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CDA Transform and the XPHR [message #22067] Fri, 03 November 2006 21:36 Go to next message
Corey Spears is currently offline Corey SpearsFriend
Messages: 18
Registered: July 2009
Junior Member
Hi,
I noticed that the online portal (http://ibmod235.dal-ebis.ihost.com:8080/)
does a transform of the CDA documents as you view them, so they are
formatted into html. I was wondering where I could get a copy of the xslt
to have as a starting point.
Does the xslt include the necessary elements to support display of all of
the XPHR?


Also, are there any example PHRs out there. I have been going through the
documents on the RHIOs and I have not been able to find any yet. Perhaps
one of the PHRs or other xPHR sources in the group could provide a couple of
samples.


Thank you,
Corey Spears
Re: CDA Transform and the XPHR [message #22119 is a reply to message #22067] Fri, 03 November 2006 22:01 Go to previous messageGo to next message
Eclipse UserFriend
Originally posted by: eishays.us.ibm.com

Yes,

The XSL in under the org.eclipse.ohf.bridge.client project named
"ClinicalDocument.xsl".
The XSL is very basic and does not support a full CDA or XPHR.
We will appropriate help extending the XSL to support more elements.

If you wish to contribute back improvements to the XSL, please send them
by opening a bugzilla bug report on the bridge component and
attaching/pasting your changes. See:
http://wiki.eclipse.org/index.php/Submit_Bugs_to_OHF
It is important to our legal process as well as to acknowledging you as
a contributer.

I don't know about PHR examples, maybe Sarah or someone from CapMed?

--eishay

Corey Spears wrote:
> Hi,
> I noticed that the online portal (http://ibmod235.dal-ebis.ihost.com:8080/)
> does a transform of the CDA documents as you view them, so they are
> formatted into html. I was wondering where I could get a copy of the xslt
> to have as a starting point.
> Does the xslt include the necessary elements to support display of all of
> the XPHR?
>
>
> Also, are there any example PHRs out there. I have been going through the
> documents on the RHIOs and I have not been able to find any yet. Perhaps
> one of the PHRs or other xPHR sources in the group could provide a couple of
> samples.
>
>
> Thank you,
> Corey Spears
>
>
Re: CDA Transform and the XPHR [message #22168 is a reply to message #22119] Sat, 04 November 2006 00:18 Go to previous message
No real name is currently offline No real nameFriend
Messages: 292
Registered: July 2009
Senior Member
This is a multi-part message in MIME format.
--------------070402000706020402060704
Content-Type: text/plain; charset=ISO-8859-1; format=flowed
Content-Transfer-Encoding: 7bit

Hmmmm ... sample.xml is a document that conforms to the HL7
specification that XPHR is based on (CRS). So it's close ... but
probably not exact. The other attachment I believe conforms to the old
version of the XPHR (or XDS-MS) spcification.

This would be a good question for the IHE Connectathon Bug List
http://ihe.univ-rennes1.fr/flyspray/index.php?tasks=all& project=1&highlight=10_2

Or keep watching this page:
http://hcxw2k1.nist.gov/wiki/index.php/XDS-Examples

- Sarah

Eishay Smith wrote:
> Yes,
>
> The XSL in under the org.eclipse.ohf.bridge.client project named
> "ClinicalDocument.xsl".
> The XSL is very basic and does not support a full CDA or XPHR.
> We will appropriate help extending the XSL to support more elements.
>
> If you wish to contribute back improvements to the XSL, please send them
> by opening a bugzilla bug report on the bridge component and
> attaching/pasting your changes. See:
> http://wiki.eclipse.org/index.php/Submit_Bugs_to_OHF
> It is important to our legal process as well as to acknowledging you as
> a contributer.
>
> I don't know about PHR examples, maybe Sarah or someone from CapMed?
>
> --eishay
>
> Corey Spears wrote:
>
>> Hi,
>> I noticed that the online portal
>> (http://ibmod235.dal-ebis.ihost.com:8080/) does a transform of the CDA
>> documents as you view them, so they are formatted into html. I was
>> wondering where I could get a copy of the xslt to have as a starting
>> point.
>> Does the xslt include the necessary elements to support display of all
>> of the XPHR?
>>
>>
>> Also, are there any example PHRs out there. I have been going through
>> the documents on the RHIOs and I have not been able to find any yet.
>> Perhaps one of the PHRs or other xPHR sources in the group could
>> provide a couple of samples.
>>
>>
>> Thank you,
>> Corey Spears
>>


--------------070402000706020402060704
Content-Type: text/xml;
name="sample.xml"
Content-Transfer-Encoding: 7bit
Content-Disposition: inline;
filename="sample.xml"

