Clinical Document Architecture
2.0.1-sd - release

Clinical Document Architecture, published by Health Level 7. This guide is not an authorized publication; it is the continuous build for version 2.0.1-sd built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-core-sd/ and changes regularly. See the Directory of published versions

Example Binary: Example CDA document

This content is an example of the 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">
	<!-- 
********************************************************
  CDA Header
********************************************************
-->
	<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
	<templateId root="2.16.840.1.113883.10.20.22.1.4" extension="2024-05-01"/>
	<id extension="c266" root="2.16.840.1.113883.19.4"/>
	<code code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Consultation note"/>
	<title>Good Health Clinic Consultation Note</title>
	<effectiveTime value="20000407"/>
	<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
	<languageCode code="en-US"/>
	<setId extension="BB35" root="2.16.840.1.113883.19.7"/>
	<versionNumber value="2"/>
	<recordTarget>
		<patientRole>
			<id extension="12345" root="2.16.840.1.113883.19.5"/>
			<patient>
			<name>
					<given>Henry</given>
					<family>Levin</family>
					<suffix>the 7th</suffix>
				</name>
				<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
				<birthTime value="19320924"/>
			</patient>
			<providerOrganization>
				<id root="2.16.840.1.113883.19.5"/>
			</providerOrganization>
		</patientRole>
	</recordTarget>
	<author>
		<time value="2000040714"/>
		<assignedAuthor>
			<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
			<assignedPerson>
				<name>
					<given>Robert</given>
					<family>Dolin</family>
					<suffix>MD</suffix>
				</name>
			</assignedPerson>
			<representedOrganization>
				<id root="2.16.840.1.113883.19.5"/>
			</representedOrganization>
		</assignedAuthor>
	</author>
	<custodian>
		<assignedCustodian>
			<representedCustodianOrganization>
				<id root="2.16.840.1.113883.19.5"/>
				<name>Good Health Clinic</name>
			</representedCustodianOrganization>
		</assignedCustodian>
	</custodian>
	<legalAuthenticator>
		<time value="20000408"/>
		<signatureCode code="S"/>
		<assignedEntity>
			<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
			<assignedPerson>
				<name>
					<given>Robert</given>
					<family>Dolin</family>
					<suffix>MD</suffix>
				</name>
			</assignedPerson>
			<representedOrganization>
				<id root="2.16.840.1.113883.19.5"/>
			</representedOrganization>
		</assignedEntity>
	</legalAuthenticator>
	<relatedDocument typeCode="RPLC">
		<parentDocument>
			<id extension="a123" root="2.16.840.1.113883.19.4"/>
			<setId extension="BB35" root="2.16.840.1.113883.19.7"/>
			<versionNumber value="1"/>
		</parentDocument>
	</relatedDocument>
	<componentOf>
		<encompassingEncounter>
			<id extension="KPENC1332" root="2.16.840.1.113883.19.6"/>
			<effectiveTime value="20000407"/>
			<encounterParticipant typeCode="CON">
				<time value="20000407"/>
				<assignedEntity>
					<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
					<assignedPerson>
						<name>
							<given>Robert</given>
							<family>Dolin</family>
							<suffix>MD</suffix>
						</name>
					</assignedPerson>
					<representedOrganization>
						<id root="2.16.840.1.113883.19.5"/>
					</representedOrganization>
				</assignedEntity>
			</encounterParticipant>
			<location>
				<healthCareFacility classCode="DSDLOC">
					<!-- Note: the original published example had the wrong codeSystem (2.16.840.1.113883.5.10588) here -->
					<code code="GIM" codeSystem="2.16.840.1.113883.5.111" displayName="General internal medicine clinic"/>
				</healthCareFacility>
			</location>
		</encompassingEncounter>
	</componentOf>
	<!-- 
********************************************************
  CDA Body
********************************************************
-->
	<component>
		<structuredBody>
			<!-- 
********************************************************
  History of Present Illness section
********************************************************
-->
			<component>
				<section>
					<code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<title>History of Present Illness</title>
					<text>
						<content styleCode="Bold">Henry Levin, the 7<sup>th</sup>
						</content> is a 67 year old male referred for further asthma management. Onset of asthma in his <content revised="delete">twenties</content>
						<content revised="insert">teens</content>. He was hospitalized twice last year, and already twice this year. He has not been able to be weaned off steroids for the past several months. 
