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MEDICATION_Examples_in_empty_CCD.xml
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<?xml version="1.0"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xmlns:cda="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc">
<!-- This CCD was validated with no warnings/errors with NIST Validator for Ambulatory VDT on December 18, 2013. Note immunizations and procedures would need to be added for "Transition of Care" validation-->
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
<!-- C-CDA -->
<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
<!-- CCD -->
<id root="2.16.840.1.113883.3.3208.101.1" extension="20130607100315-CCDA-CCD"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34133-9" displayName="Summarization of Episode Note"/>
<title>This is a CCD skeleton with some sample medication results created for HL7 Example Task Force - Based on C-CDA Skeleton developed by Lisa Nelson</title>
<effectiveTime value="20131031110101+0500"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<recordTarget>
<patientRole>
<id root="2.16.840.1.113883.3.3208.101.2" extension="20130607100800-Patient1"/>
<addr use="HP">
<streetAddressLine>1111 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)111-1111" use="HP"/>
<patient>
<name use="L">
<given>Patient</given>
<family>One</family>
</name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male" codeSystemName="AdministrativeGender"/>
<birthTime value="19300911"/>
<maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatus"/>
<raceCode code="2106-3" displayName="White"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="OMB Standards for Race and Ethnicity"/>
<ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="OMB Standards for Race and Ethnicity"/>
<languageCommunication>
<languageCode code="eng"/>
<modeCode code="ESP" displayName="Expressed spoken" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/>
<proficiencyLevelCode code="E" displayName="Excellent" codeSystem="2.16.840.1.113883.5.61" codeSystemName="LanguageAbilityProficiency"/>
</languageCommunication>
</patient>
</patientRole>
</recordTarget>
<author>
<time value="20130607000000"/>
<assignedAuthor>
<id extension="22222" root="2.16.840.1.113883.4.6"/>
<code code="207QA0505X" codeSystem="2.16.840.1.113883.6.101"
displayName="Adult Medicine" codeSystemName="NUCC"/>
<addr use="HP">
<streetAddressLine>2222 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)222-2222" use="WP"/>
<assignedPerson>
<name>
<given>Doctor</given>
<family>Second</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id extension="33333" root="2.16.840.1.113883.4.6"/>
<code code="364SA2200X" displayName="Adult Health" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"/>
<addr use="WP">
<streetAddressLine>3333 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)333-3333" use="WP"/>
<assignedPerson>
<name>
<given>Nurse</given>
<family>Tertiary</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="44444" root="2.16.840.1.113883.4.6"/>
<name>CDA PRO Fictional Hospital</name>
<telecom value="tel:+1(301)444-4444" use="WP"/>
<addr use="WP">
<streetAddressLine>4444 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<legalAuthenticator>
<time value="20130607000000"/>
<signatureCode code="S"/>
<assignedEntity>
<id root="2.16.840.1.113883.3.3208.101.3" extension="20130607102400-Authenticator1"/>
<addr use="WP">
<streetAddressLine>5555 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)555-5555" use="WP"/>
<assignedPerson>
<name>
<given>Physician</given>
<family>Fifthly</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="19330316"/>
<high value="20130607"/>
</effectiveTime>
<performer typeCode="PRF">
<assignedEntity>
<id extension="66666" root="2.16.840.1.113883.4.6"/>
<code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"
displayName="Cardiovascular Disease"/>
<addr>
<streetAddressLine>6666 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)666-6666" use="WP"/>
<assignedPerson>
<name>
<given>Heartly</given>
<family>Sixer</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<!-- CDA Body -->
<component>
<structuredBody>
<!-- Allergies Section -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
<!-- Allergies (entries required) section -->
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" displayName="Allergies, adverse reactions, alerts" codeSystemName="LOINC"/>
<title>ALLERGIES</title>
<text>
<content ID="allergy1">No Information About Allergies</content>
</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<!-- Allergy Problem Act entry -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607104400-AllergyProblem"/>
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts"/>
<statusCode code="active"/>
<effectiveTime>
