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" />
<code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="311401005" displayName="Patient Education"></code>
<text>
<reference value="#patinst2" />
</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="55561003" xsi:type="CE" displayName="Active"></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="ID3sko-17jal6t8g" />
<text>
<reference value="#sig3" />
</text>
<statusCode code="completed" />
<effectiveTime xsi:type="IVL_TS">
<low value="20121002" />
<high nullFlavor="UNK" />
</effectiveTime>
<effectiveTime xsi:type="PIVL_TS" operator="A" institutionSpecified="false">
<period unit="h" value="12" />
</effectiveTime>
<doseQuantity unit="gram" 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="309057" displayName="cefepime 280 MG/ML Injectable Solution">
<originalText>
<reference value="#med3" />
</originalText>
<translation codeSystemName="RxNorm" codeSystem="2.16.840.1.113883.6.88" code="213201" displayName="cefepime 280 MG/ML Injectable Solution [Maxipime]"></translation>
<translation codeSystemName="fdbMEDID" codeSystem="2.16.840.1.113883.6.567.12.1" code="165708" displayName="cefepime 280 MG/ML Injectable Solution"></translation>
</code>
<name>cefepime 280 MG/ML Injectable Solution [Maxipime]</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<entryRelationship inversionInd="true" typeCode="SUBJ">
<act classCode="ACT" moodCode="INT">
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<statusCode code="completed" />
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<value unit="mm[Hg]" value="120.0" xsi:type="PQ"></value>
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<statusCode code="completed" />
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<value unit="kg" value="72.6" xsi:type="PQ"></value>
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<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>
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<value xsi:type="ST">12.4 g/dL</value>
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<statusCode code="completed" />
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<value xsi:type="ST">255 10*3/uL</value>
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<referenceRange>
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<reference value="#lab3" />
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<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>
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<text>4.5-11.0</text>
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<section>
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<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>
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<section>
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<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>
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<section>
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<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>
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<title>Encounters</title>
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<table width="100%" border="1">
<thead>
<tr>
<th>Encounter Diagnosis</th>
</tr>
</thead>
<tbody>
<tr>
<td ID="EncounterDiagnosis1">Neoplasm of accessory sinus</td>
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</tbody>
</table>
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<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>
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<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>
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Updated over 1 year ago