| layout | title |
|---|---|
default |
Blue Button Implementation Guide |
An electronic health record keeps a digital record of clinical information about a particular individual. With the amount of variability among Health IT systems, it is important to have a consistent set of health information for each patient.
For Blue Button, the recommended standard for representing the patient health record is the HL7 Consolidated Clinical Document Architecture also known as the Consolidated CDA.
The Consolidated CDA is a XML-based standard that specifies the encoding, structure, and semantics of a clinical document.
There are a wide-range of templates that can be represented in the Consolidated CDA standard. For Blue Button we are outlining a subset of sections and fields that should be used.
Tools: NIST Validator Web App and C-CDA Scorecard
Blue Button adopts the requirements for sections and fields from Meaningful Use Stage 2. Meaningful Use specifies the fields and content structure of clinical data that providers will share with patients at care transitions. This same structure and consistency will aid application developers as they design and build consumer tools.
Whenever the C-CDA is generated for patients, it should have the following fields, if they exist in the dataholder’s system:
| Section | Description | Quick Link |
|---|---|---|
| Header | Patient information and demographics | Jump to XML |
| Allergies, Adverse Reactions, and Alerts | Includes status and severity of each. | Jump to XML |
| Encounters | Surgeries, ED visits, etc. | Jump to XML |
| Immunizations | Immunizations and vaccines | Jump to XML |
| Medications | As prescribed by the provider | Jump to XML |
| Care Plan | Planned activities and encounters | Jump to XML |
| Discharge Medications | Part of hospital discharge summary | Jump to XML |
| Reason for Referral | Written reason for referral | Jump to XML |
| Problem List | Concerns, complaints, and observations | Jump to XML |
| Procedures | History of procedures | Jump to XML |
| Functional and Cognitive Status | List of impairments | Jump to XML |
| Results | Includes laboratory tests | Jump to XML |
| Social History | Observations like smoking, drinking, etc. | Jump to XML |
| Vital Signs | Includes height, weight, blood pressure, etc. | Jump to XML |
| Discharge Instructions | Written discharge instructions | Jump to XML |
Link to Companion Guide to Consolidated CDA produced by ONC.
Throughout the C-CDA a variety of codes are used to describe the values within it.
| Code System | Description |
|---|---|
| LOINC | Database and universal standard for identifying medical laboratory observations |
| RxNorm | Normalized names for clinical drugs |
| SNOMED CT | Collection of clinical terms |
| ICD-10 | Codes to classify diseases and a wide variety of signs and symptoms |
| ICD-9 | Codes to classify diseases and a wide variety of signs and symptoms |
If a patient or other person is the main consumer of the health record, it should include a stylesheet.
To make the C-CDA XML human readable, an XSLT stylesheet should be included. This will allow a person to easily view their information on a computer or print it.
This section dissects a well-formed C-CDA. This is the entire XML file. This is another example.
The XML file references the schema from HL7.
{% highlight xml %}
{% endhighlight %}
The CDA Header includes details about the identity of the patient, the creator of the XML document, and the reason the encounter that generated data occured.
