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<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">
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<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
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<id extension="c266" root="2.16.840.1.113883.19.4"/>
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<code code="34133-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summarization of Episode Note"/>
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<title>Nota de episodio</title>
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<effectiveTime value="202511161545"/>
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<confidentialityCode code="V" codeSystem="2.16.840.1.113883.5.25"/>
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<recordTarget>
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<patientRole>
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<id assigningAuthorityName="C�dula de extranjer�a" extension="30538292" root="2.16.840.1.113883.19.6.1.2"/>
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<id extension="1" root="2.16.840.1.113883.19.6.2.1"/>
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<id extension="2" root="2.16.840.1.113883.19.6.3.2"/>
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<id extension="1111" root="2.16.840.1.113883.19.6.4"/>
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<addr use="HP">
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<country>CO</country>
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<state>18</state>
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<city>18001</city>
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<postalCode>18001</postalCode>
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<streetAddressLine>CALLE 4</streetAddressLine>
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</addr>
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<telecom use="HP" value=""/>
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<patient>
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<name>
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<given>LOLA</given>
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<given/>
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<family>LOAIZA</family>
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<family/>
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</name>
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<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
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<birthTime value="19981120"/>
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</patient>
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</patientRole>
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</recordTarget>
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<author>
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<time value="202511161545"/>
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<assignedAuthor>
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<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
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<assignedPerson>
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<name>
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<given>ALEJANDRO </given>
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<given/>
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<family>ROA</family>
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<family/>
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<suffix>MD.</suffix>
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</name>
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</assignedPerson>
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<representedOrganization>
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<id extension="Codigo ministerio" root="2.16.840.1.113883.19.5.4"/>
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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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<id root="2.16.840.1.113883.19.5.5"/>
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<name>CLINICA VIDA SANA </name>
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<telecom/>
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<addr use="WP">
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<country>CO</country>
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<state>18</state>
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<city>18001</city>
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<postalCode>18001</postalCode>
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<streetAddressLine>CALLE 4</streetAddressLine>
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</addr>
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</representedCustodianOrganization>
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| 66 |
</assignedCustodian>
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</custodian>
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| 68 |
<componentOf>
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| 69 |
<encompassingEncounter>
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<id extension="011103" root="2.16.840.1.113883.2.17"/>
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<code code="R" codeSystem="2.16.840.1.113883.2.17" codeSystemName="CUPS" displayName="BIOPSIA DE CR�NEO"/>
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<effectiveTime>
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<low value="20251116"/>
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<high value="20251116"/>
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</effectiveTime>
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<dischargeDispositionCode code="01" codeSystem="2.16.840.1.113883.12.112" codeSystemName="HL7 Discharge Disposition" displayName="Routine Discharge1 Vivo (a)"/>
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<location>
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| 78 |
<healthCareFacility>
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<id root="2.16.540.1.113883.19.2"/>
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<location>
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<name>SALIDA </name>
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</location>
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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 extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="30525-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Age"/>
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<title>Edad</title>
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<text>26 A�o</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 extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="76437-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Primary insurance"/>
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<title>EPS</title>
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<text>COLSUBSIDIO</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 extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 108 |
<code code="45410-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Admitted from"/>
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<title>SERVICIO DE INGRESO</title>
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<text>1 Urgencias</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 extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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<code code="29299-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Reason for visit Narrative"/>
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<title>MOTIVO DE LA SOLICITUD DEL SERVICIO PERCEPCI�N DEL USUARIO</title>
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| 118 |
<text>SE SOLICITA CONSULTA POR UN FUERTE DOLOR DE CABEZ</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 extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 124 |
<code code="67800-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="EMS injury incident description Narrative NEMSIS"/>
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<title>CAUSA EXTERNA</title>
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<text>01 Accidente de trabajo</text>
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</section>
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</component>
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| 129 |
<component>
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<section>
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| 131 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 132 |
<code code="42347-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Admission diagnosis "/>
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<title>ESTADO GENERAL AL INGRESO</title>
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<text>PACIENTE QUE INDICA ESTAR EN BUENAS CONDICIONES DE SALUD SIN EMBARGO PRESENTA UN FUERTE DOLOR DE CABEZA</text>
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</section>
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| 136 |
</component>
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| 137 |
<component>
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| 138 |
<section>
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| 139 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 140 |
<code code="81267-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Setting of exposure to illness"/>
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| 141 |
<title>ENFERMEDAD ACTUAL</title>
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<text>CEFALEA </text>
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</section>
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</component>
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<component>
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| 146 |
<section>
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| 147 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 148 |
<code code="10157-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of family member diseases Narrative"/>
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<title>ANTECEDENTES FAMILIARES</title>
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<text>NINGUNO</text>
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| 151 |
</section>
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| 152 |
</component>
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| 153 |
<component>
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| 154 |
<section>
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| 155 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 156 |
<code code="11348-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Past illness Narrative"/>
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| 157 |
<title>ANTECEDENTES PERSONALES</title>
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<text>Por favor llene los espacios de antecedentes que apliquen para el paciente.