<ClinicalDocument xmlns='urn:hl7-org:v3'>
<realmCode code='US'/>
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<templateId extension="IMPL_CDAR2_LEVEL1-2REF_US_I2_2005SEP" root="2.16.840.1.113883.10"/>
<id extension='999021' root='1.3.6.4.1.4.1.2835.2'/>
<code code='34133-9' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' displayName='SUMMARIZATION OF EPISODE NOTE'/>
<title>Good Health Clinic Care Record Summary</title>
<effectiveTime value='20050329224411+0500'/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code='en-US'/>
<setId extension='999021' root='1.3.6.4.1.4.1.2835.1'/>
<versionNumber value='1'/>
<recordTarget>
<patientRole>
<id extension="12345" root="2.16.840.1.113883.3.933"/>
<addr>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(781)555-1212' use='HP'/>
<patient>
<name>
<prefix>Mrs.</prefix>
<given>Ellen</given>
<family>Ross</family>
</name>
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
<birthTime value="19600127"/>
</patient>
<providerOrganization>
<id extension="M345" root="2.16.840.1.113883.3.933"/>
<name>Good Health Clinic</name>
<telecom value='tel:(999)555-1212' use='WP'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time value='20050329224411+0500'/>
<assignedAuthor>
<id extension='1' root='1.3.6.4.1.4.1.2835.1'/>
<code code='SELF' codeSystem='2.16.840.1.113883.5.111'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Bernard</given>
<family>Wiseman</family>
<suffix>Sr.</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<author>
<time value='20050329224411+0500'/>
<assignedAuthor>
<id extension='1' root='1.3.6.4.1.4.1.2835.1'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<assignedAuthoringDevice>
<softwareName>Good Health Clinic System v1.0</softwareName>
</assignedAuthoringDevice>
</assignedAuthor>
</author>
<dataEnterer>
<time value='20050329222451+0500'/>
<assignedEntity>
<id extension='2' root='1.3.6.4.1.4.1.2835.2'/>
<assignedPerson>
<name>
<prefix>Mrs.</prefix>
<given>Bernice</given>
<family>Wiseman</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<!-- To represent a healthcare provider with a specific assigned healthcare role that can be identified by the author and authoring system.
-->
<informant>
<assignedEntity>
<id extension='3' root='1.3.6.4.1.4.1.2835.2'/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Bernard</given>
<family>Wiseman</family>
<suffix>Jr.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</informant>
<!-- To represent a mother who provides information about her child -->
<informant>
<relatedEntity classCode='PRS'>
<code code='MTH' codeSystem='2.16.840.1.113883.5.111'/>
<relatedPerson>
<name>
<prefix>Mrs.</prefix>
<given>Abigail</given>
<family>Ruth</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<!-- To represent a witness to a signicant health event -->
<informant>
<relatedEntity classCode='CON'>
<relatedPerson>
<name>
<prefix>Mr.</prefix>
<given>Joseph</given>
<given>T.</given>
<family>Jones</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<!-- To represent a healthcare provider in a healthcare role without an assigned role known or representable to the author. The example below represents a physician who was the patient's primary care provider. -->
<informant>
<relatedEntity classCode='PROV'>
<code code='59058001' codeSystem='2.16.840.1.113883.6.96'/>
<relatedPerson>
<name>
<given>Jane</given>
<family>Queen</family>
<suffix></suffix>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension='1' root='1.3.6.4.1.4.1.2835.3'/>
<name>Good Health Clinic</name>
<telecom value='tel:(999)555-1212' use='WP'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient>
<intendedRecipient>
<id extension='4' root='1.3.6.4.1.4.1.2835.2'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<informationRecipient>
<name>
<prefix>Dr.</prefix>
<given>Phil</given>
<family>Green</family>
</name>
</informationRecipient>
<receivedOrganization>
<name>Good Health Clinic</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<time value='20050329224512+0500'/>
<signatureCode code='S'/>
<assignedEntity>
<id extension='1' root='1.3.6.4.1.4.1.2835.1'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Bernard</given>
<family>Wiseman</family>
<suffix>Sr.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<authenticator>
<time value='20050329224512+0500'/>
<signatureCode code='S'/>
<assignedEntity>
<id extension='3' root='1.3.6.4.1.4.1.2835.1'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Bernard</given>
<family>Wiseman</family>
<suffix>Jr.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<participant typeCode='IND'>
<time></time>
<associatedEntity classCode='PRS'>
<code code='MTH' codeSystem='2.16.840.1.113883.5.111'/>
<addr>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<associatedPerson>
<name>
<prefix>Mrs.</prefix>
<given>Abigail</given>
<family>Ruth</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<participant typeCode='HLD'>
<time>
<low value='20050101'/>
<high value='20051231'/>
</time>
<associatedEntity classCode='POLHOLD'>
<id extension='123456789' root='00000000-0000-0000-0000-000000000000'/>
<code code='PHFAMDEP' codeSystem='2.16.840.1.113883.5.1095'/>
<!-- To show that the policy holder is the patient, the above would be:
<code code='SELF' codeSystem='2.16.840.1.113883.5.111'/>
-->
<addr>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<associatedPerson>
<name>
<prefix>Mr.</prefix>
<given>Kenneth</given>
<family>Ross</family>
</name>
</associatedPerson>
<scopingOrganization>
<name>Good Health Insurance Company</name>
<telecom value='tel:(203)555-1212' use='WP'/>
<addr>
<streetAddressLine>3191 Broadbridge Avenue</streetAddressLine>
<city>Stratford</city>
<state>CT</state>
<postalCode>06614-2559</postalCode>
<country>USA</country>
</addr>
</scopingOrganization>
</associatedEntity>
</participant>
<participant typeCode='IND'>
<associatedEntity classCode='GUAR'>
<addr>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<associatedPerson>
<name>
<prefix>Mr.</prefix>
<given>Kenneth</given>
<family>Ross</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<documentationOf>
<serviceEvent classCode='PCPR'>
<effectiveTime>
<low value='19600127'/>
<high value='20050329'/>
</effectiveTime>
<performer typeCode='PRF'>
<functionCode code='PCP' codeSystem='2.16.840.1.113883.5.88'/>
<time>
<low value='1998'/>
<high value='2005'/>
</time>
<assignedEntity>
<id extension='1' root='1.3.6.4.1.4.1.2835.1'/>
<code code='59058001'
codeSystem='2.16.840.1.113883.6.96'
codeSystemName='SNOMED CT'
