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
<Composition xmlns="http://hl7.org/fhir">
<id value="Discharge-Summary-Example"/>
<meta>
<versionId value="4"/>
<lastUpdated value="2020-08-12T21:30:18.557+00:00"/>
<source value="#csn482LCsnDWyxbW"/>
<profile
value="http://hl7.org/fhir/us/ccda/StructureDefinition/Discharge-Summary"/>
</meta>
<language value="en-US"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US">
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Document Id</span>
</td>
<td class="td_header_role_value">12345</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Document Created:</span>
</td>
<td class="td_header_role_value">June 15, 2016, 16:14, PST </td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Discharge Summary</span>
</td>
<td class="td_header_role_value">Discharge Summary for Amy
Shaw</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Performer </span>
</td>
<td class="td_header_role_value">Ronald Boone, MD</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Author</span>
</td>
<td class="td_header_role_value">Ronald Boone, MD</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Encounter Id</span>
</td>
<td class="td_header_role_value">9937012
2.16.840.1.113883.19</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Encounter Type</span>
</td>
<td class="td_header_role_value">Discharge</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Event Date</span>
</td>
<td class="td_header_role_value"> From June 15, 2016, 16:20 to
June 15, 2016, 18:20 </td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Encounter Location</span>
</td>
<td class="td_header_role_value">Inpatient Unit at Community
Health and Hospitals</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Responsible party</span>
</td>
<td class="td_header_role_value">Ronald Boone, MD</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Assigned entity</span>
</td>
<td class="td_header_role_value">Community Health and Hospitals
<br/>
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Emergency contact</span>
</td>
<td class="td_header_role_value">Michael Shaw
<br/>
<br/>
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">49 Meadow St
<br/>Amherst MA
01003, US
<br/>Tel: (555)555-1212
<br/>
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Care giver</span>
</td>
<td class="td_header_role_value">Mrs. Lillian White
<br/>
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">49 Meadow St
<br/>Amherst MA
01003, US
<br/>Tel: (555)555-1215
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Entered by</span>
</td>
<td class="td_header_role_value">Sally Jones</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Signed </span>
</td>
<td class="td_header_role_value">Ronald Boone at June 15, 2016
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Informant</span>
</td>
<td class="td_header_role_value">Henry Vincent, CPh</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1007 Pharmacy Drive
<br/>Portland, OR 99123, US
<br/>Tel: +1(555)555-1215
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Information recipient:</span>
</td>
<td class="td_header_role_value">Primary Physician, MD</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1005 St. Clair Avenue
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1666
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Legal authenticator</span>
</td>
<td class="td_header_role_value">Ronald Boone, MD signed at June
15, 2016 </td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Document maintained by</span>
</td>
<td class="td_header_role_value">Community Health and
Hospitals</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
</div>
</text>
<identifier>
<system value="urn:ietf:rfc:3986"/>
<value value="urn:uuid:3a94d1bd-c399-40d2-8574-8212e1491e9c"/>
</identifier>
<status value="preliminary"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="18842-5"/>
<display value="Discharge Summary"/>
</coding>
</type>
<subject>🔗
<reference value="Patient/example"/>
<display value="Amy V. Shaw"/>
</subject>
<date value="2016-02-28T09:10:14Z"/>
<author>🔗
<reference value="PractitionerRole/ccda-practitionerrole-example"/>
<display value="Ronald Bone, MD"/>
</author>
<title value="Discharge Summary"/>
<custodian>🔗