{% highlight xml %}
<title>Community Health and Hospitals: Health Summary</title>
<!-- CONF 5267 -->
<patientRole>
<!-- CONF 5268-->
<id
extension="1"
root="2.16.840.1.113883.4.6"/>
<!-- Fake ID using HL7 example OID. -->
<!-- Patient SSN recorded as an ID -->
<id
extension="123-101-5230"
root="2.16.840.1.113883.4.1"/>
<!-- CONF 5271 -->
<addr
use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Drive</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<!-- CONF 5280 -->
<telecom
value="tel:(816)276-6909"
use="HP"/>
<!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<!-- CONF 5283 -->
<patient>
<!-- CONF 5284 -->
<name
use="L">
<!-- L is "Legal" from HL7 EntityNameUse 2.16.840.1.113883.5.45 -->
<given>Myra</given>
<!-- CL is "Call me" from HL7 EntityNamePartQualifier 2.16.840.1.113883.5.43 -->
<family>Jones</family>
</name>
<administrativeGenderCode
code="F"
codeSystem="2.16.840.1.113883.5.1"
displayName="Female"/>
<birthTime
value="19470501"/>
<maritalStatusCode
code="M"
displayName="Married"
codeSystem="2.16.840.1.113883.5.2"
codeSystemName="MaritalStatusCode"/>
<religiousAffiliationCode
code="1013"
displayName="Christian (non-Catholic, non-specific)"
codeSystemName="HL7 Religious Affiliation "
codeSystem="2.16.840.1.113883.5.1076"/>
<!-- Need to Fix the Race Code to be from the OMB Standards -->
<raceCode
code="2106-3"
displayName="White"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="Race and Ethnicity - CDC"/>
<ethnicGroupCode
code="2186-5"
displayName="Not Hispanic or Latino"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="Race and Ethnicity - CDC"/>
<guardian>
<code
code="GPARNT"
displayName="Grandfather"
codeSystem="2.16.840.1.113883.5.111"
codeSystemName="HL7 Role code"/>
<addr
use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Drive</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom
value="tel:(816)276-6909"
use="HP"/>
<guardianPerson>
<name>
<given>Ralph</given>
<family>Jones</family>
</name>
</guardianPerson>
</guardian>
<birthplace>
<place>
<addr>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
</place>
</birthplace>
<!-- FIX the Code System to be 639.2 -->
<languageCommunication>
<languageCode
code="eng"/>
<modeCode
code="ESP"
displayName="Expressed spoken"
codeSystem="2.16.840.1.113883.5.60"
codeSystemName="LanguageAbilityMode"/>
<preferenceInd
value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id
root="1.1.1.1.1.1.1.1.4"/>
<name>Community Health and Hospitals</name>
<telecom
use="WP"
value="tel: 555-555-5000"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</providerOrganization>
</patientRole>
1002 Healthcare Drive
Portland
OR
97266
US
Dr
Henry
Seven
1002 Healthcare Drive
Portland
OR
97266
US
Mary
McDonald
1002 Healthcare Drive
Portland
OR
97266
US
Henry
Seven
Frank
Jones
Community Health and Hospitals
1002 Healthcare Drive
Portland
OR
97266
US
Henry
Seven
Community Health and Hospitals
1002 Healthcare Drive
Portland
OR
97266
US
Henry
Seven
1002 Healthcare Drive
Portland
OR
97266
US
Henry
Seven
1357 Amber Drive
Beaverton
OR
97006
US
Mr.
Ralph
Jones
1357 Amber Drive
Beaverton
OR
97006
US
Mr.
Frank
Jones
</effectiveTime>
<performer
typeCode="PRF">
<functionCode
code="PP"
displayName="Primary Care Provider"
codeSystem="2.16.840.1.113883.12.443"
codeSystemName="Provider Role">
<originalText>Primary Care Provider</originalText>
</functionCode>
<time>
<low
value="20120806"/>
<high
value="20120813"/>
</time>
<assignedEntity>
<id
extension="PseudoMD-1"
root="2.16.840.1.113883.4.6"/>
<code
code="208D00000X"
displayName="General Practice"
codeSystemName="Provider Codes"
codeSystem="2.16.840.1.113883.6.101"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
value="tel:+1-555-555-5000"
use="WP"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom
value="tel:+1-555-555-5000"
use="WP"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
<performer
typeCode="PRF">
<functionCode
code="PP"
displayName="Primary Care Provider"
codeSystem="2.16.840.1.113883.12.443"
codeSystemName="Provider Role">
<originalText>Primary Care Provider</originalText>
</functionCode>
<time>
<low
value="20120806"/>
<high
value="20120813"/>
</time>
<assignedEntity>
<id
extension="PseudoMD-3"
root="2.16.840.1.113883.4.6"/>
<code
code="208D00000X"
displayName="General Practice"
codeSystemName="Provider Codes"
codeSystem="2.16.840.1.113883.6.101"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
value="tel:+1-555-555-5000"
use="HP"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5.9999.1393"/>
<name>Community Health and Hospitals</name>
<telecom
value="tel:+1-555-555-5000"
use="HP"/>
<addr>
<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
</serviceEvent>
Dr
Henry
Seven
Dr
Henry
Seven
{% endhighlight %}
This is the start of the CDA Body which contains all the sections in the health record.
