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York College
The City University of New York Department of Health Professions
HPHS 201

Name: ___________Nicketa Kippins____________________________________________ Date:____________

Class Exercise

1. Login to your Practice Fusion account and import CCD from a patient provided. a. Go to a patient chart, summary screen. b. Click on Actions and choose “Create clinical document” c. Choose what you want generated and export continuity of care document (CCD), upload it with your lab report to the lab drop box. i. Answer the following questions: * What format is it in?
XML FORMATE * Is it an xml file? Yes, it is an XML file d. Provide instructions for how you would import CCD into practice fusion.

* select Tasks from the left navigation bar and click the Documents tab. * Click Upload and choose your CCD file. Note: While you may upload CCD documents of any file type, Practice Fusion can only read CCDs in .xml. * Assign the document to a specific patient that is Continuity of Care Document'. * Enter applicable document details and click Save.

2. Use practice fusion to generate a “Super bill”. e. Go to the last encounter for your patient f. Go to actions and choose “Add superbill”. g. Add any procedure code (CPT), enter amount associated with the service h. Add diagnosis i. Take a snapshot of the superbill, submit it with your lab report and then send it to the biller

3. Go to http://search.loinc.org/ j. Search for serum sodium k. Explore various results returned, locate the code and description for “Sodium and Potassium panel – Serum or Plasma”, then choose “Sodium in Serum” and click on it to view full description. l. Answer the following questions: ii. What is the LOINC # for this test? Specify in your lab report.

34548-8

iii. List 3 test panels in which Sodium in serum is measured in your lab report. | 24320-4 | Basic metabolic 1998 panel - Serum or Plasma | | 24321-2 | Basic metabolic 2000 panel - Serum or Plasma | | 24322-0 | Comprehensive metabolic 1998 panel - Serum or Plasma |

4. Go to http://browser.ihtsdotools.org/ SNOMED browser m. Choose United States edition of SNOMED n. Go to SEARCH o. Type in Tuberculosis p. Explore the hierarchy of where disease is found and all information associated with it q. Include a picture of the details tab in your lab report.

5. Consider the following HL7 message:

MSH (Message Header)
EVN (Event)
PID (Patient Identifier)
PV1 (Patient Visit)
IN1 (Insurance )
{[NK1]} (Next of Kin)

PID3.1 contains MRN # for patient John Appleseed which is 12345.
Answer the following questions and submit it as part of your lab report: a. Location of clinical workflow activity?
The work flow is ADT –MSH8.1

b. Location of trigger event?

MSH8.2 c. Location of patient last name?
PID5.1
d. Location of patient first name?
PID 5.2 e. Location of wife’s first name?

Nk1 2.2 6. Go to http://www.nlm.nih.gov/bsd/disted/pubmedtutorial/cover.html r. This page contains PubMed Online Training s. Take Introduction and Understanding the Vocabulary training and then take quizzes that follow those 2 sections. t. Take a picture of each quiz and submit it as part of your lab report for the day.

