Given below is the sample CDA document to be used for the initial development of the SHR CDA Handler module.
This module was generated by converting a sample hl7 message with two OBR segments (each with two OBX segments) into a CDA document.
Note that while this document purports to be a Aphp document, it is not yet fully configured as such, but will be iteratively modified as our work progresses.
<ClinicalDocument classCode="DOCCLIN" moodCode="EVN" xmlns="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<realmCode code="US"/>
<typeId displayable="false" extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<templateId displayable="false" root="2.16.840.1.113883.10.20.3"/>
<templateId displayable="false" root="1.3.6.1.4.1.19376.1.5.3.1.1.1"/>
<templateId displayable="false" root="1.3.6.1.4.1.19376.1.7.3.1.1.14.1"/>
<id displayable="false" extension="apHandP" root="2.16.840.1.113883.19.4"/>
<code code="72134-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LN" displayName="Cancer event report"/>
<title mediaType="text/plain" representation="TXT">Regenstrief Institute Clinic Continuity of Care Document</title>
<effectiveTime value="20140321081150.976-0500"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality" displayName="normal"/>
<languageCode code="en-US"/>
<recordTarget contextControlCode="OP" typeCode="RCT">
<patientRole classCode="PAT">
<id assigningAuthorityName="Wishard Memorial Hospital Medical Record Numbers" extension="91" root="1.3.6.1.4.1.12009.1.1.1"/>
<addr use="HP">
<streetAddressLine>3156 NEW ENGLAND ST</streetAddressLine>
<city>INDIANAPOLIS</city>
<state>IN</state>
<postalCode>46254</postalCode>
<useablePeriod xsi:type="IVL_TS">
<low nullFlavor="UNK"/>
<high nullFlavor="UNK"/>
</useablePeriod>
</addr>
<telecom use="HP" value="tel:+1-317-285-9073"/>
<patient>
<name>
<given>PATIENT</given>
<family>TEST</family>
</name>
<administrativeGenderCode code="U" codeSystem="1.3.6.1.4.1.12009.8.1" codeSystemName="SEX" displayName="unknown"/>
<birthTime value="19320924"/>
<maritalStatusCode code="M" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatus" displayName="Married">
<translation code="M" codeSystem="1.3.6.1.4.1.12009.1.1.8" codeSystemName="Wishard Memorial Hospital Person MARITAL STATUS codes" displayName="M"/>
</maritalStatusCode>
<raceCode nullFlavor="OTH">
<translation code="20545" codeSystem="1.3.6.1.4.1.12009.2" codeSystemName="Local Concept" displayName="refused">
<originalText>Declined to Specify</originalText>
</translation>
</raceCode>
<sdtc:raceCode nullFlavor="OTH" xmlns:sdtc="urn:hl7-org:sdtc">
<translation code="20545" codeSystem="1.3.6.1.4.1.12009.2" codeSystemName="Local Concept" displayName="refused">
<originalText>Declined to Specify</originalText>
</translation>
</sdtc:raceCode>
<ethnicGroupCode nullFlavor="OTH">
<translation nullFlavor="UNK"/>
</ethnicGroupCode>
<birthplace>
<place nullFlavor="UNK"/>
</birthplace>
</patient>
<providerOrganization>
<id displayable="false" root="1.3.6.1.4.1.12009.1.1" xsi:type="II"/>
<name xsi:type="ON">WISHARD MEMORIAL HOSPITAL</name>
<telecom nullFlavor="UNK"/>
<addr>
<streetAddressLine>1001 W Tenth Street</streetAddressLine>
<city>Indianapolis</city>
<state>IN</state>
<postalCode>46202</postalCode>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author contextControlCode="OP" typeCode="AUT">
<time value="20000407130000+0500"/>
<assignedAuthor classCode="ASSIGNED">
<id assigningAuthorityName="CDA Class Name" extension="org.regenstrief.hl7_v3.cda.KyCda.3" root="1.3.6.1.4.1.12009.9.5" xsi:type="II"/>
<id assigningAuthorityName="Abstract Form Name" extension="KY CDA" root="1.3.6.1.4.1.12009.9.6" xsi:type="II"/>
<id assigningAuthorityName="SPIN Users" extension="AMARTIN3" root="1.3.6.1.4.1.12009.1.99.7" xsi:type="II"/>
