Clinical Document Architecture with Australian Schema
1.0.0 - current
Clinical Document Architecture with Australian Schema, published by Australian Digital Health Agency. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/AuDigitalHealth/cda-au-schema/ and changes regularly. See the Directory of published versions
This content is an example of the ADHA ClinicalDocument (CDA Class) Logical Model and is not a FHIR Resource
<?xml version="1.0"?>
<!-- Sample document provided with original CDA specification -->
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:voc="urn:hl7-org:v3/voc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:ext="http://ns.electronichealth.net.au/Ci/Cda/Extensions/3.0">
<!--
********************************************************
CDA Header
********************************************************
-->
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040" />
<templateId root="1.2.36.1.2001.1001.101.100.1002.4" extension="3.4" />
<templateId root="1.2.36.1.2001.1001.100.149" extension="1.0" />
<id root="2.25.315651374623327557318119485018955754505" />
<code code="18842-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Discharge Summarization Note" />
<title>Discharge Summary</title>
<effectiveTime value="20150618175528+1000" />
<confidentialityCode nullFlavor="NA" />
<languageCode code="en-AU" />
<setId root="59395d0c-82a6-40d0-b82e-5e087af03598" />
<versionNumber value="1" />
<ext:completionCode code="F" codeSystem="1.2.36.1.2001.1001.101.104.20104" codeSystemName="NCTIS Document Status Values" displayName="Final" />
<recordTarget typeCode="RCT">
<patientRole classCode="PAT">
<id root="8364ea58-f862-4191-b801-001afef51b16" />
<addr use="H">
<country>Australia</country>
<state>NSW</state>
<city>Nehtaville</city>
<postalCode>5555</postalCode>
<streetAddressLine>1 Clinician Street</streetAddressLine>
<additionalLocator>32568931</additionalLocator>
</addr>
<addr use="TMP">
<country>New Caledonia</country>
<state>Foreign Land</state>
<postalCode>12345</postalCode>
<streetAddressLine>1 Overseas Street</streetAddressLine>
</addr>
<telecom value="tel:0345754566" use="WP" />
<telecom value="mailto:authen@globalauthens.com" use="WP" />
<patient>
<name use="L">
<family>Harding</family>
<given>Frank</given>
<given>Troy</given>
<prefix>Mr</prefix>
</name>
<name use="L">
<family>Harding</family>
<given>Frank</given>
<given>Tobie</given>
<prefix>Mr</prefix>
</name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.13.68" codeSystemName="AS 5017-2006 Health Care Client Identifier Sex" displayName="Male" />
<birthTime value="19580618" />
<ethnicGroupCode code="4" codeSystem="2.16.840.1.113883.3.879.291036" codeSystemName="METeOR Indigenous Status" displayName="Neither Aboriginal nor Torres Strait Islander origin" />
<ext:multipleBirthInd value="true" />
<ext:multipleBirthOrderNumber value="2" />
<ext:deceasedInd value="true" />
<ext:deceasedTime value="20150618" />
<birthplace>
<place>
<addr>
<country>Australia</country>
<state>QLD</state>
</addr>
</place>
</birthplace>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003608666701594" assigningAuthorityName="IHI" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.3.4" extension="123456" assigningAuthorityName="Croydon GP Centre" />
<ext:code code="MR" codeSystem="2.16.840.1.113883.12.203" codeSystemName="Identifier Type (HL7)" />
</ext:asEntityIdentifier>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.5001.1.0.7" extension="59501704511" assigningAuthorityName="Individual Medicare Card Number" />
<ext:code code="MC" codeSystem="2.16.840.1.113883.12.203" codeSystemName="Identifier Type (HL7)" />
</ext:asEntityIdentifier>
</patient>
</patientRole>
</recordTarget>
<author typeCode="AUT">
<time value="20150618085528+1000" />
<assignedAuthor>
<id root="9ea74530-6ca7-4093-9ab6-9e87c7342466" />
<code code="253111" codeSystem="2.16.840.1.113883.13.62" codeSystemName="1220.0 - ANZSCO - Australian and New Zealand Standard Classification of Occupations, First Edition, 2006" displayName="General Medical Practitioner" />
<addr nullFlavor="NA" />
<addr nullFlavor="NA" />
<telecom value="tel:0345754566" use="WP" />
<telecom value="mailto:authen@globalauthens.com" use="WP" />
<assignedPerson>
<name use="L">
<family>Smith</family>
<given>Good</given>
<prefix>Doctor</prefix>
</name>
<name use="NB">
<family>Wong</family>
<given>Davey</given>
<prefix>Brother</prefix>
<suffix>Sir</suffix>
</name>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003615833334118" assigningAuthorityName="HPI-I" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
<ext:asEmployment classCode="EMP">
<ext:employerOrganization>
<id root="a5dce448-56d8-4ce9-a1c3-b0143be58c0a" />
<name>Surgical Ward</name>
<asOrganizationPartOf>
<wholeOrganization>
<name use="ORGL">Good Hospital</name>
<telecom value="tel:0345754566" use="WP" />
