Generated Narrative: Composition composition-eicr-zika Profile: Electronic Initial Case Report Composition Composition Version Number: 1 identifier: c03eab8c-11e8-4d0c-ad2a-b385395e27db status: Final type: Public Health Case Report encounter: Ambulatory Office Visit date: 2018-01-02 22:13:23+0000 author: Henry Seven, MD title: Initial Public Health Case Report - Zika Example custodian: Salem Medical Center
Initial Public Health Case Report - Zika Example
title Reason for Visit Section code Reason for visit Narrative ( 29299-5 ) http://loinc.org Reason for Visit: Bad cough
title Chief complaint Narrative - Reported code Chief complaint Narrative - Reported ( 10154-3 ) http://loinc.org Chief Complaint: Bad cough
title History of Present Illness Section code History of Present illness Narrative ( 10164-2 ) http://loinc.org Persistent Cough REPORTED starting on 2018/03/05 Whooping Respiration not reported Paroxysms Of Coughing REPORTED starting on 2018/03/06 Post-tussive vomiting not reported
title Problems Section code Problem list - Reported ( 11450-4 ) http://loinc.org entry Common cold (disorder) id condition-eicr-eve-everywoman-common-cold meta versionId 15 lastUpdated 2019-10-10T21:21:49.000-04:00 profile http://hl7.org/fhir/us/ph-library/StructureDefinition/us-ph-condition category Problem List Item ( problem-list-item ) http://terminology.hl7.org/CodeSystem/condition-category code Common cold (disorder) ( 82272006 ) http://snomed.info/sct subject Eve Everywoman onsetDateTime 2017-09-23 asserter Henry Seven, MD
title Medications Administered Section code Medication administered Narrative ( 29549-3 ) http://loinc.org entry Azithromycin 500 MG Oral Tablet id medicationadministration-eve-everywoman-azithromycin meta versionId 10 lastUpdated 2019-10-05T03:11:22.000-04:00 status completed medicationCodeableConcept Azithromycin 500 MG Oral Tablet Azithromycin 500 MG Oral Tablet ( 248656 ) http://www.nlm.nih.gov/research/umls/rxnorm subject Eve Everywoman effectivePeriod start 2018-03-07 end 2018-03-07 dosage route Oral Route ( 26643006 ) http://snomed.info/sct method Swallow - dosing instruction imperative (qualifier value) ( 421521009 ) http://snomed.info/sct dose value 2 unit TAB system http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm code TAB
title Admission Medications Section code Medications on admission (narrative) ( 42346-7 ) http://loinc.org entry 1 ML naloxone hydrochloride 0.4 MG/ML Injection
1 ML naloxone hydrochloride 0.4 MG/ML Injection
title Medications Section code History of Medication use Narrative ( 10160-0 ) http://loinc.org entry Azithromycin 500 MG Oral Tablet
Relevant diagnostic tests/laboratory data note
title Results Section code Relevant Dx tests/lab data ( 30954-2 ) http://loinc.org entry Lymphocytes [#/​volume] in Blood by Automated count - Interpretation: High id observation-us-ph-lab-result-eve-everywoman-lymphocytes meta versionId 10 lastUpdated 2019-10-05T02:50:13.000-04:00 profile http://hl7.org/fhir/us/ph-library/StructureDefinition/us-ph-lab-result-observation status final category Laboratory Laboratory ( laboratory ) http://terminology.hl7.org/CodeSystem/observation-category code Lymphocytes [#/volume] in Blood by Automated count ( 731-0 ) http://loinc.org subject Eve Everywoman effectiveDateTime 2018-03-07 valueQuantity 5.2 http://unitsofmeasure.org 10*3/uL interpretation High ( H ) http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation referenceRange low value 1 system http://unitsofmeasure.org code 10*3/uL high value 4.8 system http://unitsofmeasure.org code 10*3/uL
Lymphocytes [#/​volume] in Blood by Automated count - Interpretation: High