						</text>
				</section>
			</component>
			<!-- 
********************************************************
  Past Medical History section
********************************************************
-->
			<component>
				<section>
					<code code="10153-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<title>Past Medical History</title>
					<text>
						<list>
							<item>
								<content ID="a1">Asthma</content>
							</item>
							<item>
								<content ID="a2">Hypertension (see HTN.cda for details)</content>
							</item>
							<item>
								<content ID="a3">Osteoarthritis, 
									<content ID="a4">right knee</content>
								</content>
							</item>
						</list>
					</text>
					<entry>
						<observation classCode="COND" moodCode="EVN">
							<code code="195967001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Asthma">
								<originalText>
									<reference value="#a1"/>
								</originalText>
							</code>
							<statusCode code="completed"/>
							<effectiveTime value="1950"/>
							<reference typeCode="XCRPT">
								<externalObservation classCode="OBS">
									<id root="2.16.840.1.113883.19.1.2765"/>
								</externalObservation>
							</reference>
						</observation>
					</entry>
					<entry>
						<observation classCode="COND" moodCode="EVN">
							<code code="59621000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="HTN">
								<originalText>
									<reference value="#a2"/>
								</originalText>
							</code>
							<statusCode code="completed"/>
							<reference typeCode="SPRT">
								<seperatableInd value="false"/>
								<externalDocument>
									<id root="2.16.840.1.113883.19.4.789"/>
									<text mediaType="multipart/related">
										<reference value="HTN.cda"/>
									</text>
									<setId root="2.16.840.1.113883.19.7.2465"/>
									<versionNumber value="1"/>
								</externalDocument>
							</reference>
							<reference typeCode="XCRPT">
								<externalObservation classCode="OBS">
									<id root="2.16.840.1.113883.19.1.2005"/>
								</externalObservation>
							</reference>
						</observation>
					</entry>
					<entry>
						<observation classCode="COND" moodCode="EVN">
							<code xsi:type="CD" code="396275006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Osteoarthritis">
								<originalText>
									<reference value="#a3"/>
								</originalText>
							</code>
							<statusCode code="completed"/>
							<targetSiteCode code="49076000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Knee joint">
								<originalText>
									<reference value="#a4"/>
								</originalText>
								<qualifier>
									<name code="78615007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="with laterality"/>
									<value code="24028007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="right"/>
								</qualifier>
							</targetSiteCode>
							<reference typeCode="XCRPT">
								<externalObservation classCode="OBS">
									<id root="2.16.840.1.113883.19.1.1805"/>
								</externalObservation>
							</reference>
						</observation>
					</entry>
				</section>
			</component>
			<!-- 
********************************************************
  Medications section
********************************************************
-->
			<component>
				<section>
					<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<title>Medications</title>
					<text>
						<list>
							<item>Theodur 200mg BID</item>
							<item>Proventil inhaler 2puffs QID PRN</item>
							<item>Prednisone 20mg qd</item>
							<item>HCTZ 25mg qd</item>
						</list>
					</text>
					<entry>
						<substanceAdministration classCode="SBADM" moodCode="EVN">
							<text>Theodur 200mg BID</text>
							<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
								<period value="12" unit="h"/>
							</effectiveTime>
							<routeCode code="PO" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration"/>
							<doseQuantity value="200" unit="mg"/>
							<consumable>
								<manufacturedProduct>
									<manufacturedLabeledDrug>
										<code code="66493003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Theophylline"/>
									</manufacturedLabeledDrug>
								</manufacturedProduct>
							</consumable>
						</substanceAdministration>
					</entry>
					<entry>
						<substanceAdministration classCode="SBADM" moodCode="EVN">
							<text>Proventil inhaler 2puffs QID PRN</text>
							<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
								<period value="6" unit="h"/>
							</effectiveTime>
							<priorityCode code="PRN"/>
							<routeCode code="IPINHL" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration" displayName="Inhalation, oral"/>
							<doseQuantity value="2"/>
							<consumable>
								<manufacturedProduct>
									<manufacturedLabeledDrug>
										<code code="91143003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Albuterol"/>
									</manufacturedLabeledDrug>
								</manufacturedProduct>
							</consumable>
						</substanceAdministration>
					</entry>
					<entry>
						<substanceAdministration classCode="SBADM" moodCode="EVN">
							<id root="2.16.840.1.113883.19.8.1"/>
							<text>Prednisone 20mg qd</text>
							<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
								<period value="24" unit="h"/>
							</effectiveTime>
