="8480-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Intravascular Systolic">
|
| 1493 |
<originalText>
|
| 1494 |
<reference value="#vitsig-2_type"/>
|
| 1495 |
</originalText>
|
| 1496 |
</code>
|
| 1497 |
<text>
|
| 1498 |
<reference value="#vitsig-2"/>
|
| 1499 |
</text>
|
| 1500 |
<statusCode code="completed"/>
|
| 1501 |
<value unit="mm[Hg]" value="110" xsi:type="PQ"/>
|
| 1502 |
</observation>
|
| 1503 |
</component>
|
| 1504 |
<component typeCode="COMP">
|
| 1505 |
<observation classCode="OBS" moodCode="EVN">
|
| 1506 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.55"/>
|
| 1507 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
|
| 1508 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.2"/>
|
| 1509 |
<templateId root="2.16.840.1.113883.10.20.1.31"/>
|
| 1510 |
<id root="E6F45742-BA20-7224-15A0-6D8836E96789"/>
|
| 1511 |
<code code="8462-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Intravascular Diastolic">
|
| 1512 |
<originalText>
|
| 1513 |
<reference value="#vitsig-3_type"/>
|
| 1514 |
</originalText>
|
| 1515 |
</code>
|
| 1516 |
<text>
|
| 1517 |
<reference value="#vitsig-3"/>
|
| 1518 |
</text>
|
| 1519 |
<statusCode code="completed"/>
|
| 1520 |
<value unit="mm[Hg]" value="70" xsi:type="PQ"/>
|
| 1521 |
</observation>
|
| 1522 |
</component>
|
| 1523 |
</organizer>
|
| 1524 |
</entry>
|
| 1525 |
<entry typeCode="DRIV">
|
| 1526 |
<organizer classCode="CLUSTER" moodCode="EVN">
|
| 1527 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.54"/>
|
| 1528 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.1"/>
|
| 1529 |
<templateId root="2.16.840.1.113883.10.20.1.32"/>
|
| 1530 |
<templateId root="2.16.840.1.113883.10.20.1.35"/>
|
| 1531 |
<id nullFlavor="NI"/>
|
| 1532 |
<code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Vital signs"/>
|
| 1533 |
<statusCode code="completed"/>
|
| 1534 |
<effectiveTime value="20210731100000+0100"/>
|
| 1535 |
<component>
|
| 1536 |
<observation classCode="OBS" moodCode="EVN">
|
| 1537 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.55"/>
|
| 1538 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
|
| 1539 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.2"/>
|
| 1540 |
<templateId root="2.16.840.1.113883.10.20.1.31"/>
|
| 1541 |
<id root="E6F45742-BA20-7224-15A0-6D8836E96123"/>
|
| 1542 |
<code code="3141-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Body Weight (Measured)">
|
| 1543 |
<originalText>
|
| 1544 |
<reference value="#vitsig-4_type"/>
|
| 1545 |
</originalText>
|
| 1546 |
</code>
|
| 1547 |
<text>
|
| 1548 |
<reference value="#vitsig-4"/>
|
| 1549 |
</text>
|
| 1550 |
<statusCode code="completed"/>
|
| 1551 |
<value unit="kg" value="85" xsi:type="PQ"/>
|
| 1552 |
</observation>
|
| 1553 |
</component>
|
| 1554 |
<component>
|
| 1555 |
<observation classCode="OBS" moodCode="EVN">
|
| 1556 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.55"/>
|
| 1557 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
|
| 1558 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.2"/>
|
| 1559 |
<templateId root="2.16.840.1.113883.10.20.1.31"/>
|
| 1560 |
<id root="E6F45742-BA20-7224-15A0-6D8836E96123"/>
|
| 1561 |
<code code="8302-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Body Height (Measured)">
|
| 1562 |
<originalText>
|
| 1563 |
<reference value="#vitsig-5_type"/>
|
| 1564 |
</originalText>
|
| 1565 |
</code>
|
| 1566 |
<text>
|
| 1567 |
<reference value="#vitsig-5"/>
|
| 1568 |
</text>
|
| 1569 |
<statusCode code="completed"/>
|
| 1570 |
<value unit="cm" value="190" xsi:type="PQ"/>
|
| 1571 |
</observation>
|
| 1572 |
</component>
|
| 1573 |
</organizer>
|
| 1574 |
</entry>
|
| 1575 |
</section>
|
| 1576 |
</component>
|
| 1577 |
|
| 1578 |
|
| 1579 |
|
| 1580 |
|
| 1581 |
|
| 1582 |
|
| 1583 |
|
| 1584 |
<component>
|
| 1585 |
<section>
|
| 1586 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.9"/>
|
| 1587 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.24"/>
|
| 1588 |
<code code="29545-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PHYSICAL EXAMINATION"/>
|
| 1589 |
<title>Physical Examination</title>
|
| 1590 |
<text>
|
| 1591 |
This is the physical examination of the patient.