title Plan of Treatment Section code Plan of care note ( 18776-5 ) http://loinc.org entry Trigger code Trigger Code: Trigger Code Display: Trigger Code System: Trigger Code Value Set: urn:oid:2.16.840.1.114222.4.11.7508 Trigger Code Value Set Version: 19/05/2018 Request for Zika virus envelope (E) gene [Presence] in Serum by Probe and target amplification method id servicerequest-eicr-zika meta versionId 9 lastUpdated 2019-10-23T13:56:36.000-04:00 profile http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-servicerequest status completed intent order category Diagnostics Procedure Diagnostic procedure (procedure) ( 103693007 ) http://snomed.info/sct code Zika RT-PCR Zika virus envelope E gene [Presence] in Serum by NAA with probe detection ( 80825-3 ) http://loinc.org subject Eve Everywoman performer Acme Labs
Request for Zika virus envelope (E) gene [Presence] in Serum by Probe and target amplification method
title Immunizations Section code History of Immunization note ( 11369-6 ) http://loinc.org entry pneumococcal polysaccharide vaccine entry Vaccine Credential Patient Assertion Observation Example
Vaccine Credential Patient Assertion Observation Example
title Procedures Section code History of Procedures Document ( 47519-4 ) http://loinc.org entry Extracorporeal membrane oxygenation (procedure)
Extracorporeal membrane oxygenation (procedure)
title Vital Signs Section code Vital signs ( 8716-3 ) http://loinc.org entry Blood pressure systolic and diastolic
title Social History Section code Social history note ( 29762-2 ) http://loinc.org entry eICR Travel History: Eve Everywoman 2018-01 id observation-travel-history-eve-everywoman-201801 meta versionId 11 lastUpdated 2019-10-05T03:15:42.000-04:00 profile http://hl7.org/fhir/us/ph-library/StructureDefinition/us-ph-travel-history status final code Travel History Travel ( 420008001 ) http://snomed.info/sct subject Eve Everywoman effectivePeriod start 2018-01-15 end 2018-01-30 component code Location ( LOC ) http://terminology.hl7.org/CodeSystem/v3-ParticipationType valueCodeableConcept Fiji ( FJI ) urn:iso:std:iso:3166 component code Location ( LOC ) http://terminology.hl7.org/CodeSystem/v3-ParticipationType valueCodeableConcept Vanuatu ( VUT ) https://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=1.0.3166.1 entry ODH Usual Work Example id observation-odh-usual-work-eve-everywoman meta versionId 2 lastUpdated 2019-10-20T10:53:14.000-04:00 profile http://hl7.org/fhir/us/odh/StructureDefinition/odh-UsualWork status final code History of Usual occupation ( 21843-8 ) http://loinc.org subject Eve Everywoman effectivePeriod start 2015-01-01 end 2018-03-07 valueCodeableConcept Human Resources Managers ( 0136 ) https://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.114222.4.5.314 component code History of Usual industry ( 21844-6 ) http://loinc.org valueCodeableConcept Hospitals ( 8190 ) https://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.114222.4.5.315
eICR Travel History: Eve Everywoman 2018-01
US Public Health Disability Status Example
US Public Health Exposure Contact Information Example
Country of Nationality Observation Example
Country of Residence Observation Example
title Pregnancy Section code Pregnancy summary Document ( 90767-5 ) http://loinc.org entry eICR Pregnancy Status Example id observation-pregnancy-status-eve-everywoman meta versionId 13 lastUpdated 2019-10-05T03:15:42.000-04:00 profile http://hl7.org/fhir/us/ph-library/StructureDefinition/us-ph-pregnancy-status-observation us-ph-date-recorded-extension 2017-10-01 date-determined-extension 2017-10-01 status final code Pregnancy Status ( 82810-3 ) http://loinc.org subject Eve Everywoman effectivePeriod start 2017-08-26 valueCodeableConcept Pregnancy (finding) ( 77386006 ) http://snomed.info/sct method Ultrasonography (procedure) ( 16310003 ) http://snomed.info/sct component date-determined-extension 2017-10-01 code Gestational age Estimated from patient reported estimated date of conception ( 53691-2 ) http://loinc.org valueQuantity 143 d component date-determined-extension 2017-10-01 code Delivery date Estimated from date fundal height reaches umb ( 57064-8 ) http://loinc.org valueDateTime 2018-05-01
