Getting Error while validating CCDA
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Gulshan Dhiman
Sep 19, 2025, 9:36:05 AMSep 19
to Edge Test Tool (ETT)
Mat Davis
Sep 19, 2025, 7:57:52 PMSep 19
to Edge Test Tool (ETT)
Hi Gulshan.
As an unofficial supporting user, I think providing more details can help the ETT Team reproduce, identify and/or resolve this issue.
1. Screenshot or details of the actual test criteria and patient you were testing
2. Full screenshot of the error
3. Confirming if the error is still occurring
4. Confirming if the error occurs from a different browser
Thanks - Mat
Gulshan Dhiman
Sep 24, 2025, 4:29:54 AM (10 days ago) Sep 24
to Edge Test Tool (ETT)
Hi Davis,
I am still getting an error on different browsers as well.
Please see the screenshots for my testing criteria.
I am still getting an error on different browsers as well.
Please see the screenshots for my testing criteria.
Mat Davis
Sep 24, 2025, 8:08:31 AM (10 days ago) Sep 24
to Edge Test Tool (ETT)
Hi Gulshan.
Based on your error message, there is a value that is expected that is not present.
The Official ETT Google Group Team can help resolve the issue but they usually require your specific XML file so they can reproduce the issue and find the exact location / cause.
Thanks - Mat
Gulshan Dhiman
Sep 24, 2025, 10:47:30 AM (10 days ago) Sep 24
to Edge Test Tool (ETT)
<?xml version="1.0" encoding="UTF-8"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!--
Title: Continuity of Care Document (CCD).
-->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xmlns="urn:hl7-org:v3"
xmlns:voc="urn:hl7-org:v3/voc"
xmlns:sdtc="urn:hl7-org:sdtc">
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2015-08-01"/><!-- conforms to CCD Template(V2) ID requirements -->
<templateId root="2.16.840.1.113883.10.20.22.1.2" extension="2015-08-01"/><!-- UNIQUE DOCUMENT IDENTIFIER -->
<!-- <id extension="Test CCDA" root="1.1.1.1.1.1.1.1.1"/> -->
<id extension="TT660" root="2.16.840.1.113883.19.5.99999.1"/>
<code code="34133-9" displayName="Summarization of patient data" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>HEALTH HISTORY & PHYSICAL</title>
<effectiveTime value="20250923132320-0400"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<recordTarget>
<patientRole>
<id root="idoc-mrn" extension="1"/>
<addr use="HP">
<streetAddressLine>Test123</streetAddressLine>
<streetAddressLine>Street4</streetAddressLine>
<city>Englewood Cliffs</city>
<state>NJ</state>
<postalCode>07632</postalCode>
<country>US</country>
</addr><!--Cures Update Previous address--><!--Cures Update Previous address-->
<addr use="H">
<streetAddressLine nullFlavor="UNK" />
<city nullFlavor="UNK" />
<state nullFlavor="UNK" />
<postalCode nullFlavor="UNK" />
<country nullFlavor="UNK" />
</addr>
<telecom value="tel:+1666-555-4448" use="HP"/>
<telecom value="tel:+1666-555-4448" use="MC"/>
<telecom value="mailto:imw...@testimw.com"/>
<patient>
<name>
<prefix>Mr.</prefix>
<given qualifier="CL">IMWTest</given>
<given>Test</given>
<family>Doe</family>
<suffix nullFlavor="UNK" />
</name><!--Cures Update Previous Name--><!--Cures Update Previous Name-->
<name>
<given nullFlavor="UNK" />
<family nullFlavor="UNK" />
</name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"
displayName="Male" codeSystemName="AdministrativeGender"/>
<birthTime value="19850220"/>
<maritalStatusCode code="S" displayName="Never Married"
codeSystem="2.16.840.1.113883.5.2" codeSystemName="MaritalStatus"/>
<raceCode code="2028-9" displayName="Asian" codeSystem="2.16.840.1.113883.6.238" codeSystemName="CDCREC"/>
<ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino"
codeSystem="2.16.840.1.113883.6.238" codeSystemName="CDCREC"/>
<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="1.1.1.1.1.1.1.1.4"/>
<name>Manchester</name>
<telecom use="WP" value="tel:+1860-649-9973"/>
<addr use="WP">
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget><!-- The author represents the person who provides the content in the document -->
<author>
<time value="20250923132320-0400"/>
<assignedAuthor>
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr use="WP">
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given qualifier="CL">ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3982" />
<name>Manchester</name>
<telecom use="WP" value="tel:+1-860-649-9973"/>
<addr use="WP">
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author><!-- The dataEnterer transferred the content created by the author into the document -->
<dataEnterer>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="1234567891"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
</assignedEntity>
</dataEnterer>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="99998899" root="2.16.840.1.113883.4.6"/>
<name>New Britain</name>
<telecom use="WP" value="tel:+1-860-649-9973"/>
<addr use="WP">
<streetAddressLine>1232 Corbin Ave. </streetAddressLine>
<city>New Britain</city>
<state>CT</state>
<postalCode>06053</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian><!-- The informationRecipient represents the intended recipient of the document -->
<informationRecipient>
<intendedRecipient classCode="ASSIGNED">
<informationRecipient>
<name>
<given nullFlavor="UNK" />
<family nullFlavor="UNK" />
</name>
</informationRecipient>
<receivedOrganization>
<name nullFlavor="UNK" />
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<time value="20250923132320-0400"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="999998899" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ECL</given>
<family>iMedicWare</family>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<documentationOf>
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="20250923132320-0400"/>
<high value="20250923132320-0400" />
</effectiveTime>
<performer typeCode="PRF">
<functionCode code="PCP" codeSystem="2.16.840.1.113883.5.88" codeSystemName="ParticipationFunction" displayName="Primary Care Provider">
<originalText>Primary Care Provider</originalText>
</functionCode>
<assignedEntity>
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<!-- <code code="207QA0505X" displayName="Adult Medicine" codeSystem="2.16.840.1.113883.6.101" codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/> -->
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3982" />
<name>Manchester</name>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<component>
<structuredBody><!-- SOCIAL HISTORY SECTION -->
<component>
<section >
<templateId root="2.16.840.1.113883.10.20.22.2.17" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.17"/>
<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social History"/>
<title>SOCIAL HISTORY</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Social History Observation</th>
<th>Description</th>
<th>Dates Observed</th>
</tr>
</thead>
<tbody>
<tr>
<td>Smoking Status</td>
<td>Current every day smoker (SNOMED-CT: 449868002)</td>
<td>September 01, 2025 - September 08, 2025</td>
</tr>
<tr>
<td ID="BirthSexInfo">Birth Sex</td>
<td>Male</td>
<td>September 08,2025</td>
</tr>
</tbody>
</table>
<br/>
<paragraph>Social Determinants of Health Assessments</paragraph>
<br/>
<table border="1" width="100%">
<thead>
<tr>
<th>SDOH Assessment</th>
<th>Effective Date</th>
<th>SDOH Response</th>
</tr>
</thead>
<tbody>
<tr>
<td ID="SDOHAssessmentCategory_1" colspan="3">Personal Characteristics</td>
</tr>
<tr>
<td ID="SDOHAssessment_1">Are you Hispanic or Latino?</td>
<td>September 04,2025</td>
<td>No</td>
</tr>
<tr>
<td ID="SDOHAssessment_2">Which race(s) are you?</td>
<td>September 03,2025</td>
<td>Asian</td>
</tr>
<tr>
<td ID="SDOHAssessment_3">At any point in the past 2 years, has season or migrant farm work been your or your familys main source of income?</td>
<td>September 04,2025</td>
<td>Yes</td>
</tr>
<tr>
<td ID="SDOHAssessment_4">Have you been discharged from the armed forces of the United States?</td>
<td>September 03,2025</td>
<td>I choose not to answer this question</td>
</tr>
<tr>
<td ID="SDOHAssessment_5">What language are you most comfortable speaking?</td>
<td>September 03,2025</td>
<td>English</td>
</tr>
<tr>
<td ID="SDOHAssessmentCategory_2" colspan="3">Family and Home</td>
</tr>
<tr>
<td ID="SDOHAssessment_6">How many family members, including yourself, do you currently live with?</td>
<td>September 03,2025</td>
<td>4</td>
</tr>
<tr>
<td ID="SDOHAssessment_7">What is your housing situation today?</td>
<td>September 03,2025</td>
<td>I have housing</td>
</tr>
<tr>
<td ID="SDOHAssessment_8">Are you worried about losing your housing?</td>
<td>September 04,2025</td>
<td>No</td>
</tr>
<tr>
<td ID="SDOHAssessment_9">What address do you live at?</td>
<td>September 04,2025</td>
<td>Test123, Street4, Englewood Cliffs, NJ, 07632, Bergen County, USA</td>
</tr>
<tr>
<td ID="SDOHAssessmentCategory_3" colspan="3">Money and Resources</td>
</tr>
<tr>
<td ID="SDOHAssessment_10">What is the highest level of school that you have finished?</td>
<td>September 04,2025</td>
<td>Less than high school degree</td>
</tr>
<tr>
<td ID="SDOHAssessment_11">What is your current work situation?</td>
<td>September 04,2025</td>
<td>Part-time or temporary work</td>
</tr>
<tr>
<td ID="SDOHAssessment_12">What is your main insurance?</td>
<td>September 04,2025</td>
<td>CHIP Medicaid</td>
</tr>
<tr>
<td ID="SDOHAssessment_13">During the past year, what was the total combined income for you and the family members you live with? This information will help us determine if you are eligible for any benefits.</td>
<td>September 04,2025</td>
<td>567687</td>
</tr>
<tr>
<td ID="SDOHAssessment_14">In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?</td>
<td>September 04,2025</td>
<td>Food</td>
</tr>
<tr>
<td ID="SDOHAssessment_15">Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living</td>
<td>September 04,2025</td>
<td>Yes (it has kept me from medical appointments or from getting my medications)</td>
</tr>
<tr>
<td ID="SDOHAssessmentCategory_4" colspan="3">Social and Emotional Health</td>
</tr>
<tr>
<td ID="SDOHAssessment_16">How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone or visiting friends or family or going to church or club meetings)?</td>
<td>September 04,2025</td>
<td>1 or 2 times a week</td>
</tr>
<tr>
<td ID="SDOHAssessment_17">Stress is when someone feels tense, nervous, anxious or can not sleep at night because their mind is troubled - how stressed are you?</td>
<td>September 04,2025</td>
<td>A little bit</td>
</tr>
<tr>
<td ID="SDOHAssessmentCategory_5" colspan="3">Optional Additional Questions</td>
</tr>
<tr>
<td ID="SDOHAssessment_18">In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?</td>
<td>September 02,2025</td>
<td>No</td>
</tr>
<tr>
<td ID="SDOHAssessment_19">Are you a refugee?</td>
<td>September 03,2025</td>
<td>Yes</td>
</tr>
<tr>
<td ID="SDOHAssessment_20">Do you feel physically and emotionally safe where you currently live?</td>
<td>September 02,2025</td>
<td>I choose not to answer this question</td>
</tr>
<tr>
<td ID="SDOHAssessment_21">In the past year, have you been afraid of your partner or ex-partner?</td>
<td>September 04,2025</td>
<td>Yes</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.78" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.78"/>
<id root="2.16.840.1.113883.19" extension="123456789" />
<code code="72166-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Tobacco smoking status NHIS"/>
<statusCode code="completed"/>
<effectiveTime nullFlavor="UNK"/>
<value xsi:type="CD" code="449868002"
displayName="Current every day smoker"
codeSystem="2.16.840.1.113883.6.96"/>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.200" extension="2016-06-01"/>
<code code="76689-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Sex Assigned At Birth"/>
<text>
<reference value="#BirthSexInfo"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250908"/>
<value xsi:type="CD" codeSystem="2.16.840.1.113883.5.1"
code="M"
displayName="Male"/>
</observation>
</entry>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.69" extension="2022-06-01"/>
<id root="5327c521-d029-42ac-a261-92e94ddd336e"/>
<code code="93043-8" displayName="Personal Characteristics" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessmentCategory_1"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250923"/>
<value xsi:type="CD" nullFlavor="NA"/>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="def47092-9655-4f17-8b76-509ccf97e1ba"/>
<code code="56051-6" displayName="Are you Hispanic or Latino?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_1"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
<value xsi:type="CO" code="LA32-8" displayName="No" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="c6e7eec3-1417-4234-a70b-bc73aaa4c6b4"/>
<code code="32624-9" displayName="Which race(s) are you?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_2"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250903"/>
<value xsi:type="CO" code="LA6156-9" displayName="Asian" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="374b2d7b-346c-437e-8918-1c5d992ab1c8"/>
<code code="93035-4" displayName="At any point in the past 2 years, has season or migrant farm work been your or your familys main source of income?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_3"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
<value xsi:type="CO" code="LA33-6" displayName="Yes" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="572af04a-358c-4eb5-94ea-cc78dc98eb46"/>
<code code="93034-7" displayName="Have you been discharged from the armed forces of the United States?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_4"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250903"/>
<value xsi:type="CO" code="LA30122-8" displayName="I choose not to answer this question" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="5d955ec9-8ce6-4639-90aa-62083408c69f"/>
<code code="54899-0" displayName="What language are you most comfortable speaking?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_5"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250903"/>
<value xsi:type="CO" code="LA43-5" displayName="English" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
</observation>
</entry>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.69" extension="2022-06-01"/>
<id root="9a567dec-94f8-4a3d-9086-f099f8818f80"/>
<code code="93042-0" displayName="Family and Home" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessmentCategory_2"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250923"/>
<value xsi:type="CD" nullFlavor="NA"/>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="5164bb26-68d8-4490-a886-f580c673819f"/>
<code code="63512-8" displayName="How many family members, including yourself, do you currently live with?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_6"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250903"/>
<value xsi:type="INT" value="4"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="51fa8be1-4872-4932-b6b1-3e261a838b85"/>
<code code="71802-3" displayName="What is your housing situation today?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_7"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250903"/>
<value xsi:type="CO" code="LA30189-7" displayName="I have housing" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="fcac204d-c90d-4709-9737-59213947a173"/>
<code code="93033-9" displayName="Are you worried about losing your housing?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_8"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
<value xsi:type="CO" code="LA32-8" displayName="No" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="7f899d8e-7c2d-4260-9fdf-7c12c49e547d"/>
<code code="56799-0" displayName="What address do you live at?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_9"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
<value xsi:type="AD">
<streetAddressLine>Test123</streetAddressLine>
<city>Englewood Cliffs</city>
<state>NJ</state>
<postalCode>07632</postalCode>
<country>USA</country>
</value>
</observation>
</entryRelationship>
</observation>
</entry>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.69" extension="2022-06-01"/>
<id root="13393eb4-20ec-4ab2-8222-92f6ece4d2d3"/>
<code code="93041-2" displayName="Money and Resources" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessmentCategory_3"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250923"/>
<value xsi:type="CD" nullFlavor="NA"/>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="8f6d2455-e6da-4324-9db1-912461363df8"/>
<code code="82589-3" displayName="What is the highest level of school that you have finished?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_10"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
<value xsi:type="CO" code="LA30191-3" displayName="Less than high school degree" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="92a15d39-56bd-4dae-b362-2aa7b77052b2"/>
<code code="67875-5" displayName="What is your current work situation?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_11"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
<value xsi:type="CO" code="LA30138-4" displayName="Part-time or temporary work" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="4e02d70a-b70c-4fe9-b879-c6c7bd571987"/>
<code code="76437-3" displayName="What is your main insurance?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_12"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
<value xsi:type="CO" code="LA30195-4" displayName="CHIP Medicaid" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="02d7b9ba-b3ce-43ca-ba9b-dc4bbe4638ac"/>
<code code="63586-2" displayName="During the past year, what was the total combined income for you and the family members you live with? This information will help us determine if you are eligible for any benefits." codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_13"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
<value xsi:type="INT" value="567687"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="71305901-f10c-4b3d-90a6-93834a2be442"/>
<code code="93031-3" displayName="In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_14"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
<value xsi:type="CO" code="LA30125-1" displayName="Food" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="2f23f4b9-b0c1-4a0c-b18e-20e7639a582f"/>
<code code="93030-5" displayName="Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_15"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
<value xsi:type="CO" code="LA30133-5" displayName="Yes (it has kept me from medical appointments or from getting my medications)" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
</observation>
</entry>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.69" extension="2022-06-01"/>
<id root="a1558414-33da-4049-8a83-cc709ed69410"/>
<code code="93040-4" displayName="Social and Emotional Health" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessmentCategory_4"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250923"/>
<value xsi:type="CD" nullFlavor="NA"/>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="9c29069f-0d43-4418-bd2e-841e0a1193c0"/>
<code code="93029-7" displayName="How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone or visiting friends or family or going to church or club meetings)?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_16"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
<value xsi:type="CO" code="LA30130-1" displayName="1 or 2 times a week" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="2703bdf1-797a-4c7e-afbf-6aa8a9302e45"/>
<code code="93038-8" displayName="Stress is when someone feels tense, nervous, anxious or can not sleep at night because their mind is troubled - how stressed are you?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_17"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
<value xsi:type="CO" code="LA13863-8" displayName="A little bit" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
</observation>
</entry>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.69" extension="2022-06-01"/>
<id root="5778f5c2-8461-4cbe-b3f4-e228b5a29b5e"/>
<code code="93039-6" displayName="Optional Additional Questions" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessmentCategory_5"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250923"/>
<value xsi:type="CD" nullFlavor="NA"/>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="f3509b9a-76f1-4ebb-8810-f87c85e75095"/>
<code code="93028-9" displayName="In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_18"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250902"/>
<value xsi:type="CO" code="LA32-8" displayName="No" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="5fe90ba7-d8a7-43c4-90a3-4f694cefab36"/>
<code code="93027-1" displayName="Are you a refugee?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_19"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250903"/>
<value xsi:type="CO" code="LA33-6" displayName="Yes" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="89573ab2-34aa-4ce1-8a9d-8b88b5702222"/>
