Disclosures/API/Costs

Developer: Astronaut, LLC

Product Name: Astronaut EHR

Version: 1709

Certificate Number: 15.02.05.3099.ASTR.01.00.1.220201

Certification Date: February 1, 2022

Criteria Certified:

170.315(a)(1) – Computerized Provider Order Entry – medications
170.315(a)(2) – Computerized Provider Order Entry – laboratory
170.315(a)(3) – Computerized Provider Order Entry – diagnostic imaging
170.315(a)(4) – Drug-Drug, Drug-Allergy Interaction Checks for CPOE
170.315(a)(5) – Demographics
170.315(a)(9) – Clinical Decision Support (CDS)
170.315(a)(12) – Family Health History
170.315(a)(14) – Implantable Device List
170.315(b)(1) – Transitions of Care
170.315(b)(3) – Electronic Prescribing
170.315(b)(10) – Electronic Health Information Export
170.315(c)(1) – Clinical Quality Measures – Record and Export
170.315(d)(1) – Authentication, Access Control, and Authorization
170.315(d)(2) – Auditable Events and Tamper-Resistance
170.315(d)(3) – Audit Reports
170.315(d)(4) – Amendments
170.315(d)(5) – Automatic Access Time-out
170.315(d)(6) – Emergency Access
170.315(d)(7) – End-User Device Encryption
170.315(d)(8) – Integrity
170.315(d)(9) – Trusted Connection
170.315(d)(12) – Encrypt Authentication Credentials
170.315(d)(13) – Multi-factor Authentication
170.315(e)(3) – Patient Health Information Capture
170.315(g)(3) – Safety-Enhanced Design
170.315(g)(4) – Quality Management System
170.315(g)(5) – Accessibility-Centered Design
170.315(g)(6) – Consolidated CDA Creation Performance
170.315(g)(7) – Application access –Patient Selection
170.315(g)(9) – Application Access – All Data Request
170.315(g)(10) – Standardized API for Patient and Population Services
170.315(h)(1) – Direct project

CQM’s Certified

CMS2v10
CMS68v10
CMS69v9
CMS117v9
CMS128v9
CMS137v9
CMS138v9
CMS149v9
CMS153v9
CMS154v9
CMS155v9
CMS156v9
CMS159v9
CMS161v9
CMS165v9
CMS177v9

Additional Software:

Newcrop, Putty

Disclaimer

“This Health IT Module is compliant with the ONC Certification Criteria for Health IT and has been certified by an ONC-ACB in accordance with the applicable certification criteria adopted by the Secretary of Health and Human Services. This certification does not represent an endorsement by the U.S. Department of Health and Human Services.”

Additional Types of Costs

Monthly Newcrop and the Surescripts network charge. Hourly charge to assist training, preparing, and submitting QRDA to the government, if participating.

Multi-Factor Authentication Use Cases

Multi-factor authentication is required for Astro-CPRS clinical client, Scheduling, system administration, and ePrescribing.

API

Required for Meaningful Use public Astronaut Application Programming Interface for

170.315(g)(7) – Application Access –patient selection
170.315(g)(9) – Application Access – all data request
170.315(g)(10) – Standardized API for patient and population services

API version: 18.01

This document can be found on the web at: https://astronautehr.com/index.php/terms-of-service/

API documentation

CCDA WEB API

Version 2021.12.19

All requests require a HTTP Basic authentication header. In order to authenticate with HTTP you must provide your username and password with an HTTP Basic authentication header.

In order to interact with the API, a user must be configured on the server and given a username and password. Also a client’s ip address must be added to a server ip whitelist.

Using the API is a two step process. First, demographic information is supplied to the system to get back a unique patient identifier. Next, this patient identifier can be used to query the system, which will return a relevant XML document.

1) PATIENT QUERY – find patient id token.

Returns the patient id or an empty value with an HTTP 404 response if no unique match is found.

GET

https://api.example.com/v1/patient?name=jones,bill&dob=1947-05-21&ssn=12345689&gender=m

Parameters:

name = last,first e.g. jones,bill (required)

dob = YYYY-MM-DD e.g. 1947-05-21 (required)

ssn = 123456789 (optional)

gender = m or f (optional)

Success response: patient_identifier

e.g. 123456

Failure response:

HTTP 404 code (with json http body)

2) PATIENT DATA – request patient record data.

Returns patient record data in XML format, filtered by query, of selected patient data fields.

Or an empty array if no results.

