170.315(g)(9) C-CDA All Data Request
Respond to requests for patient data (based on an ID or other token) for all of the data classes expressed in the standards in § 170.213 at one time and return such data (according to the specified standards, where applicable) in a summary record formatted in accordance with § 170.205(a)(4) and (5) following the CCD document template, and as specified in paragraphs (g)(9)(i)(A)(3)(i) through (iii) of this section, or . The Common Clinical Data Set in accordance with paragraphs (g)(9)(i)(A)(3)(i) through (iv) of this section for the period until May 2, 2022, and The following data classes:
- Assessment and plan of treatment. In accordance with the “Assessment and Plan Section (V2)” of the standards specified in § 170.205(a)(4); or in accordance with the “Assessment Section (V2)” and “Plan of Treatment Section (V2)” of the standards specified in § 170.205(a)(4).
- Goals. In accordance with the “Goals Section” of the standard specified in § 170.205(a)(4).
- Health concerns. In accordance with the “Health Concerns Section” of the standard specified in § 170.205(a)(4).
- Unique device identifier(s) for a patient’s implantable device(s). In accordance with the “Product Instance” in the “Procedure Activity Procedure Section” of the standard specified in § 170.205(a)(4).
Respond to requests for patient data associated with a specific date as well as requests for patient data within a specified date range.
Request
GET [base]/fhir/Patient/[id]/$cda-ccds
Parameters
| Name | Type | Description | Optional? |
|---|---|---|---|
| id | string | The patients external ID | true |
| start | date | All records relating to care provided in a certain date range. If no start date is provided, all records prior to the end date are in scope. | true |
| end | date | All records relating to care provided in a certain date range. If no end date is provided, all records subsequent to the start date are in scope. | true |
| _type | string | One or more parameters, each containing one or more comma-delimited FHIR resource types to include in the return resources. In the absence of any specified types, the server returns all resource types | true |
Date Range Filtering Rules
Data is filtered based on category. Each category is filtered by a different field in the C-CDA or FHIR bundle.
- Medications
- period start date
- Allergies
- onset (currently when allergy is created in EHR system)
- Problem Conditions
- onset (EHR start date)
- Health Concern Conditions
- onset (effective date in EHR)
- Care Plan
- end period (effective date in EHR)
- Encounters and Diagnosis
- end period (EHR chart effective date)
- Vital Signs
- effective date/time (EHR assessment date)
- Smoking Status
- effective date/time
- Labs
- start time (EHR Lab Panel report time)
- Diagnostic Images
- start time (EHR examination date)
- Procedures
- performed date/time
- Vaccination
- occurrence date/time (EHR Start of Administration)
- Encounter Diagnosis
- NP in CCDA or FHIR (EHR reviewed problems: assessment date)
Response
<?xml version="1.0" encoding="UTF-8"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xmlns:cda="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc">
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
<templateId root="2.16.840.1.113883.10.20.22.1.2" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
<id root="1bf4b0f9-3d57-4817-8a55-c4635a347f88"/>
<code code="34133-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Summarization of Episode Note"/>
<title>Patient CCDS Continuity of Care Document</title>
<effectiveTime value="20201215"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality" displayName="normal"/>
<languageCode code="en-US"/>
<setId root="1bf4b0f9-3d57-4817-8a55-c4635a347f88"/>
<versionNumber value="1"/>
<recordTarget>
<patientRole>
<id root="2.16.840.1.113883.4.1" extension="989898989"/>
<addr use="HP">
<country>USA</country>
<state>OR</state>
<county>Baltimore City</county>
<city>Beaverton</city>
<postalCode>97006</postalCode>
<streetAddressLine>1357 Amber Dr</streetAddressLine>
</addr>