<code code="93026-3" displayName="Do you feel physically and emotionally safe where you currently live?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_20"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250902"/>
<value xsi:type="CO" code="LA30122-8" displayName="I choose not to answer this question" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="116d5e7e-11b7-41fd-9b61-2c67cbbf3019"/>
<code code="76501-6" displayName="In the past year, have you been afraid of your partner or ex-partner?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_21"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
<value xsi:type="CO" code="LA33-6" displayName="Yes" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
</observation>
</entry>
</section>
</component><!-- MEDICATIONS SECTION -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of medications"/>
<title>MEDICATIONS</title>
<text>
<table border = "1" width = "100%">
<thead>
<tr>
<th>Medication</th>
<th>Start Date</th>
<th>End Date</th>
<th>Route</th>
<th>Dose</th>
<th>Frequency</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<content ID ="Med6">Restasis [RxNorm: 352951]</content>
</td>
<td>Sep 09,2025</td>
<td></td>
<td ID = "MEDROUTE6"></td>
<td ID = "MEDFORM6">1</td>
<td ID = "Instruct6">bid</td>
</tr>
<tr>
<td>
<content ID ="Med19">Ava [RxNorm: 34534]</content>
</td>
<td>Sep 09,2025</td>
<td></td>
<td ID = "MEDROUTE19"></td>
<td ID = "MEDFORM19">3</td>
<td ID = "Instruct19">sig2</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="cdbd33f0-6cde-11db-9fe1-0800200c9a66" extension="Med6" />
<text>
<reference value="#Med6"/>Restasis [RxNorm: 352951]</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20250909"/>
<high nullFlavor="NI"/>
</effectiveTime>
<routeCode code="C38287" codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="National Cancer Institute (NCI) Thesaurus"
displayName="OPHTHALMIC"/>
<approachSiteCode code="362502000" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="Entire right eye (body structure)"/>
<doseQuantity nullFlavor="NI"/>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="352951"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"
displayName="Restasis">
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="cdbd33f0-6cde-11db-9fe1-0800200c9a66" extension="Med19" />
<text>
<reference value="#Med19"/>Ava [RxNorm: 34534]</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20250909"/>
<high nullFlavor="NI"/>
</effectiveTime>
<routeCode code="C38287" codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="National Cancer Institute (NCI) Thesaurus"
displayName="OPHTHALMIC"/>
<approachSiteCode code="244486005" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="Entire eye (body structure)"/>
<doseQuantity nullFlavor="NI"/>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="34534"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"
displayName="Ava">
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component><!-- ALLERGIES SECTION -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.6.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of allergies"/>
<title>ALLERGIES & REACTIONS</title>
<text>No allergy data.</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.30" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id nullFlavor="NI"/> <!-- Allergy Problem Act template -->
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts"/>
<statusCode code="active"/>
<effectiveTime>
<low nullFlavor="NI"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN" >
<templateId root="2.16.840.1.113883.10.20.22.4.7" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id nullFlavor="NI"/> <!-- Allergy - intolerance observation template -->
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime nullFlavor="UNK"/>
<value xsi:type="CD" nullFlavor="NI"/>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code nullFlavor="NI"/>
</playingEntity>
</participantRole>
</participant>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component><!-- IMMUNIZATION SECTION -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.2.1" />
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of immunizations" />
<title>IMMUNIZATIONS</title>
<text>No immunization data found.</text>
</section>
</component><!-- VITAL SIGN SECTION -->
<component>
<section nullFlavor="NI">
<!-- Vitals Section (entries required) (V3) nullflavor -->
<templateId root="2.16.840.1.113883.10.20.22.2.4.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.4.1"/>
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="VITAL SIGNS"/>
<title>VITAL SIGNS</title>
<text>No Vital Signs Information</text>
</section>
</component><!-- PROBLEM SECTION --><!-- ***************** PROBLEM LIST *********************** -->
<!-- edited as per test doc - all data relevant -db -->
<component>
<section >
<!-- *** Problem Section (entries required) (V3) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROBLEM LIST"/>
<title>PROBLEMS</title>
<text>
<table border = "1" width = "100%">
<thead>
<tr>
<th>Problem</th>
<th>Effective Dates</th>
<th>Problem Status</th>
</tr>
</thead>
<tbody>
<tr ID = "PROBSUMMARY_1">
<td ID = "PROBKIND_1">POAG; Left Eye Mild, Right Eye Moderate Both Eyes (H40.1121, H40.1112) [SNOMED-CT: 15013002]</td>
<td>Dec 20,2017</td>
<td ID = "PROBSTATUS_1">Active</td>
</tr>
<tr ID = "PROBSUMMARY_6">
<td ID = "PROBKIND_6">CENTRAL RETINAL VEIN OCCLUSION; Left Eye w/ret neovaculaization, Right Eye w/ macular edema Both Eyes (H34.8121, H34.8110) [SNOMED-CT: 15013002]</td>
<td>Apr 18,2018</td>
<td ID = "PROBSTATUS_6">Active</td>
</tr>
<tr ID = "PROBSUMMARY_12">
<td ID = "PROBKIND_12">VITREOUS FLOATERS; Right Eye (H43.391) [SNOMED-CT: 15013002]</td>
<td>Nov 30,2018</td>
<td ID = "PROBSTATUS_12">Active</td>
</tr>
<tr ID = "PROBSUMMARY_18">
<td ID = "PROBKIND_18">AGE RELATED MACULAR DEGENERATION DRY; Right Eye (H35.3112) [SNOMED-CT: 15013002]</td>
<td>May 14,2025</td>
<td ID = "PROBSTATUS_18">Active</td>
</tr>
<tr ID = "PROBSUMMARY_20">
<td ID = "PROBKIND_20">Myopia ; Both Eyes (H52.13) [SNOMED-CT: 57190000]</td>
<td>Jun 09,2025</td>
<td ID = "PROBSTATUS_20">Active</td>
</tr>
<tr ID = "PROBSUMMARY_21">
<td ID = "PROBKIND_21">Presbyopia ; Both Eyes (H52.4) [SNOMED-CT: 41256004]</td>
<td>Jun 09,2025</td>
<td ID = "PROBSTATUS_21">Active</td>
</tr>
<tr ID = "PROBSUMMARY_27">
<td ID = "PROBKIND_27">HYPERTENSION SECONDARY TO ENDOCRINE DISORDERS (ICD-10-CM I15.2) [SNOMED-CT: 41256004]</td>
<td>Jul 28,2025</td>
<td ID = "PROBSTATUS_27">Active</td>
</tr>
</tbody>
</table>
<br/>
<paragraph>Social Determinants of Problems/Health Concern</paragraph>
<br/>
<table border="1" width="100%">
<thead>
<tr>
<th>SDOH Problem</th>
<th>Effective Dates</th>
<th>Problem Status</th>
</tr>
</thead>
<tbody>
<tr ID="SDOHProblemObs_1">
<td ID="SDOHProblem_1">ESSENTIAL (PRIMARY) HYPERTENSION (ICD-10-CM I10)</td>
<td>September 04,2025</td>
<td>Active</td>
</tr>
<tr ID="SDOHProblemObs_2">
<td ID="SDOHProblem_2">ADULT PHYSICAL ABUSE, SUSPECTED (ICD-10-CM T76.11XA)</td>
<td>September 03,2025</td>
<td>Active</td>
</tr>
<tr ID="SDOHProblemObs_5">
<td ID="SDOHProblem_5">3RD (OCULOMOTOR) NERVE PALSY (ICD-10-CM H49.011)</td>
<td>September 03,2025</td>
<td>Active</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<!-- ** Problem Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<id root="ec8a6ff8-ed4b-4f7e-89c3-e98e58b45df9" />
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" />
<!-- The statusCode represents the need to continue tracking the problem -->
<!-- This is of ongoing concern to the provider -->
<!-- The concern is not active, in terms of there being an active condition to be managed.-->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value represents when the problem was first recorded in the patients chart -->
<!-- since no test data was given for this information,
and a low element is required to exist, used nullFlavor -db -->
<low value="20171220"/><!-- The high value reflects when there was no longer a need to track the problem -->
<!-- since no test data was given for this information, used nullFlavor -db -->
<high nullFlavor="UNK"/>
</effectiveTime>
<!-- removed author as not required -db -->
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Problem observation (V3)** -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800200c2601"/>
<code code="55607006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Problem">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem" />
</code><!-- The statusCode reflects the status of the observation itself -->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value reflects the date of onset -->
<low value="20171220"/>
<!-- The high value reflects when the problem was known to be resolved -->
<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="15013002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="POAG; Left Eye Mild, Right Eye Moderate Both Eyes (H40.1121, H40.1112)"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<!-- ** Problem Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<id root="ec8a6ff8-ed4b-4f7e-89c3-e98e58b45df9" />
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" />
<!-- The statusCode represents the need to continue tracking the problem -->
<!-- This is of ongoing concern to the provider -->
<!-- The concern is not active, in terms of there being an active condition to be managed.-->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value represents when the problem was first recorded in the patients chart -->
<!-- since no test data was given for this information,
and a low element is required to exist, used nullFlavor -db -->
<low value="20180418"/><!-- The high value reflects when there was no longer a need to track the problem -->
<!-- since no test data was given for this information, used nullFlavor -db -->
<high nullFlavor="UNK"/>
</effectiveTime>
<!-- removed author as not required -db -->
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Problem observation (V3)** -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800200c2602"/>
<code code="404684003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Finding">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Finding" />
</code><!-- The statusCode reflects the status of the observation itself -->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value reflects the date of onset -->
<low value="20180418"/>
<!-- The high value reflects when the problem was known to be resolved -->
<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="15013002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="CENTRAL RETINAL VEIN OCCLUSION; Left Eye w/ret neovaculaization, Right Eye w/ macular edema Both Eyes (H34.8121, H34.8110)"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<!-- ** Problem Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<id root="ec8a6ff8-ed4b-4f7e-89c3-e98e58b45df9" />
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" />
<!-- The statusCode represents the need to continue tracking the problem -->
<!-- This is of ongoing concern to the provider -->
<!-- The concern is not active, in terms of there being an active condition to be managed.-->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value represents when the problem was first recorded in the patients chart -->
<!-- since no test data was given for this information,
and a low element is required to exist, used nullFlavor -db -->
<low value="20181130"/><!-- The high value reflects when there was no longer a need to track the problem -->
<!-- since no test data was given for this information, used nullFlavor -db -->
<high nullFlavor="UNK"/>
</effectiveTime>
<!-- removed author as not required -db -->
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Problem observation (V3)** -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800200c2603"/>
<code code="55607006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Problem">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem" />
</code><!-- The statusCode reflects the status of the observation itself -->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value reflects the date of onset -->
<low value="20181130"/>
<!-- The high value reflects when the problem was known to be resolved -->
<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="15013002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="VITREOUS FLOATERS; Right Eye (H43.391)"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<!-- ** Problem Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<id root="ec8a6ff8-ed4b-4f7e-89c3-e98e58b45df9" />
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" />
<!-- The statusCode represents the need to continue tracking the problem -->
<!-- This is of ongoing concern to the provider -->
<!-- The concern is not active, in terms of there being an active condition to be managed.-->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value represents when the problem was first recorded in the patients chart -->
<!-- since no test data was given for this information,
and a low element is required to exist, used nullFlavor -db -->
<low value="20250514"/><!-- The high value reflects when there was no longer a need to track the problem -->
<!-- since no test data was given for this information, used nullFlavor -db -->
<high nullFlavor="UNK"/>
</effectiveTime>
<!-- removed author as not required -db -->
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Problem observation (V3)** -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800200c2604"/>
<code code="55607006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Problem">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem" />
</code><!-- The statusCode reflects the status of the observation itself -->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value reflects the date of onset -->
<low value="20250514"/>
<!-- The high value reflects when the problem was known to be resolved -->
<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="15013002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="AGE RELATED MACULAR DEGENERATION DRY; Right Eye (H35.3112)"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<!-- ** Problem Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<id root="ec8a6ff8-ed4b-4f7e-89c3-e98e58b45df9" />
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" />
<!-- The statusCode represents the need to continue tracking the problem -->
<!-- This is of ongoing concern to the provider -->
<!-- The concern is not active, in terms of there being an active condition to be managed.-->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value represents when the problem was first recorded in the patients chart -->
<!-- since no test data was given for this information,
and a low element is required to exist, used nullFlavor -db -->
<low value="20250609"/><!-- The high value reflects when there was no longer a need to track the problem -->
<!-- since no test data was given for this information, used nullFlavor -db -->
<high nullFlavor="UNK"/>
</effectiveTime>
<!-- removed author as not required -db -->
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Problem observation (V3)** -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800200c2605"/>
<code code="404684003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Finding">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Finding" />
</code><!-- The statusCode reflects the status of the observation itself -->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value reflects the date of onset -->
<low value="20250609"/>
<!-- The high value reflects when the problem was known to be resolved -->
<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="57190000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Myopia ; Both Eyes (H52.13)"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<!-- ** Problem Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<id root="ec8a6ff8-ed4b-4f7e-89c3-e98e58b45df9" />
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" />
<!-- The statusCode represents the need to continue tracking the problem -->
<!-- This is of ongoing concern to the provider -->
<!-- The concern is not active, in terms of there being an active condition to be managed.-->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value represents when the problem was first recorded in the patients chart -->
<!-- since no test data was given for this information,
and a low element is required to exist, used nullFlavor -db -->
<low value="20250609"/><!-- The high value reflects when there was no longer a need to track the problem -->
<!-- since no test data was given for this information, used nullFlavor -db -->
<high nullFlavor="UNK"/>
</effectiveTime>
<!-- removed author as not required -db -->
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Problem observation (V3)** -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800200c2606"/>
<code code="404684003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Finding">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Finding" />
</code><!-- The statusCode reflects the status of the observation itself -->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value reflects the date of onset -->
<low value="20250609"/>
<!-- The high value reflects when the problem was known to be resolved -->
<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="41256004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Presbyopia ; Both Eyes (H52.4)"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<!-- ** Problem Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<id root="ec8a6ff8-ed4b-4f7e-89c3-e98e58b45df9" />
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" />
<!-- The statusCode represents the need to continue tracking the problem -->
<!-- This is of ongoing concern to the provider -->
<!-- The concern is not active, in terms of there being an active condition to be managed.-->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value represents when the problem was first recorded in the patients chart -->
<!-- since no test data was given for this information,
and a low element is required to exist, used nullFlavor -db -->
<low value="20250728"/><!-- The high value reflects when there was no longer a need to track the problem -->
<!-- since no test data was given for this information, used nullFlavor -db -->
<high nullFlavor="UNK"/>
</effectiveTime>
<!-- removed author as not required -db -->
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Problem observation (V3)** -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800200c2607"/>
<code code="404684003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Finding">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Finding" />
</code><!-- The statusCode reflects the status of the observation itself -->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value reflects the date of onset -->
<low value="20250728"/>
<!-- The high value reflects when the problem was known to be resolved -->
<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="41256004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="HYPERTENSION SECONDARY TO ENDOCRINE DISORDERS (ICD-10-CM I15.2)"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry>
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01"/>
<id root="03217647-8939-4bc7-a608-53de0585de0e"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
<text>
<reference value="#SDOHProblemObs_1"/>
</text>
<statusCode code="active"/>
<effectiveTime>
<low value="20250904"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2022-06-01"/>
<id extension="68993" root="1.2.840.114350.1.13.6289.1.7.2.768076"/>
<id root="83a0a70f-3dea-4c71-bc4a-57011d09c1d7" extension="1.1"/>
<code code="55607006" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Problem">
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Problem"/>
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20250904"/>
</effectiveTime>
<value xsi:type="CD" code="1201005"
displayName="Benign essential hypertension"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<originalText>
<reference value="#SDOHProblem_1"/>
</originalText>
<translation code="I10" codeSystem="2.16.840.1.113883.6.90"
codeSystemName="ICD-10-CM"
displayName="ESSENTIAL (PRIMARY) HYPERTENSION"/>
</value>
<author> <!--Cures Update Proverance-->
<!-- Provenance - Author Participation -->
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20250923132320-0400"/>
<assignedAuthor>
<!-- NPI of Author (example) -->
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3888" />
<name>Manchester</name>
<telecom value="tel:+1-860-649-9973"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
</observation>
</entryRelationship>
</act>
</entry>
<entry>
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01"/>
<id root="2f2d7c96-7487-4de1-86df-1415c4f51529"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
<text>
<reference value="#SDOHProblemObs_2"/>
</text>
<statusCode code="active"/>
<effectiveTime>
<low value="20250903"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2022-06-01"/>
<id extension="68993" root="1.2.840.114350.1.13.6289.1.7.2.768076"/>
<id root="a365374e-1edd-4eb6-9d0f-a8191363f7ba" extension="1.1"/>
<code code="55607006" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Problem">