displayName='General Physician'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Bernard</given>
<family>Wiseman</family>
<suffix>Sr.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<component>
<structuredBody>
<templateId extension="IMPL_CDAR2_LEVEL1-2REF_US_I2_2005SEP" root="2.16.840.1.113883.10"/>
<component>
<section>
<code code='X-RFVCC' codeSystem='2.16.840.1.113883.6.1' />
<title>Reason for Visit/Chief Complaint</title>
<text>Ankle Sprain</text>
</section>
</component>
<component>
<section>
<code code='X-RFR' codeSystem='2.16.840.1.113883.6.1' />
<title>Reason for Referral</title>
<text>Follow-up care for Ankle Sprain</text>
</section>
</component>
<component>
<section>
<code code='X-ADVDIR' codeSystem='2.16.840.1.113883.6.1'/>
<title>Advance Directives</title>
<text>
<table border='1'>
<thead>
<tr><th>Documentation</th><th>Contact</th>
<th>Effective Date</th><th>Comments</th>
</tr>
</thead>
<tbody>
<tr><td>Living Will</td>
<td>Obtain from her Husband</td><td>1994</td>
<td>Copy on file</td>
</tr>
<tr><td>Power of Attorney</td>
<td>Obtain from her Husband</td><td>1994</td><td></td>
</tr>
<tr><td>Healthcare Proxy</td>
<td>Obtain from her Husband</td><td>1994</td><td></td>
</tr>
<tr><td>Organ Donor</td>
<td>Massachusetts Registry of Motor Vehicles</td>
<td>1/27/2004 - </td><td>Registered Organ Donor</td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='10164-2' codeSystem='2.16.840.1.113883.6.1' />
<title>History of Present Illness</title>
<text>Patient slipped and fell on ice, twisting her ankle as she fell.</text>
</section>
</component>
<component>
<section>
<code code='10157-6' codeSystem='2.16.840.1.113883.6.1'/>
<title>Family History</title>
<text>
<table border='1'>
<thead>
<tr><th>Family Member</th>
<th>Problem</th>
<th>Cause of Death?</th>
</tr>
</thead>
<tbody>
<tr><td>Father</td><td>Alcoholism</td><td>No</td></tr >
<tr><td>Father</td><td>Liver Cancer</td><td>Yes</td></tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='29762-2' codeSystem='2.16.840.1.113883.6.1' />
<title>Social History</title>
<text>
<table border='1'>
<thead>
<tr>
<th>Social History</th>
<th>Comments</th>
<th>Date Range</th>
</tr>
</thead>
<tbody>
<tr>
<td>Smoking</td><td>1/2 pack per day</td><td>? - 1996</td>
</tr>
<tr>
<td>Alcohol Use</td><td>1-2 drinks per week</td><td></td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='11450-4' codeSystem='2.16.840.1.113883.6.1' />
<title>Conditions</title>
<text>
<table border='1'>
<thead>
<tr><th>Problem</th><th>Date</th><th>Comments</th>
</tr>
</thead>
<tbody>
<tr>
<td>Cholecystitis</td><td>9/28/2002 - 6/2003</td>
<td>Resolved</td>
<td>Surgery postponed until after delivery</td>
</tr>
<tr>
<td>Pregnancy</td><td>7/2001 - 4/22/2002</td>
<td>Resolved</td>
<td>Prior history of miscarraige</td>
</tr>
<tr><td>Ankle Sprain</td><td>3/28/2005</td>
<td>Current</td>
<td>Slipped on ice and fell</td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='10155-0' codeSystem='2.16.840.1.113883.6.1' />
<title>Allergies and Adverse Reactions</title>
<text>
<table border='1'>
<thead>
<tr><th>Allergen</th><th>Reaction</th>
<th>Comments</th>
</tr>
</thead>
<tbody>
<tr><td>Penicillin</td><td>Hives</td>
<td>Amoxicillin is OK</td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='10160-0' codeSystem='2.16.840.1.113883.6.1' />
<title>Medications</title>
<text>
<table border='1'>
<thead>
<tr><th>Medication</th>
<th>Prescription or Dose</th>
<th>Dates of Use</th>
</tr>
</thead>
<tbody>
<tr><td>Indomethacin</td>
<td>50mg bid with food </td>
<td>12/10/2003 - present</td>
</tr>
<tr>
<td>Acetaminophen with codeine</td>
<td>#3 1-2 tablets for pain as needed</td>
<td>03/28/2005</td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='11369-6' codeSystem='2.16.840.1.113883.6.1' />
<title>Immunizations</title>
<text>
<list>
<item>DTP - 1962</item>
<item>Polio Virus - 1961</item>
<item>MMR - 1961</item>
</list>
</text>
</section>
</component>
<component>
<section>
<code code='10167-5' codeSystem='2.16.840.1.113883.6.1' />
<title>Procedures</title>
<text>
<table border='1'>
<thead>
<tr>
<th>Procedure</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr><td>Laparoscopic Cholecystectomy</td><td>9/28/2002</td></tr>
<tr><td>Cesarian Section</td><td>3/22/2002</td></tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='11336-5' codeSystem='2.16.840.1.113883.6.1' />
<title>Prior Encounters</title>
<text>
<table border='1'>
<thead>
<tr><th>Date</th><th>Provider</th>
<th>Description</th>
</tr>
</thead>
<tbody>
<tr><td>3/28/2005</td><td>Community Hospital</td>
<td>ED Visit for Ankle Sprain</td>
</tr>
<tr><td>9/28/2002</td><td>City Hospital</td>
<td>Gall Bladder Surgery</td>
</tr>
<tr><td>3/21/2002</td><td>Community Hospital</td>
<td>Labor and Delivery</td>
</tr>
<tr><td>10/28/2001</td><td>Community Hospital</td>
<td>ED Visit for Acute Cholecystitis</td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='10187-3' codeSystem='2.16.840.1.113883.6.1' />
<title>Review of Systems</title>
<text>Normal except for left foot and ankle.</text>
</section>
</component>
<component>
<section>
<code code='10210-3' codeSystem='2.16.840.1.113883.6.1' />
<title>Physical Examination</title>
<text>Left foot and ankle are swollen profusely.</text>
<component>
<section>
<code code='29274-8' codeSystem='2.16.840.1.113883.6.1' />
<title>Vital Signs</title>
<text>
<table border='1'>
<thead>
<tr><th>Date</th><th>Height</th><th>Weight</th><th >Temperature</th>
<th>BP</th><th>Pulse</th><th>Respiration</th><th>O2 </th>
</tr>
</thead>
<tbody>
<tr><th>3/28/2005</th><th>5'9"</th><th>215 lbs.</th><th>98.7 &#xB0;F</th>
<th>120/80</th><th>68</th><th>16</th><th>99%</th>
</tr>
</tbody>
</table>
</text>
</section>
</component>
</section>
</component>
<component>
<section>
<code code='X-SS' codeSystem='2.16.840.1.113883.6.1'/>
<title>Related Reports</title>
<text>
<table border='1'>
<thead>
<tr>
<th>Study</th>
<th>Summary</th>
<th>Date of Study</th>
</tr>
</thead>
<tbody>
<tr>
<td>X-Ray Study - Left Ankle</td>
<td>No Fracture</td>
<td>3/28/2005</td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='18776-5' codeSystem='2.16.840.1.113883.6.1' />
<title>Plan of Care</title>
<text>
<paragraph>Acetaminophen with codiene prn for pain.</paragraph>
<paragraph>Stay off the foot. Keep foot elevated, and use supplied air splint and crutches.</paragraph>
<paragraph>Follow-up with orthopedist in next 5 days.</paragraph>
</text>
</section>
</component>
</structuredBody>
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</ClinicalDocument>