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN" nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<!-- Allergy - Intolerance Observation -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607105900-AllergyObservation"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD" nullFlavor="NI">
<originalText>
<reference value="#allergy1"/>
</originalText>
</value>
<participant typeCode="CSM">
<!-- Participant added to meet "SHOULD" and avoid validator warning -->
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code nullFlavor="NI">
<originalText>
<reference value="#allergy1"/>
</originalText>
</code>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="MFST" inversionInd="true">
<observation classCode="OBS" moodCode="EVN" nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.4.9"/>
<!-- Reaction Observation - added to meet "SHOULD" and avoid validator warning -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607151500-ReactionObservation"/>
<code nullFlavor="NI"/>
<text>
<reference value="#allergy1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD" code="183964008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Treatment not indicated"/>
<!-- using this SNOMED code to meet SHALL requirement for code -->
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN" nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<!-- Severity Observation -->
<code code="SEV" xsi:type="CE" nullFlavor="NI"/>
<text>
<reference value="#allergy1"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="255604002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Mild"/>
<!-- using this SNOMED code to meet SHALL requirement for code -->
</observation>
</entryRelationship>
</observation>
</entryRelationship>
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.8"/>
<!-- Severity Observation - added to meet "SHOULD" and avoid validator warning -->
<code code="SEV" xsi:type="CE" nullFlavor="NI"/>
<text>
<reference value="#allergy1"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="255604002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Mild"/>
<!-- using this SNOMED code to meet SHALL requirement for code -->
</observation>
</entryRelationship>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!-- Medication Section -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
<!-- Medication Section (entries required) -->
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Medication Use"/>
<title>MEDICATIONS</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Medication</th>
<th>Instructions</th>
<th>Dosage</th>
<th>Effective Dates (start - stop)</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr ID="Medication_0">
<td>
<content ID="MedicationName_0" xmlns="urn:hl7-org:v3">Ibuprofen 600mg Oral Tablet</content>
</td>
<td>
<content ID="MedicationSig_0" xmlns="urn:hl7-org:v3">take 1 tablet QID PRN</content>
</td>
<td>
<content ID="MedicationDosage_0" xmlns="urn:hl7-org:v3">600 MG</content>
</td>
<td>Dec-18-2013 - </td>
<td>Active</td>
</tr>
<tr ID="Medication_1">
<td>
<content ID="MedicationName_1" xmlns="urn:hl7-org:v3">Sudafed 30mg Oral Tablet</content>
</td>
<td>
<content ID="MedicationSig_1" xmlns="urn:hl7-org:v3">take 2 tablets every 4-6 hours</content>
</td>
<td>
<content ID="MedicationDosage_1" xmlns="urn:hl7-org:v3">30 MG</content>
</td>
<td>Jan-18-2014 - </td>
<td>Active</td>
</tr>
<tr ID="Medication_2">
<td>
<content ID="MedicationName_2" xmlns="urn:hl7-org:v3">Azithromycin 250mg Oral Tablet</content>
</td>
<td>
<content ID="MedicationSig_2" xmlns="urn:hl7-org:v3">take 2 tablets day one and 1 tablet days 2-5</content>
</td>
<td>
<content ID="MedicationDosage_2" xmlns="urn:hl7-org:v3">250 MG</content>
</td>
<td>Jan-10-2014 - Jan-14-2014</td>
<td>Active</td>
</tr>
<tr ID="Medication_6">
<td>
<content ID="MedicationName_6" xmlns="urn:hl7-org:v3">3 ML Insulin Glargine 100 UNT/ML Prefilled Syringe</content>
</td>
<td>
<content ID="MedicationSig_6" xmlns="urn:hl7-org:v3">take 40 units at bedtime</content>
</td>
<td>
<content ID="MedicationDosage_6" xmlns="urn:hl7-org:v3">40 units</content>
</td>
<td>Jan-10-2014 - Jan-14-2014</td>
<td>Active</td>
</tr>
<tr ID="Medication_7">
<td>
<content ID="MedicationName_7" xmlns="urn:hl7-org:v3">Aspirin 81mg Oral Tablet</content>
</td>
<td>
<content ID="MedicationSig_7" xmlns="urn:hl7-org:v3">take 2 tablets</content>
</td>
<td>
<content ID="MedicationDosage_7" xmlns="urn:hl7-org:v3">162 MG</content>
</td>
<td>Sep-11-2013</td>
<td>Completed</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="INT">
<!-- This medication use case is a medication to be administered. If it has been already administered use moodCode = "EVN". If an ordered drug then use moodCode = "RQO" -->
<!-- Dependencies exist between moodCode, statusCode and effectiveTime -->
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="47d3e719-f688-459d-bcdc-47c6de0767a9"/>
<text>
<!-- This reference refers to medication information in unstructured portion of section-->
<reference value="#Medication_0"/>
</text>
<statusCode code="active"/>
