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:ns3="urn:hl7-org:sdtc" xmlns:pharm="urn:hl7-org:pharm" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
|
| 2 |
<realmCode code="ES"/>
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| 3 |
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
|
| 4 |
<templateId root="2.16.840.1.113883.10.22.1.1"/>
|
| 5 |
<id extension="91620821763712922573" root="2.16.724.4.9.400.1"/>
|
| 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="20251121091522+0100"/>
|
| 9 |
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality" displayName="Normal"/>
|
| 10 |
<languageCode code="en-GB"/>
|
| 11 |
<recordTarget contextControlCode="OP" typeCode="RCT">
|
| 12 |
<patientRole>
|
| 13 |
<id root="2.16.724.4.40"/>
|
| 14 |
<id extension="LOPA1090109002" root="2.16.724.4.41"/>
|
| 15 |
<id extension="23819921V" root="1.3.6.1.4.1.19126.3"/>
|
| 16 |
<addr use="HP">
|
| 17 |
<streetAddressLine>Cr Justa Goicoechea 2 N</streetAddressLine>
|
| 18 |
<city>L'hospitalet De Llobregat</city>
|
| 19 |
<state>ES</state>
|
| 20 |
<postalCode>08902</postalCode>
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| 21 |
</addr>
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| 22 |
<telecom nullFlavor="NI"/>
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| 23 |
<patient>
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| 24 |
<name>
|
| 25 |
<given>Melani</given>
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| 26 |
<family>Lopez</family>
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| 27 |
<family>Pascual</family>
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| 28 |
</name>
|
| 29 |
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender" displayName="Female"/>
|
| 30 |
<birthTime value="20090109"/>
|
| 31 |
</patient>
|
| 32 |
</patientRole>
|
| 33 |
</recordTarget>
|
| 34 |
<author contextControlCode="OP" typeCode="AUT">
|
| 35 |
<time value="20251121091522+0100"/>
|
| 36 |
<assignedAuthor classCode="ASSIGNED">
|
| 37 |
<id root="2.16.724.4.9.400.1"/>
|
| 38 |
<addr nullFlavor="NA"/>
|
| 39 |
<telecom nullFlavor="NI"/>
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| 40 |
<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
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| 41 |
<softwareName>Història Clínica Compartida de Catalunya</softwareName>
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| 42 |
</assignedAuthoringDevice>
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| 43 |
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
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| 44 |
<id root="2.16.724.4.9.400.1"/>
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| 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>
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| 54 |
</representedOrganization>
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| 55 |
</assignedAuthor>
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| 56 |
</author>
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| 57 |
<custodian typeCode="CST">
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| 58 |
<assignedCustodian classCode="ASSIGNED">
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| 59 |
<representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
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| 60 |
<id root="2.16.724.4.9.400.1"/>
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| 61 |
<name>Departament de Salut</name>
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| 62 |
<telecom use="WP" value="tel:+34932272900"/>
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| 63 |
<addr>
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| 64 |
<streetAddressLine>Travessera De Les Corts, 131-159 (pavelló Ave Maria)</streetAddressLine>
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| 65 |
<city>Barcelona</city>
|
| 66 |
<state>Barcelona</state>
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| 67 |
<postalCode>08028</postalCode>
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| 68 |
<country>ES</country>
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| 69 |
</addr>
|
| 70 |
</representedCustodianOrganization>
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| 71 |
</assignedCustodian>
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| 72 |
</custodian>
|
| 73 |
<legalAuthenticator contextControlCode="OP" typeCode="LA">
|
| 74 |
<time value="20251121091522+0100"/>
|
| 75 |
<signatureCode code="S"/>
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| 76 |