|
| 1592 |
</text>
|
| 1593 |
</section>
|
| 1594 |
</component>
|
| 1595 |
|
| 1596 |
|
| 1597 |
|
| 1598 |
|
| 1599 |
|
| 1600 |
|
| 1601 |
|
| 1602 |
<component>
|
| 1603 |
<section>
|
| 1604 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.11"/>
|
| 1605 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.48"/>
|
| 1606 |
<code code="57080-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="IMPLANTED MEDICAL DEVICE"/>
|
| 1607 |
<title>Visible Implanted Medical Devices</title>
|
| 1608 |
<text>
|
| 1609 |
This is the narrative description of the visible implanted medical devices
|
| 1610 |
</text>
|
| 1611 |
</section>
|
| 1612 |
</component>
|
| 1613 |
|
| 1614 |
|
| 1615 |
|
| 1616 |
|
| 1617 |
|
| 1618 |
|
| 1619 |
|
| 1620 |
<component>
|
| 1621 |
<section>
|
| 1622 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.19"/>
|
| 1623 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.22"/>
|
| 1624 |
<code code="10183-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HOSPITAL DISCHARGE MEDICATIONS"/>
|
| 1625 |
<title>Hospital Discharge Medications</title>
|
| 1626 |
<text>
|
| 1627 |
<table>
|
| 1628 |
<tbody>
|
| 1629 |
<tr ID="meddischarge-1">
|
| 1630 |
<td ID="meddischarge-1_code">182849000</td>
|
| 1631 |
<td>No Drug Therapy Prescribed</td>
|
| 1632 |
</tr>
|
| 1633 |
</tbody>
|
| 1634 |
</table>
|
| 1635 |
</text>
|
| 1636 |
<entry typeCode="DRIV">
|
| 1637 |
|
| 1638 |
|
| 1639 |
|
| 1640 |
|
| 1641 |
|
| 1642 |
<substanceAdministration classCode="SBADM" moodCode="EVN">
|
| 1643 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.45"/>
|
| 1644 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7"/>
|
| 1645 |
<templateId root="2.16.840.1.113883.10.20.1.24"/>
|
| 1646 |
|
| 1647 |
<id root="CE1215CD-69EC-4C7B-805F-569233C5E1510"/>
|
| 1648 |
<code code="182849000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="No Drug Therapy Prescribed">
|
| 1649 |
<originalText>
|
| 1650 |
<reference value="#meddischarge-1_code"/>
|
| 1651 |
</originalText>
|
| 1652 |
</code>
|
| 1653 |
<text>
|
| 1654 |
<reference value="#meddischarge-1"/>
|
| 1655 |
</text>
|
| 1656 |
<statusCode code="completed"/>
|
| 1657 |
|
| 1658 |
<consumable>
|
| 1659 |
<manufacturedProduct classCode="MANU">
|
| 1660 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.2"/>
|
| 1661 |
<templateId root="2.16.840.1.113883.10.20.1.53"/>
|
| 1662 |
<manufacturedMaterial classCode="MMAT" determinerCode="KIND" nullFlavor="NI"/>
|
| 1663 |
</manufacturedProduct>
|
| 1664 |
</consumable>
|
| 1665 |
</substanceAdministration>
|
| 1666 |
</entry>
|
| 1667 |
</section>
|
| 1668 |
</component>
|
| 1669 |
|
| 1670 |
|
| 1671 |
|
| 1672 |
|
| 1673 |
|
| 1674 |
|
| 1675 |
|
| 1676 |
|
| 1677 |
<component>
|
| 1678 |
<section>
|
| 1679 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.13"/>
|
| 1680 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.31"/>
|
| 1681 |
<templateId root="2.16.840.1.113883.10.20.1.10"/>
|
| 1682 |
<code code="61145-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="TREATMENT PLAN"/>
|
| 1683 |
<title>Care Plan</title>
|
| 1684 |
<text>
|
| 1685 |
This is the narrative description of the care plan of the patient
|
| 1686 |
</text>
|
| 1687 |
</section>
|
| 1688 |
</component>
|
| 1689 |
|
| 1690 |
|
| 1691 |
|
| 1692 |