<!-- This first effectiveTime shows that medication was added on December 18, 2013 (not known to have stopped)-->
<effectiveTime xsi:type="IVL_TS">
<low value="20131218"/>
<high nullFlavor="NI"/>
</effectiveTime>
<!-- This second effectiveTime represents QID from medication sig. -->
<!-- InstituionSpecified = "true" means that it can be given 4 times per day but need not be exactly timed to every 6 hours-->
<!-- InstituionSpecified = "false" would mean that timing needs to be administered exactly as structured-->
<!-- Operator "A" means that this timing information is in addition to previous effectiveTime information provided-->
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
<period value="6" unit="h"/>
</effectiveTime>
<routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Oral"/>
<!-- This relates directly to the code used for medication. Since it's a tablet, then only specified needed in dose is 1x per administration-->
<doseQuantity value="1"/>
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Medication information ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<id root="2a620155-9d11-439e-92b3-5d9815ff4ee8"/>
<manufacturedMaterial>
<!-- Medications should be specified at a level corresponding to prescription when possible, such as 600mg oral tablet (non-branded)-->
<code code="197806" displayName="Ibuprofen 600mg Oral Tablet" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
<originalText>
<reference value="#MedicationName_0"/>
</originalText>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<precondition typeCode="PRCN">
<criterion>
<!-- ** Precondition for substance administration ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.25"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<!-- If a precondition were specified in medication sig, you would include code here. Include nullFlavor="NI" when PRN specified but without precondition-->
<value xsi:type="CD" nullFlavor="NI" />
</criterion>
</precondition>
</substanceAdministration>
</entry>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="INT">
<!-- This medication use case is a medication to be administered. If it has been already administered use moodCode = "EVN". If an ordered drug then use moodCode = "RQO" -->
<!-- Dependencies exist between moodCode, statusCode and effectiveTime -->
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="36edd5f0-0b15-49f6-a395-7752b4f18b77"/>
<text>
<!-- This reference refers to medication information in unstructured portion of section-->
<reference value="#Medication_1"/>
</text>
<statusCode code="active"/>
<!-- This first effectiveTime shows that medication was prescribed on January 18, 2014 (not known to have stopped)-->
<effectiveTime xsi:type="IVL_TS">
<low value="20140118"/>
<high nullFlavor="NI"/>
</effectiveTime>
<!-- This second effectiveTime represents every 4-6 hours from medication sig. -->
<!-- InstituionSpecified = "false" means that it should be exactly timed to every 4-6 hours -->
<!-- InstituionSpecified = "true" would mean that receiving institution has flexibility in dosing schedule-->
<!-- Operator "A" means that this timing information is in addition to previous effectiveTime information provided-->
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="false" operator="A">
<period xsi:type="IVL_PQ">
<low value="4" unit="h"/>
<high value="6" unit="h"/>
</period>
</effectiveTime>
<routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Oral"/>
<!-- This relates directly to the code used for medication. Since it's a tablet, then only specified needed in dose is 2x per administration-->
<doseQuantity value="2"/>
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Medication information ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<id root="0be61984-eaa5-46b3-b75b-1d1ba28b5fff"/>
<manufacturedMaterial>
<!-- Medications should be specified at a level corresponding to prescription when possible, such as 30mg oral tablet (branded)-->
<code code="1049529" displayName="Sudafed 30 MG Oral Tablet" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
<originalText>
<reference value="#MedicationName_1"/>
</originalText>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<entry typeCode="DRIV">
<!-- This medication entry will be divided into two components -->
<!-- This first component describes day 1 which has a different dose than days 2 through 5, shown in the second component-->
<organizer xmlns="urn:hl7-org:v3" classCode="CLUSTER" moodCode="EVN">
<statusCode code="active"/>
<component>
<substanceAdministration classCode="SBADM" moodCode="INT">
<!-- This medication use case is a medication to be administered. If it has been already administered use moodCode = "EVN". -->
<!-- If an ordered drug then use moodCode = "RQO" Dependencies exist between moodCode, statusCode and effectiveTime -->
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="bc22a9c5-bab4-4348-aa7e-a1b1897c9535"/>
<text>