Copy of practice fusion CCD

<?xml version="1.0"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:sdtc="urn:hl7-org:sdtc" xmlns="urn:hl7-org:v3"><realmCode code="US"/><typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/><templateId root="2.16.840.1.113883.10.20.22.1.1"/><templateId root="2.16.840.1.113883.10.20.22.1.2"/><id extension="315607" root="2.16.840.1.113883.3.3388.1.1.1"/><code code="34133-9" displayName="Summarization of episode note" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/><effectiveTime value="20160409194234" xsi:type="IVL_TS"/><confidentialityCode code="R" displayName="Restricted" codeSystemName="Confidentiality" codeSystem="2.16.840.1.113883.5.25"/><languageCode code="en-US"/><recordTarget><patientRole><id extension="F777EDD0-AFA2-4FFE-88F4-728AD55568AC" root="2.16.840.1.113883.3.3388.1.1.1.315607.3"/><addr use="H"><streetAddressLine>101-12 120th street</streetAddressLine><city>South Richmond 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</text><entry typeCode="DRIV"><act moodCode="EVN" classCode="ACT"><templateId root="2.16.840.1.113883.10.20.22.4.30"/><id extension="133245848" root="2.16.840.1.113883.3.3388.1.1.1.315607.3"/><code code="48765-2" displayName="Allergies, adverse reactions, alerts" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" xsi:type="CE"/><statusCode code="completed"/><effectiveTime><low nullFlavor="NI"/><high nullFlavor="NI"/></effectiveTime><entryRelationship typeCode="SUBJ" inversionInd="true"><observation moodCode="EVN" classCode="OBS"><templateId root="2.16.840.1.113883.10.20.22.4.7"/><id extension="133245848" root="2.16.840.1.113883.3.3388.1.1.1.315607.3"/><code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/><statusCode code="completed"/><effectiveTime nullFlavor="NI"/><value xsi:type="CE" nullFlavor="NI"/></observation></entryRelationship></act></entry></section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.9"/><code code="51847-2" displayName="Assessment and Plan" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/><text> <table><thead><tr><th>Assessment and Plan</th></tr></thead><tbody> | <tr ID="APPOC248579071"><td> MEDICATIONS: Haloperidol 2 MG Oral Tablet (stop date: 2/26/2016) prescription: discontinued during this visit</td></tr> | <tr ID="APPOC253795832"><td>No Plans indicated</td></tr></tbody></table> |
</text><entry><act moodCode="INT" classCode="ACT"><templateId root="2.16.840.1.113883.10.20.22.4.39"/><id extension="248579071" root="2.16.840.1.113883.3.3388.1.1.1.315607.3.133245848.1.3.4.1"/><code code="278448002" displayName="Care plan" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" xsi:type="CE"/><text><reference value="#APPOC248579071"/></text><statusCode code="new"/><effectiveTime value="20160226000000"/></act></entry><entry><act moodCode="INT" classCode="ACT"><templateId root="2.16.840.1.113883.10.20.22.4.39"/><id extension="253795832" root="2.16.840.1.113883.3.3388.1.1.1.315607.3.133245848.1.3.4.1"/><code code="278448002" displayName="Care plan" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" xsi:type="CE"/><text><reference value="#APPOC253795832"/></text><statusCode code="new"/><effectiveTime value="20160322000000"/></act></entry></section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.13"/><code code="46239-0" displayName="Chief Complaint and Reason For Visit" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/><text> <table><thead><tr><th>Chief Complaint or Reason for Visit</th></tr></thead><tbody> | <tr ID="ChiefComplaint_1"><td>2016-02-26 : flue like symtoms </td></tr></tbody><tbody> | <tr ID="ChiefComplaint_2"><td>2016-03-22 : No Chief Complaint or Reason for Visit given </td></tr></tbody></table> |
