International Patient Summary Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-ips/ and changes regularly. See the Directory of published versions
Generated Narrative
Resource "30551ce1-5a28-4356-b684-1e639094ad4d"
identifier: id: 3f69e0a5-2177-4540-baab-7a5d0877428f
status: final
type: Patient summary Document (LOINC#60591-5)
date: 2017-12-11 02:30:00+0100
author: Beetje van Hulp, MD
title: Patient Summary as of December 11, 2017 14:30
confidentiality: N
attester
mode: legal
time: 2017-12-11 02:30:00+0100
party: Beetje van Hulp, MD
attester
mode: legal
time: 2017-12-11 02:30:00+0100
party: Anorg Aniza Tion BV
custodian: Anorg Aniza Tion BV
- | Code | Target[x] |
* | appends | id: c2277753-9f90-4a95-8ddb-a0b3f6e7d292 |
- | Code | Period |
* | care provision (ActClass#PCPR) | ?? --> 2017-12-11 02:30:00+0100 |
Medication | Strength | Form | Dosage | Comment |
---|---|---|---|---|
Anastrozole | 1 mg | tablet | once daily | treatment for breast cancer |
Black Cohosh Extract | pil | herbal supplement |
Blood typing | ||
---|---|---|
Blood group | A+ | |
C Ab [Presence] in Serum or Plasma | Positive | |
E Ab [Presence] in Serum or Plasma | Positive | |
Little c Ab [Presence] in Serum or Plasma | Negative |
Hemoglobin A1c monitoring | ||
---|---|---|
Hemoglobin A1c/Hemoglobin.total in Blood by HPLC | 7.5 % |
Bacteriology | ||
---|---|---|
Methicillin resistant Staphylococcus aureus | ||
Healthy carrier of MRSA |
2. urn:uuid:2b90dd2b-2dab-4c75-9bb9-a355e07401e8 (Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8)
Martha DeLarosa Female, DoB: 1972-05-01 ( urn:oid:2.16.840.1.113883.2.4.6.3#574687583)
3. urn:uuid:1c616b24-3895-48c4-9a02-9a64110351ef (Practitioner/1c616b24-3895-48c4-9a02-9a64110351ef)
Generated Narrative: Practitioner
Resource Practitioner "1c616b24-3895-48c4-9a02-9a64110351ef"
identifier:
urn:oid:2.16.528.1.1007.3.1
/129854633active: true
name: Beetje van Hulp
Qualifications
Code Doctor of Medicine (v2-0360|2.7#MD)
4. urn:uuid:890751f4-2924-4636-bab7-efffc7f3cf15 (Organization/890751f4-2924-4636-bab7-efffc7f3cf15)
Generated Narrative: Organization
Resource Organization "890751f4-2924-4636-bab7-efffc7f3cf15"
identifier:
urn:oid:2.16.528.1.1007.3.3
/564738757active: true
name: Anorg Aniza Tion BV / The best custodian ever
Contacts
Telecom Address +31-51-34343400 Houttuinen 27 Dordrecht 3311 CE NL (WORK)
5. urn:uuid:c64139e7-f02d-409c-bf34-75e8bf23bc80 (Condition/c64139e7-f02d-409c-bf34-75e8bf23bc80)
Generated Narrative: Condition
Resource Condition "c64139e7-f02d-409c-bf34-75e8bf23bc80"
identifier:
urn:oid:1.2.3.999
/c87bf51c-e53c-4bfe-b8b7-aa62bdd93002clinicalStatus: Active (Condition Clinical Status Codes#active)
verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)
category: Problem (LOINC#75326-9)
severity: Moderate (LOINC#LA6751-7)
code: Menopausal flushing (finding) (SNOMED CT#198436008; ICD-10#N95.1 "Menopausal and female climacteric states")
subject: See above (Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8)
onset: 2015
recordedDate: 2016-10
6. urn:uuid:c220e36c-eb67-4fc4-9ba1-2fabc52acec6 (MedicationStatement/c220e36c-eb67-4fc4-9ba1-2fabc52acec6)
Generated Narrative: MedicationStatement
Resource MedicationStatement "c220e36c-eb67-4fc4-9ba1-2fabc52acec6"
identifier:
urn:oid:1.2.3.999
/b75f92cb-61d4-469a-9387-df5ef70d25f0status: RECORDED
subject: See above (Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8)
effective: 2015-03 --> (ongoing)
dosage
7. urn:uuid:47524493-846a-4a26-bae2-4ab03e60f02e (MedicationStatement/47524493-846a-4a26-bae2-4ab03e60f02e)
Generated Narrative: MedicationStatement