							<routeCode code="PO" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration"/>
							<doseQuantity value="20" unit="mg"/>
							<consumable>
								<manufacturedProduct>
									<manufacturedLabeledDrug>
										<code code="10312003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Prednisone preparation"/>
									</manufacturedLabeledDrug>
								</manufacturedProduct>
							</consumable>
						</substanceAdministration>
					</entry>
					<entry>
						<substanceAdministration classCode="SBADM" moodCode="EVN">
							<text>HCTZ 25mg qd</text>
							<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
								<period value="24" unit="h"/>
							</effectiveTime>
							<routeCode code="PO" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration"/>
							<consumable>
								<manufacturedProduct>
									<manufacturedLabeledDrug>
										<code code="376209006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hydrochlorothiazide 25mg tablet"/>
									</manufacturedLabeledDrug>
								</manufacturedProduct>
							</consumable>
						</substanceAdministration>
					</entry>
				</section>
			</component>
			<!-- 
********************************************************
  Allergies & Adverse Reactions section
********************************************************
-->
			<component>
				<section>
					<code code="10155-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<title>Allergies and Adverse Reactions</title>
					<text>
						<list>
							<item>Penicillin - Hives</item>
							<item>Aspirin - Wheezing</item>
							<item>Codeine - Itching and nausea</item>
						</list>
					</text>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<code xsi:type="CD" code="247472004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hives"/>
							<statusCode code="completed"/>
							<entryRelationship typeCode="MFST">
								<observation classCode="OBS" moodCode="EVN">
									<code xsi:type="CD" code="91936005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Allergy to penicillin"/>
									<statusCode code="completed"/>
								</observation>
							</entryRelationship>
						</observation>
					</entry>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<code code="56018004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Wheezing"/>
							<statusCode code="completed"/>
							<entryRelationship typeCode="MFST">
								<observation classCode="OBS" moodCode="EVN">
									<code code="293586001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Allergy to aspirin"/>
									<statusCode code="completed"/>
								</observation>
							</entryRelationship>
						</observation>
					</entry>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<code code="32738000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Pruritis"/>
							<statusCode code="completed"/>
							<entryRelationship typeCode="MFST">
								<observation classCode="OBS" moodCode="EVN">
									<id root="2.16.840.1.113883.19.1.2010"/>
									<code code="62014003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Adverse reaction to drug">
										<qualifier>
											<name code="246075003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="causative agent"/>
											<value code="1476002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="codeine"/>
										</qualifier>
									</code>
									<statusCode code="completed"/>
								</observation>
							</entryRelationship>
						</observation>
					</entry>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<code code="73879007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Nausea"/>
							<statusCode code="completed"/>
							<entryRelationship typeCode="MFST">
								<observation classCode="OBS" moodCode="EVN">
									<id root="2.16.840.1.113883.19.1.2010"/>
									<code code="84100007" codeSystem="2.16.840.1.113883.6.96"/>
								</observation>
							</entryRelationship>
						</observation>
					</entry>
				</section>
			</component>
			<!-- 
********************************************************
  Family History section
********************************************************
-->
			<component>
				<section>
					<code code="10157-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<title>Family history</title>
					<text>
						<list>
							<item>Father had fatal MI in his early 50's.</item>
							<item>No cancer or diabetes.</item>
						</list>
					</text>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<code code="22298006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="MI"/>
							<statusCode code="completed"/>
							<effectiveTime value="1970"/>
							<subject>
								<relatedSubject classCode="PRS">
									<code code="FTH" codeSystem="2.16.840.1.113883.5.111"/>
								</relatedSubject>
							</subject>
							<entryRelationship typeCode="CAUS">
								<observation classCode="OBS" moodCode="EVN">
									<code code="399347008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="death"/>
									<statusCode code="completed"/>
									<effectiveTime value="1970"/>
								</observation>
							</entryRelationship>
						</observation>
					</entry>
					<entry>
						<observation classCode="OBS" moodCode="EVN" negationInd="true">
							<code code="275937001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Family history of cancer"/>
							<statusCode code="completed"/>
							<effectiveTime>
