Examples

Contains reference examples used in our API Guides

The following is an example of a CCDA document decoded to XML.

CCDA Document in XML

<?xml-stylesheet type="text/xsl" href="CDA_ARRA2.xsl"?>
<ClinicalDocument
    xmlns:sdtc="urn:hl7-org:sdtc"
    xmlns:voc="urn:hl7-org:v3/voc"
    xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
    xmlns="urn:hl7-org:v3" xsi:schemaLocation="urn:hl7-org:v3 http://xreg2.nist.gov:8080/hitspValidation/schema/cdar2c32/infrastructure/cda/C32_CDA.xsd">
    <realmCode code="US" />
    <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3" />
    <templateId root="2.16.840.1.113883.10.20.22.1.1" />
    <templateId root="2.16.840.1.113883.10.20.22.1.2" />
    <id root="2.16.840.1.113883.3.3330.8889429.1433.2" extension="2.16.840.1.113883.3.3330.8889429.1433.2^89765..1" />
    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="34133-9" displayName="Summarization of episode note"></code>
    <title>OneRecord-OrgB-1433 Summarization Of Episode Note</title>
    <effectiveTime value="20130222094143-0500" />
    <confidentialityCode codeSystem="2.16.840.1.113883.5.25" code="N" />
    <languageCode code="en-US" />
    <recordTarget>
        <patientRole>
            <id extension="89765" root="2.16.840.1.113883.3.3330.8889429.1433.2" />
            <addr use="HP">
                <streetAddressLine>3475 Oak Place</streetAddressLine>
                <city>Arvada</city>
                <state>CO</state>
                <postalCode>38063</postalCode>
            </addr>
            <telecom value="tel:+1-(720)239-4800" use="HP" />
            <patient>
                <name use="L">
                    <given>Stephen</given>
                    <family>Pujols1433</family>
                </name>
                <administrativeGenderCode codeSystem="2.16.840.1.113883.5.1" code="F" displayName="Female"></administrativeGenderCode>
                <birthTime value="19950929" />
                <raceCode codeSystemName="Race and Ethnicity - CDC" codeSystem="2.16.840.1.113883.6.238" code="2106-3" displayName="White"></raceCode>
                <ethnicGroupCode codeSystemName="Race and Ethnicity - CDC" codeSystem="2.16.840.1.113883.6.238" code="2186-5" displayName="Not Hispanic or Latino"></ethnicGroupCode>
                <languageCommunication>
                    <languageCode nullFlavor="NI" />
                </languageCommunication>
            </patient>
        </patientRole>
    </recordTarget>
    <author>
        <time value="20130222094143-0500" />
        <assignedAuthor>
            <id extension="X68" root="2.16.840.1.113883.4.6" assigningAuthorityName="National Plan and Provider Enumeration System"></id>
            <addr>
                <streetAddressLine>1000 Hospital Way</streetAddressLine>
                <city>La Jolla</city>
                <state>CA</state>
                <postalCode>92037</postalCode>
                <country>USA</country>
            </addr>
            <telecom nullFlavor="UNK" />
            <assignedAuthoringDevice>
                <manufacturerModelName>McKesson Horizon Clinicals</manufacturerModelName>
                <softwareName>Horizon Connect</softwareName>
            </assignedAuthoringDevice>
            <representedOrganization>
                <id extension="X68" root="2.16.840.1.113883.4.6" assigningAuthorityName="National Plan and Provider Enumeration System"></id>
                <name>OneRecord-OrgB-1433</name>
                <telecom nullFlavor="UNK" />
                <addr>
                    <streetAddressLine>1000 Hospital Way</streetAddressLine>
                    <city>La Jolla</city>
                    <state>CA</state>
                    <postalCode>92037</postalCode>
                    <country>USA</country>
                </addr>
            </representedOrganization>
        </assignedAuthor>
    </author>
    <informant>
        <assignedEntity>
            <id nullFlavor="NI" />
            <addr>
                <streetAddressLine nullFlavor="NI" />
                <city nullFlavor="NI" />
                <state nullFlavor="NI" />
                <postalCode nullFlavor="NI" />
                <country nullFlavor="NI" />
            </addr>
            <telecom nullFlavor="NI" />
            <assignedPerson>
                <name nullFlavor="NI" />
            </assignedPerson>
            <representedOrganization>
                <id extension="X68" root="2.16.840.1.113883.4.6" assigningAuthorityName="National Plan and Provider Enumeration System"></id>
                <name>OneRecord-OrgB-1433</name>
                <telecom nullFlavor="NI" />
                <addr>
                    <streetAddressLine nullFlavor="NI" />
                    <city nullFlavor="NI" />
                    <state nullFlavor="NI" />
                    <postalCode nullFlavor="NI" />
                    <country nullFlavor="NI" />
                </addr>
            </representedOrganization>
        </assignedEntity>
    </informant>
    <custodian>
        <assignedCustodian>
            <representedCustodianOrganization>
                <id extension="X68" root="2.16.840.1.113883.4.6" assigningAuthorityName="National Plan and Provider Enumeration System"></id>
                <name>OneRecord-OrgB-1433</name>
                <telecom nullFlavor="UNK" />
                <addr use="WP">
                    <streetAddressLine>1000 Hospital Way</streetAddressLine>
                    <city>La Jolla</city>
                    <state>CA</state>
                    <postalCode>92037</postalCode>
                    <country>USA</country>
                </addr>
            </representedCustodianOrganization>
        </assignedCustodian>
    </custodian>
    <documentationOf>
        <serviceEvent classCode="PCPR">
            <effectiveTime>
                <low value="20121002000000-0400" />
                <high value="20121005120000-0400" />
            </effectiveTime>
            <performer typeCode="PRF">
                <templateId root="2.16.840.1.113883.10.20.21.3.1" />
                <functionCode codeSystemName="Provider Role" codeSystem="2.16.840.1.113883.12.443" code="PP" displayName="Primary Care Provider">
                    <originalText>Primary Care Provider</originalText>
                </functionCode>
                <time>
                    <low value="20130211214803-0500" />
                    <high nullFlavor="UNK" />
                </time>
                <assignedEntity>
                    <id nullFlavor="NI" />
                    <code codeSystemName="Provider Codes" codeSystem="2.16.840.1.113883.6.101" code="208D00000X"></code>
                    <addr use="WP">
                        <streetAddressLine>1002 Healthcare Dr.</streetAddressLine>
                        <city>Portland</city>
                        <country>USA</country>
                        <postalCode>97005</postalCode>
                        <state>OR</state>
                    </addr>
                    <telecom nullFlavor="NI" />
                    <assignedPerson>
                        <name>
                            <given>Martin</given>
                            <family>Borgestedt</family>
                            <suffix>MD</suffix>
                        </name>
                    </assignedPerson>
                </assignedEntity>
            </performer>
        </serviceEvent>
    </documentationOf>
    <componentOf>
        <encompassingEncounter>
            <id nullFlavor="NI" />
            <effectiveTime>
                <low value="20121002000000-0400" />
                <high value="20121005120000-0400" />
            </effectiveTime>
            <encounterParticipant typeCode="ATND">
                <templateId root="2.16.840.1.113883.10.20.6.2.2" />
                <assignedEntity>
                    <id nullFlavor="NI" />
                    <code codeSystemName="Provider Codes" codeSystem="2.16.840.1.113883.6.101" code="208D00000X"></code>
                    <addr nullFlavor="NI" />