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<!--
This document was produced by Dictaphone Enterprise Workstation (tm). Extracted clinical data
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<cda:serviceEvent classCode="PCPR">
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<!--author: Carus, Wyn-->
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<cda:section ID="section-1">
<!--Type: dss14:CHIEF COMPLAINT-->
<!--subtype: -->
<!--Temporal: -->
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<cda:title>CHIEF COMPLAINT:</cda:title>
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<cda:content ID="problem-1">Headache</cda:content> </cda:content>
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<!--Type: dss14:REASON FOR ENCOUNTER-->
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<cda:content ID="s-2">Patient wants his <cda:content ID="problem-2">headache</cda:content> to go away. </cda:content>
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<cda:paragraph ID="p-3">
<cda:content ID="s-3">Patient requests DNR if he ever does this again. </cda:content>
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</cda:text>
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<cda:paragraph ID="p-4">
<cda:content ID="s-4">
<cda:content ID="problem-3">Headache</cda:content>. </cda:content>
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<cda:low value="20050906"/>
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<cda:text>
<cda:list ID="l-1">
<cda:item ID="li-1">1. <cda:content ID="s-5">Stress </cda:content>
</cda:item> <cda:item ID="li-2">2. <cda:content ID="s-6">
<cda:content ID="problem-4">Headache</cda:content> </cda:content>
</cda:item>
</cda:list>
</cda:text>
<cda:entry>
<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
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<cda:statusCode code="completed"/>
<cda:effectiveTime>
<cda:low value="20050906"/>
<cda:high value="20050906"/>
</cda:effectiveTime>
<cda:value displayName="Headache" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="25064002" xsi:type="cda:CD">
<cda:originalText>
<cda:reference value="#problem-4"/>
</cda:originalText>
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<cda:paragraph ID="p-5">
<cda:content ID="s-7">Patient has been under stress trying to participate in something called a "<cda:content ID="problem-15">connectathon</cda:content>", which he sees as the cause of the problem. </cda:content>
</cda:paragraph>
</cda:text>
<cda:entry>
<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
<cda:templateId root="1.3.6.1.4.1.19376.1.5.3.1" extension="condition"/>
<cda:id extension="303.2.problem-15" root="1.3.6.1.4.1.21367.2005.3.7.10"/>
<cda:code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="246188002" displayName="Finding"/>
<cda:statusCode code="active"/>
<cda:effectiveTime>
<cda:low value="20050906"/>
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<cda:value displayName="connectathon" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="74732009" xsi:type="cda:CD">
<cda:originalText>
<cda:reference value="#problem-15"/>
</cda:originalText>
</cda:value>
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</cda:component>
<cda:component>
<cda:section ID="section-7">
<cda:code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="11348-0" displayName="HISTORY OF PAST ILLNESS"/>
<cda:title>PAST MEDICAL HISTORY:</cda:title>
<cda:text>
<cda:paragraph ID="p-6">
<cda:content ID="s-8">Patient has a history of <cda:content ID="problem-5">headache</cda:content> due to stress over connectathons. </cda:content>
</cda:paragraph>
</cda:text>
<cda:entry>
<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
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<cda:statusCode code="completed"/>
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<cda:low value="20050906"/>
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<cda:code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="11336-5" displayName="HISTORY OF HOSPITALIZATIONS"/>
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<cda:text>
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<cda:content ID="s-9">None </cda:content>
</cda:paragraph>
</cda:text>
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<cda:component>
<cda:section ID="section-9">
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<cda:text>
<cda:list ID="l-2">
<cda:item ID="li-3">1. <cda:content ID="s-10">
<cda:content ID="problem-6">Acute panic state</cda:content> due to <cda:content ID="problem-7">acute stress reaction</cda:content> </cda:content>
</cda:item> <cda:item ID="li-4">2. <cda:content ID="s-11">
<cda:content ID="problem-8">Acute stress disorder</cda:content> </cda:content>
</cda:item> <cda:item ID="li-5">3. <cda:content ID="s-12">Feeling <cda:content ID="problem-9">anxious</cda:content> </cda:content>
</cda:item> <cda:item ID="li-6">4. <cda:content ID="s-13">
<cda:content ID="problem-10">Headache</cda:content> </cda:content>
</cda:item> <cda:item ID="li-7">5. <cda:content ID="s-14">
<cda:content ID="problem-11">Mental disorder</cda:content> </cda:content>
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<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
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<cda:id extension="303.2.problem-8" root="1.3.6.1.4.1.21367.2005.3.7.10"/>
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<cda:effectiveTime>
<cda:low value="20050906"/>
<cda:high value="20050906"/>
</cda:effectiveTime>
<cda:value displayName="Acute stress disorder" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="67195008" xsi:type="cda:CD">
<cda:originalText>
<cda:reference value="#problem-8"/>
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</cda:value>
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<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
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<cda:id extension="303.2.problem-9" root="1.3.6.1.4.1.21367.2005.3.7.10"/>
<cda:code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="246188002" displayName="Finding"/>
<cda:statusCode code="completed"/>
<cda:effectiveTime>
<cda:low value="20030326"/>
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<cda:value displayName="Feeling anxious" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="38237000" xsi:type="cda:CD">
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<cda:reference value="#problem-9"/>
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<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
<cda:templateId root="1.3.6.1.4.1.19376.1.5.3.1" extension="condition"/>
<cda:id extension="303.2.problem-11" root="1.3.6.1.4.1.21367.2005.3.7.10"/>
<cda:code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="246188002" displayName="Finding"/>
<cda:statusCode code="active"/>
<cda:effectiveTime>
<cda:low value="20050906"/>
</cda:effectiveTime>
<cda:value displayName="Mental disorder" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="74732009" xsi:type="cda:CD">
<cda:originalText>
<cda:reference value="#problem-11"/>
</cda:originalText>
</cda:value>
</cda:observation>
</cda:entry>
</cda:section>
</cda:component>
<cda:component>
<cda:section ID="section-10">
<cda:code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="10155-0" displayName="HISTORY OF ALLERGIES"/>
<cda:title>ALLERGIES:</cda:title>
<cda:text>
<cda:list ID="l-3">
<cda:item ID="li-8">1. <cda:content ID="s-15">
<cda:content ID="allergy-1">Connectathons</cda:content> </cda:content>
</cda:item>
</cda:list>
</cda:text>
<cda:entry>
<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
<cda:templateId root="1.3.6.1.4.1.19376.1.5.3.1" extension="allergy"/>
<cda:id extension="303.2.allergy-1" root="1.3.6.1.4.1.21367.2005.3.7.10"/>
<cda:code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="10619000" displayName="Allergy"/>
<cda:statusCode code="active"/>
<cda:effectiveTime>
<cda:low value="20050906"/>
</cda:effectiveTime>
<cda:value xsi:type="cda:CD">
<cda:originalText>
Re: CDA Transform and the XPHR [message #571996 is a reply to message #22067] Fri, 03 November 2006 22:01 Go to previous message
Eishay Smith is currently offline Eishay SmithFriend
Messages: 109
Registered: July 2009
Senior Member
Yes,