<reference value="Organization/organization-1"/>
<display value="Community Health and Hospitals"/>
</custodian>
<section>
<title value="Allergies and Intolerances Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="48765-2"/>
<display value="Allergies and adverse reactions Document"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Substance</b>
</td>
<td>
<b>Overall Severity</b>
</td>
<td>
<b>Reaction</b>
</td>
<td>
<b>Reaction Severity</b>
</td>
<td>
<b>Status</b>
</td>
</tr>
<tr>
<td>Cashew Nut</td>
<td>Severe</td>
<td>Anaphylactic reaction</td>
<td>Mild</td>
<td>Active</td>
</tr>
</table>
</div>
</text>
<entry>🔗
<reference value="AllergyIntolerance/allergy-intolerance"/>
</entry>
</section>
<section>
<title value="Chief Complaint and Reason for Visit Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="46239-0"/>
<display value="Chief complaint+Reason for visit Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Cramping, bloating, and constipation.</p>
</div>
</text>
</section>
<section>
<title value="Chief Complaint Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10154-3"/>
<display value="Chief complaint Narrative - Reported"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Dark Stools</p>
</div>
</text>
</section>
<section>
<title value="Reason for Visit Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="29299-5"/>
<display value="Reason for visit"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Tenderness of lower abdomen</p>
</div>
</text>
</section>
<section>
<title value="Admission Diagnosis Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="46241-6"/>
<display value="Hospital admission diagnosis Narrative - Reported"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Appendicitis</p>
</div>
</text>
</section>
<section>
<title value="Admission Medications Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="42346-7"/>
<display value="Medications on admission (narrative)"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Medication</b>
</td>
<td>
<b>Directions</b>
</td>
<td>
<b>Start Date</b>
</td>
<td>
<b>Status</b>
</td>
<td>
<b>Indications</b>
</td>
<td>
<b>Fill Instructions</b>
</td>
</tr>
<tr>
<td>Pepcid Complete (MAGNESIUM HYDROXIDE0</td>
<td>Chew one tablet completely and swallow as needed </td>
<td>20160615</td>
<td>Active</td>
<td>Bloating</td>
<td>Generic substitution allowed</td>
</tr>
</table>
</div>
</text>
</section>
<section>
<title value="Past Medical History Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11348-0"/>
<display value="History of Past illness Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Problem Name</b>
</td>
<td>
<b>Type</b>
</td>
<td>
<b>Onset Date</b>
</td>
<td>
<b>Abatement Date</b>
</td>
<td>
<b>Status</b>
</td>
</tr>
<tr>
<td>Fever</td>
<td>Condition</td>
<td>2016-06-15</td>
<td>2016-06-15</td>
<td>Complete</td>
</tr>
</table>
</div>
</text>
<entry>🔗
<reference value="Condition/condition-problem"/>
</entry>
</section>
<section>
<title value="History of Present Illness Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10164-2"/>
<display value="History of Present illness Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>This patient was only recently discharged for a recurrent GI bleed as
described below. </p>
<p>He presented to the ER today c/o a dark stool yesterday but a normal
brown stool today. On exam he was hypotensive in the 80?s resolved
after .... .... .... </p>
<p>Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes
normal. H. pylori antibody pending. Admission hematocrit 16%,
discharge hematocrit 29%. WBC 7300, platelet count 256,000.
Urinalysis normal. Urine culture: No growth. INR 1.1, PTT 40. </p>
<p>He was transfused with 6 units of packed red blood cells with ....
.... .... </p>
<p>GI evaluation 12 September: Colonoscopy showed single red clot in
.... ........ </p>
</div>
</text>
</section>
<section>
<title value="Review of Systems Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10187-3"/>
<display value="Review of systems"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Patient denies recent history of fever or malaise. Positive for
weakness and shortness of breath. One episode of melena. No recent
headaches. Positive for osteoarthritis in hips, knees and hands.
