<?xml version="1.0" encoding="UTF-8"?>
<!-- 
  PALGA voorbeeld Histologie (T) – klein
  POCD_SN970002NL
-->
<?xml-stylesheet type="text/xsl" href="../../xsl/CDA.xsl"?>
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  <code code="22036-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
  <title>Histologie (T) – klein, patient: Jan van Dale</title>
  <effectiveTime value="200704051624"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="nl-NL"/>
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  <versionNumber value="1"/>
  <recordTarget>
    <!-- patiënt gegevens -->
    <patientRole>
      <id extension="100197245" root="2.16.840.1.113883.2.4.6.3"/>
      <patient>
        <name>
          <given>Jan</given>
          <prefix qualifier="VV">van</prefix>
          <family>Dale</family>
        </name>
        <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
        <birthTime value="19450911"/>
      </patient>
    </patientRole>
  </recordTarget>
  <author>
    <!--- author -->
    <time value="20070405"/>
    <assignedAuthor>
      <id extension="1298546" root="2.16.528.1.1007.3.1"/>
      <assignedPerson>
        <name>
          <given>Theo</given>
          <family>Driessen</family>
        </name>
      </assignedPerson>
      <representedOrganization>
        <name>Academisch Medisch Centrum, Amsterdam</name>
        <addr>
          <streetName>Meibergdreef</streetName>
          <houseNumber>9</houseNumber>
          <postalCode>1100 DD</postalCode>
          <city>Amsterdam</city>
        </addr>
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    </assignedAuthor>
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      <representedCustodianOrganization>
        <id extension="20" root="2.16.840.1.113883.2.4.3.23.3"/>
        <name>Academisch Medisch Centrum, Amsterdam</name>
        <addr>
          <streetName>Meibergdreef</streetName>
          <houseNumber>9</houseNumber>
          <postalCode>1100 DD</postalCode>
          <city>Amsterdam</city>
        </addr>
      </representedCustodianOrganization>
    </assignedCustodian>
  </custodian>
  <informationRecipient>
    <intendedRecipient>
      <id extension="67684" root="2.16.528.1.1007.3.1"/>
      <informationRecipient>
        <name>
          <given>Karel</given>
          <family>Oogappel</family>
        </name>
      </informationRecipient>
      <receivedOrganization>
        <telecom use="WP" value="fax:0251247878"/>
        <addr>
          <streetName>Ziekenhuisweg</streetName>
          <houseNumber>23</houseNumber>
          <postalCode>6734 WR</postalCode>
          <city>Assen</city>
        </addr>
      </receivedOrganization>
    </intendedRecipient>
  </informationRecipient>
  <legalAuthenticator>
    <!--- legalAuthenticator -->
    <time value="20070405"/>
    <signatureCode code="S"/>
    <assignedEntity>
      <id extension="1298546" root="2.16.528.1.1007.3.1"/>
      <assignedPerson>
        <name>
          <given>Theo</given>
          <family>Driessen</family>
        </name>
      </assignedPerson>
      <representedOrganization>
        <id extension="20" root="2.16.840.1.113883.2.4.3.23.3"/>
        <name>Academisch Medisch Centrum, Amsterdam</name>
        <addr>
          <streetName>Meibergdreef</streetName>
          <houseNumber>9</houseNumber>
          <postalCode>1100 DD</postalCode>
          <city>Amsterdam</city>
        </addr>
      </representedOrganization>
    </assignedEntity>
  </legalAuthenticator>
  <documentationOf>
    <serviceEvent>
      <code code="H" codeSystem="2.16.840.1.113883.2.4.3.23.5.1" codeSystemName="PALGA service types"/>
    </serviceEvent>
  </documentationOf>
  <componentOf>
    <encompassingEncounter classCode="ENC" moodCode="EVN">
      <code code="VR" codeSystem="2.16.840.1.113883.5.4"/>
      <effectiveTime>
        <low value="200704051017"/>
        <high value="200704051624"/>
      </effectiveTime>
    </encompassingEncounter>
  </componentOf>
  <component>
    <structuredBody>
      <component>
        <!-- Klinische gegevens -->
        <section>
          <code code="22636-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
          <title>Klinische gegevens</title>
          <text>Gepigmenteerd plekje rechter slaap.
          </text>
        </section>
      </component>
      <component>
        <!-- Macroscopie -->
        <section>
          <code code="22634-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
          <title>Macroscopie</title>
          <text>
            1 inzending.<br/>
            Een ellipsvormige huidexcisie met subcutis van 12 x 7 x 3 mm. Op de epidermis een matig 
            verheven, korrelige, lichtbruine laesie van 5 mm in diameter. T.i.<br/>
            <br/>
          </text>
        </section>
      </component>
      <component>
        <!-- Microscopie -->
        <section>
          <code code="22635-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
          <title>Microscopie</title>
          <text>
            Doorsneden door een verruca seborrhoica van het acanthotische type. De laesie werd in toto verwijderd.<br/>
          </text>
        </section>
      </component>
      <component>
        <!-- Conclusie -->
        <section>
          <code code="22034-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
          <title>Conclusie</title>
          <text>Excisie verruca seborrhoica rechter slaap.</text>
        </section>
      </component>
      <component>
        <!-- Diagnosen -->
        <section>
          <code code="22637-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
          <title>Diagnosen</title>
          <text>
            <paragraph>
              Diagtekst1: huid*gelaat*excisie*verruca seborrhoica<br/>
              Palga-codes1: <content ID="d1-1">T01000</content>*<content ID="d1-2">TY02000</content>*
              <content ID="d1-3">P11200</content>*<content ID="d1-4">M27250</content>
            </paragraph>
          </text>
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                  <statusCode code="completed"/>
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                    <low value="20071122"/>
                  </effectiveTime>
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                  <statusCode code="completed"/>
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                    <low value="20071122"/>
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                    <originalText>
                      <reference value="#d1-4"/>
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            </organizer>
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        </section>
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</ClinicalDocument>
