<?xml version="1.0"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!--
    This is the proposed Discharge note for the joint implementation venture with the Catharina Hospital Eindhoven. The header
    of the document contains information about the document itself (like id, creation time), the patient discharged, the author of the document
    and also its intended recipient. The body consists of three sections, namely the hospital discharge instructions, the prescribed medication,and the Vital Trends
    measured in the hopital. The first two contain only literal text, while the last one is made up of both literal text and structured elements.
    The coding of the medical concepts has been done according to the LOINC vocabulary, the Units are coded based on UCUM. The
    patient is identified based on his BSN and the clinicians based on their Vectis AGB identification.
    
    Creation date: 14 June 2007.
    Author: Charalampos Xanthopoulakis

-->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
    xsi:schemaLocation="urn:hl7-org:v3 cdar2-2005/schemas/CDA.xsd" xmlns="urn:hl7-org:v3"
    xmlns:voc="urn:hl7-org:v3/voc">
    <!-- 
********************************************************
  CDA Header
********************************************************
-->
    <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
    <templateId root="2.16.840.1.113883.3.27.1776"/>
    <!-- How can we uniquely identify the document? Create a new  OID or use an existing? -->
    <!-- How can we indicate that this document has a connection with the referral note sent before? -->
    <id extension="c268" root="2.16.840.1.113883.19.4"/>
    <code code="28547-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
        displayName="Discharge note"/>
    <title>Catharina Ziekenhuis Ontslagbrief</title>
    <!-- The creation time of the document -->
    <effectiveTime value="20070614"/>
    <!-- Confidentiality Normal-->
    <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
    <languageCode code="nl"/>
    <!-- No idea what this is for -->
    <setId extension="BB35" root="2.16.840.1.113883.19.7"/>
    <versionNumber value="1"/>
    <!-- The patient and the provider oranization -->
    <recordTarget>
        <patientRole>
            <!-- Patients are identified based on their BSN. The BSN value is hypothetical.-->
            <id extension="256326654" root="2.16.840.1.113883.2.4.6.3" assigningAuthorityName="BSN"/>
            <addr use="HP">
                <!-- The home address -->
                <streetName partType="STR">Dommelstraat</streetName>
                <houseNumber partType="BNR">22</houseNumber>
                <postalCode partType="ZIP">5612 RV</postalCode>
                <city partType="CTY">Eindhoven</city>
                <country partType="CNT">Nederland</country>
            </addr>
            <!-- The home telephone number -->
            <telecom use="HP" value="tel:+31409968379"/>
            <patient>
                <!-- The legal name of the patient -->
                <name use="L">
                    <!-- The initial (first) name -->
                    <given qualifier="IN">Nelleke</given>
                    <!-- Voorvoegsels -->
                    <prefix qualifier="VV">van der </prefix>
                    <!-- The family name given during birth -->
                    <family qualifier="BR">Wiel</family>
                </name>
                <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
                <!-- Female gender -->
                <birthTime value="19400324"/>
                <!-- Date of birth: March, 24, 1940 -->
            </patient>
            <providerOrganization>
                <!-- This is the Catharina Ziekenhuis identification -->
                <id extension="06011009" root="2.16.840.1.113883.2.4.6.1"
                    assigningAuthorityName="Vektis AGB-Z"/>
                <name>CATHARINA ZIEKENHUIS</name>
                <telecom use="WP" value="tel:+310402399111"/>
                <addr use="WP">
                    <streetName partType="STR">Postbus</streetName>
                    <houseNumber partType="BNR">1350</houseNumber>
                    <postalCode partType="ZIP">5602 ZA</postalCode>
                    <city partType="CTY">Eindhoven</city>
                    <country partType="CNT">Nederland</country>
                </addr>
            </providerOrganization>
        </patientRole>
    </recordTarget>
    <author>
        <time value="20070614"/>
        <!-- The same TS as in ClinicalDocument/effectiveTime -->
        <assignedAuthor>
            <!-- The author of the Discharge note -->
            <id extension="03020547" root="2.16.840.1.113883.2.4.6.1"
                assigningAuthorityName="Vektis AGB-Z"/>
            <addr use="WP">
                <streetName partType="STR">Postbus</streetName>
                <houseNumber partType="BNR">1350</houseNumber>
                <postalCode partType="ZIP">5602 ZA</postalCode>
                <city partType="CTY">Eindhoven</city>
                <country partType="CNT">Nederland</country>
            </addr>
            <telecom use="WP" value="tel:+310402399111"/>
            <assignedPerson>
                <name use="L">
                    <prefix qualifier="AC">Dr.</prefix>
                    <given qualifier="IN">J</given>
                    <prefix qualifier="VV">J. </prefix>
                    <family qualifier="BR">Koolen</family>
                </name>