The XSL in under the org.eclipse.ohf.bridge.client project named
"ClinicalDocument.xsl".
The XSL is very basic and does not support a full CDA or XPHR.
We will appropriate help extending the XSL to support more elements.

If you wish to contribute back improvements to the XSL, please send them
by opening a bugzilla bug report on the bridge component and
attaching/pasting your changes. See:
http://wiki.eclipse.org/index.php/Submit_Bugs_to_OHF
It is important to our legal process as well as to acknowledging you as
a contributer.

I don't know about PHR examples, maybe Sarah or someone from CapMed?

--eishay

Corey Spears wrote:
> Hi,
> I noticed that the online portal (http://ibmod235.dal-ebis.ihost.com:8080/)
> does a transform of the CDA documents as you view them, so they are
> formatted into html. I was wondering where I could get a copy of the xslt
> to have as a starting point.
> Does the xslt include the necessary elements to support display of all of
> the XPHR?
>
>
> Also, are there any example PHRs out there. I have been going through the
> documents on the RHIOs and I have not been able to find any yet. Perhaps
> one of the PHRs or other xPHR sources in the group could provide a couple of
> samples.
>
>
> Thank you,
> Corey Spears
>
>
Re: CDA Transform and the XPHR [message #572027 is a reply to message #22119] Sat, 04 November 2006 00:18 Go to previous message
No real name is currently offline No real nameFriend
Messages: 292
Registered: July 2009
Senior Member
This is a multi-part message in MIME format.
--------------070402000706020402060704
Content-Type: text/plain; charset=ISO-8859-1; format=flowed
Content-Transfer-Encoding: 7bit

Hmmmm ... sample.xml is a document that conforms to the HL7
specification that XPHR is based on (CRS). So it's close ... but
probably not exact. The other attachment I believe conforms to the old
version of the XPHR (or XDS-MS) spcification.

This would be a good question for the IHE Connectathon Bug List
http://ihe.univ-rennes1.fr/flyspray/index.php?tasks=all& project=1&highlight=10_2

Or keep watching this page:
http://hcxw2k1.nist.gov/wiki/index.php/XDS-Examples

- Sarah

Eishay Smith wrote:
> Yes,
>
> The XSL in under the org.eclipse.ohf.bridge.client project named
> "ClinicalDocument.xsl".
> The XSL is very basic and does not support a full CDA or XPHR.
> We will appropriate help extending the XSL to support more elements.
>
> If you wish to contribute back improvements to the XSL, please send them
> by opening a bugzilla bug report on the bridge component and
> attaching/pasting your changes. See:
> http://wiki.eclipse.org/index.php/Submit_Bugs_to_OHF
> It is important to our legal process as well as to acknowledging you as
> a contributer.
>
> I don't know about PHR examples, maybe Sarah or someone from CapMed?
>
> --eishay
>
> Corey Spears wrote:
>
>> Hi,
>> I noticed that the online portal
>> (http://ibmod235.dal-ebis.ihost.com:8080/) does a transform of the CDA
>> documents as you view them, so they are formatted into html. I was
>> wondering where I could get a copy of the xslt to have as a starting
>> point.
>> Does the xslt include the necessary elements to support display of all
>> of the XPHR?
>>
>>
>> Also, are there any example PHRs out there. I have been going through
>> the documents on the RHIOs and I have not been able to find any yet.
>> Perhaps one of the PHRs or other xPHR sources in the group could
>> provide a couple of samples.
>>
>>
>> Thank you,
>> Corey Spears
>>


--------------070402000706020402060704
Content-Type: text/xml;
name="sample.xml"
Content-Transfer-Encoding: 7bit
Content-Disposition: inline;
filename="sample.xml"

