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Security-tags-Summary-of-Care-receive-sample1.xml
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<?xml version="1.0" encoding="UTF-8"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!--
Title: Continuity of Care Document (CCD)
$LastChangedDate: 2015-8-11 11:25:09 -0400 (Wed, 11 Aug 2015) $
2015-10 AM and DB: -Altered to be error free (not considering MU rules), general updates per recommendations, and added US Realm Header Template ID.
2014-10 DB: -Created 'master doc'
MANY modifications, additions, and reorganizations were made to accommodate the requirements.
In addition, removed Advance Directives, Family History components, and others as not required by test data.
-Updated to match 170.315_b1_toc_amb_sample1.docx test data.
********************************************************
Disclaimer: This sample file contains representative data elements to represent a Continuity of Care Document (CCD).
The file depicts a fictional character's health data. Any resemblance to a real person is coincidental.
To illustrate as many data elements as possible, the clinical scenario may not be plausible.
The data in this sample file is not intended to represent real patients, people or clinical events.
This sample is designed to be used in conjunction with the C-CDA Clinical Notes Implementation Guide.
********************************************************
-->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 ../../../../../../../../../../Arcadia/schema/CDA.xsd"
xmlns="urn:hl7-org:v3"
xmlns:voc="urn:hl7-org:v3/voc"
xmlns:sdtc="urn:hl7-org:sdtc">
<realmCode code="US"/>
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<!-- US Realm Header ID-->
<templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
<!-- CCD template ID-->
<templateId root="2.16.840.1.113883.10.20.22.1.2" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
<!-- Segmented Document Profile Id for DS4P -->
<templateId root="2.16.840.1.113883.3.3251.1.1" assigningAuthorityName="HL7 Security"/>
<!-- Globally unique identifier for the document -->
<id extension="ds4p_2" root="2.16.840.1.113883.19.5.99999.1"/>
<code code="34133-9" displayName="Summarization of Episode Note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<!-- Title of this document -->
<title>170.315_b1_toc_amb_ccd_r21_sample1 test data</title>
<effectiveTime value="20150622"/>
<!-- Restricted content based on HL7 BasicConfidentialityKind value set for DS4P -->
<confidentialityCode codeSystem="2.16.840.1.113883.5.25" code="R" displayName="Restricted" codeSystemName="Confidentiality"/>
<languageCode code="en-US"/>
<setId extension="sTT988" root="2.16.840.1.113883.19.5.99999.19"/>
<!-- Version of this document -->
<versionNumber value="1"/>
<recordTarget>
<patientRole>
<id extension="444222222" root="2.16.840.1.113883.4.1"/>
<!-- Example Social Security Number using the actual SSN OID. -->
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Dr</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:+1(555)-777-1234" use="MC"/>
<telecom value="tel:+1(555)-723-1544" use="HP"/>
<!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
<patient>
<name use="L">
<given>Alice</given>
<given>Jones</given>
<family>Newman</family>
</name>
<name use="L">
<given qualifier="BR">Alicia</given>
<given>Jones</given>
<family>Newman</family>
</name>
<administrativeGenderCode code="F" displayName="Female" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender"/>
<!-- Date of birth need only be precise to the day -->
<birthTime value="19700501"/>
<maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatusCode"/>
<religiousAffiliationCode code="1013" displayName="Christian (non-Catholic, non-specific)" codeSystem="2.16.840.1.113883.5.1076" codeSystemName="HL7 Religious Affiliation"/>
<!-- CDC Race and Ethnicity code set contains the five minimum race and ethnicity
categories defined by OMB Standards -->
<raceCode code="2106-3" displayName="White" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/>
<!-- The raceCode extension is only used if raceCode is valued -->
<sdtc:raceCode code="2108-9" displayName="White European" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/>
<ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino" codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race & Ethnicity - CDC"/>
<languageCommunication>
<languageCode code="en-US"/>
<modeCode code="ESP" displayName="Expressed spoken"
codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/>
<preferenceInd value="true"/>
</languageCommunication>
</patient>
<providerOrganization>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<name>Neighborhood Physicians Practice</name>
<telecom use="WP" value="tel:+1(555)-555-5000"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<!-- The author represents the person who provides the content in the document -->
<author>
<!-- Mandatory Document Author for DS4P-->
<templateId root="2.16.840.1.113883.3.3251.1.2" assigningAuthorityName="HL7 Security"/>
<time value="20150622"/>