</text></section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.22.1"/><code code="46240-8" displayName="History of Encounters" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/><text> <table border="1" width="95%"><thead><tr><th>Encounter Type </th> | <th>Location Name</th> | <th>Performer</th> | <th>Date of Service</th></tr></thead><tbody> | <tr ID="Encounter248579071366540633"><td>Encounter: Encounter for "check-up" (procedure)</td> | <td>NYC Medical Practice, 324 Broadway Ave, New York, NY 11011 Phone: (718) 441-4411</td> | <td>Dr Nicketa Kippins MD</td> | <td>2016-02-26</td></tr> | <tr ID="Encounter253795832379546066"><td>Encounter: Encounter for "check-up" (procedure)</td> | <td>NYC Medical Practice, 324 Broadway Ave, New York, NY 11011 Phone: (718) 441-4411</td> | <td>Dr Jason Chandebal MD</td> | <td>2016-03-22</td></tr></tbody></table> |
</text><entry typeCode="DRIV"><encounter moodCode="EVN" classCode="ENC"><templateId root="2.16.840.1.113883.10.20.22.4.49"/><id extension="248579071" root="2.16.840.1.113883.3.3388.1.1.1.315607.3.133245848.1.3.2"/><code code="185349003" displayName="Encounter for "check-up" (procedure)" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" xsi:type="CE"/><text><reference value="#Encounter248579071366540633"/></text><effectiveTime><low value="20160226000000"/><high value="20160226000000"/></effectiveTime><performer typeCode="PRF"><assignedEntity><id extension="1187780" root="2.16.840.1.113883.3.3388.1.1.1.315607.1.1.3"/><addr use="WP"><streetAddressLine>324 Broadway Ave Suite 500</streetAddressLine><city>New York</city><state>NY</state><postalCode>11011</postalCode><country>United States of America</country></addr><telecom value="tel:(718)441-4411" use="WP"/><assignedPerson><name><prefix>Dr</prefix><given>Nicketa</given><family>Kippins</family><suffix>MD</suffix></name></assignedPerson></assignedEntity></performer><participant typeCode="LOC"><participantRole classCode="SDLOC"><templateId root="2.16.840.1.113883.10.20.22.4.32"/> <code nullFlavor="NI"/> <addr use="WP"><country>United States of America</country></addr> <telecom value="tel:(718)441-4411" use="WP"/></participantRole></participant></encounter></entry><entry typeCode="DRIV"><encounter moodCode="EVN" classCode="ENC"><templateId root="2.16.840.1.113883.10.20.22.4.49"/><id extension="253795832" root="2.16.840.1.113883.3.3388.1.1.1.315607.3.133245848.1.3.2"/><code code="185349003" displayName="Encounter for "check-up" (procedure)" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" xsi:type="CE"/><text><reference value="#Encounter253795832379546066"/></text><effectiveTime><low value="20160322000000"/><high value="20160322000000"/></effectiveTime><performer typeCode="PRF"><assignedEntity><id extension="1187772" root="2.16.840.1.113883.3.3388.1.1.1.315607.1.1.3"/><addr use="WP"><streetAddressLine>324 Broadway Ave Suite 500</streetAddressLine><city>New York</city><state>NY</state><postalCode>11011</postalCode><country>United States of America</country></addr><telecom value="tel:(718)441-4411" use="WP"/><assignedPerson><name><prefix>Dr</prefix><given>Jason</given><family>Chandebal</family><suffix>MD</suffix></name></assignedPerson></assignedEntity></performer><participant typeCode="LOC"><participantRole classCode="SDLOC"><templateId root="2.16.840.1.113883.10.20.22.4.32"/><code nullFlavor="NI"/><addr use="WP"><country>United States of America</country></addr><telecom value="tel:(718)441-4411" use="WP"/></participantRole></participant></encounter></entry></section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.2.1"/><code code="11369-6" displayName="History of Immunizations" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/><text> <table border="1" width="95%"><thead><tr><th>Vaccine</th> | <th>Date</th> | <th>Delivery Status</th></tr></thead><tbody> | <tr ID="immun16321295"><td>Influenza, high dose seasonal</td> | <td>2016-03-01</td> | <td>Administered</td></tr></tbody></table> |