<ClinicalDocument xmlns='urn:hl7-org:v3'>
<realmCode code='US'/>
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<templateId extension="IMPL_CDAR2_LEVEL1-2REF_US_I2_2005SEP" root="2.16.840.1.113883.10"/>
<id extension='999021' root='1.3.6.4.1.4.1.2835.2'/>
<code code='34133-9' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' displayName='SUMMARIZATION OF EPISODE NOTE'/>
<title>Good Health Clinic Care Record Summary</title>
<effectiveTime value='20050329224411+0500'/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code='en-US'/>
<setId extension='999021' root='1.3.6.4.1.4.1.2835.1'/>
<versionNumber value='1'/>
<recordTarget>
<patientRole>
<id extension="12345" root="2.16.840.1.113883.3.933"/>
<addr>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(781)555-1212' use='HP'/>
<patient>
<name>
<prefix>Mrs.</prefix>
<given>Ellen</given>
<family>Ross</family>
</name>
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
<birthTime value="19600127"/>
</patient>
<providerOrganization>
<id extension="M345" root="2.16.840.1.113883.3.933"/>
<name>Good Health Clinic</name>
<telecom value='tel:(999)555-1212' use='WP'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time value='20050329224411+0500'/>
<assignedAuthor>
<id extension='1' root='1.3.6.4.1.4.1.2835.1'/>
<code code='SELF' codeSystem='2.16.840.1.113883.5.111'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Bernard</given>
<family>Wiseman</family>
<suffix>Sr.</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<author>
<time value='20050329224411+0500'/>
<assignedAuthor>
<id extension='1' root='1.3.6.4.1.4.1.2835.1'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<assignedAuthoringDevice>
<softwareName>Good Health Clinic System v1.0</softwareName>
</assignedAuthoringDevice>
</assignedAuthor>
</author>
<dataEnterer>
<time value='20050329222451+0500'/>
<assignedEntity>
<id extension='2' root='1.3.6.4.1.4.1.2835.2'/>
<assignedPerson>
<name>
<prefix>Mrs.</prefix>
<given>Bernice</given>
<family>Wiseman</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<!-- To represent a healthcare provider with a specific assigned healthcare role that can be identified by the author and authoring system.
-->
<informant>
<assignedEntity>
<id extension='3' root='1.3.6.4.1.4.1.2835.2'/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Bernard</given>
<family>Wiseman</family>
<suffix>Jr.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</informant>
<!-- To represent a mother who provides information about her child -->
<informant>
<relatedEntity classCode='PRS'>
<code code='MTH' codeSystem='2.16.840.1.113883.5.111'/>
<relatedPerson>
<name>
<prefix>Mrs.</prefix>
<given>Abigail</given>
<family>Ruth</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<!-- To represent a witness to a signicant health event -->
<informant>
<relatedEntity classCode='CON'>
<relatedPerson>
<name>
<prefix>Mr.</prefix>
<given>Joseph</given>
<given>T.</given>
<family>Jones</family>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<!-- To represent a healthcare provider in a healthcare role without an assigned role known or representable to the author. The example below represents a physician who was the patient's primary care provider. -->
<informant>
<relatedEntity classCode='PROV'>
<code code='59058001' codeSystem='2.16.840.1.113883.6.96'/>
<relatedPerson>
<name>
<given>Jane</given>
<family>Queen</family>
<suffix></suffix>
</name>
</relatedPerson>
</relatedEntity>
</informant>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension='1' root='1.3.6.4.1.4.1.2835.3'/>
<name>Good Health Clinic</name>
<telecom value='tel:(999)555-1212' use='WP'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient>
<intendedRecipient>
<id extension='4' root='1.3.6.4.1.4.1.2835.2'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<informationRecipient>
<name>
<prefix>Dr.</prefix>
<given>Phil</given>
<family>Green</family>
</name>
</informationRecipient>
<receivedOrganization>
<name>Good Health Clinic</name>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<time value='20050329224512+0500'/>
<signatureCode code='S'/>
<assignedEntity>
<id extension='1' root='1.3.6.4.1.4.1.2835.1'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Bernard</given>
<family>Wiseman</family>
<suffix>Sr.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<authenticator>
<time value='20050329224512+0500'/>
<signatureCode code='S'/>
<assignedEntity>
<id extension='3' root='1.3.6.4.1.4.1.2835.1'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Bernard</given>
<family>Wiseman</family>
<suffix>Jr.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</authenticator>
<participant typeCode='IND'>
<time></time>
<associatedEntity classCode='PRS'>
<code code='MTH' codeSystem='2.16.840.1.113883.5.111'/>
<addr>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<associatedPerson>
<name>
<prefix>Mrs.</prefix>
<given>Abigail</given>
<family>Ruth</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<participant typeCode='HLD'>
<time>
<low value='20050101'/>
<high value='20051231'/>
</time>
<associatedEntity classCode='POLHOLD'>
<id extension='123456789' root='00000000-0000-0000-0000-000000000000'/>
<code code='PHFAMDEP' codeSystem='2.16.840.1.113883.5.1095'/>
<!-- To show that the policy holder is the patient, the above would be:
<code code='SELF' codeSystem='2.16.840.1.113883.5.111'/>
-->
<addr>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<associatedPerson>
<name>
<prefix>Mr.</prefix>
<given>Kenneth</given>
<family>Ross</family>
</name>
</associatedPerson>
<scopingOrganization>
<name>Good Health Insurance Company</name>
<telecom value='tel:(203)555-1212' use='WP'/>
<addr>
<streetAddressLine>3191 Broadbridge Avenue</streetAddressLine>
<city>Stratford</city>
<state>CT</state>
<postalCode>06614-2559</postalCode>
<country>USA</country>
</addr>
</scopingOrganization>
</associatedEntity>
</participant>
<participant typeCode='IND'>
<associatedEntity classCode='GUAR'>
<addr>
<streetAddressLine>17 Daws Rd.</streetAddressLine>
<city>Blue Bell</city>
<state>MA</state>
<postalCode>02368</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<associatedPerson>
<name>
<prefix>Mr.</prefix>
<given>Kenneth</given>
<family>Ross</family>
</name>
</associatedPerson>
</associatedEntity>
</participant>
<documentationOf>
<serviceEvent classCode='PCPR'>
<effectiveTime>
<low value='19600127'/>
<high value='20050329'/>
</effectiveTime>
<performer typeCode='PRF'>
<functionCode code='PCP' codeSystem='2.16.840.1.113883.5.88'/>
<time>
<low value='1998'/>
<high value='2005'/>
</time>
<assignedEntity>
<id extension='1' root='1.3.6.4.1.4.1.2835.1'/>
<code code='59058001'
codeSystem='2.16.840.1.113883.6.96'
