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 "Discharge-Summary-Example"] ; # fhir:meta [ fhir:versionId [ fhir:v "4" ] ; fhir:lastUpdated [ fhir:v "2020-08-12T21:30:18.557+00:00"^^xsd:dateTime ] ; fhir:source [ fhir:v "#csn482LCsnDWyxbW"^^xsd:anyURI ] ; ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/ccda/StructureDefinition/Discharge-Summary"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/ccda/StructureDefinition/Discharge-Summary> ] ) ] ; # 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\">Discharge Summary</span>\n </td>\n <td class=\"td_header_role_value\">Discharge Summary 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\">Encounter Type</span>\n </td>\n <td class=\"td_header_role_value\">Discharge</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\">Inpatient Unit 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:3a94d1bd-c399-40d2-8574-8212e1491e9c" ] ] ; # fhir:status [ fhir:v "preliminary"] ; # fhir:type [ ( fhir:coding [ a loinc:18842-5 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "18842-5" ] ; fhir:display [ fhir:v "Discharge Summary" ] ] ) ] ; # 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 "Discharge Summary"] ; # fhir:custodian [ fhir:reference [ fhir:v "Organization/organization-1" ] ; fhir:display [ fhir:v "Community Health and Hospitals" ] ] ; # 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 "Chief Complaint and Reason for Visit Section" ] ; fhir:code [ ( fhir:coding [ a loinc:46239-0 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "46239-0" ] ; fhir:display [ fhir:v "Chief complaint+Reason for visit Narrative" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Cramping, bloating, and constipation.</p>\n </div>" ] ] [ fhir:title [ fhir:v "Chief Complaint Section" ] ; fhir:code [ ( fhir:coding [ a loinc:10154-3 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "10154-3" ] ; fhir:display [ fhir:v "Chief complaint Narrative - Reported" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Dark Stools</p>\n </div>" ] ] [ fhir:title [ fhir:v "Reason for Visit Section" ] ; fhir:code [ ( fhir:coding [ a loinc:29299-5 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "29299-5" ] ; fhir:display [ fhir:v "Reason for visit" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Tenderness of lower abdomen</p>\n </div>" ] ] [ fhir:title [ fhir:v "Admission Diagnosis Section" ] ; fhir:code [ ( fhir:coding [ a loinc:46241-6 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "46241-6" ] ; fhir:display [ fhir:v "Hospital admission diagnosis Narrative - Reported" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Appendicitis</p>\n </div>" ] ] [ fhir:title [ fhir:v "Admission Medications Section" ] ; fhir:code [ ( fhir:coding [ a loinc:42346-7 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "42346-7" ] ; fhir:display [ fhir:v "Medications on admission (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>Pepcid Complete (MAGNESIUM HYDROXIDE0</td>\n <td>Chew one tablet completely and swallow as needed </td>\n <td>20160615</td>\n <td>Active</td>\n <td>Bloating</td>\n <td>Generic substitution allowed</td>\n </tr>\n </table>\n </div>" ] ] [ fhir:title [ fhir:v "Past Medical History Section" ] ; fhir:code [ ( fhir:coding [ a loinc:11348-0 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "11348-0" ] ; fhir:display [ fhir:v "History of Past illness 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>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>2016-06-15</td>\n <td>2016-06-15</td>\n <td>Complete</td>\n </tr>\n </table>\n </div>" ] ; ( fhir:entry [ fhir:reference [ fhir:v "Condition/condition-problem" ] ] ) ] [ fhir:title [ fhir:v "History of Present Illness Section" ] ; fhir:code [ ( fhir:coding [ a loinc:10164-2 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "10164-2" ] ; fhir:display [ fhir:v "History of Present illness Narrative" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>This patient was only recently discharged for a recurrent GI bleed as\n described below. </p>\n <p>He presented to the ER today c/o a dark stool yesterday but a normal\n brown stool today. On exam he was hypotensive in the 80?s resolved\n after .... .... .... </p>\n <p>Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes\n normal. H. pylori antibody pending. Admission hematocrit 16%,\n discharge hematocrit 29%. WBC 7300, platelet count 256,000.\n Urinalysis normal. Urine culture: No growth. INR 1.1, PTT 40. </p>\n <p>He was transfused with 6 units of packed red blood cells with ....\n .... .... </p>\n <p>GI evaluation 12 September: Colonoscopy showed single red clot in\n .... ........ </p>\n </div>" ] ] [ fhir:title [ fhir:v "Review of Systems Section" ] ; fhir:code [ ( fhir:coding [ a loinc:10187-3 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "10187-3" ] ; fhir:display [ fhir:v "Review of systems" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Patient denies recent history of fever or malaise. Positive for\n weakness and shortness of breath. One episode of melena. No recent\n headaches. Positive for osteoarthritis in hips, knees and hands.