Resource MedicationStatement "47524493-846a-4a26-bae2-4ab03e60f02e"
identifier:
urn:oid:1.2.3.999
/9e312d6b-c6b6-439a-a730-6efaa5dcf8bcstatus: RECORDED
subject: See above (Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8)
effective: 2016-01 --> (ongoing)
Dosages
Route Oral use (standardterms.edqm.eu#20053000)
8. urn:uuid:976d0804-cae0-45ae-afe3-a19f3ceba6bc (Medication/976d0804-cae0-45ae-afe3-a19f3ceba6bc)
Generated Narrative: Medication
Resource Medication "976d0804-cae0-45ae-afe3-a19f3ceba6bc"
code: Product containing anastrozole (medicinal product) (SNOMED CT#108774000; unknown#99872 "ANASTROZOL 1MG TABLET"; unknown#2076667 "ANASTROZOL CF TABLET FILMOMHULD 1MG"; WHO ATC#L02BG03 "anastrozole")
9. urn:uuid:8adc0999-9468-4ac9-9557-680fa133d626 (Medication/8adc0999-9468-4ac9-9557-680fa133d626)
Generated Narrative: Medication
Resource Medication "8adc0999-9468-4ac9-9557-680fa133d626"
code: Black Cohosh Extract herbal supplement (SNOMED CT#412588001 "Cimicifuga racemosa extract (substance)"; WHO ATC#G02CX04 "Cimicifugae rhizoma")
10. urn:uuid:72884cad-ebe6-4f43-a51a-2f978275f132 (AllergyIntolerance/72884cad-ebe6-4f43-a51a-2f978275f132)
Generated Narrative: AllergyIntolerance
Resource AllergyIntolerance "72884cad-ebe6-4f43-a51a-2f978275f132"
identifier:
urn:oid:1.2.3.999
/3a462598-009c-484a-965c-d6b24a821424clinicalStatus: Active (AllergyIntolerance Clinical Status Codes#active)
verificationStatus: Confirmed (AllergyIntolerance Verification Status#confirmed)
type: Allergy (AllergyIntoleranceType#allergy)
category: MEDICATION
criticality: HIGH
code: Substance with penicillin structure and antibacterial mechanism of action (substance) (SNOMED CT#373270004)
patient: See above (Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8)
onset: 2010
11. urn:uuid:c4597aa2-688a-401b-a658-70acc6de28c6 (Condition/c4597aa2-688a-401b-a658-70acc6de28c6)
Generated Narrative: Condition
Resource Condition "c4597aa2-688a-401b-a658-70acc6de28c6"
identifier:
urn:oid:1.2.3.999
/66d4a8c7-9081-43e0-a63f-489c2ae6edd6clinicalStatus: Remission (Condition Clinical Status Codes#remission)
verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)
category: Problem (LOINC#75326-9)
severity: Severe (LOINC#LA6750-9)
code: Malignant tumor of breast (SNOMED CT#254837009; International Classification of Diseases for Oncology, version 3.#8500/3 "Infiltrating duct carcinoma, NOS")
subject: See above (Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8)
onset: 2015-01
abatement: 2015-03
12. urn:uuid:45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7 (Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7)
Generated Narrative: Organization
Resource Organization "45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7"
active: true
type: Other (Organization type#other)
name: Laboratoire de charme
13. urn:uuid:aa11a2be-3e36-4be7-b58a-6fc3dace2741 (Observation/aa11a2be-3e36-4be7-b58a-6fc3dace2741)
Generated Narrative: Observation
Resource Observation "aa11a2be-3e36-4be7-b58a-6fc3dace2741"
status: FINAL
category: Laboratory (Observation Category Codes#laboratory)
code: ABO and Rh group [Type] in Blood (LOINC#882-1)
subject: See above (Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8)
effective: 2015-10-10 09:15:00+0100
performer: See above (Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7)
value: Blood group A Rh(D) positive (SNOMED CT#278149003)
14. urn:uuid:6e39ccf3-f997-4a2b-8f28-b4b71c778c70 (Observation/6e39ccf3-f997-4a2b-8f28-b4b71c778c70)
Generated Narrative: Observation
Resource Observation "6e39ccf3-f997-4a2b-8f28-b4b71c778c70"
status: FINAL