<telecom value="mailto:authen@globalauthens.com" use="WP" />
<addr nullFlavor="NA" />
<addr nullFlavor="NA" />
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003620833333789" assigningAuthorityName="HPI-O" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
</wholeOrganization>
</asOrganizationPartOf>
</ext:employerOrganization>
</ext:asEmployment>
</assignedPerson>
</assignedAuthor>
</author>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="a85989c7-7b53-4868-94f1-7b4722b3aaf9" />
<name>Burrill Lake Medical Centre</name>
<telecom value="tel:0345754566" use="WP" />
<addr use="WP">
<country>Australia</country>
<state>QLD</state>
<city>Nehtaville</city>
<postalCode>5555</postalCode>
<streetAddressLine>1 Custodian Street</streetAddressLine>
<additionalLocator>32568931</additionalLocator>
</addr>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003621231166540" assigningAuthorityName="HPI-O" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient>
<intendedRecipient>
<id root="7c95d83d-a9c7-43d7-9c04-18e0e59b6c95" />
<addr use="H">
<country>Australia</country>
<state>QLD</state>
<city>Nehtaville</city>
<postalCode>5555</postalCode>
<streetAddressLine>1 Clinician Street</streetAddressLine>
<additionalLocator>32568931</additionalLocator>
</addr>
<addr use="TMP">
<country>Albania</country>
<state>Foreign Land</state>
<postalCode>12345</postalCode>
<streetAddressLine>1 Overseas Street</streetAddressLine>
</addr>
<telecom value="tel:0345754566" use="WP" />
<telecom value="mailto:authen@globalauthens.com" use="WP" />
<informationRecipient>
<name use="L">
<family>Recipient</family>
<given>Information</given>
<prefix>Doctor</prefix>
</name>
<name use="NB">
<family>Recipient</family>
<given>Information</given>
<prefix>Mr</prefix>
</name>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.3.4.5.6677" assigningAuthorityName="SampleAuthority" />
</ext:asEntityIdentifier>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003614444567893" assigningAuthorityName="HPI-I" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
</informationRecipient>
<receivedOrganization>
<name>Specialist Clinics</name>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.3.4.5.6677" assigningAuthorityName="SampleAuthority" />
</ext:asEntityIdentifier>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003621231167886" assigningAuthorityName="HPI-O" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<informationRecipient typeCode="TRC">
<intendedRecipient>
<id root="200d2cff-aa9d-4ee5-8159-b39553808543" />
<addr use="H">
<country>Australia</country>
<state>QLD</state>
<city>Nehtaville</city>
<postalCode>5555</postalCode>
<streetAddressLine>1 Clinician Street</streetAddressLine>
<additionalLocator>32568931</additionalLocator>
</addr>
<addr use="TMP">
<country>Albania</country>
<state>Foreign Land</state>
<postalCode>12345</postalCode>
<streetAddressLine>1 Overseas Street</streetAddressLine>
</addr>
<telecom value="tel:0345754566" use="WP" />
<telecom value="mailto:authen@globalauthens.com" use="WP" />
<informationRecipient>
<name use="L">
<family>Recipient</family>
<given>Information</given>
<prefix>Doctor</prefix>
</name>
<name use="NB">
<family>Recipient</family>
<given>Information</given>
<prefix>Mr</prefix>
</name>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.3.4.5.6677" assigningAuthorityName="SampleAuthority" />
</ext:asEntityIdentifier>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003614444567893" assigningAuthorityName="HPI-I" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
</informationRecipient>
<receivedOrganization>
<name>Specialist Clinics</name>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.3.4.5.6677" assigningAuthorityName="SampleAuthority" />
</ext:asEntityIdentifier>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003621231167886" assigningAuthorityName="HPI-O" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<time value="20150618085528+1000" />
<signatureCode code="S" />
<assignedEntity>
<id root="ef23182c-fab3-4b2d-9b4d-b067b056f130" />
<code code="253111" codeSystem="2.16.840.1.113883.13.62" codeSystemName="1220.0 - ANZSCO - Australian and New Zealand Standard Classification of Occupations, First Edition, 2006" displayName="General Medical Practitioner" />
<addr use="WP">
<country>Australia</country>
<state>QLD</state>
<city>Nehtaville</city>
<postalCode>5555</postalCode>
<streetAddressLine>1 Clinician Street</streetAddressLine>
<additionalLocator>32568931</additionalLocator>
</addr>
<addr use="WP">
<country>Albania</country>
<state>Foreign Land</state>
<postalCode>12345</postalCode>
<streetAddressLine>1 Overseas Street</streetAddressLine>
</addr>
<telecom value="tel:0345754566" use="WP" />
<telecom value="mailto:authen@globalauthens.com" use="WP" />
<assignedPerson>
<name use="L">
<family>Doctor</family>
<given>Good</given>
<prefix>Doctor</prefix>
