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Microsoft word - sample_cda.doc

<?xml version="1.0"?>
<!DOCTYPE levelone PUBLIC "-//HL7//DTD CDA Level One 1.0//EN"
"levelone_1.0.dtd">
<levelone>
<clinical_document_header>
<id EX="a123" RT="2.16.840.1.113883.3.933"/>
<set_id EX="B" RT="2.16.840.1.113883.3.933"/>
<version_nbr V="2"/>
<document_type_cd V="11488-4" S="2.16.840.1.113883.6.1"
DN="Consultation note"/>
<origination_dttm V="2000-04-07"/>
<confidentiality_cd ID="CONF1" V="N" S="2.16.840.1.113883.5.1xxx"/>
<confidentiality_cd ID="CONF2" V="R" S="2.16.840.1.113883.5.1xxx"/>
<document_relationship>
<document_relationship.type_cd V="RPLC"/>
<related_document>
<id EX="a234" RT="2.16.840.1.113883.3.933"/>
<set_id EX="B" RT="2.16.840.1.113883.3.933"/>
<version_nbr V="1"/>
</related_document>
</document_relationship>
<fulfills_order>
<fulfills_order.type_cd V="FLFS"/>
<order><id EX="x23ABC" RT="2.16.840.1.113883.3.933"/></order>
<order><id EX="x42CDE" RT="2.16.840.1.113883.3.933"/></order>
</fulfills_order>
<patient_encounter>
<id EX="KPENC1332" RT="2.16.840.1.113883.3.933"/>
<practice_setting_cd V="GIM"
S="2.16.840.1.113883.5.1xxx" DN="General internal medicine clinic"/>
<encounter_tmr V="2000-04-07"/>
<service_location>
<id EX="KXLPa123" RT="2.16.840.1.113883.3.933"/>
<addr>
<HNR V="970"/>
<STR V="Post St"/>
<DIR V="NE"/>
<CTY V="Alameda"/>
<STA V="CA"/>
<ZIP V="94501"/>
</addr>
</service_location>
</patient_encounter>
<legal_authenticator>
<legal_authenticator.type_cd V="SPV"/>
<participation_tmr V="2000-04-08"/>
<signature_cd V="S"/>
<person>
<id EX="KP00017" RT="2.16.840.1.113883.3.933"/>
<person_name>
<nm>
<GIV V="Robert"/>
<FAM V="Dolin"/>
<SFX V="MD" QUAL="PT"/>
</nm>
<person_name.type_cd V="L" S="2.16.840.1.113883.5.1xxx"/>
</person_name>
<addr>
<HNR V="970"/>
<STR V="Post St"/>
<DIR V="NE"/>
<CTY V="Alameda"/>
<STA V="CA"/>
<ZIP V="94501"/>
</addr>
<phon V="tel:(358)555-1234" USE="WPN"/>
</person>
</legal_authenticator>

<originator>
<originator.type_cd V="AUT"/>
<participation_tmr V="2000-04-07"/>
<person>
<id EX="KP00017" RT="2.16.840.1.113883.3.933"/>
<person_name>
<nm>
<GIV V="Robert"/>
<FAM V="Dolin"/>
<SFX V="MD"/>
</nm>
<person_name.type_cd V="L" S="2.16.840.1.113883.5.1xxx"/>
</person_name>
</person>
</originator>
<originating_organization>
<originating_organization.type_cd V="CST"/>
<organization>
<id EX="M345" RT="2.16.840.1.113883.3.933"/>
<organization.nm V="Good Health Clinic"/>
</organization>
</originating_organization>
<provider>
<provider.type_cd V="CON"/>
<participation_tmr V="2000-04-07"/>
<person>
<id EX="KP00017" RT="2.16.840.1.113883.3.933"/>
</person>
</provider>

<patient>
<patient.type_cd V="PATSBJ"/>
<person>
<id EX="12345" RT="2.16.840.1.113883.3.933"/>
<person_name>
<nm>
<GIV V="Henry"/>
<FAM V="Levin"/>
<SFX V="the 7th"/>
</nm>
<person_name.type_cd V="L" S="2.16.840.1.113883.5.1xxx"/>
</person_name>
<person_name>
<nm>
<GIV V="Hank"/>
<FAM V="Levin"/>
</nm>
<person_name.type_cd V="A" S="2.16.840.1.113883.5.1xxx"/>
</person_name>
</person>
<birth_dttm V="1932-09-24"/>
<administrative_gender_cd V="M" S="2.16.840.1.113883.5.1xxx"/>
</patient>