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Problem"/>
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20250903"/>
</effectiveTime>
<value xsi:type="CD" code="129588001"
displayName="Adult failure to thrive syndrome"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<originalText>
<reference value="#SDOHProblem_2"/>
</originalText>
<translation code="T76.11XA" codeSystem="2.16.840.1.113883.6.90"
codeSystemName="ICD-10-CM"
displayName="ADULT PHYSICAL ABUSE, SUSPECTED"/>
</value>
<author> <!--Cures Update Proverance-->
<!-- Provenance - Author Participation -->
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20250923132320-0400"/>
<assignedAuthor>
<!-- NPI of Author (example) -->
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3888" />
<name>Manchester</name>
<telecom value="tel:+1-860-649-9973"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
</observation>
</entryRelationship>
</act>
</entry>
<entry>
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01"/>
<id root="d726e9d8-5c5d-4d72-bba9-0ae2d9991477"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
<text>
<reference value="#SDOHProblemObs_5"/>
</text>
<statusCode code="active"/>
<effectiveTime>
<low value="20250903"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2022-06-01"/>
<id extension="68993" root="1.2.840.114350.1.13.6289.1.7.2.768076"/>
<id root="dda72d64-78ae-4b75-aaa9-c5edf0f0d2f3" extension="1.1"/>
<code code="55607006" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Problem">
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Problem"/>
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20250903"/>
</effectiveTime>
<value xsi:type="CD" code="398760006"
displayName="Abducens nerve palsy"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<originalText>
<reference value="#SDOHProblem_5"/>
</originalText>
<translation code="H49.011" codeSystem="2.16.840.1.113883.6.90"
codeSystemName="ICD-10-CM"
displayName="3RD (OCULOMOTOR) NERVE PALSY"/>
</value>
<author> <!--Cures Update Proverance-->
<!-- Provenance - Author Participation -->
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20250923132320-0400"/>
<assignedAuthor>
<!-- NPI of Author (example) -->
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3888" />
<name>Manchester</name>
<telecom value="tel:+1-860-649-9973"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component><!-- LAB TESTS SECTION -->
<component>
<section nullFlavor="NI">
<!-- Results Section (entries required) (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="RESULTS"/>
<title>RESULTS</title>
<text>Laboratory Test: None. Laboratory Values/Results: No Lab Result data</text>
</section>
</component>
<component> <!--Cures Update Progress Note-->
<section>
<!-- Notes Section -->
<templateId root="2.16.840.1.113883.10.20.22.2.65" extension="2016-11-01"/>
<code code="18842-5" displayName="Discharge Summary Note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Discharge Summary Note</title>
<text>No discharge summary note found.</text>
</section>
</component><!-- ASSESSMENT SECTION -->
<!-- ASSESSMENT SECTION -->
<!-- There is no R2.1 (R2.0) version of assessment section, using R1.1 templateId only -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.8"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="51848-0" displayName="ASSESSMENTS"/>
<title>ASSESSMENTS</title>
<text>
<table border = "1" width = "100%">
<thead>
<tr>
<th>Assessment</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>Right Eye </td>
<td>Aug 20,2025</td>
</tr>
<tr>
<td>Both Eyes </td>
<td>Aug 20,2025</td>
</tr>
<tr>
<td>Both Eyes </td>
<td>Aug 20,2025</td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<!-- PLAN OF TREATMENT SECTION -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.10"/>
<templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="18776-5" displayName="PLAN OF TREATMENT"/>
<title>PLAN OF TREATMENT</title>
<text>
<table border = "1" width = "100%">
<thead>
<tr>
<th>Plan of Treatment</th>
</tr>
</thead>
<tbody>
<tr>
<td></td>
</tr>
<tr>
<td></td>
</tr>
<tr>
<td></td>
</tr>
</tbody>
</table>
</text>
</section>
</component><!-- GOALS SECTION -->
<!-- GOAL SECTION -->
<component>
<section >
<templateId root="2.16.840.1.113883.10.20.22.2.60"/>
<code code="61146-7" displayName="Goals" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Goals Section</title>
<text>
<br/>
<paragraph>Social Determinants of Health Goal</paragraph>
<br/>
<table border="1" width="100%">
<thead>
<tr>
<th>SDOH Goal</th>
<th>Effective Dates</th>
<th>Goal Code</th>
</tr>
</thead>
<tbody>
<tr ID="SDOHGoalObs_1">
<td ID="SDOHGoal_1">Good recovery from sexual assault (finding) 1144537004</td>
<td>September 04,2025</td>
<td>1144537004</td>
</tr>
<tr ID="SDOHGoalObs_2">
<td ID="SDOHGoal_2">Residence meets functional needs (finding) 611171000124102</td>
<td>September 03,2025</td>
<td>611171000124102</td>
</tr>
<tr ID="SDOHGoalObs_5">
<td ID="SDOHGoal_5">Satisfied with job (finding) 302124002</td>
<td>September 03,2025</td>
<td>302124002</td>
</tr>
</tbody>
</table>
</text>
<entry>
<observation classCode="OBS" moodCode="GOL">
<templateId root="2.16.840.1.113883.10.20.22.4.121" extension="2022-06-01"/>
<id extension="3241" root="1.2.840.114350.1.13.6289.1.7.2.737179"/>
<code code="8689-2" displayName="History of Social function"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC">
</code>
<text>
<reference value="#SDOHGoal_1"/>
</text>
<statusCode code="active"/>
<effectiveTime>
<low value="20250904"/>
<high nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD" code="1144537004" displayName="Good recovery from sexual assault (finding)"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
</value>
<author> <!--Cures Update Proverance-->
<!-- Provenance - Author Participation -->
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20250923132320-0400"/>
<assignedAuthor>
<!-- NPI of Author (example) -->
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3888" />
<name>Manchester</name>
<telecom value="tel:+1-860-649-9973"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author><!-- Embedded Reason template with ICD -->
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<!-- Reason (V2) -->
<templateId root="2.16.840.1.113883.10.20.24.3.88" extension="2023-05-01" />
<id root="4179f474-a039-43c6-ae64-aa1d33e330e7" />
<code code="77301-0" codeSystem="2.16.840.1.113883.6.1" displayName="Reason care action performed or not" codeSystemName="LOINC" />
<statusCode code="completed" />
<effectiveTime>
<low value="20250904"/>
</effectiveTime>
<value xsi:type="CD" code="I10" codeSystem="2.16.840.1.113883.6.90" codeSystemName="ICD-10-CM" displayName="ESSENTIAL (PRIMARY) HYPERTENSION"/>
</observation>
</entryRelationship>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="GOL">
<templateId root="2.16.840.1.113883.10.20.22.4.121" extension="2022-06-01"/>
<id extension="3241" root="1.2.840.114350.1.13.6289.1.7.2.737179"/>
<code code="8689-2" displayName="History of Social function"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC">
</code>
<text>
<reference value="#SDOHGoal_2"/>
</text>
<statusCode code="active"/>
<effectiveTime>
<low value="20250903"/>
<high nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD" code="611171000124102" displayName="Residence meets functional needs (finding)"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
</value>
<author> <!--Cures Update Proverance-->
<!-- Provenance - Author Participation -->
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20250923132320-0400"/>
<assignedAuthor>
<!-- NPI of Author (example) -->
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3888" />
<name>Manchester</name>
<telecom value="tel:+1-860-649-9973"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author><!-- Embedded Reason template with ICD -->
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<!-- Reason (V2) -->
<templateId root="2.16.840.1.113883.10.20.24.3.88" extension="2023-05-01" />
<id root="78fdc487-97cf-44b5-80d3-7fcf3e7f5833" />
<code code="77301-0" codeSystem="2.16.840.1.113883.6.1" displayName="Reason care action performed or not" codeSystemName="LOINC" />
<statusCode code="completed" />
<effectiveTime>
<low value="20250903"/>
</effectiveTime>
<value xsi:type="CD" code="T76.11XA" codeSystem="2.16.840.1.113883.6.90" codeSystemName="ICD-10-CM" displayName="ADULT PHYSICAL ABUSE, SUSPECTED"/>
</observation>
</entryRelationship>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="GOL">
<templateId root="2.16.840.1.113883.10.20.22.4.121" extension="2022-06-01"/>
<id extension="3241" root="1.2.840.114350.1.13.6289.1.7.2.737179"/>
<code code="8689-2" displayName="History of Social function"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC">
</code>
<text>
<reference value="#SDOHGoal_5"/>
</text>
<statusCode code="active"/>
<effectiveTime>
<low value="20250903"/>
<high nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD" code="302124002" displayName="Satisfied with job (finding)"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
</value>
<author> <!--Cures Update Proverance-->
<!-- Provenance - Author Participation -->
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20250923132320-0400"/>
<assignedAuthor>
<!-- NPI of Author (example) -->
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3888" />
<name>Manchester</name>
<telecom value="tel:+1-860-649-9973"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author><!-- Embedded Reason template with ICD -->
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<!-- Reason (V2) -->
<templateId root="2.16.840.1.113883.10.20.24.3.88" extension="2023-05-01" />
<id root="a49ab26b-ff9b-4144-a784-363ff7f83c12" />
<code code="77301-0" codeSystem="2.16.840.1.113883.6.1" displayName="Reason care action performed or not" codeSystemName="LOINC" />
<statusCode code="completed" />
<effectiveTime>
<low value="20250903"/>
</effectiveTime>
<value xsi:type="CD" code="H49.011" codeSystem="2.16.840.1.113883.6.90" codeSystemName="ICD-10-CM" displayName="3RD (OCULOMOTOR) NERVE PALSY"/>
</observation>
</entryRelationship>
</observation>
</entry>
</section>
</component><!-- HEALTH CONCERNS SECTION -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.58" extension="2015-08-01"/>
<code code="75310-3" displayName="Health Concerns Document" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Health Concerns Section</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Observations</th>
<th>Status</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="3" ID="HealthObservation_1">No Health Observation</td>
</tr>
</tbody>
</table>
<br/>
<table border="1" width="100%">
<thead>
<tr>
<th>Concern - HealthCare Concerns refer to underlying clinical facts</th>
<th>Status</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="3" ID="HealthConcern_1">No Health Concern.</td>
</tr>
</tbody>
</table>
<br/>
<table border="1" width="100%">
<thead>
<tr>
<th>Related observation</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="2">No Related Observation.</td>
</tr>
</tbody>
</table>
<br/>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.5" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.5"/>
<id root="6435a5cd-8bd1-465e-a152-6b639c02402b"/>
<code code="11323-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Health status"/>
<text>
<reference value="#HealthObservation_1"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" nullFlavor="NI"/>
</observation>
</entry>
<entry>
<act classCode="ACT" moodCode="EVN" negationInd="true">
<templateId root="2.16.840.1.113883.10.20.22.4.132" extension="2015-08-01"/>
<id root="107cedde-d47d-42ca-915e-7f69914fcc9a"/>
<code code="75310-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Health Concern"/>
<text>
<reference value="#HealthConcern_1"/>
</text>
<statusCode code="completed"/>
</act>
</entry>
</section>
</component>
<!-- ENCOUNTERS SECTION -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.22.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.22.1"/>
<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
<title>ENCOUNTERS</title>
<text>
<table border = "1" width = "100%">
<thead>
<tr>
<th>Encounter Diagnosis</th>
<th>Location</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td ID="enc_problem18">AGE RELATED MACULAR DEGENERATION DRY</td>
<td ID="enc_problem_location18">Manchester</td>
<td ID="enc_problem_date18">May 14,2025</td>
</tr>
<tr>
<td ID="enc_problem20">Myopia</td>
<td ID="enc_problem_location20">Manchester</td>
<td ID="enc_problem_date20">Jun 09,2025</td>
</tr>
<tr>
<td ID="enc_problem21">Presbyopia</td>
<td ID="enc_problem_location21">Manchester</td>
<td ID="enc_problem_date21">Jun 09,2025</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<!-- Encounter Activities -->
<templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<id root="2a620155-9d11-439e-92b3-5d9815ff4601"/>
<code code="0123" displayName="comprehensive" codeSystem="2.16.840.1.113883.6.12" codeSystemVersion="4">
<originalText>
<reference value="#enc_problem18"/>
</originalText>
<translation code="AMB" codeSystem="2.16.840.1.113883.5.4" displayName="Ambulatory" codeSystemName="HL7 ActEncounterCode"/>
</code>
<effectiveTime value="20250820"/>
<performer>
<assignedEntity>
<!-- Provider NPI "99999999" -db -->
<id nullFlavor="NI"/>
<code code="309343006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Physician"/>
</assignedEntity>
</performer>
<participant typeCode = "LOC">
<participantRole classCode = "SDLOC">
<templateId root = "2.16.840.1.113883.10.20.22.4.32"/>
<!-- Service Delivery Location template -->
<!-- the test data does not specify specific data for this code -db -->
<code nullFlavor="NI"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1860-649-9973"/>
<playingEntity classCode = "PLC">
<name>Manchester</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ" >
<act classCode="ACT" moodCode="EVN">
<!-- Encounter diagnosis act -->
<templateId root="2.16.840.1.113883.10.20.22.4.80" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.80" />
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="5a784260-6857-4f38-9638-80c851aff602"/>
<code xsi:type="CE" code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ENCOUNTER DIAGNOSIS"/>
<effectiveTime>
<low value="20250820"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<!-- Problem Observation (V3) -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800201c9603"/>
<code code="55607006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Problem">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem" />
</code><!-- Problem Observation template -->
<statusCode code="completed"/>
<effectiveTime>
<low value="20250820"/>
</effectiveTime>
<value xsi:type="CD" code="15013002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="AGE RELATED MACULAR DEGENERATION DRY"/>
</observation>
</entryRelationship>
</act>
</entryRelationship>
</encounter>
</entry>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<!-- Encounter Activities -->
<templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<id root="2a620155-9d11-439e-92b3-5d9815ff4604"/>
<code code="0123" displayName="comprehensive" codeSystem="2.16.840.1.113883.6.12" codeSystemVersion="4">
<originalText>
<reference value="#enc_problem20"/>
</originalText>
<translation code="AMB" codeSystem="2.16.840.1.113883.5.4" displayName="Ambulatory" codeSystemName="HL7 ActEncounterCode"/>
</code>
<effectiveTime value="20250820"/>
<performer>
<assignedEntity>
<!-- Provider NPI "99999999" -db -->
<id nullFlavor="NI"/>
<code code="309343006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Physician"/>
</assignedEntity>
</performer>
<participant typeCode = "LOC">
<participantRole classCode = "SDLOC">
<templateId root = "2.16.840.1.113883.10.20.22.4.32"/>
<!-- Service Delivery Location template -->
<!-- the test data does not specify specific data for this code -db -->
<code nullFlavor="NI"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1860-649-9973"/>
<playingEntity classCode = "PLC">
<name>Manchester</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ" >
<act classCode="ACT" moodCode="EVN">
<!-- Encounter diagnosis act -->
<templateId root="2.16.840.1.113883.10.20.22.4.80" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.80" />
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="5a784260-6857-4f38-9638-80c851aff605"/>
<code xsi:type="CE" code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ENCOUNTER DIAGNOSIS"/>
<effectiveTime>
<low value="20250820"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<!-- Problem Observation (V3) -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800201c9606"/>
<code code="404684003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Finding">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Finding" />
</code><!-- Problem Observation template -->
<statusCode code="completed"/>
<effectiveTime>
<low value="20250820"/>
</effectiveTime>
<value xsi:type="CD" code="57190000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Myopia"/>
</observation>
</entryRelationship>
</act>
</entryRelationship>
</encounter>
</entry>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<!-- Encounter Activities -->
<templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<id root="2a620155-9d11-439e-92b3-5d9815ff4607"/>
<code code="0123" displayName="comprehensive" codeSystem="2.16.840.1.113883.6.12" codeSystemVersion="4">
<originalText>
<reference value="#enc_problem21"/>
</originalText>
<translation code="AMB" codeSystem="2.16.840.1.113883.5.4" displayName="Ambulatory" codeSystemName="HL7 ActEncounterCode"/>
</code>
<effectiveTime value="20250820"/>
<performer>
<assignedEntity>
<!-- Provider NPI "99999999" -db -->
<id nullFlavor="NI"/>
<code code="309343006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Physician"/>
</assignedEntity>
</performer>
<participant typeCode = "LOC">
<participantRole classCode = "SDLOC">
<templateId root = "2.16.840.1.113883.10.20.22.4.32"/>
<!-- Service Delivery Location template -->
<!-- the test data does not specify specific data for this code -db -->
<code nullFlavor="NI"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1860-649-9973"/>
<playingEntity classCode = "PLC">
<name>Manchester</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ" >
<act classCode="ACT" moodCode="EVN">
<!-- Encounter diagnosis act -->
<templateId root="2.16.840.1.113883.10.20.22.4.80" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.80" />
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="5a784260-6857-4f38-9638-80c851aff608"/>
<code xsi:type="CE" code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ENCOUNTER DIAGNOSIS"/>
<effectiveTime>
<low value="20250820"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<!-- Problem Observation (V3) -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800201c9609"/>
<code code="404684003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Finding">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Finding" />
</code><!-- Problem Observation template -->
<statusCode code="completed"/>
<effectiveTime>
<low value="20250820"/>
</effectiveTime>
<value xsi:type="CD" code="41256004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Presbyopia"/>
</observation>
</entryRelationship>
</act>
</entryRelationship>
</encounter>
</entry>
</section>
</component><!-- PLAN OF CARE SECTION -->
<component>
<section><!-- ** Plan of Care Section Template -->
<templateId root="2.16.840.1.113883.10.20.22.2.10"/><!-- CCDA Plan of Care Section definition requires this code -->
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Treatment plan"/>
<title>PLAN OF CARE</title>
<text>
<table border = "1" width = "100%">
<thead>
<tr>
<th>Name</th>
<th>Result</th>
<th>Status</th>
<th>Date / Reason</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="4"></td>
</tr>
</tbody>
</table>
</text>
</section>
</component><!-- INSTRICTIONS SECTION --><!-- FUNCTIONAL STATUS SECTION -->
<!-- ********************************************************
FUNCTIONAL STATUS
******************************************************** -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.14" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.14"/>
<!-- ******** Functional status section template ******** -->
<code code="47420-5" codeSystem="2.16.840.1.113883.6.1"/>
<title>FUNCTIONAL STATUS</title>
<text>
<table border = "1" width = "100%">
<thead>
<tr>
<th>Functional Condition</th>
<th>Code/Code System</th>
<th>Status Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>Are you blind or do you have difficulty seeing? - No</td>
<td>75251-9 (LOINC)</td>
<td>Sep 15,2025</td>
</tr>
</tbody>
</table>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<!-- Disability Status Observation -->
<templateId root="2.16.840.1.113883.10.20.22.4.505" extension="2023-05-01"/>
<id root="6c22df0b-2999-45a3-bf3f-551e5a197e94"/>
<code code="89571-4" displayName="Disability Status [CUBS]" codeSystem="2.16.840.1.113883.6.1"/>
<statusCode code="completed"/>
<effectiveTime value="20250915"/>
<value xsi:type="CD" code="LA29243-5"
displayName="I'm Vulnerable - I sometimes or periodically have acute or chronic symptoms affecting housing, employment, social interactions, etc."
