From 04ff81682b33c47cf0027dcd12fbf6d5809e3766 Mon Sep 17 00:00:00 2001 From: Oliver Egger Date: Mon, 14 Oct 2019 22:31:17 +0200 Subject: [PATCH] CDA Tests with FHIRPath, ED datatype handling --- .../hl7/fhir/r5/elementmodel/XmlParser.java | 15 +- .../hl7/fhir/r5/test/CDARoundTripTests.java | 152 +- .../src/test/resources/cda/cda-original.xml | 1098 ++++++++ .../src/test/resources/cda/cda-roundtrip.json | 2360 +++++++++++++++++ .../src/test/resources/cda/cda-roundtrip.xml | 1096 ++++++++ 5 files changed, 4700 insertions(+), 21 deletions(-) create mode 100644 org.hl7.fhir.r5/src/test/resources/cda/cda-original.xml create mode 100644 org.hl7.fhir.r5/src/test/resources/cda/cda-roundtrip.json create mode 100644 org.hl7.fhir.r5/src/test/resources/cda/cda-roundtrip.xml diff --git a/org.hl7.fhir.r5/src/main/java/org/hl7/fhir/r5/elementmodel/XmlParser.java b/org.hl7.fhir.r5/src/main/java/org/hl7/fhir/r5/elementmodel/XmlParser.java index 4ebc2fcb4..a5643ad5a 100644 --- a/org.hl7.fhir.r5/src/main/java/org/hl7/fhir/r5/elementmodel/XmlParser.java +++ b/org.hl7.fhir.r5/src/main/java/org/hl7/fhir/r5/elementmodel/XmlParser.java @@ -40,6 +40,7 @@ import javax.xml.transform.sax.SAXSource; import org.hl7.fhir.exceptions.DefinitionException; import org.hl7.fhir.exceptions.FHIRException; import org.hl7.fhir.exceptions.FHIRFormatError; +import org.hl7.fhir.r5.elementmodel.Element; import org.hl7.fhir.r5.conformance.ProfileUtilities; import org.hl7.fhir.r5.context.IWorkerContext; import org.hl7.fhir.r5.elementmodel.Element.SpecialElement; @@ -244,8 +245,18 @@ public class XmlParser extends ParserBase { if (!Utilities.noString(text)) { Property property = getTextProp(properties); if (property != null) { - context.getChildren().add(new Element(property.getName(), property, property.getType(), text).markLocation(line(node), col(node))); - } else { + if ("ED.data[x]".equals(property.getDefinition().getId())) { + if ("B64".equals(node.getAttribute("representation"))) { + context.getChildren().add(new Element("dataBase64Binary", property, "base64Binary", text).markLocation(line(node), col(node))); + } else { + context.getChildren().add(new Element("dataString", property, "string", text).markLocation(line(node), col(node))); + } + } else { + context.getChildren().add( + new Element(property.getName(), property, property.getType(), text).markLocation(line(node), col(node))); + } + } + else { logError(line(node), col(node), path, IssueType.STRUCTURE, "Text should not be present", IssueSeverity.ERROR); } } diff --git a/org.hl7.fhir.r5/src/test/java/org/hl7/fhir/r5/test/CDARoundTripTests.java b/org.hl7.fhir.r5/src/test/java/org/hl7/fhir/r5/test/CDARoundTripTests.java index 48c3fdf79..ee2ea8d6f 100644 --- a/org.hl7.fhir.r5/src/test/java/org/hl7/fhir/r5/test/CDARoundTripTests.java +++ b/org.hl7.fhir.r5/src/test/java/org/hl7/fhir/r5/test/CDARoundTripTests.java @@ -1,5 +1,8 @@ package org.hl7.fhir.r5.test; +import static org.junit.Assert.assertEquals; +import static org.junit.Assert.assertTrue; + import java.io.FileInputStream; import java.io.FileNotFoundException; import java.io.FileOutputStream; @@ -13,28 +16,115 @@ import org.hl7.fhir.r5.elementmodel.Element; import org.hl7.fhir.r5.elementmodel.Manager; import org.hl7.fhir.r5.elementmodel.Manager.FhirFormat; import org.hl7.fhir.r5.formats.IParser.OutputStyle; +import org.hl7.fhir.r5.test.utils.TestingUtilities; +import org.hl7.fhir.r5.utils.FHIRPathEngine; import org.hl7.fhir.utilities.cache.PackageCacheManager; import org.hl7.fhir.utilities.cache.ToolsVersion; import org.junit.Before; +import org.junit.Ignore; import org.junit.Test; public class CDARoundTripTests { private SimpleWorkerContext context; + private FHIRPathEngine fp; @Before public void setUp() throws Exception { context = new SimpleWorkerContext(); PackageCacheManager pcm = new PackageCacheManager(true, ToolsVersion.TOOLS_VERSION); - context.loadFromPackage(pcm.loadPackage("hl7.fhir.core"), null, "StructureDefinition"); - context.loadFromPackage(pcm.loadPackage("hl7.fhir.cda"), null, "StructureDefinition"); + context.loadFromPackage(pcm.loadPackage("hl7.fhir.core", "dev"), null, "StructureDefinition"); + context.loadFromPackage(pcm.loadPackage("hl7.fhir.cda", "dev"), null, "StructureDefinition"); + fp = new FHIRPathEngine(context); + } + + @Test + public void testCDA() throws FHIRFormatError, DefinitionException, FileNotFoundException, IOException, FHIRException { + try { + + String fileSource = TestingUtilities.resourceNameToFile("cda", "cda-original.xml"); + String roundTrip = TestingUtilities.resourceNameToFile("cda", "cda-roundtrip.xml"); + String jsonRoundTrip = TestingUtilities.resourceNameToFile("cda", "cda-roundtrip.json"); + + Element e = Manager.parse(context, new FileInputStream(fileSource), FhirFormat.XML); + + Manager.compose(context, e, new FileOutputStream(roundTrip), FhirFormat.XML, OutputStyle.PRETTY, null); + Manager.compose(context, e, new FileOutputStream(jsonRoundTrip), FhirFormat.JSON, OutputStyle.PRETTY, null); + +// +// assertEquals("POCD_HD000040", fp.evaluateToString(e, "typeId.extension")); +// assertEquals("2.16.840.1.113883.1.3", fp.evaluateToString(e, "typeId.root")); +// +// assertEquals("2.16.840.1.113883.3.27.1776", fp.evaluateToString(e, "templateId.root")); +// + assertEquals("2.16.840.1.113883.19.4", fp.evaluateToString(e, "id.root")); + assertEquals("c266", fp.evaluateToString(e, "id.extension")); + +// Good Health Clinic Consultation Note + assertEquals("Good Health Clinic Consultation