{% highlight xml %}
{% endhighlight %}
This Alerts section contains a description of allergies, reactions, and alerts for the particular patient.
{% highlight xml %}
<!--
Allergies, Adverse Reactions, Alerts
-->
<title>ALLERGIES, ADVERSE REACTIONS, ALERTS</title>
Substance
Reaction
Severity
Status
Penicillin G benzathine
Hives
Moderate to severe
Inactive
Codeine
Shortness of Breath
Moderate
Active
Aspirin
Hives
Mild to moderate
Active
{% endhighlight %}
This Encounters section includes all the office visits, emergency room visits, surgeries, etc.
{% highlight xml %}
<!--
ENCOUNTERS
-->
<title>ENCOUNTERS</title>
Encounter
Performer
Location
Date
Pnuemonia
Dr Henry Seven
Community Health and Hospitals
20120806
Mild Fever
1002 Healthcare Dr
Portland
OR
97266
US
Community Health and Hospitals
<!--Encounter diagnosis act -->
<templateId root="2.16.840.1.113883.10.20.22.4.80"/>
<id root="5a784260-6856-4f38-9638-80c751aff2fb"/>
<code xsi:type="CE"
code="29308-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="ENCOUNTER DIAGNOSIS"/>
<statusCode code="active"/>
<effectiveTime>
<low value="20120806"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<observation classCode="OBS" moodCode="EVN" negationInd="false">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<!-- Problem Observation -->
<id
root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code
code="409586006"
codeSystem="2.16.840.1.113883.6.96"
displayName="Complaint"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20120806"/>
</effectiveTime>
<value
xsi:type="CD"
code="233604007"
codeSystem="2.16.840.1.113883.6.96"
displayName="Pneumonia"/>
</observation>
</entryRelationship>
</act>
</entryRelationship>
</encounter>
</entry>
</section>
</component>
{% endhighlight %}
This Immunizations section includes all the vaccines an individual has been administered.
{% highlight xml %}
<!--
IMMUNIZATIONS
-->
<title>IMMUNIZATIONS</title>
Vaccine
Date
Status
Influenza virus vaccine, IM
May 2012
Completed
Tetanus and diphtheria toxoids, IM
Aor 2012
Completed
<entry
typeCode="DRIV">
<substanceAdministration
classCode="SBADM"
moodCode="EVN"
negationInd="false">
<templateId
root="2.16.840.1.113883.10.20.22.4.52"/>
<!-- ******** Immunization activity template ******** -->
<id
root="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92"/>
<text>
<reference
value="#immun2"/>
</text>
<statusCode
code="completed"/>
<effectiveTime
xsi:type="IVL_TS"
value="20120510"/>
<routeCode
code="C28161"
codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="National Cancer Institute (NCI) Thesaurus"
displayName="Intramuscular injection"/>
<doseQuantity
value="50"
unit="mcg"/>
<consumable>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.54"/>
<!-- ******** Immunization Medication Information ******** -->
<manufacturedMaterial>
<code
code="88"
codeSystem="2.16.840.1.113883.6.59"
displayName="Influenza virus vaccine"
codeSystemName="CVX">
<originalText>Influenza virus vaccine</originalText>
<translation
code="111"
displayName="influenza, live, intranasal"
codeSystemName="CVX"
codeSystem="2.16.840.1.113883.6.59"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Health LS - Immuno Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<entryRelationship
typeCode="SUBJ" inversionInd="true">
<act