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86"/>
<id root="06ba3465-d636-4730-a22c-29415d8b2673"/>
<code code="75251-9" displayName="Are you blind or do you have difficulty seeing?" codeSystem="2.16.840.1.113883.6.1"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="LA32-8" displayName="No" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
</observation>
</entry>
</section>
</component>
<!-- ********************************************************
COGNITIVE STATUS
******************************************************** -->
<component>
<section>
<!-- There is no R1.1 version of this template -db -->
<templateId root="2.16.840.1.113883.10.20.22.2.56" extension="2015-08-01" />
<!-- Mental Status Section -->
<code code="10190-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MENTAL STATUS" />
<title>COGNITIVE STATUS (MENTAL STATUS)</title>
<text>No COGNITIVE STATUS informtion</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.74" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.74"/>
<id root="a7bc1062-8649-42a0-833d-ekd65bd013d2"/>
<code code="373930000" displayName="Cognitive function" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT">
<translation code="75275-8" displayName="Cognitive function" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
</code>
<statusCode code="completed"/>
<effectiveTime nullFlavor="NI"/>
<value xsi:type="CD" nullFlavor="UNK" />
</observation>
</entry>
</section>
</component><!-- CHIEF COMPLAINT AND REASON FOR VISIT SECTION -->
<component>
<section>
<templateId root = "2.16.840.1.113883.10.20.22.2.13"/>
<code code = "46239-0" codeSystem = "2.16.840.1.113883.6.1" codeSystemName = "LOINC" displayName = "CHIEF COMPLAINT AND REASON FOR VISIT"/>
<title>CHIEF COMPLAINT</title>
<text>
<table border = "1" width = "100%">
<thead>
<tr>
<th>Reason for Visit/Chief Complaint</th>
</tr>
</thead>
<tbody>
<tr>
<td>A 40 Yr. old male patient
</td>
</tr>
</tbody>
</table>
</text>
</section>
</component><!-- MEDICATIONS ADMINISTERED SECTION --><!-- PROCEDURES SECTION --><!-- ************** PROCEDURES ***************** -->
<component>
<section>
<!-- Procedures Section (entries required) (V2) -->
<templateId root="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PROCEDURES"/>
<title>PROCEDURES</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Name</th>
<th>Date</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td ID="proc_sx_3">Cat Sx OS</td>
<td ID="date_sx_3">Sep 09,2025</td>
<td ID="status_sx_3">Active</td>
</tr>
<tr>
<td ID="proc_sx_5">Fabric wrapping of aneurysm</td>
<td ID="date_sx_5">Sep 09,2025</td>
<td ID="status_sx_5">Active</td>
</tr>
<tr>
<td ID="proc_sx_16">Safety equipment</td>
<td ID="date_sx_16">Sep 09,2025</td>
<td ID="status_sx_16">Active</td>
</tr>
<tr>
<td ID="proc_sx_17">External ambulatory infus pu</td>
<td ID="date_sx_17">Sep 09,2025</td>
<td ID="status_sx_17">Active</td>
</tr>
</tbody>
</table>
<br/>
<paragraph>Social Determinants of Health Intervention</paragraph>
<br/>
<table border="1" width="100%">
<thead>
<tr>
<th>SDOH Intervention</th>
<th>Effective Dates</th>
<th>Intervention Status</th>
</tr>
</thead>
<tbody>
<tr ID="SDOHInterventionObs_1">
<td ID="SDOHIntervention_1">Referral to healthcare for the homeless program (procedure) 470841000124103</td>
<td>September 04,2025</td>
<td>Completed</td>
</tr>
<tr ID="SDOHInterventionObs_2">
<td ID="SDOHIntervention_2">Refer to mental health worker (procedure) 183583007</td>
<td>September 03,2025</td>
<td>Completed</td>
</tr>
<tr ID="SDOHInterventionObs_5">
<td ID="SDOHIntervention_5">Surgery, wrong body part PA</td>
<td>September 03,2025</td>
<td>Completed</td>
</tr>
</tbody>
</table>
</text>
<entry>
<procedure classCode="PROC" moodCode="EVN">
<!-- Procedure Activity Procedure V2-->
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="68da52b5-2018-42cf-8f61-4af6286c79fe"/>
<code code="25732003" displayName="Cat Sx OS" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#proc_sx_3"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250909"/>
</procedure>
</entry>
<entry>
<procedure classCode="PROC" moodCode="EVN">
<!-- Procedure Activity Procedure V2-->
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="c9ffb32d-ff75-4e9b-822b-c782444b4cf3"/>
<code code="M0301" displayName="Fabric wrapping of aneurysm" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#proc_sx_5"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250909"/>
</procedure>
</entry>
<entry>
<procedure classCode="PROC" moodCode="EVN">
<!-- Procedure Activity Procedure V2-->
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="b56b689d-ddec-4688-9723-0b2cc3a55aaf"/>
<code code="E0700" displayName="Safety equipment" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#proc_sx_16"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250909"/>
</procedure>
</entry>
<entry>
<procedure classCode="PROC" moodCode="EVN">
<!-- Procedure Activity Procedure V2-->
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="2d4c9ec9-8ce8-47c7-b2f5-dde5af835dd4"/>
<code code="E0781" displayName="External ambulatory infus pu" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#proc_sx_17"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250909"/>
</procedure>
</entry>
<entry typeCode="DRIV">
<procedure moodCode="EVN" classCode="PROC">
<templateId root="2.16.840.1.113883.10.20.22.4.14" />
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="da1f7938-2af6-4bd1-bb71-a2ee1e676f3d"/>
<code code="470841000124103" displayName="Referral to healthcare for the homeless program (procedure)"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
<text>
<reference value="#SDOHIntervention_1"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
</procedure>
</entry>
<entry typeCode="DRIV">
<procedure moodCode="EVN" classCode="PROC">
<templateId root="2.16.840.1.113883.10.20.22.4.14" />
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="f4a61ec2-84a8-4c32-82cc-37c11e200144"/>
<code code="183583007" displayName="Refer to mental health worker (procedure)"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
<text>
<reference value="#SDOHIntervention_2"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250903"/>
</procedure>
</entry>
<entry typeCode="DRIV">
<procedure moodCode="EVN" classCode="PROC">
<templateId root="2.16.840.1.113883.10.20.22.4.14" />
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="ef153809-3349-4189-b467-61c751a8811b"/>
<code code="PA" displayName="Surgery, wrong body part"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
<text>
<reference value="#SDOHIntervention_5"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250903"/>
</procedure>
</entry>
</section>
</component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.23" />
<templateId root="2.16.840.1.113883.10.20.22.2.23" extension="2014-06-09" />
<code code="46264-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medical Equipment" />
<title>Implants</title><!-- Alternative text: Patient has no history of procedures with implantable devices-->
<!-- Alternative text: Patient has no implanted devices-->
<text>
<paragraph ID="Proc">Patient has no history of implantable devices</paragraph>
</text>
<entry>
<procedure classCode="PROC" moodCode="EVN" negationInd="true">
<!-- Procedure Activity Procedure V2-->
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="d5b614bd-01ce-410d-8726-e1fd01dcc72a" />
<code code="71388002" codeSystem="2.16.840.1.113883.6.96" displayName="Procedure"/>
<text>
<reference value="#Proc"/>
</text>
<statusCode code="completed" />
<effectiveTime nullFlavor="NA" />
<participant typeCode="DEV">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.37"/>
<!-- UDI is not applicable since no procedure -->
<id nullFlavor="NA" root="2.16.840.1.113883.3.3719"/>
<playingDevice classCode="DEV">
<code code="40388003" codeSystem="2.16.840.1.113883.6.96" displayName="Implant"/>
</playingDevice>
<scopingEntity classCode="DEV">
<id root="2.16.840.1.113883.3.3719"/>
</scopingEntity>
</participantRole>
</participant>
</procedure>
</entry>
</section>
</component><!-- REASON FOR REFERRAL SECTION -->
<component>
<section>
<!-- Reason for Referral Section (V2) -->
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.1" extension="2014-06-09"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.1"/>
<code code="42349-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Reason for Referral"/>
<title>REASON FOR REFERRAL</title>
<text>No Reason for Referral information</text>
</section>
</component>
<!-- CLINICAL NOTES SECTION -->
<component> <!--Cures Update Progress Note-->
<section>
<!-- Notes Section -->
<templateId root="2.16.840.1.113883.10.20.22.2.65" extension="2016-11-01"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Laboratory note" code="11502-2"/>
<title>Laboratory Narrative</title>
<text>No Laboratory Narrative information found</text>
</section>
</component>
<component> <!--Cures Update Progress Note-->
<section>
<!-- Notes Section -->
<templateId root="2.16.840.1.113883.10.20.22.2.65" extension="2016-11-01"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Pathology Study" code="11526-1"/>
<title>Pathology Study</title>
<text>No Pathology Study information found</text>
</section>
</component>
<component> <!--Cures Update Progress Note-->
<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 its 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 -->
<!-- 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="Consultation note"/>
<title>Consultation Notes</title>
<text>
<list>
<item ID="ConsultNote9">
<paragraph>
Tylock-George Eye Care
3100 N. MacArthur Blvd., Irving, Texas 75062
Ph. (972) 258-6400 | Fax (972) 570-1103
www.tylock.com
Taj Nasser, MD | Phat Vo, OD | Mark Hayes, OD | Lema Sbenaty, OD
Dear Dr. iMW Helpdesk,
Date: 08-25-2025
We would like to provide an update on our mutual patient Mr. IMWTest Doe. This patient was last seen in our office for AGE RELATED MACULAR DEGENERATION DRY; Right Eye (H35.3112) on 08-20-2025.
Patient: Doe, IMWTest
Date of Birth: 02-20-1985
Address: Test1234, Englewood Cliffs, NJ, 07632
Right Eye (OD):
Uncorrected Vision:
Corrected Vision:
IOP:
External:
SLE:
DFE:
Left Eye (OS):
Uncorrected Vision:
Corrected Vision:
IOP:
External:
SLE:
DFE:
Assessment and Plan:
Assessment: 1. AGE RELATED MACULAR DEGENERATION DRY; Right Eye (H35.3112)2. Myopia ; Both Eyes (H52.13)3. Presbyopia ; Both Eyes (H52.4)Plan: 1. 2. 3.
Follow up:
Thank you kindly for allowing me to participate in the care of your patient. Please let me know if I can help further in any way. Please feel free to refer additional patients for all of their cataract, cornea, and refractive surgery needs.
All the best,
ecl access, Mr S
Faxed By: access, ecl
Date of Examination: 08-20-2025
</paragraph>
</item>
<item ID="ConsultNote10">
<paragraph>
Tylock-George Eye Care
3100 N. MacArthur Blvd., Irving, Texas 75062
Ph. (972) 258-6400 | Fax (972) 570-1103
www.tylock.com
Taj Nasser, MD | Phat Vo, OD | Mark Hayes, OD | Lema Sbenaty, OD
Dear Dr. iMW Helpdesk,
Date: 09-03-2025
We would like to provide an update on our mutual patient Mr. IMWTest Doe. This patient was last seen in our office for AGE RELATED MACULAR DEGENERATION DRY; Right Eye (H35.3112) on 08-20-2025.
Patient: Doe, IMWTest
Date of Birth: 02-20-1985
Address: Test1234, Englewood Cliffs, NJ, 07632
Right Eye (OD):
Uncorrected Vision:
Corrected Vision:
IOP:
External:
SLE:
DFE:
Left Eye (OS):
Uncorrected Vision:
Corrected Vision:
IOP:
External:
SLE:
DFE:
Assessment and Plan:
Assessment: 1. AGE RELATED MACULAR DEGENERATION DRY; Right Eye (H35.3112)2. Myopia ; Both Eyes (H52.13)3. Presbyopia ; Both Eyes (H52.4)Plan: 1. 2. 3.
Follow up:
Thank you kindly for allowing me to participate in the care of your patient. Please let me know if I can help further in any way. Please feel free to refer additional patients for all of their cataract, cornea, and refractive surgery needs.
All the best,
ecl access, Mr S
Faxed By: access, ecl
Date of Examination: 08-20-2025
</paragraph>
</item>
<item ID="ConsultNote11">
<paragraph>
Tylock-George Eye Care
3100 N. MacArthur Blvd., Irving, Texas 75062
Ph. (972) 258-6400 | Fax (972) 570-1103
www.tylock.com
Taj Nasser, MD | Phat Vo, OD | Mark Hayes, OD | Lema Sbenaty, OD
Dear Dr. iMW Dev,
Date: 09-03-2025
We would like to provide an update on our mutual patient Mr. IMWTest Doe. This patient was last seen in our office for AGE RELATED MACULAR DEGENERATION DRY; Right Eye (H35.3112) on 08-20-2025.
Patient: Doe, IMWTest
Date of Birth: 02-20-1985
Address: Test1234, Englewood Cliffs, NJ, 07632
Right Eye (OD):
Uncorrected Vision:
Corrected Vision:
IOP:
External:
SLE:
DFE:
Left Eye (OS):
Uncorrected Vision:
Corrected Vision:
IOP:
External:
SLE:
DFE:
Assessment and Plan:
Assessment: 1. AGE RELATED MACULAR DEGENERATION DRY; Right Eye (H35.3112)2. Myopia ; Both Eyes (H52.13)3. Presbyopia ; Both Eyes (H52.4)Plan: 1. 2. 3.
Follow up:
Thank you kindly for allowing me to participate in the care of your patient. Please let me know if I can help further in any way. Please feel free to refer additional patients for all of their cataract, cornea, and refractive surgery needs.