Note", fp.evaluateToString(e, "title.dataString")); +// + assertEquals("2000-04-07", fp.evaluateToString(e, "effectiveTime.value")); +// + assertEquals("N", fp.evaluateToString(e, "confidentialityCode.code")); + assertEquals("2.16.840.1.113883.5.25", fp.evaluateToString(e, "confidentialityCode.codeSystem")); +// + assertEquals("en-US", fp.evaluateToString(e, "languageCode.code")); +// + assertEquals("BB35", fp.evaluateToString(e, "setId.extension")); + assertEquals("2.16.840.1.113883.19.7", fp.evaluateToString(e, "setId.root")); +// + assertEquals("2", fp.evaluateToString(e, "versionNumber.value")); +// +// +// + assertEquals("12345", fp.evaluateToString(e, "recordTarget.patientRole.id.extension")); + assertEquals("2.16.840.1.113883.19.5", fp.evaluateToString(e, "recordTarget.patientRole.id.root")); +// +// +// Levin + assertEquals("Levin", fp.evaluateToString(e, "recordTarget.patientRole.patient.name.family.dataString")); +// Henry + assertEquals("Henry", fp.evaluateToString(e, "recordTarget.patientRole.patient.name.given.dataString")); +// the 7th +// +// +// +// +// +// +// +// +// + +// +// +// +//
+ +// +//
+// +// Skin Exam +// Erythematous rash, palmar surface, left index finger. +// +// + + assertEquals("Skin Exam", fp.evaluateToString(e, "component.structuredBody.component.section.component.section.where(code.code='8709-8' and code.codeSystem='2.16.840.1.113883.6.1').title.dataString")); + } catch (Exception e) { + System.out.println(e.getMessage()); + e.printStackTrace(); + throw e; + } } - @Test + @Ignore public void testDCI() throws FHIRFormatError, DefinitionException, FileNotFoundException, IOException, FHIRException { try { - Element e = Manager.parse(context, new FileInputStream("C:\\work\\org.hl7.fhir.us\\ccda-to-fhir-maps\\cda\\IAT2-Discharge_Summary-DCI.xml"), FhirFormat.XML); - Manager.compose(context, e, new FileOutputStream("C:\\temp\\ccda.xml"), FhirFormat.XML, OutputStyle.PRETTY, null); + Element e = Manager.parse(context, + new FileInputStream("C:\\work\\org.hl7.fhir.us\\ccda-to-fhir-maps\\cda\\IAT2-Discharge_Summary-DCI.xml"), + FhirFormat.XML); + + Manager.compose(context, e, new FileOutputStream("C:\\temp\\ccda.xml"), FhirFormat.XML, OutputStyle.PRETTY, null); // Manager.compose(context, e, new FileOutputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge_Summary-DCI.out.json"), FhirFormat.JSON, OutputStyle.PRETTY, null); // Manager.compose(context, e, new FileOutputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge_Summary-DCI.out.ttl"), FhirFormat.TURTLE, OutputStyle.PRETTY, null); } catch (Exception e) { @@ -44,20 +134,44 @@ public class CDARoundTripTests { } } - @Test - public void testEpic() throws FHIRFormatError, DefinitionException, FileNotFoundException, IOException, FHIRException { - Element e = Manager.parse(context, new FileInputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge-Homework-Epic.xml"), FhirFormat.XML); - Manager.compose(context, e, new FileOutputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge-Homework-Epic.out.xml"), FhirFormat.XML, OutputStyle.PRETTY, null); - Manager.compose(context, e, new FileOutputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge-Homework-Epic.out.json"), FhirFormat.JSON, OutputStyle.PRETTY, null); - Manager.compose(context, e, new FileOutputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge-Homework-Epic.out.ttl"), FhirFormat.TURTLE, OutputStyle.PRETTY, null); + @Ignore + public void testEpic() + throws FHIRFormatError, DefinitionException, FileNotFoundException, IOException, FHIRException { + Element e = Manager.parse(context, + new FileInputStream( + "C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge-Homework-Epic.xml"), + FhirFormat.XML); + Manager.compose(context, e, + new FileOutputStream( + "C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge-Homework-Epic.out.xml"), + FhirFormat.XML, OutputStyle.PRETTY, null); + Manager.compose(context, e, + new FileOutputStream( + "C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge-Homework-Epic.out.json"), + FhirFormat.JSON, OutputStyle.PRETTY, null); + Manager.compose(context, e, + new FileOutputStream( + "C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge-Homework-Epic.out.ttl"), + FhirFormat.TURTLE, OutputStyle.PRETTY, null); } - @Test - public void testDHIT() throws FHIRFormatError, DefinitionException, FileNotFoundException, IOException, FHIRException { - Element e = Manager.parse(context, new FileInputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-DS-Homework-DHIT.xml"), FhirFormat.XML); - Manager.compose(context, e, new FileOutputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-DS-Homework-DHIT.out.xml"), FhirFormat.XML, OutputStyle.PRETTY, null); - Manager.compose(context, e, new FileOutputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-DS-Homework-DHIT.out.json"), FhirFormat.JSON, OutputStyle.PRETTY, null); - Manager.compose(context, e, new FileOutputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-DS-Homework-DHIT.out.ttl"), FhirFormat.TURTLE, OutputStyle.PRETTY, null); + @Ignore + public void testDHIT() + throws FHIRFormatError, DefinitionException, FileNotFoundException, IOException, FHIRException { + Element e = Manager.parse(context, + new FileInputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-DS-Homework-DHIT.xml"), + FhirFormat.XML); + Manager.compose(context, e, + new FileOutputStream( + "C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-DS-Homework-DHIT.out.xml"), + FhirFormat.XML, OutputStyle.PRETTY, null); + Manager.compose(context, e, + new FileOutputStream( + "C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-DS-Homework-DHIT.out.json"), + FhirFormat.JSON, OutputStyle.PRETTY, null); + Manager.compose(context, e, + new FileOutputStream( + "C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-DS-Homework-DHIT.out.ttl"), + FhirFormat.TURTLE, OutputStyle.PRETTY, null); } - -} +} \ No newline at end of file diff --git a/org.hl7.fhir.r5/src/test/resources/cda/cda-original.xml b/org.hl7.fhir.r5/src/test/resources/cda/cda-original.xml new file mode 100644 index 000000000..ba6497772 --- /dev/null +++ b/org.hl7.fhir.r5/src/test/resources/cda/cda-original.xml @@ -0,0 +1,1098 @@ + + + + + + + + + + Good Health Clinic Consultation Note + + + + + + + + + + + Levin + Henry + the 7th + + + + + + + + + + + + + + + + Good Health Clinic + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + History of Present Illness + + Henry Levin, the 7th + is a 67 year old male referred for further asthma management. Onset of asthma in his twenties + 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. + +
