<ClinicalDocument>
<!-- This ClinicalDocument's structure is stubbed with the minimum elements necessary
to demonstrate the locations of the entries across multiple different sections;
however, required content like the document header and section LOINC codes
has been omitted. -->
<component>
<structuredBody>
<!-- This example is created to help with the documentation associated with the following quality measure -->
<!-- Closing the Referral Loop: https://ecqi.healthit.gov/ecqm/measures/cms50v7 -->
<!-- This includes a first section of planned referral that opens the loop and a second section of planned referral which closes loop -->
<!-- While both XML sections are included below, in real implementations, they would be expected to be split between two separate documents -->
<component>
<section>
<!-- We've attempted to align/harmonize this example with both C-CDA and guidance from the IHE 360X -->
<!-- See information on IHE 360x profile here: https://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_Suppl_360X.pdf -->
<!-- See pages 8 and 44 making recommendation for Patient Referral Act -->
<!-- The interventions section is used below since that was the recommended of IHE 360XS document -->
<!-- But this entry could also be used inside of a Reason for Referral section or other open-template section like Plan of Treatment -->
<templateId root="2.16.840.1.113883.10.20.21.2.3" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.3"/>
<code code="62387-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Interventions Provided"/>
<title>Interventions</title>
<!-- one patient referral act in the human readable text and as a discrete entry -->
<text>
<table>
<caption>Planned Referral</caption>
<thead>
<tr>
<th>Name</th>
<th>Date</th>
<th>Details</th>
</tr>
</thead>
<tbody>
<tr ID="ID0EFFFFFFCAB3">
<td ID="ID0EFAAAAACAB3">Referral to Specialist</td>
<td>June 23, 2018</td>
<td>Dr. Henry Levine Eighth, as soon as possible</td>
</tr>
</tbody>
</table>
</text>
<!-- a patient referral act -->
<entry>
<act moodCode="INT" classCode="PCPR">
<templateId root="2.16.840.1.113883.10.20.22.4.140" />
<!-- This id may be referenced in the note received afterward -->
<id root="9a6d1bac-17d3-4195-89a4-1121bc809b4e" />
<code code="103697008" displayName="Patient referral for dental care" codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96">
<originalText>
<reference value="#ID0EFAAAAACAB3"/>
</originalText>
</code>
<text>
<!-- referencing the entire text -->
<reference value="#ID0EFFFFFFCAB3"/>
</text>
<statusCode code="active" />
<effectiveTime value="20180623" />
<priorityCode code="A" codeSystem="2.16.840.1.113883.5.7" codeSystemName="ActPriority" displayName="ASAP"/>
<participant typeCode="REFT">
<participantRole>
<!-- Having this be an NPI may be used to identify completion of referral -->
<id root="2.16.840.1.113883.4.6" extension="1093929010" />
<code code="207Q00000X" displayName="Allopathic & Osteopathic Physicians; Family Medicine" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" />
<addr>
<streetAddressLine>100 Main St</streetAddressLine>
<city>Horsham</city>
<state>PA</state>
<postalCode>19044</postalCode>
<country>US</country>
</addr>
<telecom nullFlavor="UNK" />
<playingEntitye>
<name>
<family>Eighth</family>
<given>Henry</given>
<given>Levine</given>
</name>
</playingEntitye>
</participantRole>
</participant>
</act>
</entry>
</section>
</component>
<!-- The section below would likely be included in a separate document, although included here for a single sample -->
<component>
<section>
<!-- Notes Section -->
<templateId root="2.16.840.1.113883.10.20.22.2.65" extension="2016-11-01"/>
<!-- This Notes Section is not intended to replace a C-CDA Consultation Note Document -->
<!-- If your system captures Consultation Note information in Discrete sections it's not recommended to lump all the text together here. -->
<!-- This Notes Section could be included in a Consultation Note Document with other discrete sections (Results, Vitals etc.)-->
<!-- This Notes Section is most appropriate for an encounter specific document. Other sections of doucments may also close notes -->
<!-- If this Notes section were included in a CCD, each Note Activity entry should be linked to an appropriate Encounter entry in the Encounters section -->
<code code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Consult note"/>
<title>Consultation Notes</title>
<text>
<list>
<item ID="ConsultNote1">
<paragraph>Dr. Henry Level Eighth - June 23, 2018</paragraph>
<paragraph> Dear Reerring Doctor: Thank you for referring Ms. Everywoman for evaluation. As
you know, she is a 40-year-old woman who has had chronic gastrointestinal
symptoms. Approximately 18 years ago, she was hospitalized with a bleeding
ulcer. She had a CT scan of the abdomen, which revealed findings consistent with
focal nodular hyperplasia (FNH). She has had epigastric abdominal pain as well
as a significant change in her bowel movements from baseline constipation to
frequent diarrhea. The past medical history is otherwise negative. She takes no
prescription medications. The remainder of the history is not contributory. </paragraph>
<paragraph>Physical examination revealed a well-appearing woman. The vital signs
were normal. The head and neck were unremarkable. The lung fields were clear.