classCode="ACT"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.20"/>
<!-- ** Instructions Template ** -->
<code xsi:type="CE"
code="171044003"
codeSystem="2.16.840.1.113883.6.96"
displayName="immunization education"/>
<text><reference
value="#immunSect"/>Possible flu-like symptoms for three days.</text>
<statusCode
code="completed"/>
</act>
</entryRelationship>
</substanceAdministration>
</entry>
<entry
typeCode="DRIV">
<substanceAdministration
classCode="SBADM"
moodCode="EVN"
negationInd="false">
<templateId
root="2.16.840.1.113883.10.20.22.4.52"/>
<!-- ******** Immunization activity template ******** -->
<id
root="e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92"/>
<text>
<reference
value="#immun4"/>
</text>
<statusCode
code="completed"/>
<effectiveTime
xsi:type="IVL_TS"
value="20120401"/>
<routeCode
code="C28161"
codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="National Cancer Institute (NCI) Thesaurus"
displayName="Intramuscular injection"/>
<doseQuantity
value="50"
unit="mcg"/>
<consumable>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.54"/>
<!-- ******** Immunization Medication Information ******** -->
<manufacturedMaterial>
<code
code="103"
codeSystem="2.16.840.1.113883.6.59"
displayName="Tetanus and diphtheria toxoids - preservative free"
codeSystemName="CVX">
<originalText>Tetanus and diphtheria toxoids - preservative free</originalText>
<translation
code="09"
displayName="Tetanus and diphtheria toxoids - preservative free"
codeSystemName="CVX"
codeSystem="2.16.840.1.113883.6.59"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Health LS - Immuno Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<act
classCode="ACT"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.20"/>
<!-- ** Instructions Template ** -->
<code xsi:type="CE"
code="171044003"
codeSystem="2.16.840.1.113883.6.96"
displayName="immunization education"/>
<text><reference
value="#immunSect"/>Possible flu-like symptoms for three days.</text>
<statusCode
code="completed"/>
</act>
</entryRelationship>
</substanceAdministration>
</entry>
</section>
</component>
{% endhighlight %}
This section includes all the Medications prescribed to an individual. It includes the type of medication, start date, instructions, and why it was prescribed.
{% highlight xml %}
<!--
MEDICATIONS
-->
<title>Medications</title>
Medication
Directions
Start Date
Status
Indications
Fill Instructions
Albuterol 0.09 MG/ACTUAT inhalant solution
0.09 MG/ACTUAT inhalant solution, 2 puffs once
20120806
Active
Pneumonia (233604007 SNOMED CT)
Generic Substitition Allowed
Medication Factory Inc.
Community Health and Hospitals
Aerosol
Medication Factory Inc.
1002 Healthcare Dr
Portland
OR
97266
US
Dr.
Henry
Seven
label in spanish
Medication Factory Inc.
1002 Healthcare Dr
Portland
OR
97266
US
Dr.
Henry
Seven
Community Health and Hospitals
{% endhighlight %}
This Care Plan section lists all the planned activities and encounters recorded in the system.
{% highlight xml %}
<!--
CARE PLAN
-->
<title>CARE PLAN</title>
Planned Activity
Planned Date
Consultation with Dr George Potomac for Asthma
20120820
Chest X-ray
20120826
Sputum Culture
20120820
Follow up with Dr George Potomac for Asthma
{% endhighlight %}
This Hospital Discharge Summary section captures the medication prescribed at discharge.