                    <telecom nullFlavor="NI" />
                    <assignedPerson>
                        <name>
                            <prefix>Dr.</prefix>
                            <given>Martin</given>
                            <family>Borgestedt</family>
                        </name>
                    </assignedPerson>
                </assignedEntity>
            </encounterParticipant>
            <location>
                <healthCareFacility>
                    <id extension="X68" root="2.16.840.1.113883.4.6" assigningAuthorityName="National Plan and Provider Enumeration System"></id>
                    <location>
                        <name>OneRecord-OrgB-1433</name>
                        <addr use="WP">
                            <streetAddressLine>1000 Hospital Way</streetAddressLine>
                            <city>La Jolla</city>
                            <state>CA</state>
                            <postalCode>92037</postalCode>
                            <country>USA</country>
                        </addr>
                    </location>
                </healthCareFacility>
            </location>
        </encompassingEncounter>
    </componentOf>
    <component>
        <structuredBody>
            <component>
                <section>
                    <templateId root="2.16.840.1.113883.10.20.22.2.6.1" />
                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="48765-2" displayName="Allergies, Adverse Reactions, Alerts"></code>
                    <title>Allergies and Adverse Reactions</title>
                    <text>
                        <table width="100%" border="1">
                            <thead>
                                <tr>
                                    <th>Alert</th>
                                    <th>Type</th>
                                    <th>Reactions</th>
                                    <th>Severity</th>
                                    <th>Status</th>
                                </tr>
                            </thead>
                            <tbody>
                                <tr>
                                    <td ID="alert1">Aspirin drug allergy</td>
                                    <td ID="alerttype1">drug allergy</td>
                                    <td>
                                        <list listType="ordered">
                                            <item ID="reaction1">Nausea</item>
                                        </list>
                                    </td>
                                    <td />
                                    <td ID="alertstatus1">active</td>
                                </tr>
                                <tr>
                                    <td ID="alert2">Penicillin G drug allergy</td>
                                    <td ID="alerttype2">drug allergy</td>
                                    <td>
                                        <list listType="ordered">
                                            <item ID="reaction2">Hives</item>
                                        </list>
                                    </td>
                                    <td />
                                    <td ID="alertstatus2">active</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" />
                            <id root="ID4gds-17jps1rk8" />
                            <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="48765-2" displayName="Allergies, Adverse Reactions, Alerts"></code>
                            <statusCode code="active" />
                            <effectiveTime>
                                <low nullFlavor="UNK" />
                                <high nullFlavor="UNK" />
                            </effectiveTime>
                            <entryRelationship inversionInd="false" typeCode="SUBJ">
                                <observation classCode="OBS" moodCode="EVN">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.7" />
                                    <id root="ID4gds-17jps1rk8" />
                                    <code codeSystemName="ActCode" codeSystem="2.16.840.1.113883.5.4" code="ASSERTION" displayName="Assertion"></code>
                                    <statusCode code="completed" />
                                    <effectiveTime>
                                        <high nullFlavor="UNK" />
                                    </effectiveTime>
                                    <value codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" xsi:type="CD" code="416098002" displayName="drug allergy"></value>
                                    <author>
                                        <time value="20130219133933-0500" />
                                        <assignedAuthor>
                                            <id nullFlavor="NA" />
                                            <addr nullFlavor="NI" />
                                            <telecom nullFlavor="NI" />
                                            <assignedPerson>
                                                <name>
                                                    <given>INSTALL A</given>
                                                    <family>HBOC</family>
                                                </name>
                                            </assignedPerson>
                                            <representedOrganization>
                                                <id extension="OneRecord-OrgB-1433" root="2.16.840.1.113883.3.3330.8889429.1433.2" />
                                                <name>OneRecord-OrgB-1433</name>
                                                <telecom nullFlavor="NI" />
                                                <addr nullFlavor="NI" />
                                            </representedOrganization>
                                        </assignedAuthor>
                                    </author>
                                    <participant typeCode="CSM">
                                        <participantRole classCode="MANU">
                                            <playingEntity classCode="MMAT">
                                                <code codeSystemName="RxNorm" codeSystem="2.16.840.1.113883.6.88" code="1191" displayName="Aspirin">
                                                    <originalText>
                                                        <reference value="#alert1" />
                                                    </originalText>
                                                    <translation codeSystemName="fdbMedNameID" codeSystem="2.16.840.1.113883.3.567.12.2" code="1076" displayName="Aspirin"></translation>
                                                </code>
                                                <name>Aspirin</name>
                                            </playingEntity>
                                        </participantRole>
                                    </participant>
                                    <entryRelationship inversionInd="true" typeCode="MFST">
                                        <observation classCode="OBS" moodCode="EVN">
                                            <templateId root="2.16.840.1.113883.10.20.22.4.9" />
                                            <id nullFlavor="NA" />
                                            <code codeSystemName="ActCode" codeSystem="2.16.840.1.113883.5.4" code="ASSERTION" displayName="Assertion"></code>
                                            <text>
                                                <reference value="#reaction1" />
                                            </text>
                                            <statusCode code="completed" />
                                            <value codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="422587007" xsi:type="CD" displayName="Nausea"></value>
