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<?xml version="1.0" encoding="ISO-8859-1"?>
<?xml-stylesheet type="text/xsl" href="CCD.xsl"?><!-THIS DOCUMENT WAS GENERATED USING THE KAISER PERMANENTE CDA BUILDER
TOOL.
? 2008 KAISER FOUNDATION HOSPITALS
THE PROGRAM IS PROVIDED ?AS IS? WITHOUT WARRANTY OR REPRESENTATIONS OF ANY
KIND, EITHER EXPRESSED OR
IMPLIED. ANY REPRESENTATIONS OR WARRANTIES OF NON-INFRINGEMENT AND THE
IMPLIED WARRANTIES OF
MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE ARE DISCLAIMED. THE
ENTIRE RISK AS TO THE QUALITY
AND PERFORMANCE OF THE PROGRAM IS WITH YOU. SHOULD THE PROGRAM PROVE
DEFECTIVE, YOU ASSUME THE COST
OF ALL NECESSARY SERVICING, REPAIR OR CORRECTION.
IN NO EVENT WILL KAISER FOUNDATION HOSPITALS OR ANY ENTITY PARTICIPATING IN
THE KAISER PERMANENTE
MEDICAL CARE PROGRAM BE LIABLE FOR DAMAGES, INCLUDING ANY GENERAL,
SPECIAL, DIRECT, INDIRECT, EXEMPLARY,
INCIDENTAL OR CONSEQUENTIAL DAMAGES ARISING FROM THE USE OR INABILITY TO
USE THE PROGRAM
(INCLUDING BUT NOT LIMITED TO LOSS OF DATA OR DATA BEING RENDERED
INACCURATE OR LOSSES SUSTAINED BY YOU
OR THIRD PARTIES), HOWEVER CAUSED AND ON ANY THEORY OF LIABILITY, WHETHER
IN CONTRACT, STRICT LIABILITY
OR TORT, EVEN IF ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.
-->
<!-- Generated using Kaiser CDA Builder Tool -->
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3
http://xreg2.nist.gov:8080/hitspValidation/schema/cdar2c32/infrastructure/cda/C32_CDA.xsd">
<!-********************************************************
CDA Header
********************************************************
-->
Global replace of Kaiser OID with your HIE OID
Global replace of Kaiser name with your HIE name
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.10.20.1"/>
<!-- CCD v1.0 Templates Root -->
<templateId root="2.16.840.1.113883.3.88.11.32.1"/>
<!-- HITSP/C32 Registration and Medication Template -->
<id root="6858a017-39c1-4153-bbd4-eaedac72a0e7"/>
<code code="34133-9" codeSystem="2.16.840.1.113883.6.1" displayName="Summarization of episode
note"/>
<title>Kaiser Permanente</title> Change to your HIE name
<effectiveTime value="20080723142308-0500"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<recordTarget>
<patientRole>
<!-- Root OID: http://www.oid-info.com/get/1.3.6.1.4.1.26580 -->
<id root="1.3.6.1.4.1.26580" extension="1234567"/> root = Change to your HIE OID, extension
= your patient identifier
<addr use="H">
<streetAddressLine>4000 Minor St</streetAddressLine>
<city>Romanish</city>
<state>CO</state>
<postalCode>12121</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-987-555-9876" use="H"/>
<telecom value="tel:+1-987-555-9877" use="WP"/>
<patient>
<name>
<prefix>Mr</prefix>
<given>Young</given>
<given>Testcase</given>
<family>WoundedWarrior</family>
<suffix>II</suffix>
</name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
<birthTime value="19620523"/>
<maritalStatusCode code="M" displayName="Single" codeSystem="2.16.840.1.113883.5.2"
codeSystemName="MaritalStatusCode"/>
<raceCode code="2106-3" displayName="White" codeSystem="2.16.840.1.113883.6.238"
codeSystemName="CDC Race and Ethnicity"/>
<languageCommunication>
<languageCode code="en-US"/>
If your HIE does not have LanguageSpoken,
Then replace with
<templateId root="2.16.840.1.113883.3.88.11.32.2"/>
<languageCode nullFlavor="UNK"/>
</languageCommunication>
</patient>
<providerOrganization>
<!-- OID: Hardcoded to KP - http://www.oid-info.com/get/1.3.6.1.4.1.26580 -->
<id root="1.3.6.1.4.1.26580"/>
<name>Kaiser Permanente</name>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time value="20080601170000+0500"/>
<assignedAuthor>
<!-- OID - Using Kaiser OID - Should be ID of person. -->
<id root="1.3.6.1.4.1.26580"/>
<assignedAuthoringDevice>
<softwareName>Kaiser Permanente RIMBAA V1.0</softwareName>
</assignedAuthoringDevice>
<representedOrganization>
<id root="1.3.6.1.4.1.26580"/>
<name>Kaiser Permanente</name>
</representedOrganization>
</assignedAuthor>
</author>
<informant>
<assignedEntity>
