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 sct: <http://snomed.info/id/> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- #a fhir:Composition ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "Diagnostic-Imaging-Report-Example"] ; # fhir:meta [ fhir:versionId [ fhir:v "4" ] ; fhir:lastUpdated [ fhir:v "2020-08-12T21:30:12.638+00:00"^^xsd:dateTime ] ; fhir:source [ fhir:v "#csn482LCsnDWyxbW"^^xsd:anyURI ] ; ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/ccda/StructureDefinition/Diagnostic-Imaging-Report"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/ccda/StructureDefinition/Diagnostic-Imaging-Report> ] ) ] ; # 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\">Evaluation</span>\n </td>\n <td class=\"td_header_role_value\">Diagnostic Imaging Study for\n Amy 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\">Diagnotic Imaging Study</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\">Diagnostic Imaging Department\n at Acme Laboratories</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\">Diagnostic Imaging Department\n at Acme Laboratories \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\">Acme Laboratories</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:895f6f22-f7d6-4feb-90d4-dbfd49b5471e" ] ] ; # fhir:status [ fhir:v "preliminary"] ; # fhir:type [ ( fhir:coding [ a loinc:18748-4 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "18748-4" ] ; fhir:display [ fhir:v "Diagnostic imaging study" ] ] ) ] ; # fhir:subject [ fhir:reference [ fhir:v "Patient/example" ] ; fhir:display [ fhir:v "Amy V. Shaw" ] ] ; # fhir:date [ fhir:v "2016-05-16T09:10:14Z"^^xsd:dateTime] ; # fhir:author ( [ fhir:reference [ fhir:v "PractitionerRole/ccda-practitionerrole-example" ] ; fhir:display [ fhir:v "Ronald Bone, MD" ] ] ) ; # fhir:title [ fhir:v "Diagnostic Imaging Report"] ; # 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/acme-lab" ] ; fhir:display [ fhir:v "Acme Labs" ] ] ; # fhir:event ( [ ( fhir:code [ ( fhir:coding [ a sct:399208008 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ; fhir:code [ fhir:v "399208008" ] ; fhir:display [ fhir:v "Plain X-ray of chest" ] ] ) ] ) ; fhir:period [ fhir:start [ fhir:v "2016-06-15"^^xsd:date ] ; fhir:end [ fhir:v "2016-06-15"^^xsd:date ] ] ] ) ; # fhir:section ( [ fhir:title [ fhir:v "Findings Section" ] ; fhir:code [ ( fhir:coding [ fhir:system [ fhir:v "http://dicom.nema.org/resources/ontology/DCM"^^xsd:anyURI ] ; fhir:code [ fhir:v "121070" ] ; fhir:display [ fhir:v "Findings" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>The cardiomediastinum is within normal limits. The trachea is\n midline. The previously described opacity at the medial right lung\n base has cleared. There are no new infiltrates. There is a new round\n density at the left hilus, superiorly (diameter about 45mm). A CT\n scan is recommended for further evaluation. The pleural spaces are\n clear. The visualized musculoskeletal structures and the upper\n abdomen are stable and unremarkable.</p>\n </div>" ] ] [ fhir:title [ fhir:v "DICOM Object Catalog Section" ] ; fhir:code [ ( fhir:coding [ fhir:system [ fhir:v "http://dicom.nema.org/resources/ontology/DCM"^^xsd:anyURI ] ; fhir:code [ fhir:v "121181" ] ; fhir:display [ fhir:v "DICOM Object Catalog" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Computed Radiography Image Storage</p>\n </div>" ] ] ) . #
Suspected lung tumor
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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