Dental Data Exchange, published by Payer/Provider Information Exchange Work Group. 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/dental-data-exchange/ and changes regularly. See the Directory of published versions

• Narrative Content
• XML
• JSON
• TTL

: Dental Consultation Note example - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
  <id value="Dental-2-Med-Consult"/>
  <meta>
    <versionId value="24"/>
    <lastUpdated value="2021-08-24T23:27:45.426+00:00"/>
    <source value="#sBPqj3BhYLw4XXH8"/>
    <profile
             value="http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-consult-note"/>
  </meta>
  <language value="en-US"/>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"><p class="res-header-id"><b>Generated Narrative: Composition Dental-2-Med-Consult</b></p><a name="Dental-2-Med-Consult"> </a><a name="hcDental-2-Med-Consult"> </a><a name="Dental-2-Med-Consult-en-US"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">version: 24; Last updated: 2021-08-24 23:27:45+0000; Language: en-US; </p><p style="margin-bottom: 0px">Information Source: #sBPqj3BhYLw4XXH8</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-dental-consult-note.html">Dental Consult Note</a></p></div><p><b>Order Extension</b>: <a href="ServiceRequest-example-dental-referral-1.html">ServiceRequest Patient referral for dental care (procedure)</a></p><p><b>identifier</b>: <code>urn:ietf:rfc:3986</code>/urn:uuid:f28fefc8-5aac-427c-93d7-f0bc7d633a9b</p><p><b>status</b>: Final</p><p><b>type</b>: <span title="Codes:{http://loinc.org 34756-7}">Dentistry Consult note</span></p><p><b>encounter</b>: <a href="Encounter-Dental-encounter.html">Dental Referral with patient A</a></p><p><b>date</b>: 2020-02-16 09:10:14+0000</p><p><b>author</b>: <a href="Practitioner-practitioner-D.html">Dentist D, DMD</a></p><p><b>title</b>: Consultation Note</p><h3>Attesters</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Mode</b></td><td><b>Time</b></td><td><b>Party</b></td></tr><tr><td style="display: none">*</td><td>Legal</td><td>2020-03-28 09:10:14+0000</td><td><a href="Practitioner-practitioner-D.html">Dentist Dentist D, DMD</a></td></tr></table><p><b>custodian</b>: <a href="Organization-GOHC-organization.html">Good Oral Health Clinic</a></p><h3>Events</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Code</b></td><td><b>Period</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ActClass PCPR}">Care Provision</span></td><td>2020-02-16 --&gt; 2020-02-16</td></tr></table></div>
  </text>
  <extension
             url="http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension">
    <valueReference>🔗 
      <reference value="ServiceRequest/example-dental-referral-1"/>
    </valueReference>
  </extension>
  <identifier>
    <system value="urn:ietf:rfc:3986"/>
    <value value="urn:uuid:f28fefc8-5aac-427c-93d7-f0bc7d633a9b"/>
  </identifier>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="34756-7"/>
      <display value="Dentistry Consult note"/>
    </coding>
  </type>
  <subject>🔗 
    <reference value="Patient/example-dental"/>
    <display value="Patient A"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/Dental-encounter"/>
    <display value="Dental Referral with patient A"/>
  </encounter>
  <date value="2020-02-16T09:10:14Z"/>
  <author>🔗 
    <reference value="Practitioner/practitioner-D"/>
    <display value="Dentist D, DMD"/>
  </author>
  <title value="Consultation Note"/>
  <attester>
    <mode value="legal"/>
    <time value="2020-03-28T09:10:14Z"/>
    <party>🔗 
      <reference value="Practitioner/practitioner-D"/>
      <display value="Dentist Dentist D, DMD"/>
    </party>
  </attester>
  <custodian>🔗 
    <reference value="Organization/GOHC-organization"/>
    <display value="Good Oral Health Clinic"/>
  </custodian>
  <event>
    <code>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v3-ActClass"/>
        <code value="PCPR"/>
        <display value="Care Provision"/>
      </coding>
    </code>
    <period>
      <start value="2020-02-16"/>
      <end value="2020-02-16"/>
    </period>
  </event>
  <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>Penicillin G (Ingredient)</td>
                        <td>Mild</td>
                        <td>Skin rash</td>
                        <td>Mild</td>
                        <td>Active</td>
                    </tr>
                </table>
            </div>
    </text>
    <entry>🔗 
      <reference value="AllergyIntolerance/Allergy-example-dental"/>
    </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>The patient has not visited a dentist or received fluoride treatments in the past four years while away at college</p>
            </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">
                <p>Mild, Hypertension</p>
                <p>Type 1 diabetes</p>
                <p>Dental caries</p>
                <p>Unable to chew</p>
                <p>Teeth covered in plague</p>
                <p>Toothache</p>
                <p>Chronic periodontitis</p>
                <p>Infection of tooth</p>
                <p>At high risk for dental caries (finding)</p>
            </div>
    </text>
    <entry>🔗 
      <reference value="Condition/HTN-example"/>
    </entry>
    <entry>🔗 
      <reference value="Condition/DM1-example"/>
    </entry>
    <entry>🔗 
      <reference value="Condition/Dental-caries"/>
    </entry>
    <entry>🔗 
      <reference value="Condition/no-chew"/>
    </entry>
    <entry>🔗 
      <reference value="Condition/Dental-plaque-example"/>
    </entry>
    <entry>🔗 
      <reference value="Condition/toothache-example"/>
    </entry>
    <entry>🔗 
      <reference value="Condition/Chronic-periodontitis-example"/>
    </entry>
    <entry>🔗 
      <reference value="Condition/Tooth-infection18"/>
    </entry>
    <entry>🔗 
      <reference value="Condition/Caries-risk"/>
    </entry>
  </section>
  <section>
    <title value="Medication Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10160-0"/>
        <display value="History of Medication use 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>erythromycin 500 mg</td>
                        <td>Take 1 tablet every six hours X10 days</td>
                        <td/>
                        <td>Active</td>