								<high value="20000407" inclusive="true"/>
							</effectiveTime>
						</observation>
					</entry>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<code code="160274005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="No family history of diabetes"/>
							<statusCode code="completed"/>
							<effectiveTime>
								<high value="20000407" inclusive="true"/>
							</effectiveTime>
						</observation>
					</entry>
				</section>
			</component>
			<!-- 
********************************************************
  Social History section
********************************************************
-->
			<component>
				<section>
					<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<title>Social History</title>
					<text>
						<list>
							<item>Smoking :: 1 PPD between the ages of 20 and 55, and then he quit.</item>
							<item>Alcohol :: rare</item>
						</list>
					</text>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<code code="266924008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="ex-heavy cigarette smoker (20-39/day)"/>
							<statusCode code="completed"/>
							<effectiveTime>
								<low value="1955"/>
								<high value="1990"/>
							</effectiveTime>
						</observation>
					</entry>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<code code="160625004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Date ceased smoking"/>
							<statusCode code="completed"/>
							<value xsi:type="TS" value="1990"/>
						</observation>
					</entry>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<code code="266917007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Trivial drinker -  less than 1/day"/>
							<statusCode code="completed"/>
						</observation>
					</entry>
				</section>
			</component>
			<!-- 
********************************************************
  Physical Exam section
********************************************************
-->
			<component>
				<section>
					<code code="11384-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<title>Physical Examination</title>
					<!-- 
          ********************************************************
            Physical Exam  - Vital Signs
          ********************************************************
          -->
					<component>
						<section>
							<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
							<title>Vital Signs</title>
							<text>
								<table>
									<tbody>
										<tr>
											<th>Date / Time</th>
											<th>April 7, 2000 14:30</th>
											<th>April 7, 2000 15:30</th>
										</tr>
										<tr>
											<th>Height</th>
											<td>177 cm (69.7 in)</td>
										</tr>
										<tr>
											<th>Weight</th>
											<td>194.0 lbs (88.0 kg)</td>
										</tr>
										<tr>
											<th>BMI</th>
											<td>28.1 kg/m2</td>
										</tr>
										<tr>
											<th>BSA</th>
											<td>2.05 m2</td>
										</tr>
										<tr>
											<th>Temperature</th>
											<td>36.9 C (98.5 F)</td>
											<td>36.9 C (98.5 F)</td>
										</tr>
										<tr>
											<th>Pulse</th>
											<td>86 / minute</td>
											<td>84 / minute</td>
										</tr>
										<tr>
											<th>Rhythm</th>
											<td>Regular</td>
											<td>Regular</td>
										</tr>
										<tr>
											<th>Respirations</th>
											<td>16 / minute, unlabored</td>
											<td>14 / minute</td>
										</tr>
										<tr>
											<th>Systolic</th>
											<td>132 mmHg</td>
											<td>135 mmHg</td>
										</tr>
										<tr>
											<th>Diastolic</th>
											<td>86 mmHg</td>
											<td>88 mmHg</td>
										</tr>
										<tr>
											<th>Position / Cuff</th>
											<td>Left Arm</td>
											<td>Left Arm</td>
										</tr>
									</tbody>
								</table>
							</text>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="50373000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Body height measure"/>
									<statusCode code="completed"/>
									<effectiveTime value="200004071430"/>
									<value xsi:type="PQ" value="1.77" unit="m">
										<translation value="69.7" code="[in_I]" codeSystem="2.16.840.1.113883.6.8" codeSystemName="UCUM"/>
									</value>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="363808001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Body weight measure"/>
									<statusCode code="completed"/>
									<effectiveTime value="200004071430"/>
									<value xsi:type="PQ" value="194.0" unit="[lb_ap]">
										<translation value="88.0" code="kg" codeSystem="2.16.840.1.113883.6.8" codeSystemName="UCUM"/>
									</value>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="60621009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Body mass index"/>
									<statusCode code="completed"/>
									<effectiveTime value="200004071430"/>
									<value xsi:type="RTO_PQ_PQ">
										<numerator value="28.1" unit="kg"/>
										<denominator value="1" unit="ar"/>
									</value>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="301898006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Body surface area"/>
									<statusCode code="completed"/>
									<effectiveTime value="200004071430"/>
									<value xsi:type="PQ" value="2.05" unit="ar"/>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="386725007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Body temperature"/>