All the best,
ecl access, Mr S
Faxed By: access, ecl
Date of Examination: 08-20-2025
</paragraph>
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HISTORY AND PHYSICAL
Advance Directive:NA
HISTORY AND PHYSICAL
YES / NO
DESCRIPTION
CAD/MIN(W/ WO Stent OR CABG)/PVD
No
CVA/TIA/ Epilepsy, Neurological
No
HTN/ +/- CP/SOB on Exertion
No
Respiratory - Asthma / COPD / Sleep Apnea
No
Arthritis
No
Diabetes
No
History of Cancer
No
High Cholesterol
No
Thyroid Problems
Yes
Hyperthyroid
Ulcers
No
</paragraph>
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<structuredBody><!-- SOCIAL HISTORY SECTION -->
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<section >
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<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social History"/>
<title>SOCIAL HISTORY</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Social History Observation</th>
<th>Description</th>
<th>Dates Observed</th>
</tr>
</thead>
<tbody>
<tr>
<td>Smoking Status</td>
<td>Current every day smoker (SNOMED-CT: 449868002)</td>
<td>September 01, 2025 - September 08, 2025</td>
</tr>
<tr>
<td ID="BirthSexInfo">Birth Sex</td>
<td>Male</td>
<td>September 08,2025</td>
</tr>
</tbody>
</table>
<br/>
<paragraph>Social Determinants of Health Assessments</paragraph>
<br/>
<table border="1" width="100%">
<thead>
<tr>
<th>SDOH Assessment</th>
<th>Effective Date</th>
<th>SDOH Response</th>
</tr>
</thead>
<tbody>
<tr>
<td ID="SDOHAssessmentCategory_1" colspan="3">Personal Characteristics</td>
</tr>
<tr>
<td ID="SDOHAssessment_1">Are you Hispanic or Latino?</td>
<td>September 04,2025</td>
<td>No</td>
</tr>
<tr>
<td ID="SDOHAssessment_2">Which race(s) are you?</td>
<td>September 03,2025</td>
<td>Asian</td>
</tr>
<tr>
<td ID="SDOHAssessment_3">At any point in the past 2 years, has season or migrant farm work been your or your familys main source of income?</td>
<td>September 04,2025</td>
<td>Yes</td>
</tr>
<tr>
<td ID="SDOHAssessment_4">Have you been discharged from the armed forces of the United States?</td>
<td>September 03,2025</td>
<td>I choose not to answer this question</td>
</tr>
<tr>
<td ID="SDOHAssessment_5">What language are you most comfortable speaking?</td>
<td>September 03,2025</td>
<td>English</td>
</tr>
<tr>
<td ID="SDOHAssessmentCategory_2" colspan="3">Family and Home</td>
</tr>
<tr>
<td ID="SDOHAssessment_6">How many family members, including yourself, do you currently live with?</td>
<td>September 03,2025</td>
<td>4</td>
</tr>
<tr>
<td ID="SDOHAssessment_7">What is your housing situation today?</td>
<td>September 03,2025</td>
<td>I have housing</td>
</tr>
<tr>
<td ID="SDOHAssessment_8">Are you worried about losing your housing?</td>
<td>September 04,2025</td>
<td>No</td>
</tr>
<tr>
<td ID="SDOHAssessment_9">What address do you live at?</td>
<td>September 04,2025</td>
<td>Test123, Street4, Englewood Cliffs, NJ, 07632, Bergen County, USA</td>
</tr>
<tr>
<td ID="SDOHAssessmentCategory_3" colspan="3">Money and Resources</td>
</tr>
<tr>
<td ID="SDOHAssessment_10">What is the highest level of school that you have finished?</td>
<td>September 04,2025</td>
<td>Less than high school degree</td>
</tr>
<tr>
<td ID="SDOHAssessment_11">What is your current work situation?</td>
<td>September 04,2025</td>
<td>Part-time or temporary work</td>
</tr>
<tr>
<td ID="SDOHAssessment_12">What is your main insurance?</td>
<td>September 04,2025</td>
<td>CHIP Medicaid</td>
</tr>
<tr>
<td ID="SDOHAssessment_13">During the past year, what was the total combined income for you and the family members you live with? This information will help us determine if you are eligible for any benefits.</td>
<td>September 04,2025</td>
<td>567687</td>
</tr>
<tr>
<td ID="SDOHAssessment_14">In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?</td>
<td>September 04,2025</td>
<td>Food</td>
</tr>
<tr>
<td ID="SDOHAssessment_15">Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living</td>
<td>September 04,2025</td>
<td>Yes (it has kept me from medical appointments or from getting my medications)</td>
</tr>
<tr>
<td ID="SDOHAssessmentCategory_4" colspan="3">Social and Emotional Health</td>
</tr>
<tr>
<td ID="SDOHAssessment_16">How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone or visiting friends or family or going to church or club meetings)?</td>
<td>September 04,2025</td>
<td>1 or 2 times a week</td>
</tr>
<tr>
<td ID="SDOHAssessment_17">Stress is when someone feels tense, nervous, anxious or can not sleep at night because their mind is troubled - how stressed are you?</td>
<td>September 04,2025</td>
<td>A little bit</td>
</tr>
<tr>
<td ID="SDOHAssessmentCategory_5" colspan="3">Optional Additional Questions</td>
</tr>
<tr>
<td ID="SDOHAssessment_18">In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?</td>
<td>September 02,2025</td>
<td>No</td>
</tr>
<tr>
<td ID="SDOHAssessment_19">Are you a refugee?</td>
<td>September 03,2025</td>
<td>Yes</td>
</tr>
<tr>
<td ID="SDOHAssessment_20">Do you feel physically and emotionally safe where you currently live?</td>
<td>September 02,2025</td>
<td>I choose not to answer this question</td>
</tr>
<tr>
<td ID="SDOHAssessment_21">In the past year, have you been afraid of your partner or ex-partner?</td>
<td>September 04,2025</td>
<td>Yes</td>
</tr>
</tbody>
</table>
</text>
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<code code="93038-8" displayName="Stress is when someone feels tense, nervous, anxious or can not sleep at night because their mind is troubled - how stressed are you?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_17"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
<value xsi:type="CO" code="LA13863-8" displayName="A little bit" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
</observation>
</entry>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.69" extension="2022-06-01"/>
<id root="5778f5c2-8461-4cbe-b3f4-e228b5a29b5e"/>
<code code="93039-6" displayName="Optional Additional Questions" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessmentCategory_5"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250923"/>
<value xsi:type="CD" nullFlavor="NA"/>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="f3509b9a-76f1-4ebb-8810-f87c85e75095"/>
<code code="93028-9" displayName="In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_18"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250902"/>
<value xsi:type="CO" code="LA32-8" displayName="No" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="5fe90ba7-d8a7-43c4-90a3-4f694cefab36"/>
<code code="93027-1" displayName="Are you a refugee?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_19"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250903"/>
<value xsi:type="CO" code="LA33-6" displayName="Yes" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="89573ab2-34aa-4ce1-8a9d-8b88b5702222"/>
<code code="93026-3" displayName="Do you feel physically and emotionally safe where you currently live?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_20"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250902"/>
<value xsi:type="CO" code="LA30122-8" displayName="I choose not to answer this question" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
<id root="116d5e7e-11b7-41fd-9b61-2c67cbbf3019"/>
<code code="76501-6" displayName="In the past year, have you been afraid of your partner or ex-partner?" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<reference value="#SDOHAssessment_21"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
<value xsi:type="CO" code="LA33-6" displayName="Yes" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
</observation>
</entry>
</section>
</component><!-- MEDICATIONS SECTION -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of medications"/>
<title>MEDICATIONS</title>
<text>
<table border = "1" width = "100%">
<thead>
<tr>
<th>Medication</th>
<th>Start Date</th>
<th>End Date</th>
<th>Route</th>
<th>Dose</th>
<th>Frequency</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<content ID ="Med6">Restasis [RxNorm: 352951]</content>
</td>
<td>Sep 09,2025</td>
<td></td>
<td ID = "MEDROUTE6"></td>
<td ID = "MEDFORM6">1</td>
<td ID = "Instruct6">bid</td>
</tr>
<tr>
<td>
<content ID ="Med19">Ava [RxNorm: 34534]</content>
</td>
<td>Sep 09,2025</td>
<td></td>
<td ID = "MEDROUTE19"></td>
<td ID = "MEDFORM19">3</td>
<td ID = "Instruct19">sig2</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="cdbd33f0-6cde-11db-9fe1-0800200c9a66" extension="Med6" />
<text>
<reference value="#Med6"/>Restasis [RxNorm: 352951]</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20250909"/>
<high nullFlavor="NI"/>
</effectiveTime>
<routeCode code="C38287" codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="National Cancer Institute (NCI) Thesaurus"
displayName="OPHTHALMIC"/>
<approachSiteCode code="362502000" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="Entire right eye (body structure)"/>
<doseQuantity nullFlavor="NI"/>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="352951"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"
displayName="Restasis">
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<entry typeCode="DRIV">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
<id root="cdbd33f0-6cde-11db-9fe1-0800200c9a66" extension="Med19" />
<text>
<reference value="#Med19"/>Ava [RxNorm: 34534]</text>
<statusCode code="completed"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20250909"/>
<high nullFlavor="NI"/>
</effectiveTime>
<routeCode code="C38287" codeSystem="2.16.840.1.113883.3.26.1.1"
codeSystemName="National Cancer Institute (NCI) Thesaurus"
displayName="OPHTHALMIC"/>
<approachSiteCode code="244486005" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="Entire eye (body structure)"/>
<doseQuantity nullFlavor="NI"/>
<consumable>
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
<manufacturedMaterial>
<code code="34534"
codeSystem="2.16.840.1.113883.6.88"
codeSystemName="RxNorm"
displayName="Ava">
</code>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component><!-- ALLERGIES SECTION -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.6.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of allergies"/>
<title>ALLERGIES & REACTIONS</title>
<text>No allergy data.</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.30" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.30"/>
<id nullFlavor="NI"/> <!-- Allergy Problem Act template -->
<code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies, adverse reactions, alerts"/>
<statusCode code="active"/>
<effectiveTime>
<low nullFlavor="NI"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN" >
<templateId root="2.16.840.1.113883.10.20.22.4.7" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.7"/>
<id nullFlavor="NI"/> <!-- Allergy - intolerance observation template -->
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<effectiveTime nullFlavor="UNK"/>
<value xsi:type="CD" nullFlavor="NI"/>
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code nullFlavor="NI"/>
</playingEntity>
</participantRole>
</participant>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component><!-- IMMUNIZATION SECTION -->
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.2.1" />
<code code="11369-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of immunizations" />
<title>IMMUNIZATIONS</title>
<text>No immunization data found.</text>
</section>
</component><!-- VITAL SIGN SECTION -->
<component>
<section nullFlavor="NI">
<!-- Vitals Section (entries required) (V3) nullflavor -->
<templateId root="2.16.840.1.113883.10.20.22.2.4.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.4.1"/>
<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="VITAL SIGNS"/>
<title>VITAL SIGNS</title>
<text>No Vital Signs Information</text>
</section>
</component><!-- PROBLEM SECTION --><!-- ***************** PROBLEM LIST *********************** -->
<!-- edited as per test doc - all data relevant -db -->
<component>
<section >
<!-- *** Problem Section (entries required) (V3) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.5.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.5.1"/>
<code code="11450-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROBLEM LIST"/>
<title>PROBLEMS</title>
<text>
<table border = "1" width = "100%">
<thead>
<tr>
<th>Problem</th>
<th>Effective Dates</th>
<th>Problem Status</th>
</tr>
</thead>
<tbody>
<tr ID = "PROBSUMMARY_1">
<td ID = "PROBKIND_1">POAG; Left Eye Mild, Right Eye Moderate Both Eyes (H40.1121, H40.1112) [SNOMED-CT: 15013002]</td>
<td>Dec 20,2017</td>
<td ID = "PROBSTATUS_1">Active</td>
</tr>
<tr ID = "PROBSUMMARY_6">
<td ID = "PROBKIND_6">CENTRAL RETINAL VEIN OCCLUSION; Left Eye w/ret neovaculaization, Right Eye w/ macular edema Both Eyes (H34.8121, H34.8110) [SNOMED-CT: 15013002]</td>
<td>Apr 18,2018</td>
<td ID = "PROBSTATUS_6">Active</td>
</tr>
<tr ID = "PROBSUMMARY_12">
<td ID = "PROBKIND_12">VITREOUS FLOATERS; Right Eye (H43.391) [SNOMED-CT: 15013002]</td>
<td>Nov 30,2018</td>
<td ID = "PROBSTATUS_12">Active</td>
</tr>
<tr ID = "PROBSUMMARY_18">
<td ID = "PROBKIND_18">AGE RELATED MACULAR DEGENERATION DRY; Right Eye (H35.3112) [SNOMED-CT: 15013002]</td>
<td>May 14,2025</td>
<td ID = "PROBSTATUS_18">Active</td>
</tr>
<tr ID = "PROBSUMMARY_20">
<td ID = "PROBKIND_20">Myopia ; Both Eyes (H52.13) [SNOMED-CT: 57190000]</td>
<td>Jun 09,2025</td>
<td ID = "PROBSTATUS_20">Active</td>
</tr>
<tr ID = "PROBSUMMARY_21">
<td ID = "PROBKIND_21">Presbyopia ; Both Eyes (H52.4) [SNOMED-CT: 41256004]</td>
<td>Jun 09,2025</td>
<td ID = "PROBSTATUS_21">Active</td>
</tr>
<tr ID = "PROBSUMMARY_27">
<td ID = "PROBKIND_27">HYPERTENSION SECONDARY TO ENDOCRINE DISORDERS (ICD-10-CM I15.2) [SNOMED-CT: 41256004]</td>
<td>Jul 28,2025</td>
<td ID = "PROBSTATUS_27">Active</td>
</tr>
</tbody>
</table>
<br/>
<paragraph>Social Determinants of Problems/Health Concern</paragraph>
<br/>
<table border="1" width="100%">
<thead>
<tr>
<th>SDOH Problem</th>
<th>Effective Dates</th>
<th>Problem Status</th>
</tr>
</thead>
<tbody>
<tr ID="SDOHProblemObs_1">
<td ID="SDOHProblem_1">ESSENTIAL (PRIMARY) HYPERTENSION (ICD-10-CM I10)</td>
<td>September 04,2025</td>
<td>Active</td>
</tr>
<tr ID="SDOHProblemObs_2">
<td ID="SDOHProblem_2">ADULT PHYSICAL ABUSE, SUSPECTED (ICD-10-CM T76.11XA)</td>
<td>September 03,2025</td>
<td>Active</td>
</tr>
<tr ID="SDOHProblemObs_5">
<td ID="SDOHProblem_5">3RD (OCULOMOTOR) NERVE PALSY (ICD-10-CM H49.011)</td>
<td>September 03,2025</td>
<td>Active</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<!-- ** Problem Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<id root="ec8a6ff8-ed4b-4f7e-89c3-e98e58b45df9" />
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" />
<!-- The statusCode represents the need to continue tracking the problem -->
<!-- This is of ongoing concern to the provider -->
<!-- The concern is not active, in terms of there being an active condition to be managed.-->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value represents when the problem was first recorded in the patients chart -->
<!-- since no test data was given for this information,
and a low element is required to exist, used nullFlavor -db -->
<low value="20171220"/><!-- The high value reflects when there was no longer a need to track the problem -->
<!-- since no test data was given for this information, used nullFlavor -db -->
<high nullFlavor="UNK"/>
</effectiveTime>
<!-- removed author as not required -db -->
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Problem observation (V3)** -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800200c2601"/>
<code code="55607006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Problem">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem" />
</code><!-- The statusCode reflects the status of the observation itself -->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value reflects the date of onset -->
<low value="20171220"/>
<!-- The high value reflects when the problem was known to be resolved -->
<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="15013002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="POAG; Left Eye Mild, Right Eye Moderate Both Eyes (H40.1121, H40.1112)"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<!-- ** Problem Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<id root="ec8a6ff8-ed4b-4f7e-89c3-e98e58b45df9" />
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" />
<!-- The statusCode represents the need to continue tracking the problem -->
<!-- This is of ongoing concern to the provider -->
<!-- The concern is not active, in terms of there being an active condition to be managed.-->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value represents when the problem was first recorded in the patients chart -->
<!-- since no test data was given for this information,
and a low element is required to exist, used nullFlavor -db -->
<low value="20180418"/><!-- The high value reflects when there was no longer a need to track the problem -->
<!-- since no test data was given for this information, used nullFlavor -db -->
<high nullFlavor="UNK"/>
</effectiveTime>
<!-- removed author as not required -db -->
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Problem observation (V3)** -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800200c2602"/>
<code code="404684003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Finding">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Finding" />
</code><!-- The statusCode reflects the status of the observation itself -->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value reflects the date of onset -->
<low value="20180418"/>
<!-- The high value reflects when the problem was known to be resolved -->
<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="15013002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="CENTRAL RETINAL VEIN OCCLUSION; Left Eye w/ret neovaculaization, Right Eye w/ macular edema Both Eyes (H34.8121, H34.8110)"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<!-- ** Problem Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<id root="ec8a6ff8-ed4b-4f7e-89c3-e98e58b45df9" />
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" />
<!-- The statusCode represents the need to continue tracking the problem -->
<!-- This is of ongoing concern to the provider -->
<!-- The concern is not active, in terms of there being an active condition to be managed.-->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value represents when the problem was first recorded in the patients chart -->
<!-- since no test data was given for this information,
and a low element is required to exist, used nullFlavor -db -->
<low value="20181130"/><!-- The high value reflects when there was no longer a need to track the problem -->
<!-- since no test data was given for this information, used nullFlavor -db -->
<high nullFlavor="UNK"/>
</effectiveTime>
<!-- removed author as not required -db -->
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Problem observation (V3)** -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800200c2603"/>
<code code="55607006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Problem">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem" />
</code><!-- The statusCode reflects the status of the observation itself -->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value reflects the date of onset -->
<low value="20181130"/>
<!-- The high value reflects when the problem was known to be resolved -->
<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="15013002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="VITREOUS FLOATERS; Right Eye (H43.391)"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<!-- ** Problem Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<id root="ec8a6ff8-ed4b-4f7e-89c3-e98e58b45df9" />
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" />
<!-- The statusCode represents the need to continue tracking the problem -->
<!-- This is of ongoing concern to the provider -->
<!-- The concern is not active, in terms of there being an active condition to be managed.-->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value represents when the problem was first recorded in the patients chart -->