<id assigningAuthorityName="Project Name" extension="file:/C:/Users/amartin/workspace/hl7/bin/" root="1.3.6.1.4.1.12009.9.7" xsi:type="II"/>
<id assigningAuthorityName="Med Hub Class Name" extension="org.regenstrief.hl7.database.LocalMedHub" root="1.3.6.1.4.1.12009.9.8" xsi:type="II"/>
<id assigningAuthorityName="National Provider Identifier" extension="156840731" root="2.16.840.1.113883.4.6" xsi:type="II"/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Robert</given>
<family>Dolin</family>
</name>
</assignedPerson>
<addr>
<streetAddressLine>1050 Wishard Blvd.</streetAddressLine>
<city>Indianapolis</city>
<state>IN</state>
<postalCode>46202</postalCode>
</addr>
<telecom value="tel:+1-317-630-6083"/>
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
<id displayable="false" root="1.3.6.1.4.1.12009" xsi:type="II"/>
<name xsi:type="ON">REGENSTRIEF INSTITUTE, INC.</name>
<telecom value="tel:+1-317-630-6083"/>
<addr>
<streetAddressLine>1050 Wishard Blvd.</streetAddressLine>
<city>Indianapolis</city>
<state>IN</state>
<postalCode>46202</postalCode>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
<custodian typeCode="CST">
<assignedCustodian classCode="ASSIGNED">
<representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
<id displayable="false" root="1.3.6.1.4.1.12009" xsi:type="II"/>
<name xsi:type="ON">REGENSTRIEF INSTITUTE, INC.</name>
<telecom value="tel:+1-317-630-6083"/>
<addr>
<streetAddressLine>1050 Wishard Blvd.</streetAddressLine>
<city>Indianapolis</city>
<state>IN</state>
<postalCode>46202</postalCode>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<participant contextControlCode="OP" typeCode="RESP">
<time value="20140321081150.976-0500"/>
<associatedEntity classCode="PROV">
<id assigningAuthorityName="SPIN Users" extension="AMARTIN3" root="1.3.6.1.4.1.12009.1.99.7"/>
<code nullFlavor="NA"/>
<addr nullFlavor="UNK"/>
<telecom nullFlavor="UNK"/>
<associatedPerson classCode="PSN" determinerCode="INSTANCE">
<name xsi:type="PN">
<given>ANDREW</given>
<family>MARTIN</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<documentationOf typeCode="DOC">
<serviceEvent classCode="PCPR" moodCode="EVN">
<effectiveTime xsi:type="IVL_TS">
<low value="19710101000000.000-0500"/>
<high value="20140318164026.000-0500"/>
</effectiveTime>
</serviceEvent>
</documentationOf>
<component contextConductionInd="true" typeCode="COMP">
<structuredBody classCode="DOCBODY" moodCode="EVN">
<component contextConductionInd="true" typeCode="COMP">
<section classCode="DOCSECT" moodCode="EVN">
<templateId displayable="false" root="1.3.6.1.4.1.19376.1.5.3.1.3.28"/>
<id displayable="false" root="b36433c7-57b8-4e58-9aa6-4f94170b0215"/>
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LN" displayName="Relevant Dx tests/lab data"/>
<title mediaType="text/plain" representation="TXT">Results</title>
<text mediaType="text/x-hl7-text+xml">
<paragraph ID="Results-organizer">Lab results</paragraph>
<table>
<thead>
<tr>
<th>Type</th>
<th>Type Code</th>
<th>Value</th>
<th>Value Code</th>
<th>Date/Time</th>
<th>Status</th>
<th>Abnormal Flag</th>
<th>Source</th>
</tr>
</thead>
<tbody>
<tr>
<th>Hgb Elp ALK pH</th>
<td>3083 (Local Concept)</td>
<td ID="Results-value-2635222674-001-0">Methylone Ur Qn</td>
<td>43051 (Local Concept)</td>
<td>2012-03-28 13:20:00.0</td>
<td>history</td>
<td>N</td>
<td>Unknown</td>
</tr>
<tr>
<th>Hgb S Bld Ql Soly</th>
<td>6864-3 (LN), 789 (Local Concept)</td>
<td ID="Results-value-2635222675-001-0">neg</td>
<td>1325 (Local Concept)</td>
<td>2012-03-28 13:20:00.0</td>
<td>history</td>
<td>N</td>
<td>Unknown</td>
</tr>
<tr>
<th>Inhaled O2 concentration</th>
<td>3150-0 (LN), 207 (Local Concept)</td>
<td ID="Results-value-78960013-000-0" colspan="2">80</td>
<td>1996-04-19 14:45:00.0</td>
