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

## : Discharge Summary - Composition - XML Representation

Page standards status: Informative

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    <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=&quot;ordered&quot;</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>