                                        </observation>
                                    </entryRelationship>
                                    <entryRelationship inversionInd="false" typeCode="REFR">
                                        <observation classCode="OBS" moodCode="EVN">
                                            <templateId root="2.16.840.1.113883.10.20.1.39" />
                                            <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="33999-4" displayName="Status"></code>
                                            <statusCode code="completed" />
                                            <value codeSystem="2.16.840.1.113883.6.96" code="active" xsi:type="CE" displayName="active"></value>
                                        </observation>
                                    </entryRelationship>
                                </observation>
                            </entryRelationship>
                        </act>
                    </entry>
                    <entry typeCode="DRIV">
                        <act classCode="ACT" moodCode="EVN">
                            <templateId root="2.16.840.1.113883.10.20.22.4.30" />
                            <id root="ID4gdl-17jpo3ng0" />
                            <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="48765-2" displayName="Allergies, Adverse Reactions, Alerts"></code>
                            <statusCode code="active" />
                            <effectiveTime>
                                <low nullFlavor="UNK" />
                                <high nullFlavor="UNK" />
                            </effectiveTime>
                            <entryRelationship inversionInd="false" typeCode="SUBJ">
                                <observation classCode="OBS" moodCode="EVN">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.7" />
                                    <id root="ID4gdl-17jpo3ng0" />
                                    <code codeSystemName="ActCode" codeSystem="2.16.840.1.113883.5.4" code="ASSERTION" displayName="Assertion"></code>
                                    <statusCode code="completed" />
                                    <effectiveTime>
                                        <high nullFlavor="UNK" />
                                    </effectiveTime>
                                    <value codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" xsi:type="CD" code="416098002" displayName="drug allergy"></value>
                                    <author>
                                        <time value="20130219123040-0500" />
                                        <assignedAuthor>
                                            <id nullFlavor="NA" />
                                            <addr nullFlavor="NI" />
                                            <telecom nullFlavor="NI" />
                                            <assignedPerson>
                                                <name>
                                                    <given>INSTALL A</given>
                                                    <family>HBOC</family>
                                                </name>
                                            </assignedPerson>
                                            <representedOrganization>
                                                <id extension="OneRecord-OrgB-1433" root="2.16.840.1.113883.3.3330.8889429.1433.2" />
                                                <name>OneRecord-OrgB-1433</name>
                                                <telecom nullFlavor="NI" />
                                                <addr nullFlavor="NI" />
                                            </representedOrganization>
                                        </assignedAuthor>
                                    </author>
                                    <participant typeCode="CSM">
                                        <participantRole classCode="MANU">
                                            <playingEntity classCode="MMAT">
                                                <code codeSystemName="RxNorm" codeSystem="2.16.840.1.113883.6.88" code="7980" displayName="Penicillin G">
                                                    <originalText>
                                                        <reference value="#alert2" />
                                                    </originalText>
                                                    <translation codeSystemName="HIC_SEQN" codeSystem="2.16.840.1.113883.4.65" code="4977" displayName="Penicillin G"></translation>
                                                </code>
                                                <name>Penicillin G</name>
                                            </playingEntity>
                                        </participantRole>
                                    </participant>
                                    <entryRelationship inversionInd="true" typeCode="MFST">
                                        <observation classCode="OBS" moodCode="EVN">
                                            <templateId root="2.16.840.1.113883.10.20.22.4.9" />
                                            <id nullFlavor="NA" />
                                            <code codeSystemName="ActCode" codeSystem="2.16.840.1.113883.5.4" code="ASSERTION" displayName="Assertion"></code>
                                            <text>
                                                <reference value="#reaction2" />
                                            </text>
                                            <statusCode code="completed" />
                                            <value nullFlavor="NI" xsi:type="CD" displayName="Hives"></value>
                                        </observation>
                                    </entryRelationship>
                                    <entryRelationship inversionInd="false" typeCode="REFR">
                                        <observation classCode="OBS" moodCode="EVN">
                                            <templateId root="2.16.840.1.113883.10.20.1.39" />
                                            <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="33999-4" displayName="Status"></code>
                                            <statusCode code="completed" />
                                            <value codeSystem="2.16.840.1.113883.6.96" code="active" xsi:type="CE" displayName="active"></value>
                                        </observation>
                                    </entryRelationship>
                                </observation>
                            </entryRelationship>
                        </act>
                    </entry>
                </section>
            </component>
            <component>
                <section>
                    <templateId root="2.16.840.1.113883.10.20.22.2.1.1" />
                    <code codeSystem="2.16.840.1.113883.6.1" code="10160-0" displayName="History of medication use"></code>
                    <title>Medications</title>
                    <text>
                        <table width="100%" border="1">
                            <thead>
                                <tr>
                                    <th>Medication</th>
                                    <th>Dosing Information</th>
                                    <th>Special Instructions</th>
                                    <th>Medication Status</th>
                                </tr>
                            </thead>
                            <tbody>
                                <tr>
                                    <td ID="med1">cephalexin 500 mg capsule</td>
                                    <td ID="sig1">1 capsule 4 times a day</td>
                                    <td ID="patinst1" />
                                    <td ID="medstatus1">Discontinued</td>
                                </tr>