<assignedAuthor>
<!-- Mandatory Document Provenance - assigned author for DS4P -->
<templateId root="2.16.840.1.113883.3.3251.1.3" assigningAuthorityName="HL7 Security"/>
<!-- auhorId -->
<id extension="111111" root="2.16.840.1.113883.4.6"/>
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101"
displayName="Allopathic & Osteopathic Physicians"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<!-- AuthorProviderName -->
<name>
<prefix>Dr.</prefix>
<family>Albert</family>
<given>Davis</given>
</name>
</assignedPerson>
<!-- added representedOrganization for CCD requirements when we do NOT have an assignedPerson -db -->
<!-- Consol Continuity of Care Document (CCD) (V3) SHALL contain at least one [1..*] author,
where its type is Author (CONF:1198-9442) each SHALL contain exactly one [1..1] assignedAuthor,
where (CONF:1198-9443) assignedAuthor SHALL contain exactly one [1..1] assignedPerson and/or exactly one [1..1]
representedOrganization (CONF:1198-8456) -->
<representedOrganization>
<id root="2.16.840.1.113883.19.5"/>
<name>Neighborhood Physicians Practice</name>
</representedOrganization>
</assignedAuthor>
</author>
<!-- The dataEnterer transferred the content created by the author into the document -->
<dataEnterer>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="999999943252"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<given>Tracy</given>
<family>Davis</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<!-- The informant represents any sources of information for document content -->
<informant>
<assignedEntity>
<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<given>Albert</given>
<family>Davis</family>
</name>
</assignedPerson>
</assignedEntity>
</informant>
<informant>
<relatedEntity classCode="PRS">
<!-- classCode PRS represents a person with personal relationship with the patient. -->
<code code="SPS" displayName="SPOUSE" codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<relatedPerson>
<name>
<given>Matthew</given>
<family>Newman</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<!-- The custodian represents the organization charged with maintaining the original source document -->
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<name>Neighborhood Physicians Practice</name>
<telecom value="tel:+1(555)-555-1002" use="WP"/>
<addr use="WP">
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<!-- The informationRecipient represents the intended recipient of the document -->
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<prefix>Dr</prefix>
<given>Albert</given>
<family>Davis</family>
</name>
</informationRecipient>
<receivedOrganization>
<name>Neighborhood Physicians Practice</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<!-- The legalAuthenticator represents the individual who is responsible for the document -->
<legalAuthenticator>
<time value="20150622"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="999999999" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<prefix>Dr</prefix>
<given>Albert</given>
<family>Davis</family>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<!-- The authenticator represents the individual attesting to the accuracy of information in the document-->
<authenticator>
<time value="20150622"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="999999999" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<prefix>Dr</prefix>
<given>Albert</given>
<family>Davis</family>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<!-- The participant represents supporting entities -->
<participant typeCode="IND">
<!-- patient's grandfather -->
<associatedEntity classCode="PRS">
<code code="GPARNT" displayName="grandparent" codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Dr</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:+1(555)-723-1544" use="HP"/>
<associatedPerson>
<name>
<prefix>Mr</prefix>
<given>Rick</given>
<family>Holler</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<!-- Note: Entities playing multiple roles are recorded in multiple participants -->
<participant typeCode="IND">
<!-- patient's spouse -->
<associatedEntity classCode="PRS">
<code code="SPS" displayName="SPOUSE" codeSystem="2.16.840.1.113883.1.11.19563"
codeSystemName="Personal Relationship Role Type Value Set"/>
<addr use="HP">
<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
<streetAddressLine>1357 Amber Dr</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
</addr>
<telecom value="tel:+1(555)-723-1544" use="HP"/>
<associatedPerson>
<name>
<prefix>Mr</prefix>
<given>Matthew</given>
<family>Newman</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<documentationOf>
<serviceEvent classCode="PCPR">
<code code="386661006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"
displayName="Fever"/>
<!-- The effectiveTime reflects the provision of care summarized in the document.
In this scenario, the provision of care summarized is the lifetime for the patient -->
<effectiveTime>
<low value="201506221000-0500"/>
<!-- The low value represents when the summarized provision of care began.
