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cda.xml
OID
1.3.6.1.4.1.12559.11.11.4.33554
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12/2/25 6:05:16 AM (CET GMT+0100)
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EVSClient 7.4.1
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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="202512012346"/>
7   <confidentialityCode code="V" codeSystem="2.16.840.1.113883.5.25"/>
8   <recordTarget>
9     <patientRole>
10       <id assigningAuthorityName="C�dula ciudadan�a" extension="35871398" root="2.16.840.1.113883.19.6.1.1"/>
11       <id extension="1" root="2.16.840.1.113883.19.6.2.1"/>
12       <id extension="1" root="2.16.840.1.113883.19.6.3.1"/>
13       <id extension="1111" root="2.16.840.1.113883.19.6.4"/>
14       <addr use="HP">
15         <country>CO</country>
16         <state>05</state>
17         <city>5045</city>
18         <postalCode>5045</postalCode>
19         <streetAddressLine>obrero bloque 1</streetAddressLine>
20       </addr>
21       <telecom use="HP" value="3137883368"/>
22       <patient>
23         <name>
24           <given>Blanca</given>
25           <given>Nubia</given>
26           <family>Lambertinez</family>
27           <family>Gonzalez</family>
28         </name>
29         <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
30         <birthTime value="19790918"/>
31       </patient>
32     </patientRole>
33   </recordTarget>
34   <author>
35     <time value="202512012346"/>
36     <assignedAuthor>
37       <id extension="KP00017" root="2.16.840.1.113883.19.5"/>
38       <assignedPerson>
39         <name>
40           <given>Gerardo</given>
41           <given>antonio</given>
42           <family>Buena</family>
43           <family>Bertel</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>hospital Antonio Roldan</name>
57         <telecom/>
58         <addr use="WP">
59           <country>CO</country>
60           <state>05</state>
61           <city>5045</city>
62           <postalCode>5045</postalCode>
63           <streetAddressLine>obrero bloque 1 </streetAddressLine>
64         </addr>
65       </representedCustodianOrganization>
66     </assignedCustodian>
67   </custodian>
68   <componentOf>
69     <encompassingEncounter>
70       <id extension="011" root="2.16.840.1.113883.2.17"/>
71       <code code="R" codeSystem="2.16.840.1.113883.2.17" codeSystemName="CUPS" displayName="PROCEDIMIENTOS DIAGN�STICOS EN CR�NEO, CEREBRO Y MENINGES CEREBRALES"/>
72       <effectiveTime>
73         <low value="20251201"/>
74         <high value="20251201"/>
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>consulta </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>46 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>Caja de Compensaci�n Familiar del Choc� COMFACHOCO</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>2 Consulta externa � programada</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>consulta por malestar general</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>13 Enfermedad general</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 padece de mucho dolor en todo el cuerpo e inflamacion en las articulaciones</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>Lupus eritomatoso sistemico</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>Madre diabetica
151 Padre Hipertenso</text>
152         </section>
153       </component>
154       <component>
155         <section>
156           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
157           <code code="11348-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Past illness Narrative"/>
158           <title>ANTECEDENTES PERSONALES</title>
159           <text>Por favor llene los espacios de antecedentes que apliquen para el paciente.
160
161 Antecedentes quir�rgicos
162 Antecedentes inmunol�gicos
163 Antecedentes farmacol�gicos</text>
164         </section>
165       </component>
166       <component>
167         <section>
168           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
169           <code code="8687-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Review of systems - Reported"/>
170           <title>REVISI�N POR SISTEMAS</title>
171           <text>Ojos
172 O�dos
173 Nariz, boca y garganta
174 Cardiovascular
175 Respiratorio
176 Musculoesqueletico
177 Inmunolog�co
178 </text>
179         </section>
180       </component>
181       <component>
182         <section>
183           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
184           <code code="29545-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Physical findings Narrative"/>
185           <title>HALLAZGOS EXAMEN F�SICO</title>
186           <text>paciente presenta mucho dolor y cansancio en general</text>
187         </section>
188       </component>
189       <component>
190         <section>
191           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
192           <code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
193           <title>DIAGNOSTICO PRESUNTIVO INGRESO</title>
194           <text>M328 Otras formas de lupus eritematoso sistemico</text>
195         </section>
196       </component>
197       <component>
198         <section>
199           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
200           <code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
201           <title>DIAGNOSTICO RELACIONADO INGRESO</title>
202           <text>M328 Otras formas de lupus eritematoso sistemico</text>
203         </section>
204       </component>
205       <component>
206         <section>
207           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
208           <code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
209           <title>DIAGNOSTICO CONFIRMADO INGRESO</title>
210           <text>M328 Otras formas de lupus eritematoso sistemico</text>
211         </section>
212       </component>
213       <component>
214         <section>
215           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
216           <code code="86922-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Therapeutic goals panel"/>
217           <title>CONDUCTA: MANEJO TERAP�UTICO</title>
218           <text>controlar la inflamacion, prevenir brotes y proteger organos afectados</text>
219         </section>
220       </component>
221       <component>
222         <section>
223           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
224           <code code="11506-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Progress note"/>
225           <title>NOTA DE PROGRESO</title>
226           <text>Paciente con antecedente de lupus eritomatoso sistemico, que consulta por malestar general y artralgias. se encuentra hemodinamicamente estable orientado con dolor articular leve, moderado sin signos de comprpmiso de organos.</text>
227         </section>
228       </component>
229       <component>
230         <section>
231           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
232           <code code="29554-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure Narrative"/>
233           <title>RESULTADO DE PROCEDIMIENTOS</title>
234           <text>examen fisico sin hallazgos de gravedad</text>
235         </section>
236       </component>
237       <component>
238         <section>
239           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
240           <code code="59768-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure indications"/>
241           <title>INDICACIONES TERAP�UTICAS</title>
242           <text>se indican medicamentos orientados a controlar la actividad inflamatoria del lupus, prevenir progresiony disminuir sintomas articulares.</text>
243         </section>
244       </component>
245       <component>
246         <section>
247           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
248           <code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
249           <title>DIAGNOSTICO PRESUNTIVO EGRESO</title>
250           <text>M328 Otras formas de lupus eritematoso sistemico</text>
251         </section>
252       </component>
253       <component>
254         <section>
255           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
256           <code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
257           <title>DIAGNOSTICO RELACIONADO EGRESO</title>
258           <text>M328 Otras formas de lupus eritematoso sistemico</text>
259         </section>
260       </component>
261       <component>
262         <section>
263           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
264           <code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
265           <title>DIAGNOSTICO CONFIRMADO EGRESO</title>
266           <text>M328 Otras formas de lupus eritematoso sistemico</text>
267         </section>
268       </component>
269       <component>
270         <section>
271           <templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
272           <code code="18842-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Discharge summary"/>
273           <title>PLAN DE MANEJO AMBULATORIO</title>
274           <text>varios medicamentos como hidroxicloroquina 200-400 mg/dia, prednisona 5-10 mg/dia, ibuprofeno o naproxeno</text>
275         </section>
276       </component>
277     </structuredBody>
278   </component>
279 </ClinicalDocument>