<?xml version="1.0" encoding="UTF-8" standalone="yes"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!--
 Title:        Operative Note
 Filename:     C-CDA_R2_Operative_Note.xml
 Created by:   Lantana Consulting Group, LLC
 
 $LastChangedDate: 2014-11-12 23:25:09 -0500 (Wed, 12 Nov 2014) $
  
 ********************************************************
 Disclaimer: This sample file contains representative data elements to represent a Operative Note. 
 The file depicts a fictional character's health data. Any resemblance to a real person is coincidental. 
 To illustrate as many data elements as possible, the clinical scenario may not be plausible. 
 The data in this sample file is not intended to represent real patients, people or clinical events. 
 This sample is designed to be used in conjunction with the C-CDA Clinical Notes Implementation Guide.
 ********************************************************
 -->
<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" extension="2014-06-09"/>
	<!-- *** 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="2.16.840.1.113883.10.20.22.1.7" extension="2014-06-09"/>
	<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="11504-8" displayName="Surgical Operation Note"/>
	<title>Community Health and Hospitals: Operative Note</title>
	<effectiveTime value="201209161910-0400"/>
	<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="20050501"/>
				<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"/>
				<raceCode code="1966-1" displayName="Aleut" 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="GRPRN" displayName="Grandparent" 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"/>
					<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="2.16.840.1.113883.19.5.9999.1393"/>
				<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 typeCode="DOC">
		<serviceEvent classCode="PCPR">
			<code code="73761001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Colonoscopy"/>
			<effectiveTime>
				<low value="201209091910-0400"/>
				<high value="201209161910-0400"/>
			</effectiveTime>
			<performer typeCode="PPRF">
				<functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88" codeSystemName="ParticipationFunction" displayName="Primary Care Provider">
					<originalText>Primary Care Provider</originalText>
				</functionCode>
				<time>
					<low value="201209091910-0400"/>
					<high value="201209161910-0400"/>
				</time>
				<assignedEntity>
					<id extension="PseudoMD-3" 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>
	<authorization typeCode="AUTH">
		<consent classCode="CONS" moodCode="EVN">
			<id root="629deb70-5306-11df-9879-0800200c9a66"/>
			<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="64293-4" displayName="Procedure consent"/>
			<statusCode code="completed"/>
		</consent>
	</authorization>
	<!-- ********************************************************
     CDA Body
     ******************************************************** -->
	<component>
		<structuredBody>
			<!-- *********************** -->
			<!--
********************************************************
ANESTHESIA
********************************************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.22.2.25" extension="2014-06-09"/>
					<code code="59774-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE ANESTHESIA"/>
					<title>PROCEDURE ANESTHESIA</title>
					<text>
						<content ID="Med4">Conscious sedation with propofol 200 mg IV </content>
					</text>
					<entry>
						<procedure classCode="PROC" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
							<!-- ***** Procedure  Activity Procedure Template ***** -->
							<id root="d68b7e32-7810-4f5b-9cc2-acd54b0fd85d"/>
							<code code="73761001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Colonoscopy">
								<originalText> </originalText>
							</code>
							<statusCode code="completed"/>
							<effectiveTime value="20120512"/>
							<methodCode nullFlavor="UNK"/>
							<!-- ****OPTIONAL*****-->
							<specimen typeCode="SPC">
								<specimenRole classCode="SPEC">
									<id root="c2ee9ee9-ae31-4628-a919-fec1cbb58683"/>
									<specimenPlayingEntity>
										<code code="309226005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="colonic polyp sample"/>
									</specimenPlayingEntity>
								</specimenRole>
							</specimen>
							<performer>
								<assignedEntity>
									<id root="2.16.840.1.113883.19.5.9999.456" extension="2981823"/>
									<addr>
										<streetAddressLine>1001 Village Avenue</streetAddressLine>
										<city>Portland</city>
										<state>OR</state>
										<postalCode>99123</postalCode>
										<country>US</country>
									</addr>
									<telecom use="WP" value="555-555-5000"/>
									<representedOrganization>
										<id root="2.16.840.1.113883.19.5.9999.1393"/>
										<name>Community Health and Hospitals</name>
										<telecom use="WP" value="555-555-5000"/>
										<addr>
											<streetAddressLine>1001 Village Avenue</streetAddressLine>
											<city>Portland</city>
											<state>OR</state>
											<postalCode>99123</postalCode>
											<country>US</country>
										</addr>
									</representedOrganization>
								</assignedEntity>
							</performer>
							<participant typeCode="DEV">
								<!-- *** Optional *** -->
								<participantRole classCode="MANU">
									<templateId root="2.16.840.1.113883.10.20.22.4.37"/>
									<!--   Product instance template   -->
									<id root="742aee30-21c5-11e1-bfc2-0800200c9a66"/>