</name>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003615833334118" assigningAuthorityName="HPI-I" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
</assignedPerson>
<representedOrganization>
<name>Oz Health Clinic</name>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.3.4.55555" assigningAuthorityName="SampleAuthority" />
</ext:asEntityIdentifier>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003620000001144" assigningAuthorityName="HPI-O" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
</representedOrganization>
</assignedEntity>
</legalAuthenticator>
<participant typeCode="ORG">
<associatedEntity classCode="SDLOC">
<id root="96dde8ae-b7e4-4a75-805b-e4c36e22941f" />
<code>
<originalText>Ward B</originalText>
</code>
</associatedEntity>
</participant>
<participant typeCode="PART">
<functionCode code="PCP" />
<associatedEntity classCode="PROV">
<id root="168ca876-51fc-488f-9c4d-60d23c0c4ddb" />
<code code="423111" codeSystem="2.16.840.1.113883.13.62" codeSystemName="1220.0 - ANZSCO - Australian and New Zealand Standard Classification of Occupations, First Edition, 2006" displayName="Aged or Disabled Carer" />
<addr use="WP">
<country>Australia</country>
<state>QLD</state>
<city>Nehtaville</city>
<postalCode>5555</postalCode>
<streetAddressLine>1 Clinician Street</streetAddressLine>
<additionalLocator>32568931</additionalLocator>
</addr>
<telecom value="tel:0345754566" use="WP" />
<associatedPerson>
<name use="L">
<family>NominatedPrimaryHealthCareProviderPerson</family>
</name>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003610000001145" assigningAuthorityName="HPI-I" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
<ext:asEmployment classCode="EMP">
<ext:employerOrganization>
<id root="584c373e-da7f-4b61-88b4-bb2e376e1c6a" />
<name>Endocrinology</name>
<asOrganizationPartOf>
<wholeOrganization>
<name use="ORGX">Super Healthy Hospital</name>
<telecom value="tel:0345754566" use="WP" />
<addr use="WP">
<country>Australia</country>
<state>QLD</state>
<city>Nehtaville</city>
<postalCode>5555</postalCode>
<streetAddressLine>1 Clinician Street</streetAddressLine>
<additionalLocator>32568931</additionalLocator>
</addr>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003620000045562" assigningAuthorityName="HPI-O" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
</wholeOrganization>
</asOrganizationPartOf>
</ext:employerOrganization>
</ext:asEmployment>
</associatedPerson>
</associatedEntity>
</participant>
<participant typeCode="PART">
<functionCode code="PCP" />
<associatedEntity classCode="PROV">
<id root="f841338b-1847-48d0-b38e-d68e7fddd1da" />
<code code="HOSP" codeSystem="2.16.840.1.113883.1.11.17660" codeSystemName="HL7 ServiceDeliveryLocationRoleType" displayName="Hospital" />
<addr use="WP">
<country>Australia</country>
<state>QLD</state>
<city>Nehtaville</city>
<postalCode>5555</postalCode>
<streetAddressLine>1 Clinician Street</streetAddressLine>
<additionalLocator>32568931</additionalLocator>
</addr>
<telecom value="tel:0345754566" use="WP" />
<scopingOrganization>
<id root="caa41f6d-2f5a-4a1e-8556-53b7a14ab586" />
<name>Health Department</name>
<asOrganizationPartOf>
<wholeOrganization>
<name use="ORGX">Bay Hill Hospital (NominatedPrimaryHealthCareProviderOrganisation)</name>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003620000045562" assigningAuthorityName="HPI-O" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
</wholeOrganization>
</asOrganizationPartOf>
</scopingOrganization>
</associatedEntity>
</participant>
<participant typeCode="PART">
<time>
<low value="20150618085528+1000" />
<high value="20150623085528+1000" />
</time>
<associatedEntity classCode="CAREGIVER">
<id root="86d4be6e-ec47-4502-857b-5a27c1c867ef" />
<code code="254411" codeSystem="2.16.840.1.113883.13.62" codeSystemName="1220.0 - ANZSCO - Australian and New Zealand Standard Classification of Occupations, First Edition, 2006" displayName="Nurse Practitioner" />
<addr use="WP">
<country>Australia</country>
<state>QLD</state>
<city>Nehtaville</city>
<postalCode>5555</postalCode>
<streetAddressLine>Other 1 Clinician Street</streetAddressLine>
<additionalLocator>32568931</additionalLocator>
</addr>
<telecom value="tel:0345754566" use="WP" />
<associatedPerson>
<name use="L">
<family>OtherParticipant</family>
</name>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003610000001145" assigningAuthorityName="HPI-I" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
<ext:asEmployment classCode="EMP">
<ext:employerOrganization>
<id root="66d75bac-4ef5-40d0-93a5-ad978a8206c3" />
<name>Endocrinology</name>
<asOrganizationPartOf>
<wholeOrganization>
<name use="ORGE">Super Healthy Hospital</name>
<telecom value="tel:0345754566" use="WP" />
<addr use="WP">
<country>Australia</country>
<state>QLD</state>
<city>Nehtaville</city>
<postalCode>5555</postalCode>
