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:ips="urn:hl7-org:ips" xmlns:ns2="urn:hl7-org:sdtc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
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| 2 |
<realmCode code="ES"/>
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| 3 |
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
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| 6 |
<code code="60591-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient Summary"/>
|
| 7 |
<title>European Patient Summary</title>
|
| 8 |
<effectiveTime value="20251002132019+0200"/>
|
| 9 |
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality" displayName="Normal"/>
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| 10 |
<languageCode code="en-GB"/>
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| 11 |
<recordTarget contextControlCode="OP" typeCode="RCT">
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| 12 |
<patientRole>
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| 13 |
<id extension="BBBBBBBBMM949966" root="2.16.724.4.40"/>
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<id extension="MEMA0660404005" root="2.16.724.4.41"/>
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<id extension="IHER-3158" root="2.16.840.1.113883.2.19.10.5"/>
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| 16 |
<addr use="HP">
|
| 17 |
<streetAddressLine>Cr Major 5</streetAddressLine>
|
| 18 |
<city>Solsona</city>
|
| 19 |
<state>ES</state>
|
| 20 |
<postalCode>25280</postalCode>
|
| 21 |
</addr>
|
| 22 |
<telecom nullFlavor="NI"/>
|
| 23 |
<patient>
|
| 24 |
<name>
|
| 25 |
<given>Charles</given>
|
| 26 |
<family>Merlot</family>
|
| 27 |
<family>Masson</family>
|
| 28 |
</name>
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| 29 |
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender" displayName="Male"/>
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| 30 |
<birthTime value="19660404"/>
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| 31 |
</patient>
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| 32 |
</patientRole>
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</recordTarget>
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| 34 |
<author contextControlCode="OP" typeCode="AUT">
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| 35 |
<time value="20251002132019+0200"/>
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| 36 |
<assignedAuthor classCode="ASSIGNED">
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<id root="2.16.724.4.9.400.1"/>
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<addr nullFlavor="NA"/>
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<telecom nullFlavor="NI"/>
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<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
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| 41 |
<softwareName>Història Clínica Compartida de Catalunya</softwareName>
|
| 42 |
</assignedAuthoringDevice>
|
| 43 |
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
|
| 44 |
<id root="2.16.724.4.9.400.1"/>
|
| 45 |
<name>Departament de Salut</name>
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| 46 |
<telecom use="WP" value="tel:+34932272900"/>
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| 47 |
<addr>
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| 48 |
<streetAddressLine>Travessera De Les Corts, 131-159 (pavelló Ave Maria)</streetAddressLine>
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| 49 |
<city>Barcelona</city>
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| 50 |
<state>Barcelona</state>
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| 51 |
<postalCode>08028</postalCode>
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| 52 |
<country>ES</country>
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| 53 |
</addr>
|
| 54 |
</representedOrganization>
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| 55 |
</assignedAuthor>
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| 56 |
</author>
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<custodian typeCode="CST">
|
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<assignedCustodian classCode="ASSIGNED">
|
| 59 |
<representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
|
| 60 |
<id root="2.16.724.4.9.400.1"/>
|
| 61 |
<name>Departament de Salut</name>
|
| 62 |
<telecom use="WP" value="tel:+34932272900"/>
|
| 63 |
<addr>
|
| 64 |
<streetAddressLine>Travessera De Les Corts, 131-159 (pavelló Ave Maria)</streetAddressLine>
|
| 65 |
<city>Barcelona</city>
|
| 66 |
<state>Barcelona</state>
|
| 67 |
<postalCode>08028</postalCode>
|
| 68 |
<country>ES</country>
|
| 69 |
</addr>
|
| 70 |
</representedCustodianOrganization>
|
| 71 |
</assignedCustodian>
|
| 72 |
</custodian>
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<legalAuthenticator contextControlCode="OP" typeCode="LA">
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| 74 |
<time value="20251002132019+0200"/>
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<signatureCode code="S"/>
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<assignedEntity classCode="ASSIGNED">
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<id root="2.16.724.4.9.400.1"/>
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<addr nullFlavor="NI"/>
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<telecom nullFlavor="NI"/>
|
| 80 |
<assignedPerson>
|
| 81 |
<name>
|
| 82 |
<given>Olga</given>
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| 83 |
<family>Pané</family>
|
| 84 |
<family>Mena</family>
|
| 85 |
</name>
|
| 86 |
</assignedPerson>
|
| 87 |
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
|
| 88 |
<id root="2.16.724.4.9.400.1"/>
|
