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<!-- Title: US_Realm_Header_Template -->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3"
	xmlns:cda="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc">
	<!-- ******************************************************** CDA Header
		******************************************************** -->
	<realmCode code="US"/>
	<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
	<!-- US General Header Template -->
	<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
	<!-- *** Note: The next templateId, code and title will differ depending
		on what type of document is being sent. *** -->
	<!-- conforms to the document specific requirements -->
	<templateId root="2.16.840.1.113883.10.20.22.1.2"/>
	<id extension="TT988" root="2.16.840.1.113883.19.5.99999.1"/>
	<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34133-9"
		displayName="Summarization of Episode Note"/>
	<title>Community Health and Hospitals: Health Summary</title>
	<effectiveTime value="201209150000-0400"/>
	<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
	<languageCode code="en-US"/>
	<setId extension="sTT988" root="2.16.840.1.113883.19.5.99999.19"/>
	<versionNumber value="1"/>
	<recordTarget>
		<patientRole>
			<id extension="998991" root="2.16.840.1.113883.19.5.99999.2"/>
			<!-- Fake ID using HL7 example OID. -->
			<id extension="111-00-2330" root="2.16.840.1.113883.4.1"/>
			<!-- Fake Social Security Number using the actual SSN OID. -->
			<addr use="HP">
				<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
				<streetAddressLine>1357 Amber Drive</streetAddressLine>
				<city>Beaverton</city>
				<state>OR</state>
				<postalCode>97867</postalCode>
				<country>US</country>
				<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
			</addr>
			<telecom value="tel:(816)276-6909" use="HP"/>
			<!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
			<patient>
				<name use="L">
					<!-- L is "Legal" from HL7 EntityNameUse 2.16.840.1.113883.5.45 -->
					<given>Isabella</given>
					<given>Isa</given>
					<!-- CL is "Call me" from HL7 EntityNamePartQualifier 2.16.840.1.113883.5.43 -->
					<family>Jones</family>
				</name>
				<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"
					displayName="Female"/>
				<birthTime value="19750501"/>
				<maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2"
					codeSystemName="MaritalStatusCode"/>
				<religiousAffiliationCode code="1013"
					displayName="Christian (non-Catholic, non-specific)"
					codeSystemName="HL7 Religious Affiliation" codeSystem="2.16.840.1.113883.5.1076"/>
				<!-- CDC Race and Ethnicity code set contains the minimum race and ethnicity categories defined by OMB Standards for Race and Ethnicity -->
				<raceCode code="2106-3" displayName="White" codeSystem="2.16.840.1.113883.6.238"
					codeSystemName="Race &amp; Ethnicity - CDC"/>
				<ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino"
					codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race &amp; Ethnicity - CDC"/>
				<guardian>
					<code code="PRN" displayName="Parent" codeSystem="2.16.840.1.113883.5.111"
						codeSystemName="HL7 Role code"/>
					<addr use="HP">
						<!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
						<streetAddressLine>1357 Amber Drive</streetAddressLine>
						<city>Beaverton</city>
						<state>OR</state>
						<postalCode>97867</postalCode>
						<country>US</country>
						<!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
					</addr>
					<telecom value="tel:(816)276-6909" use="HP"/>
					<guardianPerson>
						<name>
							<given>Ralph</given>
							<family>Jones</family>
						</name>
					</guardianPerson>
				</guardian>
				<birthplace>
					<place>
						<addr>
							<city>Beaverton</city>
							<state>OR</state>
							<postalCode>97867</postalCode>
							<country>US</country>
						</addr>
					</place>
				</birthplace>
				<languageCommunication>
					<languageCode code="en"/>
					<!-- EN is "English" as in the IG -->
					<modeCode code="ESP" displayName="Expressed spoken"
						codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/>
					<proficiencyLevelCode code="G" displayName="Good"
						codeSystem="2.16.840.1.113883.5.61"
						codeSystemName="LanguageAbilityProficiency"/>
					<preferenceInd value="true"/>
				</languageCommunication>
			</patient>
			<providerOrganization>
				<id root="2.16.840.1.113883.4.6"/>
				<name>Community Health and Hospitals</name>
				<telecom use="WP" value="tel: 555-555-5000"/>
				<addr>
					<streetAddressLine>1001 Village Avenue</streetAddressLine>
					<city>Portland</city>
					<state>OR</state>
					<postalCode>99123</postalCode>
					<country>US</country>
				</addr>