GET

https://api.example.com/v1/patient/1234567?date=may,2015:august,2015&data=meds,ethnicity,procedures,immunizations

In this examplepatient idis1234567

date range May 2015 through August 2015 (inclusive)

data return med, ethnicity, procedures, immunization information

Parameters:

date optional. Format examples:

2015 – return data only from 2015

May,2015 – return data only from May, 2015

2015-05-21 – return data only from May 21, 2015

May,2015:2015-08-28 – return data from inclusive range of May,2015 through Aug 28,2015

If date contains “-”, then it will be treated as YYYY-MM-DD

If date contains “/”, then it will be treated as MM/DD/YYYY

data = comma delimited data values to return (optional, omit to return all fields)

(see below for more detail)

Supported Elements:

date = date[:end_date]

e.g. 2015 select just 2015 encounter

e.g. may,2015:august,2015 select date range (inclusive)

e.g. 6/20/2015:7/1/2015 select date range (inclusive)

data = comma-delimited list of section(s) to include. OPTIONAL. If not provided, then all sections will be returned

List of defined sections:

allergies

documents
immunizations

encounters

procedures

social

medications

problems

labs

vitals

Evaluations

In addition to the above, the user can specify a particular XML section be returned, using the extract parameter. NOTE: for an item to be extracted, it must be included in initial search.

(e.g. to extract Smoking_Status, would have to have social in “data”

so, if not already present, it will be forced (added to data node))

GET

https://api.example.com/v1/patient/1234567?extract=ethnicity

In this examplepatient idis1234567

extract is returning only the ethnicity section

Supported Elements:

extract can except one of the following:

Name

Sex

DOB

Race

Ethnicity

Preferred_Language

Smoking_Status

Problems

Medications

Medication_Allergies

Lab_Tests

Lab_Result

Vital_Signs

Procedures

Immunizations

Unique_Device_Identifier

Assessment

Plan_of_Treatment

Goals

Health_Concerns

Success response: XML RESULT

EXAMPLES:

(To get sex only)

https://api.example.com/v1/patient/13195?extract=sex

Returns:

<administrativeGenderCode xmlns=”urn:hl7-org:v3″ xmlns:sdtc=”urn:hl7-org:sdtc”

xmlns:voc=”urn:hl7-org:v3/voc” xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance”

code=”F” codeSystem=”2.16.840.1.113883.5.1″ codeSystemName=”AdministrativeGender”

displayName=”F”

(To get name only)

https://api.example.com/v1/patient/13195?extract=name

Returns:

<family>NEWMAN</family>

<given>ALICE</given>

<given>JONES</given>

</name>

<given qualifier=”BR”>ALICIA</given>

<family qualifier=”BR”>NEWMAN</family>

</name>

(To get Smoking_Status only)

https://api.example.com/v1/patient/13195?extract=Smoking_Status

Returns:

<td>Smokes tobacco daily (finding)</td>

<value code=”449868002″ codeSystem=”2.16.840.1.113883.6.96″

codeSystemName=”SNOMED” displayName=”Smokes tobacco daily (finding)” xsi:type=”CD”

Failure response:

HTTP 404 code (with json response body)

HTTP Basic authentication

HTTP REQUEST HEADER:

Authorization: “Basic ”+Base64(username+”:”+password)

To generate an Authorization Header for

username: Aladdin
Password: open sesame

Base64(“Aladdin:open sesame”) = QWxhZGRpbjpvcGVuIHNlc2FtZQ==

HTTP HEADER
Authorization: Basic QWxhZGRpbjpvcGVuIHNlc2FtZQ==

e.g.

https://username:password@api.example.com/your_desired_path

curl -G https://api.example.com/Accounts -u ‘<YOUR_ACCOUNT_SID>:<YOUR_AUTH_TOKEN>’

Failure responses

400 Bad Request – The server could not understand the request due to invalid syntax.

401 Unauthorized – “unauthenticated”. That is, the client must authenticate itself to get the requested response.

500 Internal Server Error – The server has encountered a situation it does not know how to handle.

404 Not Found – The server can not find the requested resource.

When a record is not found.

JSON

{“apiVersion”:”1.0″,”error”:{“code”:404,”errors”:[{“message”:”Not Found”,”reason”:404}],”message”:”Not Found”,”request”:”GET \/v1\/patient?name=smith,john&dob=1943-07-06″}}

========================================================================

ADDENDUM

John Wright 13196

curl -u username:password https://api.example.com/v1/patient/13196/?data=labs

<?xml version=”1.0″ encoding=”utf-8″ ?>

<?xml-stylesheet type=”text/xsl” href=”/resources/css/CDA.xsl”?>

<!– US Realm Header –>

<!– CCD –>

<title>Test Clinic Summarization of Episode Note</title>

<addr>

<state>OREGON</state>

<city>Beaverton </city>

<streetAddressLine>1357 Amber Rd.</streetAddressLine>

</addr>

<name>

<family>WRIGHT</family>

</name>

<!– CONF 5407: LanguageCode Code System 2.16.840.1.113883.1.11.11526 –>

</languageCommunication>

</patient>

</patientRole>

</recordTarget>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

<manufacturerModelName>WorldVistA</manufacturerModelName>

<softwareName>Opensource CDA Documents Generator</softwareName>

</assignedAuthoringDevice>

<name>Astronaut Network</name>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

