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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="20251204931"/>
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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="Cédula ciudadanÃa" extension="55132735" root="2.16.840.1.113883.19.6.1.1"/>
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<id extension="1" root="2.16.840.1.113883.19.6.2.1"/>
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<id extension="1" root="2.16.840.1.113883.19.6.3.1"/>
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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>41</state>
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<city>41396</city>
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<postalCode>41396</postalCode>
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<streetAddressLine>VDA. LA PATRICIA</streetAddressLine>
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</addr>
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<telecom use="HP" value="9876542"/>
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<patient>
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<name>
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<given>LUZ</given>
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<given>MARILIN</given>
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<family>TUNUBALA</family>
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<family>TUNUBALA</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="19851202"/>
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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="20251204931"/>
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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>DIEGO</given>
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<given>ALEJANDRO</given>
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<family>PRECIADO</family>
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<family>PISSO</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>SAN ANTONIO DE PADUA</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>41</state>
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<city>41396</city>
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<postalCode>41396</postalCode>
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<streetAddressLine>LA PLATA HUILA</streetAddressLine>
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</addr>
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</representedCustodianOrganization>
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</assignedCustodian>
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</custodian>
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<componentOf>
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<encompassingEncounter>
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<id extension="449" 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="OTROS PROCEDIMIENTOS EN ESTÓMAGO"/>
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<effectiveTime>
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<low value="20251201"/>
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<high value="20251204"/>
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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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<healthCareFacility>
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<id root="2.16.540.1.113883.19.2"/>
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<location>
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<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>40 Año</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>CAJA DE COMPENSACION FAMILIAR COMFAMILIAR CAMACOLCOMFAMILIAR CAMACOL</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="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 PERCEPCIÓN DEL USUARIO</title>
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<text>MANIFIESTA TENER MUCHO SOLOR DE CABEZA Y VOMITO </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="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>13 Enfermedad general</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="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>PRESENTA MALESTAR GENERAL </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="81267-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Setting of exposure to illness"/>
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<title>ENFERMEDAD ACTUAL</title>
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<text>NO MANIFIESTA</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="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>NO MANIFIESTA</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="11348-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Past illness Narrative"/>
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<title>ANTECEDENTES PERSONALES</title>
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<text>NO MANIFIESTA</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="8687-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Review of systems - Reported"/>
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<title>REVISIÓN POR SISTEMAS</title>
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<text>Cardiovascular
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Respiratorio
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Gastrointestinal
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</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="29545-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Physical findings Narrative"/>
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<title>HALLAZGOS EXAMEN FÃ?SICO</title>
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<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="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
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<title>DIAGNOSTICO PRESUNTIVO INGRESO</title>
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<text>A049 Infeccion intestinal bacteriana, no especificada</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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| 191 |
<code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
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<title>DIAGNOSTICO RELACIONADO INGRESO</title>
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<text>A970 Dengue sin signos de alarma</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="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
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<title>DIAGNOSTICO CONFIRMADO INGRESO</title>
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<text>A049 Infeccion intestinal bacteriana, no especificada</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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| 206 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 207 |
<code code="86922-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Therapeutic goals panel"/>
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<title>CONDUCTA: MANEJO TERAPÉUTICO</title>
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<text>N/A</text>
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</section>
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</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="11506-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Progress note"/>
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<title>NOTA DE PROGRESO</title>
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<text>En el presente campo debe relacionar. Cambios en el estado del paciente que conlleven a
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modificar la conducta o el manejo( se deben incluir complicaciones, accidentes u otro
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eventos adversos que haya surgido durante la estancia en el servicio de urgencia o
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de hospitalización)</text>
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</section>
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</component>
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| 223 |
<component>
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| 224 |
<section>
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| 225 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 226 |
<code code="29554-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure Narrative"/>
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| 227 |
<title>RESULTADO DE PROCEDIMIENTOS</title>
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| 228 |
<text>N/A</text>
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| 229 |
</section>
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| 230 |
</component>
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| 231 |
<component>
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| 232 |
<section>
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| 233 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 234 |
<code code="59768-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure indications"/>
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| 235 |
<title>INDICACIONES TERAPÉUTICAS</title>
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<text>N/A</text>
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| 237 |
</section>
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| 238 |
</component>
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| 239 |
<component>
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| 240 |
<section>
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| 241 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 242 |
<code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
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| 243 |
<title>DIAGNOSTICO PRESUNTIVO EGRESO</title>
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| 244 |
<text>A014 Fiebre paratifoidea, no especificada</text>
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| 245 |
</section>
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| 246 |
</component>
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| 247 |
<component>
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| 248 |
<section>
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| 249 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
|
| 250 |
<code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
|
| 251 |
<title>DIAGNOSTICO RELACIONADO EGRESO</title>
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| 252 |
<text>A014 Fiebre paratifoidea, no especificada</text>
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| 253 |
</section>
|
| 254 |
</component>
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| 255 |
<component>
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| 256 |
<section>
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| 257 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
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| 258 |
<code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis ICD code"/>
|
| 259 |
<title>DIAGNOSTICO CONFIRMADO EGRESO</title>
|
| 260 |
<text>A014 Fiebre paratifoidea, no especificada</text>
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| 261 |
</section>
|
| 262 |
</component>
|
| 263 |
<component>
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| 264 |
<section>
|
| 265 |
<templateId extension="2020-05-15" root="2.16.840.1.113883.2.17"/>
|
| 266 |
<code code="18842-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Discharge summary"/>
|
| 267 |
<title>PLAN DE MANEJO AMBULATORIO</title>
|
| 268 |
<text>PLAN MANEJO</text>
|
| 269 |
</section>
|
| 270 |
</component>
|
| 271 |
</structuredBody>
|
| 272 |
</component>
|
| 273 |
</ClinicalDocument>
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