<telecom value="5557231544" use="HP"/>
<telecom value="5557231544 (H)" use="HP"/>
<telecom value="5557771234" use="MC"/>
<patient>
<name use="L">
<family>Newman</family>
<given>Alice</given>
<given>Jones</given>
</name>
<name>
<family qualifier="BR">Newman</family>
<given qualifier="BR">Alicia</given>
<given>Jones</given>
</name>
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" codeSystemName="Administrative Gender" displayName="Female"/>
<birthTime value="19700501"/>
<maritalStatusCode code="M" codeSystem="2.16.840.1.113883.5.2" codeSystemName="Marital Status Code" displayName="Married"/>
<religiousAffiliationCode code="1013" codeSystem="2.16.840.1.113883.5.1076" codeSystemName="HL7 Religious Affiliation" displayName="Christian (non-Catholic, non-specific)"/>
<raceCode code="2106-3" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race And Ethnicity - CDC" displayName="White"/>
<sdtc:raceCode code="2108-9" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race And Ethnicity - CDC" displayName="European"/>
<ethnicGroupCode code="2186-5" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race And Ethnicity - CDC" displayName="Not Hispanic or Latino"/>
<languageCommunication>
<languageCode code="en"/>
<modeCode code="ESP" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode" displayName="Expressed spoken"/>
<preferenceInd value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id root="2.16.840.1.113883.4.873" extension="de9c21d8-31be-4161-a24b-e829073901bb"/>
<name>Neighborhood Physicians Practice</name>
<telecom value="5555551002" use="WP"/>
<addr use="WP">
<country>USA</country>
<state>OR</state>
<city>Beaverton</city>
<postalCode>97006-9316</postalCode>
<streetAddressLine>2472 Rocky Pl</streetAddressLine>
</addr>
<asOrganizationPartOf>
<wholeOrganization>
<id root="2.16.840.1.113883.4.873" extension="agency-f60dacf9-56fe-44ff-a2d7-4ba34b68917f"/>
<name>Demo</name>
<telecom nullFlavor="UNK"/>
</wholeOrganization>
</asOrganizationPartOf>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time value="20201215"/>
<assignedAuthor>
<id root="de9c21d8-31be-4161-a24b-e829073901bb"/>
<id nullFlavor="UNK" root="2.16.840.1.113883.4.6"/>
<addr use="WP">
<country>USA</country>
<state>OR</state>
<city>Beaverton</city>
<postalCode>97006-9316</postalCode>
<streetAddressLine>2472 Rocky Pl</streetAddressLine>
</addr>
<telecom value="5555551002" use="WP"/>
<assignedAuthoringDevice>
<manufacturerModelName>WellSKy Consolo EHR</manufacturerModelName>
<softwareName>Consolo 5.0</softwareName>
</assignedAuthoringDevice>
<representedOrganization>
<id root="2.16.840.1.113883.4.873" extension="de9c21d8-31be-4161-a24b-e829073901bb"/>
<name>Neighborhood Physicians Practice</name>
<telecom value="5555551002" use="WP"/>
<addr use="WP">
<country>USA</country>
<state>OR</state>
<city>Beaverton</city>
<postalCode>97006-9316</postalCode>
<streetAddressLine>2472 Rocky Pl</streetAddressLine>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
<informant>
<assignedEntity>
<id root="de9c21d8-31be-4161-a24b-e829073901bb"/>
<id nullFlavor="UNK" root="2.16.840.1.113883.4.6"/>
<addr use="PHYS">
<country>USA</country>
<state>OR</state>
<city>Beaverton</city>
<postalCode>97006-9316</postalCode>
<streetAddressLine>2472 Rocky Pl</streetAddressLine>
</addr>
<telecom value="5555551002" use="WP"/>
<assignedPerson>
<name>
<family>Davis</family>
<given>Tracy</given>
</name>
</assignedPerson>
</assignedEntity>
</informant>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="de9c21d8-31be-4161-a24b-e829073901bb"/>
<name>Neighborhood Physicians Practice</name>
<telecom value="5555551002" use="WP"/>
<addr use="WP">
<country>USA</country>
<state>OR</state>
<city>Beaverton</city>
<postalCode>97006-9316</postalCode>
<streetAddressLine>2472 Rocky Pl</streetAddressLine>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<family>Davis</family>
<given>Tracy</given>
</name>
</informationRecipient>
<receivedOrganization>
<name>Neighborhood Physicians Practice</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<time value="20201215"/>
<signatureCode code="S"/>
<assignedEntity>