									<statusCode code="completed"/>
									<effectiveTime value="200004071430"/>
									<value xsi:type="PQ" value="36.9" unit="Cel">
										<translation value="98.5" code="[degF]" codeSystem="2.16.840.1.113883.6.8" codeSystemName="UCUM"/>
									</value>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="364075005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Heart rate"/>
									<statusCode code="completed"/>
									<effectiveTime value="200004071430"/>
									<value xsi:type="RTO_PQ_PQ">
										<numerator value="86"/>
										<denominator value="1" unit="min"/>
									</value>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="364075005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Heart rate"/>
									<statusCode code="completed"/>
									<effectiveTime value="200004071530"/>
									<value xsi:type="RTO_PQ_PQ">
										<numerator value="84"/>
										<denominator value="1" unit="min"/>
									</value>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="364074009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Regularity of heart rhythm"/>
									<statusCode code="completed"/>
									<effectiveTime value="200004071430"/>
									<value xsi:type="CD" code="248649006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Heart regular"/>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="364074009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Regularity of heart rhythm"/>
									<statusCode code="completed"/>
									<effectiveTime value="200004071530"/>
									<value xsi:type="CD" code="248649006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Heart regular"/>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="86290005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Respiratory rate"/>
									<statusCode code="completed"/>
									<effectiveTime value="200004071430"/>
									<value xsi:type="RTO_PQ_PQ">
										<numerator value="16"/>
										<denominator value="1" unit="min"/>
									</value>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="276362002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Breathing easily"/>
									<statusCode code="completed"/>
									<effectiveTime value="200004071430"/>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="86290005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Respiratory rate"/>
									<statusCode code="completed"/>
									<effectiveTime value="200004071530"/>
									<value xsi:type="RTO_PQ_PQ">
										<numerator value="14"/>
										<denominator value="1" unit="min"/>
									</value>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="251076008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Cuff blood pressure"/>
									<statusCode code="completed"/>
									<effectiveTime value="200004071430"/>
									<targetSiteCode code="368208006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Left arm"/>
									<entryRelationship typeCode="COMP">
										<observation classCode="OBS" moodCode="EVN">
											<code code="271649006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Systolic BP"/>
											<statusCode code="completed"/>
											<effectiveTime value="200004071530"/>
											<value xsi:type="PQ" value="132" unit="mm[Hg]"/>
										</observation>
									</entryRelationship>
									<entryRelationship typeCode="COMP">
										<observation classCode="OBS" moodCode="EVN">
											<code code="271650006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Diastolic BP"/>
											<statusCode code="completed"/>
											<effectiveTime value="200004071530"/>
											<value xsi:type="PQ" value="86" unit="mm[Hg]"/>
										</observation>
									</entryRelationship>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="251076008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Cuff blood pressure"/>
									<statusCode code="completed"/>
									<effectiveTime value="200004071530"/>
									<targetSiteCode code="368208006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Left arm"/>
									<entryRelationship typeCode="COMP">
										<observation classCode="OBS" moodCode="EVN">
											<code code="271649006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Systolic BP"/>
											<statusCode code="completed"/>
											<effectiveTime value="200004071530"/>
											<value xsi:type="PQ" value="135" unit="mm[Hg]"/>
										</observation>
									</entryRelationship>
									<entryRelationship typeCode="COMP">
										<observation classCode="OBS" moodCode="EVN">
											<code code="271650006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Diastolic BP"/>
											<statusCode code="completed"/>
											<effectiveTime value="200004071530"/>
											<value xsi:type="PQ" value="88" unit="mm[Hg]"/>
										</observation>
									</entryRelationship>
								</observation>
							</entry>
						</section>
					</component>
					<!-- 
          ********************************************************
            Physical Exam  - Skin
          ********************************************************
          -->
					<component>
						<section>
							<code code="8709-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
							<title>Skin Exam</title>
							<text>Erythematous rash, palmar surface, left index finger.