|
| 1693 |
|
| 1694 |
|
| 1695 |
|
| 1696 |
|
| 1697 |
<component>
|
| 1698 |
<section>
|
| 1699 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.20"/>
|
| 1700 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.7"/>
|
| 1701 |
<code code="11535-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HOSPITAL DISCHARGE DX"/>
|
| 1702 |
<title>Discharge Diagnosis</title>
|
| 1703 |
<text>
|
| 1704 |
<table>
|
| 1705 |
<thead>
|
| 1706 |
<tr>
|
| 1707 |
<th>Diagnosis</th>
|
| 1708 |
<th>Date from</th>
|
| 1709 |
<th>Date to</th>
|
| 1710 |
<th>Status</th>
|
| 1711 |
</tr>
|
| 1712 |
</thead>
|
| 1713 |
<tbody>
|
| 1714 |
<tr ID="disdiag-1">
|
| 1715 |
<td ID="disdiag-1_diagnosis">282291009, No current problems or disability</td>
|
| 1716 |
<td>-</td>
|
| 1717 |
<td>-</td>
|
| 1718 |
<td>Completed</td>
|
| 1719 |
</tr>
|
| 1720 |
</tbody>
|
| 1721 |
</table>
|
| 1722 |
</text>
|
| 1723 |
<entry typeCode="DRIV">
|
| 1724 |
<act classCode="ACT" moodCode="EVN">
|
| 1725 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.43"/>
|
| 1726 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.1"/>
|
| 1727 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.2"/>
|
| 1728 |
<templateId root="2.16.840.1.113883.10.20.1.27"/>
|
| 1729 |
<id nullFlavor="NI"/>
|
| 1730 |
<code nullFlavor="NA"/>
|
| 1731 |
<statusCode code="completed"/>
|
| 1732 |
<effectiveTime nullFlavor="NA">
|
| 1733 |
<low nullFlavor="UNK"/>
|
| 1734 |
<high nullFlavor="UNK"/>
|
| 1735 |
</effectiveTime>
|
| 1736 |
<entryRelationship inversionInd="false" typeCode="SUBJ">
|
| 1737 |
<observation classCode="OBS" moodCode="EVN">
|
| 1738 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.44"/>
|
| 1739 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>
|
| 1740 |
<templateId root="2.16.840.1.113883.10.20.1.28"/>
|
| 1741 |
<id root="DBA414DE-6B92-4D74-30D1-46BC36770F79"/>
|
| 1742 |
<code code="282291009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Diagnosis"/>
|
| 1743 |
<text>
|
| 1744 |
<reference value="#disdiag-1"/>
|
| 1745 |
</text>
|
| 1746 |
<statusCode code="completed"/>
|
| 1747 |
<effectiveTime nullFlavor="NA">
|
| 1748 |
<low nullFlavor="UNK"/>
|
| 1749 |
<high nullFlavor="UNK"/>
|
| 1750 |
</effectiveTime>
|
| 1751 |
<value code="160245001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="’No current problems or disability" xsi:type="CD">
|
| 1752 |
<originalText>
|
| 1753 |
<reference value="#disdiag-1_diagnosis"/>
|
| 1754 |
</originalText>
|
| 1755 |
</value>
|
| 1756 |
</observation>
|
| 1757 |
</entryRelationship>
|
| 1758 |
</act>
|
| 1759 |
</entry>
|
| 1760 |
</section>
|
| 1761 |
</component>
|
| 1762 |
|
| 1763 |
|
| 1764 |
|
| 1765 |
|
| 1766 |
|
| 1767 |
|
| 1768 |
|
| 1769 |
<component>
|
| 1770 |
<section>
|
| 1771 |
<templateId root="2.16.840.1.113883.3.3731.1.210.100.22"/>
|
| 1772 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.32"/>
|
| 1773 |
<code code="8650-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HOSPITAL DISCHARGE DISPOSITION"/>
|
| 1774 |
<title>Discharge Disposition</title>
|
| 1775 |
<text>
|
| 1776 |
This is the narrative description of the discharge disposition
|
| 1777 |
</text>
|
| 1778 |
</section>
|
| 1779 |
</component>
|
| 1780 |
</structuredBody>
|
| 1781 |
</component>
|
| 1782 |
</ClinicalDocument>
|