</text><entry><substanceAdministration moodCode="EVN" classCode="SBADM" negationInd="false"><templateId root="2.16.840.1.113883.10.20.22.4.52"/><id root="BE525A77-525A-4231-AD49-A589492C340D"/><text><reference value="#immun16321295"/></text><statusCode code="completed"/><effectiveTime xsi:type="IVL_TS"><low value="20160301000000"/><high value="20160301000000"/></effectiveTime><doseQuantity value="1" unit="ML"/><consumable><manufacturedProduct classCode="MANU"><templateId root="2.16.840.1.113883.10.20.22.4.54"/><manufacturedMaterial><code code="135" displayName="Influenza, high dose seasonal" codeSystemName="CVX" codeSystem="2.16.840.1.113883.12.292"/><lotNumberText>12</lotNumberText></manufacturedMaterial><manufacturerOrganization><standardIndustryClassCode code="OTH" displayName="Other manufacturer" codeSystemName="2.16.840.1.113883.6.60" codeSystem="MVX"/></manufacturerOrganization></manufacturedProduct></consumable><performer typeCode="PRF"><assignedEntity classCode="ASSIGNED"><id extension="1187772" root="2.16.840.1.113883.3.3388.1.1.1.315607.4.1.3"/><addr><streetName>324 Broadway Ave Suite 500</streetName><city>New York</city><state>NY</state><postalCode>11011</postalCode><country>United States of America</country></addr><telecom value="tel:(718)441-4411" use="WP"/><assignedPerson><name><prefix>Dr</prefix><given>Jason</given><family>Chandebal</family><suffix>MD</suffix></name></assignedPerson></assignedEntity></performer></substanceAdministration></entry></section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.45"/><code code="69730-0" displayName="Instructions" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/><text> <table><thead><tr><th>Instructions</th></tr></thead><tbody> | <tr ID="Section248579071"><td>No Education resources were given to the patient during the visit</td></tr></tbody></table> |
</text><entry typeCode="DRIV"><act moodCode="INT" classCode="ACT"><templateId root="2.16.840.1.113883.10.20.22.4.20"/><code xsi:type="CE" nullFlavor="NI"/><text><reference value="#Section248579071"/></text><statusCode code="completed"/></act></entry></section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.1.1"/><code code="10160-0" displayName="History of Medication Use" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/><text> <table border="1" width="95%"><thead><tr><th>Material</th> | <th>RXnormCode</th> | <th>GenericName</th> | <th>ProductStrength</th> | <th>StartDate</th> | <th>StopDate</th> | <th>SIG</th></tr></thead><tbody> | <tr ID="Med161917049"><td>Tylenol 325 MG Oral Tablet</td> | <td>RxNorm: 313782</td> | <td>Acetaminophen</td> | <td>325 MG</td> | <td>Not Indicated</td> | <td>2016-02-23</td> | <td>Not Indicated</td></tr> | <tr ID="Med161917086"><td>Antibiotic Ear 3.5-10000-1 Otic Solution</td> | <td>RxNorm: 347690</td> | <td>Neomycin-Polymyxin-HC (Otic)</td> | <td>3.5-10000-1</td> | <td>Not Indicated</td> | <td>2016-02-23</td> | <td>Not Indicated</td></tr> | <tr ID="Med161917093"><td>CVS Antibiotic 3.5-400-5000 External Ointment</td> | <td>RxNorm: 1359363</td> | <td>Neomycin-Bacitracin-Polymyxin</td> | <td>3.5-400-5000</td> | <td>Not Indicated</td> | <td>2016-02-23</td> | <td>Not Indicated</td></tr> | <tr ID="Med162395189"><td>Rifampin 150 MG Oral Capsule</td> | <td>RxNorm: 198201</td> | <td>Rifampin</td> | <td>150 MG</td> | <td>Not Indicated</td> | <td>2016-02-26</td> | <td>Not Indicated</td></tr> | <tr ID="Med162395678"><td>Haloperidol 2 MG Oral Tablet</td> | <td>RxNorm: 314034</td> | <td>Haloperidol</td> | <td>2 MG</td> | <td>Not Indicated</td> | <td>2016-02-26</td> | <td>Not Indicated</td></tr> | <tr ID="Med162094678"><td>Hypertensa Oral Capsule</td> | <td>NDC: 68405100702</td> | <td>Dietary Management Product</td> | <td>Not Indicated</td> | <td>2016-02-23</td> | <td>2016-03-08</td> | <td>Not Indicated</td></tr> | <tr ID="Med162097258"><td>Tylenol 325 MG Oral Tablet</td> | <td>RxNorm: 313782</td> | <td>Acetaminophen</td> | <td>325 MG</td> | <td>Not Indicated</td> | <td>2016-03-21</td> | <td>Not Indicated</td></tr> | <tr ID="Med162394880"><td>Haloperidol 2 MG Oral Tablet</td> | <td>RxNorm: 314034</td> | <td>Haloperidol</td> | <td>2 MG</td> | <td>Not Indicated</td> | <td>Not Indicated</td> | <td>Not Indicated</td></tr> | <tr ID="Med165616089"><td>Antibiotic Ear 3.5-10000-1 Otic Solution</td> | <td>RxNorm: 347690</td> | <td>Neomycin-Polymyxin-HC (Otic)</td> | <td>3.5-10000-1</td> | <td>Not Indicated</td> | <td>Not Indicated</td> | <td>Not Indicated</td></tr> | <tr ID="Med161916832"><td>Aleve 220 MG Oral Tablet</td> | <td>RxNorm: 849574</td> | <td>Naproxen Sodium</td> | <td>220 MG</td> | <td>Not Indicated</td> | <td>Not Indicated</td> | <td>Not Indicated</td></tr></tbody></table> |
