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note_in_procedure_act.xml
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note_in_procedure_act.xml
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<?xml version="1.0" encoding="UTF-8"?>
<component>
<section>
<!-- Procedures Section (entries required) (V2) -->
<templateId root="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PROCEDURES"/>
<title>PROCEDURES</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Procedure</th>
<th>Date</th>
<th>Physician</th>
<th>Location</th>
</tr>
</thead>
<tbody>
<tr>
<td ID="Proc1">Appendectomy</td>
<td>January 25, 2018</td>
<td>Dr. Surgeon</td>
<td>Good Health Hospitals</td>
</tr>
<tr>
<td /> <!-- empty cell to indent note contents underneath previous row -->
<td ID="Proc1Note" colspan="3">
<paragraph>Operative Note - Dr. Surgeon - 01/25/2018</paragraph>
<paragraph>Anesthesia Evaluation: Patient repositioned with arms extended on arm boards,
arm straps applied; anesthetic effect assessed by anesthesiologist; electro-surgical pad
placed under buttocks</paragraph>
<paragraph>Operation started: Patient’s appendix was removed</paragraph>
<paragraph>End of Operation: Skin closure completed, antiseptic solution and top dressing applied and secured</paragraph>
<paragraph>Unit Transfer: immediate post-op care done, arm straps and electrosurgical
pad removed, kept warm with blankets, transferred to RR bed, ensured safety,
brought to recovery room per RR bed</paragraph>
</td>
</tr>
</tbody>
</table>
</text>
<!-- Examples of the same procedure are shown in different procedure entries -->
<entry typeCode="DRIV">
<procedure classCode="PROC" moodCode="EVN">
<!-- ******************** Procedure activity procedure ******************** -->
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<id root="d68b7e32-7810-4f5b-9cc2-acd54b0fd85d"/>
<code code="80146002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Appendectomy" />
<!-- Start of Note Activity as related to an existing procedure
by means of an entryRelationship -->
<entryRelationship typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.202" extension="2016-11-01"/>
<code code="34109-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Note">
<translation code="28570-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure note" />
</code>
<text>
<reference value="#Proc1Note" />
</text>
<statusCode code="completed"/>
<!-- Clinically-relevant time of the note -->
<effectiveTime value="20180125" />
<!-- Author Participation -->
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119" />
<!-- Time note was actually written -->
<time value="20180127083215-0500" />
<assignedAuthor>
<templateId root="2.16.840.1.113883.3.3251.1.3"/>
<id extension="1166245592" root="2.16.840.1.113883.4.6"/>
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101"/>
<addr use="WP">
<streetAddressLine>132 Main Street</streetAddressLine>
<city>Philadelphia</city>
<state>PA</state>
<postalCode>12345</postalCode>
</addr>
<telecom value="mailto:surgeon@gmail.com"/>
<assignedPerson>
<name>
<prefix>Dr</prefix>
<family>Surgeon</family>
<given>George</given>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<!-- Reference to encounter -->
<entryRelationship typeCode="COMP" inversionInd="true">
<encounter classCode="ENC" moodCode="EVN">
<!-- Encounter ID matches an encounter in the Encounters Section -->
<id root="1.2.3.4" extension="abc" />
</encounter>
</entryRelationship>
</act>
</entryRelationship>
</procedure>
</entry>
</section>
</component>
<!-- Encounters section (demonstrating link to encounter) -->
<component>
<section>
<!-- *** Encounters section (entries required) (V3) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.22.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.22.1"/>
<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
<title>Encounters</title>
<text>Surgery Encounter on January 25, 2018</text>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<!-- ** Encounter Activity (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<id root="1.2.3.4" extension="abc" />
<!-- Remaining encounter entry describing clinical encounter... -->
</encounter>
</entry>
</section>
</component>