The heart exam was normal. The abdomen was obese with normal bowel sounds. There
was no tenderness, mass, or hepatosplenomegaly. </paragraph>
<paragraph>Endoscopic evaluation revealed a normal colonoscopy. Biopsies taken
throughout the colon were essentially unremarkable. Stool tests for pathogenic
organisms were negative. Of note, on the upper endoscopy examination, no
significant abnormalities were seen; however, upon biopsy, features of celiac
disease were noted.</paragraph>
<paragraph> In summary, this 40-year-old woman has evidence of celiac disease. We
discussed the diagnosis in detail in the office. She was advised to undertake a
lifelong gluten-free diet. Followup laboratories in my office were notable for a
low serum iron with a low-normal ferritin. The bone density was normal. Repeat
triple-phase CT scan of the liver revealed no change in the right hepatic lobe
lesion, which is consistent with FNH. I advised periodic reevaluation of the
liver with imaging, as well as followup for any potential development of
nutritional deficiencies. She should take an iron supplement and continue on a
lifelong gluten-free diet. </paragraph>
<paragraph>Thank you for the courtesy of this referral. I would be pleased to see
Ms. Everywoman in followup.</paragraph>
</item>
</list>
</text>
<!-- Note Activity entry -->
<entry>
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.202" extension="2016-11-01"/>
<code code="34109-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Note">
<!-- Code must match or be equivalent to section code -->
<translation code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Consult note"/>
<!-- Additional SNOMED code which is equivalent to the LOINC consultation note code -->
<!-- The quality measure CMS550 v7 requires a concept from 2.16.840.1.113883.3.464.1003.121.12.1006 -->
<translation code="371530004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Clinical consultation report (record artifact)" />
</code>
<text>
<reference value="#ConsultNote1"/>
</text>
<statusCode code="completed"/>
<!-- Clinically-relevant time of the note -->
<effectiveTime value="20160908"/>
<!-- Author Participation -->
<author>
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<!-- Time note was actually written -->
<time value="20180623083215-0500"/>
<assignedAuthor>
<!-- This NPI helps track the planned referral to the person who actually performed -->
<id root="2.16.840.1.113883.4.6" extension="1093929010" />
<code code="207Q00000X" displayName="Allopathic & Osteopathic Physicians; Family Medicine" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" />
<addr nullFlavor="UNK" />
<telecom nullFlavor="UNK" />
<assignedPerson>
<name>
<family>Eighth</family>
<given>Henry</given>
<given>Levine</given>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.3.1.1.1.1." extension="0001" />
<name>Default Practice</name>
<telecom use="WP" nullFlavor="UNK" />
<addr>
<streetAddressLine>100 Main St</streetAddressLine>
<city>Horsham</city>
<state>PA</state>
<postalCode>19044</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
<reference typeCode="REFR">
<externalAct classCode="ACT" moodCode="EVN">
<!-- This refers to the Patient Referral Act act/id of the planned referral -->
<!-- The quality measure CMS550 v7 requires this identifier to link (related) the completed encounter to the requested referral -->
<id root="9a6d1bac-17d3-4195-89a4-1121bc809b4e"/>
<code code="103697008" displayName="Patient referral for dental care" codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96" />
</externalAct>
</reference>
</act>
</entry>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>