                                <tr>
                                    <td ID="med2">Fluoxetine 40 MG Oral Capsule [Prozac]</td>
                                    <td ID="sig2">1 capsule Daily</td>
                                    <td ID="patinst2" />
                                    <td ID="medstatus2">Active</td>
                                </tr>
                                <tr>
                                    <td ID="med3">cefepime 280 MG/ML Injectable Solution [Maxipime]</td>
                                    <td ID="sig3">1 gram Every 12 hours</td>
                                    <td ID="patinst3" />
                                    <td ID="medstatus3">Active</td>
                                </tr>
                                <tr>
                                    <td ID="med4">levothyroxine 50 mcg tablet</td>
                                    <td ID="sig4">1 tablet Daily</td>
                                    <td ID="patinst4" />
                                    <td ID="medstatus4">Active</td>
                                </tr>
                            </tbody>
                        </table>
                    </text>
                    <entry typeCode="DRIV">
                        <substanceAdministration classCode="SBADM" moodCode="INT">
                            <templateId root="2.16.840.1.113883.10.20.22.4.16" />
                            <id root="ID3sh0-17jcvlr5g" />
                            <text>
                                <reference value="#sig1" />
                            </text>
                            <statusCode code="completed" />
                            <effectiveTime xsi:type="IVL_TS">
                                <low value="20120920" />
                                <high value="20130214133200-0500" />
                            </effectiveTime>
                            <effectiveTime xsi:type="PIVL_TS" operator="A" institutionSpecified="true">
                                <period unit="h" value="6" />
                            </effectiveTime>
                            <routeCode codeSystemName="NCI Thesaurus" codeSystem="2.16.840.1.113883.3.26.1.1" code="C38288" displayName="Oral"></routeCode>
                            <doseQuantity unit="{CAPSULE}" value="1" />
                            <consumable>
                                <manufacturedProduct classCode="MANU">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.23" />
                                    <manufacturedMaterial>
                                        <code codeSystemName="RxNorm" codeSystem="2.16.840.1.113883.6.88" code="309114" displayName="Cephalexin 500 MG Oral Capsule">
                                            <originalText>
                                                <reference value="#med1" />
                                            </originalText>
                                            <translation codeSystemName="fdbMEDID" codeSystem="2.16.840.1.113883.6.567.12.1" code="237854" displayName="Cephalexin 500 MG Oral Capsule"></translation>
                                        </code>
                                        <name>cephalexin 500 mg capsule</name>
                                    </manufacturedMaterial>
                                </manufacturedProduct>
                            </consumable>
                            <entryRelationship inversionInd="true" typeCode="SUBJ">
                                <act classCode="ACT" moodCode="INT">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.20" />
                                    <code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="311401005" displayName="Patient Education"></code>
                                    <text>
                                        <reference value="#patinst1" />
                                    </text>
                                    <statusCode code="completed" />
                                </act>
                            </entryRelationship>
                            <entryRelationship typeCode="REFR">
                                <observation classCode="OBS" moodCode="EVN">
                                    <templateId root="2.16.840.1.113883.10.20.1.47" />
                                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="33999-4" displayName="Status"></code>
                                    <statusCode code="Completed" />
                                    <value codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="73425007" xsi:type="CE" displayName="Inactive"></value>
                                </observation>
                            </entryRelationship>
                        </substanceAdministration>
                    </entry>
                    <entry typeCode="DRIV">
                        <substanceAdministration classCode="SBADM" moodCode="INT">
                            <templateId root="2.16.840.1.113883.10.20.22.4.16" />
                            <id root="ID3sh1-17j65bbp8" />
                            <text>
                                <reference value="#sig2" />
                            </text>
                            <statusCode code="completed" />
                            <effectiveTime xsi:type="IVL_TS">
                                <low value="20111110" />
                                <high nullFlavor="UNK" />
                            </effectiveTime>
                            <effectiveTime xsi:type="PIVL_TS" operator="A" institutionSpecified="true">
                                <period unit="h" value="24" />
                            </effectiveTime>
                            <routeCode codeSystemName="NCI Thesaurus" codeSystem="2.16.840.1.113883.3.26.1.1" code="C38288" displayName="Oral"></routeCode>
                            <doseQuantity unit="{CAPSULE}" value="1" />
                            <consumable>
                                <manufacturedProduct classCode="MANU">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.23" />
                                    <manufacturedMaterial>
                                        <code codeSystemName="RxNorm" codeSystem="2.16.840.1.113883.6.88" code="313989" displayName="Fluoxetine 40 MG Oral Capsule">
                                            <originalText>
                                                <reference value="#med2" />
                                            </originalText>
                                            <translation codeSystemName="RxNorm" codeSystem="2.16.840.1.113883.6.88" code="261287" displayName="Fluoxetine 40 MG Oral Capsule [Prozac]"></translation>
                                            <translation codeSystemName="fdbMEDID" codeSystem="2.16.840.1.113883.6.567.12.1" code="151828" displayName="Fluoxetine 40 MG Oral Capsule"></translation>
                                        </code>
                                        <name>Fluoxetine 40 MG Oral Capsule [Prozac]</name>
                                    </manufacturedMaterial>
                                </manufacturedProduct>
                            </consumable>
                            <entryRelationship inversionInd="true" typeCode="SUBJ">
                                <act classCode="ACT" moodCode="INT">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.20" />
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                    <text>
                        <table width="100%" border="1">
                            <thead>
                                <tr>
                                    <th>Social History Element</th>
                                    <th>Description</th>
                                    <th>Effective Dates</th>
                                </tr>
                            </thead>
                            <tbody>
                                <tr>
                                    <td>Smoking Status</td>