</p>
</div>
</text>
</section>
<section>
<title value="Family History Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10157-6"/>
<display value="History of family member diseases Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Relationship</b>
</td>
<td>
<b>Diagnosis</b>
</td>
<td>
<b>Age at Onset</b>
</td>
</tr>
<tr>
<td>Father</td>
<td>Myocardial Infarction(cause of Death)</td>
<td>57</td>
</tr>
<tr>
<td>Father</td>
<td>Diabetes</td>
<td>40</td>
</tr>
</table>
</div>
</text>
</section>
<section>
<title value="Social History Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="29762-2"/>
<display value="Social history Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Social History Element</b>
</td>
<td>
<b>Description</b>
</td>
<td>
<b>Effective Dates</b>
</td>
</tr>
<tr>
<td>Smoking</td>
<td>1 pack tobacco per day</td>
<td>2005/05/01 - 2010/02/28</td>
</tr>
</table>
</div>
</text>
<entry>🔗
<reference value="Observation/observation-smoker"/>
</entry>
</section>
<section>
<title value="Functional Status Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="47420-5"/>
<display value="Functional status assessment note"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Functional or Cognitive Finding</b>
</td>
<td>
<b>Observation</b>
</td>
<td>
<b>Observation Date</b>
</td>
<td>
<b>Condition Status</b>
</td>
</tr>
<tr>
<td>Ambulation (Dependent to Independent</td>
<td>Independently able</td>
<td>2010/03/11</td>
<td>Active</td>
</tr>
<tr>
<td>Finding of Functional Performance and Activity</td>
<td>Dyspnea</td>
<td>2008/02/16</td>
<td>Active</td>
</tr>
<tr>
<td>Cognitive Function Finding</td>
<td>Memory Impairment</td>
<td>2014/04/29</td>
<td>Active</td>
</tr>
</table>
</div>
</text>
</section>
<section>
<title value="Hospital Course Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="8648-8"/>
<display value="Hospital course"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Following a colonoscopy, the patient was admitted and started on
Lovenox and nitroglycerin paste. The patient had serial cardiac
enzymes and was ruled out for myocardial infarction. The patient
underwent a dual isotope stress test. There was no evidence of
reversible ischemia on the Cardiolite scan. The patient has been
ambulated. The patient had a Holter monitor placed but the report is
not available at this time. The patient has remained hemodynamically
stable. Will discharge.</p>
</div>
</text>
</section>
<section>
<title value="Hospital Consultations Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="18841-7"/>
<display value="Hospital consultations Document"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>listType="ordered"</p>
<p>Gastroenterology</p>
<p>Cardiology</p>
<p>Dietitian</p>
</div>
</text>
</section>
<section>
<title value="Plan of Treatment Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="18776-5"/>
<display value="Plan of care note"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Planned Activity</b>
</td>
<td>
<b>Period</b>
</td>
<td>
<b>Status</b>
</td>
</tr>
<tr>
<td>Colonoscopy</td>
<td>2016/08/16 - 2016/08/16</td>
<td>Completed</td>
</tr>
<tr>
<td>Recommendation to Exercise</td>
<td>2016/06/29</td>
<td>Ongoing</td>
</tr>
</table>
</div>
</text>
</section>
<section>
<title value="Problem Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11450-4"/>
<display value="Problem list - Reported"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Problem Name</b>
</td>
<td>
<b>Type</b>
</td>
<td>
<b>Onset Date</b>
</td>
<td>
<b>Abatement Date</b>
</td>
<td>
<b>Status</b>
</td>
</tr>
<tr>
<td>Fever</td>
<td>Condition</td>
<td>2016-04-01</td>
<td>2016-04-14</td>
<td>Complete</td>
</tr>
</table>
</div>
</text>
<entry>🔗
<reference value="Condition/condition-problem"/>
</entry>
</section>
<section>
<title value="Procedures Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="47519-4"/>
<display value="History of Procedures Document"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Procedure Name</b>
</td>
<td>
<b>Body Site</b>
</td>
<td>
<b>Performer</b>
</td>
<td>
<b>Date Performed</b>
</td>
<td>
<b>Reason</b>
</td>
</tr>
<tr>
<td>Appendectomy (Procedure)</td>
<td>Abdomen</td>
<td>Dr. Adam Everyman</td>
<td>20160405</td>
<td>Generalized abdominal pain 24 hours. Localized in RIF with
rebound and guarding</td>
</tr>
</table>
</div>
</text>
<entry>🔗
<reference value="Procedure/procedure-rehab"/>
</entry>
</section>
<section>
<title value="Discharge Diagnosis Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11535-2"/>
<display value="Hospital discharge Dx Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Diverticula of intestine</p>
</div>
</text>
</section>
<section>
<title value="Discharge Medications Section (entries required)"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10183-2"/>
<display value="Hospital discharge medications"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Medication</b>
</td>
<td>
<b>Directions</b>
</td>
<td>
<b>Start Date</b>
</td>
<td>
<b>Status</b>
</td>
<td>
<b>Indications</b>
</td>
<td>
<b>Fill Instructions</b>
</td>
</tr>
<tr>
<td>Acetaminophen Tab 325 mg</td>
<td>Take 2 tablet(s) every four hours if needed</td>
<td>20160618</td>
<td>Active</td>
<td>Pain management</td>
<td>Generic substitution allowed</td>
</tr>
</table>
</div>
</text>
</section>
<section>
<title value="Hospital Discharge Instructions Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="8653-8"/>
<display value="Hospital discharge instructions"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Take all of your prescription medication as directed. </p>
<p>Make an appointment with your doctor to be seen two weeks from the
date of your procedure. </p>
<p>You may feel slightly bloated after the procedure because of air that
was introduced during the examination. </p>
<p> Call your physician if you notice:
<br/> Bleeding or black stools.