<assignedEntity classCode="ASSIGNED">
|
| 77 |
<id root="2.16.724.4.9.400.1"/>
|
| 78 |
<addr nullFlavor="NI"/>
|
| 79 |
<telecom nullFlavor="NI"/>
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| 80 |
<assignedPerson>
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| 81 |
<name>
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<given>Olga</given>
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<family>Pané</family>
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<family>Mena</family>
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</name>
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| 86 |
</assignedPerson>
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| 87 |
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
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| 88 |
<id root="2.16.724.4.9.400.1"/>
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| 89 |
<name>Departament de Salut</name>
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| 90 |
<telecom use="WP" value="tel:+34932272900"/>
|
| 91 |
<addr>
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| 92 |
<streetAddressLine>Travessera De Les Corts, 131-159 (pavelló Ave Maria)</streetAddressLine>
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| 93 |
<city>Barcelona</city>
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| 94 |
<state>Barcelona</state>
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| 95 |
<postalCode>08028</postalCode>
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| 96 |
<country>ES</country>
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| 97 |
</addr>
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| 98 |
</representedOrganization>
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| 99 |
</assignedEntity>
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| 100 |
</legalAuthenticator>
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| 101 |
<participant typeCode="IND">
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| 102 |
<templateId root="2.16.840.1.113883.10.22.2.5"/>
|
| 103 |
<functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88"/>
|
| 104 |
<associatedEntity classCode="PRS">
|
| 105 |
<addr nullFlavor="NI"/>
|
| 106 |
<telecom nullFlavor="NI"/>
|
| 107 |
<scopingOrganization classCode="ORG" determinerCode="INSTANCE">
|
| 108 |
<id root="2.16.724.4.9.400.1"/>
|
| 109 |
<name>Departament de Salut</name>
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| 110 |
<telecom use="WP" value="tel:+34932272900"/>
|
| 111 |
<addr>
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| 112 |
<streetAddressLine>Travessera De Les Corts, 131-159 (pavelló Ave Maria)</streetAddressLine>
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| 113 |
<city>Barcelona</city>
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| 114 |
<state>Barcelona</state>
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| 115 |
<postalCode>08028</postalCode>
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| 116 |
<country>ES</country>
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</addr>
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| 118 |
</scopingOrganization>
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| 119 |
</associatedEntity>
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| 120 |
</participant>
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| 121 |
<documentationOf>
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| 122 |
<serviceEvent classCode="PCPR" moodCode="EVN">
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| 123 |
<effectiveTime>
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| 124 |
<low value="20090109"/>
|
| 125 |
<high nullFlavor="NA"/>
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| 126 |
</effectiveTime>
|
| 127 |
<performer typeCode="PRF">
|
| 128 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.2.3"/>
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| 129 |
<functionCode code="PP" codeSystem="2.16.840.1.113883.12.443" codeSystemName="HL7 ProviderRole" displayName="Primary Care Provider">
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| 130 |
<originalText>Primary Care Provider</originalText>
|
| 131 |
</functionCode>
|
| 132 |
<time>
|
| 133 |
<low value="20090109"/>
|
| 134 |
<high nullFlavor="NA"/>
|
| 135 |
</time>
|
| 136 |
<assignedEntity classCode="ASSIGNED">
|
| 137 |
<id root="2.16.724.4.9.400.1"/>
|
| 138 |
<addr nullFlavor="NI"/>
|
| 139 |
<telecom nullFlavor="NI"/>
|
| 140 |
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
