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<code code="34133-9" displayName="Summarization &amp; Episode Note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<!-- Title of this document -->
<title>Patient Chart &amp; Summary</title>
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<!-- Version of this document -->
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<!-- Example Social Security Number using the actual SSN OID. -->
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<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
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<city>Beaverton</city>
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<postalCode>97867</postalCode>
<country>US</country>
<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
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<telecom value="tel:+1(555)555-2003" use="HP"/>
<!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
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<given>Eve</given>
<!-- The "SP" is "Spouse" from HL7 Code System EntityNamePartQualifier 2.16.840.1.113883.5.43 -->
<family qualifier="SP">Betterhalf</family>
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<!-- Date of birth need only be precise to the day -->
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<addr>
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<!-- "en" is ISO 639-1 alpha-2 code for "English" -->
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<proficiencyLevelCode code="G" displayName="Good" codeSystem="2.16.840.1.113883.5.61" codeSystemName="LanguageAbilityProficiency"/>
<!-- Patient's preferred language -->
<preferenceInd value="true"/>
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<id extension="219BX" root="2.16.840.1.113883.4.6"/>
<name>The DoctorsTogether Physician Group</name>
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<country>US</country>
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<family>Primary</family>
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<country>US</country>
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<telecom use="WP" value="tel:+1(555)555-1025"/>
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<country>US</country>
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<family>Beaker</family>
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<country>US</country>
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<telecom use="WP" value="tel:+1(555)555-1016"/>
<assignedPerson>
<name>
<given>Susan</given>
<family>Script</family>
<suffix qualifier="AC">Pharm.D.</suffix>
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<name>People's Pharmacy</name>
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<streetAddressLine>1027 Health Drive</streetAddressLine>
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<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)555-1027"/>
<assignedPerson>
<name>
<given>Patrick</given>
<family>Pump</family>
<suffix qualifier="AC">M.D.</suffix>
</name>
</assignedPerson>
<representedOrganization>
<name>The DoctorsApart Physician Group</name>
</representedOrganization>
</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"/>
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<given qualifier="CL">Bo</given>
<family>Betterhalf</family>
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<!-- The custodian represents the organization charged with maintaining the original source document -->
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<name>Good Health HIE</name>
<telecom use="WP" value="tel:+1(555)555-1009"/>
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<streetAddressLine>1009 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
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</representedCustodianOrganization>
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<!-- The informationRecipient represents the intended recipient of the document -->
<informationRecipient>
<intendedRecipient>
<informationRecipient>
<name>
<given>Sara</given>
<family>Specialize</family>
<suffix qualifier="AC">M.D.</suffix>
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</informationRecipient>
<receivedOrganization>
<name>The DoctorsApart Physician Group</name>
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<country>US</country>
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<telecom use="WP" value="tel:+1(555)555-1004"/>
<assignedPerson>
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<given>Patricia</given>
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<family>Primary</family>
<suffix qualifier="AC">M.D.</suffix>
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</assignedPerson>
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<!-- The authenticator represents the individual attesting to the accuracy of information in the document-->
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<signatureCode code="S"/>
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<city>Portland</city>
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<telecom use="WP" value="tel:+1(555)555-1004"/>
<assignedPerson>
<name>
<given>Patricia</given>
<given qualifier="CL">Patty</given>
<family>Primary</family>
<suffix qualifier="AC">M.D.</suffix>
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</assignedPerson>
</assignedEntity>
</authenticator>
<!-- The participant represents supporting entities -->
<participant typeCode="IND">
<!-- typeCode "IND" represents an individual -->
<associatedEntity classCode="NOK">
<!-- classCode "NOK" represents the patient's next of kin-->
<addr use="HP">
<streetAddressLine>2222 Home Street</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
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<telecom value="tel:+1(555)555-2008" use="MC"/>
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<given>Boris</given>
<given qualifier="CL">Bo</given>
<family>Betterhalf</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<!-- Entities playing multiple roles are recorded in multiple participants -->
<participant typeCode="IND">
<associatedEntity classCode="ECON">
<!-- classCode "ECON" represents an emergency contact -->
<addr use="HP">
<streetAddressLine>2222 Home Street</streetAddressLine>
<city>Beaverton</city>
<state>OR</state>
<postalCode>97867</postalCode>
<country>US</country>
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<telecom value="tel:+1(555)555-2008" use="MC"/>
<associatedPerson>
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<given>Boris</given>
<given qualifier="CL">Bo</given>
<family>Betterhalf</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<documentationOf>
<serviceEvent classCode="PCPR">
<!-- 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="19750501"/>
<!-- The low value represents when the summarized provision of care began.