title Emergency Outbreak Information Section code Public health Note ( 83910-0 ) http://loinc.org entry US Public Health Emergency Outbreak Information Example
US Public Health Emergency Outbreak Information Example
title Past Medical History Section code Past Medical History Narrative ( 11348-0 ) http://loinc.org Past medical history
title Review of Systems Section code Review of Systems Section Narrative ( 10187-3 ) http://loinc.org Review of systems
Generated Narrative: MedicationAdministration medicationadministration-eve-everywoman-azithromycin Profile: US Public Health MedicationAdministration status: Completed medication: Azithromycin 500 MG Oral Tablet subject: Eve Everywoman effective: 2018-03-07 --> 2018-03-07 Dosages - Text Route Method Dose * Two tablets at once Oral route Swallow - dosing instruction imperative (qualifier value) 2 TAB (Details: Orderable Drug Form codeTAB = 'Tablet')
Swallow - dosing instruction imperative (qualifier value)
Generated Narrative: Procedure procedure-ecmo Profile: eICR Procedure identifier: <a href="http://terminology.hl7.org/6.5.0/NamingSystem-uri.html" title="As defined by RFC 3986 (http://www.ietf.org/rfc/rfc3986.txt)(with many schemes defined in many RFCs). For OIDs and UUIDs, use the URN form (urn:oid:(note: lowercase) and urn:uuid:). See http://www.ietf.org/rfc/rfc3001.txt and http://www.ietf.org/rfc/rfc4122.txt #xD;#xA;#xD;#xA;This oid is used as an identifier II.root to indicate the the extension is an absolute URI (technically, an IRI). Typically, this is used for OIDs and GUIDs. Note that when this OID is used with OIDs and GUIDs, the II.extension should start with urn:oid or urn:uuid: #xD;#xA;#xD;#xA;Note that this OID is created to aid with interconversion between CDA and FHIR - FHIR uses urn:ietf:rfc:3986 as equivalent to this OID. URIs as identifiers appear more commonly in FHIR.#xD;#xA;#xD;#xA;This OID may also be used in CD.codeSystem.">Uniform Resource Identifier (URI)/urn:uuid:b2a737f2-2fdb-49c1-b097-dac173d07afd status: Completed code: Extracorporeal membrane oxygenation (procedure) subject: Eve L Everywoman Female, DoB: 1974-11-24 ( Medical Record Number: 1032702 (use: usual, )) performed: 2020-11-01 12:55:26-0700 --> 2020-11-01 13:25:26-0700 FocalDevices - Manipulated * Device: status = active; manufacturer = ACME Biomedical; expirationDate = 2022-01-01; lotNumber = M320; serialNumber = AC222; modelNumber = 4.0; type = Extracorporeal membrane oxygenator (physical object)
Generated Narrative: MedicationAdministration medicationadministration-eve-everywoman-naloxone-response Profile: US Public Health MedicationAdministration US Public Health Therapeutic Medication Response Extension: Patient's condition improved (finding) status: Completed medication: 1 ML naloxone hydrochloride 0.4 MG/ML Injection subject: Eve Everywoman effective: 2018-03-07 --> 2018-03-07 Dosages - Route Method Dose * Gluteus maximus muscle Inject - dosing instruction imperative (qualifier value) 1 mL (Details: UCUM codemL = 'mL')
Inject - dosing instruction imperative (qualifier value)
Generated Narrative: ServiceRequest servicerequest-eicr-zika Profile: eICR ServiceRequest identifier: http://example.org/lab.smarthealthit.org/061ef612-344f-4e7b-81a8-1059ae7bbe11 status: Completed intent: Order category: Diagnostics Procedure code: Zika RT-PCR subject: Eve Everywoman performer: Acme Labs
Zika virus envelope E gene [Presence] in Serum by NAA with probe detection