</representedOrganization>

</assignedAuthor>

</author>

<name>Astronaut Network</name>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

</representedCustodianOrganization>

</assignedCustodian>

</custodian>

</effectiveTime>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

<name>

<family>ADMINISTRATOR</family>

<given>SYSTEM</given>

</name>

</assignedPerson>

</assignedEntity>

</performer>

</serviceEvent>

</documentationOf>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

<name>

<family>ADMINISTRATOR</family>

<given>SYSTEM</given>

</name>

</assignedPerson>

</assignedEntity>

</responsibleParty>

<name>Astronaut Network</name>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<postalCode>HOUSTON</postalCode>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

</location>

</healthCareFacility>

</location>

</encompassingEncounter>

</componentOf>

<!– nullFlavor of NI indicates No Information.–>

<!– Validator currently checks for entries even in case of nullFlavor – this will need to be updated if approved.–>

<!– Results Section with Coded Entries Required–>

<title>RESULTS</title>

<text>No Information</text>

</section>

</component>

</structuredBody>

</component>

</ClinicalDocument>

Rebecca Larson 13194

curl -u username:password https://api.example.com/v1/patient/13193/?date=may,2015:June,2015&data=social

<?xml version=”1.0″ encoding=”utf-8″ ?>

<?xml-stylesheet type=”text/xsl” href=”/resources/css/CDA.xsl”?>

<!– US Realm Header –>

<!– CCD –>

<title>Test Clinic Summarization of Episode Note</title>

<addr>

<state>MISSOURI</state>

<city>Beaverton</city>

<streetAddressLine>1357 Amber Dr</streetAddressLine>

</addr>

<name>

<family>LARSON</family>

<given>REBECCA</given>

<given>JONES</given>

</name>

<name><given qualifier=”BR”>ROBIN</given><family qualifier=”BR”>LARSON</family></name>

<sdtc:raceCode code=”2108-9″ codeSystem=”2.16.840.1.113883.6.238″ displayName=”White European” codeSystemName=”OMB Standards for Race and Ethnicity”/>

<!– CONF 5407: LanguageCode Code System 2.16.840.1.113883.1.11.11526 –>

</languageCommunication>

</patient>

</patientRole>

</recordTarget>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

<manufacturerModelName>WorldVistA</manufacturerModelName>

<softwareName>Opensource CDA Documents Generator</softwareName>

</assignedAuthoringDevice>

<name>Astronaut Network</name>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

</representedOrganization>

</assignedAuthor>

</author>

<name>Astronaut Network</name>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

</representedCustodianOrganization>

</assignedCustodian>

</custodian>

</effectiveTime>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

<name>

<family>ADMINISTRATOR</family>

<given>SYSTEM</given>

</name>

</assignedPerson>

</assignedEntity>

</performer>

</serviceEvent>

</documentationOf>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

<name>

<family>ADMINISTRATOR</family>

<given>SYSTEM</given>

</name>

</assignedPerson>

</assignedEntity>

</responsibleParty>

<name>Astronaut Network</name>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<postalCode>HOUSTON</postalCode>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

</location>

</healthCareFacility>

</location>

</encompassingEncounter>

</componentOf>

<title>Social History</title>

<text>

<thead>

<tr>

<th>Start Date</th>

<th>Comments</th>

<th>Source</th>

</tr>

</thead>

<tbody>

<tr>

<td>Smokes tobacco daily (finding)</td>

<td>Snomed Code: 449868002</td>

<td>Astronaut Network</td>

</tr>

</tbody>

</table>

</text>

<entry>

<text>

</text>

</effectiveTime>

<value xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance” xsi:type=”ST”>Astronaut Network</value>

</observation>

</entryRelationship>

</observation>

</entry>

</section>

</component>

</structuredBody>

</component>

</ClinicalDocument>

Kathy Bates 13193

curl -u username:password https://api.example.com/v1/patient/13193/?date=may,2015&data=allergies,immunizations

<?xml version=”1.0″ encoding=”utf-8″ ?>

<?xml-stylesheet type=”text/xsl” href=”/resources/css/CDA.xsl”?>

<!– US Realm Header –>

<!– CCD –>

<title>Test Clinic Summarization of Episode Note</title>

<addr>

<state>OREGON</state>

<city>Beaverton</city>

<streetAddressLine>1357 Amber Dr</streetAddressLine>

</addr>

<name>

<family>BATES</family>

<given>JEREMY</given>

</name>

<!– CONF 5407: LanguageCode Code System 2.16.840.1.113883.1.11.11526 –>

</languageCommunication>

</patient>

</patientRole>

</recordTarget>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

<manufacturerModelName>WorldVistA</manufacturerModelName>

<softwareName>Opensource CDA Documents Generator</softwareName>

</assignedAuthoringDevice>

<name>Astronaut Network</name>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