								 <renderMultiMedia referencedObject="MM1"/>
							</text>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="271807003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Rash"/>
									<statusCode code="completed"/>
									<methodCode code="32750006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Inspection"/>
									<targetSiteCode code="48856004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Skin of palmer surface of index finger">
										<qualifier>
											<name code="78615007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="with laterality"/>
											<value code="7771000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="left"/>
										</qualifier>
									</targetSiteCode>
									<entryRelationship typeCode="SPRT">
										<regionOfInterest classCode="ROIOVL" moodCode="EVN" ID="MM1">
											<id root="2.16.840.1.113883.19.3.1"/>
											<code code="ELLIPSE"/>
											<value value="3"/>
											<value value="1"/>
											<value value="3"/>
											<value value="7"/>
											<value value="2"/>
											<value value="4"/>
											<value value="4"/>
											<value value="4"/>
											<entryRelationship typeCode="SUBJ">
												<observationMedia classCode="OBS" moodCode="EVN">
													<id root="2.16.840.1.113883.19.2.1"/>
													<value mediaType="image/gif">
														<reference value="lefthand.gif"/>
													</value>
												</observationMedia>
											</entryRelationship>
										</regionOfInterest>
									</entryRelationship>
								</observation>
							</entry>
						</section>
					</component>
					<!-- 
          ********************************************************
            Physical Exam  - Lungs
          ********************************************************
          -->
					<component>
						<section>
							<code code="8710-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
							<title>Lungs</title>
							<text>Clear with no wheeze. Good air flow.</text>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="48348007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Chest clear"/>
									<statusCode code="completed"/>
									<methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN" negationInd="true">
									<code code="56018004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Wheezing"/>
									<statusCode code="completed"/>
									<methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/>
								</observation>
							</entry>
						</section>
					</component>
					<!-- 
          ********************************************************
            Physical Exam  - Cardiac
          ********************************************************
          -->
					<component>
						<section>
							<code code="10223-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
							<title>Cardiac</title>
							<text>RRR with no murmur, no S3, no S4.</text>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="76863003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Normal heart rate"/>
									<statusCode code="completed"/>
									<methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN" negationInd="true">
									<code code="88610006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="heart murmur"/>
									<statusCode code="completed"/>
									<methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN" negationInd="true">
									<code code="277455002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Third heart sound"/>
									<statusCode code="completed"/>
									<methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/>
								</observation>
							</entry>
							<entry>
								<observation classCode="OBS" moodCode="EVN">
									<code code="60721002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Fourth heart sound inaudible"/>
									<statusCode code="completed"/>
									<methodCode code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Auscultation"/>
								</observation>
							</entry>
						</section>
					</component>
				</section>
			</component>
			<!-- 
********************************************************
  Labs section
********************************************************
-->
			<component>
				<section>
					<code code="11502-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<title>Labs</title>
					<text>
						<list>
							<item>CXR 02/03/1999: Hyperinflated. Normal cardiac silhouette, clear lungs.</item>					
							<item>Peak Flow today: 260 l/m</item>
						</list>
					</text>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<code code="282290005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Imaging interpretation"/>
							<statusCode code="completed"/>
							<entryRelationship typeCode="COMP">
