C-CDA on FHIR
2.0.0-ballot - STU 2 Ballot
C-CDA on FHIR
2.0.0-ballot - STU 2 Ballot
C-CDA on FHIR, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/ccda-on-fhir/ and changes regularly. See the Directory of published versions
@prefix fhir: <http://hl7.org/fhir/> . @prefix loinc: <https://loinc.org/rdf/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- a fhir:Composition ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "Continuity-of-Care-Document-Example"] ; # fhir:meta [ fhir:versionId [ fhir:v "3" ] ; fhir:lastUpdated [ fhir:v "2020-08-12T21:30:17.571+00:00"^^xsd:dateTime ] ; fhir:source [ fhir:v "#csn482LCsnDWyxbW"^^xsd:anyURI ] ; ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/ccda/StructureDefinition/Continuity-of-Care-Document"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/ccda/StructureDefinition/Continuity-of-Care-Document> ] ) ] ; # fhir:language [ fhir:v "en-US"] ; # fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\">\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Document Id</span>\n </td>\n <td class=\"td_header_role_value\">12345</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Document Created:</span>\n </td>\n <td class=\"td_header_role_value\">June 15, 2016, 16:14, PST </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Care Provision</span>\n </td>\n <td class=\"td_header_role_value\">Summary of Episode for Amy\n Shaw</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Performer </span>\n </td>\n <td class=\"td_header_role_value\">Ronald Boone, MD</td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Author</span>\n </td>\n <td class=\"td_header_role_value\">Ronald Boone, MD</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n \n <br/>Amherst MA 01002, US \n <br/>Tel: +1(555)555-1003\n \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Encounter Id</span>\n </td>\n <td class=\"td_header_role_value\">9937012\n 2.16.840.1.113883.19</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Event Type</span>\n </td>\n <td class=\"td_header_role_value\">Summary of Episode</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Event Date</span>\n </td>\n <td class=\"td_header_role_value\"> From June 15, 2016, 16:20 to\n June 15, 2016, 18:20 </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Encounter Location</span>\n </td>\n <td class=\"td_header_role_value\">Ambulatory Care at Community\n Health and Hospitals</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Responsible party</span>\n </td>\n <td class=\"td_header_role_value\">Ronald Boone, MD</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n \n <br/>Amherst MA 01002, US \n <br/>Tel: +1(555)555-1003\n \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Assigned entity</span>\n </td>\n <td class=\"td_header_role_value\">Community Health and Hospitals\n \n <br/>\n </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Emergency contact</span>\n </td>\n <td class=\"td_header_role_value\">Michael Shaw \n <br/>\n <br/>\n </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">49 Meadow St \n <br/>Amherst MA\n 01003, US \n <br/>Tel: (555)555-1212 \n <br/>\n </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Care giver</span>\n </td>\n <td class=\"td_header_role_value\">Mrs. Lillian White \n <br/>\n </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">49 Meadow St \n <br/>Amherst MA\n 01003, US \n <br/>Tel: (555)555-1215 \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Entered by</span>\n </td>\n <td class=\"td_header_role_value\">Sally Jones</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n \n <br/>Amherst MA 01002, US \n <br/>Tel: +1(555)555-1003\n \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Signed </span>\n </td>\n <td class=\"td_header_role_value\">Ronald Boone at June 15, 2016\n </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n \n <br/>Amherst MA 01002, US \n <br/>Tel: +1(555)555-1003\n \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Informant</span>\n </td>\n <td class=\"td_header_role_value\">Henry Vincent, CPh</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1007 Pharmacy Drive\n \n <br/>Portland, OR 99123, US \n <br/>Tel: +1(555)555-1215\n \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Information recipient:</span>\n </td>\n <td class=\"td_header_role_value\">Primary