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Antecedentes quir�rgicos
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Antecedentes Transfusionales
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Antecedentes T�xicos
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Antecedentes inmunol�gicos
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Antecedentes al�rgicos
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Antecedentes traum�ticos
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Antecedentes psiqui�tricos
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Antecedentes ginecobst�trico
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Antecedentes farmacol�gicos
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Antecedentes familiares
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Antecedentes psicol�gicos
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Antecedentes otros
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Antecedentes medicamento_contraindicado</text>
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</section>
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</component>
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<component>
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| 176 |
<section>
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| 177 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 178 |
<code code="8687-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Review of systems - Reported"/>
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<title>REVISI�N POR SISTEMAS</title>
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<text>Ojos
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O�dos
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Nariz, boca y garganta
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Cardiovascular
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Respiratorio
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Gastrointestinal
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Genitourinarios
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Musculoesqueletico
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Linfatico
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Tegumentario
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Neurolog�co
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Endocrino
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Inmunolog�co
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Psiquiatrico</text>
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</section>
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</component>
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<component>
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| 197 |
<section>
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| 198 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 199 |
<code code="29545-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Physical findings Narrative"/>
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| 200 |
<title>HALLAZGOS EXAMEN F�SICO</title>
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<text>SE EVIDENCIA UN FUERTE DOLOR DE CABEZA DURANTE EL EXAMEN REALIZADO </text>
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| 202 |
</section>
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| 203 |
</component>
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| 204 |
<component>
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| 205 |
<section>
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| 206 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 207 |
<code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
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| 208 |
<title>DIAGNOSTICO PRESUNTIVO INGRESO</title>
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| 209 |
<text>G441 Cefalea vascular, NCOP</text>
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| 210 |
</section>
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| 211 |
</component>
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| 212 |
<component>
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| 213 |
<section>
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| 214 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 215 |
<code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
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| 216 |
<title>DIAGNOSTICO RELACIONADO INGRESO</title>
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| 217 |
<text>R51X Cefalea</text>
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| 218 |
</section>
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| 219 |
</component>
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| 220 |
<component>
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| 221 |
<section>
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| 222 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
|
| 223 |
<code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
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| 224 |
<title>DIAGNOSTICO CONFIRMADO INGRESO</title>
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| 225 |
<text>G442 Cefalea debida a tension</text>
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| 226 |
</section>
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| 227 |
</component>
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| 228 |
<component>
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| 229 |
<section>
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| 230 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
|
| 231 |
<code code="86922-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Therapeutic goals panel"/>
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| 232 |
<title>CONDUCTA: MANEJO TERAP�UTICO</title>
|
| 233 |
<text>SE LE RECOMIENDA ANTIINFLAMATORIOS Y REPOSO</text>
|
| 234 |
</section>
|
| 235 |
</component>
|
| 236 |
<component>
|
| 237 |
<section>
|
| 238 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
|
| 239 |
<code code="11506-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Progress note"/>
|
| 240 |
<title>NOTA DE PROGRESO</title>
|
| 241 |
<text>SE EVIDENCIA UNA MEJORA EN LA SALUD DEL USUARIO</text>
|
| 242 |
</section>
|
| 243 |
</component>
|
| 244 |
<component>
|
| 245 |
<section>
|
| 246 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
|
| 247 |
<code code="29554-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure Narrative"/>
|
| 248 |
<title>RESULTADO DE PROCEDIMIENTOS</title>
|
| 249 |
<text>LOS PROCEDIMIENTOS MUESTRAN UN NORMAL RESULTADO</text>
|
| 250 |
</section>
|
| 251 |
</component>
|
| 252 |
<component>
|
| 253 |
<section>
|
| 254 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
|
| 255 |
<code code="59768-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure indications"/>
|
| 256 |
<title>INDICACIONES TERAP�UTICAS</title>
|
| 257 |
<text>SE PROCEDE A SUPENDER LOS MEDICAMENTOS Y SE RECOMIENDA REPOSO</text>
|
| 258 |
</section>
|
| 259 |
</component>
|
| 260 |
<component>
|
| 261 |
<section>
|
| 262 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
|
| 263 |
<code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
|
| 264 |
<title>DIAGNOSTICO PRESUNTIVO EGRESO</title>
|
| 265 |
<text>H104 Conjuntivitis cronica</text>
|
| 266 |
</section>
|
| 267 |
</component>
|
| 268 |
<component>
|
| 269 |
<section>
|
| 270 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
|
| 271 |
<code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
|
| 272 |
<title>DIAGNOSTICO RELACIONADO EGRESO</title>
|
| 273 |
<text>G443 Cefalea postraumatica cronica</text>
|
| 274 |
</section>
|
| 275 |
</component>
|
| 276 |
<component>
|
| 277 |
<section>
|
| 278 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
|
| 279 |
<code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
|
| 280 |
<title>DIAGNOSTICO CONFIRMADO EGRESO</title>
|
| 281 |
<text>G442 Cefalea debida a tension</text>
|
| 282 |
</section>
|
| 283 |
</component>
|
| 284 |
<component>
|
| 285 |
<section>
|
| 286 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
|
| 287 |
<code code="18842-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Discharge summary"/>
|
| 288 |
<title>PLAN DE MANEJO AMBULATORIO</title>
|
| 289 |
<text>SE RECOMIENDA TOTAL REPOSO </text>
|
| 290 |
</section>
|
| 291 |
</component>
|
| 292 |
</structuredBody>
|
| 293 |
</component>
|
| 294 |
</ClinicalDocument>
|