									<playingDevice>
										<code code="90412006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Colonoscope"/>
									</playingDevice>
									<scopingEntity>
										<id root="eb936010-7b17-11db-9fe1-0800200c9b65"/>
									</scopingEntity>
								</participantRole>
							</participant>
						</procedure>
					</entry>
					<entry>
						<substanceAdministration classCode="SBADM" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
							<!-- ** MEDICATION ACTIVITY -->
							<id root="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/>
							<text>
								<reference value="#Med4"/>Propofol 20mg/mL injection emulsion 50mL vial </text>
							<statusCode code="completed"/>
							<effectiveTime xsi:type="IVL_TS">
								<low value="20120512"/>
								<high value="20120512"/>
							</effectiveTime>
							<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
								<period value="1" unit="h"/>
							</effectiveTime>
							<routeCode code="C38276" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="INTRAVENOUS"/>
							<doseQuantity value="20" unit="mg/mL"/>
							<rateQuantity value="2" unit="ml/min"/>
							<maxDoseQuantity nullFlavor="UNK">
								<numerator nullFlavor="UNK"/>
								<denominator nullFlavor="UNK"/>
							</maxDoseQuantity>
							<administrationUnitCode code="C38276" displayName="INTRAVENOUS" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus"/>
							<consumable>
								<manufacturedProduct classCode="MANU">
									<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
									<id root="2a620155-9d11-439e-92b3-5d9815ff4de9"/>
									<manufacturedMaterial>
										<code code="153475" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Propofol 20 MG/ML Injectable Suspension">
											<originalText>
												<reference value="#Med4"/>
											</originalText>
										</code>
									</manufacturedMaterial>
									<manufacturerOrganization>
										<name>Medication Factory Inc.</name>
									</manufacturerOrganization>
								</manufacturedProduct>
							</consumable>
						</substanceAdministration>
					</entry>
				</section>
			</component>
			<!--
********************************************************
COMPLICATIONS
********************************************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.22.2.37" extension="2014-06-09"/>
					<code code="55109-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Complications"/>
					<title>COMPLICATIONS</title>
					<text>
						<content ID="problem1">Asthmatic symptoms while under general anesthesia.</content>
					</text>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<!-- Problem observation template -->
							<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2014-06-09"/>
							<id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
							<code code="75322-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Complaint"/>
							<text>
								<reference value="#problem1"/>
							</text>
							<statusCode code="completed"/>
							<effectiveTime>
								<low value="20080103"/>
							</effectiveTime>
							<value xsi:type="CD" code="233604007" codeSystem="2.16.840.1.113883.6.96" displayName="Pneumonia"/>
							<entryRelationship typeCode="SUBJ" inversionInd="true">
								<observation classCode="OBS" moodCode="EVN">
									<templateId root="2.16.840.1.113883.10.20.22.4.31"/>
									<!--    Age observation template   -->
									<code code="445518008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Age At Onset"/>
									<statusCode code="completed"/>
									<value xsi:type="PQ" value="57" unit="a"/>
								</observation>
							</entryRelationship>
							<entryRelationship typeCode="REFR">
								<observation classCode="OBS" moodCode="EVN">
									<templateId root="2.16.840.1.113883.10.20.22.4.5" extension="2014-06-09"/>
									<!-- Health status observation template -->
									<id root="cd2391b0-5c71-11db-b0de-0800200c9a66"/>
									<code code="11323-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Health status"/>
									<text/>
									<statusCode code="completed"/>
									<value xsi:type="CD" code="81323004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Alive and well"/>
								</observation>
							</entryRelationship>
						</observation>
					</entry>
				</section>
			</component>
			<!--
********************************************************
OPERATIVE NOTE FLUIDS
********************************************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.7.12"/>
					<code code="10216-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="SURGICAL OPERATION NOTE FLUIDS"/>
					<title>OPERATIVE NOTE FLUIDS</title>
					<text>250 ML Ringers Lactate</text>
				</section>
			</component>
			<!--
********************************************************
OPERATIVE NOTE SURGICAL PROCEDURE
********************************************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.7.14"/>
					<code code="10223-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="SURGICAL OPERATION NOTE SURGICAL PROCEDURE"/>
					<title>SURGICAL PROCEDURE</title>
					<text>
						<content ID="Proc1">Laparoscopic Appendectomy</content>
					</text>
				</section>
			</component>
			<!--
********************************************************
PLAN OF TREATMENT
********************************************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09"/>
					<!--  **** Plan of Care section template  **** -->