Physician, MD</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1005 St. Clair Avenue\n \n <br/>Amherst MA 01002, US \n <br/>Tel: +1(555)555-1666\n \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Legal authenticator</span>\n </td>\n <td class=\"td_header_role_value\">Ronald Boone, MD signed at June\n 15, 2016 </td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n \n <br/>Amherst MA 01002, US \n <br/>Tel: +1(555)555-1003\n \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n <table style=\"border: 1pt inset #00008b; line-height: 10pt; width: 100%;\" class=\"header_table\">\n <tbody>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Document maintained by</span>\n </td>\n <td class=\"td_header_role_value\">Community Health and\n Hospitals</td>\n </tr>\n <tr>\n <td style=\"width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;\" class=\"td_header_role_name\">\n <span class=\"td_label\">Contact info</span>\n </td>\n <td class=\"td_header_role_value\">1003 Healthcare Drive\n \n <br/>Amherst MA 01002, US \n <br/>Tel: +1(555)555-1003\n \n <br/>\n </td>\n </tr>\n </tbody>\n </table>\n </div>" ] ; # fhir:identifier [ fhir:system [ fhir:v "urn:ietf:rfc:3986"^^xsd:anyURI ] ; fhir:value [ fhir:v "urn:uuid:7e63fe21-7285-46c6-b72f-e58a61341195" ] ] ; # fhir:status [ fhir:v "preliminary"] ; # fhir:type [ ( fhir:coding [ a loinc:34133-9 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "34133-9" ] ; fhir:display [ fhir:v "Summary of episode note" ] ] ) ] ; # fhir:subject [ fhir:reference [ fhir:v "Patient/example" ] ; fhir:display [ fhir:v "Amy V. Shaw" ] ] ; # fhir:date [ fhir:v "2016-02-28T09:10:14Z"^^xsd:dateTime] ; # fhir:author ( [ fhir:reference [ fhir:v "PractitionerRole/ccda-practitionerrole-example" ] ; fhir:display [ fhir:v "Ronald Bone, MD" ] ] ) ; # fhir:title [ fhir:v "Continuity of Care Document"] ; # fhir:attester ( [ fhir:mode [ fhir:v "legal" ] ; fhir:time [ fhir:v "2016-06-15T09:10:14Z"^^xsd:dateTime ] ; fhir:party [ fhir:reference [ fhir:v "PractitionerRole/ccda-practitionerrole-example" ] ; fhir:display [ fhir:v "Ronald Boone, MD" ] ] ] ) ; # fhir:custodian [ fhir:reference [ fhir:v "Organization/organization-2" ] ; fhir:display [ fhir:v "Acme Clinic" ] ] ; # fhir:event ( [ ( fhir:code [ ( fhir:coding [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v3-ActClass"^^xsd:anyURI ] ; fhir:code [ fhir:v "PCPR" ] ; fhir:display [ fhir:v "Care Provision" ] ] ) ] ) ; fhir:period [ fhir:start [ fhir:v "2016-06-15"^^xsd:date ] ; fhir:end [ fhir:v "2016-08-20"^^xsd:date ] ] ] ) ; # fhir:section ( [ fhir:title [ fhir:v "Allergies and Intolerances Section" ] ; fhir:code [ ( fhir:coding [ a loinc:48765-2 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "48765-2" ] ; fhir:display [ fhir:v "Allergies and adverse reactions Document" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Substance</b>\n </td>\n <td>\n <b>Overall Severity</b>\n </td>\n <td>\n <b>Reaction</b>\n </td>\n <td>\n <b>Reaction Severity</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Cashew Nut</td>\n <td>Severe</td>\n <td>Anaphylactic reaction</td>\n <td>Mild</td>\n <td>Active</td>\n </tr>\n </table>\n </div>" ] ; ( fhir:entry [ fhir:reference [ fhir:v "AllergyIntolerance/allergy-intolerance" ] ] ) ] [ fhir:title [ fhir:v "Medication Section" ] ; fhir:code [ ( fhir:coding [ a loinc:10160-0 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "10160-0" ] ; fhir:display [ fhir:v "History of Medication use Narrative" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Medication</b>\n </td>\n <td>\n <b>Directions</b>\n </td>\n <td>\n <b>Start Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n <td>\n <b>Indications</b>\n </td>\n <td>\n <b>Fill Instructions</b>\n </td>\n </tr>\n <tr>\n <td>Amoxicillin</td>\n <td>Amoxicillin Powder, for Suspension 250mg/5ml</td>\n <td>2016/02/28</td>\n <td>Active</td>\n <td>Pneumonia</td>\n <td>Generic substitution allowed</td>\n </tr>\n </table>\n </div>" ] ; ( fhir:entry [ fhir:reference [ fhir:v "MedicationStatement/medication-statement" ] ] ) ] [ fhir:title [ fhir:v "Problem Section" ] ; fhir:code [ ( fhir:coding [ a loinc:11450-4 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "11450-4" ] ; fhir:display [ fhir:v "Problem list - Reported" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Problem Name</b>\n </td>\n <td>\n <b>Type</b>\n </td>\n <td>\n <b>Onset Date</b>\n </td>\n <td>\n <b>Abatement Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Fever</td>\n <td>Condition</td>\n <td>2016/02/28</td>\n <td>2016/03/01</td>\n <td>Complete</td>\n </tr>\n </table>\n </div>" ] ; ( fhir:entry [ fhir:reference [ fhir:v "Condition/condition-problem" ] ] ) ] [ fhir:title [ fhir:v "Procedures Section" ] ; fhir:code [ ( fhir:coding [ a loinc:47519-4 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "47519-4" ] ; fhir:display [ fhir:v "History of Procedures Document" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Procedure Name</b>\n </td>\n <td>\n <b>Body Site</b>\n </td>\n <td>\n <b>Performer</b>\n </td>\n <td>\n <b>Date Performed</b>\n </td>\n <td>\n <b>Reason</b>\n </td>\n </tr>\n <tr>\n <td>Appendectomy (Procedure)</td>\n <td>Abdomen</td>\n <td>Dr. Adam Everyman</td>\n <td>2016/06/15</td>\n <td>Generalized abdominal pain 24 hours. Localized in RIF with\n rebound and guarding</td>\n </tr>\n </table>\n </div>" ] ; ( fhir:entry [ fhir:reference [ fhir:v "Procedure/procedure-rehab" ] ] ) ] [ fhir:title [ fhir:v "Results Section" ] ; fhir:code [ ( fhir:coding [ a loinc:30954-2 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "30954-2" ] ; fhir:display [ fhir:v "Relevant diagnostic tests/laboratory data Narrative" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Result Type</b>\n </td>\n <td>\n <b>Quantity Value</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Glucose [Moles/volume] in Blood</td>\n <td>6.3 mmol/l</td>\n <td>2016/06/15</td>\n <td>Final</td>\n </tr>\n </table>\n </div>" ] ; ( fhir:entry [ fhir:reference [ fhir:v "Observation/observation-lab-urine" ] ] ) ] [ fhir:title [ fhir:v "Advance Directives Section" ] ; fhir:code [ ( fhir:coding [ a loinc:42348-3 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "42348-3" ] ; fhir:display [ fhir:v "Advance directives" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Name</b>\n </td>\n <td>\n <b>Applies Period</b>\n </td>\n </tr>\n <tr>\n <td>Resuscitation</td>\n <td>2010/01/01 - 2025/01/01</td>\n </tr>\n </table>\n </div>" ] ] [ fhir:title [ fhir:v "Encounters Section" ] ; fhir:code [ ( fhir:coding [ a loinc:46240-8 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "46240-8" ] ; fhir:display [ fhir:v "History of Hospitalizations+Outpatient visits Narrative" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Encounter</b>\n </td>\n <td>\n <b>Performer</b>\n </td>\n <td>\n <b>Location</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n </tr>\n <tr>\n <td>Checkup Examination</td>\n <td>Dr. S. Steene</td>\n <td>Community Urgent Care Center</td>\n <td>2016/04/18</td>\n </tr>\n </table>\n </div>" ] ] [ fhir:title [ fhir:v "Family History Section" ] ; fhir:code [ ( fhir:coding [ a loinc:10157-6 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "10157-6" ] ; fhir:display [ fhir:v "History of family member diseases Narrative" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Relationship</b>\n </td>\n <td>\n <b>Diagnosis</b>\n </td>\n <td>\n <b>Age at Onset</b>\n </td>\n </tr>\n <tr>\n <td>Father</td>\n <td>Myocardial Infarction(cause of Death)</td>\n <td>57</td>\n </tr>\n <tr>\n <td>Father</td>\n <td>Diabetes</td>\n <td>40</td>\n </tr>\n </table>\n </div>" ] ] [ fhir:title [ fhir:v "Functional Status Section" ] ; fhir:code [ ( fhir:coding [ a loinc:47420-5 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "47420-5" ] ; fhir:display [ fhir:v "Functional status assessment note" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Functional or Cognitive Finding</b>\n </td>\n <td>\n <b>Observation</b>\n </td>\n <td>\n <b>Observation Date</b>\n </td>\n <td>\n <b>Condition Status</b>\n </td>\n </tr>\n <tr>\n <td>Ambulation (Dependent to Independent</td>\n <td>Independently able</td>\n <td>2016/06/15</td>\n <td>Active</td>\n </tr>\n <tr>\n <td>Finding of Functional Performance and Activity</td>\n <td>Dyspnea</td>\n <td>2016/06/15</td>\n <td>Active</td>\n </tr>\n <tr>\n <td>Cognitive Function Finding</td>\n <td>Memory Impairment</td>\n <td>2010/04/17</td>\n <td>Active</td>\n </tr>\n </table>\n </div>" ] ] [ fhir:title [ fhir:v "Immunizations Section" ] ; fhir:code [ ( fhir:coding [ a loinc:11369-6 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "11369-6" ] ; fhir:display [ fhir:v "History