			</providerOrganization>
		</patientRole>
	</recordTarget>
	<author>
		<time value="20050329224411+0500"/>
		<assignedAuthor>
			<id extension="99999999" root="2.16.840.1.113883.4.6"/>
			<code code="200000000X" codeSystem="2.16.840.1.113883.6.101"
				displayName="Allopathic &amp; Osteopathic Physicians"/>
			<addr>
				<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
				<city>Portland</city>
				<state>OR</state>
				<postalCode>99123</postalCode>
				<country>US</country>
			</addr>
			<telecom use="WP" value="tel:555-555-1002"/>
			<assignedPerson>
				<name>
					<given>Henry</given>
					<family>Seven</family>
				</name>
			</assignedPerson>
		</assignedAuthor>
	</author>
	<dataEnterer>
		<assignedEntity>
			<id root="2.16.840.1.113883.4.6" extension="999999943252"/>
			<addr>
				<streetAddressLine>1001 Village Avenue</streetAddressLine>
				<city>Portland</city>
				<state>OR</state>
				<postalCode>99123</postalCode>
				<country>US</country>
			</addr>
			<telecom use="WP" value="tel:555-555-1002"/>
			<assignedPerson>
				<name>
					<given>Henry</given>
					<family>Seven</family>
				</name>
			</assignedPerson>
		</assignedEntity>
	</dataEnterer>
	<informant>
		<assignedEntity>
			<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
			<addr>
				<streetAddressLine>1001 Village Avenue</streetAddressLine>
				<city>Portland</city>
				<state>OR</state>
				<postalCode>99123</postalCode>
				<country>US</country>
			</addr>
			<telecom use="WP" value="tel:555-555-1002"/>
			<assignedPerson>
				<name>
					<given>Henry</given>
					<family>Seven</family>
				</name>
			</assignedPerson>
		</assignedEntity>
	</informant>
	<informant>
		<relatedEntity classCode="PRS">
			<!-- classCode PRS represents a person with personal relationship with
				the patient. -->
			<code code="SPS" displayName="SPOUSE" codeSystem="2.16.840.1.113883.1.11.19563"
				codeSystemName="Personal Relationship Role Type Value Set"/>
			<relatedPerson>
				<name>
					<given>Frank</given>
					<family>Jones</family>
				</name>
			</relatedPerson>
		</relatedEntity>
	</informant>
	<custodian>
		<assignedCustodian>
			<representedCustodianOrganization>
				<id extension="99999999" root="2.16.840.1.113883.4.6"/>
				<name>Community Health and Hospitals</name>
				<telecom value="tel: 555-555-1002" use="WP"/>
				<addr use="WP">
					<streetAddressLine>1002 Healthcare Drive </streetAddressLine>
					<city>Portland</city>
					<state>OR</state>
					<postalCode>99123</postalCode>
					<country>US</country>
				</addr>
			</representedCustodianOrganization>
		</assignedCustodian>
	</custodian>
	<informationRecipient>
		<intendedRecipient>
			<informationRecipient>
				<name>
					<given>Henry</given>
					<family>Seven</family>
				</name>
			</informationRecipient>
			<receivedOrganization>
				<name>Community Health and Hospitals</name>
			</receivedOrganization>
		</intendedRecipient>
	</informationRecipient>
	<legalAuthenticator>
		<time value="20090227130000+0500"/>
		<signatureCode code="S"/>
		<assignedEntity>
			<id extension="999999999" root="2.16.840.1.113883.4.6"/>
			<addr>
				<streetAddressLine>1001 Village Avenue</streetAddressLine>
				<city>Portland</city>
				<state>OR</state>
				<postalCode>99123</postalCode>
				<country>US</country>
			</addr>
			<telecom use="WP" value="tel:555-555-1002"/>
			<assignedPerson>
				<name>
					<given>Henry</given>
					<family>Seven</family>
				</name>
			</assignedPerson>
		</assignedEntity>
	</legalAuthenticator>
	<authenticator>
		<time value="20090227130000+0500"/>
		<signatureCode code="S"/>
		<assignedEntity>
			<id extension="999999999" root="2.16.840.1.113883.4.6"/>
			<addr>
				<streetAddressLine>1001 Village Avenue</streetAddressLine>
				<city>Portland</city>
				<state>OR</state>
				<postalCode>99123</postalCode>
				<country>US</country>
			</addr>
			<telecom use="WP" value="tel:555-555-1002"/>
			<assignedPerson>
				<name>
					<given>Henry</given>
					<family>Seven</family>
				</name>
			</assignedPerson>
		</assignedEntity>
	</authenticator>
	<documentationOf>
		<serviceEvent classCode="PCPR">
			<code code="73761001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
				displayName="Colonoscopy"/>
			<effectiveTime>
				<low value="201209081245-0400"/>
				<high value="20150723175100"/>
			</effectiveTime>
			<performer typeCode="PRF">
				<functionCode code="PP" displayName="Primary Performer"
					codeSystem="2.16.840.1.113883.12.443" codeSystemName="Provider Role">
					<originalText>Primary Care Provider</originalText>
				</functionCode>
				<assignedEntity>
					<!-- Provider NPI "PseudoMD-1" -->
					<id extension="PseudoMD-1" root="2.16.840.1.113883.4.6"/>