| 89 |
<name>Departament de Salut</name>
|
| 90 |
<telecom use="WP" value="tel:+34932272900"/>
|
| 91 |
<addr>
|
| 92 |
<streetAddressLine>Travessera De Les Corts, 131-159 (pavelló Ave Maria)</streetAddressLine>
|
| 93 |
<city>Barcelona</city>
|
| 94 |
<state>Barcelona</state>
|
| 95 |
<postalCode>08028</postalCode>
|
| 96 |
<country>ES</country>
|
| 97 |
</addr>
|
| 98 |
</representedOrganization>
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| 99 |
</assignedEntity>
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| 100 |
</legalAuthenticator>
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<participant typeCode="IND">
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<templateId root="2.16.840.1.113883.10.22.2.5"/>
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<functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88"/>
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<associatedEntity classCode="PRS">
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<addr nullFlavor="NI"/>
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<telecom nullFlavor="NI"/>
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<scopingOrganization classCode="ORG" determinerCode="INSTANCE">
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<id root="2.16.724.4.9.400.1"/>
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<name>Departament de Salut</name>
|
| 110 |
<telecom use="WP" value="tel:+34932272900"/>
|
| 111 |
<addr>
|
| 112 |
<streetAddressLine>Travessera De Les Corts, 131-159 (pavelló Ave Maria)</streetAddressLine>
|
| 113 |
<city>Barcelona</city>
|
| 114 |
<state>Barcelona</state>
|
| 115 |
<postalCode>08028</postalCode>
|
| 116 |
<country>ES</country>
|
| 117 |
</addr>
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</scopingOrganization>
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</associatedEntity>
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| 120 |
</participant>
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<documentationOf>
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<serviceEvent classCode="PCPR" moodCode="EVN">
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<effectiveTime>
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<low value="19660404"/>
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<high nullFlavor="NA"/>
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</effectiveTime>
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<performer typeCode="PRF">
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.2.3"/>
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<functionCode code="PP" codeSystem="2.16.840.1.113883.12.443" codeSystemName="HL7 ProviderRole" displayName="Primary Care Provider">
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<originalText>Primary Care Provider</originalText>
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</functionCode>
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<time>
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<low value="19660404"/>
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<high nullFlavor="NA"/>
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</time>
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<assignedEntity classCode="ASSIGNED">
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<id root="2.16.724.4.9.400.1"/>
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<addr nullFlavor="NI"/>
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<telecom nullFlavor="NI"/>
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<representedOrganization classCode="ORG" determinerCode="INSTANCE">
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| 141 |
<id root="2.16.724.4.9.400.1"/>
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| 142 |
<name>Departament de Salut</name>
|
| 143 |
<telecom use="WP" value="tel:+34932272900"/>
|
| 144 |
<addr>
|
| 145 |
<streetAddressLine>Travessera De Les Corts, 131-159 (pavelló Ave Maria)</streetAddressLine>
|
| 146 |
<city>Barcelona</city>
|
| 147 |
<state>Barcelona</state>
|
| 148 |
<postalCode>08028</postalCode>
|
| 149 |
<country>ES</country>
|
| 150 |
</addr>
|
| 151 |
</representedOrganization>
|
| 152 |
</assignedEntity>
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| 153 |
</performer>
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| 154 |
</serviceEvent>
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| 155 |
</documentationOf>
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| 156 |
<component>
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<structuredBody>
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<component>
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| 159 |
<section classCode="DOCSECT">
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<templateId root="2.16.840.1.113883.10.22.3.1"/>
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<id root="73A98723-1BEB-47FD-8C90-7170ED817326"/>
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| 162 |
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" displayName="Medication Summary"/>
|
| 163 |
<title>Medication Summary</title>
|
| 164 |
<text>
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| 165 |
<paragraph>
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| 166 |
<content styleCode="Bold">Currently active medications</content>
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| 167 |
</paragraph>
|
| 168 |
<paragraph>
|
| 169 |
<content styleCode="Bold">Long-term treatments</content>
|
| 170 |
</paragraph>
|
| 171 |
<table>
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| 172 |
<tbody>
|
| 173 |
<tr>
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| 174 |
<th>
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| 175 |
