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<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
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<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
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<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
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<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
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<id extension="IHE-KIT-CCD-001" root="2.16.840.1.113883.19.5"/>
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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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| 7 |
<title>Synthetic CCD for IHE Conformance</title>
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| 8 |
<effectiveTime value="20260101120000"/>
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<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
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<recordTarget>
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<patientRole>
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<id extension="ALPHA-1001" root="2.16.840.1.113883.19.5"/>
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<patient>
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<name>
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<given>Elena</given>
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<family>MARTINEZ</family>
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</name>
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| 18 |
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
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<birthTime value="19850315"/>
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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="20260101120000"/>
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<assignedAuthor>
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<id extension="9876543210" root="2.16.840.1.113883.4.6"/>
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<assignedPerson>
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<name>
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<given>Antti</given>
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<family>Virtanen</family>
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</name>
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</assignedPerson>
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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"/>
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<name>TietAI Health System</name>
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</representedCustodianOrganization>
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</assignedCustodian>
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</custodian>
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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 root="2.16.840.1.113883.10.20.22.2.6.1"/>
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| 48 |
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies and adverse reactions Document"/>
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| 49 |
<title>Allergies and Adverse Reactions</title>
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| 50 |
<text>
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<paragraph>Allergies and Adverse Reactions — see the structured entries.</paragraph>
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</text>
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| 53 |
<entry typeCode="DRIV">
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<act classCode="ACT" moodCode="EVN">
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<id root="AC9A6C01-C2AC-4D0E-9B7B-4D82911F6B05"/>
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<code code="CONC" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode" displayName="Concern"/>
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<statusCode code="active"/>
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<effectiveTime>
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<low value="20200315"/>
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</effectiveTime>
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<entryRelationship typeCode="SUBJ">
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<observation classCode="OBS" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
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<id root="1F1D517D-8D3E-4DFC-8D2A-DC6CDF74D06E"/>
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<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
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<statusCode code="active"/>
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<effectiveTime>
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<low value="20200315"/>
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</effectiveTime>
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<value code="70618" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Penicillin" xsi:type="CD"/>
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<entryRelationship typeCode="MFST">
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<observation classCode="OBS" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.20.22.4.9"/>
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<id root="2ADA6B9E-9A11-4FAC-87BA-9B5FA2B4D959"/>
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<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
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<statusCode code="completed"/>
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<value code="247472004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hives" xsi:type="CD"/>
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<entryRelationship inversionInd="true" typeCode="SUBJ">
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<observation classCode="OBS" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
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<id root="787977DA-CFA1-480E-9335-FF48D51A0582"/>
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<code code="SEV" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode" displayName="Severity Observation"/>
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<statusCode code="completed"/>
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| 85 |
<value code="6736007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="moderate" xsi:type="CD"/>
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</observation>
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| 87 |
</entryRelationship>
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</observation>
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| 89 |
</entryRelationship>
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</observation>
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</entryRelationship>
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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="2.16.840.1.113883.10.20.22.2.5.1"/>
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| 99 |
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem list - Reported"/>
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| 100 |
<title>Problems</title>
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| 101 |
<text>
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<paragraph>Problems — see the structured entries.</paragraph>
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| 103 |
</text>
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| 104 |
<entry typeCode="DRIV">
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| 105 |
<act classCode="ACT" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
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<id root="4C98CF08-8BEB-47EA-AA41-9701C31CADD4"/>
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<code code="CONC" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode" displayName="Concern"/>
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| 109 |
<statusCode code="active"/>
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| 110 |
<effectiveTime>
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<low value="20190101"/>
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| 112 |
</effectiveTime>
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| 113 |
<entryRelationship typeCode="SUBJ">
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<observation classCode="OBS" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
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<id root="C93883AE-883C-4496-84B9-25E531A4108F"/>
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<code code="55607006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Problem"/>
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| 118 |
<statusCode code="completed"/>
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| 119 |
<effectiveTime>
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| 120 |
<low value="20190101"/>
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| 121 |
</effectiveTime>
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| 122 |
<value code="59621000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Essential Hypertension" xsi:type="CD"/>
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| 123 |
</observation>
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| 124 |
</entryRelationship>
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| 125 |
</act>
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| 126 |
</entry>
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| 127 |
</section>
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| 128 |
</component>
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| 129 |
<component>
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| 130 |
<section>
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| 131 |
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
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| 132 |
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Medication use Narrative"/>
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| 133 |
<title>Medications</title>
|
| 134 |
<text>
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| 135 |
<paragraph>Medications — see the structured entries.</paragraph>
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| 136 |
</text>
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| 137 |
<entry typeCode="DRIV">
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| 138 |
<substanceAdministration classCode="SBADM" moodCode="EVN">
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<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
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<id root="01B1C9D2-144C-480F-951A-C29DB72E6D46"/>
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<statusCode code="active"/>
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| 142 |
<effectiveTime xsi:type="IVL_TS">
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| 143 |
<low value="20190201"/>
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| 144 |
</effectiveTime>
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| 145 |
<doseQuantity unit="mg" value="10"/>
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| 146 |
<consumable>
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| 147 |
<manufacturedProduct classCode="MANU">
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| 148 |
<manufacturedMaterial>
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| 149 |
<code code="314076" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Lisinopril 10 MG Oral Tablet"/>
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| 150 |
<name>Lisinopril 10 MG Oral Tablet</name>
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| 151 |
</manufacturedMaterial>
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| 152 |
</manufacturedProduct>
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| 153 |
</consumable>
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| 154 |
</substanceAdministration>
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| 155 |
</entry>
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| 156 |
</section>
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| 157 |
</component>
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| 158 |
</structuredBody>
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| 159 |
</component>
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</ClinicalDocument>
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