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| 1 |
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
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| 2 |
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
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| 3 |
<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
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| 4 |
<templateId root="2.16.840.1.113883.10.20.22.1.8"/>
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| 5 |
<id extension="IHE-KIT-DS-001" root="2.16.840.1.113883.19.5"/>
|
| 6 |
<code code="18842-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Discharge Summary"/>
|
| 7 |
<title>Synthetic Discharge Summary for IHE Conformance</title>
|
| 8 |
<effectiveTime value="20260101120000"/>
|
| 9 |
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
|
| 10 |
<languageCode code="en-US"/>
|
| 11 |
<recordTarget>
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| 12 |
<patientRole>
|
| 13 |
<id extension="ALPHA-1001" root="2.16.840.1.113883.19.5"/>
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| 14 |
<patient>
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| 15 |
<name>
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| 16 |
<given>Elena</given>
|
| 17 |
<family>MARTINEZ</family>
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| 18 |
</name>
|
| 19 |
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
|
| 20 |
<birthTime value="19850315"/>
|
| 21 |
</patient>
|
| 22 |
</patientRole>
|
| 23 |
</recordTarget>
|
| 24 |
<author>
|
| 25 |
<time value="20260101120000"/>
|
| 26 |
<assignedAuthor>
|
| 27 |
<id extension="9876543210" root="2.16.840.1.113883.4.6"/>
|
| 28 |
<assignedPerson>
|
| 29 |
<name>
|
| 30 |
<given>Antti</given>
|
| 31 |
<family>Virtanen</family>
|
| 32 |
</name>
|
| 33 |
</assignedPerson>
|
| 34 |
</assignedAuthor>
|
| 35 |
</author>
|
| 36 |
<custodian>
|
| 37 |
<assignedCustodian>
|
| 38 |
<representedCustodianOrganization>
|
| 39 |
<id root="2.16.840.1.113883.19.5"/>
|
| 40 |
<name>TietAI Health System</name>
|
| 41 |
</representedCustodianOrganization>
|
| 42 |
</assignedCustodian>
|
| 43 |
</custodian>
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| 44 |
<component>
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| 45 |
<structuredBody>
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<component>
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| 47 |
<section>
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| 48 |
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
|
| 49 |
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies and adverse reactions Document"/>
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| 50 |
<title>Allergies and Adverse Reactions</title>
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| 51 |
<text>
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| 52 |
<paragraph>Allergies and Adverse Reactions — see the structured entries.</paragraph>
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| 53 |
</text>
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| 54 |
<entry typeCode="DRIV">
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| 55 |
<act classCode="ACT" moodCode="EVN">
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| 56 |
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
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<id root="B935E2A7-C420-44A1-B2FC-82A9F9906B43"/>
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<code code="CONC" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode" displayName="Concern"/>
|
| 59 |
<statusCode code="active"/>
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| 60 |
<effectiveTime>
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| 61 |
<low value="20200315"/>
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| 62 |
</effectiveTime>
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| 63 |
<entryRelationship typeCode="SUBJ">
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| 64 |
<observation classCode="OBS" moodCode="EVN">
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| 65 |
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