                                    <td>never a smoker</td>
                                    <td />
                                </tr>
                                <tr>
                                    <td>Tobacco use and exposure</td>
                                    <td>never a smoker</td>
                                    <td />
                                </tr>
                            </tbody>
                        </table>
                    </text>
                    <entry typeCode="DRIV">
                        <observation classCode="OBS" moodCode="EVN">
                            <templateId root="2.16.840.1.113883.10.20.22.4.38" />
                            <id root="IDsh-1070279021" />
                            <code nullFlavor="NI" />
                            <statusCode code="completed" />
                            <effectiveTime>
                                <low nullFlavor="NI" />
                                <high nullFlavor="NI" />
                            </effectiveTime>
                            <value xsi:type="ST">never a smoker</value>
                        </observation>
                    </entry>
                    <entry typeCode="DRIV">
                        <observation classCode="OBS" moodCode="EVN">
                            <templateId root="2.16.840.1.113883.10.20.22.4.78" />
                            <id root="IDsh-1070279021" />
                            <code codeSystem="2.16.840.1.113883.5.4" code="ASSERTION" />
                            <statusCode code="completed" />
                            <effectiveTime>
                                <low nullFlavor="NI" />
                                <high nullFlavor="NI" />
                            </effectiveTime>
                            <value codeSystemName="SNOMED" codeSystem="2.16.840.1.113883.6.96" code="266919005" xsi:type="CD" displayName="never a smoker "></value>
                        </observation>
                    </entry>
                </section>
            </component>
            <component>
                <section>
                    <templateId root="2.16.840.1.113883.10.20.22.2.4.1" />
                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="8716-3" displayName="Vital Signs"></code>
                    <title>Vital Signs</title>
                    <text>
                        <table width="100%" border="1">
                            <thead>
                                <tr>
                                    <th align="center">Vital Sign</th>
                                    <th>Results</th>
                                    <th>Date</th>
                                </tr>
                            </thead>
                            <tbody>
                                <tr>
                                    <td>Blood Pressure</td>
                                    <td ID="VS2">120/78 mm[Hg]</td>
                                    <td>02/12/2013</td>
                                </tr>
                                <tr>
                                    <td>Height</td>
                                    <td ID="VS3">162.6 cm</td>
                                    <td>02/12/2013</td>
                                </tr>
                                <tr>
                                    <td>Weight</td>
                                    <td ID="VS4">72.6 kg</td>
                                    <td>02/12/2013</td>
                                </tr>
                                <tr>
                                    <td>BMI</td>
                                    <td ID="VS1">27.5 kg/m2</td>
                                    <td>02/12/2013</td>
                                </tr>
                            </tbody>
                        </table>
                    </text>
                    <entry typeCode="DRIV">
                        <organizer classCode="CLUSTER" moodCode="EVN">
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                            <id root="ID2rpp20-d6ln6po1" />
                            <code codeSystemName="SNOMED" codeSystem="2.16.840.1.113883.6.96" code="46680005" displayName="Vital signs"></code>
                            <statusCode code="completed" />
                            <effectiveTime value="20130212000000-0500" />
                            <component>
                                <observation classCode="OBS" moodCode="EVN">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.27" />
                                    <id root="ID3927t-17j65v3k0mck121" />
                                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="8462-4" displayName="Diastolic blood pressure (mm Hg)"></code>
                                    <text>
                                        <reference value="#VS2" />
                                    </text>
                                    <statusCode code="completed" />
                                    <effectiveTime value="20130212000000-0500" />
                                    <value unit="mm[Hg]" value="78.0" xsi:type="PQ"></value>
                                    <interpretationCode nullFlavor="NI" />
                                </observation>
                            </component>
                            <component>
                                <observation classCode="OBS" moodCode="EVN">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.27" />
                                    <id root="ID3927r-17j65v3k0mck123" />
                                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="39156-5" displayName="Body mass index"></code>
                                    <text>
                                        <reference value="#VS1" />
                                    </text>
                                    <statusCode code="completed" />
                                    <effectiveTime value="20130212000000-0500" />
                                    <value unit="kg/m2" value="27.5" xsi:type="PQ"></value>
                                    <interpretationCode nullFlavor="NI" />
                                </observation>
                            </component>
                            <component>
                                <observation classCode="OBS" moodCode="EVN">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.27" />
                                    <id root="ID3927s-17j65v3k0mck128" />
                                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="8302-2" displayName="Height/Length (cm)"></code>
                                    <text>
                                        <reference value="#VS3" />
                                    </text>
                                    <statusCode code="completed" />
                                    <effectiveTime value="20130212000000-0500" />
                                    <value unit="cm" value="162.6" xsi:type="PQ"></value>
                                    <interpretationCode nullFlavor="NI" />
                                </observation>
                            </component>
                            <component>
                                <observation classCode="OBS" moodCode="EVN">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.27" />
                                    <id root="ID3927t-17j65v3k0mck121" />
                                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="8480-6" displayName="Systolic blood pressure (mm Hg)"></code>
                                    <text>
                                        <reference value="#VS2" />
                                    </text>
                                    <statusCode code="completed" />
                                    <effectiveTime value="20130212000000-0500" />
                                    <value unit="mm[Hg]" value="120.0" xsi:type="PQ"></value>
                                    <interpretationCode nullFlavor="NI" />
