Dental Data Exchange
2.0.0-ballot - CI Build
Dental Data Exchange
2.0.0-ballot - CI Build
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
@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <https://loinc.org/rdf/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:Composition ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "Med-2-Dental-Referral"] ; #
fhir:meta [
fhir:versionId [ fhir:v "25" ] ;
fhir:lastUpdated [ fhir:v "2021-08-26T17:48:27.238+00:00"^^xsd:dateTime ] ;
fhir:source [ fhir:v "#D3muhSqHq8nuVF61"^^xsd:anyURI ] ;
( fhir:profile [
fhir:v "http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-referral-note"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-referral-note> ] )
] ; #
fhir:language [ fhir:v "en-US"] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p class=\"res-header-id\"><b>Generated Narrative: Composition Med-2-Dental-Referral</b></p><a name=\"Med-2-Dental-Referral\"> </a><a name=\"hcMed-2-Dental-Referral\"> </a><a name=\"Med-2-Dental-Referral-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: 25; Last updated: 2021-08-26 17:48:27+0000; Language: en-US; </p><p style=\"margin-bottom: 0px\">Information Source: #D3muhSqHq8nuVF61</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-dental-referral-note.html\">Dental Referral Note</a></p></div><p><b>identifier</b>: <code>urn:ietf:rfc:3986</code>/http://any.org/1</p><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://loinc.org 57134-9}\">Dentistry Referral note</span></p><p><b>encounter</b>: <a href=\"Encounter-Med-visit-1.html\">PCP visit</a></p><p><b>date</b>: 2020-01-14 03:10:14+0000</p><p><b>author</b>: <a href=\"Practitioner-practitioner-M.html\">Dr. John M, MD</a></p><p><b>title</b>: Referral 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>2020-03-14 09:10:14+0000</td><td><a href=\"PractitionerRole-PractitionerRole-M.html\">Dr. John M, MD</a></td></tr></table><p><b>custodian</b>: <a href=\"Organization-GHC-organization.html\">Good Health Clinic</a></p></div>"
] ; #
fhir:identifier [
fhir:system [ fhir:v "urn:ietf:rfc:3986"^^xsd:anyURI ] ;
fhir:value [ fhir:v "http://any.org/1" ]
] ; #
fhir:status [ fhir:v "final"] ; #
fhir:type [
( fhir:coding [
a loinc:57134-9 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "57134-9" ] ;
fhir:display [ fhir:v "Dentistry Referral note" ] ] )
] ; #
fhir:subject [
fhir:reference [ fhir:v "Patient/example-dental" ] ;
fhir:display [ fhir:v "Patient A" ]
] ; #
fhir:encounter [
fhir:reference [ fhir:v "Encounter/Med-visit-1" ] ;
fhir:display [ fhir:v "PCP visit" ]
] ; #
fhir:date [ fhir:v "2020-01-14T03:10:14Z"^^xsd:dateTime] ; #
fhir:author ( [
fhir:reference [ fhir:v "Practitioner/practitioner-M" ] ;
fhir:display [ fhir:v "Dr. John M, MD" ]
] ) ; #
fhir:title [ fhir:v "Referral Note"] ; #
fhir:attester ( [
fhir:mode [ fhir:v "legal" ] ;
fhir:time [ fhir:v "2020-03-14T09:10:14Z"^^xsd:dateTime ] ;
fhir:party [
fhir:reference [ fhir:v "PractitionerRole/PractitionerRole-M" ] ;
fhir:display [ fhir:v "Dr. John M, MD" ] ]
] ) ; #
fhir:custodian [
fhir:reference [ fhir:v "Organization/GHC-organization" ] ;
fhir:display [ fhir:v "Good Health Clinic" ]
] ; #
fhir:section ( [
fhir:title [ fhir:v "Allergies and Intolerances Section" ] ;
fhir:code [
( fhir:coding [
a loinc:48765-2 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "48765-2" ] ;
fhir:display [ fhir:v "Allergies and adverse reactions Document" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Allergen</b>\n </td>\n <td>\n <b>Code</b>\n </td>\n <td>\n <b>Manifestation</b>\n </td>\n <td>\n <b>Severity</b>\n </td>\n </tr>\n <tr>\n <td>Penicillin G</td>\n <td>7908</td>\n <td>Skin rash</td>\n <td>mild</td>\n </tr>\n </table>\n </div>" ] ;
( fhir:entry [
fhir:reference [ fhir:v "AllergyIntolerance/Allergy-example-dental" ] ] )
] [
fhir:title [ fhir:v "Medication Section" ] ;
fhir:code [
( fhir:coding [
a loinc:10160-0 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "10160-0" ] ;