            </assignedPerson>
            <representedOrganization>
                <!-- This is the Catharina Ziekenhuis identification -->
                <id extension="06011009" root="2.16.840.1.113883.2.4.6.1"
                    assigningAuthorityName="Vektis AGB-Z"/>
                <name>CATHARINA ZIEKENHUIS</name>
                <telecom use="WP" value="tel:+310402399111"/>
                <addr use="WP">
                    <streetName partType="STR">Postbus</streetName>
                    <houseNumber partType="BNR">1350</houseNumber>
                    <postalCode partType="ZIP">5602 ZA</postalCode>
                    <city partType="CTY">Eindhoven</city>
                    <country partType="CNT">Nederland</country>
                </addr>
            </representedOrganization>
        </assignedAuthor>
    </author>
    <custodian>
        <assignedCustodian>
            <representedCustodianOrganization>
                <!-- This is the Catharina Ziekenhuis identification -->
                <id extension="06011009" root="2.16.840.1.113883.2.4.6.1"
                    assigningAuthorityName="Vektis AGB-Z"/>
                <name>CATHARINA ZIEKENHUIS</name>
                <telecom use="WP" value="tel:+310402399111"/>
                <addr use="WP">
                    <streetName partType="STR">Postbus</streetName>
                    <houseNumber partType="BNR">1350</houseNumber>
                    <postalCode partType="ZIP">5602 ZA</postalCode>
                    <city partType="CTY">Eindhoven</city>
                    <country partType="CNT">Nederland</country>
                </addr>
            </representedCustodianOrganization>
        </assignedCustodian>
    </custodian>
    <informationRecipient>
        <intendedRecipient>
            <!-- The intended recipient of the Discharge note (the Motiva nurse). The id is hypothetical -->
            <id extension="001040987" root="2.16.840.1.113883.2.4.6.1"
                assigningAuthorityName="Vektis AGB-Z"/>
            <informationRecipient>
                <name use="L">
                    <given qualifier="IN">Maggy</given>
                    <prefix qualifier="VV">van de </prefix>
                    <family qualifier="BR">Bos</family>
                </name>
            </informationRecipient>
            <receivedOrganization>
                <!-- is actually the organization of the motiva nurse -->
                <!-- The id is hypothetical. The root refers to Vectis AGB-Z-->
                <id extension="00000123" root="2.16.840.1.113883.2.4.6.1"
                    assigningAuthorityName="Vektis AGB-Z"/>
                <name>Noord Holland Gezondheid Centrum</name>
                <!-- The phone at working place -->
                <telecom use="WP" value="tel:+31208958869"/>
                <addr use="WP">
                    <!-- The address of the hypothetical institution -->
                    <streetName partType="STR">Prinsengracht</streetName>
                    <houseNumber partType="BNR">22</houseNumber>
                    <postalCode partType="ZIP">1000 PJ</postalCode>
                    <city partType="CTY">Amsterdam</city>
                    <country partType="CNT">Nederland</country>
                </addr>
            </receivedOrganization>
        </intendedRecipient>
    </informationRecipient>
    <legalAuthenticator>
        <time value="20070614"/>
        <signatureCode code="S"/>
        <assignedEntity>
            <!-- The legal authenticator is the same person as the author of the Discharge note -->
            <id extension="03020547" root="2.16.840.1.113883.2.4.6.1"
                assigningAuthorityName="Vektis AGB-Z"/>
            <addr use="WP">
                <streetName partType="STR">Postbus</streetName>
                <houseNumber partType="BNR">1350</houseNumber>
                <postalCode partType="ZIP">5602 ZA</postalCode>
                <city partType="CTY">Eindhoven</city>
                <country partType="CNT">Nederland</country>
            </addr>
            <telecom use="WP" value="tel:+310402399111"/>
            <assignedPerson>
                <name use="L">
                    <prefix qualifier="AC">Dr.</prefix>
                    <given qualifier="IN">J</given>
                    <prefix qualifier="VV">J. </prefix>
                    <family qualifier="BR">Koolen</family>
                </name>
            </assignedPerson>
            <representedOrganization>
                <!-- This is the Catharina Ziekenhuis identification -->
                <id extension="06011009" root="2.16.840.1.113883.2.4.6.1"
                    assigningAuthorityName="Vektis AGB-Z"/>
                <name>CATHARINA ZIEKENHUIS</name>
                <telecom use="WP" value="tel:+310402399111"/>
                <addr use="WP">
                    <streetName partType="STR">Postbus</streetName>
                    <houseNumber partType="BNR">1350</houseNumber>
                    <postalCode partType="ZIP">5602 ZA</postalCode>
                    <city partType="CTY">Eindhoven</city>
                    <country partType="CNT">Nederland</country>
                </addr>
            </representedOrganization>
        </assignedEntity>
    </legalAuthenticator>

    <!-- 
        ********************************************************
        CDA Body
        ********************************************************
    -->
    <component>
        <structuredBody>
            <!-- 