</representedOrganization>

</assignedAuthor>

</author>

<name>Astronaut Network</name>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

</representedCustodianOrganization>

</assignedCustodian>

</custodian>

</effectiveTime>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

<name>

<family>ADMINISTRATOR</family>

<given>SYSTEM</given>

</name>

</assignedPerson>

</assignedEntity>

</performer>

</serviceEvent>

</documentationOf>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

<name>

<family>ADMINISTRATOR</family>

<given>SYSTEM</given>

</name>

</assignedPerson>

</assignedEntity>

</responsibleParty>

<name>Astronaut Network</name>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<postalCode>HOUSTON</postalCode>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

</location>

</healthCareFacility>

</location>

</encompassingEncounter>

</componentOf>

<!– Allergies Section –>

<title>ALLERGIES</title>

<text>

<content ID=”Alg_Concern_1″>Allergy Concern:

Concern Tracker Start Date: 01/03/2014

Concern Tracker End Date:

Concern Tracker Status: Completed

<content ID=”allergy1″>No known <content ID=”adverseEvent1″>allergies.</content></content></content></text>

<!– Allergy Concern Act –>

<!– SDWG supports 48765-2 or CONC in the code element –>

<!–<code code=”CONC” codeSystem=”2.16.840.1.113883.5.6″/>–>

<high/>

</effectiveTime>

<!– No Known Allergies –>

<!– The use of negationInd corresponds with the newer Observation.valueNegationInd –>

<!– The negationInd = true negates the observation/value –>

<!– allergy – intolerance observation template –>

<!– N/A – author/time records when this assertion was made –>

</effectiveTime>

<!– The time when this was biologically relevant ie True for the patient. –>

<!– As a minimum time interval over which this is true, populate the effectiveTime/low with the current time. –>

<!– It would be equally valid to have a longer range of time over which this statement was represented as being true. –>

<!– As a maximum, you would never indicate an effectiveTime/high that was greater than the current point in time. –>

<value xsi:type=”CD” code=”419199007″

displayName=”Allergy to substance (disorder)”

codeSystem=”2.16.840.1.113883.6.96″

codeSystemName=”SNOMED CT”/>

<code code=”200000000X” codeSystem=”2.16.840.1.113883.6.101″

displayName=”Allopathic & Osteopathic Physicians”/>

<name>

<given>Henry</given>

<family>Seven</family>

</name>

</assignedPerson>

</assignedAuthor>

</author>

</playingEntity>

</participantRole>

</participant>

</observation>

</entryRelationship>

</act>

</entry>

</section>

</component>

</structuredBody>

</component>

</ClinicalDocument>

Alice Newman 13195

curl -u username:password https://api.example.com/v1/patient

<?xml version=”1.0″ encoding=”utf-8″ ?>

<?xml-stylesheet type=”text/xsl” href=”/resources/css/CDA.xsl”?>

<!– US Realm Header –>

<!– CCD –>

<title>Test Clinic Summarization of Episode Note</title>

<addr>

<state>OREGON</state>

<city>Beaverton</city>

<streetAddressLine>1357 Amber Dr</streetAddressLine>

</addr>

<name>

<family>NEWMAN</family>

<given>ALICE</given>

<given>JONES</given>

</name>

<name><given qualifier=”BR”>ALICIA</given><family qualifier=”BR”>NEWMAN</family></name>

<sdtc:raceCode code=”2108-9″ codeSystem=”2.16.840.1.113883.6.238″ displayName=”White European” codeSystemName=”OMB Standards for Race and Ethnicity”/>

<!– CONF 5407: LanguageCode Code System 2.16.840.1.113883.1.11.11526 –>

</languageCommunication>

</patient>

</patientRole>

</recordTarget>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

<manufacturerModelName>WorldVistA</manufacturerModelName>

<softwareName>Opensource CDA Documents Generator</softwareName>

</assignedAuthoringDevice>

<name>Astronaut Network</name>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

</representedOrganization>

</assignedAuthor>

</author>

<name>Astronaut Network</name>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

</representedCustodianOrganization>

</assignedCustodian>

</custodian>

</effectiveTime>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

<name>

<family>ADMINISTRATOR</family>

<given>SYSTEM</given>

</name>

</assignedPerson>

</assignedEntity>

</performer>

</serviceEvent>

</documentationOf>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

<name>

<family>ADMINISTRATOR</family>

<given>SYSTEM</given>

</name>

</assignedPerson>

</assignedEntity>

</responsibleParty>

<name>Astronaut Network</name>

<addr>

<state>TEXAS</state>

<city>HOUSTON</city>

<postalCode>HOUSTON</postalCode>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