<originating_device ID="DEV1">
<originating_device.type_cd V="ODV"/>
<device>
<id EX="devX3498" RT="2.16.840.1.113883.3.933"/>
<responsibility>
<responsibility.type_cd V="MNT" S="2.16.840.1.113883.5.1xxx"/>
<person>
<id EX="KP03257" RT="2.16.840.1.113883.3.933"/>
</person>
</responsibility>
</device>
</originating_device>
<local_header ignore="all" descriptor="MyLocalTag">
. extra stuff that is only used locally .
</local_header>
</clinical_document_header>
<body confidentiality="CONF1">
<section>
<caption>
<caption_cd V="8684-3" S="2.16.840.1.113883.6.1"/>
History of Present Illness
</caption>
<paragraph>
<content>
Henry Levin, the 7th is a 67 year old male referred for further
asthma management. Onset of asthma in his teens. He was
hospitalized twice last year, and already twice this year. He has
not been able to be weaned off steroids for the past several
months.
</content>
</paragraph>
</section>
<section>
<caption>Past Medical History</caption>
<list>
<item><content>Asthma</content></item>
<item><content>Hypertension</content></item>
<item><content>Osteoarthritis, right knee</content></item>
</list>
</section>
<section>
<caption>
<caption_cd V="10160-0" S="2.16.840.1.113883.6.1"/>Medications
</caption>
<list>
<item><content>Theodur 200mg BID</content></item>
<item><content>Proventil inhaler 2puffs QID PRN</content></item>
<item><content>Prednisone 20mg qd</content></item>
<item><content>HCTZ 25mg qd</content></item>
</list>
</section>
<section>
<caption>Allergies</caption>
<list>
<item><content>Penicillin - Hives</content></item>
<item><content>Aspirin - Wheezing</content></item>
</list>
</section>
<section>
<caption>Social History</caption>
<list>
<item>
<content>
Smoking :: 1 PPD between the ages of 20 and 55, and then he quit.
</content>
</item>
<item><content>Alcohol :: rare</content></item>
</list>
</section>

<section>
<caption>
<caption_cd V="11384-5" S="2.16.840.1.113883.6.1"/>
Physical Examination
</caption>
<section>
<caption>
<caption_cd V="8716-3" S="2.16.840.1.113883.6.1"/>Vital Signs
</caption>
<list>
<item><content>BP 118/78</content></item>
<item><content>Resp 16 and unlabored</content></item>
<item><content>T 98.6F</content></item>
<item><content>HR 86 and regular</content></item>
</list>
</section>
<section>
<caption>
<caption_cd V="8709-8" S="2.16.840.1.113883.6.1"/>Skin
</caption>
<paragraph>
<content>Erythematous rash, palmar surface, left index finger.
<observation_media>
<observation_media.value MT="image/jpeg">
<REF V="rash.jpeg"/>
</observation_media.value>
</observation_media>
</content>
</paragraph>
</section>
<section>
<caption>
<caption_cd V="11391-0" S="2.16.840.1.113883.6.1"/>Lungs
</caption>
<paragraph>
<content>Clear with no wheeze. Good air flow.</content>
</paragraph>
</section>
<section>
<caption>Cardiac</caption>
<paragraph>
<content>RRR with no murmur, no S3, no S4.</content>
</paragraph>
</section>
</section>

<section confidentiality="CONF2">
<caption>
<caption_cd V="11502-2" S="2.16.840.1.113883.6.1"/>Labs
</caption>
<list>
<item>
<content>
CXR 02/03/1999: Hyperinflated. Normal cardiac silhouette,
clear lungs.
</content>
</item>
<item originator="DEV1"><content>Peak Flow
today: 260 l/m</content></item>
</list>
</section>
<section>
<caption>
<caption_cd V="11496-7" S="2.16.840.1.113883.6.1"/>Assessment
</caption>
<list>
<item>
<content>
<content ID="String001">Asthma</content>, with prior smoking
history. Difficulty weaning off steroids. Will try
gradual taper.
<coded_entry>
<coded_entry.value ORIGTXT="String001"
V="D2-51000" S="2.16.840.1.113883.6.5"/>
</coded_entry>
</content>
</item>
<item><content>Hypertension, well-controlled.</content></item>
<item><content>Contact dermatitis on finger.</content></item>
</list>
</section>
<section>
<caption>
<caption_cd V="1234-X" S="2.16.840.1.113883.6.1"/>Plan
</caption>
<list>
<item><content>Complete PFTs with lung volumes.</content></item>
<item><content>Chem-7</content></item>
<item>
<content>
Provide educational material on inhaler usage and
peak flow self-monitoring.
</content>
</item>
<item>
<content>Decrease prednisone to 20qOD alternating
with 18qOD.</content>
</item>
<item><content>Hydrocortisone cream to finger BID.</content></item>
<item><content>RTC 1 week.</content></item>
</list>

</section>
</body>
</levelone>

Source: http://www.engr.uconn.edu/~steve/Cse300/Sample_CDA.pdf

6540-02

DOSAGE FORMS AND STRENGTHS A long-term open-label extension study of subjects from the two short-term efficacy studies was also conducted 12.2 Pharmacodynamics in which subjects were treated with 3900 mg/day for up to 5 days during each menstrual period for up to Tranexamic acid, at in vitro concentrations of 25 - 100 M, reduces by 20 - 60% the maximal rate of plasmin lysis (tranexamic a

Microsoft word - chapter 6.doc

CHAPTER 6 Chemotherapeutic Agents Questions DIRECTIONS (Questions 462 through 563): Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered that is BEST in each case. 462. Which of the following beta-lactam antibiotics is most resistant to staphylococcal beta-lactamases? (A) amoxicillm (C) oxacillin (D)

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