					<code code="207RG0100X" displayName="Gastroenterologist"
						codeSystemName="Provider Codes" codeSystem="2.16.840.1.113883.6.101"/>
					<addr>
						<streetAddressLine>1001 Village Avenue</streetAddressLine>
						<city>Portland</city>
						<state>OR</state>
						<postalCode>99123</postalCode>
						<country>US</country>
					</addr>
					<telecom value="tel:+1-555-555-5000" use="HP"/>
					<assignedPerson>
						<name>
							<prefix>Dr.</prefix>
							<given>Henry</given>
							<family>Seven</family>
						</name>
					</assignedPerson>
					<representedOrganization>
						<id root="2.16.840.1.113883.19.5.9999.1393"/>
						<name>Community Health and Hospitals</name>
						<telecom value="tel:+1-555-555-5000" use="HP"/>
						<addr>
							<streetAddressLine>1001 Village Avenue</streetAddressLine>
							<city>Portland</city>
							<state>OR</state>
							<postalCode>99123</postalCode>
							<country>US</country>
						</addr>
					</representedOrganization>
				</assignedEntity>
			</performer>
		</serviceEvent>
	</documentationOf>
	<!-- ********************************************************
     CDA Body
     ******************************************************** -->
	<component>
		<structuredBody>
			<!--
********************************************************
FUNCTIONAL and COGNITIVE STATUS
********************************************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.22.2.14"/>
					<!--  ******** Functional status section template   ******** -->
					<code code="47420-5" codeSystem="2.16.840.1.113883.6.1"/>
					<title>FUNCTIONAL STATUS</title>
					<text>
						<table border="1" width="100%">
							<thead>
								<tr>
									<th>Finding</th>
									<th>Functional Condition</th>
									<th>Effective Dates</th>
									<th>Condition Status</th>
								</tr>
							</thead>
							<tbody>
								<tr>
									<td>Cognitive function finding</td>
									<td>
										<content ID="fs1">Dependence on cane</content>
									</td>
									<td>2008</td>
									<td>Active</td>
								</tr>
								<tr>
									<td>Functional limitation</td>
									<td>
										<content ID="fs2">Memory impairment</content>
									</td>
									<td>2008</td>
									<td>Active</td>
								</tr>
								<tr>
									<td>Cognitive function finding</td>
									<td>
										<content ID="fs3">Comatose</content>
									</td>
									<td>04-2007 to 06-2007</td>
									<td>Negative</td>
								</tr>
							</tbody>
						</table>
					</text>
					<!-- FUNC.STATUS -->
					<entry typeCode="DRIV">
						<observation classCode="OBS" moodCode="EVN">
							<!-- Problem observation template -->
							<templateId root="2.16.840.1.113883.10.20.22.4.68"/>
							<id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
							<code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="373930000" displayName="Cognitive function finding"/>
							<text>
								<reference value="#fs1"/>
							</text>
							<statusCode code="completed"/>
							<effectiveTime>
								<low value="20081101"/>
							</effectiveTime>
							<value xsi:type="CD" code="105504002" codeSystem="2.16.840.1.113883.6.96" displayName="Dependence on Cane"/>
						</observation>
					</entry>
					<entry typeCode="DRIV">
						<observation classCode="OBS" moodCode="EVN">
							<!-- Problem observation template -->
							<templateId root="2.16.840.1.113883.10.20.22.4.68"/>
							<id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
							<code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="248536006" displayName="Functional limitation"/>
							<text>
								<reference value="#fs2"/>
							</text>
							<statusCode code="completed"/>
							<effectiveTime>
								<low value="20081101"/>
								<high nullFlavor="UNK"/>
							</effectiveTime>
							<value xsi:type="CD" code="386807006" codeSystem="2.16.840.1.113883.6.96" displayName="Memory Impairment"/>
						</observation>
					</entry>
					<entry typeCode="DRIV">
						<observation classCode="OBS" moodCode="EVN" negationInd="true">
							<!-- Cognitive Status Problem observation template -->
							<templateId root="2.16.840.1.113883.10.20.22.4.73"/>
							<id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
							<code xsi:type="CE" code="373930000" codeSystem="2.16.840.1.113883.6.96" displayName="Cognitive Function Finding"/>
							<statusCode code="completed"/>
							<effectiveTime>
								<low value="200704"/>
								<high value="200706"/>
							</effectiveTime>
							<value xsi:type="CD" code=" 371632003" codeSystem="2.16.840.1.113883.6.96" displayName="Comatose"/>
						</observation>
					</entry>
				</section>
			</component>
		</structuredBody>
	</component>
</ClinicalDocument>