<id nullFlavor="UNK" root="2.16.840.1.113883.4.6"/>
<addr use="PHYS">
<country>USA</country>
<state>OR</state>
<city>Beaverton</city>
<postalCode>97006-9316</postalCode>
<streetAddressLine>2472 Rocky Pl</streetAddressLine>
</addr>
<telecom value="5555551002" use="WP"/>
<assignedPerson>
<name>
<family>Davis</family>
<given>Tracy</given>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<authenticator>
<time value="20201215"/>
<signatureCode code="S"/>
<assignedEntity>
<id nullFlavor="UNK" root="2.16.840.1.113883.4.6"/>
<addr use="PHYS">
<country>USA</country>
<state>OR</state>
<city>Beaverton</city>
<postalCode>97006-9316</postalCode>
<streetAddressLine>2472 Rocky Pl</streetAddressLine>
</addr>
<telecom value="5555551002" use="WP"/>
<assignedPerson>
<name>
<family>Davis</family>
<given>Tracy</given>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="20201214"/>
<high value="20150621"/>
</effectiveTime>
<performer typeCode="PRF">
<time value="20201215"/>
<assignedEntity>
<id root="48cd014b-8e5f-4257-b2cc-7c93b4cab5f0"/>
<code code="309343006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Physician"/>
<addr use="HP">
<country>USA</country>
<state>OR</state>
<city>Beaverton</city>
<postalCode>97006</postalCode>
<streetAddressLine>2472 Rocky Place</streetAddressLine>
</addr>
<telecom value="8591111111" use="WP"/>
<telecom value="5555551002" use="WP"/>
<assignedPerson>
<name>
<family>Davis</family>
<given>Albert</given>
</name>
</assignedPerson>
</assignedEntity>
</performer>
<performer typeCode="PRF">
<time value="20201215"/>
<assignedEntity>
<id root="8c6f9523-aeaa-4a79-8435-9cff40679749"/>
<code code="163W00000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC Health Care Provider Taxonomy" displayName="Registered Nurse"/>
<addr use="HP">
<country>USA</country>
</addr>
<telecom nullFlavor="UNK"/>
<assignedPerson>
<name>
<family>Davis</family>
<given>Tracy</given>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of medication use"/>
<title>MEDICATIONS</title>
<text>
<table>
<thead>
<tr>
<th>Medication</th>
<th>Instructions</th>
<th>Start Date</th>
<th>End Date</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>CefTRIAXone Sodium 100</td>
<td>CefTRIAXone Sodium 100 GM INTRAMUSCULAR 1 unit 2 times a day INTRAMUSCULAR (100 GM SOLR)</td>
<td>2015-06-22</td>
<td>2021-06-30</td>
<td>active</td>
</tr>
<tr>
<td>Aranesp (Albumin Free) 500</td>
<td>Aranesp (Albumin Free) 500 MCG/ML INTRAMUSCULAR 1 unit 1 times a week INTRAMUSCULAR (500 MCG/ML SOSY)</td>
<td>2015-06-22</td>
<td/>
<td>active</td>
</tr>
<tr>
<td>Tylenol Extra Strength 500</td>
<td>Tylenol Extra Strength 500 MG ORAL 1 unit ORAL As Needed (500 MG TABS)</td>
<td>2015-06-22</td>
<td>2021-07-01</td>
<td>active</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="9ce83680-b4b9-4189-a65e-e74d52f679c1"/>
<text>CefTRIAXone Sodium 100 GM INTRAMUSCULAR 1 unit 2 times a day INTRAMUSCULAR (100 GM SOLR)</text>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20150622"/>
<high value="20210630"/>
</effectiveTime>
<effectiveTime operator="A" xsi:type="PIVL_TS">
<period value="1.0" unit="d"/>
</effectiveTime>
<effectiveTime operator="A" institutionSpecified="false" xsi:type="PIVL_TS">
<period value="12.0" unit="h"/>
</effectiveTime>
<routeCode code="C28161" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="National Cancer Institute (NCI) Thesaurus" displayName="INTRAMUSCULAR"/>
<doseQuantity value="1.0"/>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<id root="bccc447b-a77c-4d00-9fa9-925862f9ea1d"/>
<manufacturedMaterial>
<code code="309090" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="CefTRIAXone Sodium 100"/>
<name>CefTRIAXone Sodium 100</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<author>
<time value="20150622"/>
<assignedAuthor>
<id root="48cd014b-8e5f-4257-b2cc-7c93b4cab5f0"/>
<addr nullFlavor="UNK"/>
<telecom nullFlavor="UNK"/>
<assignedPerson>
<name>
<family>Davis</family>
<given>Albert</given>
</name>
</assignedPerson>
</assignedAuthor>
</author>
</substanceAdministration>
</entry>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="1667cdd6-b912-4e4b-b222-57788a1ab240"/>
