Difference between revisions of "APS Example"
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− | ' | + | The example xml file can be downloaded here [[media:IHE_APSExample_FormC.xml | IHE_APSExample_FormC.xml]]. To get around wiki security (it doesn't like the <text> sections w/html tags) the file was zipped, and then the extension was renamed to .xml. To view the file you will have to right-click on the file and choose Save Target As to download the file, rename the extension back to .zip, and then unzip. |
===CDA Header=== | ===CDA Header=== | ||
+ | |||
<pre> | <pre> | ||
Line 24: | Line 25: | ||
<id root='db734647-fc99-424c-a864-7e3cda82e703'/> | <id root='db734647-fc99-424c-a864-7e3cda82e703'/> | ||
− | + | <code code='2.16.1.2' codeSystem='2.4' displayName='loinc'/> | |
<title>Good Health Clinic Visit Summary Flowsheet</title> | <title>Good Health Clinic Visit Summary Flowsheet</title> | ||
Line 52: | Line 53: | ||
<time value='20000407130000+0500'/> | <time value='20000407130000+0500'/> | ||
<assignedAuthor> | <assignedAuthor> | ||
− | <id root=' | + | <id root='20cf14fb-b65c-4c8c-a54d-b0cca834ceww'/> |
<assignedAuthoringDevice> | <assignedAuthoringDevice> | ||
<softwareName>Good Health Clinic System v1.0</softwareName> | <softwareName>Good Health Clinic System v1.0</softwareName> | ||
Line 62: | Line 63: | ||
</author> | </author> | ||
− | <!-- | + | <!-- Physicians --> |
+ | <!-- are referenced in Visit Summary and Problems sections --> | ||
<author> | <author> | ||
<time value='20000407130000+0500'/> | <time value='20000407130000+0500'/> | ||
Line 68: | Line 70: | ||
<id root='20cf14fb-b65c-4c8c-a54d-b0cca834c18c'/> | <id root='20cf14fb-b65c-4c8c-a54d-b0cca834c18c'/> | ||
<assignedPerson> | <assignedPerson> | ||
− | <name><prefix>Dr.</prefix><given>Robert</given><family>Dolin</family></name> | + | <name> |
+ | <prefix>Dr.</prefix> | ||
+ | <given>Robert</given> | ||
+ | <family>Dolin</family> | ||
+ | </name> | ||
</assignedPerson> | </assignedPerson> | ||
<representedOrganization> | <representedOrganization> | ||
Line 76: | Line 82: | ||
</assignedAuthor> | </assignedAuthor> | ||
</author> | </author> | ||
− | |||
− | |||
<author> | <author> | ||
<time value='20000407130000+0500'/> | <time value='20000407130000+0500'/> | ||
Line 87: | Line 91: | ||
<given>Robert</given> | <given>Robert</given> | ||
<family>Dolin</family> | <family>Dolin</family> | ||
+ | </name> | ||
+ | </assignedPerson> | ||
+ | <representedOrganization> | ||
+ | <id root='2.16.840.1.113883.19.5'/> | ||
+ | <name>Good Health Clinic</name> | ||
+ | </representedOrganization> | ||
+ | </assignedAuthor> | ||
+ | </author> | ||
+ | <author> | ||
+ | <time value='20000407130000+0500'/> | ||
+ | <assignedAuthor> | ||
+ | <id root='2a6ae35c-bbd7-4c26-ab3d-6cd160fec66c'/> | ||
+ | <assignedPerson> | ||
+ | <name> | ||
+ | <prefix>Dr.</prefix> | ||
+ | <given>D.</given> | ||
+ | <family>Dzubin</family> | ||
+ | </name> | ||
+ | </assignedPerson> | ||
+ | <representedOrganization> | ||
+ | <id root='2.16.840.1.113883.19.5'/> | ||
+ | <name>Good Health Clinic</name> | ||
+ | </representedOrganization> | ||
+ | </assignedAuthor> | ||
+ | </author> | ||
+ | <author> | ||
+ | <time value='20000407130000+0500'/> | ||
+ | <assignedAuthor> | ||
+ | <id root='14d465a5-b47d-45a8-ad2c-7d1a51e9ed56'/> | ||
+ | <assignedPerson> | ||
+ | <name> | ||
+ | <prefix>Dr.</prefix> | ||
+ | <given>E.</given> | ||
+ | <family>Pickett</family> | ||
+ | </name> | ||
+ | </assignedPerson> | ||
+ | <representedOrganization> | ||
+ | <id root='2.16.840.1.113883.19.5'/> | ||
+ | <name>Good Health Clinic</name> | ||
+ | </representedOrganization> | ||
+ | </assignedAuthor> | ||
+ | </author> | ||
+ | <author> | ||
+ | <time value='20000407130000+0500'/> | ||
+ | <assignedAuthor> | ||
+ | <id root='3047e209-5926-4556-b3c9-5f35c4269279'/> | ||
+ | <assignedPerson> | ||
+ | <name> | ||
+ | <prefix>Dr.</prefix> | ||
+ | <given>E.</given> | ||
+ | <family>Robinson</family> | ||
</name> | </name> | ||
</assignedPerson> | </assignedPerson> | ||
Line 147: | Line 202: | ||
<documentationOf> | <documentationOf> | ||
<serviceEvent classCode='PCPR'> | <serviceEvent classCode='PCPR'> | ||
− | <effectiveTime><low value='19320924'/><high value='20000407'/></effectiveTime> | + | <effectiveTime> |
+ | <low value='19320924'/> | ||
+ | <high value='20000407'/> | ||
+ | </effectiveTime> | ||
<performer typeCode='PRF'> | <performer typeCode='PRF'> | ||
<functionCode code='PCP' codeSystem='2.16.840.1.113883.5.88'/> | <functionCode code='PCP' codeSystem='2.16.840.1.113883.5.88'/> | ||
Line 154: | Line 212: | ||
<id root='20cf14fb-b65c-4c8c-a54d-b0cca834c18c'/> | <id root='20cf14fb-b65c-4c8c-a54d-b0cca834c18c'/> | ||
<assignedPerson> | <assignedPerson> | ||
− | <name><prefix>Dr.</prefix><given>Robert</given><family>Dolin</family></name> | + | <name> |
+ | <prefix>Dr.</prefix> | ||
+ | <given>Robert</given> | ||
+ | <family>Dolin</family> | ||
+ | </name> | ||
</assignedPerson> | </assignedPerson> | ||
<representedOrganization> | <representedOrganization> | ||
Line 163: | Line 225: | ||
</serviceEvent> | </serviceEvent> | ||
</documentationOf> | </documentationOf> | ||
− | |||
<!-- | <!-- | ||
******************************************************** | ******************************************************** | ||
Line 170: | Line 231: | ||
--> | --> | ||
<component> | <component> | ||
− | + | <structuredBody> | |
</pre> | </pre> | ||
===Allergies=== | ===Allergies=== | ||
+ | |||
<pre> | <pre> | ||
+ | |||
<!-- | <!-- | ||
******************************************************** | ******************************************************** | ||
Line 215: | Line 278: | ||
<value xsi:type='CD' code='300916003' displayName='Latex allergy (disorder)' | <value xsi:type='CD' code='300916003' displayName='Latex allergy (disorder)' | ||
codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'> | codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'> | ||
− | <originalText><reference value='#Allergy'/></originalText> | + | <originalText> |
+ | <reference value='#Allergy'/> | ||
+ | </originalText> | ||
</value> | </value> | ||
</observation> | </observation> | ||
Line 253: | Line 318: | ||
<code code='(xx-bld-transf-ok)' | <code code='(xx-bld-transf-ok)' | ||
displayName='Blood Transfusion Preference-FIND-PT-^PATIENT-ORD-PATIENT REPORTED' | displayName='Blood Transfusion Preference-FIND-PT-^PATIENT-ORD-PATIENT REPORTED' | ||
− | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | + | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'> |
+ | <originalText> | ||
+ | <reference value="#BloodTransfusion"/> | ||
+ | </originalText> | ||
+ | </code> | ||
<statusCode code='complete'/> | <statusCode code='complete'/> | ||
<effectiveTime value='20061129'/> | <effectiveTime value='20061129'/> | ||
− | |||
<value xsi:type='BL' value='true'/> | <value xsi:type='BL' value='true'/> | ||
</observation> | </observation> | ||
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</section> | </section> | ||
</component> | </component> | ||
− | + | ||
</pre> | </pre> | ||
Line 300: | Line 368: | ||
<code code='(xx-anest-cons-pland)' codeSystem='2.16.840.1.113883.6.1' | <code code='(xx-anest-cons-pland)' codeSystem='2.16.840.1.113883.6.1' | ||
displayName='Anesthesia Consult Status-FIND-PT-^PATIENT-ORD-' | displayName='Anesthesia Consult Status-FIND-PT-^PATIENT-ORD-' | ||
− | codeSystemName='LOINC'/> | + | codeSystemName='LOINC'> |
+ | <originalText><reference value='#AnesthesiaPlanned'/></originalText> | ||
+ | </code> | ||
<statusCode code='complete'/> | <statusCode code='complete'/> | ||
<effectiveTime value='20061129'/> | <effectiveTime value='20061129'/> | ||
<value xsi:type='BL' value='true'/> | <value xsi:type='BL' value='true'/> | ||
− | </observation> | + | </observation> |
+ | </entry> | ||
+ | <entry typeCode='DRIV'> <!-- anesthesia consult planned --> | ||