In this scenario, the patient's date of birth -->
<high value="201506221030-0500"/>
<!-- The high value represents when the summarized provision of care being ended.
In this scenario, when chart summary was created -->
</effectiveTime>
<!-- since there are two Care Team members we need two performer elements. -db -->
<!-- Note: example of Care Team here:
https://github.com/gecole/HL7-Task-Force-Examples/blob/master/CareTeamToC170.314b2Ambulatory.xml
db -->
<performer typeCode="PRF">
<functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88" codeSystemName="ParticipationFunction" displayName="Primary Care Provider">
<originalText>Primary Care Provider</originalText>
</functionCode>
<assignedEntity>
<id extension="5555555555" root="2.16.840.1.113883.4.6"/>
<code code="207QA0505X" displayName="Adult Medicine" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<prefix qualifier="TITLE">Dr</prefix>
<given>Albert</given>
<family>Davis</family>
</name>
</assignedPerson>
<representedOrganization>
<id extension="99999999" root="2.16.840.1.113883.4.6"/>
<name>Neighborhood Physicians Practice</name>
<telecom value="tel:+1(555)-555-5000" use="WP"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
<performer typeCode="PRF">
<!-- we do not have a function code for this person since recording as RN for now -->
<time>
<low nullFlavor="UNK"/>
</time>
<assignedEntity>
<!-- this provider has an id, but it is not an NPI -->
<id extension="91138" root="1.3.6.1.4.1.22812.4.99930.4"/>
<!-- the provider is a Registered Nurse - may not be so -->
<!-- note: we don't know what Tracy is from the test data
but since not specified, RN should not be an issue -db -->
<code codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC Health Care Provider Taxonomy" code="163W00000X" displayName="Registered Nurse"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<name>
<given>Tracy</given>
<family>Davis</family>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<!-- added componentOf to represent encounter and to represent length of stay better as per SME suggestion -db -->
<componentOf>
<encompassingEncounter>
<id extension="9937012" root="2.16.840.1.113883.19"/>
<effectiveTime>
<!-- represents length of time spent in hospital -db -->
<low value="201506221000-0500"/>
<high value="201506221030-0500"/>
</effectiveTime>
</encompassingEncounter>
</componentOf>
<!-- ******************************************************** CDA Body ******************************************************** -->
<component>
<structuredBody>
<component>
<!--
********************************************************
Privacy and Security Markings Section
********************************************************
-->
<section>
<!-- Privacy Markings section template -->
<templateId root="2.16.840.1.113883.3.3251.1.5"
assigningAuthorityName="HL7 Security"/>
<code code="57017-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Privacy policy Organization"/>
<title>Security and Privacy Prohibitions</title>
<text>
Section Author: Dr. Davis Albert, Neighborhood Physicians Practice <br/>
PROHIBITION ON REDISCLOSURE OF CONFIDENTIAL INFORMATION: <br/> This notice
accompanies a disclosure of information concerning a client in alcohol/drug
treatment, made to you with the consent of such client. This information has
been disclosed to you from records protected by federal confidentiality
rules (42 C.F.R. Part 2). The federal rules prohibit you from making any
further disclosure of this information unless further disclosure is
expressly permitted by the written consent of the person to whom it pertains
or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for
the release of medical or other information is NOT sufficient for this
purpose. The federal rules restrict any use of the information to criminally
investigate or prosecute any alcohol or drug abuse patient. </text>
<confidentialityCode code="R" codeSystem="2.16.840.1.113883.5.25"
codeSystemName="HL7 Confidentiality"/>
<author>
<!-- Mandatory Document Author for DS4P-->
<templateId root="2.16.840.1.113883.3.3251.1.2" assigningAuthorityName="HL7 Security"/>
<time value="20150622"/>
<assignedAuthor>
<!-- Mandatory Document Provenance - assigned author for DS4P -->
<templateId root="2.16.840.1.113883.3.3251.1.3" assigningAuthorityName="HL7 Security"/>
<!-- auhorId -->
<id extension="111111" root="2.16.840.1.113883.4.6"/>
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101"
displayName="Allopathic & Osteopathic Physicians"/>
<addr>
<streetAddressLine>2472 Rocky place</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97006</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)-555-1002"/>