<!-- This reference refers to medication information in unstructured portion of section-->
<reference value="#Medication_2"/>
</text>
<statusCode code="active"/>
<!-- This effectiveTime shows medication administration for day 1. -->
<!-- To include any times during the day, the high interval should either be set to end of day (as shown) or the day after last day of medication administration.-->
<!-- See C-CDA DSTU 383 more detail on effectiveTime/high -->
<effectiveTime xsi:type="IVL_TS">
<low value="20140310000000"/>
<high value="20140310235959" inclusive="true"/>
<!-- inclusive indicator is optional -->
</effectiveTime>
<!-- This second effectiveTime represents once per day from medication sig. -->
<!-- InstituionSpecified = "false" means that it must be administered exactly once per day-->
<!-- InstituionSpecified = "true" would mean that receiving institution has flexibility in dosing schedule-->
<!-- Operator "A" means that this timing information is in addition to previous effectiveTime information provided-->
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="false" operator="A">
<period value="1" unit="d"/>
</effectiveTime>
<routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Oral"/>
<!-- This relates directly to the code used for medication. This medication is administered as an oral table, so no unit is needed -->
<!-- Azithromycin is commonly prescribed 2 tablets on day 1, which is shown below -->
<doseQuantity value ="2" />
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Medication information ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<id root="a9a55f64-3953-4f2c-b52e-c77399b854ae"/>
<manufacturedMaterial>
<!-- Medications should be specified at a level corresponding to prescription when possible, such as 250mg oral tablet (non-branded)-->
<code code="308460" displayName="Azithromycin 250 MG Oral Tablet" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
<originalText>
<reference value="#MedicationName_2"/>
</originalText>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</component>
<component>
<substanceAdministration classCode="SBADM" moodCode="INT">
<!-- This medication use case is a medication to be administered. If it has been already administered use moodCode = "EVN". If an ordered drug then use moodCode = "RQO" -->
<!-- Dependencies exist between moodCode, statusCode and effectiveTime -->
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="bc22a9c5-bab4-4348-aa7e-a1b1897cxxxx"/>
<text>
<!-- This reference refers to medication information in unstructured portion of section-->
<reference value="#Medication_2"/>
</text>
<statusCode code="active"/>
<!-- This effectiveTime shows medication administration starting on day 2-->
<!-- To include any times during the day, the high interval should either be set to end of day or the day after last day of medication administration (as shown).-->
<!-- See C-CDA DSTU 383 more detail on effectiveTime/high -->
<effectiveTime xsi:type="IVL_TS">
<low value="20140311"/>
<high value="20140315"/>
</effectiveTime>
<!-- This second effectiveTime represents once per day from medication sig. -->
<!-- InstituionSpecified = "false" means that it must be administered exactly once per day-->
<!-- InstituionSpecified = "true" would mean that receiving institution has flexibility in dosing schedule-->
<!-- Operator "A" means that this timing information is in addition to previous effectiveTime information provided-->
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="false" operator="A">
<period value="1" unit="d"/>
</effectiveTime>
<routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Oral"/>
<!-- This relates directly to the code used for medication. This medication is administered as an oral table, so no unit is needed, but it has varying dosage over its course. -->
<!-- Azithromycin is commonly prescribed 2 tablets on day 1 then 1 tablet daily thereafter. -->
<doseQuantity value ="1" />
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Medication information ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<id root="a9a55f64-3953-4f2c-b52e-c77399b8xxxx"/>
<manufacturedMaterial>
<!-- Medications should be specified at a level corresponding to prescription when possible, such as 250mg oral tablet (non-branded)-->
<code code="308460" displayName="Azithromycin 250 MG Oral Tablet" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
<originalText>
<reference value="#MedicationName_2"/>
</originalText>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</component>
</organizer>
</entry>
<entry>
<substanceAdministration classCode="SBADM" moodCode="INT">
<!-- This medication use case is a medication to be administered. If it has been already administered use moodCode = "EVN". If an ordered drug then use moodCode = "RQO" -->
<!-- Dependencies exist between moodCode, statusCode and effectiveTime -->
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="1310a2d3-f888-4722-b4c4-a3c5911ac7f9"/>