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value="20160308060000"/></effectiveTime><consumable><manufacturedProduct classCode="MANU"><templateId root="2.16.840.1.113883.10.20.22.4.23"/><id extension="162094678" root="2.16.840.1.113883.3.3388.1.1.1.315607.3.133245848.1.4.1"/><manufacturedMaterial><code code="68405100702" displayName="Hypertensa Oral Capsule " codeSystemName="NDC" codeSystem="2.16.840.1.113883.6.69"/></manufacturedMaterial></manufacturedProduct></consumable><entryRelationship typeCode="SUBJ" inversionInd="true"><act moodCode="INT" classCode="ACT"><templateId root="2.16.840.1.113883.10.20.22.4.20"/><code code="409073007" displayName="instruction" codeSystem="2.16.840.1.113883.6.96" xsi:type="CE"/><statusCode code="completed"/></act></entryRelationship></substanceAdministration></entry><entry typeCode="DRIV"><substanceAdministration moodCode="EVN" classCode="SBADM"><templateId root="2.16.840.1.113883.10.20.22.4.16"/><id extension="162097258" 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typeCode="DRIV"><substanceAdministration moodCode="EVN" classCode="SBADM"><templateId root="2.16.840.1.113883.10.20.22.4.16"/><id extension="162394880" root="2.16.840.1.113883.3.3388.1.1.1.315607.3.133245848.1.4.1"/><text><reference value="#Med162394880"/></text><statusCode code="completed"/><effectiveTime xsi:type="IVL_TS"><low nullFlavor="NI"/><high nullFlavor="NI"/></effectiveTime><consumable><manufacturedProduct classCode="MANU"><templateId root="2.16.840.1.113883.10.20.22.4.23"/><id extension="162394880" root="2.16.840.1.113883.3.3388.1.1.1.315607.3.133245848.1.4.1"/><manufacturedMaterial><code code="314034" displayName="Haloperidol 2 MG" codeSystemName="RxNorm" codeSystem="2.16.840.1.113883.6.88"/></manufacturedMaterial></manufacturedProduct></consumable><entryRelationship typeCode="SUBJ" inversionInd="true"><act moodCode="INT" classCode="ACT"><templateId root="2.16.840.1.113883.10.20.22.4.20"/><code code="409073007" displayName="instruction" codeSystem="2.16.840.1.113883.6.96" 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ID="problem139082199"><td>Influenza</td> | <td>2016-02-21</td> | <td>active</td></tr> | <tr ID="problem139084198"><td>Hypertensive disorder</td> | <td>2016-02-23</td> | <td>active</td></tr> | <tr ID="problem139262149"><td>Hypertensive disorder</td> | <td>Not Applicable</td> | <td>active</td></tr> | <tr ID="problem139262172"><td>Influenza-like illness</td> | <td>Not Applicable</td> | <td>active</td></tr></tbody></table> |
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negationInd="false"><templateId root="2.16.840.1.113883.10.20.22.4.4"/><id extension="139262149" root="2.16.840.1.113883.3.3388.1.1.1.315607.3.133245848.2.1"/><code code="282291009" displayName="Diagnosis" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96"/><text><reference value="#problem139262149"/></text><statusCode code="completed"/><value code="38341003" displayName="Hypertensive disorder" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" xsi:type="CD"/><interpretationCode code="401.9" displayName="Hypertension" codeSystemName="ICD9CM" codeSystem="2.16.840.1.113883.6.103"/><performer typeCode="PRF"><assignedEntity><id extension="1187780" root="2.16.840.1.113883.3.3388.1.1.315607.4.1.3"/><addr use="WP"><streetAddressLine>324 Broadway Ave Suite 500</streetAddressLine><city>New York</city><state>NY</state><postalCode>11011</postalCode><country>United States of