</addr>

</location>

</healthCareFacility>

</location>

</encompassingEncounter>

</componentOf>

<title>Allergies</title>

<text>

<thead>

<tr>

<th>Allergies</th>

<th>Reaction</th>

<th>Severity</th>

<th>Comments</th>

<th>Source</th>

</tr>

</thead>

<tbody>

<tr>

<td>PENICILLIN (Rxnorm: 7980)</td>

<td>HIVES</td>

<td>MODERATE</td>

<td>Hives </td>

<td>SEVEN,HENRY</td>

</tr>

<tr>

<td>AMPICILLIN (Rxnorm: 733)</td>

<td>HIVES</td>

<td>MODERATE</td>

<td>Hives </td>

<td>SEVEN,HENRY</td>

</tr>

</tbody>

</table>

</text>

<entry>

</effectiveTime>

</effectiveTime>

</originalText>

</code>

<name>PENICILLIN</name>

</playingEntity>

</participantRole>

</participant>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

<text>

</text>

</observation>

</entryRelationship>

<text>Hives

</text>

</act>

</entryRelationship>

<value xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance” xsi:type=”ST”>SEVEN,HENRY</value>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</act>

</entry>

<entry>

</effectiveTime>

</effectiveTime>

</originalText>

</code>

<name>AMPICILLIN</name>

</playingEntity>

</participantRole>

</participant>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

<text>

</text>

</observation>

</entryRelationship>

<text>Hives

</text>

</act>

</entryRelationship>

<value xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance” xsi:type=”ST”>SEVEN,HENRY</value>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</act>

</entry>

</section>

</component>

<title> REFERRING</title>

<list>

<item> Referring or Transitioning Providers Name </item>

<item> Full Name: Dr Albert Davis First Name: Albert Last Name: Davis </item>

<item>Office Contact Information </item>

<item> Full Name: Tracy Davis First Name: Tracy Last Name: Davis Telephone: 555-555-1002 Address: 2472, Rocky place, Beaverton, OR97006 </item>

</list>

</text>

</section>

</component>

<title> LAB ORDERS</title>

<list>

<item>24357-6 LOINC Urinanalysis macro (dipstick) panel 6/22/2015</item>

<item>24357-6 LOINC Urinanalysis macro (dipstick) panel 6/29/2015 </item>

</list>

</text>

</section>

</component>

<list>

<item>UDI: (01)00643169007222(17)160128(21)BLC200461H Assigning Authority: FDA </item>

</list>

</text>

</section>

</component>

<title> COGNITIVE STATUS</title>

<list>

<item> Amnesia 48167000 SNOMED-CT 5/1/2005 </item>

</list>

</text>

</section>

</component>

<title> FUNCTIONAL STATUS</title>

<list>

<item> Dependence on Cane 105504002 SNOMED-CT 5/1/2005 </item>

</list>

</text>

</section>

</component>

<title> REASON FOR REFERRAL</title>

<list>

<item> Ms Alice Newman is being referred to Community Health Hospitals Inpatient facility because of the high fever noticed and suspected Anemia. </item>

</list>

</text>

</section>

</component>

<title> HEALTH CONCERNS</title>

<list>

<item> a. Chronic Sickness exhibited by patient b. HealthCare Concerns refer to underlying clinical facts i. Documented HyperTension problem ii. Documented HypoThyroidism problem iii. Watch Weight of patient</item>

</list>

</text>

</section>

</component>

<title> GOALS</title>

<list>

<item> a. Get rid of intermittent fever that is occurring every few weeks. b. Need to gain more energy to do regular activities </item>

</list>

</text>

</section>

</component>

<title> PLAN OF TREATMENT</title>

<list>

<item> i. Get an EKG done on 6/23/2015. ii. Get a Chest X-ray done on 6/23/2015 showing the Lower Respiratory Tract Structure. iii. Take Clindamycin 300mg three times a day as needed if pain does not subside/ iv. Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2015.</item>

</list>

</text>

</section>

</component>

<title> ASSESSMENT</title>

<list>

<item> The patient was found to have fever and Dr Davis is suspecting Anemia based on the patient history. So Dr Davis asked the patient to closely monitor the temperature and blood pressure and get admitted to Community Health Hospitals if the fever does not subside within a day. </item>

</list>

</text>

</section>

</component>

<title>CARE TEAM MEMBERS</title>

<list>

<item>DAVIS,ALBERT 2472 Rocky Place, Beaverton,OREGON 97006 Phone: 555-555-1002</item>

<item>DAVIS,TRACY 2472, Rocky place, Beaverton,OREGON 97006 Phone: 5555551002</item>

<item>SEVEN,HENRY 1002, Healthcare Dr, Portland,OREGON 97266 Phone: 5555551002</item>

</list>

</text>

</section>

</component>

<title>Immunization</title>

<text>

<thead>

<tr>

<th>Vaccine</th>

<th>Location</th>

<th>Status</th>

<th>Additional Comments</th>

</tr>

</thead>

<tbody>

<tr>

<td>influenza, intradermal, quadrivalent, preservative free (CVX: 166) (INFLUENZA-H1N1-09, NOVEL (PANDEMIC))</td>