<!-- since no test data was given for this information,
and a low element is required to exist, used nullFlavor -db -->
<low value="20250514"/><!-- The high value reflects when there was no longer a need to track the problem -->
<!-- since no test data was given for this information, used nullFlavor -db -->
<high nullFlavor="UNK"/>
</effectiveTime>
<!-- removed author as not required -db -->
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Problem observation (V3)** -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800200c2604"/>
<code code="55607006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Problem">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem" />
</code><!-- The statusCode reflects the status of the observation itself -->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value reflects the date of onset -->
<low value="20250514"/>
<!-- The high value reflects when the problem was known to be resolved -->
<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="15013002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="AGE RELATED MACULAR DEGENERATION DRY; Right Eye (H35.3112)"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<!-- ** Problem Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<id root="ec8a6ff8-ed4b-4f7e-89c3-e98e58b45df9" />
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" />
<!-- The statusCode represents the need to continue tracking the problem -->
<!-- This is of ongoing concern to the provider -->
<!-- The concern is not active, in terms of there being an active condition to be managed.-->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value represents when the problem was first recorded in the patients chart -->
<!-- since no test data was given for this information,
and a low element is required to exist, used nullFlavor -db -->
<low value="20250609"/><!-- The high value reflects when there was no longer a need to track the problem -->
<!-- since no test data was given for this information, used nullFlavor -db -->
<high nullFlavor="UNK"/>
</effectiveTime>
<!-- removed author as not required -db -->
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Problem observation (V3)** -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800200c2605"/>
<code code="404684003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Finding">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Finding" />
</code><!-- The statusCode reflects the status of the observation itself -->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value reflects the date of onset -->
<low value="20250609"/>
<!-- The high value reflects when the problem was known to be resolved -->
<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="57190000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Myopia ; Both Eyes (H52.13)"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<!-- ** Problem Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<id root="ec8a6ff8-ed4b-4f7e-89c3-e98e58b45df9" />
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" />
<!-- The statusCode represents the need to continue tracking the problem -->
<!-- This is of ongoing concern to the provider -->
<!-- The concern is not active, in terms of there being an active condition to be managed.-->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value represents when the problem was first recorded in the patients chart -->
<!-- since no test data was given for this information,
and a low element is required to exist, used nullFlavor -db -->
<low value="20250609"/><!-- The high value reflects when there was no longer a need to track the problem -->
<!-- since no test data was given for this information, used nullFlavor -db -->
<high nullFlavor="UNK"/>
</effectiveTime>
<!-- removed author as not required -db -->
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Problem observation (V3)** -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800200c2606"/>
<code code="404684003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Finding">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Finding" />
</code><!-- The statusCode reflects the status of the observation itself -->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value reflects the date of onset -->
<low value="20250609"/>
<!-- The high value reflects when the problem was known to be resolved -->
<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="41256004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Presbyopia ; Both Eyes (H52.4)"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry typeCode="COMP">
<act classCode="ACT" moodCode="EVN">
<!-- ** Problem Concern Act (V3) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01" />
<templateId root="2.16.840.1.113883.10.20.22.4.3" />
<id root="ec8a6ff8-ed4b-4f7e-89c3-e98e58b45df9" />
<code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern" />
<!-- The statusCode represents the need to continue tracking the problem -->
<!-- This is of ongoing concern to the provider -->
<!-- The concern is not active, in terms of there being an active condition to be managed.-->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value represents when the problem was first recorded in the patients chart -->
<!-- since no test data was given for this information,
and a low element is required to exist, used nullFlavor -db -->
<low value="20250728"/><!-- The high value reflects when there was no longer a need to track the problem -->
<!-- since no test data was given for this information, used nullFlavor -db -->
<high nullFlavor="UNK"/>
</effectiveTime>
<!-- removed author as not required -db -->
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- ** Problem observation (V3)** -->
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800200c2607"/>
<code code="404684003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Finding">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Finding" />
</code><!-- The statusCode reflects the status of the observation itself -->
<statusCode code="completed"/>
<effectiveTime>
<!-- The low value reflects the date of onset -->
<low value="20250728"/>
<!-- The high value reflects when the problem was known to be resolved -->
<high nullFlavor="UNK"/>
</effectiveTime>
<value xsi:type="CD" code="41256004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="HYPERTENSION SECONDARY TO ENDOCRINE DISORDERS (ICD-10-CM I15.2)"/>
</observation>
</entryRelationship>
</act>
</entry>
<entry>
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01"/>
<id root="03217647-8939-4bc7-a608-53de0585de0e"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
<text>
<reference value="#SDOHProblemObs_1"/>
</text>
<statusCode code="active"/>
<effectiveTime>
<low value="20250904"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2022-06-01"/>
<id extension="68993" root="1.2.840.114350.1.13.6289.1.7.2.768076"/>
<id root="83a0a70f-3dea-4c71-bc4a-57011d09c1d7" extension="1.1"/>
<code code="55607006" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Problem">
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Problem"/>
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20250904"/>
</effectiveTime>
<value xsi:type="CD" code="1201005"
displayName="Benign essential hypertension"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<originalText>
<reference value="#SDOHProblem_1"/>
</originalText>
<translation code="I10" codeSystem="2.16.840.1.113883.6.90"
codeSystemName="ICD-10-CM"
displayName="ESSENTIAL (PRIMARY) HYPERTENSION"/>
</value>
<author> <!--Cures Update Proverance-->
<!-- Provenance - Author Participation -->
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20250923132320-0400"/>
<assignedAuthor>
<!-- NPI of Author (example) -->
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3888" />
<name>Manchester</name>
<telecom value="tel:+1-860-649-9973"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
</observation>
</entryRelationship>
</act>
</entry>
<entry>
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01"/>
<id root="2f2d7c96-7487-4de1-86df-1415c4f51529"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
<text>
<reference value="#SDOHProblemObs_2"/>
</text>
<statusCode code="active"/>
<effectiveTime>
<low value="20250903"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2022-06-01"/>
<id extension="68993" root="1.2.840.114350.1.13.6289.1.7.2.768076"/>
<id root="a365374e-1edd-4eb6-9d0f-a8191363f7ba" extension="1.1"/>
<code code="55607006" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Problem">
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Problem"/>
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20250903"/>
</effectiveTime>
<value xsi:type="CD" code="129588001"
displayName="Adult failure to thrive syndrome"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<originalText>
<reference value="#SDOHProblem_2"/>
</originalText>
<translation code="T76.11XA" codeSystem="2.16.840.1.113883.6.90"
codeSystemName="ICD-10-CM"
displayName="ADULT PHYSICAL ABUSE, SUSPECTED"/>
</value>
<author> <!--Cures Update Proverance-->
<!-- Provenance - Author Participation -->
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20250923132320-0400"/>
<assignedAuthor>
<!-- NPI of Author (example) -->
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3888" />
<name>Manchester</name>
<telecom value="tel:+1-860-649-9973"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
</observation>
</entryRelationship>
</act>
</entry>
<entry>
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.3"/>
<templateId root="2.16.840.1.113883.10.20.22.4.3" extension="2015-08-01"/>
<id root="d726e9d8-5c5d-4d72-bba9-0ae2d9991477"/>
<code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>
<text>
<reference value="#SDOHProblemObs_5"/>
</text>
<statusCode code="active"/>
<effectiveTime>
<low value="20250903"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2022-06-01"/>
<id extension="68993" root="1.2.840.114350.1.13.6289.1.7.2.768076"/>
<id root="dda72d64-78ae-4b75-aaa9-c5edf0f0d2f3" extension="1.1"/>
<code code="55607006" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT" displayName="Problem">
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Problem"/>
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20250903"/>
</effectiveTime>
<value xsi:type="CD" code="398760006"
displayName="Abducens nerve palsy"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
<originalText>
<reference value="#SDOHProblem_5"/>
</originalText>
<translation code="H49.011" codeSystem="2.16.840.1.113883.6.90"
codeSystemName="ICD-10-CM"
displayName="3RD (OCULOMOTOR) NERVE PALSY"/>
</value>
<author> <!--Cures Update Proverance-->
<!-- Provenance - Author Participation -->
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20250923132320-0400"/>
<assignedAuthor>
<!-- NPI of Author (example) -->
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3888" />
<name>Manchester</name>
<telecom value="tel:+1-860-649-9973"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
</observation>
</entryRelationship>
</act>
</entry>
</section>
</component><!-- LAB TESTS SECTION -->
<component>
<section nullFlavor="NI">
<!-- Results Section (entries required) (V3) -->
<templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="RESULTS"/>
<title>RESULTS</title>
<text>Laboratory Test: None. Laboratory Values/Results: No Lab Result data</text>
</section>
</component>
<component> <!--Cures Update Progress Note-->
<section>
<!-- Notes Section -->
<templateId root="2.16.840.1.113883.10.20.22.2.65" extension="2016-11-01"/>
<code code="18842-5" displayName="Discharge Summary Note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Discharge Summary Note</title>
<text>No discharge summary note found.</text>
</section>
</component><!-- ASSESSMENT SECTION -->
<!-- ASSESSMENT SECTION -->
<!-- There is no R2.1 (R2.0) version of assessment section, using R1.1 templateId only -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.8"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="51848-0" displayName="ASSESSMENTS"/>
<title>ASSESSMENTS</title>
<text>
<table border = "1" width = "100%">
<thead>
<tr>
<th>Assessment</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>Right Eye </td>
<td>Aug 20,2025</td>
</tr>
<tr>
<td>Both Eyes </td>
<td>Aug 20,2025</td>
</tr>
<tr>
<td>Both Eyes </td>
<td>Aug 20,2025</td>
</tr>
</tbody>
</table>
</text>
</section>
</component>
<!-- PLAN OF TREATMENT SECTION -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.10"/>
<templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="18776-5" displayName="PLAN OF TREATMENT"/>
<title>PLAN OF TREATMENT</title>
<text>
<table border = "1" width = "100%">
<thead>
<tr>
<th>Plan of Treatment</th>
</tr>
</thead>
<tbody>
<tr>
<td></td>
</tr>
<tr>
<td></td>
</tr>
<tr>
<td></td>
</tr>
</tbody>
</table>
</text>
</section>
</component><!-- GOALS SECTION -->
<!-- GOAL SECTION -->
<component>
<section >
<templateId root="2.16.840.1.113883.10.20.22.2.60"/>
<code code="61146-7" displayName="Goals" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Goals Section</title>
<text>
<br/>
<paragraph>Social Determinants of Health Goal</paragraph>
<br/>
<table border="1" width="100%">
<thead>
<tr>
<th>SDOH Goal</th>
<th>Effective Dates</th>
<th>Goal Code</th>
</tr>
</thead>
<tbody>
<tr ID="SDOHGoalObs_1">
<td ID="SDOHGoal_1">Good recovery from sexual assault (finding) 1144537004</td>
<td>September 04,2025</td>
<td>1144537004</td>
</tr>
<tr ID="SDOHGoalObs_2">
<td ID="SDOHGoal_2">Residence meets functional needs (finding) 611171000124102</td>
<td>September 03,2025</td>
<td>611171000124102</td>
</tr>
<tr ID="SDOHGoalObs_5">
<td ID="SDOHGoal_5">Satisfied with job (finding) 302124002</td>
<td>September 03,2025</td>
<td>302124002</td>
</tr>
</tbody>
</table>
</text>
<entry>
<observation classCode="OBS" moodCode="GOL">
<templateId root="2.16.840.1.113883.10.20.22.4.121" extension="2022-06-01"/>
<id extension="3241" root="1.2.840.114350.1.13.6289.1.7.2.737179"/>
<code code="8689-2" displayName="History of Social function"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC">
</code>
<text>
<reference value="#SDOHGoal_1"/>
</text>
<statusCode code="active"/>
<effectiveTime>
<low value="20250904"/>
<high nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD" code="1144537004" displayName="Good recovery from sexual assault (finding)"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
</value>
<author> <!--Cures Update Proverance-->
<!-- Provenance - Author Participation -->
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20250923132320-0400"/>
<assignedAuthor>
<!-- NPI of Author (example) -->
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3888" />
<name>Manchester</name>
<telecom value="tel:+1-860-649-9973"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author><!-- Embedded Reason template with ICD -->
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<!-- Reason (V2) -->
<templateId root="2.16.840.1.113883.10.20.24.3.88" extension="2023-05-01" />
<id root="4179f474-a039-43c6-ae64-aa1d33e330e7" />
<code code="77301-0" codeSystem="2.16.840.1.113883.6.1" displayName="Reason care action performed or not" codeSystemName="LOINC" />
<statusCode code="completed" />
<effectiveTime>
<low value="20250904"/>
</effectiveTime>
<value xsi:type="CD" code="I10" codeSystem="2.16.840.1.113883.6.90" codeSystemName="ICD-10-CM" displayName="ESSENTIAL (PRIMARY) HYPERTENSION"/>
</observation>
</entryRelationship>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="GOL">
<templateId root="2.16.840.1.113883.10.20.22.4.121" extension="2022-06-01"/>
<id extension="3241" root="1.2.840.114350.1.13.6289.1.7.2.737179"/>
<code code="8689-2" displayName="History of Social function"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC">
</code>
<text>
<reference value="#SDOHGoal_2"/>
</text>
<statusCode code="active"/>
<effectiveTime>
<low value="20250903"/>
<high nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD" code="611171000124102" displayName="Residence meets functional needs (finding)"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
</value>
<author> <!--Cures Update Proverance-->
<!-- Provenance - Author Participation -->
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20250923132320-0400"/>
<assignedAuthor>
<!-- NPI of Author (example) -->
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3888" />
<name>Manchester</name>
<telecom value="tel:+1-860-649-9973"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author><!-- Embedded Reason template with ICD -->
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<!-- Reason (V2) -->
<templateId root="2.16.840.1.113883.10.20.24.3.88" extension="2023-05-01" />
<id root="78fdc487-97cf-44b5-80d3-7fcf3e7f5833" />
<code code="77301-0" codeSystem="2.16.840.1.113883.6.1" displayName="Reason care action performed or not" codeSystemName="LOINC" />
<statusCode code="completed" />
<effectiveTime>
<low value="20250903"/>
</effectiveTime>
<value xsi:type="CD" code="T76.11XA" codeSystem="2.16.840.1.113883.6.90" codeSystemName="ICD-10-CM" displayName="ADULT PHYSICAL ABUSE, SUSPECTED"/>
</observation>
</entryRelationship>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="GOL">
<templateId root="2.16.840.1.113883.10.20.22.4.121" extension="2022-06-01"/>
<id extension="3241" root="1.2.840.114350.1.13.6289.1.7.2.737179"/>
<code code="8689-2" displayName="History of Social function"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC">
</code>
<text>
<reference value="#SDOHGoal_5"/>
</text>
<statusCode code="active"/>
<effectiveTime>
<low value="20250903"/>
<high nullFlavor="NI"/>
</effectiveTime>
<value xsi:type="CD" code="302124002" displayName="Satisfied with job (finding)"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
</value>
<author> <!--Cures Update Proverance-->
<!-- Provenance - Author Participation -->
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20250923132320-0400"/>
<assignedAuthor>
<!-- NPI of Author (example) -->
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3888" />
<name>Manchester</name>
<telecom value="tel:+1-860-649-9973"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author><!-- Embedded Reason template with ICD -->
<entryRelationship typeCode="RSON">
<observation classCode="OBS" moodCode="EVN">
<!-- Reason (V2) -->
<templateId root="2.16.840.1.113883.10.20.24.3.88" extension="2023-05-01" />
<id root="a49ab26b-ff9b-4144-a784-363ff7f83c12" />
<code code="77301-0" codeSystem="2.16.840.1.113883.6.1" displayName="Reason care action performed or not" codeSystemName="LOINC" />
<statusCode code="completed" />
<effectiveTime>
<low value="20250903"/>
</effectiveTime>
<value xsi:type="CD" code="H49.011" codeSystem="2.16.840.1.113883.6.90" codeSystemName="ICD-10-CM" displayName="3RD (OCULOMOTOR) NERVE PALSY"/>
</observation>
</entryRelationship>
</observation>
</entry>
</section>
</component><!-- HEALTH CONCERNS SECTION -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.58" extension="2015-08-01"/>
<code code="75310-3" displayName="Health Concerns Document" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Health Concerns Section</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Observations</th>
<th>Status</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="3" ID="HealthObservation_1">No Health Observation</td>
</tr>
</tbody>
</table>
<br/>
<table border="1" width="100%">
<thead>
<tr>
<th>Concern - HealthCare Concerns refer to underlying clinical facts</th>
<th>Status</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="3" ID="HealthConcern_1">No Health Concern.</td>
</tr>
</tbody>
</table>
<br/>
<table border="1" width="100%">
<thead>
<tr>
<th>Related observation</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="2">No Related Observation.</td>
</tr>
</tbody>
</table>
<br/>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.5" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.5"/>
<id root="6435a5cd-8bd1-465e-a152-6b639c02402b"/>
<code code="11323-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Health status"/>
<text>
<reference value="#HealthObservation_1"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" nullFlavor="NI"/>
</observation>
</entry>
<entry>
<act classCode="ACT" moodCode="EVN" negationInd="true">