<assignedPerson>
<!-- AuthorProviderName -->
<name>
<prefix>Dr.</prefix>
<family>Albert</family>
<given>Davis</given>
</name>
</assignedPerson>
<!-- added representedOrganization for CCD requirements when we do NOT have an assignedPerson -db -->
<!-- Consol Continuity of Care Document (CCD) (V3) SHALL contain at least one [1..*] author,
where its type is Author (CONF:1198-9442) each SHALL contain exactly one [1..1] assignedAuthor,
where (CONF:1198-9443) assignedAuthor SHALL contain exactly one [1..1] assignedPerson and/or exactly one [1..1]
representedOrganization (CONF:1198-8456) -->
<representedOrganization>
<id root="2.16.840.1.113883.19.5"/>
<name>Neighborhood Physicians Practice</name>
</representedOrganization>
</assignedAuthor>
</author>
<entry typeCode="COMP">
<!-- Privacy Marking Entry to indicate the precise/computable security obligations and refrains -->
<templateId root="2.16.840.1.113883.3.3251.1.9"
assigningAuthorityName="HL7 Security"/>
<organizer classCode="CLUSTER" moodCode="EVN">
<!-- Privacy Annotations are organized using template "2.16.840.1.113883.3.3251.1.4" -->
<templateId root="2.16.840.1.113883.3.3251.1.4"
assigningAuthorityName="HL7 Security"/>
<statusCode code="active"/>
<component typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<!-- Security Observation -->
<templateId root="2.16.840.1.113883.3.445.21"
assigningAuthorityName="HL7 CBCC"/>
<!-- Confidentiality Code template -->
<templateId root="2.16.840.1.113883.3.445.12"
assigningAuthorityName="HL7 CBCC"/>
<!-- Confidentiality Security Observation - the only mandatory element of a Privacy Annotation -->
<code code="SECCLASSOBS"
codeSystem="2.16.840.1.113883.1.11.20457"
displayName="Security Classification"
codeSystemName="HL7 SecurityObservationTypeCodeSystem"/>
<!-- value set constrained to "2.16.840.1.113883.1.11.16926" -->
<value xsi:type="CE" code="R"
codeSystem="2.16.840.1.113883.5.1063"
codeSystemName="SecurityObservationValueCodeSystem"
displayName="Restricted">
<originalText>Restricted Confidentiality</originalText>
</value>
</observation>
</component>
<component typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<!-- Security Observation -->
<templateId root="2.16.840.1.113883.3.445.21"
assigningAuthorityName="HL7 CBCC"/>
<!-- Refrain Policy Code template -->
<templateId root="2.16.840.1.113883.3.445.23"
assigningAuthorityName="HL7 CBCC"/>
<code code="SECCONOBS" codeSystem="2.16.840.1.113883.1.11.20457"
displayName="Security Classification"
codeSystemName="HL7 SecurityObservationTypeCodeSystem"/>
<!-- Value set constraint "2.16.840.1.113883.1.11.20446" -->
<value xsi:type="CE" code="NORDSLCD"
codeSystem="2.16.840.1.113883.5.1063"
codeSystemName="SecurityObservationValueCodeSystem"
displayName="Prohibition on redisclosure without patient consent directive">
<originalText>Prohibition on redisclosure without patient
consent directive</originalText>
</value>
</observation>
</component>
<component typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<!-- Security Observation -->
<templateId root="2.16.840.1.113883.3.445.21"
assigningAuthorityName="HL7 CBCC"/>
<!-- Purpose Of Use Code template -->
<templateId root="2.16.840.1.113883.3.445.22"
assigningAuthorityName="HL7 CBCC"/>
<code code="SECCONOBS" codeSystem="2.16.840.1.113883.1.11.20457"
displayName="Security Classification"
codeSystemName="HL7 SecurityObservationTypeCodeSystem"/>
<!-- Value set constraint "2.16.840.1.113883.1.11.20448" -->
<value xsi:type="CE" code="TREAT"
codeSystem="2.16.840.1.113883.5.1063"
codeSystemName="SecurityObservationValueCodeSystem"
displayName="Treatment">
<originalText>Information intended for
treatment</originalText>
</value>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
<!-- ***************** ALLERGIES *************** -->
<!-- edited as per test doc - all data relevant -db -->
<component>
<section>
<!-- *** Allergies and Intolerances Section (entries required) (V3) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.6.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
<!-- Alerts section template -->
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>ALLERGIES AND ADVERSE REACTIONS</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Substance</th>
<th>Reaction</th>
<th>Severity</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<content ID="product1">Penicillin G benzathine</content>
</td>
<td>
<content ID="reaction1">Hives</content>
</td>
<td>
<content ID="severity1">Moderate</content>
</td>
<td>Active</td>
</tr>
<tr>
<td>
<content ID="product2">Ampicillin Sodium</content>