<streetAddressLine>Other 1 Clinician Street</streetAddressLine>
<additionalLocator>32568931</additionalLocator>
</addr>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003620000045562" assigningAuthorityName="HPI-O" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
</wholeOrganization>
</asOrganizationPartOf>
</ext:employerOrganization>
</ext:asEmployment>
</associatedPerson>
</associatedEntity>
</participant>
<componentOf>
<encompassingEncounter>
<effectiveTime>
<high value="20150618085528+1000" />
</effectiveTime>
<dischargeDispositionCode code="5" codeSystem="2.16.840.1.113883.13.65" codeSystemName="AIHW Mode of Separation" displayName="Administrative Discharge" />
<encounterParticipant typeCode="DIS">
<time>
<width value="12" unit="a" />
</time>
<assignedEntity>
<id root="1f1b1b9c-604e-470e-9b66-57d3dd7037a2" />
<code code="542112" codeSystem="2.16.840.1.113883.13.62" codeSystemName="1220.0 - ANZSCO - Australian and New Zealand Standard Classification of Occupations, First Edition, 2006" displayName="Admissions Clerk" />
<addr use="WP">
<country>Australia</country>
<state>QLD</state>
<city>Nehtaville</city>
<postalCode>5555</postalCode>
<streetAddressLine>1 Clinician Street</streetAddressLine>
<additionalLocator>32568931</additionalLocator>
</addr>
<telecom value="tel:0345754566" use="WP" />
<assignedPerson>
<name use="L">
<family>Smith</family>
<given>John</given>
<given>Middle</given>
<prefix>Miss</prefix>
</name>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003610000001145" assigningAuthorityName="HPI-I" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
<ext:asEmployment classCode="EMP">
<ext:employerOrganization>
<id root="30559873-e69e-4ce8-888a-a56d7bc61ac5" />
<name>Endocrinology</name>
<asOrganizationPartOf>
<wholeOrganization>
<name use="ORGE">Super Healthy Hospital</name>
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003620000021100" assigningAuthorityName="HPI-O" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
</wholeOrganization>
</asOrganizationPartOf>
</ext:employerOrganization>
</ext:asEmployment>
</assignedPerson>
</assignedEntity>
</encounterParticipant>
<location>
<healthCareFacility>
<id root="458b47e5-dea5-449b-8c8a-6b1c78222855" />
<code code="8534" codeSystem="1.2.36.1.2001.1005.47" codeSystemName="ANSZIC 2006" displayName="Chiropractic and Osteopathic Services" />
<serviceProviderOrganization>
<id root="bc44a84d-fafa-4287-9be5-0b3caab67ffa" />
<name>Department Name</name>
<asOrganizationPartOf>
<id root="a31d3ca5-16a6-4212-992c-e54a2f345fbd" />
<wholeOrganization>
<name use="ORGY">Canberra Hospital</name>
<telecom value="tel:0262442229" use="WP" />
<addr nullFlavor="NA" />
<ext:asEntityIdentifier classCode="IDENT">
<ext:id root="1.2.36.1.2001.1003.0.8003627500000328" assigningAuthorityName="HPI-O" />
<ext:assigningGeographicArea classCode="PLC">
</ext:assigningGeographicArea>
</ext:asEntityIdentifier>
</wholeOrganization>
</asOrganizationPartOf>
</serviceProviderOrganization>
</healthCareFacility>
</location>
</encompassingEncounter>
</componentOf>
<!--
********************************************************
CDA Body
********************************************************
-->
<component>
<structuredBody>
<component>
<section>
<id root="47c56131-f252-45b2-b2c1-3e15011da076" />
<code code="101.16011" codeSystem="1.2.36.1.2001.1001.101" codeSystemName="NCTIS Data Components" displayName="Health Profile" />
<title>Health Profile</title>
<text mediaType="text/x-hl7-text+xml">
<paragraph>This section may contain the following subsections Adverse Reactions and Alerts.</paragraph>
</text>
<component>
<section>
<id root="89ca82bf-508e-4961-b3f9-8711b603703c" />
<code code="101.20113" codeSystem="1.2.36.1.2001.1001.101" codeSystemName="NCTIS Data Components" displayName="Adverse Reactions" />
<title>Adverse Reactions</title>
<text mediaType="text/x-hl7-text+xml">
<table>
<caption>Adverse Reactions</caption>
<thead>
<tr>
<th>Substance/Agent</th>
<th>Manifestations</th>
<th>Adverse Reaction Type</th>
</tr>
</thead>
<tbody>
<tr>
<td>Penicillin -class of antibiotic-</td>
<td>
<list>
<item>Urticaria</item>
<item>Trunk structure</item>
<item>Entire lower limb</item>
<item>Nausea and vomiting</item>
</list>
</td>
<td>Urticaria</td>
</tr>
<tr>
<td>Metoprolol</td>
<td>
<list>
<item>Chronic obstructive airways disease NOS</item>
</list>
</td>
<td>Urticaria</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
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<title>Alerts</title>
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<title>Event</title>
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<paragraph>This section may contain the following subsections Problems/Diagnoses This Visit, Clinical Interventions Performed This Visit and Clinical Synopsis and Diagnostic Investigations.</paragraph>
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<thead>