<!-- Details of plan if known --> | <!-- Details of plan if known --> | ||
<observation classCode='OBS' moodCode='RQO'> | <observation classCode='OBS' moodCode='RQO'> | ||
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<id root='1e782c18-b738-448c-87df-7b6a38caedec'/> | <id root='1e782c18-b738-448c-87df-7b6a38caedec'/> | ||
<code code='(xx-type-of-anesth-pland)' codeSystem='2.16.840.1.113883.6.1' | <code code='(xx-type-of-anesth-pland)' codeSystem='2.16.840.1.113883.6.1' | ||
− | displayName='Anesthesia Consult Plans' | + | displayName='Anesthesia Consult Plans??' |
− | codeSystemName='LOINC' | + | codeSystemName='LOINC'> |
+ | <!-- TODO: Determine displayName --> | ||
+ | <originalText><reference value='#AnesthesiaDetails'/></originalText> | ||
+ | </code> | ||
<statusCode code='complete'/> | <statusCode code='complete'/> | ||
<effectiveTime value='20061129'/> | <effectiveTime value='20061129'/> | ||
− | |||
<value xsi:type='ED'/> | <value xsi:type='ED'/> | ||
</observation> | </observation> | ||
− | |||
</entry> | </entry> | ||
− | |||
</section> | </section> | ||
</component> | </component> | ||
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<!-- | <!-- | ||
******************************************************** | ******************************************************** | ||
− | Medications | + | Medications |
******************************************************** | ******************************************************** | ||
--> | --> | ||
Line 342: | Line 414: | ||
<table border='1'> | <table border='1'> | ||
<thead> | <thead> | ||
− | <tr | + | <tr><td>Medication List</td></tr> |
<tr> | <tr> | ||
<th>Medication Name</th> | <th>Medication Name</th> | ||
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<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> | ||
<id root='b98f68e3-4cdb-4baf-bec3-6d87579b7c4d'/> | <id root='b98f68e3-4cdb-4baf-bec3-6d87579b7c4d'/> | ||
− | |||
− | |||
<statusCode code='completed'/> | <statusCode code='completed'/> | ||
<!-- Start/Stop Date --> | <!-- Start/Stop Date --> | ||
Line 386: | Line 456: | ||
<high value='20070201'/> | <high value='20070201'/> | ||
</effectiveTime> | </effectiveTime> | ||
− | </ | + | <consumable> |
+ | <manufacturedProduct> | ||
+ | <manufacturedLabeledDrug> | ||
+ | <name>Crinone</name> | ||
+ | </manufacturedLabeledDrug> | ||
+ | </manufacturedProduct> | ||
+ | </consumable> | ||
+ | </substanceAdministration> | ||
</entry> | </entry> | ||
<entry> <!-- Med-2 --> | <entry> <!-- Med-2 --> | ||
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<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> | ||
<id root='acd970a0-31b8-46b2-954a-7b127927d47c'/> | <id root='acd970a0-31b8-46b2-954a-7b127927d47c'/> | ||
− | |||
− | |||
<statusCode code='completed'/> | <statusCode code='completed'/> | ||
<!-- Start/Stop Date --> | <!-- Start/Stop Date --> | ||
Line 401: | Line 476: | ||
<high value='20061213'/> | <high value='20061213'/> | ||
</effectiveTime> | </effectiveTime> | ||
− | </ | + | <consumable> |
+ | <manufacturedProduct> | ||
+ | <manufacturedLabeledDrug> | ||
+ | <name>Macrobid Oral Capsule 100 mg bid 10 Ref:0</name> | ||
+ | </manufacturedLabeledDrug> | ||
+ | </manufacturedProduct> | ||
+ | </consumable> | ||
+ | </substanceAdministration> | ||
</entry> | </entry> | ||
<entry> <!-- Med-3 --> | <entry> <!-- Med-3 --> | ||
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<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> | ||
<id root='8fb9160b-c7c3-44fa-886e-d367a522ba80'/> | <id root='8fb9160b-c7c3-44fa-886e-d367a522ba80'/> | ||
− | |||
− | |||
<statusCode code='completed'/> | <statusCode code='completed'/> | ||
<!-- Start/Stop Date --> | <!-- Start/Stop Date --> | ||
Line 416: | Line 496: | ||
<high value='20061129'/> | <high value='20061129'/> | ||
</effectiveTime> | </effectiveTime> | ||
− | </ | + | <consumable> |
+ | <manufacturedProduct> | ||
+ | <manufacturedLabeledDrug> | ||
+ | <name>Prozac</name> | ||
+ | </manufacturedLabeledDrug> | ||
+ | </manufacturedProduct> | ||
+ | </consumable> | ||
+ | </substanceAdministration> | ||
</entry> | </entry> | ||
<entry> <!-- Med-4 --> | <entry> <!-- Med-4 --> | ||
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<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> | ||
<id root='5d989f63-d02d-4a1e-a4ea-f9377679320b'/> | <id root='5d989f63-d02d-4a1e-a4ea-f9377679320b'/> | ||
− | |||
− | |||
<statusCode code='completed'/> | <statusCode code='completed'/> | ||
<!-- Start/Stop Date --> | <!-- Start/Stop Date --> | ||
Line 431: | Line 516: | ||
<high value='20071224'/> | <high value='20071224'/> | ||
</effectiveTime> | </effectiveTime> | ||
− | </ | + | <consumable> |
+ | <manufacturedProduct> | ||
+ | <manufacturedLabeledDrug> | ||
+ | <name>PrimaCare ONE Oral Capsule 27-1-300 m...</name> | ||
+ | </manufacturedLabeledDrug> | ||
+ | </manufacturedProduct> | ||
+ | </consumable> | ||
+ | </substanceAdministration> | ||
</entry> | </entry> | ||
</section> | </section> | ||
Line 450: | Line 542: | ||
<section> | <section> | ||
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/> | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/> | ||
− | |||
− | |||
<title>Problems</title> | <title>Problems</title> | ||
<text> <!-- Narrative --> | <text> <!-- Narrative --> | ||
<table border='1'> | <table border='1'> | ||
<thead> | <thead> | ||
− | <tr><td | + | <tr><td>Problems/Plans</td></tr> |
<tr> | <tr> | ||
<th>Problem</th> | <th>Problem</th> | ||
Line 466: | Line 556: | ||
<tbody> | <tbody> | ||
<tr> <!-- Problem #1 --> | <tr> <!-- Problem #1 --> | ||
− | <td | + | <td ID='Problem-1'>Hx of: Depression</td> |
− | <td | + | <td ID='StartDate-1'>11/29/2006</td> |
− | <td | + | <td ID='StopDate-1'></td> |
− | <td | + | <td ID='Physician-1'>D. Dzubin</td> |
</tr> | </tr> | ||
<tr> <!-- Problem #2 --> | <tr> <!-- Problem #2 --> | ||
− | <td | + | <td ID='Problem-2'>Current: Gestational Diabetes (diet)</td> |
− | <td | + | <td ID='StartDate-2'>3/19/2007</td> |
− | <td | + | <td ID='StopDate-2'></td> |
− | <td | + | <td ID='Physician-2'>E. Pickett</td> |
</tr> | </tr> | ||
<tr> <!-- Problem #3 --> | <tr> <!-- Problem #3 --> | ||
− | <td | + | <td ID='Problem-3'>Hx of: Infertility</td> |
− | <td | + | <td ID='StartDate-3'>11/29/2006</td> |
− | <td | + | <td ID='StopDate-3'></td> |
− | <td | + | <td ID='Physician-3'>D. Dzubin</td> |
</tr> | </tr> | ||
<tr> <!-- Problem #4 --> | <tr> <!-- Problem #4 --> | ||
− | <td | + | <td ID='Problem-4'>D. Dzubin IVF pregnancy</td> |
− | <td | + | <td ID='StartDate-4'>12/14/2006</td> |
− | <td | + | <td ID='StopDate-4'></td> |
− | <td | + | <td ID='Physician-4'>E. Robinson</td> |
</tr> | </tr> | ||
</tbody> | </tbody> | ||
Line 496: | Line 586: | ||
<templateId root='1.3.6.1.4.1.19376.1.5.3.1'/> | <templateId root='1.3.6.1.4.1.19376.1.5.3.1'/> | ||
<id root='dc6d49d1-9371-40bb-9507-90ca93e181a6'/> | <id root='dc6d49d1-9371-40bb-9507-90ca93e181a6'/> | ||
− | < | + | <code code='11450-4' displayName='Problem List' |
− | <reference value="#Problem-1"/> | + | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'> |
− | </ | + | <originalText><reference value="#Problem-1"/></originalText> |
+ | </code> | ||
<effectiveTime> | <effectiveTime> | ||
<low value='20061129'/> | <low value='20061129'/> | ||
− | </effectiveTime> | + | </effectiveTime> |
<author typeCode='AUT'> <!-- Physician --> | <author typeCode='AUT'> <!-- Physician --> | ||
+ | <time value='20061129'/> | ||
<assignedAuthor> | <assignedAuthor> | ||
<id root='2a6ae35c-bbd7-4c26-ab3d-6cd160fec66c'/> <!-- links to header element --> | <id root='2a6ae35c-bbd7-4c26-ab3d-6cd160fec66c'/> <!-- links to header element --> | ||
Line 513: | Line 605: | ||
<templateId root='1.3.6.1.4.1.19376.1.5.3.1'/> | <templateId root='1.3.6.1.4.1.19376.1.5.3.1'/> | ||
<id root='00448a62-d986-4be9-8cff-f8d5b12c3233'/> | <id root='00448a62-d986-4be9-8cff-f8d5b12c3233'/> | ||