|
| 141 |
<id root="2.16.724.4.9.400.1"/>
|
| 142 |
<name>Departament de Salut</name>
|
| 143 |
<telecom use="WP" value="tel:+34932272900"/>
|
| 144 |
<addr>
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| 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>
|
| 154 |
</serviceEvent>
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| 155 |
</documentationOf>
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| 156 |
<component>
|
| 157 |
<structuredBody>
|
| 158 |
<component>
|
| 159 |
<section classCode="DOCSECT">
|
| 160 |
<templateId root="2.16.840.1.113883.10.22.3.1"/>
|
| 161 |
<id root="FEF4FDC8-5765-49FB-8E92-E5549F14B5A2"/>
|
| 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>
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| 169 |
<content styleCode="Bold">Long-term treatments</content>
|
| 170 |
</paragraph>
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| 171 |
<table>
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| 172 |
<tbody>
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| 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>
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| 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>SIMVASTATINA ALMUS 20MG 28 COMPRIMIDOS RECUBIERTOS CON PELICULA EFG</content>
|
| 191 |
<br/>
|
| 192 |
<content>Tablet</content>
|
| 193 |
</td>
|
| 194 |
<td>
|
| 195 |
<content>1.7 Tablet</content>
|
| 196 |
<br/>
|
| 197 |
<content>1 DAYS</content>
|
| 198 |
</td>
|
| 199 |
<td>
|
| 200 |
<content>Oral use</content>
|
| 201 |
</td>
|
| 202 |
<td>
|
| 203 |
<content>From 2025-02-11</content>
|
| 204 |
<br/>
|
| 205 |
<content>to 2025-07-14</content>
|
| 206 |
</td>
|
| 207 |
<td>
|
| 208 |
<content/>
|
| 209 |
</td>
|
| 210 |
</tr>
|
| 211 |
<tr ID="MED.2">
|
| 212 |
<td>
|
| 213 |
<content>IRUXOL MONO 1 TUBO 30G POMADA</content>
|
| 214 |
<br/>
|
| 215 |
<content>Ointment</content>
|
| 216 |
</td>
|
| 217 |
<td>
|
| 218 |
<content>1.7 Tablet</content>
|
| 219 |
<br/>
|
| 220 |
<content>1 DAYS</content>
|
| 221 |
</td>
|
| 222 |
<td>
|
| 223 |
<content>Cutaneous use</content>
|
| 224 |
</td>
|
| 225 |
<td>
|
| 226 |
<content>From 2025-07-14</content>
|
| 227 |
<br/>
|
| 228 |
<content>to 2025-08-06</content>
|
| 229 |
</td>
|
| 230 |
<td>
|
| 231 |
<content/>
|
| 232 |
</td>
|
| 233 |
</tr>
|
| 234 |
</tbody>
|
| 235 |
</table>
|
| 236 |
<paragraph>
|
| 237 |
<content styleCode="Bold">Just in case treatments</content>
|
| 238 |
</paragraph>
|
| 239 |
</text>
|
| 240 |
<entry typeCode="DRIV">
|
| 241 |
<substanceAdministration classCode="SBADM" moodCode="INT">
|
| 242 |
<templateId root="2.16.840.1.113883.10.22.4.4"/>
|
| 243 |
<id extension="P1E007799242" root="2.16.724.4.9.30.40"/>
|
| 244 |
<code code="DRUG" codeSystem="2.16.840.1.113883.5.4"/>
|
| 245 |
<text>
|
| 246 |
<reference value="#MED.1"/>
|
| 247 |
</text>
|
| 248 |
<statusCode code="completed"/>
|
| 249 |
<effectiveTime xsi:type="IVL_TS">
|
| 250 |
<low value="20250211"/>
|
| 251 |
<high value="20250714"/>
|
| 252 |
</effectiveTime>
|
| 253 |
<routeCode code="20053000" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="IPSRouteOfAdmin"/>
|
| 254 |
<consumable typeCode="CSM">
|
| 255 |
<manufacturedProduct classCode="MANU">
|
| 256 |
<templateId root="2.16.840.1.113883.10.22.4.2"/>
|
| 257 |
<manufacturedMaterial classCode="MMAT" determinerCode="KIND">
|
| 258 |
<templateId root="2.16.840.1.113883.10.22.4.3"/>
|
| 259 |
<code code="650619" codeSystem="2.16.724.4.21.5.15.4" displayName="SIMVASTATINA ALMUS 20MG 28 COMPRIMIDOS RECUBIERTOS CON PELICULA EFG"/>
|
| 260 |
<name>SIMVASTATINA ALMUS 20MG 28 COMPRIMIDOS RECUBIERTOS CON PELICULA EFG</name>
|
| 261 |
<pharm:formCode code="CO" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="EDQM" displayName="Tablet"/>
|
| 262 |
<pharm:asSpecializedKind classCode="GRIC">
|
| 263 |
<pharm:generalizedMaterialKind classCode="MMAT" determinerCode="KIND">
|
| 264 |
<pharm:code code="C10AA01" codeSystem="2.16.840.1.113883.6.73" codeSystemName="Simvastatina" displayName="WHO ATC"/>
|
| 265 |
</pharm:generalizedMaterialKind>
|
| 266 |
</pharm:asSpecializedKind>
|
| 267 |
<pharm:ingredient classCode="ACTI">
|
| 268 |
<pharm:quantity>
|
| 269 |
<numerator unit="mg" value="20.0" xsi:type="PQ"/>
|
| 270 |
<denominator unit="{tablet}" value="1.7" xsi:type="PQ"/>
|
| 271 |
</pharm:quantity>
|
| 272 |
<pharm:ingredientSubstance classCode="MMAT" determinerCode="KIND">
|
| 273 |
<pharm:code code="RE0315" codeSystem="2.16.724.4.103.1.1.101.2" codeSystemName="AEMPS"/>
|
| 274 |
<pharm:name>SIMVASTATINA</pharm:name>
|
