<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:mif="urn:hl7-org:v3/mif" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd"> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3" /> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4' /> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1' /> <id root='1' extension='1' /> <code code='34117-2' displayName='HISTORY AND PHYSICAL' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <title>Antepartum History and Physical</title> <effectiveTime value='20140409012005' /> <confidentialityCode code='N' displayName='Normal' codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' /> <languageCode code='en-US' /> <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" /> <name>Organization Name</name> </providerOrganization> </patientRole> </recordTarget> <author> <time value="20000407121000" /> <assignedAuthor> <id extension="123456789" root="2.16.840.1.113883.19.5.1" /> <assignedPerson> <name> <given>Robert</given> <family>Dolin</family> <suffix>MD</suffix> </name> </assignedPerson> <representedOrganization> <id root="2.16.840.1.113883.19.5" /> <name>Organization Name</name> </representedOrganization> </assignedAuthor> </author> <custodian> <assignedCustodian> <representedCustodianOrganization> <id root="2.16.840.1.113883.19.5" /> <name>Organization Name</name> </representedCustodianOrganization> </assignedCustodian> </custodian> <component> <structuredBody> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1' /> <!-- Required Chief Complaint Section content --> <id root='1' extension='2' /> <code code='10154-3' displayName='CHIEF COMPLAINT' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <text> Text as described above </text> </section> </component> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4' /> <!-- Required History of Present Illness Section content --> <id root='1' extension='2' /> <code code='10164-2' displayName='HISTORY OF PRESENT ILLNESS' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <text> Text as described above </text> </section> </component> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8' /> <!-- Required History of Past Illness Section content --> <id root='1' extension='2' /> <code code='11348-0' displayName='HISTORY OF PAST ILLNESS' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <text> Text as described above </text> </section> </component> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1' /> <id root='1' extension='2' /> <code code='XX-HistoryOfInfection' displayName='HISTORY OF INFECTION' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <text> Text as described above </text> </section> </component> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4' /> <!-- Required Pregnancy History Section content --> <id root='1' extension='2' /> <code code='10162-6' displayName='HISTORY OF PREGNANCIES' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <text> Text as described above </text> <entry> <!-- Required Pregnancy Observation element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5' /> <observation classCode="OBS" moodCode="EVN"> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13' /> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.5" /> <id root='1' extension='2' /> <code code='11636-8' displayName='BIRTHS LIVE (REPORTED)' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <statusCode code='completed' /> <effectiveTime value="2011" /> <repeatNumber /> <value code="1325" codeSystem="1.3.6.1.4.1.12009.2" codeSystemName="LOINC" displayName="CODED ANSWER" xsi:type="CD" /> <!-- <value xsi:type='INT' value='1'/> --> <interpretationCode code="Value" /> <methodCode code="Value" /> <targetSiteCode code="1506555919" /> </observation> </entry> <entry> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5' /> <observation classCode="OBS" moodCode="EVN"> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13' /> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.5" /> <id root='1' extension='2' /> <code code='11636-8-A' displayName='A' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <statusCode code='completed' /> <effectiveTime value="2011" /> <repeatNumber /> <value xsi:type='INT' value='1' /> <interpretationCode code="Value" /> <methodCode code="Value" /> <targetSiteCode code="1506555919" /> </observation> </entry> <entry> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5' /> <observation classCode="OBS" moodCode="EVN"> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13' /> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.5" /> <id root='1' extension='2' /> <code code='11636-8-B' displayName='B' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <statusCode code='completed' /> <effectiveTime value="2011" /> <repeatNumber /> <value xsi:type='ST'>TEST</value> <interpretationCode code="Value" /> <methodCode code="Value" /> <targetSiteCode code="1506555919" /> </observation> </entry> <entry> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.5' /> <observation classCode="OBS" moodCode="EVN"> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13' /> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.5" /> <id root='1' extension='2' /> <code code='11636-8-C' displayName='C' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <statusCode code='completed' /> <effectiveTime value="2011" /> <repeatNumber /> <value xsi:type='TS' value='20110101' /> <interpretationCode code="Value" /> <methodCode code="Value" /> <targetSiteCode code="1506555919" /> </observation> </entry> </section> </component> <component> <section> <templateId root='2.16.840.1.113883.10.20.1.15' /> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16' /> <!-- Required Social History Section content --> <id root='1' extension='2' /> <code code='29762-2' displayName='SOCIAL HISTORY' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <title>boink</title> <text> Text as described above </text> </section> </component> <component> <section> <templateId root='2.16.840.1.113883.10.20.1.4' /> <!-- Required Coded Family Medical History Section content --> <id root='1' extension='2' /> <code code='10157-6' displayName='HISTORY OF FAMILY MEMBER DISEASES' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <title>boink</title> <text> Text as described above </text> </section> </component> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18' /> <!-- Required Review of Systems Section content --> <id root='1' extension='2' /> <code code='10187-3' displayName='REVIEW OF SYSTEMS' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <text> Text as described above </text> </section> </component> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24' /> <!-- Required Physical Examination Section content --> <id root='1' extension='2' /> <code code='29545-1' displayName='PHYSICAL EXAMINATION' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <text> Text as described above </text> </section> </component> <component> <section> <templateId root='2.16.840.1.113883.10.20.1.16' /> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25' /> <!-- Conditional Vital Signs Section content --> <id root='1' extension='2' /> <code code='8716-3' displayName='VITAL SIGNS' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /> <title>boink</title> <text> Text as described above </text> </section> </component> </structuredBody> </component> </ClinicalDocument>
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