Sample Aphp Messages for Review
- Suranga Kasthurirathne
- Michael Downey
- Vaibhav Agarwal
Owned by Suranga Kasthurirathne
We will use this page to keep track of how sample Aphp messages look like during step of the development process. At this point, the latest version of the document being generated is as follows,
Complete APHP CDA message (8th August 2014)
<?xml version="1.0" encoding="UTF-8"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.10" extension="IMPL_CDAR2_LEVEL1"/>
<templateId root="2.16.840.1.113883.10.20.3"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.1"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.2"/>
<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="2.16.840.1.113883.5" extension="APHP"/>
<code code="34117-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Antepartum History and Physical</title>
<effectiveTime value="20140808090034"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<recordTarget>
<patientRole>
<id root="2.16.840.1.113883.5" extension="10698-S"/>
<addr><streetAddressLine>Legend Apartment,Flat no.107Banjara Hills</streetAddressLine><city>Hyderabad</city><state>Telangana</state><country>India</country><postalCode>500000</postalCode></addr>
<telecom nullFlavor="UNK"/>
<patient>
<name><given>Sakhsi</given><family>Gupta</family></name>
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
<birthTime value="19700104"/>
<maritalStatusCode code="MARRIED"/>
<ethnicGroupCode code="Asian"/>
</patient>
<providerOrganization>
<id root="2.16.840.1.113883.5"/>
<name>OpenMRS</name>
<telecom nullFlavor="UNK"/>
<addr><county> </county></addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<time value="20140808090034"/>
<assignedAuthor>
<id root="2.16.840.1.113883.5"/>
<addr><country> </country></addr>
<telecom nullFlavor="UNK"/>
<assignedAuthoringDevice>
<softwareName>OpenMRS</softwareName>
</assignedAuthoringDevice>
</assignedAuthor>
</author>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="2.16.840.1.113883.5"/>
<name>OpenMRS</name>
<telecom nullFlavor="UNK"/>
<addr><country> </country></addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<participant typeCode="IND">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.2.4"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.2.4.1"/>
<associatedEntity classCode="PRS">
<code code="184142008" codeSystem="2.16.840.1.113883.5.111" codeSystemName="SNOMED CT" displayName="patient's next of kin"/>
<addr><streetAddressLine>Legend Apartments,Flat no 107Banjara Hills</streetAddressLine><city>Hyderabad</city><country>India</country></addr>
<telecom value="tel: + " use=""/>
<associatedPerson>
<name><given>Mahendra</given><family>Gupta</family></name>
</associatedPerson>
</associatedEntity>
</participant>
<participant typeCode="IND">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.2.4"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.2.4.2"/>
<associatedEntity classCode="PRS">
<code code="xx-fatherofbaby" codeSystem="2.16.840.1.113883.5.111" codeSystemName="SNOMED CT" displayName="Father of Baby"/>
<addr><streetAddressLine>Legend Apartments,Flat no 107Banjara Hills</streetAddressLine><city>Hyderabad</city><country>India</country></addr>
<telecom value="tel: + " use=""/>
<associatedPerson>
<name><given>Mahendra</given><family>Gupta</family></name>
</associatedPerson>
</associatedEntity>
</participant>
<participant typeCode="IND">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.2.4"/>
<time/>
<associatedEntity classCode="PRS">
<code code="CHILD" codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode" displayName="Child"/>
<addr><streetAddressLine>Royal Residency,Flat no 412 Kandlaguda</streetAddressLine><city>Vishakhapatnam</city><country>India</country></addr>
<telecom nullFlavor="UNK"/>
<associatedPerson>
<name><family>Gupta</family><given>Abhimanyu</given></name>
</associatedPerson>
</associatedEntity>
</participant>
<participant typeCode="IND">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.2.4"/>
<time/>
<associatedEntity classCode="PRS">
<code code="Spouse" codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode" displayName="Spouse"/>
<addr><streetAddressLine>Legend Apartment,Flat no.107 Banjara Hills</streetAddressLine><city>Hyderabad</city><country>India</country></addr>
<telecom nullFlavor="UNK"/>
<associatedPerson>
<name><family>Gupta</family><given>Mahendra</given></name>
</associatedPerson>
</associatedEntity>
</participant>
<participant typeCode="IND">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.2.4"/>
<time/>
<associatedEntity classCode="PRS">
<code code="DOCTOR" codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode" displayName="Doctor"/>
<addr><streetAddressLine>Yashoda Hosiptals Somajiguda</streetAddressLine><city>Hyderabad</city><country>India</country></addr>
<telecom nullFlavor="UNK"/>
<associatedPerson>
<name><family>Bajaj</family><given>Ramesh</given></name>
</associatedPerson>
</associatedEntity>
</participant>
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="20140808090034"/>
<high value="20140808090034"/>
</effectiveTime>
<performer typeCode="PPRF">
<functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88"/>
<time>
<low value="20140808090034"/>
<high value="20140808090034"/>
</time>
<assignedEntity>
<id root="2.16.840.1.113883.5"/>