In this scenario, the patient's date of birth -->
<high value="20130815"/>
<!-- The high value represents when the summarized provision of care being ended.
In this scenario, when chart summary was created -->
</effectiveTime>
<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>1004 Healthcare Drive </streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)555-1004"/>
<assignedPerson>
<name>
<given>Patricia</given>
<given qualifier="CL">Patty</given>
<family>Primary</family>
<suffix qualifier="AC">M.D.</suffix>
</name>
</assignedPerson>
<representedOrganization>
<id extension="219BX" root="1.2.16.840.1.113883.4.6"/>
<name>The DoctorsTogether Physician Group</name>
<telecom use="WP" value="tel: +1(555)555-5000"/>
<addr>
<streetAddressLine>1004 Health Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<!-- ******************************************************** CDA Body ******************************************************** -->
<component>
<structuredBody>
<!-- ************* ADVANCE DIRECTIVES *************** -->
<component>
<section>
<!-- *** Advance Directives section with entries required *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.21" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.21"/>
<code code="42348-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>ADVANCE DIRECTIVES</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Directive</th>
<th>Description</th>
<th>Verification</th>
<th>Supporting Document(s)</th>
</tr>
</thead>
<tbody>
<tr>
<td>Resuscitation status</td>
<td ID="AD1">Do not resuscitate</td>
<td>Dr. Patricia Primary, Feb 19, 2011</td>
<td>
<linkHtml href="AdvanceDirective.b50b7910.pdf">Advance directive</linkHtml>
</td>
</tr>
</tbody>
</table>
</text>
<entry>
<!-- *** Advance Directive Organizer (V2) template -->
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.108" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.108"/>
<id root="af6ebdf2-d996-11e2-a5b8-f23c91aec05e"/>
<code code="45473-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="advance directive - living will"/>
<statusCode code="completed"/>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="201308011235-0800"/>
<assignedAuthor>
<id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c"/>
<code code="163W00000X" displayName="Registered nurse" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/>
<assignedPerson>
<name>
<given>Nurse</given>
<family>Nightingale</family>
<suffix>RN</suffix>
</name>
</assignedPerson>
<representedOrganization classCode="ORG">
<id root="2.16.840.1.113883.19.5"/>
<name>Good Health Hospital</name>
</representedOrganization>
</assignedAuthor>
</author>
<component>
<!-- ** Advance Directive Observation (V3) ** -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.48" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.48"/>
<id root="9b54c3c9-1673-49c7-aef9-b037ed72ed27"/>
<code code="304251008" displayName="Resuscitation" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96">
<translation code="75320-2" displayName="Advance directive" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20110219"/>
<high nullFlavor="NA"/>
</effectiveTime>
<value xsi:type="CD" code="304253006" displayName="Do not resuscitate" codeSystem="2.16.840.1.113883.6.96"/>
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="201308011235-0800"/>
<assignedAuthor>
<id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c"/>
<code code="163W00000X" displayName="Registered nurse" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/>
<assignedPerson>
<name>
<given>Nurse</given>
<family>Nightingale</family>
<suffix>RN</suffix>
</name>
</assignedPerson>
<representedOrganization classCode="ORG">
<id root="2.16.840.1.113883.19.5"/>
<name>Good Health Hospital</name>
</representedOrganization>
</assignedAuthor>
</author>
<participant typeCode="VRF">
<templateId root="2.16.840.1.113883.10.20.1.58"/>
<time value="201102019"/>
<participantRole>
<id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c"/>
<code code="207QA0505X" displayName="Adult Medicine" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/>
<playingEntity>
<name>
<prefix>Dr.</prefix>
<family>Patricia</family>
<given>Primary</given>
</name>
</playingEntity>
</participantRole>
</participant>
<participant typeCode="CST">
<participantRole classCode="AGNT">
<addr>
<streetAddressLine>1004 Health Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1(555)555-1004"/>
<playingEntity>
<name>
<prefix>Dr.</prefix>
<family>Patricia</family>
<given>Primary</given>
</name>
</playingEntity>
</participantRole>
</participant>
<reference typeCode="REFR">
<seperatableInd value="false"/>
<externalDocument>
<id root="b50b7910-7ffb-4f4c-bbe4-177ed68cbbf3"/>
<text mediaType="application/pdf">
<reference value="AdvanceDirective.b50b7910.pdf"/>
</text>
</externalDocument>
</reference>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
<!-- ***************** ALLERGIES *************** -->
<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"/>
<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>
</tr>
</thead>
<tbody>
<tr>
<td ID="substance1">Penicillin</td>
<td ID="reaction1">Nausea</td>
</tr>
<tr>
<td ID="substance2">Codeine</td>
<td ID="reaction2">Wheezing</td>
</tr>
</tbody>
</table>
</text>
<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 -->
<!-- Concern was documented on May 1, 1998 -->
<low value="199805011145-0800"/>
</effectiveTime>
<author typeCode="AUT">