<td>Astronaut Network</td>

<td>Completed</td>

</tr>

<tr>

<td>DTaP, 5 pertussis antigens (CVX: 106) (TETANUS DIPTHERIA (TD-ADULT))</td>

<td>Astronaut Network</td>

<td>Completed</td>

</tr>

<tr>

<td>influenza, intradermal, quadrivalent, preservative free (CVX: 166) (INFLUENZA-H1N1-09, NOVEL (PANDEMIC))</td>

<td>Astronaut Network</td>

<td>Cancelled</td>

<td>Immunization was not given – Patient rejected immunization</td>

</tr>

</tbody>

</table>

</text>

<entry>

<!– Immunization Activity entry template –>

<!– Immunization Medication Information template –>

</originalText>

</code>

</manufacturedMaterial>

<name>Influenza Vaccine Company</name>

</manufacturerOrganization>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

<entry>

<!– Immunization Activity entry template –>

<!– Immunization Medication Information template –>

</originalText>

</code>

</manufacturedMaterial>

<name>Influenza Vaccine Company</name>

</manufacturerOrganization>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

<entry>

<!– Immunization Activity entry template –>

<!– Immunization Medication Information template –>

</originalText>

</code>

</manufacturedMaterial>

<name>Influenza Vaccine Company</name>

</manufacturerOrganization>

</manufacturedProduct>

</consumable>

</substanceAdministration>

</entry>

</section>

</component>

<!– Encounters Section – required entries –>

<title>Encounters</title>

<text>

<thead>

<tr>

<th>Encounter</th>

<th>Performer</th>

<th>Location</th>

</tr>

</thead>

<tbody>

<tr>

<td ID=”uri_9000010-90793″>Fever (SCT 386661006) 386661006</td>

<td>DAVIS,ALBERT</td>

<td>NPP Astronaut Network</td>

</tr>

<tr>

<td ID=”uri_9000010-90815″>NPP VISIT </td>

<td>DAVIS,ALBERT</td>

<td>NPP Astronaut Network</td>

</tr>

</tbody>

</table>

</text>

<!– Encounter Activities –>

<!–********Encounteractivitytemplate********–>

<originalText>NPP VISIT<reference value=”#uri_9000010-90793″/>

</originalText>

</code>

</assignedEntity>

</performer>

<!– Service Delivery Location template –>

<addr>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

<city>HOUSTON</city>

<state>TEXAS</state>

</addr>

<name>Astronaut Network</name>

</playingEntity>

</participantRole>

</participant>

<!–Encounter diagnosis act –>

</effectiveTime>

<!– Problem Observation –>

</code>

</effectiveTime>

</observation>

</entryRelationship>

</act>

</entryRelationship>

</encounter>

</entry>

<!– Encounter Activities –>

<!–********Encounteractivitytemplate********–>

<originalText>NPP VISIT<reference value=”#uri_9000010-90815″/>

</originalText>

</code>

</assignedEntity>

</performer>

<!– Service Delivery Location template –>

<addr>

<streetAddressLine>7505 Fannin 170</streetAddressLine>

<city>HOUSTON</city>

<state>TEXAS</state>

</addr>

<name>Astronaut Network</name>

</playingEntity>

</participantRole>

</participant>

</encounter>

</entry>

</section>

</component>

<title>Procedure</title>

<text>

<thead>

<tr>

<th>Procedure</th>

</tr>

</thead>

<tbody>

<tr>

<td>Nebuliser therapy – 56251003 (CODE: 56251003) Nebuliser therapy – 56251003</td>

</tr>

<tr>

<td>Intro-cardiac pacemaker – 175136005 (CODE: 175135009) Intro-cardiac pacemaker – 175136005</td>

</tr>

</tbody>

</table>

</text>

</effectiveTime>

</procedure>

</entry>

</effectiveTime>

<!– ** Product instance ** –>

<!– UDI -db –>

<!– this UDI provided by the test data is not valid as per CDA schema -db –>

<!– <id root=”00643169007222″/> –>

<!– <id root=”d68b7e32-7810-4f5b-9cc2-acd54b0fd85e” extension=”00643169007222″/> –>

<!– root is FDA OID, extension is the UDI id –>

<!– the actual UDI device -db –>

</code>

</playingDevice>

<!– FDA Scoping Entity OID for UDI-db –>

</scopingEntity>

</participantRole>

</participant>

</procedure>

</entry>

</section>

</component>

<title>Social History</title>

<text>

<thead>

<tr>

<th>Start Date</th>

<th>Comments</th>

<th>Source</th>

</tr>

</thead>

<tbody>

<tr>

<td>Smokes tobacco daily (finding)</td>

<td>Snomed Code: 449868002</td>

<td>Astronaut Network</td>

</tr>

</tbody>

</table>

</text>

<entry>

<text>

</text>

</effectiveTime>

<value xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance” xsi:type=”ST”>Astronaut Network</value>