<addr><country> </country></addr>
<telecom nullFlavor="UNK"/>
<assignedPerson>
<name><prefix> </prefix><given> </given><family> </family></name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.19.5"/>
<name>OpenMRS</name>
<telecom nullFlavor="UNK"/>
<addr><county> </county></addr>
</representedOrganization>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<component>
<structuredBody>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.4"/>
<code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PRESENT ILLNES"/>
<title>This contains a narrative description of the patient's Present Illness histroy</title>
<text><paragraph>This patient was only recently discharged for a recurrent GI bleed as described below. She presented to the ER today c/o a dark stool yesterday but a normal brown stool today. She was hypotensive in the 80?s resolved after.
Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes normal. H. pylori antibody pending. Admission hematocrit 16%, discharge hematocrit 29%. WBC 7300, platelet count 256,000. Urinalysis normal.
Urine culture: No growth. INR 1.1, PTT 40.She was transfused with 6 units of packed red blood cells with GI evaluation 12 September: Colonoscopy showed single red clot.
this is latest observation</paragraph></text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"/>
<code code="10154-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Chief Complaint"/>
<title>This contains a narrative description of the patient's chief complaint</title>
<text><paragraph>Latest Obs 1</paragraph></text>
</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"/>
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social History"/>
<title>The social history section shall contain a narrative description of the person’s beliefs, home life, community life, work life, hobbies, and risky habits</title>
<text>
<table>
<thead>
<tr>
<th>Social History Element</th>
<th>Description</th>
<th>Effective Dates</th>
</tr>
</thead>
<tbody>
<tr>
<td ID = "_5" >Type of tobacco product</td>
<td>Traditional tobacco product</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_6" >Alcohol use status</td>
<td>Never</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_7" >Patient-generated history: Social history section text</td>
<td>This is patient's social history.........................</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_8" >Illicit Drug Consumption</td>
<td>Never</td>
<td>07-14-2014</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.38"/>
<id root="6fef408c-3c3e-415f-9cde-ecd2fb9d9adb"/>
<code code="266918002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Type of tobacco product">
<originalText><reference value="#_5"/></originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20140808090035"/>
<value xsi:type="ED">Traditional tobacco product</value>
</observation>
</entry>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.38"/>
<id root="a5c7867f-24f4-45da-9827-61ea975e27cc"/>
<code code="160573003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Alcohol use status">
<originalText><reference value="#_6"/></originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20140808090035"/>
<value xsi:type="ED">Never</value>
</observation>
</entry>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.38"/>
<id root="29f1d091-5ad6-4b4c-a78d-4f954a814b2d"/>
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient-generated history: Social history section text">
<originalText><reference value="#_7"/></originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20140808090035"/>
<value xsi:type="ED">This is patient's social history.........................</value>
</observation>
</entry>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.38"/>
<id root="60249758-a583-4ec2-9caf-6bea4cb60002"/>
<code code="xx-illicitdrugs" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Illicit Drug Consumption">
<originalText><reference value="#_8"/></originalText>
</code>
<statusCode code="completed"/>
<effectiveTime value="20140808090035"/>
<value xsi:type="ED">Never</value>
</observation>
</entry>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.18"/>
<code code="10187-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="REVIEW OF SYSTEMS"/>
<title>The review of systems section shall contain a narrative description of the responses the patient gave to a set of routine questions on the functions of each anatomic body system.</title>
<text>
<table>
<thead>
<tr>
<th>Review of System Element</th>
<th>Description</th>
<th>Effective Dates</th>
</tr>
</thead>
<tbody>
<tr>
<td ID = "_9" >Review of systems, HEENT</td>
<td>HEARING DIFFICULTIES</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_10" >Review of systems, general</td>
<td>WEIGHT GAIN</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_11" >Review of systems, Obstetrical/Pregnancy</td>
<td>Abdominal pain</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_12" >Review of systems, gastrointestinal</td>
<td>NEGATIVE</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_13" >Review of systems, genitourinary</td>
<td>MENSTRUATING</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_14" >Review of systems, musculoskeletal</td>
<td>Joint pain</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_15" >Review of systems, cardiopulmonary</td>