<templateId root="2.16.840.1.113883.10.20.22.4.132" extension="2015-08-01"/>
<id root="107cedde-d47d-42ca-915e-7f69914fcc9a"/>
<code code="75310-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Health Concern"/>
<text>
<reference value="#HealthConcern_1"/>
</text>
<statusCode code="completed"/>
</act>
</entry>
</section>
</component>
<!-- ENCOUNTERS SECTION -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.22.1" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.22.1"/>
<code code="46240-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of encounters"/>
<title>ENCOUNTERS</title>
<text>
<table border = "1" width = "100%">
<thead>
<tr>
<th>Encounter Diagnosis</th>
<th>Location</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td ID="enc_problem18">AGE RELATED MACULAR DEGENERATION DRY</td>
<td ID="enc_problem_location18">Manchester</td>
<td ID="enc_problem_date18">May 14,2025</td>
</tr>
<tr>
<td ID="enc_problem20">Myopia</td>
<td ID="enc_problem_location20">Manchester</td>
<td ID="enc_problem_date20">Jun 09,2025</td>
</tr>
<tr>
<td ID="enc_problem21">Presbyopia</td>
<td ID="enc_problem_location21">Manchester</td>
<td ID="enc_problem_date21">Jun 09,2025</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<!-- Encounter Activities -->
<templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<id root="2a620155-9d11-439e-92b3-5d9815ff4601"/>
<code code="0123" displayName="comprehensive" codeSystem="2.16.840.1.113883.6.12" codeSystemVersion="4">
<originalText>
<reference value="#enc_problem18"/>
</originalText>
<translation code="AMB" codeSystem="2.16.840.1.113883.5.4" displayName="Ambulatory" codeSystemName="HL7 ActEncounterCode"/>
</code>
<effectiveTime value="20250820"/>
<performer>
<assignedEntity>
<!-- Provider NPI "99999999" -db -->
<id nullFlavor="NI"/>
<code code="309343006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Physician"/>
</assignedEntity>
</performer>
<participant typeCode = "LOC">
<participantRole classCode = "SDLOC">
<templateId root = "2.16.840.1.113883.10.20.22.4.32"/>
<!-- Service Delivery Location template -->
<!-- the test data does not specify specific data for this code -db -->
<code nullFlavor="NI"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1860-649-9973"/>
<playingEntity classCode = "PLC">
<name>Manchester</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ" >
<act classCode="ACT" moodCode="EVN">
<!-- Encounter diagnosis act -->
<templateId root="2.16.840.1.113883.10.20.22.4.80" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.80" />
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="5a784260-6857-4f38-9638-80c851aff602"/>
<code xsi:type="CE" code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ENCOUNTER DIAGNOSIS"/>
<effectiveTime>
<low value="20250820"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<!-- Problem Observation (V3) -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800201c9603"/>
<code code="55607006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Problem">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem" />
</code><!-- Problem Observation template -->
<statusCode code="completed"/>
<effectiveTime>
<low value="20250820"/>
</effectiveTime>
<value xsi:type="CD" code="15013002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="AGE RELATED MACULAR DEGENERATION DRY"/>
</observation>
</entryRelationship>
</act>
</entryRelationship>
</encounter>
</entry>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<!-- Encounter Activities -->
<templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<id root="2a620155-9d11-439e-92b3-5d9815ff4604"/>
<code code="0123" displayName="comprehensive" codeSystem="2.16.840.1.113883.6.12" codeSystemVersion="4">
<originalText>
<reference value="#enc_problem20"/>
</originalText>
<translation code="AMB" codeSystem="2.16.840.1.113883.5.4" displayName="Ambulatory" codeSystemName="HL7 ActEncounterCode"/>
</code>
<effectiveTime value="20250820"/>
<performer>
<assignedEntity>
<!-- Provider NPI "99999999" -db -->
<id nullFlavor="NI"/>
<code code="309343006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Physician"/>
</assignedEntity>
</performer>
<participant typeCode = "LOC">
<participantRole classCode = "SDLOC">
<templateId root = "2.16.840.1.113883.10.20.22.4.32"/>
<!-- Service Delivery Location template -->
<!-- the test data does not specify specific data for this code -db -->
<code nullFlavor="NI"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1860-649-9973"/>
<playingEntity classCode = "PLC">
<name>Manchester</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ" >
<act classCode="ACT" moodCode="EVN">
<!-- Encounter diagnosis act -->
<templateId root="2.16.840.1.113883.10.20.22.4.80" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.80" />
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="5a784260-6857-4f38-9638-80c851aff605"/>
<code xsi:type="CE" code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ENCOUNTER DIAGNOSIS"/>
<effectiveTime>
<low value="20250820"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<!-- Problem Observation (V3) -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800201c9606"/>
<code code="404684003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Finding">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Finding" />
</code><!-- Problem Observation template -->
<statusCode code="completed"/>
<effectiveTime>
<low value="20250820"/>
</effectiveTime>
<value xsi:type="CD" code="57190000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Myopia"/>
</observation>
</entryRelationship>
</act>
</entryRelationship>
</encounter>
</entry>
<entry typeCode="DRIV">
<encounter classCode="ENC" moodCode="EVN">
<!-- Encounter Activities -->
<templateId root="2.16.840.1.113883.10.20.22.4.49" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<id root="2a620155-9d11-439e-92b3-5d9815ff4607"/>
<code code="0123" displayName="comprehensive" codeSystem="2.16.840.1.113883.6.12" codeSystemVersion="4">
<originalText>
<reference value="#enc_problem21"/>
</originalText>
<translation code="AMB" codeSystem="2.16.840.1.113883.5.4" displayName="Ambulatory" codeSystemName="HL7 ActEncounterCode"/>
</code>
<effectiveTime value="20250820"/>
<performer>
<assignedEntity>
<!-- Provider NPI "99999999" -db -->
<id nullFlavor="NI"/>
<code code="309343006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Physician"/>
</assignedEntity>
</performer>
<participant typeCode = "LOC">
<participantRole classCode = "SDLOC">
<templateId root = "2.16.840.1.113883.10.20.22.4.32"/>
<!-- Service Delivery Location template -->
<!-- the test data does not specify specific data for this code -db -->
<code nullFlavor="NI"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1860-649-9973"/>
<playingEntity classCode = "PLC">
<name>Manchester</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="SUBJ" >
<act classCode="ACT" moodCode="EVN">
<!-- Encounter diagnosis act -->
<templateId root="2.16.840.1.113883.10.20.22.4.80" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.80" />
<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
<id root="5a784260-6857-4f38-9638-80c851aff608"/>
<code xsi:type="CE" code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ENCOUNTER DIAGNOSIS"/>
<effectiveTime>
<low value="20250820"/>
</effectiveTime>
<entryRelationship typeCode="SUBJ" inversionInd="false">
<!-- Problem Observation (V3) -->
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.4"/>
<id root="ab1791b0-5c71-11db-b0de-0800201c9609"/>
<code code="404684003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Finding">
<!-- a. This code SHALL contain at least one [1..*] translation, which SHOULD be selected from ValueSet Problem Type (LOINC) -->
<!-- Diagnosis seems like the best option:
No EXACT requirement was given in the test data -db -->
<translation code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Finding" />
</code><!-- Problem Observation template -->
<statusCode code="completed"/>
<effectiveTime>
<low value="20250820"/>
</effectiveTime>
<value xsi:type="CD" code="41256004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Presbyopia"/>
</observation>
</entryRelationship>
</act>
</entryRelationship>
</encounter>
</entry>
</section>
</component><!-- PLAN OF CARE SECTION -->
<component>
<section><!-- ** Plan of Care Section Template -->
<templateId root="2.16.840.1.113883.10.20.22.2.10"/><!-- CCDA Plan of Care Section definition requires this code -->
<code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Treatment plan"/>
<title>PLAN OF CARE</title>
<text>
<table border = "1" width = "100%">
<thead>
<tr>
<th>Name</th>
<th>Result</th>
<th>Status</th>
<th>Date / Reason</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="4"></td>
</tr>
</tbody>
</table>
</text>
</section>
</component><!-- INSTRICTIONS SECTION --><!-- FUNCTIONAL STATUS SECTION -->
<!-- ********************************************************
FUNCTIONAL STATUS
******************************************************** -->
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.14" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.14"/>
<!-- ******** Functional status section template ******** -->
<code code="47420-5" codeSystem="2.16.840.1.113883.6.1"/>
<title>FUNCTIONAL STATUS</title>
<text>
<table border = "1" width = "100%">
<thead>
<tr>
<th>Functional Condition</th>
<th>Code/Code System</th>
<th>Status Date</th>
</tr>
</thead>
<tbody>
<tr>
<td>Are you blind or do you have difficulty seeing? - No</td>
<td>75251-9 (LOINC)</td>
<td>Sep 15,2025</td>
</tr>
</tbody>
</table>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<!-- Disability Status Observation -->
<templateId root="2.16.840.1.113883.10.20.22.4.505" extension="2023-05-01"/>
<id root="6c22df0b-2999-45a3-bf3f-551e5a197e94"/>
<code code="89571-4" displayName="Disability Status [CUBS]" codeSystem="2.16.840.1.113883.6.1"/>
<statusCode code="completed"/>
<effectiveTime value="20250915"/>
<value xsi:type="CD" code="LA29243-5"
displayName="I'm Vulnerable - I sometimes or periodically have acute or chronic symptoms affecting housing, employment, social interactions, etc."
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.86"/>
<id root="06ba3465-d636-4730-a22c-29415d8b2673"/>
<code code="75251-9" displayName="Are you blind or do you have difficulty seeing?" codeSystem="2.16.840.1.113883.6.1"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="LA32-8" displayName="No" codeSystem="2.16.840.1.113883.6.1"/>
</observation>
</entryRelationship>
</observation>
</entry>
</section>
</component>
<!-- ********************************************************
COGNITIVE STATUS
******************************************************** -->
<component>
<section>
<!-- There is no R1.1 version of this template -db -->
<templateId root="2.16.840.1.113883.10.20.22.2.56" extension="2015-08-01" />
<!-- Mental Status Section -->
<code code="10190-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MENTAL STATUS" />
<title>COGNITIVE STATUS (MENTAL STATUS)</title>
<text>No COGNITIVE STATUS informtion</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.74" extension="2015-08-01"/>
<templateId root="2.16.840.1.113883.10.20.22.4.74"/>
<id root="a7bc1062-8649-42a0-833d-ekd65bd013d2"/>
<code code="373930000" displayName="Cognitive function" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT">
<translation code="75275-8" displayName="Cognitive function" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
</code>
<statusCode code="completed"/>
<effectiveTime nullFlavor="NI"/>
<value xsi:type="CD" nullFlavor="UNK" />
</observation>
</entry>
</section>
</component><!-- CHIEF COMPLAINT AND REASON FOR VISIT SECTION -->
<component>
<section>
<templateId root = "2.16.840.1.113883.10.20.22.2.13"/>
<code code = "46239-0" codeSystem = "2.16.840.1.113883.6.1" codeSystemName = "LOINC" displayName = "CHIEF COMPLAINT AND REASON FOR VISIT"/>
<title>CHIEF COMPLAINT</title>
<text>
<table border = "1" width = "100%">
<thead>
<tr>
<th>Reason for Visit/Chief Complaint</th>
</tr>
</thead>
<tbody>
<tr>
<td>A 40 Yr. old male patient
</td>
</tr>
</tbody>
</table>
</text>
</section>
</component><!-- MEDICATIONS ADMINISTERED SECTION --><!-- PROCEDURES SECTION --><!-- ************** PROCEDURES ***************** -->
<component>
<section>
<!-- Procedures Section (entries required) (V2) -->
<templateId root="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PROCEDURES"/>
<title>PROCEDURES</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Name</th>
<th>Date</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td ID="proc_sx_3">Cat Sx OS</td>
<td ID="date_sx_3">Sep 09,2025</td>
<td ID="status_sx_3">Active</td>
</tr>
<tr>
<td ID="proc_sx_5">Fabric wrapping of aneurysm</td>
<td ID="date_sx_5">Sep 09,2025</td>
<td ID="status_sx_5">Active</td>
</tr>
<tr>
<td ID="proc_sx_16">Safety equipment</td>
<td ID="date_sx_16">Sep 09,2025</td>
<td ID="status_sx_16">Active</td>
</tr>
<tr>
<td ID="proc_sx_17">External ambulatory infus pu</td>
<td ID="date_sx_17">Sep 09,2025</td>
<td ID="status_sx_17">Active</td>
</tr>
</tbody>
</table>
<br/>
<paragraph>Social Determinants of Health Intervention</paragraph>
<br/>
<table border="1" width="100%">
<thead>
<tr>
<th>SDOH Intervention</th>
<th>Effective Dates</th>
<th>Intervention Status</th>
</tr>
</thead>
<tbody>
<tr ID="SDOHInterventionObs_1">
<td ID="SDOHIntervention_1">Referral to healthcare for the homeless program (procedure) 470841000124103</td>
<td>September 04,2025</td>
<td>Completed</td>
</tr>
<tr ID="SDOHInterventionObs_2">
<td ID="SDOHIntervention_2">Refer to mental health worker (procedure) 183583007</td>
<td>September 03,2025</td>
<td>Completed</td>
</tr>
<tr ID="SDOHInterventionObs_5">
<td ID="SDOHIntervention_5">Surgery, wrong body part PA</td>
<td>September 03,2025</td>
<td>Completed</td>
</tr>
</tbody>
</table>
</text>
<entry>
<procedure classCode="PROC" moodCode="EVN">
<!-- Procedure Activity Procedure V2-->
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="68da52b5-2018-42cf-8f61-4af6286c79fe"/>
<code code="25732003" displayName="Cat Sx OS" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#proc_sx_3"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250909"/>
</procedure>
</entry>
<entry>
<procedure classCode="PROC" moodCode="EVN">
<!-- Procedure Activity Procedure V2-->
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="c9ffb32d-ff75-4e9b-822b-c782444b4cf3"/>
<code code="M0301" displayName="Fabric wrapping of aneurysm" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#proc_sx_5"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250909"/>
</procedure>
</entry>
<entry>
<procedure classCode="PROC" moodCode="EVN">
<!-- Procedure Activity Procedure V2-->
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="b56b689d-ddec-4688-9723-0b2cc3a55aaf"/>
<code code="E0700" displayName="Safety equipment" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#proc_sx_16"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250909"/>
</procedure>
</entry>
<entry>
<procedure classCode="PROC" moodCode="EVN">
<!-- Procedure Activity Procedure V2-->
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="2d4c9ec9-8ce8-47c7-b2f5-dde5af835dd4"/>
<code code="E0781" displayName="External ambulatory infus pu" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
<text>
<reference value="#proc_sx_17"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250909"/>
</procedure>
</entry>
<entry typeCode="DRIV">
<procedure moodCode="EVN" classCode="PROC">
<templateId root="2.16.840.1.113883.10.20.22.4.14" />
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="da1f7938-2af6-4bd1-bb71-a2ee1e676f3d"/>
<code code="470841000124103" displayName="Referral to healthcare for the homeless program (procedure)"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
<text>
<reference value="#SDOHIntervention_1"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250904"/>
</procedure>
</entry>
<entry typeCode="DRIV">
<procedure moodCode="EVN" classCode="PROC">
<templateId root="2.16.840.1.113883.10.20.22.4.14" />
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="f4a61ec2-84a8-4c32-82cc-37c11e200144"/>
<code code="183583007" displayName="Refer to mental health worker (procedure)"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
<text>
<reference value="#SDOHIntervention_2"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250903"/>
</procedure>
</entry>
<entry typeCode="DRIV">
<procedure moodCode="EVN" classCode="PROC">
<templateId root="2.16.840.1.113883.10.20.22.4.14" />
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="ef153809-3349-4189-b467-61c751a8811b"/>
<code code="PA" displayName="Surgery, wrong body part"
codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
<text>
<reference value="#SDOHIntervention_5"/>
</text>
<statusCode code="completed"/>
<effectiveTime value="20250903"/>
</procedure>
</entry>
</section>
</component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.23" />
<templateId root="2.16.840.1.113883.10.20.22.2.23" extension="2014-06-09" />
<code code="46264-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medical Equipment" />
<title>Implants</title><!-- Alternative text: Patient has no history of procedures with implantable devices-->
<!-- Alternative text: Patient has no implanted devices-->
<text>
<paragraph ID="Proc">Patient has no history of implantable devices</paragraph>
</text>
<entry>
<procedure classCode="PROC" moodCode="EVN" negationInd="true">
<!-- Procedure Activity Procedure V2-->
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<id root="d5b614bd-01ce-410d-8726-e1fd01dcc72a" />
<code code="71388002" codeSystem="2.16.840.1.113883.6.96" displayName="Procedure"/>
<text>
<reference value="#Proc"/>
</text>
<statusCode code="completed" />
<effectiveTime nullFlavor="NA" />
<participant typeCode="DEV">
<participantRole classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.22.4.37"/>
<!-- UDI is not applicable since no procedure -->
<id nullFlavor="NA" root="2.16.840.1.113883.3.3719"/>
<playingDevice classCode="DEV">
<code code="40388003" codeSystem="2.16.840.1.113883.6.96" displayName="Implant"/>
</playingDevice>
<scopingEntity classCode="DEV">
<id root="2.16.840.1.113883.3.3719"/>
</scopingEntity>
</participantRole>
</participant>
</procedure>
</entry>
</section>
</component><!-- REASON FOR REFERRAL SECTION -->
<component>
<section>
<!-- Reason for Referral Section (V2) -->
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.1" extension="2014-06-09"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.1"/>
<code code="42349-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Reason for Referral"/>
<title>REASON FOR REFERRAL</title>
<text>No Reason for Referral information</text>
</section>
</component>
<!-- CLINICAL NOTES SECTION -->
<component> <!--Cures Update Progress Note-->
<section>
<!-- Notes Section -->
<templateId root="2.16.840.1.113883.10.20.22.2.65" extension="2016-11-01"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Laboratory note" code="11502-2"/>
<title>Laboratory Narrative</title>
<text>No Laboratory Narrative information found</text>
</section>
</component>
<component> <!--Cures Update Progress Note-->
<section>
<!-- Notes Section -->
<templateId root="2.16.840.1.113883.10.20.22.2.65" extension="2016-11-01"/>
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Pathology Study" code="11526-1"/>
<title>Pathology Study</title>
<text>No Pathology Study information found</text>
</section>
</component>
<component> <!--Cures Update Progress Note-->
<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 its 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 -->
<!-- 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="Consultation note"/>
<title>Consultation Notes</title>
<text>
<list>
<item ID="ConsultNote9">
<paragraph>
Tylock-George Eye Care
3100 N. MacArthur Blvd., Irving, Texas 75062
Ph. (972) 258-6400 | Fax (972) 570-1103
www.tylock.com
Taj Nasser, MD | Phat Vo, OD | Mark Hayes, OD | Lema Sbenaty, OD
Dear Dr. iMW Helpdesk,
Date: 08-25-2025
We would like to provide an update on our mutual patient Mr. IMWTest Doe. This patient was last seen in our office for AGE RELATED MACULAR DEGENERATION DRY; Right Eye (H35.3112) on 08-20-2025.