Generated Narrative: Condition condition-eicr-eve-everywoman-common-cold Profile: US Public Health Condition Encounter Diagnosis category: Encounter Diagnosis code: Common cold (disorder) subject: Eve Everywoman onset: 2017-09-23 asserter: Henry Seven, MD
Generated Narrative: Encounter encounter-eicr-eve-everywoman-outpatient Profile: eICR Encounter identifier: http://example.org/hospital.smarthealthit.org/9937012 status: Finished class: ActCode: AMB (ambulatory) type: Office Visit subject: Eve Everywoman Participants - Type Individual * attender Henry Seven, MD period: 2018-04-01 10:00:00-0500 --> 2018-04-02 10:15:00-0500 diagnosis eICR Trigger Code Flag Extension triggerCodeValueSet: urn:oid:2.16.840.1.114222.4.11.7508 triggerCodeValueSetVersion: 12/12/2018 triggerCode: SNOMED CT: 3928002 (Zika virus disease (disorder)) condition: Condition Zika virus disease (disorder) diagnosis condition: Condition Common cold (disorder) Locations - Location * Clinic Bldg A, Salem Medical Center, 4646 Brown Rd, Salem, MA 02368 serviceProvider: Salem Medical Center, 22222 Health Authority Drive, Ann Arbor MI, 99999
Clinic Bldg A, Salem Medical Center, 4646 Brown Rd, Salem, MA 02368
Salem Medical Center, 22222 Health Authority Drive, Ann Arbor MI, 99999
Generated Narrative: Observation observation-pregnancy-status-eve-everywoman Profile: US Public Health Pregnancy Status Observation US Public Health Date Determined Extension: 2017-10-01 status: Final category: Social History code: Pregnancy status subject: Eve Everywoman effective: 2017-08-26 performer: PractitionerRole Primary Care Clinic/Center value: Pregnancy (finding) method: Ultrasonography (procedure) component US Public Health Date Determined Extension: 2017-10-01 code: Gestational age Estimated from patient reported estimated date of conception value: 143 d component US Public Health Date Determined Extension: 2017-10-01 code: Delivery date Estimated from date fundal height reaches umb value: 2018-05-01
Gestational age Estimated from patient reported estimated date of conception
Delivery date Estimated from date fundal height reaches umb
Generated Narrative: Observation observation-vaccine-credential-assertion-eve-everywoman Profile: eICR Vaccine Credential Patient Assertion status: Final code: Immunization status - Reported subject: Eve Everywoman effective: 2020-11-10 22:33:22+0000 performer: PractitionerRole Primary Care Clinic/Center value: Yes
Generated Narrative: Observation observation-us-ph-emergency-outbreak-info-eve-everywoman Profile: US Public Health Emergency Outbreak Information status: Final category: Social History code: Employee desk distance from mail sorter subject: Eve Everywoman effective: 2020-11-18 22:33:22+0000 performer: PractitionerRole Primary Care Clinic/Center value: 2 m
Generated Narrative: Observation observation-country-of-nationality-eve-everywoman Profile: US Public Health Country of Nationality status: Final category: Social History code: Ethnicity / related nationality data (observable entity) subject: Eve Everywoman effective: 2020-11-10 22:33:22+0000 performer: PractitionerRole Primary Care Clinic/Center value: Australia
Ethnicity / related nationality data (observable entity)
Generated Narrative: Patient patient-ecr-eve-everywoman Profile: US Public Health Patient Eve L Everywoman Female, DoB: 1974-11-24 ( Medical Record Number: 1032702 (use: usual, )) Active: true Deceased: false Contact Detail ph: 1-(404)555-1212(Home) eve.everywoman@example.org 2222 Home Street Ann Arbor MI 99999 US Language: English <td style="background-color: #f3f5da" title="Concepts classifying the person into a named category of humans sharing common history, traits, geographical origin or nationality. The ethnicity codes used to represent these concepts are based upon the [CDC ethnicity and Ethnicity Code Set Version 1.0](http://www.cdc.gov/phin/resources/vocabulary/index.html) which