<text>Aranesp (Albumin Free) 500 MCG/ML INTRAMUSCULAR 1 unit 1 times a week INTRAMUSCULAR (500 MCG/ML SOSY)</text>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20150622"/>
<high/>
</effectiveTime>
<effectiveTime operator="A" xsi:type="PIVL_TS">
<period value="1.0" unit="wk"/>
</effectiveTime>
<routeCode code="C28161" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="National Cancer Institute (NCI) Thesaurus" displayName="INTRAMUSCULAR"/>
<doseQuantity value="1.0"/>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<id root="e5c2f896-8820-4383-99ee-30bc323ec26d"/>
<manufacturedMaterial>
<code code="731241" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Aranesp (Albumin Free) 500"/>
<name>Aranesp (Albumin Free) 500</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<author>
<time value="20150622"/>
<assignedAuthor>
<id root="48cd014b-8e5f-4257-b2cc-7c93b4cab5f0"/>
<addr nullFlavor="UNK"/>
<telecom nullFlavor="UNK"/>
<assignedPerson>
<name>
<family>Davis</family>
<given>Albert</given>
</name>
</assignedPerson>
</assignedAuthor>
</author>
</substanceAdministration>
</entry>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="72b5c821-5ae3-4b45-be86-a03364a565b2"/>
<text>Tylenol Extra Strength 500 MG ORAL 1 unit ORAL As Needed (500 MG TABS)</text>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20150622"/>
<high value="20210701"/>
</effectiveTime>
<effectiveTime operator="A" xsi:type="PIVL_TS">
<period value="1.0" unit="d"/>
</effectiveTime>
<routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="National Cancer Institute (NCI) Thesaurus" displayName="ORAL"/>
<doseQuantity value="1.0"/>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<id root="0d7056b4-fbad-423f-a501-65b7bf110964"/>
<manufacturedMaterial>
<code code="209459" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Tylenol Extra Strength 500"/>
<name>Tylenol Extra Strength 500</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<author>
<time value="20150622"/>
<assignedAuthor>
<id root="48cd014b-8e5f-4257-b2cc-7c93b4cab5f0"/>
<addr nullFlavor="UNK"/>
<telecom nullFlavor="UNK"/>
<assignedPerson>
<name>
<family>Davis</family>
<given>Albert</given>
</name>
</assignedPerson>
</assignedAuthor>
</author>
</substanceAdministration>
</entry>
</section>
</component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.6.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts"/>
<title>ALLERGIES, ADVERSE REACTIONS, ALERTS</title>
<text>
<table>
<thead>
<tr>
<th>Substance</th>
<th>Reaction</th>
<th>Severity</th>
<th>Status</th>
<th>Verification Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Ampicillin</td>
<td>Weal (disorder)</td>
<td>moderate</td>
<td>completed</td>
<td>Confirmed</td>
</tr>
<tr>
<td>Penicillin</td>
<td>Weal (disorder)</td>
<td>moderate</td>
<td>completed</td>
<td>Confirmed</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.30" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id root="66e12c3c-f9db-4176-abd4-0b622e36a9fc"/>
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts"/>
<statusCode code="active"/>
<effectiveTime>
<low value="20201215"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.7" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="2de8008b-f08e-4815-abe3-8ccc5019373a"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" displayName="Assertion"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="20201215"/>
</effectiveTime>
<value code="419511003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Propensity to adverse reaction to drug" xsi:type="CD">
<originalText>Ampicillin</originalText>
</value>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code code="733" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Ampicillin"/>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.8" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<id root="2de8008b-f08e-4815-abe3-8ccc5019373a"/>