                        <td/>
                        <td/>
                    </tr>
                    <tr>
                        <td>ibuprofen (OTC)  200 mg tab</td>
                        <td>Take 2-3 tablets every 8 hours as needed for pain</td>
                        <td>Take 2-3 tablets every 8 hours as needed for pain</td>
                        <td/>
                        <td>Active</td>
                        <td/>
                        <td/>
                    </tr>
                    <tr>
                        <td>acetaminophen (OTC) 325 mg</td>
                        <td>Take 2 tablets every 4-6 hours as needed for pain</td>
                        <td/>
                        <td>Active</td>
                        <td/>
                        <td/>
                    </tr>
                    <tr>
                        <td>Lisinopril 10 mg tab</td>
                        <td>1 tab once a day</td>
                        <td/>
                        <td>Active</td>
                        <td/>
                        <td/>
                    </tr>
                </table>
            </div>
    </text>
    <entry>🔗 
      <reference value="MedicationRequest/erythromycin-medreq-2"/>
    </entry>
    <entry>🔗 
      <reference value="MedicationRequest/Ibuprofen-medreq-2"/>
    </entry>
    <entry>🔗 
      <reference value="MedicationRequest/Tylenol-med-dental"/>
    </entry>
    <entry>🔗 
      <reference value="MedicationRequest/Lisinopril-medreq"/>
    </entry>
  </section>
  <section>
    <title value="Assessment Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="51848-0"/>
        <display value="Evaluation note"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
                <p> Patient reports inability to chew on left side due to pain and
        sensitivity, a condition that has increased in severity in the two days
        since his medical appointment </p>
                <p> Significant decay on the left lower second molar (tooth #18)
         with signs of infection  </p>
                <p> Early signs of a caries lesion (decay) on the right upper
        lateral incisor (tooth #7) </p>
                <p> Recommend an extraction of the left lower second molar(tooth
        #18) and a restoration on the right upper lateral incisor (tooth #7) due
        to a caries lesion </p>
            </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 border="1" width="100%">
                    <thead>
                        <tr>
                            <th>Vaccine</th>
                            <th>Date</th>
                            <th>Status</th>
                        </tr>
                    </thead>
                    <tbody>
                        <tr>
                            <td>
              Hepatitis B vaccine
            </td>
                            <td>January 4, 2020</td>
                            <td>Completed</td>
                        </tr>
                    </tbody>
                </table>
            </div>
    </text>
    <entry>🔗 
      <reference value="Immunization/imm-1"/>
    </entry>
  </section>
  <section>
    <title value="Medical Equipment Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="46264-8"/>
        <display value="History of medical device use"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
                <table border="1" width="100%">
                    <thead>
                        <tr>
                            <th>Device Type</th>
                            <th>Procedure</th>
                            <th>Implant Date</th>
                        </tr>
                    </thead>
                    <tbody>
                        <tr>
                            <td>Insulin Pump</td>
                            <td>Insertion of insulin pump (procedure)</td>
                            <td>November 3, 2013</td>
                        </tr>
                    </tbody>
                </table>
            </div>
    </text>
    <entry>🔗 
      <reference value="Procedure/Insulin-pump-insertion"/>
    </entry>
  </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 border="1" width="100%">
                    <thead>
                        <tr>
                            <th>Date</th>
                            <th>Code</th>
                            <th>Description</th>
                            <th>Mouth Location</th>
                        </tr>
                    </thead>
                    <tbody>
                        <tr>
                            <td>Feb 23, 2020</td>
                            <td>D7140</td>
                            <td>Extraction, erupted tooth or exposed root (elevation and/or
                forceps removal)</td>
                            <td>Tooth #18</td>
                        </tr>
                        <tr>
                            <td>Mar 3, 2020</td>
                            <td>D1352</td>
                            <td>Preventive resin restoration in a moderate to high caries
                risk patient-permanent tooth</td>
                            <td>Tooth #7</td>
                        </tr>
                        <tr>
                            <td>Mar 10, 2020</td>
                            <td>D0150</td>
                            <td>comprehensive oral evaluation - new or established
                patient</td>
                            <td>N/A</td>
                        </tr>
                        <tr>
                            <td>Mar 10, 2020</td>
                            <td>D1110</td>
                            <td>Prophylaxis - Adult</td>
                            <td>N/A</td>
                        </tr>
                        <tr>
                            <td>Mar 10, 2020</td>
                            <td>D0210</td>
                            <td>Full mouth radiographic survey</td>
                            <td>N/A</td>
                        </tr>
                    </tbody>
                </table>
            </div>
    </text>
    <entry>🔗 
      <reference value="ServiceRequest/Dental-extraction-example"/>
    </entry>
    <entry>🔗 
      <reference value="ServiceRequest/Resin-restore-example"/>
    </entry>