<td>Cough</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_16" >Review of systems, developmental</td>
<td>MEMORY PROBLEMS</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_17" >Review of systems, central nervous system</td>
<td>FOCAL WEAKNESS</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_21" >Age of menarche</td>
<td>1</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_22" >CURRENTLY USING BIRTH CONTROL</td>
<td>true</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_20" >Duration of menstrual period</td>
<td>2</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_19" >Total Mensus Monthly</td>
<td>2 to 4 times a month</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_18" >LAST MENSTRUAL PERIOD</td>
<td>2014-07-01 00:00:00</td>
<td>07-14-2014</td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.14"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.15"/>
<templateId root="2.16.840.1.113883.10.20.1.4"/>
<code code="10157-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF FAMILY MEMBER DISEASES "/>
<title>The family history section shall include entries for family history as described in the Entry Content Modules</title>
<text>
<table>
<thead>
<tr>
<th>Family History Element</th>
<th>Description</th>
<th>Effective Dates</th>
</tr>
</thead>
<tbody>
<tr>
<td ID = "_86" >History of Cystic Fibrosis</td>
<td>UNKNOWN</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_83" >Maternal Metabolic Disorder</td>
<td>NO</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_94" >Family History of Thalassemia</td>
<td>YES</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_93" >Family History of Canavan Disease</td>
<td>NO</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_99" >Pregnancy Complication, Habitual Aborter</td>
<td>NO</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_80" >Autism</td>
<td>UNKNOWN</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_98" >Family History of Tay-Sachs</td>
<td>UNKNOWN</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_89" >Hemophilia</td>
<td>YES</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_85" >History of Huntington's Chorea</td>
<td>NO</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_97" >Family History of Down's Syndrome</td>
<td>NO</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_84" >History of Mental Retardation</td>
<td>NO</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_82" >Chrosomosal Disorder</td>
<td>NO</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_81" >Dysmorphism (Birth Defect)</td>
<td>NO</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_90" >Family History of Sick Cell Trait</td>
<td>YES</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_95" >Family History of Neural Tube Defect</td>
<td>NO</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_88" >Blood Disorders</td>
<td>NO</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_87" >History of Muscular Dystrophy</td>
<td>YES</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_96" >Family History of Congenital Heart Defect</td>
<td>UNKNOWN</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_92" >Family History of Familial Dysautonomia</td>
<td>NO</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_91" >Family History of Sick Cell Disease</td>
<td>YES</td>
<td>07-14-2014</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.23"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.15"/>
<id root="75b69379-b715-4b6d-bb62-4db9eb022ce9"/>
<statusCode code="completed"/>
<subject typeCode="SBJ">
<relatedSubject classCode="PRS">
<code code="10157-6" codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode"/>
<addr><country> </country></addr>
<telecom nullFlavor="UNK"/>
<subject>
<name/>
<administrativeGenderCode code="A"/>
<birthTime nullFlavor="UNK"/>
</subject>
</relatedSubject>
</subject>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.3"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
<templateId root="2.16.840.1.113883.10.20.1.22"/>
<id root="75b69379-b715-4b6d-bb62-4db9eb022ce9"/>
<code code="190905008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="History of Cystic Fibrosis"/>
<text><reference value="#_86"/></text>
<statusCode code="completed"/>
<effectiveTime value="20140808090035"/>
<value xsi:type="ED">UNKNOWN</value>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
<methodCode codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<targetSiteCode xsi:type="CE" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
</component>
</organizer>
</entry>
<entry typeCode="DRIV">
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.23"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.15"/>
<id root="16286ef6-b36a-4485-8340-79db5e3a5951"/>
<statusCode code="completed"/>
<subject typeCode="SBJ">
<relatedSubject classCode="PRS">
<code code="10157-6" codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode"/>
<addr><country> </country></addr>
<telecom nullFlavor="UNK"/>
<subject>
<name/>
<administrativeGenderCode code="A"/>
<birthTime nullFlavor="UNK"/>
</subject>
</relatedSubject>
</subject>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.3"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
<templateId root="2.16.840.1.113883.10.20.1.22"/>
<id root="16286ef6-b36a-4485-8340-79db5e3a5951"/>