</observation>

</entryRelationship>

</observation>

</entry>

</section>

</component>

<title>Medications</title>

<text>

<thead>

<tr>

<th>Medication</th>

<th>Directions</th>

<th>Status</th>

<th>Source</th>

</tr>

</thead>

<tbody>

<tr>

<td>ceftriaxone 1 gram Solution for Injection (RxNorm: 309090)</td>

<td>1 unit intramuscular inject DAILY</td>

<td>active</td>

<td>DAVIS,ALBERT</td>

</tr>

<tr>

<td>acetaminophen 500 mg Tab (RxNorm: 209459)</td>

<td>1 tablet by mouth as directed PRN</td>

<td>active</td>

<td>DAVIS,ALBERT</td>

</tr>

<tr>

<td>Aranesp (polysorbate) 500 mcg/mL Syringe (RxNorm: 731184)</td>

<td>1 mL intramuscular inject Q1wk</td>

<td>active</td>

<td>DAVIS,ALBERT</td>

</tr>

</tbody>

</table>

</text>

<entry>

<text>

</text>

</effectiveTime>

</originalText>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</substanceAdministration>

</entry>

<entry>

<text>

</text>

</effectiveTime>

</originalText>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</substanceAdministration>

</entry>

<entry>

<text>

</text>

</effectiveTime>

</originalText>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</substanceAdministration>

</entry>

</section>

</component>

<title>Problems</title>

<text>

<thead>

<tr>

<th>Problems</th>

<th>Status</th>

<th>Source</th>

</tr>

</thead>

<tbody>

<tr>

<td>Essential hypertension (SCT 59621000)</td>

<td>ACTIVE</td>

<td>DAVIS,ALBERT</td>

</tr>

<tr>

<td>Severe hypothyroidism (SCT 83986005)</td>

<td>ACTIVE</td>

<td>DAVIS,ALBERT</td>

</tr>

<tr>

<td>Chronic rejection of renal transplant (SCT 236578006)</td>

<td>ACTIVE</td>

<td>DAVIS,ALBERT</td>

</tr>

<tr>

<td>Fever (SCT 386661006)</td>

<td>ACTIVE</td>

<td>DAVIS,ALBERT</td>

</tr>

<tr>

<td>Overweight (SCT 238131007)</td>

<td>INACTIVE</td>

<td>DAVIS,ALBERT</td>

</tr>

</tbody>

</table>

</text>

<entry>

</effectiveTime>

</code>

</text>

</effectiveTime>

<originalText>Essential hypertension (SCT 59621000)</originalText>

</value>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</act>

</entry>

<entry>

</effectiveTime>

</code>

</text>

</effectiveTime>

<originalText>Severe hypothyroidism (SCT 83986005)</originalText>

</value>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</act>

</entry>

<entry>

</effectiveTime>

</code>

</text>

</effectiveTime>

<originalText>Chronic rejection of renal transplant (SCT 236578006)</originalText>

</value>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</act>

</entry>

<entry>

</effectiveTime>

</code>

</text>

</effectiveTime>

<originalText>Fever (SCT 386661006)</originalText>

</value>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</act>

</entry>

<entry>

</effectiveTime>

</code>

</text>

</effectiveTime>

<originalText>Overweight (SCT 238131007)</originalText>

</value>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</observation>

</entryRelationship>

</act>

</entry>

</section>

</component>

<title>Lab Results</title>

<text>

<thead>

<tr>

<th>Result Code</th>

<th>Code System</th>

<th>Value</th>

<th>Reference Range</th>

</tr>

</thead>

<tbody>

<tr>

<td>LOINC</td>

<td>URINE PH</td>

<td>Value=5 units=[pH]</td>

</tr>

<tr>

<td>LOINC</td>

<td>URINE PROTEIN</td>

<td>Value=100 units=mg/dL</td>

</tr>

<tr>

<td>LOINC</td>

<td>URINE GLUCOSE</td>

<td>Value=50 units=mg/dL</td>

</tr>

<tr>

<td>LOINC</td>

<td>URINE KETONES</td>

<td>Value=Neg units=</td>

</tr>

<tr>

<td>LOINC</td>

<td>URINE COLOR</td>

<td>Value=YELLOW units=</td>

</tr>

<tr>

<td>LOINC</td>

<td>URINE DENSITY</td>

<td>Value=1.015 units=1</td>

</tr>

<tr>

<td>LOINC</td>

<td>APPEARANCE OF URINE</td>

<td>Value=CLEAR units=</td>

</tr>

</tbody>

</table>

</text>

<entry>

<originalText>URINE PH</originalText>

</code>

</text>

<value xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance” xsi:type=”ST”>Astronaut Network</value>

</observation>

</entryRelationship>

<text mediaType=”text/plain” representation=”TXT”>low: 4.5 high: 8.0 units: </text>

