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RESULT_Examples_in_empty_CCD.xml
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RESULT_Examples_in_empty_CCD.xml
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<?xml version="1.0"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!-- This is an empty C-CDA skeleton which will be used by HL7 CDA Example Task Force -->
<!-- This document was based on prior work by Lisa Nelson and Brian Weiss. contact John D'Amore with questions -->
<!-- See http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force -->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 ../90%20HL7/00%20Standard%20-%20C-CDA/20130409%20C-CDA%20R1dot1_2012JUL/Updated_CDA_Schema_Files_Extension_Support/CDA_Schema_Files/infrastructure/cda/CDA_SDTC.xsd"
xmlns="urn:hl7-org:v3"
xmlns:cda="urn:hl7-org:v3"
xmlns:sdtc="urn:hl7-org:sdtc">
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
<!-- C-CDA -->
<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
<!-- CCD -->
<id root="2.16.840.1.113883.3.3208.101.1" extension="20130607100315-CCDA-CCD"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34133-9" displayName="Summarization of Episode Note"/>
<title>Empty CCD Skeleton That Validates on TTT. Note this was based on work by Lisa Nelson and Brian Weiss</title>
<effectiveTime value="20130607000000-0000"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<recordTarget>
<patientRole>
<id root="2.16.840.1.113883.3.3208.101.2" extension="20130607100800-Patient1"/>
<addr use="HP">
<streetAddressLine>1111 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)111-1111" use="HP"/>
<patient>
<name use="L">
<given>Patient</given>
<family>One</family>
</name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male" codeSystemName="AdministrativeGender"/>
<birthTime value="19300911"/>
<maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatus"/>
<raceCode code="2106-3" displayName="White"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="OMB Standards for Race and Ethnicity"/>
<ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="OMB Standards for Race and Ethnicity"/>
<languageCommunication>
<languageCode code="eng"/>
<modeCode code="ESP" displayName="Expressed spoken" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/>
<proficiencyLevelCode code="E" displayName="Excellent" codeSystem="2.16.840.1.113883.5.61" codeSystemName="LanguageAbilityProficiency"/>
</languageCommunication>
</patient>
</patientRole>
</recordTarget>
<author>
<time value="20130607000000"/>
<assignedAuthor>
<id extension="22222" root="2.16.840.1.113883.4.6"/>
<code code="207QA0505X" codeSystem="2.16.840.1.113883.6.101"
displayName="Adult Medicine" codeSystemName="NUCC"/>
<addr use="HP">
<streetAddressLine>2222 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)222-2222" use="WP"/>
<assignedPerson>
<name>
<given>Doctor</given>
<family>Second</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id extension="33333" root="2.16.840.1.113883.4.6"/>
<code code="364SA2200X" displayName="Adult Health" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"/>
<addr use="WP">
<streetAddressLine>3333 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)333-3333" use="WP"/>
<assignedPerson>
<name>
<given>Nurse</given>
<family>Tertiary</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="44444" root="2.16.840.1.113883.4.6"/>
<name>CDA PRO Fictional Hospital</name>
<telecom value="tel:+1(301)444-4444" use="WP"/>
<addr use="WP">
<streetAddressLine>4444 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<legalAuthenticator>
<time value="20130607000000"/>
<signatureCode code="S"/>
<assignedEntity>
<id root="2.16.840.1.113883.3.3208.101.3" extension="20130607102400-Authenticator1"/>
<addr use="WP">
<streetAddressLine>5555 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)555-5555" use="WP"/>
<assignedPerson>
<name>
<given>Physician</given>
<family>Fifthly</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="19330316"/>
<high value="20130607"/>
</effectiveTime>
<performer typeCode="PRF">
<assignedEntity>
<id extension="66666" root="2.16.840.1.113883.4.6"/>
<code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"
displayName="Cardiovascular Disease"/>
<addr>
<streetAddressLine>6666 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)666-6666" use="WP"/>
<assignedPerson>
<name>
<given>Heartly</given>
<family>Sixer</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<!-- CDA Body -->
<component>
<structuredBody>
<!-- Allergies Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
<!-- Allergies (entries required) section -->
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" displayName="Allergies, adverse reactions, alerts" codeSystemName="LOINC"/>
<title>ALLERGIES</title>
<text>No Information</text>
</section>
</component>
<!-- Medication Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
<!-- Medication Section (entries required) -->