<!-- Using Kaiser OID: Should be a person OID -->
<id root="1.3.6.1.4.1.26580"/>
<representedOrganization>
<!-- OID: Hardcoded to KP - http://www.oid-info.com/get/1.3.6.1.4.1.26580 -->
<id root="1.3.6.1.4.1.26580"/>
<name>Kaiser Permanente</name>
</representedOrganization>
</assignedEntity>
</informant>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<!-- OID: Hardcoded to KP - http://www.oid-info.com/get/1.3.6.1.4.1.26580 -->
<id root="1.3.6.1.4.1.26580"/> Replace with your HIE OID
<name>Kaiser Permanente</name> Replace with your HIE name
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<legalAuthenticator>
<time value="20080619070000+0500"/>
<signatureCode code="S"/>
<assignedEntity>
<id nullFlavor="NI"/>
<representedOrganization>
<!-- OID: Hardcoded to KP - http://www.oid-info.com/get/1.3.6.1.4.1.26580 -->
<id root="1.3.6.1.4.1.26580"/> Replace with your HIE OID
<name>Kaiser Permanente</name> Replace with your HIE name
</representedOrganization>
</assignedEntity>
</legalAuthenticator>
<participant typeCode="IND">
<templateId root='2.16.840.1.113883.3.88.11.32.3'/>
<time value="20080227000000-0600"/>
<associatedEntity classCode='NOK'>
<code code='FAMMEMB' displayName='Parent' codeSystem='2.16.840.1.113883.5.111'
codeSystemName='RoleCode'/>
<addr use="H">
<streetAddressLine>4000 Minor St</streetAddressLine>
<city>Romanish</city>
<state>CO</state>
<postalCode>12121</postalCode>
<country>United States of America</country>
</addr>
<telecom value="tel:+1-987-555-9876" use="H"/>
<telecom value="tel:+1-111-555-9877" use="WP"/>
<associatedPerson>
<name>
<prefix>Mr</prefix>
<given>Fatherof</given>
<given>Y</given>
<family>Woundedwarrior</family>
<suffix>Jr.</suffix>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="2002"/>
<high value="20071103"/>
</effectiveTime>
<performer typeCode="PRF">
<functionCode code="PP" codeSystem="2.16.840.1.113883.12.443" displayName="Primary
Care Provider"/>
<time>
<low value="2001"/>
</time>
<assignedEntity>
<!-- OID is Dr. Sydney's NPI -->
<id root="2.16.840.1.113883.4.6.1013905751"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Sydney</given>
<given>R</given>
<family>Garfield</family>
</name>
</assignedPerson>
<representedOrganization>
<!-- OID: http://www.oid-info.com/get/1.3.6.1.4.1.26580 -->
<id root="1.3.6.1.4.1.26580"/>
<name>Kaiser Permanente</name>
</representedOrganization>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<!-- Pick a required field for each module and counte how many times it occurs in the input -->
<!-- TOOL DEBUG: allergy entry count: 0,
problem entry count: 1,
meds entry count : 2
-->
<!-- CDA Body -->
<component>
<structuredBody>
<!-- Problems section -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.11"/>
<!-- Problem section template -->
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1"/>
<title>Problems</title>
<text>
<table border="2" xmlns:voc="urn:hl7-org:v3/voc" xmlns:n3="http://www.w3.org/1999/xhtml"
xmlns:n2="urn:hl7-org:v3/meta/voc" xmlns:n1="urn:hl7-org:v3"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<thead>
<tr>
<th>Problem</th><th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Urinary Tract Infection</td><td>Resolved</td>
</tr>
<tr>
<td>PTSD</td><td>Resolved</td>
</tr>
</tbody>
</table>
</text>
<!-- Problem Entry # 0 -->
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.27"/>
<templateId root="2.16.840.1.113883.3.88.11.32.7"
assigningAuthorityName="HITSP/C32"/>
<!-- Problem act template -->
<id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7"/>
<code nullFlavor="NA"/>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28"/>
<!-- Problem observation template -->
<id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code code="282291009" codeSystem="2.16.840.1.113883.6.96"
displayName="Diagnosis"/>
<text>
<reference value="#prob1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="2008"/>
</effectiveTime>
<value xsi:type="CD" code="68566005" codeSystem="2.16.840.1.113883.6.96"