								<observation classCode="OBS" moodCode="EVN">
									<id root="2.16.840.1.113883.19.1.3005"/>
									<code code="249674001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Chest hyperinflated"/>
								</observation>
							</entryRelationship>
							<entryRelationship typeCode="COMP">
								<observation classCode="OBS" moodCode="EVN">
									<id root="2.16.840.1.113883.19.1.5505"/>
									<code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" nullFlavor="OTH">
										<originalText>normal cardiac silhouette</originalText>
									</code>
								</observation>
							</entryRelationship>
							<entryRelationship typeCode="COMP">
								<observation classCode="OBS" moodCode="EVN" negationInd="true">
									<id root="2.16.840.1.113883.19.1.6675"/>
									<code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" nullFlavor="OTH">
										<originalText>radiopacities</originalText>
									</code>
								</observation>
							</entryRelationship>
							<reference typeCode="SPRT">
								<externalObservation classCode="DGIMG">
									<id root="2.16.840.1.113883.19.1.14"/>
									<code code="56350004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Chest-X-ray"/>
								</externalObservation>
							</reference>
						</observation>
					</entry>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<id root="2.16.840.1.113883.19.1.7005"/>
							<code code="313193002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Peak flow"/>
							<statusCode code="completed"/>
							<effectiveTime value="20000407"/>
							<value xsi:type="RTO_PQ_PQ">
								<numerator value="260" unit="l"/>
								<denominator value="1" unit="min"/>
							</value>
						</observation>
					</entry>
				</section>
			</component>
			<!-- 
********************************************************
  In-office Procedure section
********************************************************
-->
			<component>
				<section>
					<code code="29554-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<title>In-office Procedures</title>
					<text>
						<list>
							<item>Suture removal, left forearm.</item>
						</list>
					</text>
					<entry>
						<procedure classCode="PROC" moodCode="EVN">
							<code code="30549001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Suture removal"/>
							<statusCode code="completed"/>
							<effectiveTime value="200004071430"/>
							<targetSiteCode code="66480008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Left forearm"/>
						</procedure>
					</entry>
				</section>
			</component>
			<!-- 
********************************************************
  Assessment section
********************************************************
-->
			<component>
				<section>
					<code code="11496-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<title>Assessment</title>
					<text>
						<list>
							<item>Asthma, with prior smoking history. Difficulty weaning off steroids. Will try gradual taper.</item>
							<item>Hypertension, well-controlled.</item>
							<item>Contact dermatitis on finger.</item>
						</list>
					</text>
					<entry>
						<observation classCode="COND" moodCode="EVN">
							<code code="14657009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Established diagnosis"/>
							<statusCode code="completed"/>
							<effectiveTime value="200004071530"/>
							<value xsi:type="CD" code="195967001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Asthma">
								<translation code="49390" codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD9CM" displayName="ASTHMA W/O STATUS ASTHMATICUS"/>
							</value>
							<reference typeCode="ELNK">
								<externalObservation classCode="COND">
									<id root="2.16.840.1.113883.19.1.35"/>
								</externalObservation>
							</reference>
						</observation>
					</entry>
					<entry>
						<observation classCode="COND" moodCode="EVN">
							<code code="14657009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Established diagnosis"/>
							<statusCode code="completed"/>
							<effectiveTime value="200004071530"/>
							<value xsi:type="CD" code="59621000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Essential hypertension">
								<translation code="4019" codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD9CM" displayName="HYPERTENSION NOS"/>
							</value>
							<reference typeCode="ELNK">
								<externalObservation classCode="COND">
									<id root="2.16.840.1.113883.19.1.37"/>
								</externalObservation>
							</reference>
						</observation>
					</entry>
					<entry>
						<observation classCode="COND" moodCode="EVN">
							<code code="14657009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Established diagnosis"/>
							<statusCode code="completed"/>
							<effectiveTime value="200004071530"/>