fhir:display [ fhir:v "History of Medication use Narrative" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Medication</b>\n </td>\n <td>\n <b>Directions</b>\n </td>\n <td>\n <b>Start Date</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n <td>\n <b>Indications</b>\n </td>\n <td>\n <b>Fill Instructions</b>\n </td>\n </tr>\n <tr>\n <td>Lisinopril 10 mg tab</td>\n <td>1 tab once/day</td>\n <td/>\n <td>Active</td>\n <td/>\n <td>Generic substitution allowed</td>\n </tr>\n </table>\n </div>" ] ;
( fhir:entry [
fhir:reference [ fhir:v "MedicationRequest/Lisinopril-medreq" ] ] )
] [
fhir:title [ fhir:v "Problem Section" ] ;
fhir:code [
( fhir:coding [
a loinc:11450-4 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "11450-4" ] ;
fhir:display [ fhir:v "Problem list - Reported" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Mild, Hypertension</p>\n <p>Type 1 diabetes</p>\n <p>Teeth covered in plague</p>\n <p>Toothache</p>\n <p>Swollen Gums</p>\n <p>Bleeding Gums</p>\n <p>At high risk for dental carries</p>\n </div>" ] ;
( fhir:entry [
fhir:reference [ fhir:v "Condition/HTN-example" ] ] [
fhir:reference [ fhir:v "Condition/DM1-example" ] ] [
fhir:reference [ fhir:v "Condition/Dental-plaque-example" ] ] [
fhir:reference [ fhir:v "Condition/toothache-example" ] ] [
fhir:reference [ fhir:v "Condition/Swollen-gums-example" ] ] [
fhir:reference [ fhir:v "Condition/Bleeding-gums-example" ] ] [
fhir:reference [ fhir:v "Condition/Caries-risk" ] ] )
] [
fhir:title [ fhir:v "Reason for Referral Section" ] ;
fhir:code [
( fhir:coding [
a loinc:42349-1 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "42349-1" ] ;
fhir:display [ fhir:v "Reason for referral (narrative)" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Toothache</p>\n <p>Left lower quadrant pain</p>\n <p>Bleeding gums</p>\n </div>" ] ;
( fhir:entry [
fhir:reference [ fhir:v "ServiceRequest/example-dental-referral-1" ] ] )
] [
fhir:title [ fhir:v "Plan of Treatment Section" ] ;
fhir:code [
( fhir:coding [
a loinc:18776-5 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "18776-5" ] ;
fhir:display [ fhir:v "Plan of care note" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>D0150 - Comprehensive Oral Evaluation</p>\n </div>" ] ;
( fhir:entry [
fhir:reference [ fhir:v "Encounter/Comp-oral-eval" ] ] )
] [
fhir:title [ fhir:v "Assessment Section" ] ;
fhir:code [
( fhir:coding [
a loinc:51848-0 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "51848-0" ] ;
fhir:display [ fhir:v "Evaluation note" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Patient has pain in his lower left jaw and occassional bleeding from his gums - referring for dental evaluation.</p>\n </div>" ]
] [
fhir:title [ fhir:v "History of Present Illness Section" ] ;
fhir:code [
( fhir:coding [
a loinc:10164-2 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "10164-2" ] ;
fhir:display [ fhir:v "History of Present illness Narrative" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>The patient has not visited a dentist or received flouride treatments in the past 4 years while away at college</p>\n </div>" ]
] [
fhir:title [ fhir:v "Immunizations Section" ] ;
fhir:code [
( fhir:coding [
a loinc:11369-6 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "11369-6" ] ;
fhir:display [ fhir:v "History of Immunization Narrative" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Vaccine</th>\n <th>Date</th>\n <th>Status</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>\n Hepatitis B vaccine\n </td>\n <td>January 4, 2020</td>\n <td>Completed</td>\n </tr>\n </tbody>\n </table>\n </div>" ] ;
( fhir:entry [
fhir:reference [ fhir:v "Immunization/imm-1" ] ] )
] [
fhir:title [ fhir:v "Medical Equipment Section" ] ;
fhir:code [
( fhir:coding [
a loinc:46264-8 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "46264-8" ] ;
fhir:display [ fhir:v "History of medical device use" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table border=\"1\" width=\"100%\">\n <thead>\n <tr>\n <th>Device Type</th>\n <th>Procedure</th>\n <th>Implant Date</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>Insulin Pump</td>\n <td>Insertion of insulin pump (procedure)</td>\n <td>November 3, 2013</td>\n </tr>\n </tbody>\n </table>\n </div>" ] ;