<code code="75934005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Maternal Metabolic Disorder"/>
<text><reference value="#_83"/></text>
<statusCode code="completed"/>
<effectiveTime value="20140808090035"/>
<value xsi:type="ED">NO</value>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
<methodCode codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<targetSiteCode xsi:type="CE" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
</component>
</organizer>
</entry>
<entry typeCode="DRIV">
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.23"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.15"/>
<id root="26a7be11-5661-4f64-b40a-6bbaaecbfa71"/>
<statusCode code="completed"/>
<subject typeCode="SBJ">
<relatedSubject classCode="PRS">
<code code="10157-6" codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode"/>
<addr><country> </country></addr>
<telecom nullFlavor="UNK"/>
<subject>
<name/>
<administrativeGenderCode code="A"/>
<birthTime nullFlavor="UNK"/>
</subject>
</relatedSubject>
</subject>
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.3"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
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<title>The pregnancy history section contains coded entries describing the patient history of pregnancies</title>
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<thead>
<tr>
<th>Pregnancy History Element</th>
<th>Description</th>
<th>Effective Dates</th>
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<td ID = "_7010162-6" >Patient Body weight at birth</td>
<td>80</td>
<td>07-15-2014</td>
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<tr>
<td ID = "_2910162-6" >NUMBER OF BIRTHS FROM CURRENT PREGNANCY</td>
<td>1</td>
<td>07-17-2014</td>
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<tr>
<td ID = "_3410162-6" >Gravida</td>
<td>1</td>
<td>07-14-2014</td>
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<tr>
<td ID = "_1810162-6" >LAST MENSTRUAL PERIOD</td>
<td>2014-07-01 00:00:00</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_4010162-6" >number of full term pregnancies</td>
<td>1</td>
<td>07-16-2014</td>
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<tr>
<td ID = "_3210162-6" >TOTAL NUMBER OF LIVING CHILDREN</td>
<td>1</td>
<td>07-14-2014</td>
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<tr>
<td ID = "_3010162-6" >Number of preterm births</td>
<td>1</td>
<td>07-16-2014</td>
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<td ID = "_3310162-6" >Number of abortions/miscarriages</td>
<td>0</td>
<td>07-14-2014</td>
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<td ID = "_3810162-6" >Menstrual status</td>
<td>CURRENTLY PREGNANT</td>
<td>07-14-2014</td>
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<tr>
<td ID = "_110162-6" >PREGNANCY STATUS</td>
<td>YES</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_5110162-6" >Total Births</td>
<td>2</td>
<td>07-22-2014</td>
</tr>
<tr>
<td ID = "_3510162-6" >gestational age at birth (weeks)</td>
<td>30</td>
<td>07-14-2014</td>
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<tr>
<td ID = "_3910162-6" >ESTIMATED DATE OF CONFINEMENT</td>
<td>2014-10-02 00:00:00</td>
<td>07-14-2014</td>
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<tr>
<td ID = "_3610162-6" >Duration of labor</td>
<td>7</td>
<td>07-14-2014</td>
</tr>
</tbody>
</table>
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<code code="XX-HistoryOfInfection" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF INFECTION"/>
<title>The history of infection section shall contain a narrative description of any infections the patient may have contracted prior to the patient's current condition</title>
<text>
<table>
<thead>
<tr>
<th>History Of Infection Element</th>
<th>Description</th>
<th>Effective Dates</th>
</tr>
</thead>
<tbody>
<tr>
<td ID = "_52" >History of Genital Herpes</td>
<td>NO</td>
<td>07-22-2014</td>
</tr>
<tr>
<td ID = "_73" >viral illness since LMP</td>
<td>UNKNOWN</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_50" >PATIENT LIVES WITH CONFIRMED TB CASE</td>
<td>UNKNOWN</td>
<td>07-21-2014</td>
</tr>
<tr>
<td ID = "_72" >Rash since LMP</td>
<td>NO</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_53" >Exposed to Genital Herpes</td>
<td>false</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_76" >History of Hepatitis C</td>
<td>YES</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_54" >HIV INFECTED</td>
<td>NEGATIVE</td>
<td>07-22-2014</td>
</tr>
<tr>
<td ID = "_71" >History of STD</td>
<td>NO</td>
<td>08-07-2014</td>
</tr>
<tr>
<td ID = "_78" >History of Syphilis</td>
<td>NO</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_77" >history of Hepatitis B infection</td>
<td>YES</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_74" >History of Gonorrhea</td>
<td>UNKNOWN</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_75" >History of Chlamydia</td>
<td>NO</td>
<td>07-14-2014</td>
</tr>
<tr>
<td ID = "_79" >History of human papilloma virus</td>
<td>UNKNOWN</td>
<td>07-14-2014</td>
</tr>
</tbody>
</table>
</text>
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<text><reference value="#_52"/></text>
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<value xsi:type="ED">NO</value>