<content>Product and</content>
|
| 176 |
<br/>
|
| 177 |
<content>dose form</content>
|
| 178 |
</th>
|
| 179 |
<th>
|
| 180 |
<content>Dose and</content>
|
| 181 |
<br/>
|
| 182 |
<content>frequency</content>
|
| 183 |
</th>
|
| 184 |
<th>Route</th>
|
| 185 |
<th>Duration</th>
|
| 186 |
<th>Comments</th>
|
| 187 |
</tr>
|
| 188 |
<tr ID="MED.1">
|
| 189 |
<td>
|
| 190 |
<content>COSOPT 20MG/ML + 5MG/ML COLIRIO EN SOLUCION FRASCO DE 5ML</content>
|
| 191 |
<br/>
|
| 192 |
<content>Eye drops, solution</content>
|
| 193 |
</td>
|
| 194 |
<td>
|
| 195 |
<content>1.7 Tablet</content>
|
| 196 |
<br/>
|
| 197 |
<content>1 DAYS</content>
|
| 198 |
</td>
|
| 199 |
<td>
|
| 200 |
<content>Ocular use</content>
|
| 201 |
</td>
|
| 202 |
<td>
|
| 203 |
<content>From 2025-06-13</content>
|
| 204 |
<br/>
|
| 205 |
<content>to 2026-06-13</content>
|
| 206 |
</td>
|
| 207 |
<td>
|
| 208 |
<content>Proves LMS</content>
|
| 209 |
<br/>
|
| 210 |
<content>Dinner:2</content>
|
| 211 |
</td>
|
| 212 |
</tr>
|
| 213 |
</tbody>
|
| 214 |
</table>
|
| 215 |
<paragraph>
|
| 216 |
<content styleCode="Bold">Just in case treatments</content>
|
| 217 |
</paragraph>
|
| 218 |
</text>
|
| 219 |
<entry typeCode="DRIV">
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| 220 |
<substanceAdministration classCode="SBADM" moodCode="INT">
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<templateId root="2.16.840.1.113883.10.22.4.4"/>
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<id extension="P1E007559227" root="2.16.724.4.9.30.40"/>
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<code code="DRUG" codeSystem="2.16.840.1.113883.5.4"/>
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| 224 |
<text>
|
| 225 |
<reference value="#MED.1"/>
|
| 226 |
</text>
|
| 227 |
<statusCode code="active"/>
|
| 228 |
<effectiveTime xsi:type="IVL_TS">
|
| 229 |
<low value="20250613"/>
|
| 230 |
<high value="20260613"/>
|
| 231 |
</effectiveTime>
|
| 232 |
<routeCode code="20051000" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="IPSRouteOfAdmin"/>
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<consumable typeCode="CSM">
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<manufacturedProduct classCode="MANU">
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<templateId root="2.16.840.1.113883.10.22.4.2"/>
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<manufacturedMaterial classCode="MMAT" determinerCode="KIND">
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<templateId root="2.16.840.1.113883.10.22.4.3"/>
|
| 238 |
<code code="840702" codeSystem="2.16.724.4.21.5.15.4" displayName="COSOPT 20MG/ML + 5MG/ML COLIRIO EN SOLUCION FRASCO DE 5ML"/>
|
| 239 |
<name>COSOPT 20MG/ML + 5MG/ML COLIRIO EN SOLUCION FRASCO DE 5ML</name>
|
| 240 |
</manufacturedMaterial>
|
| 241 |
</manufacturedProduct>
|
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</consumable>
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<entryRelationship typeCode="COMP">
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<substanceAdministration classCode="SBADM" moodCode="INT">
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<id root="2.16.840.1.113883.10.22.4.33"/>
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<statusCode code="active"/>
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<effectiveTime institutionSpecified="true" xsi:type="PIVL_TS">
|
| 248 |
<period unit="d" value="1"/>
|
| 249 |
</effectiveTime>
|
| 250 |
<doseQuantity unit="{tablet}" value="1.7"/>
|
| 251 |
<consumable>
|
| 252 |
<manufacturedProduct>
|
| 253 |
<manufacturedMaterial nullFlavor="NA"/>
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</manufacturedProduct>
|
| 255 |
</consumable>
|
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</substanceAdministration>
|
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</entryRelationship>
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</substanceAdministration>
|
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</entry>
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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="2.16.840.1.113883.10.22.3.2"/>
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<id root="E4B98FD3-D4B4-4769-8B3C-F50610FB69BE"/>
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<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Alergies, adverse reactions, alerts"/>
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| 267 |
<title>Allergies and Other Adverse Reactions</title>
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<text>
|
| 269 |
<content ID="ALE">No known allergies</content>
|
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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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<id root="11B79731-9FBA-421C-9E57-69CECC31F6F5"/>
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<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
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<statusCode code="active"/>
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<effectiveTime>
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<low nullFlavor="UNK"/>
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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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<code code="OINT" codeSystem="2.16.840.1.113883.5.4" displayName="Allergy or Intolerances"/>
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<statusCode code="completed"/>
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| 285 |
<effectiveTime>
|
| 286 |
<low nullFlavor="NA"/>
|
| 287 |
</effectiveTime>
|
| 288 |
<value code="no-known-allergies" codeSystem="2.16.840.1.113883.5.1150.1" displayName="No known allergies" xsi:type="CD"/>