− | < | + | <code code='11450-4' displayName='Problem List' |
− | <reference value="#Problem-2"/> | + | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'> |
− | </ | + | <originalText><reference value="#Problem-2"/></originalText> |
+ | </code> | ||
<effectiveTime> | <effectiveTime> | ||
<low value='20070319'/> | <low value='20070319'/> | ||
</effectiveTime> | </effectiveTime> | ||
<author typeCode='AUT'> <!-- Physician --> | <author typeCode='AUT'> <!-- Physician --> | ||
+ | <time value='20070319'/> | ||
<assignedAuthor> | <assignedAuthor> | ||
− | <id root='14d465a5-b47d-45a8-ad2c-7d1a51e9ed56'/> <!-- links to header element --> | + | <id root='14d465a5-b47d-45a8-ad2c-7d1a51e9ed56'/><!-- links to header element --> |
</assignedAuthor> | </assignedAuthor> | ||
</author> | </author> | ||
Line 530: | Line 624: | ||
<templateId root='1.3.6.1.4.1.19376.1.5.3.1'/> | <templateId root='1.3.6.1.4.1.19376.1.5.3.1'/> | ||
<id root='219e87a0-b2fb-4ffb-917e-8cdeede4af79'/> | <id root='219e87a0-b2fb-4ffb-917e-8cdeede4af79'/> | ||
− | < | + | <code code='11450-4' displayName='Problem List' |
− | <reference value="#Problem-3"/> | + | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'> |
− | </ | + | <originalText><reference value="#Problem-3"/></originalText> |
+ | </code> | ||
<effectiveTime> | <effectiveTime> | ||
<low value='20061129'/> | <low value='20061129'/> | ||
</effectiveTime> | </effectiveTime> | ||
<author typeCode='AUT'> <!-- Physician --> | <author typeCode='AUT'> <!-- Physician --> | ||
+ | <time value='20061129'/> | ||
<assignedAuthor> | <assignedAuthor> | ||
<id root='2a6ae35c-bbd7-4c26-ab3d-6cd160fec66c'/> <!-- links to header element --> | <id root='2a6ae35c-bbd7-4c26-ab3d-6cd160fec66c'/> <!-- links to header element --> | ||
Line 547: | Line 643: | ||
<templateId root='1.3.6.1.4.1.19376.1.5.3.1'/> | <templateId root='1.3.6.1.4.1.19376.1.5.3.1'/> | ||
<id root='9ad41ad5-9687-4b0a-9c4d-d003f31198ab'/> | <id root='9ad41ad5-9687-4b0a-9c4d-d003f31198ab'/> | ||
− | < | + | <code code='11450-4' displayName='Problem List' |
− | <reference value="#Problem-4"/> | + | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'> |
− | </ | + | <originalText><reference value="#Problem-4"/></originalText> |
+ | </code> | ||
<effectiveTime> | <effectiveTime> | ||
<low value='20061214'/> | <low value='20061214'/> | ||
</effectiveTime> | </effectiveTime> | ||
<author typeCode='AUT'> <!-- Physician --> | <author typeCode='AUT'> <!-- Physician --> | ||
+ | <time value='20061214'/> | ||
<assignedAuthor> | <assignedAuthor> | ||
<id root='3047e209-5926-4556-b3c9-5f35c4269279'/> <!-- links to header element --> | <id root='3047e209-5926-4556-b3c9-5f35c4269279'/> <!-- links to header element --> | ||
Line 581: | Line 679: | ||
<table border="1"> <!-- Initial EDD --> | <table border="1"> <!-- Initial EDD --> | ||
<thead> | <thead> | ||
− | <tr>< | + | <tr><td>Initial EDD Confirmation</td></tr> |
<tr> | <tr> | ||
<th>Method</th> | <th>Method</th> | ||
Line 612: | Line 710: | ||
<table border="1"> <!-- Final EDD --> | <table border="1"> <!-- Final EDD --> | ||
<thead> | <thead> | ||
− | <tr>< | + | <tr><td>18-20 Week Update</td></tr> |
<tr> | <tr> | ||
<th>Method</th> | <th>Method</th> | ||
Line 640: | Line 738: | ||
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <!-- SimpleObservation OID --> | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <!-- SimpleObservation OID --> | ||
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1' /> <!-- EDD Observation --> | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1' /> <!-- EDD Observation --> | ||
+ | <id root='2c878572-136a-11dc-8314-0800200c9a66'/> | ||
+ | <code code='11778-8' | ||
+ | displayName='DELIVERY DATE-TMSTP-PT-^PATIENT-QN-CLINICAL.ESTIMATED' | ||
+ | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | ||
+ | <text><reference value='#InitialEDD'/></text> | ||
<statusCode code='completed'/> | <statusCode code='completed'/> | ||
<effectiveTime value='20061129' /> | <effectiveTime value='20061129' /> | ||
+ | <value xsi:type='TS'/> | ||
<author typeCode='AUT'> <!-- Provider Initials --> | <author typeCode='AUT'> <!-- Provider Initials --> | ||
<time value='20061129'/> <!-- Visit Date --> | <time value='20061129'/> <!-- Visit Date --> | ||
Line 648: | Line 752: | ||
</assignedAuthor> | </assignedAuthor> | ||
</author> | </author> | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
<!-- LMP --> | <!-- LMP --> | ||
<entryRelationship typeCode='SPRT'> | <entryRelationship typeCode='SPRT'> | ||
<observation classCode='OBS' moodCode='EVN'> | <observation classCode='OBS' moodCode='EVN'> | ||
<id root='40a0ebdc-1397-11dc-8314-0800200c9a66'/> | <id root='40a0ebdc-1397-11dc-8314-0800200c9a66'/> | ||
− | |||
− | |||
<code code='11779-6' | <code code='11779-6' | ||
displayName='DELIVERY DATE-TMSTP-PT-^PATIENT-QN-ESTIMATED FROM LAST MENSTRUAL PERIOD' | displayName='DELIVERY DATE-TMSTP-PT-^PATIENT-QN-ESTIMATED FROM LAST MENSTRUAL PERIOD' | ||
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | ||
− | <text><reference value="#InitialEDDDate-2" ></ | + | <!-- EDD based on LMP --> |
+ | <text><reference value="#InitialEDDDate-2"/></text> | ||
+ | <statusCode code='completed'/> | ||
+ | <effectiveTime value='20060925'/> <!-- Date of LMP --> | ||
<value xsi:type='TS'/> | <value xsi:type='TS'/> | ||
</observation> | </observation> | ||
Line 671: | Line 770: | ||
<observation classCode='OBS' moodCode='EVN'> | <observation classCode='OBS' moodCode='EVN'> | ||
<id root='5d12d9bc-138b-11dc-8314-0800200c9a66'/> | <id root='5d12d9bc-138b-11dc-8314-0800200c9a66'/> | ||
− | |||
− | |||
<code code='11781-2' | <code code='11781-2' | ||
displayName='DELIVERY DATE-TMSTP-PT-^PATIENT-QN-US.COMPOSITE.ESTIMATED' | displayName='DELIVERY DATE-TMSTP-PT-^PATIENT-QN-US.COMPOSITE.ESTIMATED' | ||
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | ||
− | <text><reference value="#InitialEDDDate-2" ></ | + | <!-- EDD based on Ultrasound --> |
− | <value type='TS'/> | + | <text><reference value="#InitialEDDDate-2"/></text> |
+ | <effectiveTime value='20061109'/> <!-- Date Ultrasound was taken --> | ||
+ | <value xsi:type='TS'/> | ||
<!-- Weeks Gestation --> | <!-- Weeks Gestation --> | ||
− | <entryRelationship typeCode=' | + | <entryRelationship typeCode='SPRT'> |
<observation classCode='OBS' moodCode='EVN'> | <observation classCode='OBS' moodCode='EVN'> | ||
<id root='4f475f30-1370-11dc-8314-0800200c9a66'/> | <id root='4f475f30-1370-11dc-8314-0800200c9a66'/> | ||
− | < | + | <!-- TODO: informant? --> |
− | < | + | <!--<informant><reference id=''/></informant>--> |
− | |||
<code code='11888-5' | <code code='11888-5' | ||
displayName='GESTATIONAL AGE-TIME-PT-^FETUS-QN-US.COMPOSITE.ESTIMATED' | displayName='GESTATIONAL AGE-TIME-PT-^FETUS-QN-US.COMPOSITE.ESTIMATED' | ||
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | ||
<text><reference value='#InitialEDDWeeks-2'/></text> | <text><reference value='#InitialEDDWeeks-2'/></text> | ||
− | <value xsi:type='PQ' | + | <statusCode code='completed'/> |
+ | <effectiveTime value='20061129'/> | ||
+ | <value xsi:type='PQ' unit='d' value='47'/> <!-- (6 x 7) + 5 = 47--> | ||
</observation> | </observation> | ||
</entryRelationship> | </entryRelationship> | ||
Line 700: | Line 800: | ||
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <!-- SimpleObservation OID --> | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <!-- SimpleObservation OID --> | ||
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1' /> <!-- EDD Observation --> | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1' /> <!-- EDD Observation --> | ||
− | <statusCode code='completed'/> | + | <id root='54bbe9d2-139e-11dc-8314-0800200c9a66'/> |
+ | <code code='11778-8' | ||
+ | displayName='DELIVERY DATE-TMSTP-PT-^PATIENT-QN-CLINICAL.ESTIMATED' | ||
+ | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | ||