                                </observation>
                            </component>
                            <component>
                                <observation classCode="OBS" moodCode="EVN">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.27" />
                                    <id root="ID3927u-17j65v3k0mck173" />
                                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="3141-9" displayName="Weight (kg)"></code>
                                    <text>
                                        <reference value="#VS4" />
                                    </text>
                                    <statusCode code="completed" />
                                    <effectiveTime value="20130212000000-0500" />
                                    <value unit="kg" value="72.6" xsi:type="PQ"></value>
                                    <interpretationCode nullFlavor="NI" />
                                </observation>
                            </component>
                        </organizer>
                    </entry>
                </section>
            </component>
            <component>
                <section>
                    <templateId root="2.16.840.1.113883.10.20.22.2.3.1" />
                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="30954-2" displayName="RESULTS"></code>
                    <title>Results</title>
                    <text>
                        <paragraph styleCode="Bold">Lab Results</paragraph>
                        <table width="100%" border="1">
                            <thead>
                                <tr>
                                    <th>Test</th>
                                    <th>Date</th>
                                    <th>Result</th>
                                    <th>Description</th>
                                </tr>
                            </thead>
                            <tbody>
                                <tr>
                                    <td align="left" ID="lab1">Hemoglobin:MCnc:Pt:Bld:Qn:</td>
                                    <td>Oct 2 2012</td>
                                    <td>12.4 g/dL</td>
                                    <td>
                                        The above 1 analytes were performed by Main Laboratory
                                        1000 Hospital Way, La Jolla, CA 92037
                                    </td>
                                </tr>
                                <tr>
                                    <td align="left" ID="lab2">Platelets:NCnc:Pt:Bld:Qn:Manual count</td>
                                    <td>Oct 2 2012</td>
                                    <td>255 10*3/uL</td>
                                    <td>
                                        The above 1 analytes were performed by Main Laboratory
                                        1000 Hospital Way, La Jolla, CA 92037
                                    </td>
                                </tr>
                                <tr>
                                    <td align="left" ID="lab3">Leukocytes:NCnc:Pt:Bld:Qn:Automated count</td>
                                    <td>Oct 2 2012</td>
                                    <td>19.1 HH 10*3/uL</td>
                                    <td>
                                        The above 1 analytes were performed by Main Laboratory
                                        1000 Hospital Way, La Jolla, CA 92037
                                    </td>
                                </tr>
                            </tbody>
                        </table>
                    </text>
                    <entry typeCode="DRIV">
                        <organizer classCode="BATTERY" moodCode="EVN">
                            <templateId root="2.16.840.1.113883.10.20.22.4.1" />
                            <id extension="4149589" root="2.16.840.1.113883.3.3330.8889429.1433.2" />
                            <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="UNK" displayName="Hemoglobin, Bld"></code>
                            <statusCode code="completed" />
                            <effectiveTime value="20130212031200-0500" />
                            <component>
                                <observation classCode="OBS" moodCode="EVN">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.2" />
                                    <id extension="3443966" root="2.16.840.1.113883.3.3330.8889429.1433.2" />
                                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="718-7" displayName="Hemoglobin:MCnc:Pt:Bld:Qn:"></code>
                                    <text>
                                        <reference value="#lab1" />
                                    </text>
                                    <statusCode code="completed" />
                                    <effectiveTime value="20121002050000-0400" />
                                    <value xsi:type="ST">12.4 g/dL</value>
                                    <interpretationCode codeSystemName="ObservationInterpretation" codeSystem="2.16.840.1.113883.5.83" code="N"></interpretationCode>
                                    <referenceRange>
                                        <observationRange>
                                            <text>12.1-15.9</text>
                                        </observationRange>
                                    </referenceRange>
                                </observation>
                            </component>
                        </organizer>
                    </entry>
                    <entry typeCode="DRIV">
                        <organizer classCode="BATTERY" moodCode="EVN">
                            <templateId root="2.16.840.1.113883.10.20.22.4.1" />
                            <id extension="4149591" root="2.16.840.1.113883.3.3330.8889429.1433.2" />
                            <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="UNK" displayName="Platelet Count,"></code>
                            <statusCode code="completed" />
                            <effectiveTime value="20130212031200-0500" />
                            <component>
                                <observation classCode="OBS" moodCode="EVN">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.2" />
                                    <id extension="3443967" root="2.16.840.1.113883.3.3330.8889429.1433.2" />
                                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="778-1" displayName="Platelets:NCnc:Pt:Bld:Qn:Manual count"></code>
                                    <text>
                                        <reference value="#lab2" />
                                    </text>
                                    <statusCode code="completed" />
                                    <effectiveTime value="20121002050000-0400" />
                                    <value xsi:type="ST">255 10*3/uL</value>
                                    <interpretationCode codeSystemName="ObservationInterpretation" codeSystem="2.16.840.1.113883.5.83" code="N"></interpretationCode>
                                    <referenceRange>
                                        <observationRange>
                                            <text>140-400</text>
                                        </observationRange>
                                    </referenceRange>
                                </observation>
                            </component>
                        </organizer>
                    </entry>
                    <entry typeCode="DRIV">
                        <organizer classCode="BATTERY" moodCode="EVN">
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                            <statusCode code="completed" />
                            <effectiveTime value="20130212031200-0500" />
                            <component>