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| 66 |
<id root="87F76738-25C2-4C05-AAA5-64017DAD8909"/>
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| 67 |
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
|
| 68 |
<statusCode code="active"/>
|
| 69 |
<effectiveTime>
|
| 70 |
<low value="20200315"/>
|
| 71 |
</effectiveTime>
|
| 72 |
<value code="70618" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Penicillin" xsi:type="CD"/>
|
| 73 |
<entryRelationship typeCode="MFST">
|
| 74 |
<observation classCode="OBS" moodCode="EVN">
|
| 75 |
<templateId root="2.16.840.1.113883.10.20.22.4.9"/>
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| 76 |
<id root="AC68AD89-B392-47D8-A258-A50FB30FBB43"/>
|
| 77 |
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
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| 78 |
<statusCode code="completed"/>
|
| 79 |
<value code="247472004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hives" xsi:type="CD"/>
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| 80 |
<entryRelationship inversionInd="true" typeCode="SUBJ">
|
| 81 |
<observation classCode="OBS" moodCode="EVN">
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| 82 |
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
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| 83 |
<id root="D73DE131-F8A0-488F-ABE6-7276D8645FFF"/>
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| 84 |
<code code="SEV" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode" displayName="Severity Observation"/>
|
| 85 |
<statusCode code="completed"/>
|
| 86 |
<value code="6736007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="moderate" xsi:type="CD"/>
|
| 87 |
</observation>
|
| 88 |
</entryRelationship>
|
| 89 |
</observation>
|
| 90 |
</entryRelationship>
|
| 91 |
</observation>
|
| 92 |
</entryRelationship>
|
| 93 |
</act>
|
| 94 |
</entry>
|
| 95 |
</section>
|
| 96 |
</component>
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| 97 |
<component>
|
| 98 |
<section>
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| 99 |
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
|
| 100 |
<templateId extension="2015-08-01" root="2.16.840.1.113883.10.20.22.2.5.1"/>
|
| 101 |
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem list - Reported"/>
|
| 102 |
<title>Problems</title>
|
| 103 |
<text>
|
| 104 |
<paragraph>Problems — see the structured entries.</paragraph>
|
| 105 |
</text>
|
| 106 |
<entry typeCode="DRIV">
|
| 107 |
<act classCode="ACT" moodCode="EVN">
|
| 108 |
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
|
| 109 |
<templateId extension="2015-08-01" root="2.16.840.1.113883.10.20.22.4.3"/>
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| 110 |
<id root="65C60A57-21A7-4539-8680-CCE728E5ECAE"/>
|
| 111 |
<code code="CONC" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode" displayName="Concern"/>
|
| 112 |
<statusCode code="active"/>
|
| 113 |
<effectiveTime>
|
| 114 |
<low value="20190101"/>
|
| 115 |
</effectiveTime>
|
| 116 |
<entryRelationship typeCode="SUBJ">
|
| 117 |
<observation classCode="OBS" moodCode="EVN">
|
| 118 |
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
|
| 119 |
<templateId extension="2015-08-01" root="2.16.840.1.113883.10.20.22.4.4"/>
|
| 120 |
<id root="99E17BA9-7701-4B6A-8CE0-97EF13F4D3A7"/>
|
| 121 |
<code code="55607006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Problem">
|
| 122 |
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem"/>
|
| 123 |
</code>
|
| 124 |
<statusCode code="completed"/>
|
| 125 |
<effectiveTime>
|
| 126 |
<low value="20190101"/>
|
| 127 |
</effectiveTime>
|
| 128 |
<value code="59621000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Essential Hypertension" xsi:type="CD"/>
|
| 129 |
</observation>
|
| 130 |
</entryRelationship>
|
| 131 |
</act>
|
| 132 |
</entry>
|
| 133 |
</section>
|
| 134 |
</component>
|
| 135 |
<component>
|
| 136 |
<section>
|
| 137 |
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
|
| 138 |
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Medication use Narrative"/>
|
| 139 |
<title>Medications</title>
|
| 140 |
<text>
|
| 141 |
<paragraph>Medications — see the structured entries.</paragraph>