+ | <text><reference value='#FinalEDD'/></text> | ||
+ | <statusCode code='completed' /> | ||
<effectiveTime value='20061129' /> | <effectiveTime value='20061129' /> | ||
− | <author typeCode='AUT'> <!-- Provider Initials --> | + | <value xsi:type='TS'/> |
+ | <author typeCode='AUT' > <!-- Provider Initials --> | ||
<time value='20061129'/> <!-- Visit Date --> | <time value='20061129'/> <!-- Visit Date --> | ||
<assignedAuthor> | <assignedAuthor> | ||
Line 708: | Line 814: | ||
</assignedAuthor> | </assignedAuthor> | ||
</author> | </author> | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
<!-- Ultrasound --> | <!-- Ultrasound --> | ||
<entryRelationship typeCode='SPRT'> | <entryRelationship typeCode='SPRT'> | ||
<observation classCode='OBS' moodCode='EVN'> | <observation classCode='OBS' moodCode='EVN'> | ||
<id root='6d86f6ee-139e-11dc-8314-0800200c9a66'/> | <id root='6d86f6ee-139e-11dc-8314-0800200c9a66'/> | ||
− | |||
− | |||
<code code='11781-2' | <code code='11781-2' | ||
displayName='DELIVERY DATE-TMSTP-PT-^PATIENT-QN-US.COMPOSITE.ESTIMATED' | displayName='DELIVERY DATE-TMSTP-PT-^PATIENT-QN-US.COMPOSITE.ESTIMATED' | ||
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | ||
− | <text><reference value="# | + | <!-- EDD based on Ultrasound --> |
− | <value type='TS'/> | + | <text><reference value="#InitialEDDDate-2"/></text> |
+ | <effectiveTime value='20061109'/> <!-- Date Ultrasound was taken --> | ||
+ | <value xsi:type='TS'/> | ||
<!-- Weeks Gestation --> | <!-- Weeks Gestation --> | ||
− | <entryRelationship typeCode=' | + | <entryRelationship typeCode='SPRT'> |
<observation classCode='OBS' moodCode='EVN'> | <observation classCode='OBS' moodCode='EVN'> | ||
<id root='62915e78-139e-11dc-8314-0800200c9a66'/> | <id root='62915e78-139e-11dc-8314-0800200c9a66'/> | ||
− | < | + | <!-- TODO: informant? --> |
− | < | + | <!--<informant><reference id=''/></informant>--> |
− | |||
<code code='11888-5' | <code code='11888-5' | ||
displayName='GESTATIONAL AGE-TIME-PT-^FETUS-QN-US.COMPOSITE.ESTIMATED' | displayName='GESTATIONAL AGE-TIME-PT-^FETUS-QN-US.COMPOSITE.ESTIMATED' | ||
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | ||
<text><reference value='#UpdateEDDWeeks-1'/></text> | <text><reference value='#UpdateEDDWeeks-1'/></text> | ||
− | <value xsi:type='PQ' | + | <statusCode code='completed'/> |
+ | <effectiveTime value='20061129'/> | ||
+ | <value xsi:type='PQ' unit='d' value='145'/><!-- (20 x 7) + 5 = 145--> | ||
</observation> | </observation> | ||
</entryRelationship> | </entryRelationship> | ||
Line 745: | Line 846: | ||
</section> | </section> | ||
</component> | </component> | ||
− | |||
</pre> | </pre> | ||
Line 753: | Line 853: | ||
<pre> | <pre> | ||
− | + | <!-- | |
******************************************************** | ******************************************************** | ||
Visit Summary Flowsheet | Visit Summary Flowsheet | ||
Line 764: | Line 864: | ||
<text> | <text> | ||
<table border='1'> | <table border='1'> | ||
− | <tr><td>Pre-pregnancy Weight</td> <td>220</td></tr> | + | <thead> |
+ | <tr> | ||
+ | <td>Pre-pregnancy Weight</td> | ||
+ | </tr> | ||
+ | </thead> | ||
+ | <tbody> | ||
+ | <tr> | ||
+ | <td>220</td> | ||
+ | </tr> | ||
+ | </tbody> | ||
</table> | </table> | ||
<table border='1'> | <table border='1'> | ||
− | |||
<thead> | <thead> | ||
− | <tr | + | <tr> |
+ | <td colspan='19'>Visit Summary</td> | ||
+ | </tr> | ||
<tr> | <tr> | ||
<th>Weeks Gestation</th> | <th>Weeks Gestation</th> | ||
Line 793: | Line 903: | ||
</thead> | </thead> | ||
<tbody> | <tbody> | ||
− | |||
<tr > | <tr > | ||
<td ID='WeeksGestation-1'>9.3</td> | <td ID='WeeksGestation-1'>9.3</td> | ||
Line 842: | Line 951: | ||
<!-- pre-pregancy weight --> | <!-- pre-pregancy weight --> | ||
<entry> | <entry> | ||
− | <observation | + | <observation classCode='OBS' moodCode='EVN'> |
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> | ||
<id root='23e87612-1000-11dc-8314-0800200c9a66'/> | <id root='23e87612-1000-11dc-8314-0800200c9a66'/> | ||
Line 863: | Line 972: | ||
displayName='ACOG Summary Visit Battery---PT--' | displayName='ACOG Summary Visit Battery---PT--' | ||
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | ||
+ | <statusCode code='completed'/> | ||
<effectiveTime value='200611291242-08'/> | <effectiveTime value='200611291242-08'/> | ||
− | |||
<author typeCode='AUT'> <!-- Provider Initials --> | <author typeCode='AUT'> <!-- Provider Initials --> | ||
<time value='20061129'/> <!-- Visit Date --> | <time value='20061129'/> <!-- Visit Date --> | ||
Line 882: | Line 991: | ||
<text><reference value='#WeeksGestation-1'/></text> | <text><reference value='#WeeksGestation-1'/></text> | ||
<statusCode code='completed'/> | <statusCode code='completed'/> | ||
− | <value xsi:type='PQ' | + | <value xsi:type='PQ' unit='d' value='66'/> <!-- (9 x 7) + 3 = 66 --> |
</observation> | </observation> | ||
</component> | </component> | ||
Line 894: | Line 1,003: | ||
displayName='FUNDAL HEIGHT-LEN-PT-UTERUS-QN-TAPE MEASURE' | displayName='FUNDAL HEIGHT-LEN-PT-UTERUS-QN-TAPE MEASURE' | ||
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | ||
− | <text><reference value='#FundalHeight-1'/></text> | + | <text><reference value='#FundalHeight-1'/></text> |
<statusCode code='completed'/> | <statusCode code='completed'/> | ||
<value xsi:type='PQ'/> | <value xsi:type='PQ'/> | ||
Line 923: | Line 1,032: | ||
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | ||
<text><reference value='#FHR-1'/></text> | <text><reference value='#FHR-1'/></text> | ||
− | <statusCode code='completed'/> | + | <statusCode code='completed'/> |
− | <value xsi:type=' | + | <value xsi:type='PQ'> |
+ | </value> | ||
</observation> | </observation> | ||
</component> | </component> | ||
Line 1,135: | Line 1,245: | ||
displayName='ACOG Summary Visit Battery---PT--' | displayName='ACOG Summary Visit Battery---PT--' | ||
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> | ||
+ | <statusCode code='completed'/> | ||
<effectiveTime value='200611291242-08'/> | <effectiveTime value='200611291242-08'/> | ||
− | |||
<author typeCode='AUT'> <!-- Provider Initials --> | <author typeCode='AUT'> <!-- Provider Initials --> | ||
<time value='20061129'/> <!-- Visit Date --> | <time value='20061129'/> <!-- Visit Date --> | ||
Line 1,154: | Line 1,264: | ||
<text><reference value='#WeeksGestation-2'/></text> | <text><reference value='#WeeksGestation-2'/></text> | ||
<statusCode code='completed'/> | <statusCode code='completed'/> | ||
− | <value xsi:type='PQ' | + | <value xsi:type='PQ' unit='d' value='81'/> <!-- (11 x 7) + 4 = 81 --> |
</observation> | </observation> | ||
</component> | </component> | ||
Line 1,196: | Line 1,306: | ||
<text><reference value='#FHR-2'/></text> | <text><reference value='#FHR-2'/></text> | ||
<statusCode code='completed'/> | <statusCode code='completed'/> | ||
− | <value xsi:type=' | + | <value xsi:type='PQ'/> |
</observation> | </observation> | ||
</component> | </component> | ||
Line 1,395: | Line 1,505: | ||
</observation> | </observation> | ||
</component> | </component> | ||
− | + | ||
</organizer> | </organizer> | ||
− | </entry> | + | </entry> |
− | |||
</section> | </section> | ||
</component> | </component> | ||
− | + | ||
+ | </structuredBody> | ||
+ | </component> | ||
+ | </ClinicalDocument> | ||
</pre> | </pre> | ||
+ | |||
+ | |||
+ | ==External Links== | ||
+ | [http://www.newhopefertility.com/ IVF] |
Latest revision as of 04:10, 8 April 2009
The example xml file can be downloaded here IHE_APSExample_FormC.xml. To get around wiki security (it doesn't like the <text> sections w/html tags) the file was zipped, and then the extension was renamed to .xml. To view the file you will have to right-click on the file and choose Save Target As to download the file, rename the extension back to .zip, and then unzip.