+ + + +
+ + Past Medical History + + + + Asthma + + + Hypertension (see HTN.cda for details) + + + Osteoarthritis, + right knee + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + Medications + + + Theodur 200mg BID + Proventil inhaler 2puffs QID PRN + Prednisone 20mg qd + HCTZ 25mg qd + + + + + Theodur 200mg BID + + + + + + + + + + + + + + + + + Proventil inhaler 2puffs QID PRN + + + + + + + + + + + + + + + + + + + Prednisone 20mg qd + + + + + + + + + + + + + + + + + HCTZ 25mg qd + + + + + + + + + + + + + +
+ + + +
+ + Allergies and Adverse Reactions + + + Penicillin - Hives + Aspirin - Wheezing + Codeine - Itching and nausea + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + Family history + + + Father had fatal MI in his early 50's. + No cancer or diabetes. + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + Social History + + + Smoking :: 1 PPD between the ages of 20 and 55, and then he quit. + Alcohol :: rare + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + Physical Examination + + +
+ + Vital Signs + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
Date / TimeApril 7, 2000 14:30April 7, 2000 15:30
Height177 cm (69.7 in)
Weight194.0 lbs (88.0 kg)
BMI28.1 kg/m2
BSA2.05 m2
Temperature36.9 C (98.5 F)36.9 C (98.5 F)
Pulse86 / minute84 / minute
RhythmRegularRegular
Respirations16 / minute, unlabored14 / minute
Systolic132 mmHg135 mmHg
Diastolic86 mmHg88 mmHg
Position / CuffLeft ArmLeft Arm
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + Skin Exam + Erythematous rash, palmar surface, left index finger. + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + Lungs + Clear with no wheeze. Good air flow. + + + + + + + + + + + + + + +
+ + + +
+ + Cardiac + RRR with no murmur, no S3, no S4. + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ +
+ + + +
+ + Labs + + + CXR 02/03/1999: Hyperinflated. Normal cardiac silhouette, clear lungs. + Peak Flow today: 260 l/m + + + + + + + + + + + + + + + + + normal cardiac silhouette + + + + + + + + radiopacities + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + In-office Procedures + + + Suture removal, left forearm. + + + + + + + + + + +
+ + + +
+ + Assessment + + + Asthma, with prior smoking history. Difficulty weaning off steroids. Will try gradual taper. + Hypertension, well-controlled. + Contact dermatitis on finger. + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + + Plan + + + Complete PFTs with lung volumes. + Chem-7 tomorrow. + Teach peak flow rate measurement. + Decrease prednisone to 20qOD alternating with 18qOD. + Hydrocortisone cream to finger BID. + RTC 1 week. + + + + + + + Complete PFTs with lung volumes. + + + + + + + + + + + Chem-7 + + + Chem-7 tomorrow + + + + + + + + + + + + + + + + + prednisone 20qOD alternating with 18qOD. + + + + + + + + + + + + + Hydrocortisone cream to finger BID. + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + + diff --git a/org.hl7.fhir.r5/src/test/resources/cda/cda-roundtrip.json b/org.hl7.fhir.r5/src/test/resources/cda/cda-roundtrip.json new file mode 100644 index 000000000..5c0e75a74 --- /dev/null +++ b/org.hl7.fhir.r5/src/test/resources/cda/cda-roundtrip.json @@ -0,0 +1,2360 @@ +{ + "resourceType": "ClinicalDocument", + "id": { + "extension": "c266", + "root": "2.16.840.1.113883.19.4" + }, + "code": { + "code": "11488-4", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC", + "displayName": "Consultation note" + }, + "title": { + "dataString": "Good Health Clinic Consultation Note" + }, + "effectiveTime": { + "value": "2000-04-07" + }, + "confidentialityCode": { + "code": "N", + "codeSystem": "2.16.840.1.113883.5.25" + }, + "languageCode": { + "code": "en-US" + }, + "setId": { + "extension": "BB35", + "root": "2.16.840.1.113883.19.7" + }, + "versionNumber": { + "value": 2 + }, + "recordTarget": [ + { + "patientRole": { + "id": [ + { + "extension": "12345", + "root": "2.16.840.1.113883.19.5" + } + ], + "patient": { + "name": [ + { + "family": [ + { + "dataString": "Levin" + } + ], + "given": [ + { + "dataString": "Henry" + } + ], + "suffix": [ + { + "dataString": "the 7th" + } + ] + } + ], + "administrativeGenderCode": { + "code": "M", + "codeSystem": "2.16.840.1.113883.5.1" + }, + "birthTime": { + "value": "1932-09-24" + } + }, + "providerOrganization": { + "id": [ + { + "root": "2.16.840.1.113883.19.5" + } + ] + } + } + } + ], + "author": [ + { + "time": { + "value": "2000-04-07T14:00:00" + }, + "assignedAuthor": { + "id": [ + { + "extension": "KP00017", + "root": "2.16.840.1.113883.19.5" + } + ], + "assignedPerson": { + "name": [ + { + "family": [ + { + "dataString": "Dolin" + } + ], + "given": [ + { + "dataString": "Robert" + } + ], + "suffix": [ + { + "dataString": "MD" + } + ] + } + ] + }, + "representedOrganization": { + "id": [ + { + "root": "2.16.840.1.113883.19.5" + } + ] + } + } + } + ], + "custodian": { + "assignedCustodian": { + "representedCustodianOrganization": { + "id": [ + { + "root": "2.16.840.1.113883.19.5" + } + ], + "name": { + "dataString": "Good Health