					<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Treatment plan"/>
					<title>PLAN OF TREATMENT</title>
					<text>
						<table border="1" width="100%">
							<thead>
								<tr>
									<th>Planned Activity</th>
									<th>Planned Date</th>
								</tr>
							</thead>
							<tbody>
								<tr>
									<td>Colonoscopy</td>
									<td>20120512</td>
								</tr>
							</tbody>
						</table>
					</text>
					<entry>
						<procedure moodCode="RQO" classCode="PROC">
							<templateId root="2.16.840.1.113883.10.20.22.4.41" extension="2014-06-09"/>
							<!-- ** Plan of Care Activity Procedure template ** -->
							<id root="9a6d1bac-17d3-4195-89c4-1121bc809b5a"/>
							<code code="73761001" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Colonoscopy"/>
							<statusCode code="new"/>
							<effectiveTime>
								<center value="20120512"/>
							</effectiveTime>
						</procedure>
					</entry>
				</section>
			</component>
			<!--
********************************************************
PLANNED PROCEDURE
********************************************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.22.2.30" extension="2014-06-09"/>
					<!--  ******** Planned Procedure Section template  ******** -->
					<code code="59772-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Planned Procedure"/>
					<title>PLANNED PROCEDURE</title>
					<text>Colonoscopy</text>
					<entry>
						<procedure moodCode="RQO" classCode="PROC">
							<templateId root="2.16.840.1.113883.10.20.22.4.41" extension="2014-06-09"/>
							<!-- ** Plan of Care Activity Procedure template ** -->
							<id root="9a6d1bac-17d3-4195-89c4-1121bc809b5a"/>
							<code code="274025005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Colonic polypectomy"/>
							<statusCode code="new"/>
							<effectiveTime>
								<center value="20000421"/>
							</effectiveTime>
						</procedure>
					</entry>
				</section>
			</component>
			<!--
********************************************************
POSTOPERATIVE DIAGNOSIS
********************************************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.22.2.35"/>
					<code code="10218-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="POSTOPERATIVE DIAGNOSIS"/>
					<title>POSTOPERATIVE DIAGNOSIS</title>
					<text>Appendicitis with periappendiceal abscess</text>
				</section>
			</component>
			<!--
********************************************************
PREOPERATIVE DIAGNOSIS
********************************************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.22.2.34" extension="2014-06-09"/>
					<code code="10219-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="SURGICAL OPERATION NOTE PREOPERATIVE DX"/>
					<title>PREOPERATIVE DIAGNOSIS</title>
					<text ID="preOpDx">Appendicitis</text>
					<entry>
						<act moodCode="EVN" classCode="ACT">
							<templateId root="2.16.840.1.113883.10.20.22.4.65" extension="2014-06-09"/>
							<!-- ** Preoperative Diagnosis Entry ** -->
							<code code="10219-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Preoperative Diagnosis"/>
							<entryRelationship typeCode="SUBJ">
								<observation classCode="OBS" moodCode="EVN">
									<!-- Problem observation template -->
									<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2014-06-09"/>
									<id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
									<code code="75322-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Complaint"/>
									<text>
										<reference value="#preOpDx"/>
									</text>
									<statusCode code="completed"/>
									<effectiveTime>
										<low value="20080103"/>
									</effectiveTime>
									<value xsi:type="CD" code="74400008" codeSystem="2.16.840.1.113883.6.96" displayName="Appendicitis"/>
								</observation>
							</entryRelationship>
						</act>
					</entry>
				</section>
			</component>
			<!--
********************************************************
PROCEDURE DESCRIPTION
********************************************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.22.2.27"/>
					<code code="29554-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE DESCRIPTION"/>
					<title>PROCEDURE DESCRIPTION</title>
					<text>The patient was brought to the operating room, placed in the supine position, and general anesthesia was induced. A detailed technical
            narrative of a laparoscopic appendectomy from initial incision to placement of any dressings follows.</text>
				</section>
			</component>
			<!-- ***********************************
     PROCEDURE DISPOSITION
     *********************************** -->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.18.2.12"/>
					<code code="59775-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE DISPOSITION"/>
					<title>PROCEDURE DISPOSITION</title>
					<text>The patient was taken to the Endoscopy Recovery Unit in stable condition.</text>
				</section>
			</component>
			<!--
********************************************************
PROCEDURE ESTIMATED BLOOD LOSS
********************************************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.18.2.9"/>
					<code code="59770-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE ESTIMATED BLOOD LOSS"/>
					<title>PROCEDURE ESTIMATED BLOOD LOSS</title>
					<text>Minimal</text>
				</section>
			</component>
			<!--
********************************************************
PROCEDURE FINDINGS