CDA Header
<?xml version='1.0' encoding='UTF-8'?> <ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 infrastructure/cda/CDA.xsd" xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc"> <!-- ******************************************************** CDA Header ******************************************************** --> <typeId xmlns='urn:hl7-org:v3' xmlns:xsi='http://www.w3.org/2001/XMLSchema-instance' xsi:schemaLocation='urn:hl7-org:v3 infrastructure/cda/CDA.xsd' root='2.16.840.1.113883.1.3' extension='POCD_HD000040'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.11.2'/> <id root='db734647-fc99-424c-a864-7e3cda82e703'/> <code code='2.16.1.2' codeSystem='2.4' displayName='loinc'/> <title>Good Health Clinic Visit Summary Flowsheet</title> <effectiveTime value='20000407130000+0500'/> <confidentialityCode code='N' codeSystem='2.16.840.1.113883.5.25'/> <languageCode code='en-US'/> <recordTarget> <patientRole> <id root='d9ec96bd-f756-4aaa-95d8-62053bbd81a1'/> <patient> <name> <given>Henry</given> <family>Levin</family> <suffix>the 7th</suffix> </name> <administrativeGenderCode code='M' codeSystem='2.16.840.1.113883.5.1'/> <birthTime value='19320924'/> </patient> <providerOrganization> <id root='2.16.840.1.113883.19.5'/> </providerOrganization> </patientRole> </recordTarget> <!-- Clinic --> <author> <time value='20000407130000+0500'/> <assignedAuthor> <id root='20cf14fb-b65c-4c8c-a54d-b0cca834ceww'/> <assignedAuthoringDevice> <softwareName>Good Health Clinic System v1.0</softwareName> </assignedAuthoringDevice> <representedOrganization> <id root='2.16.840.1.113883.19.5'/> </representedOrganization> </assignedAuthor> </author> <!-- Physicians --> <!-- are referenced in Visit Summary and Problems sections --> <author> <time value='20000407130000+0500'/> <assignedAuthor> <id root='20cf14fb-b65c-4c8c-a54d-b0cca834c18c'/> <assignedPerson> <name> <prefix>Dr.</prefix> <given>Robert</given> <family>Dolin</family> </name> </assignedPerson> <representedOrganization> <id root='2.16.840.1.113883.19.5'/> <name>Good Health Clinic</name> </representedOrganization> </assignedAuthor> </author> <author> <time value='20000407130000+0500'/> <assignedAuthor> <id root='4d87816b-1000-11dc-8314-0800200c9a66'/> <assignedPerson> <name> <prefix>Dr.</prefix> <given>Robert</given> <family>Dolin</family> </name> </assignedPerson> <representedOrganization> <id root='2.16.840.1.113883.19.5'/> <name>Good Health Clinic</name> </representedOrganization> </assignedAuthor> </author> <author> <time value='20000407130000+0500'/> <assignedAuthor> <id root='2a6ae35c-bbd7-4c26-ab3d-6cd160fec66c'/> <assignedPerson> <name> <prefix>Dr.</prefix> <given>D.</given> <family>Dzubin</family> </name> </assignedPerson> <representedOrganization> <id root='2.16.840.1.113883.19.5'/> <name>Good Health Clinic</name> </representedOrganization> </assignedAuthor> </author> <author> <time value='20000407130000+0500'/> <assignedAuthor> <id root='14d465a5-b47d-45a8-ad2c-7d1a51e9ed56'/> <assignedPerson> <name> <prefix>Dr.</prefix> <given>E.</given> <family>Pickett</family> </name> </assignedPerson> <representedOrganization> <id root='2.16.840.1.113883.19.5'/> <name>Good Health Clinic</name> </representedOrganization> </assignedAuthor> </author> <author> <time value='20000407130000+0500'/> <assignedAuthor> <id root='3047e209-5926-4556-b3c9-5f35c4269279'/> <assignedPerson> <name> <prefix>Dr.</prefix> <given>E.</given> <family>Robinson</family> </name> </assignedPerson> <representedOrganization> <id root='2.16.840.1.113883.19.5'/> <name>Good Health Clinic</name> </representedOrganization> </assignedAuthor> </author> <custodian> <assignedCustodian> <representedCustodianOrganization> <id root='2.16.840.1.113883.19.5'/> <name>Good Health Clinic</name> </representedCustodianOrganization> </assignedCustodian> </custodian> <legalAuthenticator> <time value='20000407130000+0500'/> <signatureCode code='S'/> <assignedEntity> <id root='2.16.840.1.113883.19.5'/> <representedOrganization> <id root='2.16.840.1.113883.19.5'/> </representedOrganization> </assignedEntity> </legalAuthenticator> <participant typeCode='IND'> <associatedEntity classCode='GUAR'> <id root='4ff51570-83a9-47b7-91f2-93ba30373141'/> <addr> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> </addr> <telecom value='tel:(888)555-1212'/> <associatedPerson> <name> <given>Kenneth</given> <family>Ross</family> </name> </associatedPerson> </associatedEntity> </participant> <participant typeCode='IND'> <associatedEntity classCode='NOK'> <id root='4ac71514-6a10-4164-9715-f8d96af48e6d'/> <code code='MTH' codeSystem='2.16.840.1.113883.5.111'/> <telecom value='tel:(999)555-1212'/> <associatedPerson> <name> <given>Abigail</given> <family>Ruth</family> </name> </associatedPerson> </associatedEntity> </participant> <documentationOf> <serviceEvent classCode='PCPR'> <effectiveTime> <low value='19320924'/> <high value='20000407'/> </effectiveTime> <performer typeCode='PRF'> <functionCode code='PCP' codeSystem='2.16.840.1.113883.5.88'/> <time><low value='1990'/><high value='20000407'/></time> <assignedEntity> <id root='20cf14fb-b65c-4c8c-a54d-b0cca834c18c'/> <assignedPerson> <name> <prefix>Dr.</prefix> <given>Robert</given> <family>Dolin</family> </name> </assignedPerson> <representedOrganization> <id root='2.16.840.1.113883.19.5'/> </representedOrganization> </assignedEntity> </performer> </serviceEvent> </documentationOf> <!-- ******************************************************** CDA Body ******************************************************** --> <component> <structuredBody>
Allergies
<!-- ******************************************************** Allergies ******************************************************** --> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/> <code code='10155-0' displayName='HISTORY OF ALLERGIES' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Allergies</title> <text> <!-- Narrative --> <table border='1'> <thead> <tr> <td>Allergy</td> </tr> </thead> <tbody> <tr> <td ID='Allergy'>Latex</td> </tr> </tbody> </table> </text> <entry> <!-- Latex Allergy --> <!-- negationInd will be true if patient does NOT have latex allergy --> <observation classCode='COND' moodCode='EVN' negationInd='false'> <templateId extension='allergy' root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/> <id root='dc6d49d1-9371-40bb-9507-90ca93e181a6'/> <!-- TODO: what is EALG? --> <code xsi:type='CD' code='EALG' displayName='ObservationEnvironmentAllergyType' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode' /> <statusCode code='active'/> <effectiveTime> <low value='20041101'/> </effectiveTime> <value xsi:type='CD' code='300916003' displayName='Latex allergy (disorder)' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'> <originalText> <reference value='#Allergy'/> </originalText> </value> </observation> </entry> </section> </component>
Advance Directives (Blood Transfusion)
<!-- ******************************************************** Advance Directives - Blood Transfusion ******************************************************** --> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34' /> <title>Is Blood Transfusion Acceptable?</title> <text> <table border='1'> <thead> <tr><th>Is Blood Transfusion Acceptable?</th></tr> </thead> <tbody> <tr><td ID='BloodTransfusion'>yes</td></tr> </tbody> </table> </text> <entry> <!-- Blood Transfusion Acceptable? --> <observation classCode='OBS' moodCode='RQO'> <templateId root='2.16.840.1.113883.10.20.1.25'/> <id root='9a6d1bac-17d3-4195-89a4-1121bc809b4a'/> <code code='(xx-bld-transf-ok)' displayName='Blood Transfusion Preference-FIND-PT-^PATIENT-ORD-PATIENT REPORTED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'> <originalText> <reference value="#BloodTransfusion"/> </originalText> </code> <statusCode code='complete'/> <effectiveTime value='20061129'/> <value xsi:type='BL' value='true'/> </observation> </entry> </section> </component>
Plan of Care - Anesthesia Consult
<!-- ******************************************************** Plan of Care - Anesthesia Consult, Plans (from problem section) ******************************************************** --> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31' /> <id root='78385836-15cd-11dc-8314-0800200c9a66'/> <title>Plan of Care</title> <text> <table border='1'> <thead> <tr><th>Anesthesia Consult Planned?</th><th>Plan Details</th><th>Planned Date</th></tr> </thead> <tbody> <tr> <td ID='AnesthesiaPlanned'>yes</td> <td ID='AnesthesiaDetails'>Epidural</td> <td ID='AnesthesiaDate'>8/19/2007</td> </tr> </tbody> </table> </text> <entry typeCode='DRIV'> <!-- anesthesia consult planned --> <!-- Was consult planned? --> <observation classCode='OBS' moodCode='RQO'> <templateId root='2.16.840.1.113883.10.20.1.25'/> <id root='cff15bec-720b-4431-8e54-a29532f81a2a'/> <code code='(xx-anest-cons-pland)' codeSystem='2.16.840.1.113883.6.1' displayName='Anesthesia Consult Status-FIND-PT-^PATIENT-ORD-' codeSystemName='LOINC'> <originalText><reference value='#AnesthesiaPlanned'/></originalText> </code> <statusCode code='complete'/> <effectiveTime value='20061129'/> <value xsi:type='BL' value='true'/> </observation> </entry> <entry typeCode='DRIV'> <!-- anesthesia consult planned --> <!-- Details of plan if known --> <observation classCode='OBS' moodCode='RQO'> <templateId root='2.16.840.1.113883.10.20.1.25'/> <id root='1e782c18-b738-448c-87df-7b6a38caedec'/> <code code='(xx-type-of-anesth-pland)' codeSystem='2.16.840.1.113883.6.1' displayName='Anesthesia Consult Plans??' codeSystemName='LOINC'> <!-- TODO: Determine displayName --> <originalText><reference value='#AnesthesiaDetails'/></originalText> </code> <statusCode code='complete'/> <effectiveTime value='20061129'/> <value xsi:type='ED'/> </observation> </entry> </section> </component>
Medications