Clinic" + } + } + } + }, + "legalAuthenticator": { + "time": { + "value": "2000-04-08" + }, + "signatureCode": { + "code": "S" + }, + "assignedEntity": { + "id": [ + { + "extension": "KP00017", + "root": "2.16.840.1.113883.19.5" + } + ], + "assignedPerson": { + "name": [ + { + "family": [ + { + "dataString": "Dolin" + } + ], + "given": [ + { + "dataString": "Robert" + } + ], + "suffix": [ + { + "dataString": "MD" + } + ] + } + ] + }, + "representedOrganization": { + "id": [ + { + "root": "2.16.840.1.113883.19.5" + } + ] + } + } + }, + "relatedDocument": [ + { + "typeCode": "RPLC", + "parentDocument": { + "id": [ + { + "extension": "a123", + "root": "2.16.840.1.113883.19.4" + } + ], + "setId": { + "extension": "BB35", + "root": "2.16.840.1.113883.19.7" + }, + "versionNumber": { + "value": 1 + } + } + } + ], + "componentOf": { + "encompassingEncounter": { + "id": [ + { + "extension": "KPENC1332", + "root": "2.16.840.1.113883.19.6" + } + ], + "effectiveTime": { + "value": "2000-04-07" + }, + "encounterParticipant": [ + { + "typeCode": "CON", + "time": { + "value": "2000-04-07" + }, + "assignedEntity": { + "id": [ + { + "extension": "KP00017", + "root": "2.16.840.1.113883.19.5" + } + ], + "assignedPerson": { + "name": [ + { + "family": [ + { + "dataString": "Dolin" + } + ], + "given": [ + { + "dataString": "Robert" + } + ], + "suffix": [ + { + "dataString": "MD" + } + ] + } + ] + }, + "representedOrganization": { + "id": [ + { + "root": "2.16.840.1.113883.19.5" + } + ] + } + } + } + ], + "location": { + "healthCareFacility": { + "classCode": "DSDLOC", + "code": { + "code": "GIM", + "codeSystem": "2.16.840.1.113883.5.10588", + "displayName": "General internal medicine clinic" + } + } + } + } + }, + "component": { + "structuredBody": { + "component": [ + { + "section": { + "code": { + "code": "10164-2", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC" + }, + "title": { + "dataString": "History of Present Illness" + }, + "text": "
Henry Levin, the 7th is a 67 year old male referred for further asthma management. Onset of asthma in his twentiesteens. 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. \n\t\t\t\t\t\t
" + } + }, + { + "section": { + "code": { + "code": "10153-2", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC" + }, + "title": { + "dataString": "Past Medical History" + }, + "text": "
  • Asthma
  • Hypertension (see HTN.cda for details)
  • Osteoarthritis, \n\t\t\t\t\t\t\t\t\tright knee
", + "entry": [ + { + "observation": { + "classCode": "COND", + "moodCode": "EVN", + "code": { + "code": "195967001", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Asthma", + "originalText": { + "reference": { + "value": "#a1" + } + } + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "1950" + }, + "reference": [ + { + "typeCode": "XCRPT", + "externalObservation": { + "id": [ + { + "root": "2.16.840.1.113883.19.1.2765" + } + ] + } + } + ] + } + }, + { + "observation": { + "classCode": "COND", + "moodCode": "EVN", + "code": { + "code": "59621000", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "HTN", + "originalText": { + "reference": { + "value": "#a2" + } + } + }, + "statusCode": { + "code": "completed" + }, + "reference": [ + { + "typeCode": "SPRT", + "seperatableInd": { + "value": false + }, + "externalDocument": { + "id": [ + { + "root": "2.16.840.1.113883.19.4.789" + } + ], + "text": { + "mediaType": "multipart/related", + "reference": { + "value": "HTN.cda" + } + }, + "setId": { + "root": "2.16.840.1.113883.19.7.2465" + }, + "versionNumber": { + "value": 1 + } + } + }, + { + "typeCode": "XCRPT", + "externalObservation": { + "id": [ + { + "root": "2.16.840.1.113883.19.1.2005" + } + ] + } + } + ] + } + }, + { + "observation": { + "classCode": "COND", + "moodCode": "EVN", + "code": { + "code": "396275006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Osteoarthritis", + "originalText": { + "reference": { + "value": "#a3" + } + } + }, + "statusCode": { + "code": "completed" + }, + "targetSiteCode": [ + { + "code": "49076000", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Knee joint", + "originalText": { + "reference": { + "value": "#a4" + } + }, + "qualifier": [ + { + "name": { + "code": "78615007", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "with laterality" + }, + "value": { + "code": "24028007", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "right" + } + } + ] + } + ], + "reference": [ + { + "typeCode": "XCRPT", + "externalObservation": { + "id": [ + { + "root": "2.16.840.1.113883.19.1.1805" + } + ] + } + } + ] + } + } + ] + } + }, + { + "section": { + "code": { + "code": "10160-0", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC" + }, + "title": { + "dataString": "Medications" + }, + "text": "
  • Theodur 200mg BID
  • Proventil inhaler 2puffs QID PRN
  • Prednisone 20mg qd
  • HCTZ 25mg qd
", + "entry": [ + { + "substanceAdministration": { + "classCode": "SBADM", + "moodCode": "EVN", + "text": { + "dataString": "Theodur 200mg BID" + }, + "effectiveTime": [ + { + "institutionSpecified": true, + "period": { + "unit": "h", + "value": 12 + } + } + ], + "routeCode": { + "code": "PO", + "codeSystem": "2.16.840.1.113883.5.112", + "codeSystemName": "RouteOfAdministration" + }, + "doseQuantity": { + "unit": "mg", + "value": 200 + }, + "consumable": { + "manufacturedProduct": { + "manufacturedLabeledDrug": { + "code": { + "code": "66493003", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Theophylline" + } + } + } + } + } + }, + { + "substanceAdministration": { + "classCode": "SBADM", + "moodCode": "EVN", + "text": { + "dataString": "Proventil inhaler 2puffs QID PRN" + }, + "effectiveTime": [ + { + "institutionSpecified": true, + "period": { + "unit": "h", + "value": 6 + } + } + ], + "priorityCode": { + "code": "PRN" + }, + "routeCode": { + "code": "IPINHL", + "codeSystem": "2.16.840.1.113883.5.112", + "codeSystemName": "RouteOfAdministration", + "displayName": "Inhalation, oral" + }, + "doseQuantity": { + "value": 2 + }, + "consumable": { + "manufacturedProduct": { + "manufacturedLabeledDrug": { + "code": { + "code": "91143003", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Albuterol" + } + } + } + } + } + }, + { + "substanceAdministration": { + "classCode": "SBADM", + "moodCode": "EVN", + "id": [ + { + "root": "2.16.840.1.113883.19.8.1" + } + ], + "text": { + "dataString": "Prednisone 20mg qd" + }, + "effectiveTime": [ + { + "institutionSpecified": true, + "period": { + "unit": "h", + "value": 24 + } + } + ], + "routeCode": { + "code": "PO", + "codeSystem": "2.16.840.1.113883.5.112", + "codeSystemName": "RouteOfAdministration" + }, + "doseQuantity": { + "unit": "mg", + "value": 20 + }, + "consumable": { + "manufacturedProduct": { + "manufacturedLabeledDrug": { + "code": { + "code": "10312003", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Prednisone preparation" + } + } + } + } + } + }, + { + "substanceAdministration": { + "classCode": "SBADM", + "moodCode": "EVN", + "text": { + "dataString": "HCTZ 25mg qd" + }, + "effectiveTime": [ + { + "institutionSpecified": true, + "period": { + "unit": "h", + "value": 24 + } + } + ], + "routeCode": { + "code": "PO", + "codeSystem": "2.16.840.1.113883.5.112", + "codeSystemName": "RouteOfAdministration" + }, + "consumable": { + "manufacturedProduct": { + "manufacturedLabeledDrug": { + "code": { + "code": "376209006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Hydrochlorothiazide 25mg tablet" + } + } + } + } + } + } + ] + } + }, + { + "section": { + "code": { + "code": "10155-0", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC" + }, + "title": { + "dataString": "Allergies and Adverse Reactions" + }, + "text": "
  • Penicillin - Hives
  • Aspirin - Wheezing
  • Codeine - Itching and nausea
", + "entry": [ + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "247472004", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Hives" + }, + "statusCode": { + "code": "completed" + }, + "entryRelationship": [ + { + "typeCode": "MFST", + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "91936005", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Allergy to penicillin" + }, + "statusCode": { + "code": "completed" + } + } + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "56018004", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Wheezing" + }, + "statusCode": { + "code": "completed" + }, + "entryRelationship": [ + { + "typeCode": "MFST", + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "293586001", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Allergy to aspirin" + }, + "statusCode": { + "code": "completed" + } + } + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "32738000", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Pruritis" + }, + "statusCode": { + "code": "completed" + }, + "entryRelationship": [ + { + "typeCode": "MFST", + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "id": [ + { + "root": "2.16.840.1.113883.19.1.2010" + } + ], + "code": { + "code": "62014003", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Adverse reaction to drug", + "qualifier": [ + { + "name": { + "code": "246075003", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "causative agent" + }, + "value": { + "code": "1476002", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "codeine" + } + } + ] + }, + "statusCode": { + "code": "completed" + } + } + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "73879007", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Nausea" + }, + "statusCode": { + "code": "completed" + }, + "entryRelationship": [ + { + "typeCode": "MFST", + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "id": [ + { + "root": "2.16.840.1.113883.19.1.2010" + } + ], + "code": { + "code": "84100007", + "codeSystem": "2.16.840.1.113883.6.96" + } + } + } + ] + } + } + ] + } + }, + { + "section": { + "code": { + "code": "10157-2", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC" + }, + "title": { + "dataString": "Family history" + }, + "text": "
  • Father had fatal MI in his early 50's.
  • No cancer or diabetes.
", + "entry": [ + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "22298006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "MI" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "1970" + }, + "subject": { + "relatedSubject": { + "classCode": "PRS", + "code": { + "code": "FTH", + "codeSystem": "2.16.840.1.113883.5.111" + } + } + }, + "entryRelationship": [ + { + "typeCode": "CAUS", + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "399347008", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "death" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "1970" + } + } + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "negationInd": true, + "code": { + "code": "275937001", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Family history of cancer" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "high": { + "inclusive": true, + "value": "2000-04-07" + } + } + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "160274005", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "No family history of diabetes" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "high": { + "inclusive": true, + "value": "2000-04-07" + } + } + } + } + ] + } + }, + { + "section": { + "code": { + "code": "29762-2", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC" + }, + "title": { + "dataString": "Social History" + }, + "text": "
  • Smoking :: 1 PPD between the ages of 20 and 55, and then he quit.