<text>
<!-- This reference refers to medication information in unstructured portion of section-->
<reference value="#Medication_6"/>
</text>
<statusCode code="active"/>
<!-- This first effectiveTime shows that medication was added on April 9, 2014 (not known to have stopped)-->
<effectiveTime xsi:type="IVL_TS">
<low value="20140409"/>
<high nullFlavor="NI"/>
</effectiveTime>
<!-- The second effectiveTime specifies dose frequency, which can be either a period (PIVL_TS) or event (EIVL_TS). -->
<!-- This long-lasting insulin is administered once per day before bedtime, which is an event-->
<effectiveTime xsi:type="EIVL_TS" operator="A">
<event code="HS"/>
</effectiveTime>
<routeCode code="C38299" codeSystem="2.16.840.1.113883.3.26.1.1" displayName="SUBCUTANEOUS" codeSystemName="National Cancer Institute Thesaurus" />
<!-- Since this dose is not pre-coordinated, specify both the amount with units in UCUM. [IU] is international units -->
<!-- Note that this basal insulin is not administered on a sliding scale and a specific dose is administered-->
<doseQuantity value="40" unit="[IU]"/>
<consumable typeCode="CSM">
<manufacturedProduct classCode="MANU">
<!-- ** Medication information ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial classCode="MMAT" determinerCode="KIND">
<!-- Medications should be specified at a level corresponding to prescription when possible (branded medication below)-->
<code code="847232" codeSystem="2.16.840.1.113883.6.88" displayName="3 ML Insulin Glargine 100 UNT/ML Prefilled Syringe" codeSystemName="RxNorm">
<originalText>
<reference value="#MedicationName_6"/>
</originalText>
</code>
</manufacturedMaterial>
<manufacturerOrganization classCode="ORG" determinerCode="INSTANCE">
<name>SANOFI-AVE</name>
</manufacturerOrganization>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<!-- This medication use case is a medication administered a single time in the past. If it to be administered use moodCode = "INT". If an ordered drug then use moodCode = "RQO" -->
<!-- Dependencies exist between moodCode, statusCode and effectiveTime -->
<templateId root="2.16.840.1.113883.10.20.22.4.16" />
<id root="1061a257-3b5c-4b09-9dc7-23e59b788b18"/>
<text>
<!-- This reference refers to medication information in unstructured portion of section-->
<reference value="#Medication_7" />
</text>
<statusCode code="completed"/>
<!-- This is a one-time administration, so low and high times are not used -->
<!-- This format was determined as appropriate in San Antonio meeting, January 2014 -->
<!-- Timing information may not validate until xsi:type of "TS" is added to validator (C-CDA 1.1 DSTU 423) -->
<effectiveTime xsi:type="TS" value="201309111603-0700"/>
<!-- Since this is a one-time administration, there is no inclusion of dose frequency (PIVL_TS or EIVL_TS)-->
<routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" displayName="ORAL" codeSystemName="National Cancer Institute Thesaurus" />
<doseQuantity value="2" />
<consumable>
<manufacturedProduct classCode="MANU">
<!-- ** Medication information ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.23" />
<manufacturedMaterial>
<!-- Medications should be specified at a level corresponding to prescription when possible (non-branded below)-->
<code code="243670" codeSystem="2.16.840.1.113883.6.88" displayName="Aspirin 81 MG Oral Tablet">
<originalText>
<reference value="#MedicationName_7"/>
</originalText>
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
<author>
<!-- Time the author noted that patient is on medication -->
<time value="201309111603-0700"/>
<assignedAuthor>
<id extension="66666" root="2.16.840.1.113883.4.6"/>
<code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"
displayName="Cardiovascular Disease"/>
<addr>
<streetAddressLine>6666 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)666-6666" use="WP"/>
<assignedPerson>
<name>
<given>Heartly</given>
<family>Sixer</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
</substanceAdministration>
</entry>
</section>
</component>
<!-- Problem Section -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
<!-- Problem Section with Coded Entries Required -->
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem List"/>
<title>PROBLEMS</title>
<text>
<content ID="problems1">No Information About Problems</content>
</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
<!-- Problem Concern Act (Condition) -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607113300-ProblemConcern"/>
<code code="CONC" displayName="Concern" codeSystem="2.16.840.1.113883.5.6" codeSystemName="HL7ActClass"/>
<statusCode code="active"/>
<effectiveTime>
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN" nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<!-- Problem Observation -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607113430-ProblemObservation"/>