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<th>Clinical Synopsis</th>
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</thead>
<tbody>
<tr>
<td>Admitted for elective, right Total Knee Replacement (cemented prosthesis). Day 3, developed bilateral basal atelectasis. The FBC showed high WCC (20.0) and high neutrophils (16.0). Commenced on doxycycline and chest physio. Due to mild anaemia prior to surgery and subsequent operative blood loss, required a blood transfusion of three units. Subsequently made steady progress, regaining good mobility in his knee and is able to mobilise with the aid of a stick. Right knee Xray showed no fracture or dislocation, with the total knee prosthesis well positioned post surgery.</td>
</tr>
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<text>Admitted for elective, right Total Knee Replacement (cemented prosthesis). Day 3, developed bilateral basal atelectasis. The FBC showed high WCC (20.0) and high neutrophils (16.0). Commenced on doxycycline and chest physio. Due to mild anaemia prior to surgery and subsequent operative blood loss, required a blood transfusion of three units. Subsequently made steady progress, regaining good mobility in his knee and is able to mobilise with the aid of a stick. Right knee Xray showed no fracture or dislocation, with the total knee prosthesis well positioned post surgery.</text>
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<table>
<thead>
<tr>
<th>Type</th>
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</tr>
</thead>
<tbody>
<tr>
<td>Accidental bisacodyl overdose</td>
<td>Infection by Spirura</td>
</tr>
<tr>
<td>Principal diagnosis</td>
<td>Systemic aspergillosis</td>
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<table>
<caption>Clinical Intervention Description</caption>
<thead>
<tr>
<th>Value(s)</th>
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</thead>
<tbody>
<tr>
<td>Primary cemented total knee replacement</td>
</tr>
<tr>
<td>Insulin C-peptide measurement</td>
</tr>
<tr>
<td>Transfusion of packed red blood cells</td>
</tr>
</tbody>
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<thead>
<tr>
<th>Field</th>
<th>Value</th>
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<tr>
<td>Test Name</td>
<td>Chemistry studies (set)</td>
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<tr>
<td>Result Status</td>
<td>Final</td>
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<tr>
<td>Date Time</td>
<td>16 Jun 2015 08:55:28+1000</td>
</tr>
<tr>
<td>Comment</td>
<td>test</td>
</tr>
</tbody>
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<table>
<tbody>
<tr>
<td>
<paragraph styleCode="xPre">
GLUCOSE - FASTING
BLOOD GLUCOSE 10.8 * mmol/L (3.9-6.0)
Values for Diagnosis of Diabetes Mellitus and other Hyperglycaemia
DIABETES MELLITUS (DM)
Fasting &gt; 6.9 mmol/L
or 2 hrs post load &gt; 11.0 mmol/L
IMPAIRED FASTING GLYCAEMIA (IFG)
Fasting &gt; 6.0 mmol/L and &lt; 7.0 mmol/L
Date Collected : 07/07/2005
Time Collected : 12:15 Reference
Episode : 1 Units Range
============== ==========
GLUCOSE - FASTING
BLOOD GLUCOSE : 10.8 * mmol/L (3.9-6.0)
</paragraph>
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<text>test</text>
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<code code="102.16144" codeSystem="1.2.36.1.2001.1001.101" codeSystemName="NCTIS Data Components" displayName="Pathology Test Result" />
<title>Pathology Test Result</title>
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<caption>PhysicalDetails 3</caption>
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<caption>physicalDetailsImage X-Ray</caption>
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<caption>PhysicalDetails 1</caption>
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<table>
<caption>Pathology Test Result(s)</caption>
<thead>
<tr>
<th>Result DateTime</th>
<th>Result Name</th>
<th>Diagnostic Service</th>
<th>Overall Result Status</th>
<th>Clinical Information</th>
<th>Diagnosis</th>
<th>Conclusion</th>
<th>Comment</th>
<th>Result Representation</th>
</tr>
</thead>
<tbody>
<tr>
<td>16 Jun 2015 08:55:28+1000</td>
<td>Serum chemistry test</td>
<td>Chemistry</td>
<td>Final</td>
<td>Hepatitus</td>
<td>
<list>
<item>Normal</item>
<item>Abnormal</item>
</list>
</td>
<td>Test Result Group Conclusion</td>
<td>Test Result Group Comment</td>
<td>Lipase 150 U/L (RR < 70)</td>
</tr>
</tbody>
</table>
<table>
<caption>Test Request Details</caption>
<thead>
<tr>
<th>Laboratory Test Result Identifier</th>
<th>Test Requested Name(s)</th>
</tr>
</thead>
<tbody>
<tr>
<td>Laboratory Test Result Identifier</td>
<td>
<list>
<item>Urinary microscopy, culture and sensitivities</item>
<item>Urinary microscopy, culture and sensitivities</item>
</list>
</td>
</tr>
<tr>
<td>Laboratory Test Result Identifier</td>
<td>
<list>
<item>Urinary microscopy, culture and sensitivities</item>
