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SMOKING_Examples_in_empty_CCD.xml
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SMOKING_Examples_in_empty_CCD.xml
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<?xml version="1.0"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!-- This is an empty C-CDA skeleton which will be used by HL7 CDA Example Task Force -->
<!-- This document was based on prior work by Lisa Nelson and Brian Weiss. contact John D'Amore with questions -->
<!-- See http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force -->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 ../90%20HL7/00%20Standard%20-%20C-CDA/20130409%20C-CDA%20R1dot1_2012JUL/Updated_CDA_Schema_Files_Extension_Support/CDA_Schema_Files/infrastructure/cda/CDA_SDTC.xsd"
xmlns="urn:hl7-org:v3"
xmlns:cda="urn:hl7-org:v3"
xmlns:sdtc="urn:hl7-org:sdtc">
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
<!-- C-CDA -->
<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
<!-- CCD -->
<id root="2.16.840.1.113883.3.3208.101.1" extension="20130607100315-CCDA-CCD"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34133-9" displayName="Summarization of Episode Note"/>
<title>Empty CCD Skeleton That Validates on TTT. Note this was based on work by Lisa Nelson and Brian Weiss</title>
<effectiveTime value="20130607000000-0000"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<recordTarget>
<patientRole>
<id root="2.16.840.1.113883.3.3208.101.2" extension="20130607100800-Patient1"/>
<addr use="HP">
<streetAddressLine>1111 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)111-1111" use="HP"/>
<patient>
<name use="L">
<given>Patient</given>
<family>One</family>
</name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male" codeSystemName="AdministrativeGender"/>
<birthTime value="19300911"/>
<maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatus"/>
<raceCode code="2106-3" displayName="White"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="OMB Standards for Race and Ethnicity"/>
<ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="OMB Standards for Race and Ethnicity"/>
<languageCommunication>
<languageCode code="eng"/>
<modeCode code="ESP" displayName="Expressed spoken" codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/>
<proficiencyLevelCode code="E" displayName="Excellent" codeSystem="2.16.840.1.113883.5.61" codeSystemName="LanguageAbilityProficiency"/>
</languageCommunication>
</patient>
</patientRole>
</recordTarget>
<author>
<time value="20130607000000"/>
<assignedAuthor>
<id extension="22222" root="2.16.840.1.113883.4.6"/>
<code code="207QA0505X" codeSystem="2.16.840.1.113883.6.101"
displayName="Adult Medicine" codeSystemName="NUCC"/>
<addr use="HP">
<streetAddressLine>2222 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)222-2222" use="WP"/>
<assignedPerson>
<name>
<given>Doctor</given>
<family>Second</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<dataEnterer>
<assignedEntity>
<id extension="33333" root="2.16.840.1.113883.4.6"/>
<code code="364SA2200X" displayName="Adult Health" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"/>
<addr use="WP">
<streetAddressLine>3333 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)333-3333" use="WP"/>
<assignedPerson>
<name>
<given>Nurse</given>
<family>Tertiary</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="44444" root="2.16.840.1.113883.4.6"/>
<name>CDA PRO Fictional Hospital</name>
<telecom value="tel:+1(301)444-4444" use="WP"/>
<addr use="WP">
<streetAddressLine>4444 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<legalAuthenticator>
<time value="20130607000000"/>
<signatureCode code="S"/>
<assignedEntity>
<id root="2.16.840.1.113883.3.3208.101.3" extension="20130607102400-Authenticator1"/>
<addr use="WP">
<streetAddressLine>5555 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)555-5555" use="WP"/>
<assignedPerson>
<name>
<given>Physician</given>
<family>Fifthly</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="19330316"/>
<high value="20130607"/>
</effectiveTime>
<performer typeCode="PRF">
<assignedEntity>
<id extension="66666" root="2.16.840.1.113883.4.6"/>
<code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC"
displayName="Cardiovascular Disease"/>
<addr>
<streetAddressLine>6666 StreetName St.</streetAddressLine>
<city>Silver Spring</city>
<state>MD</state>
<postalCode>20901</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1(301)666-6666" use="WP"/>
<assignedPerson>
<name>
<given>Heartly</given>
<family>Sixer</family>
<suffix>MD</suffix>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<!-- CDA Body -->
<component>
<structuredBody>
<!-- Allergies Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
<!-- Allergies (entries required) section -->
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" displayName="Allergies, adverse reactions, alerts" codeSystemName="LOINC"/>
<title>ALLERGIES</title>
<text>No Information</text>
</section>
</component>
<!-- Medication Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
<!-- Medication Section (entries required) -->
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Medication Use"/>
<title>MEDICATIONS</title>
<text>No Information</text>
</section>
</component>
<!-- Problem Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<!-- conforms to Problems section with entries required -->
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="PROBLEM LIST"/>
<title>PROBLEMS</title>
<text>No Information</text>
</section>
</component>
<!-- Procedures Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
<!-- Procedures Section with Coded Entries Required-->
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Procedures"/>
<title>PROCEDURES</title>
<text>No Information</text>
</section>
</component>
<!-- Results Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
<!-- Results Section with Coded Entries Required-->
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Relevant diagnostic tests and/or laboratory data"/>
<title>RESULTS</title>
<text>No Information</text>
</section>
</component>
<!-- Plan of Care Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.10"/>
<!-- Plan of Care Section-->
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Plan of Care"/>
<title>PLAN OF CARE</title>
<text>No Information</text>
</section>
</component>
<!-- Social History (with Smoking Status Observation) -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.17"/>
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social History"/>
<title>Social History</title>