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Medication Use"/>
<title>MEDICATIONS</title>
<text>No Information</text>
</section>
</component>
<!-- Problem Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<!-- conforms to Problems section with entries required -->
<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>No Information</text>
</section>
</component>
<!-- Procedures Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
<!-- Procedures Section with Coded Entries Required-->
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Procedures"/>
<title>PROCEDURES</title>
<text>No Information</text>
</section>
</component>
<!-- Results Section -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
<!-- Results Section with Coded Entries Required-->
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Relevant diagnostic tests and/or laboratory data"/>
<title>Results</title>
<text>
<table border="1">
<thead>
<tr>
<th>Description</th>
<th>Value / Unit</th>
<th>Interpretation</th>
<th>Reference Range</th>
</tr>
</thead>
<tbody>
<tr>
<th colspan="4">Lab Results For HL7 Example Task Force</th>
</tr>
<tr>
<th colspan="4">Urine Color at 10-23-2013 9:10a</th>
</tr>
<tr>
<td ID="SomeReferenceGoesHere1">Urine Color</td>
<td >Yellow</td>
<td>Normal</td>
<td></td>
</tr>
<tr>
<th colspan="4">Natriuretic Peptide B [Mass/Volume] In Blood at 10-20-2013 9:08a </th>
</tr>
<tr>
<td ID="SomeReferenceGoesHere2">Natriuretic Peptide B [Mass/Volume] In Blood</td>
<td ><= 5pg/dL</td>
<td>Normal</td>
<td>0-100 pg/dL</td>
</tr>
<tr>
<th colspan="4">Chlamydia trachomatis/Neisseria gonorrhoeae rRNA panel at 10-22-2013 2:26p</th>
</tr>
<tr>
<td ID="SomeReferenceGoesHere3">Chlamydia trachomatis rRNA</td>
<td >Negative</td>
<td>Normal</td>
<td>Negative</td>
</tr>
<tr>
<td ID="SomeReferenceGoesHere4">Neisseria gonorrhoeae rRNA</td>
<td >Positive</td>
<td>Abnormal</td>
<td>Negative</td>
</tr>
<tr>
<th colspan="4">Platelets [#/volume] in Blood at 10-20-2013 9:08a </th>
</tr>
<tr>
<td ID="SomeReferenceGoesHere5">Platelets [#/volume] in Blood</td>
<td >152 10*3/uL</td>
<td>Normal</td>
<td>150-400 10*3/uL</td>
</tr>
</tbody>
</table>
</text>
<entry>
<organizer classCode="BATTERY" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.1"/>
<id root="f1aa44dd-6f39-4f5c-b267-897c3824b563"/>
<code code="5778-6" displayName="Color of Urine" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<statusCode code="completed"/>
<effectiveTime value="201310230910+0500"/>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.2"/>
<id root="f1aa44dd-6f39-4f5c-b267-897c3824b563"/>
<code code="5778-6" displayName="Color of Urine" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SomeReferenceGoesHere1"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20131023090823+0500"/>
<!-- Representing a result returned as unstructured string-->
<value xsi:type="ST">Yellow</value>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
</observation>
</component>
</organizer>
</entry>
<entry>
<organizer classCode="BATTERY" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.1"/>
<id root="df0f809e-f0a9-4a30-aad0-92b5cc868b67"/>
<code code="42637-9" displayName="Natriuretic Peptide B [Mass/Volume] In Blood" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<statusCode code="completed"/>
<effectiveTime value="201310200908+0500"/>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.2"/>
<id root="df0f809e-f0a9-4a30-aad0-92b5cc868b67"/>
<code code="42637-9" displayName="Natriuretic Peptide B [Mass/Volume] In Blood" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SomeReferenceGoesHere2"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="201310200908+0500"/>
<!-- Representing a result of less than with type of interval -->
<value xsi:type="IVL_PQ">
<!-- The lower bound for most physical measures of less than will be zero-->
<!-- Note that if the inclusive attribute is not specified, then it defaults to true -->
<low value="0" unit="pg/mL" inclusive="true"/>
<!-- The upper bound is based upon information returned in lab result, such as less than or equal to 5pg/mL (Note this is different than less than)-->
<!-- Note that if the inclusive attribute is not specified, then it defaults to true -->
<high value="5" unit="pg/mL" inclusive="true"/>
</value>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
<referenceRange>
<observationRange>
<!-- Reference ranges can be expressed as structured physical quantity interval-->
<value xsi:type="IVL_PQ">
<low value="0" unit="pg/mL"/>
<high value="100" unit="pg/mL"/>
</value>
<!-- This interpretation code denotes that this reference range is for normal results. This is not the interpretation a specific patient value-->
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
</observationRange>
</referenceRange>
</observation>
</component>
</organizer>
</entry>
<entry>
<organizer classCode="BATTERY" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.1"/>
<id root="b5684bf0-eb6f-46dd-9f2e-b6cbcc4196fd"/>