  • Alcohol :: rare
", + "entry": [ + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "266924008", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "ex-heavy cigarette smoker (20-39/day)" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "low": { + "value": "1955" + }, + "high": { + "value": "1990" + } + } + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "160625004", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Date ceased smoking" + }, + "statusCode": { + "code": "completed" + }, + "value": [ + { + "value": "1990" + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "266917007", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Trivial drinker - less than 1/day" + }, + "statusCode": { + "code": "completed" + } + } + } + ] + } + }, + { + "section": { + "code": { + "code": "11384-5", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC" + }, + "title": { + "dataString": "Physical Examination" + }, + "component": [ + { + "section": { + "code": { + "code": "8716-3", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC" + }, + "title": { + "dataString": "Vital Signs" + }, + "text": "
Date / TimeApril 7, 2000 14:30April 7, 2000 15:30
Height177 cm (69.7 in)
Weight194.0 lbs (88.0 kg)
BMI28.1 kg/m2
BSA2.05 m2
Temperature36.9 C (98.5 F)36.9 C (98.5 F)
Pulse86 / minute84 / minute
RhythmRegularRegular
Respirations16 / minute, unlabored14 / minute
Systolic132 mmHg135 mmHg
Diastolic86 mmHg88 mmHg
Position / CuffLeft ArmLeft Arm
", + "entry": [ + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "50373000", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Body height measure" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T14:30:00" + }, + "value": [ + { + "unit": "m", + "value": 1.77, + "translation": [ + { + "code": "[in_I]", + "codeSystem": "2.16.840.1.113883.6.8", + "codeSystemName": "UCUM", + "value": 69.7 + } + ] + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "363808001", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Body weight measure" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T14:30:00" + }, + "value": [ + { + "unit": "[lb_ap]", + "value": 194.0, + "translation": [ + { + "code": "kg", + "codeSystem": "2.16.840.1.113883.6.8", + "codeSystemName": "UCUM", + "value": 88.0 + } + ] + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "60621009", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Body mass index" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T14:30:00" + }, + "value": [ + { + "numerator": { + "unit": "kg", + "value": 28.1 + }, + "denominator": { + "unit": "ar", + "value": 1 + } + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "301898006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Body surface area" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T14:30:00" + }, + "value": [ + { + "unit": "ar", + "value": 2.05 + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "386725007", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Body temperature" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T14:30:00" + }, + "value": [ + { + "unit": "Cel", + "value": 36.9, + "translation": [ + { + "code": "[degF]", + "codeSystem": "2.16.840.1.113883.6.8", + "codeSystemName": "UCUM", + "value": 98.5 + } + ] + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "364075005", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Heart rate" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T14:30:00" + }, + "value": [ + { + "numerator": { + "value": 86 + }, + "denominator": { + "unit": "min", + "value": 1 + } + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "364075005", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Heart rate" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T15:30:00" + }, + "value": [ + { + "numerator": { + "value": 84 + }, + "denominator": { + "unit": "min", + "value": 1 + } + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "364074009", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Regularity of heart rhythm" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T14:30:00" + }, + "value": [ + { + "code": "248649006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Heart regular" + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "364074009", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Regularity of heart rhythm" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T15:30:00" + }, + "value": [ + { + "code": "248649006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Heart regular" + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "86290005", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Respiratory rate" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T14:30:00" + }, + "value": [ + { + "numerator": { + "value": 16 + }, + "denominator": { + "unit": "min", + "value": 1 + } + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "276362002", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Breathing easily" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T14:30:00" + } + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "86290005", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Respiratory rate" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T15:30:00" + }, + "value": [ + { + "numerator": { + "value": 14 + }, + "denominator": { + "unit": "min", + "value": 1 + } + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "251076008", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Cuff blood pressure" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T14:30:00" + }, + "targetSiteCode": [ + { + "code": "368208006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Left arm" + } + ], + "entryRelationship": [ + { + "typeCode": "COMP", + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "271649006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Systolic BP" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T15:30:00" + }, + "value": [ + { + "unit": "mm[Hg]", + "value": 132 + } + ] + } + }, + { + "typeCode": "COMP", + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "271650006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Diastolic BP" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T15:30:00" + }, + "value": [ + { + "unit": "mm[Hg]", + "value": 86 + } + ] + } + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "251076008", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Cuff blood pressure" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T15:30:00" + }, + "targetSiteCode": [ + { + "code": "368208006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Left arm" + } + ], + "entryRelationship": [ + { + "typeCode": "COMP", + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "271649006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Systolic BP" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T15:30:00" + }, + "value": [ + { + "unit": "mm[Hg]", + "value": 135 + } + ] + } + }, + { + "typeCode": "COMP", + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "271650006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Diastolic BP" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T15:30:00" + }, + "value": [ + { + "unit": "mm[Hg]", + "value": 88 + } + ] + } + } + ] + } + } + ] + } + }, + { + "section": { + "code": { + "code": "8709-8", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC" + }, + "title": { + "dataString": "Skin Exam" + }, + "text": "
Erythematous rash, palmar surface, left index finger.\n\t\t\t\t\t\t\t\t
", + "entry": [ + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "271807003", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Rash" + }, + "statusCode": { + "code": "completed" + }, + "methodCode": [ + { + "code": "32750006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Inspection" + } + ], + "targetSiteCode": [ + { + "code": "48856004", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Skin of palmer surface of index finger", + "qualifier": [ + { + "name": { + "code": "78615007", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "with laterality" + }, + "value": { + "code": "7771000", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "left" + } + } + ] + } + ], + "entryRelationship": [ + { + "typeCode": "SPRT", + "regionOfInterest": { + "classCode": "ROIOVL", + "moodCode": "EVN", + "id": [ + { + "root": "2.16.840.1.113883.19.3.1" + } + ], + "code": { + "code": "ELLIPSE" + }, + "value": [ + { + "value": 3 + }, + { + "value": 1 + }, + { + "value": 3 + }, + { + "value": 7 + }, + { + "value": 2 + }, + { + "value": 4 + }, + { + "value": 4 + }, + { + "value": 4 + } + ], + "entryRelationship": [ + { + "typeCode": "SUBJ", + "observationMedia": { + "classCode": "OBS", + "moodCode": "EVN", + "id": [ + { + "root": "2.16.840.1.113883.19.2.1" + } + ], + "value": { + "mediaType": "image/gif", + "reference": { + "value": "lefthand.gif" + } + } + } + } + ] + } + } + ] + } + } + ] + } + }, + { + "section": { + "code": { + "code": "8710-6", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC" + }, + "title": { + "dataString": "Lungs" + }, + "text": "
Clear with no wheeze. Good air flow.
", + "entry": [ + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "48348007", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Chest clear" + }, + "statusCode": { + "code": "completed" + }, + "methodCode": [ + { + "code": "37931006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Auscultation" + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "negationInd": true, + "code": { + "code": "56018004", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Wheezing" + }, + "statusCode": { + "code": "completed" + }, + "methodCode": [ + { + "code": "37931006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Auscultation" + } + ] + } + } + ] + } + }, + { + "section": { + "code": { + "code": "10223-2", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC" + }, + "title": { + "dataString": "Cardiac" + }, + "text": "
RRR with no murmur, no S3, no S4.
