<?xml version="1.0"?><!DOCTYPE levelone PUBLIC "-//HL7//DTD CDA Level One 1.0//EN" "levelone_1.0.dtd"><levelone> <clinical_document_header> <id EX="a123" RT="2.16.840.1.113883.3.933"/> <set_id EX="B" RT="2.16.840.1.113883.3.933"/> <version_nbr V="2"/> <document_type_cd V="11488-4" S="2.16.840.1.113883.6.1" DN="Consultation note"/> <origination_dttm V="2000-04-07"/> <confidentiality_cd ID="CONF1" V="N" S="2.16.840.1.113883.5.1xxx"/> <confidentiality_cd ID="CONF2" V="R" S="2.16.840.1.113883.5.1xxx"/> <document_relationship> <document_relationship.type_cd V="RPLC"/> <related_document> <id EX="a234" RT="2.16.840.1.113883.3.933"/> <set_id EX="B" RT="2.16.840.1.113883.3.933"/> <version_nbr V="1"/> </related_document> </document_relationship> <fulfills_order> <fulfills_order.type_cd V="FLFS"/> <order><id EX="x23ABC" RT="2.16.840.1.113883.3.933"/></order> <order><id EX="x42CDE" RT="2.16.840.1.113883.3.933"/></order> </fulfills_order><patient_encounter> <id EX="KPENC1332" RT="2.16.840.1.113883.3.933"/> <practice_setting_cd V="GIM" S="2.16.840.1.113883.5.1xxx" DN="General internal medicine clinic"/> <encounter_tmr V="2000-04-07"/> <service_location> <id EX="KXLPa123" RT="2.16.840.1.113883.3.933"/> <addr> <HNR V="970"/> <STR V="Post St"/> <DIR V="NE"/> <CTY V="Alameda"/> <STA V="CA"/> <ZIP V="94501"/> </addr> </service_location> </patient_encounter> <legal_authenticator> <legal_authenticator.type_cd V="SPV"/> <participation_tmr V="2000-04-08"/> <signature_cd V="S"/> <person> <id EX="KP00017" RT="2.16.840.1.113883.3.933"/> <person_name> <nm> <GIV V="Robert"/> <FAM V="Dolin"/> <SFX V="MD" QUAL="PT"/> </nm> <person_name.type_cd V="L" S="2.16.840.1.113883.5.1xxx"/> </person_name> <addr> <HNR V="970"/> <STR V="Post St"/> <DIR V="NE"/> <CTY V="Alameda"/> <STA V="CA"/> <ZIP V="94501"/> </addr> <phon V="tel:(358)555-1234" USE="WPN"/> </person> </legal_authenticator><originator> <originator.type_cd V="AUT"/> <participation_tmr V="2000-04-07"/> <person> <id EX="KP00017" RT="2.16.840.1.113883.3.933"/> <person_name> <nm> <GIV V="Robert"/> <FAM V="Dolin"/> <SFX V="MD"/> </nm> <person_name.type_cd V="L" S="2.16.840.1.113883.5.1xxx"/> </person_name> </person> </originator> <originating_organization> <originating_organization.type_cd V="CST"/> <organization> <id EX="M345" RT="2.16.840.1.113883.3.933"/> <organization.nm V="Good Health Clinic"/> </organization> </originating_organization> <provider> <provider.type_cd V="CON"/> <participation_tmr V="2000-04-07"/> <person> <id EX="KP00017" RT="2.16.840.1.113883.3.933"/> </person> </provider><patient> <patient.type_cd V="PATSBJ"/> <person> <id EX="12345" RT="2.16.840.1.113883.3.933"/> <person_name> <nm> <GIV V="Henry"/> <FAM V="Levin"/> <SFX V="the 7th"/> </nm> <person_name.type_cd V="L" S="2.16.840.1.113883.5.1xxx"/> </person_name> <person_name> <nm> <GIV V="Hank"/> <FAM V="Levin"/> </nm> <person_name.type_cd V="A" S="2.16.840.1.113883.5.1xxx"/> </person_name> </person> <birth_dttm V="1932-09-24"/> <administrative_gender_cd V="M" S="2.16.840.1.113883.5.1xxx"/> </patient> <originating_device ID="DEV1"> <originating_device.type_cd V="ODV"/> <device> <id EX="devX3498" RT="2.16.840.1.113883.3.933"/> <responsibility> <responsibility.type_cd V="MNT" S="2.16.840.1.113883.5.1xxx"/> <person> <id EX="KP03257" RT="2.16.840.1.113883.3.933"/> </person> </responsibility> </device> </originating_device> <local_header ignore="all" descriptor="MyLocalTag"> ... extra stuff that is only used locally ... </local_header> </clinical_document_header><body confidentiality="CONF1"> <section> <caption> <caption_cd V="8684-3" S="2.16.840.1.113883.6.1"/> History of Present Illness </caption> <paragraph> <content> Henry Levin, the 7th is a 67 year old male referred for further asthma management. Onset of asthma in his teens. He was hospitalized twice last year, and already twice this year. He has not been able to be weaned off steroids for the past several months. </content> </paragraph> </section> <section> <caption>Past Medical History</caption> <list> <item><content>Asthma</content></item> <item><content>Hypertension</content></item> <item><content>Osteoarthritis, right knee</content></item> </list> </section> <section> <caption> <caption_cd V="10160-0" S="2.16.840.1.113883.6.1"/>Medications </caption> <list> <item><content>Theodur 200mg BID</content></item> <item><content>Proventil inhaler 2puffs QID PRN</content></item> <item><content>Prednisone 20mg qd</content></item> <item><content>HCTZ 25mg qd</content></item> </list> </section> <section> <caption>Allergies</caption> <list> <item><content>Penicillin - Hives</content></item> <item><content>Aspirin - Wheezing</content></item> </list> </section> <section> <caption>Social History</caption> <list> <item> <content> Smoking :: 1 PPD between the ages of 20 and 55, and then he quit. </content> </item> <item><content>Alcohol :: rare</content></item> </list> </section><section> <caption> <caption_cd V="11384-5" S="2.16.840.1.113883.6.1"/> Physical Examination </caption> <section> <caption> <caption_cd V="8716-3" S="2.16.840.1.113883.6.1"/>Vital Signs </caption> <list> <item><content>BP 118/78</content></item> <item><content>Resp 16 and unlabored</content></item> <item><content>T 98.6F</content></item>
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