codeSystemName='SNOMED CT'
displayName='General Physician'/>
<addr>
<streetAddressLine>21 North Ave</streetAddressLine>
<city>Burlington</city>
<state>MA</state>
<postalCode>01803</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(999)555-1212' use='WP'/>
<assignedPerson>
<name>
<prefix>Dr.</prefix>
<given>Bernard</given>
<family>Wiseman</family>
<suffix>Sr.</suffix>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<component>
<structuredBody>
<templateId extension="IMPL_CDAR2_LEVEL1-2REF_US_I2_2005SEP" root="2.16.840.1.113883.10"/>
<component>
<section>
<code code='X-RFVCC' codeSystem='2.16.840.1.113883.6.1' />
<title>Reason for Visit/Chief Complaint</title>
<text>Ankle Sprain</text>
</section>
</component>
<component>
<section>
<code code='X-RFR' codeSystem='2.16.840.1.113883.6.1' />
<title>Reason for Referral</title>
<text>Follow-up care for Ankle Sprain</text>
</section>
</component>
<component>
<section>
<code code='X-ADVDIR' codeSystem='2.16.840.1.113883.6.1'/>
<title>Advance Directives</title>
<text>
<table border='1'>
<thead>
<tr><th>Documentation</th><th>Contact</th>
<th>Effective Date</th><th>Comments</th>
</tr>
</thead>
<tbody>
<tr><td>Living Will</td>
<td>Obtain from her Husband</td><td>1994</td>
<td>Copy on file</td>
</tr>
<tr><td>Power of Attorney</td>
<td>Obtain from her Husband</td><td>1994</td><td></td>
</tr>
<tr><td>Healthcare Proxy</td>
<td>Obtain from her Husband</td><td>1994</td><td></td>
</tr>
<tr><td>Organ Donor</td>
<td>Massachusetts Registry of Motor Vehicles</td>
<td>1/27/2004 - </td><td>Registered Organ Donor</td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='10164-2' codeSystem='2.16.840.1.113883.6.1' />
<title>History of Present Illness</title>
<text>Patient slipped and fell on ice, twisting her ankle as she fell.</text>
</section>
</component>
<component>
<section>
<code code='10157-6' codeSystem='2.16.840.1.113883.6.1'/>
<title>Family History</title>
<text>
<table border='1'>
<thead>
<tr><th>Family Member</th>
<th>Problem</th>
<th>Cause of Death?</th>
</tr>
</thead>
<tbody>
<tr><td>Father</td><td>Alcoholism</td><td>No</td></tr >
<tr><td>Father</td><td>Liver Cancer</td><td>Yes</td></tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='29762-2' codeSystem='2.16.840.1.113883.6.1' />
<title>Social History</title>
<text>
<table border='1'>
<thead>
<tr>
<th>Social History</th>
<th>Comments</th>
<th>Date Range</th>
</tr>
</thead>
<tbody>
<tr>
<td>Smoking</td><td>1/2 pack per day</td><td>? - 1996</td>
</tr>
<tr>
<td>Alcohol Use</td><td>1-2 drinks per week</td><td></td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='11450-4' codeSystem='2.16.840.1.113883.6.1' />
<title>Conditions</title>
<text>
<table border='1'>
<thead>
<tr><th>Problem</th><th>Date</th><th>Comments</th>
</tr>
</thead>
<tbody>
<tr>
<td>Cholecystitis</td><td>9/28/2002 - 6/2003</td>
<td>Resolved</td>
<td>Surgery postponed until after delivery</td>
</tr>
<tr>
<td>Pregnancy</td><td>7/2001 - 4/22/2002</td>
<td>Resolved</td>
<td>Prior history of miscarraige</td>
</tr>
<tr><td>Ankle Sprain</td><td>3/28/2005</td>
<td>Current</td>
<td>Slipped on ice and fell</td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='10155-0' codeSystem='2.16.840.1.113883.6.1' />
<title>Allergies and Adverse Reactions</title>
<text>
<table border='1'>
<thead>
<tr><th>Allergen</th><th>Reaction</th>
<th>Comments</th>
</tr>
</thead>
<tbody>
<tr><td>Penicillin</td><td>Hives</td>
<td>Amoxicillin is OK</td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='10160-0' codeSystem='2.16.840.1.113883.6.1' />
<title>Medications</title>
<text>
<table border='1'>
<thead>
<tr><th>Medication</th>
<th>Prescription or Dose</th>
<th>Dates of Use</th>
</tr>
</thead>
<tbody>
<tr><td>Indomethacin</td>
<td>50mg bid with food </td>
<td>12/10/2003 - present</td>
</tr>
<tr>
<td>Acetaminophen with codeine</td>
<td>#3 1-2 tablets for pain as needed</td>
<td>03/28/2005</td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='11369-6' codeSystem='2.16.840.1.113883.6.1' />
<title>Immunizations</title>
<text>
<list>
<item>DTP - 1962</item>
<item>Polio Virus - 1961</item>
<item>MMR - 1961</item>
</list>
</text>
</section>
</component>
<component>
<section>
<code code='10167-5' codeSystem='2.16.840.1.113883.6.1' />
<title>Procedures</title>
<text>
<table border='1'>
<thead>
<tr>
<th>Procedure</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr><td>Laparoscopic Cholecystectomy</td><td>9/28/2002</td></tr>
<tr><td>Cesarian Section</td><td>3/22/2002</td></tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='11336-5' codeSystem='2.16.840.1.113883.6.1' />
<title>Prior Encounters</title>
<text>
<table border='1'>
<thead>
<tr><th>Date</th><th>Provider</th>
<th>Description</th>
</tr>
</thead>
<tbody>
<tr><td>3/28/2005</td><td>Community Hospital</td>
<td>ED Visit for Ankle Sprain</td>
</tr>
<tr><td>9/28/2002</td><td>City Hospital</td>
<td>Gall Bladder Surgery</td>
</tr>
<tr><td>3/21/2002</td><td>Community Hospital</td>
<td>Labor and Delivery</td>
</tr>
<tr><td>10/28/2001</td><td>Community Hospital</td>
<td>ED Visit for Acute Cholecystitis</td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='10187-3' codeSystem='2.16.840.1.113883.6.1' />
<title>Review of Systems</title>
<text>Normal except for left foot and ankle.</text>
</section>
</component>
<component>
<section>
<code code='10210-3' codeSystem='2.16.840.1.113883.6.1' />
<title>Physical Examination</title>
<text>Left foot and ankle are swollen profusely.</text>
<component>
<section>
<code code='29274-8' codeSystem='2.16.840.1.113883.6.1' />
<title>Vital Signs</title>
<text>
<table border='1'>
<thead>
<tr><th>Date</th><th>Height</th><th>Weight</th><th >Temperature</th>
<th>BP</th><th>Pulse</th><th>Respiration</th><th>O2 </th>
</tr>
</thead>
<tbody>
<tr><th>3/28/2005</th><th>5'9"</th><th>215 lbs.</th><th>98.7 &#xB0;F</th>
<th>120/80</th><th>68</th><th>16</th><th>99%</th>
</tr>
</tbody>
</table>
</text>
</section>
</component>
</section>
</component>
<component>
<section>
<code code='X-SS' codeSystem='2.16.840.1.113883.6.1'/>
<title>Related Reports</title>
<text>
<table border='1'>
<thead>
<tr>
<th>Study</th>
<th>Summary</th>
<th>Date of Study</th>
</tr>
</thead>
<tbody>
<tr>
<td>X-Ray Study - Left Ankle</td>
<td>No Fracture</td>
<td>3/28/2005</td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<code code='18776-5' codeSystem='2.16.840.1.113883.6.1' />
<title>Plan of Care</title>
<text>
<paragraph>Acetaminophen with codiene prn for pain.</paragraph>
<paragraph>Stay off the foot. Keep foot elevated, and use supplied air splint and crutches.</paragraph>
<paragraph>Follow-up with orthopedist in next 5 days.</paragraph>
</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>