{% highlight xml %}
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.11.1"/>
<!-- Entries Required -->
<!-- Hospital Discharge Summary templateId -->
<code
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
code="10183-2"
displayName=" HOSPITAL DISCHARGE MEDICATIONS "/>
<title>HOSPITAL DISCHARGE MEDICATIONS</title>
<!-- Unstructured text field -->
<text>
<table
border="1"
width="100%">
<thead>
<tr>
<th>Medication</th>
<th>Directions</th>
<th>Start Date</th>
<th>Status</th>
<th>Indications</th>
<th>Fill Instructions</th>
</tr>
</thead>
<tbody>
<tr>
<td><content ID="DM">120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler</content></td>
<td><content ID="DM1">0.11 MG/ACTUAT Metered Dose Once Daily</content></td>
<td>20120813</td>
<td>Active</td>
<td>Bronchitis (32398004 SNOMED CT)</td>
<td><content ID="FillIns_DM">Generic Substitition Allowed</content></td>
</tr>
</tbody>
</table>
</text>
<entry
typeCode="DRIV">
<act
classCode="ACT"
moodCode="EVN">
<!-- Discharge Medication Entry -->
<templateId
root="2.16.840.1.113883.10.20.22.4.35"/>
<id
root="5a784260-6856-4f38-9638-80c751aff2fb"/>
<code
code="10183-2"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Discharge medication"/>
<statusCode
code="active"/>
<effectiveTime>
<low value="20120813"/>
<high value="20120813"/>
</effectiveTime>
<entryRelationship
typeCode="SUBJ">
<substanceAdministration
classCode="SBADM"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.16"/>
<!-- ** MEDICATION ACTIVITY -->
<id
root="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/>
<text>
<reference
value="#DM1"/>0.11 MG/ACTUAT Metered Dose Once Daily </text>
<statusCode
code="completed"/>
<effectiveTime
xsi:type="IVL_TS">
<low value="20120813"/>
<high value="20120813"/>
</effectiveTime>
<effectiveTime
xsi:type="PIVL_TS"
institutionSpecified="true"
operator="A">
<period
value="24"
unit="h"/>
</effectiveTime>
<routeCode
code="C38216"
codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="NCI Thesaurus"
displayName="RESPIRATORY (INHALATION)"/>
<doseQuantity
value="1"
unit="mg/actuat"/>
<rateQuantity
value="110"
unit="ml/min"/>
<maxDoseQuantity
nullFlavor="UNK">
<numerator
nullFlavor="UNK"/>
<denominator
nullFlavor="UNK"/>
</maxDoseQuantity>
<administrationUnitCode
code="C42944"
displayName="INHALANT"
codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="NCI Thesaurus"/>
<consumable>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.23"/>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code
code="896001"
codeSystem="2.16.840.1.113883.6.88"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler">
<originalText><reference
value="#DM"/></originalText>
<translation
code="896001"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Medication Factory Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
<performer>
<assignedEntity>
<id
nullFlavor="NI"/>
<addr
nullFlavor="UNK"/>
<telecom
nullFlavor="UNK"/>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5.9999.1395"/>
<name>Community Health and Hospitals</name>
<telecom
nullFlavor="UNK"/>
<addr
nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
<participant
typeCode="CSM">
<participantRole
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.24"/>
<code
code="412307009"
displayName="drug vehicle"
codeSystem="2.16.840.1.113883.6.96"/>
<playingEntity
classCode="MMAT">
<code
code="324049"
displayName="Aerosol"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
<name>Aerosol</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship
typeCode="RSON">
<observation
classCode="OBS"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.19"/>
<id
root="db734647-fc99-424c-a864-7e3cda82e703"
extension="45665"/>
<code
code="404684003"
displayName="Finding"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20110113"/>
</effectiveTime>
<value
xsi:type="CD"
code="32398004"
displayName="Bronchitis"
codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entryRelationship>
<entryRelationship
typeCode="REFR">
<supply
classCode="SPLY"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.17"/>
<id
nullFlavor="NI"/>
<statusCode
code="completed"/>
<effectiveTime
xsi:type="IVL_TS">
<low
value="20120813"/>
<high
nullFlavor="UNK"/>