<item>Urinary microscopy, culture and sensitivities</item>
</list>
</td>
</tr>
</tbody>
</table>
<table>
<caption>Pathology Test Specimen Detail</caption>
<thead>
<tr>
<th>Received DateTime</th>
<th>Identifier</th>
<th>Parent Identifier</th>
<th>Container</th>
<th>Physical Description</th>
<th>Physical Details</th>
<th>Sampling Preconditions</th>
<th>Collection Date</th>
<th>Collection Procedure</th>
<th>Collection Setting</th>
<th>Image / File</th>
</tr>
</thead>
<tbody>
<tr>
<td>18 Jun 2015 08:55:28+1000</td>
<td>cb279998-11ed-4776-8688-58bfce0cb9f8</td>
<td>4b20c0ce-e762-4392-854d-6388665e769e</td>
<td>AZH45218964</td>
<td>Urine sample</td>
<td>
<list>
<item>20kg</item>
</list>
</td>
<td>fasting</td>
<td>6 Jun 2015 08:55:28+1000</td>
<td>Urine specimen</td>
<td>Ward 3B</td>
<td>See above..</td>
</tr>
</tbody>
</table>
<table>
<caption>Result Group Specimen Detail</caption>
<thead>
<tr>
<th>Received DateTime</th>
<th>Identifier</th>
<th>Parent Identifier</th>
<th>Container</th>
<th>Tissue Type</th>
<th>Physical Description</th>
<th>Physical Details</th>
<th>Sampling Preconditions</th>
<th>Collection Date</th>
<th>Collection Procedure</th>
<th>Collection Setting</th>
<th>Image / File</th>
</tr>
</thead>
<tbody>
<tr>
<td>18 Jun 2015 08:55:28+1000</td>
<td>a4510627-6487-4cec-94cf-79e535e3c635</td>
<td>a5981635-ad6d-4522-af62-85aabe187bf7</td>
<td>CNH45218964</td>
<td>Body tissue structure</td>
<td>physicalDetails-Description</td>
<td>
<list>
<item>6ml</item>
</list>
</td>
<td>fasting</td>
<td>27 May 2015 08:55:28+1000</td>
<td>Collection of blood specimen for laboratory</td>
<td>Ward 1A</td>
<td>See above..</td>
</tr>
</tbody>
</table>
<table>
<caption>Test Result Group</caption>
<thead>
<tr>
<th>Group Name</th>
<th>Result Name</th>
<th>Result Value</th>
<th>Status</th>
<th> Reference Range Details</th>
<th>Result Comment</th>
<th>Reference Range Guidance</th>
<th>Result Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Chemistry Studies (Set)</td>
<td>Serum Creatinine</td>
<td>
<list>
<item>12.88 ml</item>
</list>
</td>
<td>Normal</td>
<td>
<list>
<item>High</item>
<item>High: 50ml Low: 100mlLow</item>
<item>High: 10ml Low: 20ml</item>
</list>
</td>
<td>
<list>
<item>Sodium test result comments</item>
<item>More comments</item>
<item>Another comment</item>
</list>
</td>
<td>Reference range guidance comments for Sodium; eg. the quantity should be between the high and low values</td>
<td>Interim</td>
</tr>
<tr>
<td>Chemistry Studies (Set)</td>
<td>Serum Creatinine</td>
<td>
<list>
<item>5 km</item>
</list>
</td>
<td>Normal</td>
<td>
<list>
<item>High</item>
<item>High: 50ml Low: 100mlLow</item>
<item>High: 10ml Low: 20ml</item>
</list>
</td>
<td>
<list>
<item>Blood test result comments</item>
<item>More comments</item>
<item>Another comment</item>
</list>
</td>
<td>Reference range guidance comments for blood; eg. the quantity should be between the high and low values</td>
<td>Final</td>
</tr>
</tbody>
</table>
<table>
<caption>Result Group Specimen Detail</caption>
<thead>
<tr>
<th>Received DateTime</th>
<th>Identifier</th>
<th>Parent Identifier</th>
<th>Container</th>
<th>Physical Description</th>
<th>Physical Details</th>
<th>Sampling Preconditions</th>
<th>Collection Date</th>
<th>Collection Procedure</th>
<th>Collection Setting</th>
<th>Image / File</th>
</tr>
</thead>
<tbody>
<tr>
<td>18 Jun 2015 08:55:28+1000</td>
<td>5977cef7-3f2b-4425-b44c-43fdfa7b1d42</td>
<td>e1dab8bf-61ef-4c23-84bf-2eb0ddfcbe18</td>
<td>AZH45218964</td>
<td>Urine sample</td>
<td>
<list>
<item>20kg</item>
</list>
</td>
<td>fasting</td>
<td>6 Jun 2015 08:55:28+1000</td>
<td>Urine specimen</td>
<td>Ward 3B</td>
<td>See above..</td>
</tr>
</tbody>
</table>
<table>
<caption>Test Result Group</caption>
<thead>
<tr>
<th>Group Name</th>
<th>Result Name</th>
<th>Result Value</th>
<th>Status</th>
<th> Reference Range Details</th>
<th>Result Comment</th>
<th>Reference Range Guidance</th>
<th>Result Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Chemistry Studies (Set)</td>
<td>Blood</td>
<td>
<list>
<item>5 km</item>
</list>
</td>
<td>Normal</td>
<td>
<list>
<item>High</item>
<item>High: 2psi Low: 150psiLow</item>
<item>High: 15psi Low: 200psi</item>
</list>
</td>
<td>
<list>
<item>Heart test result comments</item>
<item>More comments</item>
<item>Another comment</item>
</list>
</td>
<td>Reference range guidance comments for heart; eg. the quantity should be between the high and low values</td>
<td>Final</td>
</tr>
</tbody>
</table>
<table>
<caption>Anatomical Site(s)</caption>
<thead>
<tr>
<th>Identifier</th>
<th>Location</th>
<th>Side</th>
</tr>
</thead>
<tbody>
<tr>
<td>cb279998-11ed-4776-8688-58bfce0cb9f8</td>
<td>Subcutaneous tissue structure of lateral surface of index finger</td>
<td>Left</td>
</tr>
<tr>
<td>a4510627-6487-4cec-94cf-79e535e3c635</td>
<td>Subcutaneous tissue structure of lateral surface of index finger</td>
<td>Left</td>