| 275 |
</pharm:ingredientSubstance>
|
| 276 |
</pharm:ingredient>
|
| 277 |
</manufacturedMaterial>
|
| 278 |
</manufacturedProduct>
|
| 279 |
</consumable>
|
| 280 |
<entryRelationship typeCode="COMP">
|
| 281 |
<substanceAdministration classCode="SBADM" moodCode="INT">
|
| 282 |
<id root="2.16.840.1.113883.10.22.4.33"/>
|
| 283 |
<statusCode code="completed"/>
|
| 284 |
<effectiveTime institutionSpecified="true" xsi:type="PIVL_TS">
|
| 285 |
<period unit="d" value="1"/>
|
| 286 |
</effectiveTime>
|
| 287 |
<doseQuantity unit="{tablet}" value="1.7"/>
|
| 288 |
<consumable>
|
| 289 |
<manufacturedProduct>
|
| 290 |
<manufacturedMaterial nullFlavor="NA"/>
|
| 291 |
</manufacturedProduct>
|
| 292 |
</consumable>
|
| 293 |
</substanceAdministration>
|
| 294 |
</entryRelationship>
|
| 295 |
</substanceAdministration>
|
| 296 |
</entry>
|
| 297 |
<entry typeCode="DRIV">
|
| 298 |
<substanceAdministration classCode="SBADM" moodCode="INT">
|
| 299 |
<templateId root="2.16.840.1.113883.10.22.4.4"/>
|
| 300 |
<id extension="P1E007809226" root="2.16.724.4.9.30.40"/>
|
| 301 |
<code code="DRUG" codeSystem="2.16.840.1.113883.5.4"/>
|
| 302 |
<text>
|
| 303 |
<reference value="#MED.2"/>
|
| 304 |
</text>
|
| 305 |
<statusCode code="active"/>
|
| 306 |
<effectiveTime xsi:type="IVL_TS">
|
| 307 |
<low value="20250714"/>
|
| 308 |
<high value="20250806"/>
|
| 309 |
</effectiveTime>
|
| 310 |
<routeCode code="20003000" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="IPSRouteOfAdmin"/>
|
| 311 |
<consumable typeCode="CSM">
|
| 312 |
<manufacturedProduct classCode="MANU">
|
| 313 |
<templateId root="2.16.840.1.113883.10.22.4.2"/>
|
| 314 |
<manufacturedMaterial classCode="MMAT" determinerCode="KIND">
|
| 315 |
<templateId root="2.16.840.1.113883.10.22.4.3"/>
|
| 316 |
<code code="771808" codeSystem="2.16.724.4.21.5.15.4" displayName="IRUXOL MONO 1 TUBO 30G POMADA"/>
|
| 317 |
<name>IRUXOL MONO 1 TUBO 30G POMADA</name>
|
| 318 |
<pharm:formCode code="PO" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="EDQM" displayName="Tablet"/>
|
| 319 |
<pharm:asSpecializedKind classCode="GRIC">
|
| 320 |
<pharm:generalizedMaterialKind classCode="MMAT" determinerCode="KIND">
|
| 321 |
<pharm:code code="D03BA52" codeSystem="2.16.840.1.113883.6.73" codeSystemName="Colagenasa, combinaciones con" displayName="WHO ATC"/>
|
| 322 |
</pharm:generalizedMaterialKind>
|
| 323 |
</pharm:asSpecializedKind>
|
| 324 |
<pharm:ingredient classCode="ACTI">
|
| 325 |
<pharm:quantity>
|
| 326 |
<numerator unit="[iu]" value="1.2" xsi:type="PQ"/>
|
| 327 |
<denominator unit="{tablet}" value="1.7" xsi:type="PQ"/>
|
| 328 |
</pharm:quantity>
|
| 329 |
<pharm:ingredientSubstance classCode="MMAT" determinerCode="KIND">
|
| 330 |
<pharm:code code="MI2058" codeSystem="2.16.724.4.103.1.1.101.2" codeSystemName="AEMPS"/>
|
| 331 |
<pharm:name>CLOSTRIDIOPEPTIDASA</pharm:name>
|
| 332 |
</pharm:ingredientSubstance>
|
| 333 |
</pharm:ingredient>
|
| 334 |
<pharm:ingredient classCode="ACTI">
|
| 335 |
<pharm:quantity>
|
| 336 |
<numerator unit="[iu]" value="0.24" xsi:type="PQ"/>
|
| 337 |
<denominator unit="{tablet}" value="1.7" xsi:type="PQ"/>
|
| 338 |
</pharm:quantity>
|
| 339 |
<pharm:ingredientSubstance classCode="MMAT" determinerCode="KIND">
|
| 340 |
<pharm:code code="MI3467" codeSystem="2.16.724.4.103.1.1.101.2" codeSystemName="AEMPS"/>
|
| 341 |
<pharm:name>PROTEOLITICS ENZIMS</pharm:name>
|
| 342 |
</pharm:ingredientSubstance>
|
| 343 |
</pharm:ingredient>
|
| 344 |
</manufacturedMaterial>
|
| 345 |
</manufacturedProduct>
|
| 346 |
</consumable>
|
| 347 |
<entryRelationship typeCode="COMP">
|
| 348 |
<substanceAdministration classCode="SBADM" moodCode="INT">
|
| 349 |
<id root="2.16.840.1.113883.10.22.4.33"/>
|
| 350 |
<statusCode code="active"/>
|
| 351 |
<effectiveTime institutionSpecified="true" xsi:type="PIVL_TS">
|
| 352 |
<period unit="d" value="1"/>
|
| 353 |
</effectiveTime>
|
| 354 |
<doseQuantity unit="{tablet}" value="1.7"/>
|
| 355 |
<consumable>
|
| 356 |
<manufacturedProduct>
|
| 357 |
<manufacturedMaterial nullFlavor="NA"/>
|
| 358 |
</manufacturedProduct>
|
| 359 |
</consumable>
|
| 360 |
</substanceAdministration>
|
| 361 |
</entryRelationship>
|
| 362 |
</substanceAdministration>
|
| 363 |
</entry>
|
| 364 |
</section>
|
| 365 |
</component>
|
| 366 |
<component>
|
| 367 |
<section>
|
| 368 |
<templateId root="2.16.840.1.113883.10.22.3.2"/>
|
| 369 |
<id root="33A7306D-AF7C-4AA4-9BD6-E8D480CDE7C8"/>
|
| 370 |
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Alergies, adverse reactions, alerts"/>
|
| 371 |