( fhir:entry [
fhir:reference [ fhir:v "Procedure/Insulin-pump-insertion" ] ] )
] [
fhir:title [ fhir:v "Procedures Section" ] ;
fhir:code [
( fhir:coding [
a loinc:47519-4 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "47519-4" ] ;
fhir:display [ fhir:v "History of Procedures Document" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>No Procedures performed</p>\n </div>" ]
] [
fhir:title [ fhir:v "Social History Section" ] ;
fhir:code [
( fhir:coding [
a loinc:29762-2 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "29762-2" ] ;
fhir:display [ fhir:v "Social history Narrative" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Social History Element</b>\n </td>\n <td>\n <b>Description</b>\n </td>\n <td>\n <b>Effective Dates</b>\n </td>\n </tr>\n <tr>\n <td>Smoking Status</td>\n <td>NA</td>\n <td>2005/05/01 - 2020/03/28</td>\n </tr>\n <tr>\n <td>Highest Education Received</td>\n <td>Collect Education</td>\n <td>2010/05/01 - 2014/03/28</td>\n </tr>\n <tr>\n <td>Employment</td>\n <td>Full-time accountant</td>\n <td>2015/05/01 - current</td>\n </tr>\n </table>\n </div>" ] ;
( fhir:entry [
fhir:reference [ fhir:v "Observation/Smoker-obs-example-dental" ] ] [
fhir:reference [ fhir:v "Observation/Education-level-example-dental" ] ] [
fhir:reference [ fhir:v "Observation/Present-job-example-dental" ] ] )
] [
fhir:title [ fhir:v "Vital Signs Section" ] ;
fhir:code [
( fhir:coding [
a loinc:8716-3 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "8716-3" ] ;
fhir:display [ fhir:v "Vital signs" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Vital Sign</b>\n </td>\n <td>\n <b>Date</b>\n </td>\n <td>\n <b>Value</b>\n </td>\n </tr>\n <tr>\n <td>Temperature</td>\n <td>2020/04/15</td>\n <td>98.5</td>\n </tr>\n <tr>\n <td>Heart Rate</td>\n <td>2020/04/15</td>\n <td>78</td>\n </tr>\n <tr>\n <td>Respiration Rate</td>\n <td>2020/04/15</td>\n <td>20</td>\n </tr>\n <tr>\n <td>Blood Pressure</td>\n <td>2020/04/15</td>\n <td>120/80</td>\n </tr>\n </table>\n </div>" ] ;
( fhir:entry [
fhir:reference [ fhir:v "Observation/vitals-panel" ] ] )
] [
fhir:title [ fhir:v "Goals Section" ] ;
fhir:code [
( fhir:coding [
a loinc:61146-7 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "61146-7" ] ;
fhir:display [ fhir:v "Goals" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>No soda/sugary drinks/energy drinks</p>\n <p>Use fluoride toothpaste</p>\n </div>" ]
] [
fhir:title [ fhir:v "Health Concerns Section" ] ;
fhir:code [
( fhir:coding [
a loinc:75310-3 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "75310-3" ] ;
fhir:display [ fhir:v "Health concerns Document" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Neuropathy due to diabetes mellitus</p>\n </div>" ]
] [
fhir:title [ fhir:v "Instructions Section" ] ;
fhir:code [
( fhir:coding [
a loinc:69730-0 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "69730-0" ] ;
fhir:display [ fhir:v "Instructions" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Pt. Education. Advised to see dentist regularly, brush 2x/day w/ fluoride\n toothpaste, floss</p>\n </div>" ] ;
( fhir:entry [
fhir:reference [ fhir:v "Communication/dental-education" ] ] )
] [
fhir:title [ fhir:v "Payers Section" ] ;
fhir:code [
( fhir:coding [
a loinc:48768-6 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "48768-6" ] ;
fhir:display [ fhir:v "Payment sources Document" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Aetna Comprehensive Medical /Dental Insurance</p>\n </div>" ] ;
( fhir:entry [
fhir:reference [ fhir:v "Coverage/Dental-Aetna" ] ] )
] [
fhir:title [ fhir:v "Dental Findings Section" ] ;
fhir:code [
( fhir:coding [
a loinc:8704-9 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "8704-9" ] ;
fhir:display [ fhir:v "Physical findings of Mouth and Throat and Teeth" ] ] ) ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>No Information</p>\n </div>" ]
] ) . #
IG © 2020+ Payer/Provider Information Exchange Work Group. Package hl7.fhir.us.dental-data-exchange#2.0.0-ballot based on FHIR 4.0.1. Generated 2024-09-11
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