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<value xsi:type="ED">UNKNOWN</value>
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<text><reference value="#_72"/></text>
<statusCode code="completed"/>
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<value xsi:type="ED">NO</value>
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<text><reference value="#_76"/></text>
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<value xsi:type="ED">YES</value>
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<text><reference value="#_54"/></text>
<statusCode code="completed"/>
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<value xsi:type="ED">NEGATIVE</value>
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<text><reference value="#_71"/></text>
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<value xsi:type="ED">NO</value>
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<text><reference value="#_78"/></text>
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<text><reference value="#_74"/></text>
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<value xsi:type="ED">UNKNOWN</value>
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<text><reference value="#_75"/></text>
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<text><reference value="#_79"/></text>
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<value xsi:type="ED">UNKNOWN</value>
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</section>
</component>
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<section>
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<code code="11348-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PAST ILLNESS"/>
<title>The History of Past Illness section shall contain a narrative description of the conditions the patient suffered in the past. It shall include entries for problems as described in the Entry Content Modules</title>
<text>Text as described above</text>
<entry>
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.27"/>
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<low nullFlavor="UNK"/>
</effectiveTime>
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<code code="282291009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>dehydration fever</text>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="UNK"/>
<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="1284" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="DIAGNOSIS LIST"/>
</observation>
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<code code="418799008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>FEVER</text>
<statusCode code="completed"/>
<effectiveTime>
<low nullFlavor="UNK"/>
<high nullFlavor="UNK"/>
</effectiveTime>
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</observation>
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<title>The physical exam section shall contain only the required and optional subsections performed.</title>
<text>Text as described above</text>
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<table>
<thead>
<tr>
<th>Vital Signs Element</th>
<th>Description</th>
<th>Effective Dates</th>
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<td ID = "_49" >HEAD CIRCUMFERENCE</td>
<td>21</td>
<td>07-14-2014</td>
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<tr>
<td ID = "_45" >DIASTOLIC BLOOD PRESSURE</td>
<td>85</td>
<td>07-14-2014</td>
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<tr>
<td ID = "_48" >Weight (kg)</td>
<td>63</td>
<td>07-14-2014</td>
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<tr>
<td ID = "_43" >Pulse</td>
<td>15</td>
<td>07-14-2014</td>
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<tr>
<td ID = "_41" >Respiratory rate</td>
<td>15</td>
<td>07-21-2014</td>
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<tr>
<td ID = "_47" >Height (cm)</td>
<td>168</td>
<td>07-14-2014</td>
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<tr>
<td ID = "_46" >Temperature (C)</td>
<td>28</td>
<td>07-14-2014</td>
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<tr>
<td ID = "_42" >Blood oxygen saturation</td>
<td>58</td>
<td>07-21-2014</td>
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<tr>
<td ID = "_44" >SYSTOLIC BLOOD PRESSURE</td>
<td>115</td>
<td>07-14-2014</td>
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<text><reference value="#_46"/></text>
<statusCode code="completed"/>
<effectiveTime value="20140808090039"/>
<value xsi:type="PQ" value="28" unit="DEGC"/>
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<code xsi:type="CE" code="8480-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="SYSTOLIC BLOOD PRESSURE"/>
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<section>
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<code code="10210-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="General Appearance Section"/>
<title>The general appearance section shall contain a description of the overall, visibly-apparent condition of the patient</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.48"/>
<code code="TBD" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Visible Implanted Medical Devices Section"/>
<title>The visible implanted medical devices section shall contain a description of the medical devices apparent on physical exam that have been inserted into the patient, whether internal or partially external.</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.17"/>