|
| 142 |
</text>
|
| 143 |
<entry typeCode="DRIV">
|
| 144 |
<substanceAdministration classCode="SBADM" moodCode="EVN">
|
| 145 |
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
|
| 146 |
<id root="48E84E5F-CC79-400C-9B3A-0E8226B88A6D"/>
|
| 147 |
<statusCode code="active"/>
|
| 148 |
<effectiveTime xsi:type="IVL_TS">
|
| 149 |
<low value="20190201"/>
|
| 150 |
</effectiveTime>
|
| 151 |
<doseQuantity unit="mg" value="10"/>
|
| 152 |
<consumable>
|
| 153 |
<manufacturedProduct classCode="MANU">
|
| 154 |
<manufacturedMaterial>
|
| 155 |
<code code="314076" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Lisinopril 10 MG Oral Tablet"/>
|
| 156 |
<name>Lisinopril 10 MG Oral Tablet</name>
|
| 157 |
</manufacturedMaterial>
|
| 158 |
</manufacturedProduct>
|
| 159 |
</consumable>
|
| 160 |
</substanceAdministration>
|
| 161 |
</entry>
|
| 162 |
</section>
|
| 163 |
</component>
|
| 164 |
<component>
|
| 165 |
<section>
|
| 166 |
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
|
| 167 |
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Procedures Document"/>
|
| 168 |
<title>Procedures</title>
|
| 169 |
<text>
|
| 170 |
<paragraph>Procedures — see the structured entries.</paragraph>
|
| 171 |
</text>
|
| 172 |
<entry typeCode="DRIV">
|
| 173 |
<procedure classCode="PROC" moodCode="EVN">
|
| 174 |
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
|
| 175 |
<id root="58390A92-53DB-4CF5-8041-2B08E0F8E06B"/>
|
| 176 |
<code code="268400002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Electrocardiogram"/>
|
| 177 |
<statusCode code="completed"/>
|
| 178 |
<effectiveTime value="20260101"/>
|
| 179 |
</procedure>
|
| 180 |
</entry>
|
| 181 |
</section>
|
| 182 |
</component>
|
| 183 |
<component>
|
| 184 |
<section>
|
| 185 |
<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
|
| 186 |
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Relevant diagnostic tests/laboratory data Narrative"/>
|
| 187 |
<title>Results</title>
|
| 188 |
<text>
|
| 189 |
<paragraph>Results — see the structured entries.</paragraph>
|
| 190 |
</text>
|
| 191 |
<entry typeCode="DRIV">
|
| 192 |
<organizer classCode="CLUSTER" moodCode="EVN">
|
| 193 |
<templateId root="2.16.840.1.113883.10.20.22.4.1"/>
|
| 194 |
<id root="9F28CFE7-8D33-4046-815C-725BD33F5541"/>
|
| 195 |
<code code="51990-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Basic Metabolic Panel"/>
|
| 196 |
<statusCode code="completed"/>
|
| 197 |
<component>
|
| 198 |
<observation classCode="OBS" moodCode="EVN">
|
| 199 |
<templateId root="2.16.840.1.113883.10.20.22.4.2"/>
|
| 200 |
<id root="06113A5C-D30A-480E-B871-101F495302F0"/>
|
| 201 |
<code code="2823-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Potassium"/>
|
| 202 |
<statusCode code="completed"/>
|
| 203 |
<effectiveTime value="20260101"/>
|
| 204 |
<value unit="mmol/L" value="4.1" xsi:type="PQ"/>
|
| 205 |
<referenceRange>
|
| 206 |
<observationRange>
|
| 207 |
<value xsi:type="IVL_PQ">
|
| 208 |
<low unit="mmol/L" value="3.5"/>
|
| 209 |
<high unit="mmol/L" value="5.1"/>
|
| 210 |
</value>
|
| 211 |
</observationRange>
|
| 212 |
</referenceRange>
|
| 213 |
</observation>
|
| 214 |
</component>
|
| 215 |
<component>
|
| 216 |
<observation classCode="OBS" moodCode="EVN">
|
| 217 |
<templateId root="2.16.840.1.113883.10.20.22.4.2"/>
|
| 218 |
<id root="82DB2A71-BFEB-49B4-8521-31D72F3B9C12"/>
|
| 219 |
<code code="2345-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Glucose"/>
|
| 220 |
<statusCode code="completed"/>
|
| 221 |
<effectiveTime value="20260101"/>
|
| 222 |
<value unit="mmol/L" value="5.4" xsi:type="PQ"/>
|
| 223 |
<referenceRange>
|
| 224 |
<observationRange>
|
| 225 |
<value xsi:type="IVL_PQ">
|
| 226 |
<low unit="mmol/L" value="3.9"/>
|
| 227 |
<high unit="mmol/L" value="5.8"/>
|
| 228 |
</value>
|
| 229 |
</observationRange>
|
| 230 |
</referenceRange>
|
| 231 |
</observation>
|
| 232 |
</component>
|
| 233 |
</organizer>
|
| 234 |
</entry>
|
| 235 |
</section>
|
| 236 |
</component>
|
| 237 |
<component>
|
| 238 |
<section>
|
| 239 |
<templateId root="2.16.840.1.113883.10.20.22.2.4.1"/>
|
| 240 |
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital signs"/>
|