                ********************************************************
                Hospital Discharge Instructions section 
                ********************************************************
            -->
            <component>
                <!-- This section contains only literal text -->
                <section>
                    <code code="8653-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
                        displayName="Hospital discharge instructions"/>
                    <title>Ziekenhuisontslag Instructies</title>
                    <text> Bij het onderzoek van <content styleCode="Bold">Nelleke van der Wiel
                        </content> in mijn kantoor op 14 donderdag juni 2007, constateerde ik dat
                        zij aan hypertensie wegens haar zoute dieet lijdt. Ik adviseer mijn patiënt
                        om gewicht te verliezen, meer fruit en groenten te eten en verzadigde vetten
                        te vermijden. Het is belangrijk dat zij de hoeveelheid van natrium in haar
                        dieet tot maximal 2.300 milligram per dag vermindert (dat is ongeveer 6 gram
                        of minder dan 1 theelepel zout). Verder zou moeten stoppen met roken en max
                        een alcoholisch drankje per dag mogen drinken. </text>
                </section>
            </component>

            <!-- 
                ********************************************************
                Hospital Discharge Medications section
                ********************************************************
            -->
            <component>
                <!-- This section contains only literal text -->
                <section>
                    <code code="10183-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
                        displayName="Hospital discharge medications"/>
                    <title>Medicatie</title>
                    <text>
                        <list>
                            <item>Lotensin (benazepril) , 3 pillen [25 mg per pil], 1 maal per dag</item>
                            <item>Diovan (valsartan), 1 pil [25 mg per pil], 3 maal per dag</item>
                        </list>
                    </text>
                </section>
            </component>

            <!-- 
                ********************************************************
                Physical Exam section
                ********************************************************
            -->
            <component>
                <section>
                    <code code="11384-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
                        displayName="Physical examination by organ systems"/>
                    <title>Lichamelijke onderzoeken</title>
                    <!-- 
                        ********************************************************
                        Physical Exam  - Vital Signs
                        ********************************************************
                    -->
                    <component>
                        <!-- This section contains both literal text and structured elements for the vital trends supported by Motiva -->
                        <section>
                            <!-- Supported vital trends are weight, heart rate, systolic/diastolic blood pressure, and glucose -->
                            <code code="8716-3" codeSystem="2.16.840.1.113883.6.1"
                                codeSystemName="LOINC" displayName="Physical findings"/>
                            <title>Functie Onderzoeken</title>
                            <text>
                                <table>
                                    <tbody>
                                        <tr>
                                            <th>Datum / Tijd</th>
                                            <th>juni 14, 2007 14:30</th>
                                            <th>Basislijnen</th>
                                        </tr>
                                        <tr>
                                            <th>Gewicht</th>
                                            <td>162.0 lbs (73.5 kg)</td>
                                            <td>155.0 lbs (70.3 kg)</td>
                                        </tr>
                                        <tr>
                                            <th>Hartslag</th>
                                            <td>88 / minuut</td>
                                            <td>81 / minuut</td>
                                        </tr>
                                        <tr>
                                            <th>Systolische</th>
                                            <td>135 mmHg</td>
                                            <td>120 mmHg</td>
                                        </tr>
                                        <tr>
                                            <th>Diastolische</th>
                                            <td>88 mmHg</td>
                                            <td>80 mmHg</td>
                                        </tr>
                                    </tbody>
                                </table>
                            </text>
                            <entry>
                                <observation classCode="OBS" moodCode="EVN">
                                    <code code="29463-7" codeSystem="2.16.840.1.113883.6.1"