<code code="SEV" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<value code="6736007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="moderate" xsi:type="CD"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="MFST" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.9" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.9"/>
<id root="2de8008b-f08e-4815-abe3-8ccc5019373a"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" displayName="Assertion"/>
<statusCode code="completed"/>
<effectiveTime value="20201215"/>
<value code="247472004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Weal (disorder)" xsi:type="CD"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
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<td>The patient was found to have fever and Dr Davis is suspecting Anemia based on the patient history. So Dr Davis asked the patient to closely monitor the temperature and blood pressure and get admitted to Community Health Hospitals if the fever does not subside within a day</td>
<td>Urinanalysis macro (dipstick) panel Date: 06/29/2015 Get an EKG done on 6/23/2015. Take Clindamycin 300mg three times a day as needed if pain does not subside. Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2015.</td>
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<item>
<caption>Birth Sex: </caption>Female
</item>
</list>
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<code code="72166-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Tobacco smoking status NHIS"/>
<text>Current every day smoker</text>
<statusCode code="completed"/>
<effectiveTime value="20150622"/>
<value code="449868002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Current every day smoker" xsi:type="CD"/>
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<text>Female</text>
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<section>
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<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Relevant diagnostic tests and/or laboratory data"/>
<title>RESULTS</title>
<text>
<table>
<thead>
<tr>
<th>test code</th>
<th>panel</th>
<th>status</th>
<th>category</th>
<th>result code</th>
<th>name</th>
<th>value</th>
<th>laboratory</th>
<th>reference range</th>
<th>effective</th>
</tr>
</thead>
<tbody>
<tr>
<td>24357-6</td>
<td>Urinalysis macro (dipstick) panel (U)</td>
<td>final</td>
<td>Laboratory</td>
<td>5778-6</td>
<td>Color (U)</td>
<td>YELLOW</td>
<td>Value Labs </td>
<td> - </td>
<td>2015-06-22T14:00:00-04:00</td>
</tr>
<tr>
<td>24357-6</td>
<td>Urinalysis macro (dipstick) panel (U)</td>
<td>final</td>
<td>Laboratory</td>
<td>5767-9</td>
<td>Appearance (U)</td>
<td>CLEAR</td>
<td>Value Labs </td>
<td> - </td>
<td>2015-06-22T14:00:00-04:00</td>
</tr>
<tr>
<td>24357-6</td>
<td>Urinalysis macro (dipstick) panel (U)</td>
<td>final</td>
<td>Laboratory</td>
<td>5803-2</td>
<td>pH Test strip (U)</td>
<td>5.0 [pH]</td>
<td>Value Labs </td>
<td>5 - 8</td>
<td>2015-06-22T14:00:00-04:00</td>
</tr>
<tr>
<td>24357-6</td>
<td>Urinalysis macro (dipstick) panel (U)</td>
<td>final</td>
<td>Laboratory</td>
<td>5811-5</td>
<td>Specific gravity Test strip (U) [Rel density]</td>
<td>1.015 g/cm3</td>
<td>Value Labs </td>
<td>1.005 - 1.03</td>
<td>2015-06-22T14:00:00-04:00</td>
</tr>
<tr>
<td>24357-6</td>
<td>Urinalysis macro (dipstick) panel (U)</td>
<td>final</td>
<td>Laboratory</td>
<td>5804-0</td>
<td>Protein Test strip (U) [Mass/Vol]</td>
<td>100.0 mg/dL</td>
<td>Value Labs </td>
<td> - </td>
<td>2015-06-22T14:00:00-04:00</td>
</tr>
<tr>
<td>24357-6</td>
<td>Urinalysis macro (dipstick) panel (U)</td>
<td>final</td>
<td>Laboratory</td>
<td>5792-7</td>
<td>Glucose Test strip (U) [Mass/Vol]</td>
<td>50.0 mg/dL</td>
<td>Value Labs </td>
<td>50.0 mg/dL</td>
<td>2015-06-22T14:00:00-04:00</td>
</tr>
<tr>
<td/>
<td/>
<td>final</td>
<td>Diagnostic Image Result</td>
<td>36643-5</td>
<td>Chest X-ray 2 Views</td>
<td>Anemia. Other tests are required to determine the presence or absence of Anemia.</td>
<td> </td>
<td>Anemia. Other tests are required to determine the presence or absence of Anemia.</td>
<td>2015-06-22T00:00:00-04:00</td>
</tr>
</tbody>
</table>
</text>
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<author>
<time value="20150622"/>