<!-- DON'T DO THIS...THE MULTIPLE ENTRIES BELOW ARE FOR VALIDATION ONLY!!!-->
<text>
<list>
<caption>Smoking Status</caption>
<item>
<content>Unknown if ever smoked</content>
<content>Started: </content>
<content>Stopped:</content>
<content>Recorded June 6, 2014 10:32am</content>
</item>
</list>
<list>
<caption>Smoking Status</caption>
<item>
<content>Current every day smoker</content>
<content>Started: 1992</content>
<content>Stopped:</content>
<content>Recorded June 6, 2014 10:32am</content>
</item>
</list>
<list>
<caption>Smoking Status</caption>
<item>
<content>Former Smoker</content>
<content>Started: January 1994</content>
<content>Stopped: March 2011</content>
<content>Recorded June 6, 2014 10:32am</content>
</item>
</list>
<list>
<caption>Smoking Status</caption>
<item>
<content>Never smoked</content>
<content>Started: </content>
<content>Stopped:</content>
<content>Recorded June 6, 2014 10:32am</content>
</item>
</list>
</text>
<!-- A best practice is to only include one smoking status per patient to avoid confusion. -->
<!-- DON'T DO THIS...THE MULTIPLE ENTRIES BELOW ARE FOR VALIDATION ONLY!!!-->
<!-- While multiple smoking statuses are permissible in C-CDA 1.1, a cardinality revision in C-CDA 2.0 is proposed. -->
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.78"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime>
<!-- effectiveTime/low is nullFlavor when smoking status is unknown.-->
<!-- Please note that there may be revisions to this assignment in C-CDA R2.0-->
<!-- Other nullFlavors have been discussed and may be appropriate -->
<low nullFlavor="UNK"/>
</effectiveTime>
<!-- The use of a specfic SNOMED code for unknown smoker is an encouraged variation from C-CDA practices in other sections -->
<value xsi:type="CD" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="266927001" displayName="Unknown if ever smoked"/>
<author>
<time value="201406061032+0500"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="99999999"/>
<!-- Root means NPI number. -->
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101"
displayName="Allopathic and Osteopathic Physicians"/>
<telecom use="WP" value="tel:+1(555)555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.78"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime>
<!-- effectiveTime/low is the date when the person started smoking. -->
<!-- The month is included if the patient remembers to the month of status-->
<low value="199401"/>
<!-- effectiveTime/high is the date when the person stopped smoking and only used for former smokers. -->
<!-- This is a point of common confusion given its divergence from other principles. This is NOT the date the person stopped being a "former smoker." -->
<!-- Smoking status may be revised -->
<high value="201103"/>
</effectiveTime>
<value xsi:type="CD" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="8517006" displayName="Former smoker"/>
<author>
<time value="201406061032+0500"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="99999999"/>
<!-- Root means NPI number. -->
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101"
displayName="Allopathic and Osteopathic Physicians"/>
<telecom use="WP" value="tel:+1(555)555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.78"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime>
<!-- effectiveTime/low is populated with the date the patient started smoking-->
<!-- This is an example of year precision timing when month and day are not specified-->
<low value="1992"/>
<!-- effectiveTime/high should not be populated with observation date for a current smoker-->
</effectiveTime>
<value xsi:type="CD" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="449868002" displayName="Current every day smoker"/>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.78"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime>
<!-- effectiveTime/low is populated with the date the patient started smoking-->
<!-- This is an example of year precision timing when month and day are not specified-->
<low value="1992"/>
<!-- effectiveTime/high should not be populated with observation date for a current smoker-->
</effectiveTime>
<value xsi:type="CD" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="449868002" displayName="Current every day smoker"/>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<!-- ** Social history observation template ** -->
<!--- You can used a social history observation template entry for additional smoking detail, such as smoking quantity-->
<templateId root="2.16.840.1.113883.10.20.22.4.38"/>
<id root="45efb604-7049-4a2e-ad33-d38556c9636c"/>
<code code="229819007" codeSystem="2.16.840.1.113883.6.96" displayName="Tobacco use and exposure"/>
<statusCode code="completed"/>
<effectiveTime>
<low value="1992"/>
</effectiveTime>
<!--- This code would not work for a smoking status since not in the HL7 or MU accceptable value set-->
<value xsi:type="CD" codeSystem="2.16.840.1.113883.6.96" code="160604004" displayName="Moderate cigarette smoker (10-19 cigs/day)"/>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.78"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime>
<!-- effectiveTime/low is nullFlavor when smoking status is unknown.-->
<!-- Please note that there may be revisions to this assignment in C-CDA R2.0-->
<!-- Other nullFlavors have been discussed and may be appropriate -->
<low nullFlavor="NA"/>
</effectiveTime>
<!-- The use of a specfic SNOMED code for unknown smoker is an encouraged variation from C-CDA practices in other sections -->
<value xsi:type="CD" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="266919005" displayName="Never Smoker"/>
<author>
<time value="201406061032+0500"/>
<assignedAuthor>
<id root="2.16.840.1.113883.4.6" extension="99999999"/>
<!-- Root means NPI number. -->
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101"
displayName="Allopathic and Osteopathic Physicians"/>
<telecom use="WP" value="tel:+1(555)555-1002"/>
<assignedPerson>
<name>
<given>Henry</given>
<family>Seven</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
</observation>
</entry>
</section>
</component>
<!-- Vital Signs Section (entries required) -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<!-- Validator currently checks for entries even in case of nullFlavor - this will need to be updated if approved.-->
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.4.1"/>
<!-- Vital Signs (entries required) -->
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital Signs"/>
<title>VITAL SIGNS</title>
<text>No Information</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>