</tr>
<tr>
<td>5977cef7-3f2b-4425-b44c-43fdfa7b1d42</td>
<td>Subcutaneous tissue structure of lateral surface of index finger</td>
<td>Left</td>
</tr>
</tbody>
</table>
</text>
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<thead>
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<th>Location</th>
<th>Side</th>
<th>Image / File</th>
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</thead>
<tbody>
<tr>
<td>Subcutaneous tissue structure of lateral surface of index finger</td>
<td>Left</td>
<td>See above..</td>
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<th>Field</th>
<th>Value</th>
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<tr>
<td>Imaging Examination Result Date Time</td>
<td>16 Jun 2015 08:55:28+1000</td>
</tr>
<tr>
<td>Result name</td>
<td>Image test 1</td>
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<tr>
<td>Modality</td>
<td>Ultrasonography</td>
</tr>
<tr>
<td>Result Status</td>
<td>Final</td>
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<tr>
<td>Clinical Information</td>
<td>Patient pregnant. Confirm dates. Estimate from LNMP 18 weeks.</td>
</tr>
<tr>
<td>Findings</td>
<td>Normal obstetric ultrasound with foetal biometry indicating getational age of 18W0D.</td>
</tr>
<tr>
<td>Result Representation</td>
<td>ResultRepresentation</td>
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<th>Value</th>
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<th>Comment</th>
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<td>ultrasound scan - obstetric</td>
<td>Serum Creatinine</td>
<td>
<list>
<item>Ultrasonography</item>
</list>
</td>
<td>Normal</td>
<td>
<list>
<item>Normal range</item>
<item>High: 17ml Low: 13mlHigh</item>
<item>High: 50ml Low: 100ml</item>
</list>
</td>
<td>
<list>
<item>Femur measured during ultrasound scan.</item>
<item>Legs measured during ultrasound scan.</item>
</list>
</td>
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<th>Location</th>
<th>Side</th>
<th>Image / File</th>
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</thead>
<tbody>
<tr>
<td>Subcutaneous tissue structure of lateral surface of index finger</td>
<td>Left</td>
<td>See above..</td>
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<th>Result Group</th>
<th>Name</th>
<th>Value</th>
<th>Status</th>
<th>Range</th>
<th>Comment</th>
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<td>Ultrasonography</td>
<td>
<list>
<item>Ultrasonography</item>
</list>
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<td>Normal</td>
<td>
<list>
<item>Normal range</item>
<item>High: 15ml Low: 18mlHigh</item>
<item>High: 60ml Low: 110ml</item>
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<td>
<list>
<item>Waist measured during ultrasound scan.</item>
<item>Waist measured during ultrasound scan.</item>
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<tr>
<th>Location</th>
<th>Side</th>
<th>Image / File</th>
</tr>
</thead>
<tbody>
<tr>
<td>Subcutaneous tissue structure of lateral surface of index finger</td>
<td>Left</td>
<td>See above..</td>
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<th>Identifiers</th>
<th>Subject Position</th>
<th>Image / File</th>
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<item>A/U Obstetric - Dating</item>
<item>another name</item>
</list>
</td>
<td>18 Jun 2015 08:55:28+1000</td>
<td>
<list>
<item>DICOM Study ID: Accession Number Group: 0008 Element: 0050</item>
<item>Report ID: 3355552BHU-23.3</item>
<item>DICOM Series ID: Series Identifier</item>
</list>
</td>
<td>Supine</td>
<td>See above..</td>
</tr>
<tr>
<td>
<list>
<item>A/U Skin - Stuff</item>
<item>another name</item>
</list>
</td>
<td>
<list>
<item>18 Jun 2015 08:55:28+1000</item>
<item>18 Jun 2015 08:55:28+1000</item>
</list>
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<td>
<list>
<item>DICOM Study ID: Accession Number Group: 0008 Element: 0050</item>
<item>Report ID: 3355552BHU-23.3</item>
<item>DICOM Series ID: Series IdentifierDICOM Series ID: Series Identifier</item>
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<td>
<list>
<item>Sublime</item>
<item>Head</item>
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</td>
<td>See above..</td>
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<th>Location</th>
<th>Side</th>
<th>Image / File</th>
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</thead>
<tbody>
<tr>
<td>Subcutaneous tissue structure of lateral surface of index finger</td>
<td>Left</td>
<td>See above..</td>
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<tr>
<th>Field</th>
<th>Value</th>
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<tr>
<td>Imaging Examination Result Date Time</td>
<td>16 Jun 2015 08:55:28+1000</td>
</tr>
<tr>
<td>Result name</td>
<td>Image test 2</td>
</tr>
<tr>
<td>Modality</td>
<td>Ultrasonography</td>
</tr>
<tr>
<td>Result Status</td>
<td>Final</td>