| 241 |
<title>Vital Signs</title>
|
| 242 |
<text>
|
| 243 |
<paragraph>Vital Signs — see the structured entries.</paragraph>
|
| 244 |
</text>
|
| 245 |
<entry typeCode="DRIV">
|
| 246 |
<organizer classCode="CLUSTER" moodCode="EVN">
|
| 247 |
<templateId root="2.16.840.1.113883.10.20.22.4.26"/>
|
| 248 |
<id root="2FAE531F-8431-4F14-A6DC-6FD8A6E0D63C"/>
|
| 249 |
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital signs"/>
|
| 250 |
<statusCode code="completed"/>
|
| 251 |
<component>
|
| 252 |
<observation classCode="OBS" moodCode="EVN">
|
| 253 |
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
|
| 254 |
<id root="27BDBD3F-5FC2-459A-9A90-F299E8295BFE"/>
|
| 255 |
<code code="8480-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Systolic Blood Pressure"/>
|
| 256 |
<statusCode code="completed"/>
|
| 257 |
<effectiveTime value="20260101"/>
|
| 258 |
<value unit="mm[Hg]" value="128" xsi:type="PQ"/>
|
| 259 |
</observation>
|
| 260 |
</component>
|
| 261 |
<component>
|
| 262 |
<observation classCode="OBS" moodCode="EVN">
|
| 263 |
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
|
| 264 |
<id root="F6E07946-FEED-4131-93C1-6C20C367F9DE"/>
|
| 265 |
<code code="8462-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diastolic Blood Pressure"/>
|
| 266 |
<statusCode code="completed"/>
|
| 267 |
<effectiveTime value="20260101"/>
|
| 268 |
<value unit="mm[Hg]" value="82" xsi:type="PQ"/>
|
| 269 |
</observation>
|
| 270 |
</component>
|
| 271 |
<component>
|
| 272 |
<observation classCode="OBS" moodCode="EVN">
|
| 273 |
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
|
| 274 |
<id root="4A5AD81B-093E-4BE9-A3A5-5769028F5C0A"/>
|
| 275 |
<code code="8867-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Heart Rate"/>
|
| 276 |
<statusCode code="completed"/>
|
| 277 |
<effectiveTime value="20260101"/>
|
| 278 |
<value unit="/min" value="72" xsi:type="PQ"/>
|
| 279 |
</observation>
|
| 280 |
</component>
|
| 281 |
</organizer>
|
| 282 |
</entry>
|
| 283 |
</section>
|
| 284 |
</component>
|
| 285 |
<component>
|
| 286 |
<section>
|
| 287 |
<templateId root="2.16.840.1.113883.10.20.22.2.22.1"/>
|
| 288 |
<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Hospitalizations+Outpatient visits Narrative"/>
|
| 289 |
<title>Encounters</title>
|
| 290 |
<text>
|
| 291 |
<paragraph>Encounters — see the structured entries.</paragraph>
|
| 292 |
</text>
|
| 293 |
<entry typeCode="DRIV">
|
| 294 |
<encounter classCode="ENC" moodCode="EVN">
|
| 295 |
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
|
| 296 |
<id root="17F91A1F-1AD9-437C-9796-4AF7B6A62FD9"/>
|
| 297 |
<code code="183452005" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4" displayName="Inpatient stay"/>
|
| 298 |
<statusCode code="completed"/>
|
| 299 |
<effectiveTime>
|
| 300 |
<low value="20251228"/>
|
| 301 |
<high value="20260101"/>
|
| 302 |
</effectiveTime>
|
| 303 |
</encounter>
|
| 304 |
</entry>
|
| 305 |
</section>
|
| 306 |
</component>
|
| 307 |
<component>
|
| 308 |
<section>
|
| 309 |
<templateId root="2.16.840.1.113883.10.20.22.2.2.1"/>
|
| 310 |
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Immunization Narrative"/>
|
| 311 |
<title>Immunizations</title>
|
| 312 |
<text>
|
| 313 |
<paragraph>Immunizations — see the structured entries.</paragraph>
|
| 314 |
</text>
|
| 315 |
<entry typeCode="DRIV">
|
| 316 |
<substanceAdministration classCode="SBADM" moodCode="EVN">
|
| 317 |
<templateId root="2.16.840.1.113883.10.20.22.4.52"/>
|
| 318 |
<id root="BD70309E-46E1-4B06-B377-3CB0F1E3E59A"/>
|
| 319 |
<statusCode code="completed"/>
|
| 320 |
<effectiveTime value="20251015"/>
|
| 321 |
<consumable>
|
| 322 |
<manufacturedProduct classCode="MANU">
|
| 323 |
<manufacturedMaterial>
|
| 324 |
<code code="141" codeSystem="2.16.840.1.113883.12.292" codeSystemName="CVX" displayName="Influenza, seasonal, injectable"/>
|
| 325 |
<name>Influenza, seasonal, injectable</name>
|
| 326 |
</manufacturedMaterial>
|
| 327 |
</manufacturedProduct>
|
| 328 |
</consumable>
|
| 329 |
</substanceAdministration>
|
| 330 |
</entry>
|
| 331 |
</section>
|
| 332 |
</component>
|
| 333 |
</structuredBody>
|
| 334 |
</component>
|
| 335 |
</ClinicalDocument>
|