", + "entry": [ + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "76863003", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Normal heart rate" + }, + "statusCode": { + "code": "completed" + }, + "methodCode": [ + { + "code": "37931006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Auscultation" + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "negationInd": true, + "code": { + "code": "88610006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "heart murmur" + }, + "statusCode": { + "code": "completed" + }, + "methodCode": [ + { + "code": "37931006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Auscultation" + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "negationInd": true, + "code": { + "code": "277455002", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Third heart sound" + }, + "statusCode": { + "code": "completed" + }, + "methodCode": [ + { + "code": "37931006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Auscultation" + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "60721002", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Fourth heart sound inaudible" + }, + "statusCode": { + "code": "completed" + }, + "methodCode": [ + { + "code": "37931006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Auscultation" + } + ] + } + } + ] + } + } + ] + } + }, + { + "section": { + "code": { + "code": "11502-2", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC" + }, + "title": { + "dataString": "Labs" + }, + "text": "
  • CXR 02/03/1999: Hyperinflated. Normal cardiac silhouette, clear lungs.
  • Peak Flow today: 260 l/m
", + "entry": [ + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "code": { + "code": "282290005", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Imaging interpretation" + }, + "statusCode": { + "code": "completed" + }, + "entryRelationship": [ + { + "typeCode": "COMP", + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "id": [ + { + "root": "2.16.840.1.113883.19.1.3005" + } + ], + "code": { + "code": "249674001", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Chest hyperinflated" + } + } + }, + { + "typeCode": "COMP", + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "id": [ + { + "root": "2.16.840.1.113883.19.1.5505" + } + ], + "code": { + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "nullFlavor": "OTH", + "originalText": { + "dataString": "normal cardiac silhouette" + } + } + } + }, + { + "typeCode": "COMP", + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "negationInd": true, + "id": [ + { + "root": "2.16.840.1.113883.19.1.6675" + } + ], + "code": { + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "nullFlavor": "OTH", + "originalText": { + "dataString": "radiopacities" + } + } + } + } + ], + "reference": [ + { + "typeCode": "SPRT", + "externalObservation": { + "classCode": "DGIMG", + "id": [ + { + "root": "2.16.840.1.113883.19.1.14" + } + ], + "code": { + "code": "56350004", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Chest-X-ray" + } + } + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "EVN", + "id": [ + { + "root": "2.16.840.1.113883.19.1.7005" + } + ], + "code": { + "code": "313193002", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Peak flow" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07" + }, + "value": [ + { + "numerator": { + "unit": "l", + "value": 260 + }, + "denominator": { + "unit": "min", + "value": 1 + } + } + ] + } + } + ] + } + }, + { + "section": { + "code": { + "code": "29554-3", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC" + }, + "title": { + "dataString": "In-office Procedures" + }, + "text": "
  • Suture removal, left forearm.
", + "entry": [ + { + "procedure": { + "classCode": "PROC", + "moodCode": "EVN", + "code": { + "code": "30549001", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Suture removal" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T14:30:00" + }, + "targetSiteCode": [ + { + "code": "66480008", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Left forearm" + } + ] + } + } + ] + } + }, + { + "section": { + "code": { + "code": "11496-7", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC" + }, + "title": { + "dataString": "Assessment" + }, + "text": "
  • Asthma, with prior smoking history. Difficulty weaning off steroids. Will try gradual taper.
  • Hypertension, well-controlled.
  • Contact dermatitis on finger.
", + "entry": [ + { + "observation": { + "classCode": "COND", + "moodCode": "EVN", + "code": { + "code": "14657009", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Established diagnosis" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T15:30:00" + }, + "value": [ + { + "code": "195967001", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Asthma", + "translation": [ + { + "code": "49390", + "codeSystem": "2.16.840.1.113883.6.2", + "codeSystemName": "ICD9CM", + "displayName": "ASTHMA W/O STATUS ASTHMATICUS" + } + ] + } + ], + "reference": [ + { + "typeCode": "ELNK", + "externalObservation": { + "classCode": "COND", + "id": [ + { + "root": "2.16.840.1.113883.19.1.35" + } + ] + } + } + ] + } + }, + { + "observation": { + "classCode": "COND", + "moodCode": "EVN", + "code": { + "code": "14657009", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Established diagnosis" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T15:30:00" + }, + "value": [ + { + "code": "59621000", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Essential hypertension", + "translation": [ + { + "code": "4019", + "codeSystem": "2.16.840.1.113883.6.2", + "codeSystemName": "ICD9CM", + "displayName": "HYPERTENSION NOS" + } + ] + } + ], + "reference": [ + { + "typeCode": "ELNK", + "externalObservation": { + "classCode": "COND", + "id": [ + { + "root": "2.16.840.1.113883.19.1.37" + } + ] + } + } + ] + } + }, + { + "observation": { + "classCode": "COND", + "moodCode": "EVN", + "code": { + "code": "14657009", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Established diagnosis" + }, + "statusCode": { + "code": "completed" + }, + "effectiveTime": { + "value": "2000-04-07T15:30:00" + }, + "value": [ + { + "code": "40275004", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Contact dermatitis", + "translation": [ + { + "code": "692.9", + "codeSystem": "2.16.840.1.113883.6.2", + "codeSystemName": "ICD9CM", + "displayName": "Contact Dermatitis, NOS" + } + ] + } + ], + "targetSiteCode": [ + { + "code": "48856004", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Skin of palmer surface of index finger", + "qualifier": [ + { + "name": { + "code": "78615007", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "with laterality" + }, + "value": { + "code": "7771000", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "left" + } + } + ] + } + ] + } + } + ] + } + }, + { + "section": { + "code": { + "code": "18776-5", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC" + }, + "title": { + "dataString": "Plan" + }, + "text": "
  • Complete PFTs with lung volumes.
  • Chem-7 tomorrow.
  • Teach peak flow rate measurement.
  • Decrease prednisone to 20qOD alternating with 18qOD.
  • Hydrocortisone cream to finger BID.
  • RTC 1 week.