</value>

</observationRange>

</referenceRange>

</observation>

</component>

</organizer>

</entry>

<entry>

<originalText>URINE PROTEIN</originalText>

</code>

</text>

<value xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance” xsi:type=”ST”>Astronaut Network</value>

</observation>

</entryRelationship>

<text mediaType=”text/plain” representation=”TXT”>low: 0.0 high: 20.0 units: </text>

</value>

</observationRange>

</referenceRange>

</observation>

</component>

</organizer>

</entry>

<entry>

<originalText>URINE GLUCOSE</originalText>

</code>

</text>

<value xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance” xsi:type=”ST”>Astronaut Network</value>

</observation>

</entryRelationship>

<text mediaType=”text/plain” representation=”TXT”>low: 0.0 high: 0.8 units: mg/dL</text>

</value>

</observationRange>

</referenceRange>

</observation>

</component>

</organizer>

</entry>

<entry>

<originalText>URINE KETONES</originalText>

</code>

</text>

<value xsi:type=”ST”>Negative</value>

<value xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance” xsi:type=”ST”>Astronaut Network</value>

</observation>

</entryRelationship>

<text mediaType=”text/plain” representation=”TXT”>low: 0.6 high: 1.5 units: </text>

</observationRange>

</referenceRange>

</observation>

</component>

</organizer>

</entry>

<entry>

<originalText>URINE COLOR</originalText>

</code>

</text>

<value xsi:type=”ST”>YELLOW</value>

<value xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance” xsi:type=”ST”>Astronaut Network</value>

</observation>

</entryRelationship>

</observationRange>

</referenceRange>

</observation>

</component>

</organizer>

</entry>

<entry>

<originalText>URINE DENSITY</originalText>

</code>

</text>

<value xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance” xsi:type=”ST”>Astronaut Network</value>

</observation>

</entryRelationship>

<text mediaType=”text/plain” representation=”TXT”>low: 1.005 high: 1.030 units: </text>

</value>

</observationRange>

</referenceRange>

</observation>

</component>

</organizer>

</entry>

<entry>

<originalText>APPEARANCE OF URINE</originalText>

</code>

</text>

<value xsi:type=”ST”>CLEAR</value>

<value xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance” xsi:type=”ST”>ASTRONAUT HARRRIS COUNTY NET</value>

</observation>

</entryRelationship>

</observationRange>

</referenceRange>

</observation>

</component>

</organizer>

</entry>

</section>

</component>

<title>Vital Signs</title>

<text>

<thead>

<tr>

<th>Vital Sign</th>

<th>Value</th>

<th>Details</th>

<th>Source</th>

</tr>

</thead>

<tbody>

<tr>

<td>BLOOD PRESSURE</td>

</tr>

<tr>

<td>HEIGHT</td>

</tr>

<tr>

<td>PULSE</td>

</tr>

<tr>

<td>PULSE OXIMETRY</td>

</tr>

<tr>

<td>RESPIRATION</td>

</tr>

<tr>

<td>TEMPERATURE</td>

</tr>

<tr>

<td>WEIGHT</td>

</tr>

<tr>

<td>INHALED OXYGEN CONCENTRATION</td>

<td>Clinic One1 </td>

</tr>

</tbody>

</table>

</text>

<entry>

</code>

<originalText>BLOOD PRESSURE</originalText>

</code>

</text>

</observation>

</entryRelationship>

</observation>

</component>

<originalText>BLOOD PRESSURE</originalText>

</code>

</text>

</observation>

</entryRelationship>

</observation>

</component>

<originalText>HEIGHT</originalText>

</code>

</text>

</observation>

</entryRelationship>

</observation>

</component>

<originalText>PULSE</originalText>

</code>

</text>

</observation>

</entryRelationship>

</observation>

</component>

<originalText>PULSE OXIMETRY</originalText>

</code>

</text>

</observation>

</entryRelationship>

</observation>

</component>

<originalText>RESPIRATION</originalText>

</code>

</text>

</observation>

</entryRelationship>

</observation>

</component>

<originalText>TEMPERATURE</originalText>

</code>

</text>

</observation>

</entryRelationship>

</observation>

</component>

<originalText>WEIGHT</originalText>

</code>

</text>

</observation>

</entryRelationship>

</observation>

</component>

</organizer>

</entry>

<entry>

</code>

<originalText>INHALED OXYGEN CONCENTRATION</originalText>

</code>

</text>

<value xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance” xsi:type=”ST”>Clinic One1</value>

</observation>

</entryRelationship>

</observation>

</component>

<originalText>PULSE OXIMETRY</originalText>

</code>

</text>

<value xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance” xsi:type=”ST”>Clinic One1</value>

</observation>

</entryRelationship>

</observation>

</component>

</organizer>

</entry>

</section>

</component>

</structuredBody>

</component>

</ClinicalDocument>