<br/> Abdominal pain.
<br/> Fever or chills.
<br/> Nausea or
vomiting.
<br/> Any unusual pain or problem.
<br/> Pain or redness
at the site where the intravenous needle was placed.
<br/>
</p>
<p>Do not drink alcohol for 24 hours. Alcohol amplifies the effect of
the sedatives given. </p>
<p>Do not drive or operate machinery for 24 hours.</p>
</div>
</text>
</section>
<section>
<title value="Hospital Discharge Physical Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10184-0"/>
<display value="Hospital discharge physical findings Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>GENERAL: Well-developed, slightly obese man. </p>
<p>NECK: Supple, with no jugular venous distension.</p>
<p>HEART: Intermittent tachycardia without murmurs or gallops. </p>
<p>PULMONARY: Decreased breath sounds, but no clear-cut rales or
wheezes.</p>
<p>EXTREMITIES: Free of edema.</p>
</div>
</text>
</section>
<section>
<title value="Hospital Discharge Studies Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11493-4"/>
<display value="Hospital discharge studies summary"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table border="1" width="100%">
<thead>
<tr>
<th>Laboratory Information</th>
<th>Chemistries and drug levels</th>
</tr>
</thead>
<tbody>
<tr>
<td>Potasium</td>
<td>4.0</td>
</tr>
<tr>
<td>NA (135-145meq/l)</td>
<td>140</td>
</tr>
</tbody>
</table>
<br/>
<table border="1" width="100%">
<thead>
<tr>
<th>Other Tests</th>
<th>Results</th>
</tr>
</thead>
<tbody>
<tr>
<td>EKG</td>
<td>Sinus rhythm without acute changes.</td>
</tr>
</tbody>
</table>
</div>
</text>
</section>
<section>
<title value="Immunizations Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11369-6"/>
<display value="History of Immunization Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Vaccine</b>
</td>
<td>
<b>Date</b>
</td>
<td>
<b>Status</b>
</td>
</tr>
<tr>
<td>Fluvax (Influenza)</td>
<td>2016-04-05</td>
<td>Completed</td>
</tr>
</table>
</div>
</text>
<entry>🔗
<reference value="Immunization/immunization"/>
</entry>
</section>
<section>
<title value="Nutrition Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="61144-2"/>
<display value="Diet and nutrition Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Date</b>
</td>
<td>
<b>Nutritional Status</b>
</td>
<td>
<b>Diet</b>
</td>
</tr>
<tr>
<td>2016/06/15</td>
<td>Well nourished</td>
<td>Low sodium diet, excessive carbohydrate</td>
</tr>
<tr>
<td>2016/06/15</td>
<td>Slight dehydration</td>
<td>High protein, low fibre</td>
</tr>
</table>
</div>
</text>
</section>
<section>
<title value="Vital Signs Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="8716-3"/>
<display value="Vital signs"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Vital Sign</b>
</td>
<td>
<b>Date</b>
</td>
<td>
<b>Value</b>
</td>
</tr>
<tr>
<td>Temperature</td>
<td>2016/06/15</td>
<td>39 Degrees Celcius</td>
</tr>
</table>
</div>
</text>
<entry>🔗
<reference value="Observation/observation-vitals-temp"/>
</entry>
</section>
</Composition>
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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