</tr>
<tr>
<td>Clinical Information</td>
<td>Patient pregnant. Confirm dates. Estimate from LNMP 18 weeks.</td>
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<tr>
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<td>Normal obstetric ultrasound with foetal biometry indicating getational age of 18W0D.</td>
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<tr>
<td>Result Representation</td>
<td>ResultRepresentation</td>
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<th>Value</th>
<th>Status</th>
<th>Range</th>
<th>Comment</th>
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<td>ultrasound scan - obstetric</td>
<td>Serum Creatinine</td>
<td>
<list>
<item>Ultrasonography</item>
</list>
</td>
<td>Normal</td>
<td>
<list>
<item>Normal range</item>
<item>High: 17ml Low: 13mlHigh</item>
<item>High: 50ml Low: 100ml</item>
</list>
</td>
<td>
<list>
<item>Femur measured during ultrasound scan.</item>
<item>Legs measured during ultrasound scan.</item>
</list>
</td>
</tr>
</tbody>
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<table>
<caption>Anatomical Site(s)</caption>
<thead>
<tr>
<th>Location</th>
<th>Side</th>
<th>Image / File</th>
</tr>
</thead>
<tbody>
<tr>
<td>Subcutaneous tissue structure of lateral surface of index finger</td>
<td>Left</td>
<td>See above..</td>
</tr>
</tbody>
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<table>
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<thead>
<tr>
<th>Result Group</th>
<th>Name</th>
<th>Value</th>
<th>Status</th>
<th>Range</th>
<th>Comment</th>
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<tr>
<td>Ultrasonography</td>
<td>Ultrasonography</td>
<td>
<list>
<item>Ultrasonography</item>
</list>
</td>
<td>Normal</td>
<td>
<list>
<item>Normal range</item>
<item>High: 15ml Low: 18mlHigh</item>
<item>High: 60ml Low: 110ml</item>
</list>
</td>
<td>
<list>
<item>Waist measured during ultrasound scan.</item>
<item>Waist measured during ultrasound scan.</item>
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<thead>
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<th>Location</th>
<th>Side</th>
<th>Image / File</th>
</tr>
</thead>
<tbody>
<tr>
<td>Subcutaneous tissue structure of lateral surface of index finger</td>
<td>Left</td>
<td>See above..</td>
</tr>
</tbody>
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<th>Image Date</th>
<th>Identifiers</th>
<th>Subject Position</th>
<th>Image / File</th>
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<item>A/U Obstetric - Dating</item>
<item>another name</item>
</list>
</td>
<td>18 Jun 2015 08:55:28+1000</td>
<td>
<list>
<item>DICOM Study ID: Accession Number Group: 0008 Element: 0050</item>
<item>Report ID: 3355552BHU-23.3</item>
<item>DICOM Series ID: Series Identifier</item>
</list>
</td>
<td>Supine</td>
<td>See above..</td>
</tr>
<tr>
<td>
<list>
<item>A/U Skin - Stuff</item>
<item>another name</item>
</list>
</td>
<td>
<list>
<item>18 Jun 2015 08:55:28+1000</item>
<item>18 Jun 2015 08:55:28+1000</item>
</list>
</td>
<td>
<list>
<item>DICOM Study ID: Accession Number Group: 0008 Element: 0050</item>
<item>Report ID: 3355552BHU-23.3</item>
<item>DICOM Series ID: Series IdentifierDICOM Series ID: Series Identifier</item>
</list>
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<td>
<list>
<item>Sublime</item>
<item>Head</item>
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<td>See above..</td>
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<td>paracetamol 500 mg + codeine phosphate 30 mg tablet</td>
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<td>18 Jun 2015 08:55:28+1000 -> 30 Oct 2016 08:55:28+1000</td>
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<td>Orthopaedic outpatient clinic appointment for 4 weeks post-discharge progress review</td>
<td>18 Jun 2015 08:55:28+1000 -> 8 Jul 2015 08:55:28+1000</td>
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<td>Dr Jane ANDERSON</td>
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<linkHtml href="mailto:Jane@Hospital.com">Jane@Hospital.com</linkHtml>
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<tr>
<td>Orthopaedic outpatient clinic appointment for 4 weeks post-discharge progress review</td>
<td>18 Jun 2015 08:55:28+1000 -> 17 Aug 2015 08:55:28+1000</td>
<td>Appointment</td>
<td>Bay Hill Hospital</td>
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<linkHtml href="mailto:BayHill@BayHill.com.au">BayHill@BayHill.com.au</linkHtml>
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<td>Please remove the staples on Aug 24 2010. Please ensure aspirin is recommenced 3 days post discharge. Please follow-up anaemia.</td>
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IG © 2024+ Australian Digital Health Agency. Package au.digitalhealth.cda.schema#1.0.0 based on FHIR 5.0.0. Generated 2024-11-22
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