<code code="29302-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="INTEGUMENTARY SYSTEM"/>
<title>The integumentary system section shall contain a description of any type of integumentary system exam.</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.18"/>
<code code="10199-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HEAD"/>
<title>The head section shall contain a description of any type of head exam</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.19"/>
<code code="10197-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="EYE"/>
<title>The eyes section shall contain a description of any type of eye exam</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.20"/>
<code code="11393-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Ears, Nose, Mouth and Throat"/>
<title>The ears, nose, mouth, and throat section shall contain a description of any type of ears, nose, mouth, or throat exam</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.21"/>
<code code="10195-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="EAR"/>
<title>The ears section shall contain a description of any type of ear exam</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.22"/>
<code code="10203-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="NOSE"/>
<title>The nose section shall contain a description of any type of nose exam</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.23"/>
<code code="10201-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MOUTH and THROAT and TEETH"/>
<title>The mouth, throat, and teeth section shall contain a description of any type of mouth, throat, or teeth exam</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.24"/>
<code code="11411-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="NECK"/>
<title>The neck section shall contain a description of any type of neck exam</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.25"/>
<code code="29307-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ENDOCRINE SYSTEM"/>
<title>The endocrine system section shall contain a description of any type of endocrine system exam</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.26"/>
<code code="10207-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="THORAX+LUNGS"/>
<title>The thorax and lungs section shall contain a description of any type of thoracic or lung exams</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.27"/>
<code code="11392-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="CHEST WALL"/>
<title>The chest wall section shall contain a description of any type of chest wall exam.</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.28"/>
<code code="10193-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="BREASTS"/>
<title>The breast section shall contain a description of any type of breast exam.</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.29"/>
<code code="10200-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HEART"/>
<title>The heart section shall contain a description of any type of heart exam</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.30"/>
<code code="11412-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="RESPIRATORY SYSTEM"/>
<title>The respiratory system section shall contain a description of any type of respiratory exam</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.31"/>
<code code="10191-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ABDOMEN"/>
<title>he abdomen system section shall contain a description of any type of abdominal exam</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.32"/>
<code code="11447-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HEMATOLOGIC+LYMPHATIC+IMMUNOLOGIC SYSTEM"/>
<title>The lymphatic system section shall contain a description of any type of lymphatic exam</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.33"/>
<code code="10208-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="VESSELS"/>
<title>The vessels section shall contain a description of any type of vessels exam</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.34"/>
<code code="11410-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MUSCULOSKELETAL SYSTEM"/>
<title>The musculoskeletal system section shall contain a description of any type of musculoskeletal exam</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.35"/>
<code code="10202-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="NEUROLOGIC SYSTEM"/>
<title>The neurologic system section shall contain a description of any type of neurologic exam</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.36"/>
<code code="11400-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="GENITALIA"/>
<title>The genitalia section shall contain a description of any type of genital exam</title>
<text>Text as described above</text>
</section>
</component>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9.37"/>
<code code="10205-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="RECTUM"/>
<title>The rectum section shall contain a description of any type of rectal exam</title>
<text>Text as described above</text>
</section>
</component>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>