includes over 900 concepts for representing race and ethnicity of which 43 reference ethnicity. The ethnicity concepts are grouped by and pre-mapped to the 2 OMB ethnicity categories: - Hispanic or Latino - Not Hispanic or Latino.">US Core Ethnicity Extension: ombCategory: CDC Race and Ethnicity: 2186-5 (Not Hispanic or Latino) text: Not Hispanic or Latino US Core Birth Sex Extension F <td style="background-color: #f3f5da" title="Concepts classifying the person into a named category of humans sharing common history, traits, geographical origin or nationality. The race codes used to represent these concepts are based upon the [CDC Race and Ethnicity Code Set Version 1.0](http://www.cdc.gov/phin/resources/vocabulary/index.html#3) which includes over 900 concepts for representing race and ethnicity of which 921 reference race. The race concepts are grouped by and pre-mapped to the 5 OMB race categories:#xA;#xA; - American Indian or Alaska Native#xA; - Asian#xA; - Black or African American#xA; - Native Hawaiian or Other Pacific Islander#xA; - White.">US Core Race Extension: ombCategory: CDC Race and Ethnicity: 2106-3 (White) text: White US Core Tribal Affiliation Extension: tribalAffiliation: Fort Mojave Indian Tribe of Arizona, California & Nevada isEnrolled: true
Fort Mojave Indian Tribe of Arizona, California & Nevada
Generated Narrative: Immunization immunization-ecr-pneumo Profile: US Core Immunization Profileversion: null6.1.0) status: Completed vaccineCode: pneumococcal polysaccharide PPV23 patient: Eve Everywoman occurrence: 2018-09-01 primarySource: true
Generated Narrative: Observation observation-country-of-residence-eve-everywoman Profile: eICR Country of Residence status: Final code: Country of usual residence subject: Eve Everywoman effective: 2020-11-10 22:33:22+0000 performer: PractitionerRole Primary Care Clinic/Center value: United Kingdom of Great Britain and Northern Ireland
United Kingdom of Great Britain and Northern Ireland
Generated Narrative: PractitionerRole practitionerrole-henry-seven Profile: US Public Health PractitionerRole identifier: United States National Provider Identifier/9941339108 practitioner: Henry Seven, MD organization: Salem Medical Center code: Primary Care Clinic/Center specialty: Family practice location: Salem Medical Center telecom: henry.seven@example.com
Generated Narrative: Observation observation-blood-pressure-eve-everywoman Profile: US Core Blood Pressure Profileversion: null6.1.0) status: Final category: Vital Signs code: Blood pressure systolic and diastolic subject: Eve Everywoman encounter: GP Visit effective: 2020-07-02 performer: PractitionerRole Primary Care Clinic/Center component code: Systolic blood pressure value: 109 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]') component code: Diastolic blood pressure value: 44 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')
Blood pressure panel with all children optional
Generated Narrative: Observation observation-us-ph-exposure-contact-info-football-game Profile: US Public Health Exposure Contact Information status: Final category: An interaction between entities that provides opportunity for transmission of a physical, chemical, or biological agent from an exposure source entity to an exposure target entity. code: Mass gathering (football game) subject: Eve Everywoman focus: City Football Stadium effective: 2020-01-11 18:00:00+0000 --> 2020-01-11 21:30:00+0000 performer: PractitionerRole Primary Care Clinic/Center value: City Football Stadium Components - Code Value[x] * ExposureAgent Severe acute respiratory syndrome coronavirus 2 (organism)
An interaction between entities that provides opportunity for transmission of a physical, chemical, or biological agent from an exposure source entity to an exposure target entity.