<td>history</td>
<td>N</td>
<td>Unknown</td>
</tr>
<tr>
<th>Inhaled O2 flow rate</th>
<td>3151-8 (LN), 6458 (Local Concept)</td>
<td ID="Results-value-78964285-000-0" colspan="2">15</td>
<td>1996-04-19 14:45:00.0</td>
<td>history</td>
<td>N</td>
<td>Unknown</td>
</tr>
</tbody>
</table>
</text>
<entry contextConductionInd="true" typeCode="COMP">
<organizer classCode="BATTERY" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.32"/>
<templateId root="2.16.840.1.113883.10.20.22.4.1"/>
<id nullFlavor="NA"/>
<code code="8996" codeSystem="1.3.6.1.4.1.12009.2" codeSystemName="Local Concept" displayName="ANEMIA STUDIES"/>
<statusCode code="completed"/>
<effectiveTime value="20120328132000.000-0500"/>
<component>
<procedure classCode="PROC" moodCode="EVN">
<templateId assigningAuthorityName="HITSP/C83-[DE-17-CDA-1]" root="2.16.840.1.113883.3.88.11.83.17"/>
<templateId assigningAuthorityName="HITSP/C83-[DE-17-CDA-2]" root="1.3.6.1.4.1.19376.1.5.3.1.4.19"/>
<templateId assigningAuthorityName="HL7 CCD CONF-427" root="2.16.840.1.113883.10.20.1.29"/>
<id nullFlavor="NA"/>
<code>
<originalText>
<reference value="#Results-organizer"/>
</originalText>
</code>
<text>
<reference value="#Results-organizer"/>
</text>
<statusCode code="completed"/>
</procedure>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId displayable="false" root="2.16.840.1.113883.10.20.1.31"/>
<templateId displayable="false" root="2.16.840.1.113883.3.88.11.83.15.1"/>
<templateId displayable="false" root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
<templateId displayable="false" root="2.16.840.1.113883.10.20.22.4.2"/>
<id displayable="false" extension="2635222674-001-0" root="1.3.6.1.4.1.12009.1.1.12" xsi:type="II"/>
<code code="3083" codeSystem="1.3.6.1.4.1.12009.2" codeSystemName="Local Concept" displayName="Hgb Elp ALK pH"/>
<text mediaType="text/plain">
<reference value="#Results-value-2635222674-001-0"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20120328132000.000-0500"/>
<value code="43051" codeSystem="1.3.6.1.4.1.12009.2" codeSystemName="Local Concept" displayName="Methylone Ur Qn" xsi:type="CD"/>
<interpretationCode nullFlavor="NI" xsi:type="CE"/>
<participant typeCode="LOC">
<templateId root="2.16.840.1.113883.10.20.1.45"/>
<participantRole classCode="SDLOC">
<id assigningAuthorityName="Wishard Memorial Hospital Service Locations" extension="FM MED" root="1.3.6.1.4.1.12009.1.1.3"/>
<addr>
<streetAddressLine>1001 W Tenth Street</streetAddressLine>
<city>Indianapolis</city>
<state>IN</state>
<postalCode>46202</postalCode>
</addr>
<telecom nullFlavor="UNK"/>
<playingEntity classCode="PLC">
<name>Forest Manor Health Center</name>
</playingEntity>
<scopingEntity>
<id displayable="false" root="1.3.6.1.4.1.12009.1.1" xsi:type="II"/>
<desc>WISHARD MEMORIAL HOSPITAL</desc>
</scopingEntity>
</participantRole>
</participant>
<participant typeCode="AUT">
<participantRole>
<addr nullFlavor="UNK"/>
<telecom nullFlavor="UNK"/>
<playingEntity>
<code code="G3PP" codeSystem="1.3.6.1.4.1.12009.9.2"/>
<desc>G3 Post Processor</desc>
</playingEntity>
<scopingEntity>
<id displayable="false" root="1.3.6.1.4.1.12009.1.1" xsi:type="II"/>
<desc>WISHARD MEMORIAL HOSPITAL</desc>
</scopingEntity>
</participantRole>
</participant>
<referenceRange typeCode="REFV">
<observationRange classCode="OBS" moodCode="EVN.CRT">
<text nullFlavor="NA" xsi:type="ST"/>
</observationRange>
</referenceRange>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId displayable="false" root="2.16.840.1.113883.10.20.1.31"/>
<templateId displayable="false" root="2.16.840.1.113883.3.88.11.83.15.1"/>
<templateId displayable="false" root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
<templateId displayable="false" root="2.16.840.1.113883.10.20.22.4.2"/>