of Immunization Narrative" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Vaccine</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Fluvax (Influenza)</td>\n <td>2014/05/29</td>\n <td>Completed</td>\n </tr>\n </table>\n </div>" ] ; ( fhir:entry [ fhir:reference [ fhir:v "Immunization/immunization" ] ] ) ] [ fhir:title [ fhir:v "Nutrition Section" ] ; fhir:code [ ( fhir:coding [ a loinc:61144-2 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "61144-2" ] ; fhir:display [ fhir:v "Diet and nutrition Narrative" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Nutritional Status</b>\n </td>\n <td>\n <b>Diet</b>\n </td>\n </tr>\n <tr>\n <td>2016/06/15</td>\n <td>Well nourished</td>\n <td>Low sodium diet, excessive carbohydrate</td>\n </tr>\n <tr>\n <td>2016/06/15</td>\n <td>Slight dehydration</td>\n <td>High protein, low fibre</td>\n </tr>\n </table>\n </div>" ] ] [ fhir:title [ fhir:v "Mental Status Section" ] ; fhir:code [ ( fhir:coding [ a loinc:10190-7 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "10190-7" ] ; fhir:display [ fhir:v "Mental status" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Mental Status</b>\n </td>\n <td>\n <b>Support System</b>\n </td>\n </tr>\n <tr>\n <td>2016/06/15</td>\n <td>Good</td>\n <td>Not required</td>\n </tr>\n <tr>\n <td>2012/04/29</td>\n <td>Dimentia</td>\n <td>Daily Home Care</td>\n </tr>\n </table>\n </div>" ] ] [ fhir:title [ fhir:v "Social History Section" ] ; fhir:code [ ( fhir:coding [ a loinc:29762-2 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "29762-2" ] ; fhir:display [ fhir:v "Social history Narrative" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Social History Element</b>\n </td>\n <td>\n <b>Description</b>\n </td>\n <td>\n <b>Effective Dates</b>\n </td>\n </tr>\n <tr>\n <td>Smoking</td>\n <td>1 pack tobacco per day</td>\n <td>2010/01/01 - 2016/06/15</td>\n </tr>\n </table>\n </div>" ] ; ( fhir:entry [ fhir:reference [ fhir:v "Observation/observation-smoker" ] ] ) ] [ fhir:title [ fhir:v "Plan of Treatment Section" ] ; fhir:code [ ( fhir:coding [ a loinc:18776-5 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "18776-5" ] ; fhir:display [ fhir:v "Plan of care note" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Planned Activity</b>\n </td>\n <td>\n <b>Period</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Colonoscopy</td>\n <td>2016/06/15 - 2015/06/15</td>\n <td>Completed</td>\n </tr>\n <tr>\n <td>Recommendation to Exercise</td>\n <td>2016/06/15</td>\n <td>Ongoing</td>\n </tr>\n </table>\n </div>" ] ] [ fhir:title [ fhir:v "Payers Section" ] ; fhir:code [ ( fhir:coding [ a loinc:48768-6 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "48768-6" ] ; fhir:display [ fhir:v "Payment sources Document" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Payer Name</b>\n </td>\n <td>\n <b>Policy ID</b>\n </td>\n <td>\n <b>Policy Holder</b>\n </td>\n </tr>\n <tr>\n <td>United Healthcare</td>\n <td>12341</td>\n <td>Self</td>\n </tr>\n <tr>\n <td>Cigna</td>\n <td>53123</td>\n <td>Spouse</td>\n </tr>\n </table>\n </div>" ] ] [ fhir:title [ fhir:v "Medical Equipment Section" ] ; fhir:code [ ( fhir:coding [ a loinc:46264-8 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "46264-8" ] ; fhir:display [ fhir:v "History of medical device use" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Supply/Device</b>\n </td>\n <td>\n <b>Date Supplied</b>\n </td>\n </tr>\n <tr>\n <td>Automatic Implantable cardioverter/defbrillator</td>\n <td>2015/05/29</td>\n </tr>\n <tr>\n <td>Wheelchair</td>\n <td>2016/06/15</td>\n </tr>\n </table>\n </div>" ] ] [ fhir:title [ fhir:v "Vital Signs Section" ] ; fhir:code [ ( fhir:coding [ a loinc:8716-3 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "8716-3" ] ; fhir:display [ fhir:v "Vital signs" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Vital Sign</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Value</b>\n </td>\n </tr>\n <tr>\n <td>Temperature</td>\n <td>2016/06/15</td>\n <td>39 Degrees Celcius</td>\n </tr>\n </table>\n </div>" ] ; ( fhir:entry [ fhir:reference [ fhir:v "Observation/observation-vitals-temp" ] ] ) ] ) . #
IG © 2020+ HL7 International / Cross-Group Projects. Package hl7.fhir.us.ccda#2.0.0-ballot based on FHIR 4.0.1. Generated 2024-12-17
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