Severe acute respiratory syndrome coronavirus 2 (organism)
Generated Narrative: Observation observation-travel-history-eve-everywoman-201801 Profile: US Public Health Travel History status: Final category: Social History code: Travel History subject: Eve Everywoman effective: 2018-01-15 --> 2018-01-30 performer: PractitionerRole Primary Care Clinic/Center component code: Location value: Vanuatu component code: Type of activity (attribute) value: Active duty military (occupation)
Generated Narrative: Observation observation-disability-status-eve-everywoman Profile: US Public Health Disability Status status: Final category: Disability Status code: Are you deaf, or do you have serious difficulty hearing subject: Eve Everywoman effective: 2020-11-10 22:33:22+0000 performer: PractitionerRole Primary Care Clinic/Center value: Yes
Are you deaf, or do you have serious difficulty hearing
Generated Narrative: Observation observation-us-ph-lab-result-eve-everywoman-lymphocytes Profile: US Public Health Laboratory Result Observation Profile status: Final category: Laboratory code: Lymphocytes [#/volume] in Blood by Automated count subject: Eve Everywoman effective: 2018-03-07 performer: Organization Acme_Labs value: 5.2 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL') interpretation: High ReferenceRanges - Low High * 1 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL') 4.8 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')
Lymphocytes [#/volume] in Blood by Automated count
Generated Narrative: Organization organization-ecr-acme-laboratory Profile: US Public Health Organization identifier: United States National Provider Identifier/1144221847 active: true type: outpatient laboratory name: Acme_Labs telecom: +1-555-555-4444, mail@acme-labs.com address: 7777 Laboratory Drive Ann Arbor MI 99999
Generated Narrative: Observation observation-odh-usual-work-eve-everywoman Profile: Usual Work status: Final code: History of Usual occupation subject: Eve Everywoman effective: 2015-01-01 --> 2018-03-07 performer: Practitioner Seven Henry value: Human Resources Managers Components - Code Value[x] * History of Usual industry Hospitals
Generated Narrative: Location location-ecr-salem-medical-center Profile: US Public Health Location identifier: United States National Provider Identifier/1144221995 status: Active name: Clinic Bldg A, Salem Medical Center type: Hospital telecom: ph: (+1) (555)555-3001, fax: (+1) (555)555-3002, mail@smc.org address: Clinic Bldg A 4444 Healthcare Drive Ann Arbor MI 99999 managingOrganization: Organization Salem Medical Center
Generated Narrative: Location location-ecr-city-football-stadium Profile: US Core Location Profileversion: null6.1.0) status: Active name: City Football Stadium type: City Football Stadium address: 99 Football Stadium Road My City AZ 8562
Generated Narrative: Organization organization-ecr-salem-medical-center Profile: US Public Health Organization identifier: United States National Provider Identifier/1144221847 active: true type: Outpatient facility name: Salem Medical Center telecom: +1-555-555-1111, mail@salemmedicalcenter.com address: 22222 Health Authority Drive Ann Arbor MI 99999
Generated Narrative: Condition condition-eicr-eve-everywoman-zika Profile: US Public Health Condition Encounter Diagnosis category: Encounter Diagnosis code: Zika virus disease (disorder) subject: Eve Everywoman onset: 2017-08-23 asserter: Henry Seven, MD
Generated Narrative: Practitioner practitioner-us-core-henry-seven Profile: US Core Practitioner Profileversion: null6.1.0) identifier: United States National Provider Identifier/9941339100 name: Seven Henry telecom: henry.seven@example.org address: 1002 Healthcare Drive Ann Arbor MI 99999 US
Generated Narrative: Device device-ecmo UdiCarriers - DeviceIdentifier CarrierHRF EntryType * 99863313444316 (01)99863313444316(17)220101(10)M320(21)AC222 RFID status: Active manufacturer: ACME Biomedical expirationDate: 2022-01-01 lotNumber: M320 serialNumber: AC222 DeviceNames - Name Type * ACME Extracorporeal membrane oxygenator UDI Label name modelNumber: 4.0 type: Extracorporeal membrane oxygenator (physical object) patient: Eve Everywoman
Extracorporeal membrane oxygenator (physical object)