    <entry>🔗 
      <reference value="ServiceRequest/prophylaxis-example"/>
    </entry>
    <entry>🔗 
      <reference value="ServiceRequest/Radiograph-survey"/>
    </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 border="1" width="100%">
                    <thead>
                        <tr>
                            <th>Date</th>
                            <th>Code</th>
                            <th>Description</th>
                            <th>Mouth Location</th>
                        </tr>
                    </thead>
                    <tbody>
                        <tr>
                            <td>Feb 16, 2020</td>
                            <td>D1206</td>
                            <td>topical application of fluoride varnish</td>
                            <td>N/A</td>
                        </tr>
                    </tbody>
                </table>
            </div>
    </text>
    <entry>🔗 
      <reference value="Procedure/Dental-flouride-tx-example"/>
    </entry>
  </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>Patient referred for evaluation and treatment for toothache lower left</p>
            </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 Status - Meaningful Use</td>
                        <td>Never smoked tobacco</td>
                        <td>Feb 14, 2020</td>
                    </tr>
                    <tr>
                        <td>Highest Education Level</td>
                        <td>College Education</td>
                        <td>2005/05/01 - 2010/02/28</td>
                    </tr>
                    <tr>
                        <td>Employment</td>
                        <td>Accountaint, Full Time</td>
                        <td>2005/05/01 - 2010/02/28</td>
                    </tr>
                </table>
            </div>
    </text>
    <entry>🔗 
      <reference value="Observation/Smoker-obs-example-dental"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/Education-level-example-dental"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/Present-job-example-dental"/>
    </entry>
  </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 border="1" width="100%">
                    <thead>
                        <tr>
                            <th>Observation Type</th>
                            <th>Value</th>
                            <th>Units</th>
                        </tr>
                    </thead>
                    <tbody>
                        <tr>
                            <td>Body Temperature</td>
                            <td>99</td>
                            <td>[degF]</td>
                        </tr>
                        <tr>
                            <td>Heart Rate</td>
                            <td>82</td>
                            <td>/min</td>
                        </tr>
                        <tr>
                            <td>Blood Pressure - Diastolic</td>
                            <td>80</td>
                            <td>mmHg</td>
                        </tr>
                        <tr>
                            <td>Blood Pressure - Systolic</td>
                            <td>120</td>
                            <td>mmHg</td>
                        </tr>
                    </tbody>
                </table>
            </div>
    </text>
    <entry>🔗 
      <reference value="Observation/body-temperature"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/heart-rate"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/blood-pressure"/>
    </entry>
  </section>
  <section>
    <title value="Instructions Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="69730-0"/>
        <display value="Instructions"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
                <p>Patient educated on the benefits of using a fluoride toothpaste, daily
          flossing, and bi-annual routine dental cleaning visits.</p>
            </div>
    </text>
    <entry>🔗 
      <reference value="Communication/dental-education2"/>
    </entry>
  </section>
  <section>
    <title value="Payers Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="48768-6"/>
        <display value="Payment sources Document"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
                <p>Aetna Comprehensive Medical /Dental Insurance</p>
            </div>
    </text>
    <entry>🔗 
      <reference value="Coverage/Dental-Aetna"/>
    </entry>
  </section>
  <section>
    <title value="Dental Findings Section"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8704-9"/>
        <display value="Physical findings of Mouth and Throat and Teeth"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">
                <table border="1" width="100%">
                    <thead>
                        <tr>
                            <th>Finding Type</th>
                            <th>Value</th>
                            <th>Location</th>
                        </tr>
                    </thead>
                    <tbody>
                        <tr>
                            <td>Problem</td>
                            <td>Dental Caries</td>
                            <td>Tooth #18</td>
                        </tr>
                        <tr>
                            <td>Problem</td>
                            <td>Infection of Tooth</td>
                            <td>Tooth #18</td>
                        </tr>
                        <tr>
                            <td>Problem</td>
                            <td>Dental Caries</td>
                            <td>Tooth #7</td>
                        </tr>
                        <tr>
                            <td>Result</td>
                            <td>Overjet</td>
                            <td>3mm</td>
                        </tr>
                    </tbody>
                </table>
            </div>
    </text>
    <entry>🔗 
      <reference value="Condition/Mandibular-perm18-example"/>
    </entry>
    <entry>🔗 
      <reference value="Condition/Tooth-infection18"/>
    </entry>
    <entry>🔗 
      <reference value="Condition/Maxillary-perm7-example"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/Overjet"/>
    </entry>
  </section>
</Composition>