</effectiveTime>
<repeatNumber
value="1"/>
<quantity
value="75"/>
<product>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.23"/>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code
code="896001"
codeSystem="2.16.840.1.113883.6.88"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler">
<originalText><reference
value="#DM"/></originalText>
<translation
code="896001"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Medication Factory Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</product>
<performer>
<assignedEntity>
<id
extension="2981825"
root="2.16.840.1.113883.19.5.9999.456"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
</assignedEntity>
</performer>
<author>
<time
nullFlavor="UNK"/>
<assignedAuthor>
<id
root="2a620155-9d11-439e-92b3-5d9815fe4de8"/>
<addr
nullFlavor="UNK"/>
<telecom
nullFlavor="UNK"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<entryRelationship
typeCode="SUBJ"
inversionInd="true">
<act
classCode="ACT"
moodCode="INT">
<templateId
root="2.16.840.1.113883.10.20.22.4.20"/>
<!-- ** Instructions Template ** -->
<code xsi:type="CE"
code="409073007"
codeSystem="2.16.840.1.113883.6.96"
displayName="instruction"/>
<text><reference
value="#FillIns_DM"/>Generic Substitution Allowed</text>
<statusCode
code="completed"/>
</act>
</entryRelationship>
</supply>
</entryRelationship>
<entryRelationship
typeCode="REFR">
<supply
classCode="SPLY"
moodCode="EVN">
<templateId
root="2.16.840.1.113883.10.20.22.4.18"/>
<!-- ** Medication Dispense Template ** -->
<id
root="1.2.3.4.56789.1"
extension="cb734647-fc99-424c-a864-7e3cda82e704"/>
<statusCode
code="completed"/>
<effectiveTime
value="20120813"/>
<repeatNumber
value="1"/>
<quantity
value="75"/>
<product>
<manufacturedProduct
classCode="MANU">
<templateId
root="2.16.840.1.113883.10.20.22.4.23"/>
<id
root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code
code="896001"
codeSystem="2.16.840.1.113883.6.88"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler">
<originalText><reference
value="#DM"/></originalText>
<translation
code="896001"
displayName="120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"/>
</code>
</manufacturedMaterial>
<manufacturerOrganization>
<name>Medication Factory Inc.</name>
</manufacturerOrganization>
</manufacturedProduct>
</product>
<performer>
<time
nullFlavor="UNK"/>
<assignedEntity>
<id
root="2.16.840.1.113883.19.5.9999.456"
extension="2981825"/>
<addr>
<streetAddressLine>1002 Healthcare Dr</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>97266</postalCode>
<country>US</country>
</addr>
<telecom
nullFlavor="UNK"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
<representedOrganization>
<id
root="2.16.840.1.113883.19.5.9999.1395"/>
<name>Community Health and Hospitals</name>
<telecom
nullFlavor="UNK"/>
<addr
nullFlavor="UNK"/>
</representedOrganization>
</assignedEntity>
</performer>
</supply>
</entryRelationship>
<precondition
typeCode="PRCN">
<templateId
root="2.16.840.1.113883.10.20.22.4.25"/>
<criterion>
<code
code="ASSERTION"
codeSystem="2.16.840.1.113883.5.4"/>
<value
xsi:type="CE"
code="56018004"
codeSystem="2.16.840.1.113883.6.96"
displayName="Wheezing"/>
</criterion>
</precondition>
</substanceAdministration>
</entryRelationship>
</act>
</entry>
</section>
</component>
{% endhighlight %}
This Referral section is a free text field that captures the reason for the referral.
{% highlight xml %}
<!--
REASON FOR REFERRAL
-->
<title>REASON FOR REFERRAL</title>
Follow up with Dr George Potomac for Asthma
{% endhighlight %}
The Problem List section includes all concerns, complaints, and observations; with their corresponding status.
{% highlight xml %}
<!--
PROBLEM LIST
-->
<title>PROBLEMS</title>
Pneumonia : Status - Resolved
Asthma : Status - Active
{% endhighlight %}
The Procedures section details a history of procedures like x-rays.
{% highlight xml %}
<!--
PROCEDURES
-->
<title>PROCEDURES</title>
Procedure
Date
Chest X-Ray
8/7/2012
1002 Healthcare Dr
Portland
OR
97266
US
Community Health and Hospitals
1002 Healthcare Dr
Portland
OR
97266
US
Community Health and Hospitals
{% endhighlight %}
This Functional Status section details the different functional and cognitive impairments.