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<!-- Same as Concern effectiveTime/low -->
<time value="199805011145-0800"/>
<assignedAuthor>
<id extension="555555555" 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)"/>
</assignedAuthor>
</author>
<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"/>
<text>
<reference value="#allergytype1"/>
</text>
<!-- 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 -->
<!-- Based on patient symptoms, presumed onset is May 1, 1998 -->
<low value="19980501"/>
<!-- The high value reflects when the allergy was known to be resolved (and will generally be absent) -->
</effectiveTime>
<value xsi:type="CD" code="419199007" displayName="Allergy to substance" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<author typeCode="AUT">
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="199805011145-0800"/>
<assignedAuthor>
<id extension="222223333" root="2.16.840.1.113883.4.6"/>
<code code="207KA0200X" displayName="Allergy" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/>
</assignedAuthor>
</author>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code code="70618" displayName="Penicillin" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"/>
</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="#allergyseverity1"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="371924009" displayName="Moderate to severe" 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-9fe1-0800200c9a64"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<text>
<reference value="#reaction1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="200802260805-0800"/>
<high value="200802281205-0800"/>
</effectiveTime>
<value xsi:type="CD" code="422587007" codeSystem="2.16.840.1.113883.6.96" displayName="Nausea"/>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Severity observation ** -->
<!-- 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"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="255604002" displayName="Mild" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<!-- ** Allergy concern act ** -->
<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 -->
<!-- Concern was documented on May 1, 1998 -->
<low value="199805011145-0800"/>
</effectiveTime>
<author typeCode="AUT">
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<!-- Same as Concern effectiveTime/low -->
<time value="199805011145-0800"/>
<assignedAuthor>
<id extension="555555555" 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)"/>
</assignedAuthor>
</author>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Allergy observation ** -->
<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="901db0f8-9355-4794-81cd-fd951ef07917"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<text>
<reference value="#allergytype2"/>
</text>
<!-- 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 nullFlavor="UNK"/>
<!-- The high value reflects when the allergy was known to be resolved (and will generally be absent) -->
</effectiveTime>
<value xsi:type="CD" code="419199007" displayName="Allergy to substance" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<author typeCode="AUT">
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="201010110915-0800"/>
<assignedAuthor>
<id extension="222223333" root="2.16.840.1.113883.4.6"/>
<code code="207KA0200X" displayName="Allergy" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/>
</assignedAuthor>
</author>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code code="2670" displayName="Codeine" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"/>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="MFST" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Reaction observation ** -->
<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="38c63dea-1a43-4f84-ab71-1ffd04f6a1dd"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<text>
<reference value="#reaction2"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="56018004" displayName="Wheezing" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Severity observation ** -->
<!-- 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="#reactionseverity2"/>
</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>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Severity observation ** -->
<!-- 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="#allergyseverity2"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="255604002" displayName="Mild" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!-- ************************ ENCOUNTERS *********************** -->
<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>
<table border="1" width="100%">
<thead>
<tr>
<th>Encounter</th>
<th>Performer</th>
<th>Location</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td ID="Encounter1"> Checkup Examination </td>
<td>Performer Name</td>
<td>Community Urgent Care Center</td>
<td>September 27, 2012 at 1:00pm</td>
</tr>
</tbody>
</table>
</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="2a620155-9d11-439e-92b3-5d9815ff4de8"/>
<code code="99213" displayName="Office outpatient visit 15 minutes" codeSystemName="CPT-4" codeSystem="2.16.840.1.113883.6.12">
<originalText>
<reference value="#Encounter1"/>
</originalText>
<!-- MAY MAY contain zero or one [0..1] translation (CONF:1198-32323)
The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) valueset to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) valueset.