                                <observation classCode="OBS" moodCode="EVN">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.2" />
                                    <id extension="3443968" root="2.16.840.1.113883.3.3330.8889429.1433.2" />
                                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="6690-2" displayName="Leukocytes:NCnc:Pt:Bld:Qn:Automated count"></code>
                                    <text>
                                        <reference value="#lab3" />
                                    </text>
                                    <statusCode code="completed" />
                                    <effectiveTime value="20121002050000-0400" />
                                    <value xsi:type="ST">19.1 HH 10*3/uL</value>
                                    <interpretationCode codeSystemName="ObservationInterpretation" codeSystem="2.16.840.1.113883.5.83" code="A"></interpretationCode>
                                    <referenceRange>
                                        <observationRange>
                                            <text>4.5-11.0</text>
                                        </observationRange>
                                    </referenceRange>
                                </observation>
                            </component>
                        </organizer>
                    </entry>
                </section>
            </component>
            <component>
                <section>
                    <templateId root="2.16.840.1.113883.3.88.11.83.121" assigningAuthorityName="HITSP/C83" />
                    <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.5" assigningAuthorityName="IHE PCC" />
                    <code codeSystem="2.16.840.1.113883.6.1" code="8648-8" displayName="Hospital Course"></code>
                    <title>Discharge Summary</title>
                    <text>
                        <table width="100%" border="1">
                            <thead>
                                <tr>
                                    <th>Discharge Summary</th>
                                </tr>
                            </thead>
                            <tbody>
                                <tr>
                                    <td>No Discharge Summary Information</td>
                                </tr>
                            </tbody>
                        </table>
                    </text>
                </section>
            </component>
            <component>
                <section>
                    <templateId root="2.16.840.1.113883.10.20.22.2.41" />
                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="8653-8" displayName="Hospital Discharge Instructions"></code>
                    <title>Hospital Discharge Instructions</title>
                    <text>
                        <table width="100%" border="1">
                            <thead>
                                <tr>
                                    <th align="left">Discharge Instructions</th>
                                </tr>
                            </thead>
                            <tbody>
                                <tr>
                                    <td>
                                        <content styleCode="BoldItalics">Summary of Encounter</content>
                                    </td>
                                </tr>
                                <tr>
                                    <td>- You were admitted to OneRecord-OrgB-1433 on 10/2/2012 with a diagnosis of left maxillary sinus mass. You underwent a biopsy of the sinus mass and were treated with IV antibiotics.</td>
                                </tr>
                                <tr>
                                    <td>
                                        <content styleCode="BoldItalics">Follow Up for Encounter</content>
                                    </td>
                                </tr>
                                <tr>
                                    <td>- You tolerated the procedure without complications and your condition improved. You were discharged from OneRecord-OrgB-1433 on 10/5/2012 with instructions to follow up with Dr. Rodriguez.</td>
                                </tr>
                                <tr>
                                    <td>
                                        <content styleCode="BoldItalics">Follow Up for Encounter Continued</content>
                                    </td>
                                </tr>
                                <tr>
                                    <td>- Should you have any questions prior to discharge, please contact a member of your healthcare team. If you have left the hospital and have any questions, please contact your primary care physician.</td>
                                </tr>
                                <tr>
                                    <td>
                                        <content styleCode="BoldItalics">Take all medications as prescribed</content>
                                    </td>
                                </tr>
                                <tr>
                                    <td>
                                        <content styleCode="BoldItalics">Activity</content>
                                    </td>
                                </tr>
                                <tr>
                                    <td>- No heavy lifting, straining, or nose blowing.</td>
                                </tr>
                                <tr>
                                    <td>
                                        <content styleCode="BoldItalics">Call your primary care physician or return to the emergency room</content>
                                    </td>
                                </tr>
                                <tr>
                                    <td>
                                        <content styleCode="BoldItalics">if you experience any of the following symptoms:</content>
                                    </td>
                                </tr>
                                <tr>
                                    <td>- Any other unusal symptoms.</td>
                                </tr>
                                <tr>
                                    <td>- Chest pain.</td>
                                </tr>
                                <tr>
                                    <td>- Dizziness or light-headedness.</td>
                                </tr>
                                <tr>
                                    <td>- High fever.</td>
                                </tr>
                                <tr>
                                    <td>- Intractable nausea or vomiting.</td>
                                </tr>
                                <tr>
                                    <td>- Pain or redness at the site of any previous intravenous catheter.</td>
                                </tr>
                                <tr>
                                    <td>- Shortness of breath.</td>
                                </tr>
                                <tr>
                                    <td>- Uncontrollable bleeding.</td>
                                </tr>
                                <tr>
                                    <td>
                                        <content styleCode="BoldItalics">if you experience any of the following symptoms:</content>
                                    </td>
                                </tr>
                                <tr>
                                    <td>- Any other unusal symptoms.</td>
                                </tr>
                                <tr>
                                    <td>- Chest pain.</td>
                                </tr>
                                <tr>
                                    <td>- Dizziness or light-headedness.</td>