<assignedAuthor>
<id root="2.16.840.1.113883.19.5"/>
<addr use="WP">
<country>USA</country>
<state>OR</state>
<city>Beaverton</city>
<postalCode>97006</postalCode>
<streetAddressLine>2474 Rocky place</streetAddressLine>
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<representedOrganization>
<name>Value Labs</name>
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<value xsi:type="ST">YELLOW</value>
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<value value="100.0" unit="mg/dL" xsi:type="PQ"/>
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<statusCode code="completed"/>
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<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital Signs"/>
<title>VITAL SIGNS</title>
<text>
<table>
<thead>
<tr>
<th>Reading</th>
<th>Value</th>
<th>Performed By</th>
<th>Assessment Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>Respiratory Rate</td>
<td>18 breaths/minute</td>
<td>Davis, Albert</td>
<td>2015-06-22</td>
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<tr>
<td>Heart Rate</td>
<td>80 beats/minute</td>
<td>Davis, Albert</td>
<td>2015-06-22</td>
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<tr>
<td>Oxygen Saturation</td>
<td>95.0 %</td>
<td>Davis, Albert</td>
<td>2015-06-22</td>
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<tr>
<td>Inhaled Oxygen Concentration</td>
<td>4.0 liters/minute</td>
<td>Davis, Albert</td>
<td>2015-06-22</td>
</tr>
<tr>
<td>Body Temperature</td>
<td>100.4 F</td>
<td>Davis, Albert</td>
<td>2015-06-22</td>
</tr>
<tr>
<td>Body Height</td>
<td>69.7 in</td>
<td>Davis, Albert</td>
<td>2015-06-22</td>
</tr>
<tr>
<td>Body Weight</td>
<td>194.0 lbs</td>
<td>Davis, Albert</td>
<td>2015-06-22</td>
</tr>
<tr>
<td>Body Mass Index</td>
<td>28 kg/m2</td>
<td>Davis, Albert</td>
<td>2015-06-22</td>
</tr>
<tr>
<td>Blood pressure systolic &amp; diastolic</td>
<td>145 mmHg / 88 mmHg</td>
<td>Davis, Albert</td>
<td>2015-06-22</td>
</tr>
</tbody>
</table>
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<statusCode code="completed"/>
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<value value="145.0" unit="mm[Hg]" xsi:type="PQ"/>
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<section>
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<title>CARE TEAM</title>
<text>
<table>
<thead>
<tr>
<th>Name</th>
<th>Role</th>
</tr>
</thead>
<tbody>
<tr>
<td>Davis, Albert</td>
<td>Physician</td>
</tr>
<tr>
<td>Davis, Tracy</td>
<td>Registered Nurse</td>
</tr>
</tbody>
</table>
</text>
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<section>
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<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Procedures"/>
<title>PROCEDURES</title>
<text>
<table>
<thead>
<tr>
<th>Procedure</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>Implanted Device Procedure</td>
<td>2011-10-05T00:00:00-04:00</td>
</tr>
<tr>
<td>Nebulizer Therapy</td>
<td>2015-06-22T00:00:00-04:00</td>
</tr>
<tr>
<td>Introduction of cardiac pacemaker system via vein</td>
<td>2011-10-05T00:00:00-04:00</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
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<code code="56251003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Nebulizer Therapy"/>
<statusCode code="completed"/>
<effectiveTime value="20150622"/>
<performer>
<assignedEntity>
<id root="8c5f4d7f-af36-47ba-a81d-cf71b067ad14"/>
<addr use="WP">
<country>US</country>
<state>Beaverton</state>
<city>place</city>
<postalCode>OR-97006</postalCode>
<streetAddressLine>Neighborhood Physicians Practice 2472 Rocky</streetAddressLine>
</addr>
<telecom value="5555551002" use="WP"/>
<representedOrganization classCode="ORG">
<id root="7e1b2cb5-b04d-4ce8-a49e-3a9271b89b47"/>
<name>Albert Davis</name>
<telecom value="5555551002" use="WP"/>
<addr use="WP">
<country>US</country>
<state>Beaverton</state>
<city>place</city>
<postalCode>OR-97006</postalCode>
<streetAddressLine>Neighborhood Physicians Practice 2472 Rocky</streetAddressLine>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
</procedure>
