MSH-Message header segment (20 fields)
MSH-03: Sending Application (3 components)
namespace id: SOMEAPP
MSH-04: Sending Facility (3 components)
namespace id: SOMEAPP
MSH-05: Receiving Application (3 components)
namespace id: YOURAPP
MSH-06: Receiving Facility (3 components)
namespace id: YOURAPP
MSH-07: Date/Time Of Message (2 components)
time stamp data: 20031111163831+0000
degree of precision (optional): S
MSH-08: Security (1 component)
Value: NO SECURITY
MSH-09: Message Type (4 components)
component 1: ADT
component 2: A08
MSH-10: Message Control ID (1 component)
Value: 153681279959711
MSH-11: Processing ID (2 components)
processing id: T
MSH-12: Version ID (3 components)
version id: 2.3
MSH-13: Sequence Number (1 component)
Value: 000000000611811
MSH-15: Accept Acknowledgment Type (1 component)
Value: AL
EVN-Event type segment (6 fields)
EVN-01: Event Type Code (1 component)
Value: A08
EVN-02: Recorded Date/Time (2 components)
time stamp data: 20031111163831+0000
degree of precision (optional): S
EVN-04: Event Reason Code (1 component)
Value: 00102
EVN-05: Operator ID (7 components)
id number: 00002
PID-Patient identification segment (30 fields)
PID-02: Patient ID (6 components)
id: 1524321408
PID-03: Patient Identifier List (6 components)
id: 1524321408
PID-04: Alternate Patient ID - PID (6 components)
id: 234166342
PID-05: Patient Name (7 components)
family name (last name): Eriksson
given name (first name): Elizabeth
middle initial or name: M
PID-07: Date/Time of Birth (2 components)
time stamp data: 19760824
PID-08: Sex (1 component)
Value: F
PID-11: Patient Address (9 components)
street address: 5008 SOMEPLACE RD
other designation: APT215
city: FT WORTH
state or province: TX
zip or postal code: 76132-0000
PID-13: Phone Number - Home (8 components)
telecommunications use code: (817)555-1212
PID-14: Phone Number - Business (8 components)
telecommunications use code: (214)555-1212X00019
PID-18: Patient Account Number (6 components)
id: 234166342
PID-19: SSN Number - Patient (1 component)
Value: 234166342
PV1-Patient visit segment (52 fields)
PV1-02: Patient Class (1 component)
Value: P
PV1-03: Assigned Patient Location (9 components)
point of care:
room:
bed:
facility: 00002
PV1-04: Admission Type (1 component)
Value: R
PV1-06: Prior Patient Location (9 components)
point of care: 00019
PV1-07: Attending Doctor (7 components)
id number: 06543
family name (last name): HOOPER
given name (first name): DENNIS
middle initial or name: L
PV1-20: Financial Class (2 components)
financial class: 00111
DG1-Diagnosis segment (19 fields)
DG1-01: Set ID - DG1 (1 component)
Value: 0001
DG1-02: Diagnosis Coding Method (1 component)
Value: I9
DG1-04: Diagnosis Description (1 component)
Value: NODX
DG1-06: Diagnosis Type (1 component)
Value: W
DG1-15: Diagnosis Priority (1 component)
Value: 01
DG1-16: Diagnosing Clinician (7 components)
id number: 06543
family name (last name): HOOPER
given name (first name): DENNIS
middle initial or name: L
GT1-Guarantor segment (55 fields)
GT1-01: Set ID - GT1 (1 component)
Value: 0001
GT1-02: Guarantor Number (6 components)
id: 3322261701
GT1-03: Guarantor Name (7 components)
family name (last name): Harris
given name (first name): Dominic
middle initial or name: M
GT1-05: Guarantor Address (9 components)
street address: 5008 SOMEPLACE RD
other designation: APT215
city: FT WORTH
state or province: TX
zip or postal code: 76132-0000
GT1-06: Guarantor Ph Num-Home (8 components)
telecommunications use code: (817)555-1212
GT1-07: Guarantor Ph Num-Business (8 components)
telecommunications use code: (214)555-1212X00019
IN1-Insurance segment (49 fields)
IN1-01: Set ID - IN1 (1 component)
Value: 0001
IN1-02: Insurance Plan ID (6 components)
identifier: 0000008
IN1-03: Insurance Company ID (6 components)
id: 0000114
IN1-04: Insurance Company Name (8 components)
organization name: UNITED HEALTH 87726
IN1-05: Insurance Company Address (9 components)
street address: P O BOX 740800
other designation:
city: ATLANTA
state or province: GA
zip or postal code: 30374-0800
IN1-07: Insurance Co Phone Number (8 components)
telecommunications use code: (800)842-5724
IN1-12: Plan Effective Date (1 component)
Value: 20000401
IN1-15: Plan Type (1 component)
Value: P
IN1-16: Name Of Insured (7 components)
family name (last name): OYLE
given name (first name): OLIVE
middle initial or name: M
IN1-17: Insured's Relationship To Patient (6 components)
identifier: 00002
IN1-18: Insured's Date Of Birth (2 components)
time stamp data: 19760824
IN1-19: Insured's Address (9 components)
street address: 5008 SOMEPLACE RD
other designation: APT215
city: FT WORTH
state or province: TX
zip or postal code: 76132-0000
IN1-20: Assignment Of Benefits (1 component)
Value: Y
IN1-21: Coordination Of Benefits (1 component)
Value: Y
IN1-27: Release Information Code (1 component)
Value: A
IN1-36: Policy Number (1 component)
Value: 234166342
IN1-43: Insured's Sex (1 component)
Value: F
IN2-Insurance additional information segment (72 fields)
IN2-02: Insured's Social Security Number (1 component)
Value: 234166342
IN2-03: Insured's Employer's Name and ID (7 components)
id number: 0009999
family name (last name): UNKNOWN
IN2-05: Mail Claim Party (1 component)
Value: I
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