\n </p>\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 "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>2005/05/01 - 2010/02/28</td>\n </tr>\n </table>\n </div>" ] ; ( fhir:entry [ fhir:reference [ fhir:v "Observation/observation-smoker" ] ] ) ] [ 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>2010/03/11</td>\n <td>Active</td>\n </tr>\n <tr>\n <td>Finding of Functional Performance and Activity</td>\n <td>Dyspnea</td>\n <td>2008/02/16</td>\n <td>Active</td>\n </tr>\n <tr>\n <td>Cognitive Function Finding</td>\n <td>Memory Impairment</td>\n <td>2014/04/29</td>\n <td>Active</td>\n </tr>\n </table>\n </div>" ] ] [ fhir:title [ fhir:v "Hospital Course Section" ] ; fhir:code [ ( fhir:coding [ a loinc:8648-8 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "8648-8" ] ; fhir:display [ fhir:v "Hospital course" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Following a colonoscopy, the patient was admitted and started on\n Lovenox and nitroglycerin paste. The patient had serial cardiac\n enzymes and was ruled out for myocardial infarction. The patient\n underwent a dual isotope stress test. There was no evidence of\n reversible ischemia on the Cardiolite scan. The patient has been\n ambulated. The patient had a Holter monitor placed but the report is\n not available at this time. The patient has remained hemodynamically\n stable. Will discharge.</p>\n </div>" ] ] [ fhir:title [ fhir:v "Hospital Consultations Section" ] ; fhir:code [ ( fhir:coding [ a loinc:18841-7 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "18841-7" ] ; fhir:display [ fhir:v "Hospital consultations Document" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>listType="ordered"</p>\n <p>Gastroenterology</p>\n <p>Cardiology</p>\n <p>Dietitian</p>\n </div>" ] ] [ 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>2016/08/16 - 2016/08/16</td>\n <td>Completed</td>\n </tr>\n <tr>\n <td>Recommendation to Exercise</td>\n <td>2016/06/29</td>\n <td>Ongoing</td>\n </tr>\n </table>\n </div>" ] ] [ 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>2016-04-01</td>\n <td>2016-04-14</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>20160405</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 "Discharge Diagnosis Section" ] ; fhir:code [ ( fhir:coding [ a loinc:11535-2 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "11535-2" ] ; fhir:display [ fhir:v "Hospital discharge Dx Narrative" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Diverticula of intestine</p>\n </div>" ] ] [ fhir:title [ fhir:v "Discharge Medications Section (entries required)" ] ; fhir:code [ ( fhir:coding [ a loinc:10183-2 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "10183-2" ] ; fhir:display [ fhir:v "Hospital discharge medications" ] ] ) ] ; 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>Acetaminophen Tab 325 mg</td>\n <td>Take 2 tablet(s) every four hours if needed</td>\n <td>20160618</td>\n <td>Active</td>\n <td>Pain management</td>\n <td>Generic substitution allowed</td>\n </tr>\n </table>\n </div>" ] ] [ fhir:title [ fhir:v "Hospital Discharge Instructions Section" ] ; fhir:code [ ( fhir:coding [ a loinc:8653-8 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "8653-8" ] ; fhir:display [ fhir:v "Hospital discharge instructions" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Take all of your prescription medication as directed. </p>\n <p>Make an appointment with your doctor to be seen two weeks from the\n date of your procedure. </p>\n <p>You may feel slightly bloated after the procedure because of air that\n was introduced during the examination. </p>\n <p> Call your physician if you notice: \n <br/> Bleeding or black stools.\n \n <br/> Abdominal pain. \n <br/> Fever or chills. \n <br/> Nausea or\n vomiting. \n <br/> Any unusual pain or problem. \n <br/> Pain or redness\n at the site where the intravenous needle was placed. \n <br/>\n </p>\n <p>Do not drink alcohol for 24 hours. Alcohol amplifies the effect of\n the sedatives given. </p>\n <p>Do not drive or operate machinery for 24 hours.</p>\n </div>" ] ] [ fhir:title [ fhir:v "Hospital Discharge Physical Section" ] ; fhir:code [ ( fhir:coding [ a loinc:10184-0 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "10184-0" ] ; fhir:display [ fhir:v "Hospital discharge physical findings Narrative" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>GENERAL: Well-developed, slightly obese man. </p>\n <p>NECK: Supple, with no jugular venous distension.</p>\n <p>HEART: Intermittent tachycardia without murmurs or gallops. </p>\n <p>PULMONARY: Decreased breath sounds, but no clear-cut rales or\n wheezes.</p>\n <p>EXTREMITIES: Free of edema.</p>\n </div>" ] ] [ fhir:title [ fhir:v "Hospital Discharge Studies Section" ] ; fhir:code [ ( fhir:coding [ a loinc:11493-4 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "11493-4" ] ; fhir:display [ fhir:v "Hospital discharge studies summary" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Laboratory Information</th>\n <th>Chemistries and drug levels</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Potasium</td>\n <td>4.0</td>\n </tr>\n <tr>\n <td>NA (135-145meq/l)</td>\n <td>140</td>\n </tr>\n </tbody>\n </table>\n <br/>\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Other Tests</th>\n <th>Results</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>EKG</td>\n <td>Sinus rhythm without acute changes.</td>\n </tr>\n </tbody>\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>2016-04-05</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 "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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