</td>
<td>
<content ID="reaction2">Hives</content>
</td>
<td>
<content ID="severity2">Moderate</content>
</td>
<td>Active</td>
</tr>
</tbody>
</table>
</text>
<!-- replaced Allergy Problem Act (R1.1) with
Allergy Concern Act (V3) to meet R2.1 validation requirements -DB-->
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<!-- ** Allergy Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.30" extension="2015-08-01"/>
<!--Critical Change-->
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
<!-- The statusCode represents the need to continue tracking the allergy -->
<!-- This is of ongoing concern to the provider -->
<statusCode code="active"/>
<effectiveTime>
<!-- The low value represents when the allergy was first recorded in the patient's chart -->
<low value="19800501"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Allergy observation (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.7" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<!-- Observation statusCode represents the status of the act of observing -->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value reflects the date of onset of the allergy -->
<low value="19800501"/>
<!-- The high value reflects when the allergy was known to be resolved (and will generally be absent) -->
</effectiveTime>
<value xsi:type="CD" code="419511003"
displayName="Propensity to adverse reaction to drug"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT">
</value>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code code="7980"
displayName="Penicillin G benzathine"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm">
<originalText>
<reference value="#product1"/>
</originalText>
</code>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Severity Observation (V2)** -->
<!-- When the Severity Observation is associated directly with an allergy it characterizes the allergy.
When the Severity Observation is associated with a Reaction Observation it characterizes a Reaction. -->
<templateId root="2.16.840.1.113883.10.20.22.4.8" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<code code="SEV" displayName="Severity Observation" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
<text>
<reference value="#severity1"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="6736007"
displayName="Moderate"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="MFST" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Reaction Observation (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.9" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.9"/>
<id root="4adc1020-7b14-11db-9fe1-0800200c9a67"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<text>
<reference value="#reaction1"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="247472004"
codeSystem="2.16.840.1.113883.6.96"
displayName="Hives"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<!-- ** Allergy Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.30" extension="2015-08-01"/>
<!--Critical Change-->
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id root="b03805bd-2eb6-4ab8-a9ff-473c6653971a"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
<!-- The statusCode represents the need to continue tracking the allergy -->
<!-- This is of ongoing concern to the provider -->
<statusCode code="active"/>
<effectiveTime>
<!-- The low value represents when the allergy was first recorded in the patient's chart -->
<low value="19800501"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Allergy observation (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.7" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id root="4adc1020-7b14-11db-9fe1-0800200c9a68"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<!-- Observation statusCode represents the status of the act of observing -->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value reflects the date of onset of the allergy -->
<low value="19800501"/>
<!-- The high value reflects when the allergy was known to be resolved (and will generally be absent) -->
</effectiveTime>
<value xsi:type="CD" code="419511003"
displayName="Propensity to adverse reaction to drug"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT">
</value>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code code="733"
displayName="Ampicillin"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm">
<originalText>
<reference value="#product2"/>
</originalText>
</code>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Severity Observation (V2)** -->
<!-- When the Severity Observation is associated directly with an allergy it characterizes the allergy.