|
| 289 |
</observation>
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| 290 |
</entryRelationship>
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</act>
|
| 292 |
</entry>
|
| 293 |
</section>
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</component>
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<component>
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<section>
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<templateId root="2.16.840.1.113883.10.22.3.7"/>
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<id root="CB395BE1-C6FC-4564-A558-110607189F7C"/>
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<code code="11348-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Past Illness"/>
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| 300 |
<title>History of Past Illness</title>
|
| 301 |
<text>
|
| 302 |
<table>
|
| 303 |
<tbody>
|
| 304 |
<tr>
|
| 305 |
<th>Problem</th>
|
| 306 |
<th>Onset time</th>
|
| 307 |
<th>End date</th>
|
| 308 |
<th>Resolution circumstances</th>
|
| 309 |
</tr>
|
| 310 |
<tr ID="HPRO.1">
|
| 311 |
<td>ICD_10_MC Z01.89 Encounter for other specified special examinations</td>
|
| 312 |
<td>2024-05-09</td>
|
| 313 |
<td>2025-06-11</td>
|
| 314 |
<td>No Disponible</td>
|
| 315 |
</tr>
|
| 316 |
</tbody>
|
| 317 |
</table>
|
| 318 |
</text>
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| 319 |
<entry typeCode="COMP">
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<act classCode="ACT" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.22.4.7"/>
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<id root="B192BC06-A992-42FF-A43C-3AA1D432C922"/>
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<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
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<statusCode code="completed"/>
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<effectiveTime>
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<low value="20240509"/>
|
| 327 |
<high value="20250611"/>
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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="2.16.840.1.113883.10.22.4.8"/>
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<id root="064A507C-B72D-4DFB-8FA8-F2194C0B2D10"/>
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<code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">
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<originalText>
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<reference value="#HPRO.1"/>
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</code>
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<statusCode code="completed"/>
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<effectiveTime>
|
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<low value="20240509"/>
|
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<high value="20250611"/>
|
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</effectiveTime>
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<value code="Z01.89" codeSystem="2.16.840.1.113883.6.90" codeSystemName="ICD_10_MC" displayName="Encounter for other specified special examinations" xsi:type="CD"/>
|
| 344 |
</observation>
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</act>
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</entry>
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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="2.16.840.1.113883.10.22.3.3"/>
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<id root="7505FEFD-9636-4DA1-8203-EDA409CD3EE2"/>
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<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem list"/>
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<title>Active Problems</title>
|
| 356 |
<text>
|
| 357 |
<table>
|
| 358 |
<tbody>
|
| 359 |
<tr>
|
| 360 |
<th>Problem</th>
|
| 361 |
<th>Onset time</th>
|
| 362 |
</tr>
|
| 363 |
<tr ID="APRO.1">
|
| 364 |
<td>ICD_10_MC H40.01 Open angle with borderline findings, low risk</td>
|
| 365 |
<td>2025-06-12</td>
|
| 366 |
</tr>
|
| 367 |
<tr ID="APRO.2">
|
| 368 |
<td>ICD_10_MC J12.8 Other viral pneumonia</td>
|
| 369 |
<td>2025-06-12</td>
|
| 370 |
</tr>
|
| 371 |
</tbody>
|
| 372 |
</table>
|
| 373 |
</text>
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<entry typeCode="COMP">
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<act classCode="ACT" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.22.4.7"/>
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<id root="36AF3AE2-3702-40ED-A823-6D883DD9577B"/>
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<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
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<statusCode code="active"/>
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<effectiveTime>
|
| 381 |
<low value="20250612"/>
|
| 382 |
</effectiveTime>
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| 383 |
<entryRelationship inversionInd="false" typeCode="SUBJ">
|
| 384 |
<observation classCode="OBS" moodCode="EVN">
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| 385 |
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| 389 |
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| 393 |
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| 397 |
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| 398 |
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| 399 |
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| 400 |
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<value code="J12.8" codeSystem="2.16.840.1.113883.6.90" codeSystemName="ICD_10_MC" displayName="Other viral pneumonia" xsi:type="CD"/>
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