                                </tr>
                                <tr>
                                    <td>- High fever.</td>
                                </tr>
                                <tr>
                                    <td>- Intractable nausea or vomiting.</td>
                                </tr>
                                <tr>
                                    <td>- Pain or redness at the site of any previous intravenous catheter.</td>
                                </tr>
                                <tr>
                                    <td>- Shortness of breath.</td>
                                </tr>
                                <tr>
                                    <td>- Uncontrollable bleeding.</td>
                                </tr>
                                <tr>
                                    <td>
                                        <content styleCode="BoldItalics">Special Instructions:</content>
                                    </td>
                                </tr>
                                <tr>
                                    <td>- Schedule a follow up appointment with your primary care physician in one week.</td>
                                </tr>
                            </tbody>
                        </table>
                    </text>
                </section>
            </component>
            <component>
                <section>
                    <templateId root="2.16.840.1.113883.10.20.22.2.10" />
                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="18776-5" displayName="Treatment plan"></code>
                    <title>Plan of Care</title>
                    <text>
                        <table width="100%" border="1">
                            <thead>
                                <tr>
                                    <th>Diagnosis (Problem)</th>
                                    <th>Goal</th>
                                    <th>Instructions</th>
                                </tr>
                            </thead>
                            <tbody>
                                <tr>
                                    <td />
                                    <td>Weight loss</td>
                                    <td>diet and exercise counseling provided during visit</td>
                                </tr>
                            </tbody>
                        </table>
                    </text>
                </section>
            </component>
            <component>
                <section>
                    <templateId root="2.16.840.1.113883.10.20.22.2.22.1" />
                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="46240-8" displayName="History of encounters"></code>
                    <title>Encounters</title>
                    <text>
                        <table width="100%" border="1">
                            <thead>
                                <tr>
                                    <th>Encounter Diagnosis</th>
                                </tr>
                            </thead>
                            <tbody>
                                <tr>
                                    <td ID="EncounterDiagnosis1">Neoplasm of accessory sinus</td>
                                </tr>
                            </tbody>
                        </table>
                    </text>
                    <entry typeCode="DRIV">
                        <encounter classCode="ENC" moodCode="EVN">
                            <templateId root="2.16.840.1.113883.10.20.22.4.49" />
                            <id nullFlavor="NI" />
                            <code nullFlavor="NI" />
                            <effectiveTime xsi:type="IVL_TS">
                                <low value="20121002000000-0400" />
                                <high value="20121005120000-0400" />
                            </effectiveTime>
                            <entryRelationship inversionInd="false" typeCode="SUBJ">
                                <act classCode="ACT" moodCode="EVN">
                                    <templateId root="2.16.840.1.113883.10.20.22.4.80" />
                                    <id root="f9a73070-7cfd-11e2-84a3-8d1de02a5fbc" />
                                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="29308-4" displayName="ENCOUNTER DIAGNOSIS"></code>
                                    <statusCode code="active" />
                                    <entryRelationship inversionInd="false" typeCode="SUBJ">
                                        <observation classCode="OBS" moodCode="EVN" negationInd="false">
                                            <templateId root="2.16.840.1.113883.10.20.22.4.4" />
                                            <id root="PDT32-16m4qsn40" />
                                            <code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="409586006" displayName="Complaint"></code>
                                            <text>
                                                <reference value="#EncounterDiagnosis1" />
                                            </text>
                                            <statusCode code="completed" />
                                            <value codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="126675008" xsi:type="CD" displayName="Neoplasm of accessory sinus"></value>
                                        </observation>
                                    </entryRelationship>
                                </act>
                            </entryRelationship>
                        </encounter>
                    </entry>
                </section>
            </component>
            <component>
                <section>
                    <templateId root="2.16.840.1.113883.10.20.22.2.14" />
                    <code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="47420-5"></code>
                    <title>Functional Status</title>
                    <text>
                        <table width="100%" border="1">
                            <thead>
                                <tr>
                                    <th>Functional Assessment</th>
                                    <th>Onset Date</th>
                                    <th>Resolution Date</th>
                                    <th>Condition Status</th>
                                </tr>
                            </thead>
                            <tbody>
                                <tr>
                                    <td ID="FunctionalStatus1">Cane</td>
                                    <td>9/20/2012</td>
                                    <td />
                                    <td>Active</td>
                                </tr>
                            </tbody>
                        </table>
                        <table width="100%" border="1">
                            <thead>
                                <tr>
                                    <th>Cognitive Assessment</th>
                                    <th>Onset Date</th>
                                    <th>Resolution Date</th>
                                    <th>Condition Status</th>
                                </tr>
                            </thead>
                            <tbody>
                                <tr>
                                    <td ID="CognativeStatus1">Short term memory deficit</td>
                                    <td>10/5/2012</td>
                                    <td />
                                    <td>Active</td>
                                </tr>
                            </tbody>
                        </table>
                    </text>
                    <entry typeCode="DRIV">
                        <observation classCode="OBS" moodCode="EVN">
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