", + "entry": [ + { + "act": { + "classCode": "ACT", + "moodCode": "INT", + "id": [ + null + ], + "code": { + "code": "23426006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Pulmonary function test" + }, + "text": { + "dataString": "Complete PFTs with lung volumes." + }, + "entryRelationship": [ + { + "typeCode": "COMP", + "act": { + "classCode": "ACT", + "moodCode": "INT", + "code": { + "code": "252472004", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Lung volume test" + } + } + } + ] + } + }, + { + "observation": { + "classCode": "OBS", + "moodCode": "INT", + "code": { + "code": "24320-4", + "codeSystem": "2.16.840.1.113883.6.1", + "codeSystemName": "LOINC", + "originalText": { + "dataString": "Chem-7" + }, + "translation": [ + { + "code": "aYU7t6", + "codeSystem": "2.16.840.1.113883.19.278.47", + "codeSystemName": "MyLocalCodeSystem", + "displayName": "Chem7" + } + ] + }, + "text": { + "dataString": "Chem-7 tomorrow" + }, + "effectiveTime": { + "value": "2000-04-08" + } + } + }, + { + "act": { + "classCode": "ACT", + "moodCode": "INT", + "id": [ + null + ], + "code": { + "code": "223468009", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Teaching of skills", + "qualifier": [ + { + "name": { + "code": "363702006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "has focus" + }, + "value": { + "code": "29893006", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Peak flow rate measurement" + } + } + ] + } + } + }, + { + "substanceAdministration": { + "classCode": "SBADM", + "moodCode": "RQO", + "text": { + "dataString": "prednisone 20qOD alternating with 18qOD." + }, + "routeCode": { + "code": "PO", + "codeSystem": "2.16.840.1.113883.5.112", + "codeSystemName": "RouteOfAdministration" + }, + "consumable": { + "manufacturedProduct": { + "manufacturedLabeledDrug": { + "code": { + "code": "10312003", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Prednisone preparation" + } + } + } + } + } + }, + { + "substanceAdministration": { + "classCode": "SBADM", + "moodCode": "RQO", + "text": { + "dataString": "Hydrocortisone cream to finger BID." + }, + "effectiveTime": [ + { + "institutionSpecified": true, + "period": { + "unit": "h", + "value": 12 + } + } + ], + "routeCode": { + "code": "SKIN", + "codeSystem": "2.16.840.1.113883.5.112", + "codeSystemName": "RouteOfAdministration", + "displayName": "Topical application, skin" + }, + "approachSiteCode": [ + { + "code": "48856004", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Skin of palmer surface of index finger", + "qualifier": [ + { + "name": { + "code": "78615007", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "with laterality" + }, + "value": { + "code": "7771000", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "left" + } + } + ] + } + ], + "consumable": { + "manufacturedProduct": { + "manufacturedLabeledDrug": { + "code": { + "code": "331646005", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Hydrocortisone cream" + } + } + } + } + } + }, + { + "encounter": { + "classCode": "ENC", + "moodCode": "RQO", + "code": { + "code": "185389009", + "codeSystem": "2.16.840.1.113883.6.96", + "codeSystemName": "SNOMED CT", + "displayName": "Follow-up visit" + }, + "effectiveTime": { + "low": { + "value": "2000-04-12" + }, + "high": { + "value": "2000-04-17" + } + } + } + } + ] + } + } + ] + } + } +} \ No newline at end of file diff --git a/org.hl7.fhir.r5/src/test/resources/cda/cda-roundtrip.xml b/org.hl7.fhir.r5/src/test/resources/cda/cda-roundtrip.xml new file mode 100644 index 000000000..b2cce8b5c --- /dev/null +++ b/org.hl7.fhir.r5/src/test/resources/cda/cda-roundtrip.xml @@ -0,0 +1,1096 @@ + + + + + + + + Good Health Clinic Consultation Note + + + + + + + + + + + Levin + Henry + the 7th + + + + + + + + + + + + + + + + Good Health Clinic + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + History of Present Illness + + Henry Levin, the 7 + th + is a 67 year old male referred for further asthma management. Onset of asthma in his + twenties + 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. + + +
+ + + +
+ + Past Medical History + + + + Asthma + + + Hypertension (see HTN.cda for details) + + + Osteoarthritis, + + right knee + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + Medications + + + Theodur 200mg BID + Proventil inhaler 2puffs QID PRN + Prednisone 20mg qd + HCTZ 25mg qd + + + + + Theodur 200mg BID + + + + + + + + + + + + + + + + + Proventil inhaler 2puffs QID PRN + + + + + + + + + + + + + + + + + + + Prednisone 20mg qd + + + + + + + + + + + + + + + + + HCTZ 25mg qd + + + + + + + + + + + + + +
+ + + +
+ + Allergies and Adverse Reactions + + + Penicillin - Hives + Aspirin - Wheezing + Codeine - Itching and nausea + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + Family history + + + Father had fatal MI in his early 50's. + No cancer or diabetes. + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + Social History + + + Smoking :: 1 PPD between the ages of 20 and 55, and then he quit. + Alcohol :: rare + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + Physical Examination + + +
+ + Vital Signs + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
Date / TimeApril 7, 2000 14:30April 7, 2000 15:30
Height177 cm (69.7 in)
Weight194.0 lbs (88.0 kg)
BMI28.1 kg/m2
BSA2.05 m2
Temperature36.9 C (98.5 F)36.9 C (98.5 F)
Pulse86 / minute84 / minute
RhythmRegularRegular
Respirations16 / minute, unlabored14 / minute
Systolic132 mmHg135 mmHg
Diastolic86 mmHg88 mmHg
Position / CuffLeft ArmLeft Arm
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + Skin Exam + Erythematous rash, palmar surface, left index finger. + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + Lungs + Clear with no wheeze. Good air flow. + + + + + + + + + + + + + + +
+ + + +
+ + Cardiac + RRR with no murmur, no S3, no S4. + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ +
+ + + +
+ + Labs + + + CXR 02/03/1999: Hyperinflated. Normal cardiac silhouette, clear lungs. + Peak Flow today: 260 l/m + + + + + + + + + + + + + + + + + normal cardiac silhouette + + + + + + + + radiopacities + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + In-office Procedures + + + Suture removal, left forearm. + + + + + + + + + + +
+ + + +
+ + Assessment + + + Asthma, with prior smoking history. Difficulty weaning off steroids. Will try gradual taper. + Hypertension, well-controlled. + Contact dermatitis on finger. + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + +
+ + Plan + + + Complete PFTs with lung volumes. + Chem-7 tomorrow. + Teach peak flow rate measurement. + Decrease prednisone to 20qOD alternating with 18qOD. + Hydrocortisone cream to finger BID. + RTC 1 week. + + + + + + + Complete PFTs with lung volumes. + + + + + + + + + + + Chem-7 + + + Chem-7 tomorrow + + + + + + + + + + + + + + + + + prednisone 20qOD alternating with 18qOD. + + + + + + + + + + + + + Hydrocortisone cream to finger BID. + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + + \ No newline at end of file