America</country></addr><telecom value="tel:(718)441-4411" use="WP"/><assignedPerson><name><prefix>Dr</prefix><given>Nicketa</given><family>Kippins</family><suffix>MD</suffix></name></assignedPerson></assignedEntity></performer><entryRelationship typeCode="SUBJ" inversionInd="true"><observation moodCode="EVN" classCode="OBS"><templateId root="2.16.840.1.113883.10.20.22.4.31"/><code code="445518008" displayName="Age At Onset" codeSystem="2.16.840.1.113883.6.96" xsi:type="CE"/><statusCode code="completed"/><value value="21" xsi:type="PQ" unit="a"/></observation></entryRelationship><entryRelationship typeCode="REFR"><observation moodCode="EVN" classCode="OBS"><templateId root="2.16.840.1.113883.10.20.22.4.6"/><id extension="139262149" root="2.16.840.1.113883.3.3388.1.1.1.315607.3.133245848.2.1"/><code code="33999-4" displayName="Status" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" xsi:type="CE"/><text><reference value="#problem139262149"/></text><statusCode code="completed"/><effectiveTime><low nullFlavor="NI"/><high nullFlavor="NI"/></effectiveTime><value code="55561003" displayName="Active" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" xsi:type="CD"/></observation></entryRelationship></observation></entryRelationship></act></entry><entry typeCode="DRIV"><act moodCode="EVN" classCode="ACT"><templateId root="2.16.840.1.113883.10.20.22.4.3"/><id extension="133245848" root="2.16.840.1.113883.3.3388.1.1.1.315607.3"/><code code="CONC" displayName="Concern" codeSystem="2.16.840.1.113883.5.6" xsi:type="CE"/><statusCode code="active"/><effectiveTime><low nullFlavor="NI"/><high nullFlavor="NI"/></effectiveTime><entryRelationship typeCode="SUBJ"><observation moodCode="EVN" classCode="OBS" negationInd="false"><templateId root="2.16.840.1.113883.10.20.22.4.4"/><id extension="139262172" root="2.16.840.1.113883.3.3388.1.1.1.315607.3.133245848.2.1"/><code code="282291009" displayName="Diagnosis" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96"/><text><reference value="#problem139262172"/></text><statusCode code="completed"/><value code="95891005" displayName="Influenza-like illness" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" xsi:type="CD"/><interpretationCode code="487.1" displayName="Flu-like symptoms" codeSystemName="ICD9CM" codeSystem="2.16.840.1.113883.6.103"/><performer typeCode="PRF"><assignedEntity><id extension="1187780" root="2.16.840.1.113883.3.3388.1.1.315607.4.1.3"/><addr use="WP"><streetAddressLine>324 Broadway Ave Suite 500</streetAddressLine><city>New York</city><state>NY</state><postalCode>11011</postalCode><country>United States of America</country></addr><telecom value="tel:(718)441-4411" use="WP"/><assignedPerson><name><prefix>Dr</prefix><given>Nicketa</given><family>Kippins</family><suffix>MD</suffix></name></assignedPerson></assignedEntity></performer><entryRelationship typeCode="SUBJ" inversionInd="true"><observation moodCode="EVN" classCode="OBS"><templateId root="2.16.840.1.113883.10.20.22.4.31"/><code code="445518008" displayName="Age At Onset" codeSystem="2.16.840.1.113883.6.96" xsi:type="CE"/><statusCode code="completed"/><value value="21" xsi:type="PQ" unit="a"/></observation></entryRelationship><entryRelationship typeCode="REFR"><observation moodCode="EVN" classCode="OBS"><templateId root="2.16.840.1.113883.10.20.22.4.6"/><id extension="139262172" root="2.16.840.1.113883.3.3388.1.1.1.315607.3.133245848.2.1"/><code code="33999-4" displayName="Status" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" xsi:type="CE"/><text><reference value="#problem139262172"/></text><statusCode code="completed"/><effectiveTime><low nullFlavor="NI"/><high nullFlavor="NI"/></effectiveTime><value code="55561003" displayName="Active" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" xsi:type="CD"/></observation></entryRelationship></observation></entryRelationship></act></entry></section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.7.1"/><code code="47519-4" displayName="Procedures" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/><text> <table border="1" width="95%"><thead><tr><th>Procedure</th> | <th>Date</th></tr></thead><tbody> | <tr ID="procedure3795461360783"><td>Examination of retina (procedure)</td> | <td>Performed: 2016-03-22</td></tr></tbody></table> |