<!-- ******************************************************** Medications ******************************************************** --> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19' /> <id root='601b5a7b-67f0-4cd8-b856-1ba4c2b8f444' /> <title>Medication List</title> <text> <!-- narrative --> <table border='1'> <thead> <tr><td>Medication List</td></tr> <tr> <th>Medication Name</th> <th>Start Date</th> <th>Stop Date</th> </tr> </thead> <tbody> <tr > <td ID='MedName-1'>Pt Rtp: Crinone</td> <td ID='MedStartDate-1'>11/29/2006</td> <td ID='MedStopDate-1'>2/1/2007</td> </tr> <tr> <td ID='MedName-2'>Rx: Macrobid Oral Capsule 100 mg bid 10 Ref:0</td> <td ID='MedStartDate-2'>12/8/2006</td> <td ID='MedStopDate-2'>12/13/2006</td> </tr> <tr> <td ID='MedName-3'>Pt Rpt: Prozac</td> <td ID='MedStartDate-3'>3/16/2004</td> <td ID='MedStopDate-3'>11/29/2006</td> </tr> <tr> <td ID='MedName-4'>Rx: PrimaCare ONE Oral Capsule 27-1-300 m...</td> <td ID='MedStartDate-4'>11/29/2006</td> <td ID='MedStopDate-4'>12/24/2007</td> </tr> </tbody> </table> </text> <entry> <!-- Med-1 --> <substanceAdministration classCode='SBADM' moodCode='EVN'> <templateId root='2.16.840.1.113883.10.20.1.24'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> <id root='b98f68e3-4cdb-4baf-bec3-6d87579b7c4d'/> <statusCode code='completed'/> <!-- Start/Stop Date --> <effectiveTime xsi:type='IVL_TS'> <low value='20061129'/> <high value='20070201'/> </effectiveTime> <consumable> <manufacturedProduct> <manufacturedLabeledDrug> <name>Crinone</name> </manufacturedLabeledDrug> </manufacturedProduct> </consumable> </substanceAdministration> </entry> <entry> <!-- Med-2 --> <substanceAdministration classCode='SBADM' moodCode='INT'> <templateId root='2.16.840.1.113883.10.20.1.24'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> <id root='acd970a0-31b8-46b2-954a-7b127927d47c'/> <statusCode code='completed'/> <!-- Start/Stop Date --> <effectiveTime xsi:type='IVL_TS'> <low value='20061208'/> <high value='20061213'/> </effectiveTime> <consumable> <manufacturedProduct> <manufacturedLabeledDrug> <name>Macrobid Oral Capsule 100 mg bid 10 Ref:0</name> </manufacturedLabeledDrug> </manufacturedProduct> </consumable> </substanceAdministration> </entry> <entry> <!-- Med-3 --> <substanceAdministration classCode='SBADM' moodCode='EVN'> <templateId root='2.16.840.1.113883.10.20.1.24'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> <id root='8fb9160b-c7c3-44fa-886e-d367a522ba80'/> <statusCode code='completed'/> <!-- Start/Stop Date --> <effectiveTime xsi:type='IVL_TS'> <low value='20040316'/> <high value='20061129'/> </effectiveTime> <consumable> <manufacturedProduct> <manufacturedLabeledDrug> <name>Prozac</name> </manufacturedLabeledDrug> </manufacturedProduct> </consumable> </substanceAdministration> </entry> <entry> <!-- Med-4 --> <substanceAdministration classCode='SBADM' moodCode='INT'> <templateId root='2.16.840.1.113883.10.20.1.24'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> <id root='5d989f63-d02d-4a1e-a4ea-f9377679320b'/> <statusCode code='completed'/> <!-- Start/Stop Date --> <effectiveTime xsi:type='IVL_TS'> <low value='20061129'/> <high value='20071224'/> </effectiveTime> <consumable> <manufacturedProduct> <manufacturedLabeledDrug> <name>PrimaCare ONE Oral Capsule 27-1-300 m...</name> </manufacturedLabeledDrug> </manufacturedProduct> </consumable> </substanceAdministration> </entry> </section> </component>
Problems
<!-- ******************************************************** Problems ******************************************************** --> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/> <title>Problems</title> <text> <!-- Narrative --> <table border='1'> <thead> <tr><td>Problems/Plans</td></tr> <tr> <th>Problem</th> <th>Start Date</th> <th>Stop Date</th> <th>Physician</th> </tr> </thead> <tbody> <tr> <!-- Problem #1 --> <td ID='Problem-1'>Hx of: Depression</td> <td ID='StartDate-1'>11/29/2006</td> <td ID='StopDate-1'></td> <td ID='Physician-1'>D. Dzubin</td> </tr> <tr> <!-- Problem #2 --> <td ID='Problem-2'>Current: Gestational Diabetes (diet)</td> <td ID='StartDate-2'>3/19/2007</td> <td ID='StopDate-2'></td> <td ID='Physician-2'>E. Pickett</td> </tr> <tr> <!-- Problem #3 --> <td ID='Problem-3'>Hx of: Infertility</td> <td ID='StartDate-3'>11/29/2006</td> <td ID='StopDate-3'></td> <td ID='Physician-3'>D. Dzubin</td> </tr> <tr> <!-- Problem #4 --> <td ID='Problem-4'>D. Dzubin IVF pregnancy</td> <td ID='StartDate-4'>12/14/2006</td> <td ID='StopDate-4'></td> <td ID='Physician-4'>E. Robinson</td> </tr> </tbody> </table> </text> <entry> <!-- Problem #1 --> <observation classCode='COND' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1'/> <id root='dc6d49d1-9371-40bb-9507-90ca93e181a6'/> <code code='11450-4' displayName='Problem List' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'> <originalText><reference value="#Problem-1"/></originalText> </code> <effectiveTime> <low value='20061129'/> </effectiveTime> <author typeCode='AUT'> <!-- Physician --> <time value='20061129'/> <assignedAuthor> <id root='2a6ae35c-bbd7-4c26-ab3d-6cd160fec66c'/> <!-- links to header element --> </assignedAuthor> </author> </observation> </entry> <entry> <!-- Problem #2 --> <observation classCode='COND' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1'/> <id root='00448a62-d986-4be9-8cff-f8d5b12c3233'/> <code code='11450-4' displayName='Problem List' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'> <originalText><reference value="#Problem-2"/></originalText> </code> <effectiveTime> <low value='20070319'/> </effectiveTime> <author typeCode='AUT'> <!-- Physician --> <time value='20070319'/> <assignedAuthor> <id root='14d465a5-b47d-45a8-ad2c-7d1a51e9ed56'/><!-- links to header element --> </assignedAuthor> </author> </observation> </entry> <entry> <!-- Problem #3 --> <observation classCode='COND' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1'/> <id root='219e87a0-b2fb-4ffb-917e-8cdeede4af79'/> <code code='11450-4' displayName='Problem List' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'> <originalText><reference value="#Problem-3"/></originalText> </code> <effectiveTime> <low value='20061129'/> </effectiveTime> <author typeCode='AUT'> <!-- Physician --> <time value='20061129'/> <assignedAuthor> <id root='2a6ae35c-bbd7-4c26-ab3d-6cd160fec66c'/> <!-- links to header element --> </assignedAuthor> </author> </observation> </entry> <entry> <!-- Problem #4 --> <observation classCode='COND' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1'/> <id root='9ad41ad5-9687-4b0a-9c4d-d003f31198ab'/> <code code='11450-4' displayName='Problem List' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'> <originalText><reference value="#Problem-4"/></originalText> </code> <effectiveTime> <low value='20061214'/> </effectiveTime> <author typeCode='AUT'> <!-- Physician --> <time value='20061214'/> <assignedAuthor> <id root='3047e209-5926-4556-b3c9-5f35c4269279'/> <!-- links to header element --> </assignedAuthor> </author> </observation> </entry> </section> </component>
Estimated Due Dates
<!-- ******************************************************** Estimated Due Dates ******************************************************** --> <component> <section> <id/> <title>Estimated Due Date</title> <text> <!-- narrative --> <table border="1"> <!-- Initial EDD --> <thead> <tr><td>Initial EDD Confirmation</td></tr> <tr> <th>Method</th> <th>Date</th> <th>Weeks</th> <th>EDD</th> </tr> </thead> <tbody> <tr> <td ID='InitialEDDMethod-1'>LMP</td> <td ID='InitialEDDDate-1'>9/25/2006</td> <td ID='InitialEDDWeeks-1'>N/A</td> <td ID='InitialEDD-1'>7/2/2007</td> </tr> <tr> <td ID='InitialEDDMethod-2'>Ultrasound</td> <td ID='InitialEDDDate-2'> 11/9/2006</td> <td ID='InitialEDDWeeks-2'>6.5</td> <td ID='InitialEDD-2'>6/30/2007</td> </tr> <tr> <td>Initial EDD</td> <td>N/A</td> <td>N/A</td> <td ID='InitialEDD'>7/2/2007</td> </tr> </tbody> </table> <table border="1"> <!-- Final EDD --> <thead> <tr><td>18-20 Week Update</td></tr> <tr> <th>Method</th> <th>Date</th> <th>Weeks</th> <th>EDD</th> </tr> </thead> <tbody> <tr> <td ID='UpdateEDDMethod-1'>Ultrasound</td> <td ID='UpdateEDDDate-1'>2/12/2007</td> <td ID='UpdateEDDWeeks-1'>20.5</td> <td ID='UpdateEDD-1'>6/27/2007</td> </tr> <tr> <td>Final EDD</td> <td>N/A</td> <td>N/A</td> <td ID='FinalEDD'>7/2/2007</td> </tr> </tbody> </table> </text> <entry> <!-- Initial EDD Confirmation --> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <!-- SimpleObservation OID --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1' /> <!-- EDD Observation --> <id root='2c878572-136a-11dc-8314-0800200c9a66'/> <code code='11778-8' displayName='DELIVERY DATE-TMSTP-PT-^PATIENT-QN-CLINICAL.ESTIMATED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#InitialEDD'/></text> <statusCode code='completed'/> <effectiveTime value='20061129' /> <value xsi:type='TS'/> <author typeCode='AUT'> <!-- Provider Initials --> <time value='20061129'/> <!-- Visit Date --> <assignedAuthor> <id root='20cf14fb-b65c-4c8c-a54d-b0cca834c18c' /> <!-- links to header element --> </assignedAuthor> </author> <!-- LMP --> <entryRelationship typeCode='SPRT'> <observation classCode='OBS' moodCode='EVN'> <id root='40a0ebdc-1397-11dc-8314-0800200c9a66'/> <code code='11779-6' displayName='DELIVERY DATE-TMSTP-PT-^PATIENT-QN-ESTIMATED FROM LAST MENSTRUAL PERIOD' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <!-- EDD based on LMP --> <text><reference value="#InitialEDDDate-2"/></text> <statusCode code='completed'/> <effectiveTime value='20060925'/> <!-- Date of LMP --> <value xsi:type='TS'/> </observation> </entryRelationship> <!-- Ultrasound --> <entryRelationship typeCode='SPRT'> <observation classCode='OBS' moodCode='EVN'> <id root='5d12d9bc-138b-11dc-8314-0800200c9a66'/> <code code='11781-2' displayName='DELIVERY DATE-TMSTP-PT-^PATIENT-QN-US.COMPOSITE.ESTIMATED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <!