<?xml version="1.0" encoding="UTF-8"?>
<!-- 
  PALGA voorbeeld Cytologie (C)
  POCD_SN970003NL
-->
<?xml-stylesheet type="text/xsl" href="../../xsl/CDA.xsl"?>
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:sciphox="urn::sciphox-org/sciphox"
  xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 ../../schemas/CDA.xsd">
  <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
  <id extension="C0784693A" root="2.16.840.1.113883.2.4.3.23.3.20"/>
  <code code="33716-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
  <title>Cytologie (C), patient: Ton Thijssen</title>
  <effectiveTime value="200711221456"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <languageCode code="nl-NL"/>
  <setId extension="C0784693" root="2.16.840.1.113883.2.4.3.23.3.20"/>
  <versionNumber value="1"/>
  <recordTarget>
    <!-- patiënt gegevens -->
    <patientRole>
      <id extension="767545323" root="2.16.840.1.113883.2.4.6.3"/>
      <patient>
        <name>
          <given>Ton</given>
          <family>Thijssen</family>
        </name>
        <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
        <birthTime value="19310711"/>
      </patient>
    </patientRole>
  </recordTarget>
  <author>
    <!--- author -->
    <time value="20071122"/>
    <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>
      </representedOrganization>
    </assignedAuthor>
  </author>
  <custodian>
    <assignedCustodian>
      <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="20071122"/>
    <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="C" 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="20071121"/>
        <high value="200711221456"/>
      </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>
            Hoofdcarina punctie long op glaasjes --> maligniteit?<br/>
            18 uitstrijken (G) ontvangen.
          </text>
        </section>
      </component>
       <component>
        <!-- Microscopie -->
        <section>
          <code code="22635-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
          <title>Microscopie</title>
          <text>
            Celrijk materiaal waarin losliggende en groepen dissocierende wanordelijk gelegen sterk 
            atypische cellen met vergrote, polymorfe en hyperchromatische kernen, forse anisonucleose, 
            prominente nucleoli, grof chromatinepatroon en zeer onregelmatig en soms verhoornend cytoplasma.<br/>
            Daarnaast veel granulocyten, lymfocyten, cylinderepitheelcellen en veel bloed.
          </text>
        </section>
      </component>
      <component>
        <!-- Conclusie -->
        <section>
          <code code="22034-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
          <title>Conclusie</title>
          <text>long punctie hoofdcarina: planocellulair carcinoom.</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: long*punctie*carina*verhoornend planocellulair carcinoom<br/>
              Palga-codes1: <content ID="d1-1">T28000</content>*<content ID="d1-2">P31430</content>*
              <content ID="d1-3">T25200</content>*<content ID="d1-4">M80713</content>
            </paragraph>
          </text>
          <entry typeCode="DRIV">
            <organizer classCode="CLUSTER" moodCode="EVN">
              <statusCode code="completed"/>
              <component typeCode="COMP">
                <sequenceNumber value="1"/>
                <observation classCode="OBS" moodCode="EVN">
                  <code code="DX" codeSystem="2.16.840.1.113883.5.4"/>
                  <statusCode code="completed"/>
                  <effectiveTime>
                    <low value="20071122"/>
                  </effectiveTime>
                  <value xsi:type="CD" code="T28000" codeSystem="2.16.840.1.113883.2.4.3.23.5.2" codeSystemName="PALGA codes">
                    <originalText>
                      <reference value="#d1-1"/>
                    </originalText>
                  </value>
                </observation>
              </component>
              <component typeCode="COMP">
                <sequenceNumber value="2"/>
                <observation classCode="OBS" moodCode="EVN">
                  <code code="DX" codeSystem="2.16.840.1.113883.5.4"/>
                  <statusCode code="completed"/>
                  <effectiveTime>
                    <low value="20071122"/>
                  </effectiveTime>
                  <value xsi:type="CD" code="P31430" codeSystem="2.16.840.1.113883.2.4.3.23.5.2" codeSystemName="PALGA codes">
                    <originalText>
                      <reference value="#d1-2"/>
                    </originalText>
                  </value>
                </observation>
              </component>
              <component typeCode="COMP">
                <sequenceNumber value="3"/>
                <observation classCode="OBS" moodCode="EVN">
                  <code code="DX" codeSystem="2.16.840.1.113883.5.4"/>
                  <statusCode code="completed"/>
                  <effectiveTime>
                    <low value="20071122"/>
                  </effectiveTime>
                  <value xsi:type="CD" code="T25200" codeSystem="2.16.840.1.113883.2.4.3.23.5.2" codeSystemName="PALGA codes">
                    <originalText>
                      <reference value="#d1-3"/>
                    </originalText>
                  </value>
                </observation>
              </component>
              <component typeCode="COMP">
                <sequenceNumber value="4"/>
                <observation classCode="OBS" moodCode="EVN">
                  <code code="DX" codeSystem="2.16.840.1.113883.5.4"/>
                  <statusCode code="completed"/>
                  <effectiveTime>
                    <low value="20071122"/>
                  </effectiveTime>
                  <value xsi:type="CD" code="M80713" codeSystem="2.16.840.1.113883.2.4.3.23.5.2" codeSystemName="PALGA codes">
                    <originalText>
                      <reference value="#d1-4"/>
                    </originalText>
                  </value>
                </observation>
              </component>
            </organizer>
            </entry>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>