<title>Allergies and Other Adverse Reactions</title>
|
| 372 |
<text>
|
| 373 |
<content ID="ALE">No known allergies</content>
|
| 374 |
</text>
|
| 375 |
<entry typeCode="DRIV">
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<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of immunizations"/>
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<title>Immunizations</title>
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<text>
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<table>
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<tbody>
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<tr>
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| 409 |
<th>
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<content>Vaccination</content>
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<br/>
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<content>Brand name</content>
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| 413 |
</th>
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<th>Vaccination date</th>
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<tr ID="IMU.1">
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<td>
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<content>SNOMED CT 840534001 Vacunació contra SARS-CoV-2</content>
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| 419 |
<br/>
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<content>Marca Comercial Description</content>
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| 421 |
</td>
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| 422 |
<td>2025-11-21</td>
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| 423 |
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<statusCode code="completed"/>
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<value value="1" xsi:type="INT"/>
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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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<title>History of Past Illness</title>
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| 466 |
<text>
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| 467 |
<table>
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| 468 |
<tbody>
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| 469 |
<tr>
|
| 470 |
<th>Problem</th>
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| 471 |
<th>Onset time</th>
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| 472 |
<th>End date</th>
|
| 473 |
<th>Resolution circumstances</th>
|
| 474 |
</tr>
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| 475 |
<tr ID="HPRO.1">
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| 476 |
<td>ICD_9_CM 465.0 Laringofaringitis aguda</td>
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| 477 |
<td>2020-01-21</td>
|
| 478 |
<td>2022-11-21</td>
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| 479 |
<td>No Disponible</td>
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| 480 |
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| 481 |
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| 482 |
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<statusCode code="completed"/>
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<value code="465.0" codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD_9_CM" displayName="Laringofaringitis aguda" xsi:type="CD"/>
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<title>Active Problems</title>
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<tr>
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<th>Problem</th>
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<th>Onset time</th>
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<tr ID="APRO.1">
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<td>ICD_9_CM 460 Rinofaringitis aguda [refredat comú]</td>
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| 530 |
<td>2022-11-21</td>
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| 531 |
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| 532 |
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| 533 |
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<low value="20221121"/>
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<value code="460" codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD_9_CM" displayName="Rinofaringitis aguda [refredat comú]" xsi:type="CD"/>
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| 558 |
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</ClinicalDocument>
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