</text><entry typeCode="DRIV"><observation moodCode="EVN" classCode="OBS"><templateId root="2.16.840.1.113883.10.20.22.4.13"/><id extension="379546136" root="2.16.840.1.113883.3.3388.1.1.1.315607.3.133245848.1.9"/><code code="274798009" displayName="Examination of retina (procedure)" codeSystemName="SNOMED-CT" codeSystem="2.16.840.1.113883.6.96" xsi:type="CE"/><text><reference value="#procedure3795461360783"/></text><statusCode code="completed"/><effectiveTime value="20160322"/><priorityCode nullFlavor="NI"/><value xsi:type="CD" nullFlavor="NI"/><methodCode nullFlavor="NI"/><targetSiteCode nullFlavor="NI"/><performer typeCode="PRF"><assignedEntity><id extension="1187772" root="2.16.840.1.113883.3.3388.1.1.1.315607.1.1.3"/><addr use="WP"><streetAddressLine>NYC Medical Practice</streetAddressLine><streetAddressLine>324 Broadway Ave Suite 500</streetAddressLine><city>New York</city><state>NY</state><postalCode>11011</postalCode><country>United States of America</country></addr><telecom value="tel:(718)441-4411" use="WP"/><assignedPerson><name><prefix>Dr</prefix><given>Jason</given><family>Chandebal</family><suffix>MD</suffix></name></assignedPerson></assignedEntity></performer><participant typeCode="LOC"><participantRole classCode="SDLOC"><templateId root="2.16.840.1.113883.10.20.22.4.32"/><code nullFlavor="NI"/><addr use="WP"><streetAddressLine>NYC Medical Practice</streetAddressLine><streetAddressLine>324 Broadway Ave Suite 500</streetAddressLine><city>New York</city><state>NY</state><postalCode>11011</postalCode><country>United States of America</country></addr><telecom value="tel:(718)441-4411" use="WP"/><playingEntity classCode="PLC"/></participantRole></participant></observation></entry></section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.3.1"/><code code="30954-2" displayName="Results" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/><text>Not indicated</text><entry typeCode="DRIV"><organizer moodCode="EVN" classCode="BATTERY"><templateId root="2.16.840.1.113883.10.20.22.4.1"/><id nullFlavor="UNK"/><code xsi:type="CE" nullFlavor="UNK"/><statusCode nullFlavor="UNK"/><effectiveTime nullFlavor="UNK"/><component><observation moodCode="EVN" classCode="OBS"><templateId root="2.16.840.1.113883.10.20.22.4.2"/><id nullFlavor="NI"/><code xsi:type="CE" nullFlavor="NI"/><statusCode code="completed"/><effectiveTime nullFlavor="NI"/><value xsi:type="PQ" nullFlavor="NI"/></observation></component></organizer></entry></section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.17"/><code code="29762-2" displayName="Social History" codeSystem="2.16.840.1.113883.6.1"/><text> <table border="1" width="95%"><thead><tr><th>Social History</th> | <th>Effective Date</th></tr></thead><tbody> | <tr ID="SmokingStatus_1"><td>Never smoker</td> | <td>2016-02-25</td></tr></tbody></table> |
</text><entry typeCode="DRIV"><observation moodCode="EVN" classCode="OBS"><templateId root="2.16.840.1.113883.10.20.22.4.78"/><code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" xsi:type="CE"/><text><reference value="#SmokingStatus_1"/></text><statusCode code="completed"/><effectiveTime><low value="20160225020023"/></effectiveTime><value code="266919005" displayName="Never smoker" codeSystem="2.16.840.1.113883.6.96" xsi:type="CD"/></observation></entry></section></component><component><section><templateId root="2.16.840.1.113883.10.20.22.2.4"/><code code="8716-3" displayName="Vital Signs" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/><text>Not indicated</text></section></component></structuredBody></component></ClinicalDocument>

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