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<code code="175135009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Introduction of cardiac pacemaker system via vein"/>
<statusCode code="completed"/>
<effectiveTime value="20111005"/>
<performer>
<assignedEntity>
<id root="3aebbbd2-ac45-4728-9438-590ebf744867"/>
<addr use="WP">
<country>US</country>
<state>Beaverton</state>
<city>Avenue</city>
<postalCode>OR-97006</postalCode>
<streetAddressLine>Community Health Hospitals 3525 Newberry</streetAddressLine>
</addr>
<telecom value="5555551003" use="WP"/>
<representedOrganization classCode="ORG">
<id root="4209409d-d399-42aa-bce3-bc31fee889af"/>
<name>Albert Davis</name>
<telecom value="5555551003" use="WP"/>
<addr use="WP">
<country>US</country>
<state>Beaverton</state>
<city>Avenue</city>
<postalCode>OR-97006</postalCode>
<streetAddressLine>Community Health Hospitals 3525 Newberry</streetAddressLine>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
</procedure>
</entry>
</section>
</component>
<component>
<section>
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<templateId root="2.16.840.1.113883.10.20.22.2.23"/>
<code code="46264-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medical Equipment"/>
<title>MEDICAL EQUIPMENT</title>
<text>
<table>
<thead>
<tr>
<th>Device</th>
<th>Status</th>
<th>UDI</th>
<th>Lot or Batch Number</th>
<th>Serial Number</th>
<th>Identification Code</th>
<th>Expiration Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>Cardiac resynchronization therapy implantable defibrillator</td>
<td>Active</td>
<td>(01)00643169007222(17)160128(21)BLC200461H</td>
<td>BLC200461H</td>
<td>00643169007222</td>
<td>2016-01-28</td>
</tr>
</tbody>
</table>
</text>
<entry>
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<id root="a73bad19-8a15-43bc-b2e6-d7c51c7b144d"/>
<code nullFlavor="UNK"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="20111005"/>
</effectiveTime>
<participant typeCode="DEV">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.37"/>
<id root="2.16.840.1.113883.3.3719" extension="(01)00643169007222(17)160128(21)BLC200461H" assigningAuthorityName="FDA"/>
<playingDevice>
<code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<manufacturerModelName>Viva™ Quad XT CRT-D</manufacturerModelName>
</playingDevice>
<scopingEntity>
<id root="2.16.840.1.113883.3.3719"/>
</scopingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="COMP">
<organizer classCode="CLUSTER" moodCode="EVN">
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<id root="2.16.840.1.113883.3.3719" extension="(01)00643169007222(17)160128(21)BLC200461H" assigningAuthorityName="FDA"/>
<code code="74711-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Unique Device Identifier" xsi:type="CE"/>
<statusCode code="completed"/>
<component>
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<code code="C101722" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Primary DI Number"/>
<value root="1.3.160" extension="00643169007222" assigningAuthorityName="GS1" displayable="true" xsi:type="II"/>
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<component>
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<code code="C101671" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Serial Number"/>
<value xsi:type="ST">BLC200461H</value>
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<component>
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<templateId root="2.16.840.1.113883.10.20.22.4.309" extension="2019-06-21"/>
<code code="C101670" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Expiration Date"/>
<value value="20160128" xsi:type="TS"/>
</observation>
</component>
<component>
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<templateId root="2.16.840.1.113883.10.20.22.4.308" extension="2019-06-21"/>
<code code="C113843" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Distinct Identification"/>
<value xsi:type="ST">00643169007222</value>
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<component>
<observation classCode="OBS" moodCode="EVN">