-- EDD based on Ultrasound --> <text><reference value="#InitialEDDDate-2"/></text> <effectiveTime value='20061109'/> <!-- Date Ultrasound was taken --> <value xsi:type='TS'/> <!-- Weeks Gestation --> <entryRelationship typeCode='SPRT'> <observation classCode='OBS' moodCode='EVN'> <id root='4f475f30-1370-11dc-8314-0800200c9a66'/> <!-- TODO: informant? --> <!--<informant><reference id=''/></informant>--> <code code='11888-5' displayName='GESTATIONAL AGE-TIME-PT-^FETUS-QN-US.COMPOSITE.ESTIMATED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#InitialEDDWeeks-2'/></text> <statusCode code='completed'/> <effectiveTime value='20061129'/> <value xsi:type='PQ' unit='d' value='47'/> <!-- (6 x 7) + 5 = 47--> </observation> </entryRelationship> </observation> </entryRelationship> </observation> </entry> <entry> <!-- 18-20 week EDD Update --> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <!-- SimpleObservation OID --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.1' /> <!-- EDD Observation --> <id root='54bbe9d2-139e-11dc-8314-0800200c9a66'/> <code code='11778-8' displayName='DELIVERY DATE-TMSTP-PT-^PATIENT-QN-CLINICAL.ESTIMATED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#FinalEDD'/></text> <statusCode code='completed' /> <effectiveTime value='20061129' /> <value xsi:type='TS'/> <author typeCode='AUT' > <!-- Provider Initials --> <time value='20061129'/> <!-- Visit Date --> <assignedAuthor> <id root='20cf14fb-b65c-4c8c-a54d-b0cca834c18c' /> <!-- links to header element --> </assignedAuthor> </author> <!-- Ultrasound --> <entryRelationship typeCode='SPRT'> <observation classCode='OBS' moodCode='EVN'> <id root='6d86f6ee-139e-11dc-8314-0800200c9a66'/> <code code='11781-2' displayName='DELIVERY DATE-TMSTP-PT-^PATIENT-QN-US.COMPOSITE.ESTIMATED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <!-- EDD based on Ultrasound --> <text><reference value="#InitialEDDDate-2"/></text> <effectiveTime value='20061109'/> <!-- Date Ultrasound was taken --> <value xsi:type='TS'/> <!-- Weeks Gestation --> <entryRelationship typeCode='SPRT'> <observation classCode='OBS' moodCode='EVN'> <id root='62915e78-139e-11dc-8314-0800200c9a66'/> <!-- TODO: informant? --> <!--<informant><reference id=''/></informant>--> <code code='11888-5' displayName='GESTATIONAL AGE-TIME-PT-^FETUS-QN-US.COMPOSITE.ESTIMATED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#UpdateEDDWeeks-1'/></text> <statusCode code='completed'/> <effectiveTime value='20061129'/> <value xsi:type='PQ' unit='d' value='145'/><!-- (20 x 7) + 5 = 145--> </observation> </entryRelationship> </observation> </entryRelationship> </observation> </entry> </section> </component>
Visit Summary Flowsheet
<!-- ******************************************************** Visit Summary Flowsheet ******************************************************** --> <component> <section> <id/> <title>Visit Summary Flowsheet</title> <text> <table border='1'> <thead> <tr> <td>Pre-pregnancy Weight</td> </tr> </thead> <tbody> <tr> <td>220</td> </tr> </tbody> </table> <table border='1'> <thead> <tr> <td colspan='19'>Visit Summary</td> </tr> <tr> <th>Weeks Gestation</th> <th>Fundal Height(cm)</th> <th>Presentation</th> <th>FHR</th> <th>Fetal Movement</th> <th>Preterm Labor Symptoms</th> <th>Cervix Exam-Dilation</th> <th>Cervix Exam-Effacement</th> <th>Cervix Exam-Station</th> <th>BP - Systolic</th> <th>BP - Diastolic</th> <th>Weight</th> <th>Urine-Albumin</th> <th>Urine-Glucose</th> <th>Edema</th> <th>Pain Scale (0-10)</th> <th>Next Appt</th> <th>Provider Initials</th> <th>Comments</th> </tr> </thead> <tbody> <tr > <td ID='WeeksGestation-1'>9.3</td> <td ID='FundalHeight-1'></td> <td ID='Presentation-1'>NULL^UNKNOWN</td> <td ID='FHR-1'>Not Heard</td> <td ID='Quickening-1'>no</td> <td ID='PretermLabor-1'>no</td> <td ID='CervixDil-1'>closed</td> <td ID='CervixEff-1'>0</td> <td ID='CervixSta-1'>unengaged</td> <td ID='BPSystolic-1'>110</td> <td ID='BPDiastolic-1'>60</td> <td ID='Weight-1'>218</td> <td ID='UrineAlbumin-1'>Neg</td> <td ID='UrineGlucose-1'>NL</td> <td ID='Edema-1'>None</td> <td ID='PainScale-1'>0</td> <td ID='NextAppt-1'>2 Weeks</td> <td ID='ProviderInitials-1'>DD</td> <td ID='Comments-1'>33 yo G1 IVF implantation 10/10 here for IP...</td> </tr> <tr> <td ID='WeeksGestation-2'>11.4</td> <td ID='FundalHeight-2'>12</td> <td ID='Presentation-2'>NULL^UNKNOWN</td> <td ID='FHR-2'>Not Heard</td> <td ID='Quickening-2'>no</td> <td ID='PretermLabor-2'>no</td> <td ID='CervixDil-2'></td> <td ID='CervixEff-2'></td> <td ID='CervixSta-2'></td> <td ID='BPSystolic-2'>110</td> <td ID='BPDiastolic-2'>63</td> <td ID='Weight-2'>217</td> <td ID='UrineAlbumin-2'>Neg</td> <td ID='UrineGlucose-2'>NL</td> <td ID='Edema-2'>None</td> <td ID='PainScale-2'>0</td> <td ID='NextAppt-2'>4 Weeks</td> <td ID='ProviderInitials-2'>ER</td> <td ID='Comments-2'>11.3wk by LMP c/w 6.5 wk U/S. No FHT tod...</td> </tr> </tbody> </table> </text> <!-- pre-pregancy weight --> <entry> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='23e87612-1000-11dc-8314-0800200c9a66'/> <code code='8348-5' displayName='BODY WEIGHT^PRE PREGNANCY-MASS-PT-QN-MEASURED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#PrePregWeight-1'/></text> <statusCode code='completed'/> <effectiveTime value='200609211242-08'/> <value xsi:type='PQ' /> </observation> </entry> <!-- panel date 11/29/06 --> <entry> <organizer classCode='BATTERY' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2'/> <id root='4d878166-1000-11dc-8314-0800200c9a66'/> <code code='(xx-acog-battery)' displayName='ACOG Summary Visit Battery---PT--' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <statusCode code='completed'/> <effectiveTime value='200611291242-08'/> <author typeCode='AUT'> <!-- Provider Initials --> <time value='20061129'/> <!-- Visit Date --> <assignedAuthor> <id root='20cf14fb-b65c-4c8c-a54d-b0cca834c18c' /> <!-- links to header element --> </assignedAuthor> </author> <!-- Weeks Gestation --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='4d878167-1000-11dc-8314-0800200c9a66'/> <code code='11884-4' displayName='GESTATIONAL AGE-TIME-PT-^FETUS-QN-CLINICAL.ESTIMATED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#WeeksGestation-1'/></text> <statusCode code='completed'/> <value xsi:type='PQ' unit='d' value='66'/> <!-- (9 x 7) + 3 = 66 --> </observation> </component> <!-- Fundal Height (cm) --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='4d878168-1000-11dc-8314-0800200c9a66'/> <code code='11881-0' displayName='FUNDAL HEIGHT-LEN-PT-UTERUS-QN-TAPE MEASURE' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#FundalHeight-1'/></text> <statusCode code='completed'/> <value xsi:type='PQ'/> </observation> </component> <!-- Presentation (value set) --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='4d878169-1000-11dc-8314-0800200c9a66'/> <code code='11876-0' displayName='FETAL PRESENTATION-TYPE-PT-PELVIS-NOM-PALPATION' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#Presentation-1'/></text> <statusCode code='completed'/> <value xsi:type='CO'/> </observation> </component> <!-- Fetal Heart Rate --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='694f9f23-ed2f-4534-89c2-3bf4ccb6581e'/> <code code='11948-7' displayName='HEART RATE-NRAT-PT-^FETUS-QN-US.MEASURED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#FHR-1'/></text> <statusCode code='completed'/> <value xsi:type='PQ'> </value> </observation> </component> <!-- Fetal Movement/Quickening --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='b7c8d2dc-405f-4cb1-8d53-9395e414f3a5'/> <code code='(xx-fetal-movement)' displayName='MOVEMENT-FIND-PT-^FETUS-ORD-PATIENT REPORTED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#Quickening-1'/></text> <statusCode code='completed'/> <value xsi:type='CO'/> </observation> </component> <!-- Preterm Labor Symptoms --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='4e58accc-2668-4329-b9af-d7be78f86af4'/> <code code='(xx-SS-Preterm-Labor)' displayName='PRETERM LABOR SYMPTOMS-FIND-PT-^PATIENT-QL-CLINICAL JUDGEMENT' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#PretermLabor-1'/></text> <statusCode code='completed'/> <value xsi:type='BL'/> </observation> </component> <!-- Cervix Exam - Dilation --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='a53c8593-d822-4722-9aa6-b7e74debc6b0'/> <code code='(xx-cerv-dil-palp)' displayName='DILATION-LEN-PT-CERVIX-QN-PALPATION' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <text><reference value='#CervixDil-1'/></text> <statusCode code='completed'/> <value xsi:type='PQ'/> </observation> </component> <!-- Cervix Exam - Effacement --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='a53c8593-d822-4722-9aa6-b7e74debc6b0'/> <code code='11867-9' displayName='EFFACEMENT-PRCTL-PT-CERVIX-ORD-PALPATION ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#CervixEff-1'/></text> <statusCode code='completed'/> <value xsi:type='CO'/> </observation> </component> <!-- Cervix Exam - Station --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='a53c8593-d822-4722-9aa6-b7e74debc6b0'/> <code code='11961-0' displayName='LONG AXIS-LEN-PT-CERVIX-QN-US.MEASURED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#CervixSta-1'/></text> <statusCode code='completed'/> <value xsi:type='PQ'/> </observation> </component> <!-- Blood Pressure - Systolic --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='4773a849-db3f-4e21-b3a9-7b5b467d91e9'/> <code code='8480-6' displayName='INTRAVASCULAR SYSTOLIC-PRES-PT-ARTERIAL SYSTEM-QN' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <text><reference value='#BPSystolic-1'/></text> <statusCode code='completed'/> <value xsi:type='PQ'/> </observation> </component> <!