                                        codeSystemName="LOINC" displayName="Body weight"/>
                                    <statusCode code="completed"/>
                                    <effectiveTime value="200706141430"/>
                                    <value xsi:type="PQ" value="162.0" unit="[lb_ap]">
                                        <!-- The unit corresponds to a valid UCUM entry -->
                                        <translation value="73.5" code="kg"
                                            codeSystem="2.16.840.1.113883.6.8" codeSystemName="UCUM"
                                        />
                                    </value>
                                    <referenceRange>
                                        <observationRange>
                                            <value xsi:type="IVL_PQ">
                                                <low value="155.0" inclusive="true" unit="[lb_ap]"/>
                                                <high value="155.0" inclusive="true" unit="[lb_ap]"
                                                />
                                            </value>
                                        </observationRange>
                                    </referenceRange>
                                </observation>
                            </entry>
                            <entry>
                                <observation classCode="OBS" moodCode="EVN">
                                    <code code="11948-7" codeSystem="2.16.840.1.113883.6.1"
                                        codeSystemName="LOINC" displayName="Heart rate"/>
                                    <statusCode code="completed"/>
                                    <effectiveTime value="200706141430"/>
                                    <value xsi:type="RTO_PQ_PQ">
                                        <numerator value="88"/>
                                        <denominator value="1" unit="min"/>
                                        <!-- The unit corresponds to a valid UCUM entry -->
                                    </value>
                                    <referenceRange>
                                        <observationRange>
                                            <value xsi:type="RTO_PQ_PQ">
                                                <numerator value="81"/>
                                                <denominator value="1" unit="min"/>
                                                <!-- The unit corresponds to a valid UCUM entry -->
                                            </value>
                                        </observationRange>
                                    </referenceRange>
                                </observation>
                            </entry>
                            <entry>
                                <observation classCode="OBS" moodCode="EVN">
                                    <code code="8480-6" codeSystem="2.16.840.1.113883.6.1"
                                        codeSystemName="LOINC" displayName="Intravascular systolic"/>
                                    <statusCode code="completed"/>
                                    <effectiveTime value="200706141430"/>
                                    <value xsi:type="PQ" value="135" unit="mm[Hg]"/>
                                    <!-- This is not a valid UCUM entry but apprears in the official CDA example document. In UCUM, the valid entry is m[Hg], not mm[Hg]-->
                                    <referenceRange>
                                        <observationRange>
                                            <value xsi:type="IVL_PQ">
                                                <low value="120.0" inclusive="true" unit="mm[Hg]"/>
                                                <high value="120.0" inclusive="true" unit="mm[Hg]"/>
                                            </value>
                                        </observationRange>
                                    </referenceRange>
                                </observation>
                            </entry>
                            <entry>
                                <observation classCode="OBS" moodCode="EVN">
                                    <code code="8462-4" codeSystem="2.16.840.1.113883.6.1"
                                        codeSystemName="LOINC" displayName="Intravascular diastolic"/>
                                    <statusCode code="completed"/>
                                    <effectiveTime value="200706141430"/>
                                    <value xsi:type="PQ" value="88" unit="mm[Hg]"/>
                                    <referenceRange>
                                        <observationRange>
                                            <value xsi:type="IVL_PQ">
                                                <low value="80.0" inclusive="true" unit="mm[Hg]"/>
                                                <high value="80.0" inclusive="true" unit="mm[Hg]"/>
                                            </value>
                                        </observationRange>
                                    </referenceRange>
                                </observation>
                            </entry>
                        </section>
                    </component>
                </section>
            </component>
        </structuredBody>
    </component>
</ClinicalDocument>