<translation code="AMB" codeSystem="2.16.840.1.113883.5.4" displayName="Ambulatory" codeSystemName="HL7 ActEncounterCode"/>
-->
</code>
<effectiveTime value="201209271300+0500"/>
<performer>
<assignedEntity>
<!-- Provider NPI "333444555" -->
<id extension="333444555" root="2.16.840.1.113883.4.6"/>
<code code="59058001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="General Physician"/>
</assignedEntity>
</performer>
<participant typeCode="LOC">
<participantRole classCode="SDLOC">
<templateId root="2.16.840.1.113883.10.20.22.4.32"/>
<!-- Service Delivery Location template -->
<code code="1160-1" codeSystem="2.16.840.1.113883.6.259" codeSystemName="HL7 HealthcareServiceLocation" displayName="Urgent Care Center"/>
<addr>
<streetAddressLine>1007 Health Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel: +1(555)555-1030"/>
<playingEntity classCode="PLC">
<name>Good Health Urgent Care</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="RSON">
<!-- ** Indivcation (V2) ** -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.19" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/>
<!-- code is required; MAY be selected from ValueSet Problem Type (LOINC) urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2014-09-02 (CONF:1098-31229) -->
<code code="404684003" displayName="Finding" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96">
<!-- of course this MAY be present
<translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Clinical finding"/>
-->
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="201209251130+0500"/>
</effectiveTime>
<value xsi:type="CD" code="233604007" displayName="Pneumonia" codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entryRelationship>
</encounter>
</entry>
</section>
</component>
<!-- ************************ FAMILY HISTORY *********************** -->
<component>
<section>
<!-- *** Family history section (V3) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.15" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.15"/>
<code code="10157-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>FAMILY HISTORY</title>
<text>
<paragraph>Father (deceased)</paragraph>
<table border="1" width="100%">
<thead>
<tr>
<th>Diagnosis</th>
<th>Age At Onset</th>
</tr>
</thead>
<tbody>
<tr>
<td>Myocardial Infarction (cause of death)</td>
<td>57</td>
</tr>
<tr>
<td>Diabetes</td>
<td>40</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<organizer moodCode="EVN" classCode="CLUSTER">
<!-- ** Family history organizer (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.45" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.45"/>
<id root="d42ebf70-5c89-11db-b0de-0855200c9a66"/>
<statusCode code="completed"/>
<subject>
<relatedSubject classCode="PRS">
<code code="FTH" displayName="Father" codeSystemName="FamilyRelationshipRoleType" codeSystem="2.16.840.1.113883.5.111">
<!--
<translation code="9947008" displayName="Biological father" codeSystemName="SNOMED" codeSystem="2.16.840.1.113883.6.96"/>
-->
</code>
<subject>
<sdtc:id root="2.16.840.1.113883.19.5.99999.2" extension="99999999"/>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.1.11.1" displayName="Male"/>
<birthTime value="1910"/>
<!-- Example use of sdtc extensions included below in comments -->
<!-- <sdtc:deceasedInd value="true"/> <sdtc:deceasedTime value="1967"/> -->
</subject>
</relatedSubject>
</subject>
<component>
<observation classCode="OBS" moodCode="EVN">
<!-- ** Family history observation (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.46" extension="2015-08-01"/>
<!--Critical Change-->
<templateId root="2.16.840.1.113883.10.20.22.4.46"/>
<id root="d42ebf70-5c89-11db-b0de-0800200c9a66"/>
<code code="64572001" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" displayName="Condition">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC)
<translation code="75323-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Condition"/>
very likely that the following is present, but use of LOINC as shown above would be better -->
<translation nullFlavor="NI"/>