********************************************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.22.2.28" extension="2014-06-09"/>
					<code code="59776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE FINDINGS"/>
					<title>PROCEDURE FINDINGS</title>
					<text>A <content ID="finding1">6 mm sessile polyp</content> was found in the ascending colon and removed by snare, no cautery. Bleeding was
            controlled. <content ID="finding2">Moderate diverticulosis</content> and <content ID="finding3">hemorrhoids</content> were incidentally
            noted. </text>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<!-- Problem observation template -->
							<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2014-06-09"/>
							<id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
							<code code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Clinical finding"/>
							<text>
								<reference value="#finding1"/>
							</text>
							<statusCode code="completed"/>
							<effectiveTime>
								<low value="20080103"/>
							</effectiveTime>
							<value xsi:type="CD" code="103679000" codeSystem="2.16.840.1.113883.6.96" displayName="Sessile Polyp"/>
							<author>
								<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
								<time value="20050329224411+0500"/>
								<assignedAuthor>
									<id extension="99999999" root="2.16.840.1.113883.4.6"/>
								</assignedAuthor>
							</author>
						</observation>
					</entry>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<!-- Problem observation template -->
							<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2014-06-09"/>
							<id root="cd1791b0-5c71-11db-b0de-0800200c9a66"/>
							<code code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Clinical finding"/>
							<text>
								<reference value="#finding2"/>
							</text>
							<statusCode code="completed"/>
							<effectiveTime>
								<low value="20080103"/>
							</effectiveTime>
							<value xsi:type="CD" code="429430001" codeSystem="2.16.840.1.113883.6.96" displayName="diverticulosis of sigmoid"/>
							<author>
								<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
								<time value="20050329224411+0500"/>
								<assignedAuthor>
									<id extension="99999999" root="2.16.840.1.113883.4.6"/>
								</assignedAuthor>
							</author>
						</observation>
					</entry>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<!-- Problem observation template -->
							<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2014-06-09"/>
							<id root="cd1791b0-5c71-11db-b0de-0800200c9a66"/>
							<code code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Clinical finding"/>
							<text>
								<reference value="#finding3"/>
							</text>
							<statusCode code="completed"/>
							<effectiveTime>
								<low value="20080103"/>
							</effectiveTime>
							<value xsi:type="CD" code="90458007" codeSystem="2.16.840.1.113883.6.96" displayName="internal hemorrhoids"/>
							<author>
								<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
								<time value="20050329224411+0500"/>
								<assignedAuthor>
									<id extension="99999999" root="2.16.840.1.113883.4.6"/>
								</assignedAuthor>
							</author>
						</observation>
					</entry>
				</section>
			</component>
			<!--
********************************************************
PROCEDURE IMPLANTS
********************************************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.22.2.40"/>
					<code code="59771-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE IMPLANTS"/>
					<title>PROCEDURE IMPLANTS</title>
					<text>No implants were placed.</text>
				</section>
			</component>
			<!--
********************************************************
PROCEDURE INDICATIONS
***********************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.22.2.29" extension="2014-06-09"/>
					<code code="59768-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE INDICATIONS"/>
					<title>PROCEDURE INDICATIONS</title>
					<text>The procedure is performed for screening in a low risk individual. </text>
					<entry>
						<observation classCode="OBS" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.19" extension="2014-06-09"/>
							<id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/>
							<code code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Clinical finding"/>
							<statusCode code="completed"/>
							<effectiveTime>
								<low value="20091023"/>
							</effectiveTime>
							<value xsi:type="CD" code="414992000" displayName="Painless rectal bleeding" codeSystem="2.16.840.1.113883.6.96"/>
						</observation>
					</entry>
				</section>
			</component>
			<!--
********************************************************
PROCEDURE SPECIMENS TAKEN
********************************************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.22.2.31"/>
					<code code="59773-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE SPECIMENS TAKEN"/>
					<title>PROCEDURE SPECIMENS TAKEN</title>
					<text>Ascending colon polyp</text>
				</section>
			</component>
			<!--
********************************************************
SURGICAL DRAINS
***********************************
-->
			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.7.13"/>
					<code code="11537-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="SURGICAL DRAINS"/>
					<title>SURGICAL DRAINS</title>
					<text>Penrose drain placed</text>
				</section>
			</component>
		</structuredBody>
	</component>
</ClinicalDocument>