When the Severity Observation is associated with a Reaction Observation it characterizes a Reaction. -->
<templateId root="2.16.840.1.113883.10.20.22.4.8" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<code code="SEV" displayName="Severity Observation" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
<text>
<reference value="#severity2"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="6736007"
displayName="Moderate"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="MFST" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Reaction Observation (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.9" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.9"/>
<id root="4adc1020-7b14-11db-9fe1-0800200c9a69"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<text>
<reference value="#reaction2"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="247472004"
codeSystem="2.16.840.1.113883.6.96"
displayName="Hives"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!-- ******************************* MEDICATIONS ***************************** -->
<!-- edited as per test doc - all data relevant -db -->
<component>
<section>
<!-- *** Medications Section (entries required) (V2) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF MEDICATION USE"/>
<title>MEDICATIONS</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Medication</th>
<th>Directions</th>
<th>Start Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>Ceftriaxone 100MG/ML</td>
<td>BID</td>
<td>June 22, 2015</td>
</tr>
<tr>
<td>Tylenol 500mg</td>
<td>For 10 days As needed</td>
<td>June 22, 2015</td>
</tr>
<tr>
<td>Darbepoetin Alfa 0.5 MG/ML</td>
<td>Once a week</td>
<td>June 22, 2015</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<!-- ** Medication Activity (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20150622"/>
<high value="20150630"/>
</effectiveTime>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
<period value="12" unit="h"/>
</effectiveTime>
<routeCode code="C38276" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="INTRAVENOUS"/>
<doseQuantity value="1"/>
<!-- we don't need an administrationUnitCode element since we have an exact amount specified for injection
nor would any code match if we did:
reference: https://art-decor.org/art-decor/decor-valuesets search AdministrableDrugForm -db -->
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Medication information ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<id root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<code code="309090" codeSystem="2.16.840.1.113883.6.88" displayName="Ceftriaxone 100MG/ML"/>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<!-- removed participant, performer, and, removed entryRelationships Indication (V2), Medication supply order (V2), and Medication dispense (v2) as not required -db -->
<!-- removed precondition as not required -db -->
</substanceAdministration>
</entry>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<!-- ** Medication activity (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="6c844c75-aa34-411c-b7bd-5e4a9f206e29"/>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20150622"/>
<high value="20150701"/>
</effectiveTime>
<!-- InstituionSpecified = "true" means that interval of time for taking need not be exact
In this case it alters every 24 hours to mean PRN / take 'as needed' -db -->
<!-- Operator "A" means that this timing information is in addition to previous effectiveTime information provided-->
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
<period value="24" unit="h"/>
</effectiveTime>
<routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="ORAL"/>
<doseQuantity value="1"/>
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Medication information ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<id root="2a620155-9d11-439e-92b3-5d9816ff4ee8"/>
<manufacturedMaterial>
<code code="209459" displayName="Tylenol 500mg" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"/>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<!-- removed Indication (V2) entryRelatioship as not required.
if included would probably be fever -db -->
</substanceAdministration>
</entry>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<!-- ** Medication Activity (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="cdbd33f0-6cde-11db-9fe1-0800200c9a67"/>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20150622"/>
<high nullFlavor="UNK"/>
</effectiveTime>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
<period value="7" unit="d"/>
</effectiveTime>
<routeCode code="C38276" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="INTRAVENOUS"/>
<doseQuantity value="1"/>
<!-- we don't need an administrationUnitCode element since we have an exact amount specified for injection
nor would any code match if we did:
reference: https://art-decor.org/art-decor/decor-valuesets search AdministrableDrugForm -db -->
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Medication information ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<id root="2a620155-9d11-439e-92b3-5d9817ff4ee8"/>
<manufacturedMaterial>
<code code="731184" codeSystem="2.16.840.1.113883.6.88" displayName="Darbepoetin Alfa 0.5 MG/ML"/>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<!-- removed participant, performer, and, removed entryRelationships Indication (V2), Medication supply order (V2), and Medication dispense (v2) as not required -db -->
<!-- removed precondition as not required -db -->
</substanceAdministration>
</entry>
</section>
</component>
<!-- ***************** PROBLEM LIST *********************** -->
<!-- edited as per test doc - all data relevant -db -->
<component>
<section>
<!-- *** Problem Section (entries required) (V3) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROBLEM LIST"/>
<title>PROBLEMS</title>
<text>
<paragraph>Active Concerns</paragraph>
<list>
<item>Problem #1
<list>
<item>Essential hypertension (Disorder)</item>
</list>
</item>
<item>Problem #2
<list>
<item>Severe Hypothyroidism (Disorder)</item>
</list>
</item>
<item>Problem #3
<list>
<item>Chronic rejection of renal transplant (disorder)</item>
</list>
</item>
<item>Problem #4
<list>
<item>Fever (finding)</item>
</list>
</item>
</list>
<paragraph>Resolved Concerns</paragraph>
<list>
<item>Problem #5
<list>
<item>Overweight (finding)</item>
</list>
</item>
</list>
<list>
<item>Problem #6
<list>
<item>Emancipation (Disorder)</item>
</list>
</item>
</list>
</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">