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<code code="C54131" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Company Name"/>
<value xsi:type="ST">MEDTRONIC, INC.</value>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.305" extension="2019-06-21"/>
<code code="C160939" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Device Status Implant"/>
<value code="C45329" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="active" xsi:type="CD"/>
</observation>
</component>
</organizer>
</entryRelationship>
</procedure>
</entry>
</section>
</component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.2.1"/>
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of immunizations"/>
<title>IMMUNIZATIONS</title>
<text>
<table>
<thead>
<tr>
<th>Vaccine</th>
<th>Code System</th>
<th>Vaccine Name</th>
<th>Date</th>
<th>Status</th>
<th>Lot Number</th>
<th>Manufacturer</th>
<th>Additional Notes</th>
</tr>
</thead>
<tbody>
<tr>
<td>DTaP, 5 pertussis antigens</td>
<td>CVX</td>
<td>dtap, 5 pertussis antigens</td>
<td>2012-01-04T00:00:00-05:00</td>
<td>completed</td>
<td>2</td>
<td>Immuno-U.S., Inc.</td>
<td/>
</tr>
<tr>
<td>influenza, intradermal, quadrivalent, preservative free</td>
<td>CVX</td>
<td>influenza, intradermal, quadrivalent, preservative free</td>
<td>2015-06-22T00:00:00-04:00</td>
<td>#</td>
<td/>
<td>Immuno-U.S., Inc.</td>
<td>Immunization was not given - Patient rejected immunization</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="true">
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<id root="dda66832-21a4-4703-b209-9a2f0747b432"/>
<text>DTaP, 5 pertussis antigens</text>
<statusCode code="completed"/>
<effectiveTime value="20120104"/>
<consumable>
<manufacturedProduct classCode="MANU">
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<manufacturedMaterial>
<code code="106" codeSystem="2.16.840.1.113883.12.292" codeSystemName="CVX" displayName="DTaP, 5 pertussis antigens"/>
</manufacturedMaterial>
<manufacturerOrganization>
<name/>
</manufacturerOrganization>
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</consumable>
</substanceAdministration>
</entry>
<entry typeCode="DRIV">
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<id root="81ef05ab-a36b-4750-878b-04cdcce31040"/>
<text>influenza, intradermal, quadrivalent, preservative free</text>
<statusCode code="completed"/>
<effectiveTime value="20150622"/>
<consumable>
<manufacturedProduct classCode="MANU">
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<manufacturedMaterial>
<code code="166" codeSystem="2.16.840.1.113883.12.292" codeSystemName="CVX" displayName="influenza, intradermal, quadrivalent, preservative free"/>
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<manufacturerOrganization>
<name/>
</manufacturerOrganization>
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</consumable>
<entryRelationship typeCode="RSON">
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<code code="PATOBJ" codeSystem="2.16.840.1.113883.5.8" codeSystemName="HL7 ActNoImmunizationReason" displayName="Patient Objection" xsi:type="CE"/>
<statusCode code="completed"/>
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</section>
</component>
<component>
<section>
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<templateId root="2.16.840.1.113883.10.20.22.2.14"/>
<code code="47420-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Functional Status"/>
<title>FUNCTIONAL STATUS</title>
<text>Dependence on cane.</text>
</section>
</component>
<component>
<section>
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<code code="42349-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Reason for Referral"/>
<title>REASON</title>
<text>Ms Alice Newman is being referred to Community Health Hospitals Inpatient facility because of the high fever noticed and suspected Anemia.</text>
</section>
</component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.56" extension="2015-08-01"/>
<code code="10190-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Mental Status"/>
<title>MENTAL STATUS</title>
<text>Amnesia.</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>