displayName="Urinary Tract Infection"/>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<templateId root='2.16.840.1.113883.10.20.1.50'/> <!-- Problem status
observation template -->
<code code="33999-4" codeSystem="2.16.840.1.113883.6.1"
displayName="Status"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="413322009"
codeSystem="2.16.840.1.113883.6.96" displayName="Resolved"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
<!-- Problem Entry # 1 -->
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.27"/>
<templateId root="2.16.840.1.113883.3.88.11.32.7"
assigningAuthorityName="HITSP/C32"/>
<!-- Problem act template -->
<id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7"/>
<code nullFlavor="NA"/>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.28"/>
<!-- Problem observation template -->
<id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
<code code="282291009" codeSystem="2.16.840.1.113883.6.96"
displayName="Diagnosis"/>
<text>
<reference value="#prob1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="2008"/>
</effectiveTime>
<value xsi:type="CD" code="68566005" codeSystem="2.16.840.1.113883.6.96"
displayName="PTSD"/>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<templateId root='2.16.840.1.113883.10.20.1.50'/> <!-- Problem status
observation template -->
<code code="33999-4" codeSystem="2.16.840.1.113883.6.1"
displayName="Status"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="413322009"
codeSystem="2.16.840.1.113883.6.96" displayName="Resolved"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!-- Alerts section -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.2"/>
<!-- Alerts section template -->
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1"/>
<title>Allergies, Adverse Reactions, Alerts</title>
<text>
<table border="2" xmlns:voc="urn:hl7-org:v3/voc" xmlns:n3="http://www.w3.org/1999/xhtml"
xmlns:n2="urn:hl7-org:v3/meta/voc" xmlns:n1="urn:hl7-org:v3"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<thead>
<tr>
<th>Substance</th><th>Reaction</th><th>Severity</th><th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Compazine</td><td>Dystonia</td><td>Moderate</td><td>Active</td>
</tr>
</tbody>
</table>
</text>
<!-- Allergy Entry # 0 -->
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.27" assigningAuthorityName="CCD"/>
<templateId root="2.16.840.1.113883.3.88.11.32.6"
assigningAuthorityName="HITSP/C32"/>
<!-- Problem act template -->
<id root="36e3e930-7b14-11db-9fe1-0800200c9a66"/>
<code nullFlavor="NA"/>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.18"/>
<!-- Alert observation template -->
<id root="4adc1020-7b14-11db-9fe1-0800200c9a66"/>
<code code="416098002" codeSystem="2.16.840.1.113883.6.96"
displayName="Drug Allergy"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="282100009" codeSystem="2.16.840.1.113883.6.96"
displayName="Adverse reaction to substance"/>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code code="203546" displayName="Compazine"
codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"/>
<name>Compazine</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="MFST" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.54"/>
<!-- Reaction observation template -->
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="15802004"
codeSystem="2.16.840.1.113883.6.96" displayName="Dystonia"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.55"/>
<code code="SEV" displayName="Severity"
codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode" />
<text>
<reference value="#severity-1"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="6736007" displayName="Moderate"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" />
</observation>
</entryRelationship>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.39"/>
<!-- Alert status observation template -->
<code code="33999-4" codeSystem="2.16.840.1.113883.6.1"
displayName="Status"/>
<statusCode code="completed"/>
<value xsi:type="CE" code="55561003"
codeSystem="2.16.840.1.113883.6.96" displayName="Active"/>