<id displayable="false" extension="2635222675-001-0" root="1.3.6.1.4.1.12009.1.1.12" xsi:type="II"/>
<code code="6864-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LN" displayName="Hgb S Bld Ql Soly">
<translation code="789" codeSystem="1.3.6.1.4.1.12009.2" codeSystemName="Local Concept" displayName="Hgb S Screen (Solubility)"/>
</code>
<text mediaType="text/plain">
<reference value="#Results-value-2635222675-001-0"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20120328132000.000-0500"/>
<value code="1325" codeSystem="1.3.6.1.4.1.12009.2" codeSystemName="Local Concept" displayName="neg" xsi:type="CD"/>
<interpretationCode nullFlavor="NI" xsi:type="CE"/>
<participant typeCode="LOC">
<templateId root="2.16.840.1.113883.10.20.1.45"/>
<participantRole classCode="SDLOC">
<id assigningAuthorityName="Wishard Memorial Hospital Service Locations" extension="FM MED" root="1.3.6.1.4.1.12009.1.1.3"/>
<addr>
<streetAddressLine>1001 W Tenth Street</streetAddressLine>
<city>Indianapolis</city>
<state>IN</state>
<postalCode>46202</postalCode>
</addr>
<telecom nullFlavor="UNK"/>
<playingEntity classCode="PLC">
<name>Forest Manor Health Center</name>
</playingEntity>
<scopingEntity>
<id displayable="false" root="1.3.6.1.4.1.12009.1.1" xsi:type="II"/>
<desc>WISHARD MEMORIAL HOSPITAL</desc>
</scopingEntity>
</participantRole>
</participant>
<participant typeCode="AUT">
<participantRole>
<addr nullFlavor="UNK"/>
<telecom nullFlavor="UNK"/>
<playingEntity>
<code code="G3PP" codeSystem="1.3.6.1.4.1.12009.9.2"/>
<desc>G3 Post Processor</desc>
</playingEntity>
<scopingEntity>
<id displayable="false" root="1.3.6.1.4.1.12009.1.1" xsi:type="II"/>
<desc>WISHARD MEMORIAL HOSPITAL</desc>
</scopingEntity>
</participantRole>
</participant>
<referenceRange typeCode="REFV">
<observationRange classCode="OBS" moodCode="EVN.CRT">
<text nullFlavor="NA" xsi:type="ST"/>
</observationRange>
</referenceRange>
</observation>
</component>
</organizer>
</entry>
<entry contextConductionInd="true" typeCode="COMP">
<organizer classCode="BATTERY" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.32"/>
<templateId root="2.16.840.1.113883.10.20.22.4.1"/>
<id nullFlavor="NA"/>
<code code="24338-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LN" displayName="Gas Pnl Bld">
<translation code="5635" codeSystem="1.3.6.1.4.1.12009.2" codeSystemName="Local Concept" displayName="BLD GAS PANEL 1"/>
</code>
<statusCode code="completed"/>
<effectiveTime value="19960419144500.000-0500"/>
<component>
<procedure classCode="PROC" moodCode="EVN">
<templateId assigningAuthorityName="HITSP/C83-[DE-17-CDA-1]" root="2.16.840.1.113883.3.88.11.83.17"/>
<templateId assigningAuthorityName="HITSP/C83-[DE-17-CDA-2]" root="1.3.6.1.4.1.19376.1.5.3.1.4.19"/>
<templateId assigningAuthorityName="HL7 CCD CONF-427" root="2.16.840.1.113883.10.20.1.29"/>
<id nullFlavor="NA"/>
<code>
<originalText>
<reference value="#Results-organizer"/>
</originalText>
</code>
<text>
<reference value="#Results-organizer"/>
</text>
<statusCode code="completed"/>
</procedure>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId displayable="false" root="2.16.840.1.113883.10.20.1.31"/>
<templateId displayable="false" root="2.16.840.1.113883.3.88.11.83.15.1"/>
<templateId displayable="false" root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
<templateId displayable="false" root="2.16.840.1.113883.10.20.22.4.2"/>
<id displayable="false" extension="78960013-000-0" root="1.3.6.1.4.1.12009.1.1.12" xsi:type="II"/>
<code code="3150-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LN" displayName="Inhaled O2 concentration">
<translation code="207" codeSystem="1.3.6.1.4.1.12009.2" codeSystemName="Local Concept" displayName="Inspired O2"/>
</code>
<text mediaType="text/plain">