category: Laboratory (Observation Category Codes#laboratory)
code: C Ab [Presence] in Serum or Plasma (LOINC#945-6)
subject: See above (Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8)
effective: 2015-10-10 09:35:00+0100
performer: See above (Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7)
value: Positive (SNOMED CT#10828004)
15. urn:uuid:b4916505-a06b-460c-9be8-011609282457 (Observation/b4916505-a06b-460c-9be8-011609282457)
Generated Narrative: Observation
Resource Observation "b4916505-a06b-460c-9be8-011609282457"
status: FINAL
category: Laboratory (Observation Category Codes#laboratory)
code: E Ab [Presence] in Serum or Plasma (LOINC#1018-1)
subject: See above (Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8)
effective: 2015-10-10 09:35:00+0100
performer: See above (Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7)
value: Positive (SNOMED CT#10828004)
16. urn:uuid:a6a5a1d5-c896-4c7e-b922-888fcc7e6ae4 (Observation/a6a5a1d5-c896-4c7e-b922-888fcc7e6ae4)
Generated Narrative: Observation
Resource Observation "a6a5a1d5-c896-4c7e-b922-888fcc7e6ae4"
status: FINAL
category: Laboratory (Observation Category Codes#laboratory)
code: little c Ab [Presence] in Serum or Plasma (LOINC#1156-9)
subject: See above (Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8)
effective: 2015-10-10 09:35:00+0100
performer: See above (Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7)
value: Negative (SNOMED CT#260385009)
17. urn:uuid:2639657a-c19a-48e2-82cc-471e13b8ad94 (Observation/2639657a-c19a-48e2-82cc-471e13b8ad94)
Generated Narrative: Observation
Resource Observation "2639657a-c19a-48e2-82cc-471e13b8ad94"
status: FINAL
category: Laboratory (Observation Category Codes#laboratory)
code: Blood typing ()
subject: See above (Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8)
effective: 2015-10-10
performer: See above (Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7)
hasMember:
18. urn:uuid:cc354e00-a419-47ea-8b6c-1768b2a01646 (Observation/cc354e00-a419-47ea-8b6c-1768b2a01646)
Generated Narrative: Observation
Resource Observation "cc354e00-a419-47ea-8b6c-1768b2a01646"
status: FINAL
category: Laboratory (Observation Category Codes#laboratory)
code: Hemoglobin A1c/Hemoglobin.total in Blood by HPLC (LOINC#17856-6)
subject: See above (Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8)
effective: 2017-11-10 08:20:00+0100
performer: See above (Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7)
value: 7.5 % (Details: UCUM code % = '%')
note: Above stated goal of 7.0 %
19. urn:uuid:26bee0a9-5997-4557-ab9d-c6adbb05b572 (Observation/26bee0a9-5997-4557-ab9d-c6adbb05b572)
Generated Narrative: Observation
Resource Observation "26bee0a9-5997-4557-ab9d-c6adbb05b572"
status: FINAL
category: Laboratory (Observation Category Codes#laboratory)
code: Bacteria identified in Isolate (LOINC#42803-7)
subject: See above (Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8)
effective: 2017-12-10 08:20:00+0100
performer: See above (Organization/45a5c5b1-4ec1-4d60-b4b2-ff5a84a41fd7)
value: Methicillin resistant Staphylococcus aureus (SNOMED CT#115329001)
note: Healthy carrier of MRSA
20. urn:uuid:c7781f44-6df8-4a8b-9e06-0b34263a47c5 (AllergyIntolerance/c7781f44-6df8-4a8b-9e06-0b34263a47c5)
Generated Narrative: AllergyIntolerance
Resource AllergyIntolerance "c7781f44-6df8-4a8b-9e06-0b34263a47c5"
clinicalStatus: Active (AllergyIntolerance Clinical Status Codes#active)
code: No known food allergies (Absent and Unknown Data - IPS#no-known-food-allergies)
patient: See above (Patient/2b90dd2b-2dab-4c75-9bb9-a355e07401e8)