<code code="70163-1" displayName="Chlamydia trachomatis/Neisseria gonorrhoeae rRNA panel" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<statusCode code="completed"/>
<effectiveTime value="201310221426+0500"/>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.2"/>
<id root="5a6be91a-32d5-4d24-a8bd-07d10a3ef14d"/>
<code code="50387-0" displayName="Chlamydia trachomatis rRNA" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SomeReferenceGoesHere3"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="201310221426+0500"/>
<!-- Representing a result of an ordinal test (See LOINC axes) as negative in SNOMED-->
<value xsi:type="CO" code="260385009" codeSystemName="SNOMED-CT" displayName ="Negative" codeSystem ="2.16.840.1.113883.6.96" />
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
<referenceRange>
<observationRange>
<value xsi:type="CO" code="260385009" codeSystemName="SNOMED-CT" displayName ="Negative" codeSystem ="2.16.840.1.113883.6.96" />
<!-- This interpretation code denotes that this reference range is for normal results. This is not the interpretation a specific patient value-->
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
</observationRange>
</referenceRange>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.2"/>
<id root="404bba0e-1c76-4265-afb5-1a57b55e128b"/>
<code code="50388-8" displayName="Neisseria gonorrhoeae rRNA" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SomeReferenceGoesHere4"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="201310221426+0500"/>
<!-- Representing a result of an ordinal test (See LOINC axes) as positive in SNOMED-->
<value xsi:type="CO" code="10828004" codeSystemName="SNOMED-CT" displayName ="Positive" codeSystem ="2.16.840.1.113883.6.96" />
<interpretationCode code="A" codeSystem="2.16.840.1.113883.5.83"/>
<referenceRange>
<observationRange>
<value xsi:type="CO" code="260385009" codeSystemName="SNOMED-CT" displayName ="Negative" codeSystem ="2.16.840.1.113883.6.96" />
<!-- This interpretation code denotes that this reference range is for normal results. This is not the interpretation a specific patient value-->
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
</observationRange>
</referenceRange>
</observation>
</component>
</organizer>
</entry>
<entry>
<organizer classCode="BATTERY" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.1"/>
<id root="f16043d8-8d93-41a1-9682-a6cc7215572c"/>
<code code="26515-7" displayName="Platelets [#/volume] in Blood" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<statusCode code="completed"/>
<effectiveTime value="201310200908+0500"/>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.2"/>
<id root="f16043d8-8d93-41a1-9682-a6cc7215572c"/>
<code code="26515-7" displayName="Platelets [#/volume] in Blood" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SomeReferenceGoesHere5"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="201310200908+0500"/>
<!-- Representing a result which has been translated from a non-UCUM code (e.g. result reported from external lab)-->
<value xsi:type="PQ" value="152" unit="10*3/uL" />
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
<!-- This presents the translation from originalText to the units-->
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<code code="246514001" displayName="units" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" />
<value xsi:type="CD" code="10*3/uL" codeSystem="2.16.840.1.113883.6.8" codeSystemName="UCUM">
<originalText>THOUS/MCL</originalText>
</value>
</observation>
</entryRelationship>
<referenceRange>
<observationRange>
<!-- Reference ranges can be expressed as structured physical quantity interval-->
<value xsi:type="IVL_PQ">
<low value="150" unit="10*3/uL"/>
<high value="400" unit="10*3/uL"/>
</value>
<!-- This interpretation code denotes that this reference range is for normal results. This is not the interpretation a specific patient value-->
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
</observationRange>
</referenceRange>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
<!-- Plan of Care Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.10"/>
<!-- Plan of Care Section-->
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of Care"/>
<title>PLAN OF CARE</title>
<text>No Information</text>
</section>
</component>
<!-- Social History (with Smoking Status Observation) -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.17"/>
<!-- Social History Section -->
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" displayName="Social History"/>
<title>SOCIAL HISTORY</title>
<text>No Information</text>
</section>
</component>
<!-- Vital Signs Section (entries required) -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.4.1"/>
<!-- Vital Signs (entries required) -->
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital Signs"/>
<title>VITAL SIGNS</title>
<text>No Information</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>