-- Blood Pressure - Diastolic --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='4773a849-db3f-4e21-b3a9-7b5b467d91e9'/> <code code='8462-4' displayName='INTRAVASCULAR DIASTOLIC-PRES-PT-ARTERIAL SYSTEM-QN' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#BPDiastolic-1'/></text> <statusCode code='completed'/> <value xsi:type='PQ'/> </observation> </component> <!-- Weight --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='22c470bc-db0a-4b66-a9e6-d2fac31db930'/> <code code='3141-9' displayName='BODY WEIGHT-MASS-PT-^PATIENT-QN-MEASURED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#Weight-1'/></text> <statusCode code='completed'/> <value xsi:type='PQ'/> </observation> </component> <!-- Urine - Albumin --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='13599834-be6f-44fc-9db1-e5dc6a79d565'/> <code code='1753-3' displayName='ALBUMIN-ACNC-PT-UR-ORD' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#UrineAlbumin-1'/></text> <statusCode code='completed'/> <value xsi:type='CO'/> </observation> </component> <!-- Urine - Glucose --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='13599834-be6f-44fc-9db1-e5dc6a79d565'/> <code code='2349-9' displayName='GLUCOSE-ACNC-PT-UR-ORD' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#UrineGlucose-1'/></text> <statusCode code='completed'/> <value xsi:type='CO'/> </observation> </component> <!-- Edema --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='3b3fb536-e9ad-47f4-8199-c58c017b6186'/> <code code='44966-0' displayName='EDEMA-FIND-PT-^PATIENT-ORD' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#Edema-1'/></text> <statusCode code='completed'/> <value xsi:type='CO'/> </observation> </component> <!-- Pain Scale (1-10) --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='78e08791-af8c-4b05-98a0-8949eae03e59'/> <code code='38208-5' displayName='PAIN SEVERITY-FIND-PT-^PATIENT-ORD-REPORTED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#PainScale-1'/></text> <statusCode code='completed'/> <value xsi:type='CO'/> </observation> </component> <!-- Next Appointment --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='4fb5998e-11e4-416e-ab2c-e5b6f7c424a4'/> <code code='(xx-time-to-next-appt)' displayName='TIME TO NEXT VISIT-' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#NextAppt-1'/></text> <statusCode code='completed'/> <value xsi:type='ED'/> </observation> </component> <!-- Comments --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='e53fec4b-f3c0-486e-b4e0-22fb65e7f547'/> <code code='48767-8' displayName='(comment field)' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#Comments-1'/></text> <statusCode code='completed'/> <value xsi:type='ED'/> </observation> </component> </organizer> </entry> <!-- panel date 4/26/07 --> <entry> <organizer classCode='BATTERY' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2'/> <id root='4d878166-1000-11dc-8314-0800200c9a66'/> <code code='(xx-acog-battery)' displayName='ACOG Summary Visit Battery---PT--' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <statusCode code='completed'/> <effectiveTime value='200611291242-08'/> <author typeCode='AUT'> <!-- Provider Initials --> <time value='20061129'/> <!-- Visit Date --> <assignedAuthor> <id root='20cf14fb-b65c-4c8c-a54d-b0cca834c18c' /> <!-- links to header element --> </assignedAuthor> </author> <!-- Weeks Gestation --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='4d878167-1000-11dc-8314-0800200c9a66'/> <code code='11884-4' displayName='GESTATIONAL AGE-TIME-PT-^FETUS-QN-CLINICAL.ESTIMATED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#WeeksGestation-2'/></text> <statusCode code='completed'/> <value xsi:type='PQ' unit='d' value='81'/> <!-- (11 x 7) + 4 = 81 --> </observation> </component> <!-- Fundal Height (cm) --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='4d878168-1000-11dc-8314-0800200c9a66'/> <code code='11881-0' displayName='FUNDAL HEIGHT-LEN-PT-UTERUS-QN-TAPE MEASURE' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#FundalHeight-2'/></text> <statusCode code='completed'/> <value xsi:type='PQ'/> </observation> </component> <!-- Presentation (value set) --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='4d878169-1000-11dc-8314-0800200c9a66'/> <code code='11876-0' displayName='FETAL PRESENTATION-TYPE-PT-PELVIS-NOM-PALPATION' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#Presentation-2'/></text> <statusCode code='completed'/> <value xsi:type='CO'/> </observation> </component> <!-- Fetal Heart Rate --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='694f9f23-ed2f-4534-89c2-3bf4ccb6581e'/> <code code='11948-7' displayName='HEART RATE-NRAT-PT-^FETUS-QN-US.MEASURED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#FHR-2'/></text> <statusCode code='completed'/> <value xsi:type='PQ'/> </observation> </component> <!-- Fetal Movement/Quickening --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='b7c8d2dc-405f-4cb1-8d53-9395e414f3a5'/> <code code='(xx-fetal-movement)' displayName='MOVEMENT-FIND-PT-^FETUS-ORD-PATIENT REPORTED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#Quickening-2'/></text> <statusCode code='completed'/> <value xsi:type='CO'/> </observation> </component> <!-- Preterm Labor Symptoms --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='4e58accc-2668-4329-b9af-d7be78f86af4'/> <code code='(xx-SS-Preterm-Labor)' displayName='PRETERM LABOR SYMPTOMS-FIND-PT-^PATIENT-QL-CLINICAL JUDGEMENT' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#PretermLabor-2'/></text> <statusCode code='completed'/> <value xsi:type='BL'/> </observation> </component> <!-- Cervix Exam - Dilation --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='a53c8593-d822-4722-9aa6-b7e74debc6b0'/> <code code='(xx-cerv-dil-palp)' displayName='DILATION-LEN-PT-CERVIX-QN-PALPATION' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <text><reference value='#CervixDil-2'/></text> <statusCode code='completed'/> <value xsi:type='PQ'/> </observation> </component> <!-- Cervix Exam - Effacement --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='a53c8593-d822-4722-9aa6-b7e74debc6b0'/> <code code='11867-9' displayName='EFFACEMENT-PRCTL-PT-CERVIX-ORD-PALPATION ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#CervixEff-2'/></text> <statusCode code='completed'/> <value xsi:type='CO'/> </observation> </component> <!-- Cervix Exam - Station --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='a53c8593-d822-4722-9aa6-b7e74debc6b0'/> <code code='11961-0' displayName='LONG AXIS-LEN-PT-CERVIX-QN-US.MEASURED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#CervixSta-2'/></text> <statusCode code='completed'/> <value xsi:type='PQ'/> </observation> </component> <!-- Blood Pressure - Systolic --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='4773a849-db3f-4e21-b3a9-7b5b467d91e9'/> <code code='8480-6' displayName='INTRAVASCULAR SYSTOLIC-PRES-PT-ARTERIAL SYSTEM-QN' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <text><reference value='#BPSystolic-2'/></text> <statusCode code='completed'/> <value xsi:type='PQ'/> </observation> </component> <!-- Blood Pressure - Diastolic --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='4773a849-db3f-4e21-b3a9-7b5b467d91e9'/> <code code='8462-4' displayName='INTRAVASCULAR DIASTOLIC-PRES-PT-ARTERIAL SYSTEM-QN' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#BPDiastolic-2'/></text> <statusCode code='completed'/> <value xsi:type='PQ'/> </observation> </component> <!-- Weight --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='22c470bc-db0a-4b66-a9e6-d2fac31db930'/> <code code='3141-9' displayName='BODY WEIGHT-MASS-PT-^PATIENT-QN-MEASURED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#Weight-2'/></text> <statusCode code='completed'/> <value xsi:type='PQ'/> </observation> </component> <!-- Urine - Albumin --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='13599834-be6f-44fc-9db1-e5dc6a79d565'/> <code code='1753-3' displayName='ALBUMIN-ACNC-PT-UR-ORD' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#UrineAlbumin-2'/></text> <statusCode code='completed'/> <value xsi:type='CO'/> </observation> </component> <!-- Urine - Glucose --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='13599834-be6f-44fc-9db1-e5dc6a79d565'/> <code code='2349-9' displayName='GLUCOSE-ACNC-PT-UR-ORD' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#UrineGlucose-2'/></text> <statusCode code='completed'/> <value xsi:type='CO'/> </observation> </component> <!-- Edema --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='3b3fb536-e9ad-47f4-8199-c58c017b6186'/> <code code='44966-0' displayName='EDEMA-FIND-PT-^PATIENT-ORD' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#Edema-2'/></text> <statusCode code='completed'/> <value xsi:type='CO'/> </observation> </component> <!-- Pain Scale (1-10) --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='78e08791-af8c-4b05-98a0-8949eae03e59'/> <code code='38208-5' displayName='PAIN SEVERITY-FIND-PT-^PATIENT-ORD-REPORTED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#PainScale-2'/></text> <statusCode code='completed'/> <value xsi:type='CO'/> </observation> </component> <!-- Next Appointment --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='4fb5998e-11e4-416e-ab2c-e5b6f7c424a4'/> <code code='(xx-time-to-next-appt)' displayName='TIME TO NEXT VISIT-' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#NextAppt-2'/></text> <statusCode code='completed'/> <value xsi:type='ED'/> </observation> </component> <!-- Comments --> <component> <observation classCode='OBS' moodCode='EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/> <id root='e53fec4b-f3c0-486e-b4e0-22fb65e7f547'/> <code code='48767-8' displayName='(comment field)' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text><reference value='#Comments-2'/></text> <statusCode code='completed'/> <value xsi:type='ED'/> </observation> </component> </organizer> </entry> </section> </component> </structuredBody> </component> </ClinicalDocument>