<reference value="#Results-value-78960013-000-0"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="19960419144500.000-0500"/>
<value unit="%" value="80.0" xsi:type="PQ"/>
<interpretationCode nullFlavor="NI" xsi:type="CE"/>
<participant typeCode="LOC">
<templateId root="2.16.840.1.113883.10.20.1.45"/>
<participantRole classCode="SDLOC">
<id assigningAuthorityName="Wishard Memorial Hospital Service Locations" extension="WMH" root="1.3.6.1.4.1.12009.1.1.3"/>
<addr>
<streetAddressLine>1001 W Tenth Street</streetAddressLine>
<city>Indianapolis</city>
<state>IN</state>
<postalCode>46202</postalCode>
</addr>
<telecom nullFlavor="UNK"/>
<playingEntity classCode="PLC">
<name>Wishard Memorial Hospital</name>
</playingEntity>
<scopingEntity>
<id displayable="false" root="1.3.6.1.4.1.12009.1.1" xsi:type="II"/>
<desc>WISHARD MEMORIAL HOSPITAL</desc>
</scopingEntity>
</participantRole>
</participant>
<participant typeCode="AUT">
<participantRole>
<addr nullFlavor="UNK"/>
<telecom nullFlavor="UNK"/>
<playingEntity>
<code code="PULWMH" codeSystem="1.3.6.1.4.1.12009.9.2"/>
<desc>Wishard Pulmonary Lab</desc>
</playingEntity>
<scopingEntity>
<id displayable="false" root="1.3.6.1.4.1.12009.1.1" xsi:type="II"/>
<desc>WISHARD MEMORIAL HOSPITAL</desc>
</scopingEntity>
</participantRole>
</participant>
<referenceRange typeCode="REFV">
<observationRange classCode="OBS" moodCode="EVN.CRT">
<text nullFlavor="NA" xsi:type="ST"/>
</observationRange>
</referenceRange>
</observation>
</component>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId displayable="false" root="2.16.840.1.113883.10.20.1.31"/>
<templateId displayable="false" root="2.16.840.1.113883.3.88.11.83.15.1"/>
<templateId displayable="false" root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
<templateId displayable="false" root="2.16.840.1.113883.10.20.22.4.2"/>
<id displayable="false" extension="78964285-000-0" root="1.3.6.1.4.1.12009.1.1.12" xsi:type="II"/>
<code code="3151-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LN" displayName="Inhaled O2 flow rate">
<translation code="6458" codeSystem="1.3.6.1.4.1.12009.2" codeSystemName="Local Concept" displayName="Oxygen Flow Rate"/>
</code>
<text mediaType="text/plain">
<reference value="#Results-value-78964285-000-0"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="19960419144500.000-0500"/>
<value unit="L/min" value="15.0" xsi:type="PQ"/>
<interpretationCode nullFlavor="NI" xsi:type="CE"/>
<participant typeCode="LOC">
<templateId root="2.16.840.1.113883.10.20.1.45"/>
<participantRole classCode="SDLOC">
<id assigningAuthorityName="Wishard Memorial Hospital Service Locations" extension="WMH" root="1.3.6.1.4.1.12009.1.1.3"/>
<addr>
<streetAddressLine>1001 W Tenth Street</streetAddressLine>
<city>Indianapolis</city>
<state>IN</state>
<postalCode>46202</postalCode>
</addr>
<telecom nullFlavor="UNK"/>
<playingEntity classCode="PLC">
<name>Wishard Memorial Hospital</name>
</playingEntity>
<scopingEntity>
<id displayable="false" root="1.3.6.1.4.1.12009.1.1" xsi:type="II"/>
<desc>WISHARD MEMORIAL HOSPITAL</desc>
</scopingEntity>
</participantRole>
</participant>
<participant typeCode="AUT">
<participantRole>
<addr nullFlavor="UNK"/>
<telecom nullFlavor="UNK"/>
<playingEntity>
<code code="PULWMH" codeSystem="1.3.6.1.4.1.12009.9.2"/>
<desc>Wishard Pulmonary Lab</desc>
</playingEntity>
<scopingEntity>
<id displayable="false" root="1.3.6.1.4.1.12009.1.1" xsi:type="II"/>
<desc>WISHARD MEMORIAL HOSPITAL</desc>
</scopingEntity>
</participantRole>
</participant>
<referenceRange typeCode="REFV">
<observationRange classCode="OBS" moodCode="EVN.CRT">
<text nullFlavor="NA" xsi:type="ST"/>
</observationRange>
</referenceRange>
</observation>
</component>
</organizer>
</entry>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument> |