Patient: Doe, IMWTest
Date of Birth: 02-20-1985
Address: Test1234, Englewood Cliffs, NJ, 07632
Right Eye (OD):
Uncorrected Vision:
Corrected Vision:
IOP:
External:
SLE:
DFE:
Left Eye (OS):
Uncorrected Vision:
Corrected Vision:
IOP:
External:
SLE:
DFE:
Assessment and Plan:
Assessment: 1. AGE RELATED MACULAR DEGENERATION DRY; Right Eye (H35.3112)2. Myopia ; Both Eyes (H52.13)3. Presbyopia ; Both Eyes (H52.4)Plan: 1. 2. 3.
Follow up:
Thank you kindly for allowing me to participate in the care of your patient. Please let me know if I can help further in any way. Please feel free to refer additional patients for all of their cataract, cornea, and refractive surgery needs.
All the best,
ecl access, Mr S
Faxed By: access, ecl
Date of Examination: 08-20-2025
</paragraph>
</item>
<item ID="ConsultNote10">
<paragraph>
Tylock-George Eye Care
3100 N. MacArthur Blvd., Irving, Texas 75062
Ph. (972) 258-6400 | Fax (972) 570-1103
www.tylock.com
Taj Nasser, MD | Phat Vo, OD | Mark Hayes, OD | Lema Sbenaty, OD
Dear Dr. iMW Helpdesk,
Date: 09-03-2025
We would like to provide an update on our mutual patient Mr. IMWTest Doe. This patient was last seen in our office for AGE RELATED MACULAR DEGENERATION DRY; Right Eye (H35.3112) on 08-20-2025.
Patient: Doe, IMWTest
Date of Birth: 02-20-1985
Address: Test1234, Englewood Cliffs, NJ, 07632
Right Eye (OD):
Uncorrected Vision:
Corrected Vision:
IOP:
External:
SLE:
DFE:
Left Eye (OS):
Uncorrected Vision:
Corrected Vision:
IOP:
External:
SLE:
DFE:
Assessment and Plan:
Assessment: 1. AGE RELATED MACULAR DEGENERATION DRY; Right Eye (H35.3112)2. Myopia ; Both Eyes (H52.13)3. Presbyopia ; Both Eyes (H52.4)Plan: 1. 2. 3.
Follow up:
Thank you kindly for allowing me to participate in the care of your patient. Please let me know if I can help further in any way. Please feel free to refer additional patients for all of their cataract, cornea, and refractive surgery needs.
All the best,
ecl access, Mr S
Faxed By: access, ecl
Date of Examination: 08-20-2025
</paragraph>
</item>
<item ID="ConsultNote11">
<paragraph>
Tylock-George Eye Care
3100 N. MacArthur Blvd., Irving, Texas 75062
Ph. (972) 258-6400 | Fax (972) 570-1103
www.tylock.com
Taj Nasser, MD | Phat Vo, OD | Mark Hayes, OD | Lema Sbenaty, OD
Dear Dr. iMW Dev,
Date: 09-03-2025
We would like to provide an update on our mutual patient Mr. IMWTest Doe. This patient was last seen in our office for AGE RELATED MACULAR DEGENERATION DRY; Right Eye (H35.3112) on 08-20-2025.
Patient: Doe, IMWTest
Date of Birth: 02-20-1985
Address: Test1234, Englewood Cliffs, NJ, 07632
Right Eye (OD):
Uncorrected Vision:
Corrected Vision:
IOP:
External:
SLE:
DFE:
Left Eye (OS):
Uncorrected Vision:
Corrected Vision:
IOP:
External:
SLE:
DFE:
Assessment and Plan:
Assessment: 1. AGE RELATED MACULAR DEGENERATION DRY; Right Eye (H35.3112)2. Myopia ; Both Eyes (H52.13)3. Presbyopia ; Both Eyes (H52.4)Plan: 1. 2. 3.
Follow up:
Thank you kindly for allowing me to participate in the care of your patient. Please let me know if I can help further in any way. Please feel free to refer additional patients for all of their cataract, cornea, and refractive surgery needs.
All the best,
ecl access, Mr S
Faxed By: access, ecl
Date of Examination: 08-20-2025
</paragraph>
</item>
</list>
</text>
<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="Consultation note"/>
</code>
<text>
<reference value="#ConsultNote9"/>
</text>
<statusCode code="completed" />
<effectiveTime value="20250820" />
<author> <!--Cures Update Proverance-->
<!-- Provenance - Author Participation -->
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20250923132320-0400"/>
<assignedAuthor>
<!-- NPI of Author (example) -->
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3999" />
<name>Manchester</name>
<telecom value="tel:+1-860-649-9973"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
</act>
</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="Consultation note"/>
</code>
<text>
<reference value="#ConsultNote10"/>
</text>
<statusCode code="completed" />
<effectiveTime value="20250820" />
<author> <!--Cures Update Proverance-->
<!-- Provenance - Author Participation -->
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20250923132320-0400"/>
<assignedAuthor>
<!-- NPI of Author (example) -->
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3999" />
<name>Manchester</name>
<telecom value="tel:+1-860-649-9973"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
</act>
</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="Consultation note"/>
</code>
<text>
<reference value="#ConsultNote11"/>
</text>
<statusCode code="completed" />
<effectiveTime value="20250820" />
<author> <!--Cures Update Proverance-->
<!-- Provenance - Author Participation -->
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20250923132320-0400"/>
<assignedAuthor>
<!-- NPI of Author (example) -->
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3999" />
<name>Manchester</name>
<telecom value="tel:+1-860-649-9973"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
</act>
</entry>
</section>
</component>
<component> <!--Cures Update Procedure Note-->
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.65" extension="2016-11-01" />
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure note" code="28570-0" />
<title>Procedure Note</title>
<text>No Procedure Notes information found</text>
</section>
</component>
<component> <!--Cures Update Progress Note-->
<section>
<!-- Notes Section -->
<templateId root="2.16.840.1.113883.10.20.22.2.65" extension="2016-11-01" />
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Progress note" code="11506-3" />
<title>Progress Note</title>
<text>No Progress Notes information found</text>
</section>
</component>
<component> <!--Cures Update Procedure Note-->
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.65" extension="2016-11-01" />
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="34117-2" displayName="History and Physical Note"/>
<title>History and Physical Note</title>
<text>
<list>
<item ID="H_PNote1">
<paragraph>
HISTORY AND PHYSICAL
Advance Directive:NA
HISTORY AND PHYSICAL
YES / NO
DESCRIPTION
CAD/MIN(W/ WO Stent OR CABG)/PVD
No
CVA/TIA/ Epilepsy, Neurological
No
HTN/ +/- CP/SOB on Exertion
No
Respiratory - Asthma / COPD / Sleep Apnea
No
Arthritis
No
Diabetes
No
History of Cancer
No
High Cholesterol
No
Thyroid Problems
Yes
Hyperthyroid
Ulcers
No
</paragraph>
</item>
</list>
</text>
<entry> <!--Cures Update Procedure Note-->
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.202" extension="2016-11-01" />
<id root="9a6d1bac-17d3-4195-89a4-1231bc809301" />
<code code="34109-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Note">
<translation code="34117-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History and Physical Note"/>
</code>
<text>
<reference value="#H_PNote1"/>
</text>
<statusCode code="completed" />
<effectiveTime value="20250609081213" />
<author> <!--Cures Update Proverance-->
<!-- Provenance - Author Participation -->
<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
<time value="20250923132320-0400"/>
<assignedAuthor>
<!-- NPI of Author (example) -->
<id extension="1234567891" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1-860-649-9973"/>
<assignedPerson>
<name>
<given>ecl</given>
<family>access</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="78A150ED-B890-49dc-B716-5EC0027B3301" />
<name>Manchester</name>
<telecom value="tel:+1-860-649-9973"/>
<addr>
<streetAddressLine>178 Hartford Rd.</streetAddressLine>
<city>Manchester</city>
<state>CT</state>
<postalCode>06040</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
</act>
</entry>
</section>
</component>
<component>
<section nullFlavor="NI">
<templateId root="2.16.840.1.113883.10.20.22.2.500" extension="2019-07-01"/>
<templateId root="2.16.840.1.113883.10.20.22.2.500" extension="2022-06-01"/>
<code code="85847-2" codeSystem="2.16.840.1.113883.6.1"/>
<title>Care Teams</title>
<text>No care team information available</text>
</section>
</component><!-- *********************** PAYERS ********************** -->
<component>
<section>
<!-- *** Payers Section (V2) *** -->
<templateId root="2.16.840.1.113883.10.20.22.2.18" extension="2014-06-09" />
<code code="48768-6" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Payer" />
<title>INSURANCE PROVIDERS</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Payer name</th>
<th>Policy ID</th>
<th>Plan Name</th>
<th>Group ID</th>
<th>Policy Type</th>
<th>Policy Holder</th>
</tr>
</thead>
<tbody>
<tr ID="insuranceDetails1">
<td>MEDICARE 2NDARY</td>
<td>8181E4tax33DA08</td>
<td>zfd</td>
<td>287825</td>
<td>primary</td>
<td>Patient</td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<!-- ** Coverage activity ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.60" extension="2014-06-09" />
<id root="6ce1c51d-a3c3-48df-9615-b776afe706c5" />
<code code="48768-6" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="Payment sources" />
<statusCode code="completed" />
<entryRelationship typeCode="COMP">
<sequenceNumber value="1" />
<act classCode="ACT" moodCode="EVN">
<!-- ** Policy activity ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.61" extension="2014-06-09" />
<id root="8b5c6483-adab-4dff-a3e1-4f59c4d1cb6e" />
<code nullFlavor="NI"/>
<statusCode code="completed" /><!-- Insurance Company Information -->
<performer typeCode="PRF">
<templateId root="2.16.840.1.113883.10.20.22.4.87" />
<assignedEntity>
<id root="2.16.840.1.113883.19" />
<code code="PAYOR" codeSystem="2.16.840.1.113883.5.110"
codeSystemName="HL7 RoleCode" displayName="invoice payor" />
<addr use="WP">
<streetAddressLine>PO BOX 660031</streetAddressLine>
<city>Dallas</city>
<state>TX</state>
<postalCode>75266</postalCode>
<country>US</country>
<country>US</country>
</addr>
<representedOrganization>
<name>MEDICARE 2NDARY</name>
<addr use="WP">
<streetAddressLine>PO BOX 660031</streetAddressLine>
<city>Dallas</city>
<state>TX</state>
<postalCode>75266</postalCode>
<country>US</country>
</addr>
</representedOrganization>
</assignedEntity>
</performer><!-- Guarantor Information -->
<performer typeCode="PRF">
<templateId root="2.16.840.1.113883.10.20.22.4.88" />
<time>
<low nullFlavor="UNK" />
<high nullFlavor="UNK" />
</time>
<assignedEntity>
<id root="e5174706-f5a5-4be8-b814-ce861f433696" />
<code code="GUAR" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 RoleCode" />
<addr use="HP">
<streetAddressLine>Test123</streetAddressLine>
<city>Englewood Cliffs</city>
<state>NJ</state>
<postalCode>07632</postalCode>
<country>US</country>
</addr>
<telecom value="tel:+1666-555-4448" use="HP"/>
<telecom value="tel:+1666-555-4448" use="MC"/>
<assignedPerson>
<name>
<given>IMWTest</given>
<family>Doe</family>
</name>
</assignedPerson>
</assignedEntity>
</performer>
<participant typeCode="COV">
<!-- Covered Party Participant -->
<templateId root="2.16.840.1.113883.10.20.22.4.89.2" />
<time>
<low nullFlavor="UNK" />
<high nullFlavor="UNK" />
</time>
<participantRole classCode="PAT">
<!-- Health plan ID for patient. -->
<id root="8d97c9a6-c7f9-4e93-9f64-25b9060856ca" extension="8181E4tax33DA08" />
<code code="SELF" codeSystem="2.16.840.1.113883.5.111" displayName="self" />
<addr use="HP">
<streetAddressLine>Test123 Street4</streetAddressLine>
<city>Englewood Cliffs</city>
<state>NJ</state>
<postalCode>07632</postalCode>
<country>US</country>
</addr>
<playingEntity classCode="PSN">
<name>
<!-- Name is needed if different than health plan name. -->
<given>IMWTest</given>
<family>Doe</family>
</name>
<sdtc:birthTime value="19850220" />
</playingEntity>
</participantRole>
</participant><!-- Policy Holder -->
<participant typeCode="HLD">
<templateId root="2.16.840.1.113883.10.20.22.4.90.2" />
<participantRole classCode="POLHOLD">
<id extension="8181E4tax33DA08" root="2.16.840.1.113883.19" />
<addr use="HP">
<streetAddressLine>Test123 Street4</streetAddressLine>
<city>Englewood Cliffs</city>
<state>NJ</state>
<postalCode>07632</postalCode>
<country>US</country>
</addr>
</participantRole>
</participant>
<entryRelationship typeCode="REFR">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.19"/>
<id root="164d18fa-90b6-4e6e-a264-abe0b2a57fb1"/>
<code nullFlavor="NA"/>
<entryRelationship typeCode="SUBJ">
<procedure classCode="PROC" moodCode="PRMS"/>
</entryRelationship>
</act>
</entryRelationship>
</act>
</entryRelationship>
</act>
</entry>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>
Gulshan Dhiman
Sep 25, 2025, 5:08:22 AM (9 days ago) Sep 25
to Edge Test Tool (ETT)
Hi Mat,
I have shared the xml file. Can you help why we are facing java Lang server error?
I have shared the xml file. Can you help why we are facing java Lang server error?
Mat Davis
Sep 25, 2025, 5:20:48 AM (9 days ago) Sep 25
to Gulshan Dhiman, Edge Test Tool (ETT)
Can you possibly attach as an XML vs pasting? Looks like the full content is not present.
Thanks - Mat
Gulshan Dhiman
Sep 25, 2025, 5:25:14 AM (9 days ago) Sep 25
to Edge Test Tool (ETT)
I am only getting an option to attach photo not other file
Mat Davis
Sep 25, 2025, 8:17:28 AM (9 days ago) Sep 25
to Gulshan Dhiman, Edge Test Tool (ETT)
If you can’t paste all the XML and you can’t attach the XML file then see below.
This might sound tedious and is only a suggestion but what you can do is:
1 - remove a section
2 - save a new version of the XML each time
3 - keep doing this until only 1 section is left
4 - test each file in the validator
5 - see which XMLs pass and which XMLs fail
6 - this should get you the section(s) that are causing the error
Thanks - Mat
Gulshan Dhiman
Sep 25, 2025, 11:41:46 AM (9 days ago) Sep 25
to Mat Davis, Edge Test Tool (ETT)
Hi Davis,
I have attached the CCDA xml file which is causing issue with validation server.
I have attached the CCDA xml file which is causing issue with validation server.
From: Mat Davis <mdavis.dyna...@gmail.com>
Sent: Thursday, September 25, 2025 5:47 PM
To: Gulshan Dhiman <gulshan...@sightview.com>
Cc: Edge Test Tool (ETT) <edge-te...@googlegroups.com>
Subject: Re: Getting Error while validating CCDA
Sent: Thursday, September 25, 2025 5:47 PM
To: Gulshan Dhiman <gulshan...@sightview.com>
Cc: Edge Test Tool (ETT) <edge-te...@googlegroups.com>
Subject: Re: Getting Error while validating CCDA
___________________________________________________________________________________________________________________________
This electronic communication is intended by the sender only for the access and use by the addressee and may contain confidential information. If you are not the addressee, you are notified that any transmission, disclosure, use, access to, storage or photocopying of this e-mail and any attachments is strictly prohibited. The confidentiality attached to this e-mail and any attachments is not waived, lost or destroyed by reason of a mistaken delivery to you. If you have received this e-mail and any attachments in error please immediately delete it and all copies from your system and notify the sender by e-mail. Nothing in this communication is intended to operate as an electronic signature under any applicable law.
This electronic communication is intended by the sender only for the access and use by the addressee and may contain confidential information. If you are not the addressee, you are notified that any transmission, disclosure, use, access to, storage or photocopying of this e-mail and any attachments is strictly prohibited. The confidentiality attached to this e-mail and any attachments is not waived, lost or destroyed by reason of a mistaken delivery to you. If you have received this e-mail and any attachments in error please immediately delete it and all copies from your system and notify the sender by e-mail. Nothing in this communication is intended to operate as an electronic signature under any applicable law.
Mat Davis
Sep 26, 2025, 4:54:16 AM (8 days ago) Sep 26
to Edge Test Tool (ETT)
Thanks for this info Gulshan.
This should help the ETT Google Group Team move forward.
A reminder that I am an unofficial supporter so no further action will be taken on my end.
Until the ETT Google Group Team responds, you could try the method I mentioned in the previous emails
This might sound tedious and is only a suggestion but what you can do is:
1 - remove a section
2 - save a new version of the XML each time
3 - keep doing this until only 1 section is left
4 - test each file in the validator
5 - see which XMLs pass and which XMLs fail
6 - this should get you the section(s) that are causing the error
Thanks - Mat
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