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<!--
This document was produced by Dictaphone Enterprise Workstation (tm). Extracted clinical data
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<cda:serviceEvent classCode="PCPR">
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<!--author: Carus, Wyn-->
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<cda:section ID="section-1">
<!--Type: dss14:CHIEF COMPLAINT-->
<!--subtype: -->
<!--Temporal: -->
<cda:code nullFlavor="UNK"/>
<cda:title>CHIEF COMPLAINT:</cda:title>
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<cda:content ID="s-1">
<cda:content ID="problem-1">Headache</cda:content> </cda:content>
</cda:paragraph>
</cda:text>
<cda:entry>
<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
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<!--Type: dss14:REASON FOR ENCOUNTER-->
<!--subtype: -->
<!--Temporal: -->
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<cda:content ID="s-2">Patient wants his <cda:content ID="problem-2">headache</cda:content> to go away. </cda:content>
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<cda:paragraph ID="p-3">
<cda:content ID="s-3">Patient requests DNR if he ever does this again. </cda:content>
</cda:paragraph>
</cda:text>
</cda:section>
</cda:component>
<cda:component>
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<cda:paragraph ID="p-4">
<cda:content ID="s-4">
<cda:content ID="problem-3">Headache</cda:content>. </cda:content>
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<cda:statusCode code="completed"/>
<cda:effectiveTime>
<cda:low value="20050906"/>
<cda:high value="20050906"/>
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<cda:value displayName="Headache" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="25064002" xsi:type="cda:CD">
<cda:originalText>
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<cda:code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="11535-2" displayName="HOSPITAL DISCHARGE DX"/>
<cda:title>DISCHARGE DX:</cda:title>
<cda:text>
<cda:list ID="l-1">
<cda:item ID="li-1">1. <cda:content ID="s-5">Stress </cda:content>
</cda:item> <cda:item ID="li-2">2. <cda:content ID="s-6">
<cda:content ID="problem-4">Headache</cda:content> </cda:content>
</cda:item>
</cda:list>
</cda:text>
<cda:entry>
<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
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<cda:code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="246188002" displayName="Finding"/>
<cda:statusCode code="completed"/>
<cda:effectiveTime>
<cda:low value="20050906"/>
<cda:high value="20050906"/>
</cda:effectiveTime>
<cda:value displayName="Headache" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="25064002" xsi:type="cda:CD">
<cda:originalText>
<cda:reference value="#problem-4"/>
</cda:originalText>
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<cda:component>
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<cda:title>HISTORY OF PRESENT ILLNESS:</cda:title>
<cda:text>
<cda:paragraph ID="p-5">
<cda:content ID="s-7">Patient has been under stress trying to participate in something called a "<cda:content ID="problem-15">connectathon</cda:content>", which he sees as the cause of the problem. </cda:content>
</cda:paragraph>
</cda:text>
<cda:entry>
<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
<cda:templateId root="1.3.6.1.4.1.19376.1.5.3.1" extension="condition"/>
<cda:id extension="303.2.problem-15" root="1.3.6.1.4.1.21367.2005.3.7.10"/>
<cda:code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="246188002" displayName="Finding"/>
<cda:statusCode code="active"/>
<cda:effectiveTime>
<cda:low value="20050906"/>
</cda:effectiveTime>
<cda:value displayName="connectathon" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="74732009" xsi:type="cda:CD">
<cda:originalText>
<cda:reference value="#problem-15"/>
</cda:originalText>
</cda:value>
</cda:observation>
</cda:entry>
</cda:section>
</cda:component>
<cda:component>
<cda:section ID="section-7">
<cda:code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="11348-0" displayName="HISTORY OF PAST ILLNESS"/>
<cda:title>PAST MEDICAL HISTORY:</cda:title>
<cda:text>
<cda:paragraph ID="p-6">
<cda:content ID="s-8">Patient has a history of <cda:content ID="problem-5">headache</cda:content> due to stress over connectathons. </cda:content>
</cda:paragraph>
</cda:text>
<cda:entry>
<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
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<cda:code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="365854008" displayName="History Finding"/>
<cda:statusCode code="completed"/>
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<cda:low value="20050906"/>
<cda:high value="20050906"/>
</cda:effectiveTime>
<cda:value displayName="Headache" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="25064002" xsi:type="cda:CD">
<cda:originalText>
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</cda:originalText>
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<cda:code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="11336-5" displayName="HISTORY OF HOSPITALIZATIONS"/>
<cda:title>PRIOR HOSPITALIZATIONS:</cda:title>
<cda:text>
<cda:paragraph ID="p-7">
<cda:content ID="s-9">None </cda:content>
</cda:paragraph>
</cda:text>
</cda:section>
</cda:component>
<cda:component>
<cda:section ID="section-9">
<cda:code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="11450-4" displayName="PROBLEM LIST"/>
<cda:title>PROBLEMS:</cda:title>
<cda:text>
<cda:list ID="l-2">
<cda:item ID="li-3">1. <cda:content ID="s-10">
<cda:content ID="problem-6">Acute panic state</cda:content> due to <cda:content ID="problem-7">acute stress reaction</cda:content> </cda:content>
</cda:item> <cda:item ID="li-4">2. <cda:content ID="s-11">
<cda:content ID="problem-8">Acute stress disorder</cda:content> </cda:content>
</cda:item> <cda:item ID="li-5">3. <cda:content ID="s-12">Feeling <cda:content ID="problem-9">anxious</cda:content> </cda:content>
</cda:item> <cda:item ID="li-6">4. <cda:content ID="s-13">
<cda:content ID="problem-10">Headache</cda:content> </cda:content>
</cda:item> <cda:item ID="li-7">5. <cda:content ID="s-14">
<cda:content ID="problem-11">Mental disorder</cda:content> </cda:content>
</cda:item>
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</cda:text>
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<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
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<cda:code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="246188002" displayName="Finding"/>
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<cda:low value="20030326"/>
<cda:high value="20050906"/>
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<cda:value displayName="Feeling anxious" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="38237000" xsi:type="cda:CD">
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<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
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<cda:code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="246188002" displayName="Finding"/>
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<cda:high value="20050906"/>
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<cda:value displayName="Acute stress disorder" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="67195008" xsi:type="cda:CD">
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<cda:entry>
<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
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<cda:id extension="303.2.problem-8" root="1.3.6.1.4.1.21367.2005.3.7.10"/>
<cda:code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="246188002" displayName="Finding"/>
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<cda:effectiveTime>
<cda:low value="20050906"/>
<cda:high value="20050906"/>
</cda:effectiveTime>
<cda:value displayName="Acute stress disorder" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="67195008" xsi:type="cda:CD">
<cda:originalText>
<cda:reference value="#problem-8"/>
</cda:originalText>
</cda:value>
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<cda:entry>
<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
<cda:templateId root="1.3.6.1.4.1.19376.1.5.3.1" extension="condition"/>
<cda:id extension="303.2.problem-9" root="1.3.6.1.4.1.21367.2005.3.7.10"/>
<cda:code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="246188002" displayName="Finding"/>
<cda:statusCode code="completed"/>
<cda:effectiveTime>
<cda:low value="20030326"/>
<cda:high value="20050906"/>
</cda:effectiveTime>
<cda:value displayName="Feeling anxious" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="38237000" xsi:type="cda:CD">
<cda:originalText>
<cda:reference value="#problem-9"/>
</cda:originalText>
</cda:value>
</cda:observation>
</cda:entry>
<cda:entry>
<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
<cda:templateId root="1.3.6.1.4.1.19376.1.5.3.1" extension="condition"/>
<cda:id extension="303.2.problem-10" root="1.3.6.1.4.1.21367.2005.3.7.10"/>
<cda:code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="246188002" displayName="Finding"/>
<cda:statusCode code="completed"/>
<cda:effectiveTime>
<cda:low value="20050906"/>
<cda:high value="20050906"/>
</cda:effectiveTime>
<cda:value displayName="Headache" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="25064002" xsi:type="cda:CD">
<cda:originalText>
<cda:reference value="#problem-10"/>
</cda:originalText>
</cda:value>
</cda:observation>
</cda:entry>
<cda:entry>
<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
<cda:templateId root="1.3.6.1.4.1.19376.1.5.3.1" extension="condition"/>
<cda:id extension="303.2.problem-11" root="1.3.6.1.4.1.21367.2005.3.7.10"/>
<cda:code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="246188002" displayName="Finding"/>
<cda:statusCode code="active"/>
<cda:effectiveTime>
<cda:low value="20050906"/>
</cda:effectiveTime>
<cda:value displayName="Mental disorder" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" code="74732009" xsi:type="cda:CD">
<cda:originalText>
<cda:reference value="#problem-11"/>
</cda:originalText>
</cda:value>
</cda:observation>
</cda:entry>
</cda:section>
</cda:component>
<cda:component>
<cda:section ID="section-10">
<cda:code codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="10155-0" displayName="HISTORY OF ALLERGIES"/>
<cda:title>ALLERGIES:</cda:title>
<cda:text>
<cda:list ID="l-3">
<cda:item ID="li-8">1. <cda:content ID="s-15">
<cda:content ID="allergy-1">Connectathons</cda:content> </cda:content>
</cda:item>
</cda:list>
</cda:text>
<cda:entry>
<cda:observation negationInd="false" moodCode="EVN" classCode="COND">
<cda:templateId root="1.3.6.1.4.1.19376.1.5.3.1" extension="allergy"/>
<cda:id extension="303.2.allergy-1" root="1.3.6.1.4.1.21367.2005.3.7.10"/>
<cda:code codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" code="10619000" displayName="Allergy"/>
<cda:statusCode code="active"/>
<cda:effectiveTime>
<cda:low value="20050906"/>
</cda:effectiveTime>
<cda:value xsi:type="cda:CD">
<cda:originalText>
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