{% highlight xml %}
<!--
FUNCTIONAL and COGNITIVE STATUS
-->
<title>FUNCTIONAL STATUS</title>
Functional Condition
Effective Dates
Condition Status
Dependence on cane
2008
Active
Memory impairment
2008
Active
</effectiveTime>
<value
xsi:type="CD"
code="386807006"
codeSystem="2.16.840.1.113883.6.96"
displayName="Memory Impairment"/>
</observation>
</entry>
<entry
typeCode="DRIV">
<observation
classCode="OBS"
moodCode="EVN">
<!-- Cognitive Status Problem observation template -->
<templateId
root="2.16.840.1.113883.10.20.22.4.73"/>
<id
root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code xsi:type="CE"
code="373930000"
codeSystem="2.16.840.1.113883.6.96"
displayName="Cognitive Function Finding"/>
<text>
<reference
value="#fs2"/>
</text>
<statusCode
code="completed"/>
<effectiveTime>
<low
value="20081101"/>
<high nullFlavor="UNK"/>
</effectiveTime>
<value
xsi:type="CD"
code="48167000"
codeSystem="2.16.840.1.113883.6.96"
displayName="Amnesia"/>
</observation>
</entry>
</section>
</component>
{% endhighlight %}
This Results section includes all laboratory results.
{% highlight xml %}
<!--
RESULTS
-->
<title>RESULTS</title>
LABORATORY INFORMATION
Chemistries and drug levels
HGB (M 13-18 g/dl; F 12-16 g/dl)
13.2
WBC (4.3-10.8 10+3/ul)
6.7
PLT (135-145 meq/l)
123 (L)
M 13-18 g/dl; F 12-16 g/dl
{% endhighlight %}
This Social History section includes observations like smoking and drinking habits.
{% highlight xml %}
<!--
SOCIAL HISTORY
-->
<title>SOCIAL HISTORY</title>
Social History Element
Description
Effective Dates
Former smoker (smoked from 2005-2011)
{% endhighlight %}
The Vital Signs section captures vitals that change over time like height, weight, and blood pressure.
{% highlight xml %}
<!--
VITAL SIGNS
-->
<title>VITAL SIGNS</title>
Date / Time:
Nov 1, 2011
August 6, 2012
Height
69 inches
69 inches
Weight
189 lbs
194 lbs
Blood Pressure
132/86 mmHg
145/88 mmHg
{% endhighlight %}
The Hospital Discharge Instructions section is a free text field that captures the discharge instructions as written by the provider.
{% highlight xml %}
<!--
HOSPITAL DISCHARGE INSTRUCTIONS
-->
<component>
<section>
<templateId
root="2.16.840.1.113883.10.20.22.2.41"/>
<code
code="8653-8"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="HOSPITAL DISCHARGE INSTRUCTIONS"/>
<title>HOSPITAL DISCHARGE INSTRUCTIONS</title>
<!-- Unstructured text field -->
<text>
<content>
Ms. Jones, you have been seen by Dr. Henry Seven at Local Community Hospital from August 8th until August 13th 2012. You are currently being discharged from Local Community Hospital. Dr. Seven has provided the following instructions to you at this time; should you have any questions please contact a member of your healthcare team prior to discharge. If you have left the hospital and have questions, please contact Dr. Seven at 555-555-1002.
Instructions:
</content>
<list
listType="ordered">
<item>Take all medications as prescribed.</item>
<item>Please monitor your peak flows. If your peak flows drop to 50% of normal, call my office immediately or return to the Emergency Room.</item>
<item>If you experience any of the following symptoms, call my office immediately or return to the Emergency Room:
<list listType="ordered">
<item>Shortness of Breath</item>
<item>Dizziness or Light-headedness</item>
<item>Fever, chills, or diffuse body aches</item>
<item>Pain or redness at the site of any previous intravenous catheter</item>
<item>Any other unusual problem</item>
</list>
</item>
</list>
</text>
</section>
</component>
{% endhighlight %}
{% highlight xml %}
{% endhighlight %}