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!-- Medications section -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.1.8"/>
<!-- Medications section template -->
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1"/>
<title>Medications</title>
<text>
<table border="2" xmlns:voc="urn:hl7-org:v3/voc" xmlns:n3="http://www.w3.org/1999/xhtml"
xmlns:n2="urn:hl7-org:v3/meta/voc" xmlns:n1="urn:hl7-org:v3"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<thead>
<tr>
<th>Medication</th><th>Route</th><th>Interval</th><th>StartDate</th><th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Bactrim DS</td><td>Oral</td><td>12h</td><td>20080101</td><td>active</td>
</tr>
<tr>
<td>Ativan</td><td>Oral</td><td>12h</td><td>20080101</td><td>active</td>
</tr>
<tr>
<td>Prozac</td><td>Oral</td><td>12h</td><td>20080101</td><td>active</td>
</tr>
</tbody>
</table>
</text>
<!-- Medication Entry # 0 -->
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<templateId root="2.16.840.1.113883.3.88.11.32.8"
assigningAuthorityName="HITSP/C32"/>
<!-- Medication activity template -->
<id root="cdbd5b05-6cde-11db-9fe1-0800200c9a66"/>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20080101"/>
<high value="20090101"/>
</effectiveTime>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
<period value="12" unit="h"/>
</effectiveTime>
<routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="RouteOfAdministration" displayName="Oral"/>
<doseQuantity value="1"/>
<consumable>
<manufacturedProduct>
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<!-- Product template -->
<manufacturedMaterial>
<code code="4011701" codeSystem="2.16.840.1.113883.6.88"
displayName="Bactrim DS">
<originalText>Sulfamethoxazole 800 MG / Trimethoprim 160 MG Oral
Tablet</originalText>
<translation code="291919" displayName="291919"
codeSystem='2.16.840.1.113883.6.88' codeSystemName='RxNorm'/>
</code>
<name>Bactrim DS</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<!-- Medication Entry # 1 -->
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<templateId root="2.16.840.1.113883.3.88.11.32.8"
assigningAuthorityName="HITSP/C32"/>
<!-- Medication activity template -->
<id root="cdbd5b05-6cde-11db-9fe1-0800200c9a66"/>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20080101"/>
<high value="20090101"/>
</effectiveTime>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
<period value="12" unit="h"/>
</effectiveTime>
<routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="RouteOfAdministration" displayName="Oral"/>
<doseQuantity value="1"/>
<consumable>
<manufacturedProduct>
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<!-- Product template -->
<manufacturedMaterial>
<code code="4011701" codeSystem="2.16.840.1.113883.6.88"
displayName="Ativan">
<originalText>Lorazepam</originalText>
<translation code="104719" displayName="104719"
codeSystem='2.16.840.1.113883.6.88' codeSystemName='RxNorm'/>
</code>
<name>Bactrim DS</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<!-- Medication Entry # 2 -->
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<templateId root="2.16.840.1.113883.3.88.11.32.8"
assigningAuthorityName="HITSP/C32"/>
<!-- Medication activity template -->
<id root="cdbd5b05-6cde-11db-9fe1-0800200c9a66"/>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20080101"/>
<high value="20090101"/>
</effectiveTime>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
<period value="12" unit="h"/>
</effectiveTime>
<routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="RouteOfAdministration" displayName="Oral"/>
<doseQuantity value="1"/>
<consumable>
<manufacturedProduct>
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<!-- Product template -->
<manufacturedMaterial>
<code code="4011701" codeSystem="2.16.840.1.113883.6.88"
displayName="Prozac">
<originalText>Fluoxetine</originalText>
<translation code="104849" displayName="104849"
codeSystem='2.16.840.1.113883.6.88' codeSystemName='RxNorm'/>
</code>
<name>Bactrim DS</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>
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