<code nullFlavor="NI"/>
<text>
<reference value="#problems1"/>
</text>
<statusCode code="completed" />
<effectiveTime>
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD" nullFlavor="NI" />
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component>
<!-- Procedures Section -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
<!-- Procedures Section with Coded Entries Required-->
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Procedures"/>
<title>PROCEDURES</title>
<text>
<content ID="procedures1">No Information About Procedures</content>
</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
<!-- Procedure Activity Act-->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607114600-ProcedureActivity"/>
<code xsi:type="CE" nullFlavor="NI">
<originalText>
<reference value="#procedures1"/>
</originalText>
</code>
<statusCode code="completed" />
<effectiveTime nullFlavor="NI"/>
<performer>
<!-- Added to meet "SHOULD" requirment and avoid validator warning -->
<assignedEntity>
<id root="2.16.840.1.113883.3.3208.101.3" extension="20130607154800-UnknownPersonnel"/>
<addr nullFlavor="NI"/>
<telecom nullFlavor="NI"/>
<representedOrganization nullFlavor="NI">
<id root="2.16.840.1.113883.3.3208.101.5" extension="20130607155400-UnknownOrg" />
<telecom nullFlavor="NI" />
<addr nullFlavor="NI" />
</representedOrganization>
</assignedEntity>
</performer>
</act>
</entry>
</section>
</component>
<!-- Results Section -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
<!-- Results Section with Coded Entries Required-->
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Relevant diagnostic tests and/or laboratory data"/>
<title>RESULTS</title>
<text>
<content ID="results1">No Information About Results</content>
</text>
<entry typeCode="DRIV">
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.1"/>
<!-- Result Organizer -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607113300-ResultOrganizer"/>
<code xsi:type="CE" nullFlavor="NI"/>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="NI"/>
<high value="20130607000000-0000"/>
</effectiveTime>
<!-- Up until now. -->
<!-- Brian's sample had a weird date in here. -->
<component>
<observation classCode="OBS" moodCode="EVN" >
<!-- removed this: nullFlavor="NI"-->
<templateId root="2.16.840.1.113883.10.20.22.4.2"/>
<!-- Results Observation -->
<id nullFlavor="NI"/>
<code nullFlavor="NI" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<!-- No code here -->
<text>
<reference value="#results1"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="NI"/>
<high value="20130607000000-0000"/>
</effectiveTime>
<!-- Up until now. -->
<value xsi:type="CD" nullFlavor="NI"/>
<interpretationCode nullFlavor="NI"/>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
<!-- Plan of Care Section -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.10"/>
<!-- Plan of Care Section-->
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of Care"/>
<title>PLAN OF CARE</title>
<text>No Information About Plan of Care</text>
</section>
</component>
<!-- Social History (with Smoking Status Observation) -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.17"/>
<!-- Social History Section -->
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" displayName="Social History"/>
<title>SOCIAL HISTORY</title>
<text>
<content ID="socialhist1">No Information About Social History</content>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN" nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.4.78"/>
<!-- Smoking Status Observation -->
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="NI"/>
<high nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD" code="266927001" displayName="Unknown if ever smoked" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
</entry>
</section>
</component>
<!-- Vital Signs Section (entries required) -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.4.1"/>
<!-- Vital Signs (entries required) -->
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital Signs"/>
<title>VITAL SIGNS</title>
<text>
<content ID="vitalsigns1">No Information About Vital Signs</content>
</text>
<entry typeCode="DRIV">
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.26" />
<!-- Vital Signs Organizer -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607125100-VitalSignsOrganizer"/>
<code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Vital signs"/>
<statusCode code="completed"/>
<effectiveTime nullFlavor="NI"/>
<component>
<observation classCode="OBS" moodCode="EVN" nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
<!-- Vital Signs Observation -->
<id root="2.16.840.1.113883.3.3208.101.10" extension="20130607125100-VitalSignsObservation"/>
<code nullFlavor="NI"/>
<text>
<reference value="#vitalsigns1"/>
</text>
<statusCode code="completed"/>
<effectiveTime nullFlavor="NI"/>
<value xsi:type="PQ" nullFlavor="NI"/>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>