							<value xsi:type="CD" code="40275004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Contact dermatitis">
								<translation code="692.9" codeSystem="2.16.840.1.113883.6.2" codeSystemName="ICD9CM" displayName="Contact Dermatitis, NOS"/>
							</value>
							<targetSiteCode code="48856004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Skin of palmer surface of index finger">
								<qualifier>
									<name code="78615007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="with laterality"/>
									<value code="7771000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="left"/>
								</qualifier>
							</targetSiteCode>
						</observation>
					</entry>
				</section>
			</component>
			<!-- 
********************************************************
  Plan section
********************************************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09"/>
					<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<title>Plan</title>
					<text>
						<list>
							<item>Complete PFTs with lung volumes.</item>
							<item>Chem-7 tomorrow.</item>
							<item>Teach peak flow rate measurement.</item>
							<item>Decrease prednisone to 20qOD alternating with 18qOD.</item>
							<item>Hydrocortisone cream to finger BID.</item>
							<item>RTC 1 week.</item>
						</list>
					</text>
					<entry>
						<act classCode="ACT" moodCode="INT">
							<id nullFlavor="UNK"/>
							<code code="23426006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Pulmonary function test"/>
							<text>Complete PFTs with lung volumes.</text>
							<entryRelationship typeCode="COMP">
								<act classCode="ACT" moodCode="INT">
									<code code="252472004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Lung volume test"/>
								</act>
							</entryRelationship>
						</act>
					</entry>
					<entry>
						<observation classCode="OBS" moodCode="INT">
							<code code="24320-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC">
								<originalText>Chem-7</originalText>
								<translation code="aYU7t6" codeSystem="2.16.840.1.113883.19.278.47" codeSystemName="MyLocalCodeSystem" displayName="Chem7"/>
							</code>
							<text>Chem-7 tomorrow</text>
							<effectiveTime value="20000408"/>
						</observation>
					</entry>
					<entry>
						<act classCode="ACT" moodCode="INT">
							<id nullFlavor="UNK"/>
							<code code="223468009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Teaching of skills">
								<qualifier>
									<name code="363702006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="has focus"/>
									<value code="29893006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Peak flow rate measurement"/>
								</qualifier>
							</code>
						</act>
					</entry>
					<entry>
						<substanceAdministration classCode="SBADM" moodCode="RQO">
							<text>prednisone 20qOD alternating with 18qOD.</text>
							<routeCode code="PO" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration"/>
							<consumable>
								<manufacturedProduct>
									<manufacturedLabeledDrug>
										<code code="10312003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Prednisone preparation"/>
									</manufacturedLabeledDrug>
								</manufacturedProduct>
							</consumable>
						</substanceAdministration>
					</entry>
					<entry>
						<substanceAdministration classCode="SBADM" moodCode="RQO">
							<text>Hydrocortisone cream to finger BID.</text>
							<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
								<period value="12" unit="h"/>
							</effectiveTime>
							<routeCode code="SKIN" codeSystem="2.16.840.1.113883.5.112" codeSystemName="RouteOfAdministration" displayName="Topical application, skin"/>
							<approachSiteCode code="48856004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Skin of palmer surface of index finger">
								<qualifier>
									<name code="78615007" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="with laterality"/>
									<value code="7771000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="left"/>
								</qualifier>
							</approachSiteCode>
							<consumable>
								<manufacturedProduct>
									<manufacturedLabeledDrug>
										<code code="331646005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hydrocortisone cream"/>
									</manufacturedLabeledDrug>
								</manufacturedProduct>
							</consumable>
						</substanceAdministration>
					</entry>
					<entry>
						<encounter classCode="ENC" moodCode="RQO">
							<code code="185389009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Follow-up visit"/>
							<effectiveTime>
								<low value="20000412"/>
								<high value="20000417"/>
							</effectiveTime>
						</encounter>
					</entry>
				</section>
			</component>
		</structuredBody>
	</component>
</ClinicalDocument>